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Introduction The global coronavirus disease 2019 (COVID-19) pandemic caused by the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus began in Wuhan, China, in December 2019, and it has affected over 4.4 million people worldwide, with 302,169 deaths as of May 16, 2020. 1 Though respiratory symptoms are the most common presentation of COVID-19, cardiac involvement is a prominent feature of this disease, occurring in 20% to 30% of hospitalized patients and contributing to 40% of deaths. 2-4 COVID-19-related [...]

OBJECTIVES Undernourished children with cancer are at major risk for adverse outcomes. We intended to model nutritional status as risk factor for hospital death. METHODS Retrospective analysis of two cohorts of children admitted in an oncology/hematology intensive care unit. Logistic regression was used for model building. RESULTS The derivation cohort had 155 patients, with a median age of 104.9 mo., and 36 deaths (23.2%). Twenty-eight children (18.1%) had the z score of the body mass index < -2. A multivariate model with the variables "relapse of oncological disease" (Odds Ratio 3.14, P = 0.025), "surgical case" (OR 0.22, P = 0.002), "intubation/mechanical ventilation" (OR 8.38, P = 0.000) and "body mass index z score < -2" (OR 3.21, P = 0.024) generated a logit with good predictive capacity for "hospital death". In the validation cohort, with 450 patients (median age of 92.7 mo.), the model was able to predict 55.5 of the 58 observed deaths (Standardized Mortality Rate = 1.04, 95% CI 0.80-1.34, P = 0.72), with P = 0.68 in the Hosmer test. The AUC was 0.90 (95% CI 0.86-0.93). CONCLUSION Undernutrition increases the risk of death, and is a variable that should be included in predictive mortality algorithms.

RESUMO Objetivo: Avaliar a prevalência e identificar os fatores associados ao ganho de peso rápido em pré-escolares. Métodos: Estudo transversal realizado entre fevereiro e dezembro de 2014, com 136 crianças entre 24 e 35 meses de idade frequentadoras de creches públicas do município de Mogi das Cruzes. Foram realizadas entrevistas com as mães para caracterização clínica, sociodemográfica e antropometria das crianças. Considerou-se ganho de peso rápido quando as crianças apresentaram diferença superior a 0,67 entre o escore Z de peso para idade do nascimento à avaliação. Foi ajustado modelo de regressão logística para fatores associados ao ganho de peso rápido. Resultados: Do total de crianças avaliadas, 50 (36,8%) apresentaram ganho de peso rápido e 36 (26,5%) excesso de peso. Destas, 22 crianças eram do grupo ganho de peso rápido. O maior tempo total do aleitamento materno (OR 0,94, IC95% 0,88-0,99; p=0,031) foi identificado como fator de proteção e o baixo nível socioeconômico (OR 4,18, IC95% 1,04-18,60; p=0,044), como fator de risco para ganho de peso rápido. Conclusões: Encontrou-se alta prevalência de ganho de peso rápido e de excesso de peso entre pré-escolares no terceiro ano de vida frequentadores de creches públicas. Incentivar a prática do aleitamento materno de crianças nos primeiros anos de vida e orientar a alimentação adequada, principalmente nas famílias de baixo nível socioeconômico, contribui potencialmente para a redução do ganho de peso rápido e, consequentemente, de futuras complicações metabólicas do excesso de peso. ABSTRACT Objective: To evaluate the prevalence, and identify factors associated with rapid weight gain in preschool children. Methods: A cross sectional study was carried out with 136 children between 24 and 35 months of age attending public daycare centers in Mogi das Cruzes between February and December 2014. Interviews were conducted with the mothers for clinical, sociodemographic and anthropometric characterizations of the children. It was considered to be rapid weight gain when the children presented a difference greater than 0.67 between the weight for age Z score from birth to evaluation. A logistic regression model was adjusted for factors associated with rapid weight gain. Results: Fifty children (36.8%) presented rapid weight gain and 36 (26.5%) were overweight. Of these, 22 children were in the rapid weight gain group. The logistic model showed that longest total breastfeeding time (OR 0.94, 95%CI 0.88-0.99; p=0.031) was a protection factor, and low socioeconomic level (OR 4.18, 95%CI 1.04-18.60; p=0.044) was a risk factor for rapid weight gain. Conclusions: There was a high prevalence of rapid weight gain and being overweight among three year old preschoolers attending public day care centers in Brazil. Encouraging the practice of breastfeeding children in the first years of life, in addition to giving guidance about appropriate foods, especially for families with a low socioeconomic status, can potentially contribute to reduce rapid weight gain and, consequently, future metabolic complications of being overweight.

INTRODUCTION HIV-exposed, uninfected (HEU) infants are potentially at risk for cardiovascular disease due to in utero exposures. Feeding practices of the infant could compound this risk. Few studies have, however, evaluated dietary intake of HEU infants. We determined dietary factors associated with rapid weight gain (RWG) among HEU infants from birth to 6 months followed at the University of Miami HIV Screening Program. METHODS In this cross-sectional analysis, logistic regression was used to determine dietary factors associated with RWG defined as a >0.67 SD change in weight-for-age z score from birth to assessment (0.3-6 months). Other covariates included demographics, birth, maternal and gestational characteristics, and antiretroviral exposures. RESULTS A total of 86 full-term HEU infants with a mean age of 3.4 months (SD 1.8 months) were included in this analysis. Fifty-five percent of mothers were obese. Overall, 39.5% of infants exhibited RWG. A significant association between consumption of infant cereal and RWG (odds ratio, 3.52; 95% confidence interval, 1.02-12.10) was found after adjusting for birth weight, current age, and energy intake. Those infants who consumed the highest tertile of protein were less likely to gain weight rapidly after adjusting for the same covariates (odds ratio, 0.15; 95% confidence interval, 0.02-0.94). CONCLUSIONS Overall differences in weight gain during early infancy are at least partly explained by means of infant feeding in young HEU infants in the United States. Dietary counseling for families of HEU should reinforce current feeding practice recommendations of the American Academy of Pediatrics.

