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Nesse grupo de risco estariam os indiv&#237;duos da etnia negra&#44; obesos&#44; gestantes&#44; lactantes e portadores de determinadas doen&#231;as&#44; como doen&#231;as end&#243;crinas e renais&#44; entre outras&#46; Os portadores de alergia &#224; prote&#237;na do leite de vaca &#40;APLV&#41; n&#227;o est&#227;o inclu&#237;dos&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">De outra forma&#44; alguns estudos internacionais&#44; feitos principalmente em crian&#231;as com formas imediatas de APLV&#44; mediadas por IgE&#44; sugeriram uma maior frequ&#234;ncia de defici&#234;ncia de vitamina D nesse grupo&#46;<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">4&#8211;7</span></a> Baixos n&#237;veis da vitamina D em crian&#231;as s&#227;o relacionados a fatores como deficiente transfer&#234;ncia materno&#8208;fetal por hipovitaminose materna&#44; inadequada exposi&#231;&#227;o solar&#44; uso inadequado de suplementos de vitamina D e baixa ingest&#227;o atrav&#233;s da dieta&#46;<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">1&#44;8&#44;9</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Estudos sobre os n&#237;veis de vitamina D em crian&#231;as portadoras de APLV s&#227;o importantes para avaliar a possibilidade de essas serem um grupo de risco para a ocorr&#234;ncia de defici&#234;ncia de vitamina D&#46; Uma vez que a maioria dos estudos que analisaram n&#237;veis de vitamina D em crian&#231;as com APLV foi conduzido em crian&#231;as sem manifesta&#231;&#227;o gastrointestinal&#44;<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">4&#8211;7</span></a> restam lacunas em rela&#231;&#227;o ao conhecimento desse problema&#46; Al&#233;m disso&#44; poucas pesquisas foram feitas em crian&#231;as com APLV residentes em regi&#245;es ensolaradas onde se pressup&#245;e haver exposi&#231;&#227;o adequada aos raios ultravioletas&#46; O objetivo do nosso estudo foi verificar se os lactentes com APLV apresentam n&#237;veis inadequados de vitamina D&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">M&#233;todo</span><p id="par0020" class="elsevierStylePara elsevierViewall">Estudo observacional&#44; de corte transversal&#44; no qual foram comparados os n&#237;veis de vitamina D de um grupo de lactentes com diagn&#243;stico cl&#237;nico de APLV e um grupo de lactentes saud&#225;veis &#40;grupo de compara&#231;&#227;o&#41;&#46; A pesquisa foi feita de mar&#231;o de 2013 a abril de 2015&#44; nos ambulat&#243;rios de Gastroenterologia Pedi&#225;trica&#44; Alergologia Pedi&#225;trica e Puericultura do Hospital das Cl&#237;nicas da Universidade Federal de Pernambuco &#40;HC&#47;UFPE&#41;&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">O grupo de crian&#231;as com APLV foi composto por 59 lactentes de ambos os sexos que apresentaram manifesta&#231;&#245;es cl&#237;nicas adversas relacionadas &#224; APLV&#46; Para concluir o diagn&#243;stico levaram&#8208;se em considera&#231;&#227;o a hist&#243;ria cl&#237;nica&#44; o exame f&#237;sico e os antecedentes e foi confirmado pelo teste de desencadeamento oral aberto&#44; conforme indicado pelas principais diretrizes vigentes&#46;<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">10&#44;11</span></a> O teste de desencadeamento foi contraindicado pelos pesquisadores nas seguintes situa&#231;&#245;es&#58; relato de manifesta&#231;&#245;es imediatas associadas a um resultado de IgE positivo&#59; manifesta&#231;&#245;es tardias compat&#237;veis com APLV&#44; associados &#224; desnutri&#231;&#227;o&#46; O grupo de compara&#231;&#227;o foi formado por 61 crian&#231;as saud&#225;veis&#46; Foram exclu&#237;das as crian&#231;as com suspeita cl&#237;nica de outras patologias ou fatores que pudessem influenciar nos n&#237;veis de vitamina D&#44; como doen&#231;as infecciosas agudas ou cr&#244;nicas&#44; outras doen&#231;as inflamat&#243;rias intestinais&#44; doen&#231;as renais ou gastrointestinais&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Para a avalia&#231;&#227;o antropom&#233;trica foi obtido o peso do lactente e usado o indicador peso&#47;idade &#40;P&#47;I&#41; proposto pela Organiza&#231;&#227;o Mundial da Sa&#250;de &#40;OMS&#41;&#46; Para avalia&#231;&#227;o do P&#47;I&#44; foram adotados os seguintes pontos de cortes&#58;<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#8722;2 escore z para peso baixo para a idade&#44; &#8805; &#8722;2 e<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#43;2 escore z para peso adequado para a idade e &#8805; &#43;2 escore z para peso elevado para a idade&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">12</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Em rela&#231;&#227;o &#224; vitamina D&#44; foram analisados os n&#237;veis e graus de sufici&#234;ncia&#44; categorizados em insuficiente&#47;deficiente e suficiente&#46; Foi considerada defici&#234;ncia quando a 25&#40;OH&#41;D foi igual ou inferior a 20<span class="elsevierStyleHsp" style=""></span>ng&#47;mL&#44; insufici&#234;ncia quando os n&#237;veis se encontravam entre 21&#8208;29<span class="elsevierStyleHsp" style=""></span>ng&#47;mL e sufici&#234;ncia quando foram iguais ou superiores a 30<span class="elsevierStyleHsp" style=""></span>ng&#47;mL&#46;<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">3&#44;13</span></a> Para essa an&#225;lise&#44; foi coletada uma amostra de sangue &#40;4<span class="elsevierStyleHsp" style=""></span>ml&#41;&#44; por profissional capacitado&#44; armazenada em tubo com gel separador e levada para o laborat&#243;rio conveniado &#224; pesquisa&#46; A dosagem da 25 &#40;OH&#41;D foi feita pela t&#233;cnica de quimioluminesc&#234;ncia e foi usado o kit comercial Liaison<span class="elsevierStyleSup">&#174;</span>&#46; Para as crian&#231;as que cursaram com n&#237;veis inadequados de vitamina D&#44; foram prestadas orienta&#231;&#245;es aos pais sobre a necessidade de suplementa&#231;&#227;o&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Para a classifica&#231;&#227;o da pr&#225;tica atual do aleitamento materno &#40;AM&#41; foi usada a categoriza&#231;&#227;o da OMS&#44; foram considerados AM exclusivo &#40;quando a crian&#231;a recebe s&#243; leite materno sem outros l&#237;quidos ou s&#243;lidos&#41;&#44; AM predominante &#40;quando a crian&#231;a recebe&#44; al&#233;m do leite materno&#44; &#225;gua ou bebidas &#224; base de &#225;gua&#41;&#44; AM complementado &#40;quando a crian&#231;a recebe&#44; al&#233;m do leite materno&#44; qualquer alimento s&#243;lido ou semiss&#243;lido com a finalidade de complement&#225;&#8208;lo&#44; e n&#227;o substitu&#237;&#8208;lo&#41; e AM misto ou parcial &#40;quando a crian&#231;a recebe leite materno e outros tipos de leite&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">14</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Na avalia&#231;&#227;o da exposi&#231;&#227;o solar&#44; foram usadas as orienta&#231;&#245;es da Sociedade Brasileira de Pediatria &#40;SBP&#41;&#46; Ela recomenda que a crian&#231;a deve receber exposi&#231;&#227;o direta da pele &#224; luz solar a partir da segunda semana de vida&#44; &#233; suficiente a cota semanal de 30 minutos de exposi&#231;&#227;o solar com a crian&#231;a apenas de fraldas&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">15</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">A constru&#231;&#227;o do banco de dados foi feita com o programa Epi&#8208;Info vers&#227;o 6&#46;04d &#40;Epi&#8208;info 6&#46;04&#44; WHO&#47;CDC&#44; Atlanta&#44; USA&#41;&#46; As an&#225;lises estat&#237;sticas foram feitas com o <span class="elsevierStyleItalic">Statistical Package for the Social Sciences</span> &#40;SPSS&#41; vers&#227;o 13&#46;0 para Windows &#40;SPSS Inc&#46;&#44; Chicago&#44; IL&#44; EUA&#41;&#46; As vari&#225;veis cont&#237;nuas foram testadas quanto &#224; normalidade da distribui&#231;&#227;o pelo teste de Kolmogorov&#8208;Smirnov&#44; foram expressas por m&#233;dia e desvio&#8208;padr&#227;o quando de distribui&#231;&#227;o sim&#233;trica e mediana e quartis se distribui&#231;&#227;o assim&#233;trica&#46; As diferen&#231;as de frequ&#234;ncia e a associa&#231;&#227;o entre as vari&#225;veis categ&#243;ricas foram testadas pelo m&#233;todo qui&#8208;quadrado de Pearson ou teste exato de Fisher quando indicado&#46; O n&#237;vel de signific&#226;ncia empregado em todos os testes foi de 5&#37;&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Os respons&#225;veis foram informados verbalmente sobre os objetivos da pesquisa e assinaram o termo de consentimento livre e esclarecido&#46; O projeto de pesquisa foi registrado na Comiss&#227;o Nacional de &#201;tica em Pesquisa &#40;Conep&#47;Plataforma Brasil&#41; e submetido &#224; aprova&#231;&#227;o do Comit&#234; de &#201;tica em Pesquisa em Seres Humanos do Centro de Ci&#234;ncias da Sa&#250;de da Universidade Federal de Pernambuco&#44; com CAAE&#58; 12878313&#46;4&#46;0000&#46;5208&#47;2013&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Resultados</span><p id="par0060" class="elsevierStylePara elsevierViewall">A mediana de idade da amostra total foi de 8&#44;5 meses &#40;P25&#58; 6&#44;0&#59; P75&#58; 14&#44;0&#41;&#44; nas crian&#231;as com APLV foi de sete meses &#40;P25&#58; 4&#59; <span class="elsevierStyleItalic">vs</span>&#46; das crian&#231;as com APLV&#46; Verificou&#8208;se tamb&#233;m uma maior frequ&#234;ncia de atopia entre as m&#227;es &#40;62&#44;7&#37; <span class="elsevierStyleItalic">vs&#46;</span> 34&#44;4&#37;&#41; e pais &#40;46&#44;6&#37; <span class="elsevierStyleItalic">vs&#46;</span> 28&#44;3&#37;&#41; das crian&#231;as com APLV&#46; Quando avaliado o estado nutricional&#44; observou&#8208;se um maior percentual de eutrofia na amostra&#44; com frequ&#234;ncias semelhantes em ambos os grupos &#40;91&#44;5&#37; no grupo com APLV e 96&#44;6&#37; no grupo controle&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">tabela 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">Nas crian&#231;as com diagn&#243;stico de APLV&#44; as manifesta&#231;&#245;es cl&#237;nicas mais frequentes foram do tipo imediatas &#40;59&#44;3&#37;&#41;&#46; As manifesta&#231;&#245;es imediatas observadas foram&#58; angioedema&#44; urtic&#225;ria e hiperemia cut&#226;nea&#44; v&#244;mitos&#44; diarreia&#44; tosse e sibil&#226;ncia&#46; As manifesta&#231;&#245;es tardias encontradas foram&#58; regurgita&#231;&#245;es e v&#244;mitos compat&#237;veis com doen&#231;a do refluxo gastroesof&#225;gico &#40;DRGE&#41;&#44; diarreia&#44; diarreia com sangue &#40;compat&#237;vel com colite&#41;&#44; proctite&#44; baixo ganho ou perda de peso&#44; choro excessivo e distens&#227;o abdominal&#44; dificuldade evacuat&#243;ria e eczema at&#243;pico&#46; Entre as manifesta&#231;&#245;es imediatas destacaram&#8208;se urtic&#225;ria em 28&#44;8&#37;&#44; angioedema em 15&#44;3&#37; e tosse em 15&#44;3&#37;&#46; No grupo com manifesta&#231;&#227;o tardia&#44; 40&#44;7&#37; apresentaram v&#244;mito e diarreia&#44; sinais de colite em 35&#44;6&#37; e sintomas compat&#237;veis com DRGE em 22&#37;&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">A m&#233;dia dos n&#237;veis de vitamina D entre as crian&#231;as com APLV foi de 30&#44;93<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>12&#44;33<span class="elsevierStyleHsp" style=""></span>ng&#47;ml e de 35&#44;29<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>10&#44;74<span class="elsevierStyleHsp" style=""></span>ng&#47;ml nas crian&#231;as saud&#225;veis &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;041&#41;&#46; A <a class="elsevierStyleCrossRef" href="#fig0005">figura 1</a> mostra as frequ&#234;ncias dos diferentes graus de sufici&#234;ncia da vitamina D nos dois grupos&#44; nos quais se observou que dentre o total das crian&#231;as houve uma maior frequ&#234;ncia de n&#237;veis deficientes naquelas com APLV &#40;20&#44;3&#37; <span class="elsevierStyleItalic">vs&#46;</span> 8&#44;2&#37;&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;049&#41;&#46; Vale salientar que nenhuma crian&#231;a se encontrava em uso de suplemento de vitamina D no momento da entrevista e apenas nove das m&#227;es de crian&#231;as com APLV relataram ter feito suplementa&#231;&#227;o com vitamina D durante o per&#237;odo gestacional&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">A <a class="elsevierStyleCrossRef" href="#tbl0010">tabela 2</a> mostra que dentre as crian&#231;as com APLV as que eram submetidas a AM exclusivo&#47;predominante no momento da entrevista tiveram uma maior