Asia-Pacific consensus statement on integrated 24-hour activity guidelines for the early years

Background

Early childhood is a vital period for development and growth. Promoting beneficial lifestyle behaviours in early childhood can help optimise children's health, development and learning, shape their behaviours in adulthood and offer the best protection against future non-communicable diseases (NCDs). In the Asia-Pacific region, NCDs are significant causes of healthcare burden and mortality. Furthermore, there is also a high prevalence of adverse metabolic risk factors and unhealthy lifestyle behaviours among these children.

Method

Representatives from 19 Asia-Pacific nations and/or jurisdictions developed a consensus statement on integrated 24-hour activity guidelines for the early years using the GRADE-ADOLOPMENT framework.

Findings

These guidelines apply to all infants, toddlers and pre-schoolers below 5 years of age. The guidelines aim to provide a holistic and practical approach to lifestyle activities by framing physical activity, sedentary behaviour and sleep within a 24-hour period. Dietary patterns were included as they play an integral role in metabolic health and energy balance.

Interpretation

Aligned with the World Health Organization's Global Action Plan for the Prevention and Control of NCDs through health promotion interventions in early life, through cultivating healthy lifestyle behaviours in the children's early years, we aim to provide children with the best start in life and reduce the burden of future NCDs in the Asia-Pacific region.

Funding

Funded by Integrated platform for research in advancing metabolic health outcomes of women and children.

Asia-Pacific Consensus Statement on integrated 24-hour activity guidelines for children and adolescents

Non-communicable diseases (NCDs) constitute a significant public health challenge and pose a great burden on health and social systems throughout the world. The Asia-Pacific region is in a vulnerable position as the prevalence of NCDs will inevitably increase with rapid socioeconomic transitions; yet it is ill prepared for this public health challenge as Asian children are among the most physically inactive in the world. Aligned with the WHO's global strategy to control NCDs via preventive measures and health promotion policies, representatives from the Asia-Pacific region came together to develop consensus statement on integrated 24-hour activity guidelines for children and adolescents. These guidelines apply to children and adolescents, aged 5-18 years, in the Asia-Pacific region, regardless of gender, cultural background or socioeconomic status. These guidelines aim to provide the latest evidence-based recommendations, taking a holistic approach to lifestyle activities and adopting a practical perspective by framing these activities within a 24-hour period. Eating and dietary elements were incorporated as they closely influence the energy balance of the movement behaviours and vice versa. By investing in the younger generations through advocacy for healthier lifestyles, we aim to reduce the burden of NCDs in the Asia-Pacific region.

Vitamin D insufficiency and its contributing factors in primary school-aged children in Indonesia, a sun-rich country

PURPOSE

The prevalence of rickets is increasing worldwide in association with an increase in vitamin D deficiency. This study aimed to investigate the vitamin D profile of healthy school-aged children in a sun-rich country and its contributing factors.

METHODS

This cross-sectional study was conducted in 120 healthy children from 7-12 years of age who live in Jakarta, Indonesia. Their demographic status, sun exposure duration time, and lifestyle were recorded using a structured questionnaire. Serum calcium, phosphate, bone-alkaline phosphatase (B-ALP), and 25-hydroxy vitamin D (25(OH)2D3) levels were measured. The participants were categorized into vitamin D sufficient and non-vitamin D sufficient groups, and we analyzed variables that contributed to the 25(OH)2D3 level.

RESULTS

Of the participants, 73 (60.8%) were vitamin D sufficient, 45 (37.5%) were vitamin D insufficient, and 2 (1.7%) were vitamin D deficient. Sex, age, body mass index, Fitzpatrick skin type, daily milk intake, and clothing type were not different between the vitamin D sufficient and non-vitamin D sufficient groups. There were no differences in serum calcium, phosphate, and B-ALP between the 2 groups. Sun exposure time was significantly longer in the vitamin D sufficient group compared with that in the non-vitamin D sufficient group (511.4 min/wk vs. 318.7 min/wk, P=0.004), and this effect remained consistent on multivariate analysis after adjustment for covariates (adjusted odds ratio, 1.002; 95% confidence interval, 1.000-1.003). More participants in the vitamin D sufficient group did not use sunscreen (59 vs. 27, P=0.02), but this finding was inconsistent with our multivariate analysis.

