Ary Lopes Cardoso

Risk factors for atherosclerosis in children and adolescents with family history of premature coronary artery disease

OBJECTIVES To identify the prevalence of dyslipidemia in a group of 109 children and adolescents with a family history of premature coronary artery disease and to investigate the association between dyslipidemia and other risk factors for atherosclerosis. METHODS Total cholesterol, low density lipoprotein cholesterol (LDL-C), high density lipoprotein cholesterol (HDL-C), triglycerides, body mass index, blood pressure, physical activity, smoking, per capita income and maternal schooling were investigated. RESULTS Total cholesterol and LDL-C levels were higher than desirable in 27.5% and 19.3%, respectively, of our patients; 13.8% had lower HDL-C values and 13.0% presented hypertriglyceridemia. Obesity and excess weight were observed in 25.7% of the cases. Out of these, 57.1% had abnormal lipid values. Dyslipidemia was observed in 38.5%, either alone or in combination with other risk factors. Smoking was observed in 3.6%, hypertension in 2.7% and physical inactivity in 72.5%. There was no relationship between dyslipidemia and per capita income, maternal schooling and physical inactivity. However, obesity and excess weight were identified as significantly associated with the occurrence of dyslipidemia (p = 0.02; odds ratio = 2.82, 95% CI = 1.6-6.81). CONCLUSION In children and adolescents with a family history of premature coronary artery disease, early identification of the risk factors for atherosclerosis is essential to allow the implementation of preventive measures.

A survey on clinical presentation and nutritional status of infants with suspected cow' milk allergy.

BackgroundCows milk is the most common food allergen in infants and the diagnosis of cows milk allergy is difficult, even with the use of several diagnostic tests. Therefore, elimination diets and challenge tests are essential for the diagnosis and treatment of this disorder. The aim of this study is to report the clinical presentation and nutritional status of children evaluated by pediatric gastroenterologists for the assessment of symptoms suggestive of cows milk allergy.MethodsAn observational cross-sectional study was performed among 9,478 patients evaluated by 30 pediatric gastroenterologists for 40 days in 5 different geographical regions in Brazil. Clinical data were collected from patients with symptoms suggestive of cows milk allergy. The nutritional status of infants (age ≤ 24 months) seen for the first time was evaluated according to z-scores for weight-for-age, weight-for-height, and height-for-age. Epi-Info (CDC-NCHS, 2000) software was used to calculate z-scores.ResultsThe prevalence of suspected cows milk allergy in the study population was 5.4% (513/9,478), and the incidence was 2.2% (211/9,478). Among 159 infants seen at first evaluation, 15.1% presented with a low weight-for-age z score (< -2.0 standard deviation - SD), 8.7% with a low weight-for-height z score (< -2.0 SD), and 23.9% with a low height-for-age z score (< -2.0 SD).ConclusionThe high prevalence of nutritional deficits among infants with symptoms suggestive of cows milk allergy indicates that effective elimination diets should be prescribed to control allergy symptoms and to prevent or treat malnutrition.

Nutritional follow-up of cystic fibrosis patients: the role of nutrition education

OBJECTIVE To evaluate the nutritional status of a group of cystic fibrosis patients and establish the role of nutrition education addressed to them in a comparative study before and after intervention. METHODS All cystic fibrosis patients in regular follow-up in the pulmonology clinic of Instituto da Crianca during 1996-99 were prospectively monitored for 3.5 years. Measurements of weight, height, mid upper arm circumference, skinfolds and calculations of weight/age, height/age, weight/height, mid upper arm circumference and triceps z scores, percentage of ideal weight for height, percentage of body fat, check of the use of enzymes with meals and of the use of nutritional supplements were performed at four points in time: initial (I), 7 (II), 13 (III) and 43 (IV) months after the first evaluation. Nutritional counseling was given both verbally and in writing (booklet) to all patients. RESULTS Seventy-four patients, 38F/36M, age range 6 months to 18.4 years were evaluated. At study entry the anthropometric data showed: percentage of ideal weight for height = 94+/-13, percentage of body fat = 15+/-7.1, z scores for weight/age = -1.13+/-1.3, z scores for height/age = -0.94+/-1.2, z scores for weight/height = -0.69+/-1.1, z scores for mid upper arm circumference = -1.35+/-1.3, triceps z scores = -0.74+/-0.9. Compliance with enzyme therapy and use of high-calorie supplements improved during the study period. There was a significant increase in weight/height and triceps z scores and percentage of body fat throughout the study period. After stratifying patients into three age groups the anthropometric improvement was only significant among children under 5 years of age CONCLUSIONS Mild malnutrition was present in this group of cystic fibrosis patients. The nutrition education led to an improvement in compliance with enzyme therapy, use of nutritional supplements and in nutritional status, mostly among the younger patients.

