Secular trends and social inequalities in child behavioural problems across three Brazilian cohort studies (1993, 2004 and 2015).

AIMS: Previous epidemiological evidence identified a concerning increase in behavioural problems among young children from 1997 to 2008 in Brazil. However, it is unclear whether behavioural problems have continued to increase, if secular changes vary between sociodemographic groups and what might explain changes over time. We aimed to monitor changes in child behavioural problems over a 22-year period from 1997 to 2019, examine changing social inequalities and explore potential explanations for recent changes in behavioural problems between 2008 and 2019. METHODS: The Child Behaviour Checklist was used to compare parent-reported behavioural problems in 4-year-old children across three Brazilian birth cohorts assessed in 1997 (1993 cohort, n = 633), 2008 (2004 cohort, n = 3750) and 2019 (2015 cohort, n = 577). Response rates across all three population-based cohorts were over 90%. Moderation analyses tested if cross-cohort changes differed by social inequalities (demographic and socioeconomic position), while explanatory models explored whether changes in hypothesized risk and protective factors in prenatal development (e.g., smoking during pregnancy) and family life (e.g., maternal depression and harsh parenting) accounted for changes in child behavioural problems from 2008 to 2019. RESULTS: Initial increases in child behavioural problems from 1997 to 2008 were followed by declines in conduct problems (mean change = -2.75; 95% confidence interval [CI]: -3.56, -1.94; P < 0.001), aggression (mean change = -1.84; 95% CI: -2.51, -1.17; P < 0.001) and rule-breaking behaviour (mean change = -0.91; 95% CI: -1.13, -0.69 P < 0.001) from 2008 to 2019. Sex differences in rule-breaking behaviour diminished during this 22-year period, whereas socioeconomic inequalities in behavioural problems emerged in 2008 and then remained relatively stable. Consequently, children from poorer and less educated families had higher behavioural problems, compared to more socially advantaged children, in the two more recent cohorts. Changes in measured risk and protective factors partly explained the reduction in behavioural problems from 2008 to 2019. CONCLUSIONS: Following a rise in child behavioural problems, there was a subsequent reduction in behavioural problems from 2008 to 2019. However, social inequalities increased and remained high. Continued monitoring of behavioural problems by subgroups is critical for closing the gap between socially advantaged and disadvantaged children and achieving health equity for the next generation.

Two decades of socioeconomic inequalities in the prevalence of untreated dental caries in early childhood: Results from three birth cohorts in southern Brazil.

OBJECTIVES: To estimate the socioeconomic disparities in untreated dental caries in early childhood according to socioeconomic characteristics in three birth cohorts in Southern Brazil. METHODS: The socioeconomic data to this study were collected at the 48-month follow-up and oral health studies of 1993, 2004 and 2015 Pelotas birth cohort studies. The outcome was untreated dental caries in children aged 6 (1993 cohort), 5 (2004 cohort) and 4 years (2015 cohort), dichotomized into absence/presence. Analyses were stratified by maternal skin colour/race, maternal education and family income. For statistical purposes, the prevalence difference, relative risk and absolute and relative indices of health inequality (Slope Index of Inequality-SII and Concentration Index-CIX) were used. RESULTS: The prevalence of untreated dental caries in primary dentition was 63.4%, 45.5% and 15.6%, in 1993, 2004 and 2015 cohorts, respectively. The prevalence of untreated dental caries was concentrated in the poorest quintile and lower maternal education group in both absolute (SII) and relative (CIX) measures of inequality, being characterized as a pro-poor event. A higher risk of untreated caries was found in the poorest quintile of family income compared with the richest quintile in the 1993 cohort (RR 1.44 [95% CI 1.05; 1.98]). That risk was higher considering the 2004 Cohort (RR 1.78 [95% CI 1.42; 2.23]) and 2015 cohort (RR 4.20 [95% CI 2.97; 5.94]) data. CONCLUSIONS: Over the course of two decades, a higher prevalence of untreated dental caries is concentrated among the most socioeconomically deprived children.

Construction and validation of the Oxford Neurodevelopment Assessment (OX-NDA) in 1-year-old Brazilian children.

BACKGROUND: Over 250 million children under 5 years, globally, are at risk of developmental delay. Interventions during the first 2 years of life have enduring positive effects if children at risk are identified, using standardized assessments, within this window. However, identifying developmental delay during infancy is challenging and there are limited infant development assessments suitable for use in low- and middle-income (LMIC) settings. Here, we describe a new tool, the Oxford Neurodevelopment Assessment (OX-NDA), measuring cognition, language, motor, and behaviour, outcomes in 1-year-old children. We present the results of its evaluation against the Bayley Scales of Infant Development IIIrd edition (BSID-III) and its psychometric properties. METHODS: Sixteen international tools measuring infant development were analysed to inform the OX-NDA's construction. Its agreement with the BSID-III, for cognitive, motor and language domains, was evaluated using intra-class correlations (ICCs, for absolute agreement), Bland-Altman analyses (for bias and limits of agreement), and sensitivity and specificity analyses (for accuracy) in 104 Brazilian children, aged 12 months (SD 8.4 days), recruited from the 2015 Pelotas Birth Cohort Study. Behaviour was not evaluated, as the BSID-III's adaptive behaviour scale was not included in the cohort's protocol. Cohen's kappas and Cronbach's alphas were calculated to determine the OX-NDA's reliability and internal consistency respectively. RESULTS: Agreement was moderate for cognition and motor outcomes (ICCs 0.63 and 0.68, p < 0.001) and low for language outcomes (ICC 0.30, p < 0.04). Bland-Altman analysis showed little to no bias between measures across domains. The OX-NDA's sensitivity and specificity for predicting moderate-to-severe delay on the BSID-III was 76, 73 and 43% and 75, 80 and 33% for cognition, motor and language outcomes, respectively. Inter-rater (k = 0.80-0.96) and test-rest (k = 0.85-0.94) reliability was high for all domains. Administration time was < 20 minutes. CONCLUSION: The OX-NDA shows moderate agreement with the BSID-III for identifying infants at risk of cognitive and motor delay; agreement was low for language delay. It is a rapid, low-cost assessment constructed specifically for use in LMIC populations. Further work is needed to evaluate its use (i) across domains in populations beyond Brazil and (ii) to identify language delays in Brazilian children.

