The influence of low birth weight body proportionality and postnatal weight gain on anthropometric measures of 8-year-old children: a cohort study in Northeast Brazil.

BACKGROUND/OBJECTIVES: Low birth weight (LBW) and rapid postnatal weight gain are associated with future high body adiposity; however, the cumulative effect of LBW and postnatal weight gain remains unclear. The aim of this study was to investigate the influence of body proportionality of LBW infants and postnatal weight gain on body mass index (BMI) and waist circumference (WC) of 8-year-old children. SUBJECTS/METHODS: A nested cross-sectional study was conducted in a cohort of children followed from birth to 6 months and reassessed at 8 years of age. The sample consisted of 167 children born at full term (67 with LBW and 100 with appropriate birth weight). Stunted LBW was defined as length <-2 z-score and wasted LBW as length ⩾ -2 z- score and Ponderal Index <2.5. Rapid growth was defined as weight gain greater than 0.67 s.d. score from birth to 6 months. Multivariate linear regression analysis was used to investigate the net effect of LBW and postnatal weight gain on BMI and WC, controlled for sex, total breastfeeding, socioeconomic status and maternal nutrition. RESULTS: The stunted and wasted LBW contributed significantly to the reduction of BMI and WC, and together explained 10% of the variation of these measurements. Rapid weight gain in the first 6 months of life, shorter total breastfeeding duration, higher socioeconomic status and maternal BMI significantly explained the increase in child BMI and WC. CONCLUSIONS: It was concluded that LBW led to lower body measurements, whereas rapid postnatal weight gain determined higher BMI and WC among school age children.

Risk factors associated with hepatic steatosis: a study in patients in the Northeast Brazil.

INTRODUCTION: Although there are several studies in the international literature regarding hepatic steatosis, few large-scale studies of risk factors are available. OBJECTIVE: To verify potential risk factors associated with hepatic steatosis, such as: alcohol consumption, overweight, dyslipidemia, hypertension, and type 2 diabetes mellitus. METHODS: This is a case series study including a control group (without hepatic steatosis), carried out at the gastroenterology outpatient clinic in Northeast Brazil. The sample was composed of 219 patients with hepatic steatosis and 82 without the disease. RESULTS: There was an association between hepatic steatosis and socioeconomic status. Prevalence Ratio (PR) for family income ≤ 2 minimum wage was (PR = 1.35 CI 95%, 1.18-1.54) and education level < primary education (PR = 1.44, CI 95%,1.27-1.64). Regarding anthropometric and clinical characteristics and lipid profile, there was an association with overweight (PR = 1.59, CI 95%, 1.38-1.83), abdominal circumference in the range of very high risk (PR = 2.28, IC 95%,1.68-3.09), hypertension (PR = 1.30, CI 95%, 1.15-1.48) and type 2 diabetes mellitus (PR = 1.23, CI 95%, 1.07-1.64), low HDL-cholesterol (PR = 1,96, CI 95%, 1.55-2.48), hypertriglyceridemia (PR = 2.10, CI 95%, 1.64-2.68). In the regression model three variables remained independently associated to hepatic steatosis, abdominal circumference in the range of very high risk (PRadjusted = 1.74), low HDL-cholesterol (PRadjusted = 1.39) and overweight (PRadjusted = 1.28). CONCLUSION: The results showed an association of hepatic steatosis with some risk factors, being abdominal circumference (very high risk) the most strongly associated, followed by low HDL-cholesterol and overweight.

Determinants of mental and motor development at 12 months in a low income population: a cohort study in northeast Brazil.

AIM: To identify biological and environmental factors associated with poorer mental and motor development at age 12 mo in urban communities in northeast Brazil. METHODS: A cohort of 245 infants born during January August 1998 in six hospitals in the interior of Pernambuco was followed twice weekly from birth until 12 mo of age. Socio-economic, demographic and environmental data were collected, together with daily information on morbidity and feeding patterns. Gestational age, birth anthropometry and nutritional status at 12 mo were measured. Multiple linear regression analysis was used to identify variables that had independent effects on mental and motor development assessed at 12 mo of age with the Bayley Scales of Infant Development. RESULTS: Environmental factors explained about 21% and 19% of the variance in mental and motor development, respectively. Of these, the most important were poverty-related. Significant biological factors associated with mental development were birthweight and infant sex. For motor development, the biological factors were weight-for-age and haemoglobin concentration. Biological factors explained only 6% and 5% of the variance in mental and motor development, respectively. CONCLUSION: Of the variables examined, environmental factors had a greater detrimental effect on child development than biological factors in this population. Interventions that enhance social capital and alleviate poverty are advocated.

