\documentclass[twocolumn,twoside]{article}
\makeatletter\if@twocolumn\PassOptionsToPackage{switch}{lineno}\else\fi\makeatother

\usepackage{amsfonts,amssymb,amsbsy,latexsym,amsmath,tabulary,graphicx,times,xcolor}

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
% Following additional macros are required to function some 
% functions which are not available in the class used.
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
\usepackage{url,multirow,morefloats,floatflt,cancel,tfrupee}
\makeatletter


\AtBeginDocument{\@ifpackageloaded{textcomp}{}{\usepackage{textcomp}}}
\makeatother
\usepackage{colortbl}
\usepackage{xcolor}
\usepackage{pifont}
\usepackage[nointegrals]{wasysym}
\urlstyle{rm}
\makeatletter

%%%For Table column width calculation.
\def\mcWidth#1{\csname TY@F#1\endcsname+\tabcolsep}

%%Hacking center and right align for table
\def\cAlignHack{\rightskip\@flushglue\leftskip\@flushglue\parindent\z@\parfillskip\z@skip}
\def\rAlignHack{\rightskip\z@skip\leftskip\@flushglue \parindent\z@\parfillskip\z@skip}

%Etal definition in references
\@ifundefined{etal}{\def\etal{\textit{et~al}}}{}


%\if@twocolumn\usepackage{dblfloatfix}\fi
\usepackage{ifxetex}
\ifxetex\else\if@twocolumn\@ifpackageloaded{stfloats}{}{\usepackage{dblfloatfix}}\fi\fi

\AtBeginDocument{
\expandafter\ifx\csname eqalign\endcsname\relax
\def\eqalign#1{\null\vcenter{\def\\{\cr}\openup\jot\m@th
  \ialign{\strut$\displaystyle{##}$\hfil&$\displaystyle{{}##}$\hfil
      \crcr#1\crcr}}\,}
\fi
}

%For fixing hardfail when unicode letters appear inside table with endfloat
\AtBeginDocument{%
  \@ifpackageloaded{endfloat}%
   {\renewcommand\efloat@iwrite[1]{\immediate\expandafter\protected@write\csname efloat@post#1\endcsname{}}}{\newif\ifefloat@tables}%
}%

\def\BreakURLText#1{\@tfor\brk@tempa:=#1\do{\brk@tempa\hskip0pt}}
\let\lt=<
\let\gt=>
\def\processVert{\ifmmode|\else\textbar\fi}
\let\processvert\processVert

\@ifundefined{subparagraph}{
\def\subparagraph{\@startsection{paragraph}{5}{2\parindent}{0ex plus 0.1ex minus 0.1ex}%
{0ex}{\normalfont\small\itshape}}%
}{}

% These are now gobbled, so won't appear in the PDF.
\newcommand\role[1]{\unskip}
\newcommand\aucollab[1]{\unskip}
  
\@ifundefined{tsGraphicsScaleX}{\gdef\tsGraphicsScaleX{1}}{}
\@ifundefined{tsGraphicsScaleY}{\gdef\tsGraphicsScaleY{.9}}{}
% To automatically resize figures to fit inside the text area
\def\checkGraphicsWidth{\ifdim\Gin@nat@width>\linewidth
	\tsGraphicsScaleX\linewidth\else\Gin@nat@width\fi}

\def\checkGraphicsHeight{\ifdim\Gin@nat@height>.9\textheight
	\tsGraphicsScaleY\textheight\else\Gin@nat@height\fi}

\def\fixFloatSize#1{}%\@ifundefined{processdelayedfloats}{\setbox0=\hbox{\includegraphics{#1}}\ifnum\wd0<\columnwidth\relax\renewenvironment{figure*}{\begin{figure}}{\end{figure}}\fi}{}}
\let\ts@includegraphics\includegraphics

\def\inlinegraphic[#1]#2{{\edef\@tempa{#1}\edef\baseline@shift{\ifx\@tempa\@empty0\else#1\fi}\edef\tempZ{\the\numexpr(\numexpr(\baseline@shift*\f@size/100))}\protect\raisebox{\tempZ pt}{\ts@includegraphics{#2}}}}

%\renewcommand{\includegraphics}[1]{\ts@includegraphics[width=\checkGraphicsWidth]{#1}}
\AtBeginDocument{\def\includegraphics{\@ifnextchar[{\ts@includegraphics}{\ts@includegraphics[width=\checkGraphicsWidth,height=\checkGraphicsHeight,keepaspectratio]}}}

\DeclareMathAlphabet{\mathpzc}{OT1}{pzc}{m}{it}

\def\URL#1#2{\@ifundefined{href}{#2}{\href{#1}{#2}}}

%%For url break
\def\UrlOrds{\do\*\do\-\do\~\do\'\do\"\do\-}%
\g@addto@macro{\UrlBreaks}{\UrlOrds}