frequ&#234;ncia de defici&#234;ncia de vitamina D&#44; foi observado que 25&#44;9&#37; de crian&#231;as foram deficientes e apenas 3&#44;1&#37; delas apresentaram n&#237;veis suficientes&#46; O mesmo foi observado naquelas em AM parcial &#40;25&#44;9&#37; <span class="elsevierStyleItalic">vs&#46;</span> 6&#44;3&#37;&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;002&#41;&#46; Crian&#231;as com APLV e n&#227;o amamentadas&#44; ou seja&#44; que estavam em uso de f&#243;rmulas infantis&#44; apresentaram em sua maioria n&#237;veis de sufici&#234;ncia &#40;78&#44;1&#37;&#41;&#46; No grupo comparativo&#44; n&#227;o houve associa&#231;&#227;o das diferentes pr&#225;ticas alimentares e os graus de sufici&#234;ncia da vitamina D &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;189&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">No grupo das crian&#231;as al&#233;rgicas&#44; a frequ&#234;ncia da exposi&#231;&#227;o solar n&#227;o interferiu no grau de sufici&#234;ncia da vitamina D&#44; os resultados foram semelhantes naquelas com graus de defici&#234;ncia&#47;insufici&#234;ncia e nas suficientes &#40;entre os deficientes&#47;suficientes&#44; 14 eram expostas adequadamente ao sol&#44; enquanto 12 n&#227;o eram&#59; entre os suficientes 17 eram adequadamente expostos e 13 n&#227;o eram&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;972&#41;&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discuss&#227;o</span><p id="par0085" class="elsevierStylePara elsevierViewall">Nesta pesquisa&#44; feita entre crian&#231;as em sua maioria eutr&#243;fica e submetidas a tempos semelhantes de aleitamento materno&#44; as crian&#231;as com APLV imediata e tardia apresentaram um maior percentual de defici&#234;ncia quando comparadas com as crian&#231;as saud&#225;veis &#40;20&#44;3&#37; <span class="elsevierStyleItalic">vs&#46;</span> 8&#44;2&#37;&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;049&#41;&#46; Embora as m&#233;dias de vitamina D se encontrassem dentro da normalidade em ambos os grupos&#44; uma menor m&#233;dia foi observada nas crian&#231;as al&#233;rgicas &#40;30&#44;93 <span class="elsevierStyleItalic">vs&#46;</span> 35&#44;29&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;041&#41;&#44; o que refor&#231;a a tend&#234;ncia das crian&#231;as al&#233;rgicas de terem menores n&#237;veis da vitamina&#46; Alguns estudos j&#225; investigaram a rela&#231;&#227;o entre a defici&#234;ncia de vitamina D e alergia alimentar&#44; mas a maioria deles foi conduzido em crian&#231;as com APLV forma imediata&#44; mediada por IgE&#46;<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">4&#8211;7</span></a> Este estudo desperta para esse problema tamb&#233;m nas formas tardias&#44; n&#227;o mediadas por IgE e usualmente manifestas por sintomas gastrointestinais&#46; Existe embasamento emp&#237;rico para se acreditar que n&#237;veis insuficientes de vitamina D nos per&#237;odos iniciais da vida podem interferir no desenvolvimento da imunidade&#44; podem colaborar para o surgimento de doen&#231;as al&#233;rgicas&#44; inclusive a alergia alimentar&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">16</span></a> O principal mecanismo atrav&#233;s do qual ela atuaria na regula&#231;&#227;o imune seria ao favorecer uma maior diferencia&#231;&#227;o de linf&#243;citos T naive em c&#233;lulas T reguladoras &#40;Tregs&#41;&#44; que inibiriam as respostas imunes danosas tanto TH1 quanto TH2&#46;<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">16&#44;17</span></a> Deve ser considerado que&#44; apesar de terem sido verificados n&#237;veis de defici&#234;ncia de vitamina D nos lactentes com APLV&#44; o desenho do estudo&#44; transversal&#44; n&#227;o permitiu estabelecer a exist&#234;ncia de uma rela&#231;&#227;o causal entre a defici&#234;ncia de vitamina D e o surgimento de alergia&#46; Pode&#8208;se at&#233; especular que a rela&#231;&#227;o possa ser oposta&#44; se considerarmos que a pr&#243;pria patog&#234;nese da APLV pode ter favorecido as baixas concentra&#231;&#245;es de vitamina D&#44; tanto por possibilitar m&#225; absor&#231;&#227;o quanto pelo fato de poder se associar &#224; resposta inflamat&#243;ria&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">18</span></a> A resposta inflamat&#243;ria sist&#234;mica&#44; que pode ser gerada durante o processo al&#233;rgico&#44; pode estar associada &#224;s baixas concentra&#231;&#245;es de vitaminas lipossol&#250;veis&#44; inclusive a vitamina D&#46;<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">18&#44;19</span></a> Os baixos n&#237;veis poderiam ainda estar relacionados ainda ao fato de as m&#227;es das crian&#231;as com APLV em AM exclusivo fazerem dieta de restri&#231;&#227;o de leite de e vaca e derivados&#44; sem suplementa&#231;&#227;o de vitamina D&#44; fato j&#225; relacionado a defici&#234;ncias desse e de outros micronutrientes&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">20</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">As principais fontes de vitamina D para os lactentes s&#227;o a dieta&#44; exposi&#231;&#227;o solar e os suplementos vitam&#237;nicos&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">21</span></a> O LM pode conferir um efeito protetor no desenvolvimento de v&#225;rios tipos de alergias devido &#224; presen&#231;a de fatores imunol&#243;gicos e nutrientes funcionais que favorecem um microambiente saud&#225;vel para o desenvolvimento imunit&#225;rio e matura&#231;&#227;o intestinal&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">22</span></a> Entretanto&#44; como tem baixas concentra&#231;&#245;es de vitamina D&#44;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">23</span></a> crian&#231;as em AM&#44; principalmente quando amamentadas de forma exclusiva e sem receber exposi&#231;&#227;o solar adequada&#44; podem representar um grupo de maior risco para a defici&#234;ncia de vitamina D&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">24</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">Baixos n&#237;veis de vitamina D foram observados nas crian&#231;as al&#233;rgicas submetidas ao AM&#44; foi observada maior frequ&#234;ncia de n&#237;veis deficientes&#47;insuficientes da vitamina D dentre as crian&#231;as com APLV submetidas ao AM exclusivo&#47;predominante &#40;25&#44;9&#37;&#41;&#46; Evid&#234;ncias sugerem que crian&#231;as que desenvolvem APLV&#44; mesmo em AM exclusivo&#44; t&#234;m fatores gen&#233;ticos que as predisp&#245;em a esse desfecho&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">24</span></a> &#201; poss&#237;vel que no lactente em AM exclusivo que j&#225; tem uma predisposi&#231;&#227;o gen&#233;tica para a APLV&#44; a ocorr&#234;ncia de defici&#234;ncia de vitamina D atue como um gatilho para o desenvolvimento da doen&#231;a&#46; Nesse sentido&#44; foi observado que dos oito beb&#234;s que estavam em AM exclusivo&#47;predominante e desenvolveram APLV &#40;a maioria colite al&#233;rgica&#41;&#44; sete encontravam&#8208;se com n&#237;veis inadequados de vitamina D&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Estudos feitos em diferentes pa&#237;ses sugerem a necessidade de suplementa&#231;&#227;o do beb&#234; em AM&#44; e por vezes de sua m&#227;e&#44; mesmo quando residente em regi&#227;o ensolarada&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">25</span></a> Nenhuma das crian&#231;as desse estudo fazia suplementa&#231;&#227;o vitam&#237;nica e apenas nove m&#227;es das crian&#231;as com APLV &#40;15&#44;3&#37;&#41; e quatro m&#227;es das crian&#231;as saud&#225;veis &#40;6&#44;6&#37;&#41; estavam em uso de suplemento&#46; Foi verificado que em nosso meio a indica&#231;&#227;o de suplemento de vitamina D no per&#237;odo pr&#233;&#8208;natal e durante o aleitamento ainda n&#227;o &#233; uma pr&#225;tica comum e talvez fosse necess&#225;rio consider&#225;&#8208;la&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">A exposi&#231;&#227;o solar &#233; considerada um dos determinantes mais importantes do status da vitamina D&#46; Os n&#237;veis de vitamina D do beb&#234; tendem a diminuir ao longo dos primeiros meses de vida&#44; caso ele n&#227;o seja exposto &#224; luz solar ou receba&#44; por via digestiva&#44; o adequado aporte de vitamina D&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">26</span></a> No Nordeste do Brasil&#44; ocorrem raios solares abundantes durante quase toda parte do ano&#46; Entretanto&#44; o fato de residir em regi&#227;o ensolarada pode n&#227;o proteger os lactentes dessa defici&#234;ncia vitam&#237;nica&#46; Ao analisar a rela&#231;&#227;o da exposi&#231;&#227;o solar com os n&#237;veis de vitamina D nessa pesquisa&#44; foi verificado que a exposi&#231;&#227;o solar adequada n&#227;o assegurou n&#237;veis suficientes de vitamina D&#46; Em estudo recente feito nessa mesma regi&#227;o&#44; n&#237;veis insuficientes de vitamina D tamb&#233;m foram observados no bin&#244;mio m&#227;e&#47;rec&#233;m&#8208;nascido&#44;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">27</span></a> corroboraram outros dados que apontam para o fato de que mesmo em cidades com elevada irradia&#231;&#227;o solar podem ocorrer frequ&#234;ncias elevadas de hipovitaminose D&#46; O fato de a exposi&#231;&#227;o solar n&#227;o ter se relacionado aos n&#237;veis adequados de vitamina D nesta pesquisa pode ter sido devido &#224; influ&#234;ncia de outros fatores&#44; como o hor&#225;rio em que a crian&#231;a foi exposta&#44; a cor da pele e o uso de protetor solar&#44; os quais n&#227;o foi poss&#237;vel analisar&#46; &#201; prov&#225;vel que pese contra uma exposi&#231;&#227;o solar adequada o temor dos efeitos mal&#233;ficos do sol sobre a pele&#46; De fato&#44; os dermatologistas recomendam que beb&#234;s at&#233; seis meses n&#227;o devam ser expostos &#224; luz solar direta&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">28</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">Na an&#225;lise dos resultados deste estudo devem ser consideradas as suas limita&#231;&#245;es&#46; A complexidade do problema a ser estudado constituiu uma das principais dificuldades encontradas e outros fatores que poderiam estar relacionados aos n&#237;veis de vitamina D n&#227;o foram controlados&#44; como a restri&#231;&#227;o de leite e derivados na dieta materna&#44; o uso da vitamina D durante a gesta&#231;&#227;o e a ades&#227;o a essa orienta&#231;&#227;o&#44; o tipo de parto e outros aspectos associados &#224; microbiota intestinal do beb&#234;&#46; A heterogeneidade da amostra foi considerada um dos problemas devido &#224;s diferen&#231;as individuais da doen&#231;a&#46; Tamb&#233;m pode ter ocorrido vi&#233;s de classe social devido &#224; procura do ambulat&#243;rio de Gastropediatria por fam&#237;lias de melhor condi&#231;&#227;o socioecon&#244;mica com o objetivo de obter laudo m&#233;dico para receber as f&#243;rmulas especializadas fornecidas pelo servi&#231;o p&#250;blico&#46; Dificuldades inerentes &#224; aplica&#231;&#227;o do question&#225;rio tamb&#233;m podem ter ocorrido&#44; j&#225; que foi aplicado por duas pesquisadoras&#44; assim como relacionadas &#224; fidedignidade das informa&#231;&#245;es prestadas pelas m&#227;es&#46; O n&#250;mero amostral &#233; pequeno&#44; talvez insuficiente para subsidiar mudan&#231;as nas orienta&#231;&#245;es previamente estabelecidas pelas sociedades regulamentadoras&#44; por&#233;m suficiente para servir de alerta e despertar estudos complementares randomizados e prospectivos sobre o assunto&#46; Um maior n&#250;mero amostral poderia permitir que os lactentes com APLV fossem agrupados e analisados de acordo com as manifesta&#231;&#245;es cl&#237;nicas apresentadas &#40;imediatas e tardias&#41; e fossem levados em conta os diferentes mecanismos imunol&#243;gicos envolvidos na patog&#234;nese da APLV&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">A falta de um consenso em rela&#231;&#227;o aos pontos de corte que definem o status de vitamina D tamb&#233;m foi considerado um dos vieses&#44; dificultou o entendimento sobre quais valores teriam efeito patog&#234;nico e comprometeu a compara&#231;&#227;o com estudos que usaram outros valores de refer&#234;ncia&#46; Enquanto que Sociedade de Endocrinologia Norte&#8208;Americana estabelece que n&#237;veis deficientes s&#227;o aqueles inferiores a 20<span class="elsevierStyleHsp" style=""></span>ng&#47;ml e suficientes os iguais ou acima de 30<span class="elsevierStyleHsp" style=""></span>ng&#47;ml&#44;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">29</span></a> o