J. Pediatr. (Rio J.) vol.92 número3

www.jped.com.br

ORIGINAL

ARTICLE

Growth

and

development

and

their

environmental

and

biological

determinants

夽

Kelly

da

Rocha

Neves,

Rosane

Luzia

de

Souza

Morais

_,

_Romero

_Alves

_Teixeira,

Priscilla

Avelino

Ferreira

Pinto

PostgraduatePrograminHealth,SocietyandEnvironment(SaSA),UniversidadeFederaldosValesdoJequitinhonhaeMucuri (UFVJM),Unaí,MG,Brazil

Received25March2015;accepted5August2015 Availableonline6January2016

KEYWORDS Failuretothrive; Childdevelopment; Childhealth

Abstract

Objective: Toinvestigate childgrowth,cognitive/language development,andtheir environ-mentalandbiologicaldeterminants.

Methods: This was across-sectional, predictivecorrelationstudy withall 92 children aged 24---36monthswhoattendedthemunicipalearlychildhoodeducationnetworkinatowninthe ValedoJequitinhonha region,in2011.The socioeconomicprofilewasdeterminedusingthe questionnaireoftheAssociac¸ãoBrasileiradeEmpresasdePesquisa.Thesocio-demographicand maternal andchildhealthprofileswere createdthroughaself-preparedquestionnaire.The height-for-ageindicatorwasselected torepresentgrowth. Cognitive/languagedevelopment wasassessedthroughtheBayleyScaleofInfantandToddlerDevelopment.Thequalityof educa-tionalenvironmentswasassessedbyInfant/ToddlerEnvironmentScale;thehomeenvironment was assessedbytheHomeObservationfor MeasurementoftheEnvironment. The neighbor-hoodqualitywasdeterminedbyaself-preparedquestionnaire.Amultivariatelinearregression analysiswasperformed.

Results: FamilieswerepredominantlyfromsocioeconomicclassD,withlowparental educa-tion.Theprevalenceofstuntedgrowthwas14.1%;cognitiveandlanguagedevelopmentwere belowaverageat28.6%and28.3%,respectively.Educationalinstitutionswereclassifiedas inad-equate,and69.6%ofhomeswereclassifiedaspresentingariskfordevelopment.Factorssuch asaccesstoparksandpharmaciesandperceivedsecurityreceivedtheworstscoreregarding neighborhoodenvironment.Biologicalvariablesshowedagreaterassociationwithgrowthand environmentalvariableswithdevelopment.

夽

Pleasecitethisarticleas:daRochaNevesK,deSouzaMoraisRL,TeixeiraRA,PintoPA.Growthanddevelopmentandtheirenvironmental andbiologicaldeterminants.JPediatr(RioJ).2016;92:241---50.

∗_{Correspondingauthor.}

E-mail:rosanesmorais@gmail.com(R.L.deSouzaMorais).

http://dx.doi.org/10.1016/j.jped.2015.08.007

Conclusion: Theresultsshowedahighprevalenceofstuntingandbelow-average resultsfor cognitive/language development among theparticipating children. Bothenvironmental and biological factors were related to growth and development. However, biological variables showedagreaterassociationwithgrowth,whereasenvironmentalvariableswereassociated withdevelopment.

©2015SociedadeBrasileiradePediatria.PublishedbyElsevierEditoraLtda.Allrightsreserved.

PALAVRAS-CHAVE Insuficiênciade crescimento; Desenvolvimento infantil;

Saúdedacrianc¸a

Crescimentoedesenvolvimentoeseusdeterminantesambientaisebiológicos

Resumo

Objetivo: Investigarocrescimentoedesenvolvimentocognitivo/linguagemdecrianc¸aseseus determinantesambientaisebiológicos.

Método: Estudo transversal, correlacional preditivo, com todas as 92 crianc¸as entre 24-36 meses,frequentadorasdaredemunicipaldeeducac¸ãoinfantildeumacidadenoValedo Jequit-inhonha,ano 2011.Trac¸ou-seoperfil econômicoutilizando-se oquestionáriodaAssociac¸ão Brasileira de Empresasde Pesquisa.Operfil sociodemográficoe saúdematerno-infantilpor questionáriopróprio.Elegeu-se o indicadorestatura/idade para representar ocrescimento. Odesenvolvimentocognitivo/linguagemfoiavaliado pormeiodoBayleyScaleofInfantand ToddlerDevelopment.Avaliou-seosambienteseducacionaispeloInfant/ToddlerEnvironment Scale,eoambientedomiciliarpeloHomeObservationfor MeasurementoftheEnvironment. Aferiu-seaqualidadedavizinhanc¸aatravésdequestionáriopróprio.Foramrealizadasanálises deregressãolinearmultivariada.

