Bridging Obstetrics and Pediatrics to Close the Life Span Gap in Child Obesity Research

Childhood obesity prevention efforts are increasingly focused on the prenatal period, but the effects of these interventions on birth weight have been mixed.¹  In this issue of Pediatrics, Moore et al²  present evidence suggesting the importance of neonatal adiposity, as opposed to birth weight alone, as a predictor of overweight in early childhood. The effects were robust: at age 5 years, the difference in the prevalence of overweight among children born 1 SD above versus below the mean for neonatal adiposity was 23% vs 3%. Contributors to neonatal adiposity may include shared genetics as well as epigenetic changes or metabolic priming caused by intrauterine exposure to a myriad of known (eg, diet and smoking) and unknown factors in the maternal environment. For the pediatric provider, the results raise the possibility that our postnatal interventions in infancy and early childhood are too little, too late.

Although neonatal adiposity is an end point for prenatal obstetrical interventions, it is a starting point for pediatric interventions. If neonatal adiposity is nearly entirely explained by shared genetics between the mother and child, efforts to modify the environment will have limited effect. If the link between mother and child adiposity is explained by modifiable factors in the environment, the next most pressing question is to determine when interventions to disrupt the pathways of association can be most effective. Should efforts be focused on helping women achieve a healthy weight even before conception, if metabolic programming occurs even in the first trimester? Should obstetrical providers recommend earlier delivery or intensify supports to ensure optimal nutrition and physical activity among pregnant women? If the link between neonatal adiposity and later obesity is more modifiable than fat accretion in utero, should pediatric providers focus on modifying infant sleep, diet, physical activity, and caregiving behavior? Ultimately, large, multisite, longitudinal studies will be needed to determine the relative effects of intervention during the preconception, pregnancy, or postnatal periods as well as whether interventions during each of these developmental periods have additive or multiplicative effects. Disentangling these relationships will be important for health care providers, both obstetrical and pediatric, to develop clinically actionable recommendations that take into consideration prenatal and postnatal environments.

The results of this study illuminate the connection between pediatrics and obstetrics. Specialization in medicine has contributed to dramatic reductions in maternal, infant, and child mortality over the last century³  but has simultaneously created silos of expertise.⁴  Pediatrics and obstetrics share a common goal of supporting the interdependent health of the mother and child, but our individual training paths have fragmented our focus on either the prenatal or neonatal period. Within this siloed framework, it is difficult to approach maternal-infant care and research with a continuous life span perspective.

The moment of birth marks the child’s abrupt transition of care from obstetrics to pediatrics, and the scientific literature corresponds with this divide. Interprofessional collaboration could bridge this gap. Both the American Academy of Pediatrics and American College of Obstetricians and Gynecologists support patient-centered, team-based care by engaging team members from a variety of medical specialties and support systems.^5,6  This strategy could be applied to maternal-infant care and research to connect pediatrics with obstetrics, especially considering the time frame from conception to age 2 years is a major determinant of later health status.⁷  An improved care-continuum between pediatrics and obstetrics provides the opportunity to bridge the discontinuity in our fields and address the public health crisis of obesity.⁸  Few previous studies have tested childhood obesity interventions spanning from the second trimester into early infancy.⁹  A collaborative perspective spanning preconception to adolescence will be needed to understand the nuanced relationship between neonatal fat accretion and risk of overweight or obesity in later childhood.

While pursuing this life span approach, it is critical to consider the burden of responsibility being placed on the woman. The “management” of the intrauterine environment biologically falls to the mother. This responsibility to prevent neonatal fat mass accretion, on top of the many other societal expectations placed on women during pregnancy, is a lot for a woman to carry.¹⁰  Childhood obesity cannot be viewed as the product of a failure of maternal self-control during pregnancy. It is heavily influenced by societal factors, yet there are few societal supports for pregnant women and mothers in the United States and many other nations around the world. Life span intervention and prevention clinical care programs and research should also include other family members (ie, fathers, grandparents).

As Helen Keller once said, “Alone we can do so little; together we can do so much.” Childhood obesity prevention requires a collaborative transdisciplinary approach in both risk factor research and intervention design. Such interventions may only be effective in coordination with robust supports for families and children across the life course, from preconception through adolescence.