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Esses s&#227;o dois fen&#243;tipos distintos&#44; com diferentes tempo e dura&#231;&#227;o dos acometimentos s&#250;bitos causais&#44; fatores de risco espec&#237;ficos e distribui&#231;&#245;es variadas em todas as popula&#231;&#245;es e diferentes progn&#243;sticos&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">9</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">V&#225;rios estudos antropom&#233;tricos com crian&#231;as e adolescentes de ecossistemas de altitude indicam que essa popula&#231;&#227;o&#44; em compara&#231;&#227;o com os que vivem perto do n&#237;vel do mar&#44; s&#227;o mais baixos e mais leves&#46;<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">10&#44;11</span></a> Principalmente&#44; nos rec&#233;m&#8208;nascidos de Jujuy&#44; o peso ao nascer&#44; bem como os indicadores de comprometimento grave do crescimento intrauterino&#44; que &#233; independentemente associado &#224; altitude geogr&#225;fica&#46;<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">2&#44;12&#8211;15</span></a> Contudo&#44; a maior parte dos estudos do efeito da altitude sobre o crescimento fetal &#233; limitada a rec&#233;m&#8208;nascidos a termo&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">O objetivo foi usar o padr&#227;o do IG&#8208;21 para avaliar a preval&#234;ncia e os fatores de risco comuns de abaixo do peso&#44; baixa estatura e emacia&#231;&#227;o por idade gestacional &#40;IG&#41; em rec&#233;m&#8208;nascidos de Jujuy com rela&#231;&#227;o aos n&#237;veis de alta altitude&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material e m&#233;todos</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Popula&#231;&#227;o estudada</span><p id="par0040" class="elsevierStylePara elsevierViewall">Este foi um estudo observacional&#44; anal&#237;tico e retrospectivo feito em nascimentos consecutivos registrados pelo Sistema de Inform&#225;tica Perinatal &#40;SIP&#44; Minist&#233;rio da Sa&#250;de da Prov&#237;ncia de Jujuy&#44; Argentina&#41; entre 2009 e 2014&#46; Os crit&#233;rios de exclus&#227;o foram &#40;1&#41; IG &#60; 24<span class="elsevierStyleSup">&#43;0</span> e &#62; 42<span class="elsevierStyleSup">&#43;6</span> semanas&#59; &#40;2&#41; falta de dados sobre peso&#44; estatura&#44; IG&#44; sexo e local de resid&#234;ncia da m&#227;e durante a gravidez&#59; &#40;3&#41; gravidez de g&#234;meos&#46; O crit&#233;rio de Alexander foi aplicado para corrigir as incompatibilidades entre o peso ao nascer e a idade gestacional&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">16</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Avalia&#231;&#227;o dos dados</span><p id="par0050" class="elsevierStylePara elsevierViewall">Os dados foram agrupados de acordo com a altitude geogr&#225;fica do local de resid&#234;ncia da m&#227;e em um grupo de baixa altitude &#40;BA&#41; &#40;&#60; 2&#46;000 m&#46;a&#46;s&#46;l&#46;&#41; e um grupo de alta altitude &#40;AA&#41; &#40;<span class="elsevierStyleUnderline">&#62;</span>2&#46;000 m&#46;a&#46;s&#46;l&#46;&#41;&#46; O estado nutricional dos rec&#233;m&#8208;nascidos foi determinado de acordo com o padr&#227;o IG&#8208;21&#44; com os seguintes fen&#243;tipos no nascimento&#58; &#40;a&#41; Baixa estatura &#40;percentil &#60; 3 para comprimento&#47;IG&#41;&#59; &#40;b&#41; Emacia&#231;&#227;o &#40;percentil &#60; 3 para IMC &#91;Kg&#47;m<span class="elsevierStyleSup">2</span>&#93;&#47;IG&#41;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">9</span></a> e &#40;c&#41; um terceiro fen&#243;tipo &#8211; n&#227;o inclu&#237;do no padr&#227;o IG&#8208;21&#44; <span class="elsevierStyleItalic">abaixo do peso</span> &#40;percentil PN &#60; 3 para idade e sexo&#41;&#44; indicando um acometimento s&#250;bito grave&#59; isso elimina a chance de inclus&#227;o err&#244;nea de um rec&#233;m&#8208;nascido normal na distribui&#231;&#227;o de menor PN&#46; Como o Projeto IG&#8208;21 n&#227;o fornece uma avalia&#231;&#227;o de IMC abaixo de 33<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleSup">0</span> A s de IG&#44; os dados do estudo atual inclu&#237;ram abaixo do peso e baixa estatura entre 24<span class="elsevierStyleSup">&#43;0</span> e 42<span class="elsevierStyleSup">&#43;6</span> semanas e emacia&#231;&#227;o entre 33<span class="elsevierStyleSup">&#43;0</span> e 42<span class="elsevierStyleSup">&#43;6</span> semanas&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Foram analisadas as seguintes caracter&#237;sticas&#58; &#40;1&#41; biol&#243;gicas e sociodemogr&#225;ficas da m&#227;e&#58; idade &#40;&#60; 20&#44; 20&#8208;24&#44; 25&#8208;29&#44; 30&#8208;35 e &#8805; 35 anos&#41;&#44; paridade &#40;0&#44; 1&#44; 2 e &#8805; 3&#41;&#44; IMC &#40;&#60; 18&#44;5 desnutri&#231;&#227;o&#44; 18&#44;5&#8208;24&#44;9 nutri&#231;&#227;o normal&#44; 25&#44;0&#8208;29&#44;9 sobrepeso&#59; 30&#8208;34&#44;9 obesidade tipo I e &#8805;35<span class="elsevierStyleHsp" style=""></span>kg&#47;m<span class="elsevierStyleSup">2</span> obesidade tipo II&#41; e escolaridade &#40;&#60; 8&#59; 8&#8208;11 e &#8805; 12 anos&#41;&#59; &#40;2&#41; diabetes&#44; hipertens&#227;o&#44; pr&#233;&#8208;ecl&#226;mpsia e tuberculose durante a gravidez&#59; e &#40;3&#41; sexo&#44; prematuridade &#40;&#60; 37<span class="elsevierStyleSup">&#43;0</span> semanas&#41; e malforma&#231;&#245;es cong&#234;nitas dos rec&#233;m&#8208;nascidos&#46; As vari&#225;veis biol&#243;gicas e sociodemogr&#225;ficas das m&#227;es foram categ&#243;ricas&#59; as restantes foram dicot&#244;micas&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">An&#225;lise estat&#237;stica</span><p id="par0065" class="elsevierStylePara elsevierViewall">A preval&#234;ncia dos diferentes fen&#243;tipos foi estimada pela propor&#231;&#227;o &#40;IC de 95&#37; &#91;intervalo de confian&#231;a&#93;&#41;&#44; ao passo que as diferen&#231;as populacionais foram analisadas com um teste qui&#8208;quadrado e risco univariado&#58; raz&#227;o de chance &#40;RC e IC de 95&#37;&#41;&#46; Foi feita uma an&#225;lise de regress&#227;o log&#237;stica multivariada para estimar o risco de abaixo do peso&#44; baixa estatura e emacia&#231;&#227;o com rela&#231;&#227;o ao n&#237;vel de altitude &#40;vari&#225;vel de exposi&#231;&#227;o&#41; e ela foi ajustada para idade&#44; n&#237;vel de escolaridade&#44; IMC&#44; paridade&#44; tuberculose&#44; diabetes&#44; hipertens&#227;o&#44; pr&#233;&#8208;ecl&#226;mpsia&#44; sexo&#44; prematuridade e malforma&#231;&#245;es cong&#234;nitas da m&#227;e&#46; A refer&#234;ncia foi baixa altitude&#46; A qualidade do ajuste foi testada com o teste de Hosmer&#8208;Lemeshow&#46; Foram usados os <span class="elsevierStyleItalic">softwares</span> estat&#237;sticos SPSS &#40;IBM SPSS Estat&#237;stica para Windows&#44; Vers&#227;o 22&#46;0&#46; NY&#44; EUA&#41; e Stata &#40;Stata Software de estat&#237;stica&#58; Vers&#227;o 11&#46; College Station&#44; TX&#44; EUA&#41;&#46; O n&#237;vel estat&#237;stico foi estabelecido em p &#60; 0&#44;05&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Quest&#245;es &#233;ticas</span><p id="par0075" class="elsevierStylePara elsevierViewall">O Comit&#234; de &#201;tica de Pesquisa em Sa&#250;de da Prov&#237;ncia de Jujuy&#44; Argentina&#44; aprovou este estudo&#46;</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Resultados</span><p id="par0085" class="elsevierStylePara elsevierViewall">Entre 2009 e 2014&#44; nasceram 79&#46;504 neonatos vivos na Prov&#237;ncia de Jujuy&#59; 57&#46;471 foram registrados pelo SIP&#46; Ap&#243;s aplicar os crit&#233;rios de sele&#231;&#227;o&#44; 48&#46;656 &#40;84&#44;6&#37;&#44; IC de 95&#37;&#58; 84&#44;3&#8208;84&#44;9&#41; rec&#233;m&#8208;nascidos foram inclu&#237;dos no estudo&#59; desses 16&#44;8&#37; &#40;16&#44;5&#8208;17&#44;2&#41; moravam em AA &#40;<a class="elsevierStyleCrossRef" href="#sec0065">material adicional S1&#44; fig&#46; 1</a>&#41;&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">A preval&#234;ncia de abaixo do peso&#44; baixa estatura e emacia&#231;&#227;o foi 1&#44;27&#37; &#40;1&#44;18&#8208;1&#44;38&#41;&#44; 3&#44;39&#37; &#40;3&#44;24&#8208;3&#44;36&#41; e 4&#44;68&#37; &#40;4&#44;49&#8208;4&#44;87&#41;&#44; respectivamente&#46; A taxa de baixa estatura mais emacia&#231;&#227;o foi de 0&#44;16&#37; &#40;0&#44;12&#8208;0&#44;20&#41;&#46; A taxa de neonatos abaixo do peso em AA foi 1&#44;13 vez maior &#40;0&#44;80&#8208;1&#44;49&#41; do que a taxa de AA equivalente&#44; ao passo que as taxas de baixa estatura e emacia&#231;&#227;o foram 2&#44;68 &#40;2&#44;10&#8208;3&#44;29&#41; e 5&#44;26 &#40;4&#44;61&#8208;5&#44;95&#41; vezes maiores&#44; respectivamente&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Em geral&#44; as m&#227;es de rec&#233;m&#8208;nascidos abaixo do peso em AA mostraram idade significativamente mais avan&#231;ada&#44; maior desnutri&#231;&#227;o&#44; hipertens&#227;o&#44; prematuridade e malforma&#231;&#245;es cong&#234;nitas&#44; por&#233;m menor sobrepeso e obesidade tipo I do que as m&#227;es em BA&#46; As