Domingos Palma

Riscos isolados e agregados de anemia em crianças frequentadoras de berçários de creches

OBJECTIVE: To identify and quantify isolated and combined risk factors for anemia, providing a comprehensive view of the likelihood of its occurrence. METHODS: Cross-sectional study with 482 children aged 4 to 29 months attending the nurseries of philanthropic and public daycare centers in the city of Sao Paulo, Brazil, who participated in two surveys (2004 and 2007). Mothers were interviewed, blood was collected using digital puncture, and anthropometry was performed. Anemia was characterized by hemoglobin levels below 11 g/dL. Unconditional logistic regression was adjusted for anemia risk factors. A value of p < 0.05 indicated statistically significant associations. Post-test odds and likelihood ratios were calculated to define post-test probabilities. Epi-InfoTM 2000 and Stata 10.0 software packages were used for statistical analysis. RESULTS: Prevalence of anemia was 43.6% (95%CI 39.1-48.1). The final logistic model included five categorical variables: mothers age less than 28 years (OR = 1.50; p = 0.041), per capita income below half a minimum wage (OR = 1.56; p = 0.029), exclusive breastfeeding less than 2 months (OR = 1.71; p = 0.009), decrease in weight/age z score from birth to survey (OR = 1.47; p = 0.050), and age less than 17 months (OR = 2.44; p < 0,001). Post-test probabilities in the associations of isolated and combined risk factors for anemia ranged from 54.5 to 100%. CONCLUSIONS: The probability of anemia progressively increased as the identified risk factors were added. This calculation provides a simple and rapid tool for suspicion of anemia in children both in clinical practice and population screening.

Nutritional gains of underprivileged children attending a day care center in S.Paulo City, Brazil: a nine month follow-up study

The efficacy of a well-operated day care center in providing better nutrition to poor children in Brazil was assessed. We collected data for 9 months from 180 under-five children attending a day care center located in a slum. Every working day each child received at least 100% of the age-group recommended dietary allowances plus iron fortified milk and, every six months, treatment for helminth infections. Statistical analyses were restricted to the 168 children (93%) who had measurements from at least five months. As outcome variables, weight-for-height, height-for-age, and weight-for-age Z scores were dichotomized so that a Z score < -1 indicated a child was at risk of malnutrition. We examined the proportion of children at nutritional risk in each month and used multivariate statistical techniques to adjust for confounding and to account for intra-subject correlation. The percentage of children at nutritional risk decreased over time, from 10.1% to 3.4% for weight for height, 29.8% to 15.2 % for weight for age, and from 50.0% to 44.8% for height for age. Most of the reduction took place between the third and fourth months of enrollment. The correlated data models for the three dichotomized outcomes showed a two to three-fold reduction in the occurrence of wasting and underweight. We concluded that attendance to well-operated daycare protects against nutritional risk, and approximately four months are required for a benefit to be seen.

Padrões alimentares de adolescentes obesos e diferentes repercussões metabólicas

OBJECTIVE: This study assessed the association between dietary patterns and metabolic changes in obese adolescents. METHODS: This was a cross-sectional study of 76 students (both genders, 14-19 years old, BMI³P95 and Tanner stage ³4) enrolled in public schools from 2006 to 2007 in Sao Paulo city, Brazil. A sociodemographic questionnaire and 4-day food record were administered and anthropometric and biochemical data were collected. Scores for dietary patterns were assessed by factor analysis and after potential confounders were controlled, multilinear regression was used to associate the three identified patterns with biological risk factors. RESULTS: The Traditional Pattern (rice and cereals, beans, red meat, sausage, oils and sweets) was positively associated with insulin, blood glucose and triglycerides and negatively associated with high-density lipoprotein. The In-Transition pattern (fish, poultry, eggs, bread, butter, milk and dairy products, vegetables, fruits, fruit juice and white sugar), presented the same positive associations in addition to an association with diastolic blood pressure. The Fast Food pattern (high fat bakery products, hamburger, mayonnaise, cookies and crackers, chocolate and sodas) presented a positive association with cholesterol, low-density lipoprotein, systolic and diastolic blood pressure and a negative association with insulin and high-density lipoprotein. CONCLUSION: The Traditional and In-Transition patterns were differently related to glucose and lipid metabolism when compared with the fast food pattern. The three patterns could be considered obesogenic, however the Fast Food pattern seems to be the most atherogenic and promoter of hypertension.

