Associations of vitamin D status, bone health and anthropometry, with gross motor development and performance of school-aged Indian children who were born at term with low birth weight

Association Between Vitamin D Insufficiency and Impaired Bone Density Among Adolescents With Perinatally Acquired HIV Infection

Background

Stunting and pubertal delay are common among children growing up with human immunodeficiency virus (HIV) and are associated with bone and muscle impairments. We investigated factors associated with bone density and muscle function in adolescents living with HIV (ALWH).

Methods

The VITALITY trial (PACTR202009897660297) investigated whether vitamin D and calcium supplementation improves musculoskeletal health among ALWH. A total of 842 ALWH aged 11-19 years, established on antiretroviral therapy (ART) for ≥6 months, were enrolled from HIV clinics in Zambia and Zimbabwe. Clinical history and examination were undertaken, and serum 25-hydroxyvitamin D3 (25[OH]D3) was measured. Dual-energy X-ray absorptiometry measured total-body-less-head bone mineral density adjusted for height (TBLH-BMDHT), and lumbar spine bone mineral apparent density (LS-BMAD) z scores. The association between a priori-defined covariates and musculoskeletal outcomes were investigated using baseline enrollment data and multivariable logistic regression.

Results

TBLH-BMDHT  z scores were impaired (mean, -1.42 for male and -0.63 female participants), as were LS-BMAD z scores (mean -1.15 for male and -0.47 for female participants). In bivariate analysis, early pubertal stage, less physical activity, and older age at ART initiation were associated with lower TBLH-BMDHT  z scores. Younger age, early pubertal stage, and low socioeconomic status were associated with lower LS-BMAD z scores. Grip-strength-for-height and jump-power-for-height z scores were associated with lower TBLH-BMDHT and LS-BMAD z scores. Low dietary vitamin D and calcium were associated with lower adjusted TBLH-BMDHT  z scores. Lower 25(OH)D3 was associated with lower adjusted TBLH-BMDHT and LS-BMAD z scores.

Conclusions

Deficits in bone density are common in ALWH. Vitamin D and calcium supplementation and promotion of exercise may improve musculoskeletal health among perinatally infected ALWH.

The impact of HIV infection on skeletal maturity in peripubertal children in Zimbabwe: a cross-sectional study

INTRODUCTION

HIV infection and its treatment compromises skeletal development (growth and maturation). Skeletal maturity is assessed as bone age (BA) on hand and wrist radiographs. BA younger than chronological age (CA) indicates delayed development. We conducted a cross-sectional study to determine differences between BA and CA (i.e., skeletal maturity deviation [SMD]), and risk factors associated with SMD in peripubertal children with and without HIV established on antiretroviral therapy (ART) including use of tenofovir disoproxil fumarate (TDF).

METHODS

Children with HIV taking ART for at least two years and a comparison group of HIV-negative children, aged 8-16 years and frequency-matched by age and sex, were recruited from HIV clinics and local schools in the same catchment area, in Harare, Zimbabwe. BA was assessed from non-dominant hand-wrist radiographs using the Tanner Whitehouse 3 method. Negative SMD values correspond to delayed development, i.e., BA younger than CA. Multivariable linear regression models determined factors associated with SMD overall, and in children with HIV.

RESULTS

In total, 534 participants (54% males) were included; by design CA was similar in males and females, whether living with or without HIV. Mean (SD) SMD was more negative in CWH than in HIV-negative children in both males [-1.4(1.4) vs. -0.4(1.1) years] and females [-1.1(1.3) vs. -0.0(1.2) years]. HIV infection and weight-for-age Z-score<-2 were associated with more negative SMD in both males and females after adjusting for socio-economic status, orphanhood, pubertal stage, and calcium intake. Age at ART initiation was associated with SMD in both males and females with those starting ART later more delayed: starting ART aged 4-8 years 1.14 (-1.84, -0.43), or over 8 years 1.47 (-2.30, -0.65) (p-value for trend < 0.001). Similar non-significant trends were seen in males. TDF exposure TDF exposure whether < 4years or ≥ 4 years was not associated with delayed development.

CONCLUSION

Perinatally-acquired HIV infection and being underweight were independently associated with delayed skeletal maturation in both males and females. Starting ART later was independently associated with skeletal maturation delay in CWH. Given the known effects of delayed development on later health, it is important to find interventions to ensure healthy weight gain through early years and in CWH to initiate ART as early as possible.

Perinatal HIV infection is associated with deficits in muscle function in children and adolescents in Zimbabwe

OBJECTIVES

To determine how muscle strength, power, mass, and density (i.e. quality) differ between children living with HIV (CWH) and those uninfected, and whether antiretroviral therapy (ART) regime is associated with muscle quality.

DESIGN

A cross-sectional study in Harare, Zimbabwe.

METHODS

The study recruited CWH aged 8-16 years, taking ART for at least 2 years, from HIV clinics, and HIV-uninfected children from local schools. Muscle outcomes comprised grip strength measured by hand-held Jamar dynamometer, lower limb power measured by standing long-jump distance, lean mass measured by dual-energy X-ray absorptiometry, and muscle density (reflecting intramuscular fat) by peripheral quantitative computed tomography. Linear regression calculated adjusted mean differences (aMD) by HIV status.

RESULTS

Overall, 303 CWH and 306 without HIV, had mean (SD) age 12.5 (2.5) years, BMI 17.5 (2.8), with 50% girls. Height and fat mass were lower in CWH, mean differences (SE) 7.4 (1.1) cm and 2.7 (0.4)kgs, respectively. Male CWH had lower grip strength [aMD 2.5 (1.1-3.9) kg, P  < 0.001], long-jump distance [7.1 (1.8-12.5) cm, P  = 0.006], muscle density [0.58 (0.12-1.05) mg/cm 3 , P  = 0.018, but not lean mass 0.06 (-1.08 to 1.21) kg, P  = 0.891) versus boys without HIV; differences were consistent but smaller in girls. Mediation analysis suggested the negative effect of HIV on jumping power in boys was partially mediated by muscle density ( P  = 0.032). CWH taking tenofovir disoproxil fumarate (TDF) had lower muscle density [0.56 (0.00-1.13)mg/cm 3 , P  = 0.049] independent of fat mass, than CWH on other ART.

