REVISTA
PAULISTA
DE
PEDIATRIA
www.rpped.com.br
REVIEW
ARTICLE
Characterization
of
anthropometric
assessment
studies
of
Brazilian
children
attending
daycare
centers
Dixis
Figueroa
Pedraza
∗,
Tarciana
Nobre
de
Menezes
UniversidadeEstadualdaParaíba(UEPB),CampinaGrande,PB,Brazil
Received13April2015;accepted30June2015 Availableonline27January2016
KEYWORDS
Anthropometrics; Children; Daycarecenters; Systematicreview
Abstract
Objective: Toobtainanoverviewofavailableinformationontheanthropometricassessment ofBrazilianchildrenattendingdaycarecenters.
Datasource: AliteraturesearchwascarriedoutinthePubMed,LILACSandSciELOdatabasesof studiespublishedfrom1990to2013inPortugueseandEnglishlanguages.Thefollowingsearch strategywasused:(nutritionalstatusORanthropometricsORmalnutritionORoverweight)AND daycarecenters,aswellastheequivalenttermsinPortuguese.InthecaseofMEDLINEsearch, thedescriptorBrazilwasalsoused.
Datasynthesis: Itwasverifiedthatthe33studiesincludedinthereviewwerecomparablefrom amethodologicalpointofview.Thestudies,ingeneral,werecharacterizedbytheirrestrictive nature,geographicalconcentrationanddispersionofresultsinrelationtotime.Considering thestudiespublishedfrom2010onwards,lowprevalenceofacutemalnutritionandsignificant ratesofstuntingandoverweightwereobserved.
Conclusions: Despitethelimitations,consideringthemostrecentstudiesthatusedtheWHO growth curves (2006), itis suggested that the anthropometric profileof Brazilian children attendingdaycarecentersischaracterizedbyanutritionaltransitionprocess,withsignificant prevalenceofoverweightandshortstature.Weemphasizetheneedtodevelopa multicen-tersurveythatwillmoreaccuratelydefinethecurrentanthropometricnutritionalstatusof Brazilianchildrenattendingdaycarecenters.
©2015SociedadedePediatriadeSãoPaulo.PublishedbyElsevierEditoraLtda.Thisisanopen accessarticleundertheCCBYlicense(https://creativecommons.org/licenses/by/4.0/).
∗Correspondingauthor.
E-mail:[email protected](D.FigueroaPedraza).
http://dx.doi.org/10.1016/j.rppede.2016.01.002
2359-3482/©2015SociedadedePediatriadeSãoPaulo.PublishedbyElsevierEditoraLtda.ThisisanopenaccessarticleundertheCCBY
PALAVRAS-CHAVE
Antropometria; Crianc¸as; Creches;
Revisãosistemática
Caracterizac¸ãodosestudosdeavaliac¸ãoantropométricadecrianc¸asbrasileiras assistidasemcreches
Resumo
Objetivo: Trac¸arumpanoramadainformac¸ãodisponívelsobreaavaliac¸ãoantropométricade crianc¸asbrasileirasassistidasemcreches.
Fontesdedados: PesquisabibliográficanasbasesdedadosPubMed,LILACSeSciELOdeestudos publicadosde1990a2013nosidiomasportuguêseinglês.Foiutilizadaaseguinteestratégia debusca:(estadonutricionalORantropometriaORdesnutric¸ãoORsobrepeso)ANDcreches. NocasodabuscanoMEDLINEodescritorBraziltambémfoiusado.
Síntesedosdados: Verificou-se que os 33 estudos incluídos apresentaram comparabilidade do ponto de vista metodológico. Os estudos, no seu conjunto, caracterizaram-se por sua naturezarestritiva,concentrac¸ãogeográficaedispersãodosresultadosemrelac¸ãoaotempo. Considerando os estudos publicados a partir de 2010, observam-se baixas prevalências de desnutric¸ãoagudaetaxasexpressivasdedéficitdeestaturaedesobrepeso.
