Doenças sazonais de verão: diarreia e a utilização de fórmulas infantis sem lactose para rápida recuperação / Seasonal summer illnesses: diarrhoea and the use of lactose free infantile formulations for a quick recovery

A autora aborda as alterações sazonais cíclicas e sua influência sobre o bem-estar infantil, em particular como causa comum de diarreias virais e bacterianas no verão. Discute a fisiopatologia da doença e sua interferência com a nutrição da criança. O trabalho destaca a importância de boa hidratação e a terapia nutricional indicada para a recuperação do paciente, discutindo o lugar das fórmulas infantis sem lactose nas diarreias sazonais, seu tratamento e prevenção...

Celiac disease prevalence in children and adolescents with myocarditis and dilated cardiomiopathy.

OBJECTIVE: To determine the prevalence of celiac disease in patients with myocarditis and dilated cardiomyopathy. METHODS: Fifty-six patients between 1 and 18 years old with dilated cardiomyopathy or myocarditis were evaluated and followed up at Instituto de Medicina Integral Professor Fernando Figueira. Patients with previous diagnosis of celiac disease were excluded. The functional classification was determined according to the American Heart Association criteria (classes I, II, III and IV). Diagnosis of myocarditis was reported in the patients' medical records. Dilated cardiomyopathy was diagnosed by echocardiogram with systolic dysfunction of one or both ventricles, ejection fraction lower than 55%, ventricular dilatation, and left ventricular diastolic diameter bigger than 112%. Patients answered a questionnaire about gastrointestinal and cardiac symptoms; next, anti-tissue transglutaminase (tTG) and anti-endomysial (EMA) antibodies were dosed. Those with positive antibody results were referred to intestinal biopsy and histological evaluation to detect celiac disease according to Marsh classification. RESULTS: One of the 56 children (1.8%) had positive tTG antibody level, but negative EMA. Intestinal histological evaluation showed total villous atrophy. Approximately, 30% of patients had heart failure. Gastrointestinal symptoms and signs were frequent, especially abdominal pain (70%, 39/56). CONCLUSION: Celiac disease prevalence in pediatric patients with dilated cardiomyopathy or myocarditis was 1.8%. It is important to investigate celiac disease in patients with these conditions to avoid the progression of such diseases and patients' clinical deterioration.

Prevalência de doença celíaca em crianças e adolescentes com miocardite e cardiomiopatia dilatada / Celiac disease prevalence in children and adolescents with myocarditis and dilated cardiomiopathy

OBJETIVO: Determinar a prevalência de doença celíaca em pacientes portadores de cardiomiopatia dilatada e miocardite. MÉTODOS: Foram avaliados 56 pacientes, com idade entre 1 e 18 anos, portadores de cardiomiopatia dilatada ou miocardite, acompanhados no Instituto Materno Infantil Professor Fernando Figueira. Foram excluídos pacientes com diagnóstico prévio de doença celíaca. A classe funcional da insuficiência cardíaca foi determinada segundo os critérios da American Heart Association, como classe funcional I, II, III e IV. O diagnóstico de miocardite foi relatado em prontuário, e o de cardiomiopatia dilatada, pelo ecocardiograma, a partir da presença de disfunção sistólica de um ou ambos os ventrículos, com fração de ejeção menor que 55% e dilatação ventricular, com diâmetro diastólico final ventricular esquerdo maior que 112%. Nos pacientes incluídos no estudo, foi aplicado um formulário com informações sobre sintomatologia gastrointestinal e cardiológica; em seguida, dosadas sorologias para anticorpos antitransglutaminase tecidual humana e antiendomísio. Aqueles com sorologia positiva foram encaminhados à biópsia intestinal para avaliação histológica para doença celíaca, segundo os critérios de Marsh. RESULTADOS: Uma das 56 crianças apresentou sorologia antitransglutaminase positiva (1,8%), porém anticorpo antiendomísio negativo. A histologia intestinal demonstrou atrofia total das vilosidades. Cerca de 30% dos pacientes apresentaram insuficiência cardíaca. Sinais e sintomas gastrointestinais foram frequentes nos pacientes, em especial dor abdominal (70%, 39/56). CONCLUSÃO: A frequência de doença celíaca em pacientes com cardiomiopatia dilatada e miocardite foi de 1,8%. É importante investigar doença celíaca nos pacientes com essas doenças cardíacas para evitar evolução das doenças e deterioração clínica do paciente.

OBJECTIVE: To determine the prevalence of celiac disease in patients with myocarditis and dilated cardiomyopathy. METHODS: Fifty-six patients between 1 and 18 years old with dilated cardiomyopathy or myocarditis were evaluated and followed up at Instituto de Medicina Integral Professor Fernando Figueira. Patients with previous diagnosis of celiac disease were excluded. The functional classification was determined according to the American Heart Association criteria (classes I, II, III and IV). Diagnosis of myocarditis was reported in the patients' medical records. Dilated cardiomyopathy was diagnosed by echocardiogram with systolic dysfunction of one or both ventricles, ejection fraction lower than 55%, ventricular dilatation, and left ventricular diastolic diameter bigger than 112%. Patients answered a questionnaire about gastrointestinal and cardiac symptoms; next, anti-tissue transglutaminase (tTG) and anti-endomysial (EMA) antibodies were dosed. Those with positive antibody results were referred to intestinal biopsy and histological evaluation to detect celiac disease according to Marsh classification. RESULTS: One of the 56 children (1.8%) had positive tTG antibody level, but negative EMA. Intestinal histological evaluation showed total villous atrophy. Approximately, 30% of patients had heart failure. Gastrointestinal symptoms and signs were frequent, especially abdominal pain (70%, 39/56). CONCLUSION: Celiac disease prevalence in pediatric patients with dilated cardiomyopathy or myocarditis was 1.8%. It is important to investigate celiac disease in patients with these conditions to avoid the progression of such diseases and patients' clinical deterioration.

