Secondary Logo

Journal Logo

Medical Position Paper

Research and the Promotion of Child Health

A Position Paper of the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition

Koletzko, Berthold*; Kolacek, Sanja; Phillips, Alan; Troncone, Riccardo§; Vandenplas, Yvan||; Baumann, Ulrich; van Goudoever, Johannes#; de Swarte, Casper**; Benninga, Marc††; Mearin, Luisa‡‡

Author Information
Journal of Pediatric Gastroenterology and Nutrition: August 2014 - Volume 59 - Issue 2 - p 274-278
doi: 10.1097/MPG.0000000000000411

Abstract

Erratum

In the article that appeared on page 274 of the August 2014 issue, two names were omitted from the author byline. The byline should read:

* Berthold Koletzko, Sania Kolacek, Alan Phillips, § Riccardo Troncone, || Yvan Vandenplas, Nikhil Thapar, Ulrich Baumann, # Johannes van Goudoever, §§ Walter Mihatsch, ** Casper de Swarte, †† Marc Benninga, and ‡‡ Luisa Mearin

Walter Mihatsch's affiliation is Department of Paediatrics, Harlaching, City Hospital of Munich, Munich, Germany.

Journal of Pediatric Gastroenterology and Nutrition. 61(2):265, August 2015.

Promoting good health is an integral part of the European Union's 10-year economic growth strategy, Europe 2020. Health policy is important to Europe 2020's objectives for smart and inclusive growth because keeping people healthy and active for longer enhances productivity and competitiveness. Innovation will make the health care sector more sustainable and find new cures for health conditions (1). The European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) is a European multiprofessional organisation whose aim is to promote the health of children with special attention to the gastrointestinal tract, liver, and nutritional status. ESPGHAN achieves its goals through knowledge creation, the dissemination of science-based information, the promotion of best practices in the delivery of care, and the provision of high-quality education for paediatric gastroenterology, hepatology, and nutrition professionals in Europe and beyond.

Children represent approximately one-fifth of the European population, which is approximately 100 million people. Supporting and promoting children's health and development is key for our societies at present and for their future. It ought to be a priority to guarantee children's healthy and optimal development. Children's health relates to their needs up to adulthood. Infants, younger and older children, and adolescents are distinct subgroups within childhood, with different physiological and psychosocial conditions and health determinants, requiring different services, different measures of health, and different surveillance systems (2). The predominant characteristic of childhood is rapid growth and developmental changes, including the development of the gastrointestinal tract and liver, as well as changing nutritional needs. Prevention and treatment of gastrointestinal, liver, and nutrition-related illnesses during this critical period of childhood are of key importance for lifelong health, performance, and the ability to contribute to society. Safeguarding health through the implementation of effective prevention and health promotion programs and the early diagnosis of health conditions throughout the life cycle are of key importance to a healthy and productive life until old age (3).

Investing in child health will lead to healthy longevity and economic growth

The aim of this position paper was to highlight the importance of, and opportunities for, investing in gastrointestinal, liver, and nutrition research in children to promote child health. We also aimed to delineate the priority of research in paediatric gastrointestinal, hepatic, and nutritional health, based on the need for knowledge, the potential for remedial action, and societal impact. We focus on present strategies up to 2025, when the last activities in the framework of the new European program for research and innovation, Horizon 2020, are expected to be finalised and the knowledge and innovations gained in this programme will be implemented in the practice of medicine and other fields.

We expect that research on child health will uncover major changes in the coming decade. The policy, socioeconomic, and technological framework in which paediatric health care is delivered is shifting. To build strategies that are future-proof, these changes need to be anticipated.

RESEARCH AND INNOVATION POLICY

Two major drivers are expected to change the policy on research and innovation.

  1. In the past, research policy and funding was mainly focused on a project-based approach. In the coming years, it is expected that research policy will shift to programme-based approaches, with even stronger emphasis on multidisciplinary collaboration. As part of a larger trend across industrialised nations, European research policy discourse has placed increasing emphasis on sociotechnical integration: the explicit incorporation of activities devoted to broader social aspects into scientific activities. Quantitative analysis reveals an overall trend towards increasing integration of science with industrial and socioeconomic aspects (4).
  2. Research policy will comprise both fighting and preventing diseases as well as promoting health, which is of particular importance with respect to children. The European Council Conclusions on Healthy Ageing across the Lifecycle puts added focus on health care from the early years of life onwards throughout the life cycle. This strategy can be achieved by fostering the implementation of health promotion and disease prevention programmes from childhood and adolescence onwards throughout life (5) and the input of paediatric expertise will be essential for its success.