Conclusões: Apesardaslimitac¸ões,considerandoosestudosmaisrecentesqueutilizaramas curvasdecrescimentoOMS(2006),sugere-sequeoperfilantropométricodecrianc¸asbrasileiras assistidasemcrechescaracteriza-seporumprocessodetransic¸ãonutricionalcomprevalências expressivasdesobrepesoedebaixaestatura.Ressalta-seanecessidadedodesenvolvimento de um inquérito multicêntrico para delimitar de forma mais precisa o estado nutricional antropométricoatualdascrianc¸asbrasileirasquefrequentamcreches.
©2015SociedadedePediatriadeSãoPaulo.PublicadoporElsevierEditoraLtda.Esteéumartigo OpenAccesssobalicençaCCBY(https://creativecommons.org/licenses/by/4.0/deed.pt).
Introduction
Nutritional status has asignificant influence onmorbidity andmortalityandtheprocessofchildgrowthand develop-ment.Thus,theassessmentofthenutritionalstatusofthe Pediatricpopulationisessentialtoidentifytheappropriate interventionstoimprovehealthandlifeconditions.1
Anthro-pometrics is the most universally used method to assess children’snutritionalstatus.Itstandsout becauseit isan easilyapplied,lowcostandnon-invasivemethod,aswellas objectiveandsensitive.2,3
Child malnutrition remains one of the most important publichealthproblemsintheworldtoday,duetoits mag-nitudeanddevastatingconsequencesforchildren’sgrowth, developmentandsurvival.4Nationalsurveysonhealthand
nutritionshowanongoingdecreaseincasesofmalnutrition in Brazil.This improvementis attributedtothe favorable evolutionof socioeconomicandhealth careconditions,so thattheadequatenutritionofthepoorestsegmentsof soci-etyremainamajorchallengeforpublicpoliciesinBrazil.5,6
The benefit offered by daycare centers is considered an important strategy of developing countriesto improve growth and development of children belonging to lower social strata. The demand for these services is high, due to the growing participation of women in the labor mar-ket, especially in large and medium cities in Brazil, with anincreaseinthenumberofdaycarecentersandassisted children.7 Therefore, daycare centers have been
gradu-allychangingby turningintopublicpolicy proposalin the education, nutrition and health care areas. The benefit constitutesthemainpublicpolicyinstrumentaimedat pro-motingfoodandnutritionsecurityoftheurbanpopulation ofinfantsandpreschoolchildrenfromlowincomefamilies.8
However,theincrease in infectiousdiseases and the non-compliancewithstandardsthatregulatethecareofchildren in daycare centers are factors that have been reported, with possible negative effects on the attainment of the program objectives.8,9 Methodologically, the tendency for
childrenattendingdaycarecenterstoimprovetheir nutri-tionalstatusand/ortoacquiremoreinfectiousdiseasescan be determined through anthropometric indicators, viable andsafepredictorsofhealthstatus,functionalimpairment andmortality.10
Theidentificationoftheanthropometricprofileof chil-drenattendingdaycarecentersis,therefore,akeystepin thedesign and/or redesignof actionsin day care centers thataimtopromoteadequatenutritionalstatusandoverall healthoftheassistedchildren.Giventheabove,thisstudy aimstoprovideanoverviewofavailableinformationonthe anthropometricassessment ofBrazilian childrenattending daycarecenters.
Method
To calculate the total number of the identified stud-ies,theirduplicationortriplicationwasverifiedamongthe databasesandeachitemwascountedonlyonce.The deci-sion on the inclusion of articles included two steps: (a) screening by reading the titles and abstracts, (b) read-ing of the full text. In the screening phase, intervention studies,reviewstudies,booksorthesis,studiesperformed out of Brazil and studies of children not attending day-care centers were eliminated. At the full-text reading phase, observational studies with representative samples that analyzed anthropometric indices (height z-score for age,weightz-scoreforheight,weightz-scoreforage,body mass index) of Brazilian children attending daycare cen-ters wereincluded. Studies withunrepresentative and/or non-randomly selected samples, based on the analysis of secondarydata, andshowingnoresults of theprevalence ofmalnutritionand/oroverweight,wereexcluded.
The included studies were organized according to the study location into four groups: (a) national studies and South, Southeast, Midwest and North studies; (b) studies in the Northeast region;(c) studies in other cities rather than the capital of the state of São Paulo; (d) studies in thecapital city of São Paulo. The characterizationof the studieswasperformedaccordingtotheauthorandyearof publication,location,anthropometricassessmentmethod, referencestandardandoutcomes(prevalenceof anthropo-metricdeviations).
