Health in Brazil 2 Maternal and child health in Brazil: progress and challenges

In the past three decades, Brazil has undergone rapid changes in major social determinants of health and in the organisation of health services. In this report, we examine how these changes have affected indicators of maternal health, child health, and child nutrition. We use data from vital statistics, population censuses, demographic and health surveys, and published reports. In the past three decades, infant mortality rates have reduced substantially, decreasing by 5.5% a year in the 1980s and 1990s, and by 4.4% a year since 2000 to reach 20 deaths per 1000 livebirths in 2008. Neonatal deaths account for 68% of infant deaths. Stunting prevalence among children younger than 5 years decreased from 37% in 1974-75 to 7% in 2006-07. Regional differences in stunting and child mortality also decreased. Access to most maternal-health and child-health interventions increased sharply to almost universal coverage, and regional and socioeconomic inequalities in access to such interventions were notably reduced. The median duration of breastfeeding increased from 2.5 months in the 1970s to 14 months by 2006-07. Official statistics show stable maternal mortality ratios during the past 10 years, but modelled data indicate a yearly decrease of 4%, a trend which might not have been noticeable in official reports because of improvements in death registration and the increased number of investigations into deaths of women of reproductive age. The reasons behind Brazil`s progress include: socioeconomic and demographic changes (economic growth, reduction in income disparities between the poorest and wealthiest populations, urbanisation, improved education of women, and decreased fertility rates), interventions outside the health sector (a conditional cash transfer programme and improvements in water and sanitation), vertical health programmes in the 1980s (promotion of breastfeeding, oral rehydration, and immunisations), creation of a tax-funded national health service in 1988 (coverage of which expanded to reach the poorest areas of the country through the Family Health Program in the mid-1990s); and implementation of many national and state-wide programmes to improve child health and child nutrition and, to a lesser extent, to promote women`s health. Nevertheless, substantial challenges remain, including overmedicalisation of childbirth (nearly 50% of babies are delivered by caesarean section), maternal deaths caused by illegal abortions, and a high frequency of preterm deliveries.

Outcomes of newborns admitted in the intensive care unit at a public hospital

Background: We evaluated the outcome of newborns admitted in the neonatal Intensive Care Unit (ICU) in Diadema, Brazil. Methods: We evaluated 72 newborns, data were extracted from research forms, newborns` hospital records, mothers interviews, domiciliary inquiry made with the responsible for the newborn care, and paediatric accompaniment cards. Results: 48.93% presented low birth weight, 48% were considered to have normal birth weight and 2% had a birth weight higher than 4000g. Concerning gestational age, 57.44% were younger than 37 weeks old. During hospitalisation, newborn had appointments with doctors from other specialties (inter-appointments), around 40% were cardiologists. After hospital discharge 82.98% were referred to local primary health care units, and the main specialities were cardiology and neurology. Among the newborns evaluated 85.11% were accompanied by paediatric health care units. Conclusion: The implementation of a specialised newborn health accompaniment program in Brazil after ICU discharge is important for positive outcomes regarding newborns growth and development.

The impact of maternal cortisol concentrations on child arterial elasticity

Epidemiological studies suggest that glucocorticoid excess in the fetus may contribute to the pathophysiology of cardiovascular diseases in adulthood. However, the impact of maternal glucocorticoid on the cardiovascular system of the offspring has not been much explored in studies involving humans, especially in childhood. The objective of this study was to assess the influence of maternal cortisol concentrations on child arterial elasticity. One hundred and thirty pregnant women followed from 1997 to 2000, and respective children 5-7 years of age followed from 2004 to 2006 were included in the study. Maternal cortisol was determined in saliva by an enzyme immunoassay utilizing the mean concentration of nine samples of saliva. Arterial elasticity was assessed by the large artery elasticity index (LAEI; the capacitive elasticity of large arteries) by recording radial artery pulse wave, utilizing the equipment HDI/PulseWave CR-2000 Cardiovascular Profiling System (R). The nutritional status of the children was determined by the body mass index (BMI). Insulin concentration was assessed by chemiluminescence, and insulin resistance by the homeostasis model assessment. Blood glucose, total cholesterol and fractions (LDL-c and HDL-c) and triglyceride concentrations were determined by automated enzymatic methods. The association between maternal cortisol and child arterial elasticity was assessed by multivariate linear regression analysis. There was a statistically significant association between maternal cortisol and LAEI (P=0.02), controlling for birth weight, age, BMI and HDL-c of the children. This study suggests that exposure to higher glucocorticoid concentrations in the prenatal period is associated to lower arterial elasticity in childhood, an earlier cardiovascular risk marker.