Breastfeeding and early weaning practices in northeast Brazil: a longitudinal study.

OBJECTIVES: To describe breastfeeding practices from 0 to 12 months of age in 4 small towns that are representative of urban northeast Brazil and to identify factors associated with introduction of other milk in the first month of life. METHODS: From January to August 1998, 364 mothers were interviewed at delivery to ascertain antenatal care; delivery room practices; and their intentions regarding breastfeeding, pacifiers, and introduction of water, teas, and other milk. Their perceptions of home support and the advantages of breastfeeding also were assessed. Thereafter, daily information about feeding practices was collected at twice-weekly home visits. When other milk was started, a second interview was conducted to ascertain initial and current breastfeeding problems and use of a pacifier. Reasons for starting other milk were investigated using 5-point Likert scales. RESULTS: Mothers were positive toward breastfeeding, and 99% breastfed their new infant. Few intended to breastfeed exclusively, and in the first week 80% gave water/tea and 56% used a pacifier. The median duration of exclusive breastfeeding was 0 days, and the median age for starting other milk was 24 days. The median duration of breastfeeding was 65 days for mothers who started other milk within 1 month and 165 days for other mothers. After adjustment for confounding variables, the main factors associated with introduction of other milk within 1 month were pacifier use in the first week (odds ratio [OR], 4.01; 95% confidence interval [CI]: 2.07-7.78), intention to start other milk in the first month (OR, 3.79; 95% CI: 1.74-8.24), giving water/tea in the first week (OR, 3.07; 95% CI: 1.56-6.03), and leaving the maternity ward before breastfeeding was started (OR, 2.59; 95% CI: 1.34-5.04). CONCLUSION: Although breastfeeding is common in this community, it rarely is exclusive and takes place for a relatively short duration. Identification of risk factors for early introduction of other milk offers potential avenues for future intervention, including improvement of breastfeeding support in antenatal and maternity services.

Prevalence of anemia in children 6-59 months old in the state of Pernambuco, Brazil.

OBJECTIVE: To determine the prevalence of anemia in children 6-59 months old in Pernambuco, a state in northeastern Brazil, so as to help guide health and nutrition policies there. METHODS: In 1997 a representative sample of 777 young children had their hemoglobin concentration measured. The sampling process was in three stages. First, 18 municipalities were randomly selected to represent the state and its three geographic areas (metropolitan region of Recife, urban interior, and rural interior). Next, using census lists, 45 census sectors were randomly chosen. Finally, 777 children aged 6-59 months old were selected. Blood was collected by venipuncture, and hemoglobin was measured with a portable hemoglobinometer. In the analysis, prevalence was weighted to reflect the census age distribution. RESULTS: The prevalence of anemia among children 6-59 months old was 40.9% for the state as a whole. Prevalence in the metropolitan region of Recife was 39.6%, and it was 35.9% in the urban interior. The rural interior had the highest prevalence, 51.4%. Prevalence was twice as high in children aged 6-23 months as among those 24-59 months old, 61.8% vs. 31.0% (chi 2 = 77.9, P < 0.001). The mean hemoglobin concentrations in the younger and older age groups were 10.4 g/dL (standard deviation (SD) = 1.5) and 11.4 g/dL (SD = 1.4), respectively. There was no statistically significant difference between the sexes in terms of prevalence. CONCLUSIONS: This is the first statewide assessment of anemia prevalence among young children in Brazil. Given the very high prevalence of anemia among the children studied in Pernambuco, especially those in the age group of 6-23 months, public health interventions are needed.

Effect of breastfeeding and morbidity on the development of low birthweight term babies in Brazil.

Low birthweight (LBW) occurs in 17% of births in developing countries and many of them are full term. The subsequent development of LBW term infants is poorer than higher birthweight children and more likely to be affected by poor social circumstances. We investigated the effects of morbidity and breastfeeding on the development of these LBW term infants. Two parallel cohorts (n = 131 + 131) of LBW term (1500-2499 g) and higher birthweight (3000-3499 g) infants were recruited from six maternity centers in northeast Brazil. The longitudinal prevalence of morbidity and the frequency of breastfeeding over the first 6 mo of life were assessed. The infants' development was assessed on the Bayley Scales at 6 and 12 mo, and we previously reported that the low birthweight group had lower scores than the higher birthweight group. Hospitalizations in the first 6 mo were negatively associated with 6-mo and 12-mo Bayley scores in both groups. Among LBW infants, but not higher birthweight infants, there were significant associations between the prevalence of diarrhea and mental and motor development at 6 mo and mental development at 12 mo. Breastfeeding frequency in the first 4 wk of life was positively associated with mental development in both birthweight groups at 6 mo but not at 12 mo. Breastfeeding beyond 4 wk was not associated with the children's development. We conclude that low birthweight infants are especially vulnerable to the effects of diarrhea, and the greater frequency and differential effect of diarrhea partly explains their poorer development.