Resultados: AsfamíliaserampredominantementedaclasseDcombaixaescolaridadedospais. Aprevalênciadedéficitdeestaturafoi14,1%;desenvolvimentoabaixodamédianalinguagem 28,6% e cognitivo 28,3%. As instituic¸ões educacionais classificaram-se como inadequadas e 69,6%dosdomicílioscomo deriscopara odesenvolvimento.Aspectoscomo,disponibilidade deprac¸asefarmáciaseseguranc¸aforamaspectosdepiorpontuac¸ãonoambientevizinhanc¸a. Variáveisbiológicasdemonstrarammaiorassociac¸ãocomocrescimentoevariáveisambientais aodesenvolvimento.

Conclusão: Observou-se elevado déficit de estatura e de resultados abaixo da média para desenvolvimento cognitivo/linguagementreas crianc¸as participantes.Fatores ambientais e biológicosrelacionaram-setantoaocrescimentoquantoaodesenvolvimento.Entretanto, var-iáveisbiológicasdemonstrarammaiorassociac¸ãocomocrescimentoevariáveisambientaiscom odesenvolvimento.

©2015SociedadeBrasileiradePediatria.PublicadoporElsevierEditoraLtda.Todososdireitos reservados.

Introduction

Overthepastfewyears,Brazilhasobservedadecreasein childhoodmortalityrates onaccountof measuressuch as immunization coverage, prenatal care, and breastfeeding promotion.1 _{In this new scenario, healthcare}

profession-als, the government, and researchers have turned their attentiontothemonitoring of adequatechild growthand development.2_{Once survivalisguaranteed,itisnecessary}

to giveall children the opportunity toachieve academic successandreachtheirfullcapacitiesasadults.3

Themonitoringofchildgrowthanddevelopmentis nec-essary, as deficits in these parameterscan have negative effects throughout life. It is estimated that, in countries wherethedevelopmentdeficit ratesaffectmorethan20% oftheiradultpopulation,thenationaleconomymaysuffer a negativeimpact.3 _{Among the negativeconsequences of}

shortstaturein women arelosses inreproductive health, survival, and stunting of their children.4,5 _{For men, low}

economicproductivityhasbeenidentifiedasaresultofshort stature,originatedinchildhood.4

Child growth and development are multifactorial constructs,3,6 _{associated with environmental,}

socioecono-mic,andbiologicalaspects.Studieshaveeitherinvestigated riskfactorsrelatedtochilddevelopmentaldelay3,7,8_orthe

risk factors associated withmalnutrition.6 _{It is observed,}

however, that these constructs are associated and have many determinants in common. Factors associated with poverty, suchasrestrictionsin diet,consumergoods, and services;insufficientpsychosocialstimuli;andadverse peri-natalconditionshavebeenreportedasriskfactorsforboth childgrowthanddevelopment.3,5---7,9---11

Thus, the aim of this study was to investigate the environmental, socioeconomic, and biological risk fac-tors associated with and growth and child development, regardingeconomicallyunderprivilegedchildrenin atown inValedoJequitinhonha,aregionwithlowsocioeconomic indicatorslocatedinsoutheasternBrazil.1

Methods

This was a cross-sectional, predictive correlation study, approvedbytheResearchEthicsCommitteeofUniversidade FederaldeMinasGerais(585/2010).

Thestudyconsistedofchildrenaged24---36monthswith normal development, i.e., no congenital or acquired dis-abilities.Additionally,theyhadtobeattending,foratleast six months, the municipalearly childhoodeducation net-workinatownlocatedinValedoJequitinhonha,in2011.To ensurerepresentativeness,allteninstitutionslocatedinthe urbanregionwereincluded.Asthiswasasmallpopulation, itwasdecidedthatallchildrenwhometthecriteriawould beeligible.Atotalof96childrenwereconsideredeligible; however,afterexcludingsomeparticipantsduetothelack ofcooperationfromthechildandlackofparentalconsent, 92childrenwereenrolledinthestudy.

