Abstract Objective: To evaluate the validity of the computerized version of the pediatric triage system CLARIPED. Methods: Prospective, observational study in a tertiary emergency department (ED) from Jan-2018 to Jan-2019. A convenience sample of patients aged 0-18 years who had computerized triage and outcome variables registered. Construct validity was assessed through the association between urgency levels and patient outcomes. Sensitivity, specificity, positive and negative predictive values (PPVand NPV), undertriage, and overtriage rates were assessed. Results: 19,122 of 38,321 visits were analyzed. The urgency levels were: RED (emergency) 0.02%, ORANGE (high urgency) 3.21%, YELLOW (urgency) 35.69%, GREEN (low urgency) 58.46%, and BLUE (no urgency) 2.62%. The following outcomes increased according to the increase in the level of urgency: hospital admission (0.4%, 0.6%, 3.1%, 11.9% and 25%), stay in the ED observation room (2.8%, 4.7%, 15.9%, 40.4%, 50%), ≥ 2 diagnostic or therapeutic resources (7.8%, 16.5%, 33.7%, 60.6%, 75%), and ED length of stay in minutes (18, 24, 67,120, 260). The odds of using ≥ 2 resources or being hospitalized were significantly greater in the most urgent patients (Red, Orange, and Yellow) compared to the least urgent (Green and Blue): OR 7.88 (95%CI: 5.35-11.6) and OR 2.85 (95%CI: 2.63-3.09), respectively. The sensitivity to identify urgency was 0.82 (95%CI: 0.77-0.85); specificity, 0.62 (95%CI: 0.61-0.6; NPV, 0.99 (95%CI: 0.99-1.00); overtriage rate, 4.28% and undertriage, 18.41%. Conclusion: The computerized version of CLARIPED is a valid and safe pediatric triage system, with a significant correlation with clinical outcomes, good sensitivity, and low undertriage rate.

Abstract Objectives: To describe the concept of toxic stress, present the basics of epigenetics and discuss their relationship with child development. Data source: Narrative literature review through a search in the SciELO, Lilacs, Medline databases using the terms Adverse Childhood Experience OR Early Life Stress, Epigenomic OR Epigenetic, Child Development OR Infant Development. Data synthesis: Continuing stress response, known as toxic stress, can occur when a child experiences intense, frequent, and/or prolonged adversity–such as physical or emotional abuse, chronic neglect, for example–without adequate adult support. This toxic stress can have harmful effects on learning, behavior, and health throughout life. Epigenetics, an emerging scientific research area, shows how environmental influences affect gene expressions and explains how early experiences can impact throughout life. Conclusions: Toxic stress causes changes in the human body response systems that can be explained in part by epigenetic changes, which can be temporary or long-lasting. Pediatricians must be aware of these mechanisms and their consequences, seeking to prevent them and thus promote the health, well-being, and quality of life of children, contributing to their full development.

RESUMO Objetivo: Avaliar o resultado funcional da cirurgia de correção de pé caído em pacientes hansênicos e comparar as escalas Screening of Activity Limitation and Safety Awareness (SALSA) e de Participação social pós-operatórias com o escore da American Orthopaedic Foot and Ankle Society (AOFAS). Métodos: Avaliamos 22 pacientes submetidos à transposição do tibial posterior para o dorso do pé com mínimo de seguimento de 12 e máximo de 131 meses operados entre janeiro de 2013 e dezembro de 2017. Utilizamos o coeficiente de Pearson (r) para medir o grau de correlação entre as escalas funcionais e consideramos o valor de p < 0,05 na análise dos valores pré e pós-operatórios da AOFAS. Resultados: A média da AOFAS foi de 59,6 no pré-op (mín 35, máx 74) e 77,2 no pós-op (mín 36, máx 97) (p < 0,0001) e das escalas SALSA e participação social de 30,6 e 22,5 no pós-operatório. A análise estatística demonstrou correlação positiva forte (r = −0,83) com as escalas SALSA e de participação social (r = −0,78) quando comparadas ao AOFAS. O grau de dorsiflexão atingido foi de 5,4 graus em média. Linha de pesquisa: Evidência clínica e organizacional, modelos assistenciais, educacionais e avaliação de qualidade em APS - Pós-graduação em Clínica Médica da Faculdade de Medicina da UFRJ. Conclusão: A melhora da função através da correção cirúrgica do pé caído possui correlação direta na melhora da qualidade de vida dos pacientes portadores de hanseníase. Nível de Evidência III, Estudo Retrospectivo.

