www.jped.com.br
REVIEW
ARTICLE
The
formation
of
citizens:
the
pediatrician’s
role
夽
Dioclécio
Campos
Júnior
a,baDepartmentofPediatrics,FaculdadedeMedicina,UniversidadedeBrasília,Brasília,DF,Brazil
bExecutiveCommittee,GlobalPediatricEducationConsortium(GPEC)
Received8December2015;accepted15December2015 Availableonline17March2016
KEYWORDS
Epigenetics; Prevention; Toxicstress
Abstract
Objective: Thisreviewarticleaimstodefinethefundamentalroleofthepediatricianinthe formationofcitizensinthe21stcentury.
Sourceofdata: Significant bibliographical contributionsproduced by neuroscience, ecology, andepigeneticsintheearlychildhoodscenario.
Synthesisofdata: Manydiseasesthatimpairthelivesofadultsresultfromsevereandoften uncontrollabledisorders thatoccurinearlychildhood, anirreplaceableperiod for thesafe constructionofthehumanbrain,personality,andintelligence.Thereisnoteworthyscientific evidencethathasbecomeunquestionable,according towhich abuseandneglectandother formsofviolencetowhichchildrenareexposedduringthecourseoftheirlives,arethe gen-esisofmanyphysicalailmentsandothermentaldiseases,includingdepressivemorbidityand schizophrenia.Conversely,itisalsoemphasizedthathealthypracticessuchasreadingand lis-teningto/playingmusicareabletointensivelycontributetotheexerciseofcognitivecapacity inherenttothisperiodoflife,asaprerequisitefortheacquisitionoflearningindispensableto thehigheducationalperformanceduringtheschoolingperiod.
Conclusion: Inthelightofthedisclosedscientificevidence,thepediatricianemergesasthe mostdifferentiatedprofessionaltoprovidepreventiveandcurativecareindispensabletothe skilledformationofahealthycitizen.
©2016SociedadeBrasileiradePediatria.PublishedbyElsevierEditoraLtda.Allrightsreserved.
PALAVRAS-CHAVE
Epigenética; Prevenc¸ão; Estressetóxico
Aformac¸ãodocidadão:papeldopediatra
Resumo
Objetivo: Opresenteartigo derevisãocientíficatem porobjetivoconfiguraropapel funda-mentaldopediatranaformac¸ãodocidadãodoséculoXXI.
夽
Pleasecitethisarticleas:CamposJúniorD.Theformationofcitizens:thepediatrician’srole.JPediatr(RioJ).2016;92(3Suppl1):S23---9. E-mail:[email protected]
http://dx.doi.org/10.1016/j.jped.2015.12.002
Fontesdosdados: Contribuic¸ões bibliográficas importantes produzidas pela neurociência, ecologiaeepigenéticanoâmbitodaprimeirainfância.
Síntesedosdados: Grande númerode doenc¸asque desqualificama vidadepessoas adultas resultadesérios,emuitasvezesincontroláveisdistúrbios,queocorremnaprimeirainfância, períodoinsubstituívelparaaconstruc¸ãoseguradocérebro,dapersonalidadeedainteligência humana. Destaca-se aevidência científicaque setornou inquestionável, segundo aqual os abusosenegligênciaeoutrasformasdeviolência,àsquaisacrianc¸aéexpostaduranteociclo devidademaiscomplexadinâmicaexistencial,estãonagênesedeváriasenfermidadesfísicas eoutrasdenaturezamental,inclusiveasmorbidadesdepressivaseaprópriaesquizofrenia. Ressalta,poroutrolado,aspráticassaudáveiscomoaleituraeamúsica,capazesdecontribuir intensamenteparaoexercíciodacapacidadecognitivainerenteaesteperíododevidacomo pré-requisitoparaaquisic¸ãodaaprendizagemindispensávelàaltaperformanceeducacionalno períododaescolaridade.
Conclusão: Àluzdasevidências científicasarroladas, opediatraemergecomooprofissional mais diferenciado para a prestac¸ão dos cuidados preventivos e curativos indispensáveis à estruturac¸ãoqualificadadeumcidadãosaudável.
©2016SociedadeBrasileiradePediatria.PublicadoporElsevierEditoraLtda.Todososdireitos reservados.
