Gut Microbiota of Young Children Living in Four Brazilian Cities.

Recent studies have demonstrated that gut microbiota development is influenced by human biogeographic factors such as race, ethnicity, diet, lifestyle or culture-specific variations, and other environmental influences. However, biogeographic variation in gut microbiota assembly remains largely unexplored in Latin America. In this paper, we compared food recall information and microbiota composition of toddlers living in geographically separated urban populations within four states of Brazil. 16S RNA gene sequencing revealed that alpha diversity was similar between the four different populations. Gut microbiota compositions were dominated by members of the phyla Firmicutes and Bacteroidetes, resembling a more adult-like microbiota as compared with those of Western European toddlers of similar age. These findings suggest that inter-individual and nutrition-induced differences were apparent in the fecal microbiota. We conclude that urban dietary pattern plays a larger role in influencing the gut microbiota composition than do biogeographic factors.

Dificuldades alimentares em pré-escolares, práticas alimentares pregressas e estado nutricional / Feeding difficulties in preschool children, previous feeding practices, and nutritional status

RESUMO Objetivo: Identificar a prevalência de dificuldade alimentar (DA) em pré-escolares, sua associação com fatores epidemiológicos e práticas alimentares pregressas, bem como sua repercussão sobre o estado nutricional. Métodos: Estudo transversal com aplicação de questionário às mães de 301 crianças de dois a seis anos de creches públicas e privadas em Natal, Rio Grande do Norte, em 2014 e 2015. Identificou-se DA segundo critérios de Kerzner, incluindo os perfis de "ingestão altamente seletiva", "criança agitada com baixo apetite", "fobia alimentar" e "criança com distúrbio psicológico ou negligenciada". As variáveis de associação analisadas por regressão logística foram: tempo de aleitamento materno, idade de introdução de leite de vaca e da alimentação complementar, faixa etária, renda familiar, tipo de escola, perfil das mães (responsivas ou não responsivas) e índice de massa corpórea (IMC). Resultados: DA foi encontrada em 37,2% dos casos analisados, com predomínio de "ingestão altamente seletiva" (25,4%). Não houve associação entre DA e práticas alimentares na fase de lactente, renda familiar e tipo de escola. Não houve diferença entre as médias de escore Z IMC para os grupos com e sem DA (1,0±1,5DP e 1,1±1,4DP, respectivamente). A faixa etária de cinco a seis anos apresentou maior ocorrência de DA (OR 1,8; IC95% 1,1-2,9) e filhos de mães com perfil responsivo tiveram menores chances de apresentar DAs (OR 0,4; IC95% 0,2-0,8). Conclusões: DA foi de alta prevalência. Não houve repercussão sobre o estado nutricional nem associação às práticas alimentares pregressas. O perfil responsivo das mães é fator protetor para as DAs e reforça a importância da natureza comportamental e da interação mãe-filho.

ABSTRACT Objective: To identify the prevalence of feeding difficulties in preschoolers, its association with epidemiological factors and previous eating habits, and repercussion on nutritional status. Methods: Cross-sectional study with a questionnaire given to the mothers of 301 children aged 2-6 years enrolled in public and private kindergartens in Natal, Northeast Brazil, conducted in 2014-2015. Feeding difficulty was assessed according to Kerzner's criteria, resulting in the profiles "highly selective intake", "active child with small appetite", "fear of feeding", and "child with psychological disorder or neglected". Association with the following independent variables was analyzed by logistic regression: breastfeeding time, age of cows' milk and complementary feeding introduction, age range, family income, type of school, mothers' profile (responsive or nonresponsive), and body mass index (BMI). Results: Feeding difficulty was found in 37.2% of cases, with predominance of "highly selective intake" (25.4%). It was not associated with infancy feeding practices, family income or type of school. There were no differences between the BMI Z score means for the groups with and without feeding difficulty (1.0±1.5 SD and 1.1±1.4 SD, respectively). The five-to-six age range had more occurrences (OR 1.8; 95%CI 1.1-2.9). Children of responsive mothers were less likely to have feeding difficulties (OR 0.4; 95%CI 0.2-0.8). Conclusions: Feeding difficulties were very frequent. Nutritional status was not impacted by it, and infancy eating habits were not associated with it. Responsive mothers' profile is a protective factor against eating difficulties and reinforces the importance of behavioral factors and mother-child interaction.

Consenso Brasileiro sobre Alergia Alimentar: 2018 - Parte 1 - Etiopatogenia, clínica e diagnóstico. Documento conjunto elaborado pela Sociedade Brasileira de Pediatria e Associação Brasileira de Alergia e Imunologia / Brazilian Consensus on Food Allergy: 2018 - Part 1 - Etiopathogenesis, clinical features, and diagnosis. Joint position paper of the Brazilian Society of Pediatrics and the Brazilian Association of Allergy and Immunology

A alergia alimentar é definida como uma doença consequente a uma resposta imunológica anômala, que ocorre após a ingestão e/ou contato com determinado(s) alimento(s). Atualmente é considerada um problema de saúde pública, pois a sua prevalência tem aumentado no mundo todo. É um capítulo à parte entre as reações adversas a alimentos, e de acordo com os mecanismos fisiopatológicos envolvidos, essas reações podem ser imunológicas ou não-imunológicas. Em geral, a alergia alimentar inicia precocemente na vida com manifestações clínicas variadas na dependência do mecanismo imunológico envolvido. A anafilaxia é a forma mais grave de alergia alimentar mediada por IgE. Conhecimentos recentes permitiram a melhor caracterização da Síndrome da enterocolite induzida por proteína alimentar (FPIES), assim como da esofagite eosinofílica. Vários fatores de risco, assim como novos alérgenos alimentares, têm sido identificados nos últimos anos. Tomando-se como ponto de partida o "Consenso Brasileiro sobre Alergia Alimentar: 2007" foi realizada revisão e atualização dos conceitos apresentados por grupo de alergologistas, gastroenterologistas, nutrólogos e pediatras especializados no tratamento de pacientes com alergia alimentar. Novos conceitos foram apresentados sobretudo pela melhor caracterização. O objetivo desta revisão foi elaborar um documento prático capaz de auxiliar na compreensão dos mecanismos envolvidos na alergia alimentar, assim como dos possíveis fatores de risco associados à sua apresentação, bem como sobre a sua apresentação clínica.