CONCLUSION

Despite year-round sun exposure, approximately 1 in 3 primary school-aged children had insufficient vitamin D level. Sun exposure duration was a major contributing factor.

Anthropometric, biochemical and hormonal profiles of the partially admixed pygmoid group in Rampasasa (Flores, Indonesia)

OBJECTIVES

We performed a cross-sectional study on anthropometric and laboratory characteristics of inhabitants of Rampasasa (Flores, Indonesia). Adults were categorised according to ancestry into three groups: pygmoid (P/P, offspring of pygmoid parents, n=8), mixed pygmoid (P/N, offspring of pygmoid and non-pygmoid parents, n=12) and non-pygmoid (N/N, n=10). Children (n=28) were P/N.

METHODS

Measurements included height, weight, sitting height, arm span, head circumference, haematological analysis and serum albumin, calcium, vitamin D, insulin-like growth factor-I (IGF-I) and IGF binding protein 3 (IGFBP-3). Pubertal stage and bone age was assessed in children. Anthropometric data were expressed as standard deviation score (SDS) for age. IGF-I, IGFBP-3 and IGF-I/IGFBP-3 ratio were expressed as SDS for age, bone age and pubertal stage.

RESULTS

Mean height SDS showed a gradient from P/P (-4.0) via P/N (-3.2) to N/N (-2.3) (-3.4, -3.1 and -2.2 adjusted for age-associated shrinking). Sitting height and head circumference showed similar gradients. Serum IGF-I SDS was similar among groups (approximately -1 SDS). IGFBP-3 SDS tended toward a gradient from P/P (-1.9) via P/N (-1.5) to N/N (-1.1), but IGF-I/IGFBP-3 ratio was normal in all groups. In P/P and P/N, mean head circumference SDS was >2 SD greater than mean height SDS. Children showed a progressive growth failure and bone age delay, delayed female pubertal onset and an initial low serum IGF-I, normal IGFBP-3 and low IGF-I/IGFBP-3 ratio.

CONCLUSIONS

P/P showed proportionate short stature with relative macrocephaly and relatively low IGFBP-3; P/N presented an intermediate pattern. P/N children were progressively short, showed delayed skeletal maturation, delayed puberty in girls and low IGF-I and IGF-I/IGFBP-3.

Dietary quality score is positively associated with serum adiponectin level in Indonesian preschool-age children living in the urban area of Jakarta

An unhealthy diet during childhood directly impacts the risk of developing noncommunicable diseases (NCDs) later on in life. However, well-documented information on this issue is lacking. We investigated the dietary quality of young Indonesian children and assessed the relationship to serum adiponectin levels as an early marker of NCDs. Eighty-five (44 girls and 41 boys) Indonesian preschool-age children in East Jakarta were included in this study. Dietary intake data were gathered by collecting repeated 24-hour recalls for one weekday and one day during the weekend, which were then further converted into participants' Healthy Eating Index (HEI) 2015 scores. Meanwhile, an enzyme-linked immunosorbent assay was performed to determine the serum adiponectin level. A multiple regression analysis was performed to assess the association between the HEI 2015 score and serum adiponectin, adjusting for potential confounders. The mean HEI 2015 score was 33.2 ± 8.3 points, which was far below the recommended score of ≥ 80 points, while the mean serum adiponectin was 10.3 ± 4.1 μg/mL. Multiple linear regression testing showed that a one-point increase in the HEI 2015 score was significantly associated with an increase in the serum adiponectin level by 0.115 μg/mL after adjusting for exclusive breastfeeding history (β = 0.115; 95% CI = 0.010-0.221; p = 0.032). In conclusion, better adherence of young children to a healthy diet has a positive association with their adiponectin level. This result suggests that strengthening children's dietary quality from an early age by involving all parties in the children's environment (e.g., parents, teachers at school, policymakers) may help to reduce the risk of NCDs later on in childhood and during adult life.