Instituto de Medicina dos EUA &#40;2010&#41; considera como adequados os n&#237;veis superiores a 20<span class="elsevierStyleHsp" style=""></span>ng&#47;ml&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">30</span></a> Nesta pesquisa&#44; os n&#237;veis suficientes foram aqueles a partir de 30<span class="elsevierStyleHsp" style=""></span>ng&#47;ml&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Os achados deste estudo sugerem uma maior frequ&#234;ncia de n&#237;veis inadequados de vitamina D nos lactentes com diferentes manifesta&#231;&#245;es cl&#237;nicas de APLV&#46; Apesar das diversas limita&#231;&#245;es do estudo&#44; os dados podem alertar para a necessidade de investigar os n&#237;veis de vitamina D em lactentes com APLV&#46; A pr&#225;tica do AM exclusivo&#47;predominante se relacionou com os n&#237;veis inadequados principalmente nas crian&#231;as com diagn&#243;stico de APLV&#44; enquanto que a exposi&#231;&#227;o solar parece n&#227;o ter conferido um efeito protetor nesse grupo&#46; O fato de os lactentes al&#233;rgicos n&#227;o usarem suplemento de vitamina D pode ter contribu&#237;do com os achados do estudo&#46; Assim&#44; n&#227;o &#233; possivelmente seguro confiar na exposi&#231;&#227;o solar como fonte de vitamina D&#44; principalmente nos beb&#234;s em aleitamento materno exclusivo&#44; &#233; sugerido que se avalie a suplementa&#231;&#227;o rotineira&#46; Sugere&#8208;se que outros estudos sejam conduzidos para comprovar a associa&#231;&#227;o e melhor elucidar os fatores associados aos n&#237;veis inadequados de vitamina D nos lactentes com APLV&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Financiamento</span><p id="par0125" class="elsevierStylePara elsevierViewall">Conselho Nacional de Desenvolvimento Cient&#237;fico e Tecnol&#243;gico &#40;CNPq&#41;&#44; por meio de aux&#237;lio financeiro do edital universal de 2012&#47;2013 sob o n&#250;mero de registro 488488&#47;2013&#8208;3&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conflitos de interesse</span><p id="par0130" class="elsevierStylePara elsevierViewall">Os autores declaram n&#227;o haver conflitos de interesse&#46;</p></span></span>"
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          "clase" => "keyword"
          "titulo" => "Keywords"
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          "palabras" => array:5 [
            0 => "Milk allergy"
            1 => "Infant"
            2 => "Vitamin D"
            3 => "Breast feeding"
            4 => "Sunlight"
          ]
        ]
      ]
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          "clase" => "keyword"
          "titulo" => "Palavras&#8208;chave"
          "identificador" => "xpalclavsec908952"
          "palabras" => array:5 [
            0 => "Alergia a leite"
            1 => "Lactente"
            2 => "Vitamina D"
            3 => "Aleitamento materno"
            4 => "Luz solar"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To verify whether infants with cow&#39;s milk protein allergy &#40;CMPA&#41; have inadequate vitamin D levels&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">This cross&#8208;sectional study included 120 children aged 2 years or younger&#44; one group with CMPA and a control group&#46; The children were recruited at the pediatric gastroenterology&#44; allergology&#44; and pediatric outpatient clinics of a university hospital in the Northeast of Brazil&#46; A questionnaire was administered to the caregiver and blood samples were collected for vitamin D quantification&#46; Vitamin D levels &#60;30<span class="elsevierStyleHsp" style=""></span>ng&#47;mL were considered inadequate&#46; Vitamin D level was expressed as mean and standard deviation&#44; and the frequency of the degrees of sufficiency and other variables&#44; as proportions&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Infants with CMPA had lower mean vitamin D levels &#40;30&#46;93 <span class="elsevierStyleItalic">vs</span>&#46;35&#46;29<span class="elsevierStyleHsp" style=""></span>ng&#47;mL&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;041&#41; and higher deficiency frequency &#40;20&#46;3&#37; <span class="elsevierStyleItalic">vs</span>&#46;8&#46;2&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;049&#41; than the healthy controls&#46; Exclusively or predominantly breastfed infants with CMPA had higher frequency of inadequate vitamin D levels &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;002&#41;&#46; Regardless of sun exposure time&#44; the groups had similar frequencies of inadequate vitamin D levels &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;972&#41;&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Lower vitamin D levels were found in infants with CMPA&#44; especially those who were exclusively or predominantly breastfed&#44; making these infants a possible risk group for vitamin D deficiency&#46;</p></span>"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Verificar se lactentes com alergia &#224; prote&#237;na do leite de vaca &#40;APLV&#41; apresentam n&#237;veis inadequados de vitamina D&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Estudo transversal&#44; envolveu 120 crian&#231;as de at&#233; dois anos&#44; um grupo com APLV e outro de compara&#231;&#227;o&#44; captadas dos ambulat&#243;rios de Gastroenterologia Pedi&#225;trica&#44; Alergologia Pedi&#225;trica e Puericultura de um hospital universit&#225;rio&#44; no Nordeste brasileiro&#46; Foi aplicado um formul&#225;rio e foram coletadas amostras sangu&#237;neas para a an&#225;lise da vitamina D&#44; foram considerados inadequados os n&#237;veis<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>30<span class="elsevierStyleHsp" style=""></span>ng&#47;mL&#46; N&#237;veis de vitamina D foram expressos em m&#233;dia e desvio padr&#227;o e a frequ&#234;ncia dos graus de sufici&#234;ncia e demais vari&#225;veis&#44; em propor&#231;&#245;es&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Lactentes com APLV&#44; quando comparados com os saud&#225;veis&#44; apresentaram uma menor m&#233;dia do n&#237;vel da vitamina D &#40;30&#44;93 <span class="elsevierStyleItalic">vs</span>&#46; 35&#44;29<span class="elsevierStyleHsp" style=""></span>ng&#47;mL&#41; &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;041&#41; e maior frequ&#234;ncia de defici&#234;ncia &#40;20&#44;3&#37; <span class="elsevierStyleItalic">vs</span>&#46; 8&#44;2&#41; &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;049&#41;&#46; Maior frequ&#234;ncia de n&#237;veis inadequados de vitamina D foi observada nas crian&#231;as com APLV que estavam em aleitamento materno exclusivo&#47;predominante &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;002&#41;&#46; Independentemente do per&#237;odo de exposi&#231;&#227;o solar&#44; a frequ&#234;ncia de um status inadequado de vitamina D foi semelhante entre os grupos &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;972&#41;&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclus&#245;es</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Menores n&#237;veis de vitamina D foram observados em lactentes com APLV&#44; especialmente naqueles em aleitamento materno exclusivo&#47;predominante&#44; que configura esse como um poss&#237;vel grupo de risco para essa defici&#234;ncia&#46;</p></span>"
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          "pt" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Frequ&#234;ncias dos graus de sufici&#234;ncia da vitamina D nos lactentes com APLV e no grupo controle&#44; atendidos ambulatorialmente em hospital universit&#225;rio&#44; Recife&#8211;PE &#40;2013&#8211;2015&#41;&#46;</p> <p id="spar0050" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleSup">a</span> Teste exato de Fisher&#46;</p>"
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          "leyenda" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">AME&#44; aleitamento materno exclusivo&#59; APLV&#44; alergia &#224; prote&#237;na do leite de vaca&#59; I&#44; idade&#59; P&#44; peso&#59; SM&#44; sal&#225;rio m&#237;nimo nacional&#46;</p>"
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                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">p<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " colspan="6" align="left" valign="top"><span class="elsevierStyleItalic">Sexo</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Masculino&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">25&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">42&#44;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">49&#44;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#44;454&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Feminino&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">34&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">57&#44;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">31&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">50&#44;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="6" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="6" align="left" valign="top"><span class="elsevierStyleItalic">Idade &#40;meses&#41;</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#8804; 6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">26&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">44&#44;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">19&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">31&#44;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#44;093&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>6 &#8804; 12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">18&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">30&#44;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">19&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">31&#44;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>12 &#8804; 18&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">22&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">21&#44;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>18 &#8804; 24&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&#44;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">16&#44;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="6" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="6" align="left" valign="top"><span class="elsevierStyleItalic">Grau de escolaridade materna</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Ensino fundamental&#47;m&#233;dio&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">18&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">30&#44;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">44&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">72&#44;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#60; 0&#44;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Ensino superior&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">41&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">69&#44;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">17&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">27&#44;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="6" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="6" align="left" valign="top"><span class="elsevierStyleItalic">Renda em SM</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#8804; 2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">25&#44;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">43&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">70&#44;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#60; 0&#44;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>2 &#8804; 4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">22&#44;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">11&#44;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>4 &#8804; 10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">23&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">39&#44;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9&#44;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#62;10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12&#44;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8&#44;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="6" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="6" align="left" valign="top"><span class="elsevierStyleItalic">Atopia