Abstract
The first International Conference on Nutrition and Growth brought together physicians, dietitians, nurses and scientists to discuss one of the major challenges of pediatric nutrition, namely growth. The meeting, which lasted for 2 and a half days, was well attended, with more than 1250 participants from 92 countries. This report reviews selected highlights from the conference.
The conference was opened by a plenary session on ‘Outcome measurements of nutrition and growth’ chaired by Hania Szajewska (Medical University of Warsaw, Poland) and Carlo Agostoni (University of Milan, Italy). The speakers of this session presented the manifold aspects of growth from the researcher’s (Hania Szajewska), nutritionist’s (Carlo Agostoni) and endocrinologist’s (Moshe Phillip, Schneider Children’s Medical Center of Israel, Tel-Aviv University, Israel) perspectives. Increasing evidence points to a fundamental role of early nutrition on rates of growth/development and later health; however, at present, a definite conclusion is not possible, mainly due to study design and heterogeneity of the end points. The primary role of adequate nutrition from the nutritionist’s perspective is the immediate health threats to children in resource-poor environments in developing countries where child morbidity and mortality remain high. In developed countries, appropriate nutrition and growth in infancy and childhood represent an opportunity for the prevention of adult, noncommunicable diseases. The evaluation of growth biomarkers and their relationship with nutrition and changes in the growth plate was the topic of the last lecture of the session. The changes in growth plate genes’ expression under conditions of fasting and feeding and different feeding regimens, such as the expression of hypoxia-induced factor 1, is a new area of research that may come up with meaningful growth biomarkers.
A full session was dedicated to the management of short bowel syndrome and Olivier Goulet (University of Paris 5 René Descartes, Paris, France) reviewed the double challenge of growth in the context of intestinal failure, whereas Joanne F Olieman (Erasmus MC Sophia Children’s Hospital, Rotterdam, The Netherlands) reviewed the available data and summarized the recommendations on the use of enteral nutrition for children with short bowel syndrome Citation[1].
The relationship between early nutrition and later growth was the topic of the next session. Results of the late data on growth and childhood obesity from the ‘European Childhood Obesity Group’ and of the randomized controlled trial (RCT) of low protein formula feeding in infancy were presented by Berthold Koletzko (University of Munich, Germany) Citation[2]. So far, the results of the European Union Childhood Obesity Program indicate that low-protein-content formula is associated with endocrine and metabolic benefits, as well as growth rates similar to those of breastfed infants and lower BMI at 1, 2 and 6 years of age and do not show any untoward effects. The ‘dilemma’ of ideal early growth in premature infants has been analyzed by Nicholas Embleton (Royal Victoria Infirmary, Newcastle upon Tyne, UK). The hypothesis of early origin of adult diseases and the connection between rapid postnatal growth and noncommunicable diseases in adulthood have been a source of misgivings with regard to the optimal growth for premature babies. In light of the importance of weight gain for brain growth and development, there is no argument that premature infants’ nutrition should guarantee catch-up growth as close as possible to intrauterine growth. However, rapid catch-up weight has been associated with unfavorable surrogates such as arterial flow-mediated dilatation and intra-abdominal adipose tissue deposition; therefore, the dilemma of slow versus rapid growth in premature infants has different answers for different outcomes. The influence of nutrition as an epigenetic factor and the ‘critical windows’ concept are new fields for exploration that may help us to understand the diversity of responses of different systems during different periods of time. Other topics of this session were characteristics of growth in breastfed infants (Dominique Turk, Lille University Faculty of Medicine, Lille, France) and the challenges of early infant feeding from the industry point of view when long-term growth and outcomes are in the spotlight (Ferdinand Haschke, Nestlé Nutrition Institute, Vevey, Switzerland).
The last session of the day was dedicated to new thinking in infant nutrition and metabolism. The two speakers of this session focused on new developments on infant formulas and presented comprehensive data on benefits and safety data from studies on structured fat (Sheila Innis, University of British Columbia, Vancouver, Canada) and α-lactalbumin-supplemented formulas (Claude Dupont, INRS-Institut Armand-Frappier, Québec, Canada). The first day of the conference was closed by the welcome speech of Moshe Phillips and two ‘personal point of view’ lectures by Irene Netchine, Université Pierre et Marie Curie, Paris France (lessons from the IGF-1 defects and genomic imprinting in developmental disorders) and Olivier Goulet on the challenges of growth in children with chronic disorders during different periods of life in children worldwide.
