Widening ethnic disparities in infant mortality in southern Brazil: comparison of 3 birth cohorts.

OBJECTIVES: We analyzed trends in mortality among infants born to White and to Black or mixed-race women in 3 population-based cohorts representing all births in 1982, 1993, and 2004 in Pelotas, southern Brazil. METHODS: Births were assessed during daily visits to all maternity hospitals. Maternal skin color was classified by the interviewers as White or Black or multi-racial. We used logistic regression to adjust for socioeconomic, demographic, and health services variables. RESULTS: The mortality rate among infants born to White mothers declined from 30.4 per 1000 live births in 1982 to 13.9 per 1000 in 2004, compared with 53.8 per 1000 to 30.4 per 1000 among those born to Black and mixed-race mothers. Differences for neonatal mortality were even more marked, with reductions of 47% and 11% for infants born to White and Black or mixed-race women, respectively. Adjusted analyses showed that ethnic group differences in neonatal and infant mortality were partly explained by differences in poverty and prenatal care. CONCLUSIONS: Over a 22-year period, improvements in health indicators were greater for infants born to White women than for other infants. The widening racial gap requires special attention from policymakers.

Neonatal mortality: description and effect of hospital of birth after risk adjustment.

OBJECTIVE: To assess the effect of hospital of birth on neonatal mortality. METHODS: A birth cohort study was carried out in Pelotas, Southern Brazil, in 2004. All hospital births were assessed by daily visits to all maternity hospitals and 4558 deliveries were included in the study. Mothers were interviewed regarding potential risk factors. Deaths were monitored through regular visits to hospitals, cemeteries and register offices. Two independent pediatricians established the underlying cause of death based on information obtained from medical records and home visits to parents. Logistic regression was used to estimate the effect of hospital of birth, controlling for confounders related to maternal and newborn characteristics, according to a conceptual model. RESULTS: Neonatal mortality rate was 12.7 and it was highly influenced by birthweight, gestational age, and socioeconomic variables. Immaturity was responsible for 65% of neonatal deaths, followed by congenital anomalies, infections and intrapartum asphyxia. Adjusting for maternal characteristics, a three-fold increase in neonatal mortality was seen between similar complexity hospitals. The effect of hospital remained, though lower, after controlling for newborn characteristics. CONCLUSIONS: Neonatal mortality was high, mainly related to immaturity, and varied significantly across maternity hospitals. Further investigations comparing delivery care practices across hospitals are needed to better understand NMR variation and to develop strategies for neonatal mortality reduction.

[The 2004 Pelotas birth cohort: methods and description]. / Coorte de nascimentos de Pelotas, 2004: metodologia e descrição.

OBJECTIVE: To describe a birth cohort which started in 2004, aiming to assess pre and perinatal conditions of the newborns, infant morbimortality, early life characteristics and outcomes, and access, use and financing of health care. METHODS: All children born in the urban area of Pelotas and Capão do Leão municipalities (Southern Brazil) in 2004 were identified and their mothers invited to join the study. In the first year of the study the children were seen at birth, at three and 12 months of age. These visits involved the application of a questionnaire to the mothers including questions on health; life style; use of health services; socioeconomic situation; estimation of gestational age; anthropometric measurements on the newborn (weight, length, head, chest and abdominal circumferences); anthropometric measurements on the mother (weight and height) and assessment of infant development. RESULTS: Out of the eligible infants (4,558), more than 99% were recruited to the study at birth. Follow-up rates were 96% at three months and 94% at 12 months of age. Among the initial results we highlight the following. Infant mortality rate was 19.7 per thousand, with 66% of infant deaths occurring in the neonatal period. There were frequencies of 15% premature babies and 10% low birthweight. Cesarean sections represented 45% of deliveries. CONCLUSIONS: The third Pelotas birth cohort showed an infant mortality rate similar to that of 11 years ago, with most deaths occurring in the neonatal period. The rates of prematurity and cesarean sections increased substantially.

Prevalence of exclusive breastfeeding and its determiners in the first 3 months of life in the South of Brazil.

OBJECTIVE: To determine the prevalence of exclusive breastfeeding during the first 3 months of life and its determinant factors in a city in the South region of Brazil. METHODS: Prospective study of a cohort of babies born between September 2002 and May 2003 in the city of Pelotas, RS. Data were obtained in interviews, at maternity units and during home visits, with mothers of babies aged between 1 and 3 months. Factors related to the cessation of breastfeeding were subjected to univariate, bivariate and multivariate analysis. RESULTS: Nine hundred and forty mothers of children aged 3 months or less were interviewed, 39% of whom were still exclusively breastfeeding and around 1/3 of whom no longer breastfed. Multivariate analysis by logistic regression demonstrated a significant association between interruption of exclusive breastfeeding before 3 months and maternal employment, use of a pacifier, low family income (between one and three times the minimum wage), and less than 5 years' paternal education. CONCLUSIONS: Exclusive breastfeeding throughout the first 3 months of life is an uncommon practice among the population of Pelotas, RS, in particular when the mother works away from home, the father has little education and the child is given a pacifier, which reinforces the need to continue stimulating exclusive breastfeeding during the first months of life.