m&#227;e</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Sim&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">37&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">62&#44;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">21&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">34&#44;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#44;002&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>N&#227;o&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">22&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">37&#44;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">40&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">65&#44;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="6" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="6" align="left" valign="top"><span class="elsevierStyleItalic">Atopia pai</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Sim&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">27&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">46&#44;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">17&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">28&#44;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#44;041&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>N&#227;o&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">31&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">53&#44;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">43&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">71&#44;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="6" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="6" align="left" valign="top"><span class="elsevierStyleItalic">Tipo de parto</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Transvaginal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">10&#44;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">19&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">31&#44;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#44;005&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Ces&#225;reo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">53&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">89&#44;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">42&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">68&#44;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="6" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="6" align="left" valign="top"><span class="elsevierStyleItalic">Idade gestacional</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Pr&#233;&#8208;termo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">17&#44;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">18&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#44;612&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Termo&#47;P&#243;s&#8208;termo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">48&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">82&#44;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">50&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">82&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="6" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="6" align="left" valign="top"><span class="elsevierStyleItalic">Suplementa&#231;&#227;o materna com vitamina D durante a gesta&#231;&#227;o</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Sim&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">15&#44;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6&#44;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#44;15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>N&#227;o&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">50&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">84&#44;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">57&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">93&#44;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="6" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="6" align="left" valign="top"><span class="elsevierStyleItalic">Tempo de AME &#40;meses&#41;</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#8804; 1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">17&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">28&#44;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#44;483&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>1 &#8804; 3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">25&#44;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">25&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>3 &#8804; 6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">27&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">45&#44;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">33&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">55&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="6" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="6" align="left" valign="top"><span class="elsevierStyleItalic">Avalia&#231;&#227;o antropom&#233;trica &#40;P&#47;I&#41;</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Baixo peso&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8&#44;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&#44;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#44;439&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Eutr&#243;fico&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">54&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">91&#44;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">57&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">96&#44;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Excesso de peso&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "pt" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Caracter&#237;sticas socioecon&#244;micas e biol&#243;gicas dos lactentes com APLV e do grupo controle atendidos ambulatorialmente em hospital universit&#225;rio&#44; Recife&#8208;PE &#40;2013&#8208;2015&#41;</p>"
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        "tabla" => array:3 [
          "leyenda" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">AM&#44; aleitamento materno&#46;</p>"
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col">Vari&#225;vel&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " colspan="3" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">APLV&#43;</th><th class="td" title="table-head  " colspan="3" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">APLV&#8208;</th></tr><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Vitamina D</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">p<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Vitamina D</th><th class="td" title="table-head  " align="left" valign="top" scope="col">p<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Defici&#234;ncia&#47;Insufici&#234;ncia n &#37;<br>IC 95&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Sufici&#234;ncia<br>n &#37;<br>IC 95&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Defici&#234;ncia&#47;Insufici&#234;ncia<br>n &#37;<br>IC 95&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Sufici&#234;ncia<br>n &#37;<br>IC 95&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " colspan="7" align="left" valign="top"><span class="elsevierStyleItalic">Pr&#225;tica atual do AM</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Exclusivo&#47;Predominante&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">7 &#40;25&#44;9&#41;<br>11&#44;9&#8208;46&#44;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1 &#40;3&#44;1&#41;<br>0&#44;2&#8208;18&#44;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#44;002&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3 &#40;15&#44;7&#41;<br>4&#44;2&#8208;40&#44;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1 &#40;2&#44;4&#41;<br>0&#44;1&#8208;14&#44;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#44;189&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Parcial&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">7 &#40;25&#44;9&#41;<br>11&#44;9&#8208;46&#44;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2 &#40;6&#44;3&#41;<br>1&#44;1&#8208;22&#44;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2 &#40;4&#44;7&#41;<br>0&#44;8&#8208;17&#44;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Complementar&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4 &#40;14&#44;9&#41;<br>4&#44;8&#8208;34&#44;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4 &#40;12&#44;5&#41;<br>4&#44;1&#8208;29&#44;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4 &#40;21&#44;1&#41;<br>7&#44;0&#8208;46&#44;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">12 &#40;28&#44;6&#41;<br>16&#44;2&#8208;44&#44;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>N&#227;o amamenta&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">9 &#40;33&#44;3&#41;<br>17&#44;2&#8208;54&#44;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">25 &#40;78&#44;1&#41;<br>59&#44;6&#8208;90&#44;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">12 &#40;63&#44;2&#41;<br>38&#44;6&#8208;82&#44;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">27 &#40;64&#44;3&#41;<br>48&#44;0&#8208;78&#44;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="7" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">TOTAL&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">27 &#40;100&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">32 &#40;100&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">19 &#40;100&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">42 &#40;100&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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              "identificador" => "tblfn0010"
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              "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Qui&#8208;quadrado de Pearson&#46;</p>"
            ]
          ]
        ]
        "descripcion" => array:1 [
          "pt" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Status da vitamina D dos lactentes com APLV e do grupo controle em rela&#231;&#227;o &#224; pr&#225;tica alimentar&#44; atendidos ambulatorialmente em hospital universit&#225;rio&#44; Recife&#8211;PE &#40;2013&#8208;2015&#41;</p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "Refer&#234;ncias"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:30 [
            0 => array:3 [
              "identificador" => "bib0155"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Widespread vitamin D deficiency in urban Massachusetts newborns and their mothers"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "A&#46; Merewood"
                            1 => "S&#46;D&#46; Mehta"
                            2 => "X&#46; Grossman"
                            3 => "T&#46;C&#46; Chen"
                            4 => "J&#46;S&#46; Mathieu"
                            5 => "M&#46;F&#46; Holick"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1542/peds.2009-2158"
                      "Revista" => array:6 [
                        "tituloSerie" => "Pediatrics"
                        "fecha" => "2010"
                        "volumen" => "125"
                        "paginaInicial" => "640"
                        "paginaFinal" => "647"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20308219"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0160"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The nonskeletal effects of vitamin D&#58; an endocrine society scientific statement"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "C&#46;J&#46; Rosen"
                            1 => "J&#46;S&#46; Adams"
                            2 => "D&#46;D&#46; Bikle"
                            3 => "D&#46;M&#46; Black"
                            4 => "M&#46;B&#46; Demay"
                            5 => "J&#46;E&#46; Manson"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1210/er.2012-1000"
                      "Revista" => array:6 [
                        "tituloSerie" => "Endocr Rev"
                        "fecha" => "2012"
                        "volumen" => "33"
                        "paginaInicial" => "456"
                        "paginaFinal" => "492"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22596255"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
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Artigo Original
Do infants with cow's milk protein allergy have inadequate levels of vitamin D?
Lactentes com alergia à proteína do leite de vaca apresentam níveis inadequados de vitamina D?
Cristiane M. Silvaa,
Autor para correspondência
cris.marrocos@yahoo.com.br

Autor para correspondência.
