Fabíola Isabel Suano de Souza

Alimentação complementar: práticas inadequadas em lactentes

OBJETIVO: Avaliar as praticas e o consumo alimentar de lactentes saudaveis de tres metropoles do Brasil. METODOS: Por meio de estudo prospectivo, analisaram-se registros alimentares de 7 dias consecutivos de amostra intencional, por cotas e ponderada, das cidades de Curitiba, Sao Paulo e Recife, de 179 lactentes saudaveis, entre 4 e 12 meses, que nao se encontravam em aleitamento materno (AM) exclusivo. As maes receberam orientacao verbal e escrita, por nutricionista, visando a uniformizacao da anotacao do registro alimentar. Para o calculo de ingestao, utilizou-se o Programa de Apoio a Nutricao (NutWin). RESULTADOS: A mediana de idade dos lactentes foi de 6,8 meses (4,0-12,6 meses). Observou-se que 50,3% ja nao recebiam AM. Destes, 12,0 e 6,7% dos menores e maiores de 6 meses, respectivamente, utilizavam formulas infantis em substituicao ao leite materno. A maioria dos lactentes, portanto, recebia leite de vaca integral. A diluicao da formula infantil foi correta em apenas 23,8 e 34,7% das criancas menores e maiores de 6 meses, respectivamente. Em relacao a alimentacao complementar, observou-se que a mediana de idade foi de 4 meses para sua introducao e de 5,5 meses para a alimentacao da familia. Verificou-se elevada inadequacao quantitativa na ingestao de micronutrientes para lactentes de 6 a 12 meses que nao recebiam AM, destacando-se as de zinco (75%) e ferro (45%). CONCLUSAO: O presente estudo mostrou elevada frequencia de praticas e consumo alimentar inadequados em lactentes muito jovens. E possivel que essas praticas levem a aumento no risco de desenvolvimento futuro de doencas cronicas.

Avaliação antropométrica, fatores de risco para desnutrição e medidas de apoio nutricional em crianças internadas em hospitais de ensino no Brasil

OBJECTIVE: To evaluate risk factors for malnutrition, nutritional status and nutritional support provided in hospitalized children. METHODS: This longitudinal study prospectively followed, for 3 consecutive months, all children under 5 years of age (n = 907) hospitalized in general pediatric medical wards of 10 Brazilian university-based hospitals. For data collection, a standard questionnaire was used and nutritional condition was evaluated at hospital admission and discharge: weight-for-height, weight-for-age and height-for-age z score. RESULTS: Only 56.7% of the children had their nutritional classification documented in the medical record. At hospital admission, 16.3 and 30.0% of the children had moderate/severe malnutrition and low stature, respectively. Risk of malnutrition was associated with low birth weight and younger age. A high percentage of nutritional deficiencies was observed in the children analyzed, although childs nutritional condition and the adoption of appropriate nutritional therapy were not documented in the medical records of the malnourished children. CONCLUSION: These data underscore the importance of developing qualified hospital medical wards regarding diagnosis and therapeutic approach to malnutrition, based on the conduct guidelines already available in Brazil.

Lipodystrophy, lipid profile changes, and low serum retinol and carotenoid levels in children and adolescents with acquired immunodeficiency syndrome

OBJECTIVE To assess serum retinol and levels of carotenoids in children and adolescents with acquired immunodeficiency syndrome (AIDS) and to correlate low serum retinol and carotenoid levels with the presence of lipodystrophy, lipid profile changes, lipid peroxidation, and insulin resistance. METHODS A cross-sectional, controlled observational study was carried out with 30 children and adolescents with AIDS (mean age 9.1 y) receiving antiretroviral therapy (median length of treatment 28.4 mo), including 30 uninfected healthy controls matched for age and gender. Clinical and laboratory assessments were performed to determine nutritional status, presence of lipodystrophy, serum concentrations of retinol, beta-carotene, lycopene, lipid profile (high-density lipoprotein cholesterol, high-density lipoprotein cholesterol, triacylglycerols), lipid peroxidation (thiobarbituric acid-reactive substances), glycemia, and serum insulin (homeostasis model assessment for insulin resistance, cutoff point >3). Statistical analysis was done with chi-square test and Students t test. RESULTS Lipodystrophy was observed in 53.3% of patients with AIDS, and dyslipidemia was detected in 60% and 23% of subjects with human immunodeficiency virus and control subjects, respectively (P = 0.004). A higher prevalence of retinol deficiency (60% versus 26.7%, P = 0.009) and beta-carotene deficiency (23.3% versus 3.3%, P = 0.026) was found in the group with human immunodeficiency virus than in the control group. No correlation was found for low retinol and beta-carotene levels, changes in lipid and glucose metabolism, or lipodystrophy in children and adolescents with AIDS. CONCLUSION Despite the high frequency of dyslipidemia, lipodystrophy, and retinol and beta-carotene deficiencies, it was not possible to demonstrate a correlation of these findings with lipid peroxidation and insulin resistance. More studies are needed to investigate the causes of retinol and beta-carotene deficiencies in this population and the clinical consequences of these findings.