[Use of anti-bacterial agents in pregnant women before and after regulation in Brazil: Pelotas (Brazil) birth cohorts of 2004 and 2015]. / Uso de antibacterianos em gestantes antes e após regulamentação no Brasil: coortes de nascimentos de Pelotas, Rio Grande do Sul, de 2004 e 2015.

Indiscriminate use of anti-bacterial agents during pregnancy can increase antimicrobial resistance and endanger both the mother's and the children's health. Currently, Brazil has the Collegiate Directive Resolution n. 20/2011, which controls prescription and dispensation of anti-bacterial agents. Given this scenario, this study compared the use of anti-bacterial agents by pregnant women participating in the 2004 and 2015 Pelotas (Brazil) birth cohorts, in Rio Grande do Sul, Brazil, considering the regulation issued between the two cohorts. Data were collected in the perinatal period of the two studies. The main outcome was the use of anti-bacterial agents during pregnancy. Prevalence scans were described based on independent variables and differences in percentage points (p.p.) between the two cohorts. The prevalence of anti-bacterial use was 41.9% (95%CI: 40.4; 43.3) in 2004 and 39.2% (95%CI: 37.7; 40.6) in 2015. Considering the pregnant women who reported having infection during pregnancy, a greater reduction in use was observed in 2015, when compared to 2004, in poor women (-15.4p.p., 95%CI: 9.59; 21.20) and in those who had less consultations (-17.1p.p., 95%CI: 2.81; 31.36). Considering total medications, the proportion of anti-bacterial used dropped from 20.6% (95%CI: 19.9; 21.4) in 2004 to 12.6% (95%CI: 12.1; 13.1) in 2015. The reductions found in both the prevalence of use and the proportion of anti-bacterial agents over total medications used may be a reflection of the regulatory policy implemented in 2011.

A utilização indiscriminada de antibacterianos no período gestacional pode aumentar a resistência antimicrobiana e colocar em risco a saúde da gestante e da criança. Atualmente, está em vigência no Brasil a Resolução da Diretoria Colegiada nº 20/2011, que controla a prescrição e fornecimento de antibacterianos. O objetivo deste estudo foi comparar o uso de antibacterianos pelas gestantes participantes das coortes de nascimentos de Pelotas, Rio Grande do Sul, Brasil, de 2004 e 2015, considerando a regulamentação implementada entre as duas coortes. Foram utilizados dados coletados no período perinatal dos dois estudos. O desfecho principal foi o uso de antibacterianos na gestação. As prevalências de uso foram descritas a partir de variáveis independentes e diferenças em pontos percentuais (p.p.) entre as duas coortes. A prevalência do uso de antibacterianos foi de 41,9% (IC95%: 40,4; 43,3) em 2004 e 39,2% (IC95%: 37,7; 40,6) em 2015. Considerando-se as gestantes que relataram ter infecção durante a gestação, observou-se maior redução de uso em 2015, quando comparado a 2004, nas gestantes mais pobres (-15,4p.p., IC95%: 9,59; 21,20) e naquelas que foram a menos consultas (-17,1p.p., IC95%: 2,81; 31,36). Houve redução na proporção de antibacterianos usados, considerando o total de medicamentos de 20,6% (IC95%: 19,9; 21,4) em 2004 para 12,6% (IC95%: 12,1; 13,1) em 2015. As reduções encontradas, tanto nas prevalências de uso quanto na proporção dos antibacterianos sobre o total de medicamentos utilizados, podem ser reflexo da política de regulamentação implementada em 2011.

El uso indiscriminado de antibacterianos durante el embarazo puede aumentar la resistencia a los antimicrobianos y poner en riesgo la salud de la gestante y del niño. Actualmente, está vigente en Brasil la Resolución de la Dirección Colegiada nº 20/2011, que controla la prescripción y dispensación de antibacterianos. El objetivo de este estudio fue comparar el uso de antibacterianos por gestantes participantes de las cohortes de nacimientos de Pelotas, Rio Grande do Sul, Brasil, del 2004 y del 2015, considerando la regulación implementada entre las dos cohortes. Se utilizaron los datos recopilados en el período perinatal de los dos estudios. El resultado principal fue el uso de antibacterianos durante el embarazo. Las prevalencias de uso se describieron con base en las variables independientes y diferencias en puntos porcentuales (p.p.) entre las dos cohortes. La prevalencia de uso de antibacterianos fue del 41,9% (IC95%: 40,4; 43,3) en el 2004 y del 39,2% (IC95%: 37,7; 40,6) en el 2015. Teniendo en cuenta que las gestantes que reportaron haber tenido infección durante el embarazo, hubo una mayor reducción de uso en el 2015, en comparación con el 2004, en las gestantes más pobres (-15,4p.p., IC95%: 9,59; 21,20) y en las que consultaron menos (-17,1p.p., IC95% 2,81;31,36). Hubo una reducción en la proporción de antibacterianos usados, considerando la cantidad total de medicamentos del 20,6% (IC95%: 19,9; 21,4) en el 2004 al 12,6% (IC95%: 12,1; 13,1) en el 2015. Las reducciones encontradas, tanto en las prevalencias de uso como en la proporción de antibacterianos sobre la cantidad total de medicamentos utilizados, pueden ser reflejo de la política regulatoria implementada en el 2011.

Factors associated with neonatal-near miss: birth cohorts in three Brazilian cities - Ribeirão Preto, Pelotas and São Luís, Brazil.

The aim of this study was to investigate the association of sociodemographic factors, lifestyle, maternal reproductive profile and prenatal and childbirth care with neonatal near miss (NNM) morbidity in four birth cohorts. This study involved four population-based birth cohorts: Ribeirão Preto (RP) and São Luís (SL) (2010), Pelotas 2004 (PEL04) and 2015 (PEL15). NNM was defined when one or more of the following conditions were present: birthweight <1,500 g, 5-minute Apgar score <7, gestational age <32 weeks, and report of congenital malformations. The covariates were obtained with questionnaires applied to the puerperal women. Some particularities between cohorts were identified. In the RP and SL cohorts, factors of the more distal levels (sociodemographic, lifestyle, and reproductive profile) were associated with NNM. On the other hand, proximal factors related to healthcare were more significant for the occurrence of NNM in PEL. Only the absence of prenatal care was associated with NNM in all cohorts: RP (OR=4.27, 95%CI 2.16-8.45), SL (OR=2.32, 95%CI 1.09-4.94), PEL04 (OR=4.79, 95%CI 1.59-14.46), and PEL15 (OR=5.10, 95%CI 2.60-9.97).