Triagem sorológica para doença celíaca em adolescentes e adultos jovens, estudantes universitários / Serological triage for celiac disease in adolescents and young adults attending university

Avaliar a positividade sorológica para doença celíaca em um grupo de adolescentes e adultos jovens da cidade do Recife, Nordeste do Brasil. MÉTODOS: a amostra foi composta por estudantes matriculados nos cursos de graduação do Centro de Ciências da Saúde da Universidade Federal de Pernambuco. Os estudantes foram submetidos à coleta de sangue para pesquisa sorológica do anticorpo antitransglutaminase tecidual humana e responderam a questionário sobre sintomas e condições mórbidas associadas à doença celíaca. O anticorpo antitrans-glutaminase foi pesquisado por técnica de Elisa, considerando-se positivos valores acima de 10 U/mL, conforme estabelecido pelo fabricante. Nos pacientes que tiveram sorologia positiva para o anticorpo antitransglutaminase realizou-se a sorologia para o anticorpo antiendomíseo, por imunofluorescência indireta, utilizando kit comercialmente disponível. RESULTADOS: seiscentos e oitenta e três universitários participaram da pesquisa. Os estudantes tinham entre 18 e 30 anos e mediana de idade de 21 anos. O anticorpo antitransglutaminase foi positivo em 12/683, soroprevalência de 1,76 por cento(IC95 por cento: 0,95-3,13 por cento). O anticorpo antiendomíseo foi realizado em 11 amostras e reagente em quatro. Oito estudantes com sorologia positiva tinham sintomas e/ou condições mórbidas associadas à doença celíaca. CONCLUSÕES: a elevada presença de anticorpos anti-transglutaminase encontrada neste estudo é semelhante a da Europa e Estados Unidos da América, sugere a possibilidade da triagem sorológica mesmo em populações consideradas de baixo risco...

To evaluate serum for celiac disease in a group of adolescents and young adults in the city of Recife, in the Northeast region of Brazil. METHODS: the sample was made up of students enrolled on undergraduate courses at the Center for Health Sciences of the Federal University of Pernambuco. A blood sample was taken from the students to test their serum for the human tissue antitransglutaminase antibody and they were asked to complete a questionnaire on the symptoms and morbid conditions associated with celiac disease. THE antitransglutaminase was identified using the Elisa technique, taking positive values to be those above 10 U/mL, as recommended by the manufacturer. Patients who tested positive for the antitransglutaminase antibody were subsequently tested for the antiendomysial antibody, by indirect immunofluorescence, using the commercially available kit. RESULTS: six hundred and eight-three university students took part in the study. They were aged between 18 and 30 years, with a mean age of 21 years. The antitransglutaminase antibody was found in 12/683, a prevalence of 1.76 percent (CI95 percent: 0.95-3.13 percent). The antiendomysial antibody test was carried out in eleven these samples and the reagent in four. Eight students tested positive and/or had morbid conditions associated with celiac disease. CONCLUSIONS: the high levels of anti-transglutaminase antibodies found in this study were similar to those found in Europe and the United States suggesting that serological triage can be carried out even in populations considered to be low risk...

Mechanisms and factors associated with gastrointestinal symptoms in patients with diabetes mellitus.

OBJECTIVES: To present the main mechanisms that cause gastrointestinal symptoms in patients with diabetes mellitus, their frequency, and controversies as to their occurrence in children and adolescents. SOURCES: Non-systematic review of the literature conducted in the MEDLINE/PubMed and SciELO databases (1983-2011), as well as relevant book chapters. The most relevant and up-to-date articles on the topic were selected. SUMMARY OF THE FINDINGS: Prevalence of diabetes mellitus has been increasing over the years in many countries. The complications caused by this disease in the digestive system, such as gastrointestinal symptoms (nausea, vomiting, abdominal pain, heartburn, dysphagia, constipation, diarrhea, and fecal incontinence) are well known. The pathogenesis of changes in the gastrointestinal functions in patients with diabetes mellitus is still being investigated at the same time as the role of the enteric nervous system and its neurotransmitters has gained significance. As a consequence of the complications in the digestive system, which damage the enteric nervous system, patients with diabetes mellitus may have specific gastrointestinal motility disorders, some of which may be of great relevance, such as diabetic gastroparesis, constipation, and diarrhea. Gastrointestinal dysfunction increases the morbidity of diabetes mellitus and worsens the quality of life of diabetic individuals. CONCLUSIONS: There are few studies addressing these problems in childhood and adolescence. Diabetes mellitus affects the digestive system over the years. Because this condition worsens the quality of life of diabetic individuals and leads to complications, attention must be paid to gastrointestinal symptoms when treating patients with diabetes mellitus.