Fatores de risco associados ao desmame precoce e ao período de desmame em lactentes matriculados em creches

OBJECTIVE: To evaluate risk factors associated with weaning of infants enrolled in daycare centers. METHODS: Analytical cross-sectional study comprising 56 children aged nine to 18 months in five daycare centers of Sao Paulo. A pre-tested questionnaire was applied to their mother, including questions on demographics and socioeconomic issues, gestation and birth, illness, breastfeeding, complementary feeding (when and how new foods were introduced) and children activities in daycare centers. Factors associated with early weaning and short weaning period (defined as the difference between exclusive breastfeeding period and total breastfeeding period) were determined by bivariate analyses. Conceptual hierarchical multivariate analysis (logistic regression) was applied. RESULTS: In the multivariate analysis, the independent risk factors for early weaning were: family income 25 years (OR 4.91; 95%CI 1.35-17.95); mother living without a partner (OR 6.42; 95%CI 1.28-32.20); use of pacifier before 30 days of life (OR 8.75; 95%CI 1.90-40.23). Risk factors for insufficient weaning period were: attending public daycare centers (OR 3.20; 95%CI 0.77-14.29) and late start of prenatal care (OR 4.13; 95%CI 0.70-31.29). CONCLUSIONS: Characteristics related to family and to daycare centers are risk factors for breastfeeding weaning among institutionalized infants. Such factors approach is strategic to define nutrition and health actions for favoring breastfeeding practice and to qualify daycare centers as infant health and nutrition promoters.

Custo da alimentação no primeiro ano de vida

OBJECTIVE: To estimate and compare the different alternatives of feeding regimens available for infants in the first year of life, considering the limitations of each option in relation to a feeding regimen adequate for the infants growth and development and also for the family budget. METHODS: In the first year of life, four alternatives of feeding regimens were calculated, in accordance with the current recommendations for the introduction of new foods for infants. The proposed costs were considered for the monthly consumption of such feeding. The resulting values were determined by the arithmetic mean of the best prices of foods quoted in each of two supermarket chains and a local market of the south zone of Sao Paulo city during a period of six months (January to June, 2004). RESULTS: From the calculation of the percentage cost in relation to breastfeeding plus supplementary feeding, it was observed that the use of infant formula represents a cost 3.3 times higher, and the use of cow milk 1.7 times higher than the value of breastfeeding, thus showing that the recommendation for the use of infant formula cannot be adopted by the majority of the Brazilian population due to income limitations. CONCLUSION: The development of a formula with the necessary nutrients for the infants growth and development on the same patterns of generic medicines could be a dietary option. Such a product, costing approximately R

Fatores de risco de anemia em lactentes matriculados em creches públicas ou filantrópicas de São Paulo

10.00/kg would be twice as cheap as the formulas currently available in the market.

The impact of training for day-care educators on childhood anaemia in nurseries: an institutional randomised clinical trial

OBJECTIVE: To identify and quantify the risk factors for anemia in infants enrolled in public or philanthropic day care centers in Sao Paulo city and discuss the impact of the actions of day care centers in controlling this specific nutritional deficiency. METHODS: Cross-sectional study comprising 212 infants of two public and three philanthropic day care centers. Interviews with the mothers, collection of blood by digital puncture and anthropometry were performed. Anemia was characterized by hemoglobin levels below 11g/dL. A logistic regression model for risk factors between groups of infants with and without anemia was adjusted. RESULTS: The prevalence of anemia was 51.9%. The final logistic model comprised 4 variables: presence of one or more siblings under 5 years of age (Odds Ratio=2.57; p=0.005), attending day care centers that are managed exclusively by the government (Odds Ratio=2.12; p=0.020), less than 2 months of exclusive breastfeeding (Odds Ratio=1.88; p=0.044), age under 15 months (Odds Ratio=2.32; p=0.006). CONCLUSION: The high prevalence of anemia evidences the inefficiency of the studied day care centers in controlling and preventing this nutritional deficiency; therefore, it is up to the health planner to consider the identified and quantified risks for anemia when elaborating control and prevention programs.

