www.jped.com.br
REVIEW
ARTICLE
Brazilian
infant
and
preschool
children
feeding:
literature
review
夽
Carolina
Santos
Mello
a,
Karina
Vieira
Barros
b,
Mauro
Batista
de
Morais
c,∗aUniversidadeFederaldeAlagoas(UFAL),FaculdadedeNutric¸ão,Maceió,AL,Brazil
bDanoneEarlyLifeNutrition,SãoPaulo,SP,Brazil
cUniversidadeFederaldeSãoPaulo(UNIFESP),EscolaPaulistadeMedicina(EPM),DisciplinadeGastroenterologiaPediátrica,
SãoPaulo,SP,Brazil
Received25November2015;accepted23February2016 Availableonline16June2016
KEYWORDS Feeding; Childnutrition; Infant;
Preschoolchild; Brazil
Abstract
Objective: To assess the feeding profile of Brazilian infants and preschool children aged
6monthsto6years,basedonthequalitativeandquantitativeanalysisoffood andnutrient
intake.
Datasource:ThisreviewanalyzedstudiescarriedoutinBrazilthathadfoodsurveydata on
infantsandpreschoolchildren.Thesearchwaslimitedtopublicationsfromthelast10years
includedintheLILACSandMEDLINEelectronicdatabases.
Datasummary: Theinitialsearchidentified1480articles,ofwhich1411wereexcludedafter
theanalysisofabstracts,astheywererepeatedordidnotmeettheinclusioncriteria.Ofthe
69articlesassessedinfull,31articlescontaineddataonfoodsurveyandwereselected.Only
threestudiesconcurrentlyassessedchildrenfromdifferentBraziliangeographicalregions.Of
theassessedarticles,eighthadqualitativedata,withdescriptiveanalysisoffoodconsumption
frequency,and23hadpredominantlyquantitativedata,withinformationonenergyandnutrient
consumption.
Conclusions: Thearticlesassessedinthisreviewshowedveryheterogeneousresults,making
itdifficulttocomparefindings.Overall,thefeedingofinfantsandpreschoolchildrenis
char-acterizedbylowconsumptionofmeat,fruits,andvegetables;highconsumptionofcow’smilk
andinadequatepreparationofbottles; aswellasearlyandhighintakeoffried foods,
can-dies/sweets,softdrinks,andsalt.Theseresultsprovideaidforthedevelopmentofstrategies
thataimtoachievebetterqualityfeedingofBrazilianinfantsandpreschoolers.
©2016SociedadeBrasileiradePediatria.PublishedbyElsevierEditoraLtda.Thisisanopen
accessarticleundertheCCBY-NC-NDlicense(http://creativecommons.org/licenses/by-nc-nd/
4.0/).
夽
Pleasecitethisarticleas:MelloCS,BarrosKV,MoraisMB.Brazilianinfantandpreschoolchildrenfeeding:literaturereview.JPediatr (RioJ).2016;92:451---63.
∗Correspondingauthor.
E-mail:[email protected](M.B.deMorais).
http://dx.doi.org/10.1016/j.jped.2016.02.013
PALAVRAS-CHAVE Alimentac¸ão; Nutric¸ãodacrianc¸a; Lactente;
Pré-escolar; Brasil
Alimentac¸ãodolactenteedopré-escolarbrasileiro:revisãodaliteratura
Resumo
Objetivo: Verificaroperfilalimentardolactenteedopré-escolarbrasileiro,nafaixaetáriade
6mesesaos6anos,apartirdaanálisequalitativaequantitativadoconsumodealimentose
nutrientes.
Fontesdedados: NestarevisãoforamanalisadosestudosrealizadosnoBrasilqueapresentavam
dadosdeinquéritosalimentaresdelactentesepré-escolares.Abuscafoilimitadaàspublicac¸ões
dosúltimos10anos,incluídasnasbasesdedadoseletrônicasLilacseMedline.
Síntesedosdados: Napesquisainicialforamidentificados1480artigos,1411foramexcluídos
apósanálisedosresumos,porseremrepetidosounãopreencherem oscritériosdeinclusão.
Dos69artigosavaliadosnaíntegra,foramselecionados31artigosquecontinhamdadossobre
alimentac¸ão.Apenas3trabalhosavaliaramconcomitantementecrianc¸asdediferentesregiões
geográficasbrasileiras.Dosartigosanalisados,8apresentavaminformac¸õesqualitativas,com
análisedescritivadafrequênciadeconsumoalimentare23,informac¸õespredominantemente
quantitativas,comdadosdeconsumoenergéticoedenutrientes.
Conclusões: Osartigosanalisadosnapresenterevisãoapresentaramresultadosbastante
het-erogêneos, dificultando a comparac¸ão dos achados. De um modo geral, a alimentac¸ão do
lactenteedopré-escolar écaracterizadapelobaixoconsumo decarnes,frutas,legumese
verduras,porelevadoconsumo deleite devacaeinadequac¸ãonopreparode mamadeiras,
alémde precocee elevadoconsumo de frituras,doces,refrigerantese sal.Nossos
resulta-dosconstituemsubsídiosparaaelaborac¸ãodeestratégias quevisemmelhoraqualidadeda
alimentac¸ãodolactenteedopré-escolarbrasileiro.
©2016SociedadeBrasileiradePediatria.PublicadoporElsevierEditoraLtda.Este ´eumartigo
OpenAccesssobumalicenc¸aCCBY-NC-ND(http://creativecommons.org/licenses/by-nc-nd/4.
0/).
Introduction
Growth and development are two complex, interrelated phenomena that are characteristic of pediatric patients. Growthdependsontheinteractionofgeneticfactors,which havetheir expressionmodulated by environmental, socio-economic, emotional, andnutritional factors.1 Therefore,
feeding is important not only to provide full growth and
development,butalsobecauseit is involved inthe
gene-sisof themain nutritionaldisorders inchildhood,such as
protein---energy malnutrition, obesity,iron deficiency, and
hypovitaminosisA.
One aspect that has received increasing attention in
recentdecadesistheassociationbetweenfeedingand
nutri-tionalstatusin early lifeand thedevelopmentof chronic
diseases in adulthood.2---5 In this context, a systematic
review6showedthatlong-termbreastfeedingisassociated
with lower values of blood pressure, total cholesterol,
prevalenceofoverweight,andtype2diabetesmellitus,as
wellasbetterintellectualdevelopment.
