What a general paediatrician needs to know about early life programming

The Influence of Parents' Nutritional Education Program on Their Infants' Metabolic Health

Childhood obesity is considered an epidemic in both developing and developed countries. Children obesity plays a vital role in children’s development and has a profound impact on their health in adult life. Although the etiology of obesity is multifactorial, it can be prevented. According to research, feeding practices, developing eating habits, and parenting styles are of primary importance. Despite the widespread access to information on children’s nutrition, parents still make many mistakes preparing their meals. Thus, this study aimed to evaluate the impact of parents’ nutritional education on children’s selected anthropometric-metabolic parameters during their first year of life. The study comprised a group of parents of 203 Polish infants. Their parents were randomly assigned to one of two groups: the intervention group received intensive mobile nutritional education for a year, while the control group received no intervention. Blood tests and anthropometric measures were performed on both groups at the beginning of the study and one year later. Our study showed that parental nutritional education influences, among others. the BMI Z-score (the difference between the groups was 1.039) and the TG/HDL ratio (p < 0.001) in children. The final results of our study showed that proper nutritional education could improve children’s nutritional status at the population level.

The Influence of Intensive Nutritional Education on the Iron Status in Infants

Iron is an essential nutrient for a child’s proper development at every growth stage. It is crucial for the production of red blood and muscle cells, DNA replication, and the development of the brain, nervous and immune systems. Iron deficiency is the most common micronutrient deficiency in children worldwide. Despite widespread access to nutritional information for children, parents continue to make many feeding mistakes. This study aimed to assess whether any nutritional intervention would affect the iron status in children. The parents of 203 children were randomly assigned to one of two groups: the study group received intensive mobile nutritional education for a year, while the control group received no intervention. Blood tests were performed on both groups at the beginning of the study and one year later. The educational intervention resulted in statistically significantly higher levels of RBC (red blood cells; p = 0.020), HGB (haemoglobin; p = 0.039), HCT (haematocrit; p = 0.036), MCV (mean cell volume; p = 0.018) parameters and iron dietary intake (p ≤ 0.001). Even a non-targeted dietary intervention improves the iron status in children. As iron management is insufficient in most children, an iron-targeted nutritional intervention appears necessary.

Growth and Neurodevelopment of HIV-Exposed Uninfected Children: a Conceptual Framework

Purpose of Review

The population of HIV-exposed uninfected (HEU) children is expanding rapidly, and over one million HEU infants are born each year globally. Several recent studies have reported that HEU children, particularly in low- and middle-income countries, are at risk of poor outcomes, including impaired growth and neurodevelopment. However, the reasons for poor clinical outcomes amongst HEU children remain unclear.

Recent Findings

We summarise the findings from recent large studies that have characterised growth and neurodevelopment in HEU children, identified risk factors and explored underlying mechanistic pathways. We propose a conceptual framework to explain how exposure to HIV and antiretroviral therapy (ART) may lead to adverse growth and neurodevelopment in uninfected children, and review the available evidence and research gaps.

Summary

We propose that HEU children are affected both indirectly, through the augmentation of universal risk factors underlying poor growth and neurodevelopment, and directly through HIV/ART-specific pathways, which ultimately may converge through a series of common pathogenic mechanisms. In the era of universal ART, a better understanding of these pathways is crucial to inform future prevention and intervention strategies.

Environmental influences on health and development: nutrition, substance exposure, and adverse childhood experiences

Scientific advances over the last century have generated compelling evidence of the primary and secondary effects of gestational, infant, and childhood conditions. These early environmental influences have the potential not only to impact an individual's health outcomes, such as heart disease, type 2 diabetes, and cancer, but also to confer various protections and risks to that individual's descendants. The immediate and extended ramifications of early environmental exposure bring an understanding of epidemiological impact on disease states and a hope for prevention. This review highlights the contributions of several key population studies and briefly explores specific environmental influences, including nutritional deficiencies, exposure to substances and infections, and adverse childhood experiences. Mechanisms of these influences (e.g. stress and epigenetics) are discussed, as well as possible means of mitigating their negative consequences. WHAT THIS PAPER ADDS: Substance exposures in utero are associated with epigenetic changes and negative outcomes. Adverse childhood experiences in early childhood can induce HPA and epigenetic changes.

