As diversas faces da morte de crianças na perspectiva de médicos e enfermeiros / The diverse faces of child death from the perspective of doctors and nurses

Introdução: Adoecimento e morte de crianças são eventos pouco aceitos na sociedade. Objetivo: Analisar a percepção de médicos e enfermeiros de terapia intensiva sobre a morte de crianças. Métodos: Estudo de aborda-gem qualitativa, com médicos e enfermeiros de três Unidades de Terapia Intensiva (UTI Pediátrica, UTI Neonatal e UTI Cardiológica) de um hospital de ensino. Foram realizadas entrevistas semiestruturadas gravadas, transcritas e analisadas segundo análise de conteúdo na modalidade temática. Resultados: Foram entrevistados 14 profis-sionais, com idade entre 28-53 anos, que possuíam tempo mínimo de dois anos de atuação em terapia intensiva e média de 43 horas semanais de trabalho. Os sentimentos e atitudes diante da morte emergiram da análise das falas e foram categorizados nos seguintes temas: percepção da morte na infância, obstinação terapêutica e so-frimento no encontro com as famílias. Os profissionais reconheceram lacunas na formação durante a graduação e pós-graduação para lidar com a morte de crianças. Sofrimento, ansiedade, culpa, frustração e impotência foram relatados, demonstrando a complexidade que envolve situações de morte de criança. A condição clínica e a capaci-dade de interação da criança influenciaram nas atitudes e na própria maneira do profissional lidar com a morte. A espiritualidade foi um importante mecanismo de enfrentamento. Conclusão: A morte de crianças em UTI provoca sentimentos ambivalentes em médicos e enfermeiros responsáveis pelo seu cuidado. Os profissionais sofrem pela morte de alguém que ainda não desfrutou da vida, porém a aceitam quando pensam no fim de uma vida marcada por sofrimentos e limitações impostos pela doença. O contato com o tema morte durante a formação profissional e nas discussões regulares dos serviços podem auxiliar na forma de lidar com esse evento. A espiritualidade foi um importante recurso de enfrentamento. (AU)

ntroduction: Sickness and death of children are little accepted events in society. Objective: To analyze the perception of intensive care doctors and nurses about the death of children. Methods: Qualitative approach study, with doctors and nurses from three Intensive Care Units (Pediatric ICU, Neonatal ICU and Cardiological ICU) of a teaching hospital. Recorded semi-structured interviews were carried out, transcribed and analyzed according to content analysis in the thematic modality. Results: 14 professionals were interviewed, aged 28-53 years, with a minimum of 2 years of intensive care experience time and an average of 43 hours of work per week. The feelings and attitudes towards death emerged from the speech analysis and were categorized in the following themes: per-ception of death in childhood, therapeutic obstinacy and suffering in meeting with families. Professionals recognized gaps in training during undergraduate and graduate studies to deal with the death of children. Suffering, anxiety, guilt, frustration, impotence and guilt were reported, demonstrating the complexity of child death situations. The clinical condition and the child's ability to interact influenced the attitudes and the professional's way of dealing with death. Spirituality was an important mechanism of confrontation. Conclusion: The death of children in ICU causes ambivalent feelings in doctors and nurses responsible for their care. Professionals suffer for the death of someone who has not yet enjoyed life, but accept it when they think about the end of a life marked by suffering and limitations imposed by the disease. Contact with the subject of death during professional training and in the regular discussions of services can help in the way to deal with this event. Spirituality was an important resource of coping. (AU)

Psychological distress and mother-child relationship: influence of life context on a population sample (BRISA) through the use of directed acyclic graphs (DAG)

This study aimed to investigate the association between maternal psychological distress and impairment in mother-child relationship in a sample from a Northeast capital city in Brazil with a low Human Development Index, using directed acyclic graphs (DAG). A total of 3,215 women were evaluated for the presence of psychological distress through the Self Reporting Questionnaire instrument and for the mother-child relationship by the first factor of Postpartum Bonding Questionnaire, considered the most appropriate in the literature. Demographic and socioeconomic variables were used to construct a theoretical model and, after this, multivariate logistic regression was performed using variables suggested by Directed Acyclic Graphs (DAG). Psychological distress was present in 22.7% of the women and 12.6% of them presented impaired mother-child relationships. After adjustment, the variable 'maternal mental distress' remained associated with impaired mother-child relationship (RR=3.03), and among the explanatory variables only 'primary school level' (RR=1.48) was associated as a risk factor to this outcome. The results indicated that, in this population, women with psychological distress and lower schooling are more likely to present impaired mother-child relationships.