Basedoncross-sectionalstudiescarriedoutinBrazilin
the1970s,1980s,and1990s,arapiddecreasewasobserved
inthe prevalence ofprotein---energy malnutrition, aswell
asanincreasedprevalenceofoverweightandobesity,
char-acterizing the nutritional transition phenomenon.5,7 The
observedchangeshaveparticularcharacteristicsaccording
to geographical regions of Brazil and social classes, and
are the result of profound changes in the country over
recentdecades.7 It shouldbenotedthat nutritional
tran-sition is a worldwidephenomenon. Acrossthe world, the
availabilityoffoodhasincreasedby10%,withaconsequent
reductionintheprevalence ofmalnutritionandincreasing
obesity, which has become a severe concern in terms of
public health. It is considered that this phenomenon can
be explained, at least in part, by the influence of
eco-nomicgrowth,urbanization,andglobalizationofthedietary
pattern.8
Despitetheimportanceofthedietarypatternofinfants
and preschool children, there are no nationwide data to
address this issue in Brazil, with the exception of the
NationalSurveyonWomen’sandChildren’sHealth(Pesquisa
Nacional de Demografia e Saúde da Crianc¸a e da Mulher
[PNDS]),9withthelastsurveyperformedin2006.
ItshouldbenotedthatthePNDSdataareprimarily
quali-tative,andarerelatedtobreastfeedingandcomplementary
feeding.
As it is necessary to explore further scientific
produc-tion in addition to the PNDS9 regarding dietary patterns
in childhood, this article sought to gather not only
cur-rentinformationonthefeedingqualityofBrazilianinfants
and preschool children, but also to highlight the main
inadequaciesrelatedtonutrientintakein thispopulation.
Considering that there is some concern about the
influ-enceofnutritionalinadequaciesoccurring frompregnancy
topreschoolageintheoccurrenceoflong-term
noncommu-nicablediseasesandillnesses,aswellasthehighprevalence
in Brazil of deficiency diseases in childhood, this review
aimedtoanalyzestudiesonthefeedingpatternofinfants
andBrazilianpreschoolchildren, between6monthsand6
yearsof age,analyzing qualitative andquantitative
infor-mationabouttheconsumptionofmajorfoodandnutrients
Methods
Forinclusioninthisreview,studiescarriedoutinBrazilwere selectedthroughasearchoftheLILACSandMEDLINE elec-tronic databases. The search was carried out considering fourgroupsofkeywords:1:(‘‘feeding’’OR‘‘food consump-tion’’ OR ‘‘diet’’) [Subject descriptor] AND (‘‘child’’ OR ‘‘infant’’OR‘‘preschooler’’)[Limits]ANDBrazil[Words];2: (‘‘feedingpatterns’’ OR ‘‘feedingbehavior’’OR ‘‘feeding habits’’) [Subject descriptor] AND (‘‘child’’ OR ‘‘infant’’ OR‘‘preschooler’’)[Limits]ANDBrazil[Words];3:(‘‘child feeding’’ OR ‘‘complementary feeding’’ OR ‘‘child nutri-tion’’OR‘‘childnutrition’’OR‘‘foodsupplementation’’OR ‘‘mixed feeding’’) [Subject descriptor] AND (‘‘child’’ OR ‘‘infant’’OR ‘‘preschooler’’) [Limits] AND Brazil [Words]; 4:(‘‘nutritionalstatus’’OR‘‘nutritionalsurveys’’[Subject descriptor]AND(‘‘child’’OR‘‘infant’’OR‘‘preschooler’’) [Limits]AND‘‘Brazil’’[Words].
The aim of this strategy was to identify all the arti-cles thathaddataonfeeding(fromcomplementaryfoods consumedafter6months,tothefoodsconsumedbyolder children uptotheage of 6years).Data onbreastfeeding werenotincludedintheanalysis.
There was no restriction on language; however, only original articles were selected,carried out withBrazilian children. Consideringthemagnitude ofthe initial results, the search was limited to scientific articles published in the last ten years, with the last search carried out in March2014.As theinclusioncriteria,theauthorsselected articles carried out with children under the age of 7 yearswithfoodsurveydata(24-hrecall,daily usualfood,
food record, food frequency, and/or direct weighing of food).
Atthefirstanalysis,repeatedabstractswereexcluded, thosewhichcoexistedinbothdatabases.Later,two review-ers(MBM,CSM)independentlyselectedabstractsbasedon thepredefinedeligibilitycriteria.Forabstractsthatdidnot containenoughinformationtobeincludedintheliterature review,itwasdecidedtoevaluatethefulltext.Casesof dis-agreementregardingtheselectionwerereevaluateduntila consensuswasachieved.
Fig.1describestheflowchartoftheresearch,selection,
andinclusionofscientific articlesintheliteraturereview.
Astandardizedassessmentwascarriedoutofthefollowing
informationoftheassessedarticles:studylocation,yearof
datacollection,typeofstudyandsampling,methodsused
toevaluatethefeeding,andsummaryofthemainresults.
Results
and
discussion
Usingtheinitialsearchstrategy withkeywords,1480 arti-cleswereidentifiedinthedatabases.Aftertheexclusionof repeatedarticlesandtheanalysisbasedonthepredefined inclusioncriteria,31articleswereeligible.
Analyzingthestudiesincludedin thisliteraturereview, an important heterogeneity was verified in the studies aboutthespecificobjectives,samplecomposition,methods usedtoevaluate thefeeding (surveys),and expression of results,which preventedthecomparisonofdifferent find-ings.Therefore,adescriptiveanalysisoftheresultsshown inthereviewedarticleswasperformed,aimingtoaggregate theoriginalinformationobtainedfromthedifferentstudies.
Electronic search for descriptors: 1480 articles identified (databases: Lilacs and
Medline)
Identification of 870 articlesa
Selection of 69 articles
68 articles obtained in full
Excluded 801 articles based on abstracts and/or full
articleb
31 articles included in the systematic review
Excluded 37 full articlesc 610 excluded articles with publication data before
2004
Figure1 Flowchartoftheresearch,selection,andinclusionofscientificarticlesinthesystematicreview.
aStudiespublishedinthelast10years(since2004).
bRepeatedarticles(64)/didnotmeettheinclusioncriteria(1347).