Perinatal salt restriction: A new pathway to programming adiposity indices in adult female Wistar rats

Low birth weight has been associated with increased obesity in adulthood. It has been shown that dietary salt restriction during intrauterine life induces low birth weight and insulin resistance in adult Wistar rats. The present study had a two-fold objective: to evaluate the effects that low salt intake during pregnancy and lactation has on the amount and distribution of adipose tissue; and to determine whether the phenotypic changes in fat mass in this model are associated with alterations in the activity of the renin-angiotensin system. Maternal salt restriction was found to reduce birth weight in male and female offspring. In adulthood, the female offspring of dams fed the low-salt diet presented higher adiposity indices than those seen in the offspring of dams fed a normal-salt diet. This was attributed to the fact that adipose tissue mass (retroperitoneal but not gonadal, mesenteric or inguinal) was greater in those rats than in the offspring of dams fed a normal diet. The adult offspring of dams fed the low-salt diet, compared to those dams fed a normal-salt diet, presented the following: plasma leptin levels higher in males and lower in females; plasma renin activity higher in males but not in females; and no differences in body weight, mean arterial blood pressure or serum angiotensin-converting enzyme activity. Therefore, low salt intake during pregnancy might lead to the programming of obesity in adult female offspring. (c) 2009 Elsevier Inc. All rights reserved.

Morte neonatal precoce segundo complexidade hospitalar e rede SUS e não-SUS na Região Metropolitana de São Paulo, Brasil

O objetivo foi analisar o perfil dos recém-nascidos, mães e mortalidade neonatal precoce, segundo complexidade do hospital e vínculo com o Sistema Único de Saúde (SUS), na Região Metropolitana de São Paulo, Brasil. Estudo baseado em dados de nascidos vivos, óbitos e cadastro de hospitais. Para obter a tipologia de complexidade e o perfil da clientela, empregaram-se análise fatorial e de clusters. O SUS atende mais recém-nascidos de risco e mães com baixa escolaridade, pré-natal insuficiente e adolescentes. A probabilidade de morte neonatal precoce foi 5,6‰ nascidos vivos (65% maior no SUS), sem diferenças por nível de complexidade do hospital, exceto nos de altíssima (SUS) e média (não-SUS) complexidade. O diferencial de mortalidade neonatal precoce entre as duas redes é menor no grupo de recém-nascidos < 1.500g (22%), entretanto, a taxa é 131% mais elevada no SUS para os recém-nascidos > 2.500g. Há uma concentração de nascimentos de alto risco na rede SUS, contudo a diferença de mortalidade neonatal precoce entre a rede SUS e não-SUS é menor nesse grupo de recém-nascidos. Novos estudos são necessários para compreender melhor a elevada mortalidade de recém-nascidos > 2.500g no SUS.

Ratio of weight to height gain: a useful tool for identifying children at risk of becoming overweight or obese at preschool age

PURPOSE: To analyze the usefulness of the weight gain/height gain ratio from birth to two and three years of age as a predictive risk indicator of excess weight at preschool age. METHODS: The weight and height/length of 409 preschool children at daycare centers were measured according to internationally recommended rules. The weight values and body mass indices of the children were transformed into a z-score per the standard method described by the World Health Organization. The Pearson correlation coefficients (rP) and the linear regressions between the anthropometric parameters and the body mass index z-scores of preschool children were statistically analyzed (alpha = 0.05). RESULTS: The mean age of the study population was 3.2 years (± 0.3 years). The prevalence of excess weight was 28.8%, and the prevalence of overweight and obesity was 8.8%. The correlation coefficients between the body mass index z-scores of the preschool children and the birth weights or body mass indices at birth were low (0.09 and 0.10, respectively). There was a high correlation coefficient (rP = 0.79) between the mean monthly gain of weight and the body mass index z-score of preschool children. A higher coefficient (rP = 0.93) was observed between the ratio of the mean weight gain per height gain (g/cm) and the preschool children body mass index z-score. The coefficients and their differences were statistically significant. CONCLUSION: Regardless of weight or length at birth, the mean ratio between the weight gain per g/cm of height growth from birth presented a strong correlation with the body mass index of preschool children. These results suggest that this ratio may be a good indicator of the risk of excess weight and obesity in preschool-aged children.