SOCIOECONOMIC ENVIRONMENT FOR PAEDIATRIC CARE

During the next several years 3 socioeconomic factors are expected to change medical service:

  1. The delivery of preventive and curative child health care services through specialist centres will be complemented by more homecare supported through telecommunication. Telehealth (eHealth) has an enormous potential to deliver better health care in a more cost-efficient and sustainable manner to more people. Telehealth can support health systems as they strive for better health outcomes and new models of health care, and it can support people in striving for a better quality of life. The European Commission is working on shaping a new Action Plan on eHealth, with measures to kick-start the delivery of eHealth, and encourages the sharing of best practices (6).
  2. Paediatric care is likely to be more closely linked with adult medicine. The appreciation of the continuous development of health and disease risks through the life cycle, and of the childhood origins of the populations’ major disease burdens (eg, obesity and diabetes, cardiovascular diseases [CVDs], inflammatory, allergic and autoimmune disorders, some forms of cancer), will require a more holistic approach to population health, with a much stronger input from paediatric specialists. Child health will be a component of a lifelong approach to health and well-being because the road to healthy longevity starts in childhood. Therefore, more paediatric specialists and subspecialists will be required to support the integration of paediatric and adult health care.
  3. Research performed by an individual will have a limited role. Research will be conducted mostly in large multidisciplinary teams to address complex research questions. Funding will be based on networks with strong scientific leaders and physical location will be less relevant than before, because research teams can collaborate closely across cities, countries, and continents. This international research collaboration will require network and infrastructure support as provided by scientific societies such as ESPGHAN, and will require an increasing sensitivity to varying cultural aspects in the approach to research. Many more physician scientists with appropriate paediatric training and support programmes will be needed to facilitate the 2-way communication between bench and bedside, and scientific innovations will need to be carefully evaluated in high-quality clinical trials to support their translational application. Short-term cost savings must not be allowed to endanger this strategically important priority.

SCIENTIFIC AND TECHNOLOGICAL DEVELOPMENT

It is expected that by 2025, scientific, technological, and medical development, including progress in paediatric care, will shift focus from a general treatment concept of diseases to a stronger focus on personalised prevention and treatment.

  1. Affordable high-throughput platforms, based on gene therapy, identification of environmental and metabolic triggers, and regenerative medicine concepts, will enable personalised therapies, rather than treating symptoms. Genetic analysis and the study of gene–environment interaction will have a major impact on diagnostics and therapy.
  2. Nutrition and metabolism are widely recognised as key factors determining health. The microbiome will have been largely deciphered to provide new insights into how nutrition affects health. Environmental, behavioural (including lifestyle), psychological, organisational, cultural, socioeconomic, biological, and genetic factors, in their broadest senses, will be better understood.
  3. Approaches will include the long-term study of cohorts and their linkage with data derived from “omics” research, systems biomedicine (including relevant applications of systems biology), and other methods (7). Novel technology and methodological developments with high sensitivity will enable minimally invasive investigations with particular benefits for application in infants and children.

STRATEGIC RESEARCH AND INNOVATION FRAMEWORK

The strategic framework considers healthy longevity that supports economic growth as a key objective. A strategic framework focus is on gut and liver health. The incidence of diseases with the potential to compromise gut and liver health is high, and in many cases, these diseases are preventable. Improving child health with respect to gut and liver will have a large impact on health status at an older age. The key factor to prevention of these diseases is a better understanding of the influence of the environment and genes (Fig. 1). Health is a key driver of prosperity (8). It is a societal challenge to adjust to the increasing demands on the health and care sectors arising from the ageing population, and we argue that the answer to this challenge begins in infancy and childhood. If effective health and care is to be maintained for all ages, efforts are required to improve decision making in prevention and treatment provision, to identify and support the dissemination of best practices in the health care sector, and to support integrated care. A better understanding of ageing processes and the prevention of age-related illnesses from the beginning of life onwards are the basis for keeping the European population healthy and active throughout the course of their lives. Similarly important is the wide uptake of technological, organisational, and social innovations empowering older people in particular to remain active, productive, and independent. Doing so will contribute to increasing and lengthening the duration of their physical, social, and mental well-being (9).

FIGURE 1
FIGURE 1:
Key factors in infancy and childhood to prevent chronic gastrointestinal, hepatic, and nutritional disease in later life.

