25 Giugno 2019 I primi 1000 giorni di vita: Angelo Pietrobelli Clinica Pediatrica - Università degli Studi di Verona. UOS I Primi Mille Giorni del Bambino per la Prevenzione delle Patologie Non Trasmissibili dell’Adulto Pennington Biomedical Resarch Center Baton Rouge, LA; USA DOHD Ambiente - patologia tumorale % polveri percentuali di cause di tumori Doll and Peto, 2011 Developing Brain Tra al 24 e la 42 sett. il cervello è vulnerabile agli insulti nutrizionali: - Rapida trasformazione processi neurologici - Formazione di sinapsi - Mielinizzazione (ippocampo, corteccia visiva e uditiva) - Rapido aumento di cellule gliali - Deficit proteico-energetici riducono il contenuto neuronale di DNA e RNA - Riduzione cellule neuronali - Ridotta sintesi proteica - Ipo-mielinizzazione - Riduzione delle “dimensioni” cerebrali -Anomalie di sviluppo Cognitive/Motorie - Attività verbale - Attività visiva Adattata da: Georgieff MK, Am J Clin Nutr, 2007 Fetal origins of obesity. Oken E, Gillman MW. Obes Res 2003;11:496–506. There are two different relationships between birthweight and obesity: 1) a direct relationship held for birthweight with BMI in childhood and adulthood, but 2) an inverse relationship held for low birth-weight with central adiposity, insulin resistance, and the metabolic syndrome. Cianfarani, Brambilla, Agostoni, Nobili, Pietrobelli, IJO; 2012. Canani, Brambilla, Agostoni, Nobili, Pietrobelli, Nutr Res Rev, 2011 obesità e “ambiente”: quando ? • gli errori alimentari materni durante la gravidanza rappresentano il primo “step” dell’ obesità infantile: • un aumento medio di 9 – 11 kg in gravidanza assume ruolo “protettivo” nel possibile sviluppo dell’ obesità in età pediatrica; • l’incremento di peso oltre la soglia dei 9 – 11 kg e l’ipernutrizione nel 3° trimestre di gravidanza sono chiaramente adipogenetici per il feto. obesità: in Italia ? il 35% degli Italiani sono sovrappeso; il 10.6% sono obesi; i bambini italiani sono i più grassi di tutto il continente Europa. i bambini italiani ? 600.000 bambini in sovrappeso 400.000 bambini obesi Dati della Società Italiana di Pediatria 2012 i bambini italiani: ieri, oggi, e … domani ? Maschio di 10 anni Peso: 34 kg Altezza: 138 cm Peso: 37 kg Altezza: 139 cm Femmina di 10 anni nel 1980 nel 2012 Peso: 33 kg Altezza: 138 cm Peso: 38 kg Altezza: 140 cm Maternal Perceived Stress during Pregnancy Increases Risk for Low Neonatal Iron at Delivery and Depletion of Storage Iron at One Year Rendina DN, J Pediatr. 2018 Sep;200:166-173.e2 •Iron deficiency is prevalent worldwide, more common in women, and of clinical concern for children. •Several gestational conditions can reduce iron levels in newborn infants, including maternal obesity, gestational diabetes, hypertension, and fetal overgrowth, increasing the subsequent risk for infantile iron deficiency. •Despite a reduction in clinical anemia, moderate (stage 1) iron deficiency in the US has remained stable at >7%, especially in infants of younger and poorer mothers. •The American Academy of Pediatrics Committee on Nutrition and the World Health Organization now recommend universal screening for anemic or preanemic iron deficiency at 1 year of age, in addition to earlier screening of high-risk infants. Maternal Perceived Stress during Pregnancy Increases Risk for Low Neonatal Iron at Delivery and Depletion of Storage Iron at One Year Rendina DN, J Pediatr. 2018 Sep;200:166-173.e2 Maternal stress specifically may impact iron biology at several levels. First, sequestering of iron in maternal tissue could decrease the transfer across the placenta. In addition, in a manner similar to obesity, the maternal response to a stressful pregnancy activates inflammatory processes, potentially interfering with the intestinal absorption of iron and functionally impeding placental iron transfer. Stress-induced increases in fetal oxidative metabolism and iron use may also occur, especially in the context of an obese or diabetic pregnancy. Effects of Delayed Cord Clamping on 4-Month Ferritin Levels, Brain Myelin Content, and Neurodevelopment: A Randomized Controlled Trial Mercer JS, J Pediatr. 2018 Dec;203:266-272.e2. 73 healthy term pregnant women and their singleton fetuses were randomized to either delayed umbilical cord clamping (DCC, >5 minutes) or immediate clamping (ICC, <20 seconds). Mean clamping time was: 172 seconds in the DCC vs 28 in the ICC groups (P <0.002), At 4 months of age, blood was drawn for ferritin levels. the 48-hour hematocrit was 57.6% vs 53.1% (P <0.01). Neurodevelopmental testing (Mullen Scales of Early Learning), and brain myelin content measured with magnetic resonance imaging. At 4 months, infants with DCC had significantly greater ferritin levels (96.4 vs 65.3 ng/dL, P = 0.03). Effects of Delayed Cord Clamping on 4-Month Ferritin Levels, Brain Myelin Content, and Neurodevelopment: A Randomized Controlled Trial Mercer JS, J Pediatr. 2018 Dec;203:266-272.e2. Correlation between myelin and ferritin at 4 months of age There was a positive relationship between ferritin and myelin content. Infants randomized to the DCC group had greater myelin content in the internal capsule and other early maturing brain regions associated with motor, visual, and sensory processing/function. Effects of Delayed Cord Clamping on 4-Month Ferritin Levels, Brain Myelin Content, and Neurodevelopment: A Randomized Controlled Trial Mercer JS, J Pediatr. 2018 Dec;203:266-272.e2. Correlation between myelin and ferritin at 4 months of age Endowment of iron-rich red blood cells obtained through DCC may offer a longitudinal advantage for early white matter development. Latent Iron Deficiency In Utero Is Associated with Abnormal Auditory Neural Myelination in ≥35 Weeks Gestational Age Infants Amin SB, J Ped Auditory neural myelination in infants with latent iron deficiency (cord serum ferritin, 11-75 ng/mL) and infants with normal iron status (cord serum ferritin, >75 ng/mL) at birth. Auditory brainstem evoked response (ABR) measured using 80-dB normal hearing level click stimuli at a rate of 69.9/sec within 48 hours after birth. 