gr&#225;vidas no grupo de AA com rec&#233;m&#8208;nascidos com baixa estatura foram independentemente associadas a maior desnutri&#231;&#227;o e menos obesidade tipo I&#44; ao passo que os rec&#233;m&#8208;nascidos com emacia&#231;&#227;o no grupo de AA mostraram nutri&#231;&#227;o durante a gravidez menos normal&#44; obesidade tipo I e prematuridade&#44; por&#233;m maior nuliparidade e malforma&#231;&#245;es cong&#234;nitas que as m&#227;es em BA &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">tabela 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0100" class="elsevierStylePara elsevierViewall">O PN e o desvio&#8208;padr&#227;o &#40;DP&#41; m&#233;dios dos tr&#234;s fen&#243;tipos foi 2&#46;012<span class="elsevierStyleHsp" style=""></span>g &#40;567&#41; para abaixo do peso&#44; 2&#46;933<span class="elsevierStyleHsp" style=""></span>g &#40;635&#41; para baixa estatura e 2&#46;767<span class="elsevierStyleHsp" style=""></span>g &#40;427&#41; para emacia&#231;&#227;o&#44; ao passo que foi de 3&#46;321<span class="elsevierStyleHsp" style=""></span>g &#40;531&#41; em crian&#231;as sem d&#233;ficit nutricional&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">A IG m&#233;dia &#40;DP&#41; foi de 37&#44;5 &#40;3&#44;9&#41; semanas para abaixo do peso&#44; 38&#44;6 &#40;2&#44;1&#41; semanas para baixa estatura e 39&#44;0 &#40;1&#44;3&#41; semanas para emacia&#231;&#227;o&#46; A taxa geral de prematuridade foi de 9&#44;0&#37; &#40;8&#44;79&#8208;9&#44;30&#41;&#58; 8&#44;01&#37; em AA e 9&#44;25&#37; em BA &#40;p &#60; 0&#44;001&#41;&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Na Prov&#237;ncia de Jujuy em AA&#44; os riscos de abaixo do peso&#44; baixa estatura e emacia&#231;&#227;o come&#231;am a aparecer da 29&#170;&#44; 26&#170; e 33&#170; semanas de gesta&#231;&#227;o&#44; respectivamente&#46; A preval&#234;ncia de abaixo do peso e baixa estatura entre as 24<span class="elsevierStyleSup">&#43;0</span> e 36<span class="elsevierStyleSup">&#43;</span><a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">6</span></a> semanas foi maior do que entre as 37<span class="elsevierStyleSup">&#43;0</span> e 42<span class="elsevierStyleSup">&#43;6</span> semanas &#40;p &#60; 0&#44;001&#41; para AA&#44; em compara&#231;&#227;o com a BA&#46; Por outro lado&#44; a preval&#234;ncia de emacia&#231;&#227;o entre as 37<span class="elsevierStyleSup">&#43;0</span> e 42<span class="elsevierStyleSup">&#43;6</span> semanas foi maior do que entre as 24<span class="elsevierStyleSup">&#43;0</span> e 36<span class="elsevierStyleSup">&#43;</span><a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">6</span></a> semanas na AA&#44; em compara&#231;&#227;o com a BA &#40;p &#60; 0&#44;001&#44; dados n&#227;o mostrados&#41; &#40;<a class="elsevierStyleCrossRef" href="#sec0065">material adicional S2&#44; S3 e S4&#44; figs&#46; 2&#8208;4</a>&#41;&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">A RC bruta &#40;IC de 95&#37;&#41; para abaixo do peso&#44; baixa estatura e emacia&#231;&#227;o associadas a AA foi de 1&#44;92 &#40;1&#44;63&#8208;2&#44;27&#41;&#44; 2&#44;21 &#40;1&#44;99&#8208;2&#44;45&#41; e 2&#44;39 &#40;2&#44;18&#8208;2&#44;62&#41;&#44; respectivamente &#40;p &#60; 0&#44;001&#41;&#46; Ap&#243;s o ajuste&#44; foram encontrados uma leve redu&#231;&#227;o do risco de baixa estatura e um aumento do risco para os outros fen&#243;tipos&#44; todos estatisticamente significativos &#40;<a class="elsevierStyleCrossRef" href="#sec0065">material adicional S5&#44; tabela 1</a>&#41;&#46; A qualidade do ajuste do modelo foi adequada&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">As tabelas 1 a 3 mostram as caracter&#237;sticas maternas e dos rec&#233;m&#8208;nascidos de acordo com a altitude e sua associa&#231;&#227;o &#40;RC ajustada&#44; RCA&#41; aos tr&#234;s fen&#243;tipos&#46; Para abaixo do peso&#44; idade materna superior ou igual a 35 anos&#44; IMC abaixo de 18&#44;5<span class="elsevierStyleHsp" style=""></span>kg&#47;m<span class="elsevierStyleSup">2</span>&#44; nuliparidade&#44; hipertens&#227;o gestacional&#44; prematuridade e malforma&#231;&#245;es cong&#234;nitas foram independentemente associados a risco elevado em AA&#46; Sobrepeso e obesidade tipo I foram associados a menor risco em AA &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">tabela 1</a>&#41;&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Para baixa estatura&#44; IMC materno abaixo de 18&#44;5<span class="elsevierStyleHsp" style=""></span>kg&#47;m<span class="elsevierStyleSup">2</span> e malforma&#231;&#245;es cong&#234;nitas foram independentemente associados a risco mais elevado&#44; ao passo que o IMC de obesidade tipo I mostrou menor risco &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">tabela 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0130" class="elsevierStylePara elsevierViewall">Por fim&#44; para emacia&#231;&#227;o&#44; nuliparidade e malforma&#231;&#245;es cong&#234;nitas foram independentemente associadas a risco mais elevado&#44; ao passo que sobrepeso e obesidade classe I e prematuridade foram associados a menor risco &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">tabela 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Discuss&#227;o</span><p id="par0140" class="elsevierStylePara elsevierViewall">No presente estudo&#44; os rec&#233;m&#8208;nascidos em AA na Prov&#237;ncia de Jujuy mostraram um risco significativamente maior de abaixo do peso&#44; baixa estatura e emacia&#231;&#227;o e este estudo apresenta uma comprova&#231;&#227;o cl&#237;nica e epidemiol&#243;gica para corroborar o conceito de que se trata de fen&#243;tipos antropom&#233;tricos separados de origem intrauterina&#46; Os fen&#243;tipos diferiram em termos de fatores de risco&#46; Como esperado&#44; poucas doen&#231;as foram associadas com for&#231;a semelhante aos fen&#243;tipos abaixo do peso&#44; baixa estatura e emacia&#231;&#227;o&#59; essas doen&#231;as s&#227;o&#44; em grande parte&#44; reconhecidas como fatores de risco universais&#44; ou seja&#44; IG&#44; desnutri&#231;&#227;o materna&#44; hist&#243;rico obst&#233;trico&#44; malforma&#231;&#245;es cong&#234;nitas&#46; Outros fatores&#44; em especial tuberculose&#44; t&#234;m uma ampla gama de gravidade&#44; apresenta&#231;&#245;es e tempo durante a gravidez n&#227;o espec&#237;fica aos fen&#243;tipos&#46; Por outro lado&#44; sobrepeso e obesidade tipo I mostraram redu&#231;&#227;o do risco entre 30&#37; e 50&#37; para os tr&#234;s fen&#243;tipos &#40;um efeito bem descrito que se deve ao aumento do peso ao nascer e deposi&#231;&#227;o de gordura&#41;&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">N&#227;o h&#225; registros locais compar&#225;veis sobre a preval&#234;ncia dos fen&#243;tipos nutricionais em rec&#233;m&#8208;nascidos avaliados para IG com o padr&#227;o IG&#8208;21&#44; exceto o fen&#243;tipo abaixo do peso&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">17</span></a> Digna de nota&#44; neste estudo&#44;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">17</span></a> a preval&#234;ncia de abaixo do peso calculada a partir das certid&#245;es de nascimento em 2013 no nordeste da Argentina&#44; onde a Prov&#237;ncia de Jujuy est&#225; localizada&#44; foi semelhante &#224; verificada neste estudo em rec&#233;m&#8208;nascidos a termo&#46; Os registros argentinos sobre a preval&#234;ncia desses fen&#243;tipos referem&#8208;se &#224;s popula&#231;&#245;es de crian&#231;as com mais de seis meses de idade&#44; calculada com base no padr&#227;o da OMS&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">18</span></a> O Inqu&#233;rito Nacional de Nutri&#231;&#227;o e Sa&#250;de &#91;<span class="elsevierStyleItalic">Encuesta Nacional de Nutrici&#243;n y Salud</span>&#93; feito na Argentina em 2004&#8208;2005 estabelece para a popula&#231;&#227;o de Jujuy&#44; independentemente da altitude geogr&#225;fica&#44; uma preval&#234;ncia de 1&#44;8&#37; &#40;IC de 95&#37; 0&#44;8&#8208;4&#44;1&#41;&#44; 9&#44;5&#37; &#40;IC de 95&#37; 5&#44;3&#8208;16&#44;6&#41; e 0&#44;6&#37; &#40;IC de 95&#37; 0&#44;3&#8208;1&#44;4&#41; de abaixo do peso&#44; baixa estatura e emacia&#231;&#227;o&#44; respectivamente&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">18</span></a> Um estudo latino&#8208;americano<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">19</span></a> comparou os percentis do IG&#8208;21 com os rec&#233;m&#8208;nascidos peruanos nascidos com &#62; 3&#46;400 m&#46;a&#46;s&#46;l&#46; e n&#227;o encontrou diferen&#231;as significativas com rela&#231;&#227;o ao padr&#227;o IG&#8208;21&#44; por&#233;m a preval&#234;ncia de abaixo do peso&#44; baixa estatura e emacia&#231;&#227;o n&#227;o foi estimada&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">As preval&#234;ncias observadas dos fen&#243;tipos dos rec&#233;m&#8208;nascidos foram relativamente baixas&#44; principalmente para abaixo do peso e baixa estatura&#44; pois elas tamb&#233;m s&#227;o menores do que os pontos de corte para relev&#226;ncia cl&#237;nica &#60; 