Maria de Lourdes Drachler

Impacts of the 10 Steps to Healthy Feeding in Infants: a randomized field trial

This study assesses the impact of an intervention known as the Ten Steps to Healthy Feeding: A Nutritional Guide for Children under Two on nutritional conditions and infant health in low-income families. Two hundred newborns were randomized to the intervention group and three hundred to the control group. Parents of the intervention group received nutritional orientation during the childs first year of life. Both groups received visits at 6 and 12 months and routine follow-up by their pediatricians. The results (n = 397) showed that the intervention was associated with a higher proportion of exclusive breastfeeding at 4 months (RR = 1.58; 95%CI: 1.21-2.06) and 6 months (RR = 2.34; 95%CI: 1.37-3.99) and breastfeeding at 12 months (RR = 1.26; 95%CI: 1.02-1.55) and a lower proportion of children with diarrhea (RR = 0.68; 95%CI: 0.51-0.90), respiratory problems (RR = 0.63; 95%CI: 0.46-0.85), use of medication (RR = 0.56; 95%CI: 0.34-0.91), and dental caries (RR = 0.56; 95%CI: 0.32-0.96) in the 12-16 month bracket. The intervention had no effect on the occurrence of anemia, hospitalization, or nutritional status. The results suggest that the nutritional orientation program led to positive changes in infant feeding practices and health conditions, but that it was insufficient to prevent iron deficiency anemia.

Prevalence of myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) in three regions of England: a repeated cross-sectional study in primary care

BackgroundMyalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) or chronic fatigue syndrome (CFS) has been used to name a range of chronic conditions characterized by extreme fatigue and other disabling symptoms. Attempts to estimate the burden of disease have been limited by selection bias, and by lack of diagnostic biomarkers and of agreed reproducible case definitions. We estimated the prevalence and incidence of ME/CFS in three regions in England, and discussed the implications of frequency statistics and the use of different case definitions for health and social care planning and for research.MethodsWe compared the clinical presentation, prevalence and incidence of ME/CFS based on a sample of 143,000 individuals aged 18 to 64 years, covered by primary care services in three regions of England. Case ascertainment involved: 1) electronic search for chronic fatigue cases; 2) direct questioning of general practitioners (GPs) on cases not previously identified by the search; and 3) clinical review of identified cases according to CDC-1994, Canadian and Epidemiological Case (ECD) Definitions. This enabled the identification of cases with high validity.ResultsThe estimated minimum prevalence rate of ME/CFS was 0.2% for cases meeting any of the study case definitions, 0.19% for the CDC-1994 definition, 0.11% for the Canadian definition and 0.03% for the ECD. The overall estimated minimal yearly incidence was 0.015%. The highest rates were found in London and the lowest in East Yorkshire. All but one of the cases conforming to the Canadian criteria also met the CDC-1994 criteria, however presented higher prevalence and severity of symptoms.ConclusionsME/CFS is not uncommon in England and represents a significant burden to patients and society. The number of people with chronic fatigue who do not meet specific criteria for ME/CFS is higher still. Both groups have high levels of need for service provision, including health and social care. We suggest combining the use of both the CDC-1994 and Canadian criteria for ascertainment of ME/CFS cases, alongside careful clinical phenotyping of study participants. This combination if used systematically will enable international comparisons, minimization of bias, and the identification and investigation of distinct sub-groups of patients with possibly distinct aetiologies and pathophysiologies, standing a better chance of translation into effective specific treatments.

Alguns fatores associados a excesso de peso, baixa estatura e déficit de peso em menores de 5 anos

