prevention of chronic noncommunicable diseases

Prevention of Chronic Noncommunicable Diseases: Pediatrician’s Role

Attilio BonerUniversity ofVerona, Italy

[email protected]

Introduction

If we were becoming grandma/pa

If we were politicians

But we are pediatricians

We also have a canary

Some simple things we can do

Conclusions

Health Consequences of Environmental Exposures:Causal Thinking in Global Environmental Epidemiology

Sly PD, Ann Glob Health. 2016;82(1):3-9.

In the last decades early childhood deaths have declined, but in contrast, years lived with disability (YLD) have increased.

Globally, YLD attributable to communicable, maternal, neonatal, and nutritional diseases have decreased by 19.5% between 1990 and 2010, whereas those attributable to chronic disease have increased:

cardiovascular diseases by 17.7%; chronic respiratory disease by 8.5%; neurological conditions by 12.2%; diabetes by 30.0%; mental and behavioral disorders by 5.0%.



In the last decades early childhood deaths have declined, but in contrast, years lived with disability (YLD) have increased.

Globally, YLD attributable to communicable, maternal, neonatal, and nutritional diseases have decreased by 19.5% between 1990 and 2010, whereas those attributable to chronic disease have increased:

cardiovascular diseases by 17.7%; chronic respiratory disease by 8.5%; neurological conditions by 12.2%; diabetes by 30.0%; mental and behavioral disorders by 5.0%.

Risk factors: some are “life-style” but many have an

“environmental” link.



An expert panel convened by the World Health Organization

estimated that 24% of the global disease burden and 23% of all deaths could be attributed to environmental exposures, based on data collected in the late 1990s and early 2000s.

Among children 0-14 years of age, WHO

estimates that the proportion of deathsattributable to the environment could be

as high as 36%.

Pruss-Ustun A, Corvalan C. Preventing disease through healthy environments.Towards an estimate of the environmental burden of disease. Geneva: World Health Organization; 2006.


Air pollution ?

Infant mortality, childhood nutrition, and ischaemic heart disease in England and Wales.

Barker DJ, Lancet 1986;1:1077–81.

•Barker and colleagues, in a series of papers argued that a fetus faced with undernutrition slows its growth rate to reduce its nutritional requirements, but this period of undernutrition might also lead to reduced function in key organs, altered metabolic and endocrine feedback loops, and an increased vulnerability to adverse environmentalstressors.

•CVD, •stroke, •metabolic syndrome•osteoporosis.

•Ongoing epidemiological work continued to show an association

between low birth weight and a higher risk, in later life, of

About 10%-12% of births occur before 37 completed weeksof postmenstrual age.More than 95% of these “preterm infants” survive to adulthood in most industrialized nations.

Survival may come at the expense of future adverse health and social riskscharacterized by failure to achieve optimal development or morerapid rates of decline in cardiovascular, pulmonary, and renal function or “accelerated aging.”

Long-Term Healthcare Outcomes of Preterm Birth: An Executive Summary of a Conference Sponsored by

the National Institutes of HealthRaju T. J Pediatr 2017;181:309-318

Individuals born preterm are at an increased risk for: • type 2 diabetes, • cardiovascular and cerebrovascular diseases, • hypertension, • chronic kidney disease, • asthma and pulmonary function abnormalities, • neurocognitive and psychosocial disorders • poorer social adaptation.

Even a modest increase (eg, 10%-20%) in risk for these chronic conditions can translate into a substantial population burden.

Long-Term Healthcare Outcomes of Preterm Birth: An Executive Summary of a Conference Sponsored by

the National Institutes of HealthRaju T. J Pediatr 2017;181:309-318

Outcomes of infants born near termGill JV, Arch Dis Child 2017;102:194–198

Adult health outcomes

The risk of disability in adulthood (age 18–36 years) was increased by 26% for ET births compared with that in FT controls (n=431 656) adjusted RR 1.26

Females born LPT (34-36 weeks) are at increased of gestational diabetes and preeclampsiaif they become pregnant.


[email protected]

Introduction


If were were politicians

But you are pediatricians



Conclusions


Smoking during pregnancy: increased risk on the Child for:

Spontaneous Preterm Birth and Small for Gestational Age infants.McCowan LM, BMJ 2009;338:b1081.

Wheeze/Asthma/COPD. Hollams EM, AJRCCM 2014;189:401

Child overweight. Oken E, Int J Obes (Lond) 2008;32(2):201–210.

Umbilical arteries endothelial dysfunction and early atherogenesis. Messner B, Arterioscler Thromb Vasc Biol. 2014; 34:509-15

Reduced femur length. Prabhu Thorax 2010;65:235–240

Increased Infant Irritability. Stroud LR, Pediatrics 2009;123:e842–e848.

Impaired Reading Performance Cho K, J Ped 2013;162:713

ADHD. Braun JM, Environ Health Perspect 2006;114:1904–1909.

Reduced neurodevelopment. Herrmann M, Curr Opin Pediatr 2008;20:184–190

Reduced Frontal lobe and Cerebellum volumes.Ekblad J Pediatr 2010;156:185

Criminal, antisocial behavior, anger temperament in adult offspring Paradis AD, Epidemiol Community Health 2011;65:1145-50 Paradis AD, J Psychiatr Res. 2015;68:363-370Liu T, J Psychiatr Res. 2011;45:1648-1654

Smoking during pregnancy: increased risk on the Child for:

ADVERSE ENVIRONMENTS IN UTERO

•CVD, •stroke, •hyperinsulinaemia,•hyperglycaemia, •increased plasma triglycerides, cholesterol•obesity, •hypertension,•attention deficit hyperactivity disorder•problems withemotional regulation,•Autism SD

of:

maternal obesity/overnutritionduring pregnancy, which commonly leads to increased birth weight, also associates with adverse offspring health outcomes which, perhaps surprisingly, are similar to those seen with undernutrition.

Reynolds RM, BMJ 2013;347:f4539.Drake AJ, Reproduction 2010;140:387–98.Rodriguez A. J Child Psychol Psychiatry 2010;51:134–43.

Fish Intake in Pregnancy and Child Growth: A Pooled Analysis of 15 European and US Birth Cohorts

Stratakis N, JAMA Pediatr. 2016;170:381-390

• Fish is the major dietary source of ω-3 long-chain polyunsaturated fatty acids (LC-PUFAs), which are transferred across the placenta and may not only benefit offspring neurodevelopment but also influence adipose tissue development.

• However, fish is also a common source of human exposure to persistent organic pollutants, which may exert endocrine-disrupting properties and contribute to obesity development.



• In June 2014, the US Food and Drug Administration and Environmental Protection Agency updated their advice on fish consumption for women of childbearing age, encouraging women who are pregnant, breastfeeding, or likely to become pregnant to consume more fish, but no more than 3 servings/week to limit fetal exposure to methyl-mercury.

• Fish advisories have focused on neurocognitive harms from methyl-mercury exposure but, to our knowledge, have not considered other childhood outcomes including growth and childhood obesity related to endocrine-disrupting chemicals.

Prenatal Exposure to Mercury and Fish Consumption During Pregnancy and Attention-Deficit/HyperactivityDisorder–Related Behavior in Children Sagiv K.,APAM 2012;166(12):1123-1131

•Anchovies•Butterfish•Catfish•Clam•Crab (Domestic)•Crawfish/crayfish•Croaker•Flounder•Haddock•Hake•Herring•Mackeral (N Atlantic, Chub)•Mullet•Oysters

•Perch (ocean)•Plaice•Salmon ( Canned, Fresh)•Sardines•Scallops•Shad ( American)•Shrimp•Sole•Squid ( Calamari)•Tilapia•Trout (freshwater)•Whitefish•Whiting

Lowest MercuryEnjoy two 6-oz servings per week 1 oz = 28.4 g

Healthy eating during pregnancy.



4 yrsrapid infantgrowth

In mothers with high fish intake during pregnancy (>3 times/week)

compared with ≤ 1/week OR for

1.221.14

offspring overweight/obesity at

6 yrs

1.5 –

1.0 –

0.5 –

0.0 –

1.22

Singleton deliveries from 1996 to 2011 in Belgium, France, Greece, Ireland, Italy, the Netherlands, Norway, Poland, Portugal, Spain, and Massachusetts.

26,184 pregnant women and their children.

Followed up at 2-year intervals until the age of 6 years.

• Contamination of some environmental obesogens in fish (eg, tributyltin) may be a missing link attributable to the aforementioned positive association between maternal fish consumption during pregnancy and childhood obesity.

• Tributyltin is a novel and understudied environmental obesogen.

• Because tributyltin has been used as an antifouling agent in marine paints, fish consumption is a major source of tributyltin exposure in humans.

• Prenatal exposure to tributyltin induces obesity and impaired metabolic function in the liver and adipose tissues in subsequent generations.

• Data on tributyltin exposure in humans and its health effects are still limited.

• Therefore, it is imperative to translate findings on the obesogeniceffects of tributyltin from animal studies to humans in future studies.

Fish Intake During Pregnancy and Offspring AdiposityEditorial. Bao W, JAMA Pediatr. 2016;170:808

Avoid water or baby bottles made out of hard plastic or polycarbonate(labeled #7 ) Polycarbonate plastic (even that labeled “BPA-free”) often containsBisphenol A (BPA) or similar chemicals which can interfere with hormones in the body, especially in developing fetuses.

Run the tap for 60 seconds to flush out sitting water.

Microwave in glass containers or ceramic bowls. Use a plate to cover a dish rather than plastic wrap since microwaving in plastic increases the leaching of chemicals into food.

Do not eat eat canned foods since the linings of food cans may contain a BPA-like additive.

Pesticides have many potential health harms, for both babies and adults. If you can afford fruits and vegetables grown without pesticides (including organic), you will be exposed to fewer of these harmful chemicals.

