Salud, desarrollo humano y gobernabilidad en America Latina y el Caribe a inicios del siglo XXI / Health, human development, and governance in Latin America and the Caribbean at the beginning of the 21st century

The issue of the reciprocal relationship between health and development has recently taken on greater importance in Latin America and the Caribbean (LAC), given the persistence of extreme poverty and the political and social difficulties due to macroeconomic imbalances and crises of governance. This piece reviews concepts of sustainable human development, social determinants of health in general and of health inequities in particular (gender, ethnic group, income level), and the relationship between health and economic growth in the medium term and the long term. An analysis is made of how persistent poverty in countries of LAC relates to disparities in health conditions, access to health services, and health care financing, as well as to such health determinants as nutrition and environmental sanitation. Health inequities most strongly affect the most excluded and vulnerable sectors of the population. In the face of this situation, the author stresses that putting a priority on health inequities is vital to safe-guarding the governability and the social and political stability of countries in LAC in the next decade (AU)

Sickle Cell Disease and age at menarche in Jamaican girls: observations from a cohort study

AIMS: (1) To investigate the distribution of age at menarche in a representative sample of 99 patients with homozygous sickle cell disease (ss), 69 with sickle cell haemoglobin C (sc) disease, and 100 controls with a normal haemoglobin (AA) genotype followed in a cohort study from birth. (2) To explore the determinants of the age menarche. METHODS: Children ascertained in a new-born screening programme were followed prospectively from birth to age 18-26.5 years with regular assessments of height, weight, puberal stage, and haematological indices at the Sickle Cell Clinic of the University Hospital of the West Indies. RESULTS: All subjects have now reached menarche and the mean age in normal controls (13.0 years) was significantly earlier than in SC disease (13.5 years) or SS disease (15.4 years). Greater weight and earlier age at menarche was the only association significant across all genotypes although additional contributions occured from fetal haemoglobin and red cell count in SS disease. Alpha thalassaemia, which ameliorates many of the effects of SS disease, had no discernible effect on menarche. CONCLUSIONS: Mean age at menarche is delayed by 0.5 years in SC disease and by 2.4 years in SS disease. Weight appears to be the principle determinant of age at menarche. (AU)

The effects of birth weight and postnatal linear growth retardation on blood pressure at age 11-12 years

STUDY OBJECTIVE: To determine the effects of birth weight and linear growth retardation (stunting) in early childhood on blood pressure at age 11-12 years. DESIGN: Prospective cohort study. SETTING: Kingston, Jamaica. Participants: 112 stunted children (height for age < -2 SD of the NCHS references) and 189 non-stunted children (height for age > -1 SD), identified at age 9-24 months by a survey of poor neighbourhoods in Kingston. MAIN RESULTS: Current weight was the strongest predictor of systolic blood pressure (beta= 4.90 mm Hg/SD weight 95 percent CI 3.97, 5.83). Birth weight predicted systolic blood pressure (beta= -1.28 mm Hg/SD change in birth weight, 95 percent CI -2.17, -0.38) after adjustment for current weight. There was a significant negative interaction between stunting in early childhood and current weight indicating a larger effect of increased current weight in children who experienced linear growth retardation in early childhood. There was no interaction between birth weight and current weight. The increase in blood pressure from age 7 to age 11-12 was greater in children with higher weigth at age 11-12 and less in children with higher birth weight and weight at age 7. CONCLUSIONS: Birth weight predicted systolic blood pressure in Jamaican children aged 11-12. Postnatal growth retardation may potentiate the relation between current weight and blood pressure. Greater weight gain between ages 7 and 11 was associated with a greater increase in systolic blood pressure. The relation between growth and later blood pressure is complex and has prenatal and postnatal components. (AU)

Growth and development four years after treatment for the Trichuris dysentery syndrome

A follow-up study is reported of 18 children 4 y after treatment for the Trichuris dysentery syndrome (TDS) and matched control children. The TDS children were initially severely stunted and had extremely low developmental levels. They showed catch-up in height of 1.9 z-scores even though they remained in very poor environments. Their intelligence quotients, school achievement and cognitive function remained significantly lower than those of the controls. Controlling for their earlier developmental levels, the TDS children showed a small improvement in mental development relative to the controls (Au)