Energy balance in infants born from HIV seropositive mothers

OBJECTIVES: A nutritional evaluation of infants born from HIV seropositive mothers was carried out during their follow up and diagnostic investigation. The energy balance (EB) of infected and noninfected children were compared. METHODS: The energy balance (intake energy, fecal energy, and resting energy expenditure) was prospectively determined by indirect calorimetry, considering 13 infants (6 girls and 7 boys) between 1 and 6 months of age, born from HIV positive mothers. This was made in two opportunities: before and after the diagnosis of the disease. A full nutritional assessment, including clinical examination and anthropometric measures (weight, height and skinfold thickness), was also determined in these two opportunities. After the definite diagnosis, the infants were finally assembled in 2 different groups: infected (5 in 13) and noninfected (8 in 13). The children were monthly submitted to clinical evaluations and orientation, during all the study. RESULTS: By analyzing the anthropometric measures of the two groups, it was observed that the infected group had malnutritional manifestations since the first evaluation. The resting energy expenditure (kcal/kg/dia) of the infected group was higher than that of the noninfected group: 64.5-/+16.8 vs 48.0-/+5.7 (p<0.05) at the first evaluation and 68.0-/+11.7 vs 51.8-/+3.1 (p<0.05) at the second, respectively. CONCLUSION: The higher resting energy expenditure of the children in the infected group might be the cause of the protein energy malnutrition during the asymptomatic phase when the diagnosis was uncertain.

Síndrome metabólica em adolescentes com sobrepeso e obesidade

OBJECTIVE: Evaluate the prevalence of metabolic syndrome in adolescents followed in an outpatient obesity clinic. METHODS: 84 adolescents (ten to 19 years old) were divided in two groups, one composed by overweight adolescents (OWG) and the other, by obese adolescents (OBG), according to Z scores of the body mass index (Z BMI). OWG: Z BMI>1 and 2 (2.4±0.6; 32M/26F). Three or more criteria were considered to define the presence of metabolic syndrome and tested by chi-square: Z BMI>2; fasting triglycerides >130mg/dL; high-density lipoprotein cholesterol 100mg/dL or homeostatic model assessment index (HOMA) >2.5 and blood pressure above the 90th percentile, adjusted for age, gender and length. RESULTS: The prevalence of metabolic syndrome was significantly elevated in obese adolescents (OBG: 40% versus OWG: 4%, p=0.0008). The major differences between groups were observed regarding the presence in OBG adolescents of hyperinsulinism (54% versus 19%, p=0.003), HOMA (66% versus 38%, p=0.01) and hypertriglyceridemia (21% versus 4%, p=0.04). CONCLUSIONS: It is important to be aware of the early signs of metabolic syndrome in obese adolescents, which can be screened by simple techniques. As the syndrome correlates to chronic illnesses, early detection and adequate prevention by pediatricians is mandatory.

Nutritional follow-up of critically ill infants receiving short term parenteral nutrition

Few studies have tried to characterize the efficacy of parenteral support of critically ill infants during short period of intensive care. We studied seventeen infants during five days of total parenteral hyperalimentation. Subsequently, according to the clinical conditions, the patients received nutritional support by parenteral, enteral route or both up to the 10th day. Evaluations were performed on the 1st, 5th, and 10th days. These included: clinical data (food intake and anthropometric measurements), haematological data (lymphocyte count), biochemical tests (albumin, transferrin, fibronectin, prealbumin, retinol-binding protein) and hormone assays (cortisol, insulin, glucagon). Anthropometric measurements revealed no significant difference between the first and second evaluations. Serum albumin and transferrin did not change significantly, but mean values of fibronectin (8.9 to 16 mg/dL), prealbumin (7.7 to 18 mg/dL), and retinol-binding protein (2.4 to 3. 7 mg/dL) increased significantly (p < 0.05) from the 1st to the 10th day. The hormonal study showed no difference for insulin, glucagon, and cortisol when the three evaluations were compared. The mean value of the glucose/insulin ratio was of 25.7 in the 1st day and 15. 5 in the 5th day, revealing a transitory supression of this hormone. Cortisol showed values above normal in the beginning of the study. We conclude that the anthropometric parameters were not useful due to the short time of the study; serum proteins, fibronectin, prealbumin, and retinol-binding protein were very sensitive indicators of nutritional status, and an elevated glucose/insulin ratio, associated with a slight tendency for increased cortisol levels suggest hypercatabolic state. The critically ill patient can benefit from an early metabolic support.