ABSTRACT Objective: To evaluate the functional results of surgically correcting drop foot in patients with leprosy and compare their SALSA, Social Participation, and AOFAS score. Methods: Overall, 22 patients were subjected to posterior tibial tendon transfer via the subcutaneous route to the foot dorsum with an average follow-up of 56 months (min 12, max 70). In our sample, 15 of the enrolled patients were men and seven, women, aged between 20 and 73 years old who were operated on from January 2014 to December 2017. The Pearson’s correlation test (r) was used to measure the correlation among those scales. A p < 0.05 was considered significant between the pre- and pos-operative AOFAS scale scores. Results: Pre-operative average AOFAS score was 59.6 (min 35, max 74) and 77.2 postoperative (min 36, max 97) (p < 0.0001), postoperative Salsa and Social Participation scale, 30.6 and 22.5, respectively. Statistical analysis suggests a strong positive correlation between AOFAS and Salsa scales (r = −0.83) and AOFAS and social participation (r = −0.78). Average dorsiflexion was 5.4 degrees. Conclusion: The surgical correction of drop foot positively affects the quality of life and social participation of patients with leprosy. Level of Evidence III, Retrospective Study.

Abstract Objectives To study the impact of the implementation of the Pediatric Surviving Sepsis Campaign protocol on early recognition of sepsis, 1 -h treatment bundle and mortality. Methods Retrospective, single-center study, before and after the implementation of the sepsis protocol. Outcomes: sepsis recognition, compliance with the 1 -h bundle (fluid resuscitation, blood culture, antibiotics), time interval to fluid resuscitation and antibiotics administration, and mortality. Patients with febrile neutropenia were excluded. The comparisons between the periods were performed using non-parametric tests and odds ratios or relative risk were calculated. Results We studied 84 patients before and 103 after the protocol implementation. There was an increase in sepsis recognition (OR 21.5 [95% CI: 10.1-45.7]), in the compliance with the 1 -h bundle as a whole (62% x 0%), and with its three components: fluid resuscitation (OR 31.1 [95% CI: 3.9−247.2]), blood culture (OR 15.9 [95% CI: 3.9−65.2]), and antibiotics (OR 35.6 [95% CI: 8.9−143.2]). Significant reduction between sepsis recognition to fluid resuscitation (152min × 12min, p < 0.001) and to antibiotics administration (137min × 30min) also occurred. The risk of death before protocol implementation was four times greater (RR 4.1 [95% CI: 1.2-14.4]), and the absolute death risk reduction was 9%. Conclusion Even if we considered the low precision of some estimates, the lower limits of the Confidence Intervals show that the implementation of the Pediatric Surviving Sepsis Campaign guidelines alongside a qualitive assurance initiative has led to improvements in sepsis recognition, compliance with the 1 -h treatment bundle, reduction in the time interval to fluid resuscitation and antibiotics, and reduction in sepsis mortality.

