Considerable advances have occurred in recent years in the scientific knowledge of the benefits of breastfeeding, the mechanisms underlying these benefits, and in the clinical management of breastfeeding. This policy statement on breastfeeding replaces the 1997 policy statement of the American Academy of Pediatrics and reflects this newer knowledge and the supporting publications. The benefits of breastfeeding for the infant, the mother, and the community are summarized, and recommendations to guide the pediatrician and other health care professionals in assisting mothers in the initiation and maintenance of breastfeeding for healthy term infants and high-risk infants are presented. The policy statement delineates various ways in which pediatricians can promote, protect, and support breastfeeding not only in their individual practices but also in the hospital, medical school, community, and nation.

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Breastfeeding and the Use of Human Milk

Importance Approximately 80% of US adults and adolescents are insufficiently active. Physical activity fosters normal growth and development and can make people feel, function, and sleep better and reduce risk of many chronic diseases. Objective To summarize key guidelines in thePhysical Activity Guidelines for Americans, 2nd edition (PAG). Process and Evidence Synthesis The 2018 Physical Activity Guidelines Advisory Committee conducted a systematic review of the science supporting physical activity and health. The committee addressed 38 questions and 104 subquestions and graded the evidence based on consistency and quality of the research. Evidence graded as strong or moderate was the basis of the key guidelines. The Department of Health and Human Services (HHS) based the PAG on the2018 Physical Activity Guidelines Advisory Committee Scientific Report. Recommendations The PAG provides information and guidance on the types and amounts of physical activity to improve a variety of health outcomes for multiple population groups. Preschool-aged children (3 through 5 years) should be physically active throughout the day to enhance growth and development. Children and adolescents aged 6 through 17 years should do 60 minutes or more of moderate-to-vigorous physical activity daily. Adults should do at least 150 minutes to 300 minutes a week of moderate-intensity, or 75 minutes to 150 minutes a week of vigorous-intensity aerobic physical activity, or an equivalent combination of moderate- and vigorous-intensity aerobic activity. They should also do muscle-strengthening activities on 2 or more days a week. Older adults should do multicomponent physical activity that includes balance training as well as aerobic and muscle-strengthening activities. Pregnant and postpartum women should do at least 150 minutes of moderate-intensity aerobic activity a week. Adults with chronic conditions or disabilities, who are able, should follow the key guidelines for adults and do both aerobic and muscle-strengthening activities. Recommendations emphasize that moving more and sitting less will benefit nearly everyone. Individuals performing the least physical activity benefit most by even modest increases in moderate-to-vigorous physical activity. Additional benefits occur with more physical activity. Both aerobic and muscle-strengthening physical activity are beneficial. Conclusions and Relevance ThePhysical Activity Guidelines for Americans, 2nd edition, provides information and guidance on the types and amounts of physical activity that provide substantial health benefits. Health professionals and policy makers should facilitate awareness of the guidelines and promote the health benefits of physical activity and support efforts to implement programs, practices, and policies to facilitate increased physical activity and to improve the health of the US population.

https://jamanetwork.com/journals/jama/articlepdf/2712935/jama_Piercy_2018_sc_180005.pdf

The Physical Activity Guidelines for Americans

To revise 1998 recommendations on childhood obesity, an Expert Committee, comprised of representatives from 15 professional organizations, appointed experienced scientists and clinicians to 3 writing groups to review the literature and recommend approaches to prevention, assessment, and treatment. Because effective strategies remain poorly defined, the writing groups used both available evidence and expert opinion to develop the recommendations. Primary care providers should universally assess children for obesity risk to improve early identification of elevated BMI, medical risks, and unhealthy eating and physical activity habits. Providers can provide obesity prevention messages for most children and suggest weight control interventions for those with excess weight. The writing groups also recommend changing office systems so that they support efforts to address the problem. BMI should be calculated and plotted at least annually, and the classification should be integrated with other information such as growth pattern, familial obesity, and medical risks to assess the child’s obesity risk. For prevention, the recommendations include both specific eating and physical activity behaviors, which are likely to promote maintenance of healthy weight, but also the use of patient-centered counseling techniques such as motivational interviewing, which helps families identify their own motivation for making change. For assessment, the recommendations include methods to screen for current medical conditions and for future risks, and methods to assess diet and physical activity behaviors. For treatment, the recommendations propose 4 stages of obesity care; the first is brief counseling that can be delivered in a health care office, and subsequent stages require more time and resources. The appropriateness of higher stages is influenced by a patient’s age and degree of excess weight. These recommendations recognize the importance of social and environmental change to reduce the obesity epidemic but also identify ways healthcare providers and health care systems can be part of broader efforts.