[Factors associated infant development in Brazilian children: baseline of the impact assessment of the Happy Child Program]. / Fatores associados ao desenvolvimento infantil em crianças brasileiras: linha de base da avaliação do impacto do Programa Criança Feliz.

The study aimed to assess socioeconomic, family, and individual factors associated with infant development (i.e., in the first year of life) among families with social vulnerability. This was a cross-sectional analysis of baseline data from a randomized trial. The study included 3,242 children < 12 months of age living in 30 municipalities from five regions of Brazil. The choice of states and municipalities was intentional, based on the implementation of the Brazilian Happy Child Program. The sample was selected among eligible children for the Brazilian Happy Child Program, and the objective was the promotion of infant development. The Ages and Stages Questionnaire (ASQ) was used to assess infant development. A three-level analytical model (state, municipality, and individuals), using the Wald test for heterogeneity and linear trend, estimated the mean ASQ-3 and 95% confidence interval (95%CI). The analyses were adjusted for potential confounders. Information was analyzed for 3,061 (94.4%) children with available data for ASQ-3. Infant development scores (total and in all the domains) were some 12% lower in preterm children and those with intrauterine growth restriction (small for gestational age). Lower scores were seen in children of mothers with low schooling, depressive symptoms, two or more children under seven years of age living in the household, and who did not report self-perceived support or help during the pregnancy. In conclusion, potentially modifiable characteristics (schooling, maternal depression, and prematurity/intrauterine growth restriction) showed greater impact on reducing the infant development score in all the target domains.

O objetivo deste artigo foi avaliar os fatores socioeconômicos, familiares e individuais associados ao desenvolvimento infantil no primeiro ano de vida, entre famílias em vulnerabilidade social. Trata-se de uma análise transversal, com dados da linha de base de um ensaio randomizado. O estudo incluiu 3.242 crianças < 12 meses de idade, residentes em 30 municípios de cinco regiões do Brasil. A escolha de estados e municípios foi intencional, tendo como base a implementação do Programa Criança Feliz. A amostra foi selecionada a partir de crianças elegíveis para o Programa Criança Feliz, cujo objetivo é promover a estimulação e o desenvolvimento infantil. O Ages and Stages Questionnaire (ASQ) foi utilizado para avaliação do desenvolvimento infantil. Um modelo de análise multinível em três níveis (estado, município e indivíduos), usando teste de Wald para heterogeneidade e tendência linear, estimou a média do ASQ-3 e intervalo de 95% de confiança (IC95%). Análises foram ajustadas para potenciais confundidores. Foram analisadas informações de 3.061 (94,4%) crianças com dados disponíveis para ASQ-3. Escores de desenvolvimento infantil (total e em todos os domínios) foram cerca de 12% menores em crianças nascidas pré-termo e com restrição do crescimento intrauterino (pequenas para idade gestacional). Observou-se menores escores em filhos de mães com baixa escolaridade, com sintomas de depressão, com duas ou mais crianças menores de sete anos residindo no domicílio e que não relataram autopercepção de apoio/ajuda durante a gestação. Conclui-se que características potencialmente modificáveis (escolaridade, depressão materna e prematuridade/restrição do crescimento intrauterino) apresentaram maior impacto na redução do escore de desenvolvimento em todos os domínios avaliados.

El objetivo fue evaluar los factores socioeconómicos, familiares e individuales, asociados al desarrollo infantil en el primer año de vida, entre familias con vulnerabilidad social. Se trata de un análisis transversal, con datos de la base de referencia de un ensayo aleatorio. El estudio incluyó a 3.242 niños < 12 meses de edad, residentes en 30 municipios de cinco regiones de Brasil. La elección de estados y municipios fue intencional, considerando como base la implementación del Programa Niño Feliz. La muestra se seleccionó a partir de niños elegibles para el Programa Niño Feliz, cuyo objetivo es promover la estimulación y el desarrollo infantil. Se utilizó el Ages and Stages Questionnaire (ASQ) para la evaluación del desarrollo infantil. Un modelo de análisis multinivel en tres niveles (estado, municipio e individuos), usando el test de Wald para la heterogeneidad y tendencia lineal, estimó la media del ASQ-3 y el intervalo de 95% de confianza (IC95%). Los análisis se ajustaron para potenciales factores de confusión. Se analizó información de 3.061 (94,4%) niños con datos disponibles para ASQ-3. Las puntuaciones de desarrollo infantil (total y en todos los dominios) fueron cerca de un 12% menores en niños nacidos pretérmino y con restricción del crecimiento intrauterino (pequeños para la edad gestacional). Se observaron menores puntuaciones en hijos de madres con baja escolaridad, con síntomas de depresión, con dos o más niños menores de siete años residiendo en el domicilio y que no informaron autopercepción de apoyo/ayuda durante la gestación. Se concluye que las características potencialmente modificables (escolaridad, depresión materna y prematuridad/restricción del crecimiento intrauterino) presentaron un mayor impacto en la reducción de la puntuación de desarrollo en todos los dominios evaluados.

Fatores associados ao desenvolvimento infantil em crianças brasileiras: linha de base da avaliação do impacto do Programa Criança Feliz / Factors associated infant development in Brazilian children: baseline of the impact assessment of the Happy Child Program / Factores asociados al desarrollo infantil en niños brasileños: base de referencia para la evaluación del impacto del Programa Niño Feliz

Resumo: O objetivo deste artigo foi avaliar os fatores socioeconômicos, familiares e individuais associados ao desenvolvimento infantil no primeiro ano de vida, entre famílias em vulnerabilidade social. Trata-se de uma análise transversal, com dados da linha de base de um ensaio randomizado. O estudo incluiu 3.242 crianças < 12 meses de idade, residentes em 30 municípios de cinco regiões do Brasil. A escolha de estados e municípios foi intencional, tendo como base a implementação do Programa Criança Feliz. A amostra foi selecionada a partir de crianças elegíveis para o Programa Criança Feliz, cujo objetivo é promover a estimulação e o desenvolvimento infantil. O Ages and Stages Questionnaire (ASQ) foi utilizado para avaliação do desenvolvimento infantil. Um modelo de análise multinível em três níveis (estado, município e indivíduos), usando teste de Wald para heterogeneidade e tendência linear, estimou a média do ASQ-3 e intervalo de 95% de confiança (IC95%). Análises foram ajustadas para potenciais confundidores. Foram analisadas informações de 3.061 (94,4%) crianças com dados disponíveis para ASQ-3. Escores de desenvolvimento infantil (total e em todos os domínios) foram cerca de 12% menores em crianças nascidas pré-termo e com restrição do crescimento intrauterino (pequenas para idade gestacional). Observou-se menores escores em filhos de mães com baixa escolaridade, com sintomas de depressão, com duas ou mais crianças menores de sete anos residindo no domicílio e que não relataram autopercepção de apoio/ajuda durante a gestação. Conclui-se que características potencialmente modificáveis (escolaridade, depressão materna e prematuridade/restrição do crescimento intrauterino) apresentaram maior impacto na redução do escore de desenvolvimento em todos os domínios avaliados.