Thefollowingparameterswereusedtoevaluategrowth: weightforage,heightforage,weightforheight,andbody massindex(BMI)forage,consideringtheparameters recom-mendedbytheWorldHealthOrganization(WHO)ascritical

Z-scorevalues.12 _AMarte® _{digitalscale(Marte, SP,Brazil),} with a maximum capacity of 199.95kg, and precision of 50gwasusedtoassessweight.Heightwasmeasuredusing a portablestadiometer (Alturaexata®_{, MG,Brazil),with a} precisionof1mm.Thetechniquesusedtoobtainall mea-surements followed standard proceduresaccording to the manualoftheFoodandNutritionSurveillanceSystem.13

ChilddevelopmentwasassessedaccordingtotheBayley ScaleofInfantandToddlerDevelopment(BayleyIII),14 _the

gold standard, widelyusedin scientificresearchtoassess childdevelopment.15,16_{Itisbasedonthesumoftasks}

per-formedbythechildgeneratinggrossscores,thenconverted tocompositeorbalancedscores.Forthepresentstudy,the followingscaleswereused:cognitive,compositescore,with meanandstandarddeviationof10(±15)points,and expres-sivelanguagescale,balancedscore,withmeanandstandard deviationof10(±3)points.

The qualityofearlychildhoodeducationwasevaluated by the Infant/Toddler Environment Rating Scale Revised (ITERS-R).17_{Thistoolconsistsofsevensubscales:Spaceand}

Furnishings,PersonalCareRoutines,ListeningandTalking, Activities,Interactionbetweenstaffandchildren,Program Structure,ParentsandStaff.Thescoresoneachscaleand overall score range from 0 to 7, generating the follow-ingclassification:inadequate(1---2.99),minimum(3---4.99), good (5---6.99), and excellent (7).17 _{in Brazil, some}

stud-iesusedITERS-R,andtheirresultsshowedevidenceoftool validityandaccuracy.18,19

The home environment quality was assessed using the Home Observation for Measurement of the Environment (HOME) inventory,20 _{which has six subscales: parental}

responsivity,acceptanceofchild,organizationofthe envi-ronment, learning materials, parental involvement, and

varietyinexperience.Thetoolrecognizesasarisk environ-mentfor developmentascore ≤27in theoverall score.20

Accordingto Totsikaand Sylva,21 _{theHOME inventoryhas}

beensuccessfullyusedinresearchbecauseitiseasytoapply andhascharacteristicsconsideredtobeappropriate.

The qualitative assessment of the neighborhood envi-ronmentwasperformedthroughaquestionnairedeveloped based on literature,22 _{containing questions where the}

respondentexpressedhis/heropinionaboutthe accessibil-ityandqualityofservices,bothpublicandprivate,aswell associalrelationsbetweenneighbors.

Fortheeconomicclassificationofthechildren’sfamilies, the questionnaire of the Associac¸ão Brasileira de Empre-sasde Pesquisa(ABEP --- Brazilian Association ofResearch Companies)wasused.Thistooldefinessocioeconomic sta-tusaccordingtodurablegoods,thenumberofbathrooms, whetherthefamilyemployedahousemaid,andthe house-hold head’s level of education. The score is added and interpreted from the ordinal scale, ranging from class E to A1.23 _{The socio-demographic and the child’s pre- and}

post-natalhealthprofileswereobtainedusinga semistruc-tured,self-prepared questionnaire, applied tothe child’s caregiver.

Prior to the research, some pilot studies were carried out in order topractice the application of tools, as well asto performthe reliability measures. A pilot study was conductedwith20preschoolchildrentopracticetheBayley IIIapplication.Thesamechildrenunderwenthomevisitsto practicefortheHOMEapplication.Thedataobtainedfrom thesechildrenwerenotusedinthefinalstudy.

Thereliabilityamongthefourexaminerswhoappliedthe BayleyIIIscaleandtheHOMEtoolwasassessedandthe intr-aclasscorrelation(ICC)resultsofthesubscalemeanswere 0.95and0.94,respectively.TheICCbetweenthetwo exam-inerswhoappliedtheITERS-Rwas0.83.Allanthropometric measurements were performed by the same nutritionist. Theintra-examinerreliability,measuredbytheICC,showed a mean of 0.99 for weightmeasurement of and 0.98 for heightmeasurement.