The second day of the conference started with a session on skeletal growth and bone health. The session included three thorough presentations on bone growth and the interventions aimed at improving peak bone mass (PBM). Bone accretion takes place in childhood and the adult bone mass depends on the PBM achieved during this period. Studies have evaluated the efficacy of various interventions, such as calcium and vitamin D supplementation, dairy product supplements and physical exercise aimed to maximize PBM accretion in childhood, with different and sometimes conflicting results. The confusing impression that one can get from all these studies is caused by the multifactorial nature of influences that affect bone accretion during childhood (heredity, gender, nutrition, mechanical forces, puberty and nutrition). This adds to poor knowledge on bone development at different stages during childhood and adolescence and the factors that act at different stages of development (Rene Rizzoli, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland). Extensive data on the relationship between growth, pubertal development and bone accretion were presented by Babette Zemel (Children’s Hospital of Philadelphia, PA, USA) and data on prenatal influences on bone mass were presented by Nick Harvey (University of Southampton, UK). The influence of maternal lifestyle and diet, body build, vitamin D status and placenta on a baby’s bone size, shape and mineral density offers new opportunities for intervention to improve the bone health of infants.
The first session the next morning was dedicated to nutrition and growth hormone (GH). Anne Klibanski (Harvard Medical School, Boston, MA, USA) reviewed the poor bone status in adolescents with anorexia nervosa, as 50% of these girls have bone mineral density Z-scores of less than -1 standard deviation at one or more bone sites as a result of profound hormonal abnormalities (hypogonadism, GH deficiency, hypercortisolemia and low IGF-1 levels). Whether administration of recombinant human IGF-1 will provide an anabolic effect, leading to increased bone formation, is currently unknown. The role of IGF-1 as the critical connection between GH, growth and nutrition was elaborated by Martin Savage (Royal London School of Medicine and Dentistry, London, UK). Throughout childhood, nutrition, age, puberty, intercurrent illness and metabolic status can influence the production and action of IGF-I Citation[3]. Protein energy malnutrition is accompanied by low IGF-1 circulating levels and significant delay of statural growth. Nutritional rehabilitation significantly increases IGF-I levels in malnourished children in Africa. However, pure malnutrition is rare in children, and pathological states, especially when inflammatory cytokine production is increased, also impact the function of the IGF system. The role of the IGF system in growth, development and feeding was addressed by Jan-Maarten Wit (Leiden University Medical Center, Leiden, The Netherlands). Knockout models (mice), human mutations in IGF1, IGF1R and IGFALS, and association studies with IGF1 single-nucleotide polymorphisms have provided important information on the role of the IGF system on growth and development. The data collected by the Growth Genetics Consortium, an international collaboration group aiming to create a publicly available database and website for all documented molecular defects of the GH–IGF, will advance our knowledge on pre- and post-natal growth and brain development further. The relationship between nutrition, growth and the risk of diabetes has been examined by Tadej Battelino (University of Ljubljana, Slovenia). Epidemiological and observational studies have evaluated the association of diabetes mellitus in childhood (in children with high-risk HLA) with maternal BMI and weight gain during pregnancy and found no association. Early nutritional status and growth at young age (high birth weight, rapid growth in the first year, and higher weight and height at diagnosis) were all found to be associated with an increased risk of diabetes mellitus. The results of the TRIGR study, an international RCT that is testing the hypothesis that whether hydrolyzed infant formula compared with cow’s milk-based formula decreases the risk of developing Type 1 diabetes in children with increased genetic susceptibility, will offer conclusive data.
Nutrition of premature babies, between sufficiency and excess, was the subject of the next session that discussed the optimal protein intake (Ruurd van Elburg, VU University Medical Center, Amsterdam, The Netherlands) and the optimal growth trajectory for premature babies related to long-term effects on health outcomes, neurodevelopment, bone health and cardiovascular risk (Atul Sighal, Institute of Child Health, University College London, London, UK). The optimal nutrition and growth of premature babies were also the topics of an additional session on the last day of the conference (Hans Van-Goudoever, VU University Medical Center). Anita Hokken-Koelega (Erasmus University Medical Center, Rotterdam, The Netherlands) evaluated the data on growth of premature infants by a comparison with the growth of term babies and the health outcomes in young adulthood, and Thibault Senterre (University of Liège, Belgium) assessed the bone status in prematurity.
The benefits of breakfast (weight control, quality of nutrition and school performance) as the ‘most important meal of the day’ have been extensively promoted, but the mechanisms behind these effects are unknown, although the relationships between meal timing and hormonal, neurohormonal and energy metabolism responses have been extensively explored with the science of chronobiology (Corina Hartman, Schneider Children’s Medical Center of Israel, Tel Aviv University, Israel). The neurofunctional and glycemic responses of different breakfast models were presented by Livio Luzi (San Raffaele Scientific Institute, Milan, Italy). Interesting data on different types of breakfast and their effects on cognitive function, evaluated by attention and accuracy tests, have been examined in a prospective RCT in 353 children 6–8 years of age and presented by Umberto Castiello (University of Padova, Italy). The data on the role of complementary source of milk, from the HELENA study, were presented by Theodora Mouratidou (University of Zaragoza, Spain).
