Limitaçäo diagnóstica do exame físico na identificaçäo de crianças com anemia / Diagnostic restriction of the physical examination in the identification of children with anemia

Para avaliar a precisao e a reprodutibilidade dos sinais clínicos de anemia foram estudadas, no Ambulatório Geral de Pediatria da Escola Paulista de Medicina, uma amostra aleatória de 143 crianças, de seis a 68 meses de idade, analisadas por meio de dois exames clínicos independentes. A avaliaçao clínica de anemia baseou-se na presença de palidez cutânea, e de descoramento de conjuntiva, lábio-língua e palmas das maos. A prevalência de anemia, tendo como padrao de referência a hemoglobina venosa menor do que 11,0g/dL, foi de 41,3 por cento, predominando na faixa etária de seis a 24 meses (59,3 por cento). Obteve-se baixa sensibilidade tanto quando os quatro sinais clínicos foram analisados isoladamente (28,8 por cento a 52,5 por cento) como quando analisados em conjunto. Encontrou-se pelo menos um sinal clínico de anemia, na quase totalidade dos pacientes, somente quando o nível de hemoglobina foi inferior a 9,0g/dL. Verificou-se concordância leve entre os dois exames na avaliaçao da palidez cutânea (coeficiente de Kappa = +0,32) e corcordância moderada na avaliaçao da conjuntiva, do lábio-língua e das palmas das maos (coeficiente de Kappa entre +0,55 e +0,59). A reprodutibilidade do conjunto dos sinais clínicos foi maior quanto maior a gravidade de anemia. Concluiu-se que o diagnóstico clínico de anemia, considerando a precisao e a reprodutibilidade dos sinais clínicos, é limitado, sendo recomendável a dosagem rotineira da hemoglobina venosa nas faixas etárias com maior prevalência de anemia.

[Diagnostic limitations of the physical examination in the identification of children with anemia]. / Limitação diagnóstica do exame físico na identificação de crianças com anemia.

A total of 143 children was randomly selected from a Pediatric out-patients clinic in order to evaluate the accuracy and reproductibility of the clinical signs of anemia. The patients, who ranged from 6 to 68 months old, were assessed on the basis of 2 clinical examinations performed independently by 2 physicians. Clinical diagnosis of anemia relied upon the examination for the presence of pallor through an inspection of the skin, conjunctivaes, lips, tongue and palms. The reference standard taken into consideration was hemoglobin in venous blood samples. The prevalence of anemia (hemoglobin < 11.0 g/dL) consisted of 41.3%, predominating among patients who ranged from 6 to 24 months old (59.3%). The sensitivity of the different clinical signs for the 2 examinations was low ranged from 28.8% to 52.5%. Almost all the children with hemoglobin concentration lower than 9.0 g/dL presented at least one suggestive clinical sign of anemia. The Kappa coefficient (K) demonstrated a mild agreement between the 2 examinations for the assessment of cutaneous pallor (K = +0.32) and moderate agreement for the evaluation of the conjunctivaes, lips-tongue and palms (K from +0.55 to +0.59). In view of limitation of the accuracy and reproductibility of the clinical signs of anemia, we may state that the determination of hemoglobin concentration should be introduced as a routine procedure of major importance in health care services.

Malnutrition as a prognostic factor in lymphoblastic leukaemia: a multivariate analysis.

One hundred and twenty eight Brazilian children with lymphoblastic leukaemia were intensively treated with a Berlin-Frankfurt-Munich based protocol. More children had a white cell count above 50 x 10(9)/l (31%) then observed in developed countries. After a median follow up of 31 months (11-58 months), the estimated probability of relapse free survival was 41% (7%) for the whole group. After adjustment in the Cox's multivariate model, malnutrition was the most significant adverse factor affecting duration of complete remission. Age above 8 years and high peripheral white cell count were also significant adverse factors. Among the nutritional indices, the height for age and weight for age z scores were both significant, whether the cut off points of z-2 or z = -1.28 were chosen to define malnutrition. A strong statistical association between the two indices was found; the contribution of height for age z score to the prediction of relapse free survival was more significant. Children with height for age z score < -2 had a relapse risk of 8.2 (95% confidence interval 3.1 to 21.9) relative to children with z score > -2. The results of this study suggest that socioeconomic and nutritional factors should be considered in the prognostic evaluation of children with leukaemia in developing countries.