Mecanismos e fatores associados aos sintomas gastrointestinais em pacientes com diabetes melito / Mechanisms and factors associated with gastrointestinal symptoms in patients with diabetes mellitus

OBJETIVOS: Apresentar a frequência, os principais fatores causadores dos sintomas gastrointestinais em pacientes portadores do diabetes melito e controvérsias quanto à sua ocorrência em crianças e adolescentes. FONTES DOS DADOS: Revisão não sistemática nas bases de dados MEDLINE/PubMed e SciELO (1983-2011), além de capítulos de livros relevantes. Foram selecionados os artigos mais atuais e representativos do tema. SÍNTESE DOS DADOS: A prevalência do diabetes melito vem aumentando ao longo dos anos em vários países do mundo. No sistema digestório, é conhecida a ocorrência de complicações do diabetes melito, entre elas os sintomas gastrointestinais (náuseas, vômitos, dor abdominal, azia, disfagia, constipação, diarreia e incontinência fecal). A patogênese das alterações das funções gastrointestinais no diabetes melito está ainda sob investigação, e o papel do sistema nervoso entérico e seus neurotransmissores tem ganhado significância. Em decorrência do comprometimento do sistema digestório, com danos ao sistema nervoso entérico, portadores do diabetes melito podem apresentar quadros específicos de distúrbios de motilidade, alguns de grande relevância clínica, como gastroparesia diabética, constipação e diarreia. A disfunção deste sistema contribui para aumentar a morbidade desta doença e piora a qualidade de vida de seus portadores. CONCLUSÕES: O diabetes melito, ao longo dos anos, afeta o sistema digestório. Por ser uma condição que piora a qualidade de vida dos portadores e também pode indicar complicação da doença, deve ser valorizada no acompanhamento e tratamento do paciente com diabetes melito. Na infância e na adolescência, ainda existem poucos estudos que abordam o problema.

OBJECTIVES: To present the main mechanisms that cause gastrointestinal symptoms in patients with diabetes mellitus, their frequency, and controversies as to their occurrence in children and adolescents. SOURCES: Non-systematic review of the literature conducted in the MEDLINE/PubMed and SciELO databases (1983-2011), as well as relevant book chapters. The most relevant and up-to-date articles on the topic were selected. SUMMARY OF THE FINDINGS: Prevalence of diabetes mellitus has been increasing over the years in many countries. The complications caused by this disease in the digestive system, such as gastrointestinal symptoms (nausea, vomiting, abdominal pain, heartburn, dysphagia, constipation, diarrhea, and fecal incontinence) are well known. The pathogenesis of changes in the gastrointestinal functions in patients with diabetes mellitus is still being investigated at the same time as the role of the enteric nervous system and its neurotransmitters has gained significance. As a consequence of the complications in the digestive system, which damage the enteric nervous system, patients with diabetes mellitus may have specific gastrointestinal motility disorders, some of which may be of great relevance, such as diabetic gastroparesis, constipation, and diarrhea. Gastrointestinal dysfunction increases the morbidity of diabetes mellitus and worsens the quality of life of diabetic individuals. CONCLUSIONS: There are few studies addressing these problems in childhood and adolescence. Diabetes mellitus affects the digestive system over the years. Because this condition worsens the quality of life of diabetic individuals and leads to complications, attention must be paid to gastrointestinal symptoms when treating patients with diabetes mellitus.

Frequency distribution of HLA DQ2 and DQ8 in celiac patients and first-degree relatives in Recife, northeastern Brazil.

AIMS: The aim of this study was to evaluate the frequencies of the HLA genotypes DQ2 and DQ8 and the alleles A1*05, A1*0201, B1*0201 and B1*0302 in individuals with celiac disease in Recife, northeastern Brazil. METHODS: HLA DQ2 and DQ8 genotyping was performed for 73 individuals with celiac disease and 126 first-degree relatives with negative transglutaminase serology. The alleles DQA1*05, DQA1*0201, DQB1*02 and DQB1*0302 were identified by sequencing using specific primers and the EU-DQ kit from the Eurospital Laboratory, Trieste, Italy and double-checked by the All Set SPP kit (Dynal). RESULTS: Among the 73 cases, 50 (68.5%) had the genotype DQ2, 13 (17.8%) had DQ8, 5 (6.8%) had DQ2 and DQ8, and 5 did not have any of these genotypes. Among the 5 negative individuals, four had the B1*02 allele and one did not have any of the alleles studied. B1*02 was the most frequent allele in both groups (94% in the patients and 89% in the control relatives). CONCLUSIONS: In this study, celiac disease was associated with the genotypes DQ2 and DQ8. DQ2 predominated, but the distribution of the frequencies was different from what has been found in European populations and was closer to what has been found in the Americas. The high frequencies of the HLA genotypes DQ2 and DQ8 that were found in first-degree relatives would make it difficult to use these HLA genotypes for routine diagnosis of celiac disease in this group.

Allergy to cow's milk proteins: what contribution does hypersensitivity in skin tests have to this diagnosis?