Abstract Objectives: To review, analyze, and present the available evidence on the usefulness of point-of-care pulmonary ultrasound in the diagnosis and monitoring of community-acquired pneumonia (CAP), aiming to facilitate its potential inclusion into pediatric clinical reference guidelines. Source of data: A non-systematic research was carried out in the MEDLINE (PubMed), LILACS, and SciELO databases, from January 1985 to September 2019. The articles that were considered the most relevant were selected. Synthesis of data: CAP is a relevant cause of morbidity and mortality in pediatrics and its clinical management remains a major challenge. The systematic use of chest X-ray for its diagnosis is controversial because it exposes the child to ionizing radiation and there are interobserver differences in its interpretation. Recently, the use of point-of-care pulmonary ultrasound by the pediatrician has been presented as an alternative for the diagnosis and monitoring of CAP. A great deal of evidence has disclosed its high sensitivity and diagnostic specificity, with the advantages of no ionizing radiation, relatively low cost, immediate results, portability, and the possibility of repetition according to the requirements of disease evolution. Moreover, its use can help rule out possible bacterial etiology and thus prevent inappropriate antibiotic treatments that favor bacterial resistance. Conclusions: Point-of-care ultrasonography represents an opportunity to improve the diagnosis and monitoring of CAP. However, as an operator-dependent technique, training is required for adequate image acquisition, correct interpretation, and integration with clinical data for correct decision-making.

RESUMO Objetivo: Realizar adaptação transcultural para o Brasil da Richmond Agitation-Sedation Scale (RASS) para avaliação da sedação em terapia intensiva pediátrica Métodos: Processo de adaptação transcultural incluindo as etapas de equivalência conceitual, de itens, semântica e operacional, de acordo com recomendações atuais. Resultados: Pré-testes, divididos em duas etapas, incluíram 30 profissionais da unidade de terapia intensiva pediátrica de um hospital universitário, que aplicaram a RASS traduzida em pacientes de 29 dias a 18 anos. Os pré-testes mostraram Índice de Validade de Conteúdo acima de 0,90 para todos os itens: 0,97 na primeira etapa de pré-testes e 0,99 na segunda. Conclusão: A adaptação transcultural da RASS para o português do Brasil resultou em versão com excelente compreensão e aceitabilidade em cenário de terapia intensiva pediátrica. Estudos de confiabilidade e de validade devem ser realizados para avaliar as propriedades psicométricas da versão adaptada para o português do Brasil da RASS.

ABSTRACT Objective: To perform a cross-cultural adaptation of the Richmond Agitation-Sedation Scale (RASS) to Brazilian Portuguese for the evaluation of sedation in pediatric intensive care. Methods: Cross-cultural adaptation process including the conceptual, item, semantic and operational equivalence stages according to current recommendations. Results: Pretests, divided into two stages, included 30 professionals from the pediatric intensive care unit of a university hospital, who administered the translated RASS to patients aged 29 days to 18 years. The pretests showed a content validity index above 0.90 for all items: 0.97 in the first stage of pretests and 0.99 in the second. Conclusion: The cross-cultural adaptation of RASS to Brazilian Portuguese resulted in a version with excellent comprehensibility and acceptability in a pediatric intensive care setting. Reliability and validity studies should be performed to evaluate the psychometric properties of the Brazilian Portuguese version of the RASS.

RESUMO Objetivo: Apresentar as atuais evidências sobre as características clínicas e laboratoriais da infecção pelo coronavírus da síndrome respiratória aguda grave 2 (SARS-CoV-2) durante a infância e a adolescência. Fonte de dados: Revisão narrativa realizada nas bases de dados Medical Literature Analysis and Retrieval System Online (MEDLINE/PubMed), Literatura Latino-Americana e do Caribe em Ciências da Saúde na Biblioteca Virtual em Saúde (LILACS/BVS), Scopus, Web of Science, Cochrane Library, portal da Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES), Scientific Electronic Library Online (SciELO), ScienceDirect e Cumulative Index to Nursing and Allied Health Literature (CINAHL), com o uso dos termos SARS-CoV-2, COVID-19 e novo coronavírus e criança, recém-nascido e adolescente. Síntese dos dados: Diferentemente dos adultos, as crianças infectadas pelo SARS-CoV-2 apresentam formas clínicas leves ou assintomáticas na maior parte dos casos. As crianças sintomáticas apresentam predominantemente febre baixa e tosse, com alguns sintomas gastrointestinais associados. Casos graves são a minoria e ocorrem especialmente abaixo de um ano de idade. A detecção de partículas virais em fezes parece ser mais persistente em crianças, podendo servir como ferramenta diagnóstica e de controle do tempo de quarentena. Diferentemente dos adultos, as crianças podem apresentar respostas inflamatórias distintas, como tem ocorrido nos novos casos de síndrome de Kawasaki-like associada à infecção pelo SARS-CoV-2. Conclusões: Crianças, na sua maioria, apresentam quadros assintomáticos ou leves, com predomínio de febre, tosse e sintomas gastrointestinais. Novos relatos de diferentes reações sistêmicas inflamatórias em crianças têm sido notados, com manifestações clínicas distintas daquelas tipicamente observadas em adultos.