Cárie dentária e práticas alimentares entre crianças de creches do município de São Paulo

OBJECTIVE To test the impact of training for educators on the health of children enrolled in public and philanthropic day-care nurseries. DESIGN A randomised, institutional, non-blind clinical trial was conducted. An educational intervention was performed in four day-care centres and the control group consisted of four other day-care centres. Interviews with the mothers, collection of blood from the children by digital puncture and anthropometry were performed. The chosen indicator for the improvement of health was anaemia (Hb <11 g/dl). An unconditional logistic regression model was set for the risk factors for anaemia, considering associations with P ≤ 0·05 as statistically significant. SETTING Eight day-care centres in the city of Sao Paulo, Brazil. SUBJECTS Two hundred and fifty-two children from day-care nurseries. RESULTS The children from the day-care centres that were not subject to intervention presented a 2·11 times greater risk (95% CI 1·04, 4·30; P = 0·40) of having anaemia at the end of the study independent of the control variables (sex, age, time in the day-care centre, anaemia at the beginning of the study, maternal age, use of oral iron supplements, number of siblings, per capita family income, use of antibiotics and the necessity of avoidable hospitalisations) used in the construction of the final logistical model. CONCLUSIONS The assessed educational intervention promoted significant changes in the health status of the children, reinforcing the importance of training for professionals who care for young children in day-care centres in developing countries in order to promote child health.

Double-blind randomized controlled trial of rolls fortified with microencapsulated iron

OBJECTIVE: The present study investigated associations between the prevalence of dental caries and introduction of complementary foods in children aged 11 to 34 months attending daycare centers. METHODS: This cross-sectional study included 288 children from eight daycare centers in Sao Paulo, 2007. The modified decay-missing-filled index, used for diagnosis, was investigated by a team of three trained dentists aiming at precision and accuracy. Food introduction was assessed using a pre-codified and pre-tested questionnaire. The Chisquare test was used to quantify associations and logistic regression models (p<0.05) were adjusted for multivariate analysis. RESULTS: The sample consisted of 228 children aged 11 to 34 months (M=24 months, SD=6.02). Of these, 53.9% were male and 57.45% attended philanthropic daycare centers. Seventy-seven percent of the sample had modified decay-missing-filled index ≥1 and the average modified decay-missing-filled index of the population is 3.8. Significant risk factors according to modified decay-missing-filled index were being male (OR=1.815, p=0.03) and paternal formal education of less than eight years (OR=1.94, p=0.02). The logistic regression model identified the exposure to simple carbohydrates as an independent risk factor, after controlling for the effects of sex and parental educational. Such exposure increased the chances of having modified decay-missing-filled index ≥1 by 2.5 times. CONCLUSION: Special attention should be given to this group of individuals, implementing preventive policies in oral health and building healthy food habits in daycare centers.

BabyCare: apoio à decisão na atenção primária materno-infantil com computadores de mão

OBJECTIVE To evaluate the impact of the fortification of rolls with microencapsulated iron sulfate with sodium alginate on the hemoglobin levels in preschoolers as compared to controls. METHODS Double-blind randomized controlled trial comprised of children aged 2 to 6 years with initial hemoglobin exceeding 9 g/dL from four not-for-profit daycares randomly selected in the city of São Paulo - Brazil. Children of 2 daycares (n = 88) received rolls with fortified wheat flour as the exposed group (EC) and children of 2 daycares (n = 85) received rolls without fortification as the control group (CG) over a 24-week period. Rolls with 4 mg iron each were offered once a day, five days a week. Hemoglobin concentrations were determined in capillary blood by HemoCue® at three moments of trial: baseline (Ml), after 12 and 24 weeks of intervention (M2, M3). RESULTS Hemoglobin concentration presented significant increase up to M3 in EG (11.7-12.5-12.6 g/dL) and in CG (11.1-12.4-12.3 g/dL) with higher elevations in children initially with anemia. There was significant reduction in the occurrence of anemia from 22% to 9% in EG and from 47% to 8.2% in CG at M3. CONCLUSION Rolls fortified with microencapsulated iron sulfate were well tolerated, increased hemoglobin levels and reduced the occurrence of anemia, but with no difference compared to the control group.