Tulio Konstantyner

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.

Fatores de risco para perda ponderal de crianças frequentadoras de berçários em creches do município de São Paulo

Objective: To identify and quantify risk factors related to the aggravation of nutritional condition from birth until the date of the study. Methods: Cross-sectional study with 270 children attending nurseries of eight public and non-for-profit daycare centers in the city of Sao Paulo, Brazil. Ponderal loss was considered when children presented negative difference of Z score for weight-for-age (W/A) from birth until the date of the present inquiry. Chi-square was used to test associations and considered significant if p<0.05. Multivariate logistic regression model adjusted Odds Ratio estimates for confounding variables and/or covariables. Results: Anthropometric analysis showed 7.1% prevalence of malnutrition (W/A<-2 Z score) at birth and 4.4% by the time of measurement. Ponderal evolution with unfavorable Z score was present in 50.7% of studied children (n=137). In the bivariate analyses, the variables: birth weight (OR=5.35; p<0.001), anemia (OR=1.81; p=0.019) and age less than 19 months (OR=1.67; p=0.036) were statistically significant.

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

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.

Prevalence and factors associated with overweight among Brazilian children younger than 2 years

OBJECTIVE To describe the prevalence of overweight, analyze its progression from 1989 to 2006 and identify factors associated with it among children younger than two years in Brazil. METHODS Data for the Women and Children National Demography and Health Survey (PNDS 2006) were collected using questionnaires and anthropometric measurements. The study sample included 1,735 children aged 0 to 24 months (910 boys; 825 girls). Nutritional status was defined according to the weight-for-height index (W/H; WHO, 2006), and children were classified as overweight if their W/H z score was greater than +2. RESULTS Prevalence of overweight in Brazil was 6.54%. The highest prevalence of overweight was found in the southern (10.0%) and midwestern (11.1%) regions, among families with a per capita income higher than one minimum wage (11.8%), in social classes with a greater purchasing power (9.7%), among children whose birth weight was greater than 3 kg (8.04%) and whose exclusive breastfeeding lasted less than five months (7.4%). According to a fitted multiple logistic regression model, factors associated with overweight were: birth weight ≥ 3 kg [odds ratio (OR) = 5.2, 95% confidence interval (95%CI) 2.56-10.56], per capita income ≥ 1 minimum wage (OR = 2.50, 95%CI 1.20-5.21), residence in midwestern region (OR = 2.40, 95%CI 1.01-5.72). CONCLUSIONS The comparison of the prevalence found in the 2006 survey with the 1989 and 1996 values revealed that overweight among children younger than two years tends to decrease. The risk factors identified suggest that further actions should be conducted to prevent obesity among infants living in the midwestern region of Brazil, whose birth weight was greater than 3 kg and whose families had a per capita income higher than one minimum wage.

Risk Factors for Anemia among Brazilian Infants from the 2006 National Demographic Health Survey

Iron deficiency is an important public health problem. An understanding of anemia risk factors is essential to informed health policies. We performed a cross-sectional study of 1,382 infants from the 2006 Brazilian National Survey on Demography and the Health of Women and Children. Mild and moderate anemia was characterised by hemoglobin levels below 11.0 and 9.5 g/dL, respectively. Rates for mild and moderate anemia were 25.9% and 9.9%, respectively. The logistic model included three risk factors for mild anemia—urban residence area (OR = 2.5; P = 0.004), fever in the past 2 weeks (OR = 2.4; P < 0.001), and age less than 12 months (OR = 1.7; P = 0.024). Strategies to control infant anemia should include health promotion and nutritional education for families from all socioeconomic levels. Lifestyle quality improvement based on adequate food consumption must be achieved by communities in all macroregions, and especially in urban areas.

Prevalência e fatores associados ao excesso de peso em crianças brasileiras menores de 2 anos

OBJECTIVE: To describe the prevalence of overweight, analyze its progression from 1989 to 2006 and identify factors associated with it among children younger than two years in Brazil. METHODS: Data for the Women and Children National Demography and Health Survey (PNDS 2006) were collected using questionnaires and anthropometric measurements. The study sample included 1,735 children aged 0 to 24 months (910 boys; 825 girls). Nutritional status was defined according to the weight-for-height index (W/H; WHO, 2006), and children were classified as overweight if their W/H z score was greater than +2. RESULTS: Prevalence of overweight in Brazil was 6.54%. The highest prevalence of overweight was found in the southern (10.0%) and midwestern (11.1%) regions, among families with a per capita income higher than one minimum wage (11.8%), in social classes with a greater purchasing power (9.7%), among children whose birth weight was greater than 3 kg (8.04%) and whose exclusive breastfeeding lasted less than five months (7.4%). According to a fitted multiple logistic regression model, factors associated with overweight were: birth weight > 3 kg [odds ratio (OR) = 5.2, 95% confidence interval (95%CI) 2.56-10.56], per capita income > 1 minimum wage (OR = 2.50, 95%CI 1.20-5.21), residence in midwestern region (OR = 2.40, 95%CI 1.01-5.72). CONCLUSIONS: The comparison of the prevalence found in the 2006 survey with the 1989 and 1996 values revealed that overweight among children younger than two years tends to decrease. The risk factors identified suggest that further actions should be conducted to prevent obesity among infants living in the midwestern region of Brazil, whose birth weight was greater than 3 kg and whose families had a per capita income higher than one minimum wage.