ABSTRACT Objective: To present the current evidence on clinical and laboratory characteristics of infection by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) during childhood and adolescence. Data source: This is a narrative review conducted in the databases: Medical Literature Analysis and Retrieval System Online (MEDLINE/PubMed), Latin American and Caribbean Health Sciences Literature in the Virtual Health Library (LILACS/VHL), Scopus, Web of Science, Cochrane Library, portal of the Coordination for the Improvement of Higher Education Personnel (Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - CAPES), Scientific Electronic Library Online (SciELO), ScienceDirect, and Cumulative Index to Nursing and Allied Health Literature (CINAHL). The terms used were SARS-CoV-2, COVID-19, novel coronavirus, child, newborn, and adolescent. Data synthesis: Unlike adults, most children infected by SARS-CoV-2 have mild or asymptomatic clinical presentations. Symptomatic children mainly have low fever and cough, with some associated gastrointestinal symptoms. Severe cases are rare and occur especially in infants under one year of age. Detection of viral particles in feces seems to be more persistent in children and can be used as a tool for diagnosis and control of the quarantine period. Different from adults, children can present distinct inflammatory responses, as has happened in new cases of Kawasaki-like syndrome associated with SARS-CoV-2 infection. Conclusions: Most children have asymptomatic or mild presentations, with a prevalence of fever, cough, and gastrointestinal symptoms. New cases with different systemic inflammatory reactions in children have been reported, with clinical manifestations distinct from those typically found in adults.

Abstract Introduction The association between prenatal Zika virus infection and hearing alterations in offspring has been the object of some studies, although few have assessed children without microcephaly. However, a current trend to include prenatal Zika virus exposure in the group of risk indicators for hearing loss is noted. Objective To present a series of 27 children prenatally exposed to the Zika virus submitted to multiple hearing assessments over time. Methods A cohort of children born to symptomatic mothers with laboratorial Zika virus infection confirmation during pregnancy was submitted to an otoacoustic emission test, auditory brainstem response test (automated, neurodiagnostic and frequency-specific), audiometry, and imitanciometry over a period of 36 months since birth. The hearing assessment was performed independently of the presence of microcephaly or other apparent signs of congenital Zika syndrome. Results The hearing tests presented predominantly normal results. Some children had signs of middle ear pathology. The only microcephalic child had normal electrophysiological tests, as well as preserved audiometric thresholds, but presented altered motor responses to sound. Conclusion Prenatal exposure to Zika virus does not always determine hearing impairment. This risk seems to be more associated to the severity of the central nervous system damage. Hearing screening and follow-ups of the affected children are important, as well as further research in this area.

