Educating patients: one-year anniversary of the JAMA Patient Page.

Abstract

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 costeffective. 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 colleagues 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” and suggest some implications for health policy and clinical practice. Mercy and Saul 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. In 217 healthy 18to 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 Sweden 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