The Challenges of Managing Pediatric Diabetes and Other Endocrine Disorders During the COVID-19 Pandemic: Results From an International Cross-Sectional Electronic Survey

BACKGROUND

Frequency, dimensions, management, and outcomes of the COVID-19 pandemic in children with endocrine disorders and diabetes were assessed.

METHODS

A cross-sectional electronic survey was distributed to the global network of endocrine societies. Respondents' professional and practice profiles, clinic sizes, their country of practice, and the impact of COVID-19 on endocrine diseases were investigated.

RESULTS

Respondents from 131 pediatric endocrine centers in 51 countries across all continents completed the survey. Routine check-ups and education were altered in most pediatric endocrine clinics. Over 20% of clinics experienced a shortage of critical medications or essential supplies. ICU treatment was required for patients with diabetes and COVID-19 in 21.2% of centers. In diabetes, 44% of respondents reported increased diabetic ketoacidosis episodes in newly diagnosed cases and 30% in established cases. Biopsychosocial and behavioral changes were explicitly reported to be occurring among pediatric patients with endocrine disorders.

CONCLUSIONS

This large global survey conducted during the COVID-19 pandemic highlights that diabetes is more challenging to manage than any other pediatric endocrine disorder, with an increased risk of morbidity. Psychological distress due to COVID-19 needs to be recognized and addressed. The importance of close contact with healthcare professionals should be emphasized, and medical supplies should be readily available to all patients.

Environmental stimulation on height: The story from Indonesia

Background: Since the 19^th century, sexual dimorphism has been known to be sensitive to adverse environmental conditions. Migrants are sensitive to economic and political affluence, and tend to adjust in height towards height of their hosts. We aim to study growth, sexual dimorphism, and height of native and migrant children in three primary schools in Nabire, Papua, Indonesia. Material and Methods 1: Cross-sectional data on height were obtained from 186 children (59 and 56 native Papuan girls and boys, respectively; 38 and 33 trans-migrant girls and boys respectively; who are aged 7.0-7.7 (mean 7.45) years from three primary schools in Nabire, Papua, Indonesia. The Indonesian National Growth Charts were used as references for height. Results 1: With 118.4 cm (SD 6.7) cm, trans-migrant 7-year old boys were almost 3 cm taller compared to their native-age-matched-peers (115.7 cm (5.0 SD) cm, p < 0.05). The case was different among the girls. Trans-migrant girls were not significantly taller than native girls. Material and Method 2: We re-analyzed the height data from over 300,000 infants, children and adolescents, age 0-18 year, from 34 Indonesian provinces. The data were obtained from the latest Indonesian 2013 National Basic Health Survey (NHBS), and have previously been used to construct National Indonesian Growth Charts. St. Nicolas House Analysis was used to translate correlation matrices into network graphs and visualizing chains of associations between parameters that were multiply correlated. Results 2: St. Nicolas House Analysis suggested that the growth of male sex were more sensitive to population crowding, and that crowding contributes to the greater height dimorphism in taller populations. Conclusion: Economic prosperity and increased population density stimulate male adult height to a greater extent than female adult height, and increase the sexual dimorphism in height among the tall populations of densely populated wealthy countries.

Global immunization systems strengthening through pediatric societies: the promise of private-public partnerships in Indonesia

Vaccines are one of the most successful health interventions in history. Yet, vaccine-preventable diseases still claim the lives of 2.5 million individuals globally every year. Approximately 60% of the 19.4 million infants that did not have access to routine immunization services in 2018 live in 10 countries, one of which is Indonesia. In order to reach global targets, it is critical for countries such as Indonesia to prioritize, tailor, and operationalize vaccination strategies to address immunization gaps. Pediatricians and national pediatric societies (NPS) are trusted stakeholders in their countries and are uniquely qualified to promote vaccination programs. The American Academy of Pediatrics (AAP) partnered with the Indonesian Pediatric Society (IPS), with support from the US Centers for Disease Control and Prevention (CDC), to initiate a multiyear project to build the capacity of IPS, individual members, and other child health clinicians to strategically advocate for improved immunization services across both public and private sectors.