Television viewing habits and their influence on physical activity and childhood overweight.

OBJECTIVES: To assess the prevalence of television (TV) viewing habits and their association with childhood sedentary lifestyle and overweight in 8-year-old children, from a cohort in a city in Southern Brazil. METHODS: A prospective cohort study with hospital screening of all births that occurred from September of 2002 to May of 2003. This study refers to a cross-sectional analysis of data collected during the cohort's follow-up conducted at 8 years of age. To evaluate the level of physical activity, a physical activity questionnaire for children and adolescents was used (PAQ-C), during the consultation at 8 years of age. RESULTS: Of the 616 interviewed children, a prevalence of sedentary lifestyle>70% was found, as well as the habit of watching TV for more than two hours a day in 60% of the sample, regardless of gender (p=0.30), income (p=0.57), or family socioeconomic level (p=0.90). The daily time spent watching TV was inversely associated with physical activity (p<0.05) and positively associated with excess weight (p<0.01). Regarding physical activity, running was the most frequently practiced sports modality among the population. CONCLUSIONS: Considering the high prevalence of sedentary lifestyle and children who watch TV for an excessive period of time, it is necessary to motivate such individuals to perform interactive activities, as well as promote a more active lifestyle, by decreasing the time children spend in front of the TV.

[Risk factors associated with hospitalization for bronchiolitis in the post-neonatal period]. / Fatores de risco associados à hospitalização por bronquiolite aguda no período pós-neonatal.

OBJECTIVE: To investigate the relationship between socioeconomic factors, maternal characteristics, breastfeeding, and hospitalization for bronchiolitis in the post-neonatal period. METHODS: A nested case-control study with a cohort of 5,304 children born in the city of Pelotas, Brazil, was conducted. The cohort study consisted of four sub-studies with their own methods and logistics. Mothers were interviewed using a standard questionnaire during in-hospital and home visits. Cases were defined as any child aged 28 to 364 days who had been hospitalized for bronchiolitis. RESULTS: Among 5,304 cohort children, 113 (2.1%) were hospitalized for bronchiolitis. The hierarchical multivariate analysis performed using logistic regression showed the following results: family income and gestational age were inversely associated with the risk of hospitalization for bronchiolitis. Breastfeeding showed to have a protective effect; children who were breastfed for less than one month had 7 times less risk for being hospitalized for acute bronchiolitis in the first three months of life. The risk for hospitalization for bronchiolitis is 57% higher in those exposed to maternal smoking than in those non-exposed. CONCLUSIONS: Hospitalization for acute bronchiolitis is inversely associated with family income, gestational age and duration of breastfeeding and positively associated with maternal smoking. There was not an association with either parity or maternal history of asthma.

Preterm premature rupture of the fetal membranes: association with sociodemographic factors and maternal genitourinary infections.

OBJECTIVE: this study aimed to investigate the incidence of premature rupture of fetal membranes in preterm singleton pregnancies and its association with sociodemographic factors and maternal self-reported genitourinary infections. METHODS: this was a population-based cross-sectional study, which included all mothers of newborns of singleton deliveries that occurred in 2010, with birth weight ≥ 500 grams, who resided in the city of Rio Grande. Women were interviewed in the two maternity hospitals. Cases were women who had lost amniotic fluid before hospitalization and whose gestational age was less than 37 weeks. Statistical analysis was performed by levels to control for confounding factors using Poisson regression. RESULTS: of the 2,244 women eligible for the study, 3.1% had preterm premature rupture of fetal membranes, which was more frequent, after adjustment, in women of lower socioeconomic status, (prevalence ratio [PR]=1.94), with lower level of schooling (PR=2.43), age > 29 years (PR=2.49), and smokers (PR=2.04). It was also associated with threatened miscarriage (PR=1.68) and preterm labor, (PR=3.40). There was no association with maternal urinary tract infection or presence of genital discharge. CONCLUSIONS: the outcome was more common in puerperal women with lower level of schooling, lower socioeconomic status, older, and smokers, as well as those with a history of threatened miscarriage and premature labor. These factors should be considered in the prevention, diagnosis, and therapy approach.

Impact of breastfeeding on the intelligence quotient of eight-year-old children.

