Birth interval and stunting in children under five years of age in Peru (1996-2014).

BACKGROUND: Examine the evolution of stunting in <5 years of age in Peru and its relationship with birth interval (BI), and associated factors from 1996 to 2014. METHODS: Data were extracted from the National Demographic and Health Survey of Peru (DHS) for the years 1996, 2000, 2005, 2010 and 2014 on children <5 years of age for stunting (height / age ≤ 2DS). The main independent variable of interest was BI dichotomized by interval between date of last and penultimate birth (≤24 months vs. >24 months) and others sociodemographic variables. Crude and adjusted odds ratios with 95% confidence intervals were estimated in logistic regression for the effect of BI and other variables on stunting by each survey year. RESULTS: Between 1996 and 2014, stunting declined in both BI groups: ≤24 months: 35.8% to 21.8%; >24 months: 29.5% to 14.3%. BI was associated with stunting after adjustment for other variables in each survey except 2005. Of the other factors, sex, birth order (fourth child or more), maternal education and poverty were independently associated with stunting in all survey years. Residence in rural areas and in Amazon forest and highland regions was associated with stunting 1996 and 2000. Maternal age was not independently associated with stunting. CONCLUSIONS: While stunting showed a decreasing trend from 1996 to 2014, birth interval exceeding 24 months exerted a protective effect on stunting across the years surveyed. Poverty, low maternal education and high birth order were associated with stunting in all survey years.

Quality of antenatal care as a risk factor for early onset neonatal infections in Rio de Janeiro, Brazil

Background: Neonatal infection is a serious public health problem. The aim of this study was to assess the influence of the antenatal care on the risk of early-onset neonatal healthcare associated infection in two Brazilian maternities. Methods: Cohort study - Newborns admitted at two public neonatal intensive care units from 2008 to 2009 were included in the study. Data on antenatal and perinatal variables were collected from maternal prenatal cards and medical charts. Newborns were actively surveyed for early-onset neonatal healthcare associated infection, defined as a neonatal infection diagnosed within 48 h after birth. Multiple logistic regression was used to assess variables independently associated with early-onset neonatal healthcare associated infection. Results: 561 neonate-mother pairs were included in the study. Early-onset neonatal health-care associated infection was diagnosed in 283 neonates (51%), an incidence rate of 43.5/1000 live births. Neonates whose mothers had less then six antenatal visits were under risk significantly higher for early-onset neonatal healthcare associated infection (OR = 1.69, 95% CI = 1.11-2.57), after adjusting for birth weight, membranes ruptured for >18 h, maternal complications during delivery, maternal infection at admission, and hospital where patients received care. Conclusions: The risk of neonatal early-onset neonatal healthcare associated infection was significantly associated with insufficient number of antenatal care visits. Further studies assessing the quality of antenatal care and targeting its improvement are warranted. .

Quality of antenatal care as a risk factor for early onset neonatal infections in Rio de Janeiro, Brazil.

BACKGROUND: Neonatal infection is a serious public health problem. The aim of this study was to assess the influence of the antenatal care on the risk of early-onset neonatal healthcare associated infection in two Brazilian maternities. METHODS: Cohort study - Newborns admitted at two public neonatal intensive care units from 2008 to 2009 were included in the study. Data on antenatal and perinatal variables were collected from maternal prenatal cards and medical charts. Newborns were actively surveyed for early-onset neonatal healthcare associated infection, defined as a neonatal infection diagnosed within 48h after birth. Multiple logistic regression was used to assess variables independently associated with early-onset neonatal healthcare associated infection. RESULTS: 561 neonate-mother pairs were included in the study. Early-onset neonatal healthcare associated infection was diagnosed in 283 neonates (51%), an incidence rate of 43.5/1000 live births. Neonates whose mothers had less then six antenatal visits were under risk significantly higher for early-onset neonatal healthcare associated infection (OR=1.69, 95% CI=1.11-2.57), after adjusting for birth weight, membranes ruptured for >18h, maternal complications during delivery, maternal infection at admission, and hospital where patients received care. CONCLUSIONS: The risk of neonatal early-onset neonatal healthcare associated infection was significantly associated with insufficient number of antenatal care visits. Further studies assessing the quality of antenatal care and targeting its improvement are warranted.