1 Division of Nutrology, Departament of Pediatrics, Escola Paulista de Medicina, Universidade Federal de Sao Paulo (UNIFESP/EPM), 04040-032, Sao Paulo, SP, Brazil. Division of Pediatric Infectious Diseases, Departament of Pediatrics, Escola Paulista de Medicina, Universidade Federal de Sao Paulo (UNIFESP/EPM), 04040-003 Sao Paulo, SP, Brazil. Division of Rheumatology, Department of Medicine, Escola Paulista de Medicina, Universidade Federal de Sao Paulo (UNIFESP/EPM), 04023-900, Sao Paulo, Brazil.

To evaluate the prevalence, and identify factors associated with rapid weight gain in preschool children.A cross sectional study was carried out with 136 children between 24 and 35 months of age attending public daycare centers in Mogi das Cruzes between February and December 2014. Interviews were conducted with the mothers for clinical, sociodemographic and anthropometric characterizations of the children. It was considered to be rapid weight gain when the children presented a difference greater than 0.67 between the weight for age Z score from birth to evaluation. A logistic regression model was adjusted for factors associated with rapid weight gain.Fifty children (36.8%) presented rapid weight gain and 36 (26.5%) were overweight. Of these, 22 children were in the rapid weight gain group. The logistic model showed that longest total breastfeeding time (OR 0.94, 95%CI 0.88-0.99; p=0.031) was a protection factor, and low socioeconomic level (OR 4.18, 95%CI 1.04-18.60; p=0.044) was a risk factor for rapid weight gain.There was a high prevalence of rapid weight gain and being overweight among three year old preschoolers attending public day care centers in Brazil. Encouraging the practice of breastfeeding children in the first years of life, in addition to giving guidance about appropriate foods, especially for families with a low socioeconomic status, can potentially contribute to reduce rapid weight gain and, consequently, future metabolic complications of being overweight.Avaliar a prevalência e identificar os fatores associados ao ganho de peso rápido em pré-escolares.Estudo transversal realizado entre fevereiro e dezembro de 2014, com 136 crianças entre 24 e 35 meses de idade frequentadoras de creches públicas do município de Mogi das Cruzes. Foram realizadas entrevistas com as mães para caracterização clínica, sociodemográfica e antropometria das crianças. Considerou-se ganho de peso rápido quando as crianças apresentaram diferença superior a 0,67 entre o escore Z de peso para idade do nascimento à avaliação. Foi ajustado modelo de regressão logística para fatores associados ao ganho de peso rápido.Do total de crianças avaliadas, 50 (36,8%) apresentaram ganho de peso rápido e 36 (26,5%) excesso de peso. Destas, 22 crianças eram do grupo ganho de peso rápido. O maior tempo total do aleitamento materno (OR 0,94, IC95% 0,88-0,99; p=0,031) foi identificado como fator de proteção e o baixo nível socioeconômico (OR 4,18, IC95% 1,04-18,60; p=0,044), como fator de risco para ganho de peso rápido.Encontrou-se alta prevalência de ganho de peso rápido e de excesso de peso entre pré-escolares no terceiro ano de vida frequentadores de creches públicas. Incentivar a prática do aleitamento materno de crianças nos primeiros anos de vida e orientar a alimentação adequada, principalmente nas famílias de baixo nível socioeconômico, contribui potencialmente para a redução do ganho de peso rápido e, consequentemente, de futuras complicações metabólicas do excesso de peso.

Objective The objective of the study was to assess the nutritional status and metabolic alterations in HIV-exposed uninfected (HIVe) children compared with HIV-unexposed (HIVn) children. Methods A cross-sectional study was carried out with 76 children distributed into two groups: HIVe (n = 31) and HIVn (n = 45). Biochemical data (hematologic test, lipid profile, insulin resistance, hepatic profile, and C-reactive protein) were evaluated. Anthropometric parameters and body composition analyses were performed. Results The groups were similar regarding body mass index-for-age z-scores ( P = 0.297) and height-for-age z-scores ( P = 0.666). HIVe had a higher dyslipidemia prevalence (38.7% versus 11.1%; P = 0.010), altered total cholesterol (TC) values (19.4% versus 2.2%; P = 0.016) higher LDL-C mean levels (97.8 mg/dl versus 86 mg/dl; P = 0.028), borderline low-density lipoprotein cholesterol (LDL-C) (40% versus 14%; P = 0.011) and TC (41.9% versus 20%; P = 0.038) compared with HIVn. Conclusion Despite the similar nutritional status between groups, our data clearly demonstrated a higher prevalence of dyslipidemia, altered TC, higher LDL-C levels and also LDL-C and TC borderline values in HIVe children.

The aim of this study was to compare bioelectrical impedance analysis (BIA) equations developed for healthy pediatric populations and for HIV-infected children using dual-energy X-ray absorptiometry (DXA) as the gold standard.A cross-sectional study was carried out with 40 prepubertal, HIV-infected children who regularly attended the Pediatric Infectious Disease Clinic at the Universidade Federal de São Paulo, São Paulo, Brazil. The study was conducted from August to November 2008. Demographic data, clinical parameters, immunological status, and use of antiretroviral therapy were obtained from the patients' medical records. We performed anthropometric parameters and body composition analyses, analyzed body composition by BIA and DXA, and compared the results obtained from BIA through using equations for both healthy and HIV-infected populations.The mean ± SD age of the study population was 9.8 ± 1.2 years. Half of the population were females, and 82.5% of the children were clinically classified as B and C. Total body fat, by both absolute mass and by percentage, exhibited high homogeneity between the results obtained from BIA and DXA. However, there was no concordance in fat-free mass. The equation for healthy children showed good sensitivity and specificity when comparing the percentage of total body fat measured by DXA.BIA provides reliable data on total body fat but not fat-free mass when compared with DXA. The BIA equation developed for healthy pediatric populations can be used to determine total body fat in HIV-infected children.

OBJETIVO: Avaliar esteatose hepatica pelo metodo de ultrassom como fator de risco concomitante entre adolescentes com sobrepeso. METODOS: Estudo de caso-controle incluindo 83 casos (47 com sobrepeso e 36 obesos) e 89 controles (peso normal), frequencia pareada por genero, ano de nascimento, estagio pubertario (Tanner 4/5) e renda. Casos e controles foram selecionados de 1.420 alunos matriculados em uma escola publica de ensino medio na Vila Mariana, Sao Paulo. Os criterios de Must et al. foram usados para classificacao do estado nutricional. A doenca hepatica gordurosa nao-alcoolica foi diagnosticada por meio de ultrassonografia realizada e analisada por um radiologista. Foram medidas atividades enzimaticas hepaticas (alanina e aspartato transaminases, fosfatase alcalina, gama-glutamil transpeptidase) e bilirrubina direta. Oito co-variaveis foram inseridas em modelos de regressao logistica; o criterio de inclusao de variaveis foi a associacao com sobrepeso nas analises bivariadas (p 24 U/L foram 10,77 (2,45-47,22) e 4,18 (1,46-11,94), respectivamente. CONCLUSOES: Este e o primeiro estudo populacional mostrando que a esteatose hepatica tem forte associacao com sobrepeso/obesidade entre adolescentes matriculados em uma escola publica brasileira. A ferramenta de diagnostico usada nesta investigacao e um metodo nao-invasivo que poderia ser aplicado para monitorar adolescentes com sobrepeso e obesos e propor acoes para prevenir doencas hepaticas mais graves na fase adulta.

Objective: To discuss risk factors of atherosclerosis in pediatrics, dietary and physical activity guidelines, and, mainly, drug treatment of high-risk lipid abnormalities. Sources : Data were obtained from articles indexed in MEDLINE, published over the last 5 years. Summary of the findings : Children with severe dyslipidemia or additional risk factors such as family history of early cardiovascular disease or other signs of metabolic syndrome may need treatment with hypolipidemic drugs. New recommendations from the U.S. guidelines indicate drug treatment before the age of 10 years according to the magnitude of the additional risk factors for cardiovascular disease. Pediatricians should know when to diagnose dyslipidemia, when to indicate drug treatment and which medication can be used in children and adolescents with the least risk or harm to their development. Conclusions: The first-line treatment of dyslipidemia consists of lifestyle changes, focusing on prevention. Children with high-risk lipid abnormalities should be considered for drug treatment. Decisions to be made together with the parents must be evaluated taking into consideration risks and benefits of the medication to the patient.

OBJETIVO: Avaliar o estado nutricional e os níveis hematológicos e séricos de ferro em pré-escolares de municípios com diferentes índices de desenvolvimento infantil (IDI). MÉTODOS: Estudo transversal de 34 pré-escolares com idade de três a seis anos do município de Laranjal, Paraná, com IDI baixo e com o mesmo número de crianças pareadas por idade e gênero, provenientes de Presidente Prudente, São Paulo, município com IDI médio. Avaliou-se o estado nutricional por meio do escore Z das relações peso/estatura e estatura/idade. A avaliação bioquímica constou de dosagens de hemoglobina, hematócrito, ferro sérico e ferritina. Para a análise estatística foram usados os testes t de Student, Mann-Whitney, qui-quadrado e o exato de Fisher. RESULTADOS: Peso, estatura e escore Z das relações antropométricas foram significantemente menores no grupo de crianças de Laranjal comparados aos de Presidente Prudente. A prevalência de anemia em ambos os grupos foi 8,8%, não havendo diferença significante para a prevalência de ferropenia e para os valores de ferritina sérica. CONCLUSÕES: Pré-escolares do município com IDI baixo apresentam mais desnutrição, enquanto sobrepeso e obesidade são predominantes nos pré-escolares do município com IDI médio. Quanto às alterações dos níveis hematológicos e séricos de ferro, não há diferença entre os pré-escolares dos municípios estudados. OBJECTIVE: To evaluate nutritional status and iron hematological and serum levels of preschool children from cities with different child development indexes (CDI). METHODS: This cross-sectional study enrolled 34 preschool children aged between three to six years from two municipalities of Brazil: Laranjal, Paraná, with a low CDI, and Presidente Prudente, São Paulo, with a medium CDI. Children of both cities were matched by age and gender. The nutritional status was evaluated by Z score for weight/height and height/age. The biochemical evaluation included hemoglobin, hematocrit, seric iron and ferritin levels. The following tests were used for statistical analysis: t test, Mann-Whitney, chi-square and Fisher's exact test. RESULTS: The weight, height and Z score of the anthropometric relationships were significantly lower in the group of Laranjal children. Anemia was present in 8.8% of the children studied in both cities, without significant differences in the prevalence of iron deficiency or in the ferritin levels. CONCLUSIONS: The preschool children from the city with low CDI presented mainly malnutrition, while overweight and obesity were more prevalent on preschool children from the city with a medium CDI. Hematimetric values, iron and ferritin levels were similar between the preschool children of both cities. Universidade Federal de São Paulo (UNIFESP) UNIFESP Universidade Federal de São Paulo, EPM, São Paulo, Brazil SciELO

We evaluated the role of an interdisciplinary team in improving the nutrient intake and nutritional status of children with heart diseases.Thirty-five children 10.0 +/- 7.5 mo old were studied over a 6-mo period with regard to anthropometric measurements and dietary intake.On admission, malnutrition prevalence was 57% and vitamin and mineral intakes were below estimated average requirement levels (dietary reference intakes) in the majority of patients. Stunting and wasting were more frequent among patients with pulmonary hypertension and/or uncompensated congestive heart failure. Follow-up analyses showed increased Z scores of weight for height (-1.17 +/- 1.03 versus -0.32 +/- 1.08, P0.01) and height for age (-1.09 +/- 0.96 versus -0.51 +/- 1.36, P0.01). In patients with pulmonary hypertension or uncompensated congestive heart failure, the height-for-age index remained unchanged. Energy intake did not differ (112.0 +/- 20.4 and 119.0 +/- 18.0 kcal.kg(-1).d(-1)) and significant increases were seen in intakes of micronutrients and minerals over the study period.Intervention by an interdisciplinary team improved the nutrient intake and nutritional status of patients overall but was insufficient to improve growth in the subgroup with pulmonary hypertension or uncompensated congestive heart failure. Nutritional support should be made routine in the treatment of children with heart disease.