2013;163:1267 30 – 25 – 20 – 15 – 10 – 05 – 0 % newborn with latent iron deficiency 26.6% (12/45) Iron-Deficiency Anemia in Infancy and Social Emotional Development in Preschool-Aged Chinese Children Chang S, Pediatrics 2011;127:e927 Children who had chronic IDA in infancy Children with iron-deficiency displayed: anemia (IDA) in infancy whose 1.less positive affect anemia was not corrected before and frustration 24 months (chronic IDA) (n=27). tolerance; 2.more passive Children with IDA in infancy whose behavior and physical anemia was corrected before 24 self-soothing in the months (corrected IDA) (n=70). stranger approach; Children who were non-anemic in 3.delay of gratification. infancy and at 24 months (n =64). 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). In contrast, the behavior and affect of children whose anemia was corrected before 24 mo of age were comparable to those of children who were non-anemic throughout infancy. Functional Significance of Early-Life Iron Deficiency: Outcomes at 25 Years Lozoff B, J Pediatr. 2013 ;163(5):1260-6 At 25 years, 33 subjects with chronic iron deficiency in infancy vs 89 who were ironsufficient before and/or after iron therapy. Education, employment, marital status, and physical and mental health. •Anemia was defined as Hb ≤105 g/L non-anemia as Hb ≥120 g/L, Hb concentration 106-119 g/L considered intermediate. •Iron deficiency was defined as serum ferritin <12 ng/mL and - free erythrocyte protoporphyrin ≥1.77 µmol/L (100 µg/dL) of red blood cells and/or - transferrin saturation <10% Functional Significance of Early-Life Iron Deficiency: Outcomes at 25 Years Lozoff B, J Pediatr. 2013 ;163(5):1260-6 At 25 years, 33 subjects with chronic iron deficiency in infancy vs 89 who were ironsufficient before and/or after iron therapy. Education, employment, marital status, and physical and mental health. 60 % subjects who did not complete secondary school – 50 – 58.1% 40 – p=0.003 30 – 20 – 19.8% 10 – 0 chronic iron deficiency iron sufficient Functional Significance of Early-Life Iron Deficiency: Outcomes at 25 Years Lozoff B, J Pediatr. 2013 ;163(5):1260-6 At 25 years, 33 subjects with chronic iron deficiency in infancy vs 89 who were ironsufficient before and/or after iron therapy. Education, employment, marital status, and physical and mental health. indirect paths for chronic iron deficiency and not completing secondary school via poorer cognitive functioning in early adolescence more negative emotions via behavior problems in adolescence, indicating a cascade of adverse outcomes. Association Between Total Duration of Breastfeeding and Iron Deficiency Maguire, Pediatrics 2013;131:1530 Association between total breastfeeding duration and iron deficiency 1647 healty children, aged 1 to 6 years association between total breastfeeding duration and serum ferritin, iron deficiency, and iron deficiency anemia The solid line represents the predicted probability of iron deficiency as a function of total breastfeeding duration, and the gray area represents the 95% CIs for the predicted probabilities Association Between Total Duration of Breastfeeding and Iron Deficiency Maguire, Pediatrics 2013;131:1530 Association between total breastfeeding duration and iron deficiency 1647 healty children, aged 6 years The1 to odds of iron deficiency association between increased by 4.8% total breastfeeding for and each duration serum additional ferritin, ironmonth of breastfeeding deficiency, and iron deficiency anemia The solid line represents the predicted probability of iron deficiency as a function of total breastfeeding duration, and the gray area represents the 95% CIs for the predicted probabilities Association Between Total Duration of Breastfeeding and Iron Deficiency Maguire, Pediatrics 2013;131:1530 1647 healty children, aged 1 to 6 years association between total breastfeeding duration and serum ferritin, iron deficiency, and iron deficiency anemia OR for iron deficiency 2.0 – 1.0 – 0.0 1.71 Children breastfed over versus under 12 months of age Association Between Total Duration of Breastfeeding and Iron Deficiency Maguire, Pediatrics 2013;131:1530 1647 healty children, aged 1 to 6 years Increased total breastfeeding association between is totalduration breastfeeding associated duration and serum with decreased ferritin, iron deficiency, and iron iron stores OR for iron deficiency 2.0 – 1.0 – 1.71 deficiency anemia 0.0 Children breastfed over versus under 12 months of age Iron status of children in southern Sweden: effects of cow's milk and follow-on formula Bramhagen AC, Acta Paediatr 1999;88:1333-1337 % children with 10 – 367 healthy 2.5-y-old children. Amounts of cow's milk and formula consumed. B-haemoglobin, Sferritin, S-iron, total iron binding capacity and mean corpuscular volume. 09 – 08 – 07 – 06 – 05 – 10% 10 % S-ferritin < 12 microg/l. Iron deficient, with or without anaemia 7% 04 – 03 – 02 – 01 – 00 Iron deficiency anaemia (Hb <110g/l) Iron status of children in southern Sweden: effects of cow's milk and follow-on formula Bramhagen AC, Acta Paediatr 1999;88:1333-1337 50 – 367 healthy 2.5-y-old children. Amounts of cow's milk and formula consumed. B-haemoglobin, Sferritin, S-iron, total iron binding capacity and mean corpuscular volume. % children consuming follow-on formula 43% 40 – 30 – P=0.0002 20 – 10 – 11% 00 iron-deficient children iron-sufficient children Iron status of children in southern Sweden: effects of cow's milk and follow-on formula Bramhagen AC, Acta Paediatr 1999;88:1333-1337 Intake of cow's milk 367 healthy 2.5-y-old is significantly higher children. in children with Amounts of cow's milk iron deficiency. and formula consumed. In contrast, iron B-haemoglobin, Sdeficiency is less ferritin, S-iron, total ironfrequent among binding thoseand consuming capacity follow-on. mean corpuscular volume. 50 – % children consuming follow-on formula 43% 40 – 30 – 20 – 10 – P=0.0002 11% 00 iron-deficient children iron-sufficient children Iron status of children in southern Sweden: effects of cow's milk and follow-on formula Bramhagen AC, Acta Paediatr 1999;88:1333-1337 intake of cow's milk (mL/day) 500 – 367 healthy 2.5-y-old children. Amounts of cow's milk and formula consumed. B-haemoglobin, Sferritin, S-iron, total iron binding capacity and mean corpuscular volume. 