Current Pediatric Reviews (v.8, #3)

Editorial (Hot Topic: Foods versus Drugs in Disease Prevention and Treatment) by Peter J.H. Jones, Emanuel Lebenthal (195-195).

Food Bioactives versus Drugs – Introduction by Emanuel Lebenthal, Peter J.H. Jones (196-198).
Food bioactives represent diet based molecules that perform physiological roles related to disease prevention and/or treatment. As such considerable overlap exists between food bioactives and drugs, the purpose of this overview is to present the case for comparing and contrasting foods versus drugs in several models of health and disease, some of which are presented in further detail in subsequent chapters of this miniseries. The present review concludes that in some instances distinction is difficult between metabolic processes influenced by foods versus drugs and that the two types of compounds exerts overlapping or identical actions in prevention and treatment of disease. In summary, there appears to be evidence of a role for functional foods in disease treatment, thus we need to look at a paradigm shift to decrease the dependency on drugs and increase the use of food based materials for therapeutic use. Over the longer term, functional foods and nutraceuticals must find ways to compete with pharmaceuticals on an even playing field.

Mounting evidence points to dietary habits as an important determinant of health/disease prevention. Although the linkages with diet are intriguing, the literature is also laden with many inconsistencies. The reasons for these inconsistencies are likely multi-factorial, but probably reflect variation in the ability of bioactive constituents to reach or to influence a specific and critical molecular target(s). Knowledge about three types of biomarkers will assist in comparing the effectiveness of foods and drugs: (1) exposure (amount and time needed to bring about a response), (2) effect (amounts and activity of specific molecular target[s]) and (3) susceptibility determinants (agent-gene interactions or diet-drug interactions). As the era of molecular nutrition unfolds, a greater understanding of how foods and their components influence normal cellular process and ultimately health will surely arise. Knowledge about the molecular targets for bioactive food components may also help explain individuality in response to drugs. Such information will be critical in the development of effective tailored strategies for optimizing health.

Inflammation is a key factor of many diseases including obesity. It is a physiological component of the gut barrier. Many drugs target inflammation, and some foods are traditionally classified as either hot or cold. The rising question is whether food and drugs are acting on the same biological target(s), or not? More challenging, is whether physiology and pathology are regulated through the same mechanism(s)? The example of inflammation is used to explore this challenge. Inflammation can be assessed by 1) clinical symptoms, 2) a set of biological blood parameters, or 3) at the molecular cell level with the COX enzymesand#x2019; activation. There is ample literature to compare the efficacy of the food ingredient omega-3 fatty acids, and the drug, acetylsalicylic acid, on the three levels: clinical, biological and molecular. Both are active on the four classical symptoms of inflammation, but aspirin is active on a broader range of related diseases, and acts faster than omega-3. Some biological mediators are decreased by both products, but not all of them and data are missing to make a full assessment of all the parameters for both products. Both target the COX enzymes, but aspirin is active on the inducible and non-inducible parts of COX, whereas omega-3 is active only against the inducible part. In this example the food ingredient is different from the selected drug. It is worthwhile to expand this kind of assessment for a more comprehensive view on the differences between foods and drugs.

Foods for Health and to Treat Diseases by John H. Cummings (208-213).
Most people try and eat and#x201C;healthilyand#x201D; because they believe that food has an important part to play, alongside other lifestyle changes, in maintaining health. With the advent of the functional food concept it has become clear that foods can be used not only to prevent disease, but also to treat it. Thus the role of food and drugs overlap and are both needed throughout life. Diet is especially important for the prevention of the chronic non-communicable diseases of the developed world such as coronary heart disease, obesity, diabetes, high blood pressure and some cancers. But foods can be used to treat and prevent acute conditions also. Probiotics, usually found in dairy products, have a well-established benefit in childhood diarrhoea, necrotising enterocolitis, antibiotic-associated diarrhoea, Clostridium difficile infection, pouchitis and the management of ulcerative colitis. Plant sterols can be used to lower blood cholesterol whilst prebiotics are gaining ground as their physiological effects on the gut microflora are established. Health and disease are not clearly different states for us all and when the question is asked, and#x201C;how might I treat, or prevent this condition' then the role of food should always be considered alongside drugs and other lifestyle changes.

The series of papers in this thematic issue discuss the differences and similarities of foods versus drugs in disease prevention and treatment. The main focus of each contribution is considered in this review. The use as well as advantages and drawbacks of combination therapy employing drugs and foods are also elaborated on. Examples of combining the use of pharmaceuticals and food bioactives including using statins or ezetimibe in conjunction with plant sterols are provided. In summary, the present paper makes a case for adoption of food bioactives in both prevention and treatment approaches to disease, and recommends that functional foods can serve as efficacious adjuncts to pharmacotherapy during all stages of treatment of numerous diseases.

