Lung function in obese children and adolescents without respiratory disease: a systematic review.

BACKGROUND: Obesity in children and adolescents is associated with increased morbidity and mortality due to multisystemic impairment, including deleterious changes in lung function, which are poorly understood. OBJECTIVES: To perform a systematic review to assess lung function in children and adolescents affected by obesity and to verify the presence of pulmonary changes due to obesity in individuals without previous or current respiratory diseases. METHODS: A systematic search was performed in the MEDLINE-PubMed (Medical Literature Analysis and Retrieval System Online), Embase (Excerpta Medica Database) and VHL (Virtual Health Library/Brazil) databases using the terms "Lung Function" and "Pediatric Obesity" and their corresponding synonyms in each database. A period of 10 years was considered, starting in February/2008. After the application of the filters, 33 articles were selected. Using the PICOS strategy, the following information was achieved: (Patient) children and adolescents; (Intervention/exposure) obesity; (Control) healthy children and adolescents; (Outcome) pulmonary function alterations; (Studies) randomized controlled trial, longitudinal studies (prospective and retrospective studies), cross-over studies and cross-sectional studies. RESULTS: Articles from 18 countries were included. Spirometry was the most widely used tool to assess lung function. There was high variability in lung function values, with a trend towards reduced lung function markers (FEV1/FVC, FRC, ERV and RV) in obese children and adolescents. CONCLUSION: Lung function, measured by several tools, shows numerous markers with contradictory alterations. Differences concerning the reported results of lung function do not allow us to reach a consensus on lung function changes in children and adolescents with obesity, highlighting the need for more publications on this topic with a standardized methodology.

The relationship between physical functional capacity and lung function in obese children and adolescents.

BACKGROUND: There is no consensus regarding obesity repercussions for lung function in children and adolescents. Therefore, the aim of the study was to determine whether obesity is associated with poor physical conditioning and damaged lung function in children and adolescents, and to correlate lung function with six-minute walk test (6MWT) results. METHODS: This cross-sectional study included 38 obese subjects of both sexes, ranging between 5 and 17 years of age, as well as 56 control subjects paired by sex and age for the 6MWT, and 39 subjects for spirometry. Subjects performed spirometry according to the guidelines of the American Thoracic Society (ATS) and the European Respiratory Society. The obese group repeated spirometry after receiving bronchodilator (BD) treatments. Physical performance was evaluated via the 6MWT according to ATS guidelines. RESULTS: The obese group demonstrated lower forced expiratory volumes in the first second compared with the control group based on forced vital capacity indices (p < 0.01), findings consistent with airway obstruction in 36.8% of patients in the obese group. Walking distances were shorter in the obese group than in the control group. Changes in lung function did not correlate directly with performance on the 6MWT among obese patients. However, there was a correlation between lung function and variables indicative of effort during exercise. CONCLUSION: In the present study, the obese group walked shorter distances and demonstrated lower values in some markers of lung function. However, there is no relationship between their physical conditions and these test results. Therefore, we cannot conclusively state that poor physical performance results from damaged pulmonary function.

Association between Pulmonary Function and Body Composition in Children and Adolescents with and without Obesity.

Lung function in children and adolescents with obesity must consider the coexistence of two complex and related phenomena: obesity and growth. The assessment of body composition can identify changes in respiratory dynamics arising, exclusively or jointly, from adiposity and lean body mass. This study aimed to compare pulmonary function and the dysanapsis indices of children and adolescents without asthma, with and without obesity, considering body composition, pubertal development, and physical activity practice. We performed a cross-sectional study with 69 participants, 41 (59.42%) of whom have obesity. All participants carried out spirometry and the assessment of, respectively, body composition by dual-energy X-ray absorptiometry, vital signs, pubertal development, and physical activity practice. In our data, the group with obesity had higher values of forced vital capacity (FVC) and lower values of the ratio between forced expiratory volume in one second and FVC (FEV1/FVC). Analyzing the entire sample, we found a positive correlation between FVC and a negative correlation between FEV1/FVC with fat mass markers. At the same time, inspiratory capacity, expiratory reserve volume, and peak expiratory flow were correlated with lean body mass markers. In addition, participants with obesity presented a lower dysanapsis index. In conclusion, children and adolescents with obesity showed increased FVC and reduced FEV1/FVC. Our findings are possibly related to the increase in fat mass, not to lean body mass. We hypothesize that these findings are associated with the dysanaptic growth pattern, which is higher in obesity, evidenced by the reduction of the dysanapsis index.

Concordance between whole- and half-body scans to evaluate body composition in dual-energy X-ray absorptiometry in children and adolescents with different nutritional and pubertal conditions.

OBJECTIVES: Evaluation of body composition is a relevant clinical instrument for the follow-up assessments of children and adolescents, and dual-energy X-ray absorptiometry (DXA) is an accurate method for the pediatric population. However, DXA has limited scan area for the obese population. Thus, half-body scans emerged as an alternative to evaluate individuals with obesity. The aim of this study was to compare the body composition of children and adolescents with whole- and half-body DXA scans, considering nutritional status, pubertal development, sex, and age. METHODS: This was a cross-sectional, analytical, and diagnostic intervention study with a sample of 82 participants of both sexes between 4 and 20 y of age. Body composition was evaluated by DXA using an iDXA bone densitometer (GE Healthcare Lunar, Madison, WI, USA). Two evaluations were performed: whole-body and half-body scans. The Bland-Altman correlation and linear regression tests were applied to identify the presence of association bias between the techniques. α = 0.05 was set. RESULTS: Of the 82 participants, 20 were excluded. A high correlation was observed between the data (correlation coefficient ∼0.999). Bland-Altman plots and regression analyses demonstrated correlation and randomness bias between whole- and half-body scan techniques in obese or normal weight participants for all DXA markers. CONCLUSIONS: The use of half-body scans was feasible and accurate to evaluate whole-body composition. The difference bias between techniques occurred randomly and was clinically irrelevant. A high correlation was observed between half- and whole-body analysis techniques.

