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Reported are the results of a randomized controlled trial to assess the effectiveness of the WHO/UNICEF 40-hour course ``Breastfeeding counselling: a training course''. The course was conducted in a maternity hospital which provides care to a low-income population in a metropolitan area in São Paulo, Brazil...

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To assess the impact on child growth of the nutrition-counseling component of the Integrated Management of Childhood Illnesses (IMCI) strategy, a randomized trial was implemented. All 28 government health centers in a Southern Brazil city were paired according to baseline nutritional indicators. One center from each pair was randomly selected and its doctors received 20-h training in nutrition counseling. Thirty-three doctors were included and 12-13 patients < 18 mo of age from each doctor were recruited. The study included testing the knowledge of doctors, observing consultations and visiting the children at home 8, 45 and 180 d after the initial consultation. Maternal knowledge, practices and adherence to nutritional recommendations were assessed, and anthropometric measurements were taken. Day-long dietary intake was evaluated on a subsample of children. Doctors in the intervention group had better knowledge of child nutrition and improved assessment and counseling practices. Maternal recall of recommendations was higher in the intervention than in the control group, as was satisfaction with the consultation. Reported use of recommended foods was also increased. Daily fat intake was higher in the intervention than in the control group; mean daily intakes of energy and zinc also tended to improve. Children 12 mo of age or older had improved weight gain and a positive but nonsignificant improvement in length. Nutrition-counseling training improved doctors' performances, maternal practices and the diets and weight gain of children. The randomized design with blind outcome evaluation strongly supports a causal link. These results should be replicated in other settings.

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Reported are the results of a randomized controlled trial to assess the effectiveness of the WHO/UNICEF 40-hour course "Breastfeeding counselling: a training course". The course was conducted in a maternity hospital which provides care to a low-income population in a metropolitan area in São Paulo, Brazil. Health workers from 60 health units were randomly assigned to be either participants (20) or controls (40), and their breastfeeding knowledge and skills were assessed before and immediately after the course, as well as 3 months later. Immediately after the course the participants' knowledge of breastfeeding had increased significantly compared to controls. Both their clinical and counselling skills also improved significantly. When assessed 3 months later, the scores remained high with only a small decrease. The implementation of the course was also evaluated. The methods used were participatory observation, key interviews and focus group discussion. In the 33 sessions of the course, the average score was 8.43 out of 10. Scores were highest for content and methodology of the theory sessions, and lowest for "use of time", "clinical management of lactation", and "discussion of clinical practice". "Breastfeeding counselling: a training course" therefore effectively increases health workers' knowledge and their clinical and counselling skills for the support of breastfeeding. The course can be conducted adequately using the material and methodology proposed, but could be more satisfactory if the time allocated to exercises and clinical practice sessions were increased.

PIP: This document presents a report which assesses the effectiveness of the WHO/UNICEF 40-hour course "Breastfeeding counseling: a training course" (BFC). The course was conducted in a maternity hospital which provides services to a low-income population in Sao Paulo, Brazil. The randomized controlled trial was composed of 60 health professionals divided into an "exposed" group (20) and a control group (40). The participants' breastfeeding knowledge and skills were assessed before, immediately after, and 3 months after the course. Results showed that the participants' knowledge of breastfeeding together with their clinical and counseling skills had markedly improved by the period immediately after the course. Three months after the course, their knowledge skills remained high with only a slight decrease. Participatory observation, key interviews and focus group discussions were used in evaluating the course implementation. The content and methodology of the theory sessions received the highest scores whereas "use of time", "clinical management of lactation", and "discussion of clinical practice" got the lowest scores. In general, BFC was effective in increasing the health workers' clinical and counseling skills for the support of breastfeeding. The course, however, does need to be improved with regard to the time allocated for exercises and clinical practice sessions.