\edef\fntEncoding{\f@encoding}
\def\EUoneEnc{EU1}
\makeatother
\def\floatpagefraction{0.8} 
\def\dblfloatpagefraction{0.8}
\def\style#1#2{#2}
\def\xxxguillemotleft{\fontencoding{T1}\selectfont\guillemotleft}
\def\xxxguillemotright{\fontencoding{T1}\selectfont\guillemotright}

\newif\ifmultipleabstract\multipleabstractfalse%
\newenvironment{typesetAbstractGroup}{}{}%

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

\usepackage[authoryear]{natbib}



\newif\ifnokeywords\nokeywordsfalse

\makeatletter\input{size10-pointfive.clo}\makeatother%
\definecolor{kwdboxcolor}{RGB}{242,242,242}
\usepackage[hidelinks,colorlinks=true,allcolors=blue]{hyperref}
\linespread{1}                 
\def\floatpagefraction{0.8}

\usepackage[paperheight=11.69in,paperwidth=8.26in,top=1in,bottom=1in,left=1in,right=.75in,headsep=24pt]{geometry}

\usepackage{multirow-custom}

\makeatletter

\def\hlinewd#1{%
  \noalign{\ifnum0=`}\fi\hrule \@height #1%
  \futurelet\reserved@a\@xhline}
\def\tbltoprule{\hlinewd{1pt}\\[-14pt]}
\def\tblbottomrule{\noalign{\vspace*{6pt}}\hline\noalign{\vspace*{2pt}}}
\def\tblmidrule{\hline\noalign{\vspace*{2pt}}}



\let\@articleType\@empty
\let\@journalDoi\@empty
\let\@journalVolume\@empty
\let\@journalIssue\@empty
\let\@crossMarkLink\@empty
\let\@receivedDate\@empty
\let\@acceptedDate\@empty
\let\@revisedDate\@empty
\let\@publishedDate\@empty
\let\@copyrightYear\@empty
\let\@firstPage\@empty
\def\articleType#1{\gdef\@articleType{#1}}
\def\journalDoi#1{\gdef\@journalDoi{#1}}
\def\crossMarkLink#1{\gdef\@crossMarkLink{#1}}
\def\receivedDate#1{\gdef\@receivedDate{#1}}
\def\acceptedDate#1{\gdef\@acceptedDate{#1}}
\def\revisedDate#1{\gdef\@revisedDate{#1}}
\def\publishedDate#1{\gdef\@publishedDate{#1}}
\def\copyrightYear#1{\gdef\@copyrightYear{#1}}
\def\journalVolume#1{\gdef\@journalVolume{#1}}
\def\journalIssue#1{\gdef\@journalIssue{#1}}
\def\firstPage#1{\gdef\@firstPage{#1}}
\let\@issuelogo\@empty%
\let\@issuelogoex\@empty%
\def\issuelogo#1{\gdef\@issuelogo{#1}}
\def\issuelogoex#1{\gdef\@issuelogoex{#1}}


\def\author#1{%
  \gdef\@author{%
    \hskip-\dimexpr(\tabcolsep)\hskip5pt%
    \parbox{\dimexpr\textwidth-1pt}%
    {\fontsize{11}{13}\selectfont\raggedright #1}%
  }%
}


\usepackage{pharmascope-abs}
\usepackage{caption}
\usepackage{lastpage}
\usepackage{fancyhdr}
\usepackage[noindentafter,explicit]{titlesec}
\usepackage{fontspec}

\setmainfont[%
BoldFont=cambriab.ttf,%
ItalicFont=CAMBRIAI.TTF,%
BoldItalicFont=CAMBRIAZ.TTF]{Cambria.ttf}
\lefthyphenmin = 3

\def\title#1{%
  \gdef\@title{%
      \vspace*{-40pt}%
       \ifx\@articleType\@empty\else{\fontsize{10}{12}\scshape\selectfont\hspace{8pt}\@articleType\hfill\mbox{}\par\vspace{2pt}}\fi%
       \minipage{\linewidth}
         \hrulefill\\[-0.7pt]%%{\includegraphics[width=75pt,height=50pt]{ijrps_logo.png}}\hfill
         \mbox{~}\hspace{5pt}\parbox{.1\linewidth}{\IfFileExists{images/\@issuelogo.\@issuelogoex}{\includegraphics[width=79pt,height=61pt]{images/\@issuelogo.\@issuelogoex}}{\includegraphics[width=75pt,height=50pt]{ijrps_logo.png}}}\hfill
         \fcolorbox{kwdboxcolor}{kwdboxcolor}{\parbox{.792\linewidth}{%
          \begin{center}\fontsize{17}{17}\selectfont\scshape\vskip-7pt International Journal of Research in Pharmaceutical Sciences\hfill\end{center}%
          \vspace*{-10pt}\hspace*{4pt}{\fontsize{8}{9}\selectfont Published by JK Welfare \& Pharmascope Foundation\hfill  Journal Home Page: \href{www.ijrps.com}{\color{blue}\underline{\smash{www.ijrps.com}}}}\hspace*{4pt}\mbox{}}}%
       \par\vspace*{-1pt}\rule{\linewidth}{1.3pt}%
       \endminipage%
    \par\vspace*{9.2pt}\parbox{.98\linewidth}{\linespread{.9}\raggedright\fontsize{14}{17}\selectfont #1}%
    \vspace*{-8pt}%
  }
}