10&#37; e &#60; 20&#37;&#44; respectivamente&#44; sugeridos pela OMS&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">20</span></a> A baixa estatura ao nascer parece ter uma preval&#234;ncia relativamente baixa mesmo em configura&#231;&#245;es de baixa renda&#44; por&#233;m aumenta de forma acentuada com a idade gestacional&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">21</span></a> Esses resultados s&#227;o de certa forma semelhantes a um estudo anterior<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">9</span></a> de comprometimento do crescimento fetal&#44; que atende aos crit&#233;rios de elegibilidade individuais&#44; ao passo que a baixa estatura afetou 3&#44;8&#37; e emacia&#231;&#227;o 3&#44;4&#37; de uma popula&#231;&#227;o de rec&#233;m&#8208;nascidos de baixo risco&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">Em uma an&#225;lise recente dos fatores de riscos de baixa estatura na inf&#226;ncia em pa&#237;ses em desenvolvimento&#44; o principal fator de risco em todo o mundo foi restri&#231;&#227;o do crescimento fetal &#40;RCF&#41;&#44; definido como nascimento a termo e pequeno para a idade gestacional&#44; que enfatiza a necessidade de indicadores confi&#225;veis do crescimento fetal&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">22</span></a> Das 12 doen&#231;as estudadas&#44; idade materna avan&#231;ada&#44; IMC abaixo de 18&#44;5<span class="elsevierStyleHsp" style=""></span>kg&#47;m<span class="elsevierStyleSup">2</span>&#44; hipertens&#227;o&#44; malforma&#231;&#245;es cong&#234;nitas e prematuridade foram mais fortemente associados ao risco mais elevado ajustado de abaixo do peso do que baixa estatura e emacia&#231;&#227;o em AA&#46; A preval&#234;ncia de tuberculose &#233; tr&#234;s vezes maior em altitude &#40;53 x 10&#46;000 rec&#233;m&#8208;nascidos&#41; e ela foi associada somente a emacia&#231;&#227;o&#44; ao passo que a nuliparidade mostrou risco semelhante de abaixo do peso e emacia&#231;&#227;o&#46; N&#227;o foi encontrada comprova&#231;&#227;o estatisticamente significativa de associa&#231;&#227;o independente com quaisquer dos fen&#243;tipos estudados para as outras doen&#231;as&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Em AA&#44; as malforma&#231;&#245;es cong&#234;nitas foram associadas &#224; duplica&#231;&#227;o do risco de baixa estatura &#40;RCA&#58; 2&#44;62&#41; e emacia&#231;&#227;o &#40;RCA&#58; 2&#44;52&#41;&#44; por&#233;m o risco foi sete vezes maior para abaixo do peso &#40;RCA&#58; 7&#44;66&#41;&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">Na Prov&#237;ncia de Jujuy&#44; e com o uso da mesma fonte&#44; Grandi et al&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">23</span></a> demonstraram que a preval&#234;ncia de prematuridade&#44; PIG e restri&#231;&#227;o do crescimento fetal mostram um aumento da rela&#231;&#227;o com a altitude geogr&#225;fica&#44; na qual os dois &#250;ltimos indicadores &#8211; acima de 3&#46;500 m&#46;a&#46;s&#46;l&#46; &#8211; podem significativamente duplicar os valores encontrados no n&#237;vel do mar&#46; No noroeste da Argentina&#44; outros estudos chegaram &#224; mesma conclus&#227;o&#44;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">24</span></a> na qual um aumento na prematuridade devido a um aumento na altitude pode at&#233; mesmo representar uma vantagem adaptativa para os nascimentos prematuros nessas condi&#231;&#245;es&#44; conforme encontrado neste estudo para emacia&#231;&#227;o&#44; com redu&#231;&#227;o do risco ajustado de quase 40&#37;&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">Outra explica&#231;&#227;o &#233; que h&#225; tr&#234;s poss&#237;veis op&#231;&#245;es para a presen&#231;a de um acometimento s&#250;bito que comprometa o crescimento fetal nessas condi&#231;&#245;es&#58; continuidade da gesta&#231;&#227;o resultando em um rec&#233;m&#8208;nascido com restri&#231;&#227;o do crescimento fetal&#44; interrup&#231;&#227;o espont&#226;nea da gravidez ou indicada pelo m&#233;dico com nascimento prematuro consequente ou morte fetal&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">Esse hist&#243;rico justificaria a hip&#243;tese de que&#44; em regi&#245;es de altitude e por meio de um mecanismo evolucion&#225;rio&#44; podem ocorrer prematuridade e morte fetal devido &#224;s redu&#231;&#245;es evidentes da tens&#227;o de O<span class="elsevierStyleInf">2</span> acima de 2&#46;000 m&#46;a&#46;s&#46;l&#46;&#44; sugere um efeito limite al&#233;m do qual as pequenas redu&#231;&#245;es no fornecimento de O<span class="elsevierStyleInf">2</span> podem reduzir substancialmente a oxigena&#231;&#227;o fetal&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">25</span></a> Isso &#233; reafirmado por um relat&#243;rio do Departamento de Estat&#237;sticas e Informa&#231;&#245;es de Sa&#250;de do Minist&#233;rio da Sa&#250;de da Argentina &#40;DEIS&#41;&#44; informa que a contribui&#231;&#227;o dos fetos prematuros &#40;&#60; 37<span class="elsevierStyleSup">&#43;0</span> semanas&#41; para a mortalidade fetal em Jujuy foi de 72&#37; em 2013&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">A altitude geogr&#225;fica e as complica&#231;&#245;es de hipertens&#227;o na gravidez podem reduzir de maneira independente o peso ao nascer&#44;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">26</span></a> um fen&#244;meno encontrado em rec&#233;m&#8208;nascidos na Prov&#237;ncia de Jujuy acima de 2&#46;000 m&#46;a&#46;s&#46;l&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">12&#44;15</span></a> e no estudo atual &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">tabela 1</a>&#41;&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">A baixa estatura constitui um indicador global de bem&#8208;estar infantil&#44; reflete as desigualdades sociais e descreve os resultados espec&#237;ficos frequentes do per&#237;odo neonatal &#40;baixo peso ao nascer&#44; pequeno para a idade gestacional&#44; prematuridade&#44; baixo para a idade gestacional e per&#237;metro cef&#225;lico pequeno&#41;&#46; Por esse motivo&#44; a import&#226;ncia da avalia&#231;&#227;o desse indicador em rec&#233;m&#8208;nascidos foi recentemente enfatizada do ponto de vista dos primeiros 1&#46;000 dias de vida&#46; A baixa estatura fetal pode estar relacionada a condi&#231;&#245;es org&#226;nicas &#40;por exemplo&#44; malforma&#231;&#245;es&#41; e &#233; amplamente considerada um processo cumulativo de longo prazo an&#225;logo &#224; desnutri&#231;&#227;o cr&#244;nica em crian&#231;as&#44;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">27</span></a> que precisa de exposi&#231;&#227;o a um ou mais fatores de risco por v&#225;rios meses ou durante toda a gravidez&#46; Por outro lado&#44; a emacia&#231;&#227;o neonatal provavelmente reflete as exposi&#231;&#245;es agudas nas semanas anteriores ao parto&#44; com deposi&#231;&#227;o de gordura mais r&#225;pida&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">28</span></a> Outro&#44; contudo&#44; sugere que as diferen&#231;as na gravidade&#44; em vez do tempo e da dura&#231;&#227;o dos acometimentos s&#250;bitos&#44; resultam em fen&#243;tipos distintos de comprometimento do crescimento fetal e a emacia&#231;&#227;o representa os casos mais graves&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">29</span></a> O fato de que a preval&#234;ncia dos fen&#243;tipos difere em termos da apresenta&#231;&#227;o e da preval&#234;ncia da IG entre as gravidezes prematuras e a termo sugere diferentes fatores de risco &#40;como diabetes&#44; hipertens&#227;o ou pr&#233;&#8208;ecl&#226;mpsia em AA&#41; e&#44; consequentemente&#44; aumento da interrup&#231;&#227;o das gravidezes por indica&#231;&#227;o m&#233;dica para proteger o bem&#8208;estar materno e fetal&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">A maior parte dos fatores maternos considerados neste estudo foi fracamente associada ou constitui um fator de prote&#231;&#227;o com diferen&#231;as de fen&#243;tipo devido &#224; altitude&#44; principalmente baixa estatura&#46; Portanto&#44; essas diferen&#231;as provavelmente podem ser atribu&#237;das ao efeito enfatizado da hip&#243;xia de altitude que interage com outras caracter&#237;sticas desses ecossistemas n&#227;o considerados nesta an&#225;lise &#40;nutricionais&#44; socioecon&#244;micas&#44; gen&#233;ticas&#44; &#233;tnicas&#44; sociodemogr&#225;ficas e geogr&#225;ficas&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">10&#44;11&#44;30</span></a> O padr&#227;o de crescimento pr&#233;&#8208;natal dos rec&#233;m&#8208;nascidos na Prov&#237;ncia de Jujuy lembra o padr&#227;o encontrado nos ecossistemas de altitude em outros est&#225;gios ontogen&#233;ticos&#46; De fato&#44; v&#225;rios estudos com crian&#231;as&#44; adolescentes e adultos da Prov&#237;ncia de Jujuy sobre seu crescimento indicam que as crian&#231;as s&#227;o mais baixas e mais leves do que as que moram pr&#243;ximo ao n&#237;vel do mar&#46;<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">10&#44;13</span></a> Contudo&#44; como o