Onlythreearticlesassessedchildrenfromdifferent geo-graphicalregions:(1)astudywith4322children,carriedout basedonPNDS/2006data10;(2)astudywith3058children
livingin nineBrazilian cities11;and (3),astudy with
chil-dren fromthree cities: Recife, São Paulo, and Curitiba.12
Theotherarticles(n=28)werecarriedoutasfollows:four
intheNorth,ninein theNortheast,ten intheSoutheast,
andfiveintheSouthregion.Itshouldbenotedthatthree
studiesintheNortheastcarriedoutinPernambuco13---15and
threefromtheSouthregioninSãoLeopoldo16---18addressed
differentresultsfromthesamepopulationsurvey.
Thearticlesweredividedintotwocategories:thosewith
mainlyqualitativeinformationandthosewithquantitative
information.Thearticleswerecharacterizedasqualitative
whenthey had only descriptivedata onthe frequency of
consumptionofspecificfoodsorfoodgroups.The
quantita-tivearticleswerethosewithinformationrelatedtoenergy
and/or nutrient consumption. Tables 1 and2 disclose the
basicinformationontheeightqualitativeand23
quantita-tivestudies,respectively.
Itshouldbenotedthatasignificantportionofthe
col-lected articles did not assess probabilistic samples that
adequatelyrepresented theentire Brazilian population of
theassessedagegroup.Therefore,theanalyzeddata
can-not beextrapolated to the entire Brazilian population of
infantsandpreschoolers.Inturn,theinformationobtained
representstheonlycurrentlyavailabledataandshouldbe
usedwithcaution,untilstudieswhosesamplingtakesinto
accountallthepeculiarcharacteristicsofBrazil(e.g.,urban
and rural settings, different weather conditions,
socio-economicstatus,culturalandregionaldifferences,among
others)arecarriedout.
The following are critical comments integrating the
resultsofdifferentsurveysaccordingtothedifferent
cate-goriesoffoodandnutrientgroups.
Consumptionofcow’smilkanddairyproducts
Ingeneral,itcanbestatedthatcow’smilkisoneofthemost commonlyconsumedfoodsbyBrazilianchildren.Wholemilk wasconsumeddaily onaverage by 76.9% ofthe children, considering different studies that included children aged between1and7years.19---21 InthestateofParaíba,itwas
foundthat 85.9%ofchildren aged6---12monthsconsumed
dairy foods daily.22 Regarding the consumption of infant
formula,onestudy foundthat only6.7% ofchildren older
than6monthsreceivedformulaasasubstitutionforbreast
milk.10
Regarding the number of daily recommended servings
ofdairyfoods, itwasobservedinDuquedeCaxias,inRio
deJaneiro,23 thatchildrenaged6---30monthshadan
aver-ageconsumption oftwoservings/day,whichis considered
belowthethreeservingsrecommendedbynational
guide-linesonfoodandnutrition.24 Meanwhile,inasmallgroup
of children aged2---3 yearsfrom Paquetá Island (RJ), the
average consumption was even smaller, 1.8 servings/day,
alsobelow the recommendation when considering the US
dietary guidelines as reference,25 which recommend two
servings/day. As for the per capita daily consumption of
cow’smilkanddairy products,accordingtodataobtained
inSalvador(BA),children aged6---12monthsconsumedan
averageof528.9mL/dayandchildrenaged12---24months,
548.1mL/day.26
Inastudyconductedwithchildrenagedbetween4and12
months,livinginthreeBraziliancities(Curitiba,SaoPaulo,
andRecife),12themeanageforintroductionofformulawas
threemonths,whereasthemeanagefortheintroductionof
complementaryfeedingandfamilyfoodswas4monthsand
5.5months,respectively.
Accordingtoworldwideguidelines,thecontinuation of
breastfeedingshouldbeencouragedastheexclusivesource
of dairyfoods milkupto2 yearsof ageor older, andthe
introductionofwholecow’smilkshouldbecontraindicated
before 12 months of life.27 It is already well established
thatearlyand/orexcessiveconsumptionofcow’smilkmay
be related to the occurrence of iron deficiency anemia,
foodallergy,andobesity.27,28Infantformulas,despite
hav-ingintactproteins,arethefirstchoiceofdiaryfeedingfor
weanedchildren,mainlyduetotheadequacyofproteinand
micronutrientrequirementsforinfants.27
Consumptionofmeat
Regarding the frequency of weekly consumption, the PNDS/2006 assessed 4322 children from five Brazilian regions,ages6---59months,andfoundthat24.6%consumed beefdaily,6.1%consumedchicken,and1.5%consumedfish; i.e.,thedailyconsumption ofsometypeofmeatwas ver-ified inonly32.2%oftheassessedchildren.10 InSãoPaulo
state,29 it was found thatthe probabilitychildren aged 6
monthswouldconsumemeatinsoupsorcookedmealswas
54%and25%,respectively,showingatrendofincreasing
con-sumption close to12 months of age. The consumption of
somekindofmeatinthelast24h,forchildrenaged6---12
months,occurredonaverageinapproximately35%of
chil-dren,according todatafromdifferentstudies,26,29andon
averagein47.3%ofchildrenaged12---24months.22,26
Regarding the consumption of daily servings, it was
observedinSãoLeopoldo(RS)18 that78.4%ofchildrenate
meat, but in insufficient quantities. In Campinas (SP),30
in children aged 2---6 years, a consumption of 1.32
serv-ings/day from the meat food group was observed, with
nodifferencebetweenthemaleandfemalegenders.Both
national andinternationalguidelinesrecommendthe
con-sumption of two servings per day from the meat food
group.24,25
In Salvador (BA),26 an average per capitaconsumption
ofmeatof13.3g/daywasobservedinchildrenaged6and
12months,and24.4g/dayinchildrenaged12---24months.
Regarding the daily energy equivalent, a study in Acre31
observedthatthemeatfoodgroup(beef,chicken,andfish)
contributed3%ofthetotalenergyintakeofchildrenaged
6---11monthsand5%inchildrenaged12---24months.
Meatscomprisethefoodgroupthatconstitutesasource
ofironwithhighbioavailability,andinadditiontobeinga
sourceofheme iron,itpotentiatestheabsorptionof
non-hemeiron.Oneshouldbeawareofthedifficultyinaccepting
meatbyinfantsandpreschoolchildren,especiallyin
rela-tiontotheconsistencyoftheofferedfood.Anotherfactor
thatconfirmsthedeficientintakeisthecostoffood.
