Individual and neighbourhood social capital and all-cause mortality in Brazilian adults: a prospective multilevel study.

OBJECTIVE: The relationship between social capital and mortality is not clear-cut. There have been few longitudinal studies investigating this association so far. The objective was to assess the effect of different dimensions of social capital on mortality among adults of a Brazilian city. STUDY DESIGN: This is a prospective multilevel study. Baseline data were obtained from a population-based random sample of 846 adults (aged 18 years or more) residing in 38 neighbourhoods (census blocks). METHODS: Participants were interviewed in 2006-7 and their vital status investigated in 2013. Social capital was assessed by five scales (social cohesion, informal social control, neighbours' support, social action and political efficacy). The outcome was all-cause mortality. Data analysis used multilevel logistic regression models. RESULTS: At the individual level social cohesion was positively related to mortality in the unadjusted model but this association lost significance after adjustment for other variables in multivariable models. At the neighbourhood level, high mortality rates were associated with low social action independently of demographic, socio-economic, behavioural and health-related variables. CONCLUSION: We found more evidence for a contextual than individual level effect of social capital on mortality.

Seasonal variation in food intake and the interaction effects of sex and age among adults in southern Brazil.

BACKGROUND/OBJECTIVES: Because studies have evidenced variations in nutrient intake, further investigation of the interaction between demographic characteristics and the seasons is necessary. We aimed to test the differences in food intake throughout the seasons and the interaction between the seasons and sex and age. SUBJECTS/METHODS: This study included 273 individuals. Food intake was evaluated with 24-hour dietary recalls, and the reported food items were sorted into food groups. We performed the test on the differences in intake of food groups throughout the seasons with repeated measures and on the interaction effect by using the Generalized Estimate Equation. RESULTS: Intake of fruits and natural fruit juices and sweetened beverages was lower, whereas that of grains and derivatives was higher in the winter. The intake of leafy vegetables and fish and seafood was lower in the autumn. The consumption of coffee and eggs was higher in the spring. Intake of chocolate powder and sugar, salt and lean poultry was higher in the winter. The variation in consumption of grains and derivatives, eggs, fatty poultry and processed meat over the seasons was more likely to be modified by sex. Age interacted with the seasons for leafy vegetables, beans and lentils, lean beef, lean poultry, low fat milk and light yogurt, vegetable oil and unsalted margarine, chocolate powder and sugar and processed meat. CONCLUSIONS: This study shows that food intake may change seasonally and that seasonal variation depends on sex and age, which might aggregate a specific co-variation component.

Factors associated with metabolic syndrome in climacteric women of southern Brazil.

AIM: To investigate the association between socioeconomic, demographic, behavioral, and reproductive factors and the metabolic syndrome (MS) in climacteric women. METHOD: This cross-sectional study was carried out in a sample of 527 women aged 40-65 years seen at an outpatient menopause and gynecologic surgery clinic in Southern Brazil. MS was defined according to NCEP-ATP III diagnostic criteria. Poisson regression was used to calculate crude and adjusted prevalence ratios and their respective 95% confidence intervals (CI). RESULTS: The prevalence of MS was 54.8% (95% CI 50.6-59.1%), varying with menopausal status (45.7% before menopause, 56.3% in perimenopause, and 57.5% in postmenopausal women). Among the components of MS, hypertension and abdominal obesity were the most prevalent (84.8% and 66.8%, respectively). The prevalence of MS rose with advancing age and increasing parity. Women with low education (years of schooling) showed a higher prevalence of MS compared to those with a high education level (64% vs. 36.8%). Women with early menarche (≤11 years of age) showed an increase of 32% in MS prevalence (95% CI 1.08-1.62) compared to those with a late menarche (≥14 years of age). CONCLUSION: These findings are relevant to public health, particularly as they show the significance of exposure to long-term, hard-to-reverse effects, such as early menarche and low educational achievement, in the development of metabolic syndrome.

Periodontal disease and perinatal outcomes: a case-control study.