OBJECTIVE: This study aimed to determine the influence of breastfeeding on the intellectual capacity of children from a cohort in a developing country, with a control for the main confounding factors. METHODS: A prospective cohort study was performed including all infants born in the hospitals of a medium-size city, and a random sample of these newborns was monitored at 30, 90, and 180 days of life, and at age 8 years. Several aspects of breastfeeding were assessed in the follow-up and, at 8 years, general intellectual capacity was assessed through the Raven's Colored Progressive Matrices test. The statistical analyses used Student's t-test, ANOVA, and linear regression and logistics, considering p-values less than 0.05 as statistically significant associations. RESULTS: At age 8 years, 560 children were assessed with Raven's Colored Progressive Matrices test. The average score was 22.56 points, with a standard deviation of 5.93. The difference in the averages found between the breastfed and non-breastfed groups at six months of age was 1.33 (p=0.008). Mother's and child's skin color, social and economic class, maternal education and smoking, and breastfeeding at six months of age (p=0.007) were still associated with the outcome. CONCLUSIONS: Children that were breastfed for six months or more had better performance in the general intellectual assessment, even after adjusting for the main confounding factors.

Avoidable deaths in the first four years of life among children in the 2004 Pelotas (Brazil) birth cohort study.

Avoidable deaths have been employed as indicators of health care quality. The aim of this study was to identify factors associated with avoidable deaths from birth to four years of age among children from the 2004 Pelotas (Brazil) birth cohort study. From January 1st, 2004, to December 31st, 2005, deaths were monitored on a daily basis and the causes were investigated and classified according to avoidability. After the first year, deaths were monitored through the Mortality Information System. A total of 94 children died during this period. It was possible to classify 92 deaths, 70 of which were preventable. Low family income, fewer prenatal visits and poor-quality prenatal care, preterm birth, low 5-minute Apgar score, and no breastfeeding in the first 24 hours of life were associated with increased risk of death. Prematurity was present in 39 deaths, but only five of these would have been prevented by measures provided during prenatal care. Although limited, compliance with antenatal care program guidelines is still the most important strategy for preventing avoidable deaths in childhood, particularly among the poorest children.

Television viewing habits and their influence on physical activity and childhood overweight / Hábito de assistir a televisão e sua influência sobre a atividade física e o excesso de peso infantis

OBJECTIVES: To assess the prevalence of television (TV) viewing habits and their association with childhood sedentary lifestyle and overweight in 8-year-old children, from a cohort in a city in Southern Brazil.METHODS: A prospective cohort study with hospital screening of all births that occurred from September of 2002 to May of 2003. This study refers to a cross-sectional analysis of data collected during the cohort's follow-up conducted at 8 years of age. To evaluate the level of physical activity, a physical activity questionnaire for children and adolescents was used (PAQ-C), during the consultation at 8 years of age.RESULTS: Of the 616 interviewed children, a prevalence of sedentary lifestyle > 70% was found, as well as the habit of watching TV for more than two hours a day in 60% of the sample, regardless of gender (p = 0.30), income (p = 0.57), or family socioeconomic level (p = 0.90). The daily time spent watching TV was inversely associated with physical activity (p < 0.05) and positively associated with excess weight (p < 0.01). Regarding physical activity, running was the most frequently practiced sports modality among the population.CONCLUSIONS: Considering the high prevalence of sedentary lifestyle and children who watch TV for an excessive period of time, it is necessary to motivate such individuals to perform interactive activities, as well as promote a more active lifestyle, by decreasing the time children spend in front of the TV.

OBJETIVOS: Avaliar a prevalência do hábito de assistir a televisão (TV) e sua relação com o sedentarismo infantil e o excesso de peso em crianças aos oito anos pertencentes a uma coorte de uma cidade do Sul do Brasil.MÉTODOS: Estudo de coorte prospectivo, com triagem hospitalar de todos os nascimentos ocorridos entre setembro de 2002 e maio de 2003. O presente estudo refere-se a uma análise transversal dos dados coletados no acompanhamento da coorte ocorrido aos oito anos. Para avaliar o nível de atividade física, um questionário de atividade física para crianças e adolescentes foi usado (PAQ-C), durante a visita aos oito anos.RESULTADOS: Nas 616 crianças entrevistadas, encontrou-se uma prevalência de sedentarismo superior a 70% e o hábito de assistir a TV por um período superior a duas horas diárias em 60% da amostra, independentemente do gênero (p = 0,30), renda (p = 0,57) ou nível socioeconômico (p = 0,90). O tempo diário assistindo a televisão associou-se inversamente à prática de atividade física (p < 0,05) e positivamente ao excesso de peso (p < 0,01). Com relação à atividade física, corrida foi a prática esportiva mais frequente na população.CONCLUSÕES: Diante da elevada prevalência de sedentarismo e de jovens que assistem a TV por um período excessivo, faz-se necessário o estímulo a atividades interativas, bem como a promoção de um estilo de vida mais ativo, com a redução do tempo que jovens dispensam em frente à TV.

