In the last fortnight I was fortunate to have attended the Pediatric Academic Societies (PAS) annual meeting in San Francisco at the vast Moscone Convention Center. Around 6000, mostly US-based, delegates attended and yet were all comfortably accommodated within just one of the three parts of the centre (and the smaller one at that).
The influence of epigenetics
PAS draws together a range of sub-specialties in paediatrics, which meant the programme was highly diverse. There were some sessions that I had been keen to attend, including an invited science workshop on epigenetics and the influence of the antenatal and postnatal environment on gene expression. Put simply this is about how experiences before and after birth can alter the way that a child’s genes will influence his or her subsequent health and behaviour. For example, it is suggested that abuse suffered by some children in infancy may activate (or suppress) genes which could then alter fundamental biological processes and adversely affect health later in life.
This is a topic we spent some time looking at a couple of years ago as part of the Building Blocks trial although our plans never came to fruition. One talk I particularly enjoyed was by Alicia Smith from Atlanta who described her work from the Grady Trauma Project and the potential for accelerated biological aging in children exposed to community violence. A fascinating talk by Jeffery Craig from Melbourne explored the role of twin studies and in particular in twins who developed from a single egg but with different adult characteristics. Some of these differences may be due to non-shared antenatal environments impacting on gene expression. I came away feeling (a bit more) educated but realizing I need to find out more. I bought a book online and signed up for a workshop in Bristol!
With our work on breast feeding (for example, the Mam-Kind study) there was plenty to explore on matters of infant feeding. An interesting talk on micronutrients in breast milk by Lindsay Allen (UC Davis) dealt with some of the uncertainty when establishing reference values for milk micro-nutrients. For example, the values recommended by the US Institute of Medicine for vitamin A are based on a sample of just three American women. By the way, for those who are interested, freezing breast milk does not apparently affect the micronutrients but exposure to light may do. Another salutary presentation from Christine Stewart (also UC Davis) described how much of the apparent beneficial intervention effect in one breast feeding promotion study was actually down to reporting bias by mums in the study. Something for us to watch out for in our own studies!
Adverse Childhood Experiences (ACEs)
Other key sessions were on attachment, on maltreatment and on other toxic aspects of the early childhood environment. ACEs – Adverse Childhood Experiences – was very much on the agenda, including interventions for clinicians to better explore for ACEs within routine well kid checks. It’s sobering that 15 million children live in poverty in the US, that’s one in 5. Some public health challenges have a particular presence in the US setting – a study reporting the independent effect of community gun violence in Chicago upon birth weight after controlling for socio-demographic factors being an example.
Research ethics and children
There were stimulating posters about both about the history and ethics of medical experimentation involving children, some of which has driven the development of research ethics. For example, the famous study in Willowbrook State School, NY in the 1960s where children with developmental disorders were intentionally exposed to hepatitis – including some being fed extracts of stools from infected individuals. The researchers then observed the natural history and also response to gamma globulin. It’s worth looking the debates around pros and cons of the experiments (go on, Google it) including contemporary correspondence in The Lancet in 1971. Research easier to value, but as hard to read about was that on the effects of starvation conducted clandestinely by Jewish doctors caring for children and families in the Warsaw ghetto in the Second World War. A team of 28 physicians led by Dr Israel Milezkowski used equipment smuggled into the ghetto to conduct landmark observational research on the effects of semi-starvation, conditions which the researchers themselves were experiencing (longer narrative account here).
From grapes to engineering
Another example of circumstances and necessity driving medical innovation was found in a slightly more unexpected setting. On a day off we went exploring the wineries of Sonoma and Napa valleys. Our first port of call was the Jacuzzi Family Vineyards. Familiar name? The Jacuzzi family originated from Italy in the early twentieth century and as well as growing grapes several of the family’s adult brothers were accomplished engineers. When one of the families’ children developed rheumatoid arthritis, the uncles invented a small aerating pump for baths to provide hydrotherapeutic pain relief. The rest is history.
For me two other well-established features of the San Francisco tourist skyline retain contemporary relevance, the Golden Gate and Bay Bridges. Both iconic but did you know were financed in an effort to support the economy following the consequences of the Great Depression? I quite like this one commentators quote:
But perhaps the most spectacular feature of the Golden Gate Bridge is the fact that it was funded by the people — people who managed to see past the bleakness that had swept the nation and get on board with the notion that all was not lost.
– Professor Mike Robling
Director of Population Health Trials
South East Wales Trials Unit
Centre for Trials Research