Food allergy is defined as a disease resulting from an anomalous immune response that occurs after ingestion of and/or contact with certain foods. It is currently considered a public health problem because of its increased prevalence worldwide. Food allergy is a major entity among adverse reactions to foods; depending on the pathophysiological mechanisms involved, these reactions may be immunological or non-immunological. In general, food allergy starts early in life with varied clinical manifestations depending on the immune mechanism involved. Anaphylaxis is the most severe form of IgE-mediated food allergy. Recent knowledge has allowed to better characterize food protein-induced enterocolitis syndrome (FPIES), as well as eosinophilic esophagitis. Several risk factors as well as new food allergens have been identified in recent years. Taking the 2007 Brazilian Consensus on Food Allergy as a starting point, the concepts presented were reviewed and updated by a group of allergologists, gastroenterologists, nutrologists and pediatricians specialized in the treatment of patients with food allergy. The objective of this review was to develop a hands-on document capable of helping improve the understanding of the mechanisms involved in food allergy, possible associated risk factors, as well as clinical presentation.

Consenso Brasileiro sobre Alergia Alimentar: 2018 - Parte 2 - Diagnóstico, tratamento e prevenção. Documento conjunto elaborado pela Sociedade Brasileira de Pediatria e Associação Brasileira de Alergia e Imunologia / Brazilian Consensus on Food Allergy: 2018 - Part 2 - Diagnosis, treatment and prevention. Joint position paper of the Brazilian Society of Pediatrics and the Brazilian Association of Allergy and Immunology

Na última década o conhecimento sobre a etiopatogenia da alergia alimentar (AA) avançou muito. A identificação de novas formas clínicas de apresentação, aliada à aquisição de novos métodos laboratoriais, possibilitaram a realização do diagnóstico etiológico de modo mais preciso, sobretudo quanto à reatividade cruzada entre alimentos e mesmo na identificação de marcadores indicativos de formas clínicas transitórias, persistentes e quadros mais graves. A padronização dos testes de provocação oral permitiu a sua realização de forma mais segura e possibilitou a sua inclusão entre as ferramentas disponíveis para uso na confirmação etiológica da AA. Apesar disso, a exclusão do alimento responsável pelas manifestações clínicas continua sendo a principal conduta terapêutica a ser empregada. Entre os pacientes alérgicos às proteínas do leite de vaca, a disponibilidade de fórmulas especiais, por exemplo parcialmente hidrolisadas, extensamente hidrolisadas à base da proteína do leite de vaca e fórmulas de aminoácidos, tem facilitado o tratamento substitutivo do leite de vaca para esses pacientes. A abordagem atual da anafilaxia é revisada, uma vez que os alimentos são os principais agentes etiológicos em crianças. Avanços na conduta de algumas manifestações gastrintestinais também são abordados. Na atualidade, a imunoterapia oral tem sido cada vez mais utilizada. A aquisição de novos agentes, os imunobiológicos, também são apresentados à luz das evidências científicas e clínicas atuais. Considerações sobre história natural da AA, assim como sobre formas de prevenção da AA também são abordadas. Em conclusão, o Consenso Brasileiro sobre Alergia Alimentar de 2018 objetivou rever os métodos diagnósticos e esquemas de tratamento disponíveis e empregados no acompanhamento de pacientes com AA, visando a melhor abordagem terapêutica desses pacientes.

Over the last decade, knowledge about the etiopathogenesis of food allergy (FA) has advanced a great deal. The identification of new clinical presentations, associated with the acquisition of new laboratory methods, have made the diagnostic process more accurate, especially with regard to cross-reactivity between foods and the identification of biomarkers suggestive of transitory, persistent clinical forms and/or more severe manifestations. The standardization of oral provocation tests has made their performance safer and has allowed their inclusion among the tools available for use in the etiological confirmation of FA. Despite this, exclusion of the food involved in the clinical manifestations remains as the main therapeutic strategy. Among patients allergic to cow's milk proteins, the availability of special formulas, e.g., partially hydrolyzed and extensively hydrolyzed cow's milk protein-based formulas, in addition to amino acid formulas, has facilitated the introduction of substitute formulas for these patients. The current approach to anaphylaxis is reviewed, since food is the major etiological agent in children. Advances in the management of some gastrointestinal manifestations are also addressed. Currently, oral immunotherapy has been increasingly used. The acquisition of new agents, namely, immunobiological agents, is also described in light of current scientific and clinical evidence. Considerations on the natural history of FA, as well as on ways how to prevent FA, are addressed. In conclusion, the 2018 Brazilian Consensus on Food Allergy aimed to review the diagnostic methods and treatment schemes available and used in the follow-up of patients with FA, with a view to adopting the best possible therapeutic approach to these patients.

FEEDING DIFFICULTIES IN PRESCHOOL CHILDREN, PREVIOUS FEEDING PRACTICES, AND NUTRITIONAL STATUS. / DIFICULDADES ALIMENTARES EM PRÉ-ESCOLARES, PRÁTICAS ALIMENTARES PREGRESSAS E ESTADO NUTRICIONAL.