, Silvia A. da Silvaa, Margarida M. de C. Antunesb, Gisélia Alves Pontes da Silvac, Emanuel Sávio Cavalcanti Sarinhoc,d, Katia G. Brandtb
a Universidade Federal de Pernambuco (UFPE), Programa de Pós‐Graduação em Saúde da Criança e do Adolescente, Recife, PE, Brasil
b Universidade Federal de Pernambuco (UFPE), Departamento Materno‐Infantil, Serviço de Gastroenterologia Pediátrica HC‐UFPE, Recife, PE, Brasil
c Universidade Federal de Pernambuco (UFPE), Departamento Materno‐Infantil, Programa de Pós‐Graduação em Saúde da Criança e do Adolescente, Recife, PE, Brasil
d Universidade Federal de Pernambuco (UFPE), Departamento Materno‐Infantil, Serviço de Alergologia e Imunologia HC‐UFPE, Recife, PE, Brasil
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          "pt" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Frequ&#234;ncias dos graus de sufici&#234;ncia da vitamina D nos lactentes com APLV e no grupo controle&#44; atendidos ambulatorialmente em hospital universit&#225;rio&#44; Recife&#8211;PE &#40;2013&#8211;2015&#41;&#46;</p> <p id="spar0050" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleSup">a</span> Teste exato de Fisher&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introdu&#231;&#227;o</span><p id="par0005" class="elsevierStylePara elsevierViewall">A defici&#234;ncia de vitamina D tem sido reconhecida como um problema frequente da atualidade&#44; ocorre em adultos e crian&#231;as&#44; nessas por vezes ainda no per&#237;odo neonatal&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">1</span></a> Classicamente a defici&#234;ncia de vitamina D est&#225; relacionada a doen&#231;as &#243;sseas&#44; mas nos &#250;ltimos anos tem sido associada a diversos desfechos extra&#243;sseos&#44; inclusive doen&#231;as imunes&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">2</span></a> Ela parece ocorrer com maior frequ&#234;ncia em determinados grupos de indiv&#237;duos&#44; de forma que a Sociedade de Endocrinologia recomenda que o <span class="elsevierStyleItalic">screening</span> para defici&#234;ncia de vitamina D seja feito apenas no grupo de indiv&#237;duos considerado de risco&#46; Nesse grupo de risco estariam os indiv&#237;duos da etnia negra&#44; obesos&#44; gestantes&#44; lactantes e portadores de determinadas doen&#231;as&#44; como doen&#231;as end&#243;crinas e renais&#44; entre outras&#46; Os portadores de alergia &#224; prote&#237;na do leite de vaca &#40;APLV&#41; n&#227;o est&#227;o inclu&#237;dos&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">De outra forma&#44; alguns estudos internacionais&#44; feitos principalmente em crian&#231;as com formas imediatas de APLV&#44; mediadas por IgE&#44; sugeriram uma maior frequ&#234;ncia de defici&#234;ncia de vitamina D nesse grupo&#46;<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">4&#8211;7</span></a> Baixos n&#237;veis da vitamina D em crian&#231;as s&#227;o relacionados a fatores como deficiente transfer&#234;ncia materno&#8208;fetal por hipovitaminose materna&#44; inadequada exposi&#231;&#227;o solar&#44; uso inadequado de suplementos de vitamina D e baixa ingest&#227;o atrav&#233;s da dieta&#46;<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">1&#44;8&#44;9</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Estudos sobre os n&#237;veis de vitamina D em crian&#231;as portadoras de APLV s&#227;o importantes para avaliar a possibilidade de essas serem um grupo de risco para a ocorr&#234;ncia de defici&#234;ncia de vitamina D&#46; Uma vez que a maioria dos estudos que analisaram n&#237;veis de vitamina D em crian&#231;as com APLV foi conduzido em crian&#231;as sem manifesta&#231;&#227;o gastrointestinal&#44;<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">4&#8211;7</span></a> restam lacunas em rela&#231;&#227;o ao conhecimento desse problema&#46; Al&#233;m disso&#44; poucas pesquisas foram feitas em crian&#231;as com APLV residentes em regi&#245;es ensolaradas onde se pressup&#245;e haver exposi&#231;&#227;o adequada aos raios ultravioletas&#46; O objetivo do nosso estudo foi verificar se os lactentes com APLV apresentam n&#237;veis inadequados de vitamina D&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">M&#233;todo</span><p id="par0020" class="elsevierStylePara elsevierViewall">Estudo observacional&#44; de corte transversal&#44; no qual foram comparados os n&#237;veis de vitamina D de um grupo de lactentes com diagn&#243;stico cl&#237;nico de APLV e um grupo de lactentes saud&#225;veis &#40;grupo de compara&#231;&#227;o&#41;&#46; A pesquisa foi feita de mar&#231;o de 2013 a abril de 2015&#44; nos ambulat&#243;rios de Gastroenterologia Pedi&#225;trica&#44; Alergologia Pedi&#225;trica e Puericultura do Hospital das Cl&#237;nicas da Universidade Federal de Pernambuco &#40;HC&#47;UFPE&#41;&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">O grupo de crian&#231;as com APLV foi composto por 59 lactentes de ambos os sexos que apresentaram manifesta&#231;&#245;es cl&#237;nicas adversas relacionadas &#224; APLV&#46; Para concluir o diagn&#243;stico levaram&#8208;se em considera&#231;&#227;o a hist&#243;ria cl&#237;nica&#44; o exame f&#237;sico e os antecedentes e foi confirmado pelo teste de desencadeamento oral aberto&#44; conforme indicado pelas principais diretrizes vigentes&#46;<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">10&#44;11</span></a> O teste de desencadeamento foi contraindicado pelos pesquisadores nas seguintes situa&#231;&#245;es&#58; relato de manifesta&#231;&#245;es imediatas associadas a um resultado de IgE positivo&#59; manifesta&#231;&#245;es tardias compat&#237;veis com APLV&#44; associados &#224; desnutri&#231;&#227;o&#46; O grupo de compara&#231;&#227;o foi formado por 61 crian&#231;as saud&#225;veis&#46; Foram exclu&#237;das as crian&#231;as com suspeita cl&#237;nica de outras patologias ou fatores que pudessem influenciar nos n&#237;veis de vitamina D&#44; como doen&#231;as infecciosas agudas ou cr&#244;nicas&#44; outras doen&#231;as inflamat&#243;rias intestinais&#44; doen&#231;as renais ou gastrointestinais&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Para a avalia&#231;&#227;o antropom&#233;trica foi obtido o peso do lactente e usado o indicador peso&#47;idade &#40;P&#47;I&#41; proposto pela Organiza&#231;&#227;o Mundial da Sa&#250;de &#40;OMS&#41;&#46; Para avalia&#231;&#227;o do P&#47;I&#44; foram adotados os seguintes pontos de cortes&#58;<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#8722;2 escore z para peso baixo para a idade&#44; &#8805; &#8722;2 e<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#43;2 escore z para peso adequado para a idade e &#8805; &#43;2 escore z para peso elevado para a idade&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">12</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Em rela&#231;&#227;o &#224; vitamina D&#44; foram analisados os n&#237;veis e graus de sufici&#234;ncia&#44; categorizados em insuficiente&#47;deficiente e suficiente&#46; Foi considerada defici&#234;ncia quando a 25&#40;OH&#41;D foi igual ou inferior a 20<span class="elsevierStyleHsp" style=""></span>ng&#47;mL&#44; insufici&#234;ncia quando os n&#237;veis se encontravam entre 21&#8208;29<span class="elsevierStyleHsp" style=""></span>ng&#47;mL e sufici&#234;ncia quando foram iguais ou superiores a 30<span class="elsevierStyleHsp" style=""></span>ng&#47;mL&#46;<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">3&#44;13</span></a> Para essa an&#225;lise&#44; foi coletada uma amostra de sangue &#40;4<span class="elsevierStyleHsp" style=""></span>ml&#41;&#44; por profissional capacitado&#44; armazenada em tubo com gel separador e levada para o laborat&#243;rio conveniado &#224; pesquisa&#46; A dosagem da 25 &#40;OH&#41;D foi feita pela t&#233;cnica de quimioluminesc&#234;ncia e foi usado o kit comercial Liaison<span class="elsevierStyleSup">&#174;</span>&#46; Para as crian&#231;as que cursaram com n&#237;veis inadequados de vitamina D&#44; foram prestadas orienta&#231;&#245;es aos pais sobre a necessidade de suplementa&#231;&#227;o&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Para a classifica&#231;&#227;o da pr&#225;tica atual do aleitamento materno &#40;AM&#41; foi usada a categoriza&#231;&#227;o da OMS&#44; foram considerados AM exclusivo &#40;quando a crian&#231;a recebe s&#243; leite materno sem outros l&#237;quidos ou s&#243;lidos&#41;&#44; AM predominante &#40;quando a crian&#231;a recebe&#44; al&#233;m do leite materno&#44; &#225;gua ou bebidas &#224; base de &#225;gua&#41;&#44; AM complementado &#40;quando a crian&#231;a recebe&#44; al&#233;m do leite materno&#44; qualquer alimento s&#243;lido ou semiss&#243;lido com a finalidade de complement&#225;&#8208;lo&#44; e n&#227;o substitu&#237;&#8208;lo&#41; e AM misto ou parcial &#40;quando a crian&#231;a recebe leite materno e outros tipos de leite&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">14</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Na avalia&#231;&#227;o da exposi&#231;&#227;o solar&#44; foram usadas as orienta&#231;&#245;es da Sociedade Brasileira de Pediatria &#40;SBP&#41;&#46; Ela recomenda que a crian&#231;a deve receber exposi&#231;&#227;o direta da pele &#224; luz solar a partir da segunda semana de vida&#44; &#233; suficiente a cota semanal de 30 minutos de exposi&#231;&#227;o solar com a crian&#231;a apenas de fraldas&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">15</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">A constru&#231;&#227;o do banco de dados foi feita com o programa Epi&#8208;Info vers&#227;o 6&#46;04d &#40;Epi&#8208;info 6&#46;04&#44; WHO&#47;CDC&#44; Atlanta&#44; USA&#41;&#46; As an&#225;lises estat&#237;sticas foram feitas com o <span class="elsevierStyleItalic">Statistical Package for the Social Sciences</span> &#40;SPSS&#41; vers&#227;o 13&#46;0 para Windows &#40;SPSS Inc&#46;&#44; Chicago&#44; IL&#44; EUA&#41;&#46; As vari&#225;veis cont&#237;nuas foram testadas quanto &#224; normalidade da distribui&#231;&#227;o pelo teste de Kolmogorov&#8208;Smirnov&#44; foram expressas por m&#233;dia e desvio&#8208;padr&#227;o quando de distribui&#231;&#227;o sim&#233;trica e mediana e quartis se distribui&#231;&#227;o assim&#233;trica&#46; As diferen&#231;as de frequ&#234;ncia e a associa&#231;&#227;o entre as vari&#225;veis categ&#243;ricas foram testadas pelo m&#233;todo qui&#8208;quadrado de Pearson ou teste exato de Fisher quando indicado&#46; O n&#237;vel de signific&#226;ncia empregado em todos os testes foi de 5&#37;&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Os respons&#225;veis foram informados verbalmente sobre os objetivos da pesquisa e assinaram o termo de consentimento livre e esclarecido&#46; O projeto de pesquisa foi registrado na Comiss&#227;o Nacional de &#201;tica em Pesquisa &#40;Conep&#47;Plataforma Brasil&#41; e submetido &#224; aprova&#231;&#227;o do Comit&#234; de &#201;tica em Pesquisa em Seres Humanos do Centro de Ci&#234;ncias da Sa&#250;de da Universidade Federal de Pernambuco&#44; com CAAE&#58; 12878313&#46;4&#46;0000&#46;5208&#47;2013&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Resultados</span><p id="par0060" class="elsevierStylePara elsevierViewall">A mediana de idade da amostra total foi de 8&#44;5 meses &#40;P25&#58; 6&#44;0&#59; P75&#58; 14&#44;0&#41;&#44; nas crian&#231;as com APLV foi de sete meses &#40;P25&#58; 4&#59; <span class="elsevierStyleItalic">vs</span>&#46; das crian&#231;as com APLV&#46; Verificou&#8208;se tamb&#233;m uma maior frequ&#234;ncia de atopia entre as m&#227;es &#40;62&#44;7&#37; <span class="elsevierStyleItalic">vs&#46;</span> 34&#44;4&#37;&#41; e pais &#40;46&#44;6&#37; <span class="elsevierStyleItalic">vs&#46;</span> 28&#44;3&#37;&#41; das crian&#231;as com APLV&#46; Quando avaliado o estado nutricional&#44; observou&#8208;se um maior percentual de eutrofia na amostra&#44; com frequ&#234;ncias semelhantes em ambos os grupos &#40;91&#44;5&#37; no grupo com APLV e 96&#44;6&#37; no grupo controle&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">tabela 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">Nas crian&#231;as com diagn&#243;stico de APLV&#44; as manifesta&#231;&#245;es cl&#237;nicas mais frequentes foram do tipo imediatas &#40;59&#44;3&#37;&#41;&#46; As manifesta&#231;&#245;es imediatas observadas foram&#58; angioedema&#44; urtic&#225;ria e hiperemia cut&#226;nea&#44; v&#244;mitos&#44; diarreia&#44; tosse e sibil&#226;ncia&#46; As manifesta&#231;&#245;es tardias encontradas foram&#58; regurgita&#231;&#245;es e v&#244;mitos compat&#237;veis com doen&#231;a do refluxo gastroesof&#225;gico &#40;DRGE&#41;&#44; diarreia&#44; diarreia com sangue &#40;compat&#237;vel com colite&#41;&#44; proctite&#44; baixo ganho ou perda de peso&#44; choro excessivo e distens&#227;o abdominal&#44; dificuldade evacuat&#243;ria e eczema at&#243;pico&#46; Entre as manifesta&#231;&#245;es imediatas destacaram&#8208;se urtic&#225;ria em 28&#44;8&#37;&#44; angioedema em 15&#44;3&#37; e tosse em 15&#44;3&#37;&#46; No grupo com manifesta&#231;&#227;o tardia&#44; 40&#44;7&#37; apresentaram v&#244;mito e diarreia&#44; sinais de colite em 35&#44;6&#37; e sintomas