Antenatal and Postnatal Determinants of Behavioural Difficulties in Early Childhood: Evidence from Growing Up in New Zealand

Behavioural difficulties during early childhood have significant implications for multiple outcomes later in life. Child behavioural difficulties at 2 years of age (N = 6246) were assessed by mothers enrolled in a longitudinal, population-based New Zealand cohort study. 10.1% of children had total difficulties scores in the abnormal range on the preschool version of the Strengths and Difficulties Questionnaire. After controlling for maternal education, poverty, and child's birth age/weight, several antenatal and postnatal maternal health and family risk factors were significant for: (i) emotional problems (antenatal maternal perceived stress, lack of periconceptional folate, and moderate to severe maternal postnatal anxiety); (ii) hyperactivity-inattention (antenatal maternal perceived stress, mothers' antenatal exposure to secondhand smoke, moderate to severe maternal postnatal anxiety, and low maternal self-evaluation); (iii) conduct problems and total difficulties (antenatal maternal perceived stress, verbal inter-parental conflict and low maternal self-evaluation). The identification of risk and protective factors associated with early childhood difficulties are vital for guiding intervention and prevention efforts.

Preterm birth and the timing of puberty: a systematic review

BACKGROUND

An estimated 11% of births occur preterm, and survival is improving. Early studies suggested an association between preterm birth and earlier puberty. Given the adverse outcomes associated with early puberty this could have significant public health implications. The objective of this review was to assess the timing of puberty after preterm birth.

METHODS

Pubmed, Embase, Popline, Global Health and Global Health Library were searched using terms relating to "premature birth", "menarche", "puberty" and "follow up studies". Inclusion criteria were a population consisting of pubertal or post-pubertal adolescents and adults; studies which defined preterm delivery in participants and compared outcomes to those after term delivery; and a quantitative assessment of pubertal onset. Assessment of risk of bias was conducted using principles from the Critical Appraisal Study Process.

RESULTS

Our search identified 1051 studies, of which 16 met the inclusion criteria. In females, 8 studies found no association between preterm birth and the timing of menarche. Five studies found earlier onset in preterm infants, 1 found later onset, and 1 showed both earlier and later menarche, depending on birth weight. The range of effect of studies showing earlier menarche was - 0.94 to -0.07 years in the preterm group, with a median of - 0.3 years. In males, 2 studies showed earlier onset of puberty in the preterm group, 5 showed no difference, and 1 showed later onset. Most studies did not present outcomes in the form of a mean with standard deviation, precluding a meta-analysis. There was insufficient data to address potential confounding factors.

CONCLUSIONS

The published evidence does not suggest that being born preterm leads to a significant acceleration in the onset of puberty. This should prove reassuring for public health purposes, and for clinicians counseling parents of infants born preterm.

Searching the web: a survey on the quality of advice on postnatal sequelae of intrauterine growth restriction and the implication of developmental origins of health and disease

Intrauterine growth restriction (IUGR) and fetal growth restriction (FGR) are pregnancy complications associated with morbidity in later life. Despite a growing body of evidence from current research on developmental origins of health and disease (DOHaD), little information is currently provided to parents on long-term metabolic, cardiovascular and neurologic consequences. As parents strongly rely on internet-based health-related information, we examined the quality of information on IUGR/FGR sequelae and DOHaD in webpages used by laypersons. Simulating non-clinicians experience, we entered the terms 'IUGR consequences' and 'FGR consequences' into Google and Yahoo search engines. The quality of the top search-hits was analyzed with regard to the certification through the Health On the Net Foundation (HON), currentness of cited references, while reliability of information and DOHaD-related consequences were assessed via the DISCERN Plus score (DPS). Overall the citation status was not up-to-date and only a few websites were HON-certified. The results of our analysis showed a dichotomy between the growing body of evidence regarding IUGR/FGR-related sequelae and lack of current guidelines, leaving parents without clear directions. Furthermore, detailed information on the concept of DOHaD is not provided. These findings emphasize the responsibility of the individual physician for providing advice on IUGR/FGR-related sequelae, monitoring and follow-up.

Nutritional interventions or exposures in infants and children aged up to 3 years and their effects on subsequent risk of overweight, obesity and body fat: a systematic review of systematic reviews

This study, performed as part of the international EarlyNutrition research project (http://www.project-earlynutrition.eu), provides a systematic review of systematic reviews on the effects of nutritional interventions or exposures in children (up to 3 years of age) on the subsequent risk of obesity, overweight and adiposity. Electronic databases (including MEDLINE, Embase and Cochrane Library) were searched up until September 2015. Forty systematic reviews were included. A consistent association of breastfeeding with a modest reduction in the risk of later overweight and obesity in childhood and adulthood was found (the odds decreased by 13% based on high-quality studies), but residual confounding cannot be excluded. Lowering the protein content of infant formula is a promising intervention to reduce the risk of later overweight and obesity in children. There is no consistent evidence of an association of the age of introducing complementary foods, sugar-sweetened beverage or energy intake in early childhood with later overweight/obesity, but there are some indications of an association of protein intake during the complementary feeding period with later overweight/obesity. There was inadequate evidence to determine the effects of other nutritional interventions or exposures, including modifications of infant formula composition, fat intake or consumption of different food groups.