Introduction
The concept of citizenship is an important advancement in thehistory of civilization. It includes rights andduties asattributes of individuals living in society, progressively incorporatedaccordingtothedifferentstagesoflife,during whichtheindividual’sphysicalandmentalmaturityis con-solidated,andhe/shestartstoexercisetherelevantroleof citizen.
BraziliansociologistGilbertoFreyre1definedthestages
of the citizen’s formation. The first stage corresponds to the child who comes into the world as a human being, as it belongs to the Homo sapiens species. Then, dur-ing childhood, the individual is structured as a result of thecontinuousawakeningof theirpersonalitythroughthe emotionalbondwiththeir motherandother family mem-bers.Duetotheinteractiondevelopedwithothermembers of society, in all environments he/she experiences, the socializedindividualbecomesaperson.Atthenextstage, the person becomes a citizen through the maturation of thelearning process and awareness, duringwhich he/she reachesthemostdifferentiatedlevel,necessary tolivein society.
Insidethisevolutionarycontext,thedegreeofknowledge correspondingtobraindifferentiation,thesafe environmen-talconditionsandfactorsonwhichtheadequateexpression of thegenes that comprise the DNAdepend, hasallowed for the elucidation of the mechanisms that ensure or inhibit decisive phenomena to construct the phenotype.2
Thus, broad transformation perspectives are opened in public health that can contribute to the improvement of the evolutionary pattern on which the citizen’s essence depends.
Three scientific production fields have developed in recent decades, providing information capable of con-tributingtotherequirementsfor qualityofhumanbeings’ formationsinceconception.Indeed,ecology,neuroscience,
and epigenetics have significantly developed in research aimedmainlyattherealneedsofhumansociety.
Inthe health context,the findingsthat emergedin all three domains of knowledge reinforce observations that highlight the primary importance of preventive actions against diseases. However, pursuant to the logic of the healthsystemsofseveralcountries,investmentsinthe diag-nosisandtreatmentofdiseasesthatcompromisethehealthy developmentofindividualsstillprevail.
Anexampleistheimpactofthehealthcarebudgetofthe UnitedStates,showingtheabsenceoftheabovementioned priority of preventive practices. In that country, massive investmentsofhealthresourcespersistinthemaintenance andsupplyofnetworkservicesrelatedtothediagnosisand treatmentofdiseases.Accordingtoaresearchcarriedout usingmortality reductionasan objectiveindicator of the impact produced by the different actions of the Ameri-can health care system, the results areclear: 90% of the resourcesinvestedinthehealingdynamicsresultina reduc-tionofonly11%ofmortalityinthecountry;1.5%,investedin lifestylechanges,leadtoa43%decreaseinmortality;1.6%, aimed at improving the qualityof theenvironment result in a19%decrease inmortality;and7.9%,spent onhealth biology,decreasethatindicatorby27%.
There is no bigger proof of the need for change in theoperatinglogic for diseaseprevention toprevail.This changenotonlybringsaremarkablereductioninthecosts of health systems, makingthem sustainable,but also the expansionofhealthypopulations,anirreplaceable prereq-uisiteforqualifiedcitizenshipexercise.3
Importanceoftheenvironmentalinthecitizen’s formation
forthbytheUnitedNationsConferenceontheHuman Envi-ronment,heldin Stockholmin1972: ‘‘Theenvironmentis thesetofphysical,chemical,biologicalandsocial compo-nents capable of having direct or indirect effects, in the shortorlongterm,onlivingbeingsandhumanactivities’’.4
The environmentalimpactonthestructuresand physi-ologicalreactions ofthehumanbodybearsadimensionof unquestionablescientific evidence.The citizens’physical, mental, and social well-being effectively existonly when thereis a healthy balance withenvironmental factors on whichtheirhealthdepends.Thisisparticularlytrueinthe socialscenarioinwhichchildrenandadolescentsdevelop. Ecologyhasbeencontributingtoelucidatethegrowing asso-ciationsbetweeninjuriesthatoccurinthisagerangeandthe diseasesthatoccurinadulthood.