Isolated Growth Hormone Deficiency Type 2 due to a novel GH1 Mutation: A Case Report

Isolated growth hormone (GH) deficiency (IGHD) type 2 is a rare autosomal dominant disorder characterized by severe short stature with low GH level. Timely diagnosis is important for optimal results of recombinant human GH (rhGH) treatment and detection of additional pituitary deficiencies in affected relatives. A male child presented at the age of one year with severe, proportionate short stature [-4.9 standard deviation score (SDS)] and with a normal body mass index (-1.1 SDS). Physical examination revealed frontal bossing, midfacial hypoplasia, normal external genitalia and no dysmorphic features. Paternal and maternal heights were -6.1 and -1.9 SDS. Serum insulin-like growth factor-1 (IGF-1) and IGF-binding protein-3 were undetectable and the peak GH concentration by clonidine stimulation test was extremely low (0.18 ng/mL). Brain magnetic resonance imaging showed anterior pituitary hypoplasia. Genetic analysis identified a novel heterozygous mutation (c.291+2T>G) expected to lead to splicing out exon 3 of GH1. rhGH from age 2.4 years led to appropriate catch-up. In conclusion, we identified a novel GH1 gene mutation in an infant with classical IGHD type 2 presentation.

Correction: Stunting is not a synonym of malnutrition

An amendment to this paper has been published and can be accessed via a link at the top of the paper.

Kompetensi dan Kinerja Petugas First Line Badan Penanggulangan Bencana Provinsi Sulawesi Barat

Provinsi Sulawesi Barat adalah salah satu daerah rawan bencana karena berada dalam jalur tektonik cincin api dunia.  Wilayah ini memiliki kerentanaan tinggi terhadap kemungkinan terjadinya bencana a am geologi, seperti gempa bumi tektonik, gerakan tanah atau tanah longsor maupun banjir. Pelatihan kompetensi petugas first line Badan Penanggulangan Bencana sangat diperlukan untuk peningkatan kompetensi dan kinerja petugas sehingga dapat melakukan pertolongan pada saat terjadi bencana dengan cepat dan tepat. Tujuan penelitian ini adalah menentukan kompetensi dan kinerja petugas first line setelah dilakukan pelatihan pertolongan pertama saat terjadi bencana. Penelitian ini merupakan quasi eksperiment dengan rancangan one group pre-post test design. Subjek penelitian diambil secara purposive sampling sebanyak 33 orang. Data dianalisa menggunakan paired t-test. Hasil penelitian menunjukkan peningkatan kompetensi (p = 0,005) dan kinerja (p = 0,005) petugas first li e Badan Penanggulangan Bencana Daerah Provinsi Sulawesi Barat setelah dilakukan pelatihan. Disarankan untuk mencapai optimalisasi kinerja petugas first line perlu dilaksanakan simulasi atau latihan bersama dan seminar penanggulangan bencana terpadu setiap semester.

Pengobatan Testosteron pada Mikropenis

Mikropenis atau hipogenitalism adalah suatu keadaan penis dengan bentuk normalnamun dengan ukuran kurang dari 2.5 SD di bawah rerata menurut umur dan statusperkembangan pubertas. Pengukuran penis dilakukan secara fully stretched, menggunakanspatula kayu yang diletakkan sejajar dengan dorsum penis dan ditekan sampai simfisispubis. Panjang penis adalah jarak dari simfisis pubis sampai ujung glans penis dan tidakdalam keadaan ereksi. Pengobatan mikropenis terhadap 23 anak dengan rerata usia 9.6tahun dilakukan dengan pemberian testosteron ester intramuskular setiap 3 minggusebanyak 4 kali. Pasca terapi penis bertambah panjang 85% dibandingkan sebelum terapi.Tidak terlihat adanya pertambahan usia tulang dengan protokol yang digunakan.