AIM: Our aim was to measure the association of maternal periodontitis with low birth weight (LBW), pre-term LBW, and intra-uterine growth restriction. MATERIAL AND METHODS: An inclusive case-control design including subjects examined for periodontitis through attachment loss, information on perinatal outcomes and general health. Data were analysed through conditional logistic regression. RESULTS: Cases (n=304) and controls (n=611) had similar prevalence and severity of periodontitis, defined as at least three sites, in different teeth, with loss of three or more millimetres of clinical attachment level. Several factors were associated with the outcome, but the crude odds ratio for periodontitis was not significant. Odds ratio were 0.93 [95% confidence interval (CI): 0.63-1.41] for LBW and 0.92 (95% CI:0.54-1.57) for pre-term LBW in the presence of periodontitis, after adjustment for maternal age, previous pregnancies, pre-natal care, smoking, previous low birth or premature birth and other medical conditions, on a hierarchical model. CONCLUSIONS: Results do not support the hypothesis of association observed in previous studies after appropriate controlling for confounding variables. Negative peri-natal outcomes are better explained by determinants other than periodontal health. This study adds to the growing body of literature on the relationship between periodontal diseases and systemic health.

The validity and 4-year test-retest reliability of the Brazilian version of the Eating Attitudes Test-26.

In a cross-sectional study conducted four years ago to assess the validity of the Brazilian version of the Eating Attitudes Test-26 (EAT-26) for the identification of abnormal eating behaviors in a population of young females in Southern Brazil, 56 women presented abnormal eating behavior as indicated by the EAT-26 and the Edinburgh Bulimic Investigation Test. They were each matched for age and neighborhood to two normal controls (N = 112) and were re-assessed four years later with the two screening questionnaires plus the Composite International Diagnostic Interview (CIDI). The EAT results were then compared to diagnoses originating from the CIDI. To evaluate the temporal stability of the two screening questionnaires, a test-retest design was applied to estimate kappa coefficients for individual items. Given the prevalence of eating disorders of 6.2%, the CIDI psychiatry interview was applied to 161 women. Of these, 0.6% exhibited anorexia nervosa and 5.6%, bulimia nervosa (10 positive cases). The validity coefficients of the EAT were: 40% sensitivity, 84% specificity, and 14% positive predictive value. Cronbach's coefficient was 0.75. For each EAT item, the kappa index was not higher than 0.344 and the correlation coefficient was lower than 0.488. We conclude that the EAT-26 exhibited low validity coefficients for sensitivity and positive predictive value, and showed a poor temporal stability. It is reasonable to assume that these results were not influenced by the low prevalence of eating disorders in the community. Thus, the results cast doubts on the ability of the EAT-26 test to identify cases of abnormal eating behaviors in this population.

The validity and 4-year test-retest reliability of the Brazilian version of the Eating Attitudes Test-26

In a cross-sectional study conducted four years ago to assess the validity of the Brazilian version of the Eating Attitudes Test-26 (EAT-26) for the identification of abnormal eating behaviors in a population of young females in Southern Brazil, 56 women presented abnormal eating behavior as indicated by the EAT-26 and the Edinburgh Bulimic Investigation Test. They were each matched for age and neighborhood to two normal controls (N = 112) and were re-assessed four years later with the two screening questionnaires plus the Composite International Diagnostic Interview (CIDI). The EAT results were then compared to diagnoses originating from the CIDI. To evaluate the temporal stability of the two screening questionnaires, a test-retest design was applied to estimate kappa coefficients for individual items. Given the prevalence of eating disorders of 6.2 percent, the CIDI psychiatry interview was applied to 161 women. Of these, 0.6 percent exhibited anorexia nervosa and 5.6 percent, bulimia nervosa (10 positive cases). The validity coefficients of the EAT were: 40 percent sensitivity, 84 percent specificity, and 14 percent positive predictive value. Cronbach's coefficient was 0.75. For each EAT item, the kappa index was not higher than 0.344 and the correlation coefficient was lower than 0.488. We conclude that the EAT-26 exhibited low validity coefficients for sensitivity and positive predictive value, and showed a poor temporal stability. It is reasonable to assume that these results were not influenced by the low prevalence of eating disorders in the community. Thus, the results cast doubts on the ability of the EAT-26 test to identify cases of abnormal eating behaviors in this population.