Zlatnik MG. Midwifery Womens Health. 2016;61:442-55.

Healthy eating during pregnancy.

Industrial chemical production hasincreased over the past 30 to 40 years.

Basic science, animal models, and epidemiologic data suggest that certain chemicals may act as endocrine disruptors (substances that interfere with normal hormonal action)

Endocrine-Disrupting Chemicals and Reproductive Health.Zlatnik MG. Midwifery Womens Health. 2016;61:442-55.

plasticizers (eg, phthalates and phenols),

flame retardants,

perfluorinated compounds, (Pfas)

pesticides, fungicides, herbicides.

(used for waterproofing, stain resistance, and lubrication)

Endocrine-Disrupting Chemicals and Reproductive Health.Zlatnik MG. Midwifery Womens Health. 2016;61:442-55.

•Endocrine-disrupting chemicals (EDCs) can act as an agonist and activate the receptor in the same way as the normal ligand, or the EDC can bind to the receptor as an antagonist and turn off the normal hormonal action of the receptor.

•Alternatively, EDCs can interact with hormonal pathways, bypassing the receptor and activating or inactivating second messenger systems, or interfering with gene activation, or by changing levels of hormone-binding proteins.

•To further complicate the scientific study of EDCs, some may act in multiple ways, depending on dose, tissue type, and sex.

•The timing of endocrine disruption during the individual lifespan is often important; there are windows of varying susceptibility, including during embryogenesis in early pregnancy as well as throughout fetal life, infancy, childhood, and adolescence.

Exposure to perfluoroalkyl substances (PFAS) and thyroid function in pregnant women and children: A systematic review of epidemiologic studies.

Ballesteros V, Environ Int. 2017;99:15-28.

•Perfluoroalkyl substances (PFAS) are synthetic chemicals withunique properties, such as insolubility in both organic solvents and water, and the ability to repel oils and water.

•They have been manufactured for industrial applications since the 1940s, and they are found and used in many common industrial and consumer products such as: fire-fighting foams, alkaline cleaners, floor polishes,photographic films, shampoos, ant insecticides, soil- and stain resistant coatings for fabrics, carpets and leather, as well as in grease- and oil-resistant coatings for paper products, among others.

Exposure to perfluoroalkyl substances (PFAS) and thyroid function in pregnant women and children: A systematic review of epidemiologic studies.

Ballesteros V, Environ Int. 2017;99:15-28.

3 cross-sectional, 1 case-control, and 6 cohort studies (publication: 2011-2015),

prenatal life (n=7), childhood (n=2) or both periods (n=1).

we found some consistency of a positive association between maternal or teenage male exposure to some PFAS and TSH levels (thyroid function impairment).

However, further studies are required to confirm

these possible relationships.

Early-life exposure to EDCs: role in childhood obesity and neurodevelopment.

Braun JM. Nat Rev Endocrinol. 2017;13(3):161-173.

intellectualdisabilities(IQ <70)

In the unexposed population, the mean IQ is 100 (SD = 15), whereas in the exposed population the mean IQ is 95 (SD = 15).

This five-point shift in IQ results in nearly a doubling in the proportion of people with IQ scores consistent with intellectual disabilities in the exposed population compared with the unexposed population (4.48% and 2.27%, respectively).

100

95



PPAR, peroxisomeproliferator-activated

receptor

EDC mechanisms of action and biological targets



Early- life PFAS exposure and child adiposity

Notonly

PFAS

Transport of perfluoroalkyl substances (PFAS) from anarctic glacier to downstream locations: implications for

sources. Kwok KY, Sci Total Environ. 2013 Mar 1;447:46-55.

Population based Avon Longitudinal Study of Parents and Children.

Frequency of use of 11 chemical based domestic products determined from questionnaires completed by women during pregnancy.

A total chemical burden (TCB) score was derived.

2.3

2.5 –

2.0 –

1.5 –

1.0 –

0.5 –

0.0

OR FOR PERSISTENT WHEEZE

In children whose mothers had high TCB scores (>90th centile) than children whose mothers had a low

TCB score (<10th centile).

P=0.012

Frequent use of chemical household products is associated with persistent wheezing in pre-school age

children. Sherriff A, Thorax. 2005;60(1):45-9.

Population based Avon Longitudinal Study of Parents and Children.

Frequency of use of 11 chemical based domestic products determined from questionnaires completed by women during pregnancy.

A total chemical burden (TCB) score was derived.

2.3

2.5 –

2.0 –

1.5 –

1.0 –

0.5 –

0.0

OR FOR PERSISTENT WHEEZE

In children whose mothers had high TCB scores (>90th centile) than children whose mothers had a low

TCB score (<10th centile).

P=0.012

Frequent use of chemical household products is associated with persistent wheezing in pre-school age

children. Sherriff A, Thorax. 2005;60(1):45-9.

A dose-dependent relationship was

observed between frequency of use of common household

chemical products in the prenatal period

and persistent wheeze in the resulting

offspring.

OR FOR5 -

4 -

3 –

2 –

1 –

0

A prospective association between synthetic cocoon use in infancy and childhooh asthma.

Trevillian Paed Perin Epidem 2004:18:281

Sleeping environmentof 863 infantsevaluated at 1 month of life

Follow-up: 7 years

4.33

IN CH. SLEEPING IN A SYNTHETIC COCOON AT 1 MONTH OF AGE

RECENT WHEEZE AT AGE 7 YEARS

3.35NIGHT

WHEEZE AT AGE 7 YEARSX

Bedding type at 1mo

Wheeze at 7 yrs

(n=6,378 ch)

7 –

6 –

5 –

4 –

3 –

2 –

1 –

0 -

OR for wheezing at 7 yrs

2.5

5.2

syntheticpillow

+syntheticquilt

+

Synthetic bedding and wheeze in childhood.Ponsonby AL, Epidemiology. 2003;14(1):37-44


of:

Exposure of pregnant mothers to a significant life event

(death of a loved one, exposure to terrorism or a natural

disaster) or stress is also associated with

programmed effects and an increased risk

infants with:

•lower birth weight

•behavioral immmaturity and higher irritability,

•behavioural and emotional problems at the age of 4 years,

•decreased grey matter density,

•lower cognitive and language abilities in childhood.

•asthma, atopic dermatitis.

•Harville EW, Obstet Gynecol Surv 2010;65:713.•Rieger M, Ann N Y Acad Sci 2004;1032:228.•O’Connor TG, Br J Psychiatry 2002;180:502. •Buss C, Psychoneuroendocrinology 2010;35:141.•van de Loo KF, Eur Respir J. 2016;47(1):133. •Laplante DP, J Am Acad Child Adolesc Psychiatry 2008;47:1063.

•maternal infection,

•alcohol consumption,

•recreational drug use,

•treatment with certain medications(eg, sodium valproate)

•prenatal exposure to toxinssuch as arsenic and lead, mercury…


have all been associated with an increased risk of:

adverse neurodevelopmentaloutcomes includingschizophrenia and autism.


[email protected]

Introduction






Conclusions


Air pollution and brain damage.Calderón-Garcidueñas L, Toxicol Pathol. 2002;30(3):373-89.

32 healthy mongrel canine residents

in Southwest Metropolitan Mexico

City (SWMMC), a highly polluted urban

region.

8 dogs from Tlaxcala, a less polluted,

control city.

expression of nuclear neuronal NF-kappaBin cortical endothelial cells occurred at ages 2 weeks;

subsequent damage included alterations of the blood-brainbarrier (BBB), degenerating cortical neurons, apoptotic glialwhite matter cells.

Neurodegenerative disorders such as Alzheimer's may begin early in lifewith air pollutants playing a crucial role.

Early Alzheimer's and Parkinson's disease pathology in urban children: Friend versus Foe responses:

it is time to face the evidenceCalderón-Garcidueñas L, Biomed Res Int. 2013;2013:161687

Chronic exposure to particulate matter air pollution is known to cause inflammation leading to respiratory-and cardiovascular-related sickness and death.

Mexico City Metropolitan Area children exhibit an early brain imbalance in genes involved in oxidative stress, inflammation, and innate and adaptive immune responses.

Early dysregulated neuroinflammation, brain microvascular damage, production of potent vasoconstrictors, and perturbations in the integrity of the neurovascular unit likely contribute to progressive neurodegenerative processes.

The accumulation of misfolded proteins coincides with the anatomical distribution observed in the early stages of both Alzheimer's and Parkinson's diseases.

Early Alzheimer's and Parkinson's disease pathology in urban children: Friend versus Foe responses:

it is time to face the evidenceCalderón-Garcidueñas L, Biomed Res Int. 2013;2013:161687

Mexico City Metropolitan Area (MCMA)children with no known risk factors for neurological or cognitive disorders exhibit significant deficits in a combination of fluid and crystallized cognition tasks, "the process of thought“,versus control children.

56% of MCMA children showed prefrontal white matter hyperintense lesions by MRI and similar lesions were observed in MCMA dogs (57%).

(-)

Residential proximity to freeways and autism in the CHARGE study.

Volk HE, Environ Health Perspect. 2011; 119:873-77

304 autism cases and 259 typically developing controls enrolled in the Childhood Autism Risks from Genetics and the Environment (CHARGE) study.

2.5 –

2.0 –

1.5 –

1.0 –

0.5 –

00

2.2

OR for Autism

Residential proximity to a freeway during

the third trimester

“As I made my journey and drew near to Damascus, about noon a great light from heaven suddenly shone about me.

2 ottobre 186930 gennaio 1948,

• Recently, programs have been developed that incorporate physical activity into the teaching of academic lesson content.