Zinc supplementation, morbidity and growth in stunted Jamaican children

We investigated whether there was a morbidity or growth response to zinc supplementation of nutrition clinic attenders in Kingston, which would indicate zinc deficiency. Children selected were singletons aged 6 to 24 months and stunted (<2.0 sd length for age, NCHS references). They were stratified by gender and age (6-11, 12-17, 18-24 mo.) and randomly assigned to receive zinc supplementation (n=31) (5mg elemental zinc), or placebo (n=30) daily for 12 weeks. Adequately nourished comparison children (n=24) were recruited from a well-baby clinic. Caretakers were interviewed to obtain social background data. Anthropometric measurements were done on enrolment and after 6 weeks, 12 weeks and 12 months. A weekly questionnaire to determine the stunted children's health was given to the caretakers during the supplementation period. The zinc supplemented and placebo groups were very similar on enrolment. The adequately nourished children were significantly better socio-economic circumstances. Five placebo children, but no zinc supplemented children, were hospitalized during the supplemented period (Fisher's exact test, two-tailed, p=0.02), indicating reduced severity of illness with supplementation, which suggests a response to zinc deficiency. There were no significant differences in hair zinc content among the three groups. Regression analyses showed that there were no significant effects of supplementation of length, height or head circumference, or on the incidence of any symptom. Mean duration of the episodes were significantly shorter for skin rashes in the supplemented group compared with the placebo group (ANCOVA, P=0.02), and longer for vomiting (ANCOVA, p=0.02).(AU)

Zinc supplementation: effects on the growth and morbidity of undernourished Jamaican children

OBJECTIVE: We investigated whether there was a growth or morbidity response to zinc supplementation. DESIGN: The study was randomized, placebo-controlled, and double-blind. SETTING: Children were recruited at clinics in Kingston, Jamaica, and supplemented at home. SUBJECTS: Children selected were singletons aged 6-24 months, and stunted (< -2.0 s.d. length for age, NCHS references). They were stratified by sex and age and randomly assigned to receive zinc supplement (n = 31) or placebo (n = 30). Four children were excluded because of hospitalization; all others had all measurements. Adequately nourished children (n = 24) were recruited from a well-baby clinic. INTERVENTIONS: The supplement provided 5 mg elemental zinc in a syrup daily for 12 weeks; the placebo comprised the syrup only. MAIN OUTCOME MEASURES: Caretakers were interviewed to obtain social background data, number of clinic visits and hospitalizations. Anthropometric measurements were done on enrolment, and after 6 weeks, 12 weeks and 12 months. Children's health was determined by weekly questionnaire to caretakers of the undernourished groups during the supplementation period. RESULTS: The supplemented and placebo groups were similar on enrolment. The adequately nourished children were from significantly better socio-economic circumstances. Mean initial hair zinc content was 5.5 +/- 4.8 mumol/g (supplemented group) and 6.7 +/1 12.1 mumol/g (placebo) (n.s.). Regression analyses showed that there were no significant effects of supplementation on length, height or head circumference, nor on the incidence of any morbidity symptom. Mean duration of the episodes was significantly shorter for skin rashes in the supplemented group compared with the control group (ANCOVA, P = 0.02), and longer for vomiting (P = 0.02). The incidence of hospitalization was significantly greater in the control group (Fisher's exact test, P = 0.02). CONCLUSIONS: Zinc supplementation reduced the hospitalizations which probably reflect severity of morbidity, but did not improve growth.(Au)

Exercise in the treatment of children with diabetes

The normal development of children should be first and foremost, and secondly physical education and sport should be regarded as fun along with the competitive aspect, which makes sport exciting. The same principles which apply to normal children apply to children with diabetes. This means considering their developmental stage, physiological development and physical capabilities, as well as the organisation of sport, suitability of equipment, appropriate coaching strategies and parental guidance. The benefits and risks of exercise for the child with diabetes are similar to those for adults. Evidence is lacking as to whether long-term control as a result of exercise is probable and whether there will be retardation or progression of complications. Young children with diabetes should be in optimal metabolic control to benefit from participation in sport.(AU)