The emphasisonthesocialcomponentsthatconstitute theenvironmentreinforcesthebasesofepigenetics,a sci-encethathighlightsthevitalroleofenvironmentalfactors fortheexpression ofDNAgenes. Theknowledgefromthis newfieldofresearchhaveallowedfor theestablishment, withahigh degreeof probability,ofthe causeandeffect relationshipbetweenviolenceagainstchildrenand adoles-centsandmanyofthediseasesthatareidentifiedinyoung adults.5
The main triggering factor is stress, through which abuse generates morbidities in the anatomic and physio-logicuniverseofthebody.6Theendogenoussubstancesthat
originatefromthisdamage,amongwhichcortisol,resultin disturbancesinsynapticconnections,triggeringalterations thatareatthegenesisofdifficult-to-controldiseases.
Theassociationbetweenexposuretoadversitiesin child-hood and adolescenceand the different morbid disorders inadulthoodhasbeenclearlydemonstratedinstudies con-ductedoverthepastdecades.Thus,itbecomesveryclear theroleofanadequateenvironmentforthehealthygrowth anddevelopmentof human beings atthe differentstages thatarepartofthecitizen’sformation.Severallinesof evi-denceprovetheaccuracyofsuchconcept.Aclassicstudyin psychology7demonstratesthatmaternaldeprivationinthis
agegroupisapredisposingfactorforaggressiveandviolent behaviorsinadulthood.
Additionally, itappearsthatmanyoftheadultdiseases arisefromdisordersandabnormalitiesofgrowthand devel-opment, the two phenomenathat characterize childhood andadolescence;thereisgrowingevidencetosupportthis, andsomeexamplesarehighlyillustrative.Ameta-analysis studydemonstrated,withhigh statisticalsignificance, the association betweenabuseandmistreatment inchildhood andahighriskoftypeIIdiabetesinadulthood.8Theeffect
ofneglectwasfarmorepronouncedthanthatofabuse. Another meta-analysis study indicated a close associa-tionbetweentheadversitiesfacedinchildhood---especially physical, sexual, and emotional abuse --- and obesity in adulthood.9 Another scientificanalysis correlatedphysical
and sexual abuse, aswell as domestic parentalviolence, with inflammatory bowel disease, particularly ulcerative colitis. Those authors speculated that epigenetic and neuroendocrineagentscouldactasapossible physiopatho-logicalbasisforthedescribedassociation.10Thehypothesis
ofcauseandeffectassociationbetweenthe damages suf-feredinchildhoodandadultdiseaseswasemphasizedina cross-sectionalstudyconductedin theUnitedStatesusing
CDCdata,whichestablishedacloseassociationbetweenthe occurrenceofsuchadversitiesintheabovementionedage rangeandasthmainadults.11
Thephysiopathologicalmechanismsthroughwhichabuse andneglectsuffered inchildhooddetermine several mor-bidities throughout life are not well clarified. For this purpose, the scientific assessments have highlighted the concept of allostasis, understood as a degree of stability achievedthroughadaptiveadjustments,aswellasthe accu-mulatedstressoflife,understoodastheallostaticloadof McEwen.12Botharetakenintoaccountsothatthe
nosolog-icaleffectsofchildhoodonadulthoodcanbeunderstood.
Contributionsfromneuroscience
Inadditiontothefull physicalgrowthgeneratedby trans-formationsthroughoutthebody,thefullscopeofacitizen’s formationrequiresthecomplexstructuringofthebrain,an organwhoseadequatefunctionisanindispensable prerequi-siteforqualityoflife.Itcorrespondstothefoundationthat supportstheconstructionofcognitivecapacity,thegenesis ofmentaldynamicsessentialtointelligencethatensuresthe expressionofeach individual’soriginality, theirinnovative strengthsandcreativeprofile.
Brain growth and differentiation occursin the first six years of life, defined as infancy. Not only brain volume increasessignificantly in this period, but there is also an exponentialincreaseinthenumberofestablishedsynapses. Thereareapproximately15,000ofthemforeachneuronin thefirstthreeyearsofage,withanaverageof700 connec-tionspersecond.Subsequently,thepruningprocessoccurs, whichselectsandmaintains thesynapses,establishingthe brainprofilethatpersistsintoadulthood.13
The establishment of these synaptic connections pre-supposes adequate nutrition and emotional stimulation compatiblewiththespecificneedsofthepersonalityunder construction.Itisfurtherproofoftheenvironment’s deci-siveroleinthegenesisoftheindividual,theperson,andthe citizen.14 It istheembodimentofasocial uterusinwhich
thenewbornstartsgrowinganddevelopingafterovercoming thetraumaofbirth.Itcomprisesnotonlythefamily,which isequivalenttoanextrauterineplacenta,butallmembers ofsociety.