The anthropometric assessment and the application of Bayley III scale and ITERS-R inventorywere performed in thedaycare center,while theother tools wereappliedat thechildren’shomesbytwopreviouslytrainedexaminers.

Thedescriptiveandinferentialanalyseswereperformed usingSPSSforWindows(IBMCorp.Released2011.IBMSPSS StatisticsforWindows,Version20.0;NY,USA).Asignificance levelof0.05wasusedtoanalyzetheassociationbetween environmental and biological conditions and investigated phenomena,bothintheunivariatelinearregressionandthe multivariateanalyses.Theunivariateanalysesincludedthe independentvariableswithp-value≤0.20inSpearman’s cor-relationtestandshowednomulticollinearitywiththeother variables.

Results

Table1 Socioeconomiccharacterizationandbiologicalprofileofthe92participants.Diamantina,Brazil,2011.

Variables Categories n(92) %

Gender Male 53 57.6

Female 39 42.4

Paternallevelofschooling Illiterateordidnotfinish4thGrade 13 16.5

Finished4thGrade 31 39.2

FinishedElementarySchool 27 34.2

FinishedHighSchool 8 10.1

Maternallevelofschooling Illiterateordidnotfinish4thGrade 5 5.6

Finished4thGrade 31 34.4

FinishedElementarySchool 29 32.2

FinishedHighSchool 20 22.2

FinishedCollege/University 5 5.6

Socioeconomicclass C1 15 16.3

C2 33 35.9

D 39 42.4

E 5 5.4

Familytype Mononucleara _{19 20.6}

Nuclearb _{39 42.4}

Expandednuclearc _{10 10.9}

ExpandedmononuclearId _{24 26.1}

Maternalage 18---30 66 71.7

31---47 26 28.3

N.ofsiblings 0---2 67 72.8

≥3 25 27.2

N.ofpeopleinhousehold ≤5 53 58.2

≥6 38 41.8

Pregnancycomplications Yes 29 31.5

No 63 68.5

Prenatalconsultations <6 51 56.7

≥6 39 43.3

Gestationalage(inweeks) Preterme _{6 6.5}

Full-termf _{86 93.5}

Birthweight(kg) ≤2.5 3 3.3

>2.5 88 96.7

Birthlength <3rdpercentileg _{9 10.2}

>3rdpercentileg _{79 89.8}

Maternalbreastfeeding Yes 91 98.9

No 1 1.1

Exclusivebreastfeeding(months) <6 57 61.9

≥6 35 40.2

Chronicdiseases Yes 45 48.9

No 47 51.1

Infectiousdiseases Yes 48 53.3

No 43 46.7

Hospitaladmissions Yes 22 23.9

No 70 76.1

n,absolutenumber;%,percentage. a_{Mononuclear:motherandchildren.} b _{Nuclear:father,mother,andchildren.}

c _{Expandednuclear:father,mother,children,andothers.} d _{ExpandedmononuclearI:mother,children,andothers.} e _{Full-term:≥37gestationalweeks.}

f _{Preterm:≤36gestationalweeks.}

g_{BasedonthegrowthcurveaccordingtotheWorldHealthOrganization.}12

andthepercentageof biologicalparents whodidnot live withtheirchildren (46.7%).Mostchildrenwerebornafter over 37 weeks of gestation and pregnancy complications were infrequent, as well as birth weight <2.5kg.

Table2 Resultsofthegrowthanddevelopmentassessment.Diamantina,Brazil,2011.

Indicators Cutoffs Classification n(92) %

Anthropometrica

Weight/age Z-score

<−3 Verylowweightforage 0 0

−3⊢−2 Lowweightforage 2 2.2

−2⊢+2 Adequateweightforage 89 96.7

≥+2 Overweightforage 1 1.1

Weight/height Z-score

<−3 Markedthinness 0 0

−3⊢−2 Thinness 0 0

−2⊢+1 Normalweight 87 94.4

+1⊢+2 Overweightrisk 1 1.1

+2⊣+3 Overweight 2 2.2

>+3 Obesity 2 2.2

Height/age Z-score

<−3 Verylowheightforage 1 1.1

<−2 Lowheightforage 13 14.1

≥+2 Adequateheightforage 78 84.7

BMI/age Z-score

<−3 Markedthinness 0 0

≥−3<−2 Thinness 0 0

−2⊢+1 Normalweight 57 61.9

+1⊢+2 Overweightrisk 26 28.2

+2⊢+3 Overweight 7 7.6

≥+3 Obesity 2 2.1

Developmentb_(meanandSD)

Language(8.77±1.95) Balancedscorec ₍₉₁₎e

<7 Belowaverage 26 28.6

7---13 Average 65 71.4

>13 Aboveaverage 0 0

Cognitive(98.8±9.1) Compositescored

<85 Belowaverage 26 28.3

115---85 Average 65 70.7

>115 Aboveaverage 1 1.1

n,absolutenumber;%,percentage;SD,standarddeviation;BMI,bodymassindex;---|,including. a _{StandardreferenceoftheWorldHealthOrganization.}12

b _{AccordingtoBayleyIIIscale.}

c _{Balancedscore,expectedaverage,10±3points.}

d _{Compositescore,expectedaverage,100±15points.}

e _{OnechildrefusedtoparticipateintheBayleylanguagedomain.}

ofthechildrenhadhadchronic(45%)and/orinfectious dis-eases(48%)inthelastthreemonthspriortodatacollection.

Table2showstheresultsforthegrowthanddevelopment constructs.Amongtheindicatorsofgrowth,heightforage showedthehighestpercentageofdeficit,andwasthus cho-senasthedependentvariableinthesubsequentinferential analyses. The percentage of children withbelow-average languageand cognitive developmentshowed a difference ofonly0.3%betweeneachother.Thus,bothwereusedfor theuni- and multilinear regressionanalyses asdependent variables,representativeofthedevelopmentconstruct.

Table3showstheresultsfortheassessedenvironmental factors:neighborhood,home,andpreschools.Inthe neigh-borhoodenvironment,intheinfrastructurecategory,street pavement and sanitation showed higher levels of inade-quacy. Amongtheofferedservices,thelowerscores were related to parks and playgrounds. Neighborhood security,

interactionandtrustbetweenneighbors,andsocialturmoil alsoshowednegativeresults.Athome,itwasobservedthat 69.6%ofthechildren’senvironmentwasconsideredatrisk, accordingtoHOME.Regardingthequalityofpreschools,the medianoverall score in ITERS-R(2.17) showed thatthese environmentswereinadequate.

Table3 Qualityofenvironments:neighborhood,home,andearlychildhoodeducation institutionsfor the92participants. Diamantina,Brazil,2011.

Variables n(92) % Scalereference

range(ordinal)

Minimum/Maximum Median

Neighborhood(infrastructure)a Basicsanitation

Yes 77 83.7 --- ---

---No 15 16.3 --- ---

---Electricity

Yes 91 98.9 --- ---

---No 1 1.1 --- ---

---Drinkingwater

Yes 90 97.8 --- ---

---No 2 2.2 --- ---

---Wastedisposal

Yes 82 89.1 --- ---

---No 10 10.9 --- ---

---Pavedstreet

Yes 71 77.2 --- ---

---No 21 22.8 --- ---

---Neighborhood(qualityofservices)a

Publicdaycarecenter --- --- 0---2 1---2 2

Familyhealthstrategy --- --- 0---2 0---2 2

Square/park --- --- 0---2 0---2 0

Playground --- --- 0---2 0---2 0

Grocerystoreorsmallstore --- --- 0---2 0---2 2

Pharmacy/drugstore --- --- 0---2 0---2 0

Overallscore --- --- 0---12 2---10 6

Neighborhooda

Institutionalactivities --- --- 0---12 0---11 6

Interactionandtrust --- --- 0---12 0---12 6

Interactionandretaliation --- --- 0---6 0---6 4

Childassistance --- --- 0---12 2---12 10

Qualityofneighborhood --- --- 0---16 3---14 9

Mobility --- --- 0---4 0---4 4

Security --- --- 0---5 0---5 2

Socialturmoil --- --- 0---4 0---4 2

Overallscore --- --- 0---113 37---81 58

Householdenvironment(HOME)