Abstract: The study aimed to assess socioeconomic, family, and individual factors associated with infant development (i.e., in the first year of life) among families with social vulnerability. This was a cross-sectional analysis of baseline data from a randomized trial. The study included 3,242 children < 12 months of age living in 30 municipalities from five regions of Brazil. The choice of states and municipalities was intentional, based on the implementation of the Brazilian Happy Child Program. The sample was selected among eligible children for the Brazilian Happy Child Program, and the objective was the promotion of infant development. The Ages and Stages Questionnaire (ASQ) was used to assess infant development. A three-level analytical model (state, municipality, and individuals), using the Wald test for heterogeneity and linear trend, estimated the mean ASQ-3 and 95% confidence interval (95%CI). The analyses were adjusted for potential confounders. Information was analyzed for 3,061 (94.4%) children with available data for ASQ-3. Infant development scores (total and in all the domains) were some 12% lower in preterm children and those with intrauterine growth restriction (small for gestational age). Lower scores were seen in children of mothers with low schooling, depressive symptoms, two or more children under seven years of age living in the household, and who did not report self-perceived support or help during the pregnancy. In conclusion, potentially modifiable characteristics (schooling, maternal depression, and prematurity/intrauterine growth restriction) showed greater impact on reducing the infant development score in all the target domains.

Resumen: El objetivo fue evaluar los factores socioeconómicos, familiares e individuales, asociados al desarrollo infantil en el primer año de vida, entre familias con vulnerabilidad social. Se trata de un análisis transversal, con datos de la base de referencia de un ensayo aleatorio. El estudio incluyó a 3.242 niños < 12 meses de edad, residentes en 30 municipios de cinco regiones de Brasil. La elección de estados y municipios fue intencional, considerando como base la implementación del Programa Niño Feliz. La muestra se seleccionó a partir de niños elegibles para el Programa Niño Feliz, cuyo objetivo es promover la estimulación y el desarrollo infantil. Se utilizó el Ages and Stages Questionnaire (ASQ) para la evaluación del desarrollo infantil. Un modelo de análisis multinivel en tres niveles (estado, municipio e individuos), usando el test de Wald para la heterogeneidad y tendencia lineal, estimó la media del ASQ-3 y el intervalo de 95% de confianza (IC95%). Los análisis se ajustaron para potenciales factores de confusión. Se analizó información de 3.061 (94,4%) niños con datos disponibles para ASQ-3. Las puntuaciones de desarrollo infantil (total y en todos los dominios) fueron cerca de un 12% menores en niños nacidos pretérmino y con restricción del crecimiento intrauterino (pequeños para la edad gestacional). Se observaron menores puntuaciones en hijos de madres con baja escolaridad, con síntomas de depresión, con dos o más niños menores de siete años residiendo en el domicilio y que no informaron autopercepción de apoyo/ayuda durante la gestación. Se concluye que las características potencialmente modificables (escolaridad, depresión materna y prematuridad/restricción del crecimiento intrauterino) presentaron un mayor impacto en la reducción de la puntuación de desarrollo en todos los dominios evaluados.

Uso de antibacterianos em gestantes antes e após regulamentação no Brasil: coortes de nascimentos de Pelotas, Rio Grande do Sul, de 2004 e 2015 / Use of anti-bacterial agents in pregnant women before and after regulation in Brazil: Pelotas (Brazil) birth cohorts of 2004 and 2015 / Uso de antibacterianos en gestantes antes y después de la regulación en Brasil: cohortes de nacimientos de Pelotas, Río Grande do Sul, del 2004 y del 2015

A utilização indiscriminada de antibacterianos no período gestacional pode aumentar a resistência antimicrobiana e colocar em risco a saúde da gestante e da criança. Atualmente, está em vigência no Brasil a Resolução da Diretoria Colegiada nº 20/2011, que controla a prescrição e fornecimento de antibacterianos. O objetivo deste estudo foi comparar o uso de antibacterianos pelas gestantes participantes das coortes de nascimentos de Pelotas, Rio Grande do Sul, Brasil, de 2004 e 2015, considerando a regulamentação implementada entre as duas coortes. Foram utilizados dados coletados no período perinatal dos dois estudos. O desfecho principal foi o uso de antibacterianos na gestação. As prevalências de uso foram descritas a partir de variáveis independentes e diferenças em pontos percentuais (p.p.) entre as duas coortes. A prevalência do uso de antibacterianos foi de 41,9% (IC95%: 40,4; 43,3) em 2004 e 39,2% (IC95%: 37,7; 40,6) em 2015. Considerando-se as gestantes que relataram ter infecção durante a gestação, observou-se maior redução de uso em 2015, quando comparado a 2004, nas gestantes mais pobres (-15,4p.p., IC95%: 9,59; 21,20) e naquelas que foram a menos consultas (-17,1p.p., IC95%: 2,81; 31,36). Houve redução na proporção de antibacterianos usados, considerando o total de medicamentos de 20,6% (IC95%: 19,9; 21,4) em 2004 para 12,6% (IC95%: 12,1; 13,1) em 2015. As reduções encontradas, tanto nas prevalências de uso quanto na proporção dos antibacterianos sobre o total de medicamentos utilizados, podem ser reflexo da política de regulamentação implementada em 2011.

Indiscriminate use of anti-bacterial agents during pregnancy can increase antimicrobial resistance and endanger both the mother's and the children's health. Currently, Brazil has the Collegiate Directive Resolution n. 20/2011, which controls prescription and dispensation of anti-bacterial agents. Given this scenario, this study compared the use of anti-bacterial agents by pregnant women participating in the 2004 and 2015 Pelotas (Brazil) birth cohorts, in Rio Grande do Sul, Brazil, considering the regulation issued between the two cohorts. Data were collected in the perinatal period of the two studies. The main outcome was the use of anti-bacterial agents during pregnancy. Prevalence scans were described based on independent variables and differences in percentage points (p.p.) between the two cohorts. The prevalence of anti-bacterial use was 41.9% (95%CI: 40.4; 43.3) in 2004 and 39.2% (95%CI: 37.7; 40.6) in 2015. Considering the pregnant women who reported having infection during pregnancy, a greater reduction in use was observed in 2015, when compared to 2004, in poor women (-15.4p.p., 95%CI: 9.59; 21.20) and in those who had less consultations (-17.1p.p., 95%CI: 2.81; 31.36). Considering total medications, the proportion of anti-bacterial used dropped from 20.6% (95%CI: 19.9; 21.4) in 2004 to 12.6% (95%CI: 12.1; 13.1) in 2015. The reductions found in both the prevalence of use and the proportion of anti-bacterial agents over total medications used may be a reflection of the regulatory policy implemented in 2011.

El uso indiscriminado de antibacterianos durante el embarazo puede aumentar la resistencia a los antimicrobianos y poner en riesgo la salud de la gestante y del niño. Actualmente, está vigente en Brasil la Resolución de la Dirección Colegiada nº 20/2011, que controla la prescripción y dispensación de antibacterianos. El objetivo de este estudio fue comparar el uso de antibacterianos por gestantes participantes de las cohortes de nacimientos de Pelotas, Rio Grande do Sul, Brasil, del 2004 y del 2015, considerando la regulación implementada entre las dos cohortes. Se utilizaron los datos recopilados en el período perinatal de los dos estudios. El resultado principal fue el uso de antibacterianos durante el embarazo. Las prevalencias de uso se describieron con base en las variables independientes y diferencias en puntos porcentuales (p.p.) entre las dos cohortes. La prevalencia de uso de antibacterianos fue del 41,9% (IC95%: 40,4; 43,3) en el 2004 y del 39,2% (IC95%: 37,7; 40,6) en el 2015. Teniendo en cuenta que las gestantes que reportaron haber tenido infección durante el embarazo, hubo una mayor reducción de uso en el 2015, en comparación con el 2004, en las gestantes más pobres (-15,4p.p., IC95%: 9,59; 21,20) y en las que consultaron menos (-17,1p.p., IC95% 2,81;31,36). Hubo una reducción en la proporción de antibacterianos usados, considerando la cantidad total de medicamentos del 20,6% (IC95%: 19,9; 21,4) en el 2004 al 12,6% (IC95%: 12,1; 13,1) en el 2015. Las reducciones encontradas, tanto en las prevalencias de uso como en la proporción de antibacterianos sobre la cantidad total de medicamentos utilizados, pueden ser reflejo de la política regulatoria implementada en el 2011.

Corrigendum: Trends and Inequalities in Unplanned Pregnancy in Three Population-Based Birth Cohorts in Pelotas, Brazil.

[This corrects the article DOI: 10.1007/s00038-020-01505-0.].

Vaccination coverage in children up to 2 years old, receiving financial support from the Family Income Transfer Program, Brazil. / Cobertura vacinal em crianças de até 2 anos de idade beneficiárias do Programa Bolsa Família, Brasil.

OBJECTIVE: To assess vaccination coverage, based on the National Immunization Program schedule, among children receiving financial support from the Family Income Transfer Program, Brazil, according to the family socioeconomic status and maternal characteristics. METHODS: 3,242 children under 12 months old were assessed between August/2018 and April/2019, of whom 3,008 were reassessed between September/2019 and January/2020. The analyses were performed using multilevel models (level 3, Federative Unit; level 2, municipality; level 1, children). RESULTS: Vaccination coverage was 2.5 fold higher in the first follow-up (61.0% - 95% CI 59.3;62.6%), compared to the second follow-up (24.8% - 95% CI 22.8;25.9%) (p<0.001). In the first follow-up, coverage was higher in the richest quintile (67.9%) and in children whose mothers had ≥9 years of schooling (63.3%). In the second follow-up, there were no differences. The highest coverage occurred between 0.5-2.5 (93.5%) and 12.5-15.5 months (34.4%), respectively, first and second follow-ups. CONCLUSION: Low coverage was found, both in the first and second year of life.

Cobertura vacinal em crianças de até 2 anos de idade beneficiárias do Programa Bolsa Família, Brasil / Cobertura de vacunación de niños hasta 2 años, beneficiarios del Programa Bolsa Familia, Brasil / Vaccination coverage in children up to 2 years old, receiving financial support from the Family Income Transfer Program, Brazil

Objetivo: Avaliar a cobertura vacinal, conforme o calendário do Programa Nacional de Imunizações, entre crianças beneficiárias do Programa Bolsa Família, Brasil, segundo nível socioeconômico da família e características maternas. Métodos: Foram avaliadas 3.242 crianças menores de 12 meses de vida entre agosto de 2018 e abril de 2019, sendo 3.008 delas reavaliadas entre setembro de 2019 e janeiro de 2020. As análises foram realizadas utilizando-se modelos multiníveis (nível 3, Unidade da Federação; nível 2, município; nível 1, crianças). Resultados: A cobertura vacinal foi 2,5 vezes maior no primeiro (61,0% - IC95% 59,3;62,6%), comparado ao segundo acompanhamento (24,8% - IC95% 22,8;25,9%) (p<0,001). No primeiro acompanhamento, a cobertura foi maior no quintil mais rico (67,9%) e entre as crianças cujas mães tinham ≥9 anos de escolaridade (63,3%). No segundo acompanhamento, não houve diferenças. As maiores coberturas ocorreram entre 0,5-2,5 (93,5%) e 12,5-15,5 meses (34,4%), respectivamente primeiro e segundo acompanhamentos. Conclusão: Encontrou-se baixa cobertura, tanto no primeiro quanto no segundo ano de vida.