Body mass index cutoff point estimation as obesity diagnostic criteria in Down syndrome adolescents.

INTRODUCTION: Adolescents with Down syndrome (DS) show high rate of overweight and tend to accumulate high amount of fat compared to the same people without the syndrome. OBJECTIVE: To estimate the cutoff point of the Body Mass Index (BMI) for the diagnosis of obesity in adolescents with DS according to different references for BMI in relation to the percentage of body fat (%BF) measured by dual-energy X-ray absorptiometry (DXA). METHODS: The sample was composed of 34 adolescents with DS (aged: 10 to 17 years old). BMI was evaluated according to the references of the International Obesity Task Force (IOTF), the World Health Organization (WHO) for the general population, and Myrelid et al. and Styles et al. for people with DS. The %BF was assessed by whole body DXA and classified according to National Health And Nutrition Examination Survey (NHANES, 2011). RESULTS: The boys were significantly taller than the girls and this %BF higher than boys. All references who have used BMI to assess obesity was positively associated with %BF measured by DXA in the diagnosis of obesity. Using the ROC curve in relation to %BF by DXA, all references showed high sensitivity, but the z-score of BMI by WHO showed better specificity, with the value of the accuracy of 0.82 for the cutoff point above 2.14. CONCLUSIONS: All the references used for the diagnosis of obesity were associated with %BF measured by DXA, and the cutoff point of z-scores above 2.14 by WHO showed better specificity.

Bariatric surgery: is it reasonable before the age of 16?

OBJECTIVE:: to assess the severity of obesity in children and adolescents through the presence of comorbidities and the potential indication of bariatric surgery. METHODS:: we conducted a cross-sectional study with clinical and laboratory data of the first consultation of patients at the childhood obesity clinic at a tertiary hospital from 2005 to 2013. We divided the patients into groups with or without potential indication for surgery, and recorded age, gender, birth weight, age of obesity onset, BMI Z score, presence of acanthosis nigricans, blood pressure, total cholesterol and fractions, triglycerides, blood glucose and fasting insulin, HOMA1-IR, CRP and ESR. The group with potential indication for surgery included: BMI > 40 or between 35-40 with comorbidities (Triglycerides >130mg/dl, glucose levels >100mg/dl, HOMA1-IR >3.16, Total Cholesterol >200mg/dl, LDL >130mg/dl and HDL <45mg/dl), regardless of age, epiphysis consolidation and previous treatment. RESULTS:: of the 296 patients included in the study, 282 (95.3%) were younger than 16 years. The most frequent change was the HDL (63.2%), followed by HOMA1-IR (37.5%). Of the group of 66 patients with potential indication for surgery (22.3%), only ten (15.1%) had more than 16 years. Acanthosis nigricans, the average HOMA1-IR, insulin, CRP, ESR, age, BMI Z score and systolic and diastolic blood pressure were significant in the group with potential surgical indication. CONCLUSION:: bariatric surgery might be indicated by BMI and comorbidities in children and adolescents under 16 years. OBJETIVO:: avaliar a gravidade da obesidade em crianças e adolescentes pela presença de comorbidades e pela potencial indicação de cirurgia bariátrica. MÉTODOS:: estudo transversal com dados clínicos e laboratoriais da primeira consulta de pacientes do ambulatório de obesidade infantil em um hospital terciário no período de 2005 a 2013. Os pacientes foram divididos em grupos com ou sem potencial indicação cirúrgica, e associados com idade, sexo, peso de nascimento, idade de início da obesidade, escore z de IMC, presença de acantose nigricans, pressão arterial, colesterol total e frações, triglicérides, glicemia e insulina de jejum, HOMA1-IR, PCR e VHS. O grupo com potencial indicação cirúrgica incluiu: IMC >40 ou IMC entre 35-40 com comorbidades (Triglicérides >130mg/dl, Glicemia >100mg/dl, HOMA1-IR >3,16, Colesterol total >200mg/dl, LDL >130mg/dl e HDL <45mg/dl), independente da idade, consolidação das epífises e tratamento prévio. RESULTADOS:: de 296 pacientes incluídos no estudo, 282 (95,3%) tinham menos de 16 anos. A alteração mais frequente foi a do HDL (63,2%), seguido do HOMA1-IR (37,5%). Do grupo de 66 pacientes com potencial indicação cirúrgica (22,3%), apenas dez (15,1%) tinham mais de 16 anos. Acantose nigricans, as médias de HOMA1-IR, insulina, PCR, VHS, idade, escore z de IMC e pressões sistólica e diastólica foram significantes no grupo com potencial indicação cirúrgica. CONCLUSÃO:: os resultados sugerem que a cirurgia bariátrica, poderia estar indicada pelo IMC e presença de comorbidades, em crianças e adolescentes com menos de 16 anos.

Metabolic syndrome in obese adolescents: what is enough?