Postobturation pain and associated factors in adolescent patients undergoing one- and two-visit root canal treatment.

OBJECTIVES: This prospective study evaluated the frequency and intensity of postobturation pain and associated factors in adolescents undergoing one- and two-visit root canal treatment. METHODS: 121 patients aged 11-18 years presenting with molars with pulp necrosis were assigned randomly into two treatment groups: one- and two-visit (including interappointment dressing with calcium hydroxide paste). The canals of all teeth were prepared using a preflaring (2/3 middle-cervical) and step-back (1/3 apical) preparation techniques and filled with laterally compacted gutta-percha and sealer. Postobturation pain was recorded on a visual analogue scale (VAS) of 0-5. Data were statistically analyzed using multivariate logistic regression. RESULTS: The frequencies of postobturation pain were 10.5% (6/57) in the one-visit group and 23.0% (14/61) in the two-visit group. There were no statistically significant differences between the groups (p=0.07). The intensity of the pain was similar in both groups, particularly flare-ups, with a prevalence of 1.75% in the one-visit group and 1.65% in the two-visit group. Postobturation pain was significantly associated with the presence of preoperative pain (p=0.04; OR=3.54; CI 95%=1.02-12.30) and a positive culture at the time of obturation (p=0.00; OR=9.43; CI 95%=2.93-30.35). CONCLUSIONS: Postobturation pain was more present in the two-visit group, but was not statistically significant. The intensity of postobturation pain was similar. Effective microbiological control and the presence of preoperative pain may influence the postobturation pain in adolescents.

Amantadine and rimantadine for influenza A in children and the elderly.

BACKGROUND: Although amantadine (AMT) and rimantadine (RMT) are used to relieve or treat influenza A symptoms in healthy adults, little is known about the effectiveness and safety of these antivirals in preventing and treating influenza A in children and the elderly. OBJECTIVES: The aim of this review was to systematically consider evidence on the effectiveness and safety of AMT and RMT in preventing and treating influenza A in children and the elderly. SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, 2007, issue 3); MEDLINE (1966 to July 2007) and EMBASE (1980 to July 2007). SELECTION CRITERIA: Randomised or quasi-randomised trials comparing AMT and/or RMT in children and the elderly with placebo, control, other antivirals or comparing different doses or schedules of AMT and/or RMT or no intervention. DATA COLLECTION AND ANALYSIS: Two review authors independently selected trials for inclusion and assessed methodological quality. Disagreements were resolved by consensus. In all comparisons except for one, the trials in children and in the elderly were analysed separately. Data were analysed and reported using Cochrane Review Manager 4.2. software. MAIN RESULTS: In children, RMT was effective in the abatement of fever on day three of treatment. AMT showed a prophylactic effect against influenza A infection. AMT and RMT were not related to an increase in the occurrence of adverse effects. RMT also was considered to be well tolerated by the elderly, but showed no prophylactic effect. Different doses were comparable in the prophylaxis of influenza in the elderly, as well as in reporting adverse effects. Zanamivir prevented influenza A more effectively than RMT in the elderly. AUTHORS' CONCLUSIONS: AMT was effective in the prophylaxis of influenza A in children. As confounding matters might have affected our findings, caution should be taken when considering which patients should to be given this prophylactic. Our conclusions about effectiveness of both antivirals for the treatment of influenza A in children were limited to a proven benefit of RMT in the abatement of fever on day three of treatment. Due to the small number of available studies we could not reach a definitive conclusion on the safety of AMT or the effectiveness of RMT in preventing influenza in children and the elderly.

Sensitisation to aeroallergens in Brazilian adolescents living at the periphery of large subtropical urban centres.