OBJECTIVE: To identify the prevalence of feeding difficulties in preschoolers, its association with epidemiological factors and previous eating habits, and repercussion on nutritional status. METHODS: Cross-sectional study with a questionnaire given to the mothers of 301 children aged 2-6 years enrolled in public and private kindergartens in Natal, Northeast Brazil, conducted in 2014-2015. Feeding difficulty was assessed according to Kerzner's criteria, resulting in the profiles "highly selective intake", "active child with small appetite", "fear of feeding", and "child with psychological disorder or neglected". Association with the following independent variables was analyzed by logistic regression: breastfeeding time, age of cows' milk and complementary feeding introduction, age range, family income, type of school, mothers' profile (responsive or nonresponsive), and body mass index (BMI). RESULTS: Feeding difficulty was found in 37.2% of cases, with predominance of "highly selective intake" (25.4%). It was not associated with infancy feeding practices, family income or type of school. There were no differences between the BMI Z score means for the groups with and without feeding difficulty (1.0±1.5 SD and 1.1±1.4 SD, respectively). The five-to-six age range had more occurrences (OR 1.8; 95%CI 1.1-2.9). Children of responsive mothers were less likely to have feeding difficulties (OR 0.4; 95%CI 0.2-0.8). CONCLUSIONS: Feeding difficulties were very frequent. Nutritional status was not impacted by it, and infancy eating habits were not associated with it. Responsive mothers' profile is a protective factor against eating difficulties and reinforces the importance of behavioral factors and mother-child interaction.

OBJETIVO: Identificar a prevalência de dificuldade alimentar (DA) em pré-escolares, sua associação com fatores epidemiológicos e práticas alimentares pregressas, bem como sua repercussão sobre o estado nutricional. MÉTODOS: Estudo transversal com aplicação de questionário às mães de 301 crianças de dois a seis anos de creches públicas e privadas em Natal, Rio Grande do Norte, em 2014 e 2015. Identificou-se DA segundo critérios de Kerzner, incluindo os perfis de "ingestão altamente seletiva", "criança agitada com baixo apetite", "fobia alimentar" e "criança com distúrbio psicológico ou negligenciada". As variáveis de associação analisadas por regressão logística foram: tempo de aleitamento materno, idade de introdução de leite de vaca e da alimentação complementar, faixa etária, renda familiar, tipo de escola, perfil das mães (responsivas ou não responsivas) e índice de massa corpórea (IMC). RESULTADOS: DA foi encontrada em 37,2% dos casos analisados, com predomínio de "ingestão altamente seletiva" (25,4%). Não houve associação entre DA e práticas alimentares na fase de lactente, renda familiar e tipo de escola. Não houve diferença entre as médias de escore Z IMC para os grupos com e sem DA (1,0±1,5DP e 1,1±1,4DP, respectivamente). A faixa etária de cinco a seis anos apresentou maior ocorrência de DA (OR 1,8; IC95% 1,1-2,9) e filhos de mães com perfil responsivo tiveram menores chances de apresentar DAs (OR 0,4; IC95% 0,2-0,8). CONCLUSÕES: DA foi de alta prevalência. Não houve repercussão sobre o estado nutricional nem associação às práticas alimentares pregressas. O perfil responsivo das mães é fator protetor para as DAs e reforça a importância da natureza comportamental e da interação mãe-filho.

The celiac iceberg: from the clinical spectrum to serology and histopathology in children and adolescents with type 1 diabetes mellitus and Down syndrome.

OBJECTIVE: The objective of this study is to investigate the occurrence of gastrointestinal (GI) and extraintestinal symptoms in children and adolescents with type 1 diabetes mellitus (DM1) and Down syndrome (DS) and their association with specific antibodies and histopathology of celiac disease (CelD), representing its clinical forms in the iceberg. MATERIAL AND METHODS: Cross-sectional study (November 2009-December 2012) conducted at an outpatient care facility in Northeast Brazil including patients [DM1 (n = 111); DS (n = 77)] aged 10 months-18 years old. Measurement of anti-endomysial (EmA) and anti-tissue transglutaminase (anti-tTG) IgA antibodies was performed, as was that of anti-tTG-IgG in the cases with low serum IgA. The patients with antibody positivity were subjected to small intestine biopsy. RESULTS: GI symptoms occurred in 53.7% of the sample, extraintestinal symptoms in 4.3%, and antibody positivity in 28.2% (n = 53). Of those who underwent biopsy (n = 40), histopathological findings of CelD were found in 37.5% [DM1 = 5/111 (4.5%), DS = 10/77 (13.0%)]. GI symptoms were associated with antibody positivity, but not with the histopathology. The GI (32.5%), silent (5.0%), and potential (62.5%) forms of disease were detected. CONCLUSIONS: The prevalence of GI symptoms was high in groups DM1 and DS, and the occurrence of such symptoms was associated with antibody positivity. The lack of association between the symptoms and histopatholological findings points to the inconsistency of the former as indicators of CelD. Although the GI form predominated among the cases with active CelD, its contribution to the celiac iceberg was smaller compared with the potential form, which determined the large and submerged base of the iceberg representing the high-risk groups investigated.

Clinical and follow up assessment of children in a program directed at the use of formulas for cow's milk protein allergy.