Impacto do aleitamento materno no coeficiente de inteligência de crianças de oito anos de idade / Impact of breastfeeding on the intelligence quotient of eight-year-old children

Objetivo: O objetivo deste estudo foi determinar a influencia do aleitamento materno na capacidade intelectual de crianças pertencentes a uma coorte de um país em desenvolvimento, controlando para os principais fatores de confusão. Métodos: Foi realizado um estudo de coorte prospectiva com todos os recém-nascidos nos hospitais de uma cidade de porte médio e acompanhou-se uma amostra aleatória destes aos 30, 90 e 180 dias de vida e aos 8 anos. No acompanhamento foram avaliados diversos aspectos da amamentação e, aos 8 anos, foi realizada avaliação da capacidade intelectual geral aplicando-se o Teste de Raven. As análises estatísticas utilizaram Teste T, ANOVA e regressão linear e logística, considerando como associações estatisticamente significativas aquelas cujo valor de p foi inferior a 0,05. Resultados: Aos 8 anos 560 crianças participaram da avaliação com o Teste de Raven. A média da pontuação das crianças no teste foi de 22,56 pontos com desvio padrão de 5,93. A diferença de médias entre os grupos em aleitamento materno ou não, aos seis meses, foi de 1,33 (p = 0,008). Permaneceram associadas ao desfecho, após regressão linear e logística, a cor materna e da criança, classe socioeconômica, escolaridade e tabagismo maternos e o aleitamento materno aos 6 meses de idade (p = 0,007). Conclusões: As crianças que mamaram por seis meses ou mais tiveram melhor desempenho na avaliação intelectual geral, mesmo após ajuste para os principais fatores de confundimento.

Objective: This study aimed to determine the influence of breastfeeding on the intellectual capacity of children from a cohort in a developing country, with a control for the main confounding factors. Methods: A prospective cohort study was performed including all infants born in the hospitals of a medium-size city, and a random sample of these newborns was monito-red at 30, 90, and 180 days of life, and at age 8 years. Several aspects of breastfeeding were assessed inthe follow-up and, at 8 years, general intellectual capacity was assessed through the Raven's Colored Progressive Matrices test. The statistical analyses used Student's t-test, ANOVA, and linear regression and logistics, considering p-values less than 0.05 as statistically significant associations. Results: At age 8 years, 560 children were assessed with Raven's Colored Progressive Matrices test. The average score was 22.56 points, with a standard deviation of 5.93. The difference inthe averages foundbetweenthe breastfed and non-breastfed groups at six months of age was 1.33 (p = 0.008). Mother's and child's skin color, social and economic class, maternal education and smoking, and breastfeeding at six months of age (p = 0.007) were still associated with the outcome. Conclusions: Children that were breastfed for six months or more had better performance in the general intellectual assessment, even after adjusting for the main confounding factors.

Prevalence of congenital heart defects in patients with Down syndrome in the municipality of Pelotas, Brazil.

OBJECTIVE: To determine the prevalence of congenital heart defects in patients with Down syndrome in the municipality of Pelotas, Brazil, describing the most frequent types and assessing the associated factors. METHODS: Cross-sectional study including children with Down syndrome who were born and lived in Pelotas from January 2000 to December 2005. Data were collected by means of home interviews with mothers or guardians. Univariate and bivariate analyses were carried out to analyze the factors related to congenital heart defect. RESULTS: Forty-seven mothers of patients with Down syndrome were interviewed. Twenty-two (46.8%) of the patients had a diagnosis of congenital heart defect. Of them, 28% had early cardiac evaluation before 3 months of life. The most frequent heart defect was interatrial communication (17%); atrioventricular septal defect affected five patients. Bivariate analysis between the outcome congenital heart defect and the predicting factors maternal age, paternal age, parents' and child's skin color, presence of other malformations and child's sex showed that the associations were not statistically significant. CONCLUSIONS: The prevalence of Down syndrome and congenital heart defects in our region is similar to the rates found by other authors; therefore, we highlight the importance of diagnostic suspicion and early referral by pediatricians to cardiac evaluation. Another relevant aspect is the small number of patients who underwent karyotype testing. In addition, the number of associated malformations was lower than that found by other authors.