comprometimento do crescimento fetal encontrado na popula&#231;&#227;o em AA &#233; uma s&#237;ndrome complexa&#44; s&#227;o necess&#225;rias caracteriza&#231;&#227;o e valida&#231;&#227;o adicionais dos fen&#243;tipos em diferentes popula&#231;&#245;es&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">Os principais pontos fortes do estudo s&#227;o a grande amostra representativa de altitude geogr&#225;fica&#44; a identifica&#231;&#227;o dos fatores de risco de tr&#234;s fen&#243;tipos associados &#224; restri&#231;&#227;o do crescimento fetal&#44; sabidamente associados a baixo peso ao nascer&#44; e a introdu&#231;&#227;o do IG&#8208;21 como uma boa ferramenta epidemiol&#243;gica a ser usada em estudos futuros&#46;</p><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Limita&#231;&#245;es</span><p id="par0205" class="elsevierStylePara elsevierViewall">A principal limita&#231;&#227;o &#233; a amostra final&#44; 61&#44;2&#37; dos rec&#233;m&#8208;nascidos vivos&#44; provavelmente porque foram inclu&#237;dos somente nascimentos registrados em instala&#231;&#245;es p&#250;blicas&#46; As outras limita&#231;&#245;es foram informa&#231;&#245;es incompletas e a IG estimada pela data da &#250;ltima menstrua&#231;&#227;o&#44; conforme recomendado pelo DEIS&#46; Por outro lado&#44; os modelos explicaram riscos de baixa altitude de acordo com os diferentes fen&#243;tipos&#44; pois os fatores sabidamente associados ao crescimento fetal &#40;tabagismo materno&#44; uso de drogas il&#237;citas&#44; hist&#243;rico de baixo peso ao nascer e prematuridade&#44; condi&#231;&#227;o etc&#46;&#41; n&#227;o foram registrados&#46;</p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Conclus&#227;o</span><p id="par0215" class="elsevierStylePara elsevierViewall">Os riscos de abaixo do peso&#44; baixa estatura e emacia&#231;&#227;o foram maiores em altitude mais elevada e foram associados a doen&#231;as maternas e fetais reconhecidas&#46; O uso desses tr&#234;s fen&#243;tipos ajudar&#225; a priorizar as interven&#231;&#245;es preventivas e focar no manejo da desnutri&#231;&#227;o fetal&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Conflitos de interesse</span><p id="par0220" class="elsevierStylePara elsevierViewall">Os autores declaram n&#227;o haver conflitos de interesse&#46;</p></span></span>"
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            0 => "Retardo do crescimento fetal"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To assess the prevalence and risks of underweight&#44; stunting and wasting by gestational age in newborns of the Jujuy Province&#44; Argentina at different altitude levels&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Live newborns &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>48&#44;656&#41; born from 2009&#8211;2014 in public facilities with a gestational age between 24<span class="elsevierStyleSup">&#43;0</span> to 42<span class="elsevierStyleSup">&#43;6</span> weeks&#46; Phenotypes of underweight &#40;<span class="elsevierStyleHsp" style=""></span>weight&#47;age&#41;&#44; stunting &#40;<span class="elsevierStyleHsp" style=""></span>length&#47;age&#41; and wasting &#40;<span class="elsevierStyleHsp" style=""></span>body mass index&#47;age&#41; were calculated using Intergrowth&#8208;21st standards&#46; Risk factors were maternal age&#44; education&#44; body mass index&#44; parity&#44; diabetes&#44; hypertension&#44; preeclampsia&#44; tuberculosis&#44; prematurity&#44; and congenital malformations&#46; Data were grouped by the geographic altitude&#58; &#8805;2&#46;000 or &#60;2&#46;000<span class="elsevierStyleHsp" style=""></span>m&#46;a&#46;s&#46;l&#46; Chi&#8208;squared test and a multivariate logistic regression analysis were performed to estimate the risk of the phenotypes associated with an altitudinal level &#8805;2&#46;000<span class="elsevierStyleHsp" style=""></span>m&#46;a&#46;s&#46;l&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The prevalence of underweight&#44; stunting and wasting were 1&#46;27&#37;&#44; 3&#46;39&#37; and 4&#46;68&#37;&#44; respectively&#44; and significantly higher at &#62;2&#46;000<span class="elsevierStyleHsp" style=""></span>m&#46;a&#46;s&#46;l&#46; Maternal age&#44; body mass index &#62;35<span class="elsevierStyleHsp" style=""></span>kg&#47;m<span class="elsevierStyleSup">2</span>&#44; hypertension&#44; congenital malformations&#44; and prematurity were more strongly associated with underweight rather than stunting or wasting at &#8805;2&#46;000<span class="elsevierStyleHsp" style=""></span>m&#46;a&#46;s&#46;l&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Underweight&#44; stunting&#44; and wasting risks were higher at a higher altitude&#44; and were associated with recognized maternal and fetal conditions&#46; The use of those three phenotypes will help prioritize preventive interventions and focus the management of fetal undernutrition&#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">Avaliar a preval&#234;ncia e os riscos de rec&#233;m&#8208;nascidos abaixo do peso&#44; baixa estatura e emacia&#231;&#227;o por idade gestacional da Prov&#237;ncia de Jujuy&#44; Argentina&#44; em diferentes n&#237;veis de altitude&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Rec&#233;m&#8208;nascidos vivos &#40;n &#61; 48&#46;656&#41; nascidos entre 2009 e 2014 em instala&#231;&#245;es p&#250;blicas entre 24<span class="elsevierStyleSup">&#43;0</span>&#8208;42<span class="elsevierStyleSup">&#43;6</span> semanas de idade gestacional&#46; Os fen&#243;tipos de abaixo do peso &#40;&#60; P3 peso&#47;idade&#41;&#44; baixa estatura &#40;&#60; P3 comprimento&#47;idade&#41; e emacia&#231;&#227;o &#40;&#60; P3 &#237;ndice de massa corporal&#47;idade&#41; foram calculados com os padr&#245;es do INTERGROWTH-21st&#46; Os fatores de risco foram idade materna&#44; escolaridade&#44; &#237;ndice de massa corporal&#44; paridade&#44; diabetes&#44; hipertens&#227;o&#44; pr&#233;&#8208;ecl&#226;mpsia&#44; tuberculose&#44; prematuridade e malforma&#231;&#245;es cong&#234;nitas&#46; Os dados foram agrupados pela altitude geogr&#225;fica&#58; &#8805; 2&#46;000 ou &#60; 2&#46;000 m&#46;a&#46;s&#46;l&#46; O teste qui&#8208;quadrado e a an&#225;lise de regress&#227;o log&#237;stica multivariada foram feitos para estimar o risco dos fen&#243;tipos associados ao n&#237;vel de altitude &#8805; 2&#46;000 m&#46;a&#46;s&#46;l&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">A preval&#234;ncia de abaixo do peso&#44; baixa estatura e emacia&#231;&#227;o foi de 1&#44;27&#37;&#44; 3&#44;39&#37; e 4&#44;68&#37;&#44; respectivamente&#44; significativamente maiores em &#62; 2&#46;000 m&#46;a&#46;s&#46;l&#46; A idade materna&#44; &#237;ndice de massa corporal &#62; 35<span class="elsevierStyleHsp" style=""></span>kg&#47;m<span class="elsevierStyleSup">2</span>&#44; hipertens&#227;o&#44; malforma&#231;&#245;es cong&#234;nitas e prematuridade foram mais fortemente associados a abaixo do peso e n&#227;o a baixa estatura ou emacia&#231;&#227;o em &#8805; 2&#46;000 m&#46;a&#46;s&#46;l&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclus&#245;es</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Os riscos de abaixo do peso&#44; baixa estatura e emacia&#231;&#227;o foram maiores em altitude mais elevada e foram associados a condi&#231;&#245;es maternas e fetais reconhecidas&#46; O uso desses tr&#234;s fen&#243;tipos ajudar&#225; a priorizar as interven&#231;&#245;es preventivas e focar no manejo da desnutri&#231;&#227;o fetal&#46;</p></span>"
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t" scope="col">Vari&#225;vel&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2&#44;52 <a class="elsevierStyleCrossRef" href="#tblfn0045"><span class="elsevierStyleSup">c</span></a> &#40;1&#44;69&#8211;3&#44;75&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;64 <a class="elsevierStyleCrossRef" href="#tblfn0045"><span class="elsevierStyleSup">c</span></a> &#40;0&#44;48 &#8211;0&#44;84&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab2048114.png"
              ]
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          "notaPie" => array:3 [
            0 => array:3 [
              "identificador" => "tblfn0035"
              "etiqueta" => "a"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0035">RC Ajustada para todas as vari&#225;veis da tabela&#46;</p>"
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            1 => array:3 [
              "identificador" => "tblfn0040"
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              "nota" => "<p class="elsevierStyleNotepara" id="npar0040">Valores ausentes&#46;</p>"
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Artigo Original
Geographic altitude and prevalence of underweight, stunting and wasting in newborns with the INTERGROWTH‐21st standard
Altitude geográfica e prevalência de recém‐nascidos abaixo do peso, com baixa estatura e emaciação de acordo com o padrão INTERGROWTH-21st
Jorge Ivan Martíneza,b,
Autor para correspondência
jorjom@gmail.com

Autor para correspondência.