Some scientific evidence constitutes an example of the truth of such conceptual formulations. They support the recent hypothesis, based on studies of the brain’s whitemattermicrostructure, thattheadversitiessuffered in childhood are a possible physiopathological factor of schizophrenia, which appear to be responsible for alter-ationsin thestructural connectivityof thecortical-limbic networks.15
adequatedevelopmentanddifferentiationofthebrain,thus reducingtheriskofmentaldiseasesinadulthood.16
Asneuroscienceexpandstheclarificationofthe physio-logicalphenomenathatareessentialfor braingrowthand maturation, there is growing scientific evidence that the interactionofachild’sbodywithasafeandstimulating envi-ronmentisaprerequisiteforthebiopsychosocialevolution ofhumanbeingsatallstagesoftheirexistence,particularly duringearlychildhood.
Contributionsofepigenetics
Scientific discoveries in the field of epigenetics explain the associations between ecological components and the individual’s phenotypic expression since intrauterine life. Review studies have consolidated the importance of the epigenetic phenomena underlying adult neuropsychiatric morbidities,such asbehavioral alterations, anxiety disor-ders,andschizophrenia.
Thesedescribedalterationsmayreflectadysfunctionin thephysiologicalstressresponseaxis,whichremainspresent afterthedamagessufferedinchildhood,asdemonstrated bytheassessmentofresponsivenesstostressorsthroughout life.Theresultsobtainedhighlightthealterationscausedby stressoragentsonthegeneticelementslinkedtothe func-tional expression of hypothalamic---pituitary---adrenal axis, aswell asintheglucocorticoid receptorgenes. Moreover, epigeneticalterationsin othergenegroups, suchasthose relatedtoneurotrophicfactorsandserotonintransporters, alsoresultfromexposuretostressintheearly years,and becometriggersoftheadult’ssusceptibilitytothe above-mentionedpsychiatricdisorders.17
Furthermore,chronicmalnutrition,changeinsocial con-ditions,andadverseexperiencesinearlylifecanstimulate epigeneticmechanismscapableofmodifying gene expres-sionand,consequently,ofcreatingphenotypicprofilesthat contributetoriskofdiseasesatlaterstagesofadultlife.18
The aforementioned studies reinforceconcepts emerg-ingfromscientificevidence,accordingtowhichtheeffect ofadversitiesonexposedchildrenandadolescentscan pro-duce long-term pathological consequences. In this sense, theroleof toxicstressin childhoodhasbeen increasingly identifiedasamechanism that producessubsequent mor-bidities,focusingonpsychopathological,cardiovascular,and immunedisorders.
A research carried out in the Democratic Republic of Congohassupportedthebasesofthisconcept.Theresearch wasbasedonpreviousworkthatsuggestedtheassociation betweenadverselife experiencesinchildhood---including theintrauterine life period--- and increasedrisk of later-onsetchronicdiseases.
Itis alsobasedonthe assumptionthatthereisa criti-calstageinthedevelopmentoftheintrauterineplasticity whentherethemostadaptedfetalphenotypetoantenatal environmentis selected. The main meritof the initiative isthatitwasthefirststudytotesttheideathatextreme psychosocialstressors in pregnant women, asobserved in theDemocraticRepublicofCongo,canmodifythespecific ‘‘locus’’ofepigeneticmarkersinthenewborn,changingthe patternof theirhealth development.The study showeda cause-and-effectassociationbetweenprenatalstresslevel
andthenewborn’slowbirthweight,aswellasahighrateof methylationoftheNR3C1glucocorticoidreceptorpromoter inthenewborn,whichproportionaltothedegreeofstress duringintrauterinelife.Therefore,itwasobservedthatthe increasedmethylationmayconstraintheneuroplasticityat thesubsequentgeneexpression,thusrestrictingthemargin of adaptiveresponsetostressof theaffected individuals, predisposingthemtotheriskofdiseasesinadulthood.19
Thescientificfoundationsfromthisnewfieldofresearch highlight theresultsofseveralexperimental, clinical,and epidemiological trials that emphasize the role of epige-netic programming, translated into the mechanisms of DNAmethylationand deacetylation,whicharecapable of altering theexpression ofgenes that reflect onthe brain structureandfunction,withnegativerepercussions through-outlife.