Results
Atotalof141recordswereidentifiedinsearcheddatabases, which were submitted to screening. After analyzing the titles and abstracts, 61 articles that did not meet the
selection criteria were excluded. Subsequently, after the full reading of the 80 eligible articles,48 wereexcluded becausetheymetsomeoftheexclusioncriteriaandthus, 32 articles were included. The flow chart related to the identificationandselectionofthestudiesisshowninFig.1.
Tables1---4show thedistributionofthestudies
accord-ingtotheadoptedcharacterizationparameters.Ofthe32 includedarticles,11---4216weredevelopedinSãoPaulo,27---42
of which 10 in the capital.33---42 Only one study was
car-riedoutintheMidwest17 andNorth19 macro-regionseach,
whereasthreestudieswerecarriedoutintheSouth12---14and
theSoutheastregions.15---17Sevenstudiesweresystematized
inNortheast.20---26Itisalsonoteworthyastudythatincluded
theoverall nutritionalassessmentofthefivegeographical macro-regionsofthecountry.11
TheanthropometricmethodsproposedbyJelliffe(1968), Habicht(1974),Lohman(1988)andtheWorldHealth Orga-nization (WHO) (1995) were the most often used ones. Fujimoriet al.34 based their study onthespecific
recom-mendationsoftheBrazilianMinistryofHealthof2001.The anthropometricassessmentmethodwasnotreportedin15 ofthereviewedstudies.11,13,14,19,24---26,28,30,31,33,39---42
ThereferencestandardoftheNationalCentersforHealth Statistics--- NCHS(1977), recommendedby theWHO, was usedin20studies.11,14,16---19,26,29---34,36---42The standardofthe
Centersfor DiseaseControl---CDC/NCHS(2000)wasusedin four studies.15,25,28,35 Onestudy35 comparedthe results of
threenutritionalstatusclassificationcriteria:NCHS(1977), CDC/NCHS (2000), International Obesity Task Force-IOTF (2000),WHO(2006).TheWHOgrowthcurves,ofwhichfirst communicationsoccurred in 2004 andwere distributed in 2006,wereusedinallarticlespublishedfromtheyear2010 on.
Number of identified articles in PubMed, LILACS and SciELO (n=196) databases
Number of articles in duplicate or triplicate that were removed (n=55)
Number of articles analyzed to determine their eligibility (n=33)
Total number of articles included in the systematic review (n=32)
Number of single articles submitted to screening (n=141) Number of excluded articles (n=61) - Intervention studies (n=29)
- Review studies or book/thesis (n=17) - Studies performed outside Brazil (n=10) - Studies with children not attending daycare centers (n=05)
Number of excluded articles (n=48) - Non-representative and / or non-randomly selected samples (n=27)
- Based on the analysis of secondary data (n=06)
- No results of malnutrition and/or overweight prevalence (n=15)
Table1 CharacteristicsoftheobservationalarticlesonanthropometricassessmentofBrazilian childrenattendingdaycare centers(nationalstudiesandstudiesfromtheSouth,Southeast,MidwestandNorthregions).