OBJECTIVE: To determine clinical and follow up characteristics of children enrolled in a program to supply formulas for cow's milk allergy. METHODS: descriptive study of a convenience sample composed of 214 children up to three years old, with clinical diagnosis of cow's milk allergy and/or standardized oral challenge, referred to the Program of Formulas for Cow's Milk Allergy at a Pediatric University Hospital, in Natal, Rio Grande do Norte, Brazil (2007/2009). Clinical-epidemiological data and formula indication (soy, protein hydrolysates or aminoacid formula) were assessed at the first consultation. Clinical response and nutritional evolution (Anthro-OMS2006) were observed after three months. Chi-square and paired t-test were used, being p<0.05 significant. RESULTS: At the first consultation, mean age was 9.0±6.9 months. Digestive manifestations occurred in 81.8%; cutaneous ones, in 36.9% and respiratory ones in 23.8%. BMI Z-score <-2.0 standard deviations (SD) was found in 17.9% of children with isolated digestive symptoms, in 41.7% of those using cow's milk and in 8.7% of those using other formulas (p<0.01). The following formulas were used: soy in 61.2%, protein hydrolysates in 35.4% and aminoacids in 3.3%. Mean BMI Z-scores at initial consultation and after three months were, respectively: -0.24±1.47SD and 0.00±1.26SD (p=0.251), with soy formula, and -0.70±1.51SD and -0.14±1.36SD (p=0.322) with protein hydrolysates formula. CONCLUSIONS: Digestive manifestations of cow's milk allergy were preponderant, and lead to greater nutritional impairment. The use of replacement formulas (isolated soy protein and protein hydrolysates) was important to maintain the nutritional status.

Avaliação clínica e evolutiva de crianças em programa de atendimento ao uso de fórmulas para alergia à proteína do leite de vaca / Clinical and follow up assessment of children in a program directed at the use of formulas for cow's milk protein allergy / Evaluación clínica y evolutiva de niños en programas de atención al uso de fórmulas para alergia a la proteína de leche de vaca

OBJETIVO: Determinar características clínicas e evolutivas de crianças acompanhadas em programa de referência para fornecimento de fórmulas especiais para alergia ao leite de vaca. MÉTODOS: Estudo descritivo, realizado em amostra de conveniência, com 214 crianças até três anos, com diagnóstico clínico e/ou teste padronizado de provocação oral aberto, referenciadas ao Programa de Fórmulas para Alergia ao Leite de Vaca, em Hospital Universitário Pediátrico de Natal, Rio Grande do Norte (2007/2009). Avaliaram-se dados clínico-epidemiológicos e indicação de fórmulas (soja, hidrolisado ou aminoácido) à consulta inicial, além de resposta clínica e evolução nutricional (Anthro-OMS 2006) após três meses. Aplicaram-se os testes do qui-quadrado e t pareado nas análises, considerando-se significante p<0,05. RESULTADOS: Ao primeiro atendimento, a média de idade foi de 9,0±6,9 meses. Manifestações digestórias foram observadas em 81,8%; cutâneas, em 36,9%; e respiratórias, em 23,8%. Escore Z do IMC <-2,0 desvios padrão (DP) foi encontrado em 17,9% das crianças com sintomas digestórios isolados, em 41,7% em uso de leite de vaca e em 8,7% com outras fórmulas (p<0,01). Fórmula de proteína isolada de soja foi usada em 61,2%; hidrolisados, em 35,4%; e aminoácidos, em 3,3%. As médias de escore Z do IMC ao atendimento inicial e após três meses foram, respectivamente, -0,24±1,47DP e 0,00±1,26DP (p=0,251), quando em uso de soja, e -0,70±1,51DP e -0,14±1,36DP (p=0,322), em uso de hidrolisado. CONCLUSÕES: Manifestações digestórias da alergia ao leite de vaca foram preponderantes e determinaram maior comprometimento nutricional. As fórmulas de substituição ao leite de vaca mais utilizadas foram de proteína isolada de soja e hidrolisados proteicos. O uso de ambas foi importante para a manutenção do estado nutricional.

OBJECTIVE: To determine clinical and follow up characteristics of children enrolled in a program to supply formulas for cow's milk allergy. METHODS: descriptive study of a convenience sample composed of 214 children up to three years old, with clinical diagnosis of cow's milk allergy and/or standardized oral challenge, referred to the Program of Formulas for Cow's Milk Allergy at a Pediatric University Hospital, in Natal, Rio Grande do Norte, Brazil (2007/2009). Clinical-epidemiological data and formula indication (soy, protein hydrolysates or aminoacid formula) were assessed at the first consultation. Clinical response and nutritional evolution (Anthro-OMS2006) were observed after three months. Chi-square and paired t-test were used, being p<0.05 significant. RESULTS: At the first consultation, mean age was 9.0±6.9 months. Digestive manifestations occurred in 81.8%; cutaneous ones, in 36.9% and respiratory ones in 23.8%. BMI Z-score <-2.0 standard deviations (SD) was found in 17.9% of children with isolated digestive symptoms, in 41.7% of those using cow's milk and in 8.7% of those using other formulas (p<0.01). The following formulas were used: soy in 61.2%, protein hydrolysates in 35.4% and aminoacids in 3.3%. Mean BMI Z-scores at initial consultation and after three months were, respectively: -0.24±1.47SD and 0.00±1.26SD (p=0.251), with soy formula, and -0.70±1.51SD and -0.14±1.36SD (p=0.322) with protein hydrolysates formula. CONCLUSIONS: Digestive manifestations of cow's milk allergy were preponderant, and lead to greater nutritional impairment. The use of replacement formulas (isolated soy protein and protein hydrolysates) was important to maintain the nutritional status.