Nutritional evaluation of children with cholestatic diseases

OBJECTIVE To characterize the type of malnutrition and to determine the usefulness of anthropometric indices in children with chronic liver disease (CLD). METHODS 11 children (aged 5 - 105 mo) with CLD underwent anthropometric evaluation when they were clinically stable. The nutritional evaluation was made by the determination of Weight/Age (W/A), Height/Age (H/A) and Weight/Height (W/E) Z scores. The nutritional evaluation by Waterlows method was also made. The fat and protein body deposits were estimated by triceps skinfold and midarm muscular circumference measurements. The analysis of the 24-hour recall was used to evaluate the quality and pattern of the feeding. RESULTS The mean weight / age (W/A = -1.18) and height / age (H/A = - 1.26) Z scores were depressed under 1 SD, whereas mean weight / height (W/H) Z score was normal. The interpretation of the nutritional evaluation by Waterlows method shows normal mean of the weight and almost normal mean of the height. Only three patients had normal triceps skinfold thickness (TSF) Z score, and the same occurred with five of them with the midarm muscular circumference. The quality and pattern of the feeding was adequate in only 4 patients. CONCLUSIONS We conclude that chronic malnutrition is common in childhood CLD and that weight/height values underestimate the degree of acute malnutrition compared with TSF thickness, most likely because of the inflated patient weight caused by organomegaly. The reduction of the triceps skinfold thickness best reflected the nutritional impairment of the patients. The quality of feeding of the patients was mostly inadequate.

Avaliação da eficácia do colostro bovino hiperimune na infecção experimental de roedores com Cryptosporidium parvum

The hyperimmune bovine colostrum has a high concentration of antibodies anti-Cryptosporidium parvum. This product is considered one of the promising therapeutic strategies in the control of intestinal cryptosporidiosis in humans. With the purpose to evaluate the hyperimmune bovine colostrum efficacy in reducing the parasitism and preventing intestinal mucosa alterations, several strains of rats F344 and mice were experimentally infected with Cryptosporidium parvum oocysts. The results showed that the hyperimmune bovine colostrum had high levels of antibodies. The rats F344, treated either with hyperimmune or normal bovine colostrum, had reduction of the intestinal parasitism and presented little mucosa compromise. The mice C57BL/6 when treated either with hyperimmune or normal colostrum had slight reduction of the intestinal parasitism and evidenced no statistical significant differences in the histopathological mucosa changes. In conclusion, the use of hyperimmune bovine colostrum has a limited benefit in Cryptosporidium parvum infection.

Nutritional supplementation in patients with cystic fibrosis

OBJECTIVE: To evaluated the effect of short-term oral supplementation in the nutritional status of 14 patients with cystic fibrosis in 19 hospital admissions. METHODS: All patients received standard pulmonary therapy, and to 13 patients (Group I = GI) a high-fat oral supplement was offered besides the standard diet. The control group (GII) received the same diet except for the supplement. Anthropometric measurements, quantitative assessment of energy intake and serum biochemical parameters were determined on admission and prior to discharge from hospital. RESULTS: There was no difference in the weight gain between groups (median: GI=+1000 g; GII=+550 g), nor in the variations of height, skinfolds and body fat. Z scores were calculated (mean-/+SD: weight/age, GI=-2.19-/+1.0, GII=-2.57-/+1.1; height/age, GI=-1.73-/+1.4, GII=-2.06-/+1.4 ), showing that those patients had chronic severe malnutrition, with no changes in Z Score in this period. The diet offered to the patients provided the RDA for calories only in the supplemented group, and this value was significantly higher compared to the non-supplemented group (mean -/+ SD : GI= 146-/+20% RDA; GII=105-/+13%RDA). The energy intake was significantly higher in group I (mean-/+SD: GI=126-/+22%RDA; GII= 81-/+27%RDA), and it increased significantly by the end of admission in this group. The biochemical assessment revealed low levels of prealbumin in both groups on admission (mean-/+SD: GI=11-/+10mg/dl; GII=8-/+8 mg/dl), with significant increase only in group I (mean-/+SD: GI=23-/+15 mg/dl; GII=8-/+11 mg/dl). No variations in the levels of triglycerides were observed, but the cholesterol levels increased significantly in both groups. CONCLUSIONS: Although the weight gain was similar in both groups, prealbumin increased only in the supplemented group. This group had a higher energy intake than the non-supplemented one, and it reached the RDA for calories.

Amino acid formula as a new strategy for diagnosing cow’s milk allergy in infants: is it cost-effective?

Abstract Aims: To estimate the cost-effectiveness of a new strategy that uses an amino acid formula in the elimination diet of infants with suspected cow’s milk allergy (CMA). Materials and methods: This pharmacoeconomic study was developed from the perspective of the Brazilian Public Healthcare System. The new strategy proposes using an amino acid formula in the diagnostic elimination diet of infants (≤24 months) with suspected CMA. The rationale is that infants who do not respond to the amino acid formula do not suffer from CMA. Patients with a positive oral challenge test receive a therapeutic elimination diet based on Brazilian Food Allergy Guidelines. This approach was compared to the current recommendations of the Brazilian Food Allergy Guidelines. A decision model was constructed using TreeAge Pro 2012 software. Model inputs were based on a literature review and the opinions of a panel of experts. A univariate sensitivity analysis of incremental cost-effectiveness ratios was performed. Results: The mean cost per patient of the new amino acid formula strategy was R