Prevention of chronic noncommunicable diseases

Prevention of Chronic Noncommunicable Diseases:
Pediatrician’s Role
Attilio Boner
University of
Verona, Italy
attilio.boner@univr.it
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 deaths
attributable 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 environmental
stressors.
•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 weeks
of 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 risks
characterized by failure to achieve optimal development or more
rapid 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 Health
Raju 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 Health
Raju T. J Pediatr 2017;181:309-318

Outcomes of infants born near term
Gill 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 preeclampsia
if they become pregnant.

Attilio Boner
University of
Verona, Italy
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;68:363-370
Liu 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 with
emotional regulation,
•Autism SD
of:
maternal obesity/overnutrition
during 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/Hyperactivity
Disorder–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 Mercury
Enjoy two 6-oz servings per week 1 oz = 28.4 g
Healthy eating during pregnancy.

4 yrsrapid infant
growth
In mothers with high fish intake
during pregnancy (>3 times/week)
compared with ≤ 1/week OR for
1.22
1.14
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 obesogenic
effects of tributyltin from animal studies to humans in future studies.
Fish Intake During Pregnancy and Offspring Adiposity
Editorial. 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 contains
Bisphenol 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 has
increased 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.
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.
•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 with
unique 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.
intellectual
disabilities
(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, peroxisome
proliferator-activated
receptor
EDC mechanisms of action and biological targets

Early- life PFAS exposure and child adiposity
Not
only
PFAS

Transport of perfluoroalkyl substances (PFAS) from an
arctic 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
environment
of 863 infants
evaluated 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
3.35
NIGHT
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
synthetic
pillow
+synthetic
quilt
+
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 toxins
such as arsenic and lead, mercury…
have all been associated
with an increased risk of:
adverse
neurodevelopmental
outcomes including
schizophrenia and autism.

Attilio Boner
University of
Verona, Italy
Introduction
But we are pediatricians
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-kappaB
in cortical endothelial cells occurred at ages 2 weeks;
subsequent damage included alterations of the blood-brain
barrier (BBB), degenerating cortical neurons, apoptotic glial
white matter cells.
Neurodegenerative disorders such as
Alzheimer's may begin early in life
with 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 evidence
Calderón-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 evidence
Calderón-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 1869
30 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 important
for 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

•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 offspring
http://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 Parents
Shuster 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 what
they 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 of
children 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 from
the 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 from
the 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 politics
of 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 Refugee
and Migrant Children—released on Sept 7, UNICEF paints
a 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 harrowing
circumstances.

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 health
Devakumar D, Arch Dis Child. 2016;101:596-599
The advocacy cycle - a framework
for planning an advocacy strategy

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 premature
newborn 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 Perinatal
Project, a US multicenter
prospective cohort study
from 1959-1976.
 5 weight growth
trajectories of the
1957 term small for
gestational 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.

Infant obesity
(weight-for-
length) ≥ 95th
percentile for
age and sex.
if obese at 6 months
of age
OR for obesity
at 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
Infant obesity
(weight-for-
length) ≥ 95th
percentile for
age and sex.
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-called
adiposity 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-called
adiposity rebound.
cumulative incidence of
Type 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 Adulthood
Twig G, N Engl J Med 2016;374(25):2430-40
BMI during adolescence and subsequent
cardiovascular 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 Nutrition
Guidance 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 Nutrition
Guidance 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 weight
change
In children using large
(≥180ml) bottles
Bottle Size and Weight Gain in Formula-Fed Infants
Wood CT, Pediatrics 2016;138:e20154538
0.4 –
0.3 –
0.2 –
0.1 –
00 –
more change
in WAZ
more 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 Infants
Wood 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 gained
more 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 Activity
In Infants for Obesity Prevention: An RCT
Taylor BJ, Pediatrics 2017;139(3)
802 pregnant women randomized
to 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 for
adolescent 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 be
used 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 where
people smoke?
d. Does anyone ever smoke in your
home?
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 Smoke
Farber 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 advise
and 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
Postnatal
Depression
Scale
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.
HIGH
licking
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-release
factor, and
Reduced hypothalamic-pituitary-adrenal
response to stress.
increased licking and grooming