Objetivo: Evaluar la cobertura de vacunación según el Programa Nacional de Inmunizaciones, entre los niños beneficiarios del Programa Bolsa Familia, Brasil, según el nivel socioeconómico familiar y características maternas. Métodos: Analizamos 3.242 niños menores de 12 meses entre agosto/2018 y abril/2019 y se reevaluaron 3.008 entre septiembre/2019 y enero/2020. Se utilizaron modelos multinivel (nivel 3, estado; nivel 2, municipio; nivel 1, niños). Resultados: La cobertura fue 2,5 veces mayor en el primer seguimiento (61,0% - IC95% 59,3;62,6%) que en el segundo (24,8% - IC95% 22,8;25,9%) (p<0,001). En el primer seguimiento, la cobertura fue mayor en el quintil más rico (67,9%) y entre aquellos cuyas madres tenían ≥9 años de escolaridad (63,3%). En el segundo seguimiento no hubo diferencias. La mayor cobertura ocurrió entre los 0,5-2,5 (93,5%) y 12,5-15,5 meses (34,4%), respectivamente, en el primero y el segundo seguimiento. Conclusión: Se encontró baja cobertura en el primero y en el segundo año de vida.

Objective: To assess vaccination coverage, based on the National Immunization Program schedule, among children receiving financial support from the Family Income Transfer Program, Brazil, according to the family socioeconomic status and maternal characteristics. Methods: 3,242 children under 12 months old were assessed between August/2018 and April/2019, of whom 3,008 were reassessed between September/2019 and January/2020. The analyses were performed using multilevel models (level 3, Federative Unit; level 2, municipality; level 1, children). Results: Vaccination coverage was 2.5 fold higher in the first follow-up (61.0% - 95% CI 59.3;62.6%), compared to the second follow-up (24,8% - IC95% 22,8;25,9%) (p<0,001). In the first follow-up, coverage was higher in the richest quintile (67.9%) and in children whose mothers had ≥9 years of schooling (63.3%). In the second follow-up, there were no differences. The highest coverage occurred between 0.5-2.5 (93.5%) and 12.5-15.5 months (34.4%), respectively, first and second follow-ups. Conclusion: Low coverage was found, both in the first and second year of life.

Trends and inequalities in unplanned pregnancy in three population-based birth cohorts in Pelotas, Brazil.

OBJECTIVES: To assess time trends in unplanned pregnancy, stratified by sociodemographic status, reproductive history, and inequalities in family income and women's skin color, in Pelotas, Brazil. METHODS: Data from mothers of participants of the 1993 (N = 5264), 2004 (N = 4243), and 2015 (N = 4268) Pelotas birth cohorts were analyzed. Unplanned pregnancy was investigated in the perinatal period, with tests to assess changes over time among different sociodemographic and reproductive history subgroups and inequalities as a function of family income and skin color. RESULTS: The prevalence of unplanned pregnancy was 62.7% (3299/ 5264), 65.9% (2794/ 4243), and 52.2% (2226/ 4268) in the 1993, 2004, and 2015 cohorts, respectively. Black or brown women and women of lower socioeconomic status had a higher prevalence of unplanned pregnancy in all cohorts. The overall rate of unplanned pregnancy decreased over time in most subgroups. Inequality as a function of family income and skin color increased during the time frame of assessment. CONCLUSIONS: The prevalence of unplanned pregnancies decreased in the period analyzed, but it is still unjustifiably high. Efforts aimed at reducing unplanned pregnancy are vital and will require special attention to the most vulnerable groups.

Validity assessment of a portable anthropometer to measure length in 24-month children from the 2015 Pelotas Birth Cohort.

OBJECTIVE: This study aimed to assess the validity of a portable anthropometer against the gold standard among 2-year-old infants from the 2015 Pelotas (Brazil) Birth Cohort. DESIGN: Birth cohort study. SETTING: A fixed Harpenden® infant anthropometer was considered as the gold standard for measuring infant length due to its greater precision and stability. The portable SANNY® (model ES2000) anthropometer was the instrument to be validated. The acceptable mean difference in length between the anthropometers was 0·5 cm. In order to compare length estimates, the interviewers carried out two length measures for each of the anthropometers (fixed and portable) and for each child. The mean of the two lengths was calculated for each anthropometer, and their difference was calculated. PARTICIPANTS: A subsample of 252 24-month-old members of the 2015 Pelotas (Brazil) birth cohort study. RESULTS: Children's mean age was 23·5 months. According to Bland-Altman plot, there were no differences in overall lengths between the portable and the fixed anthropometers, or in lengths according to sex. There was a high overall concordance between the length estimates of the fixed and portable anthropometers (ρ = 0·94; 95 % CI 0·92, 0·95). CONCLUSIONS: The portable anthropometer proved to be accurate to measure the length of 24-month-old infants, being applicable to studies using the same standardised protocol used in the present study.

[Expenditures on childbirth care: a comparison of the 2004 and 2015 birth cohorts in Pelotas, Rio Grande do Sul State, Brazil]. / Gastos com a assistência ao parto: comparação entre as coortes de nascimento de Pelotas dos anos de 2004 e 2015, Rio Grande do Sul, Brasil.

Although most childbirth care in Brazil is financed by the Brazilian Unified National Health System (SUS), there are out-of-pocket expenditures (private personal costs) involved in births. This study aims to compare maternal out-of-pocket expenditures in births of children from the Pelotas Birth Cohorts of 2004 and 2015. The study drew on information collected right after birth and at three months of age. The target variables include sociodemographic and economic data, private health plan coverage, and expenditures related to the birth. Values from 2004 were adjusted to 2015 by the general price index. There was an increase in private health plan coverage from 33.4% (95%CI: 31.9-34.9) to 45.1% (95%IC: 43.6-46.7) in the target period, directly associated with the families' socioeconomic status (p < 0.001). There was an increase in mean expenditures on hospitalization for the birth, from BRL 60.38 (SD = 288.66) to BRL 171.15 (SD = 957.07), and in additional medical expenditures, from BRL 191.60 (SD = 612.86) to BRL 1,424.80 (SD = 4,459.16) among mothers admitted to hospital under their private health plans (and there was no significant difference in these expenditures for mothers that opted for direct payment). There was an important increase in expenditures for childbirth care, especially among mothers admitted to hospital under private health plans.

Maternal pregnancy smoking in three Brazilian cities: trends and differences according to education, income, and age.