Author,year Location Assessmentmethod Referencestandard Prevalence(%)
Silvaetal.,200011 Brazil NR NCHS,1977 W/A<−2Z:5.4
H/A<−2Z:12.6 W/H<−2Z:1.3 Rodriguesetal.,201112 Cascavel(PR) Lohmanetal.,1988 WHO,2006 W/A<−2Z:2.3
W/H<−2Z:0.4 W/H>+2Z:9.8 Dallabonaetal.,201013 BalneárioCamboriú
(SC)
NR WHO,2006 BMI/A<−2Z:2.6
BMI/A>+1Z:29.6 BMI/A>+2Z:9.5 Corsoetal.,200414 Florianópolis(SC) NR NCHS,1977 H/A<−2Z:8.7
W/H<−2Z:1.1 W/H>+2Z:8.6 Rochaetal.,200815 BeloHorizonte(MG) WHO,1995 CDC/NCHS,2000 W/A<−2Z:5.5
H/A<−2Z:4.2 W/H<−2Z:5.0 Camiloetal.,200816 Guaxupé(MG) Jelliffe,1968 NCHS,1977 H/A<−2Z:3.3
Castroetal.,200517 Vic¸osa(MG) Jelliffe,1968 NCHS,1977 W/A<−2Z:0.0
H/A<−2Z:3.5 W/H<−2Z:0.0 W/H>+2Z:4.6 Tumaetal.,200518 Brasília(DF) Jelliffe,1968 NCHS,1977 W/A<−2Z:2.2
H/A<−2Z:4.8 W/H<−2Z:0.4 W/H>+2Z:6.1 Santos,199919 CapitãoPoc¸o(PA) FAO/WHO,1985 NCHS,1977 W/A<−2Z:53.0
H/A<−2Z:55.0
W/A,weightforage;H/A,heightforage;W/H,weightforheight;BMI/A,BodyMassIndexforage;NR,notreported(unreferenced anthropometricmethod).
Table2 CharacteristicsofobservationalarticlesonanthropometricassessmentofBrazilianChildrenattendingdaycarecenters (studiesintheNortheastregion).
Author,year Location Assessmentmethod Referencestandard Prevalence(%)
Pedrazaetal.,201320 Paraíba WHO,1995 WHO,2006 H/A<−2Z:7.4
W/H<−2Z:1.1 W/H>+2Z:6.2 Sousaetal.,201221 JoãoPessoa(PB) WHO,1995 WHO,2006 H/A<−2Z:7.6
W/H<−2Z:1.6 W/H>+2Z:6.4
Pedrazaetal.,201122 Paraíba WHO,1995 WHO,2006 H/A<−2Z:7.7
Sousaetal.,201123 Paraíba WHO,1995 WHO,2006 H/A<−2Z:5.8
W/H<−2Z:0.4 W/H>+2Z:3.8
Azevedoetal.,201024 Recife(PE) NR WHO,2006 W/A<−2Z:2.5
H/A<−2Z:8.6 W/H<−2Z:1.5
Barretoetal.,200725 Natal(RN) NR CDC/NCHS,2000 BMI/A≥p85:19.7
BMI/A≥p95:7.1 Cavalcantietal.,200326 12municipalities
inParaíba(PB)
NR NCHS,1977 W/A<−2Z:6.9
Table3 CharacteristicsofobservationalarticlesonanthropometricassessmentofBrazilianchildrenattendingdaycarecenters (studiesinothercitiesofSãoPauloratherthanthecapital).
Author,year Location Assessmentmethod Referencestandard Prevalence(%)
Nascimentoetal., 201227
Taubaté Lohmanetal.,1988 WHO,2006 H/A<−2Z:2.9 BMI/A<−2Z:0.9 BMI/A>+1Z:28.9 BMI/A>+2Z:8.9 Almeidaetal.,200728 Jardinópolis NR CDC/NCHS,2000 W/A<−2Z:1.6
H/A<−2Z:0.5 W/H<−2Z:4.3 W/H>+2Z:2.2
Silva,200429 Piracicaba NR NCHS,1977 H/A<−2Z:7.0
Silvaetal.,200030 Embu NR NCHS,1977 Malnourished
(Gómezcriteria forchildren<24 monthsand Waterlowcriteria forchildren≥24 months):13.3
SilvaeSturion,199831 Piracicaba NR NCHS,1977 H/A<−2Z:5.1
W/H<−2Z:1.3 Antonioetal.,199632 Paulínia Jelliffe,1966;
Marshall,1977; Cameron,1978
NCHS,1977 Malnourished (Gómezcriteria): 21.0
W/A,weightforage;H/A,Heightforage;W/H,weightforheight;BMI/A,BodyMassIndexforage;NR,notreported(unreferenced anthropometricmethod).