Inadequação do consumo alimentar de crianças e adolescentes com artrite idiopática juvenil e lúpus eritematoso sistêmico

OBJECTIVES: To evaluate the dietary intake of children and adolescents with juvenile idiopathic arthritis (JIA) and juvenile systemic lupus erythematosus (JSLE) using a 24-hour diet recall and relating it to the patients clinical and anthropometric characteristics and to the drugs used in their treatment. METHODS: By means of a cross-sectional study, we assessed the 24-hour diet recalls of outpatients. Their nutritional status was classified according to the CDC (2000). The computer program NutWin UNIFESP-EPM was used for food intake calculation. The Recommended Dietary Allowances and the Brazilian food pyramid were used for quantitative and qualitative analysis. RESULTS: Median age was 12 years for JIA patients and 16.5 years for JSLE patients. Among the JIA patients, 37.5% had active disease, and among the JSLE patients, 68.2% showed Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) > 4. Malnutrition was found in 8.3 and 4.5% of the JIA and JSLE patients, respectively, and obesity was present in 16.7 and 18.2%. For JIA patients, the excessive intake of energy, protein, and lipids was 12.5, 75, and 31.3%, respectively. For JSLE patients, the excessive intake of energy, protein, and lipids was 13.6, 86.4, and 36.4%, respectively. Low intake of iron, zinc, and vitamin A was found in 29.2 and 50, 87.5 and 86.4, and 87.5 and 95.2% of the JIA and JSLE patients, respectively. There was not a significant association between intake, disease activity, and nutritional status. CONCLUSION: Patients with rheumatic diseases have inadequate dietary intake. There is excessive intake of lipids and proteins and low intake of micronutrients.

Freqüência de síndrome metabólica em crianças e adolescentes com sobrepeso e obesidade

OBJETIVO: Avaliar a frequencia de sindrome metabolica em criancas e adolescentes com sobrepeso ou obesos, alem de relacionar a sua presenca com variaveis socioeconomicas, atividade fisica e risco cardiovascular familiar. METODOS: Por meio de estudo transversal, 59 pacientes com sobrepeso/obesidade, matriculados em ambulatorio universitario, foram avaliados entre janeiro de 2004 e junho de 2006. Coletaram-se os seguintes dados: nivel socioeconomico, escolaridade materna, risco cardiovascular familiar e atividade fisica. Utilizou-se o percentil do indice de massa corporea (IMC) para classificar a condicao nutricional. Considerou-se sindrome metabolica quando presentes tres ou mais das seguintes alteracoes: triglicerides (>110mg/dL), HDL-c ( percentil 90), resistencia insulinica (glicemia >100mg/dL) e pressao arterial (> percentil 90). A analise estatistica foi descritiva. RESULTADOS: Dos pacientes, 52,5% eram do genero masculino e a media de idade foi 10,9±0,5 anos. A sindrome metabolica esteve presente em 42,4%. Inadequacoes das variaveis que compoem a sindrome metabolica foram observadas em 88,1% para a circunferencia abdominal; 47,5% com hipertensao arterial; 23,7% com resistencia insulinica; 42,4% com aumento dos triglicerides e 6,8% com elevacao do HDL-c. Nao se observou associacao estatisticamente significante entre sindrome metabolica e genero, idade, desenvolvimento puberal, renda per capita, escolaridade materna, horas de televisao/dia, horas de atividade fisica ou risco cardiovascular familiar. CONCLUSOES: E alta a prevalencia de sindrome metabolica em criancas e adolescentes obesos avaliados e, dentre os seus componentes, a circunferencia abdominal e a pressao arterial elevadas sao as mais frequentes.