OBJECTIVE: To study the agreement among three distinct criteria for metabolic syndrome (MS) adapted to adolescents, and to identify associated factors for MS. METHODS: Cross-sectional study with 65 obese subjects aged 10 to 18 years, attended to at the Outpatient Clinic for Obese Children and Adolescents at the Clinical Hospital of the Universidade Estadual de Campinas (Unicamp). MS was defined using the criteria of the World Health Organization (WHO), the International Diabetes Federation (IDF), and the Adult Treatment Panel III (ATP III). Clinical, anthropometrical, and laboratorial data were associated to MS. RESULTS: From the 65 subjects, none had MS according to the WHO criteria, while 18 were diagnosed with MS (27.6%) according to the IDF, and 19 (29.2%) according to the ATP III. Agreement between IDF and ATP III was excellent (kappa 81%). In this study, puberty and triglycerides levels showed significant statistical difference when comparing subjects with and without MS, the first for ATP III (p = 0.03), and the second for IDF (p = 0.005) and ATP III (p = 0.001) criteria. CONCLUSION: The WHO criteria does not seem to be adequate for adolescents. IDF and ATP III criteria had an excellent agreement. Puberty and triglycerides were associated with MS.

[Pediatric care in Brazil's Unified Health System: reflections on the role of pediatricians in Family Healthcare Strategy]. / A prática pediátrica no SUS: reflexões sobre o papel dos pediatras na Estratégia de Saúde da Família.

This essay seeks to contribute to the elucidation of the potential activities of pediatricians in the Family Healthcare Strategy. The origins, types of care and inherent implications to the process of change in the Healthcare Model that are being implemented in the Brazilian Unified Health System (SUS) since the Basic Operational Norms were instituted in 1996 are duly presented.

A interferência relativa das avós no aleitamento materno de suas filhas adolescentes / Grandmothers' relative interference with their teenage daughter's breastfeeding / La interferencia relativa de las abuelas para la lactancia materna de sus hijas adolescentes

Objetivo: Compreender influência das avós no exercício e duração do aleitamento materno de suas filhas adolescentes, durante os primeiros seis meses de vida da criança. Métodos: Estudo qualitativo, realizado com 25 futuras avós, que conviviam com suas filhas ou noras adolescentes grávidas, antes e após o nascimento de seus netos, no período de março de 2011 a janeiro de 2014. As entrevistas foram guiadas por um roteiro semiestruturado, e uma vez transcritas foram analisadas de forma temática, da qual emergiu a categoria: "O processo de amamentar para as avós". Resultados: As avós mostraram-se presentes na amamentação de seus netos desde os momentos iniciais até a introdução de alimentos complementares e as suas experiências pessoais de sucesso no aleitamento materno foram importantes para a construção do apoio à nutriz adolescente. Com passar do tempo, as avós se posicionaram na retaguarda, permitindo que as adolescentes assumissem a responsabilidade de principais cuidadoras dos bebês. Conclusão: A influência das avós na amamentação de seus netos se deu pela crença compartilhada que amamentar é importante, saudável e uma obrigação da mãe.

Objective: To understand the influence of grandmothers on the effectiveness and duration of breastfeeding of their teenage daughters during the child's first six months of life. Methods: Qualitative study conducted with 25 new grandmothers who lived with their pregnant teenage daughters or daughters-in-law before and after the birth of their grandchildren from March 2011 to January 2014. The interviews were guided by a semi-structured questionnaire; after transcription, data underwent thematic analysis, which yielded the category: "the breastfeeding process for grandmothers." Results: Grandmothers were present during the breastfeeding of their grandchildren from the earliest moments to the introduction of complementary foods; successful personal experiences with breastfeeding were important for building support for the nursing teenage mother. Over time, they stepped back and allowed the teenagers to take responsibility as the primary caregivers of the babies. Conclusion: The influence of grandmothers on the breastfeeding of their grandchildren is a result of the shared belief that breastfeeding is important, healthy and a mother's obligation.

Objetivo: Comprender la influencia de las abuelas en el ejercicio y la duración del amamantamiento materno de sus hijas adolescentes durante los primeros seis meses de vida del niño. Métodos: Estudio cualitativo realizado con 25 futuras abuelas que convivían con sus hijas o nueras adolescentes embarazadas antes y después del nacimiento de sus netos en el período entre marzo de 2011 y enero de 2014. Se utilizó para las entrevistas um guión semiestructurado y tras la transcripción las mismas fueron analizadas a través de temática de la cual emergió la categoría: "El proceso del amamantamiento para las abuelas". Resultados: Las abuelas estuvieron presentes durante el amamantamiento de sus nietos desde los primeros momentos hasta la introducción de los alimentos complementarios. Las experiencias personales de éxito para el amamantamiento materno fueron importantes para la construcción del apoyo a la adolescente y a lo largo del tiempo se pusieron en retaguardia permitiendo que las adolescentes asumieran la responsabilidad de principales cuidadoras de los bebés. Conclusión: La influencia de las abuelas para el amamantamiento de sus nietos se dio por la creencia compartida de que amamantar es importante y saludable y es una obligación de la madre.

Bariatric surgery: is it reasonable before the age of 16? / Cirurgia bariátrica: é razoável antes dos 16 anos de idade?