\setlength{\parindent}{0pt}
\setlength{\parskip}{0.4pc plus 1pt minus 1pt}

\def\abbrvJournalTitle{Int. J. Res. Pharm. Sci.}

\fancypagestyle{headings}{%
  \renewcommand{\headrulewidth}{0pt}%
  \renewcommand{\footrulewidth}{0.3pt}
  \fancyhf{}%
  \fancyhead[R]{%
    \fontsize{9.12}{11}\selectfont\RunningAuthor,\ \abbrvJournalTitle,\ \ifx\@journalVolume\@empty X\else\@journalVolume\fi%
    \ifx\@journalIssue\@empty\else(\@journalIssue)\fi%
    ,\ \ifx\@firstPage\@empty 1\else\@firstPage\fi-\pageref*{LastPage}%
  }%
  \fancyfoot[LO,RE]{\fontsize{9.12}{11}\selectfont\textcopyright\ International Journal of Research in Pharmaceutical Sciences}%
  \fancyfoot[RO,LE]{\fontsize{9.12}{11}\selectfont\thepage}
}\pagestyle{headings}

                                                         
\fancypagestyle{plain}{%
  \renewcommand{\headrulewidth}{0pt}%
  \renewcommand{\footrulewidth}{0.3pt}%
  \fancyhf{}%
  \fancyhead[R]{%
    \fontsize{9.12}{11}\selectfont\RunningAuthor,\ \abbrvJournalTitle,\ \ifx\@journalVolume\@empty X\else\@journalVolume\fi%
    \ifx\@journalIssue\@empty\else(\@journalIssue)\fi%
    ,\ \ifx\@firstPage\@empty 1\else\@firstPage\fi-\pageref*{LastPage}%
  }%
  \fancyfoot[LO,RE]{\fontsize{9.12}{11}\selectfont\textcopyright\ International Journal of Research in Pharmaceutical Sciences}%
  \fancyfoot[RO,LE]{\fontsize{9.12}{11}\selectfont\thepage}
  \ifx\@firstPage\@empty\else\setcounter{page}{\@firstPage}\fi
}


\def\NormalBaseline{\def\baselinestretch{1.1}}
\usepackage{textcase}
\setcounter{secnumdepth}{0}

\titleformat{\section}[block]{\bfseries\boldmath\NormalBaseline\filright\fontsize{10.5}{13}\selectfont}
{\thesection}
{6pt}
{\MakeTextUppercase{#1}}
[]
\titleformat{\subsection}[block]{\bfseries\boldmath\NormalBaseline\filright\fontsize{10.5}{12}\selectfont}
{\thesubsection}
{6pt}
{#1}
[]
\titleformat{\subsubsection}[block]{\NormalBaseline\filright\fontsize{10.5}{12}\selectfont}
{\thesubsubsection}
{6pt}
{#1}
[]
\titleformat{\paragraph}[block]{\NormalBaseline\filright\fontsize{10.5}{10}\selectfont}
{\theparagraph}
{6pt}
{#1}
[]
\titleformat{\subparagraph}[block]{\NormalBaseline\filright\fontsize{10.5}{12}\selectfont}
{\thesubparagraph}
{6pt}
{#1}
[]

\titlespacing{\section}{0pt}{.5\baselineskip}{.5\baselineskip}  
\titlespacing{\subsection}{0pt}{.5\baselineskip}{.5\baselineskip}  
\titlespacing{\subsubsection}{0pt}{.5\baselineskip}{.5\baselineskip}  
\titlespacing{\paragraph}{0pt}{.5\baselineskip}{.5\baselineskip}  
\titlespacing{\subparagraph}{0pt}{.5\baselineskip}{.5\baselineskip}

\captionsetup[figure]{skip=1.4pt,font=bf,labelsep=colon,justification=raggedright,singlelinecheck=false}
\captionsetup[table]{skip=1.4pt,font=bf,labelsep=colon,justification=raggedright,singlelinecheck=false}

\def\bibyear#1{#1}
%\def\bibjtitle#1{#1}   %%Publisher request
\def\bibauand{}
\setlength\bibsep{3pt}
\setlength\bibhang{8pt}