Responsivity --- --- 0---11 3---11 7.00

Acceptance --- --- 0---8 1---8 6.00

Organization --- --- 0---6 0---6 4.00

Learningmaterials --- --- 0---9 1---8 4.00

Parentalinvolvement --- --- 0---6 0---5 2.00

Varietyofexperiences --- --- 0---5 0---4 2.00

Overallscore --- --- 0---45 14---38 23.00b

Earlychildhoodeducationenvironment(ITERS-R)

Spaceandfurnishings --- --- 0---7 2.0---3.1 2.3c

Personalcareroutines --- --- 0---7 1.0---2.5 2.0c

Languageandreasoning --- --- 0---7 1.0---3.7 2.5c

Activities --- --- 0---7 1.12---2.88 1.94c

Interactionbetweenstaffandchildren --- --- 0---7 1.0---4.75 2.62c

Programstructure --- --- 0---7 1.0---4.34 2.16c

Interactionbetweenparentsandstaff --- --- 0---7 1.29---2.57 1.78c

Overallscore --- --- 0---7 1.34---3.23 2.17c

N,absolutenumber;%,percentage.

Table4 Univariateandmultivariatelinearregressionanalyses:heightforage,expressivelanguage,andcognitivedevelopment. Diamantina,Brazil,2011.

Variables Univariate Multivariate

ˇ p ˇ p

Heightforage(Z-score) (R2_=0.165)

Qualityofservices 0.174 0.162 ---

---Mobility −0.159 0.131 ---

---OverallHOMEscore 0.263 0.011a _{0.101 0.318}

Paternalabandonment −0.166 0.112 ---

---Father’spresenceathome 0.182 0.082 ---

---Numberofsiblings −0.265 0.010a _{−0.167 0.146}

Numberofindividualsinthehousehold −0.309 0.003a _{−0.208 0.096}

Gestationalage 0.244 0.018a _{0.048 0.649}

Birthweight 0.467 <0.001a _{0.355 0.004}a

Birthlength 0.292 0.005a _{−0.139 0.268}

Prenatalconsultations 0.341 0.001a _{0.215 0.027}a

Breastfeedingregardlessofhospitalaccommodation −0.269 0.009a _{−0.134 0.187}

Exclusivebreastfeeding −0.238 0.022a _{−0.137 0.187}

Expressivelanguage (R2_=0.479)

Infrastructure 0.210 0.002a _{0.267 0.022}a

Servicesandconvenience −0.054 0.609 ---

---Qualityofservices 0.111 0.057 ---

---Interactionandtrust 0.305 0.003a _{0.304 0.006}a

Socialturmoil −0.232 0.036a _{−0.173 0.115}

OverallHOMEscore 0.376 <0.001a _{0.312 0.008}

Maternallevelofschooling 0.142 0.181 ---

---Numberofsiblings −0.138 0.189 ---

---Numberofindividualsinthehousehold −0.191 0.070 ---

---Socioeconomicstatus −0.190 0.070 ---

---Birthweight 0.211 0.045a _{0.240 0.076}

Birthlength 0.231 0.030a _{−0.114 0.454}

Prenatalconsultations 0.224 0.034a _{0.093 0.415}

Ageinmonths 0.330 0.001a _{0.417 <0.001}a

Overallscoreofthequestionnaireontheneighborhood 0.255 0.015a _{−0.204 0.131}

Cognitivedevelopment (R2_=0.295)

Infrastructure 0.358 <0.001a _{0.222 0.077}

Qualityofservices 0.160 0.199 ---

---Attendedinstitutionalactivities 0.173 0.098 ---

---Neighborhoodsecurity −0.335 0.001a _{−0.145 0.205}

Socialturmoil −0.228 0.039a _{0.040 0.715}

OverallHOMEscore 0.454 <0.00a _{0.385 0.001}a

Paternallevelofschooling 0.294 0.008a _{0.077 0.475}

Maternallevelofschooling 0.215 0.041a _{−0.060 0.607}

Socioeconomicstatus −0.227 0.029a _{−0.085 0.447}

Gestationalage 0.127 0.227a _---

---Birthlength 0.252 0.017a _{0.134 0.225}

Infectiousdiseases 0.210 0.044a _{0.063 0.541}

ˇ,estimateoftheincreaseordecreaseofthedependentvariableforeachincreaseofoneunitoftheindependentvariable;p,statistical significance;R2,coefficientofdetermination.

a _p≤0.05.

and interactionand trust (p=0.006)remained among the ‘‘neighborhood’’environmentvariables;theoverallscoreof theHOMEinventory(p=0.008)andthechild’sage(p<0.001) also remained as explanatory variables of language. This groupshoweda48%explanatorypower.