Pro-viding nutritional education can promote the appropriate
Table1 Typeofstudy,placeandyearofimplementation,samplesize,age,andmethodusedforqualitativeassessmentof
dietaryintakeofeightstudieswithBrazilianinfantsandpreschoolchildren.
Reference Typeofstudy/place
andyearofcollection
Sample size/age
Foodsurvey Summaryofresults
Bortolinietal.(2012) Cross-sectional5
regionsofBrazil;
2006/2007
n=4322
6---59months
Foodfrequency
questionnaire
ThechildrenlivingintheSouth,
Southwest,andMidwestregionsmore
oftenconsumedtherecommended
foods(rice,bread,potatoes,beans,
leafyvegetables,legumes,meat,
yogurt)aswellasnon-recommended
ones(sweetsandsoftdrinks).Those
livingintheNortheastregionmore
oftenconsumedfruit,cookies,and
snacks.Thechildrenlivinginthe
urbanstratummoreoftenconsumed
recommendedandnon-recommended
foodswhencomparedtoruralareas.
Cagliarietal.(2009) Cross-sectional
CampinaGrande,PB;
2007
n=112
2---5years
Foodfrequency
questionnaire
Foodgroupsmoreoftenconsumed
everyday:rice,milk,sugar/snacks
andoil.Thelessoftenconsumed
dailywerevegetablesandmeat.
Castroetal.(2004) Cross-sectional
Tumiritinga,MG;2001
n=69
0---60years
Foodfrequency
questionnaire
Foodconsumedmoreoftenbythose
olderthan1year:legumes,cereals,
andmilk.Vegetables,fruitsand
meatsshowedlowconsumptionor
wereabsentfromthedailydiet
(47.3%,63.6,and72.7%consumed
lessthanfourtimes/week).High
consumptionofsweets(67.3%
consumedatleastonceaweek).
Gaticaetal.(2012) LongitudinalPelotas,
RS;2004---2008
n=4231
12---48years
Frequencyoffood
consumptionin
thepast24h
Low-socioeconomiclevelchildren
consumedmoresweets,coffee,
bread/cookies.High-socioeconomic
statuschildrenconsumedmore
fruits,yoghurt,andsoftdrinks.
Nobreetal.(2012) Cross-sectional
nestedinacohort
Diamantina,MG;
2009---2010
n=232
5years
Foodfrequency
questionnaire
Lowmaternaleducationwas
associatedwithagreaterchanceof
consumptionofa‘‘mixeddiet’’anda
lowerchancetoconsume‘‘snacks’’;
whilethosewithhigherpercapita
incomearemorelikelytoconsume
‘‘unhealthy’’foods.
Palmeiraetal.(2011) Cross-sectional
Paraíba---14
municipalities;2005
n=539
0---24months
24-hfoodrecall Highconsumptionofdairyproducts
between6and24months.
Insufficientdailyconsumptionoffood
sourcesofironbetween12and24
months.
Pereiraetal.(2008) Cross-sectional
Teresina,PI;2003
n=135
36---83months
Foodfrequency
questionnaire
Alowconsumptionoffoodswithhigh
ormoderatelevelsofvitaminAand
highconsumptionoffoodslowinthis
vitaminwasobserved.
Saldivaetal.(2007) Cross-sectionalSão
Paulo---136
municipalities;2004
n=24,448
6---12months
24-hfoodrecall At6monthstherewasahigh
probabilityofconsumptionofmilk
andsoups.Theprobabilityof
consumptionoffoodsourcesofiron
is66%at6monthsand90%at12
Table2 Typeofstudy,placeandyearofstudy,samplesize,ageandmethodforqualitativeandquantitativeassessmentof
dietaryconsumptionof23studieswithBrazilianinfantsandpreschoolers.
Reference Typeofstudy/place
andyearofcollection
Sample size/age
Foodsurvey Summaryofresults
Antunesetal.(2010) Cross-sectional
DuquedeCaxias,RJ;
2005
n=384
6---30months
24-hrecall
(2days)
Consumptionbelow
recommendationsforvegetablesand
dairyproducts.Thehigherthe
degreeoffoodinsecurity,thelower
theproteinandironintake.
Azevedoetal.(2010) Cross-sectional
Recife,PE;2007
n=344
24---60months
Direct
weighing+24-h
recall(2
applicationsin
20%ofchildren)
MedianconsumptionofvitaminA
higherthantheEARforchildrenaged
24---47monthsandolderthan
47months.
Barbosaetal.(2006) Longitudinal
IlhadePaquetá,RJ;
2003
n=20
2---3years
Initialassessment
bydietaryhistory
andafter6
monthsbydirect
weighingoffood
andfooddiaries
(2days)
After6monthsofdaycare
attendance,morechildrenreached
therecommendationfor:meat
(55---80%),fat(45---55%)andfruit
consumption(20---85%).The
percentageofthegroupofcereals
remainedunchanged(20%)andmilk
decreased(45---35%).Nochild
reachedtherecommendationforthe
consumptionofvegetables.
Beinneretal.(2010) Longitudinal
Diamantina,MG;2006
n=176
6---24months
Fooddiary(3
days)
Theaveragedietaryconsumptionof
zincwashigherthanthe
recommendations.30.6%ofchildren
ingestedanamountofZnbelowthe
EARand19.4%,higherthantheUL.
Bernardietal.(2011) Cross-sectional
CaxiasdoSul,RS;
2007
n=362
2---6years
Direct
weighing+food
diary(1day)
56.5%ofthedailyfoodintakeofiron
wasprovidedbytheschool;62.7%of
thedailycalciumintake,55.3%of
vitaminAintakeand51.4%ofzinc
intakewereprovidedbythehome.
Childreninprivateschoolshadhigher
intakeofironandvitaminA;thosein
publicschoolshadhigher
consumptionofzincandcalcium.
Accordingtohouseholdrecords86.8%
ofchildrenconsumeddairymeals.
Buenoetal.(2013) Cross-sectional
Multicentric(9
Braziliancities);2007
n=3058
2---6years
Direct
weighing+food
diary(1day)
Themeanfatintakeforchildren
aged2---3yearswaslowerthanthe
recommendedenergypercentage.
Higherconsumptionofsodiumand
saturatedfatwasobservedfor90%
and30%ofchildren,respectively.
Caetanoetal.(2010) Longitudinal
Curitiba,SãoPaulo
andRecife;2005
n=179
4---12months
Fooddiary
(7days)
Highfrequencyofweekly
consumptionofprocessedfoods,soft
drinksandartificialjuices.High
quantitativeinadequacyof
micronutrients:zinc(75%),iron
(45%),vitaminA(38%),calcium
(15%).