Preterm premature rupture of the fetal membranes: association with sociodemographic factors and maternal genitourinary infections / Ruptura prematura das membranas fetais pré-termo: associação com fatores sociodemográficos e infecções geniturinárias maternas

OBJECTIVE: tthis study aimed to investigate the incidence of premature rupture of fetal membranes in preterm singleton pregnancies and its association with sociodemographic factors and maternal self-reported genitourinary infections. METHODS: this was a population-based cross-sectional study, which included all mothers of newborns of singleton deliveries that occurred in 2010, with birth weight > 500 grams, who resided in the city of Rio Grande. Women were interviewed in the two maternity hospitals. Cases were women who had lost amniotic fluid before hospitalization and whose gestational age was less than 37 weeks. Statistical analysis was performed by levels to control for confounding factors using Poisson regression. RESULTS: of the 2,244 women eligible for the study, 3.1% had preterm premature rupture of fetal membranes, which was more frequent, after adjustment, in women of lower socioeconomic status, (prevalence ratio [PR] = 1.94), with lower level of schooling (PR = 2.43), age > 29 years (PR = 2.49), and smokers (PR = 2.04). It was also associated with threatened miscarriage (PR = 1.68) and preterm labor, (PR = 3.40). There was no association with maternal urinary tract infection or presence of genital discharge. CONCLUSIONS: the outcome was more common in puerperal women with lower level of schooling, lower socioeconomic status, older, and smokers, as well as those with a history of threatened miscarriage and premature labor. These factors should be considered in the prevention, diagnosis, and therapy approach. .

OBJETIVO: o objetivo deste estudo foi verificar a ocorrência da ruptura prematura das membranas fetais pré-termo em gestações únicas e sua associação com fatores sociodemográficos maternos e infecções geniturinárias autorreferidas. MÉTODOS: estudo transversal de base populacional onde foram incluídas todas as mães dos recém-nascidos dos partos únicos ocorridos no ano de 2010, com peso ao nascer igual ou superior a 500 gramas, residentes no município. As puérperas foram entrevistadas nas duas maternidades da cidade. Foram considerados casos as gestantes que perderam líquido amniótico antes da internação hospitalar e cujo tempo de gestação fosse inferior a 37 semanas. Foi realizada análise estatística por níveis, para controle de fatores de confusão por meio da regressão de Poisson. RESULTADOS: das 2.244 mulheres elegíveis para o estudo, 3,1% apresentaram ruptura prematura das membranas fetais pré-termo, a qual foi mais frequente, após ajuste, nas mulheres de menor nível econômico, razão de prevalência (RP) de 1,94, menor escolaridade, RP de 2,43, com idade superior a 29 anos, RP de 2,49 e tabagistas, RP de 2,04. Também esteve relacionada com ameaça de aborto, RP de 1,68, e de trabalho de parto pré-termo, RP de 3,40. Não houve associação com infecção urinária materna ou presença de corrimento genital. CONCLUSÕES: o desfecho foi mais frequente nas puérperas com menor escolaridade, mais pobres, mais velhas e tabagistas, assim como naquelas com histórico de ameaça de abortamento e trabalho de parto prematuro. Estes fatores devem ser considerados na sua abordagem preventiva, diagnóstica e terapêutica. .

Impacto do aleitamento materno no coeficiente de inteligência de crianças de oito anos de idade / Impact of breastfeeding on the intelligence quotient of eight-year-old children

OBJETIVO: O objetivo deste estudo foi determinar a influência do aleitamento materno na capacidade intelectual de crianças pertencentes a uma coorte de um país em desenvolvimento, controlando para os principais fatores de confusão. MÉTODOS: Foi realizado um estudo de coorte prospectiva com todos os recém-nascidos nos hospitais de uma cidade de porte médio e acompanhou-se uma amostra aleatória destes aos 30, 90 e 180 dias de vida e aos 8 anos. No acompanhamento foram avaliados diversos aspectos da amamentação e, aos 8 anos, foi realizada avaliação da capacidade intelectual geral aplicando-se o Teste de Raven. As análises estatísticas utilizaram Teste T, ANOVA e regressão linear e logística, considerando como associações estatisticamente significativas aquelas cujo valor de p foi inferior a 0,05. RESULTADOS: Aos 8 anos 560 crianças participaram da avaliação com o Teste de Raven. A média da pontuação das crianças no teste foi de 22,56 pontos com desvio padrão de 5,93. A diferença de médias entre os grupos em aleitamento materno ou não, aos seis meses, foi de 1,33 (p = 0,008). Permaneceram associadas ao desfecho, após regressão linear e logística, a cor materna e da criança, classe socioeconômica, escolaridade e tabagismo maternos e o aleitamento materno aos 6 meses de idade (p = 0,007). CONCLUSÕES: As crianças que mamaram por seis meses ou mais tiveram melhor desempenho na avaliação intelectual geral, mesmo após ajuste para os principais fatores de confundimento.