Pulse oximetry in a cohort study of sickle cell disease

Oxygen saturation was determined by pulse oximetry in a representative sample of Jamaican patients with steady state sickle cell disease in a cohort study from birth. There were 220 with homozygous sickle cell (SS) disease and 142 with sickle cell-haemoglobin C (SC) disease aged 9-18 years, and 122 with a normal haemoglobin (AA) genotype aged 15-18 years. Pulse oximetry (SpO2) values were lower in SS disease (mean [95 percent confidence interval]), 92.5 [92.0-93.3]. Inhalation of 100 percent oxygen in SS patients with 02 saturations below 90 percent consistency increased saturation to 99-100 percent. In SS disease, Sp02 correlated positively with haemoglobin and fetal haemoglobin and negatively with reticulocyte counts but not MCHC, MCV or bilirubin level. Mean Sp02 in SS subjects with a normal alpha globin gene complement (mean[SD], 91.7 [3.9]percent) was lower than in heterozygotes (93.4 [4.0] percent) or homozygotes (96.1 [3.0] percent) for alpha+thalassaemia, the effects of alpha-thalassaemia not being explained by differences in haemoglobin or MCHC. In SS disease, Sp02 levels were not associated with age (within this age range), sex, number of sick clinic visits or number of hospital admissions. Higher Sp02 levels were associated with greater heights and weights, more frequent painful crises and less frequent acute chest syndrome, but these associations were not significant after adjustment for haemoglobin level. Desaturation is common in steady-state SS disease and knowledge of the individual's steady-state value may be important in the interpreting low value during acute complications.(AU)

Pulse oximetry in cohort study of sickle cell disease

Oxygen saturation was determined by pulse oximetry in a representative sample of Jamaican patients with steady-state sickle cell disease in a cohort study from birth. There were 220 with homozygous sickle cell (SS) disease and 142 with sickle cell- haemoglobin C (SC) disease aged 9-18 years, and 122 with a normal haemoglobin (AA) genotype aged 15-18 years. Pulse oximetry (SpO2) values were lower in SS disease (mean [95 percent confidence interval], 92.5 [92.0-93.0]) than in SC disease (96.7 [96.9-96.9]) or AA controls (97.1 [96.8-97.3]). Inhalation of 100 percent oxygen in SS patients with O2 saturations below 90 percent consistently increased saturation to 99-100 percent. In SS disease, SpO2 correlated positively with haemoglobin and fetal haemoglobin and negatively with reticulocyte counts but not with MCHC, MCV or bilrubin level. Mean SpO2 in SS subjects with a normal alpha globin gene complement (mean [SD], 91.7 [3.9] percent) was lower than in heterozygotes (93.4 [4.0] percent) or homozygotes (96.1 [3.0] percent) for O+ thalassaemia, the effects of O-thalassaemia not being explained by differences in haemoglobin or MCHC. In SS disease, SpO2 levels were not associated with age (within this age range), sex, number of sick clinic visits or number of hospital admissions. Higher SpO2 levels were associated with greater height and weight, more frequent painful crises and less frequent acute chest syndrome, but these associations were not significant after adjustment for haemoglobin level. Desaturation is common in steady-state SS disease and knowledge of the individual's steady-state value may be important in the interpreting low values during acute complications.(AU)

Early childhood supplementation does not benefit the long-term growth of stunted children in Jamaica

The long-term benefits of early childhood supplementation and the extents to which catch-up growth occurs following linear growth retardation remain controversial. Stunted children (height-for-age < -2 SD of NCHS reference, n = 122) recruited from a survey of poor neighborhoods in Kingston, Jamaica, participated in a 2-yr randomized, controlled trial of supplementation beginning at ages 9-24 mo. A group of 32 non-stunted children from the same neighborhoods was also followed. Four years after the intervention ended, when children were 7 to 8 y old, there were no effects of supplementation on any anthropometric measure. From the end of the trial until follow-up, the children who had been supplemented gained 1.2 cm less (P < 0.05) than the non-supplemented children, approximately the same amount as they had gained during the trial compard with the non-supplemented children. After adjustment for regression to the mean, the height-for-age of stunted children (supplemented and non-supplemented combined) increase from enrollment to follow-up by 0.31 Z-score (95 percent CI 0.17, 0.46). The height-for-age of the non-stunted children also increase (0.96 Z-score; 95 percent CI 0.70, 1.22). Our results suggest that some catch-up growth is possible even when children remain in poor environments. Long-term benefits of supplementation to growth may not be achieved when intervention begins after age 12 mo in children who have already become undernourished.(AU)

