Ricardo Halpern

Fatores de risco para mortalidade perinatal em Pelotas, RS, 1993

INTRODUCTION Although there was a considerable reduction in infant mortality in Pelotas, Rio Grande do Sul in the last decade, its perinatal causes were reduced only by 28%. The associated factors of these causes were analysed. MATERIAL AND METHOD All hospital births and perinatal deaths were assessed by daily visits to all the maternity hospitals in the city, throughout 1993 and including the first week of 1994. RESULTS The perinatal mortality rate was 22.1 per thousand births. The multivariate analysis showed the following risk factors: low socioeconomic level, male sex and maternal age above 35 years. Among multigravidae women, the fetal mortality rate was significantly increased for mothers with a previously low birthweight and a previous stillbirth. For early neonatal mortality the risk was significantly increased by a smaller number of antenatal visits than 5 and low birthweight. CONCLUSIONS Main risk factors for perinatal mortality: low socioeconomic level, maternal age above 35 years and male sex. For early neonatal mortality the risk was significantly increased by a smaller number of antenatal visits than 5 and low birthweight.INTRODUCTION: Although there was a considerable reduction in infant mortality in Pelotas, Rio Grande do Sul in the last decade, its perinatal causes were reduced only by 28%. The associated factors of these causes were analised. MATERIAL AND METHOD: All hospital births and perinatal deaths were assessed by daily visits to all the maternity hospitals in the city, throughout 1993 and including the first week of 1994. RESULTS: The perinatal mortality rate was 22.1 per thousand births. The multivariate analysis showed the following risk factors: low socioeconomic level, male sex and maternal age above 35 years . Among multigravidae women, the fetal mortality rate was significantly increased for mothers with a previously low birthweight and a previous stillbirth. For early neonatal mortality the risk was significantly increased by a smaller number of antenatal visits than 5 and low birthweight. CONCLUSIONS: Main risk factors for perinatal mortality: low socioeconomic level, maternal age above 35 years and male sex. For early neonatal mortality the risk was significantly increased by a smaller number of antenatal visits than 5 and low birthweight.

Baixo peso ao nascer em duas coortes de base populacional no Sul do Brasil

As criancas com baixo peso ao nascer (menos de 2.500 g) apresentam um risco muitas vezes maior de morrer ou adoecer no primeiro ano de vida. O presente estudo teve como objetivo comparar a ocorrencia de baixo peso ao nascer, nascimento pre-termo e retardo de crescimento intra-uterino, nos anos de 1982 e 1993, em Pelotas, Rio Grande do Sul. Nestes dois anos foram avaliados todos os nascimentos hospitalares, que representam mais de 99% do total dos nascimentos. O baixo peso ao nascer aumentou de 9,0% para 9,8% em 1993 (p=0,2), os nascimentos pre-termo aumentaram de 5,6% em 1982 para 7,5% em 1993 (p<0,01) e o retardo de crescimento intra-uterino passou de 15,0% em 1982 para 17,5% em 1993 (p<0,05). Nos dois periodos estudados, a renda familiar esteve inversamente associada com o risco de baixo peso e retardo de crescimento intra-uterino, mas nao com nascimentos pre-termo. Em 1993, apesar da melhoria nas condicoes socio-economicas e nutricionais das maes, como tambem do aumento no numero de consultas pre-natais, observou-se um crescimento na prevalencia de baixo peso ao nascer que nao foi significativa na analise bivariada. Entretanto, apos ajuste para possiveis variaveis de confusao, por meio de regressao logistica, houve um aumento no risco de baixo peso ao nascer da ordem de 33% (p<0,01).

Estudo longitudinal da população materno-infantil da região urbana do Sul do Brasil, 1993: aspectos metodológicos e resultados preliminares

All babies born in the hospitals of the city of Pelotas, Brazil, in 1982 were studied soon after delivery and followed up prospectively during the first years of their lives. In 1993, this study was repeated with a similar methodology, with the aim of assessing eventual changes in the level of maternal and child health. All five maternity hospitals in the city were visited daily and the 5,304 babies born included in the study. They were weighed and measured, and their gestational age was assessed using the Dubowitz method. Their mothers were examined and interviewed regarding a large number of risk factors. The mortality of these children was studied through the surveillance of all hospitals, cemeteries and death registries, and all hospital admissions were also recorded. Two nested case-control studies were carried out to assess risk factors for mortality and hospital morbidity. A systematic sample of 655 children were examined at home at one and three months of age, and these infants, as well as another sample of 805 children including all low-birthweight babies were also examined at the ages of six and twelve months. Their psychomotor development was also assessed. Losses to follow-up were only 6.6% at twelve months. Relative to the 1982 indicators, perinatal mortality fell by about 30% and infant mortality by almost 50%. The median duration of breastfeeding increased from 3.1 to 4.0 months. On the other hand, there was little change in the prevalences of low birthweight or of length for age at twelve months. The article that refers this abstract describes the methodology of the study and forthcoming publications will present detailed results.