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OBJECTIVES: To investigate risk factors for dehydrating diarrhoea in infants, with special interest in the weaning period. DESIGN: Case-control study. SETTING: Metropolitan area of Porto Alegre, Brazil. SUBJECTS: Cases were 192 children aged 0-23 months hospitalised with acute diarrhoea and moderate to severe dehydration. Controls were 192 children matched for age and neighbourhood who did not have diarrhoea in the previous week. MAIN OUTCOME MEASURES: Associations between dehydrating diarrhoea and child's age, type of milk consumed, time since breast feeding stopped, and breast feeding status. RESULTS: In infants aged < 12 months the risk of dehydrating diarrhoea was significantly higher in the first 9 months of life (P < 0.001), and in those aged 12-23 months the risk was again greater in younger children (12-17 months) (P = 0.03). The type of milk consumed before start of diarrhoea episode was strongly associated with dehydration independent of socioeconomic, environmental, maternal reproductive, demographic, and health services factors. Compared with infants exclusively breast fed, bottle fed infants were at higher risk (odds ratio (95% confidence interval) for cow's milk 6.0 (1.8 to 19.8), for formula milk 6.9 (1.4 to 33.3)). Compared with those still breast feeding, children who stopped in the previous two months were more likely to develop dehydrating diarrhoea (odds ratio 8.4 (2.4 to 29.6)). This risk decreased with time since breast feeding stopped. CONCLUSION: These results confirm the protective effect of breast feeding and suggest there is a vulnerable period soon after breast feeding is stopped, which may be of relevance for developing preventive strategies.

PIP: Researchers conducted a case control study in Porto Alegre, Brazil, to examine risk factors for dehydrating diarrhea in children 0-23 months old, particularly during the weaning period. There were 192 cases hospitalized with dehydrating diarrhea and 192 age- and neighborhood-matched controls who had no diarrhea in the previous 7 days. Among infants, the risk of developing dehydrating diarrhea was highest during the first 9 months of life, especially at 2-3 months (odds ratio [OR] = 7.1) (p 0.001). For toddlers (12-23 months), the risk was greatest at 12-17 months (OR = 3.7; p = 0.03). Only 8% of cases and 23% of controls were completely breast fed. Children who had not been breast fed faced a higher risk of dehydration than those who had been exclusively breast feed (p = 0.006). The degree of risk depended on the type of breast milk substitute used. Children who consumed cow's milk only and formula only faced the greatest risk of developing dehydrating diarrhea even when adjusted for age and other factors (OR = 6 and 6.9, respectively). Partially breast fed children had intermediate levels of risk (OR = 1.3-2.2). Children who had never breast fed were at low risk of developing dehydrating diarrhea (OR = 0.7), while those who had stopped were at high risk (OR = 6.4) (p 0.001). This increased risk was greatest in the first 2 months after stopping breast feeding (OR = 8.4) and decreased thereafter. These findings support the protective effect of breast feeding. They also point to a vulnerable period soon after termination of breast feeding. Thus, health workers need to pay closer attention to recently weaned children.

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In Pelotas, Brazil, 400 newborns from low income families were followed-up until 26 wk of life to study the relationship between their feeding patterns and growth as modified by access to water and by diarrhea. Effects of access to water were the strongest among non-breastfed infants. In houses without indoor water taps, the weight gain of non-breastfed infants during the first 3 mo was approximately half that of partially or predominantly breastfed infants (P < 0.001). In houses with indoor water taps, non-breastfed infants' growth was similar to or exceeded that of predominantly breastfed infants from 2 mo. Predominantly breastfed infants' growth was similar in houses with and without water taps. Breastfed infants had less weight loss per day of diarrhea than non-breastfed infants during the first 4 mo and less diarrhea through 6 mo of life, particularly in houses without taps, in which diarrhea was most prevalent. The existence of a "weanling's dilemma" was approached by comparing the duration of the detrimental effects of not breastfeeding (i.e., 0-3 mo in this study) with the age at which breast milk alone becomes less than optimal for growth (i.e., at 5 mo). Because these two points did not coincide, we conclude that there is no "weaning's dilemma" in this population.