Thus,evidenceoftheproductionofconceptsandground rules that will supportthe profound changes inthe exer-cise of Medicine in the 21st century can beidentified on therealmofepigeneticscience.Thereisincreasinglymore evidence that new preventive strategies are being made availablesothatthepositiveexpressionof genetic poten-tialscanactuallyoccur.Newdiagnostictoolsthatwillallow fortheidentificationofchangesinnucleosomeproteinswill becomepartoftheroutineofprofessionalsworkinginthe healtharea,ensuringasolidbasisforpreventiveand ther-apeuticactions,bothindividuallyandcollectively.
New scientific knowledge indicates the relevance of actionsrelatedtoenvironmentalqualityasthetruepathso thattheimpactoftoxicstressonchildhoodcanbereduced. Therefore,theroleofepigeneticsinhealthpreventionand promotiondevelopssolidly.Itbecomespartoftheessential contentofthepediatricians’trainingsothattheirdecisive roleinthecitizen’sformationmayunfoldadequately.
Thechild’scognitiveability:thepersonality’s embryo
More recent studieshave shown thatthe child’scognitive ability,inthefirststageofextrauterineexistence(thatis, inthefirstsixyearsoflife),reachesthehighestrateofall agegroupsinhumanbeings.Thischaracteristicreflectsthe highplasticityofthecentralnervoussystem,whichfavors higherreceptivenesstoenvironmentalstimuli,whichinturn triggeranabundanceofsynapticconnections.
Thusthedevelopmentofcognitionoccursandthegreater the aforementioned plasticity, which is a structural brain featurethatgraduallydeclinesfrombirthtoadulthood,the higherthedevelopment.Forthisreason,theeffortrequired to establish synaptic connections also increases with the increasingage,andisminimalduringinfancy.Moreover,it is noteworthythatthebraingrowthratereaches its high-est levelsduring the firstsix months of extrauterine life, graduallydecreasinguntilthesixthyear.
Asthisisaperiodofhighbrainplasticity,whichwillnot berepeatedlater,itisimportanttorecognizeand appreci-atetheimportanceofthisage groupinthestructuringof personality,interactionwiththeenvironment,andlearning ofactivitiesthatareessentialfor thephysical andmental development,aswell asthe expression of originality, the creativeandoriginalcapabilitiesthateverynewbornbrings atbirth.Itisthereforeuptosocietytoensureappropriate conditionsfortheexerciseofthesecognitiveskills,which areessentialfortheevolutionofpersonality,definingeach individual’sbehavioralprofileatanearlyage.
Thereisincreasingscientificevidencethatindicatethe essential nature of this dynamic cognitive phase. Data demonstratetheuniqueness ofaperiodoflife thatneeds tobe handled withthe care it deserves,enriched by the affectiveingredientsoftendernessandlove,withoutwhich theintricate physiological componentsof infantcognition do not develop at the appropriate level, causing damage that is often irreparable to the developing mind. A rele-vantmeta-analysisstudyidentifiedthatchildrenaged6---23 months whowere breastfedhad significantly higherrates of cognitive developmentthan those whoreceived infant formula.20
A subsequent cohort study showed that breastfeeding was positively associated with good educational perfor-mance, expressed ascognitive ability at 15 years of age. Breastfeedingduringtheinfantphasewasalsosignificantly associated with good reading skills at 53 years of age, regardless of early social status and educational perfor-mance achieved at adulthood, but largely based on the high cognitive ability at age 15. The study allowsfor the conclusionthatthebenefitsofbreastfeedinghavea poten-tiallong-termimpactthroughitsinfluenceoncognitionin childhoodandonschoolperformance.21
Also regarding breastfeeding as a synthesis of affec-tive mother/child relationship, the effects produced by the practiceare remarkable.As demonstrated in another study,the longerthe durationof exclusive breastfeeding, the greaterthe corticalthickness ofthe upperand lower parietal lobes of the child. Additionally, adolescents that had received exclusive breastfeeding for a longer period performed better in tests of intelligence quotient (IQ) assessmentthanthosewhohadnotbeenbreastfed.22
An important study on the topic of cognitive ability includestheassessmentcarriedoutduringprenatal devel-opmentonadulthearing,vision,andcognitiveimpairment. Theevaluationofsuchfunctionsintheadultisrelatedtothe birthweightreportedbythemembersoftheassessed sam-ple,whichis usedasprenataldevelopmentindicator, and toadultheight,consideredanindicatorofearlychildhood development. Visual and auditory acuity were measured, aswellasreactiontimeandtheIQoftheassessedadults. Thesensoryandcognitiveperformancewasreassessedafter fouryears. Bothadult height andbirth weight showedto be positively associated with sensory and cognitive func-tions.