• The majority of the studies showed that children’s academic engagement,academic motivation, and executive functioning are enhanced shortly after physically active academic lessons.Bartholomew JB, Prev Med. 2011;52:S51–S54

Donnelly JE, Prev Med. 2009;49:336–341

Donnelly JE, Prev Med. 2011;52:S36–S42

Grieco LA, Med Sci Sports Exerc. 2009;41:1921–1926

Mahar MT, Med Sci Sports Exerc. 2006;38:2086–2094

Vazou S, Int J Sport Exerc Psychol. 2012;10:251–263

Vazou S, J Sport Exerc Psychol. 2014;36:474–485

Physically Active Math and Language Lessons Improve Academic Achievement: A Cluster Randomized Controlled Trial

Mullender-Wijnsma MJ, Pediatrics 2016;137:e20152743

• Recently, programs have been developed that incorporate physical activity into the teaching of academic lesson content.

• The majority of the studies showed that children’s academic engagement,academic motivation, and executive functioning are enhanced shortly after physically active academic lessons.Bartholomew JB, Prev Med. 2011;52:S51–S54

Donnelly JE, Prev Med. 2009;49:336–341

Donnelly JE, Prev Med. 2011;52:S36–S42

Grieco LA, Med Sci Sports Exerc. 2009;41:1921–1926

Mahar MT, Med Sci Sports Exerc. 2006;38:2086–2094

Vazou S, Int J Sport Exerc Psychol. 2012;10:251–263

Vazou S, J Sport Exerc Psychol. 2014;36:474–485



Because math and language skills play a key role in children’s educational career and are of great importance for their

social and occupational functioning in daily life, physical activity should specifically be incorporated when

teaching math and language to optimally improve those skills. .

• We recently developed “Fit & Vaardig op School” (Fit and Academically Proficient at School [F&V]), a new series of lessons in which physical exercise is specifically used when teaching math and language in Dutch elementary schools.



4°,5° + 6°,7°

most importantfor learning

499 children (mean age 8.1 yrs) from second- and third-grade classes of 12 elementary schools, randomly assigned to the intervention or control group.

the intervention group participated in F&V lessons for 2 yrs, 22 weeks per year, 3 times a week.

• After 2 yrs children in the intervention group had significantly greater gains in mathematics speed test (P < 0.001; effect size [ES] 0.51), general mathematics (P <0.001; ES 0.42), and spelling (P < 0.001; ES 0.45) scores.



499 children (mean age 8.1 yrs) from second- and third-grade classes of 12 elementary schools, randomly assigned to the intervention or control group.

the intervention group participated in F&V lessons for 2 yrs, 22 weeks per year, 3 times a week.

• After 2 yrs children in the intervention group had significantly greater gains in mathematics speed test (P < 0.001; effect size [ES] 0.51), general mathematics (P <0.001; ES 0.42), and spelling (P < 0.001; ES 0.45) scores.



This equates to 4 months more learning gains in comparison with the control group.

• Educational benefits of physical activity can be derived from the theory of brain-based learning.

• This theory, in part, suggests that moderate to vigorous physical activity (MVPA) stimulates the brain in a positive way.

• In the short term, physical activity stimulates immediate chemical changes in the brain that increases attention and may enhance cognitive performance.

• In the long-term, regular MVPA could lead to morphological changes (angiogenesis, neurogenesis, and synaptogenesis) in brain regions that are important for learning.

Improving academic performance of school-age children by physical activity in the classroom: 1-year program evaluation

Mullender-Wijnsma MJ, J Sch Health. 2015;85:365-371

http://www.flaghouse.com/General-Education/Take-10/TAKE-10-Activity-Kit-for-Kindergarten.axd

http://www.flaghouse.com/General-Education/Take-10/TAKE-10-Activity-Kit-for-Kindergarten.axd

•Crescere bambini realizzati, che diventeranno adulti di successo, non è un gioco d'azzardo. •È quasi una scienza esatta, basta sapere come fare. •Ci hanno abituato a credere che l'unica cosa che conta per raggiungere risultati importanti è l'intelligenza e in particolare il QI, l'intelligenza cognitiva, misurabile con i test e gli esami di cui è costellata la carriera scolastica. Sbagliato!

Le qualità che contano di più hanno a che fare con il carattere: •tenacia, •curiosità, •disciplina, •ottimismo, •grinta, •autocontrollo, •autostima, •capacità di attendere la gratificazione.

Breaking the Intergenerational Cycle of Disadvantage: The Three Generation Approach

Cheng TL, Pediatrics 2016;137:e20152467

Two-generation approach. G1, generation 1, parents; G2, generation 2, child

http://www.clasp.org/resources-and-publications/publication-1/Two-Gen-Brief-FINAL.pdf

The 2-generation approach aims to improve

families’ circumstances by supporting parents

in their roles as parents and as workers, thereby helping both generations

to escape poverty.

• Parenting is a key conduit through which disadvantage and poor health are passed across generations.

• Positive parenting (ie, warm and supportive parent–child relationships) is more likely to facilitate the transmission of higher socioeconomic status (SES) through greater educational attainment, better adjustment, and fewer antisocial behaviors, whereas negative parenting is more likely to have the opposite effects.

• Parenting behaviors are transmitted across generations through a variety of mechanisms, such as attachment and epigenetic regulation of the genome.

• Individuals exposed to harsh discipline, aggressive parenting, and poor supervision during childhood and adolescence (G2) display similar parenting behaviors when they become parents, reinforcing the relationships among parenting, social competence, and achievement across generations (G3).





Three-generation approach. Adol, adolescent; G1, generation 1, parents; G2, generation 2, child; G3, generation 3, future offspringhttp://www.clasp.org/resources-and-publiations/publication-1/Two-Gen-Brief-FINAL.pdf



• The 3-generation approach prioritizes building the capacity for responsive parenting through skills development long before reproductive maturity and decisions about family formation are made.

• Before the choice to be a parent has been made, universal education should be provided on child development, parenting skills, and impact on social and economic circumstances.

• Enhanced teaching of parenting skills in primary care can improve parenting practices and reduce child disruptive behaviors.

Caring for Children by Supporting ParentsShuster MA, NEJM 2017;376(5):410

• Indeed,

physicians’ greatest

effect on the health

of children may,

at times,

be the result not

of what they do for

children, but of whatthey do for parents.

What we don't see.Hostetter MK. N Engl J Med. 2012 Apr 5;366(14):1328-34.

As a courtesy of C. Capristo

Gradually, the attitude of helplessness

changed, first to inquiry and

then to responsibility.

The recognition that social, as well as divine,

intervention could influence the life and

death ofchildren took hold.

Boys Sleeping on Mulberry Street, New York City,1890.

Riis JA. How the other half lives. New York: Charles Scribner’s Sons, 1890.

Children of war: urgent action is needed to save a generation. Bhutta ZA. Lancet. 2016;388:1275-6.

•In recent wars conflict has frequently had a child’s face, often going viral across the world.

•From the fear and intensity in the eyes of the war orphan Sharbat Gula from Afghanistan, to

the sight of poor Alan Kurdi lying dead on a Turkish beach, to

the ashen faced Omran Dagnish who was pulled fromthe debris following an airstrike in Aleppo,

children have been the most egregious victims of conflict.

Children of war: urgent action is needed to save a generation. Bhutta ZA. Lancet. 2016;388:1275-6.

•In recent wars conflict has frequently had a child’s face, often going viral across the world.

•From the fear and intensity in the eyes of the war orphan Sharbat Gula from Afghanistan, to

the sight of poor Alan Kurdi lying dead on a Turkish beach, to

the ashen faced Omran Dagnish who was pulled fromthe debris following an airstrike in Aleppo,

children have been the most egregious victims of conflict.

The scores of children being killed and maimed every day cannot wait for the politicsof Brexit and US elections

to settle or for the European Union to figure out a response

to the millions of refugees in its midst.

The time for action is now.

Early life stress and later health outcomes—findings from the Helsinki Birth Cohort Study.

Eriksson M, Am J Hum Biol 2014;26:111–16.

Studies 6,370 women and 6,975 men from the Helsinki Birth Cohort Study born 1934-1944 who were sent abroad from Finland during World War II "war children."

1,781 of the 13,345 subjects (13.4%) had been evacuated, hence having experienced temporary separation from both parents.

The separated subjects were between 0.2 and 10.6 years of age, with a mean age of 4.6 years at the time of separation.

The duration of separation ranged between 0.05 and 8.1 years with the mean being 1.7 years (SD 1.6 years).

Early life stress and later health outcomes—findings from the Helsinki Birth Cohort Study.

Eriksson M, Am J Hum Biol 2014;26:111–16.

When compared with the nonseparated, in the separated individuals, when in their adulthood, HR for:

any mental health (HR 2.12),

substance use disorder (HR 2.57),

depressive symptoms (HR 1.7),

coronary heart disease (HR 2.0),

type 2 diabetes (HR 1.4),

higher systolic blood pressure (148.6 vs. 142.2 mm Hg, P < 0.0001 ).

Migrant and refugee children need our actions now. The Lancet. Lancet. 2016 Sep 17;388(10050):1130.

In a new report—Uprooted: The Growing Crisis for Refugeeand Migrant Children—released on Sept 7, UNICEF paintsa grim picture.

Worldwide, an estimated 50 million children are refugees or migrants, with the number of child migrants having doubled and the number of refugees having increased by 21% in the past 10 years.

The most vulnerable of these children are unaccompanied, and have often fled war, insecurity, and poverty under harrowingcircumstances.

What is advocacy? Advocacy can be defined

as ‘speaking out on behalf of a particular issue, idea or person’, acting as a catalyst for change.

Advocates draw attention to issues, raise the profile of issues that need to be addressed and, when required, challenge authorities.

The role of advocacy in promoting better child healthDevakumar D, Arch Dis Child. 2016;101:596-599

The advocacy cycle - a framework for planning an advocacy strategy


[email protected]

Introduction






Conclusions


discorso d'insediamento di John F. Kennedy

•The long-term consequences of early exposures are modulated by the postnatal environment.