Resumo Objetivos Apresentar as evidências atualmente disponíveis sobre transmissão, quadro clínico, métodos diagnósticos, tratamento e métodos de prevenção das principais arboviroses que ocorrem na infância. Fonte de dados Revisão não sistemática feita nas bases de dados Medline (Pubmed), Lilacs (BVS), Scopus, Web of Science, Cochrane, portal Capes e Google Scholar nos últimos cinco anos, com o uso dos termos arboviroses, dengue, chikungunya, zika, mayaro, febre do oeste do Nilo e criança, recém-nascido, adolescente. Síntese de dados Os arbovírus têm como característica principal o fato de parte de seu ciclo de replicação ocorrer em insetos vetores. Assim, são classicamente transmitidos aos seres humanos pela picada de mosquitos (artrópodes hematófagos), embora seja também possível a transmissão não vetorial desses vírus em situações específicas. Essas doenças ainda constituem um grande desafio na saúde pública, devido à inexistência de tratamento antiviral específico, à cocirculação de diferentes arbovírus em regiões endêmicas/epidêmicas, à falta de imunizações efetivas e seguras para a grande maioria desses vírus e à grande dificuldade do controle vetorial, em especial nos grandes centros urbanos. Conclusões As crianças constituem um grupo especialmente vulnerável a esse grupo de doenças, pois têm características que facilitam o desenvolvimento das formas mais graves. O conhecimento mais detalhado desse grupo de doenças permite ao pediatra diagnosticar mais precocemente, instituir o tratamento correto, vigiar os sinais de alarme para as formas mais graves e colocar em prática efetivas medidas de prevenção.

Abstract Objectives To present the currently available evidence on transmission, clinical, diagnostic methods, treatment, and prevention methods of major arboviruses that occur in childhood. Source of data Non-systematic review carried out in MEDLINE (PubMed), LILACS (VHL), Scopus, Web of Science, Cochrane, CAPES Portal, and Google Scholar databases for the past five years using the search terms arboviruses, dengue, chikungunya, Zika, Mayaro, and West Nile fever, as well as child, newborn, and adolescent. Synthesis of data The main characteristic of arboviruses is the fact that part of their replication cycle occurs inside insect vectors, thus being classically transmitted to humans through the bite of mosquitoes (hematophagous arthropods), although non-vector transmission of these viruses is also possible in specific situations. These diseases remain a major public health challenge, due to the lack of specific antiviral treatment, the co-circulation of different arboviruses in endemic/epidemic regions, the lack of effective and safe immunizations for the vast majority of these viruses, and the great difficulty in vector control, especially in large urban centers. Conclusions Children are especially vulnerable to this group of diseases due to characteristics that facilitate the development of the most severe forms. More detailed knowledge of this group of diseases allows the pediatrician to diagnose them earlier, implement the correct treatment, monitor warning signs for the most severe forms, and establish effective preventive measures.

Resumo Introdução: Possíveis associações entre a infecção pelo Zika vírus e perda auditiva foram observadas durante a epidemia nas Américas. Objetivo: Descrever as alterações auditivas, a patogênese e as recomendações de seguimento em indivíduos com infecção por Zika vírus pré-natal ou adquirida. Método: Uma pesquisa bibliográfica foi realizada em março/2018 a abril/2019 nas principais bases de dados disponíveis. A seleção dos artigos, extração de dados e avaliação de qualidade foram realizadas por dois revisores independentes. Estudos com avaliação auditiva de pacientes com infecção por Zika vírus congênita ou adquirida; e/ou hipóteses ou evidências sobre a fisiopatologia do comprometimento auditivo associado ao Zika vírus; e/ou recomendações sobre triagem e seguimento de pacientes com comprometimento auditivo pelo Zika vírus foram incluídos na pesquisa. Resultados: Um total de 27 artigos foram selecionados. Perdas auditivas neurossensorial e transitória foram relatadas em seis adultos com infecção pelo Zika vírus adquirida. Das 962 crianças estudadas, 482 apresentavam microcefalia e 145 tinham confirmação diagnóstica do Zika vírus; 515 das 624 crianças com avaliação auditiva haviam realizado apenas testes de triagem com teste de emissões otoacústicas e/ou teste de potencial evocado auditivo de tronco encefálico automático com estímulo clique. Estudos em crianças expostas no período pré-natal foram muito heterogêneos e grandes variações na frequência de emissões otoacústicas e potencial evocado auditivo de tronco encefálico automático alterados ocorreram ao longo dos estudos; alterações nas emissões otoacústicas variaram de 0% a 75%, enquanto as alterações no potencial evocado auditivo de tronco encefálico automático variaram de 0% a 29,2%. Não foi possível descartar comprometimento neurossensorial, retrococlear ou de origem central. Um estudo com camundongos infectados não encontrou dano microscópico nas células ciliadas da cóclea. Estudos sobre a patogênese das alterações auditivas em humanos estão limitados a hipóteses e recomendações ainda apresentam pontos de controvérsia. Conclusão: Os dados disponíveis ainda são insuficientes para compreender todo o espectro do envolvimento dos órgãos auditivos pelo Zika vírus, a patogênese desse envolvimento ou até mesmo para confirmar a associação causal entre o envolvimento auditivo e a infecção pelo vírus. As recomendações de triagem e seguimento ainda apresentam pontos de controvérsia.