ABSTRACT Objective: to assess the severity of obesity in children and adolescents through the presence of comorbidities and the potential indication of bariatric surgery. Methods: we conducted a cross-sectional study with clinical and laboratory data of the first consultation of patients at the childhood obesity clinic at a tertiary hospital from 2005 to 2013. We divided the patients into groups with or without potential indication for surgery, and recorded age, gender, birth weight, age of obesity onset, BMI Z score, presence of acanthosis nigricans, blood pressure, total cholesterol and fractions, triglycerides, blood glucose and fasting insulin, HOMA1-IR, CRP and ESR. The group with potential indication for surgery included: BMI > 40 or between 35-40 with comorbidities (Triglycerides >130mg/dl, glucose levels >100mg/dl, HOMA1-IR >3.16, Total Cholesterol >200mg/dl, LDL >130mg/dl and HDL <45mg/dl), regardless of age, epiphysis consolidation and previous treatment. Results: of the 296 patients included in the study, 282 (95.3%) were younger than 16 years. The most frequent change was the HDL (63.2%), followed by HOMA1-IR (37.5%). Of the group of 66 patients with potential indication for surgery (22.3%), only ten (15.1%) had more than 16 years. Acanthosis nigricans, the average HOMA1-IR, insulin, CRP, ESR, age, BMI Z score and systolic and diastolic blood pressure were significant in the group with potential surgical indication. Conclusion: bariatric surgery might be indicated by BMI and comorbidities in children and adolescents under 16 years.

RESUMO Objetivo: avaliar a gravidade da obesidade em crianças e adolescentes pela presença de comorbidades e pela potencial indicação de cirurgia bariátrica. Métodos: estudo transversal com dados clínicos e laboratoriais da primeira consulta de pacientes do ambulatório de obesidade infantil em um hospital terciário no período de 2005 a 2013. Os pacientes foram divididos em grupos com ou sem potencial indicação cirúrgica, e associados com idade, sexo, peso de nascimento, idade de início da obesidade, escore z de IMC, presença de acantose nigricans, pressão arterial, colesterol total e frações, triglicérides, glicemia e insulina de jejum, HOMA1-IR, PCR e VHS. O grupo com potencial indicação cirúrgica incluiu: IMC >40 ou IMC entre 35-40 com comorbidades (Triglicérides >130mg/dl, Glicemia >100mg/dl, HOMA1-IR >3,16, Colesterol total >200mg/dl, LDL >130mg/dl e HDL <45mg/dl), independente da idade, consolidação das epífises e tratamento prévio. Resultados: de 296 pacientes incluídos no estudo, 282 (95,3%) tinham menos de 16 anos. A alteração mais frequente foi a do HDL (63,2%), seguido do HOMA1-IR (37,5%). Do grupo de 66 pacientes com potencial indicação cirúrgica (22,3%), apenas dez (15,1%) tinham mais de 16 anos. Acantose nigricans, as médias de HOMA1-IR, insulina, PCR, VHS, idade, escore z de IMC e pressões sistólica e diastólica foram significantes no grupo com potencial indicação cirúrgica. Conclusão: os resultados sugerem que a cirurgia bariátrica, poderia estar indicada pelo IMC e presença de comorbidades, em crianças e adolescentes com menos de 16 anos.

Effects of swimming on spirometric parameters and bronchial hyperresponsiveness in children and adolescents with moderate persistent atopic asthma.

OBJECTIVE: To investigate the medium-term benefits of a swimming program in schoolchildren and adolescents with moderate persistent atopic asthma (MPAA). METHODS: A randomized, prospective study of children and adolescents (age 7-18 years) with MPAA was carried out at the Hospital de Clínicas of Universidade Estadual de Campinas (UNICAMP), Campinas, Brazil. After a 1-month run-in period, 61 patients (34 female) were randomized into two groups, a swimming group (n = 30) and a control group (n = 31), and followed for 3 months. Both patient groups received inhaled fluticasone (dry powder, 250 mcg twice a day) and salbutamol as needed. The swim training program consisted of two weekly classes over a 3-month period for a total of 24 sessions. Both groups underwent spirometric assessment and methacholine challenge test--provocative concentration of methacholine causing a 20% fall in FEV1 (PC20)--before and after the study period. Maximal inspiratory pressure (MIP) and maximal expiratory pressure (MEP) were measured only in the swimming group. RESULTS: Significant increases in PC20 (pre-training, 0.31±0.25; post-training, 0.63±0.78; p = 0.008), MIP (pre-training, 67.08±17.13 cm H2O; post-training 79.46±18.66; p < 0.001), and MEP (pre-training, 71.69±20.01 cm H2O; post-training, 78.92±21.45 cm H2O; p < 0.001) were found in the swimming group. CONCLUSION: Children and adolescents with MPAA subjected to a swim training program experienced a significant decrease in bronchial hyperresponsiveness, as determined by increased PC20 values, when compared with asthmatic controls who did not undergo swim training. Participants in the swimming group also showed improvement in elastic recoil of the chest wall.

Metabolic syndrome in obese adolescents: what is enough? / Síndrome metabólica em adolescentes obesos: o que é suficiente?

OBJECTIVE: To study the agreement among three distinct criteria for metabolic syndrome (MS) adapted to adolescents, and to identify associated factors for MS. METHODS: Cross-sectional study with 65 obese subjects aged 10 to 18 years, attended to at the Outpatient Clinic for Obese Children and Adolescents at the Clinical Hospital of the Universidade Estadual de Campinas (Unicamp). MS was defined using the criteria of the World Health Organization (WHO), the International Diabetes Federation (IDF), and the Adult Treatment Panel III (ATP III). Clinical, anthropometrical, and laboratorial data were associated to MS. RESULTS: From the 65 subjects, none had MS according to the WHO criteria, while 18 were diagnosed with MS (27.6%) according to the IDF, and 19 (29.2%) according to the ATP III. Agreement between IDF and ATP III was excellent (kappa 81%). In this study, puberty and triglycerides levels showed significant statistical difference when comparing subjects with and without MS, the first for ATP III (p = 0.03), and the second for IDF (p = 0.005) and ATP III (p = 0.001) criteria. CONCLUSION: The WHO criteria does not seem to be adequate for adolescents. IDF and ATP III criteria had an excellent agreement. Puberty and triglycerides were associated with MS.