•Early postnatal patterns of disease risk:

POSTNATAL FACTORS WHICH INFLUENCE THE RISK OF DEVELOPING NCD

- excessive early weight gain

- a high energy diet in infancy

- early ‘adiposity rebound’

- passive smoking exposure

- childhood exposure to stressful experiences

increased adiposity and childhood obesity

lower insulin sensitivity

higher childhood BP

higher risk of CVD and type 2 diabetes

asthma and COPD

mental health disordersWilliams TC, Drake AJ. Arch Dis Child 2015;100:1058–1063.

•The long-term consequences of early exposures are modulated by the postnatal environment.

•Early postnatal patterns of disease risk:

POSTNATAL FACTORS WHICH INFLUENCE THE RISK OF DEVELOPING NCD

- excessive early weight gain

- a high energy diet in infancy

- early ‘adiposity rebound’

- passive smoking exposure

- childhood exposure to stressful experiences

Williams TC, Drake AJ. Arch Dis Child 2015;100:1058–1063.

Small for gestational age (< 2500 g) and prematurenewborn are particularly

at risk but the same is true also for

normal term newborn.Hofman PL, N Engl J Med 2004;351:2179–86.

Mathai S, Diabetes 2012;61:2479–83.Bazaes RA, J Clin Endocrinol Metab

2004;89:1267–72.

increased adiposity and childhood obesity

lower insulin sensitivity

higher childhood BP

higher risk of CVD and type 2 diabetes

asthma and COPD

mental health disorders

The optimal postnatal growth trajectory for term small for gestational age babies: a prospective cohort study

Lei X, J Pediatr 2015;166:54-58

Data from the Collaborative PerinatalProject, a US multicenter prospective cohort study from 1959-1976.

5 weight growth trajectories of the 1957 term small forgestational age (SGA) babies grouped by a latent class model.

Weight growth trajectory in term SGA infants classified by latent class model

Infant Obesity: Are We Ready to Make this Diagnosis?McCormick, J Pediatr 2010;157:15-9

16%

prevalence of infant obesity(weight-for-length ≥ 95th percentile)

20 –

10 –

0

Infant obesity (weight-for-length) ≥ 95th percentile for age and sex.



if obese at 6 months of age

OR for obesityat 24 months of age

14 –

12 –

10 –

8.0 –

4.0 –

3.0 –

2.0 –

1.0 –

0.0

13.3

14%

% obesity diagnosed in obese children

(weight-for-length ≥ 95th percentile)

6 mo 24 mo

23%

at age



30 –

20 –

10 –

0

Early adiposity rebound in childhood and risk of type 2 diabetes in adult life.

Eriksson JG, Diabetologia 2003; 46: 190–194.

A longitudinal study of 8760 subjects born in Helsinki during 1934 to 1944.

On average, they had 18 measurements of height and weight between birth and 12 years of age.

In western countries BMI usually decreases after the age of 2 years and rises again at around 6 years--the so-calledadiposity rebound.

Early adiposity rebound in childhood and risk of type 2 diabetes in adult life.

Eriksson JG, Diabetologia 2003; 46: 190–194.

A longitudinal study of 8760 subjects born in Helsinki during 1934 to 1944.

On average, they had 18 measurements of height and weight between birth and 12 years of age.

In western countries BMI usually decreases after the age of 2 years and rises again at around 6 years--the so-calledadiposity rebound.

cumulative incidence ofType 2 diabetes in adulthood

9 –

8 –

7 –

6 –

5 –

4 –

3 –

2 –

1 –

0

p<0.001

1.8%

8.6%

adiposity rebound occurred at age

> 7 years < 5 years

Body-Mass Index in 2.3 Million Adolescents and Cardiovascular Death in AdulthoodTwig G, N Engl J Med 2016;374(25):2430-40

BMI during adolescence and subsequentcardiovascular mortality

On multivariable analysis, there was a graded increase in the risk of death from cardiovascular causes and all causes that started among participants in the group that was in the 50th to 74th percentiles of BMI (i.e., within the accepted normal range)

Design of a Digital-Based, Multicomponent NutritionGuidance System for Prevention of Early Childhood

Obesity. Uesugi KH. J Obes. 2016;2016:5067421.

Theoretical model for the nutrition guidance system based on: (1) Theory of Planned Behavior, (2) Health Belief Model, and (3) Social CognitiveTheory.

Design of a Digital-Based, Multicomponent NutritionGuidance System for Prevention of Early Childhood

Obesity. Uesugi KH. J Obes. 2016;2016:5067421.

Core messages and timing of delivery to provide anticipatory guidance

0.21 kg

more weightchange

In children using large(≥180ml) bottles

Bottle Size and Weight Gain in Formula-Fed InfantsWood CT, Pediatrics 2016;138:e20154538

0.4 –

0.3 –

0.2 –

0.1 –

00 –more change

in WAZmore change

in WLZ

0.31 kg

0.24 kg

Exposure to regular (<6 oz) or large (≥6 oz) bottle size at the 2-month.

Changes in weight, weight-for-age z score (WAZ), and weight-for-length z score (WLZ) at the 6-month visit.

X

between 2- and 6-month visits

Bottle Size and Weight Gain in Formula-Fed InfantsWood CT, Pediatrics 2016;138:e20154538

• A recent meta-analysis found that there is a positive, stepwise relationship in the change in weight SD score (z score) in the 1st year of life with childhood obesity. Druet C, Paediatr Perinat Epidemiol. 2012;26(1):19–26

• With a 1 U increase in weight z score, there was a twofold increased risk for obesity, and with >1.33 U increase, there was a fourfold increased risk of childhood obesity.

• The hypothesis that the mode of feeding (ie, the bottle) rather than the milk type is responsible for differences in weight gain between formula-fed and breast-fed infants is supported by longitudinal research showing that infants fed only human milk by bottle gain more weight than breastfed infants. Li R, Arch Pediatr Adolesc Med. 2012;166(5):431–436

Risk of bottle-feeding for rapid weight gain during the first year of life.Li R, Arch Pediatr Adolesc Med. 2012;166:431-6.

1899 infants with at least 3 weight measurements reported during the first year.

Compared with infants fed at the breast

infants fed only by bottle gainedmore grams per month when fed

90 –

80 –

70 –

60 –

50 –

40 –

30 –

20 –

10 –

00

+ 71 g

+ 89 g

nonhuman milk only

P <0.001

human milk only

P = 0.02

Targeting Sleep, Food, and ActivityIn Infants for Obesity Prevention: An RCT

Taylor BJ, Pediatrics 2017;139(3)

802 pregnant women randomizedto control, FAB (food, activity, and breastfeeding),sleep, or combination(both interventions) groups.

BMI measured at 24 months.

0.54

OR for infant obesity

1.0 –

0.5 –

0.0 among those receiving

the “sleep intervention” (sleep and combination compared with FAB)

8:00 p.m. or earlier

10%

16%

25 –

20 –

15 –

10 –

05 –

00 –

prevalence of adolescent obesity

after 8:00 p.m. but by 9:00 p.m.

after 9:00 p.m.

Bedtimes at Pre-School Age

Bedtime in Preschool-Aged Children and Risk for Adolescent Obesity

Anderson SE, J Pediatr. 2016;176:17-22

23% 977 participants in the

Study of Early Child Care and Youth Development.

In 1995-1996, mothers reported their preschool-aged (mean = 4.7 years) child's typical weekday bedtime.

At a mean age of 15 years, height and weight.

0.48

for preschoolers with early bedtimes compared

with preschoolers with late bedtimes

OR for foradolescent obesity

Bedtime in Preschool-Aged Children and Risk for Adolescent Obesity

Anderson SE, J Pediatr. 2016;176:17-22

1.0 –

0.5 –

0.0 -(8:00 p.m. or earlier)

977 participants in the Study of Early Child Care and Youth Development.

In 1995-1996, mothers reported their preschool-aged (mean = 4.7 years) child's typical weekday bedtime.

At a mean age of 15 years, height and weight.

That fact is that 1 in every 2

smokers will die of

a tobacco related disease.

Most smokers will lose between

10 to 15 quality life years before they die.

Inquire about tobacco use and tobacco smoke exposure as part of health supervision visits and visits for diseases that may be caused or exacerbated by tobacco smoke exposure.

RECOMMENDED ACTIONS FOR PEDIATRICIANS

Questions for parents that can beused to identify tobacco exposure

include the following:

a. Does your child live with anyone‘who uses tobacco?

b. Does anyone who provides care for your child smoke?

c. Does your child visit places wherepeople smoke?

d. Does anyone ever smoke in yourhome?

e. Does anyone ever smoke in your car?f. Do you ever smell smoke from your

‘neighbors in or near your home or‘apartment?

Recommendation Strength: Strong Recommendation

Clinical Practice Policy to Protect Children From Tobacco, Nicotine, and Tobacco SmokeFarber HJ, Pediatrics 2015;136;1008


Identifying adolescent tobacco use can be challenging. Screening questions can provide

an opening for the pediatrician. Keep in mind that the tobacco product used

might not be cigarettes. Useful questions include the following:

a. Do any of your friends use tobacco?b. Have you ever tried a tobacco product?c. How many times have you tried

‘(name of tobacco product)?d. How often do you use

(name of tobacco product)?e. Do you friends use e-cigarettes,

‘e-hookah, or vape?f. Have you tried an e-cigarette, e-hookah, or

‘vape?


Inquire about tobacco use and tobacco smoke exposure as part of health supervision visits and visits for diseases that may be caused or exacerbated by tobacco smoke exposure.