Abstract Introduction: Possible associations between Zika virus infection and hearing loss were observed during the epidemic in the Americas. Objective: To describe the auditory alterations, pathogenesis and recommendations for follow-up in individuals with prenatal or acquired Zika virus infection. Methods: Bibliographic research conducted in March/2018-April/2019 at the main available databases. Article selection, data extraction and quality evaluation were carried out by two independent reviewers. Studies containing auditory evaluation of patients with congenital or acquired Zika virus infection; and/or hypotheses or evidences on the pathophysiology of auditory impairment associated with Zika virus; and/or recommendations on screening and follow-up of patients with auditory impairment by Zika virus were included. Results: A total of 27 articles were selected. Sensorineural and transient hearing loss were reported in six adults with acquired Zika virus infection. Of the 962 studied children, 482 had microcephaly and 145 had diagnostic confirmation of Zika virus; 515 of the 624 children with auditory evaluation performed only screening tests with otoacoustic emissions testing and/or automated click-stimuli auditory brainstem response testing. Studies in prenatally exposed children were very heterogeneous and great variations in the frequency of altered otoacoustic emissions and automated click-stimuli auditory brainstem response occurred across the studies. Altered otoacoustic emissions varied from 0% to 75%, while altered automated click-stimuli auditory brainstem response varied from 0% to 29.2%. Sensorineural, retrocochlear or central origin impairment could not be ruled out. One study with infected mice found no microscopic damage to cochlear hair cells. Studies on the pathogenesis of auditory changes in humans are limited to hypotheses and recommendations still include points of controversy. Conclusion: The available data are still insufficient to understand the full spectrum of the involvement of the auditory organs by Zika virus, the pathogenesis of this involvement or even to confirm the causal association between auditory involvement and virus infection. The screening and follow-up recommendations still present points of controversy.

Resumo Duzentos milhões de crianças em idade pré-escolar não estão se desenvolvendo adequadamente. Os atrasos no desenvolvimento estão associados a múltiplos fatores. Este estudo pretende analisar se a suplementação de vitamina A está associada a melhor desenvolvimento e a forma como esse efeito pode ser mediado pelo estado nutricional. Estudo de base populacional com amostra de 8.000 famílias, 1.232 crianças 0-35 meses, no estado do Ceará, Brasil. As variáveis analisadas incluíram desenvolvimento, determinantes nutricionais e fatores de confusão. Os efeitos e as interações foram avaliados utilizando modelos regressivos de Cox. A suplementação de vitamina A foi protetora para atraso no desenvolvimento cognitivo e motor modificado pela interação com o estado nutricional. Crianças suplementadas bem nutridas apresentaram um risco 67% menor de atraso cognitivo (PRR ajustado = 0 33 [0 21-0 53]), já as crianças desnutridas não se beneficiaram (PRR ajustado = 0 97 [0 39-2 40]). A suplementação tem um efeito protetor sobre o desenvolvimento, mas não em crianças desnutridas. Isso sugere que a suplementação é eficaz na promoção do desenvolvimento, especialmente se associada a um esforço para melhorar o estado nutricional infantil, dada a importância desse mediador.

