Pedro Israel Cabral de Lira

Comparison of the effect of two systems for the promotion of exclusive breastfeeding

BACKGROUND Promotion of breastfeeding is an important child-survival intervention, yet little is known about which promotional strategies are the most effective. We aimed to compare the effects on rates of breastfeeding of two systems for promotion of breastfeeding in Brazil--a hospital-based system and the same system combined with a programme of home visits. METHODS In February, 2001, maternity staff from two hospitals in Pernambuco, Brazil, were trained according to the Baby-Friendly Hospital Initiative (BFHI). In a randomised trial between March and August, 2001, 350 mothers giving birth at these hospitals were assigned ten postnatal home visits to promote and support breastfeeding (n=175) or no home visits (n=175). Breastfeeding practices were studied on days 1, 10, 30, 60, 90, 120, 150, and 180 by researchers unaware of group allocation. The primary outcome measure was the rate of exclusive breastfeeding from birth to 6 months. Analyses were by intention to treat. FINDINGS The hospital-training intervention achieved a high rate (70%) of exclusive breastfeeding in the hospitals, but this rate was not sustained at home and at 10 days of age only 30% of infants were exclusively breastfed The patterns of exclusive breastfeeding in the two trial groups for days 10-180 differed significantly (p<0.0001), with a mean aggregated prevalence of 45% among the group assigned home visits compared with 13% for the group assigned none. INTERPRETATION The BFHI achieves high rates of exclusive breastfeeding in hospital; however, in Brazil at least, the rates fall rapidly thereafter. Reliance on the BFHI as a strategy for breastfeeding promotion should be reassessed. A combination of promotional systems (hospital-based and in the community) is needed.

Efficacy of Bifidobacterium breve and Lactobacillus casei oral supplementation on necrotizing enterocolitis in very-low-birth-weight preterm infants: a double-blind, randomized, controlled trial

BACKGROUND Probiotics are used for the prevention of necrotizing enterocolitis (NEC) because of their positive effects on intestinal motor function, modulation of inflammatory response, and mucosal barrier function. OBJECTIVE The objective was to assess whether the combined use of Lactobacillus casei and Bifidobacterium breve may prevent the occurrence of NEC stage ≥ 2 by the criteria of Bell in very-low-birth-weight preterm infants. DESIGN A double-blind, randomized, controlled clinical trial was conducted in 231 preterm infants weighing from 750 to 1499 g at birth. The intervention group was composed of 119 infants who received human milk with probiotic supplementation (B. breve and L. casei) and a control group of 112 infants who received human milk containing no probiotics. The primary outcome was the occurrence of NEC stage ≥ 2 as defined by Bells modified criteria. RESULTS Four confirmed cases of NEC stage ≥ 2 by Bells criteria occurred only in the control group. CONCLUSIONS Oral supplementation of B. breve and L. casei reduced the occurrence of NEC (Bells stage ≥ 2). It was considered that an improvement in intestinal motility might have contributed to this result. This trial was registered at www.isrctin.org as number 67165178 (International Standard Randomized Controlled Trial).

Prevalence of anemia in children 6-59 months old in the state of Pernambuco, Brazil

OBJECTIVE To determine the prevalence of anemia in children 6-59 months old in Pernambuco, a state in northeastern Brazil, so as to help guide health and nutrition policies there. METHODS In 1997 a representative sample of 777 young children had their hemoglobin concentration measured. The sampling process was in three stages. First, 18 municipalities were randomly selected to represent the state and its three geographic areas (metropolitan region of Recife, urban interior, and rural interior). Next, using census lists, 45 census sectors were randomly chosen. Finally, 777 children aged 6-59 months old were selected. Blood was collected by venipuncture, and hemoglobin was measured with a portable hemoglobinometer. In the analysis, prevalence was weighted to reflect the census age distribution. RESULTS The prevalence of anemia among children 6-59 months old was 40.9% for the state as a whole. Prevalence in the metropolitan region of Recife was 39.6%, and it was 35.9% in the urban interior. The rural interior had the highest prevalence, 51.4%. Prevalence was twice as high in children aged 6-23 months as among those 24-59 months old, 61.8% vs. 31.0% (chi 2 = 77.9, P < 0.001). The mean hemoglobin concentrations in the younger and older age groups were 10.4 g/dL (standard deviation (SD) = 1.5) and 11.4 g/dL (SD = 1.4), respectively. There was no statistically significant difference between the sexes in terms of prevalence. CONCLUSIONS This is the first statewide assessment of anemia prevalence among young children in Brazil. Given the very high prevalence of anemia among the children studied in Pernambuco, especially those in the age group of 6-23 months, public health interventions are needed.

