Dietary approaches to prevent and treat hypertension: Public and private sector policies and programs can strengthen the foundations of health through their ability to enhance the capacities of caregivers and communities in the multiple settings in which children grow up. It is constantly being regenerated and absorbed, and replaces about once every 5—6 hours. Foods with low glycemic indexes include oats, barley, bulgur, beans, lentils, legumes, pasta, pumpernickel coarse rye bread, apples, oranges, milk, yogurt, and ice cream. Stria medullaris of thalamus Thalamic reticular nucleus Taenia thalami. Language intervention strategies in aphasia and related neurogenic communication disorders 4th ed.
Although neurodevelopment continues throughout the life of a healthy person, by age 2 years the brain has undergone tremendous restructuring. Many of the developmental changes expected to occur during this period will not be able to occur in later life.
The period of fetal life and the first 2 years postpartum may be seen as a time of tremendous opportunity for neurodevelopment and a time of great vulnerability. In infants and children, toxic stress, emotional deprivation, and infection or inflammation have been shown to be associated with less optimal brain development, and a deficient diet for the child can worsen this.
The effects of early adverse experiences may be a lifetime of medical and psychosocial problems, lost academic achievement and productivity, and possible effects on the next generation. For the purposes of this discussion, our focus is on the nutritional environment of the fetus, infant, and toddler. The nutritional environment has an effect on whether brain growth and differentiation proceed normally or abnormally. Both adequate overall nutrition ie, absence of malnutrition and provision of adequate amounts of key macro- and micronutrients at critical periods in development are necessary for normal brain development.
It is important to recognize that many nutrients exhibit a U-shaped risk curve, whereby inadequate or excessive amounts both place the individual at risk. Each of these 2 forms of malnutrition affects neurodevelopment, and they may coexist in an individual. In this Policy Statement, we seek to inform pediatricians and other health care providers of the key role of nutrition in brain development in the first days of life conception to 2 years of age.
It is not meant as a comprehensive review of the data on brain-nutrient interaction for this, see Rao and Georgieff With this policy statement, we intend to support pediatricians and other health care providers in promoting healthy nutrition and advocating for the expansion of programs that affect early life nutrition as a means of providing scaffolding for later nutritional programs and preventing early developmental loss.
Macronutrient protein, fat, glucose sufficiency is essential for normal brain development. Early macronutrient undernutrition is associated with lower IQ scores, reduced school success, and more behavioral dysregulation. Two villages received a high-calorie, high-protein supplement, and 2 villages received a low-calorie supplement without protein. Both supplements contained vitamins and minerals. The supplements were provided for pregnant and lactating women and children up to age 7 years.
The investigators measured locally relevant outcomes over a period longer than 10 years, assessing children between 13 and 19 years of age. Children who had received high-calorie, high-protein supplementation before age 2 years scored higher on tests of knowledge, numeracy, reading, and vocabulary and had faster reaction times in information-processing tasks than age-matched children who received the low-calorie supplement.
In villages receiving the high-calorie, high-protein supplement, there were no differences in test scores between children of high and low socioeconomic status, but in villages receiving the low-calorie supplements, children in the higher socioeconomic group had higher test scores. In summary, early supplementation of nutrients to children at risk for macronutrient deficiency improved neurodevelopmental outcomes over an extended period of life, beyond the period of supplementation.
There are populations in the United States that, similar to the villages in Guatemala, have inadequate access to macronutrients or only access to low-quality macronutrients. Although parents shield children from the worst effects of food insecurity, in approximately half of these food-insecure households, children were food insecure. The failure to provide adequate macronutrients or key micronutrients at critical periods in brain development can have lifelong effects on a child.
In addition to generalized macronutrient undernutrition, deficiencies of individual nutrients may have a substantial effect on neurodevelopment Table 1. Prenatal and early infancy iron deficiency is associated with long-term neurobehavioral damage that may not be reversible, even with iron treatment.