This provides a biological basis for speculations about the
effects of poverty on early experience, and how exposure to
abuse, family strife, emotional neglect, and
harsh discipline may have epigenetic effects
that produce individual differences in neural
and endocrine response to stress and may
increase the susceptibility to common adult
disorders 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 Parents
Shuster 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

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
environmental
change 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
inflammatory
diseases (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 environmental
changes promote
inflammation and, as a
paediatricians, we could
already see the first hand
effects of this in the first
years of life in the epidemic
allergic inflammation.

Mental health comorbidity in patients with atopic
dermatitis Yaghmaie P, JACI 2013;131:428-33
 92642 noninstitutionalized
children aged 0 to 17 years.
 Lifetime prevalence of
provider-diagnosed
mental health conditions
for those with and without
a history of AD.
OR of having
Attention 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 Cunduct
disorder
Autism
4 -
3 -
2 –
1 –
0
In children with Atopic Dermatitis OR for

Reduced lung function both before bronchiolitis
and 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
bronchiolitis
prospectively
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 to
Chronic Obstructive Pulmonary Disease.
Lange P, N Engl J Med. 2015;373(2):111-22.

Early wheezing phenotypes and cognitive development
of 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
104.3
101.6 97.5
WHEEZING
Mental Development Index
at 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 of
hyperactivity–impulsivity
at age 13-14 years
2.73
Questionnaires at ages 8–9
and 13–14 yrs.
(American Psychiatric Association. Diagnostic
and statistical manual of mental disorders, 4th
edn. Washington, DC: American Psychiatric
Association; 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 in
adolescents 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 adolescents
OR for developing
2.09
2.0 –
1.0 –
0.0
1.83
P < 0.001 P < 0.001
depression anxiety

2 –
1 –
0
1.38
6mo
1.31
1.43
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 pairs
prospective birth cohort
study.
 Parental report of loud snoring
≥ 2 times weekly at 2 and 3 yrs
of age, children were
designated 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 Neurocognitive
Dysfunction of Obstructive Sleep Apnea Syndrome.
Zhou L, Oxid Med Cell Longev. 2016;2016:9626831.
repetitive hypoxia
and 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 Neurocognitive
Dysfunction 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 hypoxia
and reoxygenation

68 patients with newly
diagnosed 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

and 30 without OSA.
(ODI)
Serum levels of Mg,
plasma C-reactive protein (mg/L)
p < 0.0001

and 30 without OSA.
(ODI)
Serum levels of Mg,
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, including
activation 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
2.5
p=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;

Anionic surfactants and commercial detergents decrease
tight junction barrier integrity in human keratinocytes
Xian M, JACI 2016;138:890.
Increase in dextran
paracellular permeability
across NHEKs
treated with different surfactants.
us = unstimulated
p < 0.05
p < 0.05
cationic
surfactant
anionic
surfactant
d
e
x
t
r
a
n
 Direct effect of surfactants on
TJs of normal human epidermal
keratinocytes (NHEKs), at air-liquid
interface (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 prevention
Simpson 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 prevention
Simpson EL, J Allergy Clin Immunol 2014;134:818-23
Skin barrier
protection
might prevent
atopic
dermatitis
development.
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
2.86
3.0 –
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 –
0
Age 1 yrs
Age 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.