OBJETIVO: Avaliar a correlação de três critérios de síndrome metabólica (SM) para adolescentes e identificar fatores associados. MÉTODOS: Estudo transversal com 65 pacientes obesos entre 10 e 18 anos do Ambulatório de Crianças e Adolescentes Obesos do HC-Unicamp. SM foi definida de acordo com a Organização Mundial da Saúde (OMS), International Diabetes Federation (IDF) e Adult Treatment Panel III (ATP III). Buscaram-se fatores associados a SM em dados clínicos, antropométricos e laboratoriais. RESULTADOS: Dos 65 pacientes, nenhum foi diagnosticado como SM pela OMS, sendo 18 (27.6%) pelo IDF e 19 (29.2%) pelo ATP III. A correlação entre IDF e ATP III foi excelente (kappa 81%). Neste estudo, a puberdade e os triglicérides apresentaram diferença estatisticamente significativa entre pacientes com e sem SM, sendo a primeira para o ATP III (p = 0.03) e o segundo para IDF (p = 0.005) e ATPIII (p = 0.001). CONCLUSÃO: O critério da OMS não parece ser adequado para adolescentes. Há correlação excelente entre os critérios do IDF e ATP III. Puberdade e triglicérides foram fatores associados à SM.

Proposta de atuação da fisioterapia na saúde da criança e do adolescente: uma necessidade na atenção básica / Proposal for a performance of physical therapy on the health of children and adolescents: a need in primary care

Objetivo: elaborar uma proposta de assistência fisioterapêutica na rede básica de saúde objetivando sistematizar esse serviço para a saúde da criança e do adolescente. Método: revisão bibliográfica/pesquisa nas bases de dados Scielo, Lilacs e Medline. Resultados: o fisioterapeuta não apenas restaura, desenvolve e conserva a capacidade física do paciente, como também previne doenças e promove orientações. Assim, propõe-se sua atuação com base em três estratégias: orientação, assistência e acompanhamento. Conclusão: o fisioterapeuta na atenção primária pode efetivar sua integração na equipe multiprofissional das UBS, no apoio matricial e programas de saúde da família.

Objective: To develop a proposal for physical therapy in primary health aiming to systematize this service to child health and adolescent. Method: literature / research in Scielo, Lilacs and Medline. Results: the therapist not only restores, develops and retains the physical ability of the patient, also prevents diseases and promotes guidelines. Thus, we propose a performance based on three strategies: guidance, assistance and support. Conclusion: the physiotherapist in primary care can accomplish their integration into multidisciplinary team of basic health units in the matrix support programs and family health.

Peso, estatura e comprimento em crianças e adolescentes com síndrome de Down: análise comparativa de indicadores antropométricos de obesidade / Weight, height and length in children and adolescents with Down syndrome: a comparative analysis of anthropometric indicators of obesity

A obesidade é considerada uma epidemia, que acomete também crianças e adolescentes com síndrome de Down. Contudo, como não há um parâmetro consensual para diagnosticar obesidade nessa população, o objetivo deste trabalho foi realizar uma revisão crítica de artigos que estudam índices antropométricos, para avaliação do estado nutricional de crianças e adolescentes com essa síndrome. O levantamento dos artigos foi realizado nas bases de dados PubMed, MedlLine, Lilacs e SciELO, dando-se importância aos parâmetros antropométricos e sua relação com a obesidade. De 83 artigos iniciais, foram selecionados 11 para análise crítica. Nos Estados Unidos, estabeleceram uma curva de normalidade para peso e estatura de crianças e adolescentes com síndrome de Down e, quando compararam os seus valores com as curvas do National Center for Health Statistics, observaram que houve um padrão menor de crescimento em estatura. Em estudos europeus, observou-se o mesmo fato. No Brasil, Mustacchi desenvolveu índices de peso/idade e estatura/idade e observou deficit importante de estatura, quando comparou estatura/idade com as curvas do National Center for Health Statistics e com as curvas de Cronk et al. Em CONCLUSÃO:, os dados antropométricos disponíveis em curvas pôndero-estaturais são considerados relativos a uma determinada população e revelam suas características específicas, porque expressam a influência dos fatores ambientais e determinantes genéticos. Portanto, há necessidade de se definir curvas de padrão de referência para crianças e adolescentes com síndrome de Down em diferentes faixas etárias, regiões e etnias, para se diagnosticar corretamente seu estado nutricional.

Obesity is considered an epidemic and also affects children and adolescents with Down syndrome. However, since a consensual parameter for diagnosing obesity in this population does not exist, the objetive of this study was to perform a critical review of the literature on anthropometric indices to assess the nutritional status of children and adolescents with this syndrome. The databases PubMed, MedLine, Lilacs and SciELO were searched focusing on the importance of anthropometric parameters and their relationship with obesity. Of the 83 articles found, 11 were selected for critical analysis. In the United States of America, weight and height curves were established specifically for children and adolescents with Down syndrome. When these curves were compared with those of the National Center for Health Statistics, they found that children and adolescents with Down syndrome grow less. The same fact was reported by European studies. In Brazil, Mustacchi developed weight-for-age and height-for-age indices for these children and compared his height-for-age curve with those of the National Center for Health Statistics and Cronk et al.'s, and found that Brazilian children with Down syndrome are significantly shorter. In conclusion, the anthropometric data in weight-for-height curves refer to a particular population and reveal their specific characteristics since they reflect the influence of environmental factors and genetic determinants. Therefore, it is necessary to define standard reference curves for children and adolescents with Down syndrome of different ages, regions and ethnicities, so that their nutritional status can be diagnosed properly.