[Nutritional status of Indian children of Alto Xingu and evaluation of the use of arm perimeter in the diagnosis of protein-calorie malnutrition]. / Estado nutricional de crianças índias do Alto Xingu e avaliação do uso do perímetro braquial no diagnóstico da desnutrição protéico-calórica.

STUDY OBJECTIVE: The purpose of this study was to determine the presence of malnutrition in indian children of Alto Xingu region in Brazil, and to evaluate the usefulness of arm circumference and QUAC index in the diagnosis of protein-energy malnutrition (PEM). SITE: The indian population of Alto Xingu maintains most of its traditional customs. PATIENTS: 335 children were studied prospectively in at least one of seven consecutive years between 1974 and 1980, and 1278 measurements were obtained of weight, height, and arm circumference. MEASUREMENTS AND RESULTS: The annual prevalence of PEM (weight-for-height) less than 90% according to Brazilian reference tables was 4.1% in children aged under 1 year, 7.3% in children from 1 to 5 years of age, and 7.5% in children older than 5. According NCHS tables, however, values of 1.0%, 2.8%, and 1.1% were obtained for the respective age groups. The sensitivity and specificity of arm circumference and QUAC index were calculated in relation to the weight-for-height relation. According to Brazilian reference tables, arm circumference had a sensitivity of 8.9% and specificity of 99.3%, whereas the QUAC index had a sensitivity of 11.1% and specificity of 98.3%. However, according to NCHS tables, slightly different values were obtained. The sensitivity and specificity in this case were 23.5% and 99.3%, respectively, for arm circumference and 35.3% and 98.3%, respectively, for the QUAC index. CONCLUSIONS: The authors concluded that the prevalence of PEM was low in the Alto Xingu and that arm circumference and the QUAC index should only be used in situations suited to their sensitivity and specificity.

[Congential malabsorption of glucose and galactose in 2 brothers]. / Mabsorção congênita de glicose e galactose em dois irmãos.

Congeneeital glucose-galactose malabsorption is a rare clinical entity transmitted by autossomic recessive gen. The defect is in the small intestinal active transport system which is shared by glucose and galactose. Diarrhea and failure to thrive from the first week of life are the prominent symptoms. We report two sibs from consaguineous parents with diarrhea and failure to thrive since they were born. Both children had glucose and galactose malabsorption but tolerated well formula containing fructose as the only source of carbohydrate. They showed flat blood glucose curves when tested with glucose and galactose loads but normal increments of the sugar blood levels with fructose load. The small intestinal biopsy performed in both patients revealed normal villous pattern. When put under a diet containing fructose as the only source of carbohydrate, both patients had their symptoms subsided and reassumed the normal pattern of growth.

Mabsorcao congenita de glicose e galactose em dois irmaos. / Congenital malabsorption of glucose and galactose in 2 brothers

Mabsorcao congenita de glicose-galactose e uma entidade clinica rara transmitida por um gene autossomico recessivo. O defeito absortivo encontra-se localizado no sistema de transporte ativo do intestino delgado que e utilizado igualmente pela glicose e pela galactose. Diarreia e parada de crescimento, desde as primeiras semanas de vida,constituem os sintomas mais proeminentes. Descrevemos dois irmaos, filhos de pais consaguineos, que apresentavam diarreia e parada de crescimento, desde o nascimento. Ambas as criancas apresentavam mabsorcao de glicose, e galactose, mas revelaram completa tolerancia a formula contendo frutos como unica fonte de carboidrato. Eles apresentaram curvas glicemicas planas quando submetidos a teste de tolerancia a glicose e galactose; por outro lado, os incrementos dos niveis glicemicos foram normais apos sobrecarga com frutos.Biopsia do intestino delgado realizada em ambos os pacientes evidenciou mucosa do intestino delgado compativel com os padroes de normalidade. Os pacientes, quando submetidos a dieta contendo frutose, como unica fonte de carboidratos, apresentaram remissao completa dos sintomas e retomaram seus ritmos normais de crescimento

Observations of the Alto Xingu Indians (central Brazil) with special reference to nutritional evaluation in children.