Castroetal.(2009) Cross-sectional
AssisBrasiland
Acrelândia,AC;2003
n=69
0and24
months
Usualdailyfood
intake
Highintakeofcarbohydrateand
cow’smilk.Irregularconsumptionof
fruits,vegetables,beansandmeat.
Consumptionaboveandbelowthe
recommendationsforproteinand
Table2 (Continued)
Reference Typeofstudy/place
andyearofcollection
Sample size/age
Foodsurvey Summaryofresults
Cavalcanteetal.
(2006)
Cross-sectional
Vic¸osa,MG;
2003---2004
n=174
12---35months
24-hrecall+food
frequency
questionnaire(1
day)
Prevalenceofinadequateintakes:
vitaminA(36.8%),iron(13.2%)and
zinc(99.4%).Consumptionbelowthe
recommendedlevelforlipids.
Costaetal.(2011) Cross-sectional
Gameleira---PEand
SãoJoãodoTigre
---PB;2005
n=445
0---23months
24-hrecall Energy,macro-andmicronutrients
aboverecommendations,except:
VitaminA(children7---11months)
showedmedianvaluesbelowtheAI;
ironbelowandzincandcalcium
abovethereferencesinallage
groups.
Domeneetal.(2006) Cross-sectional
Campinas,SP
n=94
2and6years
Direct
weighing+24-h
recall
Lowerconsumptionofvegetablesand
fruits,cerealsandfats.Higher
consumptionoffoodsourcesof
protein(meat,dairyproductsand
legumes),richinsugarandsaturated
fat.
Fernandesetal.
(2005)
Cross-sectional
Recife,PE;
1997---1999
n=311
6---59months
Direct
weighing+24-h
recall
78.0%ofthechildrenhadadequate
vitaminAintake.Higherproportion
ofvitaminAconsumptionofanimal
origin(58%).
Fidelisetal.(2007) Cross-sectional
Pernambuco:
metropolitanregion
ofRecife,urbanand
ruralcountryside;
1997
n=948
0---5years
24-hrecall Deficitofenergyandexcessprotein
washighinallagegroupsand
geographicalareas.Highincidenceof
inadequateironandzincintakein
differentagegroups.
Garciaetal.(2011) Cross-sectional
Acrelândia,AC;
2007---2008
n=164(127
withsurvey)
6---24months
Usualdailyfood
intake
IngestionofvitaminA(42%),zinc
(46%)andiron(71%)below
recommendations.Lowconsumption
offruits,vegetablesandmeat;
excessiveconsumptionofcowmilk
andporridge.
Levy-Costa,Monteiro
(2004)
Cross-sectional
SãoPaulo,SP;
1995---1996
n=1280(598
withsurvey)
0and59
months
24-hrecall Itwasobservedthat1.1mg/1000kcal
ofironwerehemeironand
4.3mg/1000kcalwerenon-heme
iron.
Menezesetal.(2007) Cross-sectional
Pernambuco:
metropolitanregion
ofRecife,urbanand
ruralcountryside
(1997)
n=948
0---60months
24-hrecall Highoccurrenceofenergyintake
inadequacy,especiallyintheage
groupsof48---60monthsand0---6
months.Proteinintakeabove
recommendations,inallagegroups.
Oliveiraetal.(2005) Cross-sectional
Salvador,BA;1996
n=724
0---24months
24-hrecall Averageenergyandprotein
consumptionwashigherthan
recommendationsforallagegroups.
Carbohydratescontributedwiththe
highestpercentagetothetotal
energyvalueofthedietandthis
percentageincreasedwithage,while
thecontributionoflipidsdecreased.
Oliveiraetal.(2006) Cross-sectional
Pernambuco:
metropolitanregion
ofRecife,urbanand
ruralcountryside
(1997)
n=746
6---59months
24-hrecall Highconsumptionofcow’smilk
(88.9%),especiallywholemilk
powder(47.8%)andliquidmilk
(24.1%).Only7.5%ofchildren
Table2 (Continued)
Reference Typeofstudy/place
andyearofcollection
Sample size/age
Foodsurvey Summaryofresults
Portellaetal.(2010) Cross-sectional
Belém,PA;2005---2006
78food
samples
6---18months
24-hrecall
(two)+chemical
analysisoffood
Allsamplesanalyzedshowedamounts
ofironbelowtherecommended
minimum.Excesssodiumwasfound
in89.2and31.7%ofsamplesfrom
lowandhighsocioeconomicstatus
groups,respectively.
Rauberetal.(2013) Longitudinal
SãoLeopoldo,RS;
2001---2002
n=345
3---4years
24-hrecall(two) Only9.6%ofchildrenhadagood
dietarypattern.Dietaryvarietyand
dairyconsumptionwashigherand
consumptionoftotalandsaturated
fatwasloweramongchildrenwhose
mothershadhighereducationallevel.
Salles-Costa(2010) Cross-sectional
RiodeJaneiro
---metropolitanregion;
2005
n=383
6---30months
24-hrecall(two) Ageandfoodinsecurityaffectedthe
meanservingsoffoodgroups
consumedbychildren.Thevariance
ratiowashigherforgroupswith
moderatetoseverefoodinsecurity
thanthosewithfoodsecurity;
especiallyforproteininchildrenaged
6---17monthsandcarbohydrates,for
thoseaged18---30months.
Vitoloetal.(2007) Longitudinal
SãoLeopoldo,RS;
2001---2002
n=369
<1year
24-hrecall Meatconsumptionamongchildren
aged12---16monthswaspresentin
78.4%ofsurveys,buttheconsumed
portionwasinsufficient.Higheriron
andvitaminCintakeswere
associatedwiththeabsenceof
anemia.
Vitoloetal.(2010) Longitudinal
SãoLeopoldo,RS;
2001---2002
n=345
3---4years
24-hrecall(two) Dietaryadviceformothersduringthe
firstyearoflifewasassociatedwith
better-qualitydietat3---4years.
Greaternumberofservingsof
vegetablesandfruitsandagreater
varietyofthedietwasobservedin
theinterventiongroup,inadditionto
lowerconsumptionofcholesterol.
Thegroupsdidnotdifferregarding
theconsumptionofmeat,milk,
sodium,andfat.