Objective: To evaluate bone mass accrual and determine the influence of clinical, anthropometric, dietary and biochemical parameters on bone mass. Methods: A cohort study including 35 prepubertal HIV-infected children, between 7 and 12 years, attended at a referral center. At time 1 (T1) and time 2 (T2), patients were assessed according to clinical, anthropometric, dietary, biochemical parameters and bone mineral density (BMD). At T2, patients were divided into prepubertal and pubertal. Results: Despite the increase in bone mass absolute values, there was no improvement in lumbar spine BMD (LSBMD) Z-score (p = 0.512) and worsening in total body BMD (TBMD) Z-score (p = 0.040). Pubertal patients (n = 19) showed higher bone mineral content (BMC) (p = 0.001), TBMD (p = 0.006) and LSBMD (p = 0.002) compared to prepubertal patients. After multivariate linear regression analysis, the predictors of bone mass in T1 were age, BMI and HA Z-scores for BMC; BMI Z-score, adequate serum magnesium concentration and dietary calcium intake for TBMD; adequate serum concentration of magnesium, BMI and HA Z-scores for LSBMD. In T2, age, total body fat and lean body mass (kg) for BMC; BMI Z-score and puberty for TBMD; dietary fat intake, BMI Z-score for BMD and puberty for LSBMD. Conclusion: HIV-infected children have compromised bone mass and the presence of puberty seems to provide suitability of these parameters. Adequate intake of calcium and fat appears to be protective for proper bone mass accumulation factor, as well as monitoring nutritional status and serum magnesium concentration. Keywords: HIV, Child, Body composition, Bone mineral density

OBJETIVOS: Este estudo teve como finalidade avaliar a evolução nutricional de crianças hospitalizadas com doenças infecciosas, que estiveram sob acompanhamento nutricional. MÉTODOS: Foram estudadas 125 crianças com idade de 6 a 36 meses de vida, admitidas na enfermaria de infectologia pediátrica do Hospital São Paulo, durante o período de Março de 2001 a Dezembro de 2002. As avaliações do estado nutricional e da ingestão energética basearam-se nos dados obtidos em inquéritos alimentares e medições antropométricas. RESULTADOS: Das crianças avaliadas, 67 eram do sexo masculino (53,6%); a mediana de idade foi 17 meses e o tempo médio de internação, dez dias. Na época da admissão, 24,8% das crianças estavam desnutridas enquanto 10,0% delas apresentavam sobrepeso e obesidade. Prevaleceu o diagnóstico de doenças agudas (69,6%). Realizaram terapia nutricional 21,6% das crianças, sendo que destas, 81,5% receberam terapia nutricional via oral. O grupo de desnutridos teve melhora significativa do escore-Z de peso para estatura-Z peso/estatura (p=0,001); o grupo de eutróficos não teve alteração significativa de escore-Z peso/estatura (p=0,651) e o grupo com sobrepeso/obesos teve redução significativa do escore-Z peso/estatura (p=0,026). Não houve associação significativa entre realização de terapia nutricional e melhora do estado nutricional (p=0,37). A melhora doescore-Z peso/estatura esteve relacionada à ingestão de energia maior que a recomendação normal para a idade (p

OBJETIVO: Avaliar a evolução antropométrica, terapia nutricional e mortalidade de crianças desnutridas hospitalizadas em centro de referência. MÉTODOS: Em estudo retrospectivo, avaliou-se 98 prontuários de crianças desnutridas (ZPIAIM:To study anthropometric development, nutritional support and mortality rate of malnourished children hospitalized in a referral center METHODS: In a retrospective study we surveyed 98 hospitalized malnourished children (ZW

Objective: To assess the nutritional status of child and adolescent patients with cancer at diagnosis. Methods: A total of 1154 patients were included and divided into two groups: solid and hematological malignancies. The parameters used for nutritional assessment were weight, height, triceps skinfold thickness, mid-upper arm circumference, arm muscle circumference, body mass index and percentage weight loss. Results: At diagnosis, below adequate body mass index was observed by anthropometric analysis in 10.85% of the patients – 12.2% in the solid tumor group and 9.52% in the hematologic group. The average weight loss adjusted for a period of 7 days was −2.82% in the hematologic group and −2.9% in the solid tumor group. Conclusions: The prevalence of malnutrition is higher among patients with malignancies than in the general population, even though no difference was observed between the two groups.

Objective: This study aims to assess the nutritional status of selenium, copper and zinc; and also the erythrocyte superoxide dismutase activity of HIV-infected children compared to a control group. Methods: A cross-sectional study was carried out with prepubertal HIV-infected children (n = 51) and their healthy siblings (n = 32). All biochemical measurements including plasma selenium, serum copper levels, serum and erythrocyte zinc levels and erythrocyte superoxide dismutase activity were evaluated according to dietary, clinical and biochemical parameters. Results: Compared to the control group, the HIV-infected children had lower z-score values for height-for-age (p = 0.0006), higher prevalence of stunting (11.8%) (p = 0.047), lower selenium levels (p = 0.0006) and higher copper levels (p = 0.019). No difference was found concerning superoxide dismutase activity (p > 0.05). The HIV-infected group presented a higher proportion (45.1%) of children with zinc intakes below the estimated average requirement (p = 0.014); however, no association with zinc biochemical parameters was found. Conclusion: HIV-infected children have an inadequate selenium and copper nutritional status, which could influence the progression to AIDS. An adequate micronutrient status could improve the clinical conditions in these patients and minimize free radical production and cellular oxidative stress. Keywords: Antioxidants, HIV and nutrition, Oxidative stress, Trace elements

