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Advocacy For Improving Nutrition in The First 1000 Days
Advocacy For Improving Nutrition in The First 1000 Days
Maternal prenatal nutrition and the child's nutrition in the first 2 years of life abstract
(1000 days) are crucial factors in a child’s neurodevelopment and lifelong
mental health. Child and adult health risks, including obesity, hypertension,
and diabetes, may be programmed by nutritional status during this
University of Minnesota Masonic Children’s Hospital, Minneapolis,
period. Calories are essential for growth of both fetus and child but are Minnesota
not sufficient for normal brain development. Although all nutrients are Drs Schwarzenberg and Georgieff both contributed to the writing and
necessary for brain growth, key nutrients that support neurodevelopment editing of this policy statement and approved the final manuscript as
submitted.
include protein; zinc; iron; choline; folate; iodine; vitamins A, D, B6, and B12;
This document is copyrighted and is property of the American
and long-chain polyunsaturated fatty acids. Failure to provide key nutrients Academy of Pediatrics and its Board of Directors. All authors have
during this critical period of brain development may result in lifelong deficits filed conflict of interest statements with the American Academy
of Pediatrics. Any conflicts have been resolved through a process
in brain function despite subsequent nutrient repletion. Understanding the approved by the Board of Directors. The American Academy of
Pediatrics has neither solicited nor accepted any commercial
complex interplay of micro- and macronutrients and neurodevelopment involvement in the development of the content of this publication.
is key to moving beyond simply recommending a “good diet” to optimizing
Policy statements from the American Academy of Pediatrics benefit
nutrient delivery for the developing child. Leaders in pediatric health and from expertise and resources of liaisons and internal (AAP) and
external reviewers. However, policy statements from the American
policy makers must be aware of this research given its implications for Academy of Pediatrics may not reflect the views of the liaisons or the
public policy at the federal and state level. Pediatricians should refer to organizations or government agencies that they represent.
existing services for nutrition support for pregnant and breastfeeding The guidance in this statement does not indicate an exclusive course
of treatment or serve as a standard of medical care. Variations, taking
women, infants, and toddlers. Finally, all providers caring for children can into account individual circumstances, may be appropriate.
advocate for healthy diets for mothers, infants, and young children in the
All policy statements from the American Academy of Pediatrics
first 1000 days. Prioritizing public policies that ensure the provision of automatically expire 5 years after publication unless reaffirmed,
revised, or retired at or before that time.
adequate nutrients and healthy eating during this crucial time would ensure
that all children have an early foundation for optimal neurodevelopment, a 1,000 Days® is a trademark of 1,000 Days, a 501(c)(3) nonprofit
organization. The 1,000 Days mark is used with permission from 1,
key factor in long-term health. 000 Days.
DOI: https://doi.org/10.1542/peds.2017-3716
PEDIATRICS Volume 141, number 2, February 2018:e20173716 From the American Academy of Pediatrics
Downloaded from http://publications.aap.org/pediatrics/article-pdf/141/2/e20173716/917265/peds_20173716.pdf
by Pontificia Universidad Javeriana user
sequence.1,2 Changes that are too occur during this period will not be inadequate or excessive amounts
rapid or too slow in one part of able to occur in later life. both place the individual at risk.
the brain may result in the failure Each of these 2 forms of malnutrition
The period of fetal life and the first
of crucial pathway connections to affects neurodevelopment, and they
2 years postpartum may be seen as
other parts of the brain. Timing may coexist in an individual.10
a time of tremendous opportunity
is crucial; once a particular
for neurodevelopment and a time In this Policy Statement, we seek
developmental sequence fails, it
of great vulnerability.5 Healthy to inform pediatricians and other
may not be possible to retrieve
neurodevelopment is dependent on health care providers of the key role
all the lost function. Moreover,
socioeconomic, interpersonal and/or of nutrition in brain development in
neurodevelopment proceeds by a
family, and nutritional factors.6 the first 1000 days of life (conception
scaffolding process in which the
In the presence of a supportive to 2 years of age). It is not meant as
development of increasingly complex
environment, an attached primary a comprehensive review of the data
neural circuits (and the behaviors
caregiver, and a healthy diet, the on brain-nutrient interaction (for
they support) relies on successful
brain typically thrives. In infants this, see Rao and Georgieff11). With
completion of previous stages of
and children, toxic stress, emotional this policy statement, we intend
development. Thus, optimal, healthy
deprivation, and infection or to support pediatricians and other
neurobehavioral development
inflammation have been shown to be health care providers in promoting
requires that all necessary factors be
associated with less optimal brain healthy nutrition and advocating
present at their biologically defined
development, and a deficient diet for for the expansion of programs that
time points and that no inhibitory
the child can worsen this. The effects affect early life nutrition as a means
factors be present.
of early adverse experiences may be of providing scaffolding for later
a lifetime of medical and psychosocial nutritional programs and preventing
The most active period of
problems, lost academic achievement early developmental loss. In this
neurologic development occurs
and productivity, and possible way, offered in this policy is an
in the first 1000 days of life, the
effects on the next generation.7–9
opportunity to improve each child’s
period beginning at conception
These long-term issues are the true chance for the healthiest and most
and ending at the start of the third
cost to society, a cost that exceeds productive life possible.
postnatal year.3 Rapid change
that of preventing them, and we
occurs from the first development Macronutrient (protein, fat,
again emphasize the importance
of a structure recognizable as the glucose) sufficiency is essential for
of recognizing the developmental
brain (postconception day 18) to normal brain development. Early
origins of adult health and disease.