Bacillus Calmette-Guérin vaccination at birth: Effects on infant growth. A randomized clinical trial

BACKGROUND

Bacillus Calmette-Guérin vaccine (BCG) induces a complex, pro-inflammatory immune response. Obesity is associated with low-grade inflammation.

AIMS

The purpose of the study was to test whether BCG at birth has effects on infant growth and body composition.

STUDY DESIGN, SUBJECTS, AND OUTCOME MEASURES

The Danish Calmette Study is a randomized, clinical trial. The study was conducted at three university hospitals and randomized 4262 children of gestational age ≥32weeks to receive BCG within seven days of birth or to a no-intervention control group. Follow-up consisted of clinical examinations. Outcome measures were weight and length at 3months, and weight, length, mid upper-arm circumference, and triceps and subscapular skinfold at 13months. Data collectors were blinded to allocation. Anthropometric measurements were converted to z-scores using WHO reference population.

RESULTS

Follow-up was 94% complete at 3 and 13months after birth. The children were bigger than the WHO reference population. There was no effect of BCG on weight z-score at 13months (-0.028 [95% confidence interval: -0.085 to 0.029], p=0.34). There was no effect on weight and length at 3months, or length, mid-upper-arm circumference, or triceps and subscapular skinfold at 13months.

CONCLUSION

In this study, vaccination with BCG at birth did not have effects on child growth or body composition at 13months.

TRIAL REGISTRATION

www.clinicaltrials.gov, registration number NCT01694108.

The accuracy of dietary recall of infant feeding and food allergen data

BACKGROUND

Research investigating the association of infant dietary factors with later health outcomes often relies on maternal recall. It is unclear what the effect of recall bias is on the accuracy of the information obtained. The present study aimed to determine the extent of recall bias on the accuracy of infant feeding and food allergen data collected 10 years later.

METHODS

Mothers were recruited from a prospective birth cohort from the Isle of Wight. When their child was 10 years of age (2011/2012), mothers were requested to complete a retrospective infant feeding questionnaire asking the same questions as those solicited in 2001/2002.

RESULTS

In total, 125 mothers participated. There was substantial agreement for recollection of any breastfeeding (κ = 0.79) and the duration of breastfeeding from 10 years earlier (r = 0.84). Some 94% of mothers recalled accurately that their child had received formula milk. The exact age at which formula milk was first given was reliably answered (r = 0.63). The brand of formula milk was poorly recalled. Recall of age of introduction of solid food was not reliable (r = 0.16). The age of introduction of peanuts was the only food allergen that was recalled accurately (86%).

CONCLUSIONS

The present study highlights the importance of maternal recall bias of infant feeding practices over 10 years. Recall related to breastfeeding and formula feeding were reliable, whereas recalls related to age of introduction of solid or allergenic foods, apart from peanut, were not. Caution should be applied when interpreting studies relying on dietary recall.

Gastric transposition as a valid surgical option for esophageal replacement in pediatric patients: experience from three Italian medical centers

Background: Esophageal replacement in children is an option that is confined to very few situations including long-gap esophageal atresia and esophageal strictures unresponsive to other therapies (peptic or caustic ingestion). The purpose of our work was to describe the experience of gastric transposition in three Italian centers.

Methods: This is a retrospective study. The data were extrapolated from a prospective database. We included all patients who had undergone gastric transposition in the last 15 years.

Results: In the 15-year period, eight infants and children (3 males and 5 females) underwent gastric transposition for esophageal replacement. Six patients had long-gap esophageal atresia, and two had caustic esophageal stenosis. There were no deaths in the series. Three patients had an early postoperative complication: two had a self-limited salivary fistula at three weeks, and one (a patient with jejunostomy) had a jejunal perforation treated surgically. One late complication, anastomotic stricture, was recorded that required two endoscopic dilatations. The median follow-up was 60 months (range: 18–144 months). At final clinical follow-up, six patients had no eating problems, and two patients had some difficulties with eating (jejunostomy in situ), but they underwent logopedic therapy with improved outcomes. All patients had an increase in body weight and height postoperatively.

Conclusion: Our small study reports the clinical experience of three Italian centers in which gastric transposition was performed with excellent results, both in terms of surgical technique (simplicity, reproducibility, complication rate) and clinical follow-up (good oral feeding of young patients, normal social life and regular growth curves).