OBJECTIVES: To estimate and assess pregnancy smoking trends since 1978, according to sociodemographic characteristics, in three Brazilian sites. METHODS: We used cross-sectional data from the perinatal studies of nine birth cohorts, located in the southeast (Ribeirão Preto-1978/1979, 1994, and 2010), south (Pelotas-1982, 1993, 2004, and 2015), and northeast (São Luís-1997/1998 and 2010) regions of Brazil. We estimated the prevalence of pregnancy smoking at each time point according to age, education, and family income, in each cohort, and evaluated smoking trends. RESULTS: We analyzed data of 17,275 women in Ribeirão Preto, 19,819 in Pelotas, and 7753 in São Luís. Smoking decreased by 59% in Ribeirão Preto (p < 0.001), 54% in Pelotas (p < 0.001), and 32% in São Luís (p < 0.001). However, among those with 0-4 years of education, smoking did not change in Ribeirão Preto (p-trend = 0.501) nor São Luís (p = 0.556) and increased in Pelotas (p-trend = 0.003). CONCLUSIONS: Pregnancy smoking has been declining during the last decades. However, among less-educated women, pregnancy smoking did not change in two sites and increased in one of them.

The emergence of vaccine hesitancy among upper-class Brazilians: Results from four birth cohorts, 1982-2015.

Vaccine hesitancy has been increasingly reported in Brazil. We describe secular trends and socioeconomic disparities from 1982 to 2015, using data from four population-based birth cohorts carried out in the city of Pelotas. Full immunization coverage (FIC) was defined as having received four basic vaccines (one dose of BCG and measles, and three doses of polio and DTP) scheduled for the first year of life. Information on income was collected through standardized questionnaires, and the slope index of inequality (SII) was calculated to express the difference in percent points between the rich and poor extremes of the income distribution. Full immunization coverage was 80.9% (95% CI 79.8%; 82.0%) in 1982, 97.2% (96.1%; 98.0%) in 1993, 87.8% (86.7%; 88.8%) in 2004 and 77.2% (75.8%; 78.4%) in 2015. In 1982 there was a strong social gradient with higher coverage among children from wealthy families (SII = 25.0, P < 0.001); by 2015, the pattern was inverted with higher coverage among poor children (SII = -6.0; P = 0.01). Vertical immunization programs in the 1980s and creation of the National Health Services in 1980 eliminated the social gradient that had been present up to the 1980s, to reach near universal coverage. The recent decline in coverage is likely associated with the growing complexity of the vaccination schedule and underfunding of the health sector. In addition, the faster decline observed among children from wealthy families is probably due to vaccine hesitancy.

Gastos com a assistência ao parto: comparação entre as coortes de nascimento de Pelotas dos anos de 2004 e 2015, Rio Grande do Sul, Brasil / Expenditures on childbirth care: a comparison of the 2004 and 2015 birth cohorts in Pelotas, Rio Grande do Sul State, Brazil / Gastos con la asistencia al parto: comparación entre las cohortes de nacimientos de Pelotas (Rio Grande do Sul, Brasil) desde el año 2004 y 2015

Resumo: Apesar de a maioria dos partos no Brasil ser financiada pelo Sistema Único de Saúde (SUS), existem gastos diretos (pessoais privados) envolvidos no nascimento. Este estudo visa a comparar o desembolso materno para financiar os partos das crianças pertencentes às coortes de nascimento de Pelotas de 2004 e 2015. Foram utilizadas informações coletadas logo após o nascimento e aos três meses de idade. As variáveis analisadas incluem informações sociodemográficas, econômicas, cobertura por plano privado de saúde e despesas relacionadas ao parto. Os valores de 2004 foram ajustados pelo Índice Nacional de Preços ao Consumidor Amplo (IPCA). Observou-se aumento na posse de planos de saúde de 33,4% (IC95%: 31,9-34,9) para 45,1% (IC95%: 43,6-46,7) no período analisado e este esteve diretamente associado à posição econômica das famílias (p < 0,001). Ocorreu um aumento na média dos gastos com hospitalização para o parto de R$ 60,38 (DP = 288,66) para R$ 171,15 (DP = 957,07), e nos gastos adicionais com médicos de R$ 191,60 (DP = 612,86) para R$ 1.424,80 (DP = 4.459,16) entre as mães que se internaram pelo plano privado de saúde (e não houve diferença significativa nestes gastos entre as mães que optaram pelo parto particular). Houve aumento importante no gasto com a assistência ao parto principalmente entre as mães que se internaram pelo plano privado de saúde.

Abstract: Although most childbirth care in Brazil is financed by the Brazilian Unified National Health System (SUS), there are out-of-pocket expenditures (private personal costs) involved in births. This study aims to compare maternal out-of-pocket expenditures in births of children from the Pelotas Birth Cohorts of 2004 and 2015. The study drew on information collected right after birth and at three months of age. The target variables include sociodemographic and economic data, private health plan coverage, and expenditures related to the birth. Values from 2004 were adjusted to 2015 by the general price index. There was an increase in private health plan coverage from 33.4% (95%CI: 31.9-34.9) to 45.1% (95%IC: 43.6-46.7) in the target period, directly associated with the families' socioeconomic status (p < 0.001). There was an increase in mean expenditures on hospitalization for the birth, from BRL 60.38 (SD = 288.66) to BRL 171.15 (SD = 957.07), and in additional medical expenditures, from BRL 191.60 (SD = 612.86) to BRL 1,424.80 (SD = 4,459.16) among mothers admitted to hospital under their private health plans (and there was no significant difference in these expenditures for mothers that opted for direct payment). There was an important increase in expenditures for childbirth care, especially among mothers admitted to hospital under private health plans.

Resumen: A pesar de que la mayoría de los partos en Brasil esté financiado por el Sistema Único de Salud, existen gastos directos (personales privados) implicados en el nacimiento. Este estudio tiene como objetivo comparar el desembolso materno para financiar los partos de los niños, pertenecientes a las cohortes de nacimientos de Pelotas desde el 2004 al 2015. Se utilizó información recogida tras el nacimiento y a los tres meses de edad. Las variables analizadas incluyen información sociodemográfica, económica, cobertura con plan privado de salud y gastos relacionados con el parto. Los valores de 2004 se ajustaron por el Índice Nacional de Precios al Consumidor Amplio. Se observó un aumento en la posesión de planes de salud de un 33,4% (IC95%: 31,9-34,9) a un 45,1% (IC95%: 43,6-46,7) durante el período analizado y este se mostró directamente asociado a la posición económica de las familias (p < 0,001). Se produjo un aumento en la media de los gastos con hospitalización para el parto de BRL 60,38 (DE = 288,66) a BRL 171,15 (DE = 957,07), y en los gastos adicionales con médicos, de BRL 191,60 (DE = 612,86) a BRL 1.424,80 (DE = 4.459,16) entre las madres que estaban internadas por el plan privado de salud (y no hubo diferencia significativa en estos gastos entre las madres que optaron por el parto particular). Hubo un aumento importante en el gasto con asistencia al parto, principalmente, entre madres que estuvieron internadas para el parto mediante un plan privado de salud.