CONCLUSION

Perinatally acquired HIV is associated, particularly in male individuals, with reduced upper and lower limb muscle function, not mass. Intra-muscular fat (poorer muscle quality) partially explained reductions in lower limb function. TDF is a novel risk factor for impaired muscle quality.

Hand grip strength, vitamin D status, and diets as predictors of bone health in 6-12 years old school children

BACKGROUND

Vitamin D and calcium-rich foods, exposure to sunlight, and physical activities (PA) play a pivotal role in promoting the production of sufficient vitamin D and improving grip strength needed for better bone health among school children.

PURPOSE

This study aimed to determine the effects of hand grip muscle strength (HGS), vitamin D in addition to diets, and PA on bone health status among 6-12 years old schoolchildren.

METHODS

This study was based on a cross-sectional observational design, which was descriptive in nature. A diverse sample of 560 elementary school children aged 6-12 years old were invited to participate in this descriptive cross-sectional study. The Dual-Energy X-Ray Absorptiometry (DXA), QUS technique, and ACTi graph GT1M accelerometer were used respectively as a valid tools to identify BMD, BMC, and other parameters of bone health like c-BUA values and bone stiffness (SI), and physical activity (PA) of all individuals participated in this study. In addition, a hydraulic dynamometer was used to measure hand grip strength among the participants. Moreover, an immunoassay technique was used to measure the serum levels of vitamin 25(OH)D level, and bone metabolism markers; NTX, DPD, Ca, and sBAP in all participants. Bone loss (osteoporosis) was cross-sectionally predicted in 19.64% of the total population, most of whom were girls (14.3% vs. 5.4% for boys; P = 0.01). Compared to boys, the incidence of osteoporosis was higher and significantly correlated in girls with lower HGS, deficient vitamin D, inadequate vitamin D and Ca intake, greater adiposity, poor PA, and lower sun exposure. Also, in girls, lower vitamin 25(OH)D levels, and poor HGS were shown to be significantly associated with lower values of BMD, BMC, SI, and higher values of bone resorption markers; NTX, DPD, and sBAP and lower serum Ca than do in boys. The findings suggested that deficient vitamin D, lower HGS, adiposity, PA, and sun exposure as related risk factors to the pravelence of bone loss among school children, particularly in girls. In addition, these parameters might be considered diagnostic non-invasive predictors of bone health for clinical use in epidemiological contexts; however, more studies are required.

Evaluation of two methods of bone age assessment in peripubertal children in Zimbabwe

OBJECTIVES

Bone age (BA) measurement in children is used to evaluate skeletal maturity and helps in the diagnosis of growth disorders in children. The two most used methods are Greulich and Pyle (GP), and Tanner and Whitehouse 3 (TW3), both based upon assessment of a hand-wrist radiograph. To our knowledge no study has compared and validated the two methods in sub-Saharan Africa (SSA), and only a few have determined BA despite it being a region where skeletal maturity is often impaired for example by HIV and malnutrition. This study aimed to compare BA as measured by two methods (GP and TW3) against chronological age (CA) and determine which method is most applicable in peripubertal children in Zimbabwe.

METHODS

We conducted a cross-sectional study of boys and girls who tested negative for HIV. Children and adolescents were recruited by stratified random sampling from six schools in Harare, Zimbabwe. Non-dominant hand-wrist radiographs were taken, and BA assessed manually using both GP and TW3. Paired sample Student t-tests were used to calculate the mean differences between BA and chronological age (CA) in boys and girls. Bland-Altman plots compared CA to BA as determined by both methods, and agreement between GP and TW3 BA. All radiographs were graded by a second radiographer and 20 % of participants of each sex were randomly selected and re-graded by the first observer. Intraclass correlation coefficient assessed intra- and inter-rater reliability and coefficient of variation assessed precision.

RESULTS

We recruited 252 children (111 [44 %] girls) aged 8.0-16.5 years. The boys and girls were of similar mean ± SD CA (12.2 ± 2.4 and 11.7 ± 1.9 years) and BA whether assessed by GP (11.5 ± 2.8 and 11.5 ± 2.1 years) or TW3 (11.8 ± 2.5 and 11.8 ± 2.1 years). In boys BA was lower than CA by 0.76 years (95 % CI: -0.95, -0.57) when using GP, and by 0.43 years (95 % CI: -0.61, -0.24) when using TW3. Among the girls there was no difference between BA and CA by either GP [-0.19 years (95 % CI: -0.40, 0.03)] or TW3 [0.07 years (95 % CI: -0.16, 0.29)]. In both boys and girls, there were no systematic differences between CA and TW3 BA across age groups whereas agreement improved between CA and GP BA as children got older. Inter-operator precision was 1.5 % for TW3 and 3.7 % for GP (n = 252) and intra-operator precision was 1.5 % for TW3 and 2.4 % for GP (n = 52).

CONCLUSION

The TW3 BA method had better precision than GP and did not systematically differ from CA, meaning that TW3 is the preferred method of assessment of skeletal maturity in Zimbabwean children and adolescents. TW3 and GP methods do not agree for estimates of BA and therefore cannot be used interchangeably. The systematic differences in GP BA assessments over age means it is not appropriate for use in all age groups or stages of maturity in this population.

Fracture prevalence and its association with bone density among children living with HIV in Zimbabwe

OBJECTIVES

HIV infection impairs bone density in children living with HIV (CLWH). We aimed to determine the prevalence of self-reported fracture (past or current), associated risk factors and disability, by HIV status in Zimbabwean children.

DESIGN

Cross-sectional study.

METHODS

We recruited CLWH aged 8-16 years taking antiretroviral therapy (ART) for ≥2 years from HIV clinics, and HIV-uninfected children from schools in Harare. Interviewer-administered questionnaires collected data on fracture site and management, sociodemographics, dietary calcium and vitamin D, physical activity and HIV history. Dual-energy X-ray absorptiometry (DXA) measured size-adjusted bone density.