, Estela M. Romána,b, Emma L. Alfaroa,b, Carlos Grandic, José E. Dipierria,b
a Consejo Nacional de Investigaciones Científicas y Técnicas (Conicet), Instituto de Ecorregiones Andinas (Inecoa), Jujuy, Argentina
b Universidad Nacional de Jujuy, Instituto de Biología de la Altura, Jujuy, Argentina
c Universidade de São Paulo (USP), Faculdade de Medicina de Ribeirão Preto, Ribeirão Preto, SP, Brasil
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nenhuma &#233; sin&#244;nimo de restri&#231;&#227;o de crescimento intrauterino&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">4</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">A antropometria neonatal &#233; caracterizada por n&#227;o ser exata e pela falta de valida&#231;&#227;o e consenso de seus &#237;ndices dispon&#237;veis&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">5</span></a> Al&#233;m disso&#44; n&#227;o h&#225; correspond&#234;ncia e harmoniza&#231;&#227;o entre os diferentes crit&#233;rios para avaliar o estado nutricional pr&#233; e p&#243;s&#8208;natal para o monitoramento constante e cont&#237;nuo nos diferentes est&#225;gios da ontog&#234;nese&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">6</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">O Projeto Cons&#243;rcio Internacional de Crescimento Fetal e Neonatal para o S&#233;culo XXI &#40;Projeto Intergrowth&#8208;21<span class="elsevierStyleSup">st</span> &#91;IG&#8208;21&#93;&#41; publicou recentemente os padr&#245;es de peso&#44; comprimento e circunfer&#234;ncia da cabe&#231;a dos rec&#233;m&#8208;nascidos&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">7</span></a> Trata&#8208;se de um estudo transversal multic&#234;ntrico sobre o tamanho dos beb&#234;s no nascimento por sexo e IG&#44; feito com a mesma abordagem prescritiva e modelo metodol&#243;gico usados no estabelecimento dos padr&#245;es da OMS&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">8</span></a> O IG&#8208;21 sugere que baixo peso em determinada IG pode resultar de <span class="elsevierStyleItalic">baixa estatura</span> &#40;pequeno para a idade&#44; refletindo a restri&#231;&#227;o de crescimento linear&#41;&#44; <span class="elsevierStyleItalic">emacia&#231;&#227;o</span> &#40;leve para a idade&#44; ou baixo &#237;ndice de massa corporal &#91;IMC&#93; para a idade&#44; normalmente refletindo perda de peso recente&#41; ou os dois fen&#243;tipos&#46; Esses s&#227;o dois fen&#243;tipos distintos&#44; com diferentes tempo e dura&#231;&#227;o dos acometimentos s&#250;bitos causais&#44; fatores de risco espec&#237;ficos e distribui&#231;&#245;es variadas em todas as popula&#231;&#245;es e diferentes progn&#243;sticos&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">9</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">V&#225;rios estudos antropom&#233;tricos com crian&#231;as e adolescentes de ecossistemas de altitude indicam que essa popula&#231;&#227;o&#44; em compara&#231;&#227;o com os que vivem perto do n&#237;vel do mar&#44; s&#227;o mais baixos e mais leves&#46;<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">10&#44;11</span></a> Principalmente&#44; nos rec&#233;m&#8208;nascidos de Jujuy&#44; o peso ao nascer&#44; bem como os indicadores de comprometimento grave do crescimento intrauterino&#44; que &#233; independentemente associado &#224; altitude geogr&#225;fica&#46;<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">2&#44;12&#8211;15</span></a> Contudo&#44; a maior parte dos estudos do efeito da altitude sobre o crescimento fetal &#233; limitada a rec&#233;m&#8208;nascidos a termo&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">O objetivo foi usar o padr&#227;o do IG&#8208;21 para avaliar a preval&#234;ncia e os fatores de risco comuns de abaixo do peso&#44; baixa estatura e emacia&#231;&#227;o por idade gestacional &#40;IG&#41; em rec&#233;m&#8208;nascidos de Jujuy com rela&#231;&#227;o aos n&#237;veis de alta altitude&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material e m&#233;todos</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Popula&#231;&#227;o estudada</span><p id="par0040" class="elsevierStylePara elsevierViewall">Este foi um estudo observacional&#44; anal&#237;tico e retrospectivo feito em nascimentos consecutivos registrados pelo Sistema de Inform&#225;tica Perinatal &#40;SIP&#44; Minist&#233;rio da Sa&#250;de da Prov&#237;ncia de Jujuy&#44; Argentina&#41; entre 2009 e 2014&#46; Os crit&#233;rios de exclus&#227;o foram &#40;1&#41; IG &#60; 24<span class="elsevierStyleSup">&#43;0</span> e &#62; 42<span class="elsevierStyleSup">&#43;6</span> semanas&#59; &#40;2&#41; falta de dados sobre peso&#44; estatura&#44; IG&#44; sexo e local de resid&#234;ncia da m&#227;e durante a gravidez&#59; &#40;3&#41; gravidez de g&#234;meos&#46; O crit&#233;rio de Alexander foi aplicado para corrigir as incompatibilidades entre o peso ao nascer e a idade gestacional&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">16</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Avalia&#231;&#227;o dos dados</span><p id="par0050" class="elsevierStylePara elsevierViewall">Os dados foram agrupados de acordo com a altitude geogr&#225;fica do local de resid&#234;ncia da m&#227;e em um grupo de baixa altitude &#40;BA&#41; &#40;&#60; 2&#46;000 m&#46;a&#46;s&#46;l&#46;&#41; e um grupo de alta altitude &#40;AA&#41; &#40;<span class="elsevierStyleUnderline">&#62;</span>2&#46;000 m&#46;a&#46;s&#46;l&#46;&#41;&#46; O estado nutricional dos rec&#233;m&#8208;nascidos foi determinado de acordo com o padr&#227;o IG&#8208;21&#44; com os seguintes fen&#243;tipos no nascimento&#58; &#40;a&#41; Baixa estatura &#40;percentil &#60; 3 para comprimento&#47;IG&#41;&#59; &#40;b&#41; Emacia&#231;&#227;o &#40;percentil &#60; 3 para IMC &#91;Kg&#47;m<span class="elsevierStyleSup">2</span>&#93;&#47;IG&#41;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">9</span></a> e &#40;c&#41; um terceiro fen&#243;tipo &#8211; n&#227;o inclu&#237;do no padr&#227;o IG&#8208;21&#44; <span class="elsevierStyleItalic">abaixo do peso</span> &#40;percentil PN &#60; 3 para idade e sexo&#41;&#44; indicando um acometimento s&#250;bito grave&#59; isso elimina a chance de inclus&#227;o err&#244;nea de um rec&#233;m&#8208;nascido normal na distribui&#231;&#227;o de menor PN&#46; Como o Projeto IG&#8208;21 n&#227;o fornece uma avalia&#231;&#227;o de IMC abaixo de 33<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleSup">0</span> A s de IG&#44; os dados do estudo atual inclu&#237;ram abaixo do peso e baixa estatura entre 24<span class="elsevierStyleSup">&#43;0</span> e 42<span class="elsevierStyleSup">&#43;6</span> semanas e emacia&#231;&#227;o entre 33<span class="elsevierStyleSup">&#43;0</span> e 42<span class="elsevierStyleSup">&#43;6</span> semanas&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Foram analisadas as seguintes caracter&#237;sticas&#58; &#40;1&#41; biol&#243;gicas e sociodemogr&#225;ficas da m&#227;e&#58; idade &#40;&#60; 20&#44; 20&#8208;24&#44; 25&#8208;29&#44; 30&#8208;35 e &#8805; 35 anos&#41;&#44; paridade &#40;0&#44; 1&#44; 2 e &#8805; 3&#41;&#44; IMC &#40;&#60; 18&#44;5 desnutri&#231;&#227;o&#44; 18&#44;5&#8208;24&#44;9 nutri&#231;&#227;o normal&#44; 25&#44;0&#8208;29&#44;9 sobrepeso&#59; 30&#8208;34&#44;9 obesidade tipo I e &#8805;35<span class="elsevierStyleHsp" style=""></span>kg&#47;m<span class="elsevierStyleSup">2</span> obesidade tipo II&#41; e escolaridade &#40;&#60; 8&#59; 8&#8208;11 e &#8805; 12 anos&#41;&#59; &#40;2&#41; diabetes&#44; hipertens&#227;o&#44; pr&#233;&#8208;ecl&#226;mpsia e tuberculose durante a gravidez&#59; e &#40;3&#41; sexo&#44; prematuridade &#40;&#60; 37<span class="elsevierStyleSup">&#43;0</span> semanas&#41; e malforma&#231;&#245;es cong&#234;nitas dos rec&#233;m&#8208;nascidos&#46; As vari&#225;veis biol&#243;gicas e sociodemogr&#225;ficas das m&#227;es foram categ&#243;ricas&#59; as restantes foram dicot&#244;micas&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">An&#225;lise estat&#237;stica</span><p id="par0065" class="elsevierStylePara elsevierViewall">A preval&#234;ncia dos diferentes fen&#243;tipos foi estimada pela propor&#231;&#227;o &#40;IC de 95&#37; &#91;intervalo de confian&#231;a&#93;&#41;&#44; ao passo que as diferen&#231;as populacionais foram analisadas com um teste qui&#8208;quadrado e risco univariado&#58; raz&#227;o de chance &#40;RC e IC de 95&#37;&#41;&#46; Foi feita uma an&#225;lise de regress&#227;o log&#237;stica multivariada para estimar o risco de abaixo do peso&#44; baixa estatura e emacia&#231;&#227;o com rela&#231;&#227;o ao n&#237;vel de altitude &#40;vari&#225;vel de exposi&#231;&#227;o&#41; e ela foi ajustada para idade&#44; n&#237;vel de escolaridade&#44; IMC&#44; paridade&#44; tuberculose&#44; diabetes&#44; hipertens&#227;o&#44; pr&#233;&#8208;ecl&#226;mpsia&#44; sexo&#44; prematuridade e malforma&#231;&#245;es cong&#234;nitas da m&#227;e&#46; A refer&#234;ncia foi baixa altitude&#46; A qualidade do ajuste foi testada com o teste de Hosmer&#8208;Lemeshow&#46; Foram usados os <span class="elsevierStyleItalic">softwares</span> estat&#237;sticos SPSS &#40;IBM SPSS Estat&#237;stica para Windows&#44; Vers&#227;o 22&#46;0&#46; NY&#44; EUA&#41; e Stata &#40;Stata Software de estat&#237;stica&#58; Vers&#227;o 11&#46; College Station&#44; TX&#44; EUA&#41;&#46; O n&#237;vel estat&#237;stico foi estabelecido em p &#60; 0&#44;05&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Quest&#245;es &#233;ticas</span><p id="par0075" class="elsevierStylePara elsevierViewall">O Comit&#234; de &#201;tica de Pesquisa em Sa&#250;de da Prov&#237;ncia de Jujuy&#44; Argentina&#44; aprovou este estudo&#46;</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Resultados</span><p id="par0085" class="elsevierStylePara elsevierViewall">Entre 2009 e 2014&#44; nasceram 79&#46;504 neonatos vivos na Prov&#237;ncia de Jujuy&#59; 57&#46;471 foram registrados pelo SIP&#46; Ap&#243;s aplicar os crit&#233;rios de sele&#231;&#227;o&#44; 48&#46;656 &#40;84&#44;6&#37;&#44; IC de 95&#37;&#58; 