Relationship between wasting and linear growth in stunted children

Height-for-age and weight-for-height are commonly used indicators of nutritional status; however, their precise interrelationship remains unclear. We examined the relationship between weight-for-height and linear growth in 127 stunted Jamaican children aged 9 - 24 months. The children were measured every 6 months over a 2 year period. The initial weight-for-height status was positively associated with linear growth in the following 6 month interval. The change in weight-for-height in the preceeding interval was better predictor of linear growth in linear growth in the next interval than attained weight-for-height at the beginning of the interval. The results suggest that variations in weight-for-height may influence the rate of linear growth.(AU)

Factors affecting prepubertal growth in homozygous sickle cell disease

OBJECTIVE: To investigate the role of hematological indices, socioeconomic status, and morbidity in prepubertal growth in homozygous sickle cell (SS) disease from birth to 9 years at the sickle cell clinic of the University Hospital of the West Indies, Kingston, Jamaica. RESULTS: Height increment between 3 and 9 years correlated positively with total haemoglobin at age 7 years in boys but not girls. Attained height and weight at 7 years correlated positively with haemoglobin and fetal haemoglobin in boys but not girls. Only the correlation between haemoglobin and weight showed a significant gender difference. Partial correlation analysis suggested that the effect of haemoglobin was accounted for by the effect of fetal haemoglobin and further analysis indicated that height correlated with F reticulocyte count (a measure of fetal haemoglobin production) in both sexes but not with the ratio of F cells to F reticulocytes (a measure of F cell enrichment). Growth was not significantly related to mean red cell volume, proportional reticulocyte count, alpha thalassaemia, socioeconomic status, or morbidity. CONCLUSION: A high concentration of fetal haemoglobin in boys with SS disease is associated with greater linear growth. It is postulated that in boys, low concentrations of fetal haemoglobin increase haemolysis and hence metabolic requirements for erythropoiesis, putting them at greater risk of poor growth. Differences in the relationship to haemotoloy and growth between boys and girls with SS disease dictate that future analyses of growth take gender into account (AU).x

Breastfeeding prevalence among six-week infants at University Hospital of the West Indies

Eighty-five (85) mothers attending postnatal and well baby clinics were interviewed at six weeks post-partum regarding breastfeeding. An overall prevalence of 98.8 percent at six weeks of age was seen, with an exclusive breastfeeding rate of 37.6 percent. Older maternal age and multiparity favoured exclusive breastfeeding. There was no significant association between pattern of breastfeeding (exclusive versus partial) and employment or union status. Breastfeeding was found to favour good weight gain in normal birthweight babies. Normal birthweight babies who were exclusively breastfed had a higher mean weight gain than the exclusively breastfed low birthweight infants, who in turn had better weight gain when partially breastfed (AU)

Catch-up growth velocities after treatment for Trichuris dysentery syndrome - abstract

Children with trichuris dysentery syndrome (TDS) tend to have growth and nutritional deficits, as shown by their consistently short stature and variable amount of wasting (low weight for their attained height). Two previous reports have described the accelerated growth of two small series of these children in their homes after treatment of the dysentery and anaemia. We now report on the 6-month post-treatment growth velocities of a complete series of 63 children with TDS. The children had a mean age of 6.4 years (SD 1.9) at the mid-point of their 6 month interval, whereas their height-age at the mid-point was 3.2 y (SD 1.5). This shows the extent of their stunting. Over the 6-month interval after initiation of treatment the average height velocity was 10.9 cm per year (SD 3.3) and the weight velocity was 4.0 kg per year (SD 2.3). There was no effect of age on the ability to initiate catch-up from stunting (although we cannot as yet say anything about the children's final attained heights). The mean growth velocities of this complete series of Jamaican children and the distributions about these means provide the best evidence to date of the tendency to catch-up growth, without change in environment, after treatment of intense infection of Trichuris trichiura (AU)