It is therefore evident that the possibility of adverse experiencesintheprenatalperiodandinfancyposesarisk oflowcognitiveandsensoryfunctionperformance,aswell asearlieronsetofsensoryandcognitiveimpairmentinthe adult.Consideringthisimportantfinding,clearlydiscernible implicationsareidentifiedregardingtheroleofpreventive
actionstoreducetheprogressivelossofcognitiveand sen-sorycapacityatolderages.23
Inthe contextof the socialcomponentsthat are asso-ciatedwithchild development,one of them is the social competence,i.e., theability touse cognitive and behav-ioralresourcestoachieve personalgoalsinthecontextof thegroups that a child participates in preschool.A study carriedout in Portugal aimed to determine whether that competenceacquiredintheabovementionedperiodis asso-ciatedwith the pattern of the subgroups experienced by the child. The characteristics of the subgroups to which eachoneofthesamplemembersbelongedwereevaluated byanalyzingthesocialinteractiondata.Socialcompetence wasassessedusingobservationalandsociometricmeasures appropriateforthestudyobjective.Childrenwhobelonged tomorecohesivegroupswithgreaterproximityand inter-actionshowedhighersocialcompetence,while thosewho were not associated to a group had the lowest levels of this same indicator. Therefore, there is strong indication thattheaffiliationsubgroupsmaybothreflectandsupport thedifferences in thesearch for social skills during early childhood.24
In light of these researches, the progress of scientific knowledge related to the child’s brain development con-firmsthevalidityoftraditionalpracticesthatdeserveand shouldbe more widely disseminated to contribute tothe solidformationofthecitizen.Oneoftheseclearexamples referstotheroleofmusicalpractice,whichappearstobe associatedwiththedevelopmentof workingmemory dur-ingchildhoodandadolescence,anindisputableprerequisite of qualified consolidation of the personality, intelligence, and creative ability of the developing individual. One of thestudiesaimedtoclarify andverifythe effectof musi-caltrainingonthedevelopmentofcognitiveabilityduring childhood.Thestudyfocusedonthelongitudinalassessment ofchilddevelopment,whichallowedfortheanalysisofthe associationbetweenmusicalpracticeandreasoning perfor-mance,intellectualprocessingspeedandworkingmemory. Atotal of 352 individuals, aged between 6 and 25 years, wereassessedthroughneuropsychologicalevaluationsand neuroimagingintwoorthreeoccasions,twoyearsapart.It wasdemonstratedthatmusicalpracticehadabroadpositive association with working memory, intellectual processing speed,andreasoning.
Additionally, it was verified that children who played amusical instrument hada highervolume ofgray matter ofthebrain,both inthecortexofthetemporal---occipital regionand in the insular cortex, areas that have already beenreportedasrelatedtothereadingof musical notes. Changesin the working memorywere proportionaltothe numberofhoursspentweeklyinmusicalpractice.In conclu-sion,thedataconfirmedtheimportanceofthispracticefor thedevelopmentofworkingmemoryduringchildhoodand adolescence.25
live;and, if started in childhood and continued over the yearsinpreschool,itallowsfortheacquisitionofthe fun-damentaltoolstheyneedtosurviveinourculture,namely literacy,mathematics,andresearchskills.