OBJECTIVES: To evaluate the sensitization to aeroallergens determined by skin prick test (SPT) in Brazilian adolescents, and to correlate its positivity with the diagnosis of asthma and/or rhinitis based on the written questionnaire (WQ) of ISAAC phase III study. PATIENTS AND METHODS: A total of 996 adolescents (387 boys) were selected by systematic samples. A standard allergen extracts panel (positive/negative control, D pteronyssinus [Dpt], P americana [Pa], B germanica [Bg], dog, cat, fungal and grass mix) was used and its positivity compared with positive responses to asthma, rhinitis or both. RESULTS: Positive SPT to at least one allergen was observed in 466 adolescents (46.8 %), with sensitisation to Dpt in 79.1 %. Positivity to more than one allergen occurred in 232 students (49.8 %). The frequency of positive SPTs was significantly higher among adolescents with asthma (OR = 2.16), rhinitis (OR = 1.69), and asthma and rhinitis (OR = 2.03). Positive SPT to four or more allergens were higher among asthmatics (OR = 2.6) and among adolescents with asthma and rhinitis (OR = 3). CONCLUSIONS: A high sensitisation rate to aeroallergens was observed, significantly higher among those with asthma, rhinitis or a combination of both, especially in multiple sensitisations.

Tuberculosis treatment default among Brazilian children.

OBJECTIVES: To study the prevalence and time of tuberculosis (TB) treatment default among children and to compare defaulters with those who completed treatment. METHODS: Retrospective cohort study at the Hospital Municipal Jesus, Rio de Janeiro, Brazil, among TB patients aged <15 years followed from 1998 to 2002. The group that completed treatment was compared with those that defaulted. RESULTS: The records of 248 patients were studied. The default rate was 24.2% and was more frequent in the first 2 months of treatment (43.3%) and among those aged <1 year (42.4%). The following variables were associated with default: previous default (relative risk [RR] 1.99, 95%CI 1.12-3.54, P = 0.035), father not living with the child (RR 1.85, 95%CI 1.06-3.21, P = 0.030) and father using illicit drugs (RR 2.93, 95%CI 1.44-5.97, P = 0.002). CONCLUSIONS: Health professionals responsible for treating children with TB should pay special attention to children aged <1 year, those with a history of previous default, and those whose father is absent or an illicit drug user.

Latent tuberculosis infection among undergraduate medical students in Rio de Janeiro State, Brazil.

SETTING: Five medical schools in three cities with different tuberculosis (TB) incidence rates in Rio de Janeiro State, Brazil. OBJECTIVE: To estimate prevalence of and associated factors for latent tuberculosis infection (LTBI) among medical students. DESIGN: A cross-sectional survey was conducted among undergraduate students in pre-clinical, early and late clinical years from schools in cities with low (28/100,000), intermediate (63/100,000) and high (114/100,000) TB incidence rates. Information on socio-demographic profile, previous BCG vaccination, potential TB exposure, co-morbidity and use of respiratory protective masks was obtained. A tuberculin skin test (TST) was performed using the Mantoux technique by an experienced professional. A positive TST, defined as induration > or = 10 mm, was considered LTBI. RESULTS: LTBI prevalence was 6.9% (95%CI 5.4-8.6). In multivariate analysis, male sex (adjusted odds ratio [aOR] 1.8; 95% CI 1.1-3.0), late clinical years (aOR 1.9; 95% CI 1.01-3.5), intermediate TB incidence (aOR 4.3; 95% CI 1.3-14.6) and high TB incidence in the city of medical school (aOR 5.1; 95% CI 1.6-16.8) were significantly associated with LTBI. CONCLUSIONS: The higher prevalence of LTBI in late clinical years suggests that medical students are at increased risk for nosocomial Mycobacterium tuberculosis infection. The implementation of a TB control program may be necessary in medical schools, particularly in cities with higher TB incidence.

Defaulting from anti-tuberculosis treatment in a teaching hospital in Rio de Janeiro, Brazil.

SETTING: Few studies have investigated factors associated with defaulting from anti-tuberculosis (TB) therapy in hospital settings. OBJECTIVE: To identify the factors associated with defaulting from treatment among TB in-patients in Rio de Janeiro city, Brazil. DESIGN: Case-control study. METHODS: All study participants initiated anti-tuberculosis treatment in a teaching hospital. A defaulting case was defined as a person who did not return for anti-tuberculosis medications after 60 days. Cases and controls were interviewed by a trained health care worker using a standardized form. RESULTS: From 1 January to 31 December 1997, 228 TB cases were registered. After a review of the medical records, 39 were excluded. Household visits were performed in 189 patients; 46 subjects were identified as cases and 117 as controls. Defaulting from anti-tuberculosis treatment was observed in 66 cases (28.9%) before and in 46 (20.2%) after a home visit. After multivariate analysis, the strongest predictors of defaulting from treatment were: 1) returning card not provided (OR 0.099; 95%CI 0.008-1.2; P = 0.07), 2) not feeling comfortable with a doctor (OR 0.16; 95%CI 0.33-0.015; P = 0.001), and 3) blood pressure not measured (OR 0.072; 95%CI 0.036-0.79; P = 0.024). CONCLUSIONS: In this hospital, the factors associated with defaulting from anti-tuberculosis treatment highlight the necessity for a structured TB Control Program. It is expected that the implementation of such a program, pursuing specific approaches, should enhance completion of anti-tuberculosis treatment and cure.