A total of 11 studies15,17,18,24,28,30,34,36,38,41,42
consid-ered the anthropometric indices height for age (H/A), weight for height (W/H) and weight for age (W/A) to assess children’s nutritional status. The H/A was also the diagnostic object in 11 other studies,14,16,20---23,27,29,37
theW/H in eight studies12,14,16,20,21,23,31,35,37and W/A in six
studies.12,19,26,32,33,39
Theprevalenceofmalnutritionandoverweightexpressed by the standard deviation of the indexes H/A (<−2 z
score,chronic malnutritionindicator), W/H(<−2 zscore, acutemalnutritionindicator;>+2zscore,indicatorof over-weight/obesity)andW/A(<−2zscore,overallmalnutrition indicator)variedwidely.ForH/Aindex,theprevalenceof childrenwithstuntingrangedfrom0.5%28to55%,19
accord-ingtothestudiesinthemunicipalitiesofJardinópolis(SP) andCapitãoPoc¸o(PA),respectively.AsfortheW/Hindex, theprevalenceofchildrenwithacutemalnutritionranged between0%17and5%,15accordingtothestudiescarriedout
inVic¸osa(MG) andBeloHorizonte(MG), respectively. The prevalenceofoverweightchildrenrangedfrom0.7%,a ref-erencevalueforchildrenfromSãoPaulo(SP)34to9.8%,the
referencevalueforchildrenfromCascavel(PR).12Regarding
theW/Aindex,theprevalenceofchildrenwithvalues<−2
z-scorerangedbetween0%17 and53%.19
TheclassificationofGómez(1955),Waterlow(1977)and theBodyMassIndexforage(BMI/A)wasalsousedtoindicate malnutrition.Silvaetal.,30 SouzaandTaddei41andAntonio
etal.32 showed malnutrition prevalence between 13.3%30
and31%41whenusingtheGómezand/orWaterlow
classifica-tions.ThestudiesusingBMI/A13,25,27,35reportedoverweight
prevalencebetween19.7%25 and29.6%.13
In more recent studies, published from 2010 on and that used the WHO growth curves as references, acute
malnutritionrangedbetween0.4%12,23and1.8%,24and
stunt-ingrangedfrom2.9%27to8.6%.24Overweight,forthissetof
articles,showedprevalencebetween22.5%35 and29.6%,13
according to the BMI/A, and between 3.8%23 and 9.8%,12
accordingtotheW/H.
Discussion
Regardingtheanthropometricassessmentmethod,inspite of the numerous references used in the systematized articles, it is possible to assume standardization. The anthropometricmethodsappearedwiththepublicationsby Jellifeinthe60s,systematizingasametechnique.43 Since
then,anthropometricsdevelopedconstantly,makingit pos-sible to advancein the interpretation andthe search for mathematicalformulationswithimprovedaccuracyinbody compartmentestimationandtheirpredictivepower.Thus, anthropometricshasbeenshowntobethemostoftenused isolatedmethodfornutritionaldiagnosisatthepopulation level,especiallyinchildhoodandadolescence,duetobeing easytoperform,inadditiontoitslowcostandsafety.2,43
Table4 CharacteristicsofobservationalarticlesonanthropometricassessmentofBrazilianchildrenattendingdaycarecenters (studiesinthecapitalcityofthestateofSãoPaulo).
Author,year Assessmentmethod Referencestandard Prevalence(%)
Tolonietal.,200933 NR NCHS,1977 W/A<−2Z:4.4
Fujimorietal.,200734 MinistryofHealth,
2001
NCHS,1977 W/A<−2Z:0.7
H/A<−2Z:2.1 W/H<−2Z:2.7 W/H>+2Z:0.7 BuenoeFisberg,200635 Habichtetal.,1974 WHO,2006;CDC/NCHS,
2000;IOTF,2000
W/H>+2Z:6.2 BMI/A≥p85:22.5 BMI/A≥p95:9.3 ZöllnereFisberg,200636 Lohmanetal.,1988;
Habichtetal.,1974
NCHS,1977 W/A<−2Z:3.1
H/A<−2Z:5.2 W/H<−2Z:0.9 W/H>+2Z:5.0 Fisbergetal.,200437 Habicht,1974;Lohman
etal.,1998
NCHS,1977 H/A<−2Z:7.0
W/H<−2Z:0.9 Buenoetal.,200338 Habichtetal.,1974 NCHS,1977 W/A<−2Z:2.9---1.7
H/A<−2Z:7.1---3.1 W/H<−2Z:0.2---0.5 W/H>+2Z:5.7---6.9
Pradoetal.,200239 NR NCHS,1977 W/A<−2Z:1.5
Taddeietal.,200040 NR NCHS,1977 W/A<−1Z:
29.8---15.2 H/A<−1Z: 50.0---44.8 W/H<−1Z: 10.1---3.4
SouzaeTaddei,199841 NR NCHS,1977 W/A<−2Z:2.8---1.4
H/A<−2Z: 12.4---6.9
W/H<−2Z:1.4---0.0 Malnourished (Gómezcriteria): 31.0---17.2
Sivieroetal.,199742 NR Marconesetal.,1982,
Marquesetal.,1982 andNCHS,1977
W/A<−2Z:2.8---1.2 H/A<−2Z:4.4---3.3 W/H<−2Z:0.4---0.3
W/A,weightforage;H/A,Heightforage;W/H,weightforheight;BMI/A,BodyMassIndexforage;NR,notreported(unreferenced anthropometricmethod).
