Abstract

Introduction

The nutritional status of a population, especially children, is an excellent indicator of quality of life, reflecting the pattern of development of a certain society¹1. Brasil. Ministério da Saúde. Guia alimentar para crianças menores de dois anos . Secretaria de Políticas de Saúde, Organização Pan Americana da Saúde. Brasília: Ministério da Saúde, 2002a; 152 p.. To follow the nutritional status of infants is a key instrument to assess their health conditions, bringing the unique opportunity to obtain objective measures of evolution of the health conditions of a population²2. Monteiro CA, Benício MHD'A, Iunes RF, Gouveia NC, Cardoso MAA. Evolução da desnutrição infantil. In: Monteiro CA (ed.). Velhos e novos males da saúde no Brasil: a evolução do país e de suas doenças . São Paulo: HUCITEC/NUPENS/USP; 1995. pp. 93-114..

An increasing number of children with a lower socioeconomic level, living in the urban centers of Brazil, have been served by public daycare centers. There is great demand for these services, which tends to increase due to the fact that mothers have been working to contribute to the family income³3. Zöllner CC, Fisberg RM. Estado nutricional e sua relação com fatores biológicos, sociais e demográficos de crianças assistidas em creches da Prefeitura do Município de São Paulo. Rev. Bras. Saúde Matern Infant 2006; 6(3): 319-28. ^{, 4}4. Barros AJD, Gonçalves EV, Borba RSB, Lorenzatto CS, Motta DB, Silva VRL et al. Perfil das creches de uma cidade de porte médio do sul do Brasil: operação, cuidados, estrutura física e segurança. Cad Saúde Pública 1999; 15(3): 597-604.. Programs based on full-time quality child care, aimed at infants from the first months of life, can play a preventive role as they protect these infants from nutritional disorders, especially chronic malnutrition³3. Zöllner CC, Fisberg RM. Estado nutricional e sua relação com fatores biológicos, sociais e demográficos de crianças assistidas em creches da Prefeitura do Município de São Paulo. Rev. Bras. Saúde Matern Infant 2006; 6(3): 319-28.,⁵5. Silva MV, Ometto AMH, Furtuoso COM, Pipitone MAP, Sturion GL. Acesso a creches e estado nutricional das crianças brasileiras: diferenças regionais, por faixa etária e classes de renda. Rev Nutr 2000; 13(3): 193-9..

Although daycare centers are a possible protective factor of nutritional status, as they provide an adequate diet and are responsible for 2/3 of the total nutritional intake of children, their exposure to precarious housing and basic sanitation conditions predisposes them to recurrent infectious processes with resulting damage to their nutritional status, especially those aged less than 24 months⁶6. Brasil. Ministério da Saúde. Secretaria de políticas de saúde. Saúde da criança – Acompanhamento do crescimento e desenvolvimento infantil. Série Cadernos de Atenção Básica; n.11. Série A, Normas e Manuais Técnicos. Brasília, DF; 2002b; no. 173.

7. Biscegli TS, Polis LB, Santos LM, Vicentin M. Avaliação do estado nutricional e do desenvolvimento neuropsicomotor em crianças frequentadoras de creche. Rev Paul Pediatr 2007; 25(4): 337-42.

8. Bueno MB, Marchioni DML, Fisberg RM. Evolução nutricional de crianças atendidas em creches públicas no Município de São Paulo, Brasil. Rev Panam Salud Pública 2003; 14(3): 165-70. ^{- 9}9. Camillo CC, Amancio OMS, Vitalle MSS, Braga JAP, Juliano Y. Anemia ferropriva e estado nutricional de crianças de Creches de Guaxupé. Rev Assoc Med Bras 2008; 54(2): 154-9.. Additionally, as observed by Monteiro¹⁰, the height deficit of children at the age of seven years would have been established at 24 months of life. As height is a body measure that evolves slowly and progressively, its dimension reflects the history of socioeconomic and nutritional status of a population¹¹11. Waterlow JC. Observations on the natural history of the stunting. In: Waterlow, JC. Linear growth retardation in less developed countries. New York, Nestlé Nutrition Workshop series: Raven Press; 1988; 14: 1-16.. Thus, the present study aimed to assess the nutritional status of infants aged from six to 30 months, who were enrolled in public daycare centers of the city of Recife, and to verify potential factors associated with the length-for-age index.