Risk factors for suspicion of developmental delays at 12 months of age

OBJECTIVE: To investigate the prevalence of positive screening test for developmental delays in a cohort of children born in Pelotas, Brazil in 1993, and their risk factors. METHODOLOGY: A sample of 20% (1,363 children) of a cohort of children born in Pelotas, Brazil, was studied at 12 months of age regarding their development. The Denver II Test was used. The children who failed in two or more items of the test were suspected of having development delay. A set of independent variables was chosen taking into account the hierarchical relations between risk factors according to the conceptual framework (socioeconomic, reproductive and environmental, birth conditions, childreńs care, nutrition and morbidity). Analyses were performed using Mantel-Haenszel X2 and multivariate technique through conditional logistic regression, to control for possible confounding. RESULTS: At 12 months of age, 34% (463) of the total of 1,363 children failed in the screening test. After adjusting for possible confounding variables, failure was associated with family lower income children (OR= 1.5), very low birth weight (OR= 4.0), gestational age less than 37 weeks (OR= 1.6), more than three siblings (OR= 1.9), and duration of breastfeeding less than three months (OR=1.6), or no breastfeeding (OR= 1.9). Children who presented weight/age at six months of age less or equal to -2 z score of the reference population presented a risk 10 times greater of having failure in the Denver II Test. CONCLUSIONS: This study reinforces the multiple etiology of development delays and the concept of cumulative risk effect. In this population those who are economically disadvantaged accumulate risk factors (social, economic and environmental) that may render to deficits in their development.

Assistência médica materno-infantil em duas coortes de base populacional no Sul do Brasil: tendências e diferenciais

Two cohort studies of mothers and children (1982 and 1993) were used to document changes in health care utilization patterns. The cohorts included all hospital deliveries in the city of Pelotas, Southern Brazil, for the two years. Some 20% of the mothers and children were visited at home at a median interval of one year later. However, there was a reduction in the percentage of mothers seeking care after the fifth month of pregnancy. The mean number of prenatal consultations increased to 7.6. Prenatal care indicators were significantly worse for low-income and high-gestational-risk women. In 1993, caesarean sections accounted for 31% of deliveries. The proportions of deliveries assisted by medical doctors increased to 88%. Low-income and high-risk mothers were less likely to have a caesarean section or to be assisted by a medical doctor. Over half of the deliveries in the highest income group were caesareans. Vaccine coverage at 12 months increased over the decade. Socioeconomic differentials were also observed. The mean number of medical consultations during the first year of life decreased to 10.5, mainly due to a drop in preventive care. Although most health care indicators improved over the course of the decade, health services are still biased towards those who least need them.

Incidência e duração da amamentação conforme o tipo de parto: estudo longitudinal no Sul do Brasil

OBJETIVO: Comparar a incidencia de amamentacao conforme o tipo de parto. MATERIAL E METODO: Estudo de coorte prospectivo de base populacional com 655 criancas brasileiras nascidas no ano de 1993 e acompanhadas durante o primeiro trimestre de vida, atraves de duas visitas domiciliares. RESULTADOS: A duracao da amamentacao foi similar entre os nascidos por parto vaginal e cesariana emergencial. Os nascidos por cesariana eletiva apresentaram um risco tres vezes maior de interromper a lactacao no primeiro mes de vida, apos controle de fatores de confusao (razao de odds=3,09; 95% IC 1,3-7,2). Este aumento de risco nao persitiu ate o terceiro mes de vida. CONCLUSOES: Recomenda-se aos servicos de saude atencao especial a lactantes submetidas a cesarianas eletivas, para que seja promovido o aleitamento desde as primeiras semanas, evitando a interrupcao precoce.

Tendências e diferenciais na saúde materno-infantil: delineamento e metodologia das coortes de 1982 e 1993 de mães e crianças de Pelotas, Rio Grande do Sul

Mudancas ocorridas na ultima decada em termos economicos e assistenciais podem haver afetado a saude materno-infantil. Dois estudos foram realizados em Pelotas, Rio Grande do Sul. As coortes de maes e recem-nascidos nos anos de 1982 e 1993 foram estudadas desde o nascimento. As maes foram identificadas nos hospitais-maternidade e responderam a um questionario padronizado, sendo seus filhos examinados. Mais de 99% dos recem-nascidos foram incluidos nas coortes, totalizando 5.914 nascidos vivos em 1982 e 5.249 em 1993. A mortalidade das criancas foi monitorizada, e em 1993 as hospitalizacoes tambem o foram. Em 1982, tentou-se localizar cerca de 25% das criancas aos 12 meses de idade e todas com a idade media de vinte meses. Foi possivel encontrar cerca de 82% das criancas aos 12 meses e, gracas a uma mudanca de estrategia, 87% aos vinte meses. Em 1993, tentou-se acompanhar 20% das criancas e mais todos os recem-nascidos de baixo peso aos 12 meses de idade, sendo 95% localizados. Este artigo descreve os principais aspectos metodologicos de ambos os estudos, cujos principais resultados estao incluidos nos proximos artigos desse suplemento.