EAR,EstimatedAverageRequirement;UL,UpperTolerableIntakeLevel;AI,AdequateIntake.
representinganessentialstrategyforthepreventionof iron-deficiencyanemia.32
Consumptionoffruitsandvegetables
Althoughsomeauthors29reportedhighratesofconsumption
offruit(87%)bychildrenaged6---12monthsinthelast24h,
inan assessmentofweeklyfrequencyofconsumption,the
dailyconsumption offruitand naturalfruitjuice,
respec-tively,wasconfirmedby44.6%and32.5%ofthechildrenin
differentregionsofBrazil.10Itwasalsoobservedthat11.6%
of infants and preschool children did not consume fruits
throughout the entire week, and that fruit consumption
wasmorecommonin theSouth,Northeast,andSoutheast
regionsofthecountry.10
Theaveragepercapitaconsumptionoffruit,accordingto
astudycarriedoutinSalvador,was183.1g/dayforchildren
agedbetween6and12months,and223.1g/dayforchildren
aged 12---24 months. Oranges and bananas were the fruit
mostoftenconsumedbychildreninbothagegroups.26
Thegroupofvegetableswasreferredtoasirregularlyor
little consumedby several authorsin studies withinfants
and preschoolchildren.16,19,23,30,33---37 In Acre,it wasfound
that53.4%of childrenaged6---24 monthsdidnotconsume
anyvegetablesintheirmainmeals.37
Regardingtheweeklyfrequencyofconsumption,
childrenfromdaycarecentersinCampinaGrande(PB)(36%
ofthosewhostayedatschoolfulltimeand21%ofthosewho
stayedparttime).Mostchildrenfitapatternofconsumption
ofbetweenonetofourtimesperweek.19
The numberof dailyservingsdid notreachthe
recom-mendation of three servings per day24,25 for the children
attending a philanthropic daycare center.33 For children
aged between 6 and 12 months, the average per capita
consumption of vegetables was 57g/day, and potatoes,
carrots, pumpkin, and chayote were the vegetablesmost
often consumed.26 There was also a lower per capita
intake(45.7g/day)ofthisfoodgroupinchildrenaged6---12
months.26ChildrenfromtheSouth,SoutheastandMidwest
regionsshowedhigherconsumptionofvegetablesaccording
todatafromPNDS/2006.10
Nationwide studies9,38,39 have found thatthe
consump-tionoffruitsandvegetablesisnotsufficientforthemajority
of the population in all age groups. It is worth
mention-ingthatthesefoodgroupsconstituteoneofthemaindaily
sourcesofvitamins,minerals,anddietaryfibers.
Consumptionofcerealsandlegumes
Consideringtheconsumptionofcerealsintheformofflour to prepare porridge,it wasfound in Salvador (BA)26 that
corn-based products were consumed by42.5% of children
agedbetween6and12monthsand41%ofchildrenbetween
12and24monthsold.
In Diamantina (MG),34 children aged 6---24 months had
theirdietcharacterizedasshowingpoorqualityand
diver-sity. Rice, beans, and cornmeal were the main foods
prepared by their mothers or guardians.34 Practically all
assessed preschoolers in Campina Grande (PB) consumed
ricedaily,while thedailyintakeofbeanswasobservedin
71%ofthechildren.19 InaruralsettlementinMinasGerais,
itwasfoundthatinchildrenagedmorethan1year,cereals
andlegumes,moreprecisely,rice(92.7%)andbeans(94.7%),
werethemostfrequentlyconsumedfoods,consideringthat
consumptionoccurredfourtoseventimesperweek.20
Regarding the consumption pattern, it was found that
theaveragedailyconsumptionofcerealandcerealproducts
(rice,biscuits,bread,andpasta),forchildrenagedbetween
6and12months,amounted to28g/day;for beans,itwas
14g/day. Childrenaged12---24monthshadan averageper
capitaconsumptionofcerealsandlegumesof82g/dayand
40g/day,respectively.26
In thePNDS/2006, anationwidestudy,10 thedaily
con-sumption of rice and/or pasta was reported for 77.4% of
childrenaged6---59months,breadfor52%,andbeans/lentils
for 66%. Rice and bread were the most often consumed
foodsbychildrenlivingintheMidwest,Southeast,andSouth
regions.Regardingthefrequentconsumptionofbeans,the
highest frequency occurred in the Midwest and Southeast
regions.ChildrenfromtheNorthandNortheastregionshad
alowerdailyfrequencyofconsumptionofbothcereals(rice,
pasta, and bread), and legumes (beans and lentils)
com-paredtochildrenfromotherBrazilianregions.10
The daily consumption of cereals and legumes is
indi-catedinchildhood,startingfromtheperiodofintroduction
of complementary foods at 6 monthsof life. These foods
aresourcesofBvitamins,non-hemeiron,andzinc,among
othervitaminsandminerals,andtogethertheyconstitute
anexcellentsourceofprotein.27,28
Consumptionofoilsandfats
Itwasshown, considering thedata of 4322 children from thefiveregionsofBrazil(datafromPNDS/2006),that51% ofthemconsumedfriedfoodsatleastonceaweek;ahigher rateofconsumption, rangingfromonetothreetimesper week,wasfoundinchildrenfromtheSouthandSoutheast regionsofBrazil.10
Thegroupofoilshadahighfrequencyofdaily
consump-tioninastudyofpreschoolchildreninCampinaGrande,and
wereconsumedby76%ofchildrenwhoremainedfull-time
and90%whoremainedpart-timeindaycarecenters.19
InSalvador(BA),itwasfoundthattheconsumptionofoil
andmargarinewaslowforchildrenaged6---12monthsand
12---24months,withanaveragedailyintakeof0.7g/dayand
0.6g/day,respectively.26
Itisnoteworthythatindietarystudies,theconsumption
offatsandoils, aswell assalt,mayfrequentlybe
under-or overestimated, due to lack of proper identification of
the amount used in the preparationof foods.30 The
con-sumptionoffriedfoods,excessofsalt,andaddedsugarare
contraindicatedinchildren’sdiet.24
Consumptionofsugar,sweets,andsugarydrinks
Sugarsand sweetsisa groupthat shows ahigh frequency ofconsumptionbythepediatric population,asverifiedby severalauthors.10,12,19,26,30,31,40 In Curitiba, São Paulo, and
Recife,12 itwasfoundthatduringthe preparationofbaby
bottlesfor infants agedbetween 6 and12 months,sugar,
cereals, chocolate milk, or both were added to 90.4% of
themwhenpreparedwithpowderedcow’smilk.12This
addi-tion occurred in the preparation of 54.7% of the infant
formulas.