Thyroid hormone profile and PELOD score in children with sepsis

Background Thyroid hormonal dysfunction, also known aseuthyroid sick syndrome or nonthyroidal illness, can be seenin sepsis. There have been few studies on thyroid hormonedysfunction in septic children, as well as on a relationshipbetween their thyroid hormone profiles and pediatric logisticorgan dysfunction (PELOD) scores. Procakitonin (PCT) is oneof the sepsis biomarker.Objective To evaluate the thyroid hormone profile in childrenwith sepsis as well as to assess for a correlation between the thyroidlevels and PELOD scores, PCT levels, and patient outcomes.Methods This cross-sectional study included children aged 1- 18years admitted to the pediatric intensive care unit (PICU) with aprimary diagnosis of sepsis. PELOD scores and thyroid hormonallevels were assessed once during the first 24 hours after PICUadmission.Results Thirty subjects were included in the study. The medianvalues ofT3, free T4, and TSH were 45 (range 17 -133) ng/dL,0.81 (range 0.3-1.57) ng/dL, and 1.36 (range 0.05-7.78) μIU/L,respectively. The T3, free T4, and TSH levels were decreased in97%, 50% and 40% of the subjects. There were no significantdifferences between low and normal to high TSH with regards tothe PELOD score (P=0.218), PCT level (P=0.694), or patientoutcomes (P=0.55). The risk of death increased by 15 timesamong the subjects with PELOD score ~20 compared to thosewith PELOD score <20 (OR 15; 95%CI: 1.535 to 146.545;P=0.012).Conclusion Thyroid hormones are decreased in septic childrenwith the majority having low T3. A high PELOD score is stronglycorrelated with mortality and can be used as a prognostic parameterfor septic children in the PICU, but there is no correlation withdecreased TSH.

Head circumference and anterior fontanel measurements in newborns

Background Head growth and anterior fontanel (AP) closureare passive processes in response to brain growth. The growthof the brain and skull starts in the third week of intrauterinegestation. roth processes run simultaneously as a part of integralgrowth, along 'With increasing gestational age, until post􀀿birth.Measurement of head circumference (He) and AF in newbornsis done to determine if the brain and skull grew normally duringthe intrauterine period.Objectives To investigate the differences in He and AF sizebetween preterm and full􀀿term infants, and the relationshipbetween gestational age (GA) and birth weight (BW) to Heand AF size.Methods This was a descriptive analytic study on preterm andfull􀀿term newborns. Measurement of HC and AF was conductedin three phases: just after birth, 1x24 and 2x24 hours of age.Analysis of HC and AF size differences between preterm and fullterm subjects was performed, as well as analysis of the correlationbetween GA and BW to HC and AF size.Results Two hundred fifty newborns completed the study. Therewere 180 full􀀿term and 70 preterm subjects. Median HC in full􀀿term and preterm male subjects were 34 cm (range 31􀀿37 cm)and 31 cm (27􀀿34 cm), respectively. Median HC in full􀀿termand preterm female subjects were 33 cm (31􀀿36 cm) and 32 cm(27􀀿3S.S cm), respectively. Median AF in full􀀿term and pretermmale subjects were 2.17 cm (1.0SA.6 cm) and 2.22 cm (1.3SA.Scm), respectively, and in full􀀿term and preterm female subjectswere 2.02 cm (lA.1S cm) and 2.22 cm (0.7SA cm), respectively.The HC of preterms were significantly lower than the fullterms(P<O.OOl), however the AF size was not different between these2 groups of newborns (P =0 .28). Correlation test between GA andBW to HC size revealed a positive correlation (r=0.620, P<O.OO 1and r=0.801, P<O.OOl, respectively), but not to AF size (r=􀀿 0.06,p􀁀 0.279 and F- 0.049, P􀁀0.44, respectively).Concl usions We found that the HC size of pre terms wassignificantly lower than thefullterms, but no significant differences in AF size between the two groups. GA and BW were associatedwith HC size, but not associated to AF size. [paediatr lndones.2012;52:145-51].