RESULTS

We recruited 303 CLWH [mean (SD) age 12.5 (2.5) years; 50% female] and 306 children without HIV [12.5 (2.5) years; 51% female]. Median age at HIV diagnosis in CLWH was 3.0 years [interquartile range (IQR) 1.2, 5.9], and median ART duration 8.1 years [IQR 6.2, 9.5]. 53.8% CLWH had self-reported disability and/or functional impairment, vs. 29.4% children without HIV. Fracture prevalence was 5.9% with no difference by HIV status [21/306 (6.9%) vs. 14/303 (4.6%), P  = 0.24]. Male sex was associated with fractures. Low size-adjusted bone density ( Z -score < -2) was associated with prevalent fractures in CLWH {risk ratio [RR] 1.14 (95% confidence interval (CI) -0.02, 2.29]}, but not in children without HIV [RR -0.04 (-2.00, 1.91)], P -interaction = 0.27. All sought medical attention for their fracture(s), but CLWH were less often admitted to hospital [2/14 (14.3%) vs. 7/21 (33.3%)].

CONCLUSION

Prevalent fractures may be associated with low lumbar spine bone density in CLWH. Fracture surveillance and strategies to reduce future fracture risk are warranted as CLWH enter adulthood.

Impaired Bone Architecture in Peripubertal Children With HIV, Despite Treatment With Antiretroviral Therapy: A Cross-Sectional Study From Zimbabwe

HIV infection has multi-system adverse effects in children, including on the growing skeleton. We aimed to determine the association between chronic HIV infection and bone architecture (density, size, strength) in peripubertal children. We conducted a cross-sectional study of children aged 8 to 16 years with HIV (CWH) on antiretroviral therapy (ART) and children without HIV (CWOH) recruited from schools and frequency-matched for age strata and sex. Outcomes, measured by tibial peripheral quantitative computed tomography (pQCT), included 4% trabecular and 38% cortical volumetric bone mineral density (vBMD), 4% and 38% cross-sectional area (CSA), and 38% stress-strain index (SSI). Multivariable linear regression tested associations between HIV status and outcomes, stratified by sex and puberty (Tanner 1-2 versus 3-5), adjusting for age, height, fat mass, physical activity, and socioeconomic and orphanhood statuses. We recruited 303 CWH and 306 CWOH; 50% were female. Although CWH were similar in age to CWOH (overall mean ± SD 12.4 ± 2.5 years), more were prepubertal (ie, Tanner 1; 41% versus 23%). Median age at ART initiation was 4 (IQR 2-7) years, whereas median ART duration was 8 (IQR 6-10) years. CWH were more often stunted (height-for-age Z-score <-2) than those without HIV (33% versus 7%). Both male and female CWH in later puberty had lower trabecular vBMD, CSA (4% and 38%), and SSI than those without HIV, whereas cortical density was similar. Adjustment explained some of these differences; however, deficits in bone size persisted in CWH in later puberty (HIV*puberty interaction p = 0.035 [males; 4% CSA] and p = 0.029 [females; 38% CSA]). Similarly, puberty further worsened the inverse association between HIV and bone strength (SSI) in both males (interaction p = 0.008) and females (interaction p = 0.004). Despite long-term ART, we identified deficits in predicted bone strength in those living with HIV, which were more overt in the later stages of puberty. This is concerning, as this may translate to higher fracture risk later in life. © 2022 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).

The associations between stunting and wasting at 12 months of age and developmental milestones delays in a cohort of Cambodian children

Worldwide, over 250 million children under 5 years do not reach their developmental potential due to several causes, including malnutrition. In Cambodia, the prevalence of stunting and wasting among children remains high. This prospective cohort study aimed to assess acquisition of motor and cognitive developmental milestones in early childhood and their associations with stunting and wasting. Children aged from 0 to 24 months were recruited from three provinces in Cambodia and followed up to seven times from March 2016 to June 2019, until their 5 years. Data collection included anthropometry and developmental milestones. Seven motor and seven cognitive milestones were evaluated using the Cambodian Development Milestone Assessment Tool. Associations were assessed with parametric survival models. Hazard ratios (HR) below 1 stood for lower probabilities for achieving developmental milestones. Data were available for 7394 children. At 12 months, the prevalence of stunting and wasting were 23.7% and 9.6% respectively. Both were consistently associated with delays in most motor and cognitive milestones. Stunting was strongly associated with delays in gross motor milestones (HR < 0.85; p < 0.001). Wasting was more strongly associated with delays in fine motor development and most cognitive milestones (HR < 0.75; p < 0.001). Promoting nutritional programs in the first 1000 days to prevent malnutrition is essential to further the optimal growth and motor and cognitive development of Cambodian children.

Correlation between Cord Blood Vitamin D Levels and Problem-Solving Neurodevelopment in Early Childhood: A Cohort Study in Rural Indonesia

Vitamin D influence on brain development and subsequent postnatal neurodevelopment remains controversial. We explored the correlation between cord blood vitamin D levels and longitudinal neurodevelopment in early childhood. A cohort study was conducted on term infants with no congenital abnormalities, born from pregnant women from a cohort study. Cord blood samples were collected to measure vitamin D. Neurodevelopment was examined three times in infants aged 6, 12 and 24 months using the Ages and Stages Questionnaire-3, which comprises 30 questions of five developmental domains: gross motor, fine motor, communication, problem-solving and social–personal. Statistical analysis was conducted with Spearman’s rank correlation and multiple linear regression. Of the 141 babies born from previous cohort studies, only 116 participants were included. The mean level of cord blood vitamin D was 16.2 ng/mL. The percentage participants with vitamin D deficiency and insufficiency were 12.9 and 65.5, respectively. Cord blood vitamin D and the problem-solving domain for infant aged 12 and 24 months were correlated (r = 0.217 and 0.414, respectively). Multiple linear regression showed a decreased problem-solving domain score of 0.641 associated with decreased vitamin D levels. In conclusion, cord blood vitamin D levels correlated with infant neurodevelopmental status.