Methods

The present study was conducted in 13 public daycare centers situated in five of the six Health Districts of the city of Recife, state of Pernambuco, Northeastern Brazil. The centers were selected by simple random sampling from a total of 20 daycare centers that met the inclusion criteria (age and without oral iron supplementation). Infants enrolled in these centers had similar socioeconomic conditions and received the same support for the educational curriculum, diet and health care from the city's Department of Education¹².

The study had a cross-sectional design and was conducted with infants aged between six and 30 months, enrolled in these daycare centers, including a total of 321 participants. Data collection was performed from August to October 2004.

Socioeconomic and demographic factors were assessed for per capita family income, maternal level of education and age, housing and basic sanitation conditions, and ownership of household goods. The child-related variables were as follows: sex, birth weight, age, profile of maternal breastfeeding, and hemoglobin concentration. This information was collected from the children's mothers or legal guardians at the daycare centers through an interview conducted by two research assistants, using a pre-coded questionnaire.

Venous blood samples were collected for hemoglobin count, electronically determined with the ABX Pentra, ABX 120 VEP 0027 model. Values < 9.5 g/dL were considered as moderate to severe anemia; 9.5 – 10.9 g/dL as mild anemia; and ≥ 11.0 g/dL as normal¹³.

The anthropometric assessment was made by measuring weight and length, following the recommendations of the World Health Organization¹⁴14. World Health Organization. Physical Status: The use and interpretation of anthropometry . Technical Report Series 854: Geneva; 1995.. Weight was obtained with a Marte digital scale with a maximum capacity of 160kg (MS 160 model, Goiânia, Brazil) and accuracy of 50g. Length was measured with an anthropometer (Raven Equipment, England) with a maximum amplitude of 100cm and subdivisions of 0.1cm. Infants were measured two times and the difference between measurements should not exceed 0.5cm to guarantee their accuracy; when this limit was exceeded, another measurement was taken, the two closest values were recorded, and the mean of these values was used.

The nutritional status assessment used the Anthro software – 2007¹⁵15. World Health Organization. Anthro for personal computers, version 2, 2007: Software for assessing growth and development of the world's children. Geneva; 2007. [2007 Jan 23]. Disponível em: http://www.who.int/childgrowth/software/en/ (Acessado em 7 de dezembro de 2010).
http://www.who.int/childgrowth/software/... and infants were categorized according to the weight-for-age, length-for-age, weight-for-length and BMI-for-age indices expressed in Z scores. The child growth pattern used as reference to classify weight and length measurements was that of the World Health Organization (WHO)¹⁶16. World Health Organization. Multicentre Growth Reference Study Group. WHO child growth Standards based on length/height, weight and age. Acta Paediatr 2006; (S450): 76-85.. With regard to the nutritional status assessment, the following cut-off points were used: < -2 Z scores = malnutrition, -2 to < -1 Z score = risk of malnutrition, and ≥ -1 Z score = eutrophy for the length-for-age index; and < -2 Z scores = malnutrition, -2 to < -1 Z score = risk of malnutrition, ≥ -1 to < 2 Z scores = eutrophy, and ≥ 2 Z scores = overweight for the weight-for-age, weight-for-length and BMI-for-age indices. Maternal breastfeeding was defined as infants who had received or were receiving maternal milk directly or collected from breasts, regardless of any foods or liquids being provided, including non-human milk¹⁷17. World Health Organization. Indicators for assessing breastfeeding practices . Geneva; 1992..

The Epi Info software, version 6.04 (CDC, Atlanta, USA), was used to perform double data entry, aiming to check for consistency and validity of typing.