Waist circumference as a determinant of hypertension and diabetes in Brazilian women: a population-based study.

OBJECTIVE: To evaluate the role of central adiposity, as evaluated by the measurement of waist circumference (WC), as an independent risk factor for hypertension and type 2 diabetes mellitus in the setting of a developing country. DESIGN: Population-based, cross-sectional study. SETTING: A medium-sized town in southern Brazil. PARTICIPANTS: One thousand and ninety-five non-pregnant women, 20 to 69 years old, recruited by cluster random sampling between 1999 and 2000. Their mean WC was 85.3 cm (standard deviation 13.9 cm) and 23.3% (n=255) were obese (body mass index >30 kg m(-2)). The prevalence of hypertension and diabetes was 25.6% (n=280) and 6.2% (n=68), respectively. RESULTS: The risks of hypertension and diabetes were directly related to WC measurement. Women with WC>80 cm had increased risk of hypertension (odds ratio (OR)=6.2, P<0.001). The association remained significant (OR=1.04 per cm increase in WC, P=0.02) after adjusting for confounders. The effect of WC on diabetes was modified by age. The effect was stronger in women younger than 40 years old (OR=12.7, P=0.016) than in those over 40 years old (OR=2.8, P=0.013). In the multivariate analysis, the odds ratio was 5.7 (P=0.12) in those under 40 years old and 2.8 (P=0.008) in older women. CONCLUSIONS: Waist circumference is an independent determinant for hypertension and diabetes in women in this population. The stronger association between WC and diabetes in younger women suggests that the validity of this indicator to assess abdominal adiposity is age-specific. Further studies should validate the usefulness of WC measurement in different age groups.

Prevalence of abnormal eating behaviours and inappropriate methods of weight control in young women from Brazil: a population-based study.

OBJECTIVE: The aim of this epidemiological investigation was to study the prevalence of abnormal eating behaviours in a community sample of young women from Porto Alegre, RS, Brazil. METHODS: The research team visited 1524 randomly selected households in Porto Alegre and invited all of the women aged 12-29 years to participate in the study: 513 women subsequently completed a socio-economic and demographic questionnaire, the Bulimic Investigatory Test (BITE) and the Eating Attitudes Test (EAT-26). RESULTS: Clinically significant disturbed eating behaviour was revealed in the 16.5% of women who had EAT scores above the cut-off point of 21; 2.9% also had BITE symptom scores of > or = 20. The participants were categorised into three groups on the basis of a new variable combining both instruments: those with abnormal eating behaviours (10.9%), those with unusual eating patterns (23.8%), and those with normal eating behaviours (60.2%). Abnormal eating behaviours were significantly more prevalent in the 16-19 year age range (p = 0.007) and were also more prevalent among overweight/obese women (p = 0.009). Laxative use was reported by 8.5% of the women, followed by fasting (3.1%), use of diuretics (2.8%) and vomiting (1.4%). CONCLUSIONS: Abnormal eating behaviours are fairly common among young women in Brazil. In comparison with other population studies, this survey showed a similar use of laxatives, less self-induced vomiting and a greater use of diet pills (probably because they are less strictly controlled in Brazil). Educational programmes aimed at preventing abnormal eating behaviours and developing healthy weight control practices among children and young adolescents should become public health priorities.

[Race and inequality among women: an example in southern Brazil]. / Raça e desigualdade entre as mulheres: um exemplo no sul do Brasil.

This study uses epidemiological data to investigate socioeconomic proportions of distinctions raised by "racism" in Brazilian society. A population-based cross-sectional study was conducted with a sample of 2,779 women ages 14 through 49, living in a southern Brazilian city. Black and mixed-race women had less schooling, lower family income, and worse housing conditions than white women. They also used contraceptive methods less frequently, had more children, and had higher spontaneous abortion and stillbirth rates than white women. Virtually all of the results show a linear relationship between such categories, i.e., the "darker" the woman's skin color, the worse her socioeconomic and reproductive conditions. We also observed that black women were either separated, divorced, or widowed, another apparent factor for black women's impoverishment, related mainly to their limited employment opportunities. The results of the current study indicate that racial relations among women are an issue that should foster a discussion concerning citizenship in Brazil.

