MIGUEL BOYAYANEven today, pediatricians wake up in the middle of the night to treat a fever that fails to come down, a cough that does not stop, or earache that does not let the child sleep – nor its parents. Since the appearance of this medical specialty in Europe in the 18th century, pediatrics has almost exclusively addressed itself to fighting malnutrition, vermination and the infections that continue to kill, every year, millions of children all the world over. Now, a transformation under way in the scenario of the health problems of children and adolescents is making pediatricians review their role. Besides helping parents distraught with their children’s infection, they will also have to concern themselves with preventing their little customers from developing the so-called chronic degenerative diseases – problems that arise in childhood, advance silently over decades, and are only going to manifest themselves 40 or 50 years later, affecting the quality of life of the adults. This reorientation of the pediatrician’s action is being called new pediatrics, and a correction in course necessary for taking care of children that will possibly reach the age of a 100 and become aged in the 22nd century.
“The pediatrician is used to dealing with acute problems”, comments Magda Carneiro Sampaio, a professor from the School of Medicine of the University of São Paulo (FMUSP). “But those who today attend to a child in their office must pay attention to the health problems that it may develop in the future”, the pediatrician from Pernambuco explains. A specialist in immunological diseases, Magda consolidated a year ago the idea of this pediatrics focused on prevention in an ambitious project: New pediatrics for children that will live 100 years or more.
In partnership with pediatrician João Guilherme Bezerra Alves, of the Maternal and Child Institute of Pernambuco, she brought together the efforts of some 200 specialists from four Brazilian institutions that are currently investigating the origin and the evolution of five groups of chronic diseases that arise in childhood and have been becoming increasingly common: cardiovascular problems, allergies, nutritional disorders, behavioral disorders and chronic diseases of a genetic origin, which can often be avoided during pregnancy. The objective is to find ways of preventing these problems – or more efficient ways of fighting them – and to allow children to grow up without any greater mishaps than a broken arm or a bruise on the knee.
This new posture of pediatrics, which is also beginning to arise in Europe and in the United States and which will require of the pediatricians deeper knowledge of genetics, epidemiology and of the diseases of the third age, is a response to the transformation that humanity has experienced in the course of the 20th century. Since the emergence of our species 150 thousand years ago, never has the human being lived so long as today, as a consequence of the improvement in the living conditions brought about by the access to basic sanitation, medicines and vaccines. Generally speaking, anyone born at the beginning of last century had few chances of getting past the age of 50. A child today, though, in developed countries like Japan or France, will very probably reach the age of 90 or 100, close to about 120 years in age, which is believed to be the limit of human longevity.
Even in poorer nations like Brazil, the situation is not very different. The life expectancy of the Brazilians in the 1950s was 47 years on average, and nowadays it is 71 years. According to data from the Brazilian Institute of Geography and Statistics, in this period in which a good part of its people migrated from the countryside to the city, he population of the country tripled: at the moment, there are 185 million Brazilians. The proportion of people 65 years old or more has also increased continuously since 1980, and it now numbers about 11 million – accordingly to the World Health Organization (WHO), there are 600 million of elderly people in the world, two thirds of which living in developing countries.
One of the immediate effects of this increase in longevity is perceived in the public health system: the chronic degenerative diseases, like cardiovascular problems, osteoporosis or cancer, are becoming more common, often associated to the conditions in which people age. Simultaneously, the Brazilian population is going through a stage of changes that is complicating the scenario even more. Studies from the team of epidemiologist Carlos Augusto Monteiro, from USP, brought together in the book Velhos e novos males da saúde no Brasil [Old and new ills of health in Brazil], reveal that in the last two decades the Brazilians’ nutritional profile has been in transition: malnutrition has decreased amongst adults and children, particularly in the Southeast, while obesity has increased, as a result of the growth in the consumption of animal proteins and sugar. Another aggravating factor is the apparently high level of sedentary life amongst children and teenagers, which along with a higher consumption of calories than the levels recommended by the WHO, is part of the American way of life adopted in almost the whole of the West, including Brazil.
A survey of students of between 10 and 19 years old from public and private schools in Campina Grande, state of Paraíba, shows that only one quarter of the boys and one tenth of the girls carry out more than three hours of physical activity a week. In Ribeirão Preto, in the interior of São Paulo, one of the richest cities in the country, one third of the men and half of the women from 23 to 25 years old do not exercise frequently. “If a child develops a taste for sport when she or he is young, the chance that they will continue to be physically active in the adult age is greater”, Magda comments.
Invited to return to the Children’s Institute last year, after dedicating 15 years to investigating the diseases that debilitate the children’s defense system, Magda imagined that it was time to try to change the scenario that is unfolding. “Pediatricians have to be made to understand that preventive measures taken in the first 20 years of life may be decisive for the future of these children”, she explains. Why so early? For one reason that is not always obvious: “This is the most critical stage of life for the effective prevention of many diseases”, Magda explains. Besides these alterations in habits and lifestyle, something that weighed in Magda’s decision to propose a redefinition of the course of pediatrics was the recent discovery that many diseases that are common in adults have their roots in childhood.
One of the currents of research in mental health, for example, believes that some psychological disorders, like anxiety and depression, may arise in childhood or adolescence and become aggravated in the course of life. In interviews with parents of 959 public and private school students in the Butantan Health District, which includes five districts of São Paulo, the state capital, pediatricians from USP Sandra Grisi and Ana Maria Escobar found that the main complaints about the health of the children are of suspected psychological disturbances and chronic allergies. One quarter of the parents said that they believed that their children had difficulty in paying attention to what they are doing, while 21% stated that their children seemed to suffer from anxiety and from cases of allergy in a similar proportion. These figures do not indicate that these children really do have some psychiatric disorder. But they are a sign that is just as well to pay attention, since what is happening with them may be more than a healthy agitation.
In the light of this data, the teams of Sandra Grisi and Maria Cristina Kupfer, from USP’s Psychology Institute, are working on the development of a test that may help identify mental health problems from the first months of life. It consist of a questionnaire that is currently being evaluated in São Paulo, Belém, Rio, Curitiba and Brasília, which the pediatrician should apply to parents and babies to detect whether the child shows signs of psychological disturbances, one of the main causes of losing years of healthy life, according to the WHO. Another group of health problems that begin very early and impair the quality of life of the adult are the allergic diseases, like asthma, which in recent years have become more common among children and teenagers all over the world. In studies carried out in the city of São Paulo, Dirceu Solé and Charles Nasptiz, from the Federal University of São Paulo (Unifesp), found that almost 12% of the population suffers from asthma and that one in every three persons shows signs of the problem. In order to understand better the factors that unleash this kind of allergy that causes an intense lack of air and prevents the proper development of the lungs, the team of pediatrician Joaquim Carlos Rodrigues and epidemiologist Regina Cardoso has been following up for almost three years the health of almost 300 children of others with asthma at the Children’s Institute, linked to FMUSP.
But the most forthright example of a disease with roots in childhood is atherosclerosis, the accumulation of fat deposits in the blood vessels that is responsible for blocking the arrival of oxygen and nutrients in the heart, in heart attacks, or in the brain, in Cerebral vascular accidents (CVAs). Regarded as the main cause of death in the world, heart attacks and CVAs each year take the lives of 17 million persons, one third of the deaths of the planet. The costs of this problem in a country like Brazil are high. In 2002, cardiovascular diseases lead to the hospitalization of 1.2 million persons and to 50 thousand operations being carried out to reestablish the normal flow of blood to the heart, at an approximate cost of R$ 281 million, according to estimates published in Arquivos Brasileiros de Cardiologia [Brazilian Archives of Cardiology] by epidemiologists Denizar Araújo and Marcos Bosi Ferraz, from Unifesp.
Until a short time ago, it used to be believed that atherosclerosis was a problem exclusive to adults with rather unhealthy habits of life, who would never swap a game of soccer on the TV for a walk in the park, or the rump steak at lunch for a slice of leaner meat. But a study published in the 1980s in the Journal of the American Medical Association changed this idea. Jack Strong, from the Louisiana State University, United States, analyzed the arteries of the heart of American soldiers who died in the Korean War in 1952 and found that although he was dealing with young and apparently healthy individuals, between 45% and 77% of them already had partly clogged coronaries. More recent works have confirmed these results and show that this problem begins even earlier, in childhood. Studies done in Japan, where the consumption of fat is lower than in the West, indicated that 50% of the children of 1 year of age and all those 10 years old showed cardiac arteries with the initial lesions of atherosclerosis.
“The problem is that this ailment advances without any ado until the adult age, and, in one third of the cases, its first manifestation is a fatal heart attack”, explains cardiologist Francisco Fonseca, from Unifesp, one of the editors of the First Guideline for preventing atherosclerosis in childhood and adolescence, drawn up by the Brazilian Society of Cardiology. Published in English in the December 2005 issue of the Brazilian Archives of Cardiology and in English in this month’s issue of the International Journal of Atherosclerosis, this document gives guidance to pediatricians to investigate from an early age the cardiovascular health of children, in particular of those whose parents or grandparents suffer from cardiac problems. “The doctor of a child with a history of cardiac disease in the family must give guidance to the parents to encourage their children from an early age to ingest little sugar and fat and to practice exercises”, Magda says. “Habits, usually acquired early in life, are second nature to human beings. It is difficult to alter them later”, the pediatrician explains.