reference standard (2000).43 The use of this referencein
allstudiesofthisreviewreflectsitsglobalacceptance. The need toconstructa newgrowth curve ofchildren andadolescents appeared in 1995.Among other views,it wasdeemedimportanttoconsideraspectssuchas breast-feeding (children in the NCHS curves were formula-fed), inclusionofotheranthropometricindicatorsanduseofdata fromothercountries(childrenintheNCHScurveswereonly fromtheUS).44Thesecurveswerepubliclypresentedin2006
andtheiruseisrecommendedbytheMinistryofHealthof Brazil.2However,itcanbeobservedinthestudiesincluded
in this present review that the nutritional assessment of childrenattendingdaycarecenters,usingthelatter refer-ence,wasconsolidatedonlyinthearticlespublishedfrom 2010 to the present date. This fact can be explainedby thefactthat itwasimpossiblefor theauthors touse this referencestandardconsideringtheproximity betweenthe yearofpublicationofthenewgrowthcurves(2006),orits
recommendationbytheMinistryofHealth(2008),andthe dateof submission/acceptance/publicationof thearticles inthisreviewpublishedbetween2006and2013.
The anthropometric classifications by Gómez,45
Waterlow46 and WHO47 have been the most widely used
over time. Although they are no longer recommended, the classifications by Gómez and Waterlow were used in three review studies.30,32,41. The WHO47 criteria are still
currentlyused.Thesecriteriaestablish thecomparisonof anthropometricmeasurementswiththereferencestandard throughthe use of scales, of which the most common is thepercentileandstandard deviation(orzscore:number ofstandard deviations that theobtained data is deviated from its reference median).43 The z-score calculation of
In order to perform the analysis of several studies, their comparability should be assumed. This comparabil-ity depends, among other factors, on the methods used in the anthropometric assessment, on the study loca-tion/populationandtime.Fromamethodologicalpointof view,thecomparabilitypossibilitywaspreviouslydiscussed regardingthe use ofthe same indicators, reference stan-dards,cutoffsandtechniquesthatallowreducingpossible variations in the quantification of malnutrition cases. In thiscontext, it is important tonote that the Gómez and Waterlowclassificationshaveessentiallydifferentand non-comparable classification criteria from a methodological pointofview,withtheNCHSandCDC/NCHSgrowthcurves. However,inadditiontotherestrictivenatureofthe stud-ies(althoughcomparable,theyarepointwiseinvestigations) andtheconcentrationofstudies carriedoutinSãoPaulo, withscarcity in other areas of Brazil, there is an impor-tantfactorofdispersionofresultsassociatedwithtime(18 yearsfor33studies),whichbringsrestrictionstostudy com-parability.The differences betweenthe nutritionaldeficit prevalencerateshavechangedsignificantlybetween stud-ies,whichmaybeduetothedaycarecenterlocation,the children’ssocioeconomicstatus,butalsothetimeofdata collection. For instance, the H/A ratio ranged from 0.5% to55%,but onestudywascarriedoutin 1999inParáand theother one in2007 in SãoPaulo. Itis known that mal-nutritionisdecreasing withtime,inadynamic processof nutritionaltransition,whichhaschangedthenutritional sce-narioinBrazil.Therefore,conclusionsabouttheprevalence ofmalnutritionusingstudydatacollectedatdifferenttimes can show a bias, as the older data no longer represent the children’snutritional status. The results are,in fact, diachronic.The analysisof variations in nutritionalstatus indicatorsmustfacesimilardifficulties.Finally,thesituation thatencompassesalongtimeanddiversegeographicalareas producesadispersionthatneedstobeconsideredtooutline theanthropometric profile ofBrazilian childrenattending daycarecenters;however,itsadjustmentisadifficultone. Ifthepreviouslimitationcanbeclearlyobservedinall thearticlesreviewedherein,itisalsoobservedamongthe studies12,13,20---24,27,35thatconsideredasareferencestandard