A full afternoon session was dedicated to growth charts, starting with a historical perspective presented by Tim Cole (UCL Institute of Child Health). Growth charts represent the visual summary of a child’s growth status relative to a reference population, both in terms of their size and growth rate. From the first growth curve of de Montbeillard’s son in the late 18th century, through to the work of Laplace, Gauss and Galton’s in the 19th century, and culminating in the works of Tanner and Whitehouse and the WHO growth standard of 2006, the growth charts have gone through great changes. The process of design of the UK WHO growth charts, as a step towards chart implementation in the UK, was reviewed by Charlotte Wright (University of Glasgow, UK). Charts for children younger than 4 years and a specialized chart for sick and premature infants were published in 2010, and new charts for school-aged children incorporating a novel way of assessing growth in puberty are planned to be released in May 2012 in the UK. An update on the implementation status of the WHO growth standards was presented by Mecedes de Onis (WHO, Geneva, Switzerland). By May 2011, over 125 countries were at varying stages of implementing the growth standards.
A session on catch-up growth was held parallel to this session. The topics covered during this session were nutrition and catch-up growth (Galia Gat-Yablonski, Schneider Children’s Medical Center of Israel, Petah Tikva, Israel), growth faltering in developing countries (Andrew Prentice, London School of Hygiene and Tropical Medicine, UK) and complementary feeding and growth (Veit Grote, Klinikum der Universität München, Muenchen, Germany). The lecture on molecular and cellular mechanisms of catch-up growth presented the recent evidence suggesting that the mechanisms governing catch-up growth reside within the growth plate and arise in part from a delay in the normal senescence of the growth plate (Jeffrey Baron, NIH, Bethesda, MD, USA) Citation[4]. Oral and poster presentations on obesity were also displayed during the afternoon of the second day.
The third day of the meeting started with a session on obesity and growth. The lectures of this session explored the link between nutrition, growth and obesity, starting with a review of treatment options for monogenic obesity, using the model of melanocortin 4 receptor gene (MC4R) mutations (Aldhoon Hainerová, Third Faculty of Medicine, Charles University, Prague, Czech Republic) and obesity prevention (Luis Moreno, University of Zaragoza, Spain). Additional lectures examined the relationship between IGF-1, growth and early obesity (Kim Fleischer Michaelsen, University of Copenhagen, Fredericksberg, Denmark), the influence of nutrition on growth trajectories associated with adult obesity (i.e., adiposity rebound), and the reciprocal relationship between obesity and growth during puberty (Francisco Chiarelli, University of Chieti, Italy).
The morning plenary session was dedicated to nutritional programming and included a lecture on the mechanisms of programming and the epidemiological studies and the animal models that have helped to establish the concept of programming or the developmental origins of health and disease (Susan Ozanne, University of Cambridge, UK). The lecture addressed the following potential mechanisms that may underpin the developmental programming of future diseases: how developmental plasticity, although beneficial for short-term survival, can subsequently program glucose intolerance and insulin resistance in adult life by eliciting changes in key organ structures and in the epigenome; and how aberrant mitochondrial function can potentially lead to the development of Type 2 diabetes and other features of the metabolic syndrome Citation[5]. Studies that investigated the role of infant feeding on long-term obesity risk showed that a nutrient-enriched diet in infancy increases fat mass deposition later in childhood. The experimental data, supporting a causal link between faster early weight gain and a later risk of obesity, have important implications for the management of infants born small for gestational age, and suggest that the primary prevention of obesity could begin in infancy (Atul Singhal) Citation[6].
The last parallel sessions of the meeting were committed to growth in children with chronic disorders. The session opened with a lecture by Faisal Ahmed (Royal Hospital for Sick Children, Glasgow, UK) on multifactorial pathophysiology and the management of growth in chronic disorders, using the model of inflammatory bowel disorders (IBD). The topic of growth in IBD was broadened by Raanan Shamir (Schneider Children’s Medical Center of Israel, Tel Aviv University, Israel). The lecture summarized the data on the prevalence and the outcomes of growth failure in children with IBD and the therapeutic approach to promote growth in children with IBD, in particular Crohn’s disease. Growth and body composition in children with cystic fibrosis and psychology of growth were reviewed by the last two speakers of the conference, Judy Williams (Seattle Children’s Hospital, University of Washington, Seattle, WA, USA) and Alan Apter (Schneider Children’s Medical Center of Israel).
Overall, the meeting lectures covered each and every one of the aspects of the relationship between nutrition and growth, from intrauterine life (programming) to the newborn premature and term infant and children (growth in infancy and childhood and the relationship with diseases in childhood or noncommunicable diseases in adulthood). The influence of nutrition on children’s growth and health, as well as the physiology of normal growth and pathophysiology of growth delay in children with chronic disorders, were also extensively examined during keynote lectures and oral and poster presentations. The second international conference on nutrition and growth is planned in Barcelona, Spain, from January 30 to February 1, 2014.
Financial & competing interests disclosure
The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.
No writing assistance was utilized in the production of this manuscript.
References
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