The study of tuberculosis-attributed deaths as a tool for disease control planning in Rio de Janeiro, Brazil.

SETTING: Two tuberculosis (TB) reference hospitals and three general hospitals in Rio de Janeiro (RJ). OBJECTIVE: To analyze TB-attributed deaths as a tool for evaluating the TB control program in RJ. DESIGN: Retrospective study based on 302 medical records selected from the 1998 death database. RESULTS: Of 1146 registered adult (>14 years) TB-attributed deaths in RJ, 328 occurred in five hospitals, and 302 records were analyzed. Median age was 47.5 (17-89) years; 237 (78.5%) were male. Median time elapsed from onset of symptoms until diagnosis was 60 (7-730) days; median hospitalization was 60 (0-517) days. Acid-fast bacilli sputum smears were performed in 200 (69%) of 290 cases of pulmonary disease. Among 32 (36%) smear-negative patients, culture was done in only one. The recommended regimen (RHZ) was used in 175 (58%). Among 125 re-treatment patients, 55 (44%) were on RHZ instead of RHZE. Notification to health authorities was recorded in 131 (43.4%) cases. CONCLUSION: In RJ, young people die from TB. Major issues identified in the public health system were poor detection and notification and a high default rate, perpetuating the spread of TB. Treating professionals do not follow guidelines, and political commitment is needed to ensure TB control in the state and in the country.

Knowledge of pediatricians in Rio de Janeiro, Brazil, about inhalation therapy in asthmatic children.

BACKGROUND: Despite the numerous guidelines on the diagnosis and treatment of asthma, there are data that indicate that general pediatrician's knowledge of the disease and its preferred treatment is limited, which may influence the quality of care given to asthmatic children. The purpose of this study was to describe pediatrician's knowledge of spacers and of concepts of chilhood asthma, as well as their prescribing habits concerning inhalation therapy, in the public health system of the city of Rio de Janeiro. METHODS AND RESULTS: A descriptive cross-sectional study was performed in a sample of 72 pediatricians from the public health system of Rio de Janeiro. A questionnaire was used to assess prescriptions for spacers, the reasons whay spacers were not used, the models employed, classification of asthma according to clinical severity and symptom frequency, recommendation for the correct spacer volume according to age group, and the concept of asthma as an inflammatory disease. Seventy percent (51/72) of the physicians did not routinely prescribe the spacer. The reasons given were as follows: a) lack of spacer availability in the public health system in 55 % (28/51); b) high cost in 57 % (29/51); c) the complexity of their use in 35 % (18/51); d) unwillingness to use aerosol type medication in 15 % (8/51), and e)lack of knowledge of their function and utilization in 59 % (30/51). Of the 30 % (21/72) who reported they regularly and routinely prescribed the spacer in daily practice, 48 % (10/21) stated that this routine prescription, even when indicated, was below 25 % of what was expected and makeshift models were preferred by 24 % (5/21) of the pediatricians. Six percent of the pediatricians chose the appropriate spacer volume according to age group, 62.5 % (45/72) reported that they classified asthma according to severity, 16 % (7/45) gave the correct answers when classifying asthma according to national consensus, and 22 % (16/72) considered asthma to be an inflammatory disease. CONCLUSIONS: The results of this study suggest that pediatrician's knowledge of inhalation therapy with dosed aerosol spacers and of asthma-related concepts in the public health system in Rio de Janeiro is limited. This may restrict the quality of care given to the asthmatic children in the city and suggests the need for training programs for the management of asthmatic children.