OBJETIVO: Revisar os potenciais efeitos antioxidantes das vitaminas A, C e E na prevenção do desenvolvimento da arteriosclerose na infância, com ênfase na prevenção da dislipidemia. FONTES DE DADOS: Pesquisa bibliográfica em revistas científicas, livros técnicos e publicações de órgãos oficiais dos últimos 20 anos. Utilizaram-se as bases de dados Lilacs, SciELo e Medline em português, inglês e espanhol, com as palavras-chave: "antioxidantes", "arteriosclerose", "dislipidemias", "peroxidação de lipídeos", "infância", "vitamina A", "vitamina C" e "vitamina E". SÍNTESE DE DADOS: A prevalência de dislipidemia na infância e na adolescência mostra frequência crescente, provavelmente relacionada às mudanças dos hábitos alimentares e à redução na prática de atividades físicas. O elevado nível plasmático da lipoproteína de baixa densidade (LDL-c) é fator de risco para o desenvolvimento da arteriosclerose. O consumo de frutas, verduras e legumes, ricos em antioxidantes, é um dos fatores de maior importância na prevenção da peroxidação lipídica. A baixa ingestão dessas fontes naturais de antioxidantes sugere a necessidade de intervenção nutricional para atingir as metas diárias de consumo de vitaminas A, C e E, não sendo preconizada a sua suplementação medicamentosa. CONCLUSÕES: O pediatra e o nutricionista devem orientar as famílias sobre o consumo de alimentos saudáveis, principalmente frutas, verduras e legumes, por seu potencial efeito antioxidante, especialmente nos primeiros anos de vida. OBJECTIVE: To review the potential antioxidant effects of vitamins A, C and E in the prevention of atherosclerosis development during childhood, emphasizing the prevention of dyslipidemia. DATA SOURCES: Bibliographic search in scientific journals, technical books and official publications of the last 20 years. Lilacs, SciElo and Medline databases were searched for articles in Portuguese, Spanish and English using a combination of the following terms: "antioxidants", "atherosclerosis", "dyslipidemia", "lipid peroxidation", "childhood", "vitamin A", "vitamin C" and "vitamin E". DATA SYNTHESIS: There is an increasing prevalence of dyslipidemia in children and adolescents, probably related to changes in dietary habits and to the reduced practice of physical activities. The high plasma concentration of low-density lipoprotein (LDL-c) is a risk factor for atherosclerosis development. The consumption of nutrients rich in antioxidants, such as fruits and vegetables, is very important to prevent lipid peroxidation. The low intake of these natural antioxidants sources suggests the need for nutritional intervention to achieve the daily ingestion targets of vitamins A, C and E. Vitamin supplementation is not recommended. CONCLUSIONS: Children should be encouraged to increase ingestion of fruits and vegetables due to their potential antioxidant effect, especially in the first years of life.

OBJETIVOS: Apresentar a conduta para o tratamento da desnutrição energético-proteica grave e os principais aspectos fisiopatológicos da doença. FONTES DE DADOS: Tomando como base o Manual da Organização Mundial da Saúde (OMS, 1999), realizou-se uma busca por trabalhos publicados em inglês, espanhol e português sobre o tratamento hospitalar de crianças com desnutrição grave, nas bases de dados Lilacs, Medline e SciELO, publicados nos últimos dez anos, utilizando-se as palavras-chave: desnutrição, criança, hospitalização, terapia nutricional, diretrizes, OMS. SÍNTESE DE DADOS: Foram abordadas as principais características fisiopatológicas da desnutrição grave e a conduta recomendada para o tratamento. Identificaram-se as principais complicações clínico-metabólicas, como a hipotermia, a hipoglicemia, a desidratação e as infecções recorrentes, além da má absorção e a fase de estabilização ou de recuperação do desnutrido grave. A compreensão de todos esses conceitos relacionados à fisiopatologia da desnutrição energético-proteica, associada ao adequado planejamento e execução da terapia nutricional, pode reduzir o risco de morbimortalidade em crianças com idade inferior a cinco anos. CONCLUSÕES: As diretrizes da OMS devem ser implantadas levando-se em consideração a realidade de cada região e a capacitação do profissional da saúde quanto ao conhecimento da complexidade e fisiopatologia da desnutrição energético-proteica grave, para adequado diagnóstico e tratamento. O sucesso do tratamento está associado ao cuidado e à atenção ao paciente. OBJECTIVE: To identify the main physiopathological aspects of severe protein-energy malnutrition and its treatment. DATA SOURCE: Based on the World Health Organization guidelines (WHO, 1999), an electronic search for papers on hospital treatment of children with severe malnutrition was performed on Lilacs, Medline and SciELO databases. Studies in English, Spanish and Portuguese published in the last ten years were searched by the following key-words: malnutrition, child, hospitalization, nutrition therapy, practice guidelines, WHO. DATA SYNTHESIS: The main pathological aspects of severe malnutrition and its specific treatment were reviewed. The main clinical and metabolic complications of severe malnutrition were identified such as hypothermia, hypoglycemia, dehydration, usual infections, intestinal malabsorption, as well as stabilization and recovery phases, were defined. Understanding the main concepts of the physiopathology of this condition, associated with appropriate nutrition support planning, can decrease morbidity and mortality risks of children younger than five years old. CONCLUSIONS: The implementation of the 1999 WHO guidelines should take into consideration local economic and cultural aspects, as well as the professional health care training. Due to the complexity of severe malnutrition, adequate knowledge about basic aspects of this condition helps providing adequate diagnosis and treatment. UNIFESP UNIFESP SciELO

FUNDAMENTO: O excesso de peso na adolescência é fator de risco para o desenvolvimento de doenças cardiovasculares na vida adulta. OBJETIVO: Estudar a associação dos fatores de risco cardiovascular (FRC) em adolescentes com excesso de peso e eutróficos, de ambos os sexos, de 14 a 19 anos em escolas públicas. MÉTODOS: Estudo caso-controle com 163 adolescentes com excesso de peso e 151 eutróficos. Análise de regressão logística múltipla foi utilizada para avaliar as associações entre excesso de peso e os FRC (perfil lipídico, pressão arterial e insulina basal). Um conjunto de FRC foi definido para cada indivíduo, variando de 0 (nenhuma das condições) até 6 (presença de todas essas condições). RESULTADOS: Adolescentes com excesso de peso (índice de massa corporal > percentil 85) apresentaram maiores frequências dos FRC quando comparados ao grupo de eutróficos. Os FRC associados ao excesso de peso foram HDLc < 35 mg/dl (OR = 3,41; IC: 1,24-9,38), triglicérides > 150 mg/dl (OR = 3,04; IC: 1,01-9,13), insulina basal alterada > 15 µU/ml (OR = 8,65; IC: 4,03-18,56) e pressão arterial alterada (OR = 3,69; IC: 1,76-7,72). Entre os adolescentes com excesso de peso, 22,09% tinham mais do que três fatores de risco, enquanto que entre os eutróficos, este percentual foi de 6,12%. CONCLUSÃO: Adolescentes com excesso de peso apresentaram fatores de risco para doenças cardiovasculares. Ressalta-se a necessidade de programas e políticas de diagnóstico e de tratamento, a fim de reduzir os riscos de morbimortalidade na idade adulta. BACKGROUND: Overweight in adolescence is a risk factor for the development of cardiovascular diseases in adulthood. OBJECTIVE: To study the association of cardiovascular risk factors (CRF) in overweight and normal-weight adolescents of both genders aged from 14 to 19 years, attending public schools. METHODS: Case-control study including 163 overweight and 151 normal-weight adolescents. Multiple logistic regression analysis was used to evaluate the associations between overweight and CRF (lipid profile, blood pressure and baseline insulin level). A set of CRF was defined for each individual, ranging from 0 (no risk factors) to 6 (all risk factors present). RESULTS: Overweight adolescents (body mass index > 85th percentile) presented a higher frequency of CRF in comparison to the normal- weight group. The CRF associated with overweight were HDLc < 35 mg/dl (OR = 3.41; CI: 1.24-9.38), triglycerides > 150 mg/dl (OR = 3.04; CI: 1.01-9.13), abnormal baseline insulin levels > 15 µU/ml (OR = 8.65; CI: 4.03-18.56) and abnormal blood pressure (OR = 3.69; CI: 1.76-7.72). Among overweight adolescents, 22.09% had more than three risk factors, whereas this percentage dropped to 6.12% among normal-weight adolescents. CONCLUSION: Overweight adolescents presented risk factors for cardiovascular diseases. The need for programs and policies targeted at the diagnosis and treatment of this condition is pointed out in order to reduce the risks of morbidity and mortality in adulthood.