Effect of Parental Counseling on Infants' Healthy Sleep Habits in Brazil: A Randomized Clinical Trial.

Importance: Poor sleep during early childhood is associated with adverse outcomes, including obesity, cognitive impairment, and mental and behavioral disorders. Objective: To assess the efficacy of an educational intervention in the promotion of nighttime sleep duration. Design, Setting, and Participants: This single-blind, intent-to-treat randomized clinical trial included participants in Pelotas, Brazil, aged 3 months who were followed up until age 24 months. Eligibility criteria included healthy infants aged approximately 3 months who slept less than 15 hours per 24 hours. Infants were randomized to the intervention group or control group. Interventions: Information on sleep characteristics, improvements in the environment, establishment of a nighttime sleep routine, and waiting before attending nocturnal awakenings was delivered to mothers in the intervention group by trained home-visitors at baseline. The intervention group received a telephone call on the first and second day after the intervention and a home visit on the third day after the intervention. The intervention's content was reinforced at health care visits for ages 6 months and 12 months. Mothers allocated to the control group were counseled on the benefits of breastfeeding for the mother's and child's health and given written material with content on breastfeeding. Main Outcomes and Measures: Nighttime sleep duration was measured by interview and actigraphy at baseline and ages 6, 12, and 24 months and diaries at baseline and age 6 months. At ages 3 and 6 months, nighttime sleep self-regulation was calculated by subtracting nighttime sleep duration recorded by actigraphy from nighttime sleep duration recorded in the diaries and at ages 12 and 24 months by subtracting nighttime sleep duration recorded by actigraphy from nighttime sleep duration obtained by interview. Results: Among 1812 mother-infant dyads invited to participate, 798 met the inclusion criteria and 586 agreed to participate. The intervention group included 298 infants (154 [52.9%] boys), and the control group included 288 infants (164 [58.2%] boys). At age 6 months, mean (SD) nighttime sleep duration recorded in diaries was 9.80 (1.85) hours in the intervention group and 9.49 (2.07) hours in the control group, a difference of 19 minutes longer for the intervention group. At age 12 months, mean (SD) nighttime sleep duration based on the Brief Infant Sleep Questionnaire was 8.43 (1.35) hours in the intervention group and 8.52 (1.35) hours in the control group, a difference of 5 minutes shorter for the intervention group. At age 24 months, compared with information from the interview, actigraphy records showed that children in the intervention group stayed awake at night without signalizing for a mean (SD) of 0.52 (2.52) hours, whereas children in the control group stayed awake at night without signalizing for a mean (SD) of 0.23 (2.43) hours. There were no statistically significant difference between groups in any of the sleep parameters investigated. Conclusions and Relevance: This randomized clinical trial found that the educational intervention did not achieve longer nighttime sleep duration among infants in the intervention group. Trial Registration: ClinicalTrials.gov identifier: NCT02788630.

Breastfeeding exclusivity and duration: trends and inequalities in four population-based birth cohorts in Pelotas, Brazil, 1982-2015.

BACKGROUND: Brazil has made substantial improvements in the duration of breastfeeding. We use data from four population-based cohorts to examine how trends and inequalities in breastfeeding indicators changed over time in a Brazilian city. METHODS: Data from four birth cohorts, each including all births in a calendar year (1982, 1993, 2004 and 2015) in the city of Pelotas were used. Information on breastfeeding was collected when children were aged between 3 and 20 months. The prevalences of continued breastfeeding at 1 year of age and of exclusive breastfeeding at 3 months were calculated according to family income, maternal skin colour and sex. RESULTS: Prevalence of breastfeeding at 12 months increased from 16% to 41% in the 33-year period. The prevalence of exclusive breastfeeding at 3 months increased from 7% in 1993 to 45% in 2015. Increases in exclusive breastfeeding at 3 months were seen in all socioeconomic groups, but the 2015 rates remain highest (57.2%) among the women in the richest quintile, and lowest among those in the poorest quintile (34.6%). Black mothers were more likely to breastfeed at 12 months than Whites in the four cohorts. In the earlier cohorts, breastfeeding at 12 months was more common among the poor, but by 2015 these differences had disappeared. CONCLUSIONS: There were important positive changes in breastfeeding practices during this period, but less than half of the children in 2015 were receiving the full benefits of breast milk. Improved breastfeeding practices are being adopted by high-income women to a greater extent than by poor women.

Maternal anthropometry: trends and inequalities in four population-based birth cohorts in Pelotas, Brazil, 1982-2015.

BACKGROUND: Pre-pregnancy nutritional status and weight gain during pregnancy have short- and long-term consequences for the health of women and children. This study was aimed at evaluating maternal height,- and overweight or obesity at the beginning of the pregnancy and gestational weight gain, according to socioeconomic status and maternal skin colour of mothers in Pelotas, a southern Brazilian city, in 1982, 1993, 2004 and 2015. METHODS: In 1982, 1993, 2004 and 2015, the maternity hospitals in Pelotas were visited daily, all deliveries were identified and mothers who lived in the urban area of the city were interviewed. Maternal weight at the beginning of the pregnancy was self-reported by the mother or obtained from the antenatal card. Maternal height was collected from the maternity records or measured by the research team. Overweight or obesity was defined by a body mass index ≥25 kg/m2. Gestational weight gain was evaluated according to the Institute of Medicine guidelines. RESULTS: In the four cohorts, we evaluated 19 931 women. From 1982 to 2015, the prevalence of overweight or obesity at the beginning of the pregnancy increased from 22.1% to 47.0% and height increased by an average of 5.2 cm, whereas gestational weight gain did not change. Socioeconomic status was positively associated with maternal height, and the difference between the poorest and the wealthiest decreased. Overweight or obesity was lower among those mothers in the extreme categories of family income. CONCLUSIONS: Over the 33-year span, mothers were taller at the beginning of the pregnancy, but the prevalence of overweight or obesity more than doubled.