OBJECTIVE: This study aimed to determine the influence of breastfeeding on the intellectual capacity of children from a cohort in a developing country, with a control for the main confounding factors. METHODS: A prospective cohort study was performed including all infants born in the hospitals of a medium-size city, and a random sample of these newborns was monitored at 30, 90, and 180 days of life, and at age 8 years. Several aspects of breastfeeding were assessed in the follow-up and, at 8 years, general intellectual capacity was assessed through the Raven's Colored Progressive Matrices test. The statistical analyses used Student's t-test, ANOVA, and linear regression and logistics, considering p-values less than 0.05 as statistically significant associations. RESULTS: At age 8 years, 560 children were assessed with Raven's Colored Progressive Matrices test. The average score was 22.56 points, with a standard deviation of 5.93. The difference in the averages found between the breastfed and non-breastfed groups at six months of age was 1.33 (p = 0.008). Mother's and child's skin color, social and economic class, maternal education and smoking, and breastfeeding at six months of age (p = 0.007) were still associated with the outcome. CONCLUSIONS: Children that were breastfed for six months or more had better performance in the general intellectual assessment, even after adjusting for the main confounding factors.

Perinatal mortality in three population-based cohorts from Southern Brazil: trends and differences.

Trends in perinatal mortality were studied in the city of Pelotas, Southern Brazil, using three population-based cohort studies carried out in 1982, 1993 and 2004. The objective of the present study was to analyze trends and differences in perinatal mortality during the 1982-2004 period. All hospital deliveries and perinatal deaths were monitored through daily visits to maternity wards. Cause of death was determined using information from hospital records and by interviewing physicians. Perinatal mortality fell by 43% in the two decades, with a greater reduction between 1982 and 1993. Intrapartum fetal deaths decreased by 72% and deaths from asphyxia fell from 4.5 per thousand in 1982 to 1.4 per thousand in 2004. In conclusion, reductions in perinatal mortality were also seen across all birth weight categories between 1982 and 1993, but the same was not true for the 1993 to 2004 period, when mortality increased in several categories above 2,000g.

Infant mortality in three population-based cohorts in Southern Brazil: trends and differentials.

We studied time trends in infant mortality and associated factors between three cohort studies carried out in Pelotas, Rio Grande do Sul State, Brazil, in 1982, 1993, and 2004. All hospital births and deaths were determined by means of regular visits to hospitals, registrar's offices, and cemeteries. This data was used to calculate neonatal, post-neonatal, and infant mortality rates per thousand live births. Rates were also calculated according to cause of death, sex, birth weight, gestational age, and family income. The infant mortality rate fell from 36.4 per 1,000 live births in 1982 to 21.1 in 1993 and 19.4 in 2004. Major causes of infant mortality in 2004 were perinatal causes and respiratory infections. Mortality among low birth weight children from poor families fell 16% between 1993 and 2004; however, this rate increased by more than 100% among high-income families due to the increase in the number of preterm deliveries in this group. The stabilization of infant mortality in the last decade is likely to be due to excess medical interventions relating to pregnancies and delivery care.

Avoidable deaths in the first four years of life among children in the 2004 Pelotas (Brazil) birth cohort study / Óbitos evitáveis até os 4 anos de idade na coorte de nascimentos de Pelotas, Rio Grande do Sul, Brasil, 2004

Avoidable deaths have been employed as indicators of health care quality. The aim of this study was to identify factors associated with avoidable deaths from birth to four years of age among children from the 2004 Pelotas (Brazil) birth cohort study. From January 1st, 2004, to December 31st, 2005, deaths were monitored on a daily basis and the causes were investigated and classified according to avoidability. After the first year, deaths were monitored through the Mortality Information System. A total of 94 children died during this period. It was possible to classify 92 deaths, 70 of which were preventable. Low family income, fewer prenatal visits and poor-quality prenatal care, preterm birth, low 5-minute Apgar score, and no breastfeeding in the first 24 hours of life were associated with increased risk of death. Prematurity was present in 39 deaths, but only five of these would have been prevented by measures provided during prenatal care. Although limited, compliance with antenatal care program guidelines is still the most important strategy for preventing avoidable deaths in childhood, particularly among the poorest children.

Os óbitos evitáveis têm sido utilizados como indicadores de qualidade da atenção à saúde. Este estudo teve como objetivo identificar os fatores associados aos óbitos evitáveis até os 4 anos de idade entre as crianças da Coorte de Nascimentos de Pelotas, Rio Grande do Sul, Brasil, de 2004. De 1º de janeiro de 2004 a 31 de dezembro de 2005, os óbitos foram monitorados diariamente, as causes, investigadas e classificadas conforme a evitabilidade. Após o primeiro ano, os óbitos foram monitorados por meio do Sistema de Informações sobre Mortalidade. Até os 4 anos, ocorreram 94 óbitos, sendo possível classificar 92, dos quais 70 seriam evitáveis. Baixa renda, menor número de consultas pré-natais, pré-natal de pior qualidade, prematuridade, baixo Apgar no 5º minuto e não mamar nas primeiras 24 horas associaram-se a risco aumentado de morrer por cause evitável. Prematuridade estava presente em 39 óbitos, mas somente 5 desses teriam sido prevenidos por intervenções no pré-natal. Embora limitada, a adesão às normas do programa de atenção pré-natal, especialmente entre as mais pobres, ainda é a principal estratégia para a prevenção das mortes evitáveis na infância.