compat&#237;veis com DRGE em 22&#37;&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">A m&#233;dia dos n&#237;veis de vitamina D entre as crian&#231;as com APLV foi de 30&#44;93<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>12&#44;33<span class="elsevierStyleHsp" style=""></span>ng&#47;ml e de 35&#44;29<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>10&#44;74<span class="elsevierStyleHsp" style=""></span>ng&#47;ml nas crian&#231;as saud&#225;veis &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;041&#41;&#46; A <a class="elsevierStyleCrossRef" href="#fig0005">figura 1</a> mostra as frequ&#234;ncias dos diferentes graus de sufici&#234;ncia da vitamina D nos dois grupos&#44; nos quais se observou que dentre o total das crian&#231;as houve uma maior frequ&#234;ncia de n&#237;veis deficientes naquelas com APLV &#40;20&#44;3&#37; <span class="elsevierStyleItalic">vs&#46;</span> 8&#44;2&#37;&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;049&#41;&#46; Vale salientar que nenhuma crian&#231;a se encontrava em uso de suplemento de vitamina D no momento da entrevista e apenas nove das m&#227;es de crian&#231;as com APLV relataram ter feito suplementa&#231;&#227;o com vitamina D durante o per&#237;odo gestacional&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">A <a class="elsevierStyleCrossRef" href="#tbl0010">tabela 2</a> mostra que dentre as crian&#231;as com APLV as que eram submetidas a AM exclusivo&#47;predominante no momento da entrevista tiveram uma maior frequ&#234;ncia de defici&#234;ncia de vitamina D&#44; foi observado que 25&#44;9&#37; de crian&#231;as foram deficientes e apenas 3&#44;1&#37; delas apresentaram n&#237;veis suficientes&#46; O mesmo foi observado naquelas em AM parcial &#40;25&#44;9&#37; <span class="elsevierStyleItalic">vs&#46;</span> 6&#44;3&#37;&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;002&#41;&#46; Crian&#231;as com APLV e n&#227;o amamentadas&#44; ou seja&#44; que estavam em uso de f&#243;rmulas infantis&#44; apresentaram em sua maioria n&#237;veis de sufici&#234;ncia &#40;78&#44;1&#37;&#41;&#46; No grupo comparativo&#44; n&#227;o houve associa&#231;&#227;o das diferentes pr&#225;ticas alimentares e os graus de sufici&#234;ncia da vitamina D &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;189&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">No grupo das crian&#231;as al&#233;rgicas&#44; a frequ&#234;ncia da exposi&#231;&#227;o solar n&#227;o interferiu no grau de sufici&#234;ncia da vitamina D&#44; os resultados foram semelhantes naquelas com graus de defici&#234;ncia&#47;insufici&#234;ncia e nas suficientes &#40;entre os deficientes&#47;suficientes&#44; 14 eram expostas adequadamente ao sol&#44; enquanto 12 n&#227;o eram&#59; entre os suficientes 17 eram adequadamente expostos e 13 n&#227;o eram&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;972&#41;&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discuss&#227;o</span><p id="par0085" class="elsevierStylePara elsevierViewall">Nesta pesquisa&#44; feita entre crian&#231;as em sua maioria eutr&#243;fica e submetidas a tempos semelhantes de aleitamento materno&#44; as crian&#231;as com APLV imediata e tardia apresentaram um maior percentual de defici&#234;ncia quando comparadas com as crian&#231;as saud&#225;veis &#40;20&#44;3&#37; <span class="elsevierStyleItalic">vs&#46;</span> 8&#44;2&#37;&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;049&#41;&#46; Embora as m&#233;dias de vitamina D se encontrassem dentro da normalidade em ambos os grupos&#44; uma menor m&#233;dia foi observada nas crian&#231;as al&#233;rgicas &#40;30&#44;93 <span class="elsevierStyleItalic">vs&#46;</span> 35&#44;29&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;041&#41;&#44; o que refor&#231;a a tend&#234;ncia das crian&#231;as al&#233;rgicas de terem menores n&#237;veis da vitamina&#46; Alguns estudos j&#225; investigaram a rela&#231;&#227;o entre a defici&#234;ncia de vitamina D e alergia alimentar&#44; mas a maioria deles foi conduzido em crian&#231;as com APLV forma imediata&#44; mediada por IgE&#46;<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">4&#8211;7</span></a> Este estudo desperta para esse problema tamb&#233;m nas formas tardias&#44; n&#227;o mediadas por IgE e usualmente manifestas por sintomas gastrointestinais&#46; Existe embasamento emp&#237;rico para se acreditar que n&#237;veis insuficientes de vitamina D nos per&#237;odos iniciais da vida podem interferir no desenvolvimento da imunidade&#44; podem colaborar para o surgimento de doen&#231;as al&#233;rgicas&#44; inclusive a alergia alimentar&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">16</span></a> O principal mecanismo atrav&#233;s do qual ela atuaria na regula&#231;&#227;o imune seria ao favorecer uma maior diferencia&#231;&#227;o de linf&#243;citos T naive em c&#233;lulas T reguladoras &#40;Tregs&#41;&#44; que inibiriam as respostas imunes danosas tanto TH1 quanto TH2&#46;<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">16&#44;17</span></a> Deve ser considerado que&#44; apesar de terem sido verificados n&#237;veis de defici&#234;ncia de vitamina D nos lactentes com APLV&#44; o desenho do estudo&#44; transversal&#44; n&#227;o permitiu estabelecer a exist&#234;ncia de uma rela&#231;&#227;o causal entre a defici&#234;ncia de vitamina D e o surgimento de alergia&#46; Pode&#8208;se at&#233; especular que a rela&#231;&#227;o possa ser oposta&#44; se considerarmos que a pr&#243;pria patog&#234;nese da APLV pode ter favorecido as baixas concentra&#231;&#245;es de vitamina D&#44; tanto por possibilitar m&#225; absor&#231;&#227;o quanto pelo fato de poder se associar &#224; resposta inflamat&#243;ria&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">18</span></a> A resposta inflamat&#243;ria sist&#234;mica&#44; que pode ser gerada durante o processo al&#233;rgico&#44; pode estar associada &#224;s baixas concentra&#231;&#245;es de vitaminas lipossol&#250;veis&#44; inclusive a vitamina D&#46;<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">18&#44;19</span></a> Os baixos n&#237;veis poderiam ainda estar relacionados ainda ao fato de as m&#227;es das crian&#231;as com APLV em AM exclusivo fazerem dieta de restri&#231;&#227;o de leite de e vaca e derivados&#44; sem suplementa&#231;&#227;o de vitamina D&#44; fato j&#225; relacionado a defici&#234;ncias desse e de outros micronutrientes&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">20</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">As principais fontes de vitamina D para os lactentes s&#227;o a dieta&#44; exposi&#231;&#227;o solar e os suplementos vitam&#237;nicos&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">21</span></a> O LM pode conferir um efeito protetor no desenvolvimento de v&#225;rios tipos de alergias devido &#224; presen&#231;a de fatores imunol&#243;gicos e nutrientes funcionais que favorecem um microambiente saud&#225;vel para o desenvolvimento imunit&#225;rio e matura&#231;&#227;o intestinal&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">22</span></a> Entretanto&#44; como tem baixas concentra&#231;&#245;es de vitamina D&#44;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">23</span></a> crian&#231;as em AM&#44; principalmente quando amamentadas de forma exclusiva e sem receber exposi&#231;&#227;o solar adequada&#44; podem representar um grupo de maior risco para a defici&#234;ncia de vitamina D&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">24</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">Baixos n&#237;veis de vitamina D foram observados nas crian&#231;as al&#233;rgicas submetidas ao AM&#44; foi observada maior frequ&#234;ncia de n&#237;veis deficientes&#47;insuficientes da vitamina D dentre as crian&#231;as com APLV submetidas ao AM exclusivo&#47;predominante &#40;25&#44;9&#37;&#41;&#46; Evid&#234;ncias sugerem que crian&#231;as que desenvolvem APLV&#44; mesmo em AM exclusivo&#44; t&#234;m fatores gen&#233;ticos que as predisp&#245;em a esse desfecho&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">24</span></a> &#201; poss&#237;vel que no lactente em AM exclusivo que j&#225; tem uma predisposi&#231;&#227;o gen&#233;tica para a APLV&#44; a ocorr&#234;ncia de defici&#234;ncia de vitamina D atue como um gatilho para o desenvolvimento da doen&#231;a&#46; Nesse sentido&#44; foi observado que dos oito beb&#234;s que estavam em AM exclusivo&#47;predominante e desenvolveram APLV &#40;a maioria colite al&#233;rgica&#41;&#44; sete encontravam&#8208;se com n&#237;veis inadequados de vitamina D&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Estudos feitos em diferentes pa&#237;ses sugerem a necessidade de suplementa&#231;&#227;o do beb&#234; em AM&#44; e por vezes de sua m&#227;e&#44; mesmo quando residente em regi&#227;o ensolarada&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">25</span></a> Nenhuma das crian&#231;as desse estudo fazia suplementa&#231;&#227;o vitam&#237;nica e apenas nove m&#227;es das crian&#231;as com APLV &#40;15&#44;3&#37;&#41; e quatro m&#227;es das crian&#231;as saud&#225;veis &#40;6&#44;6&#37;&#41; estavam em uso de suplemento&#46; Foi verificado que em nosso meio a indica&#231;&#227;o de suplemento de vitamina D no per&#237;odo pr&#233;&#8208;natal e durante o aleitamento ainda n&#227;o &#233; uma pr&#225;tica comum e talvez fosse necess&#225;rio consider&#225;&#8208;la&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">A exposi&#231;&#227;o solar &#233; considerada um dos determinantes mais importantes do status da vitamina D&#46; Os n&#237;veis de vitamina D do beb&#234; tendem a diminuir ao longo dos primeiros meses de vida&#44; caso ele n&#227;o seja exposto &#224; luz solar ou receba&#44; por via digestiva&#44; o adequado aporte de vitamina D&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">26</span></a> No Nordeste do Brasil&#44; ocorrem raios solares abundantes durante quase toda parte do ano&#46; Entretanto&#44; o fato de residir em regi&#227;o ensolarada pode n&#227;o proteger os lactentes dessa defici&#234;ncia vitam&#237;nica&#46; Ao analisar a rela&#231;&#227;o da exposi&#231;&#227;o solar com os n&#237;veis de vitamina D nessa pesquisa&#44; foi verificado que a exposi&#231;&#227;o solar adequada n&#227;o assegurou n&#237;veis suficientes de vitamina D&#46; Em estudo recente feito nessa mesma regi&#227;o&#44; n&#237;veis insuficientes de vitamina D tamb&#233;m foram observados no bin&#244;mio m&#227;e&#47;rec&#233;m&#8208;nascido&#44;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">27</span></a> corroboraram outros dados que apontam para o fato de que mesmo em cidades com elevada irradia&#231;&#227;o solar podem ocorrer frequ&#234;ncias elevadas de hipovitaminose D&#46; O fato de a exposi&#231;&#227;o solar n&#227;o ter se relacionado aos n&#237;veis adequados de vitamina D nesta pesquisa pode ter sido devido &#224; influ&#234;ncia de outros fatores&#44; como o hor&#225;rio em que a crian&#231;a foi exposta&#44; a cor da pele e o uso de protetor solar&#44; os quais n&#227;o foi poss&#237;vel analisar&#46; &#201; prov&#225;vel que pese contra uma exposi&#231;&#227;o solar adequada o temor dos efeitos mal&#233;ficos do sol sobre a pele&#46; De fato&#44; os dermatologistas recomendam que beb&#234;s at&#233; seis meses n&#227;o devam ser expostos &#224; luz solar direta&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">28</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">Na an&#225;lise dos resultados deste estudo devem ser consideradas as suas limita&#231;&#245;es&#46; A complexidade do problema a ser estudado constituiu uma das principais dificuldades encontradas e outros fatores que poderiam estar relacionados aos n&#237;veis de vitamina D n&#227;o foram controlados&#44; como a restri&#231;&#227;o de leite e derivados na dieta materna&#44; o uso da vitamina D durante a gesta&#231;&#227;o e a ades&#227;o a essa orienta&#231;&#227;o&#44; o tipo de parto e outros aspectos associados &#224; microbiota intestinal do beb&#234;&#46; A heterogeneidade da amostra foi considerada um dos problemas devido &#224;s diferen&#231;as individuais da doen&#231;a&#46; Tamb&#233;m pode ter ocorrido vi&#233;s de classe social devido &#224; procura do ambulat&#243;rio de Gastropediatria por fam&#237;lias de melhor condi&#231;&#227;o socioecon&#244;mica com o objetivo de obter laudo m&#233;dico para receber as f&#243;rmulas especializadas fornecidas pelo servi&#231;o p&#250;blico&#46; Dificuldades inerentes &#224; aplica&#231;&#227;o do question&#225;rio tamb&#233;m podem ter ocorrido&#44; j&#225; que foi aplicado por duas pesquisadoras&#44; assim como relacionadas &#224; fidedignidade das informa&#231;&#245;es prestadas pelas m&#227;es&#46; O n&#250;mero amostral &#233; pequeno&#44; talvez insuficiente para subsidiar mudan&#231;as nas orienta&#231;&#245;es previamente estabelecidas pelas sociedades regulamentadoras&#44; por&#233;m suficiente para servir de alerta e despertar estudos complementares randomizados e prospectivos sobre o assunto&#46; Um maior n&#250;mero amostral poderia permitir que os lactentes com APLV fossem agrupados e analisados