Child development in a birth cohort: effect of child stimulation is stronger in less educated mothers

BACKGROUND Child health has improved in many developing countries, bringing new challenges, including realization of the childrens full physical and intellectual potential. This study explored child development within a birth cohort, its psychosocial determinants and interactions with maternal schooling and economic position. METHODS All children born in Pelotas, Brazil, in 2004, were recruited to a birth cohort study. These children were assessed at birth and at 3, 12 and 24 months of age. In this last assessment involving 3869 children, detailed information on socio-economic and health characteristics was collected. Child development was assessed using the screening version of Battelles Development Inventory. Five markers of cognitive stimulation and social interaction were recorded and summed to form a score ranging from 0-5. The outcomes studied were mean development score and low performance (less than 10th percentile of the sample). RESULTS Child development was strongly associated with socio-economic position, maternal schooling and stimulation. Having been told a story and owning a book were the least frequent markers among children with score 1. These children were 8.3 times more likely to present low performance than those who scored 5. The effect of stimulation was much stronger among children from mothers with a low level of schooling--one additional point added 1.7 on the childs development for children of low-schooling mothers, whereas only 0.6 was added for children of high-schooling mothers. CONCLUSIONS Our stimulation markers cannot be directly translated into intervention strategies, but strongly suggest that suitably designed cognitive stimulation can have an important effect on children, especially those from mothers with low schooling.

Prevalence and characteristics of victims and perpetrators of bullying

OBJECTIVE To determine the prevalence of bullying (victims and perpetrators) in a representative sample of sixth graders from schools located in the city of Caxias do Sul, RS, Brazil and to determine possible associations with maternal education, socioeconomic level, sedentary habits, nutritional status, dissatisfaction with body image, gender, and age. METHODS This was a school-based epidemiological study. The target population consisted of sixth graders (11-14 years). A self-administered questionnaire and anthropometric measurements of weight and height were used for the assessment of nutritional status. Bullying was assessed through the Kidscape questionnaire, and body image through the Body Shape Questionnaire. Descriptive statistics and bivariate and multivariate analyses were used. RESULTS 1,230 schoolchildren were evaluated, and the prevalences of victims and perpetrators of bullying were 10.2% and 7.1%, respectively. Those dissatisfied with their body image were three times more likely to be victims of bullying (PR=3.24; CI=1.99- 5.28), and almost twice as likely to be aggressors (PR=1.98; CI=1.53-3.73) than those who were satisfied. Schoolchildren with sedentary habits (more than three hours a day) were 55% more likely to be victims of bullying (PR=1.55; CI=1.01- 2.36) and more than twice as likely (PR=2.42; CI=1.47-3.97) to be aggressors. Boys were more than twice as likely (PR=2.45; CI=1.42-4.24) to be aggressors. CONCLUSIONS Body image and sedentary habits were associated with victims and perpetrators, and male gender was more prevalent among the perpetrators of bullying.

Risk factors for suspected developmental delay at age 2 years in a Brazilian birth cohort

de Moura DR, Costa JC, Santos IS, Barros AJD, Matijasevich A, Halpern R, Dumith S, Karam S, Barros FC. Risk factors for suspected developmental delay at age 2 years in a Brazilian birth cohort. Paediatric and Perinatal Epidemiology 2010; 24: 211–221. Many children are at risk of not achieving their full potential for development. Epidemiological studies have the advantage of being able to identify a number of associated factors potentially amenable to intervention. Our purpose was to identify risk factors for suspected developmental delay (SDD) at age 2 years among all children born in the city of Pelotas, Brazil, in 2004. This study was part of the 2004 Pelotas Birth Cohort. The Battelle Screening Developmental Inventory (BSDI) was administered to cohort children at age 2 years. A hierarchical model of determination for SDD with confounder adjustment was built including maternal sociodemographic, reproductive and gestational characteristics, as well as child and environmental characteristics. Multivariable analysis was carried out using Poisson regression. Prevalence ratios (PR) and 95% confidence intervals [95% CI] were calculated. In the results, 3.3% of the 3869 children studied screened positive for SDD. After confounder control, children more likely to show SDD were: those with positive BSDI at age 12 months (PR = 5.51 [3.59, 8.47]); with 5-min Apgar <7 (PR = 3.52 [1.70, 7.27]); with mothers who had <4 years of schooling (PR = 3.35 [1.98, 5.66]); from social classes D and E (PR = 3.00 [1.45, 6.19]); with a history of gestational diabetes (PR = 2.77 [1.34, 5.75]); born <24 months after the last sibling (PR = 2.46 [1.42, 4.27]); were not told child stories in the preceding week (PR 2.28 [1.43, 3.63]); did not have childrens literature at home (PR = 2.08 [1.27, 3.39]); with low birthweight (PR = 1.75 [1.00, 3.07]); were born preterm (PR = 1.74 [1.07, 2.81]); with <6 antenatal care appointments (PR = 1.70 [1.07, 2.68]); with history of hospitalisation (PR = 1.65 [1.09, 2.50]); and of male sex (PR = 1.43 [1.00, 2.04]). These risk factors may constitute potential targets for intervention by public policies and may provide help to paediatricians in preventing developmental delay.