Adverse effects of BCG revaccination: a report on 13 cases from Rio de Janeiro, Brazil.

SETTING: BCG revaccination is not used worldwide. In Brazil, it has been recommended since 1994 in children aged 6 to 14 years. Reports in the medical literature of adverse reactions due to revaccination are rare. BCG revaccination remains officially recommended by the Brazilian health authorities, based on the current epidemiological tuberculosis situation in the country. OBJECTIVE: We report 13 cases of children and adolescents with complications due to BCG revaccination. DESIGN: Case reports of patients followed up in a pneumology unit of a university pediatric hospital from May 1996 to December 2000. RESULTS: There were seven males and six females, whose ages ranged from 7-12 years. Adverse reactions occurred between 21 days and 9 months after BCG revaccination. All 13 cases had a scar from prior BCG vaccination. All cases treated received isoniazid, 10 mg/kg/day, in the morning until the end of cure. The duration of treatment varied, but all cases were successfully cured. CONCLUSION: Although adverse reactions are rare, it is important to continue monitoring them in order to learn more about them and to be able to orient health professionals to perform appropriate assessment and timely treatment when they occur.

[Iron deficiency anemia and nutrition in the second year of life in Rio de Janeiro, Brazil]. / Anemia ferropriva e alimentação no segundo ano de vida no Rio de Janeiro, Brasil.

OBJECTIVE: To assess the influence of feeding practices on the prevalence of anemia among breast-fed children, based on the nutritional profile of children receiving care at an outpatient pediatric clinic in the city of Rio de Janeiro, Brazil. METHODS: This was a cross-sectional study with 288 children between 12 and 18 months of age who were seen at the outpatient clinic between January and June 1993. The children were assessed in terms of the presence of iron-deficiency anemia. In addition, two questionnaires were done with the child's mother or the other person who had brought the child to the clinic: a 24-hour dietary recall and a record of the frequency of the consumption of iron-rich foods. RESULTS: Of the 288 children, 144 of them had signs of anemia (hemoglobin < 11 g/dL); of these 144, 38 of them had severe anemia (hemoglobin < 9.5 g/dL). We found low levels of bioavailable iron in the foods consumed, limited consumption of meat, and vitamin C consumption separate from meals. We found a significant association between the prevalence of severe anemia and inadequate iron intake (relative risk = 2.28; 95% confidence interval = 1.12 to 4.66; P = 0.02). The intake of bioavailable iron was higher in the group without anemia (P = 0.04). CONCLUSIONS: Individuals caring for breast-fed children should be educated concerning the nutritional contents of complementary foods so as to increase the bioavailability of iron in the children's diets. One way to achieve this objective might be through "Integrated Management of Childhood Illnesses," a strategy endorsed by a number of international organizations as a way to reduce child mortality and morbidity in developing countries.

Quality of hospital care for seriously ill children in less-developed countries.

BACKGROUND: Improving the quality of care for sick children referred to hospitals in less-developed countries may lead to better outcomes, including reduced mortality. Data are lacking, however, on the quality of priority screening (triage), emergency care, diagnosis, and inpatient treatment in these hospitals, and on aspects of these potential targets that would benefit most from interventions leading to improved health outcomes. METHODS: We did a qualitative study in 13 district hospitals and eight teaching hospitals in seven less-developed countries. Experienced paediatricians used a structured survey instrument to assess initial triage, emergency and inpatient care, staff knowledge and practices, and hospital support services. FINDINGS: Overall quality of care differed between countries and among hospitals and was generally better in teaching hospitals. 14 of 21 hospitals lacked an adequate system for triage. Initial patient assessment was often inadequate and treatment delayed. Most emergency treatment areas were poorly organised and lacked essential supplies; families were routinely required to buy emergency drugs before they could be given. Adverse factors in case management, including inadequate assessment, inappropriate treatment, and inadequate monitoring occurred in 76% of inpatient children. Most doctors in district hospitals, and nurses and medical assistants in teaching and district hospitals, had inadequate knowledge and reported practice for managing important childhood illnesses. INTERPRETATION: Strengthening care for sick children referred to hospital should focus on achievable objectives with the greatest potential benefit for health outcome. Possible targets for improvement include initial triage, emergency care, assessment, inpatient treatment, and monitoring. Priority targets for individual hospitals may be determined by assessing each hospital.

