Nestle Nutrition workshop series. Paediatric programme最新文献

This chapter surveys two segments of the economic literature on pediatric obesity: first, research regarding the impact of childhood obesity on health care expenditure, and second, research evaluating the cost-effectiveness of programs to prevent pediatric obesity. Evidence in support of the hypothesis that obese children and adolescents have higher health care costs than their otherwise similar healthy-weight peers has been found for female adolescents. Studies trying to calculate the complete lifetime health care costs attributable to childhood obesity are missing. Only a small number of studies assessing the cost-effectiveness of preventive obesity interventions among children have been published until now. The results call for the inclusion of nutrition behavior as an intervention target. There is some evidence that childhood obesity prevention might be successful in combining health gains with cost savings. However, it is not possible to rank the interventions according to their cost-effectiveness or to assess the generalizability of their results. Cost-effectiveness increasingly will be a major consideration in public reimbursement decisions. Therefore, evaluation research has to pay more attention to the economic aspects of new health technologies. Without providing good value for money, those technologies probably will not turn from inventions to innovations in health care. Moreover, future research should address various methodological and conceptual challenges and limitations which economic evaluations of preventive interventions into childhood obesity are faced with.

Due to high iron requirements, young children are at risk for iron deficiency anemia. Iron supplements are therefore often recommended, especially since iron deficiency anemia in children is associated with poor neurodevelopment. However, in contrast to most other nutrients, excess iron cannot be excreted by the human body and it has recently been suggested that excessive iron supplementation of young children may have adverse effects on growth, risk of infections, and even on cognitive development. Recent studies support that iron supplements are beneficial in iron-deficient children but there is a risk of adverse effects in those who are iron replete. In populations with a low prevalence of iron deficiency, general supplementation should therefore be avoided. Iron-fortified foods can still be generally recommended since they seem to be safer than medicinal iron supplements, but the level of iron fortification should be limited. General iron supplementation is recommended in areas with a high prevalence of iron deficiency, with the exception of malarious areas where a cautious supplementation approach needs to be adopted, based either on screening or a combination of iron supplements and infection control measures. More studies are urgently needed to better determine the risks and benefits of iron supplementation and iron-fortified foods given to iron-deficient and iron-sufficient children.

Over the last years, major scientific advances allowed to decrypt the human genome with over 22,000 protein-coding genes. We do know some of these genes, but yet only few of their functions and even less of their control and regulation as well as the complex interplay between different genes and their products. Genotyping allows to analyze particular genes, but it cannot predict phenotypes. What can we expect from the recent scientific advances with regard to the needs of the developing child or adult and the intention to prevent disease and/or to improve life quality? We address two particular points in this review: the (direct/indirect) interaction of nutrition with genes of the host and the impact of genetic variations (polymorphisms) on requirements, tolerance or metabolism of nutrition. Over the last 5 years, major research efforts were made to address the potential interaction of nutrition and genes, now named nutrigenomics (interaction of nutrition and genes) and nutrigenetics (impact of gene variants on nutrition and/or their metabolism). We give in this review examples of molecular approaches in the understanding of this bidirectional interaction between nutrition and genes, focusing also on epigenetic imprinting.

Breast milk is the initial natural food for infants, but already during the second half year complementary feeding is essential. Epidemiological research, first on celiac disease and later on atopic diseases, has driven a paradigm shift with respect to most favorable age to introduce complementary feeding. Simplified, this implies a shift from later to earlier introduction, which is now taken into account in recommendations on infant feeding. Complementary feeding, including all foods, should not be initiated for any infant before 4 months of age, and not later than around 6 months, including infants with elevated disease risk (e.g. for celiac disease or atopic diseases). Motivating reasons could be that ongoing breastfeeding provides an 'immunological umbrella' and/ or a different age interval gives a 'window of opportunity' for developing oral tolerance towards gluten and other food antigens. This will for some infants be in conflict with recent WHO recommendations on exclusive breastfeeding for 6 months. Epidemiology has evolved over time and could, if increasingly used, contribute even more to innovations in pediatric nutrition and other phenomena related to population health.

Advances in technology and understanding of fundamental human biology allow for an increasingly innovative research agenda in pediatric nutrition. All human research is governed by the norms of bioethics, which are in turn based on four primary principles: free will in participation, freedom from harm, opportunity to benefit, and non-discrimination in access. Legally, if not essentially, juveniles do not have free will to affirm their participation as research subjects. They have an absolute right, in nontherapeutic research, however, to decline. Pivotal in the discussion in nontherapeutic research in healthy children is the tolerance for risky procedures. Complicated situations include: multi-national protocols, choice of developing country sites, the inclusion of placebo treatment arms, analysis of genetic biomarkers, and research for commercial enterprises. The overly stringent interpretation of bioethical principles, as adapted to children, would stifle innovation in research. A relaxed bioethical attitude in pursuit of advancing science, by contrast, could violate essential human rights and expose a population worthy of special protection to undue risk and harm. By following the course of utility, seeking the steepest benefit-to-risk ratios, weighted toward safety and child welfare, the divergent nature of the considerations should be brought into convergence for the sake of continuing innovation.