Nutritional status of pre-school children from low income families

Background: We evaluated growth and nutritional status of preschool children between 2 and 6 years old from low income families from 14 daycare centers. Methods: Cross-sectional study with 1544 children from daycare centers of Santo Andre, Brazil. Body weight (W), height (H) and body mass index (BMI) were classified according to the 2000 National Center for Health Statistics (CDC/NCHS). Cutoff points for nutritional disorders: -2 z scores and 2.5 and 10 percentiles for malnutrition risk, 85 to 95 percentile for overweight and above BMI 95 percentile for obesity. Stepwise Forward Regression method was used including age, gender, birth weight, breastfeeding duration, age of mother at birth and period of time they attended the daycare center. Results: Children presented mean z scores of H, W and BMI above the median of the CDC/NCHS reference. Girls were taller and heavier than boys, while we observed similar BMI between both genders. The z scores tended to rise with age. A Pearson Coefficient of Correlation of 0.89 for W, 0.93 for H and 0.95 for BMI was documented indicating positive association of age with weight, height and BMI. The frequency of children below -2 z scores was lower than expected: 1.5% for W, 1.75% for H and 0% for BMI, which suggests that there were no malnourished children. The other extremity of the distribution evidenced prevalence of overweight and obesity of 16.8% and 10.8%, respectively. Conclusion: Low income preschool children are in an advanced stage of nutritional transition with a high prevalence of overweight.

Intrauterine Growth Restriction and Zinc Concentrations in Term Infants during the First Month of Life

Objective: We analyzed the influence of IUGR on the concentrations of plasma (Znpl) and erythrocyte (Zne) zinc and on the ratios of Zne to Znpl (Zne:Znpl) and Zne to hemoglobin (Zne:Hb) in term infants during the first month of life. Design: Cohort study. Setting: Tertiary Care Neonatal Unit. Subjects: Exclusively breastfed term newborns (n = 84) were divided into 3 groups: group 1, without IUGR (n = 41), group II. with mild to moderate IUGR (n = 12). and group III, with severe IUGR (n = 31). IUGR was defined as birth weight under the 5th percentile of the Alexander et at curve and as a Kramer Index (KI: ratio of birth weight to estimated weight for each gestational age) <0.85. Severe IUGR was defined as a KI <0.75. Znpl, Zne. and Hb were measured at birth. 3 days, and 1 month of life. Results: Znpl tended to decrease (P = 0.073), Zne and Zne:Znpl increased (P < 0.001), and Hb decreased (P < 0.001) during the first month of life. There was not Znpl, Zne and Zne:Znpl time by group interaction. Zne:Hb increased (P < 0.001) during the first month of life and was lower in Group II at I month of age. Differences between Groups I and If (P = 0.017) and Groups II and III at I month of age (P = 0.011) were detected. Conclusions: Our results suggest that IUGR did not have association with erythrocyte zinc and Zne:Hb ratio at birth. However. neonatal nutrition could have influenced zinc incorporation during this period, through Zne increase.