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Expert Committee Recommendations Regarding the Prevention, Assessment, and Treatment of Child and Adolescent Overweight and Obesity: Summary Report

Ten per cent of the world’s school-aged children are estimated to be carrying excess body fat (Fig. 1), with an increased risk for developing chronic disease. Of these overweight children, a quarter are obese, with a significant likelihood of some having multiple risk factors for type 2 diabetes, heart disease and a variety of other co-morbidities before or during early adulthood. The prevalence of overweight is dramatically higher in economically developed regions, but is rising significantly in most parts of the world. In many countries the problem of childhood obesity is worsening at a dramatic rate. Surveys during the 1990s show that in Brazil and the USA, an additional 0.5% of the entire child population became overweight each year. In Canada, Australia and parts of Europe the rates were higher, with an additional 1% of all children becoming overweight each year. The burden upon the health services cannot yet be estimated. Although childhood obesity brings a number of additional problems in its train – hyperinsulinaemia, poor glucose tolerance and a raised risk of type 2 diabetes, hypertension, sleep apnoea, social exclusion and depression – the greatest health problems will be seen in the next generation of adults as the present childhood obesity epidemic passes through to adulthood. Greatly increased rates of heart disease, diabetes, certain cancers, gall bladder disease, osteoarthritis, endocrine disorders and other obesityrelated conditions will be found in young adult populations, and their need for medical treatment may last for their remaining life-times. The costs to the health services, the losses to society and the burdens carried by the individuals involved will be great. The present report has been written to focus attention on the issue and to urge policy-makers to consider taking action before it is too late. Specifically, the report:

https://onlinelibrary.wiley.com/doi/pdf/10.1111/j.1467-789X.2004.00133.x

Obesity in children and young people: a crisis in public health.

The purpose was to: 1) perform a systematic review of studies examining the relation between physical activity, fitness, and health in school-aged children and youth, and 2) make recommendations based on the findings. The systematic review was limited to 7 health indicators: high blood cholesterol, high blood pressure, the metabolic syndrome, obesity, low bone density, depression, and injuries. Literature searches were conducted using predefined keywords in 6 key databases. A total of 11,088 potential papers were identified. The abstracts and full-text articles of potentially relevant papers were screened to determine eligibility. Data was abstracted for 113 outcomes from the 86 eligible papers. The evidence was graded for each health outcome using established criteria based on the quantity and quality of studies and strength of effect. The volume, intensity, and type of physical activity were considered. Physical activity was associated with numerous health benefits. The dose-response relations observed in observational studies indicate that the more physical activity, the greater the health benefit. Results from experimental studies indicate that even modest amounts of physical activity can have health benefits in high-risk youngsters (e.g., obese). To achieve substantive health benefits, the physical activity should be of at least a moderate intensity. Vigorous intensity activities may provide even greater benefit. Aerobic-based activities had the greatest health benefit, other than for bone health, in which case high-impact weight bearing activities were required. The following recommendations were made: 1) Children and youth 5-17 years of age should accumulate an average of at least 60 minutes per day and up to several hours of at least moderate intensity physical activity. Some of the health benefits can be achieved through an average of 30 minutes per day. [Level 2, Grade A]. 2) More vigorous intensity activities should be incorporated or added when possible, including activities that strengthen muscle and bone [Level 3, Grade B]. 3) Aerobic activities should make up the majority of the physical activity. Muscle and bone strengthening activities should be incorporated on at least 3 days of the week [Level 2, Grade A].

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Systematic review of the health benefits of physical activity and fitness in school-aged children and youth

A variety of methods are available for defining undernutrition (thinness/underweight/under-fat) and overnutrition (overweight/obesity/over-fat). The extent to which these definitions agree is unclear. The present cross-sectional study aimed to assess agreement between widely used methods of assessing nutritional status in children and adolescents, and to examine the benefit of body composition estimates. The main objective of the cross-sectional study was to assess underweight, overweight and obesity using four methods: (i) BMI-for-age using WHO (2007) reference data; (ii) BMI-for-age using Cole et al. and International Obesity Taskforce cut-offs; (iii) weight-for-age using the National Centre for Health Statistics/WHO growth reference 1977; and (iv) body fat percentage estimated by bio-impedance (body fat reference curves for children of McCarthy et al., 2006). Comparisons were made between methods using weighted kappa analyses. Subjects Individuals (n 1519) in three age groups (school grade 1, mean age 7 years; grade 5, mean age 11 years; grade 9, mean age 15 years). Results In boys, prevalence of unhealthy weight status (both under- and overnutrition) was much higher at all ages with body fatness measures than with simple anthropometric proxies for body fatness; agreement between fatness and weight-based measures was fair or slight using Landis and Koch categories. In girls, prevalence of unhealthy weight status was also higher with body fatness than with proxies, although agreement between measures ranged from fair to substantial. Methods for defining under- and overnutrition should not be considered equivalent. Weight-based measures provide highly conservative estimates of unhealthy weight status, possibly more conservative in boys. Simple body composition measures may be more informative than anthropometry for nutritional surveillance of children and adolescents.