The length-for-age index, selected as a dependent variable to investigate associated factors, was analyzed as a continuous variable. The associations were made according to this index as it shows a higher prevalence of nutritional deficit and as it is currently the most frequent and representative type of anthropometric deviation. Student's t test and variance analysis (ANOVA) were used to compare the differences between means in the bivariate analyses, considering a p-value ≤ 0.05 to have statistical significance. The correlation matrix did not identify multicollinearity among variables, as Pearson correlation coefficients were lower than 0.52.

The multivariate linear regression analysis was performed with the Statistical Package for the Social Sciences (SPSS) software, version 12.0.1, when assessing the impact of independent variables on the length-for-age index. Among the independent variables, birth weight, age and hemoglobin concentration were treated as continuous variables. All variables with a p-value < 0.20 in the bivariate analyses were selected to be included in the regression models, using the stepwise method. The model adopted by Lima et al.¹⁸18. Lima ACVMS, Lira PIC, Romani SAM, Eickmann SH, Piscoya MD, Lima MC. Fatores determinantes dos níveis de hemoglobina em crianças aos 12 meses de vida na Zona da Mata Meriodional de Pernambuco. Rev Bra. Saúde Mater Infant 2004 ; 4: 35-43.was used to analyze the associated factors. Initially, the regression of the 11 socioeconomic and maternal variables was performed (housing type; occupancy status; type of wall, floor and ceiling; water supply; sewage system; ownership of television, fridge and landline telephone in the household; and maternal education). Next, the child-related variables were included in the model (birth weight, age and hemoglobin concentration). This research project was approved by the Human Research Ethics Committee of the Health Sciences Center of the Federal University of Pernambuco, under protocol 299/2003. The mothers of participating infants were informed about the research objectives and procedures and signed an informed consent form to be included in the study.

Results

According to Table 1 , the percentage of malnutrition observed (< - 2 Z scores) was 2.8% and 13.4% for the weight-for-age and length-for-age indices, respectively, and 0.6% for the weight-for-length and BMI-for-age indices. Overweight was 7.5% and 10.6% for the weight-for-length and BMI-for-age, respectively.

With regard to socioeconomic variables ( Table 2 ), 53.3% of families received a per capita family income lower than 1/4 of a minimum wage, the majority of them (71.3%) lived in a house or apartment with brick or hollow tile walls (82.9%), piped water supply (81%) and flushing toilet (42.7%). In terms of household goods available, 2/3 of families or more had a television and refrigerator.

With regard to maternal variables ( Table 3 ), 9.1% of mothers were adolescents and the majority of them (69.4%) were aged between 20 and 29 years. Concerning the level of education, 44.4% had completed from five to eight years of education. Low birth weight (< 2,500g) had a frequency of 6.8%, while that of insufficient weight (2,500 – 2,999g) was 21.5%. A total of 41.4% of infants had moderate to severe anemia and 50.2% had mild anemia. With regard to maternal breastfeeding, 93.8% of infants had been or were still being breast-fed at the moment of the interview, whereas 6.2% had never been breast-fed.

Tables 2 and 3 show the association between the explanatory variables and the length-for-age index. Variables with a p-value < 0.20 were selected for the multivariate linear regression analysis.

This analysis showed that the socioeconomic condition, represented by type of ceiling and water supply, had a significant influence and contributed to 3.8% of the variation in the length-for-age index. Child-related variables, represented by birth weight, age and hemoglobin concentration, were those with a greater impact on the variation in the length-for-age index, jointly contributing 12.8%. When considered together, these variables explained 16.6% of this index ( Table 4 ).

Discussion

The results of the present study corroborate the statement that height deficit is the most frequent and representative form of anthropometric deviation of malnutrition. Consequently, daycare centers can be an important choice of care, as they enable infants to have access to a qualitatively adequate diet, which has the potential of reducing nutritional risks, among which is chronic malnutrition¹⁹19. Laurentino GEC, Arruda IKG. Nanismo nutricional em escolares no Brasil. Rev Bras Saúde Matern Infant 2003; 3(4): 377-8. ^{, 20}20. Konstantyner T, Taddei JAAC, Palma D. Fatores de risco de anemia em lactentes matriculados em creches públicas ou filantrópicas de São Paulo. Rev Nutr 2007; 20(4): 349-59..