Onestudyshowedthatthedailyconsumptionofsweets
andalsosoftdrinksoccurredinapproximately22%of
chil-dren.Consumptionofsweetsandsoftdrinksatleastoncea
weekwasverifiedformorethan70%ofchildren.Higher
fre-quencyofdailyconsumptionofsweetsandsoftdrinkswas
foundinchildrenfromtheSouthandSoutheastregions.10
Theaveragedailyconsumptionofsugarwas23g/dayfor
children aged6---12 and 37g/day for children aged 12---24
monthsinastudycarriedoutinSalvador.26InAcre,31itwas
observedthattheconsumptionofsweetsandsugarydrinks
amountedto14%ofthetotalenergyintakeforchildrenaged
6---11monthsandto18%ofthetotalenergy,forchildrenaged
between12and24months.
A multicenter study carried out in five Brazilian cities
found that the consumption of sugary drinks, including
softdrinks and artificialjuices, accounted for 37% of the
energyderived from liquids that wereconsumed daily by
children aged 3---6 years.39 The excessive consumption of
sugary drinks hasbeen associatedwiththe occurrence of
overweightinchildren,favoring theearlydevelopmentof
chronic noncommunicable diseases such as diabetes and
hypertension.Accordingtocurrentguidelines,41 freesugar
intakeshould beequivalent toless than 10% of the total
Foodsecurity
Foodinsecurityand/orlowsocioeconomicstatuswas asso-ciated with increased consumption of carbohydrates and lowerconsumptionofproteins23,35,42andiron23,31inseveral
studies.Foodsfromthegroupsofmeatandeggs,cereals,
fruits,vegetables,andfat showedvariationsin their
con-sumption,andwereusuallylittleconsumedbychildrenwith
somedegreeoffoodinsecurity.22,23,43
Greaterconsumptionofsweetsmaybeassociatedwith
lower familyincome and lower parental education.19,20,44
Highintakeofcoffee19,23,44andbreadandbiscuits19,22,44can
beseenmorefrequentlyinthosewithlowersocioeconomic
status or food insecurity. There are no recommendations
relatedtocoffee consumption; however, it is knownthat
excessiveconsumptionmayhindertheabsorptionof
nutri-entssuchasiron.27
Someauthorsemphasizetheimportanceofinstitutionsin
improvingthequalityofchildfeeding.33,35,36,45 The
guaran-teeofcareinhealthandnutritionduringtheperiodspentin
daycarecentersisfavorableforchildrenbelongingtolower
socioeconomicgroups.33
Adequacyofmacronutrientsanddietaryfiber
Amongthemacronutrients,proteinsandlipidsshowedmore frequent inadequacy findings. Protein consumption above therecommendationswasobservedinstudieswithchildren atdifferentageranges.13,14,26,35,42Lipidconsumptionbelow
the recommended was found in a multicenter study,11 in
additionto other studies carried out in Belém (PA)42 and
inVic¸osa(MG).46 However,highintakeofsaturatedfatwas
observedbysomeauthors,11,16,30whichmaycharacterizethe
qualityoftheoffereddietandthehighintakeofdairyfoods.
Thefatintakemaybeunderestimatedinsomestudiesdue
tofailuretoaccountfortheaddedfatinfoodpreparation.
AstudycarriedoutinnineBraziliancapitalcities11found
thatdietaryfiberintakewashigherthantheadequateintake
oftheDietaryReferenceIntakes(DRIs)47inonly22%of
chil-drenyoungerthanfouryearsand5%ofchildrenolderthan
fouryears.Theaveragedietaryfiberintakerangedfrom9.2
to10gper1000kcal.Dietaryfiberintakeinearlychildhood
isscarcelyinvestigated.
Micronutrientadequacy
The evaluation of the micronutrients iron,calcium, zinc, sodium, and vitamin A was considered in this literature review. Calcium and zinc, in general, showed that their requirementswere achieved,andevenexceededthe rec-ommendations in some studies.11,34,35,48 Iron and vitamin
A showed differences regarding the adequacy for
differ-entagegroups.13,31,37,48 Asforsodiumintake,consumption
higherthantherecommendedlimitwasthemostfrequent
result.11,42
Milkanddairyproducts,whicharefoodsoftenconsumed
bythepediatricpopulation,arethemainfoodsources
asso-ciated with the adequacy of calcium and zinc. However,
milkcasein,aswell asthe presenceof phytates,reduces
thebioavailabilityof zinc.49 Afterthesixthmonth oflife,
approximately 70% of the iron and zinc requirements of
infantsshouldbemetthroughsupplementaryfeeding.12
Highfrequency of children withcalcium intake higher
thantherecommendedamountswasverifiedinsome
stud-ies. A study48 with 445 children aged 0---23 months in
Pernambuco and Paraibashowed that calcium intakewas
higher thanrecommendedfor all children inthe assessed
age group. In Caxias do Sul (RS),35 it was observed that
approximately67%ofthe362 assessedchildren,aged2---6
years, had calcium intake at or above the recommended
vale.Amulticenterstudyofpreschoolchildrenfrompublic
andprivateschoolsfoundanaverageofinadequacyin
cal-ciumintakeof13.1%and44.6%inchildrenyoungerthan4
yearsandinchildrenaged≥4years,respectively.11
Astudy13 withchildren from Pernambuco showed high
percentageofvitaminAintakeinadequacyforthechildren
aged 1---3 years and 4---5 years living in the metropolitan
areaand theinadequacy (lower thanthe Estimated
Aver-ageRequirement[EAR])was27.9%and43.2%,respectively.
Amongthoselivingoftheurbancountryside,theinadequacy
in theseage groupswas48.9% and54.3%, respectively. In
childrenbelongingtotheagegroupof7---11monthsinthe
samestudy,themedianvitaminAintake(314g)wasbelow
theAdequateIntake(AI)47(500
g).Anotherstudy,also
car-riedoutinRecife(PE),foundconsumptionbelowtheEAR47
for vitaminA in8.1%of childrenaged24---47 months,and
21.3%inthoseaged48---60months,withthislower
percent-ageofinadequacybeingattributedtodietaryqualityinday
care.45
Itshouldbetakenintoaccountthatthe bioavailability
of vitamin A in animal-sourcefoods is higher when
com-pared to the carotenoids with pro-vitamin A activity.36,45
Fernandes et al.,36 in addition to verifying the adequate
intakeofvitaminAby77.9%ofchildrenunder5years,found
that approximately 58.0% of the consumption came from
animal-sourcefoods(preformedvitaminA)and35.0%from
vegetablefoods(carotenoids).