Recommendation Strength: Strong Recommendation

Address parent/caregiver tobacco dependence as part of pediatric health care.Recommendation Strength: Strong Recommendation

Recommend tobacco dependence treatment of tobacco-dependent parents and caregivers. Recommendation Strength: Strong Recommendation



TEORIA DEGLI STADI DEL CAMBIAMENTO (Prochaska J., Di Clemente C., 1980)

Give adviseand wait

Clinical Decision Support Tool for Parental Tobacco Treatment in Primary Care

Jenssen BP, Pediatrics 2016;137: e20154185

Parental tobacco treatment Clinical

Decision Support tool. NRT prescription link

Cytisine versus nicotine for smoking cessation.

Walker N, NEJM. 2014;371(25):2353-62

plant Cytisus laburnum (Golden Rain acacia).

Comparative levels of psychological distress, stress symptoms, depression and anxiety after childbirth: a prospective population-based study of mothers and

fathers. Skari H, BJOG. 2002;109(10):1154-63.

127 mothers and 122 fathers

General Health Questionnaire, State Anxiety Inventory and Impact of Event Scale at zero to 4 days after birth, at 6 weeks and at 6 months

a few days after childbirth clinically important psychological distress was reported by: 37% of the mothers and

13% of the fathers.

After 6 weeks and 6 months, the level of psychological distress including symptoms of depression fell to levels found in the general population.



127 mothers and 122 fathers

General Health Questionnaire, State Anxiety Inventory and Impact of Event Scale at zero to 4 days after birth, at 6 weeks and at 6 months


13% of the fathers.

After 6 weeks and 6 months, the level of psychological distress including symptoms of depression fell to levels found in the general population.

“you wil never be the number 1

anymore”




13% of the fathers.

Childbirth does not seem to trigger long term psychological distress in most parents.

Clinically important psychological distress occurred more frequently in mothers than in fathers (p<0.001).

Acute maternal psychological distress was predicted by being a single parent, being multiparous, and having a previous traumatic birth.

Edinburgh PostnatalDepressionScale

Score ≥ 10 = depression

SIGNIFICANCE FOR PAEDIATRICIANS

Additional support for single, poor, deprived mothers during pregnancy and first 2 years of life has been shown to improve educational performance in childhood,- less substance abuse at 12 years and - less criminal behaviour at 19 years in their offspring. Eckenrode J, Arch Pediatr Adolesc Med 2010;164:9–15.

Importantly, evidence suggests that such interventions also have the potential to improve health outcomes across generations.Thayer ZM, Epigenetics 2011;6:1–6.Lafeber HN, Am J Clin Nutr 2013;98:556S–60S.

Maternal care during

infancy regulates the development of neural systems

mediating the expression of fearfulness in

the rat.Caldji C, Proc Natl Acad Sci

USA 1998; 95:5335–

5340.

HIGHlicking

grooming

Adult rats 90 days old

The Rat Model of Nurturing

In rats, an important component of maternal care consists of licking and grooming, which varies widely across individuals.

Maternal care as a model for experience-dependent chromatin plasticity? Meaney MJ, Trends Neurosci 2005;28:456.

Increased hippocampal expression of the glucocorticoid receptor (GR) mRNA and protein,

Decreased hypothalamic corticotrophin-releasefactor, and

Reduced hypothalamic-pituitary-adrenalresponse to stress.

increased licking and grooming

This provides a biological basis for speculations about the effects of poverty on early experience, and how exposure toabuse, family strife, emotional neglect, and harsh discipline may have epigenetic effectsthat produce individual differences in neuraland endocrine response to stress and mayincrease the susceptibility to common adultdisorders such as depression and anxiety, drug abuse, and diabetes, heart disease, and obesity.

From the Rat Model of Nurturing to the Child

Powledge TM, BioScience 2011;61: 588–592. 1

What is HealthySteps?

HealthySteps is a unique, proven pediatric primary care program committed to healthy early child development and effective parenting. healthysteps.org/

A child development professional, known as a HealthySteps Specialist, connects with families during pediatric well visits as part of the primary care team.

The HealthySteps Specialist offers screening and support for common and complex parenting challenges like feeding, attachment, behavior, sleep, parental depression, and adapting to life with a baby or young child. Specialists are trained to provide guidance, referrals, care coordination, and even home visits for families who need them.

Caring for Children by Supporting ParentsShuster MA, NEJM 2017;376(5):410

Easy To Love, Difficult To Discipline Becky A Bailey

1) Il potere della Percezione: nessuno può farci arrabbiare senza il nostro permesso.

2) Il potere dell’Attenzione: la cosa su cui ci si concentra è quella che si ottiene di più.

3) Il potere del Libero Arbitrio: l’unica persona che possiamo far cambiare siamo noi stessi.

4) Il potere dell’Unità: concentratevi sulla connessione invece di cercare di essere speciali.

5) Il potere dell’Amore: vedere il meglio negli altri.

6) Il potere dell’Accettazione: questo momento è così com’è.

7) Il potere dell’Intenzione: il conflitto è un opportunità di apprendimento.

7 poteri dell’autocontrollo

1) Calma: vivere secondo i valori che si vorrebbero sviluppare nei figli. Insegna l’integrità.

2) Assertività: dire di no ed essere ascoltati. Insegna il rispetto.

3) Scelte: costruire l’autostima e la forza di volontà. Insegna l’impegno

4) Incoraggiamento: rispettare i figli per avere il loro rispetto. Insegna l’interdipendenza.

5) Intento positivo: trasformare la resistenza in collaborazione. Insegna la collaborazione.

6) Empatia: gestire le scenate e i capricci. Insegna la compassione.

7) Conseguenze: aiutare i figli ad imparare dai propri errori. Insegna la responsabilità.

7 competenze disciplinari fondamentali


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Introduction






Conclusions


Bach JF. N Engl J Med. 2002;347(12):911-20

The increased Incidence of Immune Disorders from 1950 to 2000 in different part of the world.

by a courtesy of Prof. Hans Bisgaard

An early indicator of the impact of modern environmentalchange and specific vulnerability of the immune system. This early propensity for inflammation and immune dysregulation has implications for rising risk many other later onset non-communicable inflammatorydiseases (NCDs).

The allergy epidemic as a canary in the coal mine.

Prescott S, Allergol Int. 2014;63(1):11-20

A rising propensity for inflammation is implicated in the parallel rise of virtually all NCDs.

Prescott S, Allergol Int. 2014;63(1):11-20

There was little doubt that modern environmentalchanges promoteinflammation and, as apaediatricians, we could already see the first hand effects of this in the firstyears of life in the epidemic

allergic inflammation.

Mental health comorbidity in patients with atopic dermatitis Yaghmaie P, JACI 2013;131:428-33

92642 noninstitutionalizedchildren aged 0 to 17 years.

Lifetime prevalence of provider-diagnosedmental health conditionsfor those with and withouta history of AD.

OR of havingAttention Deficit

Hyperactivity Disorder

1.87

In children with AD

2 –

1 –

0

Mental health comorbidity in patients with atopic dermatitis Yaghmaie P, JACI 2013;131:428-33

1.81

Depression

1.87

3.04

1.77

Anxiety Cunductdisorder

Autism

4 -

3 -

2 –

1 –

0

In children with Atopic Dermatitis OR for

Reduced lung function both before bronchiolitisand at 11 years. Turner SW, Arch Dis Child. 2002;87(5):417-20.

253 cohort members

Maximal expiratory flow at FRC (VmaxFRC) at 1 month of age

Individuals with bronchiolitisprospectively identified

11 yrs folow-up

Box and whisker plot for z scores for % V’maxFRC at 1 month and % FEF 25–75 at 11 years.

Lung-Function Trajectories Leading toChronic Obstructive Pulmonary Disease.

Lange P, N Engl J Med. 2015;373(2):111-22.

Early wheezing phenotypes and cognitive developmentof 3-yr-olds. Community-recruited birth cohort

study Jedrychowski PAI 2010;21:550

Birth cohort.Wheezing symptoms over first two years.Cognitive status of children at the age of 3 yr with the Bayley Mental Development Index (MDI).

90 –

80 –

70 –

60 –

50 –

40 –

30 –

20 –

10 –

0

100 –

110 –

PersistentNever Only in months 0-12

or 13-24

104.3101.6 97.5

WHEEZING

Mental Development Indexat age 3 yrs

A child cohort (n=298) in New Zealand

Physician reports for asthma

Children’s achievement in reading and math at school entry and after 12 months.

OR for Low Text Reading

3 –

2 –

1 –

0

2.0

Asthma

Beginning school with asthma independently predicts low achievement in a prospective cohort of children

Liberty CHEST 2010;138:1349

A child cohort (n=298) in New Zealand

Physician reports for asthma

Children’s achievement in reading and math at school entry and after 12 months.

OR for Low Text Reading

3 –

2 –

1 –

0

2.0

Asthma

Beginning school with asthma independently predicts low achievement in a prospective cohort of children

Liberty CHEST 2010;138:1349

there is now good evidence that the immune system plays a critical role in the establishment

of synaptic networks in the developing brain, and that the

balance of cytokine levels in the hippocampus is important for

learning and memory. •Kettenmann H, Neuron 2013;77:10-8.•Aguzzi A, Science 2013;339:156-61.•Bilbo SD, Front Neuroendocrinol

2012;33:267-86.

Association between childhood asthma and ADHD symptoms in adolescence – a prospective

population-based twin study. Mogensen N, Allergy 2011;66:1224

4 –

3 –

2 –

1 –

00

3.2

OR for ≥3 symptoms ofhyperactivity–impulsivity

at age 13-14 years

2.73

Questionnaires at ages 8–9 and 13–14 yrs.(American Psychiatric Association. Diagnosticand statistical manual of mental disorders, 4th edn. Washington, DC: American PsychiatricAssociation; 1994.)

1480 Swedish twin pairs.

Association between asthma at age 8–9 and ADHD symptoms at age 13–14.