In the present study, the number of infants with a deficit in the length-for-age index (13.4%) was higher than that expected for the reference values of 2.3%¹⁴14. World Health Organization. Physical Status: The use and interpretation of anthropometry . Technical Report Series 854: Geneva; 1995.and similar to that found in Brazil by the Pesquisa Nacional de Demografia e Saúde (PNDS – National Demographic and Health Survey)²¹21. Brasil. Ministério da Saúde. Pesquisa Nacional de Demografia e Saúde da criança e da mulher: PNDS 2006: Dimensões do processo reprodutivo e da saúde da criança . Brasília, DF; 2009.for children aged between 12 and 23 months (12.3%) and to that found by Oliveira et al.²²22. Oliveira VA, Assis AMO, Pinheiro SMC, Barreto ML. Determinantes dos déficits ponderal e de crescimento linear de crianças menores de dois anos. Rev Saúde Pública 2006; 40(5): 874-82.in a study conducted with children in the state of Bahia (12.4%). In daycare centers of the cities of São Paulo and Belo Horizonte, Zöllner and Fisberg³and Rocha et al.²³23. Rocha DS, Lamounier JA, Capanema FD, Franceschini SCC, Norton RC, Costa ABP et al. Estado nutricional e prevalência de anemia em crianças que frequentam creches em Belo Horizonte, Minas Gerais. Rev Paul Pediatr 2008; 26(1): 6-13.observed that lower prevalences of height deficit of 5.2% and 4.2%, respectively, indicate better socioeconomic conditions, reflecting regional inequalities and probably better care and infrastructure conditions of daycare centers.

The literature shows that the relationship between height growth and the environmental conditions to which children are exposed has been well documented²²22. Oliveira VA, Assis AMO, Pinheiro SMC, Barreto ML. Determinantes dos déficits ponderal e de crescimento linear de crianças menores de dois anos. Rev Saúde Pública 2006; 40(5): 874-82.,²⁴24. Kac G. Tendência secular em estatura: uma revisão da literatura. Cad Saúde Pública 1999; 15(3): 451-61.. The same can be observed with regard to socioeconomic conditions, such as family income, where the significant association with nutritional status²2. Monteiro CA, Benício MHD'A, Iunes RF, Gouveia NC, Cardoso MAA. Evolução da desnutrição infantil. In: Monteiro CA (ed.). Velhos e novos males da saúde no Brasil: a evolução do país e de suas doenças . São Paulo: HUCITEC/NUPENS/USP; 1995. pp. 93-114. ^{, 22}22. Oliveira VA, Assis AMO, Pinheiro SMC, Barreto ML. Determinantes dos déficits ponderal e de crescimento linear de crianças menores de dois anos. Rev Saúde Pública 2006; 40(5): 874-82. ^{,, 25}25. Guimarães LV, Latorre MRDO, Barros MBA. Fatores de risco para a ocorrência de déficit estatural em pré-escolares. Cad Saúde Pública 1999; 15(3): 605-15.is frequently found. Reporting one's family income involves different aspects that hinder data reliability, so that the “type of ceiling” and “water supply” variables became more representative of family socioeconomic conditions in this study and their significance remained in the multivariate regression analysis.