The atherosclerotic process starts in childhood and studies show its development in fetuses. Clinical manifestation often occurs only in the sixth decade of life. Adolescence is a critical period in the development of atherosclerosis, because fatty streaks may change to transition plaque owing to genetic and environment factors. Healthcare by professionals plays a crucial role in the prevention and treatment of atherosclerosis, identifying poor lifestyle, positive family history of early cardiovascular disease, or other diseases such as dyslipidemia, obesity, arterial hypertension and diabetes. Dyslipidemia in childhood and adolescence should be treating by dietary therapy and change in lifestyle. Children with high-risk lipid abnormalities should be considered for drug treatment.

To assess hepatic steatosis by ultrasound method as a concomitant risk factor among overweight adolescents.A case-control study including 83 cases (47 overweight and 36 obese) and 89 controls (normal weight), frequency matched by gender, year of birth, pubertal stage (Tanner 4/5), and income. Cases and controls were selected from 1,420 students enrolled in a Vila Mariana public high school, in São Paulo, Brazil. Must et al. criteria were used for nutritional status classification. Nonalcoholic fatty liver disease was diagnosed through hepatic ultrasonography performed and analyzed by one radiologist. Hepatic enzymatic activities (alanine and aspartate transaminases, alkaline phosphatase, gamma-glutamyl transpeptidase) and direct bilirubin were measured. Eight covariables were fitted into logistic regression models; criterion for inclusion of variables was the association with overweight in the bivariate analyses (p0.20). A value of p0.05 was set as the criterion for inclusion into the final logistic regression models.Prevalence of hepatic steatosis diagnosed through ultrasonography was 27.7% in overweight/obese students and 3.4% in normal weight students. Adjusted odds ratios (95%CI) for images compatible with nonalcoholic fatty liver disease and gamma-glutamyl transpeptidase24 U/L were 10.77 (2.45-47.22) and 4.18 (1.46-11.94), respectively.This is the first population-based study showing that hepatic steatosis is strongly associated with overweight/obesity among adolescents attending a Brazilian public school. The diagnostic tool used in this investigation is a non-invasive method that might be applied to monitor overweight and obese adolescents and to propose actions for preventing more severe hepatic diseases in adulthood.

Overweight in adolescence is a risk factor for the development of cardiovascular diseases in adulthood.To study the association of cardiovascular risk factors (CRF) in overweight and normal-weight adolescents of both genders aged from 14 to 19 years, attending public schools.Case-control study including 163 overweight and 151 normal-weight adolescents. Multiple logistic regression analysis was used to evaluate the associations between overweight and CRF (lipid profile, blood pressure and baseline insulin level). A set of CRF was defined for each individual, ranging from 0 (no risk factors) to 6 (all risk factors present).Overweight adolescents (body mass index85th percentile) presented a higher frequency of CRF in comparison to the normal- weight group. The CRF associated with overweight were HDLc35 mg/dl (OR = 3.41; CI: 1.24-9.38), triglycerides150 mg/dl (OR = 3.04; CI: 1.01-9.13), abnormal baseline insulin levels15 µU/ml (OR = 8.65; CI: 4.03-18.56) and abnormal blood pressure (OR = 3.69; CI: 1.76-7.72). Among overweight adolescents, 22.09% had more than three risk factors, whereas this percentage dropped to 6.12% among normal-weight adolescents.Overweight adolescents presented risk factors for cardiovascular diseases. The need for programs and policies targeted at the diagnosis and treatment of this condition is pointed out in order to reduce the risks of morbidity and mortality in adulthood.

OBJETIVO: Discutir os fatores de risco da aterosclerose na pediatria e as recomendações de dieta e exercício físico e, principalmente, o tratamento medicamentoso de anormalidades lipídicas de alto risco. FONTES DOS DADOS: Os dados foram obtidos por meio de artigos indexados na MEDLINE, publicados nos últimos 5 anos. SÍNTESE DOS DADOS: Crianças com dislipidemia grave ou outros fatores de risco, como história familiar de doença cardiovascular precoce ou outros sinais de síndrome metabólica, podem necessitar de tratamento com drogas hipolipemiantes. Novas recomendações do consenso americano indicam tratamento medicamentoso antes dos 10 anos de idade, dependendo da magnitude de outros fatores de risco para doença cardiovascular. Cabe aos pediatras saber quando diagnosticar dislipidemia, quando indicar o tratamento medicamentoso e quais as drogas que podem ser utilizadas em crianças e adolescentes com menor risco e prejuízo ao seu desenvolvimento. CONCLUSÕES: O tratamento da dislipidemia deve ser inicialmente realizado sempre por meio de mudanças nos hábitos de vida, dando-se ênfase à prevenção. Crianças com anormalidades lipídicas de alto risco merecem tratamento medicamentoso. A decisão a ser tomada junto com os pais sempre deve respeitar os riscos e os benefícios que o tratamento acarretará ao paciente. OBJECTIVE: To discuss risk factors of atherosclerosis in pediatrics, dietary and physical activity guidelines, and, mainly, drug treatment of high-risk lipid abnormalities. SOURCES: Data were obtained from articles indexed in MEDLINE, published over the last 5 years. SUMMARY OF THE FINDINGS: Children with severe dyslipidemia or additional risk factors such as family history of early cardiovascular disease or other signs of metabolic syndrome may need treatment with hypolipidemic drugs. New recommendations from the U.S. guidelines indicate drug treatment before the age of 10 years according to the magnitude of the additional risk factors for cardiovascular disease. Pediatricians should know when to diagnose dyslipidemia, when to indicate drug treatment and which medication can be used in children and adolescents with the least risk or harm to their development. CONCLUSIONS: The first-line treatment of dyslipidemia consists of lifestyle changes, focusing on prevention. Children with high-risk lipid abnormalities should be considered for drug treatment. Decisions to be made together with the parents must be evaluated taking into consideration risks and benefits of the medication to the patient.