Children with asthma at age 8–9 years

Prevalence of anxiety and depressive symptoms inadolescents with asthma: A meta-analysis and

meta-regression Lu Y., Pediatr Allergy Immunol 2012; 23:707-15

8 studies for analysis.

3546 adolescents

with asthma.

24,884 controls.

in asthmatic adolescentsOR for developing

2.092.0 –

1.0 –

0.0

1.83

P < 0.001 P < 0.001

depression anxiety

2 –

1 –

0

1.38

6mo

1.311.43

18mo 30-57mo

age of peak of symptoms

OR for Special educational need at age 8 yrs

Sleep disordered breathing (SDB) through 5 years of age (11 049 children).

Special educational need (SEN) at 8 years.

Parents reported on children’s snoring, witnessed apnea, and mouth-breathing at 6, 18, 30, 42, and 57 months.

Pediatric Sleep Disorders and Special Educational Need at 8 Years: A Population-Based Cohort Study

Bonuck K. Pediatrics 2012;130:634

Persistent Snoring in Preschool Children: Predictors and Behavioral and Developmental Correlates

Beebe, Pediatrics 2012;130;382

249 mother/child pairsprospective birth cohortstudy.

Parental report of loud snoring≥ 2 times weekly at 2 and 3 yrsof age, children weredesignated as nonsnorers, transient snores (snored at 2 or 3 years of age, but not both), or persistent snorers (snored at both ages).

In multivariable analyses, persistent

snorers had significantly higher reported overall

behavior problems, particularly

hyperactivity,depression, and

inattention.

Role of Oxidative Stress in the NeurocognitiveDysfunction of Obstructive Sleep Apnea Syndrome.

Zhou L, Oxid Med Cell Longev. 2016;2016:9626831.

repetitive hypoxiaand reoxygenation

mitochondria and endoplasmic reticulum

dysfunction

oxidative stress (OS) responses, such as:protein oxidation, lipid peroxidation, and DNA oxidation

neuron injury especially in the hippocampus*and cerebral cortex regions.

cognitive dysfunction(memory, executive function, attention/vigilance)

*primarily associated with

memory and spatial navigation.

Role of Oxidative Stress in the NeurocognitiveDysfunction of Obstructive Sleep Apnea Syndrome.

Zhou L, Oxid Med Cell Longev. 2016;2016:9626831.

mitochondria and endoplasmic reticulum

dysfunction

oxidative stress (OS) responses, such as:protein oxidation, lipid peroxidation, and DNA oxidation

neuron injury especially in the hippocampus*and cerebral cortex regions.

cognitive dysfunction(memory, executive function, attention/vigilance)

*primarily associated with

memory and spatial navigation.

antioxidant may be a promising therapeutic method to improve partially reversible neurocognitive function

repetitive hypoxiaand reoxygenation

68 patients with newlydiagnosed mild to severe OSA and 30 without OSA.

Apnea-Hypopnea Index (AHI), oxygen desaturation index(ODI)

Serum levels of Mg, plasma C-reactive protein (CRP),

Mg serum levels (mg/dL)

p < 0.0001

Serum levels of magnesium and their relationship with CRP in patients with OSA.

Karamanli H, Sleep Breath. 2017 May;21(2):549-556




plasma C-reactive protein (mg/L)

p < 0.0001






plasma C-reactive protein (mg/L)

p < 0.0001

A significant negative correlation was observed

between Mg and CRP levels (p < 0.0001).

CRP

Mg



Mg deficiency leads to an inflammatory response, includingactivation of macrophages and leukocytes, excess production of free radicals and oxidative stress, and release of inflammatory cytokines suggesting that a subclinical Mg deficiency may contribute to many pathological conditions by affecting the severity of chronic inflammatory stress.

The role of Mg in inflammation has been well defined.

Hypomagnesaemia elevates the risk of high blood pressure, atherogenic lipid profile, metabolic syndrome, and type 2 diabetes.



Allergic rhinitis, asthma, and atherosclerosis in the Bruneck and ARMY studies.

Knoflach M, Arch Intern Med 2005;165:2521-6.

The ARMY study is a cross-sectional evaluation of 141 men aged 17 or 18 years

The Bruneck Study is a prospective population-based survey of 826 men and women aged 40 to 70 years;

OR for high intima-media thickness in the ARMY study

in subjects with allergic disorders

4.0 –

3.0 –

2.0 –

1.0 –

0.0

2.5p=0.03

Allergic rhinitis, asthma, and atherosclerosis in the Bruneck and ARMY studies.

Knoflach M, Arch Intern Med 2005;165:2521-6.

OR for atherosclerosis development and progression

in the Bruneck Study

in subjects with allergic disorders

4.0 –

3.0 –

2.0 –

1.0 –

0.0

3.8p=0.007

The ARMY study is a cross-sectional evaluation of 141 men aged 17 or 18 years

The Bruneck Study is a prospective population-based survey of 826 men and women aged 40 to 70 years;


[email protected]

Introduction






Conclusions


Anionic surfactants and commercial detergents decreasetight junction barrier integrity in human keratinocytes

Xian M, JACI 2016;138:890.

Increase in dextranparacellular permeability

across NHEKstreated with different surfactants.

us = unstimulated

p < 0.05

p < 0.05

cationicsurfactant

anionicsurfactant

dextran

Direct effect of surfactants on TJs of normal human epidermalkeratinocytes (NHEKs), at air-liquidinterface (ALI) cultures of NHEKs;

3 different classes of detergents: 1) two anionic surfactants(Sodium dodecyl sulfate [SDS] and sodium dodecyl benzene sulfonate[SDBS]), 2) a cationic surfactant(benzalkonium chloride [BZC]), 3) a nonionic surfactant(sorbitan mono-oleate [Tween 20]).

124 neonates at high risk for atopic dermatitis.

Parents in the intervention arm were instructed to apply full-body emollient therapy at least once per day starting within 3 weeks of birth.

Parents in the control arm were asked to use no emollients.

Incidence of atopic dermatitis at 6 months.

Emollient enhancement of the skin barrier from birth offers effective atopic dermatitis preventionSimpson EL, J Allergy Clin Immunol 2014;134:818-23

With the use of daily emollient

0.50

1.0 –

0.5 –

0.0

RR of atopic dermatitis denvelopment

at 6 months of age

Emollient enhancement of the skin barrier from birth offers effective atopic dermatitis preventionSimpson EL, J Allergy Clin Immunol 2014;134:818-23

Skin barrierprotection

might preventatopic

dermatitisdevelopment.

FLG, Filaggrin.

Application of moisturizer to neonates prevents development of atopic dermatitis

Horimukai K, J Allergy Clin Immunol 2014;134:824-30

In infants who had AD/eczema

2.863.0 –

2.5 –

2.0 –

1.5 –

1.0 –

0.5 –

0.0

OR for sensitization

Emulsion-type moisturizer applied daily during the first 32 weeks of life to 59 of 118 neonates at high risk for AD (based on having a parent or sibling with AD).

Onset of AD (eczematous symptoms lasting >4 weeks) and eczema (lasting >2 weeks).

Cumulative incidence of (AD/eczema) at week 32 of life.

Serum levels of allergen-specific IgE.

Lessons learned from birth cohort studies conducted in diverse environments

Jackson D.J, J Allergy Clin Immunol 2017;139:379-86

Future asthma risk at various ages. contribution of:

Age of sensitization Number of allergens producing sensitization

at various ages

Infants with at least 1 first-degree relative with asthma or 2 first-degree relatives with other IgE-mediated allergic diseases.

Intervention group (N=279) or the control group (N=266) before the child’s birth.

+ + - -+ - + -

51.7%

PREVALENCE OF ASTHMA AT AGE 7 YEARS

ATOPY PRESENT

20%

7.7% 9.3%

60 –

50 –

40 –

30 –

20 –

10 –

0Age 1 yrsAge 7 yrs

OR=2.25

OR=15.5

Atopy in early life and effect of a primary prevention program for asthma in a high-risk cohort.

Chan-Yeung M, J Allergy Clin Immunol. 2007;120(5):1221-3.

545 high-risk infants with immediate FH of asthma and allergies

Intervention (avoidance of house dust) or control groups

Outcomes at 7 years

Intervention Controls

% ch. with pediatric diagnosis of asthma at age 7 yrs

30 –

20 –

10 –

0

23%

14.9%

p = 0.006

The Canadian Childhood Asthma Primary Prevention Study: outcomes at 7 years of age.

Chan-Yeung M, J Allergy Clin Immunol. 2005;116(1):49-55.

http://www.google.it/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&docid=XBkI1Ke-vYNP8M&tbnid=r-4ZVXy8j9tE3M:&ved=0CAUQjRw&url=http://healthypets.mercola.com/sites/healthypets/archive/2013/05/08/house-dust-mites.aspx&ei=p1-HU5reNYjK0QWDw4HYDg&bvm=bv.67720277,d.bGE&psig=AFQjCNFpe9TbkYF19S86elP0uJ3q4pMeYw&ust=1401467147255714

http://www.google.it/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&docid=XBkI1Ke-vYNP8M&tbnid=r-4ZVXy8j9tE3M:&ved=0CAUQjRw&url=http://healthypets.mercola.com/sites/healthypets/archive/2013/05/08/house-dust-mites.aspx&ei=p1-HU5reNYjK0QWDw4HYDg&bvm=bv.67720277,d.bGE&psig=AFQjCNFpe9TbkYF19S86elP0uJ3q4pMeYw&ust=1401467147255714

Prevention of Allergic Disease During Childhood by Allergen Avoidance: The Isle of Wight Prevention Study

Arshad JACI 2007;119:307

Infants at higher risk because of family predisposition.

Randomized to prophylactic (n=58) and control (n=62) groups.

Prophylactic group: breast-fed or extensively hydrolyzed formula, acaricide and mattress covers.

Development of allergic disease at age 1,2,4 and 8 years.