Factors associated with lowered intelligence in homozygous sickle cell disease

The intelligence quotient (IQ) of 60 patients with homozygous sickle cell (SS) disease and 60 age and sex matched controls with a normal haemoglobin (AA) genotype aged 15-18 years, followed up in a cohort study from birth, was assessed by the Wechsler intelligence scales for children and adults. IQ appeared to be normally distributed in both genotypes but mean values in SS disease were 5.6 points (95 percent confidence interval (CI) 1.0 to 10.2) lower than in AA controls (p=0.016). THe difference occurred in both verbal (5.5 points, p=0.017) and performance (5.0 points, p=0.044) subscales of the IQ defect in SS disease was associated with a significantly lower attention factor score (p=0.005) but not with other factor scores. The genotype difference in IQ was not accounted for by differences in parental occupational level, school absenteeism, or school drop out, or reported activity level. In SS disease, IQ was not related to mean steady state haemoglobin, or mean cell haemoglobin concentration, or clinical severity as judged by the frequency of painful crises, hospital admission, or sick visits. IQ, at age 15-18 years, correlated with the patients' height at all ages from 1 to 10 years (partial correlations increasing from 0.14 (p=0.15) at age 1 to 0.27 (p=0.004) at age 10). Adjusting for height reduced the mean genotype difference in IQ to 5.5 (95 percent CI 0.6 to 10.3) points at age 1 and 10 2.6 points (95 percent CI 0.6 to 10.3) points at age 10. Prepubertal height therefore accounted for much of the genotype difference in IQ. It is speculated that early factors, possibly nutritional, contribute to both impaired growth and mental development in sickle cell disease(AU)

Treatment of trichuris trichiura infections improves growth, spelling scores and school attendance in some children

The effects of treating Trichuris trichiura infections were investigated in 407 Jamaican children age 6 to 12 years. The children were randomly assigned to receive treatment (albendazole) or a placebo. The outcome variables included growth, tests of reading, spelling and arithmetic, and school attendance. After 6 months of treatment, there was no significant main effect on any of the outcomes. However, there were significant treatment-by-infection intensity interactions with spelling (P < 0.05) and body mass index (P < 0.01), and a significant treatment-by-stunting interaction with school attendance (P < 0.01). In spelling, the children with heavy infections showed improvements with treatment that approached significance d(P = 0.06), whereas those with lower intensities did not. However, the children with lower infection intensities had increased body mass index with treatment (P = 0.02), although there was no difference in children with heavy infections. In school attendance, the stunted children improved with treatment (P < 0.04), whereas there was no difference in the nonstunted children. These findings suggest that in the sample of Jamaican children examined, the treatment of T. trichiura was more likely to benefit school performance in children of poor nutritional status and those with heavy infections, and to improve weight gain in children with lighter infection intensities (AU)

Growth and iron status of children recovering from trichuris dysentery syndrome - abstract

Trichuris dysentry syndrome is a severe form of trichuriasis which develops as a result of infection by Trichuris trichuria and can adversely affect the growth and iron status of children. We examined the growth and iron status of ten Jamaican children with trichuris dysentery syndrome, aged 2 to 7 years. Data were collected before treatment and serially, for six months, after treatment. Heights and weights are expressed as standard deviation (Z) scores, which were calculated using the National Center for Health Statistics growth charts. Mean Hb, PVC, MCHC, height Z-score and median serum ferritin before and after treatment are presented in the table. There was a significant increase in the mean height Z-score, mean weight Z-score and mean haemoglobin after treatment; however, median serum ferritin concentration and mean PCV did not increase significantly. The change in average MCHC approached significance. Anthelmintic treatment and iron therapy resulted in an improvement in the Hb, PCV and MCHC levels but did not affect iron stores. Treatment resulted in an increase in the weight Z-score and height Z-score of the patients - table included (AU)

Treatment of mild to moderate trichuris trichiura infections in children: effects on school performance and growth - abstract

The effects of treating mild to moderate infections of Trichuris trichiura were investigated in 407 Jamaican children, aged 6 to 12 years. The children were randomly assigned to receive treatment (albendazole) or a placebo which were given at approximately 4-month intervals. The study lasted 17 months and the outcome variables included tests of reading, spelling and arithmetic, school attendance and growth. There was no significant treatment effect in the school achievement tests or in height gain. However, a significant treatment-by-infection intensity effect for body mass index (BMI) (p = 0.03) and a significant treatment-by-stunting effect in school attendance (p = 0.002) were found. Among the children with lower infection intensities, BMI improved with treatment (p = 0.08) after six months of the study but there was no treatment effect in the final 11 months of the investigation. On the other hand, the children with higher infection intensities were not affected during the first six months but had improved BMIs with treatment in the final 11 months of the study (p < 0.002). During the first year of the study, the school attendance of the stunted children improved with treatment (p < 0.001) while there was no effect in the non-stunted children. However, during the second year, there was an improvement in attendance in the non-stunted children with treatment (p = 0.06) while the stunted children who were treated did worse than those who received placebos (p < 0.05). These findings indicate that benefits from the treatment of T.trichiura infections depend on the nutritional status of the children, their infection intensities as well as the duration of treatment (AU)