[Reproductive characteristics of women from 15 to 49 years of age: comparative studies and planning for actions]. / Características reprodutivas de mulheres de 15 a 49 anos: estudos comparativos e planejamento de ações.

INTRODUCTION: The availability of socioeconomic, demographic and reproductive health data about women at national, regional and municipal levels allows comparisons between regions and may offer background information for planning actions of the Program of Integrated Assistance for Women's Health. METHODS: A population-based cross-sectional study was carried out in Southern Brazil. Three thousand and two women aged 15 to 49 years living in an urban area in Pelotas, were selected for inclusion in the study. A structured questionnaire was used to collect the socioeconomic, demographic and reproductive characteristics. The analysis included comparison of means and proportions. In the sterilization analysis the data were controlled for age. RESULTS: Nearly 56% of the women were married/in union and 35% were single. A third of them were housewives and 50% were wage workers. The mean of schooling was 8.5 years. Almost, half of the adolescents (15 to 19 years old) have an active sexual life, and of those 33% had already been pregnant. A high percentage of unwanted pregnancy was reported, mainly among younger women. Near the end of their reproductive life (women aged 45 to 49 years) the mean of children per woman was 2.4. The most prevalent methods were pill and sterilization. Among married women or those living in consensual union, 15% had been sterilized. The sterilization rate increased with age and attained nearly 25% of women aged over 35 years; 29.6% of sterilized women had had a stillborn child and 18.3% a pre-term baby; 20% of husbands/partners did not accept the use of any contraceptive method. CONCLUSIONS: The study results confirm the need for additional attention to and development of special programs for adolescents, improvements in the access to services, increase in the use of the contraceptive options already available and research and programatic actions related to the theme "men/reproductive health.

[Prevalence and risk factors of obesity in adults]. / Prevalência de obesidade em adultos e seus fatores de risco.

INTRODUCTION: A population-based cross-sectional study was conducted in Pelotas, Southern Brazil, with the objective of determining the prevalence of obesity and identify associated, variables as this condition increased markedly in the country between 1974 and 1989. MATERIAL AND METHODS: One thousand and thirty-five adults between 20 and 69 years of age were studied. Obesity was defined as a Body Mass Index--BMI--equal to or over 30 Kg/square meter). The multivariate analyses took into account the hierarchical model of the variables associated with obesity for both men and women. RESULTS: The prevalence for the overall population was of 21% (CI 18-23). It was higher among women--25% (CI 22-29) than for men--15% (CI 12-18). Socioeconomic status was positively associated with obesity among men, whereas the opposite situation was reported for women, with those belonging to the poorest social strata presenting increased BMI. Reported obesity in their parents was associated with increased BMI in the subjects, and this association remained statistically significant even after compensating for the effect of possible confounding variables. Self-reported diabetes and arterial hypertension doubled the risk of obesity, whereas non-smoking was associated with obesity only among women. Variables which were not associated with obesity after adjusting for confounders were alcohol consumption, marital status and parity. Women having more daily meals were less prone to obesity, even after controlling for confounders, and this association was not quite significant for men (p = 0.07). CONCLUSIONS: The prevalence of obesity was higher among women, and important differences in risk factors were noticed when the population was considered by sex.

Pacifier use and short breastfeeding duration: cause, consequence, or coincidence?