84&#44;3&#8208;84&#44;9&#41; rec&#233;m&#8208;nascidos foram inclu&#237;dos no estudo&#59; desses 16&#44;8&#37; &#40;16&#44;5&#8208;17&#44;2&#41; moravam em AA &#40;<a class="elsevierStyleCrossRef" href="#sec0065">material adicional S1&#44; fig&#46; 1</a>&#41;&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">A preval&#234;ncia de abaixo do peso&#44; baixa estatura e emacia&#231;&#227;o foi 1&#44;27&#37; &#40;1&#44;18&#8208;1&#44;38&#41;&#44; 3&#44;39&#37; &#40;3&#44;24&#8208;3&#44;36&#41; e 4&#44;68&#37; &#40;4&#44;49&#8208;4&#44;87&#41;&#44; respectivamente&#46; A taxa de baixa estatura mais emacia&#231;&#227;o foi de 0&#44;16&#37; &#40;0&#44;12&#8208;0&#44;20&#41;&#46; A taxa de neonatos abaixo do peso em AA foi 1&#44;13 vez maior &#40;0&#44;80&#8208;1&#44;49&#41; do que a taxa de AA equivalente&#44; ao passo que as taxas de baixa estatura e emacia&#231;&#227;o foram 2&#44;68 &#40;2&#44;10&#8208;3&#44;29&#41; e 5&#44;26 &#40;4&#44;61&#8208;5&#44;95&#41; vezes maiores&#44; respectivamente&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Em geral&#44; as m&#227;es de rec&#233;m&#8208;nascidos abaixo do peso em AA mostraram idade significativamente mais avan&#231;ada&#44; maior desnutri&#231;&#227;o&#44; hipertens&#227;o&#44; prematuridade e malforma&#231;&#245;es cong&#234;nitas&#44; por&#233;m menor sobrepeso e obesidade tipo I do que as m&#227;es em BA&#46; As gr&#225;vidas no grupo de AA com rec&#233;m&#8208;nascidos com baixa estatura foram independentemente associadas a maior desnutri&#231;&#227;o e menos obesidade tipo I&#44; ao passo que os rec&#233;m&#8208;nascidos com emacia&#231;&#227;o no grupo de AA mostraram nutri&#231;&#227;o durante a gravidez menos normal&#44; obesidade tipo I e prematuridade&#44; por&#233;m maior nuliparidade e malforma&#231;&#245;es cong&#234;nitas que as m&#227;es em BA &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">tabela 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0100" class="elsevierStylePara elsevierViewall">O PN e o desvio&#8208;padr&#227;o &#40;DP&#41; m&#233;dios dos tr&#234;s fen&#243;tipos foi 2&#46;012<span class="elsevierStyleHsp" style=""></span>g &#40;567&#41; para abaixo do peso&#44; 2&#46;933<span class="elsevierStyleHsp" style=""></span>g &#40;635&#41; para baixa estatura e 2&#46;767<span class="elsevierStyleHsp" style=""></span>g &#40;427&#41; para emacia&#231;&#227;o&#44; ao passo que foi de 3&#46;321<span class="elsevierStyleHsp" style=""></span>g &#40;531&#41; em crian&#231;as sem d&#233;ficit nutricional&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">A IG m&#233;dia &#40;DP&#41; foi de 37&#44;5 &#40;3&#44;9&#41; semanas para abaixo do peso&#44; 38&#44;6 &#40;2&#44;1&#41; semanas para baixa estatura e 39&#44;0 &#40;1&#44;3&#41; semanas para emacia&#231;&#227;o&#46; A taxa geral de prematuridade foi de 9&#44;0&#37; &#40;8&#44;79&#8208;9&#44;30&#41;&#58; 8&#44;01&#37; em AA e 9&#44;25&#37; em BA &#40;p &#60; 0&#44;001&#41;&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Na Prov&#237;ncia de Jujuy em AA&#44; os riscos de abaixo do peso&#44; baixa estatura e emacia&#231;&#227;o come&#231;am a aparecer da 29&#170;&#44; 26&#170; e 33&#170; semanas de gesta&#231;&#227;o&#44; respectivamente&#46; A preval&#234;ncia de abaixo do peso e baixa estatura entre as 24<span class="elsevierStyleSup">&#43;0</span> e 36<span class="elsevierStyleSup">&#43;</span><a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">6</span></a> semanas foi maior do que entre as 37<span class="elsevierStyleSup">&#43;0</span> e 42<span class="elsevierStyleSup">&#43;6</span> semanas &#40;p &#60; 0&#44;001&#41; para AA&#44; em compara&#231;&#227;o com a BA&#46; Por outro lado&#44; a preval&#234;ncia de emacia&#231;&#227;o entre as 37<span class="elsevierStyleSup">&#43;0</span> e 42<span class="elsevierStyleSup">&#43;6</span> semanas foi maior do que entre as 24<span class="elsevierStyleSup">&#43;0</span> e 36<span class="elsevierStyleSup">&#43;</span><a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">6</span></a> semanas na AA&#44; em compara&#231;&#227;o com a BA &#40;p &#60; 0&#44;001&#44; dados n&#227;o mostrados&#41; &#40;<a class="elsevierStyleCrossRef" href="#sec0065">material adicional S2&#44; S3 e S4&#44; figs&#46; 2&#8208;4</a>&#41;&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">A RC bruta &#40;IC de 95&#37;&#41; para abaixo do peso&#44; baixa estatura e emacia&#231;&#227;o associadas a AA foi de 1&#44;92 &#40;1&#44;63&#8208;2&#44;27&#41;&#44; 2&#44;21 &#40;1&#44;99&#8208;2&#44;45&#41; e 2&#44;39 &#40;2&#44;18&#8208;2&#44;62&#41;&#44; respectivamente &#40;p &#60; 0&#44;001&#41;&#46; Ap&#243;s o ajuste&#44; foram encontrados uma leve redu&#231;&#227;o do risco de baixa estatura e um aumento do risco para os outros fen&#243;tipos&#44; todos estatisticamente significativos &#40;<a class="elsevierStyleCrossRef" href="#sec0065">material adicional S5&#44; tabela 1</a>&#41;&#46; A qualidade do ajuste do modelo foi adequada&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">As tabelas 1 a 3 mostram as caracter&#237;sticas maternas e dos rec&#233;m&#8208;nascidos de acordo com a altitude e sua associa&#231;&#227;o &#40;RC ajustada&#44; RCA&#41; aos tr&#234;s fen&#243;tipos&#46; Para abaixo do peso&#44; idade materna superior ou igual a 35 anos&#44; IMC abaixo de 18&#44;5<span class="elsevierStyleHsp" style=""></span>kg&#47;m<span class="elsevierStyleSup">2</span>&#44; nuliparidade&#44; hipertens&#227;o gestacional&#44; prematuridade e malforma&#231;&#245;es cong&#234;nitas foram independentemente associados a risco elevado em AA&#46; Sobrepeso e obesidade tipo I foram associados a menor risco em AA &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">tabela 1</a>&#41;&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Para baixa estatura&#44; IMC materno abaixo de 18&#44;5<span class="elsevierStyleHsp" style=""></span>kg&#47;m<span class="elsevierStyleSup">2</span> e malforma&#231;&#245;es cong&#234;nitas foram independentemente associados a risco mais elevado&#44; ao passo que o IMC de obesidade tipo I mostrou menor risco &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">tabela 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0130" class="elsevierStylePara elsevierViewall">Por fim&#44; para emacia&#231;&#227;o&#44; nuliparidade e malforma&#231;&#245;es cong&#234;nitas foram independentemente associadas a risco mais elevado&#44; ao passo que sobrepeso e obesidade classe I e prematuridade foram associados a menor risco &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">tabela 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Discuss&#227;o</span><p id="par0140" class="elsevierStylePara elsevierViewall">No presente estudo&#44; os rec&#233;m&#8208;nascidos em AA na Prov&#237;ncia de Jujuy mostraram um risco significativamente maior de abaixo do peso&#44; baixa estatura e emacia&#231;&#227;o e este estudo apresenta uma comprova&#231;&#227;o cl&#237;nica e epidemiol&#243;gica para corroborar o conceito de que se trata de fen&#243;tipos antropom&#233;tricos separados de origem intrauterina&#46; Os fen&#243;tipos diferiram em termos de fatores de risco&#46; Como esperado&#44; poucas doen&#231;as foram associadas com for&#231;a semelhante aos fen&#243;tipos abaixo do peso&#44; baixa estatura e emacia&#231;&#227;o&#59; essas doen&#231;as s&#227;o&#44; em grande parte&#44; reconhecidas como fatores de risco universais&#44; ou seja&#44; IG&#44; desnutri&#231;&#227;o materna&#44; hist&#243;rico obst&#233;trico&#44; malforma&#231;&#245;es cong&#234;nitas&#46; Outros fatores&#44; em especial tuberculose&#44; t&#234;m uma ampla gama de gravidade&#44; apresenta&#231;&#245;es e tempo durante a gravidez n&#227;o espec&#237;fica aos fen&#243;tipos&#46; Por outro lado&#44; sobrepeso e obesidade tipo I mostraram redu&#231;&#227;o do risco entre 30&#37; e 50&#37; para os tr&#234;s fen&#243;tipos &#40;um efeito bem descrito que se deve ao aumento do peso ao nascer e deposi&#231;&#227;o de gordura&#41;&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">N&#227;o h&#225; registros locais compar&#225;veis sobre a preval&#234;ncia dos fen&#243;tipos nutricionais em rec&#233;m&#8208;nascidos avaliados para IG com o padr&#227;o IG&#8208;21&#44; exceto o fen&#243;tipo abaixo do peso&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">17</span></a> Digna de nota&#44; neste estudo&#44;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">17</span></a> a preval&#234;ncia de abaixo do peso calculada a partir das certid&#245;es de nascimento em 2013 no nordeste da Argentina&#44; onde a Prov&#237;ncia de Jujuy est&#225; localizada&#44; foi semelhante &#224; verificada neste estudo em rec&#233;m&#8208;nascidos a termo&#46; Os registros argentinos sobre a preval&#234;ncia desses fen&#243;tipos referem&#8208;se &#224;s popula&#231;&#245;es de crian&#231;as com mais de seis meses de idade&#44; calculada com base no padr&#227;o da OMS&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">18</span></a> O Inqu&#233;rito Nacional de Nutri&#231;&#227;o e Sa&#250;de &#91;<span class="elsevierStyleItalic">Encuesta Nacional de Nutrici&#243;n y Salud</span>&#93; feito na Argentina em 2004&#8208;2005 estabelece para a popula&#231;&#227;o de Jujuy&#44; independentemente da altitude geogr&#225;fica&#44; uma preval&#234;ncia de 1&#44;8&#37; &#40;IC de 95&#37; 0&#44;8&#8208;4&#44;1&#41;&#44; 9&#44;5&#37; &#40;IC de 95&#37; 5&#44;3&#8208;16&#44;6&#41; e 0&#44;6&#37; &#40;IC de 95&#37; 0&#44;3&#8208;1&#44;4&#41; de abaixo do peso&#44; baixa estatura e emacia&#231;&#227;o&#44; respectivamente&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">18</span></a> Um estudo latino&#8208;americano<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">19</span></a> comparou os percentis do IG&#8208;21 com os rec&#233;m&#8208;nascidos peruanos nascidos com &#62; 3&#46;400 m&#46;a&#46;s&#46;l&#46; e n&#227;o encontrou diferen&#231;as significativas com rela&#231;&#227;o ao padr&#227;o IG&#8208;21&#44; por&#233;m a preval&#234;ncia de abaixo do peso&#44; baixa