After the first evidence of the origin of atherosclerosis in childhood, epidemiologist David Barker, from the University of Southampton, in England, puts forward an idea that is still not a consensus amongst specialists, but indicates a more worrying scenario: cardiovascular problems may begin while the fetus is being formed. This suspicion arose from the observation that poor regions in the United Kingdom with high rates of infant mortality at the beginning of the 20th century showed higher levels of cardiovascular diseases higher than the average in the 1970’s and 1980’s.
Based on this information, Barker formulated the theory of fetal programming, according to which the organism of babies subjected to abnormal conditions in pregnancy, such as the lack of nutrients from defects in the placenta or from the malnutrition of the mother, undergo physiological adaptations and save energy during privation. One consequence in the long term is the propensity to accumulating fat in times of abundance and the probable subsequent development of obesity, a risk factor for the increase of cholesterol, diabetes and cardiovascular diseases.
Heloisa Bettiol and Marco Antonio Barbieri, from USP in Ribeirão Preto, have in recent years been seeking indications that confirm an association between the development of obesity in the adult age and inadequate nutrition in the womb – a relatively common problem, identified in 19% of the 2,839 children born in Ribeirão in 1994. An evaluation of the health of 519 boys soon after birth and later, when they were 10 and 18 years old, showed Heloisa and Barbieri that only those with signs of insufficient nutrition during pregnancy and excess weight when 10 years old continued to weigh more than the ideal weight in the adult age. Besides genetic defects, another probable cause of the restricted access to nutrients in the womb is smoking cigarettes in pregnancy.
If there are doubts about the influence of intrauterine development in the health of adults, it is taken as certain that certain characteristics of a baby at birth may indicate future problems. Children with a low weight at birth, or less than 2,500 grams, or premature children that did not complete 37 weeks of gestation, run a greater risk of developing obesity. A comparison of the conditions of health 6,746 children that were born in Ribeirão between June 1978 and May 1979 with the 2,846 born in 1994 suggests that the main reason for the births with a less than desirable weight or shorter time of gestation than normal was the increase in surgical births, which make it possible for parents and doctors to bring forward the arrival of the baby. It remains to find out how this lower birth weight, even though adequate for the gestational age, affects the development of the child and of the adult.
In Rio Grande do Sul, the group from the Federal University of Pelotas (UFPel) coordinated by epidemiologists Bernardo Horta and César Victora, observed that certain stages of childhood have greater weight than others in determining the health of the adult. Following up 6 thousand born in Pelotas in 1982, Victora’s team evaluated the blood pressure and the cholesterol levels at four moments of life: at birth, and when 2, 4 and 15 years old. The result was that the children that were fatter than normal for their age in the first two years of life did not show, in adolescence, higher blood pressure or cholesterol levels than the others. But gaining more weight than recommendable between the second and fourth year of life proved to be related to a worsening in these levels of risk factors for cardiovascular diseases. In both cases, the weight of the child at birth did not affect the health indicators. “There are apparently critical periods that influence the emergence of future health problems”, Horta explains.
Anyhow, it is not only the conditions of life at birth and in childhood that determine the health of the adult. “These chronic diseases are caused by multiple factors”, Horta reminds us. “The occurrence of one or more factors does not mean that the child will necessarily develop the disease later, but it is a sigh that it runs a greater risk”, explains the epidemiologist from UFPel. Fortunately, it is usually a long road between the exposure to risk factors and the development of health problems, which makes it possible for pediatricians to intervene to reduce the damage. The best way out, in Magda’s opinion, is not to believe in luck and to follow some of the wise counsels that in the old days children would receive from their parents: follow a balanced diet; practice physical activities; and avoid smoking and drinking. Nothing too complicated, but something that calls for effort and discipline, as well as the common sense of the parents to know when it is time to look for medical help.
1. From perinatal health to the health of the young adult (nº 00/09508-7); Modality Thematic project; Coordinator Heloisa Bettiol and Marco Antonio Barbieri – FMRP/USP; Investment R$ 684,371.94
2. Reading of the constitution and the psychopathology of social ties by means of clinical indicators (nº 03/09687-7); Modality Thematic project; Coordinator Maria Cristina Kupfer – Psychology Institute/USP; Investment R$ 478,965.20