Abstract 200 million pre-school age children are not developing properly. Delays in child development are associated with multiple factors. This study aims to analyze if vitamin A supplementation is associated with improved development and how this effect could be mediated by nutritional status. Population-based study surveyed a representative sample of 8000 households, 1232 children 0-35 months, in the state of Ceará, Brazil. The variables analysed included child developmental status, nutritional determinants and confounding factors. The main effects and interactions were evaluated using Cox regressive models. Vitamin A supplementation showed protective effect to delay in cognitive and motor development modified by interaction with nutritional status. While well-nourished supplemented children presented a 67% lower risk of cognitive delay (adjusted PRR = 0·33 [0·21–0·53]), stunted children had no benefit from supplementation (adjusted PRR = 0·97 [0·39–2·40]). Vitamin A supplementation has a protective effect on child development, but not in stunted children. This suggests that supplementation is effective in promoting child development, especially if associated to a joint effort to improve the nutritional status of children, given the importance of this mediator.

Resumo Duzentos milhões de crianças em idade pré-escolar não estão se desenvolvendo adequadamente. Os atrasos no desenvolvimento estão associados a múltiplos fatores. Este estudo pretende analisar se a suplementação de vitamina A está associada a melhor desenvolvimento e a forma como esse efeito pode ser mediado pelo estado nutricional. Estudo de base populacional com amostra de 8.000 famílias, 1.232 crianças 0-35 meses, no estado do Ceará, Brasil. As variáveis analisadas incluíram desenvolvimento, determinantes nutricionais e fatores de confusão. Os efeitos e as interações foram avaliados utilizando modelos regressivos de Cox. A suplementação de vitamina A foi protetora para atraso no desenvolvimento cognitivo e motor modificado pela interação com o estado nutricional. Crianças suplementadas bem nutridas apresentaram um risco 67% menor de atraso cognitivo (PRR ajustado = 0 33 [0 21-0 53]), já as crianças desnutridas não se beneficiaram (PRR ajustado = 0 97 [0 39-2 40]). A suplementação tem um efeito protetor sobre o desenvolvimento, mas não em crianças desnutridas. Isso sugere que a suplementação é eficaz na promoção do desenvolvimento, especialmente se associada a um esforço para melhorar o estado nutricional infantil, dada a importância desse mediador.

Abstract 200 million pre-school age children are not developing properly. Delays in child development are associated with multiple factors. This study aims to analyze if vitamin A supplementation is associated with improved development and how this effect could be mediated by nutritional status. Population-based study surveyed a representative sample of 8000 households, 1232 children 0-35 months, in the state of Ceará, Brazil. The variables analysed included child developmental status, nutritional determinants and confounding factors. The main effects and interactions were evaluated using Cox regressive models. Vitamin A supplementation showed protective effect to delay in cognitive and motor development modified by interaction with nutritional status. While well-nourished supplemented children presented a 67% lower risk of cognitive delay (adjusted PRR = 0·33 [0·21–0·53]), stunted children had no benefit from supplementation (adjusted PRR = 0·97 [0·39–2·40]). Vitamin A supplementation has a protective effect on child development, but not in stunted children. This suggests that supplementation is effective in promoting child development, especially if associated to a joint effort to improve the nutritional status of children, given the importance of this mediator.