estatura e emacia&#231;&#227;o n&#227;o foi estimada&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">As preval&#234;ncias observadas dos fen&#243;tipos dos rec&#233;m&#8208;nascidos foram relativamente baixas&#44; principalmente para abaixo do peso e baixa estatura&#44; pois elas tamb&#233;m s&#227;o menores do que os pontos de corte para relev&#226;ncia cl&#237;nica &#60; 10&#37; e &#60; 20&#37;&#44; respectivamente&#44; sugeridos pela OMS&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">20</span></a> A baixa estatura ao nascer parece ter uma preval&#234;ncia relativamente baixa mesmo em configura&#231;&#245;es de baixa renda&#44; por&#233;m aumenta de forma acentuada com a idade gestacional&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">21</span></a> Esses resultados s&#227;o de certa forma semelhantes a um estudo anterior<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">9</span></a> de comprometimento do crescimento fetal&#44; que atende aos crit&#233;rios de elegibilidade individuais&#44; ao passo que a baixa estatura afetou 3&#44;8&#37; e emacia&#231;&#227;o 3&#44;4&#37; de uma popula&#231;&#227;o de rec&#233;m&#8208;nascidos de baixo risco&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">Em uma an&#225;lise recente dos fatores de riscos de baixa estatura na inf&#226;ncia em pa&#237;ses em desenvolvimento&#44; o principal fator de risco em todo o mundo foi restri&#231;&#227;o do crescimento fetal &#40;RCF&#41;&#44; definido como nascimento a termo e pequeno para a idade gestacional&#44; que enfatiza a necessidade de indicadores confi&#225;veis do crescimento fetal&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">22</span></a> Das 12 doen&#231;as estudadas&#44; idade materna avan&#231;ada&#44; IMC abaixo de 18&#44;5<span class="elsevierStyleHsp" style=""></span>kg&#47;m<span class="elsevierStyleSup">2</span>&#44; hipertens&#227;o&#44; malforma&#231;&#245;es cong&#234;nitas e prematuridade foram mais fortemente associados ao risco mais elevado ajustado de abaixo do peso do que baixa estatura e emacia&#231;&#227;o em AA&#46; A preval&#234;ncia de tuberculose &#233; tr&#234;s vezes maior em altitude &#40;53 x 10&#46;000 rec&#233;m&#8208;nascidos&#41; e ela foi associada somente a emacia&#231;&#227;o&#44; ao passo que a nuliparidade mostrou risco semelhante de abaixo do peso e emacia&#231;&#227;o&#46; N&#227;o foi encontrada comprova&#231;&#227;o estatisticamente significativa de associa&#231;&#227;o independente com quaisquer dos fen&#243;tipos estudados para as outras doen&#231;as&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Em AA&#44; as malforma&#231;&#245;es cong&#234;nitas foram associadas &#224; duplica&#231;&#227;o do risco de baixa estatura &#40;RCA&#58; 2&#44;62&#41; e emacia&#231;&#227;o &#40;RCA&#58; 2&#44;52&#41;&#44; por&#233;m o risco foi sete vezes maior para abaixo do peso &#40;RCA&#58; 7&#44;66&#41;&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">Na Prov&#237;ncia de Jujuy&#44; e com o uso da mesma fonte&#44; Grandi et al&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">23</span></a> demonstraram que a preval&#234;ncia de prematuridade&#44; PIG e restri&#231;&#227;o do crescimento fetal mostram um aumento da rela&#231;&#227;o com a altitude geogr&#225;fica&#44; na qual os dois &#250;ltimos indicadores &#8211; acima de 3&#46;500 m&#46;a&#46;s&#46;l&#46; &#8211; podem significativamente duplicar os valores encontrados no n&#237;vel do mar&#46; No noroeste da Argentina&#44; outros estudos chegaram &#224; mesma conclus&#227;o&#44;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">24</span></a> na qual um aumento na prematuridade devido a um aumento na altitude pode at&#233; mesmo representar uma vantagem adaptativa para os nascimentos prematuros nessas condi&#231;&#245;es&#44; conforme encontrado neste estudo para emacia&#231;&#227;o&#44; com redu&#231;&#227;o do risco ajustado de quase 40&#37;&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">Outra explica&#231;&#227;o &#233; que h&#225; tr&#234;s poss&#237;veis op&#231;&#245;es para a presen&#231;a de um acometimento s&#250;bito que comprometa o crescimento fetal nessas condi&#231;&#245;es&#58; continuidade da gesta&#231;&#227;o resultando em um rec&#233;m&#8208;nascido com restri&#231;&#227;o do crescimento fetal&#44; interrup&#231;&#227;o espont&#226;nea da gravidez ou indicada pelo m&#233;dico com nascimento prematuro consequente ou morte fetal&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">Esse hist&#243;rico justificaria a hip&#243;tese de que&#44; em regi&#245;es de altitude e por meio de um mecanismo evolucion&#225;rio&#44; podem ocorrer prematuridade e morte fetal devido &#224;s redu&#231;&#245;es evidentes da tens&#227;o de O<span class="elsevierStyleInf">2</span> acima de 2&#46;000 m&#46;a&#46;s&#46;l&#46;&#44; sugere um efeito limite al&#233;m do qual as pequenas redu&#231;&#245;es no fornecimento de O<span class="elsevierStyleInf">2</span> podem reduzir substancialmente a oxigena&#231;&#227;o fetal&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">25</span></a> Isso &#233; reafirmado por um relat&#243;rio do Departamento de Estat&#237;sticas e Informa&#231;&#245;es de Sa&#250;de do Minist&#233;rio da Sa&#250;de da Argentina &#40;DEIS&#41;&#44; informa que a contribui&#231;&#227;o dos fetos prematuros &#40;&#60; 37<span class="elsevierStyleSup">&#43;0</span> semanas&#41; para a mortalidade fetal em Jujuy foi de 72&#37; em 2013&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">A altitude geogr&#225;fica e as complica&#231;&#245;es de hipertens&#227;o na gravidez podem reduzir de maneira independente o peso ao nascer&#44;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">26</span></a> um fen&#244;meno encontrado em rec&#233;m&#8208;nascidos na Prov&#237;ncia de Jujuy acima de 2&#46;000 m&#46;a&#46;s&#46;l&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">12&#44;15</span></a> e no estudo atual &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">tabela 1</a>&#41;&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">A baixa estatura constitui um indicador global de bem&#8208;estar infantil&#44; reflete as desigualdades sociais e descreve os resultados espec&#237;ficos frequentes do per&#237;odo neonatal &#40;baixo peso ao nascer&#44; pequeno para a idade gestacional&#44; prematuridade&#44; baixo para a idade gestacional e per&#237;metro cef&#225;lico pequeno&#41;&#46; Por esse motivo&#44; a import&#226;ncia da avalia&#231;&#227;o desse indicador em rec&#233;m&#8208;nascidos foi recentemente enfatizada do ponto de vista dos primeiros 1&#46;000 dias de vida&#46; A baixa estatura fetal pode estar relacionada a condi&#231;&#245;es org&#226;nicas &#40;por exemplo&#44; malforma&#231;&#245;es&#41; e &#233; amplamente considerada um processo cumulativo de longo prazo an&#225;logo &#224; desnutri&#231;&#227;o cr&#244;nica em crian&#231;as&#44;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">27</span></a> que precisa de exposi&#231;&#227;o a um ou mais fatores de risco por v&#225;rios meses ou durante toda a gravidez&#46; Por outro lado&#44; a emacia&#231;&#227;o neonatal provavelmente reflete as exposi&#231;&#245;es agudas nas semanas anteriores ao parto&#44; com deposi&#231;&#227;o de gordura mais r&#225;pida&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">28</span></a> Outro&#44; contudo&#44; sugere que as diferen&#231;as na gravidade&#44; em vez do tempo e da dura&#231;&#227;o dos acometimentos s&#250;bitos&#44; resultam em fen&#243;tipos distintos de comprometimento do crescimento fetal e a emacia&#231;&#227;o representa os casos mais graves&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">29</span></a> O fato de que a preval&#234;ncia dos fen&#243;tipos difere em termos da apresenta&#231;&#227;o e da preval&#234;ncia da IG entre as gravidezes prematuras e a termo sugere diferentes fatores de risco &#40;como diabetes&#44; hipertens&#227;o ou pr&#233;&#8208;ecl&#226;mpsia em AA&#41; e&#44; consequentemente&#44; aumento da interrup&#231;&#227;o das gravidezes por indica&#231;&#227;o m&#233;dica para proteger o bem&#8208;estar materno e fetal&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">A maior parte dos fatores maternos considerados neste estudo foi fracamente associada ou constitui um fator de prote&#231;&#227;o com diferen&#231;as de fen&#243;tipo devido &#224; altitude&#44; principalmente baixa estatura&#46; Portanto&#44; essas diferen&#231;as provavelmente podem ser atribu&#237;das ao efeito enfatizado da hip&#243;xia de altitude que interage com outras caracter&#237;sticas desses ecossistemas n&#227;o considerados nesta an&#225;lise &#40;nutricionais&#44; socioecon&#244;micas&#44; gen&#233;ticas&#44; &#233;tnicas&#44; sociodemogr&#225;ficas e geogr&#225;ficas&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">10&#44;11&#44;30</span></a> O padr&#227;o de crescimento pr&#233;&#8208;natal dos rec&#233;m&#8208;nascidos na Prov&#237;ncia de Jujuy lembra o padr&#227;o encontrado nos ecossistemas de altitude em outros est&#225;gios ontogen&#233;ticos&#46; De fato&#44; v&#225;rios estudos com crian&#231;as&#44; adolescentes e adultos da Prov&#237;ncia de Jujuy sobre seu crescimento indicam que as crian&#231;as s&#227;o mais baixas e mais leves do que as que moram pr&#243;ximo ao n&#237;vel do mar&#46;<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">10&#44;13</span></a> Contudo&#44; como o comprometimento do crescimento fetal encontrado na popula&#231;&#227;o em AA &#233; uma s&#237;ndrome complexa&#44; s&#227;o necess&#225;rias caracteriza&#231;&#227;o e valida&#231;&#227;o adicionais dos fen&#243;tipos em diferentes popula&#231;&#245;es&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">Os principais pontos fortes do estudo s&#227;o a grande amostra representativa de altitude geogr&#225;fica&#44; a identifica&#231;&#227;o dos fatores de risco de tr&#234;s fen&#243;tipos associados &#224; restri&#231;&#227;o do crescimento fetal&#44; sabidamente associados a baixo peso ao nascer&#44; e