Lower respiratory tract infections among human immunodeficiency virus-exposed, uninfected infants

Objectives: To evaluate whether maternal HIV disease severity during pregnancy is associated with an increased likelihood of lower respiratory tract infections (LRTIs) in HIV-exposed, uninfected infants. Methods: HIV-exposed, uninfected, singleton, term infants enrolled in the NISDI Perinatal Study, with birth weight >2500 g were followed from birth until 6 months of age. LRTI diagnoses, hospitalizations, and associated factors were assessed. Results: Of 547 infants, 103 (18.8%) experienced 116 episodes of LRTI (incidence = 0.84 LRTIs/100 child-weeks). Most (81%) episodes were bronchiolitis. Forty-nine (9.0%) infants were hospitalized at least once with an LRTI. There were 53 hospitalizations (45.7%) for 116 LRTI episodes. None of these infants were breastfed. The odds of LRTI in infants whose mothers had CD4% <14 at enrollment were 4.4 times those of infants whose mothers had CD4% >= 29 (p = 0.003). The odds of LRTI in infants with a CD4+ count (cells/ mm(3)) <750 at hospital discharge were 16.0 times those of infants with CD4+ >= 750 (p = 0.002). Maternal CD4+ decline and infant hemoglobin at the 6-12 week visit were associated with infant LRTIs after 6-12 weeks and before 6 months of age. Conclusions: Acute bronchiolitis is common and frequently severe among HIV-exposed, uninfected infants aged 6 months or less. Lower maternal and infant CD4+ values were associated with a higher risk of infant LRTIs. Further understanding of the immunological mechanisms of severe LRTIs is needed. (C) 2010 International Society for Infectious Diseases. Published by Elsevier Ltd. All rights reserved.

Qualidade das informações registradas nas declarações de óbito fetal em São Paulo, SP

OBJETIVO: Avaliar a qualidade da informação registrada nas declarações de óbito fetal. MÉTODOS: Estudo documental com 710 óbitos fetais em hospitais de São Paulo, SP, no primeiro semestre de 2008, registrados na base unificada de óbitos da Fundação Sistema Estadual de Análise de Dados e da Secretaria de Estado da Saúde de São Paulo. Foi analisada a completitude das variáveis das declarações de óbito fetal emitidas por hospitais e Serviço de Verificação de Óbitos. Os registros das declarações de óbito de uma amostra de 212 óbitos fetais de hospitais do Sistema Único de Saúde foram comparados com os dados dos prontuários e do registro do Serviço de Verificação de Óbitos. RESULTADOS: Dentre as declarações de óbito, 75% foram emitidas pelo Serviço de Verificação de Óbitos, mais freqüente nos hospitais do Sistema Único de Saúde (78%). A completitude das variáveis das declarações de óbito emitidas pelos hospitais foi mais elevada e foi maior nos hospitais não pertencentes ao Sistema Único de Saúde. Houve maior completitude, concordância e sensibilidade nas declarações de óbito emitidas pelos hospitais. Houve baixa concordância e elevada especificidade para as variáveis relativas às características maternas. Maior registro das variáveis sexo, peso ao nascer e duração da gestação foi observada nas declarações emitidas no Serviço de Verificação de Óbitos. A autópsia não resultou em aprimoramento da indicação das causas de morte: a morte fetal não especificada representou 65,7% e a hipóxia intrauterina, 24,3%, enquanto nas declarações emitidas pelos hospitais foi de 18,1% e 41,7%, respectivamente. CONCLUSÕES: É necessário aprimorar a completitude e a indicação das causas de morte dos óbitos fetais. A elevada proporção de autópsias não melhorou a qualidade da informação e a indicação das causas de morte. A qualidade das informações geradas de autópsias depende do acesso às informações hospitalares.

Peso insuficiente ao nascer e crescimento alcançado na idade pré-escolar, por crianças atendidas em creches filantrópicas do município de Santo André, São Paulo, Brasil

OBJETIVOS: comparar o crescimento alcançado e a prevalência de baixa estatura na idade pré-escolar entre recém-nascidos de peso insuficiente (PNI) e de peso adequado (PNA). MÉTODOS: foram estudadas 323 crianças com PNI e 886 com PNA de famílias de baixa renda de quinze creches filantrópicas de Santo André, São Paulo, Brasil, em 2001 e 2002. As variáveis foram o escore Z de peso e de estatura para a idade, pelo referencial Center for Disease Control (CDC) and National Center for Health Statistics (NCHS) 2000, comparando-se as médias dos dois grupos. Calculou-se a razão de prevalência (RP) de baixa estatura na idade pré-escolar em decorrência do peso insuficiente ao nascer. RESULTADOS: o escore z médio de peso foi -0,09 e 0,39 e o escore z médio de estatura foi de -0,06 e de 0,24 para as crianças de PNI e de PNA, respectivamente. A prevalência de baixa estatura foi de 2,78% para as crianças com PNI e de 0,79% para aquelas com PNA. A RP de baixa estatura na idade pré-escolar para as crianças de PNI foi de 3,5 (IC95% 1,3-9,4). CONCLUSÕES: as crianças com PNI apresentaram crescimento inferior e maior risco de falhas de crescimento até a idade pré-escolar, sugerindo um efeito negativo do peso insuficiente ao nascer sobre o crescimento infantil.