400 – 300 – 496 43% 382 p = 0.0024 294 200 – 272 257 232 100 – 000 YES NO iron deficiency Iron status of children in southern Sweden: effects of cow's milk and follow-on formula Bramhagen AC, Acta Paediatr 1999;88:1333-1337 500 – 367 healthy 2.5-y-old children. Amounts of cow's milk and formula Do not giveconsumed. more than B-haemoglobin, 400-500 ml Sof milk ferritin, S-iron, after total ironfirst 12 months. binding capacity and mean corpuscular volume. 400 – 300 – intake of cow's milk (mL/day) 496 43% 382 p = 0.0024 294 200 – 272 257 232 100 – 000 YES NO iron deficiency Clinical Report—Diagnosis and Prevention of Iron Deficiency and Iron-Deficiency Anemia in Infants and Young Children (0 –3 Years of Age) Baker Pediatrics 2010;126:1040-50 1. Term, healthy infants have sufficient iron for at least the first 4 months of life. Human milk contains very little iron. Exclusively breastfed infants are at increasing risk of ID after 4 completed months of age. Therefore, at 4 months of age, breastfed infants should be supplemented with 1 mg/kg per day of oral iron beginning at 4 months of age until appropriate iron-containing complementary foods (including iron-fortified cereals) are introduced in the diet. Clinical Report—Diagnosis and Prevention of Iron Deficiency and Iron-Deficiency Anemia in Infants and Young Children (0 –3 Years of Age) Baker Pediatrics 2010;126:1040-50 2. For formula-fed infants, the iron needs for the first 12 months of life can be met by a standard infant formula (iron content: 10–12 mg/L) and the introduction of iron-containing complementary foods after 4 to 6 months of age, including ironfortified cereals. Whole milk should not be used before 12 completed months of age. Clinical Report—Diagnosis and Prevention of Iron Deficiency and Iron-Deficiency Anemia in Infants and Young Children (0 –3 Years of Age) Baker Pediatrics 2010;126:1040-50 3. The iron intake between 6 and 12 months of age should be 11 mg/day. When infants are given complementary foods, red meat and vegetables with higher iron content should be introduced early. To augment the iron supply, liquid iron supplements are appropriate if iron needs are not being met by the intake of formula and complementary foods. Clinical Report—Diagnosis and Prevention of Iron Deficiency and Iron-Deficiency Anemia in Infants and Young Children (0 –3 Years of Age) Baker Pediatrics 2010; 126:1040-50 4. Toddlers 1 through 3 years of age should have an iron intake of 7 mg/day. This would be best delivered by eating red meats, cereals fortified with iron, vegetables that contain iron, and fruits with vitamin C, which augments the absorption of iron. For toddlers not receiving this iron intake, liquid supplements are suitable for children 12 through 36 months of age. Clinical Report—Diagnosis and Prevention of Iron Deficiency and Iron-Deficiency Anemia in Infants and Young Children (0 –3 Years of Age) Baker Pediatrics 2010; 126:1040-50 5. All preterm infants should have an iron intake of at least 2 mg/kg per day through 12 months of age, which is the amount of iron supplied by iron-fortified formulas. Preterm infants fed human milk should receive an iron supplement of 2 mg/kg per day by 1 month of age, and this should be continued until the infant is weaned to iron-fortified formula or begins eating complementary foods that supply the 2 mg/kg of iron. Clinical Report—Diagnosis and Prevention of Iron Deficiency and Iron-Deficiency Anemia in Infants and Young Children (0 –3 Years of Age) Baker Pediatrics 2010; 126:1040-50 6. Universal screening for anemia should be performed at approximately 12 months of age with determination of Hb concentration and an assessment of risk factors associated with ID/IDA. 7. If the Hb level is < 11.0 mg/dL at 12 months of age, then further evaluation for IDA is required to establish it as a cause of anemia. If there is a high risk of dietary ID as described in point 6 above, then further testing for ID should be performed, given the potential adverse effects on neurodevelopmental outcomes. FERRO - Essenziale per lo sviluppo cerebrale - Diretta correlazione tra anemia ferro carenziale e carente sviluppo neurologico - Un eccesso può portare un aumentato rischio infettivo, scarsa crescita e alterato assorbimento di altri minerali - E’ un potente pro-ossidante, può causare la liberazione di radicali liberi con aumento del rischio di ROP. Peso Neonatale 1500 – 2000 g: 2 mg/kg/die Peso Neonatale 1000 – 1500 g: 3 mg/kg/die Peso Neonatale < 1000 g : 4 mg/kg/die Nelle formule =: 1.2 – 1.5 mg/100 ml. Sempre supplementati gli allattati al seno. Prima Infanzia Nel primo anno di vita il bambino: • triplica il peso 50% la lunghezza 25% la circonferenza cranica Nel secondo anno di vita il bambino 20% il peso 15% la lunghezza 4 % la circonferenza cranica quali prospettive ? Prevalenza di sovrappeso ed obesità in età prescolare Wang Y et al. Int Rev Psychiatry. MeNu Group 1) Both MOTHER AND FATHER behavior matter 2) Systematize body MEASUREMENTS during pregnancy and early life 3) EXCLUSIVE BREASTFEEDING for the best start in life. 4) Begin WEANING between 4 and 6 months. 5) FRUITS AND VEGETABLES liking begins early 6) Respect the child APPETITE 7) Control ANIMAL PROTEIN intake 8) Assure adequate QUALITATIVE FAT intake 9) Let’s enjoy adapted meals IN FAMILY 10)Encourage PHYSICAL ACTIVITY and good SLEEP Proposal of 10 good practices: 1 Both MOTHER AND FATHER behavior matter MOTHER AND FATHER eating behaviors may influence the development of the offspring and contribute to obesity prevention. A balanced diet WITH ADAPTED EXCESSIVE FAT AND PROTEIN INTAKE AND FAVORING FRUITS AND VEGETABLES is recommended for both parents during conception period and pregnancy. Furthermore, overweight/obese women who plan be pregnant should reduce weight before conception. Atkinson, Pietrobelli, Int J Obes 2012; Nouta et al, Am J Clin Nutr 2013 Ask about gestational weight gain Did you gain more than 16 Kg during pregnancy ? If possible (2° birth) give advise to loose weight before pregnancy ! Vitamin D multiple effects in the developing fetus. Bone development, Immune system development, Brain development. Important regulator of lung growth. Nguyen M,. J Steroid Biochem Mol Biol 2004;89-90:93-7. Nguyen TM, Am J Physiol 1996;271:L392-9. Edelson J, Biochem Biophys Acta 1994;1221:159-66. Vitamin D Deficiency Holick NEJM 2007;357:266-81. 