OR in the prophylactic group at age 8 years

1 –

0.5 –

0

p=0.005p=0.005

p<0.005p=0.0003

0.24 0.230.14 0.13

asthma Atopic dermatitis

Allergic rhinitis

atopy

Ln sRaw GM & 95% CI (kiloPascal/second) at age 3 years

0.4 –

0.3 –

0.2 –

0.1 –

0.0 –

-.1

**

p=0.003

ALB whole-body plethysmograph

Manchester cohort128 active group111 control groupAllergen level, symptoms, sensitization and lung function at 3 years of age

Early life environmental control: effect on symptoms, sensitization, and lung function at age 3 years.

Woodcock A, Am J Respir Crit Care Med. 2004;170(4):433-9.

Ln sRaw GM & 95% CI (kiloPascal/second) at age 3 years

0.4 –

0.3 –

0.2 –

0.1 –

0.0 –

-.1

**

p=0.003

ALB whole-body plethysmograph

Manchester cohort128 active group111 control groupAllergen level, symptoms, sensitization and lung function at 3 years of age

Early life environmental control: effect on symptoms, sensitization, and lung function at age 3 years.

Woodcock A, Am J Respir Crit Care Med. 2004;170(4):433-9.

This may be animportant factorin relation to the traking effect of

lung function

Dietary total antioxidant capacity in early school age and subsequent allergic disease.

Gref A, Clin Exp Allergy. 2017 Epub ahead of print

2359 children from the Swedish birth cohort BAMSE

Dietary total antioxidant capacity(TAC) at age 8 years estimated by combining information on the child's diet the past 12 months from a food frequency questionnaire with a database of common foods analysed with the oxygen radical absorbance capacity method.

asthma and rhinitis was based on questionnaires, and serum IgE antibodies were measured at 8 and 16 years.

aOR for sensitizationto inhalant allergens

0.73P-value for trend = 0.031

TAC of the diet for the 3rd

third compared to the 1st tertileat age 8 years

1.0 –

0.5 –

0.0






aOR forallergic asthma

0.57 P-value for trend = 0.031

1.0 –

0.5 –

0.0








1.0 –

0.5 –

0.0

These findings indicate that

implementing an antioxidant-rich diet

in childhood may contribute to the

prevention of allergic disease.

0.57 P-value for trend = 0.031

aOR forallergic asthma



Fruits and vegetables in general health

Nrf2 = Nuclear factor (erythroid-derived 2)-like 2

NF-κB = nuclear factor kappa-light-chain-enhancer of activated B cells

Transcription factors involved in the process of converting, or transcribing, DNA into RNA.

curcumin

sulforaphane

quercitin

resveratrol

soy

http://www.google.it/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0CAcQjRxqFQoTCLqt597Z7scCFUlWGgodNgEJIA&url=http://smartwellness.info/?p=142&psig=AFQjCNE0VOFfNqQsuLYnKE2xhmlqDddHnA&ust=1442051264872072


http://www.google.it/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0CAcQjRxqFQoTCNSX7cff6ccCFUh-GgodMtYHCQ&url=http://www.anti-agingfirewalls.com/2013/10/28/the-master-regulator-of-aging-redox-glutatione-and-cysteine-part-1/&psig=AFQjCNHbxWyu6aBHRc0EYtGg1uep39KJKQ&ust=1441881029346472

http://www.google.it/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0CAcQjRxqFQoTCNSX7cff6ccCFUh-GgodMtYHCQ&url=http://www.anti-agingfirewalls.com/2013/10/28/the-master-regulator-of-aging-redox-glutatione-and-cysteine-part-1/&psig=AFQjCNHbxWyu6aBHRc0EYtGg1uep39KJKQ&ust=1441881029346472

Flavonoid intake and risk of chronic diseasesKnekt P, Am J Clin Nutr 2002;76:560-8

Food frequency questionnaire

Total dietary intakes of 10,054 men and women during the year preceding the baseline examination

In subjects with higher quercetinintakes OR for

1.0 –

0.9 –

0.8 –

0.7 –

0.6 –

0.5 –

0.4 –

0.3 –

0.2 –

0.1 –

0.0

0.760.82

0.79

0.42

lung cancerincidence

in men

mortality from ischemic heart disease

asthma type 2 diabetes

p=0.02 p=0.001 p=0.07p=0.005



Dietary intake of soy genistein is associated withlung function in patients with asthma.

Smith LJ, J Asthma 2004;41:833-43.

1033 asthmatics, aged 12-75 years. Food frequencyquestionnaire(intake of antioxidantvitamins, soy isoflavones, total fruits and vegetables, fats, and fiber )

100 –

90 –

80 –

70 –

60 –

50 –

40 –

30 –

20 –

10 –

0

FEV1 % predicted

82.1%p=0.006

genistein consumers of

≥250 μg/1000 Kcal/day 0 μg/1000 Kcal/day

76.2%

300 asthmatics.

Level of soy genisteinintake (little or no intake, moderate intake, or high intake).

Lung function and asthma control.

6-month follow-up period.

54%

little or no genistein

60 –

50 –

40 –

30 –

20 –

10 –

00

40%35%

P<0.001

moderate high

% patients with asthma exacerbations

soy genistein intake

>1500μg/day>10μg/day

Association of dietary soy genistein intake with lung function and asthma control: a post-hoc analysis of

patients enrolled in a prospective multicentre clinical trialBime C, Prim Care Respir J 2012 ;21:398-404

Curcumins-rich curry diet and pulmonary function in Asianolder adults. Ng TP, PLoS One. 2012;7(12):e51753

2,478 Chinese adults aged ≥ 55 years in the Singapore Longitudinal Ageing Studies.

Curry intake and spirometry

FEV1, FVC and FEV1/FVC% by levels of curry intake.

<1/6mo <1/mo <1/1w >1/1w<1/6mo <1/mo <1/1w >1/1w <1/6mo <1/mo <1/1w >1/1w

Relationship between serum 25-hydroxyvitamin D and pulmonary function in the Third National Health and

Nutrition Examination Survey.Black PN, Chest 2005;128:3792–3798.

a cross-sectional survey of 14,091 people > 20 years of age, spirometry, and serum 25-hydroxy vitamin D levels

Mean increase for the highest quintile of serum25-hydroxy vitamin D level

(>85.7 nmol/L – 34 ng/mL) compared with the lowest quintile (<40.4 nmol/L - 16 ng/mL).

200 –

150 –

100 –

50 –

0

+ 172mL

FVC FEV1

+ 126mLp<0.0001

p<0.0001

Vitamin D and respiratory tract infections: A systematic review and meta-analysis of randomized controlled trials.

Bergman P, PLoS One 2013;8:e65835

0.51

vitamin D supplemented in

OR for respiratorytract infection

1.0 –

0.5 –

0.0 daily doses vs bolus doses

0.86

P=0.01

meta-analysis of 11 placebo-controlled studies

5660 patients included

Vitamin D and respiratory tract infections: A systematic review and meta-analysis of randomized controlled trials.

Bergman P, PLoS One 2013;8:e65835

0.51

vitamin D supplemented in

OR for respiratorytract infection

1.0 –

0.5 –

0.0 daily doses vs bolus doses

0.86

P=0.01

meta-analysis of 11 placebo-controlled studies

5660 patients included

This mechanism has also been suggested to

be operating in elevating the risk for some cancers due to wide fluctuations in circulating vitamin D

levels.Weiss S.Thorax 2015;70:919-920

Vitamin D and mortality: Individual participant data meta-analysis of standardized 25-hydroxyvitamin D in 26916 individuals from a European consortium.

Gaksch M, PLoS One. 2017;12(2):e0170791.

Dose-response trend of hazard ratios of death from all causes

by standardized 25-hydroxyvitamin D.26,916 study participants (median age 61.6 years, 58% females) with a median 25(OH)D concentration of 53.8 nmol/L.

During a median follow-up time of 10.5 years, 6802 persons died.

Serum 25-Hydroxyvitamin D Has a Modest Positive Association with Leukocyte Telomere Length in Middle-

Aged US Adults.Beilfuss J. J Nutr. 2017;147(4):514-520.

data from the US NHANES 2001-2002[1542 young adults (aged 20-39 y), 1336 middle-aged adults (aged 40-59 y), and 1382 older adults (aged ≥60 y)].

Leukocyte telomere lengthmeasured by quantitative polymerase chain reaction.

Serum 25(OH)D ≥50 nmol/L were considered optimal.

•In the participants aged 40-59 y, an increment in serum 25(OH)D of 10 nmol/L was associated with a 0.03- ± 0.01-kbp longer LTL, (P = 0.001).

•In the same age group, 25(OH)D concentrations ≥50 nmol/L were associated with a 0.13- ± 0.04-kbp longer LTL than those for 25(OH)D concentrations <50 nmol/L (P = 0.01).

Upper Respiratory Tract Diseases

I. The respiratory tract is the most common site for infection by pathogens.

A. This site becomes infected frequently because it comes into direct contact with the physical environment and is exposed to microorganisms in the air.

B. The human respiratory tract is exposed to many potential pathogens via the smoke, soot, and dust that is inhaled from the air.

C. It has been calculated that the average individual inhales about 8 microorganisms per minute or 11,500 per day.

[email protected]

8 microorganisms per minute or

11,500 per day.

http://www.ariatlas.org/data_research/appendis_b

http://www.ariatlas.org/data_research/appendis_b

Nasal irrigation as an adjunctive treatment in allergicrhinitis: a systematic review and meta-analysis.

Hermelingmeier KE, Am J Rhinol Allergy. 2012;26(5):e119-25.

10 randomized, controlledtrials (>400 participants total)

primary (symptom score) and secondary parameters (medicine consumption, mucociliary clearance, and quality of life).