OBJECTIVE To explore whether socioeconomic and sanitary conditions, maternal and child factors are associated with overweight, stunting, and wasting in children under five year old in the city of São Leopoldo, southern Brazil. METHODS Cross-sectional study of 3,957 children aged 1 month to 5 years conducted in all primary care services of the city during the National Childrens Vaccination Day in 2002. Maternal and child factors were assessed by a questionnaire. Childrens height and weight were measured. Cluster analysis was used to group the areas served by the primary care services according to socioeconomic and sanitary conditions of the census tracts assessed by the 2001 National Census. RESULTS Wasting was observed in 2.6% of children, stunting in 9.1% and overweight in 9.8%. The multivariable logistic regression model suggests that overweight was associated with higher socioeconomic status and better sanitation of the area (OR = 1.47; 95%CI 1.09-1.96), single child (OR = 1.44; 95%CI 1.00-2.07) and birth weight >or= 2,500 g (OR = 2.21; 95%CI 1.27-3.83). Wasting was associated with low birth weight (OR = 3.46; 95%CI 2.06-5.80) and mothers age < 20 years (OR = 1.99; 95%CI 1.09-3.62). Stunting was associated with low socioeconomic status and poor sanitation of the area (OR = 2.36; 95%CI 1.51-3.69), three or more siblings (OR = 3.12; 95%CI 2.18-4.47), low birth weight < 2,500 g (OR = 3.49; 95%CI 2.53-4.80), child age < 36 months (OR = 1.77; 95%CI 1.37-2.29) and mothers age < 20 years (OR = 1.60; 95%CI 1.09-2.35). CONCLUSIONS Overweight and stunting were the major anthropometric problems and therefore should be a priority for public policies.

Desigualdade social nas taxas de cesariana em primíparas no Rio Grande do Sul

OBJECTIVE To investigate the effect of social inequalities in cesarean section rates among primiparae having single pregnancy and delivering in maternity hospitals. METHODS The study was carried out in Southern Brazil in 1996, 1998 and 2000. Data from the Live Birth National Information System were used to estimate annual rates and crude and adjusted odds ratios (OR) of cesarean sections according to social conditions (maternal age and education, newborn skin color/ethnicity and macro-regions), duration of pregnancy, and number of prenatal visits. RESULTS The overall cesarean section rate was 45%, and above 37% in all macro-regions. Increased rates were seen among native and black mothers, aged 30 years or more, living in metropolitan, river valley and mountain macro-regions and having attended to more than six prenatal visits. Crude and adjusted OR show that cesarean rates were negatively associated with all categories of skin color/ethnicity when compared to white newborns, particularly those of native Brazilian (ORadj=0.43; 95% CI: 0.31-0.59), and they were positively associated with higher maternal education (ORadj=3.52; 95% CI: 3.11-3.99), older age (ORadj=6.87; 95% CI: 5.90-8.00) and greater number of prenatal visits (ORadj=2.16; 95% CI: 1.99-2.35). The effects of age and education were partly mediated by the greater number of prenatal visits among higher educated older women. The OR varied among macro-regions but were greater for the wealthier mountain region. CONCLUSIONS High rates of cesarean section rates in Southern Brazil are a public health concern. They are associated with social, economic and cultural factors which can lead to misuse of medical technology during labor and delivery.

Proposta de metodologia para selecionar indicadores de desigualdade em saúde visando definir prioridades de políticas públicas no Brasil

Promover a saude com equidade e um grande desafio para os gestores publicos. A magnitude das desigualdades sociais em saude e os recursos escassos impoem que as prioridades para a gestao publica se fundamentem no conhecimento da situacao de saude e do impacto de politicas, programas, projetos e acoes sobre a saude e seus determinantes. Este artigo apresenta a proposta metodologica de construcao e selecao de indicadores de desigualdades em saude utilizada pela Pesquisa Avaliativa de Desigualdades em Saude no Rio Grande do Sul (PADS-RS) para auxiliar a definicao de prioridades para a gestao publica. Os indicadores foram construidos visando avaliar desigualdades em saude como diferencas na qualidade de vida e capacidades humanas socialmente determinadas. A metodologia baseia-se em principios de promocao ativa da equidade que orientam (1) o Sistema Unico de Saude Brasileiro, (2) as pesquisas avaliativas de desigualdades em saude realizadas no Reino Unido e (3) o metodo RAWP (Resources Allocation Working Party) de alocacao de recursos financeiros publicos em saude entre regioes e considera as peculiaridades dos sistemas oficiais de informacao no Estado e no Brasil.