OBJETIVO: Determinar características clínicas y evolutivas de niños acompañados en programa de referencia para suministro de fórmulas especiales para alergia a la leche de vaca. MÉTODOS: Estudio descriptivo, realizado en muestra de conveniencia, con 214 niños hasta tres años de edad, con diagnóstico clínico y/o prueba estandarizada de provocación oral abierta, referenciadas al Programa de Fórmulas para Alergia a la Leche de Vaca del Hospital Universitario Pediátrico en Natal, RN, Brasil (2007/2009). Se evaluaron datos clínico-epidemiológicos e indicación de fórmulas (soja, hidrolizado o aminoácido) a la consulta inicial, respuesta clínica y evolución nutricional (Anthro-OMS 2006) después de tres meses. Se aplicaron pruebas de Chi-Cuadrado y T Pareada en los análisis, siendo significante p<0,05. RESULTADOS: A la primera atención, el promedio de edad fue de 9,0±6,9 meses. Manifestaciones digestorias fueron observadas en 81,8%, cutáneas en el 36,9% y respiratorias en el 23,8%. Escore Z IMC<-2,0DE fue encontrado en 17,9% de los niños con síntomas digestorios aislados, en el 41,7% en uso de leche de vaca y en 8,7% en otras fórmulas (p<0,01). Se utilizó fórmula de proteína aislada de soja en 61,2%, hidrolizados en 35,4% y aminoácidos en 3,3%. Promedios de Escore Z IMC a la atención inicial y después de tres meses fueron -0,24±1,47DE y 0,00±1,26DE (p=0,251), cuando en uso de soja, y 0,70±1,51DE y -0,14±1,36DE (p=0,322), en uso de hidrolizado. CONCLUSIONES: Manifestaciones digestorias de la alergia a la leche de vaca fueron preponderantes y determinaron mayor comprometimiento nutricional. Las fórmulas de sustitución a la leche de vaca más utilizadas fueron de proteína aislada de soja e hidrolizados proteicos y el uso de ambas fue importante para el mantenimiento del estado nutricional.

Postnatal growth restriction and predictors of nutritional outcome in very low birth weight infants fed human milk and assisted by the Kangaroo Mother Care method.

OBJECTIVE: [corrected] The study sought to determine the prevalence of postnatal growth restriction (PNGR) and the predictors of nutritional outcome in very low birth weight (VLBW) infants. METHODS: Cross-sectional study conducted in a maternity school between July 2005 and August 2006. One-hundred and twelve VLBW infants were assessed during hospitalization, fed unfortified human milk and assisted by Kangaroo Mother Care. The dependent variables included the number of days required to reach minimum weight and regain birth weight, the percentage of weight loss, and the deterioration of nutritional status. These parameters were converted into a factor termed "nutritional outcome" using factor analysis. Multiple linear regressions were used to identify predictors of nutritional outcome. RESULTS: PNGR was observed in 89.3% of the infants at hospital discharge. The predictors of nutritional outcome were: appropriate-for-gestational-age infants, children of mothers aged ≤ 20 years old, need for mechanical ventilation, longer stays in the neonatal intensive care unit, and a greater number of days to achieve full enteral nutrition. CONCLUSION: It is important to know the factors that negatively influence the nutritional outcome of VLBW infants, as these can be modified through the improvement of perinatal care and can reduce PNGR.

Dificuldades alimentares na infância: revisão da literatura com foco nas repercussões à saúde / Feeding difficulties in infancy: review of the literature focusing on the impact

O presente trabalho foi conduzido com a finalidade de revisar os conhecimentos científicos atuais sobre as dificuldades alimentares na infância, focalizando especialmente os estudos que avaliaram suas consequências à saúde.

Length of stay in a neonatal intensive care unit and its association with low rates of exclusive breastfeeding in very low birth weight infants.

OBJECTIVE: To identify the inpatient maternal and neonatal factors associated to the weaning of very low birth weight (VLBW) infants. METHODS: One hundred nineteen VLBW (<1500 g) infants were monitored from July 2005 through August 2006, from birth to the first ambulatory visit after maternity discharge. This maternity unit uses the Kangaroo Method and the Baby Friendly Hospital Initiative. Out of 119 VLBW infants monitored until discharge, 88 (75%) returned to the facility, 22 (25%) were on exclusive breastfeeding (EB), and 66 (75%) were weaned (partial breastfeeding or formula feeding). RESULTS: Univariate analysis found an association between weaning and lower birth weight, longer stays in the neonatal intensive care unit (NICU), and longer hospitalization times, in addition to more prolonged enteral feeding and birth weight recovery period. Logistic regression showed length of NICU stay as being the main determinant of weaning. CONCLUSION: The negative repercussion on EB of an extended stay in the NICU is a significant challenge for health professionals to provide more adequate nutrition to VLBW infants.

[Regional differences in knowledge, attitudes, and practice in emergency contraceptive use among health sciences university students in Brazil]. / Diferenças regionais de conhecimento, opinião e uso de contraceptivo de emergência entre universitários brasileiros de cursos da área de saúde.

The aim of this study was to evaluate regional differences in knowledge, attitudes, and practice in emergency contraception use among Brazilian university students. A sample of university students answered a semi-structured questionnaire on knowledge, attitudes, and practice related to emergency contraception and sexual behavior. Fisher's exact test and ANOVA were used for statistical analysis. Statistical significance was set at p < 0.05. Ninety-six percent (n = 588) of the students had heard of emergency contraception, and 19% (n = 111) knew all the situations in which emergency contraception is indicated, with statistical differences between regions of the country. Forty-two percent of sexually active women in the sample had already used emergency contraception; 35% (n = 207) of students equated emergency contraception with abortion; and 81% (n = 473) thought emergency contraception involves health risks. No significant difference was observed between regions of the country regarding use and attitudes towards emergency contraception. Inter-regional differences in knowledge had no impact on students' attitudes and practice in emergency contraception. National awareness-raising campaigns are needed to improve knowledge on emergency contraception.