theinfant growth curvesby WHO 2006,48 thatmost were
published from 2010 onward, with plausible synchronous resultsofsystematization.Inthesestudies,theprevalence ofmalnutritionindicatedbytheW/Hratioislow,between 0.4%12,23 and 1.8%,24 values that indicate virtually norisk
ofmalnutritionbecausetheyrepresentsimilarfrequencies tothosefoundinthereferencedistribution.20Theassessed
children’soverweightcanalsobeverifiedconsideringallof thesearticles,accordingtoboththeBMI/A,whichreports prevalence between 22.5%35 and 29.6%,13 as well as the
W/H ratio, with numbers ranging from 3.8%23 to 9.8%.12
Consideringthe stunting prevalence, we have a weighted meanthroughtherespectivesample sizes of6.3% (range: 8.6---2.9), which corresponds to 125 children with short stature of a total of 1969 children, indicating significant rates,either considering thedistribution ofthereference populationortheWHOparameterstoclassifytheseverity oftheproblem.20
Theseanalysessuggestahighprevalenceofoverweight, no acute malnutrition, and a still significant prevalence of stunting, indicating the occurrence of a nutritional
transition process in the population of Brazilian chil-dren attending daycare centers. Nationwide Brazilian surveys,49,50whichhaveusedthenewgrowthcurvesforthe
analysisof thenutritional statusof childrenyounger than fiveyears,haveshownsimilarfindings.TheHousehold Bud-getSurvey(2008---2009)50results,moreover,showedthatthe
prevalenceofstuntinginchildrenyoungerthanfiveyearsold varies accordingtothe incomeclass,from8.2%when the familymonthlypercapitaincomeisupto¼ofaminimum wage, to 3.1%, when the household incomeis more than fiveminimumwages.Inthiscontext,thereisevidenceofa greaterpotentialvulnerabilityofchildrenattendingdaycare centers,sincethisisrealityismainlyassociatedtoalackof resources or becausethe children’smothers work outside thehome.51
Itisnoteworthythattheresultsanalyzedhererepresent the reality of children attending publicday care centers, as,intheirstudies,theresearcherspredominantlyanalyzed daycarecentersofpublicadministration. Onlytwostudies included childcare institutions administered by the pri-vatesector,13,29whichwerepublishedin200429and2010.13
Therefore,thesystematizedresults refertochildrenfrom avulnerablesocioeconomicclass,whosefamiliesneedthe servicesprovidedbypublicdaycarecenters,either munic-ipal or state-run institutions. Also, this review included articles identified in only three bibliographic databases, whichcanlimittheanalysisspectrum(possibilityoflimited numberofcases/institutionsnotknowingabout the repre-sentativeness).
Although the results of this article suggest that the nutritionaltransitionprocessobservedintheBrazilian popu-lationisalsopresentinthepopulationofchildrenattending daycarecenters,itemphasizestheneedtodevelopa mul-ticenter survey onhealth andnutrition, combinedwith a higher number of pointwise investigations, but compara-ble,aimingtomoreaccuratelyassessthecurrentbehavior of malnutrition prevalence in children attending daycare centers.Thiswouldallowaclearercomparisonofthe nutri-tionalstatusindicatorsinchildrenattendingdaycarecenters with national data and from other vulnerable groups, as well astheplanning of interventionsaimedat controlling overweightandstunting.
Funding
Thisstudydidnotreceivefunding.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
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