OBJECTIVES: Pacifiers are related to a shorter duration of breastfeeding. However, it is unclear whether this association is causal, because confounding, reverse causality, and self-selection of mothers may play a role. These issues were investigated through a combination of epidemiologic and ethnographic research in southern Brazil. METHODOLOGY: A population-based cohort of 650 mothers and infants were visited shortly after delivery and at 1, 3, and 6 months. The rate of complete follow-up was 96.8%. A subsample of 80 mothers and infants was selected for the ethnographic study, which included in-depth interviews and participant observations in the age range of 2 to 6 months with a mean of 4.5 visits. RESULTS: The epidemiologic study showed that pacifier use was common with 85% of users at 1 month. However, this was a dynamic process, with many infants starting or abandoning the pacifiers in any age range. Children who stopped breastfeeding in a given period were likely to take up the pacifier during that period. Further analyses excluded all infants not breastfed at 1 month of age and those who reportedly had breastfeeding problems, leaving 450 infants with full data. Intense pacifier users at 1 month (children who used the pacifiers during most of the day and at least until falling asleep) were four times more likely to stop breastfeeding by 6 months of age than nonusers. Users also had fewer daily breastfeedings than nonusers. After adjustment for several confounding variables, logistic regression showed that pacifier use was still associated with an odds ratio of 2.5 (95% confidence interval, 1.40 to 4.01) for stopping breastfeeding. The ethnographic analysis showed that pacifier use was widely regarded as a positive behavior and that mothers often strongly stimulated the infants to accept it. Although few mothers openly admitted that pacifiers might shorten breastfeeding, a considerable group effectively used pacifiers to get their infants off the breast or to increase the interval between feedings. The latter also had rigid breastfeeding styles that increased maternal-infant distance, had important concerns about objective aspects of infant growth and development, and were highly sensitive to infant crying. These behaviors were linked to intense comparison between themselves and other mothers and to a lack of self-confidence. Nonwhite mothers, those who delivered vaginally, and mothers of infant girls seemed to be more confident and less affected by these difficulties. The epidemiologic analysis confirmed that pacifier use was more closely associated with breastfeeding duration among nonwhite mothers and for normally delivered infants. CONCLUSIONS: Pacifiers may be an effective weaning mechanism used by mothers who have explicit or implicit difficulties in breastfeeding, but they are much less likely to affect infants whose mothers are confident about nursing. Breastfeeding promotion campaigns aimed specifically at reducing pacifier use will fail unless they also help women face the challenges of nursing and address their anxieties. The combination of epidemiologic and ethnographic methods was essential for understanding the complex relations between pacifier use and breastfeeding.

The role of conceptual frameworks in epidemiological analysis: a hierarchical approach.

BACKGROUND: This paper discusses appropriate strategies for multivariate data analysis in epidemiological studies. METHODS: In studies where determinants of disease are sought, it is suggested that the complex hierarchical inter-relationships between these determinants are best managed through the use of conceptual frameworks. Failure to take these aspects into consideration is common in the epidemiological literature and leads to underestimation of the effects of distal determinants. RESULTS: An example of this analytical approach, which is not based purely on statistical associations, is given for assessing determinants of mortality due to diarrhoea in children. CONCLUSIONS: Conceptual frameworks provide guidance for the use of multivariate techniques and aid the interpretation of their results in the light of social and biological knowledge.

Falling diarrhoea mortality in Northeastern Brazil: did ORT play a role?

The impact of oral rehydration therapy (ORT) on the recent decline in diarrhoea mortality in the northeast of Brazil was studied. Proportionate infant mortality fell from 32% in 1980 to 17% in 1989 and infant deaths attributed to diarrhoea dropped from 41% to 25%, resulting in an overall reduction of 57%. Similar decreases were observed for children aged 1-4 years. Diarrhoea admissions also fell from 57% of infant hospitalizations in 1980 to 30% in 1990. None of the other major causes of death or admissions showed such decline. ORT was introduced in the early 1980s, being used in 35% of all episodes in 1991 and in 62% of those regarded as severe by the mother. Other changes included a worsening of socioeconomic conditions and increases in water supply, vaccine coverage, breastfeeding duration and nutritional status. A simulation model estimated that changes in factors other than ORT would lead to a 21% reduction in infant diarrhoea mortality, or about one-third of the actual decline. Finally, an ecological analysis showed that ORT use rates were inversely correlated to infant diarrhoea mortality (r=-0.61; p=0.04). Despite the shortcomings of the available data, these findings suggest an important impact of ORT on diarrhoea mortality.