A prática pediátrica no SUS: reflexões sobre o papel dos pediatras na Estratégia de Saúde da Família / Pediatric care in Brazil's Unified Health System: reflections on the role of pediatricians in Family Healthcare Strategy

Este ensaio pretende contribuir para aclarar as possibilidades de atuação dos pediatras na Estratégia de Saúde da Família. Apresentam-se as origens, as modalidades de atuação e as implicações inerentes aos processos de mudança do Modelo de Atenção que, desde a Norma Operacio­nal Básica (NOB) de 1996 vem sendo implantado no Sistema Único de Saúde Brasileiro - SUS.

This essay seeks to contribute to the elucidation of the potential activities of pediatricians in the Family Healthcare Strategy. The origins, types of care and inherent implications to the process of change in the Healthcare Model that are being implemented in the Brazilian Unified Health System (SUS) since the Basic Operational Norms were instituted in 1996 are duly presented.

Avaliação espirométrica e da hiper-responsividade brônquica de crianças e adolescentes com asma atópica persistente moderada submetidos a natação / Effects of swimming on spirometric parameters and bronchial hyperresponsiveness in children and adolescents with moderate persistent atopic asthma

OBJETIVO: Investigar os benefícios a médio prazo de um programa de natação em escolares e adolescentes com asma atópica persistente moderada (AAPM). MÉTODOS: Realizou-se um estudo randomizado e prospectivo com crianças e adolescentes (7-18 anos de idade) com AAPM no Hospital de Clínicas da Universidade Estadual de Campinas (UNICAMP), Campinas (SP). Após um período de run in de um mês, 61 pacientes (34 femininos) foram randomizados em dois grupos: grupo natação (GN) (n = 30) e grupo controle (GC) (n = 31) e foram acompanhados durante 3 meses. Os dois grupos receberam fluticasona (pó) inalada (250 mcg, 2 vezes ao dia) diariamente e salbutamol inalado, quando necessário. O programa de natação consistiu em um total de 24 aulas, duas vezes por semana, por 3 meses. O GN e o GC realizaram espirometria, teste de broncoprovocação com metacolina (provocative concentration of methacholine causing a 20 por cento fall in FEV1, PC20 de metacolina), antes e após os 3 meses de estudo. Pressão inspiratória máxima (PImax) e pressão expiratória máxima (PEmax) foram realizadas somente no GN. RESULTADOS: Observou-se que o GN apresentou aumento significativo da PC20 de metacolina (inicial 0,31±0,25 e final 0,63±0,78; p = 0,008), pressão inspiratória máxima (inicial 67,08±17,13 cm H2O e final 79,46±18,66; p < 0,001), pressão expiratória máxima (inicial 71,69±20,01 cm H2O e final 78,92±21,45 cm H2O; p < 0,001). CONCLUSÃO: Crianças e adolescentes com AAPM que se submeteram a um programa de natação apresentaram diminuição estatisticamente significativa da hiper-responsividade brônquica, com aumento dos valores da PC20 de metacolina, quando comparados aos com AAPM que não realizaram natação. O GN também apresentou melhora no componente da força elástica do tórax.

OBJECTIVE: To investigate the medium-term benefits of a swimming program in schoolchildren and adolescents with moderate persistent atopic asthma (MPAA). METHODS: A randomized, prospective study of children and adolescents (age 7-18 years) with MPAA was carried out at the Hospital de Clínicas of Universidade Estadual de Campinas (UNICAMP), Campinas, Brazil. After a 1-month run-in period, 61 patients (34 female) were randomized into two groups, a swimming group (n = 30) and a control group (n = 31), and followed for 3 months. Both patient groups received inhaled fluticasone (dry powder, 250 mcg twice a day) and salbutamol as needed. The swim training program consisted of two weekly classes over a 3-month period for a total of 24 sessions. Both groups underwent spirometric assessment and methacholine challenge test - provocative concentration of methacholine causing a 20 percent fall in FEV1 (PC20) - before and after the study period. Maximal inspiratory pressure (MIP) and maximal expiratory pressure (MEP) were measured only in the swimming group. RESULTS: Significant increases in PC20 (pre-training, 0.31±0.25; post-training, 0.63±0.78; p = 0.008), MIP (pre-training, 67.08±17.13 cm H2O; post-training 79.46±18.66; p < 0.001), and MEP (pre-training, 71.69±20.01 cm H2O; post-training, 78.92±21.45 cm H2O; p < 0.001) were found in the swimming group. CONCLUSION: Children and adolescents with MPAA subjected to a swim training program experienced a significant decrease in bronchial hyperresponsiveness, as determined by increased PC20 values, when compared with asthmatic controls who did not undergo swim training. Participants in the swimming group also showed improvement in elastic recoil of the chest wall.