Lung Ultrasound in the Critically Ill Neonate by Daniel A. Lichtenstein, Philippe Mauriat (217-223).
Critical ultrasound is a new tool for first-line physicians, including neonate intensivists. The consideration of the lung as one major target allows to redefine the priorities. Simple machines work better than up-to-date ones. We use a microconvex probe. Ten standardized signs allow a majority of uses: the bat sign (pleural line), lung sliding and the A-line (normal lung surface), the quad sign and sinusoid sign indicating pleural effusion regardless its echogenicity, the tissuelike sign and fractal sign indicating lung consolidation, the B-line artifact and lung rockets (indicating interstitial syndrome), abolished lung sliding with the stratosphere sign, suggesting pneumothorax, and the lung point, indicating pneumothorax. Other signs are used for more sophisticated applications (distinguishing atelectasis from pneumonia for instance...). All these disorders were assessed in the adult using CT as gold standard with sensitivity and specificity ranging from 90 to 100and#x25;, allowing to consider ultrasound as a reasonable bedside gold standard in the critically ill. The same signs are found, with no difference in the critically ill neonate. Fast protocols such as the BLUE-protocol are available, allowing immediate diagnosis of acute respiratory failure using seven standardized profiles. Pulmonary edema e.g. yields anterior lung rockets associated with lung sliding, making the B-profile. The FALLS-protocol, inserted in a Limited Investigation including a simple model of heart and vessels, assesses acute circulatory failure using lung artifacts. Interventional ultrasound (mainly, thoracocenthesis) provides maximal safety. Referrals to CT can be postponed. CEURF proposes personnalized bedside trainings since 1990. Lung ultrasound opens physicians to a visual medicine.

Fecal Incontinence in Children and Adolescents by Timothy B. Lautz, Jayant Radhakrishnan, Anthony C. Chin (224-231).
Fecal incontinence (FI) is a devastating problem for children and adolescents. Patients are broadly classified as having functional (pseudoincontinence) or structural fecal incontinence. This distinction has important implications for management and prognosis. The classification, evaluation and management of children and adolescents with fecal incontinence are reviewed.

Magnetic resonance diffusion tensor imaging is a topic of active research, and is in constant development. Though state-of-the-art methods may not be practical for routine clinical use, small numbers of directional motionprobing gradients and relatively simple post-processing methods can yield clinically important information. Here we discuss the use of routinely acquired six-direction DTI of the brain at 3T to retrospectively study pathologies of the pediatric visual system. We discuss the use of DTI to investigate the effects of suprasellar tumors on pre-chiasmatic and chiasmatic optic nerves, and to diagnose and monitor septo-optic dysplasia and neurofibromatosis type 1. DTI can serve as a tool in surgical planning and pre-biopsy differential diagnosis. In congenital disease involving the white matter, DTI may prove useful in the diagnosis and monitoring of these conditions as they impact the pediatric visual system.

Social Determinants of Childhood Obesity: Beyond Individual Choices by Esther K. Chung, Martha C. Romney (237-252).
Childhood obesity is a major public health problem affecting children worldwide. Early strategies to address this problem have focused largely on diet and exercise, with an emphasis on changing the health behavior of individuals. Increasingly, experts recognize the impact of social factors such as neighborhood characteristics, child care and school settings, access to supermarkets, and social policies on childhood obesity. This article provides an overview of the social determinants of obesity from early childhood through adolescence. Clinicians and policy makers alike need to understand the social context in which children live in order to 1) understand the risk factors for childhood obesity and the potential barriers to acquiring good nutrition and engaging in physical activity, and 2) identify resources and potential solutions, including novel policies and community initiatives, to this growing problem.

The Patient with a Single Cardiac Ventricle by Christopher W. Mastropietro, Jeff A. Clark, Lisa M. Grimaldi, James S. Killinger, Marc Richmond (253-276).
Patients born with a single cardiac ventricle are one of the most complex and challenging subgroups of congenital heart disease to manage, from their initial diagnosis to their long-term post-surgical sequelae. Advances in antenatal detection, operative techniques, and post-operative strategies have led to improved outcomes over the past two decades, yet morbidity and mortality remain high relative to other congenital heart lesions. Optimal management and outcome depend in part on a thorough understanding of the anatomy and physiology unique to these infants by all caregivers that may be involved including neonatologists, primary care pediatricians, emergency medicine physicians, and pediatric intensivists. This review will discuss in detail the course of these infants, from their birth through to their three stage surgical palliations and beyond. This review will also highlight many of the most recent medical and surgical innovations available to these infants.