Discussion

It is indisputable that, in the past decades, several childhood-related indicators have improved, mainly those relatedtosurvival.2_{Inlight ofthisfact,itisnecessary to}

ensurethat these children have the opportunity to reach their full potential for growth and development.3,7 _Thus,

thepresentstudyaimedtoinvestigategrowthand develop-mentofunderprivilegedchildrenandtheirassociationwith environmental,socioeconomic,andbiologicalriskfactors.

Regardingtheeconomicprofile,itwasinagreementwith theBrazilianscenario,24_{whichhasshowninrecentdecades}

a decrease in the number of individuals in class E. How-ever,theproportionofhouseholdsbelongingtoclassD(46%) demonstratestheconcentrationofthestudypopulationin economicallydisadvantagedclasses.Accordingtothe liter-ature, thisfact affectsnot only the capacitytopurchase consumer goods, but also parents’ emotional well-being, whichinturncaninterferewithadequatechildgrowthand development.3,7

Thehighermaternallevelofeducation,whencompared withthepaternal,isconsistentwithnationalstatisticsthat showahighermeanofyearsofstudyamongfemales(7.6%) whencomparedwithmales(7.3%).1_However,itis

notewor-thy that only 27.8% of the mothers in this study finished high school. Maternal education has been identified as a determiningfactorforchildgrowth6,11_{anddevelopment.}3,7

The family composition alsoshowed that 46.7% of the childrendidnotlivewiththeirbiologicalparents. Accord-ingtoPilzandShermann,25_{thelikelihoodofchildrenwhose}

mothers are not supported by the fathers to have sus-pected developmental delay is seven times higher than thosechildrenwhosemothersareassistedbytheirchildren’s father.

Asforthematernalandchild’shealthhistory,itis note-worthythenumberofmotherswhohadhadfewerthansix prenatalconsultations.Thepercentageof56.7%wasfound tobemuchhigherthanthe11.8%recordedinthesoutheast regionin2006.1_{Prenatalcareisreportedasoneofthe}

deter-minantsofadequatechildgrowth.6,11_{Although98.9%ofthe}

childrenwerebreastfed,therateofexclusivebreastfeeding uptosixmonthsoflifewas2.9%,belowtheaverageforthe setofBraziliancapitalcities.21 _{Studies haveshownbotha}

protectiveeffectofbreastfeedingongrowthand develop-mentwhenitoccurs,7_{aswellastheriskwhenitdoesnot.}6

Thefactthatalmosthalfofchildrenhadarecordofchronic andinfectiousdiseasesisofconcern,giventheassociation demonstratedbyotherauthorsbetweendiseasesandgrowth anddevelopmentdeficits.3,6

Similarly to other studies,10,11,26 _{the height-for-age}

indicatorwasshowntobethemostprevalentand represen-tativeindexofmalnutrition.Theproportionof15.2%oflow heightforageinthispopulationishigherthanthatfoundin theSoutheastregionofthecountry(5.6%)intheyear2006,26

butitisclosetothatobservedinotherstudiesinareas rec-ognizedfortheirlowHumanDevelopmentIndex(HDI),such asthenorthernregionofthecountry,whichrecorded14.7% of stunting in 2006,26 _{and the Brazilian semi-arid region,}

withprevalenceratesof13%and10.9%11_{in2007and2008,}

respectively.Theseresultsreflecttheinequalityamongthe regionsofBrazil,asshownbybothhealthindicatorsandthe HDI.

Asforthequalityoftheassessedhouseholds,overhalfof themwereconsideredtorepresentariskforchild develop-ment.TheseresultscorroborateotherBrazilianstudiesthat usedHOMEinthecontextofunderprivilegedfamilies.9,27

The quality of the assessed preschool environment rangedfrompoortominimallyadequate.Someauthors,6,28

whenassessingthequalityofpreschoolenvironmentthrough ITERS, found similarresults,identifyingseveral inadequa-cies such as insufficient training of professionals, poor infrastructure,fewadequatematerialsanddevices,lackof pedagogicalproject,andlackoffamilyparticipation.

