Impact of Anesthesia and Surgery for Congenital Heart Disease on the Vitamin D Status of Infants and Children

McNally, James Dayre; Menon, Kusum; Chakraborty, Pranesh; Fisher, Lawrence; Williams, Kathryn; Al-Dirbashi, Osama Y.; Girolamo, Tara; Maharajh, Gyaandeo; Doherty, Dermot

doi:10.1097/aln.0b013e31828ce817

Cited by 50 publications

(76 citation statements)

References 44 publications

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“…Using the widely accepted cutoff of ,20 mg/dl to diagnose 25(OH)D deficiency, we reported recently that .40% of critically ill children in our hospital were deficient. Additional studies of vitamin D deficiency in the pediatric intensive care unit (ICU) (PICU) population have reported a prevalence of between 30 and 86% (18)(19)(20)(21). We found lower 25(OH)D levels to be associated with greater illness severity (22); other pediatric critical care studies have confirmed this finding (19,21,23,24), although equal numbers have reported no correlation with illness severity or ICU outcomes (18-20, 25, 26).…”

Section: Low Serum Concentrations Of Total 25-hydroxyvitamin D (25[oh]d)supporting

confidence: 75%

“…Additional studies of vitamin D deficiency in the pediatric intensive care unit (ICU) (PICU) population have reported a prevalence of between 30 and 86% (18)(19)(20)(21). We found lower 25(OH)D levels to be associated with greater illness severity (22); other pediatric critical care studies have confirmed this finding (19,21,23,24), although equal numbers have reported no correlation with illness severity or ICU outcomes (18-20, 25, 26). Despite the rapidly increasing volume of evidence linking 25(OH)D deficiency with ICU morbidity and mortality over the past 10 years (1-4, 6-8, 10, 11, 27, 28), the question of whether vitamin D repletion will improve clinical outcomes in critical illness remains unclear.…”

Section: Low Serum Concentrations Of Total 25-hydroxyvitamin D (25[oh]d)supporting

confidence: 75%

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Critically Ill Children Have Low Vitamin D Binding Protein, Influencing Bioavailability of Vitamin D

Madden¹,

Feldman²,

Chun³

et al. 2015

Annals ATS

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Rationale: Vitamin D deficiency, often defined by total serum 25-hydroxyvitamin D (25[OH]D) ,20 ng/ml, is common in critically ill patients, with associations with increased mortality and morbidity in the intensive care unit. Correction of vitamin D deficiency in critical illness has been recommended, and ongoing clinical trials are investigating the effect of repletion on patient outcome. The biologically active amount of 25(OH)D depends on the concentration and protein isoform of vitamin D-binding protein (VDBP), which is also an acutephase reactant affected by inflammation and injury.Objectives: We performed a secondary analysis of a cohort of critically ill children in which we reported a high rate of vitamin D deficiency, to examine how VDBP level and genotype would impact vitamin D status. Methods:We prospectively enrolled 511 children admitted to the pediatric intensive care unit over a 12-month period. Measurements and Main Results:We measured serum VDBP in 479 children. We genotyped single nucleotide polymorphisms rs7041 and rs4588 in the VDBP gene (GC) to determine haplotypes GC1F, GC1S, and GC2 in 178 subjects who consented, then calculated bioavailable 25(OH)D from serum 25(OH)D, VDBP, albumin, and GC haplotype. The median serum VDBP level was 159 mg/ml (interquartile range, 108-221), lower than has been reported in healthy children. Factors predicting lower levels in multivariate analysis included age ,1 year, nonwhite race, being previously healthy, 25(OH)D ,20 ng/ml and greater illness severity. In the subgroup that was genotyped, GC haplotype had the strongest association with VDBP level; carriage of one additional copy of GC1S was associated with a 37.5% higher level (95% confidence interval, 31.9-44.8; P , 0.001). Bioavailable 25(OH)D was also inversely associated with illness severity (r = 20.24, P , 0.001), and ratio to measured total 25(OH)D was variable and related to haplotype.Conclusions: Physiologic deficiency of 25(OH)D in critical illness may be more difficult to diagnose, given that lower VDBP levels increase bioavailability. Treatment studies conducted on the basis of total 25(OH)D level, without consideration of VDBP concentration and genotype, may increase the risk of falsely negative results.