Food allergy is an immunologically mediated adverse reaction to food protein. Cow's milk protein allergy (CMPA) is the most frequent type and is the one that is most difficult to diagnose. This study had the objective of analyzing the accuracy of hypersensitivity and specific IgE skin tests among children with CMPA and predominantly gastrointestinal clinical manifestations. The participants in this study were 192 children aged one and five (median of 2 yr). Among these, 122 underwent open oral challenge to the suspected food. After evaluating the sensitivity, specificity and positive and negative predictive values (respectively, PPV and NPV) of skin and specific IgE tests in relation to the gold standard (open oral challenge); all the children underwent the skin prick test (SPT), specific IgE test and atopy patch test (APT) for cow's milk, eggs, wheat and peanuts and the open oral challenge for the food to which the child was sensitive or had suspected sensitivity. Presence of food allergy was confirmed for 50 children (40.9%). Among these cases, 44/50 (88%) were of allergy to cow's milk protein. Children who presented a positive response to an oral challenge to cow's milk protein were considered to be cases, while the controls were children with negative response. Twenty-two of the 44 cases (50.0%) presented symptoms within the first 4 h after the challenge. The SPT presented 31.8% sensitivity, 90.3% specificity, 66.7% PPV and 68.4% NPV. The APT presented 25.0% sensitivity, 81.9% specificity, 45.8% PPV and 64.1% NPV. The specific IgE test presented, respectively, 20.5%, 88.9%, 52.9% and 64.6%. Despite the operational difficulty and the possible exposure risk, oral challenge is the best method for diagnosing CMPA, because of the low sensitivity and PPV of skin and specific IgE tests.

Fequency distribution of HLA DQ2 and DQ8 in celiac patients and first-degree relatives in Recife, northeastern Brazil

AIMS: The aim of this study was to evaluate the frequencies of the HLA genotypes DQ2 and DQ8 and the alleles A1*05, A1*0201, B1*0201 and B1*0302 in individuals with celiac disease in Recife, northeastern Brazil. METHODS: HLA DQ2 and DQ8 genotyping was performed for 73 individuals with celiac disease and 126 first-degree relatives with negative transglutaminase serology. The alleles DQA1*05, DQA1*0201, DQB1*02 and DQB1*0302 were identified by sequencing using specific primers and the EU-DQ kit from the Eurospital Laboratory, Trieste, Italy and double-checked by the All Set SPP kit (Dynal). RESULTS: Among the 73 cases, 50 (68.5 percent) had the genotype DQ2, 13 (17.8 percent) had DQ8, 5 (6.8 percent) had DQ2 and DQ8, and 5 did not have any of these genotypes. Among the 5 negative individuals, four had the B1*02 allele and one did not have any of the alleles studied. B1*02 was the most frequent allele in both groups (94 percent in the patients and 89 percent in the control relatives). CONCLUSIONS: In this study, celiac disease was associated with the genotypes DQ2 and DQ8. DQ2 predominated, but the distribution of the frequencies was different from what has been found in European populations and was closer to what has been found in the Americas. The high frequencies of the HLA genotypes DQ2 and DQ8 that were found in first-degree relatives would make it difficult to use these HLA genotypes for routine diagnosis of celiac disease in this group.

Determinants of physical inactivity among urban adolescents.

OBJECTIVE: To investigate determinants of physical inactivity among adolescents aged 15 to 19 years in the city of Recife, northeastern Brazil. METHOD: This case-control study involved 597 private school students aged 15 to 19 years selected by convenience sampling. Exclusion criteria were adolescents with diseases that interfered with or hindered anthropometric measurements, who were being treated with drugs or diet for excess weight or who had changed their physical activity over the past 30 days. The students were recruited according to physical activity, as determined by the International Physical Activity Questionnaire: cases - inactive (sedentary or insufficiently active); and controls - active (active and very active). The adolescents reported the number of hours per day of television watching and computer use to identify the number of sedentary hours/day. Anthropometry (weight and height) of the adolescents was measured by Gibson's technique and used to calculate the body mass index. Weight, height and educational level of mothers were self-reported. Data were analyzed by multiple logistic regression, using the SPSS software, version 11.5, in order to control for confounding variables. RESULTS: Female adolescents were twice as likely to be inactive (odds ratio = 1.94; 95% confidence interval = 1.35-2.79) compared to male adolescents. Watching television for more than 1 hour/day showed increased risk for physical inactivity compared to less than 1 hour/day (odds ratio = 1.55; 95% confidence interval = 1.01-2.39). CONCLUSION: Physical inactivity among adolescents was associated with females and longer time spent per day watching television.

Fatores determinantes de inatividade física em adolescentes de área urbana / Determinants of physical inactivity among urban adolescents