RESUMO Objetivo: Avaliar a validade e a confiabilidade de um sistema de classificação de risco para emergências pediátricas (CLARIPED) desenvolvido no Brasil. Métodos: Fase de validade: estudo observacional prospectivo em crianças de 0 a 15anos atendidas consecutivamente no serviço de emergência pediátrica (SEP) de um hospital terciário entre 2 e 18de julho de 2013. Avaliou-se a associação dos níveis de urgência com desfechos clínicos (utilização de recursos, taxa de admissão no SEP, taxa de hospitalização e tempo de permanência no SEP); e comparou-se o desempenho do CLARIPED com um padrão de referência. Fase de confiabilidade interobservadores: uma amostra de conveniência de pacientes atendidos entre abril e julho de 2013 foi submetida a duas classificações de risco consecutivas e independentes, e estimou-se o Kappa ponderado quadrático. Resultados: Em 1.416 atendimentos realizados na fase de validade, a distribuição de níveis de urgência foi: 0,0% vermelho/emergência; 5,9% laranja/muito urgente; 40,5% amarelo/urgente; 50,6% verde/pouco urgente; e 3,0% azul/sem urgência. Ospercentuais de pacientes que usaram dois ou mais recursos diminuíram do nível laranja para o amarelo, verde e azul (81, 49, 22 e 2%, respectivamente, p<0,0001), assim como a taxa de admissão no SEP, o tempo de permanência no SEP e a taxa de admissão hospitalar. Asensibilidade para discriminar pacientes muito urgentes foi de 0,89 (intervalo de confiança de 95%- IC95% 0,78-0,95), e a taxa de subtriagem foi de 7,4%. Aconfiabilidade interobservadores em 191 pacientes classificados por duas enfermeiras foi substancial (kw2=0,75; IC95% 0,74-0,79). Conclusões: O sistema CLARIPED mostrou boa validade e substancial confiabilidade para classificação de risco em um serviço de emergência pediátrica.

ABSTRACT Objective: To assess the validity and reliability of a triage system for pediatric emergency care (CLARIPED) developed in Brazil. Methods: Validity phase: prospective observational study with children aged 0 to 15 years who consecutively visited the pediatric emergency department (ED) of a tertiary hospital from July 2 to 18, 2013. We evaluated the association of urgency levels with clinical outcomes (resource utilization, ED admission rate, hospitalization rate, and ED length of stay); and compared the CLARIPED performance to a reference standard. Inter-rater reliability phase: a convenience sample of patients who visited the pediatric ED between April and July 2013 was consecutively and independently double triaged by two nurses, and the quadratic weighted kappa was estimated. Results: In the validity phase, the distribution of urgency levels in 1,416 visits was the following: 0.0% red (emergency); 5.9% orange (high urgency); 40.5% yellow (urgency); 50.6% green (low urgency); and 3.0% blue (no urgency). The percentage of patients who used two or more resources decreased from the orange level to the yellow, green, and blue levels (81%, 49%, 22%, and 2%, respectively, p<0.0001), as did the ED admission rate, ED length of stay, and hospitalization rate. The sensitivity to identify patients with high urgency level was 0.89 (confidence interval of 95% [95%CI] 0.78-0.95), and the undertriage rate was 7.4%. The inter-rater reliability in 191patients classified by two nurses was substantial (kw2=0.75; 95%CI 0.74-0.79). Conclusions: The CLARIPED system showed good validity and substantial reliability for triage in a pediatric emergency department.

ABSTRACT Objectives: The role of viral co-detection in children with severe acute respiratory infection is not clear. We described the viral detection profile and its association with clinical characteristics in children admitted to the Pediatric Intensive Care Unit (PICU) during the 2009 influenza A(H1N1) pandemic. Method: Longitudinal observational retrospective study, with patients aged 0–18 years, admitted to 11 PICUs in Rio de Janeiro, with suspected H1N1 infection, from June to November, 2009. The results of respiratory samples which were sent to the Laboratory of Fiocruz/RJ and clinical data extracted from specific forms were analyzed. Results: Of 71 samples, 38% tested positive for H1N1 virus. Of the 63 samples tested for other viruses, 58 were positive: influenza H1N1 (43.1% of positive samples), rhinovirus/enterovirus (41.4%), respiratory syncytial vírus (12.1%), human metapneumovirus (12.1%), adenovirus (6.9%), and bocavirus (3.5%). Viral codetection occured in 22.4% of the cases. H1N1-positive patients were of a higher median age, had higher frequency of fever, cough and tachypnea, and decreased leukometry when compared to H1N1-negative patients. There was no difference in relation to severity outcomes (number of organic dysfunctions, use of mechanical ventilation or amines, hospital/PICU length of stay or death). Comparing the groups with mono-detection and co-dection of any virus, no difference was found regarding the association with any clinical variable. Conclusions: Other viruses can be implicated in SARI in children. The role of viral codetection has not yet been completely elucidated.