\makeatother
\date{}


\usepackage[flushleft]{threeparttablex}

\begin{document}


\def\RunningAuthor{Lally Hanna Luke et al.}
\firstPage{844}
\articleType{Original Article}
\receivedDate{20 Oct 2020}
\acceptedDate{24 Nov 2020}
\revisedDate{22 Nov 2020}
\journalVolume{2021, 12}
\journalIssue{1}
\journalDoi{ijrps.v12i1.4208}
\copyrightYear{2021}
\def\authorCount{6}
\def\affCount{5}

\def\journalTitle{International Journal of Research in Pharmaceutical Sciences}

\title{Assessment of Serum Vitamin D, Folic acid and Vitamin B\ensuremath{_{12}} in Congenital Heart Disease Patients in a Teritary Hospital}
\author{Lally~Hanna~Luke\textsuperscript{*}\textsuperscript{1},  
            Anandhi~D\textsuperscript{2},  
            Shiva~Kumar~K\textsuperscript{3},  
            Valli~G\textsuperscript{4},  
            Revathi~K\textsuperscript{2}, 
            Binoy~Varghese~Cheriyan\textsuperscript{5}~\\[5pt]{\textsuperscript{1}Department of Clinical Nutrition, MMM College of Health Sciences, Mogappair, Chennai, Tamil Nadu, India}~\\{\textsuperscript{2}Department of Biochemistry, Meenakshi Ammal Dental College, Alappakkam, Chennai, Tamil Nadu, India}~\\{\textsuperscript{3}Department of Pediatric Cardiology, MMM, Mogappair, Chennai, Tamil Nadu, India}~\\{\textsuperscript{4}Department of Pharmacology, Meenakshi Ammal Dental College, Alappakkam, Chennai, Tamil Nadu, India}~\\{\textsuperscript{5}Department of Pharmaceutical Chemistry, School of pharmacy, VISTAS, Chennai, Tamil Nadu, India}}

\begin{abstract}
Congenital heart disease patient suffers from malnutrition irrespective of the types of cardiac defects. These children are often admitted in hospitals owing to congenital heart defects. Corrective catherization, proper nutritional intake and counselling can improve the malnutrition. To assess the vitamin status in children with congenital heart disease patients admitted in paediatric general ward of tertiary hospital. The study was a prospective observational study, a total of 100 patients were evaluated for their nutritional deficiency such as serum vitamin D\ensuremath{_{3}}, folic acid and Vitamin B\ensuremath{_{12}} by employing ELISA KITS\textbf{. } The study observed a significant levels of vitamin D\ensuremath{_{3}} and folic acid depletion in congenital heart disease patients. There was no severe depletion of vitamin B\ensuremath{_{12}} in the current study. The study had made an insight into the malnutrition status of congenital heart disease patients and recommends consumption of micronutrients in congenital heart defect patients. 
\end{abstract}\def\keywordstitle{Keywords}

\begin{keywords}Congenital heart disease,\newline Vitamin D3,\newline Vitamin B12,\newline Malnutrition
\end{keywords}
\twocolumn[ \maketitle {\printKwdAbsBox}]
\makeatletter{\raggedright\textsuperscript{*}Corresponding Author\par Name:\ Lally~Hanna~Luke~\\ Phone:\ 9791096495~\\  Email:\ lallybinoy@gmail.com
        \par}\vspace*{-11pt}\hrulefill\par{\fontsize{12}{14}\selectfont ISSN: 0975-7538}\par% 
        \textsc{DOI:}\ \href{https://doi.org/10.26452/\@journalDoi}{\textcolor{blue}{\underline{\smash{https://doi.org/10.26452/\@journalDoi}}}}\par%
        \vspace*{-11pt}\hrulefill\\{\fontsize{9.12}{10.12}\selectfont Production and Hosted by}\par{IJRPS |~\href{www.ijrps.com}{www.ijrps.com}}\par%
        \vspace*{-2pt}{\fontsize{9.12}{10.12}\selectfont\textcopyright\ \@copyrightYear\ $|$ All rights reserved.}\par%
        \vspace*{-11pt}\rule{\linewidth}{1.2pt}
        \makeatother
        
    
\section{Introduction}
Congenital heart disease (CHD) is a serious condition with an estimated prevalence of 9 per 1000 birth in the general population \unskip~\citep{951144:20929731,951144:20929740}. Congenital heart disease (CHD) patients are prone to malnutrition owing to several reasons such as decreased energy intake, increased energy requirements, or both \unskip~\citep{951144:20929738}. Malnutrition among children suffering from CHD is widely reported, irrespective of the nature of the cardiac defect. Malnutrition condition arises when a person's diet doesn't contain the right amount of nutrients. Micronutrient malnutrition is a term used to refer to the diseases caused by a dietary deficiency of vitamins or minerals. Emerging literature suggests lack of vitamins and minerals to be a highly prevalent problem in CHD population \unskip~\citep{951144:20929730,951144:20929739}. Several reports suggest women using multivitamin supplements in the preconceptional period is at lower risk of having babies with congenital heart risk \unskip~\citep{951144:20929736}. Monitoring of specific biochemical parameters can be helpful in assessment of child's nutritional status and the adequacy and effectiveness of nutritional intervention. There are only few reported studies on assessing the vitamin levels in congenital heart patients \unskip~\citep{951144:20929735,951144:20929741}. Hence the current study was designed to determine the vitamin status in children with congential heart disease patients admitted in paediatric general ward of tertiary hospital. 
    