Effect of zinc supplementation on the morbidity, immune function, and growth of low-birth-weight, full-term infants in northeast Brazil.

In Brazil, the highest incidence of low birth weight (LBW) occurs in the northeast, and diarrhea and respiratory infections are the main causes of infant mortality and morbidity. We hypothesized that LBW infants may be zinc deficient, and that this might be adversely affecting their immune function, morbidity, and postnatal growth. We therefore examined the effect of zinc supplementation on these outcomes during the first 6 mo of life. LBW full-term infants (mean birth weight 2337 g) were given daily for 8 wk either 5 mg Zn (n = 71), 1 mg Zn (n = 68), or a placebo (n = 66). Morbidity was determined prospectively through daily home visits (except on Sunday) during weeks 0-8, then twice weekly in weeks 9-26. Anthropometric measurements were made at 0, 4, 8, 17, and 26 wk. Immune function was assessed at 8 wk by the phytohemagglutinin skin test. Supplementation (5 mg Zn) was associated with a 28% reduction in diarrhea prevalence over the 6-mo period [after adjustment for confounders (P = 0.043)], and a 33% reduction in the prevalence of cough (NS, adjusted prevalence P = 0.073). All infants had a positive immune response at 8 wk. Although supplementation had no significant effect on weight and length gains from 0 to 26 wk, infants given 5 mg Zn gained more weight than infants given placebo during weeks 17-26 (P = 0.024, analysis of variance). There was no effect on any outcome with 1 mg Zn. We conclude that 5 mg Zn/d is of benefit to LBW, full-term infants who only have a modest weight deficit.

The development of low birth weight term infants and the effects of the environment in northeast Brazil.

OBJECTIVES: (1) To compare the mental and psychomotor development of low birth weight term (LBW-T) infants with that of appropriate birth weight (ABW) infants at 6 and 12 months of age. (2) To examine the relationship between developmental levels and social background. METHODS: A cohort of 131 LBW-T infants (1500 to 2499 gm) and 131 ABW infants (3000 to 3499 gm) matched for sex and time of birth, recruited from six maternity centers in Northeast Brazil were followed for 1 year. Their development was assessed with the Bayley Scales at 6 and 12 months of age, and at 12 months their behavior during the test was rated on five scales. Details of their families' socioeconomic status were recorded and the degree of stimulation in their homes was assessed. RESULTS: At 6 months of age the LBW-T infants had significantly lower scores than the ABW infants on the mental development index (MDI; 4.2 points lower, p < 0.001) and on the psychomotor development index (PDI; 7.3 points lower, p < 0.001). The difference had increased by 12 months of age (MDI 7.0 points lower, p < 0.001; PDI 9.9 points lower, p < 0.001). Socioeconomic variables were related to development at both ages in both groups. Maternal literacy was significantly related to the PDI in LBW-T infants at 12 months but not in ABW infants. Similarly, stimulation in the home was related to the MDI in LBW-T infants at 6 and 12 months but not in ABW infants. LBW-T infants were less active, cooperative, vocal, and happy, and were more inhibited than ABW infants. CONCLUSIONS: LBW-T infants had poorer development than ABW infants and differed in their behavior. There was an interaction between birth weight and the environment. LBW-T infants, but not ABW infants, were affected by the quality of stimulation in the home and maternal illiteracy.

Zinc supplementation, mental development and behaviour in low birth weight term infants in northeast Brazil.

OBJECTIVE: To test whether zinc supplementation reduces the deficits in mental development and behaviour that are found in term infants of low birth weight in the study population. DESIGN: A prospective double-blind, part-randomised efficacy trial. SETTING: A low-income population in Pernambuco, northeast Brazil, where the economy is largely dependent on sugar-cane production, and where over 90% of deliveries occur in health facilities. SUBJECTS: During a 20-month period, all singleton, term infants weighing 1500-2499 g born to families of low income ( < US $280/month) were enrolled at birth (n = 205). At 6 and 12-months, the numbers tested were 163 and 138 respectively. INTERVENTION: Infants born from January 1993-January 1994 were randomly assigned to receive daily, except Sundays, a placebo (n = 66) or 1 mg zinc (n = 68). Those born February-August 1994 were given 5 mg zinc (n = 71). Supplementation was for eight weeks, starting at birth. Field workers visited each infant at home to administer the supplement. RESULTS: At 6 and 12-months, mental and psychomotor development was assessed with the Bayley Scales of Infant Development and no significant differences in the scores of the three groups were found. At 12-months, behaviour was also assessed on 5 ratings. Ratings were highest in infants given 5 mg zinc (P = 0.042). CONCLUSIONS: Zinc supplementation (5 mg/d) for eight weeks may reverse some of the poor behaviours, particularly responsiveness, exhibited by low birth weight infants. No amelioration of their mental and psychomotor deficits was found.

