5. Epigenetics Physiology of Stress Neuroscience
The Science of Early
Brain and Child
Development
Education Health Economics
One Science – Many Implications
The critical challenge now is to translate game-changing advances in
developmental science into effective policies and practices for families
with children to improve education, health and lifelong productivity
education
5
6. Human rights
Altered Immunity
in IDA & PEM The International Convention on
Children Human Rights, to which nearly all
countries of the world adhere,
includes the right to access to food.
Hunger and malnutrition are a
violation of human rights.
Nutrition is now so much a part of the
consciousness of today’s political leaders,
that the current political and economic
crisis will not in the long run jeopardize the
remarkable progress that has been achieved
in overcoming or reducing the burden of
IDA children
PEM children
malnutrition on the population of the
Normal children country. 6
7. Intervention Types
Increase Intake of Vitamins Promote Good Nutritional
and Minerals Practices
• Vitamin A supplements • Breastfeeding
• Zinc supplements • Complementary feeding
• Micronutrient powders • Improved hygiene practices
• De-worming drugs • Diet diversification
• Iron/folic acid supplements • Wheat
for pregnant women Prevent and Treat Moderate
• Iodized oil capsules and Severe Malnutrition
• Salt iodization • Treatment of severe
• Iron fortification undernutrition with RUTF
• Fortification of staple • Prevention/treatment of
foods/bio-fortification moderate undernutrition
• Vitamins
7
8. 3 Objectives For Today
• Provide a generalist’s overview of advances in developmental
science
• Present an organizing, integrated, eco bio developmental
framework
• Discuss ways pediatricians might assist in translating science into
healthier life-courses
Critical Concept
Childhood Adversity has Lifelong Consequences.
Significant adversity in childhood is strongly associated with
unhealthy lifestyles and poor health decades later.
Barker Law states ‘Adulthood Diseases of Infancy –NCD- like-
HTN, CAD, DM, Osteo Arthritis, Cancer etc
8
9. Developing a Model of
Human Health and Disease
How do you begin What are the
to define or mechanisms
measure the underlying these
nt
Th
ecology? well-established
me
r
He havio
e
Ec
so viro
associations?
alth
p
olo
cia nm
en
And g, Be
Lea elo
la
Life Course
nd ent
g
in
y
Dev
rn
Science
ph
ysi
ca
l
Early childhood ecology
strongly associates with
lifelong developmental outcomes 9
10. Nutrition during & after pregnancy
Conception to 2nd week
– Umbilical cord not formed
– Mother’s food intake does not
have an effect on the embryo up
to 2 wks
– From 2 wks mother need extra
Energy, extra Protein, extra
EFA, extra Iron, Calcium &
other Micronutrients.
– Lactating mother need more
than in Antenatal Period.
10
11. Peak Age of Malnutrition
Feeding Practices
The incidence of malnutrition
Inappropriate feeding
rises sharply during the period
practices are major cause of
from 6 to 18 mo of age in most
the onset of malnutrition in
countries. young children.
The deficits acquired at this age
are difficult to compensate for
later in childhood. 11
12. Intelligence quotient by type of feeding
BF 12.9 points
BF 2 points higher than FF
higher than FF Study in 9.5
year-olds
Study in 3-7
1996
year-olds
1982
BF 8.3 points
higher than FF
Study in 7.5-8
BF 2.1 points year-olds
higher than FF 1992
Study in 6 months
to 2 year- olds References:
1988 BM 7.5 points
•Fergusson DM et al. Soc
higher than no BM SciMed 1982
Study in 7.5-8 •Morrow-Tlucak M et al.
BF = breastfed year-olds SocSciMed 1988
FF = formula fed •Lucas A et al. Lancet 1992
BM = breast milk 1992 •Riva Eet al. Acta Paediatr 1996
13. Early Introduction of Foods
Other Than Breast milk Has Risks
• All major medical
organizations recommend
exclusive breastfeeding the first
six months
• Infant’s digestive and immune
systems are still developing
• Starting complementary foods
too early replaces a superior
food (breast milk) with an
inferior food
13
14. Breastfeeding + Complementary Foods
• First six months: Exclusive breastfeeding
• After six months:
– Breastfeed as often as the child wants
• Begin complementary foods in small amounts
• Until two years:
– Breastfeed as often as the child wants
– Continue complementary foods, gradually increasing
quantities and frequency as the child gets older
World Health Organization, Complementary Feeding: Family foods for breastfed children.
2000.
14
15. How to Know Baby Is Ready for
Complementary Foods
• Can sit up with support
• Has good head and neck control
• Has lost the “tongue thrust” reflex and is able to
swallow solids
• Is able to pick up objects with thumb and index
finger
• Shows keen interest in family meals and reaches
for foods
15
16. Beginning Complementary Foods
• Complementary foods are an addition to breast milk, not a
replacement
• Breast milk continues to provide 35-40% of infant’s total
daily energy needs for 12-23 months
• Begin with very small amounts of complementary foods
(a few teaspoons)
– 6 to 8 months – 2-3 times/day
– 9 to 11 months – 3-4 times/day
– 12 to 24 months – 3-4 times/day plus 1-2 nutritious snacks
The requirement for breast-milk The estimated energy requirements
substitutes after six months: from complementary foods, assuming
an average breast-milk intake, are:
• At 6–8 months, 600 ml/ day 200 kcal/day for infants aged 6–8 mos,
• At 9–11 months, 550 ml/ day 300 kcal/day for infants aged 9–11 mos,
• At 12–23 months, 500 ml/ day 550 kcal/day for child aged 12–23 mos.
16
17. Complementary Food
Only Cereals Cereals & Pulses
Cereals, Pulses & Citreous Fruits
Stomach capacity of newborn to
1 yr increases by 10 times.
Stomach Volume of adult is:
20.4ml/KG of BW
& 30gm/KG of BW
17
18. Three meals Three meals and two snacks
Complementary foods
Complementary foods should be varied and include adequate quantities
of meat, poultry, fish or eggs, vitamin A-rich fruits and vegetables daily.
Where this is not possible, the use of fortified complementary foods
and vitamin mineral supplements may be necessary to ensure adequacy
of particular nutrient intakes. 18
19. Complementary foods Improvisation of House Hold Foods
• As infants grow, the consistency • Household technologies such
of complementary foods should as fermentation, soaking,
change from semisolid to solid roasting and malting can
foods and the variety of foods improve taste, texture, safety
offered should increase. and quality of
• By eight months, infants can eat complementary foods.
‘finger foods.’ • An adequate nutrient level
remains a concern,
• By 12 months, most children can
particularly in diets that are
eat the same types of food as the
mainly plant-based.
rest of the family.
• Indian diets are often more
viscous.
19
19
20. Responsive Feeding
• Offer complementary foods after • Feed infants directly; assist older
children when they feed
breastfeeding to avoid overfeeding with themselves
solids and negatively impacting • Be sensitive to hunger and satiety
mother’s milk supply cues
• Offer only one new food at a time • Feed slowly and patiently –
• Offer very small portions encourage children to eat but do
not force them
(a few teaspoons at a time)
• Experiment with food
• Vary tastes and textures combinations, tastes, and textures
• Avoid potential allergy-producing foods • Minimize distractions
(nuts, cow’s milk, casein) • Make feeding a time of learning
and love
• Learn healthy eating habits
Let the Child
Feel important & loved
Feel understood and respected
Trust that others will care for
him / her
Feel good about his / her body
20
21. Appropriate complementary feeding Improving feeding behaviors
Timely – meaning that foods are
introduced when the need for energy Improving complementary feeding
and nutrients exceeds what can be
provided through exclusive and requires attention to foods as well
frequent breastfeeding; as to feeding behavior of
Adequate – meaning that foods provide
sufficient energy, protein, and caregivers.
micronutrients to meet a growing
child’s nutritional needs; Infants and young children need
Safe – meaning that foods are assistance that is appropriate for
hygienically stored and prepared, and
fed with clean hands using clean their age and developmental needs
utensils and not bottles and teats;
to ensure that they consume
Properly fed – meaning that foods are
given consistent with a child’s signals adequate amounts of
of appetite and satiety, and that meal
frequency and feeding method – complementary food.
actively encouraging the child to
consume sufficient food using This is called responsive feeding.
fingers, spoon or self-feeding – are
suitable for age. 21
22. Responsive Feeding
• Feeding with a balance between • Feeding with positive verbal
giving assistance and encouragement, without verbal
encouraging self-feeding, as or physical coercion
appropriate to the child’s level • Feeding with age-appropriate
of development and culturally appropriate eating
• Being sensitive to their early utensils
hunger and satiety cues • Feeding in a protected and
• Feeding by an individual with comfortable environment
whom the child has a positive • Feeding times are periods of
emotional relationship and who learning and love − talk to
is aware of and sensitive to the children during feeding, with
individual child’s characteristics, eye to eye contact
including changes in physical
and emotional state.
22
23. Responsive Feeding
• Feed slowly and patiently, • Establish regular meal and
and encourage children to snack times beginning when
eat, but do not force them.
• If children refuse many child is 9-12 mos old.
foods, experiment with • Routines help children look
different food forward to each meal but
combinations, tastes, don’t make the routine very
textures and methods of strict.
encouragement. • Research shows that children
• Minimize distractions will choose a healthy diet
during meals if the child when they are offered a
loses interest easily. selection of different healthy
• Offer 3 to 4 healthy food
choices child likes at each meal. foods.
23
24. Responsive Feeding
Don’t force baby or toddler to eat Turn off the TV /computers, etc
This often results in children at mealtime.
refusing the food and eating less. • The television can distract
Don’t give up on new foods children from eating.
• Patience is the key. • It also takes time away from
• One may have to offer child a talking as a family.
new food 10 or 15 times before Healthy eating and exercise
he/ she will eat it. go hand in hand
Viscosity of Complementary Food Make active play a part of
Foods that are thick enough to stay everyday family life.
in the spoon.
24
25. Nutritional Deficiencies
• Encourage children to Deficiencies in the diet are :
drink and eat during illness • Energy
“Cocktail“
and provide extra food • Protein
Metabolic interactions
after illness to help them re • Iron
• Vitamin A should be kept in mind
cover quickly.
• Iodine while giving a "cocktail"
• Zinc of various micronutrients
• Copper in clinical practice.
• Others
are still widespread and are
common causes of excess
morbidity & mortality.
25
26. Proper Food Handling
• Wash caregivers’ and • Encourage families to
children’s hands before food continue breastfeeding if
preparation and eating baby becomes ill
• Use clean utensils, cups, and • Avoid medications or birth
bowls to prepare, serve, and control methods that can
store food disrupt or endanger
• Avoid the use of feeding breastfeeding
bottles • Encourage the use of spoons
• Serve foods immediately after and cups for feeding
preparation complementary foods,
• Store foods safely expressed breast milk, or
breast milk substitutes
26
27. Metabolic Interactions Between Various Micronutrients
There is evidence for metabolic inter-relationships between different micronutrients.
• Ascorbic acid is known to enhance the • Selenium deficiency may impair
absorption of non- haem iron. utilization of iodine because it is a key
• High intake of zinc may interfere with component of the enzyme which is
absorption of iron and copper. required to convert thyroxin to
• Riboflavin has an important role in the triiodothyronine.
absorption, metabolism and utilization of • Molybdenum intake may aggravate
iron copper deficiency because it promotes
• Vitamin A helps in iron transport, urinary excretion of copper.
hemoglobin production and thus • Vitamin E has a sparing effect on Vitamin A
improve the status of iron stores. and Ascorbic acid by protecting them from
oxidation.
• Dietary phytates and tannins are
• Magnesium facilitates absorption of Calcium
known to interfere with the absorption
from gut.
of iron.
• Calcium helps in the absorption of Vitamin
• Zinc deficiency may aggravate B12 from the ileum but
hypovitaminosis A because zinc is it interferes with
required for transport of hepatic vitamin absorption of Zinc.
A to the target tissues. • 27
All Anti- Oxidants in excess act as Pro-27
Oxidants.
29. MILK MICROBIOTA COMPOSITION &
MODE OF DELIVERY
MODE OF DELIVERY (colostrum) MODE OF DELIVERY (6 months of breastfeeding)
Cabrera-Rubio et al 2012 Am J Clin Nutr
31. Approximate yield from milk (assuming no losses)
Casein
32 kg
Skim milk
889 kg Lactose
851 kg
Casein
whey
857 kg
Cream
111 kg
Whey
whole milk 6 kg
1000 kg
(=1 tonne)
33. Brain development
5 to 6 Weeks
Forebrain
7 Weeks
Neurons forming
rapidly,1000’s/ mts Midbrain
Hindbrain
• 50,000 brain cells produced/second in
developing fetal brain
• 100 billion brain cells in adult
• 1million billion connections between
these brain cells: Determine IQ.
34. Human Brain Development
Synapse Formation Dependent on Early Experiences
Required
3 Components
1. Nutrition
2. Prevention of infection
3. Psycho Social Stimulation
Synaptic Connections
34
35. Maturation Progression
Maturation generally proceeds from the back of the brain to the front.
Explains in part…
– Preference for physical activity (back of brain)
– More risky, impulsive behaviors (limbic system)
– More moody at times (limbic system)
– Less than optimal planning and judgment (PFC)
– Poor recognition of negative consequences (PFC)
Impact of Early Stress
CHILDHOOD STRESS
Hyper-responsive stress Chronic “fight or flight;” adrenaline /cortisol
response; calm/coping
Changes in Brain Architecture
35
36. Eight Phases in Embryonic and Fetal
Development at a Cellular Level
1. Mitosi s 2. Migration 3. Aggregation 4.
Differentiation
5. Synaptogenesis 6. Death 8. Myelination
7.Rearrangement
Between
40
and 75 %
of all neurons
born in embryonic
and fetal
development do
not survive.
37. Brain Cell Connections in the Early Months
newborn 1 month 3 months 6
months
6 Years 14 Years Old
Old
37
38. Out of Balance
Prefrontal Cortex Amygdala
Cold Cognition Hot Cognition
Judgmental Emotional
Reflective Reactive
Calculating Impulsive
Think about it Just do it
Biological maturity by 24 Biological maturity by 18
Adapted from Ken Winters, Ph.D. 38
39. Parenting as Primary Prevention of Ill Health
Promoting Parenting Skills in the first 1000 days
– Parenting is personal – makes pediatricians NERVOUS!
– “Positive/Nurturing/Supportive” Parenting
– Are parenting skills “teachable?” YES!!
teachable
•Early maternal support
exerts a positive influence
on hippocampal
development
•The positive effect of
maternal support on
hippocampal volumes was
greater
in nondepressed children
Lusby et al., 2012. Available at: www.pnas.org/cgi/doi/10.1073/pnas.1118003109
39
After casein precipitation of cheese making you end up with proteins in solution that are very dilute, where you need to remove considerable water, lactose and minerals. That’s the challenge, both in terms of separation and in terms of energy efficiency.