Linear growth and zinc supplementation in children with short stature.

Physical growth retardation is an early and prominent feature of zinc deficiency, but the effect of zinc supplementation in children is still not completely clear. This study investigated the impact of zinc supplementation on linear growth, growth velocity, IGF-I levels, and skeletal maturation of short children during and after mineral supplementation. The study was designed as a double-blind, randomized, controlled trial of zinc supplementation during a 6-month period, with a subsequent 6-month follow-up. Anthropometric data were collected at 0, 6, and 12 months. Measurements included plasma Zn, IGF-I, height, weight, triceps skinfold thickness, and body mass index. Eighteen healthy pre-pubertal short children (z-score -2.0) 7 to 10 years old with normal GH and IGF-I levels were randomized to two groups, one with zinc supplementation (5 mg/kg/d of ZnSO4) and the other with placebo. In the first 6 months, only height velocity increased significantly, 5.99+/-0.80 cm/yr vs 5.05+/-0.85 cm/yr (p=0.03). After 12 months, height velocity returned to the initial values, 3.92+/-0.59 cm/yr vs 4.19+/-1.08 cm/yr (p=0.29). This study indicates that zinc supplementation increased growth velocity, but these effects did not persist after supplementation was discontinued.

[Epidemiology of childhood tuberculosis in the city of Rio de Janeiro, Brazil]. / Epidemiologia da tuberculose infantil na cidade do Rio de Janeiro, RJ.

Data was drawn from a study on the epidemiological trends of tuberculosis among children of Rio de Janeiro county, Brazil. There was an increased incidence of tuberculosis among children and epidemiological health indicators were above the national average.

[Evaluation of mother-and-child health care in an urban area of Southern Brazil]. / Avaliação da assistência à saúde da mulher e da criança em localidade urbana da região Sudeste do Brasil.

OBJECTIVE: To describe and analyze primary health care provided to mother-and-child population in Teresópolis, state of Rio de Janeiro, Brazil. METHODS: A population survey was performed at the main vaccination station on the local Vaccine National Day, to collect information about the use of health care services and preventive primary care. RESULTS: Information was collected from 329 mothers and their children. More than 90% of children had at least one pediatric visit in the past three months. Almost all had their growth chart, but in 30% of them the child's weight was not registered. There was a positive association between having a routine visit and the registration of the child's weight in the card (RP = 1.34; IC: 1.13-1.58; p = 0.0002). Around 59% of the mothers had a medical visit after giving after birth; 25% said they had never had a Pap smear test before, and 36% never had a breast examination. There was a positive association between the mother's age being over 20 years and ever having a Pap smear test (RP = 1.56; IC: 1.08-2.26; p = 0.03). Almost 70% of the mothers referred the use of any contraception method, and the most common used were contraceptive pills, condoms and tubal ligation. CONCLUSIONS: Despite some limitations, the results suggest a valid and useful methodology, which allows the identification of important needs in primary health care delivery to children and their mothers.

Medical students at risk of nosocomial transmission of Mycobacterium tuberculosis.

SETTING: University and teaching hospital in Rio de Janeiro, Brazil, a city with a high prevalence of tuberculosis (TB). OBJECTIVE: To determine whether medical students are at increased risk of nosocomial transmission of Mycobacterium tuberculosis relative to other university students. DESIGN: A cross-sectional study of medical and chemical engineering students in different levels of their training programmes. Information about socio-demographic characteristics, BCG vaccination history, and potential exposures to TB were obtained using a standardised questionnaire. Tuberculin skin testing (TST) was used to determine the prevalence of infection with TB. RESULTS: Medical students have an increasing prevalence of TST positivity as they advance in their training programme to increasing levels of study (4.6%, 7.8%, 16.2%, respectively, P < 0.001), but chemical engineering students do not (4.2%, 4.3%, 4.4%, respectively, P = 0.913). The risks are greatest during the years of clinical training, when medical students have increased contact with patients. CONCLUSIONS: Medical students in this setting may be at increased risk of M. tuberculosis infection, relative to chemical engineering students. A programme of routine tuberculin skin testing is needed, combined with interventions to reduce the risk of nosocomial transmission in the workplace.