Homocysteine and cysteine levels in prepubertal children: Association with waist circumference and lipid profile

OBJECTIVE To evaluate homocysteine and total cysteine levels in prepubertal children and to determine the association between these levels and obesity, increased waist circumference, glucose levels, and lipid profile alterations. METHODS Using a cross-sectional study, 677 prepubertal students 6 to 11 y old were assessed. The weight, height, and waist circumference of the students were measured. Laboratory analyses included triacylglycerols, total cholesterol and its fractions, glucose, vitamin B12, folate, homocysteine, and cysteine. Chi-square tests and logistic regression (forward-stepwise) were used for statistical analysis; the significance level was set at 5%. RESULTS The median age of the students was 8.9 y (6.5-11.5), and the prevalences of overweight and obesity were 90 in 677 (13.3%) and 81 in 677 (12.0%), respectively. An increase in waist circumference was observed in 180 of 677 children (26.6%). Inadequate levels of low-density lipoprotein cholesterol, triacylglycerols, and high-density lipoprotein cholesterol were found in 95 (14.0%), 129 (19.1%), and 179 (26.4%) of the 677 students, respectively. The median homocysteine and total cysteine plasma levels were 5.6 μmol/L (0.1-11.7) and 365.7 μmol/L (191.5-589.2), respectively. A multivariate analysis showed that children with a waist circumference above the 90th percentile (7.3 μmol/L) were 2.4 times (95% confidence interval 1.4-4.0) more likely to have increased homocysteine levels and that children with increased waist circumferences and those with high low-density lipoprotein cholesterol levels were 2.7 (95% confidence interval 1.6-4.6) and 2.1 (95% confidence interval 1.1-4.0) times more likely, respectively, to have total cysteine levels above the 90th percentile (445.0 μmol/L). CONCLUSION The association of abdominal obesity in prepuberty with levels of homocysteine and cysteine found in this study of a prepubertal population could be an early and independent predictor of cardiovascular risk.

Influência do índice de massa corporal e da circunferência abdominal na pressão arterial sistêmica de crianças

OBJETIVO: Avaliar os niveis pressoricos em criancas e relaciona-los ao indice de massa corporal e a circunferencia abdominal. METODOS: Por meio de estudo prospectivo e transversal, avaliaram-se 1.408 escolares com idade entre cinco anos e dez anos e 11 meses, matriculados em escolas publicas do Municipio de Santo Andre. Foram coletados: peso ao nascer; peso e estatura, expressos como escore Z do indice de massa corporal (ZIMC) e estatura para idade (ZEI). A pressao arterial (medida unica) foi aferida pelo mesmo examinador. Considerou-se: desnutricao quando ZIMC +2, baixa estatura se ZEI P90 para sexo e idade) e pressao arterial elevada quando superior ao percentil 90 para sexo, idade e estatura. A analise estatistica incluiu o teste do qui-quadrado e o calculo da Odds Ratio, adotando-se como significante o valor de p<0,05. RESULTADOS: A mediana de idade foi de sete anos, sendo 51% do sexo feminino. Niveis elevados foram encontrados em 19 e 12% dos escolares para a pressao arterial sistolica e diastolica, respectivamente. Verificaram-se: baixa estatura, desnutricao, obesidade e aumento da circunferencia abdominal em 2,6%, 3,1%, 7,3% e 13,4% da amostra, respectivamente. A presenca de obesidade foi o fator mais fortemente associado ao aumento de pressao arterial sistolica (OR 2,1; IC95% 1,3-3,3; p<0,001) e diastolica (OR 2,6; IC95% 1,6-4,3; p<0,001). A circunferencia abdominal tambem se associou com pressao arterial sistolica elevada (OR 1,6; IC95% 1,0-2,5; p=0,027). CONCLUSOES: A pressao arterial sistemica elevada em criancas associa-se a obesidade e ao aumento da circunferencia abdominal.