Diferenças regionais de conhecimento, opinião e uso de contraceptivo de emergência entre universitários brasileiros de cursos da área de saúde / Regional differences in knowledge, attitudes, and practice in emergency contraceptive use among health sciences university students in Brazil

O objetivo deste estudo foi avaliar as diferenças regionais de conhecimento, opinião e uso de anticoncepção de emergência entre universitários brasileiros. Questionário semi-estruturado abordando conhecimento, opinião, experiência com anticoncepção de emergência e comportamento sexual foi aplicado a adolescentes de universidades brasileiras. Para análise estatística utilizou-se o teste exato de Fisher e ANOVA. Diferenças foram significantes quando o valor de p < 0,05. Cerca de 96 por cento (n = 588) dos estudantes já tinham ouvido falar sobre anticoncepção de emergência, 19 por cento (n = 111) conheciam as situações nas quais está indicada, com diferenças inter-regionais; 42 por cento das meninas que tinham vida sexual ativa já tinham feito uso do método; 35 por cento (n = 207) dos estudantes consideravam contracepção de emergência abortiva e 81 por cento (n = 473) achavam que traz riscos à saúde, sem diferença significativa entre as regiões nas questões relativas a uso e à opinião. As diferenças inter-regionais sobre conhecimento não impactaram no uso e na opinião dos adolescentes sobre anticoncepção de emergência. Programas nacionais devem ser conduzidos para melhorar o conhecimento sobre o método.

The aim of this study was to evaluate regional differences in knowledge, attitudes, and practice in emergency contraception use among Brazilian university students. A sample of university students answered a semi-structured questionnaire on knowledge, attitudes, and practice related to emergency contraception and sexual behavior. Fisher's exact test and ANOVA were used for statistical analysis. Statistical significance was set at p < 0.05. Ninety-six percent (n = 588) of the students had heard of emergency contraception, and 19 percent (n = 111) knew all the situations in which emergency contraception is indicated, with statistical differences between regions of the country. Forty-two percent of sexually active women in the sample had already used emergency contraception; 35 percent (n = 207) of students equated emergency contraception with abortion; and 81 percent (n = 473) thought emergency contraception involves health risks. No significant difference was observed between regions of the country regarding use and attitudes towards emergency contraception. Inter-regional differences in knowledge had no impact on students' attitudes and practice in emergency contraception. National awareness-raising campaigns are needed to improve knowledge on emergency contraception.

Hepatic stellate cell activation and hepatic fibrosis in children with type 1 autoimmune hepatitis: an immunohistochemical study of paired liver biopsies before treatment and after clinical remission.

OBJECTIVES: The activation of hepatic stellate cells (HSC) is considered the most important event in hepatic fibrogenesis. The precise mechanism of this process is unknown in autoimmune hepatitis (AIH), and more evidence is needed on the evolution of fibrosis. The aim of this study was to assess these aspects in children with type 1 AIH. METHODS: We analyzed 16 liver biopsy samples from eight patients, paired before treatment and after clinical remission, performed an immunohistochemical study with anti-alpha actin smooth muscle antibody and graded fibrosis and inflammation on a scale of 0-4 (Batts and Ludwig scoring system). RESULTS: There was no significant reduction in fibrosis scores after 24+/-18 months (2.5+/-0.93 vs. 2.0+/-0.53, P=0.2012). There was an important decrease in inflammation: portal (2.6+/-0.74 vs. 1.3+/-0.89, P=0.0277), periportal/periseptal (3.0+/-0.76 vs. 1.4+/-1.06, P=0.0277), and lobular (2.8+/-1.04 vs. 0.9+/-0.99, P=0.0179). Anti-alpha actin smooth muscle antibodies were expressed in the HSC of the initial biopsies (3491.93+/-2051.48 mum), showing a significant reduction after remission (377.91+/-439.47 microm) (P=0.0117). CONCLUSION: HSC activation was demonstrated in the AIH of children. The reduction of this activation after clinical remission, which may precede a decrease in fibrosis, opens important perspectives in the follow-up of AIH.

Excesso de peso de escolares em região do Nordeste Brasileiro: contraste entre as redes de ensino pública e privada / Excess weight in children from Brazilian Northeast: difference between public and private schools

OBJETIVOS: estimar a prevalência de excesso de peso em escolares na cidade de Natal. Métodos estudo transversal com 1927 crianças, de 6 a 11 anos de idade, de escolas públicas e privadas nas diferentes zonas da cidade de Natal, Rio Grande do Norte, Brasil. Foram analisadas as variáveis: sexo, faixa etária, tipo de escola e zonas da cidade. Foram considerados com excesso de peso os escolares com índice de massa corporal para sexo e idade igual ou superior ao percentil 85. RESULTADOS: o excesso de peso foi encontrado em 33,6 por cento das crianças. Não houve diferenças significantes entre os sexos e faixas etárias. Nas escolas privadas, a prevalência de excesso de peso foi 54,5 por cento; nas públicas, 15,6 por cento (p<0,01; OR=6,49). Maior prevalência de excesso de peso foi encontrada nas escolas das zonas de melhor índice de qualidade de vida da cidade, isto é, zonas leste-sul (41,3 por cento), quando comparadas às zonas norte-oeste (28,4 por cento) (p<0,01). CONCLUSÕES: a prevalência de excesso de peso em escolares se mostrou alta, demonstrando a necessidade de programas de intervenção e prevenção. A maior prevalência nas escolas privadas, reforçada pelo mesmo achado nas crianças de escolas situadas nas zonas de maior poder aquisitivo da cidade, reflete a importância da associação entre os níveis socioeconômicos mais altos e o excesso de peso, sobretudo o sobrepeso, em regiões em desenvolvimento.