ObjectiveTo study risk factors for overweight among Brazilian adolescents of low-income families.DesignCase–control study of obese and non-obese adolescents.SettingAnthropometric survey including 1420 students (aged 14–19 years) attending a public high school in São Paulo, Brazil.MethodsSelection of 83 overweight (body mass index (BMI) >85th percentile) and 89 non-overweight (BMI >5th percentile and MeasurementsParents or guardians and adolescents were weighed, measured and answered a pre-tested questionnaire applied by trained nutritionists and paediatricians.ResultsThe prevalence of overweight was 15.2%. As previous risks, obese parents and obesity during infancy presented odds ratios (OR) and 95% confidence intervals (CI) of 2.23 (1.15–4.35) and 3.60 (1.47–8.80), respectively. As concurrent factors, the habit of napping, to have a best friend and reported dietary restriction presented OR (95% CI) of 3.43 (1.32–8.92), 5.15 (1.76–15.07) and 7.26 (2.95–17.88), respectively. Dietary patterns, frequency of obesogenic foods and other physical activity indicators presented no statistical significance.ConclusionIn case–control studies, OR may overestimate the true risks. Parents' obesity and previous childhood obesity were identified as risk factors; therefore these factors should be the target for preventive programmes and policies in order to prevent the burden of obesity in the near future.

Mortality rate, anthropometric development and nutritional therapy with the use of World Health Organization guidelines (WHO) were assessed. In a cross-sectional retrospective study 191 hospitalized malnourished children were assessed. To classify and evaluate nutritional rehabilitation Z-score was used: weight-for-age (ZW), height-for-age(ZH) and weight-for-height(ZWH). The children were divided in three groups (G): GI (primary malnutrition--30,9%), GII (secondary malnutrition--51,7%) and GIII (children who were admitted as GI but during internation had an identified chronic disease--12%). Nutritional therapy used was based on WHO guidelines, with slight modifications. The formulas chosen were all industrialized: lactose-free polymeric formula (PLF) for children with diarrhea, low lactose polymeric formula (PLL) for children without diarrhea and cow's milk hydrolysate (H) for sepsis or chronic diarrhea. In the rehabilitation phase, all the children used PLL formula.Student's, chi-square tests, simple linear regression. The median age and mortality rate were 10,3 months and 4,2%, respectively. The GI and GII children were older than GIII (11vs12vs7months,p=0,02) and had shorter length of stay (20vs22vs37days,p=0,010). Mortality risks in GIII were twice as frequent as in GI+GII. Pneumonia, diarrhea and poor weight gain were the main diagnosis at admission. Tubes were used more frequently in GII+GIII than GI (p=0,004). Parenteral nutrition was indicated in 5,7% of children, more often in GIII than GI+GII (p=0,037). Tolerance of the initial formula wasn't satisfactory in 20% of the children. An improvement of 87% ZWH, 74,1% ZW and 22% was observed. ZW in GI and ZWH in GIII were the indices that showed the most effective gain during hospital stay. The modified WHO guidelines were effective in the multiprofessional treatment of malnourished children, resulting in good nutritional rehabilitation with low mortality rates. A high percentage of children admitted as primary malnutrition who had a chronic disease diagnosed was observed. The late diagnosis may be responsible for the high length of stay, formula intolerance and mortality risk.

To study anthropometric development, nutritional support and mortality rate of malnourished children hospitalized in a referral center.In a retrospective study we surveyed 98 hospitalized malnourished children (ZW--2) with no chronic disease. Data collected was: birth weight, gestational age, length of exclusive breast feeding, diagnosis at admission, formula used (type, delivery route and feeding tolerance) and length of stay. Weight and height were controlled at admission and discharge. To classify and evaluate nutritional rehabilitation we used the Z-score: weight-for-age (ZW), height-for-age (ZH), weight-for-height (ZW/H). The nutritional therapy used was based on the World Health Organization (WHO) guidelines, with minor modifications. All chosen formulas were industrialized: lactose-free polymeric formula (PLF) for children with diarrhea, low lactose polymeric formula (PLL) for children without diarrhea and cow's milk hydrolysate (CMH) for sepsis or chronic diarrhea. At the rehabilitation phase, all children were given the PLL formula.Student's t and chi-square tests.The median of age and length of stay were 9.8 months and 17 days, respectively and the mortality rate was of 2%. Diarrhea and/or pneumonia were diagnosed at admission in 81.6% of the children. An improvement of 17.3 % ZW, 82.7 % ZH and 92.2 % ZW/H was observed. PLF was more frequently given at admission (47.4%) while CMH was given to only 7.4% of the children. Twenty-four percent of the children were tube fed and 5.1 % received parenteral nutrition. Tolerance of the initial formula was considered good in 66.7% of cases.The WHO guidelines were effective in the nutritional therapy of severely malnourished hospitalized children, resulting in good nutritional rehabilitation with low mortality rates.