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Con el fin de actualizar las estimaciones globales de morbilidad y mortalidad por enfermedades diarreicas en los países en desarrollo, hemos revisado varios artículos publicados desde 1980 hasta la fecha y estimado la tasa mediana de incidencia y la mortalidad por diarrea en niños menores de 5 años. Nuestra incidencia estimada de diarrea (2,6 episodios anuales por niño) fue casi igual a la de Snyder y Merson en 1982, pero la de mortalidad global fue menor (3,3 millones de defunciones anuales, con una variación de 1,5 a 5,1 millones). La estimación de la mortalidad se basa en un pequeño número de estudios prospectivos y de vigilancia activa y, por lo tanto, encierra mucha incertidumbre como consecuencia de la debilidad de la base global de datos. Sin embargo, numerosas encuestas que han revelado disminuciones de la mortalidad en distintos lugares son compatibles con una estimación más baja. Es necesario emplear con más precisión los métodos de encuesta de la OMS- entre ellos el muestreo poblacional en lugares representativos- y repetir las encuestas cada 5 años para observar los logros alcanzados por los programas de control de las enfermedades diarreicas y las tendencias de la morbilidad y mortalidad por diarrea a lo largo del tiempo

Se publica en inglés en el Bull. WHO, Vol. 70(6), 1992

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We examined the association between prolonged breastfeeding and anthropometric status in a population-based cohort study of 5,914 liveborns from the city of Pelotas in Southern Brazil. When children from all socioeconomic groups were studied, there was no important association between current breastfeeding and anthropometric status at age 12 months. Children who were still breastfed at age 20 months--and, to a lesser extent, at 43 months--presented with poorer anthropometric status than their nonbreastfed counterparts. We did not find the same pattern in all socioeconomic groups, however. Children from low-income families who were breastfed tended to present better anthropometric status than those who were not, whereas the reverse was observed for children of middle- and high-income families. After controlling for confounding variables, the nutritional advantage of breastfeeding among low-income families was no longer clear, while the superiority of nonbreastfed infants amongst middle- and high-income children persisted. These findings indicate that some of the controversy regarding the nutritional effects of prolonged breastfeeding may have been caused by confounding and effect modification. Any decisions on whether or not breastfeeding should be encouraged after the first year of life should take into account the characteristics of the population as well as the anti-infective and birth-spacing properties of breastfeeding.

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A study of breast-feeding practices over the first 6 months of life among a cohort of urban poor infants in southern Brazil indicated that the median duration of breast-feeding was 18 weeks, and at 6 months 41% of the infants were still being breast-fed. The duration of breast-feeding was significantly associated with the following: the infant's sex, mother's colour, type of first feed, timing of the first breast-feed, breast-feeding regimen and frequency of breast-feeding at 1 month, and the use of hormonal contraceptives by the mother. The following were significant risk factors for early termination of breast-feeding: the infant's sex, type of first feed, use of supplementary feeds, frequency of breast-feeding, feeding regimen, weight-for-age, and weight-for-age after controlling for birth weight. Dissatisfaction with their infant's growth rate was the most frequent reason given by mothers for supplementing the diets of infants who were exclusively breast-fed in the first 3 months of life. Also, the mothers' perception that their milk output was inadequate was the most frequent reason expressed for stopping breast-feeding in the first 4 months. The roles of health services and family support in providing favourable conditions for increasing the duration of breast-feeding in the study population are discussed, as well as the possibility of bias being introduced into studies of the relationship between infant feeding and growth by the effect of the infant's rate of growth on the mother's decision to continue breast-feeding.

PIP: A study of breastfeeding practices over the 1st 6 months of life among a cohort of urban poor infants in southern Brazil indicated that the median duration of breastfeeding was 18 weeks, and at 6 months, 41% of the infants were still being breastfed. The duration of breastfeeding was significantly associated with the following: infant's sex, mother's color, type of 1st feed, timing of the 1st breastfeed, breastfeeding regimen and frequency of breastfeeding at 1 month, and the use of hormonal contraceptives by the mother. The significant risk factors for early termination of breastfeeding were: infant's sex, type of 1st feed, use of supplementary feeds, frequency of breastfeeding, feeding regimen, weight-for-age, and weight-for age after controlling for birthweight. Dissatisfaction with infant growth rate was the most frequent reason given for mothers for supplementing the diets of those infants who were exclusively breastfed for the 1st 3 months of life. Also, them other's perception that their milk output was inadequate was the most frequent reason expressed for the cessation of breastfeeding in the 1st 4 months. The roles of health services and family support in providing favorable conditions for increasing the duration of breastfeeding in the study population are discussed, as well as the possibility of bias being introduced into studies of the relationship between infant feeding and growth by the effect of the infant's rate of growth on the mother;s decision to breastfeed. (author's)

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A population-based cohort of 1458 Brazilian infants was followed from birth to 9-15 months of age to investigate the effects of birthweight and family income on subsequent growth. There was a strong association between birthweight and attained weight and length, while virtually no malnutrition among children who weighed more than 3000 g at birth; Children with lower birthweights tended to put on less weight during the first year, but these differences were no longer significant after controlling for family income. As a result, infants of lower birthweights tended to remain behind those of higher birthweights. Children from the wealthiest families gained 20% more weight than low-income infants, irrespective of birthweight. Low birthweight infants from high-income families were therefore likely to approach the standard weight at one year old while those from poor families lagged behind.