20 ng/mL = 50 nmol/L 30 ng/mL = 75 nmol/L 150 ng/mL = 374 nmol/L To convert 25-OH vitamin D concentrations from ng/mL to nanomoles per liter, multiply by 2.496. Regulation of immune function: Innate Immunity 1,25(OH)2D induces cathelicidin in keratinocytes when activated by Staphylococcus aureus, as a result the skin might be more resistant to infections by this organism Schauber Immunology 2006;118:509–519 Vitamin D S aureus Vitamin D Treatment Strategies Current recommendations for daily vitamin D supplementation: •400 IU for children and young adults, •400 IU for adults 51–70 years old, and •600 IU for adults older than 71 years of age Are too low and do not maintain 25OHD at the desired level for many individuals. Recently, the American Academy of Pediatrics recommended increasing the dose to 600-800 IU for premature babies (52 weeks c.a.?). VITAMINA D -Apporto di 800-1000 UI/die fino a un mese di vita o termine gravidanza – con DHA (ESPGHAN 2010) - Prevenzione rachitismo/osteomalacia - Prevenzione patologie immunitarie - Lo stato vitaminico della mamma in gravidanza e allattamento influenza: - Massa ossea a 9 anni di età - Gravità dell’asma a 3 anni di età - Suscettibilità al Diabete Mellito Tipo I - Anomalie smalto denti decidui e permanenti L. Dalle Carbonare, MT Valenti, F. del Forno, E. Caneva, A. Pietrobelli. Vitamin D: Daily Vs Montly use in children and elderly – what’s going on? Nutrients 2017. VITAMIN B12 • Vitamin B12 exists in several forms and contains the mineral cobalt so compounds with vitamin B12 activity are collectively called “cobalamins”. • Vitamin B12 is required for proper red blood cell formation, neurological function, and DNA synthesis. National Institutes of Health, Office of Dietary Supplements • Vitamin B12 is naturally found in animal products, including fish, meat, poultry, eggs, milk, and milk products. Vitamin B12 is generally not present in plant foods, but fortified breakfast cereals are a readily available source of vitamin B12 with high bioavailability for vegetarians . Some nutritional yeast products also contain vitamin B12. VITAMIN B12 DEFICIENCY • Vitamin B12 deficiency is characterized by megaloblastic anemia, fatigue, weakness, constipation, loss of appetite, and weight loss. Neurological changes, such as numbness and tingling in the hands and feet, can also occur Gli estremismi…Deficit Vit B12 a 1 anno Dopo la terapia sostitutiva RMN encefalo: atrofia FRONTO TEMPORALE bilaterale RMN encefalo: COMPLETA regressione dell’atrofia cerebrale Danni neurologici PERMANENTI a 2 anni: RITARDO MOTORIO E DEL LINGUAGGIO Crescita bambini vegani e vegetariani n=404, (età 2-10 anni) Peso e altezza 25°-75° c.le CALCIO 8.9-10.5 mg/dl • L’ipocalcemia si associa a: 1. Alterazioni neurologiche 2. Cataratta sottocapsulare 3. Alterazioni cute o annessi 4. Alterazioni dentizione 5. Spasmi muscolari 6. Aritmie cardiache 7. Crisi convulsive 8. Tetania ipocalcemica Duration of Breastfeeding and Risk of Overweight: A Meta-Analysis STRONG dose-dependent association 1 month of breast-feeding 4% decreased risk Harder T; Am J Epidemiol 2005;162:397–403 CALCIO • Required for vascular contraction and vasodilation, muscle function, nerve transmission, intracellular signaling and hormonal secretion • Serum calcium (1%) is very tightly regulated, the body uses bone tissue as a reservoir for, and source of calcium, to maintain constant concentrations of calcium in blood, muscle, and intercellular fluids. • The remaining 99% of the body’s calcium is stored in the bones and teeth where it supports their structure and function . Bone itself undergoes continuous remodeling, with constant resorption and deposition of calcium into new bone. National Institutes of Health, Office of Dietary Supplements Intake of sweetened beverages (kcal), adjusted for total kcal consumed at the test meals, was negatively associated with total meal calcium (mg) (r = −0.38; p ≤ 0.001). Keller, Pietrobelli, Faith, JADA;2009 . Association Between Artificially Sweetened Beverage Consumption During Pregnancy and Infant Body Mass Index Azard et al. JAMA Pediatrics May 9, 2016 Maternal Consumption of Artificially Sweetened Beverages (ASBs) and Sugar-Sweetened Beverages (SSBs) and Infant Body Composition at 1 Year of Age for 2413 Mother-Infant Dyads INFANT BODY MASS INDEX Mutually adjusted for both types of beverages, maternal total energy intake, Healthy Eating Index score, maternal postsecondary education, maternal smoking and diabetes during pregnancy, breastfeeding duration, infant sex and introduction of solid foods before 4 months. Proposal of 10 good practices: 2 Systematize body MEASUREMENTS during pregnancy and early life. Before and during pregnancy, at birth and during early life, BODY & BODY COMPOSITION MEASUREMENTS ARE CRUCIAL. Before and during pregnancy, the mother’s Body Mass Index, weight gain and placental weight and size are relevant indicators to predict future obesity risk. During the first months of life, length, weight and head circumference of the child should be measured. By one year of age and onwards, measurement and growth monitoring should continue, and Body Mass Index must be calculated to watch for an early adiposity rebound Fields et al, 2012; Baidal et al, 2015 Section Appendicular Fat mass Fat free mass Weight 7 kg Bone Fat mass Fat free mass Bone Weight 7 kg Pietrobelli, Heymsfield, 2005 Proposal of 10 good practices: 3 EXCLUSIVE BREASTFEEDING for the best start in life. Breastfeeding may contribute to obesity prevention. Thus EXCLUSIVE BREASTFEEDING IS RECOMMENDED at the beginning of life until 6 months. When breastfeeding is not possible, the use of an infant follow-on formula should be privileged as it will bring more fat of good