Distribuição dos processos disciplinares pelo CREMESP - Conselho Regional de Medicina do Estado de São Paulo e seus resultados nas diversas especialidades médicas / Distribution of disciplinary investigations by CREMESP - Regional Council of Medicine of São Paulo State and their verdictis in the different medical specialties

O presente estudo teve como objetivo estimar a incidência de processos e condenações de médicos no CREMESP, comparando as diversas especialidades com base em coeficientes, entre os anos de 1995 e 2003. Foram coletados da base de dados do CREMESP informações sobre os processos éticodisciplinares instaurados e as condenações aplicadas entre os anos de 1995 e 2003, totalizando 4806 médicos processados e 1146 condenados. Foram desenvueltos coeficientes de incidência de processos e condenações entre as especialidades a partir de estimativas do número de especialistas tendo como base o registro de especialistas em cada área no CREMESP em 2003. Tem-se como resultados que a Ginecologia-Obstetrícia foi a especialidade médica com maior número de processos e condenações. Entretanto, analisada a correlação entre as especialidades, através de coeficientes, Cirurgia Plástica emerge como a especialidade com o maior coeficiente de processos e condenações por especialista da área. Concluiu-se que o uso de coeficientes para a análise da incidencia de processos e condenações entre as diferentes especialidades médicas permite uma melhor observação das especificidades de cada área de especialidade quanto a processos e condenações.(AU)

This study aims to identify the incidence of investigations and convictions of doctors in CREMESP, comparing the different specialties on the basis of coefficients, from the year 1995 to the year 2003. Data were searched in the database of CREMESP on ethical-disciplinary investigations done and convictions applied from 1995 to 2003, in a total of 4806 doctors investigated and 1146 convicted. Coefficients of incidence of investigation procedures and convictions distributed among specialties based on estimates of the number of specialists were developed considering the registry of specialists in each area in CREMESP in 2003. Results show that Gynecology-Obstetrics was the medical specialty with higher numbers of investigations and convictions. However, when the correlation between the specialties was analyzed by means of coefficients, Plastic Surgery emerges as the specialty with the highest coefficient of procedures and convictions by specialist. One concludes that the use of coefficients for analyzing the incidence of procedures and convictions among the different medical specialties allows a better exam of the specificities of each specialty regarding investigations and convictions.(AU)

Este estudio apunta identificar la incidencia de investigaciones y de condenaciones de doctores por el CREMESP, comparando las diversas especialidades en base de coeficientes, a partir del año 1995 hasta al año 2003. Los datos fueron buscados en la base de datos de CREMESP, se buscando informaciones acerca de las investigaciones ético-disciplinarias hechas y las condenaciones aplicadas a partir de 1995 hasta 2003, en un total de 4806 doctores investigados y 1146 condenados. Se desarrollaran coeficientes de incidencia de los procedimientos y de las condenaciones en investigaciones distribuidas entre las especialidades en base a estimativas del número de especialistas, considerando el registro de especialistas en cada área en CREMESP en 2003. Los resultados demuestran que la Ginecología-Obstetricia fue la especialidad médica con números más altos de investigaciones y de condenaciones. Sin embargo, cuando la correlación entre las especialidades fue analizada por medio de coeficientes, la cirugía plástica emerge como la especialidad con el coeficiente más alto de procedimientos y de condenaciones de especialistas. Uno concluye que el uso de coeficientes para analizar la incidencia de procedimientos y condenaciones entre las diversas especialidades médicas permite un examen mejor de las especificidades de cada especialidad respecto investigaciones y condenaciones.(AU)

Hipotireoidismo adquirido tratado como obesidade exógena: a importância do controle do crescimento / Acquired hypothyroidism treated as exogen obesity: the importance of growth follow-up

OBJETIVO: Demonstrar a importância da interpretação do acompanhamento pôndero-estatural de crianças e adolescentes obesos DESCRIÇÃO DO CASO: Menina de 12 anos e 11 meses encaminhada a um ambulatório terciário para acompanhamento de obesidade e dislipidemia. Referia ganho de peso a partir de oito anos, negava fazer atividade física e possuía alimentação adequada. Relatava obesidade na família do pai. Ao exame, bom estado geral, diminuição da pilificação e mixedema generalizados, pele ressecada e áspera. Peso com percentil entre 90 e 97, índice de massa corpórea (IMC) acima do percentil 97 e estatura abaixo do canal de crescimento. EXAMES LABORATORIAIS: T4: 0,04ng/ dL, TSH: >100uUI/mL, colesterol total: 326mg/ dL, HDL colesterol: 34mg/ dL, LDL colesterol: 45mg/ dL, triglicérides: 1599mg/ dL, glicemia em jejum: 81mg/dL e hemograma com discreta anemia normocrômica e normocítica. Fez-se o diagnóstico de hipotireoidismo e introduziu-se hormônio tireoidiano com boa resposta. A paciente trouxe 23 medidas prévias de peso e estatura, mostrando comprometimento de estatura e aumento de peso não valorizado. COMENTÁRIOS: A análise dos gráficos de crescimento é fundamental para o acompanhamento de todas as crianças e adolescentes, principalmente aquelas com sobrepeso e obesidade. A desaceleração da curva de crescimento em altura sugere doença associada; neste caso, o hipotireoidismo adquirido.

OBJECTIVE: To show the value of using the follow-up growth charts in clinical evaluation of obese children and adolescents. CASE DESCRIPTION: A 12 years and 11 months-old girl referred to a tertiary out-patient clinic to evaluate obesity and lipid abnormalities. She had weight gain since eight years old, had no physical activity and followed adequate eating habits. Obesity was referred in father's family. In physical examination, she looked well, with lack of body hair, generalized mixedema, dry and rough skin. Weight was between percentile 90 and 97; BMI was over the percentile 97 and height was under the growth channel. LABORATORY EXAMS: T4: 0.04ng/dL, TSH: >100uUI/mL, total cholesterol: 326mg/dL, HDL cholesterol: 34mg/ dL, LDL cholesterol: 45mg/dL, triglycerides: 1599mg/dL, fasting glicose: 81mg/dL and hemogram with normocromic and normocytic anemia. Hypothyroidism diagnosis was made and thyroid hormone was introduced with good response. The patient brought 23 previous heights and weight measurements, which showed height drop and weight gain in the growth chart, all of them undervalued. COMMENTS: Growth chart analysis is important for the follow-up of children and adolescents, especially those with overweight and obesity. The linear growth slowing suggests an associated sickness; in this case, an acquired hypothyroidism.