OBJECTIVES: to determine the prevalence of excess weight in schoolchildren from the city of Natal. METHODS: transversal study with 1927 children aged 6-11 from public and private schools in different zones in the city of Natal, in the State of Rio Grande do Norte, Brazil, and analyze related variables, such as gender, age-group, type of school and city zones. All scholars with a body mass index equal to or greater than the 85th percentile were considered as having excess weight. RESULTS: the prevalence of excess weight among the studied scholars was 33.6 percent. There were no significant differences between genders and age-groups. In the private schools, the prevalence of excess weight was 54.5 percent, while in the public schools, 15.6 percent (p<0.01; OR=6.49). The prevalence of excess weight was greater in schools located in the zones with the best quality of life, east-south zone (41.3 percent), if compared with schools in the north-west zone (28.4 percent) (p<0.01). CONCLUSIONS: the prevalence of excess weight in scholars was found high, demonstrating the importance of programs of treatment and prevention. The biggest prevalence in children studying in private schools and in children studying in schools located in the best zone of the city reflects the importance of association between the best socioeconomic levels and these entities in regions of developing countries.

[Prevalence of excess weight in preschoolers in the Northeast of Brazil]. / Sobrepeso: uma nova realidade no estado nutricional de pré-escolares de Natal, RN.

OBJECTIVE: Determine the prevalence of excess weight in preschoolers in Natal/RN and analyze the variables involved such as: gender, age, type of school (public and private) and city zones. METHODS: Transversal study was performed in 20 public and 20 private schools in Natal, Brazil, between August and December, 2004. A total of 3721 children, from 2 to 6 years of age were analyzed. Children whose BMI was > or = 85 percentile were considered as excess weight and those with BMI > or = 95 percentile as overweight . RESULTS: Prevalence of excess weight found was 26.5% (95%CI=24.4-28.9), with 14.1% (95%CI=13.0-15.3) risk of overweight and 12.4% (95%CI=11.4-13.6) overweight. In overweight children there were more males (13.9%, 95%CI=12.4-15.6) than females (10.8%, 95%CI=9.4-12.4) (p<0.01, Prevalence ratio [PR]=1.29, 95%CI=1.08-1.53). Excess weight was found in 19.7% (95%CI=17.1-22.7) of public school students and in 32.5% (95%CI=29.3-35.9) of private school students (p<0.01, [PR]=1.64, 95%CI=1.47-1.84). Overweight prevalence was 7.1% (95%CI=6.0-8.4) and 17.1% (95%CI=15.5-18.8), respectively (p<0.01, [PR]=2.41, 95%CI=1.98-2.93). The East + South zones, areas with a better quality of life index, showed higher percentages of excess weight (p<0.01) and overweight (p<0.01) than the North +West zones. CONCLUSION: Excess weight and overweight prevalence in preschoolers in Natal is high, mainly in private schools, showing the need to implement prevention and intervention programs.

Sobrepeso: uma nova realidade no estado nutricional de pré-escolares de Natal, RN / Prevalence of excess weight in preschoolers in the Northeast of Brazil

OBJETIVO: Determinar a prevalência do excesso de peso em pré-escolares na cidade de Natal e analisar as variáveis envolvidas como: gênero, idade, tipo de escola (pública e privada) e zonas da cidade. MÉTODOS: Estudo transversal, realizado em 20 escolas e creches públicas e 20 escolas privadas, na cidade de Natal, no período de agosto a dezembro de 2004. Foram analisadas 3721 crianças de 2 a 6 anos. Considerou-se como excesso de peso todas as crianças com IMC > percentil 85 e sobrepeso aquelas com IMC > percentil 95. RESULTADOS: A prevalência de excesso de peso encontrada foi 26,5 por cento (IC95 por cento= 24,4-28,9), sendo 14,1 por cento (IC95 por cento=13,0-15,3) risco de sobrepeso e 12,4 por cento (IC95 por cento=11,4-13,6) sobrepeso. Foi observada maior prevalência de sobrepeso no gênero masculino (13,9 por cento, IC95 por cento=12,4-15,6), que no feminino (10,8 por cento, IC95 por cento=9,4-12,4) (p<0,01, Razão de prevalência [RP]=1,29, IC95 por cento=1,08-1,53). O excesso de peso foi encontrado em 19,7 por cento (IC95 por cento=17,1-22,7) dos alunos da rede pública e em 32,5 por cento (IC95 por cento=29,3-35,9) da rede privada (p<0,01, RP=1,64, IC95 por cento=1,47-1,84). Já as prevalências de sobrepeso foram 7,1 por cento (IC95 por cento=6,0-8,4) e 17,1 por cento (IC95 por cento=15,5-18,8), respectivamente (p<0,01, RP=2,41, IC95 por cento=1,98-2,93). As zonas Leste + Sul, áreas com melhor índice de qualidade de vida da cidade, apresentaram maiores percentuais de excesso de peso (p<0,01) e sobrepeso (p<0,01). CONCLUSÃO: A prevalência do excesso de peso e sobrepeso em pré-escolares na cidade de Natal é alta, principalmente nas escolas privadas, demonstrando a necessidade de implantação de programas de prevenção e intervenção, a partir da educação infantil.