Efeito terapêutico da música em crianças em pós-operatório de cirurgia cardíaca

OBJETIVO: Verificar de forma objetiva e subjetiva o efeito da musica em criancas no pos-operatorio de cirurgia cardiaca em uma unidade de terapia intensiva cardiopediatrica, em conjunto com acoes da pratica convencional. METODOS: Ensaio clinico aleatorizado por placebo, no qual foram avaliadas 84 criancas, com faixa etaria de 1 dia a 16 anos, nas primeiras 24 horas de pos-operatorio, submetidas a sessao de 30 minutos de musicoterapia, utilizando musica classica e observadas no inicio e fim das sessoes quanto as seguintes variaveis: frequencia cardiaca, pressao arterial, pressao arterial media, frequencia respiratoria, temperatura, saturacao de oxigenio, alem de uma escala facial de dor. Foi considerado o nivel de significância estatistica de 5%. RESULTADOS: Dos 84 pacientes iniciais, cinco (5,9%) recusaram participar do estudo. O grupo de cardiopatias mais comum foi o de congenitas acianogenicas com shunt E-D (41% intervencao: 44,4% controle). Quanto a avaliacao subjetiva atraves da escala facial de dor e objetiva das frequencias cardiaca e respiratoria, observou-se diferenca estatisticamente significante entre os dois grupos apos a intervencao (p < 0,001, p = 0,04 e p = 0,02, respectivamente). CONCLUSOES: Observou-se neste estudo uma acao benefica da musica em criancas no pos-operatorio de cirurgia cardiaca, atraves de alguns sinais vitais (frequencias cardiaca e respiratoria) e na reducao da dor (escala facial de dor). Contudo, existem lacunas a serem preenchidas nesta area, necessitando a realizacao de estudos mais aprofundados.OBJECTIVE To investigate, both objectively and subjectively, the effect of music on children in a pediatric cardiac intensive care unit following heart surgery, in conjunction with standard care. METHODS Randomized clinical trial with placebo, assessing 84 children, aged 1 day to 16 years, during the first 24 hours of the postoperative period, given a 30 minute music therapy session with classical music and observed at the start and end of the session, recording heart rate, blood pressure, mean blood pressure, respiratory rate, temperature and oxygen saturation, plus a facial pain score. Statistical significance was set at 5%. RESULTS Five of the initial 84 patients (5.9%) refused to participate. The most common type of heart disease was acyanotic congenital with left-right shunt (41% of cases: 44.4% of controls). Statistically significant differences were observed between the two groups after the intervention in the subjective facial pain scale and the objective parameters heart rate and respiratory rate (p < 0.001, p = 0.04 and p = 0.02, respectively). CONCLUSIONS A beneficial effect from music was observed with children during the postoperative period of heart surgery, by means of certain vital signs (heart rate and respiratory rate) and in reduced pain (facial pain scale). Nevertheless, there are gaps to be filled in this area, and studies in greater depth are needed.

Factors associated with Hb concentration in children aged 6-59 months in the State of Pernambuco, Brazil

In 1997, the prevalence of anaemia was 40.9 % among children aged 6-59 months in the State of Pernambuco, north-east Brazil. Using the same sample of children, we have investigated possible reasons for this high prevalence. A representative sample was selected through a three-stage process: proportional systematic random sampling of municipalities in the State, systematic random sampling of census sectors within these municipalities, and finally, simple random sampling of households with children aged 6-59 months to obtain the sample of 650 children. Data collection included demographic, environmental, socio-economic and maternal variables, and nutritional status and dietary intakes of the children. Multiple linear regression analysis was based on a hierarchical model of factors associated with Hb concentration. The mean Hb concentration of children aged 6-23 months was 10 g/l lower than that of older children. In the regression analysis, child age explained 8.3 % of the variance in Hb concentration. The intake of bioavailable Fe explained a further 3.3, serum retinol 2.7, diarrhoea 2.4, water treatment 1.7, sanitation 1.3 and low birth-weight 0.5 %. The final model explained 23.4 % of the variance in Hb concentration. We conclude that child age, bioavailable-Fe intake, serum retinol concentration, diarrhoea, water treatment, sanitation and low birth-weight are independently associated with Hb concentration. In north-east Brazil, anaemia prevention programmes among children should focus on those aged <2 years and should consider feasible strategies to improve intakes of bioavailable Fe and vitamin A, and reduce infection. Supplemental Fe should be given to low birth-weight infants.

Fatores determinantes do crescimento infantil

This review focuses on factors interfering with growth during the first years of life. Information was collected from articles published in indexed scientific journals, theses, technical books and publications of international organizations. Infant growth is one of the best health indicators, and linear growth retardation is currently the most representative anthropometric characteristic of child nutrition epidemiology in Brazil. The review indicates the value of genetics in growth, focusing, however on the influence of the extrinsic factors. Growth process results from interaction between genetic and environmental factors, determining variation in genetic potential manifestations. Because of the complex nature of infant growth, several studies have been developed aiming at relating biological, socio-economic, maternal, environmental, cultural, demographic and nutritional determinants among others, with the etiology, development and maintenance of growth. This review reinforces the value of permanent investigation on infant growth, especially concerning the long term impact on infant health.