quality and limit protein intake. In that respect, cow’s milk should be avoided at least during the first year of life. Moss et al, 2013; Agostoni et al, 2008 Come soddisfare questi elevati fabbisogni di energia e nutrienti del bambino?........... ....... Con la mamma!!! Il latte materno : è un vero e proprio sistema biologico: Componenti nutrizionali (macro e micronutrienti) Componenti funzionali (anticorpi, ormoni....) Il latte materno • Colostro: (1° al 5° giorno di lattazione) immunoglobuline (immunità passiva) • Latte di transizione: (6°al 10° giorno) • Latte maturo: > 10° giorno Composizione del latte materno • Lattosio 7% • Grassi 3,5% • Oligosaccaridi prebiotici 1% • Proteine 0,9 Gli oligosaccaridi sono presenti nel latte materno in quantità superiori alle proteine Componenti funzionali del latte materno • • • Anticorpi (IgA) Lisozima Lattoferrina Batteriostatico Battericida » Peptidi » FFA » Monogliceridi Antibatterico Antivirale • HAMLET (human α-lactoalbumin made lethal to tumor cells - complesso α-lattoalbumina +ac oleico ) fattore anti cancro ( apoptosi) • Ormoni ( cortisolo, tiroxina e prolattina) • Glicopeptidi/glicoproteine Nerve Growth Factor (NGF) (differenz. e crescita neuroni, midollare del rene,linfociti T e B) Oligosaccaridi Free AA in PreTerm Human Milk vs Term Human Milk : differences at colostrum • 3-5 times higher levels of: aspartic acid, serine, glycine, alanine, threonine • 10 -15 times higher levels of:valine, phenylalanine, lysine, hysitidine, tyrosine, isoleucine, leucine • 30 times higher levels of:proline (Chuang CK et al, J Pediatr Gastroenterol Nutr 2005; 40:496-500) Oligosaccaridi latte materno: funzioni metaboliche? • Si rinvengono nelle urine vengono assorbiti come tali (praticamente non digeriti) effetti immunologici a livello sistemico? • Fonti di galattosio Galattocelebrosidi membrana neuronale sviluppo neurologico Oligosaccaridi latte materno: funzione prebiotica Crescita batteri lattici e bifidobatteri Inibizione crescita patogeni per: - pH - Effetto barriera Oligosaccaridi latte materno: funzione “anti-adesione” patogeni LATTE MATERNO: effetti a breve termine Malattie infettive: • Diminuisce incidenza e/o severità di molte infezioni, tra cui meningiti batteriche, batteremie, diarrea, infezioni respiratorie,enterocolite necrotizzante, otiti medie, infezioni delle vie urinarie e sepsi tardiva in bambini pretermine. • La mortalità post-neonatale dei bambini allattati al seno è ridotta del 21% in USA. Breastfeeding and the use of human milk. Pediatrics 2005;115;496-506. Allattamento al seno e profilassi dell’atopia: uno studio prospettico fino a 17 anni di età 150 bambini tra 236 originariamente arruolati hanno completato un follow-up suddivisi in tre gruppi: - allattati al seno per > 6 mesi - allattati al seno per un periodo tra 1-6 mesi - allattati al seno meno di 1 mese o non allattati al seno • La prevalenza di atopia a 17 anni di età è risultata nei tre gruppi rispettivamente pari a 8%, 23% e 54% (P=0.0001) Saarinen UM et al, Lancet;346:1065 Breastfeeding as prophylaxis against atopic disease: prospective follow-up study until 17 years old 236 infants enrolled 3 groups of time of breastfeeding - A: >6 months - B: 1 to 6 months - C: <1 month) Follow-up at 1, 3, 5, 10, and 17 yrs of age. 60 – 54% 50 – 40 – 30 – 23% 20 – 10 – 8% 10 A Saarinen, Um ; Kajosaari, M ,Lancet, 1995 Oct 21, Vol.346(8982), pp.1065-1069 B C Breastfeeding as prophylaxis against atopic disease: prospective follow-up study until 17 years old 236 infants enrolled 3 groups timeprolonged of In thisof study, breastfeeding breast-feeding was found to be - A: >6 months prophylactic against - B: 1 to atopic 6 months disease, including atopic - C: <1 month) eczema, food allergy, Follow-up at 1, 3, 5, and respiratory allergy 10, and 17 yrs of age. throughout childhood and adolescence. 60 – 54% 50 – 40 – 30 – 23% 20 – 10 – 8% 10 A Saarinen, Um ; Kajosaari, M ,Lancet, 1995 Oct 21, Vol.346(8982), pp.1065-1069 B C Minore rischio di obesità in età pediatrica per gli allattati al seno • tra il 21% ed il 34% OR, aggiustato: 0.66 - 0.79. Dewey K, J Hum Lact 2003;19:9. • del 22% (OR aggiustato: 0.78) Arenz S, Int J Obes 2004;28:1247. • Del 13% dopo aggiustamento per i maggiori fattori confondenti (obesità dei genitori, fumo materno, e classe sociale : 6 studi) riduzione del rischio al 7% (ancora significativo). Owen C, Pediatrics 2005;115. Duration of breast-feeding and risk of overweight in adulthood STRONG dose-dependent association 1 month of breast-feeding 4% decreased risk Harder et al 2005 Assunzione di latte nei primi 12 mesi in Italia Agostoni, et al, 2010 Formule per l’infanzia: perché • Allattamento al seno (esclusivo) fino a 6 mesi, in seguito complementazione con alimenti solidi (divezzamento) fino al 12° mese. • Il latte vaccino: solo dopo il dodicesimo mese. • Se manca il latte materno, fino al dodicesimo mese: latti formulati Allattamento artificiale: • Formule adattate per i primi tre mesi di vita • Formule di proseguimento dal 4° mese Proposal of 10 good practices: 4 Begin WEANING between 4 and 6 months. Complementary feeding timing and practices can have direct or later consequences on health with possible long-term effects related to obesity. 