Saline nasal irrigation (SNI)performed regularly over a period of up to 7 weeks mucociliary

clearancequalityof life

40 –

30 –

20 –

10 –

0

31.2% 27.9%

With Saline Nasal Irrigation% improvment in

Hair Zinc and Selenium Levels in ChildrenWith Recurrent Wheezing

Razi C. H., Pediatr Pulmonol 2012; 47: 1185–1191

300 –

200 –

100 –

000

162

236 217280

RW HC RW HC

P<0.001 P<0.001

Zn Se

Hair levels (μg/g) Zn and Se levels

65 patients with recurrent wheezing (RW) and 65 healthy children (HC)

Total antioxidant capacity (TAC) (mmol/L)

Serum heavy metal and antioxidant element levels ofchildren with recurrent wheezing.

Razi CH, Allergol Immunopathol (Madr). 2011;39:85-9.

Correlation between serum zinc levels and n° of wheezy attacks during the previous year

r:−0.776, p < 0.001

100 children with recurrent wheezing from 1 to 6 years

116 age- and sex-matched healthy children.

serum mercury, lead, aluminium, zinc, selenium, and copper levels in blood

A cohort of 9- to10-month-old infants.

The infants weregiven oral iron for3 months.

Behavioral codingfrom videotape at 12 months

Dose-Response Relationships between Iron Deficiency with or without Anemia and Infant Social-Emotional

Behavior Lozoff B, J Pediatr. 2008;152:696-702

There were significant (P <0.05) linear effects of poorer ironstatus for:

• increasing shyness,

• decreasingorientation/engagement,

• decreasing soothability,

• when an examiner attempted toengage the infants in imitative play, decreasing positive affectand engagement.

http://upload.wikimedia.org/wikipedia/commons/f/fc/Iron_deficiency_anemia.jpg

http://upload.wikimedia.org/wikipedia/commons/f/fc/Iron_deficiency_anemia.jpg

Iron-Deficiency Anemia in Infancy and Social Emotional Development in Preschool-Aged Chinese Children

Chang S, Pediatrics 2011;127:e927

Children with iron-deficiency anemia (IDA) in infancy whose anemia was not corrected before 24 months (chronic IDA) (n=27).

Children with IDA in infancy whose anemia was correctedbefore 24 months (corrected IDA) (n=70).

Children who were non-anemic in infancy and at 24 months (n =64).

Children who had chronic IDA in infancy

displayed: 1.less positive affect

and frustration tolerance;

2.more passive behavior and physical self-soothing in the stranger approach;

3.delay of gratification.

Iron Deficiency in Infancy is Associated with Altered Neural Correlates of Recognition Memory at 10 Years

Congdon, J Pediatr 2012;160:1027

Topographic distribution of scalp potentials to new and old words for A, control subjects and B, FIDA children at 344 ms post-stimulus.

Grand averaged ERP waveforms for C, control subjects and D,FIDA children over the left frontal electrode (F3).

% subjects who did not complete secondary school

58.1%

chronic irondeficiency

iron sufficient

60 –

50 –

40 –

30 –

20 –

10 –

0

19.8%

p=0.003

At 25 years, 33 subjects with chronic iron deficiency in infancy vs 89 who were iron-sufficient before and/or after iron therapy.

Education, employment, marital status, and physical and mental health.

Functional Significance of Early-Life Iron Deficiency: Outcomes at 25 Years

Lozoff B, J Pediatr. 2013 ;163(5):1260-6

% subjects who were single

83.9%

chronic irondeficiency

iron sufficient

23.7%

90 –

80 –

70 –

60 –

50 –

40 –

30 –

20 –

10 –

00

p=0.03

At 25 years, 33 subjects with chronic iron deficiency in infancy vs 89 who were iron-sufficient before and/or after iron therapy.

Education, employment, marital status, and physical and mental health.

Functional Significance of Early-Life Iron Deficiency: Outcomes at 25 Years

Lozoff B, J Pediatr. 2013 ;163(5):1260-6

Iron status of children in southern Sweden: effects of cow's milk and follow-on formula

Bramhagen AC, Acta Paediatr 1999;88:1333-1337

43%

% children consuming follow-on formula

11%

P=0.0002

50 –

40 –

30 –

20 –

10 –

00

367 healthy 2.5-y-old children.

Amounts of cow's milk and formula consumed.

B-haemoglobin, S-ferritin, S-iron, total iron binding capacity and mean corpuscular volume.

iron-deficient children

iron-sufficient children



iron deficiency

43%

YES NO

intake of cow's milk (mL/day)

496500 –

400 –

300 –

200 –

100 –

000

382

294272

257

232




p = 0.0024

http://www.google.it/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwiempma0NTOAhXFnBoKHUG9BZcQjRwIBw&url=http://www.greenstyle.it/gallerie/mucche-da-latte-le-foto&bvm=bv.129759880,d.d2s&psig=AFQjCNH1E4pQ0b4OTM5U8VOtH77r0OyP0w&ust=1471941653009239




43%

YES NO

intake of cow's milk (mL/day)

496500 –

400 –

300 –

200 –

100 –

000

382

294272

257

232




Do not give more than 400-500 ml of milk

after first 12 months.

iron deficiency

p = 0.0024



25(OH)D <50 nmol/L

Iron deficiency(serum Ferritin

<12 μg/L)

In the fortified young-child formula

(YCF) group, at age 1-3 yrs, OR for

A micronutrient-fortified young-child formula improves the iron and vitamin D status of healthy young European children:

a randomized, double-blind controlled trialAkkermans MD, Am J Clin Nutr. 2017;105:391-399

0.220.42

P<0.001P=0.036

1.0 –

0.5 –

0.0 –

318 children (1-3 yrs) allocated to receive either a micronutrient-fortified young-child formula (YCF) [1.2 mg Fe/100 mL; 1.7 μg (68 UI) vitamin D/100 mL] or nonfortified cow milk (CM) (0.02 mg Fe/100 mL; no vitamin D) for 20 wk.

Change from baseline in serum ferritin (SF) and 25(OH)D.


[email protected]

Introduction



But we are a pediatrician



Conclusions





•CVD, •stroke, •metabolic syndrome,•osteoporosis.






•CVD, •stroke, •metabolic syndrome•osteoporosis.



Over time these ideas have developed into the Developmental Origins of Health and Disease concept, whereby

early life exposures are thought to lead to ‘programming’ of cardiovascular, neuroendocrine and metabolic systems,

predisposing the individual to later life non-communicable diseases (NCDs).

"The next generation does not have to suffer from heart disease or osteoporosis.

These diseases are not mandated by the human genome.

They barely existed 100 years ago.

They are unnecessary diseases.

We could prevent them had we the will to do so."

David James Purslove Barker, physician and epidemiologist, born 29 June 1938; died 27 August 2013

Evolving Notions of Childhood Chronic IllnessHalfon N, JAMA 2010;303:665

The same adverse childhood experiences that can contributeto the onset of childhood illness can also affect stress-sensitive physiologic systems (nervous, endocrine/metabolic, immune), predisposing the same individuals to develop age-relateddiseases as adults. Danese A, Arch Pediatr Adolesc Med. 2009;163:1135.

This suggests that well-designed prevention strategiesinitiated in childhood could be a “two-for,” preventingchildhood chronic conditions as well as the adult chronicconditions that are likely to emerge in years to come.

The Developmental Origins od Adult Diseaseshas two major implications:

First, it reinforces the growing awareness thatinvestment in the health and educationof young people in relation to theirresponsibilities during pregnancy and parenthood is of fundamental importance.

Second, any rational approach to health care should embrace a life-course perspective.

MEDICAL AND PUBLIC HEALTH IMPLICATIONS

Education should prepare children to live responsibly and peacefully in a free society.

Education should teach children to respect the natural environment.

Article 29

The purpose of education is to developevery child’s personality, talents and mental and physical abilities.

Education should teach children to respect their parents, their own andother cultures.

Improving Global Child Health: Why All Pediatricians Must "Be the Change".

Arnold LD. Pediatrics. 2016;137(2):e20152748.

Pediatricians Have a Duty to Provide a Voice for All Children

•When it comes to children, there is no “them” and “us.”

•As pediatricians, we have a duty to all children.

•Individually and collectively, we must commit to improving the lives of children everywhere, by addressing global barriers to children’s health.

“How wonderful it is that nobody need wait a single moment before starting to improve the world.”

Anne Frank1929-1945

Improving Global Child Health: Why All Pediatricians Must "Be the Change".

Arnold LD. Pediatrics. 2016;137(2):e20152748.

Pediatricians Have a Duty to Provide a Voice for All Children

•When it comes to children, there is no “them” and “us.”

•As pediatricians, we have a duty to all children.

•Individually and collectively, we must commit to improving the lives of children everywhere, by addressing global barriers to children’s health.

“How wonderful it is that nobody need wait a single moment before starting to improve the world.”

Anne Frank

Children’s Futures Depend on What We Do, or Don’t Do, Today

1929-1945

The early years: silent emergency or unique opportunity?Margaret Chan, Lancet 2017;389:11-13

• Today’s children will drive growth and development in the societies of tomorrow.

•We should be deeply concerned, therefore, that an estimated 250 million children (43%) younger than 5 years in low-income and middle-income countries are at risk of falling short of their potential because of adversities they face in their early, formative years.

•Helping these children reach that potential by investing in early childhood development—and developing their physical, cognitive, emotional, andsocial capacities—will benefit not only them but also all of us.

•Failing to make such investments will have profound implications for children, their families, and their societies, exacerbating inequalities and deepening societal divisions.

When it comes to early childhood development, the cost of inaction is high.

Battle of DunkirkMay 26th

June 3rd

1940

“There is no finer investment for any community

than putting milk into babies.”

20° FORMAT Verona, /05/2018

Thank you foryour attentionto the story

my grandpa told you.

Mia Charlize Powell

prevention of chronic noncommunicable diseases

Health & Medicine