Nutritional status and social determinants of child height in the Guarita Indigenous Territory, Southern Brazil

The nutritional status of under-five children and the association between social conditions and child stature were examined using data from the program to control malnutrition and mortality in the Guarita Indigenous Territory, southern Brazil, 2001-2002. Anthropometric indices were calculated in z-scores of the CDC 2000 reference. At entrance into the program, 34.7% of the children presented stunting, 12.9% low weight for age, 4.2% wasting, and 8.7% overweight. Stunting was most prevalent among boys and children older than one year. Multivariate linear regression showed that, on average, children were shorter when the drinking water was collected directly in the environment (p = 0.046), there was no refrigerator for food preservation (p = 0.021), maternal age was less than 16 years at the birth of the oldest child among the under-fives (p = 0.019), and the mother was illiterate (p = 0.083). Sewage facilities only had an effect on the unadjusted model. There was no evidence that the number of under-five children had an effect on stature. Social inclusion policies and health and social provision which takes these factors into account are potentially relevant for improving health and nutrition in this population.

Inequalities in cesarean delivery rates by ethnicity and hospital accessibility in Brazil

To investigate inequalities in cesarean delivery rates in Brazil according to ethnic group and level of access to hospital delivery.

Depressão e suas implicações no aleitamento materno

OBJECTIVE: This study aimed at verifying the incidence of depressive symptoms in a group of mothers of children between 12 and 16 months in the municipality of Sao Leopoldo (RS, Brazil) and their associations with breast feeding and overall child development. METHOD: This study included 263 mothers who delivered at a hospital providing services to a population of low socioeconomic level. Depressive symptoms were assessed using Beck Depression Inventory. RESULTS: It was observed that 35.7% of mothers presented depressive symptoms. As to classification, 18.3% had mild, 11% moderate and 6.5% severe depression. Mothers without partners (prevalence ratio - PR = 1.70; IC95% = 1.20-2.38) and mothers from non-nuclear families presented more depressive symptoms (PR = 1.38; IC95% = 0.99-1.92). Exclusive breast feeding at 6 (PR = 1.86; IC95% = 0.94-3.68) and 12 months (PR = 1.80; IC95% = 1.26-2.58) was more frequent in the group of mothers without depressive symptoms. CONCLUSION: More attention should be given to womens mental health, considering the high prevalence of depressive symptoms in this population and the strong association with less breastfeeding time.

Social inequalities in maternal opinion of child development in southern Brazil.

AIMS AND METHODS Concurrent validity of maternal opinion of child development was estimated in a cross-sectional, population-based survey of 6-59-mo children (n=3025), using a standard measure devised from the Denver Developmental Screening Test. RESULTS Sensitivity, specificity and negative predictive value increased with maternal education and family income. Positive predictive value was higher in low-income families and children with impairments, low birthweight and long hospital stays. CONCLUSION Children at social and clinical risk should be assessed more carefully, even if maternal report is normal or advanced.

A Disease Register for ME/CFS: Report of a Pilot Study

BackgroundThe ME/CFS Disease Register is one of six subprojects within the National ME/CFS Observatory, a research programme funded by the Big Lottery Fund and sponsored by Action for ME. A pilot study in East Anglia, East Yorkshire, and London aimed to address the problem of identifying representative groups of subjects for research, in order to be able to draw conclusions applicable to the whole ME/CFS population.While not aiming for comprehensive population coverage, this pilot register sought to recruit participants with ME/CFS in an unbiased way from a large population base. Those recruited are constituting a cohort for long-term follow-up to shed light on prognosis, and a sampling frame for other studies.FindingsPatients with unidentified chronic fatigue were identified in GP databases using a READ-code based algorithm, and conformity to certain case definitions for ME/CFS determined. 29 practices, covering a population aged 18 to 64 of 143,153, participated.510 patients with unexplained chronic fatigue were identified. 265 of these conformed to one or more case definitions. 216 were invited to join the register; 160 agreed. 96.9% of participants conformed to the CDC 1994 (Fukuda) definition; the Canadian definition defined more precisely a subset of these. The addition of an epidemiological case definition increased case ascertainment by approximately 4%. A small-scale study in a specialist referral service in East Anglia was also undertaken.There was little difference in pattern of conformity to case definitions, age or sex among disease register participants compared with subjects in a parallel epidemiological study who declined to participate.One-year follow-up of 50 subjects showed little change in pain or fatigue scores. There were some changes in conformity to case definitions.ConclusionsObjective evaluation indicated that the aim of recruiting participants with ME/CFS to a Disease Register had been fulfilled, and confirmed the feasibility of our approach to case identification, data processing, transmission, storage, and analysis. Future developments should include expansion of the ME/CFS Register and its linkage to a tissue sample bank and post mortem tissue archive, to facilitate support for further research studies.