Determinants of the introduction of early complementary feeding before and after the third month of life: a multinomial analysis

The introduction of early complementary feeding (ECF) is determined by different factors depending on when it occurs. The objective of this study was to analyze factors associated with the introduction of ECF in two different moments of the infant's life: from zero to three and from four to five months of age. A cohort with 3,306 dyads studied in the BRISA survey in São Luis/MA in 2010 was used. Questionnaires were applied at birth and at follow-up when the infants were 15 to 36 months of age of women with more than 20 weeks of gestational age, residing in this municipality. A multivariate model of multinomial logistic regression was used to verify associations between independent variables and ECF at 0 to 3 months and at 4 to 5 months of age. A hierarchical analysis model was used to select variables for confounding adjustment. Variables with a P-value <0.05 were considered significant. For ECF introduced between 0-3 months, the variables "use of pacifier", "maternal paid activity", "smoking", and "postpartum pregnancy" were identified as risk factors. The variables "use of pacifier" and "maternal paid activity" remained associated as a risk for ECF introduced from 4-5 months. The variable 'mother without partner' (RR=1.26 and P=0.04) represented a risk factor for ECF only for the 4-5 months period. Although each period presented specific risk factors, the use of pacifier and maternal professional activity were associated in the two periods studied, indicating their importance for the introduction of ECF.

Birth by cesarean section and mood disorders among adolescents of a birth cohort study in northern Brazil

The increasing number of cesarean sections worldwide has encouraged research on the long-term effects of this birth type on the offspring's mental health. The objective of this study was to investigate whether there is an association between birth by cesarean section and the development of mood disorders (depression and bipolar disorders) in adolescents. A cohort study was carried out with 1603 adolescents from 18 to 19 years old who participated in the third phase of a birth cohort study in São Luís, MA, in 2016. Information on birth type and weight, prematurity, mother's age and schooling, parity, marital status, and smoking behavior during pregnancy, were collected at birth. The study outcomes were depression, bipolar disorder, and "mood disorder" construct. A Directed Acyclic Graph (DAG) was developed to select the variables for minimal adjustment for confounding and collision bias. Associations were estimated through propensity score weighting using a two-step estimation model, and confounders for cesarean birth were used in the predictive model. There was no significant association in the relationship between birth type and depression (95%CI: -0.037 to 0.017; P=0.47), bipolar disorder (95%CI: -0.019 to 0.045; P=0.43), and mood disorder (95%CI: -0.033 to 0.042; P=0.80) in adolescents of both sexes. Birth by cesarean section was not associated with the development of mood disorders in adolescents.

Why are the rates of cesarean section in Brazil higher in more developed cities than in less developed ones?

The objective of the present study was to investigate factors associated with cesarean sections in two cities located in different regions of Brazil and to determine factors that explain the higher cesarean section rate in the more developed city, Ribeirão Preto, compared to the less developed one, São Luís. Data from two cohort studies comprising 2846 women in Ribeirão Preto in 1994, and 2443 women in São Luís in 1997/1998 were used. Adjusted and non-adjusted risk estimates were calculated using a Poisson regression model. The cesarean section rate was 33.7 percent in São Luís and 50.8 percent in Ribeirão Preto. Adjusted analysis in a joint sequential model revealed a 51 percent higher risk of cesarean section in Ribeirão Preto compared to São Luís (prevalence rate ratio (PRR) = 1.51). Adjustment for category of hospital admission reduced the PRR to 1.09, i.e., this variable explained 82 percent of the difference in the cesarean section rate between the two cities. Adjustment for the variable "the same physician for prenatal care and delivery" reduced the PRR to 1.07, with the "physician" factor explaining 86 percent of the difference between rates. When simultaneously adjusted for the two variables, the PRR decreased to 1.05, with these two variables explaining 90 percent of the difference in the cesarean section rate between the two cities, and the difference was no longer significant. The difference in the cesarean section rate between the two Brazilian cities, one more and one less developed, was mainly explained by the physician factor and, to a lesser extent, by the category of hospital admission.

Social inequality and perinatal health: comparison of three Brazilian cohorts

The objective of the present study was to estimate and compare social inequality in terms of three indicators, i.e., low birth weight (LBW), preterm birth (PTB) and small for gestational age (SGA) birth, in three birth cohorts. Two cohorts were from the city of Ribeirão Preto, where data were collected for all 6748 live born singletons in 1978/79 and for one third of live born singletons (2846) in 1994. The third cohort consisted of 2443 singletons born in São Luís over a period of one year (1997/98). In Ribeirão Preto, LBW and PTB rates increased in all social strata from 1978/79 to 1994. Social inequalities regarding LBW and PTB disappeared since the increase in these rates was more accelerated in the groups with higher educational level. The percentage of SGA infants increased over the study period. Social inequality regarding SGA birth increased due to a more intense increase in SGA births in the strata with lower schooling. In São Luís, in 1997/98 there was no social inequality in LBW or PTB rates, whereas SGA birth rate was higher in mothers with less schooling. We speculate that the more accelerated increase in medical intervention, especially due to the increase in cesarean sections in the more privileged groups, could be the main factor explaining the unexpected increase in LBW and PTB rates in Ribeirão Preto and the decrease or disappearance of social inequality regarding these perinatal indicators in the two cities.