de acordo com as manifesta&#231;&#245;es cl&#237;nicas apresentadas &#40;imediatas e tardias&#41; e fossem levados em conta os diferentes mecanismos imunol&#243;gicos envolvidos na patog&#234;nese da APLV&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">A falta de um consenso em rela&#231;&#227;o aos pontos de corte que definem o status de vitamina D tamb&#233;m foi considerado um dos vieses&#44; dificultou o entendimento sobre quais valores teriam efeito patog&#234;nico e comprometeu a compara&#231;&#227;o com estudos que usaram outros valores de refer&#234;ncia&#46; Enquanto que Sociedade de Endocrinologia Norte&#8208;Americana estabelece que n&#237;veis deficientes s&#227;o aqueles inferiores a 20<span class="elsevierStyleHsp" style=""></span>ng&#47;ml e suficientes os iguais ou acima de 30<span class="elsevierStyleHsp" style=""></span>ng&#47;ml&#44;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">29</span></a> o Instituto de Medicina dos EUA &#40;2010&#41; considera como adequados os n&#237;veis superiores a 20<span class="elsevierStyleHsp" style=""></span>ng&#47;ml&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">30</span></a> Nesta pesquisa&#44; os n&#237;veis suficientes foram aqueles a partir de 30<span class="elsevierStyleHsp" style=""></span>ng&#47;ml&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Os achados deste estudo sugerem uma maior frequ&#234;ncia de n&#237;veis inadequados de vitamina D nos lactentes com diferentes manifesta&#231;&#245;es cl&#237;nicas de APLV&#46; Apesar das diversas limita&#231;&#245;es do estudo&#44; os dados podem alertar para a necessidade de investigar os n&#237;veis de vitamina D em lactentes com APLV&#46; A pr&#225;tica do AM exclusivo&#47;predominante se relacionou com os n&#237;veis inadequados principalmente nas crian&#231;as com diagn&#243;stico de APLV&#44; enquanto que a exposi&#231;&#227;o solar parece n&#227;o ter conferido um efeito protetor nesse grupo&#46; O fato de os lactentes al&#233;rgicos n&#227;o usarem suplemento de vitamina D pode ter contribu&#237;do com os achados do estudo&#46; Assim&#44; n&#227;o &#233; possivelmente seguro confiar na exposi&#231;&#227;o solar como fonte de vitamina D&#44; principalmente nos beb&#234;s em aleitamento materno exclusivo&#44; &#233; sugerido que se avalie a suplementa&#231;&#227;o rotineira&#46; Sugere&#8208;se que outros estudos sejam conduzidos para comprovar a associa&#231;&#227;o e melhor elucidar os fatores associados aos n&#237;veis inadequados de vitamina D nos lactentes com APLV&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Financiamento</span><p id="par0125" class="elsevierStylePara elsevierViewall">Conselho Nacional de Desenvolvimento Cient&#237;fico e Tecnol&#243;gico &#40;CNPq&#41;&#44; por meio de aux&#237;lio financeiro do edital universal de 2012&#47;2013 sob o n&#250;mero de registro 488488&#47;2013&#8208;3&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conflitos de interesse</span><p id="par0130" class="elsevierStylePara elsevierViewall">Os autores declaram n&#227;o haver conflitos de interesse&#46;</p></span></span>"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To verify whether infants with cow&#39;s milk protein allergy &#40;CMPA&#41; have inadequate vitamin D levels&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">This cross&#8208;sectional study included 120 children aged 2 years or younger&#44; one group with CMPA and a control group&#46; The children were recruited at the pediatric gastroenterology&#44; allergology&#44; and pediatric outpatient clinics of a university hospital in the Northeast of Brazil&#46; A questionnaire was administered to the caregiver and blood samples were collected for vitamin D quantification&#46; Vitamin D levels &#60;30<span class="elsevierStyleHsp" style=""></span>ng&#47;mL were considered inadequate&#46; Vitamin D level was expressed as mean and standard deviation&#44; and the frequency of the degrees of sufficiency and other variables&#44; as proportions&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Infants with CMPA had lower mean vitamin D levels &#40;30&#46;93 <span class="elsevierStyleItalic">vs</span>&#46;35&#46;29<span class="elsevierStyleHsp" style=""></span>ng&#47;mL&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;041&#41; and higher deficiency frequency &#40;20&#46;3&#37; <span class="elsevierStyleItalic">vs</span>&#46;8&#46;2&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;049&#41; than the healthy controls&#46; Exclusively or predominantly breastfed infants with CMPA had higher frequency of inadequate vitamin D levels &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;002&#41;&#46; Regardless of sun exposure time&#44; the groups had similar frequencies of inadequate vitamin D levels &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;972&#41;&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Lower vitamin D levels were found in infants with CMPA&#44; especially those who were exclusively or predominantly breastfed&#44; making these infants a possible risk group for vitamin D deficiency&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Objective"
          ]
          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Methods"
          ]
          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Results"
          ]
          3 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Conclusions"
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      ]
      "pt" => array:3 [
        "titulo" => "Resumo"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Verificar se lactentes com alergia &#224; prote&#237;na do leite de vaca &#40;APLV&#41; apresentam n&#237;veis inadequados de vitamina D&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Estudo transversal&#44; envolveu 120 crian&#231;as de at&#233; dois anos&#44; um grupo com APLV e outro de compara&#231;&#227;o&#44; captadas dos ambulat&#243;rios de Gastroenterologia Pedi&#225;trica&#44; Alergologia Pedi&#225;trica e Puericultura de um hospital universit&#225;rio&#44; no Nordeste brasileiro&#46; Foi aplicado um formul&#225;rio e foram coletadas amostras sangu&#237;neas para a an&#225;lise da vitamina D&#44; foram considerados inadequados os n&#237;veis<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>30<span class="elsevierStyleHsp" style=""></span>ng&#47;mL&#46; N&#237;veis de vitamina D foram expressos em m&#233;dia e desvio padr&#227;o e a frequ&#234;ncia dos graus de sufici&#234;ncia e demais vari&#225;veis&#44; em propor&#231;&#245;es&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Lactentes com APLV&#44; quando comparados com os saud&#225;veis&#44; apresentaram uma menor m&#233;dia do n&#237;vel da vitamina D &#40;30&#44;93 <span class="elsevierStyleItalic">vs</span>&#46; 35&#44;29<span class="elsevierStyleHsp" style=""></span>ng&#47;mL&#41; &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;041&#41; e maior frequ&#234;ncia de defici&#234;ncia &#40;20&#44;3&#37; <span class="elsevierStyleItalic">vs</span>&#46; 8&#44;2&#41; &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;049&#41;&#46; Maior frequ&#234;ncia de n&#237;veis inadequados de vitamina D foi observada nas crian&#231;as com APLV que estavam em aleitamento materno exclusivo&#47;predominante &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;002&#41;&#46; Independentemente do per&#237;odo de exposi&#231;&#227;o solar&#44; a frequ&#234;ncia de um status inadequado de vitamina D foi semelhante entre os grupos &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;972&#41;&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclus&#245;es</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Menores n&#237;veis de vitamina D foram observados em lactentes com APLV&#44; especialmente naqueles em aleitamento materno exclusivo&#47;predominante&#44; que configura esse como um poss&#237;vel grupo de risco para essa defici&#234;ncia&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0025"
            "titulo" => "Objetivo"
          ]
          1 => array:2 [
            "identificador" => "abst0030"
            "titulo" => "M&#233;todos"
          ]
          2 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "Resultados"
          ]
          3 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Conclus&#245;es"
          ]
        ]
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0015">Como citar este artigo&#58; Silva CM&#44; da Silva SA&#44; Antunes MM&#44; Silva GA&#44; Sarinho ES&#44; Brandt KG&#46; Do infants with cow&#39;s milk protein allergy have inadequate levels of vitamin D&#63; J Pediatr &#40;Rio J&#41;&#46; 2017&#59;93&#58;632&#8211;8&#46;</p>"
      ]
    ]
    "multimedia" => array:3 [
      0 => array:7 [
        "identificador" => "fig0005"
        "etiqueta" => "Figura 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
            "Alto" => 1546
            "Ancho" => 2102
            "Tamanyo" => 83893
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        "descripcion" => array:1 [
          "pt" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Frequ&#234;ncias dos graus de sufici&#234;ncia da vitamina D nos lactentes com APLV e no grupo controle&#44; atendidos ambulatorialmente em hospital universit&#225;rio&#44; Recife&#8211;PE &#40;2013&#8211;2015&#41;&#46;</p> <p id="spar0050" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleSup">a</span> Teste exato de Fisher&#46;</p>"
        ]
      ]
      1 => array:8 [
        "identificador" => "tbl0005"
        "etiqueta" => "Tabela 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at1"
            "detalle" => "Tabela "
            "rol" => "short"
          ]
        ]
        "tabla" => array:3 [
          "leyenda" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">AME&#44; aleitamento materno exclusivo&#59; APLV&#44; alergia &#224; prote&#237;na do leite de vaca&#59; I&#44; idade&#59; P&#44; peso&#59; SM&#44; sal&#225;rio m&#237;nimo nacional&#46;</p>"
          "tablatextoimagen" => array:1 [
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              "tabla" => array:1 [
                0 => """
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                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col">Vari&#225;veis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">APLV &#43;</th><th class="td" title="table-head  " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">APLV &#8722;</th><th class="td" title="table-head  " align="" valign="top" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">n &#40;59&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">&#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">n &#40;61&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">&#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">p<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " colspan="6" align="left" valign="top"><span class="elsevierStyleItalic">Sexo</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Masculino&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">25&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">42&#44;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">49&#44;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#44;454&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Feminino&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">34&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">57&#44;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">31&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">50&#44;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="6" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="6" align="left" valign="top"><span class="elsevierStyleItalic">Idade &#40;meses&#41;</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#8804; 6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">26&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">44&#44;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">19&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">31&#44;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#44;093&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>6 &#8804; 12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">18&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">30&#44;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">19&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">31&#44;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>12 &#8804; 18&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">22&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">21&#44;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>18 &#8804; 24&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&#44;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">16&#44;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="6" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="6" align="left" valign="top"><span class="elsevierStyleItalic">Grau de escolaridade materna</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Ensino