PIP: Severe zinc deficiency, widespread in developing countries, has been associated with cognitive and psychomotor impairment in animal studies. The capability of zinc supplementation, to reduce the deficits in mental development and behavior found in low-birth-weight term infants, was assessed in a prospective study conducted in a low-income community in Pernambuco, Brazil. All 205 singleton, term infants, delivered at the local hospital in a 20-month period and weighing 1500-2499 g at birth, were enrolled. Infants born from January 1993 to January 1994, were randomly assigned to receive either a placebo (n = 66) or 1 mg of zinc (n = 68) 6 days a week. The 71 low-birth-weight infants delivered from February to August 1994, were given 5 mg of zinc 6 days a week. Supplementation administered by local health workers was initiated at birth and lasted for 8 weeks. Mental and psychomotor development was measured at 6 and 12 months of age by the Bayley Scales of Infant Development. There were no significant differences between infants in the 3 study groups on this test. Also at 12 months, infant behavior was assessed on 5 scales. Ratings for one of these scales (responsiveness to tester) were significantly higher in infants who received 5 mg of zinc than in the 2 other groups, and the 5 mg zinc group also had the highest scores on the 4 other scales. Further studies are urged to investigate the effect of zinc provided later in life, and for longer periods of time, on the development of low-birth-weight infants.

Postnatal growth patterns of full-term low birth weight infants in Northeast Brazil are related to socioeconomic status.

Low birth weight has many adverse consequences, some of which might be ameliorated if there is good postnatal compensatory, or catch-up, growth. We monitored growth, morbidity and feeding patterns in a cohort of 133 full-term, low birth weight infants from poor families in Pernambuco, Brazil, and investigated the relative contributions of a number of socioeconomic, maternal and infant variables to postnatal growth. Growth was measured at 4, 8, 17, 26 and 52 wk of age. Differential growth patterns were most marked during the first 8 wk of life, and the gains in z-score during this interval were strongly associated with attained z-scores at 12 months (r = 0.62 for weight and 0.64 for length). In a multivariate model, socioeconomic variables explained 21.4% of the variation in maximum gain in weight-for-age z-score achieved during the 12-month period, maternal weight explained a further 4.4%, infant birth length 4.7% and neonatal illness 5.4%. For maximum gain in length-for-age z-score, socioeconomic variables accounted for 24.4% of the variance, maternal height 4.9%, maternal smoking 3.3% and neonatal illness 3.1%. We surmise that the early differential growth patterns are set in utero and are indirectly affected prenatally by socioeconomic status.

Low birth weight and morbidity from diarrhea and respiratory infection in northeast Brazil.

OBJECTIVE: To compare morbidity and mortality rates of low birth weight (LBW) and appropriate birth weight infants born at term, focusing on diarrheal and respiratory infections. STUDY DESIGN: A cohort of 133 LBW infants (1500 to 2499 gm) and 260 appropriate birth weight infants (3000 to 3499 gm), individually matched by sex and season of birth, were followed for the first 6 months of life. None had congenital anomalies and all were from poor families living in the interior of Pernambuco, northeast Brazil. Data on infant deaths, hospitalizations, and morbidity were collected prospectively through daily home visits (except Sundays) from birth through week 8, then twice weekly for weeks 9 to 26. The effects of birth weight were assessed with a variety of multivariable techniques, controlling for confounders. RESULTS: Of the LBW infants, 56% were wasted (thin), 23% were stunted, and 17% were both wasted and stunted. The LBW infants (median 2380 gm) experienced a sevenfold higher mortality rate and fourfold higher rate of hospitalization than appropriate birth weight infants. Almost all deaths and hospitalizations were in the postneonatal period. The LBW infants also experienced 33% more days with diarrhea and 32% more days with vomiting (p = 0.003 in each case). The prevalences of cough and fever were not significantly different. CONCLUSIONS: Infant deaths, hospitalizations, and diarrheal morbidity are increased in term LBW infants who have only a modest weight deficit.

