Treatment of undernutrition in urban Brazil

Summary of research¹

In Brazil, 6% of children aged less than 5 years suffer from height-forage (HAZ) deficit, while the prevalence of this condition is higher (8.2%) among the poorest sector of the population. Moreover, the prevalence of HAZ and weight-for-age (WAZ) deficits among children in the 5-9 years age range is 6.8% and 4.1% respectively. In addition, population growth in the last three decades has been intense leading to massive urbanisation, competition for resources and urban poverty. This has led to increased violence, undernutrition and family breakdown. In order to tackle this problem, the Federal University of Sao Paolo created the Centre of Nutrition Recovery and Education (CREN) in 1994 with the objectives of developing: i) methodologies for the nutritional recovery of children with respect to weight and, in particular, stature and ii) approaches for direct intervention in the complex socioeconomic and familial situation of impoverished urban areas.

More than 1000 undernourished children are assisted annually by CREN in a day hospital (n=50), in an out-patient clinic (n=700) or directly in the community (n=300) depending on the degree of undernutrition and accessibility of the centre. Children accepted into the dayhospital regime originate either from impoverished communities or from public health units and comprise those who have been diagnosed with primary undernutrition and who cannot be rehabilitated in out-patient clinics or by home visits. The routine weekday schedule at CREN comprises five daily meals together with recreational and educational activities (including hygiene practices), sleeping time after lunch and periodic medical examinations. Sick children are treated as appropriate. Children receive protein-rich food as well as vitamin supplements and prophylactic doses of iron until they are 24 months old. Children are discharged and redirected to day nurseries or preschools after effective recovery from undernutrition, i.e. when the HAZ and WAZ parameters are normalised (zscore >-1). Weight-for-height z scores and mid upper arm circumference (MUAC) are not used.

A recently published study by researchers from CREN set out to build a life table and determine the factors related to the time of treatment of undernourished children at a nutritional rehabilitation centre in Sao Paolo. The subjects for the study were undernourished children (n=228) from the southern slums of Sao Paolo who had received treatment at CREN under a day hospital regime between the years of 1994 and 2009. The average age of the children at admission was 24.45 months.

Nutritional status was assessed from WAZ, HAZ and Body Mass Index (BMI)- for-age z-scores, while neuro-psycho motor development was classified according to the milestones of childhood development. Life tables, Kaplan-Meier survival curves and Cox multiple regression models were employed in data analysis. The Kaplan-Meier curves of survival analysis showed statistically significant differences in the periods of treatment at CREN between children presenting different degrees of neuropsychomotor development (log-rank = 6.621; P = 0.037). Estimates based on multivariate Cox model revealed that children aged = 24 months at the time of admission exhibited a lower probability of nutritional rehabilitation (hazard ratio (HR) = 0.49, P = 0.046) at the end of the period compared with infants aged up to 12 months. In spite of this, it was observed that increases in HAZ were greater than in WAZ. The positive effects were observed even in children aged =24 months at the time of admission, although the magnitude of such recovery was inferior to that shown by younger individuals. Children presenting slow development were better rehabilitated in comparison with those exhibiting adequate evolution (HR = 4.48; P = 0.023). The authors believe that the positive results obtained with children presenting with delayed neuro-psychomotor development are associated with greater severity of their nutritional condition, as well as their lower age at admission compared with the other group. No significant effects of sex, degree of undernutrition or birth weight on the probability of nutritional rehabilitation were found.

The authors concluded that age and neuro-psychomotor developmental status at the time of admission to CREN are critical factors in determining the duration of treatment. These findings demonstrate the importance of early nutritional recovery and indicate that the treatment should preferentially start before the age of 24 months. Linear catch-up has also been achieved for older children at CREN, but at a lower speed and after an extended period of treatment.

¹Fernandes M et al (2011). A 15 year study on the treatment of undernourished children at a nutrition rehabilitation centre (CREN), Brazil. Public Health Nutrition: 15 (6), pp 1108-1116