Additionally, the child-related variables such as birth weight, age and hemoglobin concentration had a significant impact on the variation in the length-for-age index. Birth weight has been frequently assessed for the nutritional status of children²2. Monteiro CA, Benício MHD'A, Iunes RF, Gouveia NC, Cardoso MAA. Evolução da desnutrição infantil. In: Monteiro CA (ed.). Velhos e novos males da saúde no Brasil: a evolução do país e de suas doenças . São Paulo: HUCITEC/NUPENS/USP; 1995. pp. 93-114.and its interference with child growth and development has been continually shown in the literature²²22. Oliveira VA, Assis AMO, Pinheiro SMC, Barreto ML. Determinantes dos déficits ponderal e de crescimento linear de crianças menores de dois anos. Rev Saúde Pública 2006; 40(5): 874-82. ^{, 25}25. Guimarães LV, Latorre MRDO, Barros MBA. Fatores de risco para a ocorrência de déficit estatural em pré-escolares. Cad Saúde Pública 1999; 15(3): 605-15.

26. Eickmann SH, Lima MC, Motta MEFA, Romani SAM; Lira PIC. Crescimento de nascidos a termo com peso baixo e adequado nos dois primeiros anos de vida. Rev Saúde Pública 2006; 40(6): 1073-81.

27. Brunken GS, Guimarães LV, Fisberg M. Anemia em crianças menores de 3 anos que freqüentam creches públicas em período integral. J Pediatr 2002; 78: 50-6. ^{- 28}28. Barroso GS, Sichieri R, Salles-Costa R. Fatores associados ao déficit nutricional em crianças residentes em uma área de prevalência elevada de insegurança alimentar. Rev Bras Epidemiol 2008; 11(3): 484-94..

The impact that low weight and insufficient weight have on the height deficit was evident, as they contributed to 8.7% of the variation in the length-for-age index. It should be emphasized that approximately 1/3 of the population experienced this condition, which could reveal precarious prenatal care. As a result, birth weight among live births is directly associated with child quality of life, growth, development and mortality.²⁹29. Soares NT, Guimarães ARP, Sampaio HAC, Almeida PC, Coelho RR. Estado nutricional de lactentes em áreas periféricas de Fortaleza. Rev. Nutr. 2000; 136(2): 99-106.Thus, the importance of birth weight as a key indicator of interest for nutritional surveillance becomes evident. The importance of this indicator would be even more relevant in statistical terms if studies on the prevalence of malnutrition were not significantly affected by survival bias, resulting from the fact that deaths associated with low birth weight stop being included³⁰30. Oliveira O, Taddei JAAC. Efeito dos vieses de sobrevivência nas prevalências da desnutrição em crianças no sexto ano de vida. Brasil – PNSN, 1989. Cad Saúde Pública 1998; 14(3): 493-9..

Several factors are involved with the occurrence of low birth weight, among which is the manifestation of inadequate health and nutritional conditions of the mother-fetus pair, reflecting the pregnancy conditions and, ultimately, the socioeconomic conditions in which the mother finds herself. Consequently, the birth weight can, on the one hand, reflect what has previously occurred, while, on the other hand, it can act as a predictive factor of possible post-natal complications in the short and long term, especially if the environmental and socioeconomic conditions interfering with birth weight persist⁶6. Brasil. Ministério da Saúde. Secretaria de políticas de saúde. Saúde da criança – Acompanhamento do crescimento e desenvolvimento infantil. Série Cadernos de Atenção Básica; n.11. Série A, Normas e Manuais Técnicos. Brasília, DF; 2002b; no. 173. ^{,, 22}22. Oliveira VA, Assis AMO, Pinheiro SMC, Barreto ML. Determinantes dos déficits ponderal e de crescimento linear de crianças menores de dois anos. Rev Saúde Pública 2006; 40(5): 874-82. ^{, 26}26. Eickmann SH, Lima MC, Motta MEFA, Romani SAM; Lira PIC. Crescimento de nascidos a termo com peso baixo e adequado nos dois primeiros anos de vida. Rev Saúde Pública 2006; 40(6): 1073-81..

With regard to the hemoglobin level or iron deficiency that characterize anemia, when iron deficiency is found in the first two years of life, there is evidence of delayed psychomotor development and behavioral, cognitive and language changes, with important repercussions for the physical and mental development³¹31. Stefanini MLR, Colli C, Lerner BR, Lei DLM, Chaves SP, Di Pietro MS et al. Anemia e desnutrição em escolares da rede pública do Município de Osasco, São Paulo, Brasil . Cad Saúde Pública 1995; 11(3): 439-47..