Association of developmental coordination disorder and low motor competence with impaired bone health: A systematic review

AIMS

Individuals with developmental coordination disorder (DCD) and low motor competence (LMC) may be at increased risk of low bone health due to their lifetime physical activity patterns. Impaired bone health increases an individual's risk of osteoporosis and fracture; therefore, it is necessary to determine whether a bone health detriment is present in this group. Accordingly, this systematic review explores the association between DCD/LMC and bone health.

METHODS AND PROCEDURES

Studies were included with assessment of bone health in a DCD/LMC population. Study bias was assessed using the JBI critical appraisal checklist. Due to heterogeneity, meta-analysis was not possible and narrative synthesis was performed with effect size and direction assessed via harvest plots.

OUTCOMES AND RESULTS

A total of 16 (15 paediatric/adolescent) studies were included. Deficits in bone measures were reported for the DCD/LMC group and were more frequent in weight-bearing sites. Critical appraisal indicated very low confidence in the results, with issues relating to indirectness and imprecision relating to comorbidities.

CONCLUSIONS AND IMPLICATIONS

Individuals with DCD or LMC are at increased risk of bone health deficits. Bone impairment locations indicate insufficient loading via physical activity as a potential cause of bone deficits. Results indicate a potential for earlier osteoporosis onset.

High burden of hypovitaminosis D among the children and adolescents in South Asia: a systematic review and meta-analysis

BACKGROUND

Vitamin D is vital for the growth and development of children. While deficiency and/or insufficiency of vitamin D among South Asian children are frequently reported in the literature, the lack of a meta-analysis has left its true extent poorly characterized. In this study, we aimed to conduct a systematic review and perform meta-analyses of the prevalence of hypovitaminosis D among the children of the South Asian countries.

METHODS

Two major electronic search engines (PubMed and Scopus) and one database (Google scholar) were used; original studies, conducted among South Asian children and adolescents and published between 1 January 2001 and 31 December 2019. A random-effect meta-analysis was also performed to calculate the pooled prevalence of hypovitaminosis D followed by subgroup analyses for countries and age groups.

RESULTS

After applying inclusion and exclusion criteria, a total of 41 studies with a total population size of 18,233 were finally selected. The overall prevalence of hypovitaminosis D was 61% [95% CI: 46% to 71%] with highly significant heterogeneity (I2 = 99.72%; p < 0.0001). The average level of serum vitamin D ranged from 5 ng/mL to 34 ng/mL, with a weighted mean of 19.15 ng/mL (weighted standard deviation 11.59 ng/mL). Country-wise analysis showed that hypovitaminosis D in Afghanistan was the highest [96.2%; 95% CI: 91% to 99%], followed by Pakistan [94%; 95% CI: 90% to 96%], India [64%; 95% CI: 46% to 79%], Bangladesh [35.48%; 95% CI: 32% to 39%], Nepal [35%; 95% CI: 1% to 83%], and Sri Lanka [25%; 95% CI: 16% to 36%]. Age group analyses revealed that hypovitaminosis D was most prevalent among neonates [85%; 95% CI: 76% to 91%], followed by school-going children [57%; 95% CI: 33% to 80%], and preschool children [55%; 95% CI: 35% to 75%].

CONCLUSION

This study generates quantitative evidence and specific extent of hypovitaminosis D in the South Asian countries as a public health concern. Being the first systematic review for this region, results from this study will create awareness and will facilitate adopting mitigation strategies by the policymakers and the governments to address this problem.

Effect of HIV infection on growth and bone density in peripubertal children in the era of antiretroviral therapy: a cross-sectional study in Zimbabwe

Background

Faltered linear growth and pubertal delay, which are both common in children with HIV in sub-Saharan Africa, might affect adolescent bone accrual and future fragility fracture risk. We investigated the association of HIV with bone density adjusted for skeletal size in peripubertal children in Zimbabwe.

Methods

We did a cross-sectional study of baseline data from the IMVASK cohort, which enrolled children aged 8–16 years with HIV who had been taking antiretroviral therapy (ART) for at least 2 years, and children of the same age without HIV. Children with HIV were recruited from public sector HIV clinics at Parirenyatwa General Hospital and Harare Central Hospital (Harare, Zimbabwe), and children without HIV were recruited from six schools in the same suburbs that the hospitals serve. Sociodemographic, clinical, and anthropometric data were collected. Dual-energy X-ray absorptiometry (DXA) was used to measure the bone outcomes of total-body less-head bone mineral content for lean mass adjusted for height (TBLH-BMC^LBM), and lumbar spine bone mineral apparent density (LS-BMAD), and we assessed the prevalence of low TBLH-BMC^LBM and low LS-BMAD (defined by Z-scores of less than −2·0). Size adjustment techniques were used to overcome the size dependence of DXA measurement. We used linear regression models, with multiple imputation for missing data, to assess relationships between risk factors and TBLH-BMC^LBM and LS-BMAD Z-scores in children with and without HIV.

Findings

We recruited 303 children with HIV (mean age 12·4 years [SD 2·5]; 151 [50%] girls) and 306 children without HIV (mean age 12·5 years [SD 2·5]; 155 [51%] girls). In children with HIV, median age of HIV diagnosis was 3·0 years (IQR 1·2–5·8), and median ART duration was 8·1 years (6·2–9·5); for 102 (34%) children, ART included tenofovir disoproxil fumarate (TDF). Children with HIV had a higher prevalence of low TBLH-BMC^LBM Z-score than children without HIV (29 [10%] of 279 children with available data vs 18 [6%] of 292 with available data; p=0·066) and a higher prevalence of low LS-BMAD Z-score (40 [14%] of 279 vs 17 [6%] of 293 with available data; p=0·0007). HIV and male sex were associated with earlier pubertal (Tanner) stage. The negative associations between HIV and Z-scores for TBLH-BMC^LBM and LS-BMAD were more pronounced with pubertal maturation, particularly in girls. Among children with HIV, TDF exposure and orphanhood were associated with lower TBLH-BMC^LBM Z-score in confounder-adjusted analysis. Current TDF use (vs non-TDF-based ART) was associated with a reduction in TBLH-BMC^LBM Z-score of 0·41 (95% CI 0·08–0·74; p=0·015) and in LS-BMAD Z-score of 0·31 (0·08–0·69; p=0·12).

Interpretation

Despite ART, HIV is associated with substantial skeletal deficits towards the end of puberty. The extent of bone deficits associated with TDF and its widespread use in children in sub-Saharan Africa are a concern for future adult fracture risk.

Funding

Wellcome Trust.

Birth month and infant gross motor development: Results from the Japan Environment and Children's Study (JECS)

The association between birth month and neurodevelopmental or psychiatric disorders has been investigated in a number of previous studies; however, the results have been inconsistent. This study investigated the association between birth month and child gross motor development at 6 and 12 months of age in a large cohort of infants (n = 72,203) participating in the Japan Environment and Children’s Study (JECS). Gross motor development was assessed using the Ages and Stages Questionnaire (ASQ-3). At 6 months and 12 months, 20.7% and 14.2%, respectively, had ASQ-3 indications of gross motor problems. Birth month was strongly associated with gross motor development at both time points, particularly at 6 months. Summer-born infants had the worst outcomes at both 6 months and 12 months of age. This outcome applied to the ASQ-3 score itself and to the adjusted Relative Risk (aRR), with the highest aRRs (relative to January-born) among August-born (aRR 2.51; 95%CI 2.27–2.78 at 6 months), and June-born (aRR 1.84; 95%CI 1.63–2.09 at 12 months). Boys had better scores than girls both at 6 and 12 months of age. We speculate that seasonal factors—such as maternal vitamin D deficiency and influenza infection—affecting the fetus in early pregnancy might account for the findings.

The role of serum levels of vitamin D in children's muscle strength: A systematic review

This review aims to investigate the different levels of vitamin D and its role in muscle strength in healthy children and non-athletes. A search conducted in three databases (PubMed, Scopus, and Psycinfo) resulted in 655 articles, which were systematically analyzed and selected based on the following criteria: (a) original cross-sectional studies and clinical trials; (b) healthy children aged 5-11 years; (c) no language restriction or year of publication; and (d) studies that assessed the possible relationship between vitamin D levels and muscle strength. Six studies were included because they met all the inclusion criteria. According to the findings of this review, factors such as sex, skin color, and vitamin D supplementation early in life modulate the levels of vitamin D in the body, and there is a relationship between muscle strength and vitamin D levels. Interestingly, vitamin D supplementation is not always significantly associated with increased muscle grip strength. However, there is a scarcity of studies that aim to analyze the possible effects of different levels of vitamin D on muscle function and neuromuscular variables in physically inactive children and non-athletes without previously diagnosed disease. Further studies are warranted in the future to address the gap in the literature.

Effects of vitamin D deficiency on neurobehavioural outcomes in children: a systematic review

Introduction: Vitamin D plays an important role in brain development in experimental studies; however, the effect of vitamin D deficiency on child development remains inadequately characterized. We aimed to estimate the effects of vitamin D deficiency on neurobehavioural outcomes in children up to 18 years of age. Methods: We searched PubMed, EMBASE, PsycINFO, Scopus, Cochrane Library, Web of Science and Open Grey for published studies up to 10th January 2020. We included all studies that assessed the effects of maternal or child vitamin D status or vitamin D supplementation on neurobehavioural outcomes in children. Study findings were synthesized qualitatively as the high level of heterogeneity in study populations and methodologies precluded a quantitative meta-analysis. Results: Our search identified 5,633 studies, of which 31 studies with 31,375 participants from 18 countries were included in the systematic review. Of the studies identified, one was a randomised controlled trial (RCT) of vitamin D supplementation in children, while 30 were observational. The RCT (n=55) reported a beneficial effect of supplementation with lower doses compared to higher doses of vitamin D on motor development. Twelve mother-child studies (n=17,136) and five studies in children (n=1,091) reported an association between low maternal or child 25-hydroxyvitamin D levels and impaired neurobehavioural outcomes in children, while 15 mother-child studies (n=20,778) and eight studies in children (n=7,496) reported no association. Conclusions: Although animal studies point to an effect of vitamin D deficiency on brain development, there are few studies on the effects of vitamin D deficiency on neurobehavioural outcomes in children and their findings are inconsistent. There is a need for well-conducted, adequately powered studies to further determine these effects in children. Registration: PROSPERO ID CRD42018087619; registered on 15 February 2018.

Vitamin D Status Is Not Associated with Cognitive or Motor Function in Pre-School Ugandan Children

Vitamin D deficiency is common worldwide and young children are among the most affected groups. Animal studies suggest a key role for vitamin D in brain development. However, studies investigating the effects of vitamin D on neurobehavioural outcomes in children are inconclusive and evidence is limited in sub-Saharan Africa. We evaluated the effect of vitamin D status on cognitive and motor outcomes using prospective data from the Entebbe Mother and Baby Study birth cohort. We analysed data from 302 Ugandan children with 25-hydroxyvitamin D (25(OH)D) measurements below five years and developmental measures at five years of age. We used multivariable linear regression, adjusted for potential confounders, to estimate the effect of 25(OH)D on cognitive and motor outcomes. Of 302 children, eight (2.7%) had 25(OH)D levels <50 nmol/L, 105 (35.8%) had levels 50-75 nmol/L and 189 (62.6%) had levels >75 nmol/L. There was no evidence that earlier vitamin D status was associated with cognitive and motor outcomes in five-year-old Ugandan children. This study adds to the sparse literature and highlights the need for further longitudinal studies on vitamin D and neurobehavioural outcomes in children living in sub-Saharan Africa.

Effects of vitamin D deficiency on neurobehavioural outcomes in children: a systematic review

Introduction: Vitamin D plays an important role in brain development in experimental studies; however, the effect of vitamin D deficiency on child development remains inadequately characterized. We aimed to estimate the effects of vitamin D deficiency on neurobehavioural outcomes in children up to 18 years of age. Methods: We searched PubMed, EMBASE, PsycINFO, Scopus, Cochrane Library, Web of Science and Open Grey for published studies up to 10th January 2020. We included all studies that assessed the effects of maternal or child vitamin D status or vitamin D supplementation on neurobehavioural outcomes in children. Study findings were synthesized qualitatively as the high level of heterogeneity in study populations and methodologies precluded a quantitative meta-analysis. Results: Our search identified 5,633 studies, of which 32 studies with 31,445 participants from 18 countries were included in the systematic review. Of the studies identified, two were randomized controlled trials (RCTs) of vitamin D supplementation in children, while 30 were observational. One RCT (n=55) reported a beneficial effect of supplementation with lower doses compared to higher doses of vitamin D on motor development while the other RCT (n=70) found no beneficial effect of vitamin D supplementation on cognition in extremely preterm infants. Twelve mother-child studies (n=17,136) and five studies in children (n=1,091) reported an association between low maternal or child 25-hydroxyvitamin D levels and impaired neurobehavioural outcomes in children, while 15 mother-child studies (n=20,778) and eight studies in children (n=7,496) reported no association. Conclusions: Although animal studies point to an effect of vitamin D deficiency on brain development, there are few studies on the effects of vitamin D deficiency on neurobehavioural outcomes in children and their findings are inconsistent. There is a need for well-conducted, adequately powered studies to further determine these effects in children. Registration: PROSPERO ID CRD42018087619; registered on 15 February 2018.

Vitamin D status in early childhood is not associated with cognitive development and linear growth at 6-9 years of age in North Indian children: a cohort study

BACKGROUND

Vitamin D is important for brain function and linear growth. Vitamin D deficiency during pregnancy has been linked with impaired neurodevelopment during early childhood. However, there is limited evidence from population-based studies on the long-term impact of vitamin D deficiency on cognitive development and linear growth. The objective of the current analysis is to examine whether vitamin D deficiency during infancy and early childhood is associated with cognitive development and linear growth measured in school age.

METHODS

This is a follow-up study of a placebo-controlled trial among 1000 North Indian children 6-30 months of age. We measured growth and neurodevelopment in 791 of these children when they were 6-9 years old. Neurodevelopment was measured using the Wechsler Intelligence Scale for Children, 4th edition ^INDIA, the Crichton Verbal Scale, NEPSY-II subtests, and the BRIEF 2. We categorized vitamin D concentrations during infancy and early childhood according to the US Institute of Medicine's recommendations; serum 25(OH)D < 12 ng/ml as deficient; 12-20 ng/ml as inadequate; > 20 ng/ml as sufficient. In multivariable regression models, adjusting for relevant confounders, we estimated the association between vitamin D status, growth and neurodevelopmental outcomes.

RESULTS

Among the 791 children, baseline vitamin D status was available for 716. Of these, 45.8% were vitamin D deficient, 32.7% were inadequate, and 21.5% were sufficient. Vitamin D status was not associated with any of the cognitive outcomes or linear growth [Adjusted β coefficient for height for age z-score between deficient and sufficient children was - 0.06 (95% CI - 0.24 to 0.11)] at follow up.

CONCLUSION

Our findings do not support the notion that poor vitamin D status in early childhood is an important limitation for cognitive development and linear growth.

TRIAL REGISTRATION

The trial was first registered at www.clinicaltrials.gov as NCT00717730 in July, 2008, and at CTRI/2010/091/001090 in August, 2010 and then as CTRI/2016/11/007494 in November 2016.

The IMpact of Vertical HIV infection on child and Adolescent SKeletal development in Harare, Zimbabwe (IMVASK Study): a protocol for a prospective cohort study

INTRODUCTION

The scale-up of antiretroviral therapy (ART) across sub-Saharan Africa (SSA) has reduced mortality so that increasing numbers of children with HIV (CWH) are surviving to adolescence. However, they experience a range of morbidities due to chronic HIV infection and its treatment. Impaired linear growth (stunting) is a common manifestation, affecting up to 50% of children. However, the effect of HIV on bone and muscle development during adolescent growth is not well characterised. Given the close link between pubertal timing and musculoskeletal development, any impairments in adolescence are likely to impact on future adult musculoskeletal health. We hypothesise that bone and muscle mass accrual in CWH is reduced, putting them at risk of reduced bone mineral density (BMD) and muscle function and increasing fracture risk. This study aims to determine the impact of HIV on BMD and muscle function in peripubertal children on ART in Zimbabwe.

METHODS AND ANALYSIS

Children with (n=300) and without HIV (n=300), aged 8-16 years, established on ART, will be recruited into a frequency-matched prospective cohort study and compared. Musculoskeletal assessments including dual-energy X-ray absorptiometry, peripheral quantitative computed tomography, grip strength and standing long jump will be conducted at baseline and after 1 year. Linear regression will be used to estimate mean size-adjusted bone density and Z-scores by HIV status (ie, total-body less-head bone mineral content for lean mass adjusted for height and lumbar spine bone mineral apparent density. The prevalence of low size-adjusted BMD (ie, Z-scores <-2) will also be determined.

ETHICS AND DISSEMINATION

Ethical approval for this study has been granted by the Medical Research Council of Zimbabwe and the London School of Hygiene and Tropical Medicine Ethics Committee. Baseline and longitudinal analyses will be published in peer-reviewed journals and disseminated to research communities.

Association of maternal vitamin D deficiency and infants' neurodevelopmental status: A cohort study on vitamin D and its impact during pregnancy and childhood in Indonesia

AIM

Vitamin D deficiency in early pregnancy may cause the disruption of fetal brain development and neurodevelopmental function. This study aimed to explore the extent of neurodevelopment disruption could be associated with maternal vitamin D deficiency.

METHODS

A cohort study was conducted in Sukabumi and Waled, West Java, Indonesia, beginning in July 2016. Maternal serum 25(OH)-vitamin D was measured between 10 and 14 weeks of gestational age. Child development was measured using the Ages and Stages Questionnaire-3 (ASQ-3) at age 3, 6 and 12 months.

RESULTS

A total of 141 mother-infant pairs participated. One pair was excluded due to anencephaly of the infant. Vitamin D deficiency was found in 27 (19%) mothers, but delays occurred in gross motor function among 104 (76.1%) infants and in problem-solving functions among 61 (43.7%) infants at 3 months old. In general, the mean ASQ score at ages 3 and 6 months were lower among infants whose mothers had a vitamin D deficiency. The mean ASQ score for gross motor function at age 3 months was found to be significantly lower among these infants (31.5 vs. 37.9; P = 0.02), with increased risk for delayed motor function at age 3 months (relative risk (95% confidence interval) = 1.22 (1.09-1.49); P = 0.03).

CONCLUSION

Neurodevelopmental function disruptions among infants whose mothers had vitamin D deficiency during pregnancy were reflected in lower ASQ scores, in which gross motor function was significantly impaired at 3 months of age.

Association between fat-soluble nutrient status and auditory and visual related potentials in newly diagnosed non-screened infants with cystic fibrosis: A case-control study

Nutritional deficiencies often precede the diagnosis of cystic fibrosis (CF) in infants, and occur at a stage where the rapidly developing brain is more vulnerable to insult. We aim to compare fat-soluble nutrient status of newly diagnosed non-screened infants with CF to that of healthy infants, and explore the association with neurodevelopment evaluated by electroencephalography (EEG). Our results show that CF infants had lower levels of all fat-soluble vitamins and docosahexaenoic acid (DHA) compared to controls. The auditory evoked potential responses were higher in CF compared to controls whereas the visual components did not differ between groups. DHA levels were correlated with auditory evoked potential responses. Although resting state frequency power was similar between groups, we observed a negative correlation between DHA levels and low frequencies. This study emphasizes the need for long-term neurodevelopmental follow-up of CF infants and pursuing intervention strategies in the future.

Is There Any Relationship between Vitamin D Deficiency and Gross Motor Development in 12-Month-Old Children?

OBJECTIVE

We aimed to assess the possible relationship between vitamin D deficiency and gross motor developmental milestones in Iranian children in Tehran City, Iran.

MATERIALS & METHODS

In this cross-sectional study, 186 healthy children of one-yr-old age referring to a children hospital in Tehran, Iran from May 2015 to April 2016, were enrolled. The gross motor developmental milestone of children and their serum vitamin D concentration were evaluated.

RESULTS

Overall, 186 children, 92 males (49.5%) were studied. Twenty-four patients (12.9%) just were able to sit without support, and 40 patients (21.5%) to stand alone and to sit without support. Besides, 122 patients (65.6%) were able to walk with assistant or alone and to sit without support and stand alone. Vitamin D was sufficient in 148 children (79.6%), insufficient in 32 (17.2%) and deficient in 6 (3.2%). Sufficient vitamin D was significantly correlated with walking ability (P<0.001, OR=3.9, 95%CI=1.9-8.4).

CONCLUSION

Considering the significant correlation between vitamin D deficiency and gross motor developmental milestones in this population of children, children referring to gross motor developmental delay need to be thoroughly evaluated for vitamin D deficiency.

Is vitamin D deficiency a public health concern for low middle income countries? A systematic literature review

PURPOSE

Vitamin D deficiency has been receiving increasing attention as a potential public health concern in low and lower-middle income countries (LMICs), of which there are currently 83. We aimed to conduct a comprehensive systematic literature review (SLR) of available data on vitamin D status and prevalence of vitamin D deficiency in all 83 LMICs.

METHODS

We followed the general methodology for SLRs in the area of serum 25-hydroxyvitamin D. Highest priority was placed on identifying relevant population-based studies, followed by cross-sectional studies, and to a lesser extent case-control studies. We adopted the public health convention that a prevalence of vitamin D deficiency (serum 25-hydroxyvitamin D < 25/30 nmol/L) at > 20% in the entire population and/or at-risk population subgroups (infants, children, women of child-bearing age, pregnancy) constitutes a public health issue that may warrant intervention.

RESULTS

Our SLR revealed that of the 83 LMICs, 65% (n = 54 countries) had no published studies with vitamin D data suitable for inclusion. Using data from the remaining third, a number of LMICs had evidence of excess burden of vitamin D deficiency in one or more population subgroup(s) using the above convention (Afghanistan, Pakistan, India, Tunisia and Mongolia) as well as possibly other LMICs, albeit with much more limited data. Several LMICs had no evidence of excess burden.

CONCLUSION

Vitamin D deficiency is a public health issue in some, but certainly not all, LMICs. There is a clear need for targeting public health strategies for prevention of vitamin D deficiency in those LMICs with excess burden.

Association between muscle function and body composition, vitamin D status, and blood glucose in postmenopausal women with type 2 diabetes

AIMS

The aim of this study was to examine the association between muscle function, and body composition, vitamin D status, and blood glucose in post-menopausal women with type 2 diabetes (T2D).

METHODS

Forty post-menopausal women (62.48±7.67years; 154.6±5.11cm; 73.93±15.43kg; 31.13±5.82 BMI kg/m²) with a diagnosis of T2D participated in this cross-sectional study. The patients performed fasting blood sample exams, anthropometrics assessments, body composition, and clinical exams. Subjects performed physical tests including handgrip, timed up and go, 30-s chair stand, arm curl, and sit-to-stand. The correlation between the parameters of physical tests, age, body composition, vitamin D, and blood glucose was assessed by Pearson correlation.

RESULTS

The results showed there were significant correlations between blood glucose and relative strength (R=-0.398, p=0.011), arm curl test (R=-0.367 and p=0.020), and hip flexion (R=0.427, p=0.006).

CONCLUSIONS

These findings are important because they highlight the importance of resistance training in individuals with T2D and the relationship with a fat increase during a dicrease process. Furthermore, the concentration of serum glucose might be associated with decreases in muscle strength and muscle function in older adults. Thus, T2D patients should be involved with strength training to improve the strength and the muscle hypertrophy.

Vitamin-D status and neurodevelopment and growth in young north Indian children: a secondary data analysis

Background

Vitamin-D deficiency has been linked with impaired development in animal studies; however, the evidence from human studies is scanty. Evidence as to whether vitamin-D deficiency during early childhood affects growth is also limited and conflicting. We examined the extent to which vitamin-D deficiency (<10 ng/ml) is associated with neurodevelopment and physical growth in young children.

Methods

We used data from a randomized controlled trial (RCT) of daily folic acid and/ or vitamin B12 supplementation for six months in children aged 6 to 30 months conducted in Delhi, India. We measured vitamin-D status and  neurodevelopment by the Ages and Stages Questionnaire-3 (ASQ-3) at 12 to 36 months of age. Multiple logistic and linear regressions were used to examine the association between vitamin-D deficiency at baseline and neurodevelopment and growth 6 months follow-up.

Results

25-hydroxy-vitamin-D (25OHD) concentration was measured at baseline for 960 (96%) children. Of these, 331 (34.5%) children were vitamin-D deficient. The total and subscale (except for the Personal social scale) ASQ-3 scores, were not different between the vitamin-D deficient and non-deficient children. Vitamin-D deficiency was also not associated with physical growth at baseline and at follow -up.

Conclusion

Our data do not support the hypothesis that vitamin-D deficiency is associated with poor growth and neurodevelopment.

Trial registration

NCT00717730 and CTRI/2010/091/001090. Date of registration: 08 October, 2010

[Vitamin D level at birth and influencing factors in preterm infants]

OBJECTIVE

To investigate vitamin D level at birth and possible influencing factors in preterm infants.

METHODS

A total of 600 preterm infants were enrolled, and venous blood samples were collected within 24 hours after birth to measure the serum level of 25-hydroxyvitamin D [25(OH)D]. The effect of sex, birth weight, birth season, gestational age, mother's age, body mass index (BMI) in early pregnancy, delivery mode, and complications during pregnancy on serum 25(OH)D level was analyzed.

RESULTS

The rates of vitamin D deficiency, insufficiency, and sufficiency were 42.0%, 38.7%, and 19.3% respectively. The preterm infants born in summer and autumn had a significantly higher serum 25(OH)D level than those born in winter (P<0.05) and a significantly lower incidence rate of vitamin D deficiency than those born in spring and winter (P<0.003). Compared with those whose mothers were aged <30 years, the infants whose mothers were aged ≥30 years had a significantly higher serum 25(OH)D level (P<0.05) and a significantly lower incidence rate of vitamin D deficiency (P<0.017). Compared with those whose mothers were overweight or had normal body weight, the infants whose mothers were obese had a significantly lower serum 25(OH)D level (P<0.05) and a significantly higher incidence rate of vitamin D deficiency (P<0.006). Compared with those whose mothers had no preeclampsia, the infants whose mothers had preeclampsia during pregnancy had a significantly lower serum 25(OH)D level (P<0.05) and a significantly higher incidence rate of vitamin D deficiency (P<0.017). The multivariate analysis showed that birth in winter and spring, mother's age <30 years, and early-pregnancy BMI ≥28 kg/m² were risk factors for vitamin D deficiency (P<0.05).

CONCLUSIONS

There is a high prevalence of vitamin D deficiency in preterm infants. Vitamin D supplementation should be given to the preterm infants with high-risk factors for vitamin D deficiency.

Mechanical factors and vitamin D deficiency in schoolchildren with low back pain: biochemical and cross-sectional survey analysis

OBJECTIVE

This study was designed to evaluate the role of vitamin D, muscle fatigue biomarkers, and mechanical factors in the progression of low back pain (LBP) in schoolchildren.

BACKGROUND

Children and adolescents frequently suffer from LBP with no clear clinical causes, and >71% of schoolchildren aged 12-17 years will show at least one episode of LBP.

MATERIALS AND METHODS

A total of 250 schoolchildren aged 12-16 years were randomly enrolled in this study. For all schoolchildren height, weight, percentage of daily sun exposure and and areas of skin exposed to sun, method of carrying the bag, and bag weight and type were recorded over a typical school week. Pain scores, physical activity (PA), LBP, serum vitamin 25(OH)D level, serum bone-specific alkaline phosphatase, creatine kinase (CK), and lactate dehydrogenase (LDH) activities and calcium (Ca) concentrations were estimated using prevalidated Pain Rating Scale, modified Oswestry Low Back Pain Disability Questionnaire, short-form PA questionnaire, and colorimetric and immunoassay techniques.

RESULTS

During the period of October 2013-May 2014, LBP was estimated in 52.2% of the schoolchildren. It was classified into moderate (34%) and severe (18%). Girls showed a higher LBP (36%) compared with boys (24%). In schoolchildren with moderate and severe LBP significantly higher (P=0.01) body mass index, waist, hip, and waist-to-hip ratio measurements were observed compared with normal schoolchildren. LBP significantly correlated with less sun exposure, lower PA, sedentary activity (TV/computer use), and overloaded school bags. In addition, schoolchildren with severe LBP showed lower levels of vitamin 25(OH)D and Ca and higher levels of CK, LDH, and serum bone-specific alkaline phosphatase compared with moderate and healthy schoolchildren. Stepwise regression analysis revealed that age, gender, demographic parameters, PA, vitamin D levels, Ca, CK, and LDH associated with ~56.8%-86.7% of the incidence of LBP among schoolchildren.

CONCLUSION

In children and adolescents, LBP was shown to be linked with limited sun exposure, inadequate vitamin D diets, adiposity, lower PA, sedentary lifestyles, vitamin 25 (OH) D deficiency, and lower levels of Ca, CK, and LDH.