\section{Materials and Methods}
A prospective observational study design was adopted to carry out at a tertiary hospital at Chennai. The research protocol of the present study was approved by the Institutional Ethical Committee of Madras Medical Mission, Mogappair, Chennai (ECR/140/Ins/TN/2013/RR-16) 

The sample size of the study population was calculated using an appropriate formula for a study estimating population prevalence. The sample size was calculated using a formula proposed by \unskip~\cite{951144:20929737}  for the estimation of a population proportion with a specified relative precision (25) as follows: 

$\style{font-family:'Times New Roman'}{\style{font-size:8px}{n=\frac{Z^{2}P(1-P)}{d^{2da}}=\frac{(1.96)^{2}(0.6)(0.4)}{(0.1)^{2}}=\frac{(3.84)(0.6)(0.4)}{0.01}=\frac{0.9216}{0.01}=92.16}} $

Where,

n - the required sample size, 

z- the statistic corresponding to level of confidence, 

p - expected prevalence 

d - precision (corresponding to effect size).

Minimum sample size required is 92

The sample size taken for the current study was 100. The study was conducted for a period of one year. Assuming the severe malnutrition with observed portion 0.6 at 80\% power and 5\% level of significance derived from the study conducted by \unskip~\cite{951144:20929733}. The samples were classified into three groups based on the age. Group I~(0- 2 years) Group II (2-6 years) Group III (6-10years) and was compared with acyanotic and cyanotic heart.

\textbf{Criteria for Sample Selection}

The criteria that were followed for selection of study subjects are as follows:

\textbf{Inclusion criteria}


  
  \begin{enumerate}
  \item \relax Children from one month to ten years with congenital heart disease confirmed with echocardiogram. 
  \item \relax Children admitted for surgical or catheter based corrective intervention in the pediatric general ward was selected for the study.
  \item \relax Patients were selected on the basis of clinical and laboratory examinations including electrocardiography and echocardiography.
  \item \relax Both boys and girls were selected.
  \end{enumerate}
  \textbf{Exclusion criteria}


  
  \begin{enumerate}
  \item \relax Patients with a history of prematurity, intrauterine growth retardation, known genetic malformation
  \item \relax Dysmorphic features and neurologic disability were excluded from the study.
  \end{enumerate}
  \textbf{Estimation of serum Vitamin D\ensuremath{_{3}}, Vitamin B\ensuremath{_{12}} and folic acid}

Serum Vitamin D\ensuremath{_{3}}, Vitamin B\ensuremath{_{12}} and folic acid estimation was done by ELISA estimation kit (procedure was carried out as per manufacturer's instructions) 

\textbf{Statistical method}

Data were analyzed using SPSS software version 16.0 all values were expressed as mean \ensuremath{\pm} SD. For inferential statistics, independent t test, one-way analysis of variance was used with considering 95\% CI (5\% error).
    
\section{Result}
\textbf{Evaluation of Vitamin D\ensuremath{_{3}} levels in congenital heart patients}

The Table~\ref{tw-45c41f732d5c}  describes the vitamin D\ensuremath{_{3\ }} levels in the selected subjects. It was inferred that the mean vitamin D\ensuremath{_{3}} was 14.7\ensuremath{\pm} 2.36 ng/ml, 14.4\ensuremath{\pm} 2.73 ng/ml and 13.8\ensuremath{\pm} 2.51 ng/ml in 0-2 years, 2-6 years and 6-10years respectively. Vitamin D\ensuremath{_{3}} deficiency can be referred when the levels are below 20 - 30ng/ml. All the selected subjects had insufficient levels of vitamin D\ensuremath{_{3}}. 


\begin{table*}[!htbp]
\caption{\boldmath {Evaluation of Vitamin D\ensuremath{_{3}} levels in congenital heart patients} }
\label{tw-45c41f732d5c}
\centering 
\begin{threeparttable}