4 TO 6 MONTHS OF AGE IS THE OPTIMAL WINDOW TO INTRODUCE COMPLEMENTARY FEEDING and build the child current and future food repertoire. Then, until 1 year of age, breast milk or follow-on formula must remain the main source of feeding and COW’S MILK MUST BE AVOIDED. Pearce et al, 2013; Francescato et al, 2013 SVEZZAMENTO Latte: 50% del fabbisogno energetico giornaliero (ca. 500 ml/die) SVEZZAMENTO Latte: 50% del fabbisogno energetico giornaliero (ca. 500 ml/die) 4 - 5 - 6 Inizio divezzamento 7 - 8 - 9 10 - 11 - 12 MESI SVEZZAMENTO Latte: 50% del fabbisogno energetico giornaliero (ca. 500 ml/die) Mela, pera, banana 4 - 5 - 6 Inizio divezzamento 7 - 8 - 9 10 - 11 - 12 MESI SVEZZAMENTO Latte: 50% del fabbisogno energetico giornaliero (ca. 500 ml/die) Brodo vegetale Cereali senza glutine Omogeneizzato di carne Passato vegetale Olio extra vergine d’oliva Formaggio tipo grana Mela, pera, banana 4 - 5 - 6 Inizio divezzamento 7 - 8 - 9 10 - 11 - 12 MESI SVEZZAMENTO Latte: 50% del fabbisogno energetico giornaliero (ca. 500 ml/die) Brodo vegetale Cereali senza glutine Semolini e pastine con glutine Pesce Prosciutto cotto Omogeneizzato di carne Passato vegetale Olio extra vergine d’oliva Formaggio tipo grana Mela, pera, banana 4 - 5 - 6 Inizio divezzamento 7 - 8 - 9 10 - 11 - 12 MESI SVEZZAMENTO Latte: 50% del fabbisogno energetico giornaliero (ca. 500 ml/die) Brodo vegetale Cereali senza glutine Semolini e pastine con glutine Pesce Prosciutto cotto Omogeneizzato di carne Legumi passati senza buccia Passato vegetale Olio extra vergine d’oliva Formaggio tipo grana Mela, pera, banana 4 - 5 - 6 Inizio divezzamento 7 - 8 - 9 10 - 11 - 12 MESI SVEZZAMENTO Latte: 50% del fabbisogno energetico giornaliero (ca. 500 ml/die) Brodo vegetale Cereali senza glutine Semolini e pastine con glutine Pesce Prosciutto cotto Omogeneizzato di carne Legumi passati senza buccia Passato vegetale Tuorlo d’uovo e agrumi Olio extra vergine d’oliva Formaggio tipo grana Mela, pera, banana 4 - 5 - 6 Inizio divezzamento 7 - 8 - 9 10 - 11 - 12 MESI SVEZZAMENTO Latte: 50% del fabbisogno energetico giornaliero (ca. 500 ml/die) Brodo vegetale Cereali senza glutine Semolini e pastine con glutine Pesce Prosciutto cotto Omogeneizzato di carne Legumi passati senza buccia Passato vegetale Tuorlo d’uovo e agrumi Olio extra vergine d’oliva Albume d’uovo Biscotti secchi Cereali integrali Latte Bovino Formaggio tipo grana Mela, pera, banana 4 - 5 - 6 Inizio divezzamento 7 - 8 - 9 10 - 11 - 12 MESI 1 - 3 anni fabbisogno giornaliero in energia e nutrienti - totale calorie - proteine - lipidi - glucidi - calcio - ferro - zinco - fibre - colesterolo 1400 (96 Kcal/kg) 8-10 % kcal/totali 31 % kcal/totali 59-61 % kcal/totali 800 mg 7 mg 4 mg 6-13 gr 106 mg Protein intake IFG-1 “Adiposity rebound” Obesity later in life - An appropriate protein intake during complimentary feeding period is likely to result in an optimal growth pattern and a reduced risk of overweight. KF. Michaelsen, 2013 - The use of cow’s milk (rich in protein) as a drink should be avoided B. Koletzko, 2013 After 1 year of Age 1000 Kcal/day 4 basic nutritional groups Meat – Fish- Poultry – Eggs Dairy products Fruit and vegetables Cereals – Grain – Rice – Bread – Pasta Milk: 2 – 3 serving each day Water. 69 – 90 ml/kg/day Fruits – Vegetables Juice: 100% fruit juice (no sugar added) Timing of solid food introduction and risk of obesity in preschool-aged children Huh SY, Pediatrics 2011;127:e544-551 % children 847 children in Project Viva. 70 – Obesity at 3 years of age 60 – (BMI for age and gender ≥ 95th percentile). Timing of introduction of solid foods, categorized as <4, 4 to 5, and ≥ 6 months. 50 – 67% 40 – 30 – 20 – 10 – 00 breastfed in the first 4 months of life Timing of solid food introduction and risk of obesity in preschool-aged children Huh SY, Pediatrics 2011;127:e544-551 847 children in Project Viva. Obesity at 3 years of age (BMI for age and gender ≥ 95th percentile). Timing of introduction of solid foods, categorized as <4, 4 to 5, and ≥ 6 months. 10 – % children obese at age 3 yrs 09 – 08 – 07 – 06 – 05 – 04 – 03 – 02 – 01 – 00 9% Timing of solid food introduction and risk of obesity in preschool-aged children Huh SY, Pediatrics 2011;127:e544-551 7.0 – 847 children in Project Viva. 6.0 – Obesity at 3 years of age 5.0 – (BMI for age and gender ≥ 95th percentile). 4.0 – Timing of introduction of solid foods, categorized as <4, 4 to 5, and ≥ 6 months. OR for obesity at age 3 years 6.3 3.0 – 2.0 – 1.0 – 0.0 Among formula-fed infants, & introduction of solid foods before 4 months Timing of solid food introduction and risk of obesity in preschool-aged children Huh SY, Pediatrics 2011;127:e544-551 7.0 – 847 children in Project Viva. Among breastfed infants, the timing Obesity at 3 years of age of solid food introduction was not (BMI forassociated age andwith gender odds of obesity (OR=1.1) ≥ 95th percentile). Timing of introduction of solid foods, categorized as <4, 4 to 5, and ≥ 6 months. 6.0 – 5.0 – OR for obesity at age 3 years 6.3 4.0 – 3.0 – 2.0 – 1.0 – 0.0 Among formula-fed infants, & introduction of solid foods before 4 months Proposal of 10 good practices: 5 FRUITS AND VEGETABLES liking begins early. Complementary diet must embrace all food categories with an emphasis on vegetables and fruits. DAILY VARIETY, DIVERSITY IN A MEAL and REPEATED EXPOSURE up to 8 times are efficient strategies to increase acceptance of foods not well accepted at first. Promoting healthy foods as part of usual meals during complementary feeding is important as eating habits learned in childhood are likely to continue through life. There is NO NEED TO ADD SUGAR OR SALT and sugary fluids (juices, soda, infusion…) should be avoided during complementary feeding and onwards. Grote et al, 2012; Remy et al, 2013 Proposal of 10 good practices: Respect the child APPETITE Babies know to recognize their hunger and satiety cues but they lose this ability, probably due to external influences. AVOID COERCIVE “CLEAN YOUR PLATE” FEEDING PRACTICES. ADAPT PORTIONS OF FOOD and offer foods to the child in response to their feeling of hunger and not to use foods as reward for good behavior. Scaglioni et al, 2008; Krolier et al, 2009 6 ACQUA ... Acqua ... Acqua ... Quanta ne serve????...... • • • • • • • • 3 mesi: 600 – 900 ml 6 mesi: 800 – 1200 ml 9 mesi: 900 – 1250 ml 1 anno: 1000 – 1350 ml 2 anni: 1250 – 1500 ml 4 anni: 1400 – 1600 ml 6 anni: 1700 – 1900 ml 10 anni: 2000 ml USDHHS, 2008; LARN 2012 “Il buon giorno si vede dal mattino” 1 bambino su 5 non fa colazione prima di andare a scuola Ogni giorno ∼ 1.000.000 di bambini (19%) vanno a scuola senza aver fatto colazione 6 – 14 anni I rapporti tra prima colazione e performance scolastiche in bambini e adolescenti Incremento dei livelli di energia disponibile Fare colazione Migliore stato nutrizionale Maggiore presenza scolastica Migliore capacità apprendimento attivo Efficacia dello stare a scuola da pediatria – magazine della Società Italiana di Pediatria volume 2 numero 9 settembre 2012 