Iron-deficiency anemia is highly prevalent in Brazilian children aged less than two years and it begins very early during childhood¹1. Brasil. Ministério da Saúde. Guia alimentar para crianças menores de dois anos . Secretaria de Políticas de Saúde, Organização Pan Americana da Saúde. Brasília: Ministério da Saúde, 2002a; 152 p. ^{, 18}18. Lima ACVMS, Lira PIC, Romani SAM, Eickmann SH, Piscoya MD, Lima MC. Fatores determinantes dos níveis de hemoglobina em crianças aos 12 meses de vida na Zona da Mata Meriodional de Pernambuco. Rev Bra. Saúde Mater Infant 2004 ; 4: 35-43. ^{, 32}32. Miranda AS, Franceschini SCC, Priore SE, Euclydes MP, Araújo RMA, Ribeiro SMR et al. Anemia ferropriva e estado nutricional de crianças de 12 a 60 meses do município de Viçosa, MG. Rev Nutr 2003; 16(2): 163-9.. In the present study, the prevalence of anemia was 91.6%, of which 41.4% was moderate/severe. This had been recorded in a previously published article¹²12. Carvalho AGC, Lira PIC, Barros MFA, Aléssio MLM, Lima MC, Carbonneau MA et al. Diagnosis of iron deficiency anemia in children of Northeast Brazil. Rev Saúde Pública 2010; 44(3): 513-9.and significantly contributed to the variation in the length-for-age index of infants.

While studying the determining factors of hemoglobin level in infants at 12 months of age in the narrow coastal plain of the state of Pernambuco, Northeastern Brazil, Lima et al.¹⁸18. Lima ACVMS, Lira PIC, Romani SAM, Eickmann SH, Piscoya MD, Lima MC. Fatores determinantes dos níveis de hemoglobina em crianças aos 12 meses de vida na Zona da Mata Meriodional de Pernambuco. Rev Bra. Saúde Mater Infant 2004 ; 4: 35-43.observed a significant association with the length-for-age index, where the prevalence of anemia was 73.2%. The same occurred in the studies conducted by Brunken et al.²⁷27. Brunken GS, Guimarães LV, Fisberg M. Anemia em crianças menores de 3 anos que freqüentam creches públicas em período integral. J Pediatr 2002; 78: 50-6.on anemia among children (63.1%) who were enrolled in full-time public daycare centers and by Rocha et al.²³23. Rocha DS, Lamounier JA, Capanema FD, Franceschini SCC, Norton RC, Costa ABP et al. Estado nutricional e prevalência de anemia em crianças que frequentam creches em Belo Horizonte, Minas Gerais. Rev Paul Pediatr 2008; 26(1): 6-13.on the nutritional status and prevalence of anemia in children living in the city of Belo Horizonte (70.4% in those aged less than 24 months). However, these data do not corroborate the findings of Miranda et al.³²32. Miranda AS, Franceschini SCC, Priore SE, Euclydes MP, Araújo RMA, Ribeiro SMR et al. Anemia ferropriva e estado nutricional de crianças de 12 a 60 meses do município de Viçosa, MG. Rev Nutr 2003; 16(2): 163-9., when analyzing the association between iron-deficiency anemia (63.2%) and the nutritional status of children aged from 12 to 60 months in the city of Viçosa, and those of Stefanini et al.³¹31. Stefanini MLR, Colli C, Lerner BR, Lei DLM, Chaves SP, Di Pietro MS et al. Anemia e desnutrição em escolares da rede pública do Município de Osasco, São Paulo, Brasil . Cad Saúde Pública 1995; 11(3): 439-47., when analyzing the association between anemia (51%) and malnutrition among schoolchildren in the city of Osasco.