\def\arraystretch{1.1}
\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.2523\linewidth-2\tabcolsep}p{\dimexpr.32410000000000004\linewidth-2\tabcolsep}p{\dimexpr.259\linewidth-2\tabcolsep}p{\dimexpr.1646\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor}Age & Observed mean vitamin D\ensuremath{_{3}}  (ng/ml) & Expected Vitamin D\ensuremath{_{3}} \mbox{}\protect\newline  (ng/ml)  & P value\\
\tblmidrule 
0-2 year &
  14.7\ensuremath{\pm} 2.36 \mbox{}\protect\newline (n= 45) &
  \multicolumn{1}{p{\dimexpr(.259\linewidth-2\tabcolsep)}}{\multirow{3}{\linewidth}{\ensuremath{\leq }20 - 30ng/ml}} &
  \multicolumn{1}{p{\dimexpr(.1646\linewidth-2\tabcolsep)}}{\multirow{3}{\linewidth}{0.45}}\\
2-6 year &
  14.4\ensuremath{\pm} 2.73 \mbox{}\protect\newline (n=35 ) &
   &
  \\
6-10 year &
  13.8\ensuremath{\pm} 2.51 \mbox{}\protect\newline (n=20) &
   &
  \\
\tblbottomrule 
\end{tabulary}\par 
\begin{tablenotes}\footnotesize 
    
\item{Each value represents the mean \ensuremath{\pm} SD of n observations, where n= total number of participants in the study, SD= standard deviation P value was calculated by ANOVA, P \textless\ 0.05 is statistically significant}
\end{tablenotes}
\end{threeparttable}

\end{table*}

\begin{table*}[!htbp]
\caption{\boldmath {Comparison of Vitamin D\ensuremath{_{3\ }}levels on type of congenital heart defects} }
\label{tw-c06faca073a3}
\centering 
\begin{threeparttable}

\def\arraystretch{1.1}
\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.2252\linewidth-2\tabcolsep}p{\dimexpr.2126\linewidth-2\tabcolsep}p{\dimexpr.23060000000000002\linewidth-2\tabcolsep}p{\dimexpr.17299999999999997\linewidth-2\tabcolsep}p{\dimexpr.1586\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor}Age & Acyanotic heart defect & Cyanotic heart defect & Expected Vitamin D & P value \\
\tblmidrule 
0-2 years &
  15.8 \ensuremath{\pm} 2.13 \mbox{}\protect\newline (n=29) &
  12.7\ensuremath{\pm} 1.12* \mbox{}\protect\newline (n=16) &
  \multicolumn{1}{p{\dimexpr(.17299999999999997\linewidth-2\tabcolsep)}}{\multirow{3}{\linewidth}{\ensuremath{\leq }20 - 30ng/ml}} &
  0.000\\
2-6 years &
  15.3\ensuremath{\pm} 2.56 \mbox{}\protect\newline (n=25) &
  12.1\ensuremath{\pm} 1.50 \mbox{}\protect\newline (n=10) &
   &
  0.001\\
6-10 years &
  14.5\ensuremath{\pm} 2.71 \mbox{}\protect\newline (n=13) &
  12.5\ensuremath{\pm} 1.48 \mbox{}\protect\newline (7) &
   &
  0.009\\
\tblbottomrule 
\end{tabulary}\par 
\begin{tablenotes}\footnotesize 
    
\item{Each value represents the mean \ensuremath{\pm} SD of n observations, where n= total number of participants in the study, SD= standard deviation P value was calculated by independent ``t" test, P \textless\ 0.05 is \ensuremath{_{12}} statistically significant}
\end{tablenotes}
\end{threeparttable}

\end{table*}

\begin{table*}[!htbp]
\caption{\boldmath {Evaluation of Folic Acid and Vitamin B\ensuremath{_{12\ }} Levels in Congenital heart defect patients} }
\label{tw-d029209962d0}
\centering 
\begin{threeparttable}

\def\arraystretch{1.1}
\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.2018\linewidth-2\tabcolsep}p{\dimexpr.1982\linewidth-2\tabcolsep}p{\dimexpr.1946\linewidth-2\tabcolsep}p{\dimexpr.2054\linewidth-2\tabcolsep}p{\dimexpr.20\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor}Age & Observed mean Folic Acid  \mbox{}\protect\newline (ng/L)  & Expected Mean Folic Acid \mbox{}\protect\newline (ng/L)  & Observed mean Vitamin B\ensuremath{_{12}} \mbox{}\protect\newline (pg/ml)  & Expected Mean Vitamin B\ensuremath{_{12}} \mbox{}\protect\newline (pg/ml) \\
\tblmidrule 
2 years (n =45) &
  4.3 \ensuremath{\pm} 0.67 &
  \multicolumn{1}{p{\dimexpr(.1946\linewidth-2\tabcolsep)}}{\multirow{3}{\linewidth}{5.38 ng/ml}} &
  384\ensuremath{\pm}197 &
  \multicolumn{1}{p{\dimexpr(.20\linewidth-2\tabcolsep)}}{\multirow{3}{\linewidth}{211-911pg/ml}}\\
2-6 years (n= 35)  &
  4.5 \ensuremath{\pm} 0.88 &
   &
  458\ensuremath{\pm}218 &
  \\
6-10 years (n= 20) &
  4.5 \ensuremath{\pm}0.67 &
   &
  442\ensuremath{\pm}245 &
  \\
\tblbottomrule 
\end{tabulary}\par 
\begin{tablenotes}\footnotesize 
    