Low birth weight and morbidity from diarrhea and respiratory infection in northeast Brazil

OBJECTIVE To compare morbidity and mortality rates of low birth weight (LBW) and appropriate birth weight infants born at term, focusing on diarrheal and respiratory infections. STUDY DESIGN A cohort of 133 LBW infants (1500 to 2499 gm) and 260 appropriate birth weight infants (3000 to 3499 gm), individually matched by sex and season of birth, were followed for the first 6 months of life. None had congenital anomalies and all were from poor families living in the interior of Pernambuco, northeast Brazil. Data on infant deaths, hospitalizations, and morbidity were collected prospectively through daily home visits (except Sundays) from birth through week 8, then twice weekly for weeks 9 to 26. The effects of birth weight were assessed with a variety of multivariable techniques, controlling for confounders. RESULTS Of the LBW infants, 56% were wasted (thin), 23% were stunted, and 17% were both wasted and stunted. The LBW infants (median 2380 gm) experienced a sevenfold higher mortality rate and fourfold higher rate of hospitalization than appropriate birth weight infants. Almost all deaths and hospitalizations were in the postneonatal period. The LBW infants also experienced 33% more days with diarrhea and 32% more days with vomiting (p = 0.003 in each case). The prevalences of cough and fever were not significantly different. CONCLUSIONS Infant deaths, hospitalizations, and diarrheal morbidity are increased in term LBW infants who have only a modest weight deficit.

Does birth weight affect nutritional status at the end of first year of life

OBJECTIVE To evaluate the association between low birth weight and nutritional status at the end of the first year of life. METHODS This was a nested case-control study within a cohort. The study was carried out at maternity hospitals in four cities in the Zona da Mata Meridional in Pernambuco state, Brazil. Newborn infants were recruited during the first 24 hours of life. Their weights were measured at birth and at the end of the first year of life. Household visits were made twice weekly during the first year of life to collect data on breastfeeding and occurrence of diarrhea. In the case-control study, each case (child at nutritional risk) was a child with weight-for-age index < the 10th percentile (n = 117) and each control was a child with weight-for-age index > or = the 10th percentile (n = 411). Hierarchical logistic regression analysis was used to investigate risk factors for nutritional status at 12 months. RESULTS Low birth weight and living in a household with no latrine were significantly associated with nutritional risk at the end of the first year of life. Children born weighing 1,500 g to 2,499 g had 29 times (95% CI = 9.77-87.49) the chance of being at nutritional risk at 12 months of life than those whose birth weights had been > 3,500 g (p < 0.001). Children living in households without a flush toilet had three times (95% CI = 1.54-6.22) the chance of nutritional risk at 12 months of life in relation to those that had a latrine with a septic tank at home (p = 0.01). CONCLUSION Low birth weight is an important risk factor of nutritional risk at the end of the first year of life. It is important to adopt strategies for its reduction and prevention.

Desenvolvimento mental e motor aos 24 meses de crianças nascidas a termo com baixo peso

The objective of this study was to compare the development at 24 months of 152 full-term infants, born with low (<2500g) and appropriate birth weight (3000 to 3499g), paired in a proportion of 1:1 by sex and age. Mental and motor development were assessed through the Bayley scale. A variety of sociodemographic and environmental stimulation conditions were also assessed. The infants born with low weight had on average significantly lower mental and motor indexes than those born with appropriate weight (p<0.001), with a difference of 9.1 and 10.2 points, respectively. The multiple linear regression analysis showed that socioeconomic conditions and environmental stimulation explained 11% and 12% of the variation of mental index, and 12% and 9% of motor development, respectively. All together, they explained 23% and 21% of the variation of these indexes. Low birth weight influenced only 3% of the variation of mental index and 5% of motor index.

Determinants of mental and motor development at 12 months in a low income population: a cohort study in northeast Brazil.

Aim: To identify biological and environmental factors associated with poorer mental and motor development at age 12 mo in urban communities in northeast Brazil. Methods: A cohort of 245 infants born during January‐August 1998 in six hospitals in the interior of Pernambuco was followed twice weekly from birth until 12 mo of age. Socio‐economic, demographic and environmental data were collected, together with daily information on morbidity and feeding patterns. Gestational age, birth anthropometry and nutritional status at 12 mo were measured. Multiple linear regression analysis was used to identify variables that had independent effects on mental and motor development assessed at 12 mo of age with the Bayley Scales of Infant Development. Results: Environmental factors explained about 21% and 19% of the variance in mental and motor development, respectively. Of these, the most important were poverty‐related. Significant biological factors associated with mental development were birthweight and infant sex. For motor development, the biological factors were weight‐for‐age and haemoglobin concentration. Biological factors explained only 6% and 5% of the variance in mental and motor development, respectively.