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=0.005
p=0.005
p<0.005p=0.0003
0.24 0.23
0.14 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
cohort
128 active group
111 control group
Allergen 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
cohort
128 active group
111 control group
Allergen 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 an
important factor
in 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 sensitization
to inhalant allergens
0.73
P-value for trend = 0.031
TAC of the diet for the 3rd
third compared to the 1st tertile
at age 8 years
1.0 –
0.5 –
0.0

birth cohort BAMSE
method.
aOR for
allergic asthma
0.57
1.0 –
0.5 –
0.0
at age 8 years

birth cohort BAMSE
method.
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
aOR for
allergic asthma
at age 8 years

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

Flavonoid intake and risk of chronic diseases
Knekt 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 quercetin
intakes OR for
1.0 –
0.9 –
0.8 –
0.7 –
0.6 –
0.5 –
0.4 –
0.3 –
0.2 –
0.1 –
0.0
0.76
0.82
0.79
0.42
lung cancer
incidence
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 with
lung function in patients with asthma.
Smith LJ, J Asthma 2004;41:833-43.
1033 asthmatics,
aged 12-75 years.
Food frequency
questionnaire
(intake of antioxidant
vitamins,
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 genistein
intake (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 trial
Bime C, Prim Care Respir J 2012 ;21:398-404

Curcumins-rich curry diet and pulmonary function in Asian
older 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 serum
25-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 respiratory
tract 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 respiratory
tract 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 length
measured 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.
nchamberlain@atsu.edu
8 microorganisms
per minute or
11,500 per day.
http://www.ariatlas.org/data_research/appendis_b

Nasal irrigation as an adjunctive treatment in allergic
rhinitis: a systematic review and meta-analysis.
Hermelingmeier KE, Am J Rhinol Allergy. 2012;26(5):e119-25.
10 randomized, controlled
trials (>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
clearance
quality
of life
40 –
30 –
20 –
10 –
0
31.2% 27.9%
With Saline Nasal Irrigation
% improvment in

Hair Zinc and Selenium Levels in Children
With Recurrent Wheezing
Razi C. H., Pediatr Pulmonol 2012; 47: 1185–1191
300 –
200 –
100 –
000
162
236 217
280
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 of
children 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- to
10-month-old
infants.
 The infants were
given oral iron for
3 months.
 Behavioral coding
from 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 iron
status for:
• increasing shyness,
• decreasing
orientation/engagement,
• decreasing soothability,
• when an examiner attempted to
engage the infants in imitative
play, decreasing positive affect
and engagement.

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 corrected
before 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 iron
deficiency
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 iron
deficiency
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
294
272
257
232


children.
S-iron, total iron
p = 0.0024

43%
YES NO
intake of cow's milk (mL/day)
496500 –
400 –
300 –
200 –
100 –
000
382
294
272
257
232


children.
S-iron, total iron
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 trial
Akkermans MD, Am J Clin Nutr. 2017;105:391-399
0.22
0.42
P<0.001
P=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.

Attilio Boner
University of
Verona, Italy
Introduction
But we are a pediatrician
Conclusions

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

stressors.
•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 Illness
Halfon N, JAMA 2010;303:665
The same adverse childhood experiences that can contribute
to the onset of childhood illness can also affect stress-sensitive
physiologic systems (nervous, endocrine/metabolic, immune),
predisposing the same individuals to develop age-related
diseases as adults. Danese A, Arch Pediatr Adolesc Med. 2009;163:1135.
This suggests that well-designed prevention strategies
initiated in childhood could be a “two-for,” preventing
childhood chronic conditions as well as the adult chronic
conditions that are likely to emerge in years to come.

The Developmental Origins od Adult Diseases
has two major implications:
First, it reinforces the growing awareness that
investment in the health and education
of young people in relation to their
responsibilities 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 develop
every child’s personality,
talents and mental and
physical abilities.
Education should teach
children to respect their
parents, their own and
other 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 Frank
1929-
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, and
social 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 Dunkirk
May 26th
June 3rd
1940
“There is no finer
investment for
any community
than putting milk
into babies.”

Thank you for
your attention
to the story
my grandpa told you.
Mia Charlize Powell

Prevention of chronic noncommunicable diseases

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