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

BACKGROUND: The purpose of this pilot study was to assess the feasibility of a structured activity protocol in a room calorimeter among young children. METHODS: Five healthy children (age 5.2 +/- 0.4 y) performed an activity protocol in a room calorimeter, ranging from sedentary to vigorous-intensity activities. Energy expenditure (EE) was calculated from continuous measurements of O2-consumption and CO2-production using Weir's formula. Resting EE was defined as EE during the first 30 min of the study where participants were seated while watching television. The children wore an ActiGraph accelerometer on the right and left hip. RESULTS: The protocol was well tolerated by all children, and lasted 150 to 175 min. Further, differences were seen in both EE and accelerometer counts across 3 of the 4 activity intensities. CONCLUSIONS: It is feasible for young children to perform a structured activity protocol in a room calorimeter enhancing the possibility of conducting future studies to cross-validate existing accelerometer prediction equations.

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Feasibility of an activity protocol for young children in a whole room indirect calorimeter: a proof-of-concept study.

Aim: To assess the prevalence of growth retardation and undernutrition in a homogenous group of 30 children with spastic cerebral palsy. Methods: Standard anthropometric assessment and functional assessment of feeding ability. Results: Growth retardation was common and severe: mean length for age standard deviation score (SDS) was −2.1 (SD 1.0) and 60% of the sample were «stunted». Mean weight for height SDS was +0.2 (SD 0.9) and «wasting» was largely confined to those children identified as having feeding problems. Conclusion: Formal assessment of growth and nutritional status is indicated in children with cerebral palsy, even if health and feeding status would otherwise give little cause for concern.

Growth retardation and undernutrition in children with spastic cerebral palsy

In paediatric practice, mean reference energy requirements for groups are often used to predict individual infant energy requirements. References from the FAO/WHO/United Nations University are based on infants not fed according to the current infant feeding recommendations. The objective of the present study was to measure total energy expenditure (TEE) and determine energy requirements using criterion methods, and validate the use of TEE prediction equation and mean energy requirement references for predicting individual TEE and energy requirements, respectively, in infants who were exclusively breast-fed (EBF) to 6 months of age. EBF infants were included from Greater Glasgow for measurements at 3·5 (n 36) and 6 (n 33) months of age. TEE was measured using doubly labelled water and energy requirements were determined using the factorial approach. TEE and energy requirements were also predicted using equations based on body weight. Relationships between criterion methods and predictions were assessed using correlations. Paired t tests and Bland-Altman plots were used to assess agreement. At the population level, predicted and measured TEE were similar. The energy requirement reference significantly underestimated energy requirements by 7·2% at 3·5 months at the population level, but there was no bias at 6 months. Errors at individual levels were large and energy requirements were underestimated to a larger extent for infants with higher energy requirements. This indicates that references presently used in clinical practice to estimate energy requirements may not fully account for the different growth pattern of EBF infants. More studies in infants EBF to 6 months of age are needed to understand how growth of EBF infants influences energy requirements.

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Validation of energy requirement references for exclusively breast-fed infants

Effect of Accelerometer Cut-Points on Apparent Levels of Physical Activity and Inactivity in Young Children: 2889

Previous Active Healthy Kids Scotland Report Cards from 2013 and 2016 (www.activehealthykidsscotland.co.uk) demonstrated that only a small minority of Scottish school-aged children and adolescents meet the recommended amount of daily moderate-tovigorous intensity physical activity (MVPA; ≥60 minutes). These low levels of MVPA occur despite a favorable physical and policy environment in Scotland. Previous report cards also identified major limitations in surveillance of physical activity and related behaviors in Scotland. The aim of this short paper is to (a) summarize the Scottish grades included in the Global Matrix 3.0 (www.activehealthykids.org) and (b) highlight the continuing limitations in surveillance of physical activity among children and adolescents in Scotland.

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John J. Reilly

Papers

Feasibility of an activity protocol for young children in a whole room indirect calorimeter: a proof-of-concept study.

Growth retardation and undernutrition in children with spastic cerebral palsy

Validation of energy requirement references for exclusively breast-fed infants

Effect of Accelerometer Cut-Points on Apparent Levels of Physical Activity and Inactivity in Young Children: 2889

Results From Scotland's 2018 Report Card on Physical Activity for Children and Youth