PIP: Proportionate infant mortality in the northeast of Brazil fell from 32% in 1980 to 17% in 1989, with infant deaths attributed to diarrhea falling from 41% to 25%; these declines comprise an overall reduction of 57%. Similar decreases were observed for children aged 1-4 years. Diarrhea admissions also fell from 57% of infant hospitalizations in 1980 to 30% in 1990. No such decline was observed in any of the other major causes of death or admissions. The authors explored the impact of oral rehydration therapy (ORT) upon this recent decline in diarrhea mortality in the region. ORT was introduced in the early 1980s, being used in 35% of all episodes in 1991 and in 62% of those regarded as severe by the mother. Socioeconomic conditions worsened during the 1980s, but the levels of water supply, vaccine coverage, breastfeeding duration, and nutritional status increased. A simulation model estimated that changes in factors other than ORT would lead to a 21% reduction in infant diarrhea mortality, or approximately one third of the actual decline. An ecological analysis found ORT use rates to be inversely correlated with infant diarrhea mortality. These findings suggest that the introduction and use of ORT in northeastern Brazil had an important impact upon diarrhea mortality.

[Longitudinal study of the mother and child population in an urban region of southern Brazil, 1993: methodological aspects and preliminary results]. / Estudo longitudinal da população materno-infantil da região urbana do Sul do Brasil, 1993: aspectos metodológicos e resultados preliminares.

All babies born in the hospitals of the city of Pelotas, Brazil, in 1982 were studied soon after delivery and followed up prospectively during the first years of their lives. In 1993, this study was repeated with a similar methodology, with the aim of assessing eventual changes in the level of maternal and child health. All five maternity hospitals in the city were visited daily and the 5,304 babies born included in the study. They were weighed and measured, and their gestational age was assessed using the Dubowitz method. Their mothers were examined and interviewed regarding a large number of risk factors. The mortality of these children was studied through the surveillance of all hospitals, cemeteries and death registries, and all hospital admissions were also recorded. Two nested case-control studies were carried out to assess risk factors for mortality and hospital morbidity. A systematic sample of 655 children were examined at home at one and three months of age, and these infants, as well as another sample of 805 children including all low-birthweight babies were also examined at the ages of six and twelve months. Their psychomotor development was also assessed. Losses to follow-up were only 6.6% at twelve months. Relative to the 1982 indicators, perinatal mortality fell by about 30% and infant mortality by almost 50%. The median duration of breastfeeding increased from 3.1 to 4.0 months. On the other hand, there was little change in the prevalences of low birthweight or of length for age at twelve months. The article that refers this abstract describes the methodology of the study and forthcoming publications will present detailed results.

PIP: All babies born in the hospitals of the city of Pelotas, Brazil, in 1982 were studied soon after delivery and followed up prospectively during the first years of their lives. In 1993 this study was repeated with a similar methodology, with the aim of assessing eventual changes in the level of maternal and child health. All five maternity hospitals in the city were visited daily and the 5304 babies born included in the study. They were weighed and measured, and their gestational age was assessed using the Dubowitz method. Their mothers were examined and interviewed regarding a large number of risk factors. The mortality of these children was studied through the surveillance of all hospitals, cemeteries, and death registries, and all hospital admissions were also recorded. Two nested case-control studies were carried out to assess risk factors for mortality and hospital morbidity. A systematic sample of 655 children was examined at home at 1 and 3 months of age, and these infants, as well as another sample of 805 children including all low-birth-weight babies, were also examined at the ages of 6 and 12 months. Their psychomotor development was also assessed. Losses to follow-up were only 6.6% at 12 months. Relative to the 1982 indicators, perinatal mortality fell by about 30% and infant mortality by almost 50%. The median duration of breast feeding increased from 3.1 to 4.0 months. On the other hand, there was little change in the prevalences of low birth weight or of length for age at 12 months. The methodology of the study is described, and forthcoming publications will present detailed results. (author's modified)

Twenty-four-hour recall overestimates the dietary intake of malnourished children.

Food intake and morbidity are the two main proximal determinants of childhood malnutrition. Intake is usually assessed through the 24-h recall method. Few studies, however, have evaluated the accuracy of this method; in particular, it is not known whether accuracy varies according to the child's nutritional status. The intake of 50 children (< 2 y old), of whom 25 were underweight (weight-for-age more than 2 SD below the National Center for Health Statistics reference), as evaluated through weighing of all foods (gold standard) and through recall. The overall intakes of energy, fat and protein were significantly greater according to the recall method than by weighing. The trend towards overestimation was more marked for malnourished children than for well-nourished children. The possibility of such bias should be taken into account in future studies.