Experimental chronic low-frequency resistance training produces skeletal muscle hypertrophy in the absence of muscle damage and metabolic stress markers

Volitional animal resistance training constitutes an important approach to modeling human resistance training. However, the lack of standardization protocol poses a frequent impediment to the production of skeletal muscle hypertrophy and the study of related physiological variables (i.e., cellular damage/inflammation or metabolic stress). Therefore, the purposes of the present study were: (1) to test whether a long-term and low frequency experimental resistance training program is capable of producing absolute increases in muscle mass; (2) to examine whether cellular damage/inflammation or metabolic stress is involved in the process of hypertrophy. In order to test this hypothesis, animals were assigned to a sedentary control (C, n = 8) or a resistance trained group (RT, n = 7). Trained rats performed 2 exercise sessions per week (16 repetitions per day) during 12 weeks. Our results demonstrated that the resistance training strategy employed was capable of producing absolute mass gain in both soleus and plantaris muscles (12%, p<0.05). Furthermore, muscle tumor necrosis factor (TNF-alpha) protein expression (soleus muscle) was reduced by 24% (p<0.01) in trained group when compared to sedentary one. Finally, serum creatine kinase (CK) activity and serum lactate concentrations were not affected in either group. Such information may have practical applications if reproduced in situations where skeletal muscle hypertrophy is desired but high mechanical stimuli of skeletal muscle and inflammation are not. Copyright (C) 2010 John Wiley & Sons, Ltd.

How rare is too rare to harvest? Management challenges posed by timber species occurring at low densities in the Brazilian Amazon

Tropical forests are characterized by diverse assemblages of plant and animal species compared to temperate forests. Corollary to this general rule is that most tree species, whether valued for timber or not, occur at low densities (<1 adult tree ha(-1)) or may be locally rare. In the Brazilian Amazon, many of the most highly valued timber species occur at extremely low densities yet are intensively harvested with little regard for impacts on population structures and dynamics. These include big-leaf mahogany (Swietenia macrophylla), ipe (Tabebuia serratifolia and Tabebuia impetiginosa), jatoba (Hymenaea courbaril), and freijo cinza (Cordia goeldiana). Brazilian forest regulations prohibit harvests of species that meet the legal definition of rare - fewer than three trees per 100 ha - but treat all species populations exceeding this density threshold equally. In this paper we simulate logging impacts on a group of timber species occurring at low densities that are widely distributed across eastern and southern Amazonia, based on field data collected at four research sites since 1997, asking: under current Brazilian forest legislation, what are the prospects for second harvests on 30-year cutting cycles given observed population structures, growth, and mortality rates? Ecologically `rare` species constitute majorities in commercial species assemblages in all but one of the seven large-scale inventories we analyzed from sites spanning the Amazon (range 49-100% of total commercial species). Although densities of only six of 37 study species populations met the Brazilian legal definition of a rare species, timber stocks of five of the six timber species declined substantially at all sites between first and second harvests in simulations based on legally allowable harvest intensities. Reducing species-level harvest intensity by increasing minimum felling diameters or increasing seed tree retention levels improved prospects for second harvests of those populations with a relatively high proportion of submerchantable stems, but did not dramatically improve projections for populations with relatively flat diameter distributions. We argue that restrictions on logging very low-density timber tree populations, such as the current Brazilian standard, provide inadequate minimum protection for vulnerable species. Population declines, even if reduced-impact logging (RIL) is eventually adopted uniformly, can be anticipated for a large pool of high-value timber species unless harvest intensities are adapted to timber species population ecology, and silvicultural treatments are adopted to remedy poor natural stocking in logged stands. (C) 2008 Elsevier B.V. All rights reserved.