With regard to the age group, there was a significant inverse association between child age and the length-for-age index. These findings probably result from the dietary pattern of infants younger than 24 months and from the low coverage and quality of public health actions provided to the population. This could justify the adoption of measures in the field of diet and nutrition, aimed at fighting against such health problem affecting infants in this age group. These findings are in agreement with those observed by Oliveira et al.³³33. Oliveira JS, Lira PIC, Maia SR, Sequeira LAS, Amorim RCA, Batista Filho M. Insegurança alimentar e estado nutricional de crianças de Gameleira, zona da mata do Nordeste brasileiro. Rev Bras Saúde Matern Infant 2010; 10(2): 237-45., while studying food insecurity and the nutritional status of children in an area of high socioeconomic vulnerability; however, they diverge from the results found by Zöllner and Fisberg³3. Zöllner CC, Fisberg RM. Estado nutricional e sua relação com fatores biológicos, sociais e demográficos de crianças assistidas em creches da Prefeitura do Município de São Paulo. Rev. Bras. Saúde Matern Infant 2006; 6(3): 319-28., when describing the nutritional status of children cared for in daycare centers managed by the City Hall in São Paulo, and those obtained by Oliveira et al.²²22. Oliveira VA, Assis AMO, Pinheiro SMC, Barreto ML. Determinantes dos déficits ponderal e de crescimento linear de crianças menores de dois anos. Rev Saúde Pública 2006; 40(5): 874-82., when analyzing the determinants of weight and linear growth deficits among children in the state of Bahia.

Although this study did not find a statistical association between breastfeeding and the length-for-age index, the importance of maternal breastfeeding is well known, especially in the age group analyzed, as maternal milk contains factors that protect against infections and also represents an important source of nutrients. The literature has shown that quantitatively and qualitatively inadequate post-weaning diets promote the onset of nutritional deficits with repercussions for height growth¹1. Brasil. Ministério da Saúde. Guia alimentar para crianças menores de dois anos . Secretaria de Políticas de Saúde, Organização Pan Americana da Saúde. Brasília: Ministério da Saúde, 2002a; 152 p. ^{, 6}6. Brasil. Ministério da Saúde. Secretaria de políticas de saúde. Saúde da criança – Acompanhamento do crescimento e desenvolvimento infantil. Série Cadernos de Atenção Básica; n.11. Série A, Normas e Manuais Técnicos. Brasília, DF; 2002b; no. 173.. Although not being the object of the present study, overweight totaled 10.6%, surpassing the 2.3% expected for a reference population. In the age group in question, one should be cautious when analyzing overweight with cross-sectional data, considering the specific dietary pattern and growth process characteristics.

In this context, studies on child eating habits have become more relevant as a strategy to fight malnutrition and it is essential to understand them in the communities studied. It should be emphasized that the height deficit is invariably established during the first 24 months of life. Thus, all efforts must be directed towards providing younger children access to health care and housing infrastructure conditions and, to the extent possible, providing guidance to mothers, aiming to increase the period of maternal breastfeeding, apart from guidance and capacity-building on prenatal and child care⁵5. Silva MV, Ometto AMH, Furtuoso COM, Pipitone MAP, Sturion GL. Acesso a creches e estado nutricional das crianças brasileiras: diferenças regionais, por faixa etária e classes de renda. Rev Nutr 2000; 13(3): 193-9.. Moreover, it is necessary to establish special care for infants born with low weight, due to its repercussions in the long term, in addition to using risk criteria (birth weight, age group, hemoglobin concentration and housing conditions) as part of the normative principles for nutritional surveillance.

Acknowledgements

Authors would like to thank the daycare center workers, research assistants, mothers and children for their cooperation; the Conselho Nacional de Desenvolvimento Cientifico e Tecnológico (CNPq – National Council for Research and Technological Development) for funding the present research project and granting research scholarships to Pedro Lira and Marília Lima and a doctoral scholarship to Juliana Oliveira; and the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES – Coordination for the Improvement of Higher Education Personnel) for granting doctoral scholarships to Antonio Carvalho and Fátima Barros.

References

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