[The use of pacifiers in children: fecal contamination and association with diarrhea]. / Uso de chupeta em crianças: contaminação fecal e associação com diarréia.

A cross-sectional study of 354 children under two years of age was carried out in two periurban slums, with poor sanitary and socioeconomic conditions, located in Pelotas, southern Brazil. Most (79%) of the children studied were current users of pacifiers, 15% had never used one and the remaining 6% were ex-users. Among current users, 38% sucked a pacifier most of the time ("constant users"). Of the pacifiers in constant use, 93% were cultured for evidence of fecal contamination. Fecal coliforms were present in 49% of these. Diarrhoea was reported in 35% of all the children in the two weeks preceding the survey. Among constant pacifiers users, 40% had had diarrhoea in the preceding fortnight; this proportion was 32% for occasional users and 37% for non-users. These differences were not statistically significant.

Use of pacifiers and breastfeeding duration.

Pacifiers are widely used in many developing countries. Although their use is not recommended for breastfeeding infants, there have been no published reports on the association between pacifier use and risk of early weaning. In a study of 354 infants in Brazil, mothers were asked about pacifier use at age 1 month, duration of breastfeeding, and introduction of other foods. Among 249 children still breastfed at 1 month, the risk that a child would be weaned at any age between 1 and 24 months was higher in pacifier users than in non-users (hazard ratio 3.0, 95% CI 2.0-4.6). The association remained even after adjustment for the child's age, sex, birthweight, socioeconomic status, and age at introduction of bottle-feeding.

PIP: Epidemiologists analyze data on 354 children less than 2 years old living in slum areas of Pelotas, Brazil, to determine the relationship between pacifier use and breast feeding duration. By the age of 1 month, 67% of the infants use a pacifier, and at 3 months and older, 80% do. Breast feeding lasts for a median of 3.5 months. By age 1 month, 94% of the children have been given water and/or herbal teas and 27% are fed formula. The 166 pacifier users at 1 month have a greater likelihood of being weaned between 1 and 24 months than are the 83 nonusers (hazard ratio = 3). Further, among the 186 children who are at least 6 months old, nonusers of pacifiers are significantly less likely to be weaned at 6 months than are users of pacifiers (24% vs. 65%; p .001). Among children who use pacifiers, part-time users of pacifiers are significantly less likely to be weaned at 6 months than are full-time users (59% vs. 72%; p .001), suggesting a dose-response relationship. The association between pacifier use and weaning continues even when the researchers adjust for bottle feeding. The only other factor linked with weaning is age of introduction to bottle feeding (hazard ratio for bottle feeding 1 month = 1.6). Infants who use pacifiers at 1 month are 1.3 times more likely to have been treated for diarrhea than nonusers. The mean weight for length z score of pacifier users is much more negative than nonusers (-0.45 vs. -.21; p = .055). Possible explanations for these results are the pacifiers are causally associated with weaning, used as a means to begin weaning, or mark the beginning of breast feeding, pacifier use may decrease nipple stimulation and thereby reduce milk production. Further research is needed to understand the role of pacifiers in weaning, and breast feeding promotion efforts must incorporate the information obtained from such studies.

[Determinants of malnutrition in a low-income population: hierarchical analytical model]. / Determinantes da desnutrição infantil em uma população de baixa renda: um modelo de análise hierarquizado.

To investigate the determinants of malnutrition among low-income children, the effects of socioeconomic, environmental, reproductive, morbidity, child care, birthweight and breastfeeding variables on stunting and wasting were studied. All 354 children below two years of age living in two urban slum areas of Pelotas, southern Brazil, were included. The multivariate analyses took into account the hierarchical structure of the risk factors for each type of deficit. Variables selected as significant on a given level of the model were considered as risk factors, even if their statistical significance was subsequently lost when hierarchically inferior variables were included. The final model for stunting included the variables education and presence of the father, maternal education and employment, birthweight and age. For wasting, the variables selected were the number of household appliances, birth interval, housing conditions, borough, birthweight, age, gender and previous hospitalizations.