Truly impactful innovation can only be recognized in retrospect. Moreover, almost by definition, developing algorithmic paths on roadmaps for innovation are likely to be unsuccessful because innovators do not generally follow established routes. Nonetheless, environments can be established within Departments of Pediatrics that promote innovating thinking. The environmental factors necessary to do so include: (1) demand that academic Pediatrics Departments function in an aggressively scholarly mode; (2) capture the most fundamental science in postnatal developmental biology; (3) focus education and training on the boundaries of our knowledge, rather than the almost exclusive attention to what we think we already know; (4) devote mentoring, time and resources to only the most compelling unanswered questions in the pediatric sciences, including nutrition; (5) accept only systematic, evidence-based answers to clinical questions; (6) if systematic, evidence-based data are not available, design the proper studies to get them; (7) prize questioning the answers to further move beyond the knowledge limit; (8) support the principle that experiments in children will be required to convincingly answer clinical questions important to children, and (9) establish the multicenter resources in pediatric scientist training, clinical study design and implementation, and laboratory and instrument technologies required to answer today's questions with tomorrow's methods.

Innovation is important for life science and economy, but the value of innovation for public health depends on its impact on promoting health. Breastfeeding is not innovative but evolved slowly over 250-300 million years, yet its total benefits are not surpassed by more innovative ways of infant feeding. Until the 19th century, infants fed inadequate breast milk substitutes suffered from high mortality. In 1865 a major improvement was von Liebig's 'soup for infants', the first breast milk substitute based on chemical human milk analysis, soon followed by commercial applications. Other early innovations include whey protein-dominant formula, addition of specific carbohydrates to promote bifidobacteria ('prebiotic') and of live bacteria ('probiotic'), predecessors of apparently recent innovations. Opportunities for innovations exist since many outcomes in formula-fed infants do not match those in breastfed populations. Of concern, expected economic benefits through innovations may override scientific arguments. Business and marketing desires must be counterbalanced by independent pediatric and scientific evaluation. Developing innovations with relevant outcome effects is complex, costly and cannot be expected to occur every few years. Cooperation between academic investigators, small and medium enterprises with high innovative potential, and large industries promotes progress and should be facilitated, e.g. by public research funding.

Innovation is about making changes. When it comes to health care, innovations, though they may be something 'new', may not be beneficial if not demonstrated to be an improvement over what is current practice. Innovations in pediatric nutrition sometimes fall into this category. The establishment of safe water and milk supplies at the end of the 19th and beginning of the 20th centuries is viewed as one of the greatest advances in preventative medicine and truly was an 'innovation', with its dramatic impact on infant mortality. Other innovations in pediatric nutrition included the development of the caloric method of infant feeding which led to the large-scale adoption of a single infant formula. This required cooperation with industry and ultimately led to the development of life-saving specialty formulas for various disease states including inborn errors of metabolism. Over the last 50 years there have been further modifications of term infant formula that have included taurine, carnitine, nucleotides, whey proteins, PUFAs including decosahexenoic acid (DHA) and arachidonic acid, probiotics, and prebiotics. Many of these additions are of questionable benefit and are questioned as true innovations. Though the addition of novel nutrients to infant formula has been an area of great interest, more basic research (including randomized controlled trial) is needed to determine many pediatric nutrient requirements including the lower and upper limits of nutrients added to infant formula. Such research could be facilitated by institutions such as the US National Institute of Child Health whose establishment in 1962 was a significant 'innovation' as it led to advances in pediatric nutritional research. Much more research is needed to determine basic pediatric nutritional requirements and pediatricians should strive for such true innovations.

Understanding human brain development from the fetal life to adulthood is of great clinical importance as many neurological and neurobehavioral disorders have their origin in early structural and functional cerebral maturation. The developing brain is particularly prone to being affected by endogenous and exogenous events through the fetal and early postnatal life. The concept of 'developmental plasticity or disruption of the developmental program' summarizes these events. Increases in white matter, which speed up communication between brain cells, growing complexity of neuronal networks suggested by gray and white matter changes, and environmentally sensitive plasticity are all essential aspects in a child's ability to mentalize and maintain the adaptive flexibility necessary for achieving high sociocognitive functioning. Advancement in neuroimaging has opened up new ways for examining the developing human brain in vivo, the study of the effects of early antenatal, perinatal and neonatal events on later structural and functional brain development resulting in developmental disabilities or developmental resilience. In this review, methods of quantitative assessment of human brain development, such as 3D-MRI with image segmentation, diffusion tensor imaging to assess connectivity and functional MRI to visualize brain function will be presented.

From retrospective studies, there is substantial evidence that birthweight and the rate of weight gain during early infancy are associated with increased risk for adverse health outcomes later in life. Birthweight is the marker of the integrative effects of the prenatal environment, while the rate of weight gain after birth reflects both genetic potential and external postnatal influences. The adulthood-to-infancy associations constitute the basis for the 'fetal origins' and 'catch-up growth' hypotheses for some diseases. However, these findings are based on the assumption that anthropometric-based indices reflect body composition during both time periods, with the body mass index (weight/stature2) being the most frequently used index. More direct measures of body composition were simply not available at the time of the births of the adults participating in these studies. Nowadays, there are a number of in vivo techniques that can be used to examine body composition in infancy. In particular, what does the body mass index reflect in terms of body composition for the infant? Is it an adequate index?