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Body fatness or anthropometry for assessment of unhealthy weight status? Comparison between methods in South African children and adolescents

Aims to compare the classification of overweight, obesity and underweight using international v. national approaches in Kuwaiti adolescents. Assessment of underweight, overweight and obesity using a national approach (based on Kuwaiti reference data for BMI-for-age) was compared with assessments obtained using three international approaches: the Cole et al. and International Obesity Task Force (IOTF) definitions of thinness and of overweight and obesity (Cole-IOTF); WHO 2007; and US Centers for Disease Control and Prevention (CDC) 2000 reference data and definitions. The degree of agreement between the different methods was assessed using the weighted κ statistic (κw). Two randomly selected public intermediate schools in Kuwait City. A total of 499 10-14-year-old Kuwaiti adolescents. Prevalence of overweight and obesity using Kuwaiti reference data (36·7 %; 95 % CI 32·4, 41·1) was significantly lower than that obtained using international approaches - Cole-IOTF (44·7 %; 95 % CI 40·3, 49·2), CDC 2000 (44·9 %; 95 % CI 40·5, 49·4) and WHO 2007 (50·5 %; 95 % CI 46·0, 55·0) (P < 0·01). All three international approaches showed almost perfect agreement: IOTF v. WHO (κw = 0·82; 95 % CI 0·79, 0·85) and IOTF v. CDC (κw = 0·90; 95 % CI 0·87, 0·92). However, Kuwaiti reference data showed the lowest agreement with the three international approaches, the poorest being with WHO 2007 (κw = 0·54; 95 % CI 0·49, 0·59). Caution should be exercised when using recently collected national reference data and definitions while assessing underweight, overweight and obesity for clinical and public health applications.

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Impact of using national v. international definitions of underweight, overweight and obesity: an example from Kuwait

It has been suggested that young children regulate their daily energy intake very closely with highly stable day-to-day total energy intake. This hypothesis was developed on the basis of an experimental study of 15 children aged 26 to 62 months, which reported a within-subject coefficient of variation (CV) in daily energy intake of 10.4%. We tested the hypothesis that free-living energy intakes were highly stable on a day-to-day basis in a sample of free-living young children from Glasgow, Scotland. In 101 children (47 boys) aged 2.6-6.8 years, energy intake was measured using multiple-pass 24-h recalls. Within-subject CV was 19.2%, which was significantly higher than the 10.4% reported by previously Birch and colleagues (p<0.0001). In addition, we identified four other studies on free-living children with within-subject CVs ranging from 16.1-28.7%. This evidence indicates that young children show a wide intra-individual variation in day-to-day regulation of energy intake in a free-living environment.

https://adc.bmj.com/content/archdischild/early/2008/05/02/adc.2007.136119.full.pdf

Energy intake variability in free-living young children

Acute respiratory exacerbations have been proposed to contribute to the negative energy balance which causes undernutrition in cystic fibrosis. However, no studies have measured their effect on all components of energy balance. The aim of this study was to measure the effect of an acute respiratory exacerbation on energy balance. Fourteen children (six females, eight males, mean+/-SD age 9.9+/-2.4 yrs) were studied when well and during the course of an acute respiratory exacerbation treated with intravenous antimicrobial therapy. The total energy expenditure was measured using the doubly-labelled water method, resting energy expenditure by ventilated hood indirect calorimetry, energy intake by household measures records, and fat malabsorption from measurements of dietary fat intake and faecal fat output. The exacerbation was associated with a significant reduction in energy intake (mean paired difference 47 kJ x kg of body weight(-1) x day(-1), p<0.01). Changes in fat malabsorption and resting energy expenditure were negligible. The absence of significant changes in body weight and composition, together with the trend towards lower total energy expenditure, suggested no marked negative energy balance during the exacerbation. In conclusion, treatment of acute respiratory exacerbation with intravenous antimicrobial therapy represents a relatively minor challenge to energy balance and nutritional status in children with cystic fibrosis.

https://erj.ersjournals.com/content/erj/13/4/804.full.pdf

Energy balance during acute respiratory exacerbations in children with cystic fibrosis

Background: The Active Healthy Kids Scotland Report Card aims to consolidate existing evidence, facilitate international comparisons, encourage more evidence-informed physical activity and health policy, and improve surveillance of physical activity. Methods: Application of the Active Healthy Kids Canada Report Card process and methodology to Scotland, adapted to Scottish circumstances and availability of data. Results: The Active Healthy Kids Scotland Report Card 2013 consists of indicators of 7 Health Behaviors and Outcomes and 3 Influences on Health Behaviors and Outcomes. Grades of F were assigned to Overall Physical Activity, Sedentary Behavior (recreational screen time), and Obesity Prevalence. A C was assigned to Active Transportation and a D- was assigned to Diet. Two indicators, Active and Outdoor Play and Organized Sport Participation, could not be graded. Among the Influences, Family Influence received a D, while Perceived Safety, Access, and Availability of Spaces for Physical Activity and the...

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John J. Reilly

Papers

Body fatness or anthropometry for assessment of unhealthy weight status? Comparison between methods in South African children and adolescents

Impact of using national v. international definitions of underweight, overweight and obesity: an example from Kuwait

Energy intake variability in free-living young children

Energy balance during acute respiratory exacerbations in children with cystic fibrosis

Results from Scotland’s 2013 Report Card on Physical Activity for Children and Youth