Crianças e adolescentes obesos: dois anos de acompanhamento interdisciplinar / Obese children and adolescents: two years of interdisciplinary follow-up

OBJETIVO: Avaliar dois anos de seguimento de crianças e adolescentes obesos em ambulatório especializado. MÉTODOS: Trata-se de coorte, com coleta retrospectiva dos dados de 150 pacientes (1 a 19 anos de idade) do Ambulatório de Obesidade do Hospital de Clínicas da Universidade Estadual de Campinas. Destes pacientes, 53 por cento eram do sexo masculino e 63 por cento eram de Campinas, São Paulo. A média da idade no início de ganho de peso foi 4,3 anos. Dos 150 pacientes, 128 retornaram uma vez, com avaliação de peso, altura, índice de massa corpórea (IMC) e escores Z. Foram realizados hemograma, glicemia de jejum, insulina basal, relação glicemia/insulina, triglicérides, colesterol total e frações. Os pacientes foram divididos em dois grupos, de acordo com o seguimento. Entre os grupos, foi analisada a diferença entre idade, sexo, procedência, idade de início, acantose nigricans e os escores Z de peso, altura e IMC, proporção de exames laboratoriais alterados e a diferença dos escores Z de IMC em relação à primeira consulta. RESULTADOS: Dos 128 pacientes, 57 por cento permaneceram em seguimento, sendo que 114 retornaram pelo menos uma vez. Comparando os grupos, os moradores de Campinas foram os que mais abandonaram o ambulatório, sem diferenças em relação às demais variáveis clínicas, antropométricas e laboratoriais estudadas. Houve queda da média do escore Z do IMC em ambos os grupos, em relação à consulta inicial. CONCLUSÕES: Os pacientes deste estudo apresentaram redução da média do escore Z do IMC semelhante à literatura. Apesar do alto índice de abandono, não foram identificados fatores de risco que o justificassem, com exceção da procedência da criança.

OBJECTIVE: To study two years follow-up of obese children and adolescents from a specialized out-patient clinic. METHODS: This cohort study with retrospective collection of data enrolled 150 patients (1 to 19 years old, 53 percent males, 63 percent from Campinas, São Paulo, Brazil, and at mean age of 4.3 years when they started the weight gain). All patients were followed at the Obesity Out-Patient Clinic of the Clinical Hospital of Campinas University. Out of the 150 patients, 128 returned once and weight, height, body mass index (BMI) measurements and Z scores were obtained. Laboratory exams were colleted: hemoglobin, lipids, fasting glucose and fasting insulin. Glucose/insulin ratio was calculated. Patients were divided in two groups, if they returned or not to the clinic. Difference between both groups were analyzed regarding age, gender, city of origin, age when the weight gain started, acanthosis nigricans, weight, height, BMI Z score and proportion of altered laboratory exams. The difference in BMI Z score in relation to the first visit was also analyzed. RESULTS: Among the 128 patients, 57 percent continued to be followed in the clinic and 114 returned at least once. Comparing groups, patients from Campinas fail more to return. There were no differences in the clinical, anthropometric and laboratory variables. Both groups showed lower mean BMI Z score in the return visit compared to the first visit. CONCLUSIONS: The obese children and adolescents from the follow-up clinic showed a reduction in the mean BMI Z score similar to published data. The rate of dropping follow-up was high, but no variable could explain it, except for the patient origin.

Características clínicas e laboratoriais de crianças e adolescentes obesos / Clinical and laboratorial characteristics of obese children and adolescents

Objetivo: analisar características clínicas e laboratoriais de crianças e adolescentes obesas atendidas no Hospital de Clínicas da Universidade Estadual de Campinas (HC/Unicamp). Métodos: foram estudados 70 pacientes de 2-19 anos (57 por cento masculinos) do Ambulatório de Crinaças e Adolescentes Obesos ho HC/Unicamp, entre abril/2005 e fevereiro de 2006, sendo analisadas as taxas de hemoglobina, o lipidograma, a relação glicemia/insulina e o ácido úrico dos referidos poacientes. Resultados: a maioria dos pacientes estudados procedia da região de Campinas, encaminhada ao HC com queixa de obesidade e tratamento prévio. O início da obesidade ocorreu em 66 por cento antes dos cincos anos de idade e em 44 por cento, antes dos três anos. Das doenças concomitantes, predominou a atopia (24 por cento). O índice de massa corporal (IMC) variou de 21,1 a 58,5 (média: 31,8 e DP: 6,4), indicando obesidade em todos os pacientes. A bioimpedância não diagnosticou a obesidade em cinco crianças. Na primeira consulta, notou-se: alteração da pressão arterial (PA) em 54 por cento, acantose migricans em 58 por cento e estrias em 62 por cento dos indivíduos. Nos exames laboratorias, um paciente apresentou anemia e ácido úrico elevado; todas as glicemias de jejum foram normais; 15 por cento das dosagens de insulina estavam aumentadas e a relação glicemia/insulina <7,0 ocorreu em 53 por cento dos casos. No lipidograma, 15 por cento tinham triglicérides >130 mg/dL, 33 por cento colesterol total >170 mg/dL, 15 por cento LDL>130 mg/dL e 52 por cento HDL<45 mg/dL...