Risk factors for incomplete vaccination in children less than 18 months of age attending the nurseries of day-care centres in Sao Paulo, Brazil.

To estimate the proportion of children in day-care centres with incomplete vaccination and to identify associated risk factors, we conducted a cross-sectional study among 258 children less than 18 months of age attending public and philanthropic day-care centres in the city of Sao Paulo, Brazil. Interviews, blood collection and anthropometry were performed. Unconditional logistic regression was adjusted for incomplete vaccination risk factors. 10.9% of children had incomplete vaccination. Children who were born prematurely (OR=4.27; p=0.004), or were malnourished (OR=4.99; p=0.049), or lived in inadequate housing (OR=2.88; p=0.039), or whose mothers had had poor prenatal care (OR=4.98; p=0.040) were more likely to have incomplete vaccination. Opportunities are being missed to identify children with incomplete vaccination; strategies to enhance vaccination coverage should pay special attention to the needs of families living in inadequate housing; and health promotion actions in primary health facilities and day-care centres should be performed as concomitant activities.

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

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.

Percepções de educadores de creches acerca de práticas cotidianas na alimentação de lactentes: impacto de um treinamento

O artigo apresenta a importância da capacitacao dos profissionais envolvidos com alimentacao das criancas em creches, para que estes oferecam alimentos adequados e promovam acoes para que os lactentes incorporem praticas alimentares saudaveis desde o nascimento. Desta forma, o objetivo do presente trabalho foi avaliar o impacto de um treinamento de educadores de creches nas percepcoes e praticas acerca da alimentacao infantil. Para avaliacao do impacto do treinamento foi utilizada abordagem qualitativa, com aplicacao da tecnica do grupo focal. Foram realizados 16 grupos, sendo oito com as creches expostas ao treinamento e oito com as nao-expostas, tendo em media de seis a 11 participantes por instituicao, os quais apresentavam idades entre 19 e 66 anos. O discurso das educadoras que participaram do treinamento esta pontuado de indicios de pequenas mudancas, ou pelo menos, de reconhecimento de que e preciso e possivel mudar. Destaca-se a relevância de elaborar e executar programas de treinamento e educacao nutricional para educadores de creches com supervisao continua dos efeitos da capacitacao como estrategia de saude infantil.

Consumption of industrialized food by infants attending child day care centers

Objective: To identify the age of introduction of petit suisse cheese and instant noodles in the diet of infants attending nurseries of public day care centers and to compare the nutritional composition of these foods with the healthy recommended diet (breast milk and salt meal) for this age, in order to estimate nutritional errors. Methods: Cross-sectional study of 366 children (from nine to 36 months old) who attended day care centers, whose mothers were interviewed about the age of introduction of those foods. The means of the nutrients indicated on the labels of the most consumed brands were considered. For the calculation of the percent composition of breast milk and salt meal, Tables of Food Composition were used. To assess the nutritional adequacy, we used the Dietary Reference Intakes by age group. The percentage of adequacy evaluation of the petit suisse cheese and the instant noodles nutritional compositions was made by comparing them with those of the human milk and the salt meal, respectively. Results: The petit suisse cheese and the instant noodles were consumed by 89.6 and 65.3% of the children in the first year of life. The percentages of adequacy for carbohydrates were more than twice and the percentages for sodium were 20 times higher than those found in the recommended foods. Conclusions: Both industrialized products are inappropriate for infants, emphasizing the need for adoption of norms that can inform health professionals, educators and parents about the risks of consumption.Objetivo: Identificar a idade de introducao do queijo petit suissee do macarrao instantâneo na dieta de lactentes matriculados em bercarios de creches publicas/filantropicas e comparar suas composicoes nutricionais com a alimentacao recomendada para a idade (leite materno e refeicao salgada), visando estimar erros nutricionais.Metodos:Estudo transversal com 366 criancas (de nove a 36 meses) de bercarios de creches, cujas maes foram entrevistadas sobre idade de introducao dos alimentos. Consideraram-se as medias de nutrientes indicadas nos rotulos das marcas mais consumidas. No calculo da composicao centesimal do leite materno e da refeicao salgada, utilizaram-se Tabelas de Composicao de Alimentos. Para avaliacao da adequacao nutricional, utilizaram-se as Recomendacoes de Ingestao Diaria por faixa etaria. A avaliacao dos percentuais de adequacao das composicoes nutricionais do petit suissee do macarrao instantâneo foi feita comparando-as com as do leite materno e da refeicao salgada, respectivamente.Resultados: O petit suisse e o macarrao instantâneo foram consumidos por 89,6 e 65,3% dos lactentes ainda no primeiro ano de vida. Os percentuais de adequacao para carboidrato foram superiores a duas vezes o recomendado e os percentuais de sodio, 20 vezes superiores aos encontrados nos alimentos recomendados.Conclusoes: Os dois produtos industrializados sao improprios para lactentes, ressaltando-se a necessidade de adocao de normatizacao que possa informar os profissionais de saude, os educadores e os pais sobre os riscos do consumo.