Health Promotion and Disease Prevention in Children: Title and subTitle BreakIt's Never Too Early

Health promotion and disease prevention are as integral to childhood as play. They start in utero, when a mother takes prenatal vitamins or refrains from drinking alcohol or smoking; continue after a child is born when a mother breastfeeds; and are addressed daily, when parents make sure a child snacks on fruit instead of junk food or plays outside rather than watches television. Parents are guided in their efforts by their child's clinicians, a major portion of whose practices are devoted to health promotion and disease prevention, such as administering immunizations or recommending car seats and bicycle helmets. Many of these interventions are very cost-effective.

But despite the pervasiveness and importance of health promotion and disease prevention, research in these areas often takes a backseat to flashier studies on the newest drug or surgical intervention. This issue of JAMA focuses attention on this crucial area to a child's well-being. The articles in this issue illustrate the wide diversity of prevention efforts in pediatrics. They deal with newborns to adolescents, range from the Netherlands to Nicaragua, and study prevention of acute and chronic illnesses and promotion of physical and mental health. The articles herein describe behavioral interventions, complex technological treatments, and simple injections.

The article by Shonkoff and colleagues¹ illustrates an underappreciated reason health promotion and disease prevention in children is so critical—it can prevent disease throughout the life span. The authors address the premise that physical and mental stress in childhood underlies many adult diseases. Early experiences can affect adult health either by accumulating damage over time or by latent effects of adversity occurring during a sensitive developmental period. The authors discuss the types and effects of childhood stress, with toxic stress such as from poverty or abuse altering brain structure and increasing the risk for disease and cognitive impairment in adulthood. They acknowledge that many current prevention efforts are aimed at adults and argue that adult-focused efforts are limited. The authors propose “that a fundamental transformation in the circumstances of children who face significant adversity early in life could not only affect their own individual well-being but also improve societal health and longevity”¹ and suggest some implications for health policy and clinical practice.

Mercy and Saul² also discuss the issue of early adversity and later health in their Commentary. They specifically address programs that have been shown to promote “safe, stable and nurturing relationships and environments” to counter adverse childhood exposures. The authors argue that at least 2 of these programs are ready for implementation on a larger scale; however, the infrastructure to translate, deliver, and support such interventions is needed.

The contribution of childhood experience to adult health is also the subject of the study by Leunissen and colleagues.³ In 217 healthy 18- to 24-year-old adults in the Netherlands, increased weight gain relative to height gain in the first 3 months of life was inversely associated with markers of cardiovascular disease and type 2 diabetes. In a subgroup of 87 individuals, rapid weight gain in the first 3 months, as opposed to over the first year, was associated with the markers in early adulthood. Although the study did not have dietary information, the results suggest that early nutritional intervention might reduce the risk for cardiovascular disease and type 2 diabetes later in life.

Prevention of complications of extreme prematurity could also have immense benefits for child and adult health. The EXPRESS Group in Sweden⁴ report their experience with infants born before 27 weeks' gestation during 2004-2007. Since Sweden has universal health insurance, free pregnancy care with high adherence, centralized perinatal services, and technologically advanced neonatal care, these results are a best-case scenario. Overall, perinatal mortality was 45% and survival of live-born infants was 70% at 1 year. Perinatal survival increased with increasing gestational age, from 10% at 22 weeks to 85% at 26 weeks, rates much higher than reported for other countries or previously reported in Sweden. Tocolytic treatment, antenatal corticosteroids, surfactant treatment within 2 hours of birth, and birth at a level III hospital were all associated with a lower risk of death. At 1 year, 45% of the children had no major neonatal morbidity, such as intraventricular hemorrhage, retinopathy of prematurity, bronchopulmonary dysplasia, periventricular leukomalacia, and necrotizing enterocolitis. One-year survival without major morbidity was also correlated with gestational age, ranging from 20% for those born at 22 weeks to 63% for those born at 26 weeks.

While tertiary interventions such as treatment of high-risk pregnancies with tocolytics and steroids and treating extremely premature infants with surfactant may reduce mortality and morbidity, primary prevention of premature birth would be even more beneficial. About 1 in 8 infants is born preterm in the United States.⁵ The annual societal cost of preterm birth in the United States was $26.2 billion in 2005.⁵ However, only a few primary prevention strategies have been proven successful, such as maternal smoking cessation and screening and treatment of asymptomatic bacteriuria.⁶

The article by Patel and colleagues⁷ deals with a more traditional prevention topic—vaccines. Live oral pentavalent rotavirus vaccine was approved for use in US children in 2006 after studies showed high efficacy.^{8 - 9} However, the performance of the vaccine in developing countries with a greater burden of childhood diarrhea and different host and environmental factors is not known. In a case-control study of 285 children with infectious rotavirus admitted to the hospital or requiring intravenous hydration in the emergency department in 4 hospitals in Nicaragua and 1530 controls, vaccination with 3 doses of vaccine was associated with a lower risk of rotavirus diarrhea (odds ratio, 0.54) and of severe (odds ratio, 0.42) and very severe (odds ratio, 0.23) disease. However, the 46% effectiveness was lower than the 88% to 98% efficacy seen in a clinical trial conducted mostly in Finland and the United States.⁸ The reasons for the lower reduction in risk remain to be determined.

In February 2009, the Advisory Committee on Immunization Practices issued revised guidelines for the prevention of rotavirus disease in the United States,¹⁰ recommending either the pentavalent vaccine or a newly licensed vaccine, RV1, which requires only 2 doses. The committee also updated ages for doses, contraindications, precautions, and special situations.

Another research article in this issue deals with a completely different population—adolescents. The randomized controlled trial by Garber and colleagues¹¹ studied the prevention of depression in at-risk adolescents. The investigators randomly assigned 316 adolescents with a history of depression or current symptoms and a parent with past or current depression to receive an 8-week group cognitive-behavioral preventive intervention and 6 months of continuation sessions or usual care. Through the 9-month follow-up, the intervention group had a lower rate of incident depressive episodes (21.4% vs 32.7%; hazard ratio, 0.63) and greater improvement in self-reported depressive symptoms compared with the usual care group. Interestingly, in a number-needed-to-prevent analysis, for every 9 adolescents receiving the intervention, 1 would be expected to avoid developing a depressive episode. This result compares with a number-needed-to-treat of 10 for antidepressants in adolescent depression.

The US Preventive Services Task Force in March 2009 recommended that adolescents aged 12 to 18 years should be screened for major depressive disorder, “when systems are in place to ensure accurate diagnosis, psychotherapy (cognitive-behavioral or interpersonal), and follow-up.”¹² The task force reported that the evidence was insufficient to recommend screening children aged 7 to 11 years, however. This report updates a 2002 report that found insufficient evidence for or against screening of children or adolescents.

Finally, Strasburger tackles the issue of the influence of the media on children and adolescents.¹³ There is evidence that the media contributes to problems with violence, sex, drugs, obesity, and eating disorders. As children have easier access to media, better education of students, parents, teachers, and clinicians, limiting children's media access, and restrictions by the federal government on advertising are needed.

Many important health promotion and disease prevention topics are not addressed in this issue, such as prevention of injury, violence, and tobacco, alcohol, and drug use. Also not addressed is how to make prevention in general and prevention in children specifically higher priorities for the nation and the medical community, especially given the potentially great return on investment. Health promotion and disease prevention in children should be a daily concern for everyone, just as it is for the parent and the child's clinician.