Regarding the neighborhood environment, it was

observed that more than half of households were disad-vantaged, withthe followingsubscales showing the worst results:security,social turmoil,andinteractionandtrust. ForFariasandPinheiro,29_{changesinlifestyle,mediatedby}

increasingly moreprivateand individualizedsocialhabits, have hindered the establishment of more participative neighborhoodrelations.

As for the determinants of the growth and develop-ment construct,it appearsthatbiological factors,aswell associoeconomicandenvironmentalonesexerttheir influ-ence. However, environmental variables were associated withdevelopment, whereasbiological variables showed a greaterassociationwithgrowth.

Corroborating twoother studies, the variables number ofprenatalvisitsandbirthweightwereexplanatoryforthe height-for-age outcome. Correia et al.10 _{found an}

associ-ation between this nutritional indexand the child’s birth weight,whereasRamosetal.11_{foundaninversecorrelation}

betweenstuntingandthenumberofprenatalconsultations. Acloseassociationwasobservedbetweenthese explana-toryvariables,since,accordingtotheliterature,oneofthe most important determinants of birth weightis adequate prenatalcareassistance,whichcanonlybeachievedwith anadequatenumberofconsultations.6_{Evenifonly3.3%of}

childrenwerebornweighinglessthan2.5kg,the multivari-atelinearregressionanalysisshowedthatforevery1kgof birthweight,therewasa0.355 increaseintheZ-scoreof theheight-for-ageindex,whichisinagreementwithother studies.

Thequalityofthehomeenvironmentwastheonly deter-minantthatexplainedthecognitivedevelopmentconstruct. Forlanguage,inadditiontothequalityofthisenvironment, theneighborhoodqualityandthechild’sagewerealso rel-evant.

Theriskscenarioforchilddevelopmentinthehousehold demonstratedbytheHOMEinventoryaimedathomeis sim-ilartothatfoundbyLamyFilhoetal.9_{andbySantosetal.}27

Thelatterauthorsfoundthat,foreveryextraunitof domes-ticstimulation,therewasanimprovementofhalfapointin cognitiveperformanceforthechildrenintheirstudy.

The variables related to the neighborhood associated withexpressivelanguageperformancewereinfrastructure andinteractionandtrustbetweenneighbors.Regardingthe infrastructure,forMacintyresandEllaway,30_{thegreaterthe}

individualandthesocialenvironmentforthehuman devel-opmentprocess.This process,during childhood,isalways mediated by other individuals, whether family members, healthcareandeducationprofessionals,orevenneighbors. Itis throughtheinteractionwiththe familyand itssocial networkthatthechildassimilatestheskillspreviously con-structedthroughouthumanhistory.26

The third and last variable associated with the ‘‘expressivelanguage’’outcomecorrespondstothechild’s age.Eveniftheusedmeasurementtoolassessesthechild accordingtohis/herage’sskills,thisvariablealsoappears tobeassociatedwithperformanceinthisdomaininother studies.8,31_{Theseresultscouldbeexplainedbyboth}

biolog-icalandenvironmentalfactors.31

The model proposed in this study was based on the complexity and context of the growth and development constructs,whileconsideringenvironmental,biological,and socioeconomicvariables.Inthissense,thefamily socioeco-nomicstatusandqualityofeducationalinstitutions,which were not considered by the statistical analysis as predic-tors of the investigated outcomes, may be exerting their influenceindirectly.

Therefore,futurestudiesshouldinvestigatethetypeof influence(directorindirect),themediationandmoderation associations,andthemagnitudeofthehome,educational, and neighborhood environment impact, as well as socio-economic andbiological factorsin child developmentand growth.Onelimitationof thepresentstudywasthesmall variabilityregardingthequalityofeducationalinstitutions, whichmayhavecontributedtotheresults.

In conclusion, there was a high prevalence of height-for-agedeficit,whencomparedwiththenationalaverage, and below average results for cognitive development and expressive language among economically disadvan-taged children participating in this study. Environmental, socioeconomic,andbiologicalfactorsinfluenceboth devel-opmentandgrowth.

However,thebiologicalvariablesshowedagreater asso-ciation withgrowth andenvironmental variableswith the assessed development variables, i.e., the cognitive and expressivelanguagedomains.

Funding

CAPESandUFVJM.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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