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The article reports the effects of several socioeconomic and environmental indicators on the nutritional status (stunting, underweight, and wasting) of a sample of 802 children aged 12-35.9 months in urban and rural areas of southern Brazil. Of the social variables studied, family income and father's education level were the two risk factors that showed the strongest associations with nutritional status. The mother's education level, employment status of the head of the family, number of siblings, and family's ethnic background also showed some degree of association, but these were less significant when family income was included in the analysis. Environmental variables, particularly the type of housing, degree of crowding, and type of sewage disposal, were also strongly associated with malnutrition. The effects of having access to piped or treated water were only apparent on stunting and wasting.

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The association between duration of breast-feeding and nutritional status was studied in a population-based sample of 802 children aged 12 to 35.9 months in Southern Brazil during 1982. The prevalence of malnutrition (low weight for age, length for age, and weight for length) was smallest in those children breast-fed for 3 to 6 months, but after this age nutritional status appeared to be worse in those breast-fed for longer. Children still being breast-fed at the time of the survey presented with a significantly higher prevalence of low weight for length than those who had been totally weaned, and those receiving breast-plus bottle-feeding presented with intermediate levels. This association could not be explained by a number of possible confounding variables using a multiple logistic regression analysis. These results are also consistent with a controlled trial on supplementary feeding in the Sudan.

PIP: The association between duration of breast feeding and nutritional status was studied in a population-based sample of 802 children aged 12 to 35.9 months in Southern Brazil during 1982. The prevalence of malnutrition (low weight for age, length for age, and weight for length) was smallest in those children breastfed for 3 to 6 months, but after this age nutritional status appeared to be worse in those breastfed longer. Children still being breastfed at the time of the survey presented with a significantly higher prevalence of low weight for length than those who had been totally weaned; those receiving breast plus bottle feeding presented with intermediate levels. This association could not be explained by a number of possible confounding variables using a multiple logistic regression analysis. These variables are: 1) age of the child, divided into 8 3-month categories--associated both with prevalence of malnutrition and breastfeeding; 2) district of residence; 3) family income; 4) ethnic background (Portuguese, Italian, Black, or mixed); 5) type of family (nuclear or extended); 6) maternal education; 7) employment status of head of the family; 8) previous hospitalization due to infectious disease; 9) birth order; and 10) sex. Variables 3 to 7 were included to account for the social class differences in breastfeeding and nutrition. These results are also consistent with a controlled trial on supplementary feeding in the Sudan. This trial was carried out to assess the nutritional impact of a take home supplementary feeding program. The effect of dried skimmed milk was compared to that of local beans in children aged 6 to 26 months. The impact was measured by the average weight and height gain per month. The results suggest that children who were breastfed and received dried skim milk gained significantly more weight per month than those breastfed but given only beans.

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Numa populacao periurbana brasileira sao estudados alguns dos elementos essenciais da demanda de pacientes por servicos medicos. Criancas de zero a quatro anos sao, em numeros absolutos, o maior grupo de pacientes. Criancas e velhos demandam uma frequencia maior de consultas (frequencia media de tres a quatro consultas/ano). Os problemas que com maior frequencia trazem pacientes a consulta: infeccoes respiratorias e diarreia aguda em criancas; e problemas emocionais em adultos. Foram encaminhados para hospitais ou especialistas 10,2% do total de pacientes vistos no periodo de um ano, sendo que 81% deles tratados sem a necessidade de exames complementares

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Os autores pretendem desenvolver o estudo de parasitoses intestinais a partir da observacao conjunta dessas enfermidades, destacando seus aspectos comuns de sintomatologia, epidemiologia, metodos de investigacao e controle

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