Ifbook readingis integrated in the dailyroutine since early childhood, children will benefit from this opportu-nity to keep the prerequisites for literacy, mathematics, andresearchskillsactive.Literacyincludesseveral compo-nents,includingorallanguage,comprehensionofnarrative, andrecognitionofphonemesandletters.Therich vocabu-laryacquired in the first threeyearsof life produces the basicsofliteracy. Itstarts tobloom whenchildren under-standthe readingandthewritingprocess,looking forthe meaningofthetextcombinedwiththecourseofthestory andthelanguagestructure,incorporatingtheideathatthe printedworkrepresentsthespokenlanguageandthoughts. Thechild’sabilitytoextractmeaningfromtheprintedtext issolidifiedthroughagreaterunderstandingofthesounds oflettersandwordrecognition.
American pediatricians developed a program called ‘‘Reach Out and Read’’. It consists of three practices integratedwiththe regular officevisits, whichcomprised guidanceonthepermittedreading;theopportunityto bor-rowcomicbookstobereadat home;andthepresenceof communityvolunteerswhoreadforthechildreninthe wait-ingroomoftheoffice.Theassessmentsindicatedthatthis programincreasedthefrequencyofbookreadingathome andimprovedtheresultsofreadingskillsintheearlystages ofschooling.Thepracticeisalreadybeingemployedinother countries.
In Canada, parental follow-up indicates that approxi-mately60%ofthemreadtotheirchildrendailyandthatthe dailyreadingislowerforchildrenyoungerthan18months oflife.Accordingtotheexperimentresults,themessages thatpediatriciansshouldconveytoparentsare:(a) empha-sizethemultiplebenefitsofreadingtotheirchildren,from veryearly agesuntilthe early schoolyears;(b) prescribe dailyreadingtoyoungchildrenstartingfromtheeighthor ninthmonthoflife,usingthepediatrician’susual prescrip-tionpattern;and(c)encourageparentstoreadandthose whoshowreadingdifficultiesshouldbeencouragedtotell stories based on the books’ pictures in order to encour-agethe involvementof children in readingactivities.26 In
Brazil,similarprogramsarebeingdevelopedasaresultof partnershipsbetweentheBrazilianSocietyofPediatricsand InstitutoItaúSocial.
Thepediatrician’sroleinthecitizen’sformation
The evidence from the previously mentioned research relatedtothecitizen’s formationinthe21stcentury out-linestheprospectofasolidpediatricbasisthatcansupport thegrowing qualityof the humandifferentiation process. Forthispurpose,theprioritynatureofinvestingin preven-tiveprotectionofearlychildhoodisanirreplaceableroute. Asolidconstructioncannotbebuildwithoutafoundation. The importanceof childcarerepresents theideal logic of children’shealth careduringthedecisiveperiodonwhich anappropriatelyplannedcitizenshipdepends.
The role of pediatricians has never been so clearly defined.The uniqueness oftheir global medicalexpertise
isunquestionableasaprofessionaltrulycommittedtothe complexityofthecaretobeprovided,aimingatimproving thehealthofchildrenandadolescents.
In current pediatrics, epigenetics is an important and innovative scientific field of knowledge to be consid-ered.Fundamentally,itsummarizesthealterationsingene expression as a result of exposure to environmental fac-tors,resultinginabroadercontextforthedysfunctionsthat arethegenesis ofmostmorbidities whoseonsetoccursin childhood, especially when the child is exposed to social aggressionsresponsible for significant changesin develop-ment.Itactuallyreflectschangesingeneexpressionrather than DNA alterations, although they can be transmitted fromonegenerationtoanother.Thatiswhyknowledgeof disorders involving epigenetics is of great importancefor thepediatrician,aswellastherecordingof eventsduring childhood thatmay affect the epigenetic control of gene expression, and awareness of the new therapies as they become available. To fulfill their fundamental role in the developmenthealthycitizens,pediatriciansshouldbe pre-pared torecognize the important risk factors responsible for triggering a large number of morbidities that persist throughoutlife.27
Conflicts
of
interest
Theauthordeclaresnoconflictsofinterest.
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