Prevalência de cardiopatias congênitas em portadores da síndrome de Down na cidade de Pelotas (RS) / Prevalence of congenital heart defects in patients with Down syndrome in the municipality of Pelotas, Brazil

OBJETIVO: Determinar a prevalência de cardiopatias congênitas em portadores da síndrome de Down na cidade de Pelotas (RS), descrevendo os tipos mais frequentes e avaliando os fatores associados. MÉTODOS: Estudo transversal que incluiu crianças portadoras de síndrome de Down nascidas e residentes em Pelotas no período de janeiro de 2000 a dezembro de 2005. Os dados foram obtidos através de entrevistas realizadas nos domicílios dos pacientes, com as mães ou seus familiares legais. Para o estudo dos fatores relacionados à presença de cardiopatia congênita, foram realizadas análises univariada e bivariada. RESULTADOS: Foram entrevistadas 47 mães de pacientes com síndrome de Down, sendo que 22 (46,8 por cento) pacientes apresentavam diagnóstico de cardiopatia congênita. Destes, 28 por cento receberam avaliação cardiológica precoce, antes dos 3 meses de vida. A cardiopatia mais frequente foi a comunicação interatrial (17 por cento); o defeito do septo atrioventricular ocorreu em cinco pacientes. A análise bivariada entre o desfecho presença de cardiopatia congênita e os fatores preditores idade materna, idade paterna, cor dos pais e da criança, presença de outras malformações e sexo da criança mostraram que as associações não foram estatisticamente significativas. CONCLUSÕES: As prevalências de síndrome de Down e de cardiopatia congênita em nossa região apresentam-se semelhantes às encontradas por outros autores, ressaltando-se a importância da suspeita diagnóstica e do encaminhamento precoce por parte dos pediatras para avaliação cardiológica. Destaca-se também o baixo número de pacientes que realizaram cariótipo. Além disso, o número de malformações associadas foi inferior ao encontrado por outros autores.

OBJECTIVE: To determine the prevalence of congenital heart defects in patients with Down syndrome in the municipality of Pelotas, Brazil, describing the most frequent types and assessing the associated factors. METHODS: Cross-sectional study including children with Down syndrome who were born and lived in Pelotas from January 2000 to December 2005. Data were collected by means of home interviews with mothers or guardians. Univariate and bivariate analyses were carried out to analyze the factors related to congenital heart defect. RESULTS: Forty-seven mothers of patients with Down syndrome were interviewed. Twenty-two (46.8 percent) of the patients had a diagnosis of congenital heart defect. Of them, 28 percent had early cardiac evaluation before 3 months of life. The most frequent heart defect was interatrial communication (17 percent); atrioventricular septal defect affected five patients. Bivariate analysis between the outcome congenital heart defect and the predicting factors maternal age, paternal age, parents' and child's skin color, presence of other malformations and child's sex showed that the associations were not statistically significant. CONCLUSIONS: The prevalence of Down syndrome and congenital heart defects in our region is similar to the rates found by other authors; therefore, we highlight the importance of diagnostic suspicion and early referral by pediatricians to cardiac evaluation. Another relevant aspect is the small number of patients who underwent karyotype testing. In addition, the number of associated malformations was lower than that found by other authors.

Influência do apoio à amamentação sobre o aleitamento materno exclusivo dos bebês no primeiro mês de vida e nascidos na cidade de Pelotas, Rio Grande do Sul, Brasil / Influence of breastfeeding support on the exclusive breastfeeding of babies in the first month of life and born in the city of Pelotas, State of Rio Grande do Sul, Brazil

OBJECTIVES: to measure exclusive breastfeeding rates in the first month and compare the feeding practices of children born in the hospital adopts the Baby Friendly Hospital Initiative (BFHI) with other hospitals practices in Pelotas, Rio Grande do Sul, Brazil. METHODS: a quasi-experimental study nested in a cohort. The research comprises two separate components: hospital screening and home monitorship of one-month (30 percent). 973 mothers and their babies were monitored from an initial sample of 2741mothers. RESULTS: being born in hospitals which do not adopt the BFHI has increased the risk of absence of breastfeeding support, of babies not suckling in the first hour and receiving pacifier and tea at the hospital. The prevalence of one-month exclusive breastfeeding was 60 percent. Children born in the hospital which adopts BFHI had a larger rate of exclusive breastfeeding with one month and the use of pacifier has shown a negative association with the outcome. CONCLUSIONS: the intervention was positive and the impact would be greater if the "ten steps" implementation were total during the collection phase. The breastfeeding promotion efforts should continue after releasing the patient through the counseling groups and maybe, with the follow up until six month, the results could be better.