a introdu&#231;&#227;o do IG&#8208;21 como uma boa ferramenta epidemiol&#243;gica a ser usada em estudos futuros&#46;</p><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Limita&#231;&#245;es</span><p id="par0205" class="elsevierStylePara elsevierViewall">A principal limita&#231;&#227;o &#233; a amostra final&#44; 61&#44;2&#37; dos rec&#233;m&#8208;nascidos vivos&#44; provavelmente porque foram inclu&#237;dos somente nascimentos registrados em instala&#231;&#245;es p&#250;blicas&#46; As outras limita&#231;&#245;es foram informa&#231;&#245;es incompletas e a IG estimada pela data da &#250;ltima menstrua&#231;&#227;o&#44; conforme recomendado pelo DEIS&#46; Por outro lado&#44; os modelos explicaram riscos de baixa altitude de acordo com os diferentes fen&#243;tipos&#44; pois os fatores sabidamente associados ao crescimento fetal &#40;tabagismo materno&#44; uso de drogas il&#237;citas&#44; hist&#243;rico de baixo peso ao nascer e prematuridade&#44; condi&#231;&#227;o etc&#46;&#41; n&#227;o foram registrados&#46;</p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Conclus&#227;o</span><p id="par0215" class="elsevierStylePara elsevierViewall">Os riscos de abaixo do peso&#44; baixa estatura e emacia&#231;&#227;o foram maiores em altitude mais elevada e foram associados a doen&#231;as maternas e fetais reconhecidas&#46; O uso desses tr&#234;s fen&#243;tipos ajudar&#225; a priorizar as interven&#231;&#245;es preventivas e focar no manejo da desnutri&#231;&#227;o fetal&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Conflitos de interesse</span><p id="par0220" class="elsevierStylePara elsevierViewall">Os autores declaram n&#227;o haver conflitos de interesse&#46;</p></span></span>"
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            0 => "Fetal growth retardation"
            1 => "Newborn"
            2 => "Birth weight"
            3 => "Prematurity"
            4 => "Malformations"
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          "palabras" => array:5 [
            0 => "Retardo do crescimento fetal"
            1 => "Rec&#233;m&#8208;nascido"
            2 => "Peso ao nascer"
            3 => "Prematuridade"
            4 => "Malforma&#231;&#245;es"
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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 assess the prevalence and risks of underweight&#44; stunting and wasting by gestational age in newborns of the Jujuy Province&#44; Argentina at different altitude levels&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Live newborns &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>48&#44;656&#41; born from 2009&#8211;2014 in public facilities with a gestational age between 24<span class="elsevierStyleSup">&#43;0</span> to 42<span class="elsevierStyleSup">&#43;6</span> weeks&#46; Phenotypes of underweight &#40;<span class="elsevierStyleHsp" style=""></span>weight&#47;age&#41;&#44; stunting &#40;<span class="elsevierStyleHsp" style=""></span>length&#47;age&#41; and wasting &#40;<span class="elsevierStyleHsp" style=""></span>body mass index&#47;age&#41; were calculated using Intergrowth&#8208;21st standards&#46; Risk factors were maternal age&#44; education&#44; body mass index&#44; parity&#44; diabetes&#44; hypertension&#44; preeclampsia&#44; tuberculosis&#44; prematurity&#44; and congenital malformations&#46; Data were grouped by the geographic altitude&#58; &#8805;2&#46;000 or &#60;2&#46;000<span class="elsevierStyleHsp" style=""></span>m&#46;a&#46;s&#46;l&#46; Chi&#8208;squared test and a multivariate logistic regression analysis were performed to estimate the risk of the phenotypes associated with an altitudinal level &#8805;2&#46;000<span class="elsevierStyleHsp" style=""></span>m&#46;a&#46;s&#46;l&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The prevalence of underweight&#44; stunting and wasting were 1&#46;27&#37;&#44; 3&#46;39&#37; and 4&#46;68&#37;&#44; respectively&#44; and significantly higher at &#62;2&#46;000<span class="elsevierStyleHsp" style=""></span>m&#46;a&#46;s&#46;l&#46; Maternal age&#44; body mass index &#62;35<span class="elsevierStyleHsp" style=""></span>kg&#47;m<span class="elsevierStyleSup">2</span>&#44; hypertension&#44; congenital malformations&#44; and prematurity were more strongly associated with underweight rather than stunting or wasting at &#8805;2&#46;000<span class="elsevierStyleHsp" style=""></span>m&#46;a&#46;s&#46;l&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Underweight&#44; stunting&#44; and wasting risks were higher at a higher altitude&#44; and were associated with recognized maternal and fetal conditions&#46; The use of those three phenotypes will help prioritize preventive interventions and focus the management of fetal undernutrition&#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">Avaliar a preval&#234;ncia e os riscos de rec&#233;m&#8208;nascidos abaixo do peso&#44; baixa estatura e emacia&#231;&#227;o por idade gestacional da Prov&#237;ncia de Jujuy&#44; Argentina&#44; em diferentes n&#237;veis de altitude&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Rec&#233;m&#8208;nascidos vivos &#40;n &#61; 48&#46;656&#41; nascidos entre 2009 e 2014 em instala&#231;&#245;es p&#250;blicas entre 24<span class="elsevierStyleSup">&#43;0</span>&#8208;42<span class="elsevierStyleSup">&#43;6</span> semanas de idade gestacional&#46; Os fen&#243;tipos de abaixo do peso &#40;&#60; P3 peso&#47;idade&#41;&#44; baixa estatura &#40;&#60; P3 comprimento&#47;idade&#41; e emacia&#231;&#227;o &#40;&#60; P3 &#237;ndice de massa corporal&#47;idade&#41; foram calculados com os padr&#245;es do INTERGROWTH-21st&#46; Os fatores de risco foram idade materna&#44; escolaridade&#44; &#237;ndice de massa corporal&#44; paridade&#44; diabetes&#44; hipertens&#227;o&#44; pr&#233;&#8208;ecl&#226;mpsia&#44; tuberculose&#44; prematuridade e malforma&#231;&#245;es cong&#234;nitas&#46; Os dados foram agrupados pela altitude geogr&#225;fica&#58; &#8805; 2&#46;000 ou &#60; 2&#46;000 m&#46;a&#46;s&#46;l&#46; O teste qui&#8208;quadrado e a an&#225;lise de regress&#227;o log&#237;stica multivariada foram feitos para estimar o risco dos fen&#243;tipos associados ao n&#237;vel de altitude &#8805; 2&#46;000 m&#46;a&#46;s&#46;l&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">A preval&#234;ncia de abaixo do peso&#44; baixa estatura e emacia&#231;&#227;o foi de 1&#44;27&#37;&#44; 3&#44;39&#37; e 4&#44;68&#37;&#44; respectivamente&#44; significativamente maiores em &#62; 2&#46;000 m&#46;a&#46;s&#46;l&#46; A idade materna&#44; &#237;ndice de massa corporal &#62; 35<span class="elsevierStyleHsp" style=""></span>kg&#47;m<span class="elsevierStyleSup">2</span>&#44; hipertens&#227;o&#44; malforma&#231;&#245;es cong&#234;nitas e prematuridade foram mais fortemente associados a abaixo do peso e n&#227;o a baixa estatura ou emacia&#231;&#227;o em &#8805; 2&#46;000 m&#46;a&#46;s&#46;l&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclus&#245;es</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Os riscos de abaixo do peso&#44; baixa estatura e emacia&#231;&#227;o foram maiores em altitude mais elevada e foram associados a condi&#231;&#245;es maternas e fetais reconhecidas&#46; O uso desses tr&#234;s fen&#243;tipos ajudar&#225; a priorizar as interven&#231;&#245;es preventivas e focar no manejo da desnutri&#231;&#227;o fetal&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0050">Como citar este artigo&#58; Mart&#237;nez JI&#44; Rom&#225;n EM&#44; Alfaro EL&#44; Grandi C&#44; Dipierri JE&#46; Geographic altitude and prevalence of underweight&#44; stunting and wasting in newborns with the INTERGROWTH-21st standard&#46; J Pediatr &#40;Rio J&#41;&#46; 2019&#59;95&#58;366&#8211;73&#46;</p>"
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            "etiqueta" => "Appendix B"
            "titulo" => "Material suplementar"
            "identificador" => "sec0065"
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          "leyenda" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Qui&#8208;quadrado de Hosmer&#8208;Lemeshow &#61; 4&#44; p &#61; 0&#44;979&#46;</p><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">AA&#44; n&#237;vel de alta altitude&#59; BA&#44; n&#237;vel de baixa altitude&#46;</p>"
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                  \t\t\t\t">1 &#40;Refer&#234;ncia&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t" scope="col">Vari&#225;vel&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col">RCA &#40;IC de 95&#37;&#41;<a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Total<a class="elsevierStyleCrossRef" href="#tblfn0025"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&#44;23 &#40;0&#44;97 &#8211; 1&#44;58&#41;&nbsp;\t\t\t\t\t\t\n
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          "pt" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Preval&#234;ncia das caracter&#237;sticas maternas e dos rec&#233;m&#8208;nascidos e risco ajustado de baixa estatura de acordo com a altitude geogr&#225;fica &#40;Jujuy&#44; Argentina&#44; 2009&#8208;2014&#41;</p>"
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          "leyenda" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Qui&#8208;quadrado de Hosmer&#8208;Lemeshow &#61; 1&#44;92&#44; p &#61; 0&#44;983&#46;</p><p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">AA&#44; n&#237;vel de alta altitude&#59; BA&#44; n&#237;vel de baixa altitude&#46;</p>"
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t" scope="col">Vari&#225;vel&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Total<a class="elsevierStyleCrossRef" href="#tblfn0040"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">n&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Total<a class="elsevierStyleCrossRef" href="#tblfn0040"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">n&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">N&#237;vel de escolaridade maternal &#40;anos&#41;</td><td class="td" title="\n
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