Little information concerning the nutritional status of Brazilian Indians living primitively in a large area of the Amazon region is available at present. This study took place in the Xingu National Park, created to preserve the Indian population living in this area, along with its culture. Field work was done in three consecutive years (1974, 1975, 1976). At the end of this period 175 children had been studied (97 male and 78 female) all estimated to be under 5 yr of age. Two kinds of studies were performed: 1) cross-sectional: studying the children that entered in the nutritional survey every year, and 2) longitudinal: studying the children that were under observation for 2 or 3 consecutive yr. The nutritional status was evaluated by two age-independent anthropometric indices, namely, weight-for-height and arm-circumference-for-height. The weight-for-height index showed that 96.0% of the children examined were classified as well nourished, 3.4% suffered of 1st degree malnutrition and 0.6% of 2nd degree malnutrition. The arm-circumference-for-height revealed that 97.1% were well nourished and 2.9% were classified as suffering of a mild degree of malnutrition. Since both indices used can give normal results in a population in which there is severe stunting or nutritional dwarfism, a longitudinal study was drawn. Growth in height was studied, resulting normal in 84.8% of the measurements taken. In contrast to children from low income families living in the outskirts of large urban centers where malnutrition reaches 54.0%, the Indians remain as healthy as they were when last examined 30 yr ago.

Avaliacao nutricional das criancas indias do Alto Xingu. / Nutritional evaluation of indian children from Alto Xingu, Brazil

Avaliamos o estado nutricional das criancas indias do Alto Xingu utilizando um indice antropometrico independente da idade, a saber, a adequacao peso-altura. O trabalho de campo foi realizado no mes de julho durante tres anos consecutivos (1974-1975-1976). Ao cabo deste periodo, 175 criancas, haviam sido estudadas, 97 meninos e 78 meninas, com idade estimada menor que cinco anos. Desnutricao grau I em somente 11,3% das criancas durante tres anos consecutivos enfatiza que desnutricao nao e um problema de maior relevancia na comunidade indigena considerada. A despeito do vertigioso movimento da sociedade "civilizada" em direcao a Amazonia, os indios permaneceram ate o momento nas mesmas condicoes de saude observadas 30 anos atras

Utilizacao da prova de absorcao da D-Xilose na caracterizacao de ma absorcao. / Utilization of D-xylose absorption test in the characterization of malabsorption

O teste da D-xilose tem sido largamente usado para determinar a capacidade de absorcao intestinal. Foram estudadas 218 criancas divididas em varios grupos: I(Controle):37;II-Enteropatia Tropical: 87; III - Sindrome do Colon Irritavel: 29; IV - Diarreia Fermentativa 15; V - Diarreia Aguda: 16; VI - Doenca Celiaca nao Tratada: 14; VII - Doenca Celiaca Tratada: 16; VIII - Alergia a Proteina do Leite de Vaca: 6; IX - Resseccao de Ileo Terminal: 6; X - Nanismo Proporcionado: 11. Os valores medios e os desvios padroes de D-xilosemia de 1a. hora em mg% foram: I - 46,0 +/- 13,0; II - 30,7 +/- 11,0; III - 48,0 +/- 13,0; IV - 40,6 +/- 13,9; V - 27,4 +/- 11,6; VI - 11,4 +/- 5,7; VII - 38,2 +/- 8,2; VIII 19,9 +/- 6,1; IX - 45,5 +/- 17,4; X - 47,6 +/- 14,9. Os valores encontrados nos grupos II, V, VI, VII e VIII foram significamente inferiores aos do grupo I (p < 0,01)

Small bowel bacterial flora in normal and in children with acute diarrhea.

The aerobic bacteria microflora of the upper small bowel in normal children and in children with acute diarrhea was studied. Forty one children aging between 2 months and 5 years were divided in 3 groups: Group I--13 wellnourished children with no signs of gastrointestinal abnormalities remained intubated for less than 4 hours; Group II--11 wellnourished children that remained intubated for a period of time varying from 4 to 24 hours; Group III--17 children with acute diarrhea. There was a striking difference in the bacterial pattern between children from groups I and II and these findings were attributed to the prolonged time of intubation. In group I the jejunal fluid was sterile in approximately 40% of the children and in the others there was only growth of a GRAM positive flora while in group II the jejunal fluid never presented as a sterile one, and in approximately 73% of the cases there was a growth of a mixed GRAM positive and GRAM negative microflora, mainly due to Enterobacteria. In group III an aerobic microflora different from that one verified in group I was found in 76,4% of the patients. In 47.05% of the cases a bacterial growth equivalent to the fecal flora has been observed, in 5.89% Pseudomonas aeruginosa was located and in 23.52% yeasts were cultured from the jejunal fluid. These data confirm the hypothesis that bacterial and fungi infections are most prevalent in underdeveloped countries. This is probably due to the poor sanitary conditions observed in these countries associated with a high index of environmental contamination.