Rendimento scolastico “Il buon giorno si vede dal mattino” Importanza della 1a colazione “ La prima colazione aumenta la frequenza scolastica e migliora la qualità della vita e dell’ alimentazione dei ragazzi” (Pollitt, Am J Clin Nutr, 1998) “Il buon giorno si vede dal mattino” Importanza della 1a colazione - Macronutrienti in equilibrio fra loro: - Potenziano il funzionamento del lobo frontale dove sono situati i centri della memoria (Kennedy, 2000) - Attivano il rilascio di acetilcolina durante l’ apprendimento (Korol, 1998) - Aumentano la disponibilità di triptofano a livello cerebrale che rende la memoria più veloce (Markus, 1999) Tempo Influenza della prima colazione sul tempo medio di esecuzione di test di memoria spaziale e verbale memoria spaziale Le “performance” risultano significativamente migliori (con tempi più brevi) nei soggetti che hanno assunto la prima colazione rispetto ai soggetti a digiuno (rispettivamente P < 0.03 e P < 0.01) – da pediatria , settembre 2012 Proposal of 10 good practices: 7 Control ANIMAL PROTEIN intake. Several findings substantiate a recommendation TO LIMIT ANIMAL PROTEIN INTAKE IN EARLY LIFE to reduce the risk of an early adiposity rebound, which indicates an increased obesity risk. To meet the child nutritional requirements after 12 months, GROWING-UP MILK SHOULD BE PREFERRED TO COW’S MILK in order to limit protein intake and meet essential fatty acids and iron needs. Koletzko et al, 2009; Rolland-Cachera et al, 2004; Michaelsen et al, 2014 Early protein intake and later obesity risk: which protein sources at which time points throughout infancy and childhood are important for body mass index and body fat percentage at 7 y of age? Günther AL, Am J Clin Nutr 2007;86:1765-1772 % body fat at age 7 yrs 20 – 203 participants. 15 – Information on diet at 6 mo, 12 mo, 18-24 mo, 3-4 y, and 5-6 y. Protein intake of energy). (% 16.2% 10 – 17.21% 18.21% P for trend = 0.008 05 – 00 T1 T2 T3 Tertiles of protein intake (% of energy at age 12 mo.) Early protein intake and later obesity risk: which protein sources at which time points throughout infancy and childhood are important for body mass index and body fat percentage at 7 y of age? Günther AL, Am J Clin Nutr 2007;86:1765-1772 % body fat at age 7 yrs 20 – Dairy, but not meat or cereal 203protein participants. intake, at 12 mo was related to Information diet body fat on % at 7 y. at 6 mo, 12 mo, 18-24 mo, 3-4 y, and 5-6 y. Protein intake of energy). (% 15 – 16.2% 10 – 17.21% 18.21% P for trend = 0.008 05 – 00 T1 T2 T3 Tertiles of protein intake (% of energy at age 12 mo.) Early protein intake and later obesity risk: which protein sources at which time points throughout infancy and childhood are important for body mass index and body fat percentage at 7 y of age? Günther AL, Am J Clin Nutr 2007;86:1765-1772 The fact that animal, in particular dairy, protein at age 12 mo might be responsible for the associations reported for total protein consumption agrees with both clinical and observational studies that have suggested a specific effect of these protein sources on IGF-1 and insulin secretion. The mechanism behind the early protein hypothesis is that particularly these hormonal responses adversely affect preadipocyte differentiation and multiplication. In a 7-d intervention study in 8-y-old boys (n 24), a higher protein intake from skimmed milk but not meat increased the serum concentrations of IGF-1 and the molar ratio of IGF-1 to its binding protein IGFBP-3 Proposal of 10 good practices: Assure adequate QUALITATIVE FAT intake The restriction of fat intake during early life seems to increase the susceptibility to develop overweight. Thus, THE INTAKE OF ADEQUATE FAT CONTAINING ESSENTIAL FATTY ACIDS SHOULD BE PROMOTED. Low-fat products should be avoided from weaning period and onwards Rolland-Cachera et al, 2006 and 2013; Agostoni et al, 2012 8 Lipidi La componente lipidica della dieta è più rapidamente trasformata e immagazzinata sottoforma di grasso corporeo, con un costo energetico di conversione minimo rispetto a quello di proteine o carboidrati (Prentice AM et al, 1995). Negli ultimi decenni si è registrato un consumo crescente di grassi nella dieta a scapito dei carboidrati (ISTAT 2003). E’ da sottolineare lo scarso potere saziante dei grassi rispetto agli altri macronutrienti (Willett WC, 1998); i grassi conferiscono una maggiore densità energetica al cibo per cui, a parità di volume ingerito, la quantità di energia assunta è maggiore. Poiché la sensazione di sazietà è influenzata dal volume del cibo, i cibi ad alta densità energetica sono meno sazianti. E’ stata dimostrata e confermata un’associazione positiva tra contenuto in grassi della dieta del bambino e livello di adiposità corporea (Maffeis C et al, 1993). Modello sperimentale di ciò è rappresentato dalla dieta del lattante nei primi 6 mesi di vita, particolarmente ricca in lipidi, e suo accrescimento e composizione corporea. Cibi ad alto contenuto in grassi hanno un’elevata palatabilità e ciò favorisce il loro consumo in eccesso. GRASSO SOTTOCUTANEO E GRASSO VISCERALE PRIMA DOPO Liposuzione Proposal of 10 good practices: Let’s enjoy adapted meals IN FAMILY Parents have a model role in feeding. They should be an example for the child, make meals a moment of pleasure taken in family, including breakfast, while respecting the young child specific nutritional needs, with TV AND ALL OTHER SCREENS TURNED OFF. Birch et al, 2001; Faith et al, 2013; Wasser et al, 2013; Scaglioni et al, 2008 9 il ruolo della famiglia e del gruppo l’attività fisica dei genitori, dei fratelli, dei coetanei è una grande chance per stimolare i ragazzi alla pratica sportiva attività fisica: quale, quanta, quante volte ? Obesity has negative effects on physical attitudes, self esteem and body image. Physical activities must be enjoyable and no so difficult that obese children feel tired and ridiculous. Television Viewing, Bedroom Television, and Sleep Duration From Infancy to Mid-Childhood Bedroom TV: -31 min sleep Cespedes EM et al, Pediatrics 2014 Proposal of 10 good practices: 10 Encourage PHYSICAL ACTIVITY and good SLEEP Environmental and psycho-social factors also have a supporting role. Preventive interventions consisting in LETTING KIDS MOVE and encouraging physical activities can contribute to the prevention of pediatric obesity and obesity later on. Furthermore, a child has to get SLEEP SUFFICIENTLY as short sleep duration may be associated with increased risks of developing obesity in childhood and adulthood. Brambilla, Pietrobelli, 2011; Gutin et al, 2011; Cappuccio et al, 2008 sonno e obesità Il sonno è un importante modulatore delle funzioni neuroendocrine. La perdita di sonno interferisce negativamente con: tolleranza al glucosio sensibilità all’insulina livelli di leptina concentrazioni del cortisolo nelle ore notturne livelli di GH senso di fame e di appetito sonno? ma quanto? 