age 2 years.4 Important primary macronutrient undernutrition is
structures and processes that For the purposes of this discussion, associated with lower IQ scores,
support fundamental behaviors our focus is on the nutritional reduced school success, and
and provide scaffolds for later- environment of the fetus, infant, and more behavioral dysregulation.12
developing structures form during toddler. The nutritional environment Intervention in early nutritional
this time period. These structures has an effect on whether brain deficiency can be effective, and the
and processes include the sensory growth and differentiation proceed full effects may be felt for many
systems (especially auditory and normally or abnormally. Both years.13 In a study unlikely to be
visual), the hippocampus (declarative adequate overall nutrition (ie, replicated, investigators in rural
learning and memory), myelination absence of malnutrition) and Guatemala between 1969 and
(speed of processing), and the provision of adequate amounts of 1989 provided protein-calorie
monoamine neurotransmitter key macro- and micronutrients at supplementation of different degrees
systems (affect, reward). Even critical periods in development to different rural villages. Two
the prefrontal cortex (planning, are necessary for normal brain villages received a high-calorie,
attention, inhibition, multitasking) development. Importantly, the high-protein supplement, and 2
and brain circuits involved in social definition of malnutrition includes villages received a low-calorie
development have the onset of both undernutrition (provision of supplement without protein. Both
rapid development in the first 1000 inadequate amounts of macro- and/or supplements contained vitamins
days. Although neurodevelopment micronutrients) and also obesity and minerals. The supplements
continues throughout the life of a (provision of excessive calories, were provided for pregnant and
healthy person, by age 2 years the often at the expense of other lactating women and children up
brain has undergone tremendous crucial nutrients). It is important to to age 7 years. The investigators
restructuring. Many of the recognize that many nutrients exhibit measured locally relevant outcomes
developmental changes expected to a U-shaped risk curve, whereby over a period longer than 10 years,
should be aware of the importance of health care providers need federal levels to preserve and
these guidelines. The 2015 DGA saw to be knowledgeable about strengthen nutrition programs
an organized and concerted effort breastfeeding to educate with a focus on maternal,
by special interest groups to subvert pregnant women about fetal, and neonatal nutrition.
or dilute the results of the guideline breastfeeding and be prepared Interventions to ensure normal
process and the process itself. It is to help breastfeeding mothers neurodevelopment include
important that pediatricians, who are and their infants when problems programs to minimize adverse
familiar with using evidence-based occur. The AAP recommends environmental influences and
clinical guidelines, advocate for the exclusive breastfeeding for programs to mitigate the effects
scientific foundations of this process approximately the first 6 of adverse environmental
and support implementation of the months of life and continuation influences. These interventions
guidelines. after complementary foods have begin with nutritional health for
been introduced for at least the the pregnant woman, including
American Academy of Pediatrics
first year of life and beyond, adequate protein-energy intake,
The American Academy of Pediatrics as long as mutually desired appropriate gestational weight
(AAP) provides substantial by mother and child. Several gain, and iron sufficiency.
information on the nutritional needs organizations have reviewed To some degree, the placenta
and support of children from birth to interventions to support protects the fetus in terms
age 2 years, including information and breastfeeding.48,49
Despite the of prioritization of nutrients
guidance on breastfeeding45 and on known advantages of human from the mother. After birth,
feeding infants and toddlers.46 AAP milk in early life, estimates are human milk provides optimal
policies on breastfeeding21 and iron that 19% of children receive no neurodevelopmental nutrition
supplementation47 directly address human milk in infancy and only for at least the first 6 months.21
key issues in nutrition and cognition. 22% breastfeed exclusively for After 6 months, pediatricians and
the recommended 6 months;50 other health care providers can
2. Pediatricians, family physicians, support policies that advocate
Recommendations
obstetricians, and other child for optimal protein-calorie and
1. Pediatricians, family physicians, health care providers can micronutrient administration
obstetricians, and other child advocate at the local, state, and to infants and young children
(eg, AAP iron policy47) as well dietary recommendations. into existing nutritional advice
as programs that provide high- As the infant’s nutritional an actionable guide to healthy
quality nutrition to infants and intake moves from the relative eating as a positive choice
young children (eg, WIC); protection of breastfeeding to rather than an avoidance of
dependence on choices made by unhealthy foods. This would
3. Pediatricians and other child
his or her parents, pediatrician give pediatricians and families
health care providers can
guidance for informed food more prescriptive advice as
become conversant about food
choices becomes increasingly to optimal dietary choices.
sources that supply the critical
important. Moreover, knowing Additionally, it is important that
nutrients necessary for brain
which nutrients are at risk in the families understand that no 1
development during particularly
breastfed infant after 6 months food is alone adequate to ensure
important times. Although most
(eg, zinc, iron, vitamin D) will optimal neurodevelopment and
pediatricians are aware that
guide dietary recommendations health (ie, a “superfood”);
exclusive breastfeeding is the best
in the clinic or practice. Guidance
source of nutrition for the first 6 5. Pediatricians and other child
for pediatricians is provided in
months, dietary advice thereafter health care providers can focus
existing documents (Tables 1
is less robust. Awareness of which the attention of existing programs
and 2) but over a spectrum of
foods are “healthy,” not just on improving micro- and
resources and chapters, and it is
as alternatives to unhealthy or macronutrient offerings for infants
often without clear prescriptive
junk food but as positive factors and young children. For example,
recommendations;
targeting optimal development, providing information to existing
would allow pediatricians 4. Leaders in childhood nutrition food pantries and soup kitchens
to make more appropriate can advocate for incorporating to create food packages and meals
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.