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Section: Low Serum Concentrations Of Total 25-hydroxyvitamin D (25[oh]d)supporting

confidence: 75%

Section: Low Serum Concentrations Of Total 25-hydroxyvitamin D (25[oh]d)supporting

confidence: 75%

Critically Ill Children Have Low Vitamin D Binding Protein, Influencing Bioavailability of Vitamin D

Madden¹,

Feldman²,

Chun³

et al. 2015

Annals ATS

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“…Many other studies also showed significant decrease in serum vitD levels as a result of CPB effect in the immediate postoperative period. On the contrary, the control group showed rise in the mean value of serum vitD levels in the immediate post CPB period in sample C compared with sample B. Riad et al, 39 McNally et al, 40 Graham et al, 41 and Krishnan et al 42 studied the effect of CPB on serum vitamin D levels which is compared in ►Table 6.…”

Section: Discussionmentioning

confidence: 99%

Vitamin D Deficiency and Its Response to Supplementation as “Stoss Therapy” in Children with Cyanotic Congenital Heart Disease Undergoing Open Heart Surgery

et al. 2019

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Background Data from many studies suggest that patients with congenital heart disease are vitamin D (vitD) deficient. Following cardiac surgery as a result of intraoperative institution of cardiopulmonary bypass (CPB), serum vitD levels become even low. This may affect postoperative convalescence in terms of mechanical ventilation, inotropic support, infection, and so forth. Objective We intended to study the prevalence of vitD deficiency pre and post cardiac surgery and the effect of vitD supplementation (stoss therapy) on postoperative convalescence of the children with tetralogy of Fallot (TOF) undergoing intracardiac repair (ICR). Methodology In this randomized controlled trial (RCT), 60 children younger than 18 years with TOF and serum vitD levels < 20ng/dL were randomized into two groups. The study group received vitD supplementation as “stoss therapy” at 10,000 units/kg body weight. All these children underwent ICR with CPB. Demographic data, preoperative, intraoperative, and postoperative variables were compared between the study and the control groups. Results Prevalence of severe vitD deficiency was 93.1%. When compared with the control group, study group showed higher serum vitD levels in the immediate preoperative period (p = 0.001), postoperative period following CPB (p = 0.012), and on the first postoperative day (p = 0.003). No statistically significant difference was observed in postoperative mechanical ventilation (p = 0.35), intensive care unit (ICU) stay (p = 0.15), and inotropic duration (p = 0.19). Conclusion Children with TOF are highly deficient of vitD, its level falls further after CPB, and supplementing vitD preoperatively does not influence postoperative recovery pattern. Supplementation of vitD as “stoss therapy” was useful in raising the serum levels before and after cardiac surgery.

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“…32 A study by McNally and colleagues determined vitamin D status in children undergoing congenital heart surgery. 32 They found that 42% of patients were vitamin D deficient preoperatively and 86% of the same patients were deficient postoperatively. 32 There was a significant intraoperative decline, which appeared to coincide with cardiopulmonary bypass.…”

Section: Vitamin D and Calciummentioning

confidence: 99%

“…32 There was a significant intraoperative decline, which appeared to coincide with cardiopulmonary bypass. 32 Lower postoperative levels were associated with increased fluid requirements, ventilation days, and catecholamine requirements with heart dysfunction and other markers of organ dysfunction. 32 Although this study is limited by heterogeneity and small sample size, it suggests that current vitamin D recommendations are inadequate for the preoperative congenital heart disease patient and that preoperative and postoperative repletion may have the potential to change hospital outcomes.…”

Section: Vitamin D and Calciummentioning

confidence: 99%

Optimizing Nutrition in Pediatric Heart Failure: The Crisis Is Over and Now It’s Time to Feed

et al. 2017

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Pediatric heart failure is a complex disease occurring when cardiac output is unable to meet the metabolic demands of the body. With improved surgical interventions and medical therapies, survival rates have improved, and care has shifted from focusing on survival to optimizing quality of life and health outcomes. Based on current literature, this review addresses the nutrition needs of infants and children in heart failure and describes the pathophysiology and metabolic implications of this disease. The prevalence of wasting in pediatric heart failure has been reported to be as high as 86%, highlighting the importance of nutrition assessment through all stages of treatment to provide appropriate intake of energy, protein, and micronutrients. The etiology of malnutrition in pediatric heart failure is multifactorial and involves hypermetabolism, decreased intake, increased nutrient losses, inefficient utilization of nutrients, and malabsorption. Children in heart failure often present with tachypnea, tachycardia, fatigue, nausea, and vomiting and consequently may not be able to meet their nutrition requirements through oral intake alone. Nutrition support, including enteral nutrition and parenteral nutrition, should be considered an essential part of routine care. The involvement of multiple allied health professionals may be needed to create a feeding therapy plan to support patients and their families. With appropriate nutrition interventions, clinical outcomes and quality of life can be significantly improved.

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Impact of Anesthesia and Surgery for Congenital Heart Disease on the Vitamin D Status of Infants and Children

Abstract: Most CHD patients are vitamin-D deficient postoperatively due to low preoperative levels and a significant intraoperative decline. Interventional studies will be required to determine whether prevention of postoperative vitamin D deficiency improves outcome.

Cited by 50 publications

References 44 publications

Critically Ill Children Have Low Vitamin D Binding Protein, Influencing Bioavailability of Vitamin D

Critically Ill Children Have Low Vitamin D Binding Protein, Influencing Bioavailability of Vitamin D

Vitamin D Deficiency and Its Response to Supplementation as “Stoss Therapy” in Children with Cyanotic Congenital Heart Disease Undergoing Open Heart Surgery

Optimizing Nutrition in Pediatric Heart Failure: The Crisis Is Over and Now It’s Time to Feed

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