OBJETIVO: Investigar fatores determinantes da inatividade física entre adolescentes de 15 a 19 anos na cidade do Recife (PE). MÉTODO: O estudo foi caso-controle, envolvendo 597 adolescentes de 15 a 19 anos, estudantes de escolas particulares, selecionadas por conveniência. Os critérios de exclusão foram adolescentes com doenças que interferissem ou impossibilitassem a avaliação antropométrica, que estavam em tratamento medicamentoso ou dietético para sobrepeso ou que haviam modificado sua atividade física nos últimos 30 dias. Eles foram recrutados de acordo com a atividade física, determinada pelo International Physical Activity Questionnaire: casos - inativos (sedentários e insuficientemente ativos); e controles - ativos (ativos e muito ativos). Os adolescentes informaram quantas horas diárias assistiam televisão e usavam computador para identificar o número de horas sedentárias/dia. A antropometria (peso e estatura) dos adolescentes foi aferida pela técnica de Gibson; assim, foi calculado o índice de massa corporal. O peso, a estatura e a escolaridade das mães foram autorreferidos. Os dados foram analisados por análise múltipla de regressão logística, utilizando o programa SPSS, versão 11.5, objetivando controlar variáveis de confusão. RESULTADOS: Adolescentes do sexo feminino tiveram risco cerca de duas vezes maior de serem inativos (odds ratio = 1,94; intervalo de confiança de 95 por cento = 1,35-2,79) em relação àqueles do sexo masculino. Assistir televisão mais de 1 hora/dia foi de maior risco para inatividade física em relação a menos de 1 hora/dia (odds ratio = 1,55; intervalo de confiança de 95 por cento = 1,01-2,39). CONCLUSÃO: Inatividade física em adolescentes foi associada com o sexo feminino e maior tempo diário assistindo televisão.

OBJECTIVE: To investigate determinants of physical inactivity among adolescents aged 15 to 19 years in the city of Recife, northeastern Brazil. METHOD: This case-control study involved 597 private school students aged 15 to 19 years selected by convenience sampling. Exclusion criteria were adolescents with diseases that interfered with or hindered anthropometric measurements, who were being treated with drugs or diet for excess weight or who had changed their physical activity over the past 30 days. The students were recruited according to physical activity, as determined by the International Physical Activity Questionnaire: cases - inactive (sedentary or insufficiently active); and controls - active (active and very active). The adolescents reported the number of hours per day of television watching and computer use to identify the number of sedentary hours/day. Anthropometry (weight and height) of the adolescents was measured by Gibson's technique and used to calculate the body mass index. Weight, height and educational level of mothers were self-reported. Data were analyzed by multiple logistic regression, using the SPSS software, version 11.5, in order to control for confounding variables. RESULTS: Female adolescents were twice as likely to be inactive (odds ratio = 1.94; 95 percent confidence interval = 1.35-2.79) compared to male adolescents. Watching television for more than 1 hour/day showed increased risk for physical inactivity compared to less than 1 hour/day (odds ratio = 1.55; 95 percent confidence interval = 1.01-2.39). CONCLUSION: Physical inactivity among adolescents was associated with females and longer time spent per day watching television.

Teste de desencadeamento alimentar oral na confirmação diagnóstica da alergia à proteína do leite de vaca / Oral food challenge test to confirm the diagnosis of cow's milk allergy

OBJETIVO: Verificar a prevalência de alergia à proteína do leite de vaca em crianças com sintomas atribuídos à ingestão do leite de vaca. MÉTODOS: Foram estudadas 65 crianças com sintomas atribuídos à ingestão do leite de vaca. A definição diagnóstica ocorreu após teste de desencadeamento alimentar oral aberto, realizado no mínimo 15 dias após dieta de exclusão e ausência de sintomas, com período de observação de até 4 semanas após o teste. Considerou-se caso (alergia à proteína do leite de vaca positiva; n = 35) criança com reaparecimento do sintoma que motivou a realização do teste, e comparação (alergia à proteína do leite de vaca negativa; n = 30) aquela sem sintomas após o período de observação do teste. RESULTADOS: A mediana de idade foi 5 meses (P 25-75 por cento 2-9 meses) no grupo caso e 7 meses (P 25-75 por cento 4-11 meses) no grupo comparação (p = 0,05). O teste não confirmou alergia à proteína do leite de vaca em 46,8 por cento dos pacientes com sintomas atribuídos à ingestão de leite de vaca. Reação tardia ocorreu em 77,1 por cento (27/35) dos casos com teste positivo, sendo 18/27 na primeira, 3/27 na segunda e 6/27 na terceira semana de observação. Encontrou-se associação estatística significante entre manifestações cutâneas e teste positivo (p = 0,04), mas não com sintomas digestivos e respiratórios. CONCLUSÃO: Os resultados corroboram a necessidade do teste de desencadeamento alimentar oral para determinar os pacientes que realmente têm alergia à proteína do leite de vaca e se beneficiarão com dieta de exclusão de leite de vaca.

OBJECTIVE: To determine the prevalence of cow's milk protein allergy in children with symptoms attributed to cow's milk intake. METHODS: Sixty-five children with symptoms attributed to cow's milk intake were studied. Diagnosis was established after an open oral food challenge test carried out at least 15 days after an elimination diet and absence of symptoms, with a follow-up period of up to 4 weeks after the test. The children who remained asymptomatic after this period were considered negative for cow's milk protein allergy (n = 30), while those whose symptoms reappeared were considered positive (n = 35). RESULTS: The median age was 5 months (P 25-75 percent 2-9 months) in the case group and 7 months (P 25-75 percent 4-11 months) in the comparison group (p = 0.05). The test did not confirm cow's milk protein allergy in 46.8 percent of the patients with symptoms attributed to cow's milk intake. A delayed reaction occurred in 77.1 percent (27/35) of the cases testing positive, 18/27 in the first week, 3/27 in the second week, and 6/27 in the third week of follow-up. A statistically significant association was found between cutaneous manifestations and positive test result (p = 0.04). However, there was no association with digestive and respiratory symptoms. CONCLUSION: Our results confirm the need of an oral food challenge test to determine which patients really have cow's milk protein allergy and may therefore benefit from a diet free of cow's milk.