\item{Each value represents the mean \ensuremath{\pm} SD of n observations, where n= total number of participants in the study, SD= standard deviation, P value was calculated by ANOVA, P \textless\ 0.05 is statistically significant}
\end{tablenotes}
\end{threeparttable}

\end{table*}

\begin{table*}[!htbp]
\caption{\boldmath {Comparison of folic acid and Vitamin B\ensuremath{_{12\ }}levels on type of congenital heart defect} }
\label{tw-729bd8e3aee9}
\centering 
\begin{threeparttable}

\def\arraystretch{1.1}
\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.2155\linewidth-2\tabcolsep}p{\dimexpr.16449999999999996\linewidth-2\tabcolsep}p{\dimexpr.154\linewidth-2\tabcolsep}p{\dimexpr.16600000000000005\linewidth-2\tabcolsep}p{\dimexpr.18249999999999993\linewidth-2\tabcolsep}p{\dimexpr.11750000000000002\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor}Age & \multicolumn{2}{p{\dimexpr(.31849999999999994\linewidth-2\tabcolsep)}}{\cAlignHack Acyanotic Heart Defect} & \multicolumn{2}{p{\dimexpr(.34849999999999994\linewidth-2\tabcolsep)}}{\cAlignHack Cyanotic Heart Defect } & P value\\
\rowcolor{kwdboxcolor} & Observed mean Vitamin B12 \mbox{}\protect\newline (pg/ml)  & Observed mean Folic Acid  \mbox{}\protect\newline (ng/L) & Observed mean Vitamin B12 \mbox{}\protect\newline (pg/ml)  & Observed mean Folic Acid  \mbox{}\protect\newline (ng/L)  & \\
\tblmidrule 
2 years (n45) &
  503\ensuremath{\pm} 134* &
  4.6\ensuremath{\pm} 0.45* &
  166.8 \ensuremath{\pm} 57* &
   3.5 \ensuremath{\pm} 0.32* &
  \multicolumn{1}{p{\dimexpr(.11750000000000002\linewidth-2\tabcolsep)}}{\multirow{3}{\linewidth}{0.000}}\\
2-6 years (n 35)  &
  577\ensuremath{\pm} 122* &
  4.9\ensuremath{\pm}0.61* &
  160 \ensuremath{\pm} 40* &
  3.9\ensuremath{\pm}0.63* &
  \\
6-10 years (n 20) &
  598.7\ensuremath{\pm} 139* &
  4.9\ensuremath{\pm}0.29* &
  152 \ensuremath{\pm}22* &
  3.9\ensuremath{\pm}0.63* &
  \\
\tblbottomrule 
\end{tabulary}\par 
\begin{tablenotes}\footnotesize 
    
\item{Each value represents the mean \ensuremath{\pm} SD of n observations, where n= total number of participants in the study, SD= standard deviation P value was calculated by independent ``t'' test,* P \textless\ 0.05 is statistically significant}
\end{tablenotes}
\end{threeparttable}

\end{table*}
\textbf{Comparison of Vitamin D\ensuremath{_{3}} levels on type of congenital heart defect}

Table~\ref{tw-c06faca073a3}  illustrates the vitamin D\ensuremath{_{3}} levels on the type of congenital heart defect. It was inferred that in Acyanotic Congenital heart defect among 0-2 year 2-6 years and 6-10 years the mean vitamin D level was 15.8\ensuremath{\pm} 2.13 ng/ml, 15.3\ensuremath{\pm} 2.56 ng/ml and 14.5\ensuremath{\pm} 2.71 ng/ml respectively.

In Cyanotic Congenital heart defect among 0-2 year the mean vitamin D was 12.7\ensuremath{\pm} 1.12 ng/ml, 12.1\ensuremath{\pm} 1.50ng/ml in 2-6 year and 12.5\ensuremath{\pm} 1.49 ng/ml in 0-2 years, 2-6 years and 6-10 year respectively.

Overall, severe depletion of vitamin D\ensuremath{_{3\ }} was found highest among subjects with cyanotic congenital heart defect with significant level of 0.000 in 0-2 years, 0.001 in 2-6 year and 0.001 in 6- 10 years whereas mild to moderate depletion of vitamin D was predominant among subjects with acyanotic congenital heart  defect.

\textbf{Evaluation of Folic Acid and Vitamin B\ensuremath{_{12\ }} Levels in Congenital heart defect patients}

Table~\ref{tw-d029209962d0}  illustrates the folic acid and vitamin B\ensuremath{_{12}} levels in the CHD subjects. It was observed that the mean folic acid among 0-2 years.2-6 years and 6-10 years was 4.25 \ensuremath{\pm} 0.67ng/ml, 4.4 \ensuremath{\pm} 0.88 ng/ml and 4.5 \ensuremath{\pm}0.67ng/ml respectively. It was concluded that folic acid depletion was prevalent among all the ages among congenital heart defect. Subsequent findings on mean vitamin B\ensuremath{_{12\ }} levels was 384\ensuremath{\pm}197pg/ml, 458\ensuremath{\pm}218pg/ml and 421\ensuremath{\pm}216 pg/ml among 0-2 years, 2-6 years and 6-10 years respectively. It was found that vitamin B12 levels where within the normal range. 