OBJETIVO: Avaliar a evolução antropométrica, terapia nutricional e mortalidade de crianças desnutridas hospitalizadas em centro de referência. MÉTODOS: Em estudo retrospectivo, avaliou-se 98 prontuários de crianças desnutridas (ZPI

OBJECTIVE: the study was designed to evaluate the impact of a multidisciplinary program on children and adolescents' weight control.DESIGN: Retrospective study regarding changes in relative weight of all patients treated regularly in an out-patient care public service between January 1992 and December 1993.SUBJECTS: 198 children and adolescents (108 girls and 90 boys; mean age: 9.25 y; mean body mass index (BMI): 24.26 kg/m(2), range 19.1-40.31).MEASUREMENTS: Anthropometric data collected at the visits were obtained until June 30 1994. BMI compared to reference data was used. Dual Photon X-ray Absorptiometry (DEXA) was used for 64 patients, to determine percent body fat.RESULTS: Relative weight at the last visit was significantly lower when compared with initial relative weight for the whole sample. Significantly better outcome of relative weight was obtained when six or more visits occurred for the whole sample, and for girls when the days' interval between visits was shorter than 52d. Variables such as percent body fat, body shape at the first visit, family obesity pattern, length of obesity and pubertal stage, did not significantly influence the outcome of relative weight for the subjects during the treatment.CONCLUSION: Results obtained indicated that good outcomes can be obtained in a program using nutrition education focused on small modifications of eating habits in order to avoid excess energy intake. the best predictors of weight improvement for children and adolescents participating in the program were the higher frequency of visits and shorter intervals between them. Universidade Federal de São Paulo, Dept Pediat, BR-04040032 São Paulo, Brazil Universidade Federal de São Paulo, Dept Pediat, BR-04040032 São Paulo, Brazil Web of Science

Non discriminate screenig of high blood cholesterol levels in children seems not to be justified, except in thosecoming fiom families with high frequency of members affecled by hyperlipidemia, arterial hypertension, obesity, diabetesmcllirus and early onset coronary heart disease. Among adull as well as children obese people with high risk factors foratherosclerosis and coronary heart disease, changes in alimentary uses lo diets with lower cholesterol and saturated fatstogeihet with higher unsaturated fats conlents may be beneficial, even though there is not enough available informationon the effects of such a nutritional intervention on growth and development of the younger. Farmacological treatment,mainly with drugs that block bile acid reabsortion might be indicated in same cases that do not respond apropriately lodid therapy alone.(Key 'words: hyperlipemia, cholesterol, antichoiesteremic agents.)

OBJECTIVE: To identify lipodystrophy in prepubertal HIV-infected children using anthropometric parameters and body composition assessment. METHODS: Cross-sectional study including 40 prepubertal HIV-infected children of both genders seen at the Care Center of the Division of Pediatric Infectious Diseases - Universidade Federal de São Paulo (UNIFESP), São Paulo city, Brazil, was carried out from August to December 2008. Age, clinical and immunological status, prophylaxis, transmission and highly active antiretroviral therapy were recorded. Body mass index z-score and height-for-age z-score were calculated to characterize the nutritional status. Circumferences were measured with flexible tape and skinfolds were assessed by an adipometry. Fat mass and lean mass were determined by dual-energy X-ray absorptiometry. Presence of clinical signs of lipodystrophy was assessed by a trained clinician. Data were analyzed using SPSS 12.0 software. RESULTS: The mean age and standard deviation were 9.8 (1.2) years, 50% were girls and 82.5% children from B and C categories. Clinical lipodystrophy and dislypidemia were present in 27.5% and 70%, respectively. The trunk to arm ratio and the limb to trunk ratio had positive association with lipodystrophy. Patients with lipodystrophy had short stature, higher triglycerides values and lower HDL-cholesterol. CONCLUSION: The ratios obtained by skinfolds and dual-energy X-ray absorptiometry measurements can be considered as indicators of preclinical lipodystrophy. The cutoff points have not been determined yet; however, continuous assessment may be useful to identify early body composition changes. Universidade Federal de São Paulo (UNIFESP) Escola Paulista de Medicina UNIFESP, EPM SciELO

Introdução: A ocorrência do ganho rápido de peso infantil (GRP) pode estar associado a desfechos de peso ao longo do ciclo de vida. Os fatores de risco para o GRP incluem preditores maternos, gestacionais, infantis e contextuais e reforça-se a importância de avaliar também a hipótese sobre a possível associação com polimorfismos genéticos. Objetivo: Testar a associação entre ganho rápido de peso na infância, polimorfismos genéticos e estado nutricional de crianças. Metodologia (Manuscrito 1): Estudo transversal com bases de dados de inquéritos populacionais em crianças com peso ao nascer adequado no Brasil, Bolívia, Colômbia e Peru para estimar a associação entre GRP e excesso de peso em crianças de 0 a 5 anos. Foram estimadas as prevalências, odds ratio e IC95% por regressão logística multivariada. Metodologia (Manuscrito 2): Estudo de coorte com crianças do PROLAC no município de Viçosa, Minas Gerais, do nascimento aos seis meses. Foi obtido material biológico por swab bucal para análises genéticas de polimorfismos dos genes FTO, MC4R e APOA5. Considerou-se GRP quando a diferença (subtração) de escore-z de peso para idade (P/I) era >+0,67 entre duas avaliações. Na análise exploratória das curvas da taxa de incidência acumulada de GRP utilizou-se o estimador de Kaplan-Meier (failure), bem como o teste Log-Rank para realizar as comparações entre os grupos de interesse. Para estimar a razão de riscos utilizou-se o modelo semi-paramétrico de Cox e para verificar a qualidade do ajuste do modelo proposto foram utilizados os resíduos generalizados de Cox-Snell. Metodologia (Manuscrito 3): Estudo de coorte com 267 crianças. As crianças tinham que ter ao menos 3 avaliações antropométricas, ou seja, ao nascer, entre o nascimento e seis meses de vida e entre 4 e 7 anos de idade, e foram divididas em grupo de acordo com a presença ou ausência do GRP, diagnosticado se a diferença de escore-z de P/I peso para idade foi > +0,67 entre duas avaliações. Para analisar a trajetória da média de IMC infantil foi utilizada a função Longitudinal Analyses Data Plots, para comparação entre as médias de IMC dos grupos em cada tempo foi aplicado uma ANOVA de dois fatores e para as comparações múltiplas foi utilizado o teste Bonferroni. Resultados (Manuscrito 1): As chances de excesso de peso em crianças com GRP, ajustado por amamentação, foram de 6,1 vezes, 4,4 vezes, 6,7 vezes e 12,2 vezes quando comparado às crianças sem GRP no Brasil, Bolívia, Colômbia e Peru, respectivamente. Resultados (Manuscrito 2): A porcentagem de crianças com GRP foi 31,84% ao longo do estudo e a taxa de incidência foi estimada em 2,31 casos/1000 pessoas-dia. Apresentaram maior risco de GRP as crianças que nasceram com peso