Early neonatal morbidity and mortality in growth-discordant twins

Objective. To evaluate early neonatal morbidity and mortality in twin pregnancies with growth discordance. Design. Retrospective study. Setting. Tertiary teaching hospital, Sao Paulo, Brazil. Population. A total of 151 twin pregnancies managed and delivered at the Multiple Pregnancy Unit at Sao Paulo University Hospital between 1998 and 2004. Methods. Comparison between twin pregnancies with weight discordance 20% and pregnancies concordant for fetal weight. Cases with fetal death, abnormalities, twin-to-twin transfusion and delivery before 26 weeks or in another hospital were excluded. Outcome measures. Early neonatal morbidity (Apgar at 5 minutes 7, respiratory or neurological complications, infection, necrotizing enterocolitis, length of hospital stay) and mortality. Results. Forty (26.5%) pregnancies presented discordance 20% and 111 (73.5%) were concordant. In the discordant group, 75% of pregnancies had at least one growth restricted fetus (10th centile). In concordant twin pregnancies, monochorionic cases (22.5%) presented with lower gestational age (34.3 vs. 36.2 weeks), lower birthweight (2,067 vs. 2,334 g) and a longer period of hospital stay (5.5 vs. 3.0) compared to dichorionic concordant twins. No differences between monochorionic and dichorionic subgroups were observed in discordant twins. Pregnancies in which at least one baby was born with a birthweight below the 10th centile showed that discordant pregnancies had a lower gestational age at delivery (35.2 vs. 36.8 weeks) and a longer period of hospital stay (9 vs. 4 weeks) compared to concordant cases. Neonatal mortality was similar in discordant (3.7%) and concordant (4.5%) twins. Conclusion. Early perinatal morbidity is increased in twin pregnancies with birthweight discordance 20% only when associated with fetal growth restriction and low birthweight.

Obstetric Outcome in Pregnant Women on Long-term Dialysis: A Case Series

Background: Although still uncommon, pregnancy frequency in women on maintenance hemodialysis therapy has increased in the past 20 years. Most published reports suggest that intensified hemodialysis regimens result in better pregnancy outcomes. The small number of patients investigated in all reported series is the main limitation of the available studies. Study Design: Retrospective case series. Setting & Participants: Data for all pregnancies that occurred in 1988-2008 in women undergoing maintenance hemodialysis (52 pregnancies) at the Sao Paulo University Medical School (Sao Paulo, Brazil). Outcomes & Measurements: We analyzed maternal and fetal outcomes of 52 pregnancies, as well as their relationship with various clinical, laboratory, and hemodialysis parameters, such as pre-eclampsia, pregnancy before or after dialysis therapy, hemodialysis dose, polyhydramnios, anemia, and predialysis serum urea level. In addition, logistic regression models for a composite adverse fetal outcome (perinatal death or extremely premature delivery) and linear regression models for birth weight were built. Results: 87% overall rate of successful delivery, with a mean gestational age of 32.7 +/- 3.1 weeks. Pre-eclampsia was associated with a poor prognosis compared with pregnancies without pre-eclampsia: a successful delivery rate of 60% versus 92.9% (P = 0.02), extremely premature delivery rate of 77.8% versus 3.3% (P = 0.001), lower gestational age (P = 0.001), and birth weight (P = 0.001). Patients with an adverse composite fetal outcome had a higher frequency of pre-eclampsia (P = 0.001), lower frequency of polyhydramnios (P = 0.03), lower third-trimester hematocrit (P = 0.03), and higher predialysis serum urea level (P = 0.03). The same results were seen for birth weight. Limitations: Retrospective data analysis. The absence of creatinine clearance measurements did not allow evaluation of the impact of residual renal function on fetal outcome. Conclusions: Outcomes of pregnancy in women undergoing hemodialysis often are good. Preeclampsia, third-trimester hematocrit, polyhydramnios, and predialysis serum urea level are important variables associated with fetal outcome and birth weight. Am J Kidney Dis 56:77-85. (C) 2010 by the National Kidney Foundation, Inc.Inc