PIP: During January-December 1993, in the interior of Pernambuco State, northeast Brazil, researchers recruited 133 low birth weight (LBW) (1500-2499 g) infants and 260 sex- and birth season-matched controls of appropriate birth weight (ABW) (3000-3499 g) from the maternity wards of hospitals in five communities. All infants were randomly assigned to receive either 1 mg zinc/day for 8 weeks or a placebo. All infants came from low income families. The researchers compared their morbidity, especially diarrhea and respiratory tract infections, and mortality rates during the first 6 months of life. Zinc supplement had no effect on any of the outcome measures. LBW infants were more likely than ABW infants to die (7.5% vs. 0.8%; adjusted hazard rate ratio [AHRR] = 6.58; p = .006) and to be hospitalized (24.8% vs. 6.5%; AHRR = 4.09; p .001) during the first 6 months of life. Yet the rate of consultations with medical personnel was essentially the same for both groups. 90% of the LBW deaths occurred in the postneonatal period, the underlying causes being diarrhea and respiratory infections. For both LBW and ABW infants, diarrhea was the main cause of hospitalization. Both groups experienced little diarrhea during the first 6 weeks of life. Thereafter, LBW infants suffered a higher prevalence of diarrhea than ABW infants up until 5 months. Beginning with day 1, LBW infants experienced more vomiting than ABW infants. Both groups experienced increasing rates of cough and fever throughout the 6-month period. Differences between the two groups were less pronounced than they were for diarrhea or vomiting. LBW infants were more likely to be sick longer with diarrhea and vomiting than ABW infants (p .001), but the difference in prevalence was less significant (p = .043). The onset of diarrhea was strongly associated with feeding mode (hazard rate ratio = 1.56 for partially breast-fed infants and 2.34 for infants no longer breast fed; p .001) as was the onset of vomiting (0.95 and 1.86, respectively; p .001 for the latter). LBW infants suffered more deaths, hospitalizations, and diarrhea morbidity than ABW infants.

[Anemias in preschool children: diagnosis, treatment and evaluation, Recife-PE, Brazil]. / Anemias em pre-escolares: diagnostico, tratamento e avaliação Recife-PE, Brasil.

The diagnosis and the effects of treatment of anemia were assessed in children aged 6-71 months. A total of 1,161 preschool children from a health center of INAMPS (Instituto Nacional de Assistência Médica e Previdência Social) in Recife, Pernambuco, was studied. Hemoglobin was determined by the method described by Hainline. WHO criteria were used to identify anemia. According to their age, nutritional status and family income, the children were divided into groups, and those with anemia were treated with ferrous sulphate and an anti-helminthic (mebendazole). Anemia prevalence was substantially higher in children aged 2 years, and a statistically significant association (0.01 level) was found between anemia and nutritional status and family income. After treatment, hemoglobin values were normal in 40% of the anemic children; simultaneously, mean hemoglobin values increased from 9.11 to 10.3 g/dl which was statistically significant (p less than 0.001). This investigation is part of a collaborative study performed in four Brazilian states to offer "know-how" to a national program for combating iron deficiency anemia.

[Nutritional status of children under 6, according to land tenure, in rural areas of the State of Pernambuco, Northeast of Brazil]. / Estado nutricional de crianças menores de seis anos, segundo posse da terra, em áreas rurais do Estado de Pernambuco, Nordeste do Brasil.

The purpose of this investigation was to analyze the distribution of protein-energy malnutrition, anemia and hypovitaminosis A in relation to accessibility and size of rural lands. About 689 families from the Agreste rural area (Pernambuco, North-East Brazil) were studied. A total of 1,257 children under 6 years of age were distributed in four groups according to the size of the land. The nutritional status was assessed according to the criteria of Gómez, Ariza-Macías and Seoane-Latham, modified by Batista Filho. In accordance with the Gómez' method, 55.1% of the children suffered from some degree of malnutrition. About 67.0% of the landless families suffered from malnutrition, in contrast to 25% of the landowners who had 50 or more than 50 hectares of land (p less than 0.01). Hemoglobin was determined in 976 children; 38.9% of them suffered from anemia. No significant differences were detected among the several groups of land tenants. Serum retinol levels were measured in 412 children and a high incidence of hypovitaminosis A was detected: 24% had serum retinol levels below 20 mcg/100 ml. No significant association was found in relation to the different land tenure groups. These data demonstrate a high prevalence of protein-energy malnutrition, anemia and hypovitaminosis A. A significant correlation between protein-energy malnutrition and the size of the land was also found, demonstrating that this region is one of the most affected by food and nutritional problems.