OBJECTIVE: Determine the prevalence of excess weight in preschoolers in Natal/RN and analyze the variables involved such as: gender, age, type of school (public and private) and city zones. METHODS: Transversal study was performed in 20 public and 20 private schools in Natal, Brazil, between August and December, 2004. A total of 3721 children, from 2 to 6 years of age were analyzed. Children whose BMI was > 85 percentile were considered as excess weight and those with BMI > 95 percentile as overweight . RESULTS: Prevalence of excess weight found was 26.5 percent (95 percentCI=24.4-28.9), with 14.1 percent (95 percentCI=13.0-15.3) risk of overweight and 12.4 percent (95 percentCI=11.4-13.6) overweight. In overweight children there were more males (13.9 percent, 95 percentCI=12.4-15.6) than females (10.8 percent, 95 percentCI=9.4-12.4) (p<0.01, Prevalence ratio [PR]=1.29, 95 percentCI=1.08-1.53). Excess weight was found in 19.7 percent (95 percentCI=17.1-22.7) of public school students and in 32.5 percent (95 percentCI=29.3-35.9) of private school students (p<0.01, [PR]=1.64, 95 percentCI=1.47-1.84). Overweight prevalence was 7.1 percent (95 percentCI=6.0-8.4) and 17.1 percent (95 percentCI=15.5-18.8), respectively (p<0.01, [PR]=2.41, 95 percentCI=1.98-2.93). The East + South zones, areas with a better quality of life index, showed higher percentages of excess weight (p<0.01) and overweight (p<0.01) than the North +West zones. CONCLUSION: Excess weight and overweight prevalence in preschoolers in Natal is high, mainly in private schools, showing the need to implement prevention and intervention programs.

Bacterial contamination and nutrient content of home-prepared milk feeding bottles of infants attending a public outpatient clinic.

To evaluate the bacterial contamination and the nutrient content of home-prepared milk feeding bottles, 48 samples of their lacteal contents were collected; of these, 29 samples were cultured and 48 were analyzed to determine their macronutrients composition by chemical analyses. The medians (percentiles 25 and 75) of the counts (bacteria/ml) were mesophilic bacteria, 78,000 (500-1,125,000) and coliforms, 600 (0-44,000). Adding sugar (41/48) and cereals (39/48) to the milk was a common practice. The medians of the macronutrients contents (g/dl or kcal/dl) of the feeding bottles with and without the addition of cereals were, respectively: protein, 2.8/2.4; fat, 1.1/2.2; carbohydrate, 14.5/8.6; energy, 88.7/57.2. Feeding bottles with the addition of cereals had carbohydrate and energy contents significantly higher. Home-prepared milk feeding bottles were heavily contaminated. Most milk feeding bottles met or exceeded the recommended values proposed by European Society of Pediatric Gastroenterology and Nutrition for follow-up formulas, except for fat.

Consumo de fibra alimentar e de macronutrientes por crianças com constipação crônica funcional / Fiber and nutrients intake in constipated children

OBJETIVOS: Estimar o consumo de fibra alimentar e de macronutrientes por crianças com constipação crônica funcional atendidas em ambulatório especializado. CASUíSTICA E MÉTODOS: O estudo caso-controle foi desenvolvido no Hospital de Pediatria da Universidade Federal do Rio Grande do Norte, Natal, RN, Brasil. Foram analisadas 54 crianças na faixa etária de 2 a 12 anos com constipação crônica funcional, pareadas por sexo e faixa etária com 50 crianças sem constipação (grupo-controle). A avaliação do consumo alimentar foi feita através do registro alimentar de 3 dias e a análise e adequação das dietas foram realizadas por programa informatizado. RESULTADOS: Em 59,3 por cento dos casos a constipação teve início nos dois primeiros anos de vida. Não houve diferença quanto ao sexo no grupo com constipação, nem associação entre constipação e desnutrição nas crianças estudadas. A quantidade de alimentos ingerida por crianças com constipação foi menor quando comparada à do grupo-controle. O consumo médio diário de energia, proteínas, carboidratos e lipídios foi significativamente menor no grupo de crianças com constipação, assim como os percentuais de adequação calórica e protéica. A ingestão média de fibra alimentar total (g/dia) foi estatisticamente menor no grupo com constipação (6,9 + 3,4) do que no grupo controle (8,6 + 4,2). A proporção de crianças consumindo menos fibra alimentar em relação ao mínimo recomendado pela Fundação Americana de Saúde (idade + 5 g) foi maior no grupo com constipação (83,3 por cento) do que no grupo controle (66,0 por cento). A odds ratio foi igual a 2,6. CONCLUSÕES: Houve menor consumo de fibra alimentar, de energia, proteínas, carboidratos e lipídios por crianças com constipação, assim como menor percentual de adequação calórica e protéica. O baixo consumo de fibra alimentar foi considerado como fator de risco para o desenvolvimento de constipação crônica funcional.

[Fiber and nutrients intake in children with chronic constipation]. / Consumo de fibra alimentar e de macronutrientes por crianças com constipação crônica funcional.

OBJECTIVES: The aim of this case-control study was to evaluate the intake of fiber alimentary and macronutrients in constipated children. METHODS: Fifty-four children (aged 2-12 yr) with diagnosis of chronic functional constipation were investigated at the Pediatric Hospital, "Universidade Federal do Rio Grande do Norte", Natal, RN, Brazil. They were age and sex matched with 50 patients without constipation. A standard questionnaire was applied to both groups and a 3 day dietary record was analyzed by computer software. RESULTS: The mean age at onset of symptoms was 29,0 +/- 26,1 months. There was not sex predominance and no difference about nutritional condition between the groups. Constipated children ate less fiber, proteins, lipids, carbohydrates and less caloric and protein adequated percentuals. The proportion of children who ate less dietary fiber than recommended (age + 5 g /day) was greater in the constipated group (83,3%) than in controls (66,6%); odds ratio 2,6. CONCLUSION: Constipated children ate less fiber and macronutrients than children without constipation. Intake of dietary fiber below the minimum recommendation is a risk factor for chronic functional constipation in children.