Tratamento da desnutrição em crianças hospitalizadas em São Paulo

AIM:To study anthropometric development, nutritional support and mortality rate of malnourished children hospitalized in a referral center METHODS: In a retrospective study we surveyed 98 hospitalized malnourished children (ZW<-2) with no chronic disease. Data collected was: birth weight, gestational age, length of exclusive breast feeding, diagnosis at admission, formula used (type, delivery route and feeding tolerance) and length of stay. Weight and height were controlled at admission and discharge. To classify and evaluate nutritional rehabilitation we used the Z-score: weight-for-age (ZW), height-for-age (ZH), weight-for-height (ZW/H). The nutritional therapy used was based on the World Health Organization (WHO) guidelines, with minor modifications. All chosen formulas were industrialized: lactose-free polymeric formula (PLF) for children with diarrhea, low lactose polymeric formula (PLL) for children without diarrhea and cows milk hydrolysate (CMH) for sepsis or chronic diarrhea. At the rehabilitation phase, all children were given the PLL formula. STATISTICAL ANALYSIS: Students t and chi-square tests. RESULTS: The median of age and length of stay were 9.8 months and 17 days, respectively and the mortality rate was of 2%. Diarrhea and/or pneumonia were diagnosed at admission in 81.6% of the children. An improvement of 17.3 % ZW, 82.7 % ZH and 92.2 % ZW/H was observed. PLF was more frequently given at admission (47.4%) while CMH was given to only 7.4% of the children. Twenty-four percent of the children were tube fed and 5.1 % received parenteral nutrition. Tolerance of the initial formula was considered good in 66.7% of cases. CONCLUSIONS: The WHO guidelines were effective in the nutritional therapy of severely malnourished hospitalized children, resulting in good nutritional rehabilitation with low mortality rates.

Avaliação do hiperinsulinismo em amostra de crianças pré-puberes

OBJETIVOS: Determinar a relacao entre o indice de massa corporal (IMC), o homeostasis model assessment - insulin resistance (HOMA-IR) e a insulinemia. METODOS: Realizou-se um estudo observacional prospectivo transversal com 132 criancas pre-puberes em idade escolar e residentes no municipio de Santo Andre (SP). Fez-se a avaliacao antropometrica e a mensuracao da glicemia, da insulinemia e do indice HOMA-IR. RESULTADOS: Dentre as 132 criancas avaliadas, 78 eram meninas (59,1%) e 54 eram meninos (40,9%), com media de idade de 8,7 anos e media de IMC de 13,7 kg/m2. Observou-se uma associacao significativa e positiva entre HOMA-IR e IMC, insulina e IMC, peso e HOMA e entre insulina e peso; tambem foi constatado que, quanto maior for o IMC, maior sera o valor de HOMA. CONCLUSOES: Os resultados do presente estudo permitem concluir que ha uma forte associacao entre o hiperinsulinismo e a obesidade, devendo ser tomadas algumas medidas para evitar o ganho de peso durante a infância e a adolescencia.

Lipodystrophy in children and adolescents with acquired immunodeficiency syndrome and its relationship with the antiretroviral therapy employed.

OBJECTIVE To evaluate the presence of clinical lipodystrophy in children with the acquired immunodeficiency syndrome and to relate it to the antiretroviral regimen employed, to changes in lipid profile and to insulin resistance. METHODS This was a cross-sectional study that evaluated 30 children and adolescents (median age = 9.1 years) with the acquired immunodeficiency syndrome during 2004 and 2005. The following clinical and laboratory evaluations were performed: classification of HIV infection, anthropometric measurements (weight and height), serum glycemia, serum insulin and lipid profile (LDL-c, HDL-c, triglycerides). Lipodystrophy was diagnosed using clinical parameters. The chi-square test was used for statistical analysis. RESULTS All of the patients were taking antiretroviral therapy regularly (median duration of 28.4 months); 80% were on three drugs in combination (highly active therapy) and 30% were on protease inhibitors. Lipodystrophy and dyslipidemia were observed in 53.3 and 60% of the patients, respectively. Children on a highly active therapy regimen with protease inhibitors exhibited a higher percentage of mixed lipodystrophy; the difference between these children and the group on highly active therapy without protease inhibitors and the group not on a highly active therapy was statistically significant (44.4 vs. 16.7%; p = 0.004). There was no statistically significant association between the presence of lipodystrophy and sex, age (> 10 years), changes to the lipid profile or insulin resistance. CONCLUSIONS The elevated prevalence of dyslipidemia and lipodystrophy observed among children with acquired immunodeficiency syndrome, which exhibited a relationship with the antiretroviral regimen employed, may represent an increased risk for future complications, in particular cardiovascular problems.