fundamental&#47;m&#233;dio&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">18&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">30&#44;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">44&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">72&#44;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#60; 0&#44;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Ensino superior&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">41&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">69&#44;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">17&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">27&#44;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="6" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="6" align="left" valign="top"><span class="elsevierStyleItalic">Renda em SM</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#8804; 2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">25&#44;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">43&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">70&#44;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#60; 0&#44;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>2 &#8804; 4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">22&#44;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">11&#44;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>4 &#8804; 10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">23&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">39&#44;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9&#44;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#62;10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12&#44;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8&#44;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="6" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="6" align="left" valign="top"><span class="elsevierStyleItalic">Atopia m&#227;e</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Sim&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">37&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">62&#44;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">21&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">34&#44;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#44;002&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>N&#227;o&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">22&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">37&#44;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">40&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">65&#44;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="6" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="6" align="left" valign="top"><span class="elsevierStyleItalic">Atopia pai</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Sim&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">27&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">46&#44;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">17&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">28&#44;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#44;041&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>N&#227;o&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">31&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">53&#44;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">43&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">71&#44;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="6" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="6" align="left" valign="top"><span class="elsevierStyleItalic">Tipo de parto</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Transvaginal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">10&#44;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">19&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">31&#44;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#44;005&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Ces&#225;reo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">53&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">89&#44;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">42&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">68&#44;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="6" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="6" align="left" valign="top"><span class="elsevierStyleItalic">Idade gestacional</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Pr&#233;&#8208;termo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">17&#44;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">18&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#44;612&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Termo&#47;P&#243;s&#8208;termo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">48&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">82&#44;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">50&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">82&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="6" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="6" align="left" valign="top"><span class="elsevierStyleItalic">Suplementa&#231;&#227;o materna com vitamina D durante a gesta&#231;&#227;o</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Sim&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">15&#44;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6&#44;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#44;15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>N&#227;o&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">50&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">84&#44;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">57&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">93&#44;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="6" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="6" align="left" valign="top"><span class="elsevierStyleItalic">Tempo de AME &#40;meses&#41;</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#8804; 1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">17&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">28&#44;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#44;483&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>1 &#8804; 3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">25&#44;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">25&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>3 &#8804; 6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">27&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">45&#44;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">33&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">55&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="6" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="6" align="left" valign="top"><span class="elsevierStyleItalic">Avalia&#231;&#227;o antropom&#233;trica &#40;P&#47;I&#41;</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Baixo peso&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8&#44;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&#44;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#44;439&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Eutr&#243;fico&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">54&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">91&#44;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">57&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">96&#44;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Excesso de peso&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col">Vari&#225;vel&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</th><th class="td" title="table-head  " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Vitamina D</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">p<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Vitamina D</th><th class="td" title="table-head  " align="left" valign="top" scope="col">p<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Defici&#234;ncia&#47;Insufici&#234;ncia n &#37;<br>IC 95&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Sufici&#234;ncia<br>n &#37;<br>IC 95&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Defici&#234;ncia&#47;Insufici&#234;ncia<br>n &#37;<br>IC 95&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Sufici&#234;ncia<br>n &#37;<br>IC 95&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " colspan="7" align="left" valign="top"><span class="elsevierStyleItalic">Pr&#225;tica atual do AM</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Exclusivo&#47;Predominante&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">7 &#40;25&#44;9&#41;<br>11&#44;9&#8208;46&#44;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1 &#40;3&#44;1&#41;<br>0&#44;2&#8208;18&#44;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#44;002&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3 &#40;15&#44;7&#41;<br>4&#44;2&#8208;40&#44;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1 &#40;2&#44;4&#41;<br>0&#44;1&#8208;14&#44;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#44;189&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Parcial&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">7 &#40;25&#44;9&#41;<br>11&#44;9&#8208;46&#44;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2 &#40;6&#44;3&#41;<br>1&#44;1&#8208;22&#44;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2 &#40;4&#44;7&#41;<br>0&#44;8&#8208;17&#44;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Complementar&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4 &#40;14&#44;9&#41;<br>4&#44;8&#8208;34&#44;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4 &#40;12&#44;5&#41;<br>4&#44;1&#8208;29&#44;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4 &#40;21&#44;1&#41;<br>7&#44;0&#8208;46&#44;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">12 &#40;28&#44;6&#41;<br>16&#44;2&#8208;44&#44;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>N&#227;o amamenta&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">9 &#40;33&#44;3&#41;<br>17&#44;2&#8208;54&#44;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">25 &#40;78&#44;1&#41;<br>59&#44;6&#8208;90&#44;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">12 &#40;63&#44;2&#41;<br>38&#44;6&#8208;82&#44;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">27 &#40;64&#44;3&#41;<br>48&#44;0&#8208;78&#44;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="7" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">TOTAL&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">27 &#40;100&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">32 &#40;100&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">19 &#40;100&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">42 &#40;100&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "pt" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Status da vitamina D dos lactentes com APLV e do grupo controle em rela&#231;&#227;o &#224; pr&#225;tica alimentar&#44; atendidos ambulatorialmente em hospital universit&#225;rio&#44; Recife&#8211;PE &#40;2013&#8208;2015&#41;</p>"
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      "titulo" => "Refer&#234;ncias"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
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2024 Novembro 8 1 9
2024 Outubro 35 18 53
2024 Setembro 42 17 59
2024 Agosto 69 24 93
2024 Julho 38 33 71
2024 Junho 32 17 49
2024 Maio 23 9 32
2024 Abril 37 21 58
2024 Março 37 20 57
2024 Fevereiro 27 18 45
2024 Janeiro 30 20 50
2023 Dezembro 29 23 52
2023 Novembro 41 26 67
2023 Outubro 29 31 60
2023 Setembro 34 31 65
2023 Agosto 24 15 39
2023 Julho 23 8 31
2023 Junho 22 8 30
2023 Maio 31 16 47
2023 Abril 21 9 30
2023 Março 36 19 55
2023 Fevereiro 37 22 59
2023 Janeiro 24 26 50
2022 Dezembro 47 26 73
2022 Novembro 37 30 67
2022 Outubro 60 43 103
2022 Setembro 42 44 86
2022 Agosto 42 46 88
2022 Julho 39 40 79
2022 Junho 38 36 74
2022 Maio 36 42 78
2022 Abril 69 37 106
2022 Março 53 34 87
2022 Fevereiro 24 26 50
2022 Janeiro 40 25 65
2021 Dezembro 27 17 44
2021 Novembro 22 20 42
2021 Outubro 39 22 61
2021 Setembro 20 21 41
2021 Agosto 14 14 28
2021 Julho 14 4 18
2021 Junho 25 13 38
2021 Maio 23 17 40
2021 Abril 14 10 24
2021 Março 24 13 37
2021 Fevereiro 16 4 20
2021 Janeiro 12 7 19
2020 Dezembro 21 8 29
2020 Novembro 20 9 29
2020 Outubro 20 5 25
2020 Setembro 27 21 48
2020 Agosto 22 6 28
2020 Julho 18 6 24
2020 Junho 17 5 22
2020 Maio 24 5 29
2020 Abril 39 11 50
2020 Março 25 8 33
2020 Fevereiro 24 14 38
2020 Janeiro 21 10 31
2019 Dezembro 21 7 28
2019 Novembro 19 6 25
2019 Outubro 25 19 44
2019 Setembro 33 10 43
2019 Agosto 19 14 33
2019 Julho 18 12 30
2019 Junho 20 12 32
2019 Maio 41 21 62
2019 Abril 50 11 61
2019 Março 21 10 31
2019 Fevereiro 15 12 27
2019 Janeiro 18 12 30
2018 Dezembro 17 8 25
2018 Novembro 22 5 27
2018 Outubro 58 22 80
2018 Setembro 17 4 21
2018 Maio 17 4 21
2018 Abril 40 7 47
2018 Março 51 6 57
2018 Fevereiro 76 5 81
2018 Janeiro 271 26 297
2017 Dezembro 282 28 310
2017 Novembro 171 44 215
2017 Outubro 3 8 11
2017 Setembro 0 7 7
2017 Agosto 0 7 7
2017 Julho 0 2 2
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