Deficiency of iodine in pregnant women leads to cretinism in the child, with attendant severe, irreversible developmental delays. Mild to moderate postnatal chronic iodine deficiency is associated with reduced performance on IQ tests. Traditions in complementary feeding or restricted diets because of poverty or neglect may reduce infant intake of many key factors in normal neurodevelopment, including zinc, protein, and iron.
As the normative infant feeding, human milk and breastfeeding play a crucial role in neurodevelopment. Although randomized trials are not feasible, improved cognitive function in term and preterm infants who are fed human milk compared with those who are fed formula is supported by the weight of evidence on this topic. Although there is evidence that obesity in children and adolescents is associated with poorer educational success, studies are often complicated by small sample size, failure to control for confounding factors, and other aspects of study design.
Weight gain alone, particularly when excessive weight is gained, may not achieve the desired goal of preserving brain development in the very low birth weight preterm infant. In summary, nutrition is 1 of several factors affecting early neurodevelopment and is a factor that pediatricians and other health care providers have the capacity to improve by application of well-described, well-piloted, effective interventions. Failure to provide adequate essential nutrients during the first days of life may result in increased expenditures later in the form of medical care, psychiatric and psychological care, remedial education, loss of wages, and management of behavior.
Thus, early nutritional intervention provides enormous potential advantages across the life span and, if nutritional needs are unmet in this period, developmental losses occur that are difficult to recover. Opportunities to improve early child nutrition, and thus neurodevelopment, are currently focused in 2 areas: It should be noted that programs that serve the nutritional needs of children after the first days form a crucial link from this early period to adulthood and are most effective when building on a scaffolding of optimal early nutrition.
As such, it is the most important program providing nutritional support in the first days. WIC supports breastfeeding prenatally through education and postpartum by helping mothers breastfeed, and they perform screening for anemia in women and children receiving services through the program. Published evidence supports the impact of WIC on the health of children: Despite the impact of WIC, children in many families who do not qualify under current guidelines would benefit from the nutrients and educational support of this program.
Children whose families are on the margin of qualification for WIC may, for economic reasons, subsist on cheaper, less nutritionally replete diets. Many families fail to take advantage of the program after the first year of life, in part because of the challenge of access. Keeping families in the program longer for example, through the elimination of the requirement to recertify eligibility at 1 year of age and extending eligibility for WIC through 6 years of age will make supplemental food available to the growing toddler.
WIC is a crucial program in providing food and education to support neurodevelopment. Seventy-two percent of households served are families with children. The Child and Adult Care Food Program CACFP is administered by the USDA and, among other things, provides money to assist child care institutions and family or group day care homes in providing nutritious foods that contribute to the wellness, healthy growth, and development of children.
Completion of the revision of CACFP meal requirements to make them more consistent with the Dietary Guidelines for Americans DGA 39 should improve the nutritional quality of these meals for young children. Food pantries and soup kitchens are generally community-supported programs that serve as a safety net for children and families struggling with inadequate food.
However, many charitable food providers are not consistently able to provide healthful food in general, nutritional items appropriate for infants and toddlers, or amounts adequate to protect children from inadequate nutrition for more than a few days.
Congress established the Maternal, Infant, and Early Childhood Home Visiting Program in to provide funds for states and tribes providing voluntary, evidence-based home visiting to at-risk families. In , the Birth to 24 Months project was started to develop guidelines for children in that age group. It begins with the formulation of questions, systematic reviews through the Nutrition Evidence Library at the USDA, and the grading of evidence on the basis of study quality, consistency of findings, number of studies and subjects, impact of outcome, and generalizability of findings.
The final report and incorporation of these guidelines into the overall DGA is expected in Because these guidelines are the reference point for state and federal policies and programs, pediatricians should be aware of the importance of these guidelines. The DGA saw an organized and concerted effort by special interest groups to subvert or dilute the results of the guideline process and the process itself.
It is important that pediatricians, who are familiar with using evidence-based clinical guidelines, advocate for the scientific foundations of this process and support implementation of the guidelines.
The American Academy of Pediatrics AAP provides substantial information on the nutritional needs and support of children from birth to age 2 years, including information and guidance on breastfeeding 45 and on feeding infants and toddlers. Pediatricians, family physicians, obstetricians, and other child health care providers need to be knowledgeable about breastfeeding to educate pregnant women about breastfeeding and be prepared to help breastfeeding mothers and their infants when problems occur.
The AAP recommends exclusive breastfeeding for approximately the first 6 months of life and continuation after complementary foods have been introduced for at least the first year of life and beyond, as long as mutually desired by mother and child.
Several organizations have reviewed interventions to support breastfeeding. Pediatricians, family physicians, obstetricians, and other child health care providers can advocate at the local, state, and federal levels to preserve and strengthen nutrition programs with a focus on maternal, fetal, and neonatal nutrition.
Interventions to ensure normal neurodevelopment include programs to minimize adverse environmental influences and programs to mitigate the effects of adverse environmental influences.
These interventions begin with nutritional health for the pregnant woman, including adequate protein-energy intake, appropriate gestational weight gain, and iron sufficiency. To some degree, the placenta protects the fetus in terms of prioritization of nutrients from the mother.
After birth, human milk provides optimal neurodevelopmental nutrition for at least the first 6 months. Pediatricians and other child health care providers can become conversant about food sources that supply the critical nutrients necessary for brain development during particularly important times.
Although most pediatricians are aware that exclusive breastfeeding is the best source of nutrition for the first 6 months, dietary advice thereafter is less robust. Moreover, knowing which nutrients are at risk in the breastfed infant after 6 months eg, zinc, iron, vitamin D will guide dietary recommendations in the clinic or practice.
Guidance for pediatricians is provided in existing documents Tables 1 and 2 but over a spectrum of resources and chapters, and it is often without clear prescriptive recommendations;.
Leaders in childhood nutrition can advocate for incorporating into existing nutritional advice an actionable guide to healthy eating as a positive choice rather than an avoidance of unhealthy foods. This would give pediatricians and families more prescriptive advice as to optimal dietary choices. Pediatricians and other child health care providers can focus the attention of existing programs on improving micro- and macronutrient offerings for infants and young children.
For example, providing information to existing food pantries and soup kitchens to create food packages and meals that target the specific needs of pregnant women, breastfeeding women, and children in the first 2 years of life;. Pediatricians and other child health care providers can encourage families to take advantage of programs providing early childhood nutrition and advocate for eliminating barriers that families face to enrolling and remaining enrolled in such programs.
Many families do not take advantage of WIC services after the first year of life. Encouraging the use of services and benefits for which the family is eligible and eliminating the requirement to recertify eligibility for young children at 1 year of age can improve early life nutrition for children;.
Pediatricians and other child health care providers can oppose changes in eligibility or financing structures that would adversely affect key programs providing early childhood nutrition. Such changes include changing funding to block grants or delinking nutrition and health assistance programs, such as the adjunctive eligibility between WIC and Medicaid. Federal nutrition programs such as SNAP are successful because of eligibility rules and a funding structure that makes benefits available to children in almost all families with little income and few resources;.
Pediatricians and other child health care providers can anticipate neurodevelopmental concerns in children with early nutrient deficiency. Pediatricians can educate themselves as to which nutrients are at risk for deficiency and at what age as well as about appropriate screening for children at high risk.
For example, the risk of iron deficiency is not equal throughout the pediatric life span. Pediatricians can be aware that the newborn, the toddler, and the adolescent are at highest risk and should be aware of factors that increase those risks;.
As pediatricians consider their personal contribution to social action, involvement in 1 of these organizations is an excellent option see Table 3. This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors.
All authors have filed conflict of interest statements with the American Academy of Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication. Policy statements from the American Academy of Pediatrics benefit from expertise and resources of liaisons and internal AAP and external reviewers.
However, policy statements from the American Academy of Pediatrics may not reflect the views of the liaisons or the organizations or government agencies that they represent. The guidance in this statement does not indicate an exclusive course of treatment or serve as a standard of medical care.
Variations, taking into account individual circumstances, may be appropriate. All policy statements from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time. The 1, Days mark is used with permission from 1, Days. The authors have indicated they have no financial relationships relevant to this article to disclose. Relevant policies include both legislative and administrative actions that affect systems responsible for primary health care, public health, child care and early education, child welfare, early intervention, family economic stability including employment support for parents and cash assistance , community development including zoning regulations that influence the availability of open spaces and sources of nutritious food , housing, and environmental protection, among others.
It is also important to underscore the role that the private sector can play in strengthening the capacities of families to raise healthy and competent children, particularly through supportive workplace policies such as paid parental leave, support for breastfeeding, and flexible work hours to attend school activities and medical visits. Notwithstanding the important goal of ensuring a medical home for all children, extensive evidence on the social determinants of health indicates that the reduction of disparities in physical and mental well-being will depend on more than access to high-quality medical care alone.
Moreover, as noted previously, experience tells us that continuing calls for enhanced coordination of effort across service systems are unlikely to be sufficient if the systems are guided by different values and bodies of knowledge and the effects of their services are modest. With these caveats in mind, pediatricians are strategically situated to mobilize the science of early childhood development and its underlying neurobiology to stimulate fresh thinking about both the scope of primary health care and its relation to other programs serving young children and their families.
Indeed, every system that touches the lives of children—as well as mothers before and during pregnancy—offers an opportunity to leverage this rapidly growing knowledge base to strengthen the foundations and capacities that make lifelong healthy development possible. Toward this end, explicit investments in the early reduction of significant adversity are particularly likely to generate positive returns.
The possibilities and limitations of well-child care within a multidimensional health system have been the focus of a spirited and enduring discussion within the pediatric community. Basic recommendations for routine developmental screening and referrals to appropriate community-based services have been particularly difficult to implement. Despite long-standing calls for an explicit, community-focused approach to primary care, a recent national study of pediatric practices identified persistent difficulties in achieving effective linkages with community-based resources as a major challenge.
This challenge is further complicated by the marked variability in quality among community-based services that are available—ranging from evidence-based interventions that clearly improve child outcomes to programs that appear to have only marginal effects or no measurable impacts. Thus, although chronic difficulty in securing access to indicated services is an important problem facing most practicing pediatricians, the limited evidence of effectiveness for many of the options that are available particularly in rural areas and many states in which public investment in such services is more limited presents a serious problem that must be acknowledged and afforded greater attention.
At this point in time, the design and successful implementation of more effective models of health promotion and disease prevention for children experiencing significant adversity will require more than advocacy for increased funding.
It will require a deep investment in the development, testing, continuous improvement, and broad replication of innovative models of cross-disciplinary policy and programmatic interventions that are guided by scientific knowledge and led by practitioners in the medical, educational, and social services worlds who are truly ready to work together and to train the next generation of practitioners in new ways.
To this end, science suggests that 2 areas are particularly ripe for fresh thinking: For more than a century, child welfare services have focused on physical safety, reduction of repeated injury, and child custody. Within this context, the role of the pediatrician is focused largely on the identification of suspected maltreatment and the documentation and treatment of physical injuries. Advances in our understanding of the impact of toxic stress on lifelong health now underscore the need for a broader pediatric approach to meet the needs of children who have been abused or neglected.
In some cases, this could be provided within a medical home by skilled clinicians with expertise in early childhood mental health. In reality, however, the magnitude of needs in this area generally exceeds the capacity of most primary care practice settings. A report from the Institute of Medicine and National Research Council 15 stated that these needs could be addressed through regularized referrals from the child welfare system to the early intervention system for children with developmental delays or disabilities; subsequent federal reauthorizations of the Keeping Children and Families Safe Act and the Individuals with Disabilities Education Act Part C both included requirements for establishing such linkages.
The implementation of these federal requirements, however, has moved slowly. The Centers for Disease Control and Prevention has taken an important step forward by promoting the prevention of child maltreatment as a public health concern. The widespread absence of attention to the mother-child relationship in the treatment of depression in women with young children is another striking example of the gap between science and practice that could be reduced by targeted pediatric advocacy.
Advocating for payment mechanisms that require or provide incentives for the coordination of child and parent medical services eg, through automatic coverage for the parent-child dyad linked to reimbursement for the treatment of maternal depression offers 1 promising strategy that American Academy of Pediatrics state chapters could pursue.
As noted previously, although some medical homes may have the expertise to provide this kind of integrative treatment, most pediatricians rely on the availability of other professionals with specialized skills who are often difficult to find. Whether such services are provided within or connected to the medical home, it is clear that standard pediatric practice must move beyond screening for maternal depression and invest greater energy in securing the provision of appropriate and effective treatment that meets the needs of both mothers and their young children.
The targeted messages conveyed in these 2 examples are illustrative of the kinds of specific actions that offer promising new directions for the pediatric community beyond general calls for comprehensive, family-centered, community-based services.
Although the practical constraints of office-based practice make it unlikely that many primary care clinicians will ever play a lead role in the treatment of children affected by maltreatment or maternal depression, pediatricians are still the best positioned among all the professionals who care for young children to provide the public voice and scientific leadership needed to catalyze the development and implementation of more effective strategies to reduce adversities that can lead to lifelong disparities in learning, behavior, and health.
A great deal has been said about how the universality of pediatric primary care makes it an ideal platform for coordinating the services needed by vulnerable, young children and their families. In this respect, the medical home is strategically positioned to play 2 important roles. The first is to ensure that needs are identified, state-of-the-art management is provided as indicated, and credible evaluation is conducted to assess the effects of the services that are being delivered.
The second and, ultimately, more transformational role is to mobilize the entire pediatric community including both clinical specialists and basic scientists to drive the design and testing of much-needed, new, science-based interventions to reduce the sources and consequences of significant adversity in the lives of young children.
No other profession brings a comparable level of scientific expertise, professional stature, and public trust—and nothing short of transformational thinking beyond the hospital and office settings is likely to create the magnitude of breakthroughs in health promotion that are needed to match the dramatic advances that are currently emerging in the treatment of disease.
This new direction must be part of the new frontier in pediatrics—a frontier that brings cutting-edge scientific thinking to the multidimensional world of early childhood policy and practice for children who face significant adversity. Moving that frontier forward will benefit considerably from pediatric leadership that provides an intellectual and operational bridge connecting the basic sciences of neurobiology, molecular genetics, and developmental psychology to the broad and diverse landscape of health, education, and human services.
A vital and productive society with a prosperous and sustainable future is built on a foundation of healthy child development. When developing biological systems are strengthened by positive early experiences, children are more likely to thrive and grow up to be healthy, contributing adults.
Sound health in early childhood provides a foundation for the construction of sturdy brain architecture and the achievement of a broad range of skills and learning capacities. Together these constitute the building blocks for a vital and sustainable society that invests in its human capital and values the lives of its children.
Advances in neuroscience, molecular biology, and genomics have converged on 3 compelling conclusions: This technical report presents a framework for integrating recent advances in our understanding of human development with a rich and growing body of evidence regarding the disruptive effects of childhood adversity and toxic stress. The EBD framework that guides this report suggests that many adult diseases are, in fact, developmental disorders that begin early in life.
This framework indicates that the future of pediatrics lies in its unique leadership position as a credible and respected voice on behalf of children, which provides a powerful platform for translating scientific advances into more effective strategies and creative interventions to reduce the early childhood adversities that lead to lifelong impairments in learning, behavior, and health.
Advances in a broad range of interdisciplinary fields, including developmental neuroscience, molecular biology, genomics, epigenetics, developmental psychology, epidemiology, and economics, are converging on an integrated, basic science of pediatrics see Fig 1. Rooted in a deepening understanding of how brain architecture is shaped by the interactive effects of both genetic predisposition and environmental influence, and how its developing circuitry affects a lifetime of learning, behavior, and health, advances in the biological sciences underscore the foundational importance of the early years and support an EBD framework for understanding the evolution of human health and disease across the life span.
The biology of early childhood adversity reveals the important role of toxic stress in disrupting developing brain architecture and adversely affecting the concurrent development of other organ systems and regulatory functions. Toxic stress can lead to potentially permanent changes in learning linguistic, cognitive, and social-emotional skills , behavior adaptive versus maladaptive responses to future adversity , and physiology a hyperresponsive or chronically activated stress response and can cause physiologic disruptions that result in higher levels of stress-related chronic diseases and increase the prevalence of unhealthy lifestyles that lead to widening health disparities.
The lifelong costs of childhood toxic stress are enormous, as manifested in adverse impacts on learning, behavior, and health, and effective early childhood interventions provide critical opportunities to prevent these undesirable outcomes and generate large economic returns for all of society. The consequences of significant adversity early in life prompt an urgent call for innovative strategies to reduce toxic stress within the context of a coordinated system of policies and services guided by an integrated science of early childhood and early brain development.
An EBD framework, grounded in an integrated basic science, provides a clear theory of change to help leaders in policy and practice craft new solutions to the challenges of societal disparities in health, learning, and behavior see Fig 2. This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have filed conflict of interest statements with the American Academy of Pediatrics.
Any conflicts have been resolved through a process approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication.
The guidance in this report does not indicate an exclusive course of treatment or serve as a standard of medical care.
Variations, taking into account individual circumstances, may be appropriate. All technical reports from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time.
We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address. Skip to main content. Search for this keyword. A statement of reaffirmation for this policy was published at e From the American Academy of Pediatrics.
Shonkoff , Andrew S. Siegel , Mary I. Dobbins , Marian F. Earls , Andrew S. Abstract Advances in fields of inquiry as diverse as neuroscience, molecular biology, genomics, developmental psychology, epidemiology, sociology, and economics are catalyzing an important paradigm shift in our understanding of health and disease across the lifespan. Introduction Of a good beginning cometh a good end.
John Heywood, Proverbs The United States, like all nations of the world, is facing a number of social and economic challenges that must be met to secure a promising future. A New Framework for Promoting Healthy Development Advances in our understanding of the factors that either promote or undermine early human development have set the stage for a significant paradigm shift. Understanding the Biology of Stress Although genetic variability clearly plays a role in stress reactivity, early experiences and environmental influences can have considerable impact.
Toxic Stress and the Developing Brain In addition to short-term changes in observable behavior, toxic stress in young children can lead to less outwardly visible yet permanent changes in brain structure and function. Toxic Stress and the Early Childhood Roots of Lifelong Impairments in Physical and Mental Health As described in the previous section, stress-induced changes in the architecture of different regions of the developing brain eg, amygdala, hippocampus, and PFC can have potentially permanent effects on a range of important functions, such as regulating stress physiology, learning new skills, and developing the capacity to make healthy adaptations to future adversity.
Broadening the Framework for Early Childhood Policy and Practice Advances across the biological, behavioral, and social sciences support 2 clear and powerful messages for leaders who are searching for more effective ways to improve the health of the nation.
Defining a Distinctive Niche for Pediatrics Among Multiple Early Childhood Disciplines and Services Notwithstanding the important goal of ensuring a medical home for all children, extensive evidence on the social determinants of health indicates that the reduction of disparities in physical and mental well-being will depend on more than access to high-quality medical care alone. Summary A vital and productive society with a prosperous and sustainable future is built on a foundation of healthy child development.
Conclusions Advances in a broad range of interdisciplinary fields, including developmental neuroscience, molecular biology, genomics, epigenetics, developmental psychology, epidemiology, and economics, are converging on an integrated, basic science of pediatrics see Fig 1. Lead Authors Jack P. Shonkoff, MD Andrew S. Dobbins, MD Marian F. Earls, MD Andrew S. Consultant and Lead Author Jack P. Jaudes, MD Veronnie F.
Jones, MD David M. Rubin, MD Elaine E. Footnotes This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. The foundations of lifelong health are built in early childhood.
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