\textbf{Comparison of folic acid and Vitamin B\ensuremath{_{12}} levels on type of congenital heart defect}

Table~\ref{tw-729bd8e3aee9}  represents the comparison of mean folic acid and vitamin of B\ensuremath{_{12\ }} level between the age groups and type of congential heart defects it was observed that in acyanotic congenital heart defect that the mean folic acid among 0-2 year.2-6 years and 6- 10 years was 4.6\ensuremath{\pm} 0.45ng/ml, 4.9\ensuremath{\pm}0.61ng/ml and 4.9\ensuremath{\pm}0.29ng/ml respectively. In cyanotic congenital heart defect that the mean folic acid was 3.5 \ensuremath{\pm} 0.32ng/ml, 3.9\ensuremath{\pm}0.63ng/ml and 3.9\ensuremath{\pm}0.63ng/ml among 0-2 years, 2- 6 years and 6-10 years respectively and was found to be statistically significant

It was observed that the mean vitamin B\ensuremath{_{12}} level in acyanotic congenital heart defect among 0-2 years. 2-6 years and 6-10 years was 503\ensuremath{\pm} 134 pg/ml, 577\ensuremath{\pm} 122 pg/ml and 598.7\ensuremath{\pm} 139 pg/ml respectively. In cyanotic congenital heart defect, the mean vitamin B\ensuremath{_{12}} was 166.8 \ensuremath{\pm} 57 pg/ml, 160 \ensuremath{\pm} 40pg/ml and 152 \ensuremath{\pm}22 pg/g/ml in 0-2 years, 2-6 years and 6-10 years respectively. It was found that vitamin B\ensuremath{_{12}} levels where within the normal range.
    
\section{Discussion}
Nutritional deficiencies are quite high in patients with CHD. Children suffering from CHD are often lean and underweight. Few studies have evaluated the micronutrient deficiency in CHD patients. Deficiency often is subclinical and only detected by laboratory investigation. The identification of malnutrition in congenital heart disease patients enables doctors, paramedics and dietitians to employ corrective surgical intervention along with nutritional strategies and helps to improve the growth status of children. In the current observational study, we have evaluated the Vitamin D\ensuremath{_{3}}, B\ensuremath{_{12}} and Folic acid levels of CHD patients admitted for surgical catheterization in a tertiary hospital.

The current study observed that there was moderate depletion of Vitamin D\ensuremath{_{3}} levels in the serum while comparing between the age groups and this was not statistically significant, whereas on comparing the serum level of vitamin D\ensuremath{_{3}} with the various type of congenital heart defects a statistically significance levels of vitamin D\ensuremath{_{3}} depletion was observed with cyanotic congenital heart defect \& acyanotic congenital heart defect patients. Our findings were in correlation with previous studies \unskip~\citep{951144:20929734}. There were no depletion of vitamin B\ensuremath{_{12}} among the congenital heart patients, where as statistically significant observation of the levels of folic acid depletion was observed among cyanotic and acyanotic congenital heart defect patients. These findings were in lieu with previous findings \unskip~\citep{951144:20929732}. A study by \unskip~\cite{951144:20929742}  demonstrated low folate levels in congenital heart patients with genetic polymorphisms, the study recorded nutrient gene interaction a modifiable risk factor by supplementing folic acid.  
    
\section{Conclusion}
The study concluded that vitamin D\ensuremath{_{3}} deficiency was prevalent among congenital heart disease patients. Deficiency of vitamin D\ensuremath{_{3\ }} can be associated with cardiovascular dysfunction, prolongs ICU stay and worsens the outcome in critically ill patients. Folic acid deficiency increases the homocysteine levels which in turn is a risk factor for cardiovascular disease. Deficiency of vitamin B\ensuremath{_{12}} was ruled out in acyanotic heart defect patients whereas mild depletion was observed in cyanotic heart defect patients. The study suggests supplementation of vitamin D, Folic acid and Vitamin B\ensuremath{_{12}} rich foods to reduce the incidence of cardiovascular risk in CHD patients.
    
\section{Acknowledgement}
The authors thank Staffs of Pediatric Cardiology Department of Madras Medical Mission for support of the study.

\textbf{Conflict of Interest}

No conflict of interest was declared by the authors.

\textbf{Financial Disclosure}

The authors declared that this study has received no financial support.
    

\bibliographystyle{pharmascope_apa-custom}

\bibliography{\jobname}
\end{document}