OBJETIVOS: medir os índices de aleitamento exclusivo no primeiro mês e comparar o padrão alimentar das crianças nascidas no hospital que adota a Iniciativa Hospital Amigo da Criança (IHAC), com os demais hospitais de Pelotas, Rio Grande do Sul, Brasil. MÉTODOS: estudo quase-experimental, aninhado a uma coorte. A pesquisa contou com dois componentes: triagem hospitalar e acompanhamento domiciliar de um mês (30 por cento); foram acompanhados 973 pares mãe-bebê de uma amostra inicial de 2741 mães. RESULTADOS nascer em hospitais que não adotam a IHAC aumentou o risco das mães não terem sido incentivadas para o aleitamento, dos bebês não mamarem na primeira hora e receberem chupeta e chá no hospital. A prevalência de aleitamento exclusivo com um mês foi de 60 por cento. As crianças nascidas no hospital IHAC tiveram maior índice de aleitamento exclusivo com um mês e o uso de chupeta mostrou uma associação negativa com o desfecho. CONCLUSÕES: a intervenção foi positiva e o impacto seria maior se a implantação dos "dez passos" fosse total, na coleta de dados. O incentivo ao aleitamento deve continuar através da formação de grupos de aconselhamento às mães e, talvez, com o acompanhamento até o sexto mês, se alcançasse melhores resultados.

Neonatal mortality: description and effect of hospital of birth after risk adjustment

OBJECTIVE: To assess the effect of hospital of birth on neonatal mortality. METHODS: A birth cohort study was carried out in Pelotas, Southern Brazil, in 2004. All hospital births were assessed by daily visits to all maternity hospitals and 4558 deliveries were included in the study. Mothers were interviewed regarding potential risk factors. Deaths were monitored through regular visits to hospitals, cemeteries and register offices. Two independent pediatricians established the underlying cause of death based on information obtained from medical records and home visits to parents. Logistic regression was used to estimate the effect of hospital of birth, controlling for confounders related to maternal and newborn characteristics, according to a conceptual model. RESULTS: Neonatal mortality rate was 12.7‰ and it was highly influenced by birthweight, gestational age, and socioeconomic variables. Immaturity was responsible for 65 percent of neonatal deaths, followed by congenital anomalies, infections and intrapartum asphyxia. Adjusting for maternal characteristics, a three-fold increase in neonatal mortality was seen between similar complexity hospitals. The effect of hospital remained, though lower, after controlling for newborn characteristics. CONCLUSIONS: Neonatal mortality was high, mainly related to immaturity, and varied significantly across maternity hospitals. Further investigations comparing delivery care practices across hospitals are needed to better understand NMR variation and to develop strategies for neonatal mortality reduction.

OBJETIVO: Avaliar o efeito de hospital de nascimento na ocorrência de mortalidade neonatal. MÉTODOS: Uma coorte de nascimentos foi iniciada em Pelotas, em 2004. Todos os nascimentos hospitalares foram estudados em visitas diárias às maternidades da cidade, incluindo-se 4.558 recém-nascidos. As mães foram entrevistadas sobre fatores de risco em potencial e as mortes, monitoradas com visitas regulares aos hospitais, cemitérios e cartórios. Dois pediatras classificaram a causa básica da morte, de forma independente, a partir de informações obtidas no prontuário hospitalar e em entrevista com a família. Usou-se regressão logística para estimar o efeito do hospital de nascimento, controlando para variáveis de confusão relacionadas a características maternas e do recém-nascido. RESULTADOS: A taxa de mortalidade neonatal foi de 12,7‰. O risco esteve fortemente influenciado pelo peso ao nascer, idade gestacional e variáveis socioeconômicas. Imaturidade foi responsável por 65 por cento das mortes neonatais, seguida por anomalias congênitas, infecções e asfixia intraparto. Ajustando para características maternas, foi observado um risco relativo igual a três para hospitais de mesmo nível de complexidade. O risco relativo diminuiu, mas persistiu, após controle para características do recém-nascido. CONCLUSÕES: A mortalidade neonatal variou entre hospitais e foi alta, principalmente relacionada à imaturidade. Para entender a fonte de variação da mortalidade neonatal e reduzir sua ocorrência é necessária uma avaliação aprofundada e comparativas com as práticas de cuidado entre hospitais.