Iron-deficiency anemia and vitamin A deficiency are
nutritional deficiencies characterized as a public health
problem in Brazil. The deficiency of micronutrients such
as vitamin A, iron, and zinc impairs the normal growth
and development of children and lowers their resistance
to infectious diseases.46 Vitamin A deficiency has some
endemic areas in Brazil. According to data from the
PNDS/2006,9inadequatelevelsofvitaminA(0.70mmol/L)
were verified in 17.4% of the assessed children, with the
highest prevalenceoccurring inthe Northeast(19.0%)and
Southeast (21.6%)of the country.In the samesurvey, the
prevalence of anemia(hemoglobin<11g/dL) was20.9% in
Brazil,withthehighest prevalencefoundintheNortheast
(25.5%)andthelowestfoundintheNorth(10.4%).
One study analyzed the iron density in the diet of
children aged 6---59 months in São Paulo, and found that
1.1mg/1000kcalwerefromhemeironand4.3mg/1000kcal
werefromnon-hemeiron.50Animal-sourceironcontributed
0.6%and14.3%oftotalironingestedbychildrenaged6---11
monthsand12---24months,respectively.31
In São Leopoldo (RS),18 a study of 369 children aged
between12and16monthsfoundthattheabsenceof
ane-mia was significantly associated with higher consumption
of heme iron and vitamin C, and with lower intake of
Itwasobservedthattheaveragecow’smilkconsumption
wasstatisticallylowerinchildrenwhodidnothavesevere
anemia(523±315mL)whencomparedtothosewithsevere
anemia(648±387mL)(p=0.01).Thatis,theconsumption
ofcow’smilkcanpromoteadequatecalciumandzincintake;
however, it is related tothe inadequacy of iron and may
haveaninhibitoryeffectontheabsorptionofdietaryiron,50
favoringtheoccurrenceofiron-deficiencyanemia.15
Sodium intake higher than the recommendation was
observed on average in 98.1% of the children in a study
withpreschoolchildren frompublicandprivateschoolsin
nineBraziliancities,withanaveragedailyconsumptionof
2186.5mg.11 InBelém(PA),42 itwasdemonstratedthrough
thechemicalanalysisoffoodsamplespreparedathomefor
lunchthatthesodiumcontentwashigherinthelow
socio-economic(363.2±148.3mg)thaninthehighsocioeconomic
group (269.3±138.0; p=0.005). Excess sodium was more
frequent infoods of thelow socioeconomicgroup thanin
foods of the high socioeconomic group (89.2% vs. 31.7%;
p=0.027).
Currently, the National Plan of Sodium Reduction in
ProcessedFoodsaimstoreducesodiumintakeamong
Brazil-ians, including actions to reduce the addition of salt to
manufactured products and awareness regarding rational
consumption of added salt. These strategies are part of
the process of coping with noncommunicable diseases,
suchasarterialhypertensionandcardiovasculardiseases.51
According to data from the Household Budget Survey
(2002---2003),52 theadditionof saltandsalt-based
season-ingsconstitutedthemainsourcesofsodiuminBraziliandiet.
Inthe2008---200953survey,areductionwasobservedinthe
annualpercapitaconsumptionofsalt;however,therewas
anincreaseintheconsumptionofprocessed,ready-to-eat
foods.
The results of thisliterature review depictthe dietary
qualityofBrazilianinfantsandpreschoolersinrecentyears.
Thedietarypatternandoccurrenceofnutritionaldisorders
inchildrenremainmattersofconcern,asdemonstratedby
studiespublishedinBrazilafterthedatasearchtoperform
thisliteraturereview.54---57
From the methodologicalpoint of view, thisstudy
fol-lowedtheprinciplesforsystematicliteraturereviews;i.e.,
thesearchwasorganizedaccordingtoexplicit,
comprehen-sive,andreproduciblecriteria,followedbycriticalanalysis
oftherelevantgatheredinformation.
Conclusion
The resultsofthedifferentstudiesassessed inthis litera-turereviewallowabroaderevaluationofthefeedingprofile characteristicsofBrazilianinfantsandpreschoolers.Despite theheterogeneityoftheevaluatedarticles,onecanobserve thatirrespectiveofsocioeconomicstatus,regionoforigin, orage,qualitativeandquantitativeinadequaciesrelatedto theconsumptionoffoodandnutrientsaresimilar.Overall, alow frequency ofconsumption of meat,fruits, and veg-etables is observed. The protein adequacy in the diet is guaranteed by the high consumption of cow’s milk; how-ever, theingestionofthis nutrientisoftenexcessive.The preparation of baby bottles is inappropriate, considering theadditionofunnecessaryingredientstoinfantformulas.
Excessiveconsumption of friedfoods, softdrinks,sweets, candies,andsaltisalsoobserved.
Theoccurrenceofinadequaciesinnutrientintakemaybe associatedwiththeperpetuationofthemainpublichealth problems found in the pediatric population, such as iron deficiencyanemia,vitaminAdeficiency,andexcessweight associatedwith the early onsetof comorbidities that are highly prevalent in adults, such as diabetes mellitus and systemicarterialhypertension.
Considering that food choices are related not only to purchasingpower,butmainlytoactionsbasedonthefood andnutritioneducation,itisworthemphasizingthe impor-tance of more effective adoption and implementation of healthpoliciesaimedatthisvulnerablepopulation,inorder topromote adequate growthand developmentas well as toprevent diseases and nutritional disorders. The results assessedinthisreviewrepresentaidsforthedevelopmentof strategiestoimprovethedietaryqualityofBrazilianinfants andpreschoolers.
Conflicts
of
interest
CSMandMBM participatedin the internationalproject by Danone Early Nutrition known as NUTRIPLANET (2013) in Brazil;KVB is part of the team of DanoneEarly Nutrition inBrazil.
Acknowledgements
ThisresearchwassupportedbyDanoneEarlyNutritionasan extensionoftheNUTRIPLANETprojectinBrazil(2013).The contentof this article wasbased exclusively onscientific evidenceand is not linked toany product of the suppor-ting company. The scientific contentof the article is the responsibilityoftheauthors.
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