Health problems with early origins are frequent. Common adult chronic somatic and mental disorders have modifiable precursors that arise during childhood, including obesity, diabetes, CVD, chronic inflammatory bowel diseases, food intolerances and allergies, liver failure, and many others. The life-course model of how health evolves provides a scientific basis for understanding the continuity between child and adult health. Life-course health policies seek to promote the well-being of the young, both because of its intrinsic value and because doing so will improve the health of the population throughout all ages.

The life-course model of health demonstrates how children's health and environmental exposures are connected to the development of disorders, disability, and death among adults. Health is produced across the lifespan, wherein childhood is a critical period. Unique environmental interactions occur during early development, some of which have profound effects on future health (10).

It is expected that by 2025, child health will be understood as a major factor influencing health and longevity in later life. Paediatric health care will thus have to be centrally integrated in a life-course model for health care, aiming to lead to a better quality of life.

Genetic Factors and Gene–Environment Interaction

New scientific research shows that health and lifestyle in childhood actually affect whether and how our genes are expressed throughout life via epigenetic modification (ie, early environmental cues can determine how genes are turned on and off, and whether some are expressed at all). Thus, the old ideas that genes are “set in stone,” or that they alone determine development, have been disproven. Therefore, environmental factors and the health and nutrition experiences children have early in life shape their developing brain architecture, immune system, and gut and hepatic function, and strongly affect whether they grow up to be healthy, productive members of society.

This new knowledge has motivated scientists to look more closely at the factors that shape epigenetic modification of gene expression by environmental cues (epigenome) and to study whether interventions can reverse these modifications when negative changes occur. Epigenetic instructions that change how and when certain genes are turned on or off can cause temporary or enduring health consequences. As we get older, new experiences can continue to change our epigenome. Chemical signatures imprinted on our genes during foetal and infant development can have significant influences on the architecture of the brain and other organs that last a lifetime. Improved understanding of the epigenome will provide an explanation, at the molecular level, for why and how early positive and negative experiences can have a lifelong impact. This knowledge should lead to effective interventions that can alter how children's genes work and, thereby, have long-lasting effects on their mental and physical health, learning, and behaviour. Policymakers could use this understanding to make informed decisions about the allocation of resources for interventions that affect the life circumstances of young children. In this respect, the epigenome is the crucial link between the external environments that shape our experiences and the genes that guide our development (11).

It is expected that in 2025 epigenetics will provide an important tool for early assessment of risk, prediction of disease outcomes, and a personalised approach to treatment.

Nutrition and Environment

To effectively reduce the incidence of chronic diseases, it is imperative that we begin to understand how an imbalance of key factors and paramechanisms result in the development of a chronic disease within an individual (Fig. 2) (11). Only through this process will we begin to understand, for example, how diseases such as CVDs and type 2 diabetes mellitus develop as a result of poor nutrition and lifestyle choices or how early nutrition and the microbiome influence the development of chronic gastrointestinal and hepatic diseases. This process should also help identify which paramechanisms (metabolic, genetic, and/or immune) propagate the disease state. A nutritional and physical activity strategy, therefore, aims to promote health and activity and prevent nutrition deficiencies and chronic diseases, such as CVDs, gastrointestinal and hepatic diseases, and cancer. The strategy works to ensure optimal health and cognition, especially in population groups with a lower socioeconomic status (including immigrant communities and ethnic minorities) and during critical periods throughout life, such as pregnancy, lactation, infancy, childhood, and older age.

FIGURE 2
FIGURE 2:
Environmental factors and paramechanisms involved in the development of chronic diseases, including gastrointestinal, hepatic, and nutritional disorders.

Inputs are also required from the consumer sciences and humanities, particularly in relation to changing children's food habits, promoting healthier eating, and increasing physical activity to achieve an early imprinting of lifelong health. More insights into the influence of the physical and social–cultural food environment in childhood can facilitate people's making healthy food choices. Often choices are automatic responses to environmental cues. Socioeconomic status can be a factor in determining the behaviour of children and their families, but more work is needed to understand this interrelationship. Work is also needed to understand the development of food preferences and food habits from birth and during childhood onwards into adulthood.

Gut Health

The gastrointestinal tract is the key interface between food and the human body, and its role in human health, including immune function, needs to be fully elucidated (2). To prevent chronic diseases in later life, it is important that we understand how to maintain normal gut homeostasis in childhood and to elucidate the early influence of inflammation, microbiome, and immunity to maintain a healthy gut function. It is becoming clear that variations in the microbiota are linked to diverse chronic diseases, including irritable bowel syndrome, inflammatory bowel disease, coeliac disease, food intolerance, and allergy. Recent studies have shown that one of the principal determinants of microbiota composition is diet, and that variations in the microbiota caused by diet can have an impact on health and chronic diseases (12). We expect that in 2025 the microbiome will be deciphered and a clear distinction can be made between inflammatory and noninflammatory microbiota. A personalised treatment will be available targeting specific species of the microbiota to normalise homeostasis in the gut, liver, and other organs.