14-16 h/dì per il lattante, 12-14 h/dì da 1 a 3 anni, 11-12 h/dì nell’infanzia, 9-10 h/dì nell’adolescenza. Are Early Physical Activity and Sedentary Behaviors Related to Working Memory at 7 and 14 Years of Age? M López-Vicente, J Pediatr. 2017;188:35-44 A birth cohort across 4 Spanish regions (n = 1093). • Low physical activity levels at 4 years of age were associated with a Parents reported lifestyle habits of child at age 4 yrs. Children performed a computerized working memory task at 7 yrs of age. • nonsignificant reduction of correct responses in the working memory task at age 7 years of age. Are Early Physical Activity and Sedentary Behaviors Related to Working Memory at 7 and 14 Years of Age? M López-Vicente, J Pediatr. 2017;188:35-44 A birth cohort across 4 Spanish regions (n = 1093). • Low physical activity levels at 6 years of age were associated with a Parents reported lifestyle habits of child at age 4 yrs. Children performed a computerized working memory task at 7 yrs of age. • 4.22% reduction of correct responses at age 14 years. Are Early Physical Activity and Sedentary Behaviors Related to Working Memory at 7 and 14 Years of Age? M López-Vicente, J Pediatr. 2017;188:35-44 A birth cohort across 4 Spanish regions (n = 1093). Parents reported lifestyle • Other sedentary behaviors at 6 year of age were associated with a habits of child at age 4 yrs. Children performed a computerized working memory task at 7 yrs of age. • 5.07% (95% CI −9.68 to −0.46) reduction of correct responses in boys at 14 years of age. Are Early Physical Activity and Sedentary Behaviors Related to Working Memory at 7 and 14 Years of Age? M López-Vicente, J Pediatr. 2017;188:35-44 Many studies have observed the positive cross-sectional relationship between physical activity and cognitive functions in children, especially executive functions. Chronic physical activity has been associated with: • larger brain volume in regions supporting memory and executive functions, • improvement in the connectivity of brain networks, • higher levels of brain-derived neurotrophic factor, • enhanced cerebrovascular function. Bidirectional Associations Between Child Sleep Problems and Internalizing and Externalizing Difficulties from Preschool to Early Adolescence. Quach JL, JAMA Pediatr. 2018 Feb 5;172(2):e174363. Prospective cohort study using nationally representative data from 5 waves 2004 (4983 children mean age of 4.7 ), 2006, 2008, 2010, and 2012) kindergarten cohort (4983 children aged 4-5 years in 2004) Sleep problems were defined using parent-reported child sleep problem severity and specific difficulties: 1. difficulty getting to sleep at night, 2. not happy sleeping alone, 3. waking during the night, 4. restless sleep on 4 or more nights of the week. Bidirectional Associations Between Child Sleep Problems and Internalizing and Externalizing Difficulties from Preschool to Early Adolescence. Quach JL, JAMA Pediatr. 2018 Feb 5;172(2):e174363. Prospective cohort study using nationally representative data from 5 waves 2004 (4983 children mean age of 4.7 ), 2006, 2008, 2010, and 2012) kindergarten cohort (4983 children aged 4-5 years in 2004) Child behavioral difficulties using the parent-reported Strengths and Difficulties Questionnaire for 1. externalizing difficulties (conduct problems and hyperactivity/inattention subscales) and 2. internalizing difficulties (emotional problems subscale). Bidirectional Associations Between Child Sleep Problems and Internalizing and Externalizing Difficulties from Preschool to Early Adolescence. Quach JL, JAMA Pediatr. 2018 Feb 5;172(2):e174363. Prospective cohort study using nationally representative data from 5 waves 2004 (4983 children mean age of 4.7 ), 2006, 2008, 2010, and 2012) kindergarten cohort (4983 children aged 4-5 years in 2004) •Significant bidirectional associations were detected between sleep problems and externalizing difficulties during the elementary school transition period, with •greater sleep problems associated with later externalizing behavior and vice versa SIGNIFICANCE FOR PAEDIATRICIANS Parents’ education & behavior, Maternal obesity, Addressing modifiable risk factors Excess gestational weight gain, Maternal smoking, Breastfeeding duration & weaning, Iron deficiency, Zinc deficiency, Vitamin D deficiency. could make a significant contribution to child health, and by implication, improve adult health. Robinson SM, Am J Clin Nutr 2015;101:368–75. TAKE HOME MESSAGE 5 ANNI 35 ANNI TAKE HOME MESSAGE obesità infantile: l’attuale generazione di bambini (2010 – 2015) non vivrà così a lungo come i loro genitori. The Womb. Your Mother. Yourself. Annie M Paul Time October 4, 2018 “No woman who is pregnat today can escape hearing the message that what she does affect the fetus”. The Womb. Your Mother. Yourself. Annie M Paul Time October 4, 2010 “No woman who is pregnat today can escape hearing the message that what she does affect the fetus”. Collaboration - Pennington Biomedical Research Center: Steven B. Heymsfield - Buffalo University: Myles S. Faith - University of Birmingham (AL): David B. Allison - Modena University (Italy): Nino C. Battistini - Malmö University (Sweden): Carl-Erik Flodmark - Vienna Medical School (Austria): Kurt Widhalm - Roma (Bambino Gesù): Valerio Nobili, Stefano Cianfarani Grazie per l’attenzione! [email protected]