Oral food challenge test to confirm the diagnosis of cow's milk allergy.

OBJECTIVE: To determine the prevalence of cow's milk protein allergy in children with symptoms attributed to cow's milk intake. METHODS: Sixty-five children with symptoms attributed to cow's milk intake were studied. Diagnosis was established after an open oral food challenge test carried out at least 15 days after an elimination diet and absence of symptoms, with a follow-up period of up to 4 weeks after the test. The children who remained asymptomatic after this period were considered negative for cow's milk protein allergy (n = 30), while those whose symptoms reappeared were considered positive (n = 35). RESULTS: The median age was 5 months (P 25-75% 2-9 months) in the case group and 7 months (P 25-75% 4-11 months) in the comparison group (p = 0.05). The test did not confirm cow's milk protein allergy in 46.8% of the patients with symptoms attributed to cow's milk intake. A delayed reaction occurred in 77.1% (27/35) of the cases testing positive, 18/27 in the first week, 3/27 in the second week, and 6/27 in the third week of follow-up. A statistically significant association was found between cutaneous manifestations and positive test result (p = 0.04). However, there was no association with digestive and respiratory symptoms. CONCLUSION: Our results confirm the need of an oral food challenge test to determine which patients really have cow's milk protein allergy and may therefore benefit from a diet free of cow's milk.

Early weaning and other potential risk factors for overweight among preschool children.

OBJECTIVE: To investigate whether early weaning constitutes a risk factor for overweight at preschool age and to identify other factors that affect this association. METHODS: This was a case-control study of 366 children aged 2 to 6 years (176 boys and 190 girls) from three cities. The case group comprised overweight children, as defined by body mass index (BMI) for age greater than or equal to the 85(th) percentile. The main exposure analyzed was early weaning (exclusive or predominant breastfeeding for less than four months). RESULTS: Early weaning was a significant risk factor for overweight in univariate analysis (OR = 1.69; 95% CI: 1.10-2.60; p = 0.02), but not in multivariate analysis (OR = 1.42; 95% CI: 0.86-2.34; p = 0.17). Maternal overweight, birth weight > or = 3,500 g and sedentarism were the main risk factors for overweight in multivariate analysis. DISCUSSION: In our study, the protective effect of breastfeeding against overweight was only shown in univariate analysis; it did not persist after controlling for other variables. It is possible that breastfeeding has only a small protective role against overweight in comparison with other variables of greater importance. CONCLUSION: Our results suggest that the potential protective effect of breastfeeding against overweight among preschool children is weaker than genetic and other environmental factors.

Early weaning and other potential risk factors for overweight among preschool children

OBJECTIVE: To investigate whether early weaning constitutes a risk factor for overweight at preschool age and to identify other factors that affect this association. METHODS: This was a case-control study of 366 children aged 2 to 6 years (176 boys and 190 girls) from three cities. The case group comprised overweight children, as defined by body mass index (BMI) for age greater than or equal to the 85th percentile. The main exposure analyzed was early weaning (exclusive or predominant breastfeeding for less than four months). RESULTS: Early weaning was a significant risk factor for overweight in univariate analysis (OR = 1.69; 95 percent CI: 1.10-2.60; p = 0.02), but not in multivariate analysis (OR = 1.42; 95 percent CI: 0.86-2.34; p = 0.17). Maternal overweight, birth weight > 3,500 g and sedentarism were the main risk factors for overweight in multivariate analysis. DISCUSSION: In our study, the protective effect of breastfeeding against overweight was only shown in univariate analysis; it did not persist after controlling for other variables. It is possible that breastfeeding has only a small protective role against overweight in comparison with other variables of greater importance. CONCLUSION: Our results suggest that the potential protective effect of breastfeeding against overweight among preschool children is weaker than genetic and other environmental factors.

Prevalence of low bone mineral density in children and adolescents with celiac disease under treatment / Prevalência de baixa densidade mineral óssea em crianças e adolescentes com doença celíaca em tratamento

Context and objective: Low bone mineral density may be a finding among children and adolescents with celiac disease, including those undergoing treatment with a gluten-free diet, but the data are contradictory. The aim of this study was to determine the frequency of bone mineral density abnormalities in patients on a gluten-free diet, considering age at diagnosis and duration of dietary treatment. Design and setting: Cross-sectional prevalence study at the Pediatric Gastroenterology Outpatient Clinic of Instituto Materno Infantil Professor Fernando Figueira. Methods: Thirty-one patients over five years of age with celiac disease and on a gluten-free diet were enrolled. Bone mineral density (in g/cm²) was measured in the lumbar spine and whole body using bone densitometry and categorized using the criteria of the International Society for Clinical Densitometry, i.e. low bone mineral density for chronological age < -2.0 Z-scores. Age at diagnosis and duration of dietary treatment were confirmed according to the date of starting the gluten-free diet. Results: Low bone density for chronological age was present in 3/31 patients in the lumbar spine and 1/31 in the whole body (also with lumbar spine abnormality). At diagnosis, three patients with low bone mineral density for the chronological age were more than 7.6 years old. These patients had been on a gluten-free diet for six and seven months and 3.4 years. Conclusion: Pediatric patients with celiac disease on long-term treatment are at risk of low bone mineral density. Early diagnosis and long periods of gluten-free diet are directly implicated in bone density normalization.

Contexto e objetivo: Baixa densidade mineral óssea pode ser encontrada em crianças e adolescentes com doença celíaca, incluindo aqueles em tratamento com dieta sem glúten, mas dados são contraditórios. O objetivo deste estudo foi determinar a frequência de alteração da densidade mineral óssea nos pacientes em dieta sem glúten, conforme a idade ao diagnóstico e o tempo de tratamento dietético. Tipo de estudo e local: Foi realizado estudo transversal de prevalência no Ambulatório de Gastroenterologia Pediátrica do Instituto Materno Infantil Professor Fernando Figueira (IMIP). Métodos: Trinta e um pacientes maiores de cinco anos com doença celíaca que estavam em dieta sem gluten foram avaliados. A densidade mineral óssea (em g/cm²) foi medida na coluna lombar e no corpo inteiro utilizando densitometria óssea, categorizando-a pelo critério da Sociedade Internacional para Densitometria Clínica (baixa densidade mineral óssea para a idade cronológica < -2.0 escores Z). A idade ao diagnóstico e o tempo de tratamento foram confirmados pela data de início da dieta sem glúten. Resultados: Baixa densidade mineral óssea para a idade cronológica foi detectada em 3/31 pacientes na coluna lombar e 1/31 no corpo inteiro (também apresentava alteração da coluna lombar). Ao diagnóstico, três pacientes com baixa densidade mineral óssea para a idade cronológica estavam com mais de 7,6 anos. Esses pacientes estavam em dieta sem glúten por seis e sete meses e 3,4 anos. Conclusão: Pacientes pediátricos com doença celíaca em tratamento a longo prazo são de risco para baixa densidade mineral óssea. Diagnóstico precoce e longo período de dieta sem glúten são diretamente implicados na normalização da densidade óssea.

Prevalence of low bone mineral density in children and adolescents with celiac disease under treatment.

CONTEXT AND OBJECTIVE: Low bone mineral density may be a finding among children and adolescents with celiac disease, including those undergoing treatment with a gluten-free diet, but the data are contradictory. The aim of this study was to determine the frequency of bone mineral density abnormalities in patients on a gluten-free diet, considering age at diagnosis and duration of dietary treatment. DESIGN AND SETTING: Cross-sectional prevalence study at the Pediatric Gastroenterology Outpatient Clinic of Instituto Materno Infantil Professor Fernando Figueira. METHODS: Thirty-one patients over five years of age with celiac disease and on a gluten-free diet were enrolled. Bone mineral density (in g/cm(2)) was measured in the lumbar spine and whole body using bone densitometry and categorized using the criteria of the International Society for Clinical Densitometry, i.e. low bone mineral density for chronological age < -2.0 Z-scores. Age at diagnosis and duration of dietary treatment were confirmed according to the date of starting the gluten-free diet. RESULTS: Low bone density for chronological age was present in 3/31 patients in the lumbar spine and 1/31 in the whole body (also with lumbar spine abnormality). At diagnosis, three patients with low bone mineral density for the chronological age were more than 7.6 years old. These patients had been on a gluten-free diet for six and seven months and 3.4 years. CONCLUSION: Pediatric patients with celiac disease on long-term treatment are at risk of low bone mineral density. Early diagnosis and long periods of gluten-free diet are directly implicated in bone density normalization.

Características clínicas de pacientes pediátricos com constipação crônica de acordo com o grupo etário / Clinical characteristics of pediatric patients with chronic constipation according to age group

RACIONAL: Não existem estudos avaliando as características clínicas de constipação de acordo com os grupos etários pediátricos. OBJETIVO: Avaliar as características da constipação crônica de acordo com o grupo etário. MÉTODOS: Estudo retrospectivo para avaliar informações demográficas e características clínicas de pacientes pediátricos atendidos em ambulatório especializado entre maio de 1995 e dezembro de 2002. Os dados obtidos foram analisados de acordo com o grupo etário (lactentes, pré-escolares, escolares e adolescentes). RESULTADOS: Foram estudados 561 pacientes, predominando o grupo etário de pré-escolares (42,9 por cento), seguido de escolares (26,9 por cento), lactentes (19,1 por cento) e adolescentes (11,0 por cento). Não se observou diferença estatisticamente significante entre os gêneros nas quatro faixas etárias. Menos que três evacuações por semana foi observado em maior percentual nos pré-escolares (65,8 por cento) e escolares (59,6 por cento) do que nos lactentes (52,4 por cento) e adolescentes (43,1 por cento). Escape fecal foi observado em 75,6 por cento dos pré-escolares com idade maior do que 48 meses, 68,2 por cento dos escolares e 76,7 por cento dos adolescentes. Maior freqüência de escape fecal no gênero masculino (80,7 por cento) do que no feminino (50,0 por cento) foi observada apenas no grupo etário de escolares. Comportamento de retenção (67,6 por cento, 40,7 por cento, 27,2 por cento), medo de defecar (70,2 por cento, 44,2 por cento, 29,7 por cento) e dor abdominal (80,8 por cento, 69,6 por cento, 73,6 por cento) foram observados, respectivamente, com maior freqüência nos pré-escolares do que nos escolares e adolescentes. CONCLUSÃO: Observaram-se diferenças nas características clínicas de pacientes com constipação crônica segundo o grupo etário, no entanto, em todas as faixas etárias observou-se duração prolongada da queixa de constipação e elevada freqüência de complicações como dor abdominal e escape fecal.

BACKGROUND: There was no study evaluating clinical characteristics of constipation according pediatric age groups. AIM: To evaluate the clinical characteristics of patients with chronic constipation according to age group. METHODS: This retrospective study evaluated the demographic data and clinical characteristics of pediatric patients with chronic constipation who had been admitted to an outpatient clinic between May 1995 and December 2000. Data was analyzed according to the followings age groups: infants, pre-school, school age and adolescent. RESULTS: Five hundred and sixty one patients were included in the study. The percentage of patients according to age groups were: infants (19.1 percent), pre-school (42.9 percent), school age (26.9 percent), and adolescents (11.0 percent). There was no statistical gender difference among the four age groups. Less than three bowel movements per week were observed more frequently in pre-school (65.8 percent) and school age (59.6 percent) than in infants (52.4 percent) and adolescents (43.1 percent). Fecal escape ("soiling") was found in 75.6 percent of the pre-school patients aged more than 48 months, in 68.2 percent of the school age and in 76.7 percent of the adolescents. Soiling was more frequent in boys (80.7 percent) than in girls (50.0 percent) only in school age children. Retentive posture (67.6 percent, 40.7 percent, 27.2 percent), fear for defecation (70.2 percent, 44.2 percent, 29.7 percent) and abdominal pain (80.8 percent, 69.6 percent, 73.6 percent) were observed, respectively, more frequently in pre-school than in school age and adolescents. CONCLUSION: There were differences in clinical characteristics according to age group. However, prolonged duration of constipation and an elevated number of complications were observed in all age groups, especially fecal soiling and abdominal pain.

Fatores de risco de maior ocorrência de episódios diarréicos durante o primeiro ano de vida / Risk factors of higher occurrence of diarrheal episodes in the first year of life

Introdução: A doença diarréica constitui problema de saúde relevante no mundo, sobretudo em países em desenvolvimento. Este estudo caso-controle aninhado em uma coorte objetivou identificar fatores determinantes para a ocorrência de maior número de episódios diarréicos durante o primeiro ano de vida. Metodologia: recém-nascidos foram recrutados para a coorte nas primeiras 24 horas de vida e visitados no domicílio duas vezes por semana no primeiro ano de vida para averiguar aleitamento materno e episódios diarréicos. Considerou-se caso a criança com seis ou mais controles e aquela com até cinco episódios de diarréia no primeiro ano de vida (N=87e 515, respectivamente). Empregou-se análise de regressão logística visando eliminar fatores de confundimento. Resultados: escolaridade materna e peso ao nascer explicaram o alto número de episódios de diarréia no primeiro ano de vida. As crianças cujas mães tinham até quatro anos de estudo formal tiveram chance duas vezes mais (1C 95%=1,13-3,27) de apresentar seis ou mais episódios de diarréia em relação às de mães que estudaram cinco ou mais anos (p=0,02). A chance de seis ou mais episódios de diarréia foi duas vezes maior para as crianças com peso ao nascer abaixo de 2.500 g (IC 95%=1,20-5,70; p=0,02) em relação às com 3.500 g ou mais. Conclusão: conclui-se que o baixo peso ao nascer e a escolaridade materna são fatores importantes na morbidade por diarréia no primeiro ano de vida.

A respiração oral em crianças e suas repercussões no estado nutricional / Mouth breathing in children and its repercussions in the nutritional state

OBJETIVO: identificar o estado nutricional, função mastigatória, aeração nasal, dados sobre o sono, olfato e paladar de crianças respiradoras orais e compará-las com um grupo de crianças respiradoras nasais. MÉTODOS: avaliou-se estado nutricional, modo respiratório e mastigação de 77 crianças respiradoras orais e 154 respiradoras nasais entre seis e dez anos. RESULTADOS: os respiradores orais apresentaram alterações no padrão mastigatório, quando comparados aos respiradores nasais, porém não houve diferença estatisticamente significante em relação ao estado nutricional. CONCLUSÃO: em crianças respiradoras orais houve maior alteração no sono, diminuição da ingestão de carboidratos e aumento da ingestão de lipídeos, porém não foram encontrados dados consistentes que apontem a associação entre a respiração oral e o estado nutricional.

PURPOSE: identify nutritional state, masticatory function, respiratory mode, sense of smell and sense of taste among mouth breathing children. METHODS: nasal aeration, mastication, nutritional state of 77 mouth breathing children and 154 nasal breathers children between six and ten years were evaluated. RESULTS: mouth breathers exhibited alterations in the masticatory pattern when compared to the nasal-breathers, but did not have statistical significance in nutritional state. CONCLUSION: the oral-breathing children had more alteration in sleep, reduction in the ingestion of carbohydrate and increase in ingestion of lipids, however, no consistent data were found pointing out the association between mouth breathing and nutritional condition.