Healthy Liver

Paediatric liver diseases are a major health problem with long-term impact. These conditions can lead to a multitude of symptoms, including malnutrition, life-threatening bleeding, brain dysfunction, and liver failure. A rising paediatric liver disorder linked to the present epidemic of childhood obesity is fatty liver disease, also known as nonalcoholic steatohepatitis. Fatty liver disease can cause severe damage in childhood and in adult life, including liver cirrhosis, liver failure, and cancer. Apart from the important intervention of diet and exercise, there are few effective medical therapies for nonalcoholic steatohepatitis (12); in many cases a liver transplant in later life is the only option. It is the vision of ESPGHAN that in 2025 we will have a good understanding of why children develop acute liver disease, and there will be treatments for chronic liver disease, preventing the need for liver transplantations.

CONCLUSIONS AND PERSPECTIVES

Improvements in child health will enhance healthy longevity and economic growth. Improvements in child and population health, however, require a stronger emphasis on, and support of, paediatric research, with particular opportunities for successful interventions in paediatric gastroenterology, hepatology, and nutrition. The life cycle approach that aims to produce healthy ageing by preventing chronic diseases from early life onwards requires paediatric health care and research to be strongly interconnected with “adult” health care, and expertise in child health must be included to ensure success. There is a growing base of evidence that gut and liver health are dependent on an interaction among genetics, nutrition, and the environment.

REFERENCES

1. European Commission on Health website. Europe 2020—for a healthier EU. http://ec.europa.eu/health/europe_2020_en.htm . Accessed April 17, 2014.
2. European Public Health Alliance. Policy Briefing on Child Health. Brussels, European Public Health Alliance, Brussels; 2001. https://www.google.de/search?q=European+Public+Health+Allaince++Policy+briefing+on+child+health . Accessed April 17, 2014.
3. Online archive of the 2012 Cyprus EU Presidency Web site. http://www.cy2012.eu/index.php/en/news-categories/press-release-health-protection-throughout-the-lifecycle-can-lead-to-healthy-ageing . Accessed April 17, 2014.
4. Rodríguez H, Fisher E, Schuurmans D. Integrating science and society in European Framework Programmes: trends in project-level solicitations. Res Pol 2013; 42:1126–1137.
5. Council of the European Union. Council conclusions on Healthy Ageing Across the Lifecycle. 3206th Employment, Social Policy, Health and Consumer Affairs Council Meeting, Brussels, December 7, 2012. http://www.consilium.europa.eu/uedocs/cms_data/docs/pressdata/en/lsa/134097.pdf . Accessed April 17, 2014.
6. Dalli J. Commissioner Dalli delivers a speech on telehealth; , 2012. http://ec.europa.eu/commission_2010-2014/dalli/docs/speech_telehealth_27032012_en.pdf . Accessed April 17, 2014.
7. Council Decision of 3 December 2013 establishing the specific programme implementing Horizon 2020—the Framework Programme for Research and Innovation (2014–2020) and repealing decisions 2006/971/EC, 2006/972/EC, 2006/973/EC, 2006/974/EC and 2006/975/EC. Official Journal of the European Union, L 347/965; , 2013. http://erc.europa.eu/sites/default/files/document/file/Specific%20Programme%20Horizon%202020_council_decision_establishing_the_specific_programme_implementing_Horizon_2020.pdf . Accessed April 17, 2014.
8. Kondratieff.net. http://www.kondratieff.net . Accessed April 17, 2014.
9. Forrest CB, Riley AW. Childhood origins of adult health: a basis for life-course health policy. Health Aff 2004; 23:155–164.
10. National Science Council on the Developing Child. Early experiences can alter gene expression and affect long-term development. http://developingchild.harvard.edu/index.php/resources/reports_and_working_papers/working_papers/wp10 . Published 2010. Accessed June 30, 2014.
11. JPI. A healthy diet for a healthy life. Research agenda. www.healthydietforhealthylife.eu . Accessed June 30, 2014.
12. Versalovic J. The human microbiome and probiotics: implications for pediatrics. Ann Nutr Metab 2013; 63 (Suppl 2):42–52.
Keywords:

disease prevention; early diagnosis; health promotion; lifecycle; paediatric research priorities; research policy

© 2014 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology,