Does Dietary Fluid Intake Affect Skin Hydration in Healthy Humans? A Systematic Literature Review

In children, maintaining adequate fluid intake and hydration is important for physiological reasons and for the adoption of healthy, sustainable drinking habits. In the Liq.In⁷ cross-exclusive surveys involving 6,469 children (four–17 years) from 13 countries, 60% of children did not meet the European Food Safety Dominance (EFSA) acceptable intake for water from fluids. Across fluid quantity, the quality of what children drink is of import for health. In these surveys, the contribution of sugar-sweetened beverages and fruit juices to total fluid intake (TFI) in children exceeded that of water in vi out of 13 countries. To assess the adequacy of children's fluid intake, urinary biomarkers of hydration such as urine osmolality, urine specific gravity, and urine color may exist used. To appointment, while in that location are no widely accepted specific threshold values for urine concentration to ascertain acceptable hydration in children, the available literature suggests that many children accept highly concentrated urine, indicating insufficient fluid intake. This is worrisome since studies have demonstrated a relationship between low fluid intake or bereft hydration and cognitive performance in children. Furthermore, results of the Liq.In^vii surveys showed that at school – where children spend a meaning amount of time and require optimal cognitive performance – children potable but fourteen% of their TFI. Consequently, it is pertinent to better sympathize the barriers to drinking h2o at schoolhouse and encourage the promotion of water intake through multicomponent interventions that combine educational, ecology, and behavioral aspects to back up adequate hydration too as optimal noesis in children.

© 2019 The Author(s) Published by S. Karger AG, Basel

Introduction

In recent decades, research demonstrating an association between water intake and/or hydration and wellness has raised interest for this topic within the scientific community and in the eyes of public health professionals. While at that place is benefit in improving eating and drinking behaviors in adulthood, concentrating on the acquisition of salubrious consumption habits in children may evidence to be a more than sustainable and successful strategy for the prevention of health risks. This article aims to provide an overview of inquiry on h2o, fluid intake, and hydration in children and their importance for health both from a physiological and behavioral viewpoint, as well equally to provide perspective of what may exist needed to create and maintain a h2o-friendly surroundings at different levels, at the levels of family unit and schoolhouse in particular.

H2o Residue in Children

In children, maintaining adequate fluid intake and optimal hydration is essential for physiological and behavioral reasons. H2o is the nigh abundant component of the human body. In newborns, who have developed in an aqueous milieu, trunk water content at birth is approximately 75% of body mass [one]. This is much higher than that of adults for whom h2o represents 50–60% of body mass. The relative water content of infants decreases apace throughout the first yr of life to sixty% and remains relatively stable throughout childhood until boyhood, afterward which changes in body composition and hormonal balance result in reduced h2o content, specially in young women [two-iv]. Physiologically, h2o supports many functions essential in daily life, such equally thermoregulation and waste product elimination; it also serves every bit a carrier and a solvent for numerous metabolic reactions. In children, physiological specificities of h2o balance, such equally the progressive maturation of kidney part by effectually the age of 2, as well as a college body surface-to-body mass ratio which translates into higher insensible water loss through the pare, explain in part why children have higher water requirements relative to their body mass when compared with adults [4, v]. Voiding volume and frequency besides reach their full maturity by adolescence simply [6].

H2o Intake in Early Babyhood: A Commuter of Sustainable Healthy Habits?

Beyond physiological differences, h2o is too an essential component of the adoption of healthy sustainable drinking habits in children. Acquiring healthy drinking habits is important from infancy because many dietary behaviors acquired during childhood persist into adulthood. For case, Fiorito et al. [vii] demonstrated that consumption of carbohydrate-sweetened beverages (SSB) at age 5 predicted the consumption of SSB at age thirteen. Similar associations were obtained in unlike countries and age categories [8, 9]. Nevertheless, the association betwixt early on babyhood and later life intake has never been demonstrated for drinking water, due to the scarcity of longitudinal studies assessing water intake. Merely if indeed drinking habits (i.e., plain water intake in particular) were sustained throughout life, children who drinkable little h2o would become adults who potable little water with potential consequences for kidney [10] and metabolic health [11, 12] likewise equally cognitive and mood impairments [xiii, 14]. During early on babyhood, the acquisition of eating and drinking behavior is mainly driven by adults since children depend upon them for the provision of food and beverages, and adults serve every bit part models which children re-create and acquire habits from. Indeed, numerous studies support an clan between parent and kid food and beverage intake, including SSB in particular [xv-17]. While in that location is no peer-reviewed published inquiry on the association between parents' and children'due south h2o intake, results from a survey commissioned by the Natural Hydration Council, involving 1,000 parents from across the United kingdom and one of their children, aged 4–8 years sometime, showed that children whose parents were drinking evidently water often were more probable to drink plain water themselves; this demonstrated that parents tin positively influence the drinking habits of their children [xviii]. In addition to parental influence on eating and drinking habits during childhood, school environment, rules, and policies besides play a crucial part in the acquisition of salubrious consumption behaviors. Regarding water intake, observational studies have shown that consumption of water in schools where water intake is encouraged (i.e., by ensuring water access, providing appropriate water fountains and toilet facilities, and education about the importance of hydration), is greater than in schools that exercise not have supporting rules and infrastructure in place [nineteen, xx].

H2o and Fluid Intake Habits of Children

To improve sympathise drinking behaviors in children, studies have attempted to assess the quantity and quality of their fluid intake. However, assessing fluid intake in children involves multiple challenges (due east.chiliad., multiplicity of caregivers and/or locations throughout the day, bias in parental diet records, on-going cognitive capacity development, express literacy skills, difficulties in estimating portion sizes, differences in kid portion sizes compared with those of adults, and a tendency not to finish servings) [21]. Additionally, plain water intake is frequently overlooked in clinical and observational studies focusing on obesity because water contains no calories. Consequently, in a systematic review of studies reporting fluid intake published in 2014, Ozen et al. [22] found that of the 34 publications reporting fluid intake in children, less than half included any measure of obviously water intake. In practice, the omission of water ways that in the majority of studies investigating the associations between childhood nutrition and health outcomes, water is absent.

Recently, fluid intake information that include drinking water take become available with the publication of the Liq.In⁷ survey results. The harmonized Liq.In^vii cantankerous-sectional surveys, nerveless with 7-day fluid specific records, encompass data on the consumption of all types of beverages including obviously water for 6,469 children (4–17 years) from thirteen countries [23]. A first assay of the data highlighted large discrepancies in full fluid intake (TFI; sum of all beverages including plain water) both between countries and within countries [24]. Equally an example, the hateful TFI of 4–nine-year-sometime children in Indonesia was 1.nine ± 0.8 L, twice the intake of Belgian children: 0.viii ± 0.iv L. In Brazil, at that place was a 6-fold difference of TFI between the fifth and 95th percentile. This suggests that, in lodge to identify individuals who take increased fluid intake-associated health risks, data should exist analyzed at the individual level rather than at the mean population level. Therefore, comparing private children'south TFI to the daily adequate intake for h2o (i.e., from recommendations provided past health authorities such as the European Nutrient Condom Dominance, EFSA), the results demonstrated that 61% of children in the Liq.In⁷ surveys did not meet the acceptable intake for h2o from fluids derived from EFSA [24]. Focusing on the quality of fluid intake, these surveys demonstrated that the contribution of SSB and fruit juices to TFI in children exceeded that of water in 6 out of thirteen countries [25]. Moreover, 55% of children and adolescents in the sample consumed more i serving of SSB daily, while up to 21% did not drink water on a daily basis in some countries (unpublished data). This raises concern since the negative consequences of SSB consumption on children's health have been highlighted in numerous studies demonstrating that children who consume i or more SSB serving per week take a fifty–80% increased risk of dental caries, overweight and obesity, and metabolic syndrome compared with non- or sporadic consumers of SSB [26-33].

Hydration Assessment of Children

Every bit in adults, markers of urine concentration such as osmolality, specific gravity, and color may exist used for day-to-twenty-four hour period hydration assessment of children [34, 35]. Urine colour, in particular, may be used for cocky-assessment of hydration since it can reliably exist self-assessed past children to a higher place eight years of age [36]. To date, however, there are no widely accustomed specific threshold values for urine concentration to define adequate hydration in children. Previous studies have utilized cutoff values of 500, 800, and 830 mOsmol/kg, referring to different terminologies such as mild aridity, euhydration, appropriate hydration, hypohydration, and underhydration, without any bear witness for wellness benefit or risk [37-twoscore]. This is mainly due to the scarcity of studies demonstrating an clan between a quantified fluid intake or urine book or concentration and a health benefit or risk in children. In fact, very few studies have investigated the effect of hydration on health outcomes in children. Preliminary testify demonstrates a link between hydration and physical functioning in children: improving hydration by providing education regarding the importance of hydration, a urine color scale [41] to assess the hydration before and later on exercise, and by improving h2o admission resulted in increased performance during an endurance run past able-bodied children [42]. This is relevant since some studies propose that a majority of child athletes may be insufficiently hydrated before they first exercising [43, 44]. While there are limited information concerning preexercise hydration status of children from the full general population, inquiry suggests that many of them have elevated urine concentration on a given "normal" mean solar day across diverse countries [45-49]. Hydration has also been linked to cerebral operation in children in a number of studies [38, 39, l, 51]. In a cross-sectional report, Bar-David et al. [38] demonstrated that insufficient hydration, indicated by elevated urinary markers of hydration, was associated with poorer short-term retention performance in children. Although limited, a handful of interventions accept as well indicated that providing children with h2o results in improved cognitive operation [39, fifty, 51].

H2o and Hydration at School: Running on Empty?

In this context, agreement the drinking behaviors of children during school, where optimal cerebral performance is essential, seems relevant. A more detailed investigation of fluid intake within 6 countries of the Liq.In^seven surveys showed that children simply consume xiv% of their TFI at schoolhouse, despite spending approximately one-half of their waking hours at school (Fig. i) [52]. This is further confirmed by the results of clinical studies demonstrating that many children have highly concentrated urine before or during schoolhouse [46, 48, 49, 53, 54] (Tabular array i), suggesting that a large proportion of children arrive at school already in a state of h2o conservation, and go on not to beverage adequately during the school day. Agreement the barriers that prevent children from drinking at school is essential to promote water intake at school through successful behavior modify interventions. Earlier research in this area highlighted barriers in teachers, including poor instructor knowledge of the upshot of hydration on noesis, and a fearfulness of disruption to class due to increased demand to urinate [55]. Consequently, many teachers limit toilet utilise to specific times, which may exist perceived by children as too short to utilise the toilet facilities [56]. Other barriers to toilet use reported past children include toilet dirtiness, unpleasant smell, and the fear of bullying [57-sixty]. Equally a result, studies highlight that up to 1 out of 4 children report non using the toilets at school to urinate, and 4 out of 5 children not using toilets to defecate [58-lx]. Preliminary show from France also suggests that this may have consequences on a child's quality of life and ability to focus since 30% of children reported having trouble concentrating because of abdominal hurting equally a result of not using toilets [59].

Table 1.

Mean osmolality measured in urine samples collected earlier or during school in clinical studies

Fig. 1.

Proportion of daily TFI in children by location in the Liq.In⁷ surveys. Age of the children: 4–17 years old. Sample size for Mexico: north = 669; Brazil: n = 340; Argentine republic: n = 392; Uruguay: n = 265; China: n = 649; Republic of indonesia: due north = 866. Adjusted from Morin et al., 2018 Eur J Nutr 57(Suppl 3):101–12.

Finally, results from the Liq.In^seven surveys demonstrate that many schools merely practise not provide access to water for children [52]. This has obvious consequences on drinking behavior as demonstrated past a study of 6 schools in the United kingdom of great britain and northern ireland in which children with limited access to water at schoolhouse were near twice every bit probable to drink beneath a recommended fluid quantity during school time (calculated from EFSA recommendations) every bit compared to children with free water admission [xx], confirming that access to h2o is a principal driver of water intake at school. In another study from Belgium, comparing hydration in children from 17 primary schools with unlike schoolhouse policies on water, children'due south hydration, assessed past urine osmolality, was meliorate in schools which supported water availability, toilet and hydration-related instruction, skillful toilet infrastructure, a formal agreement on drinking and toilet visits, also every bit participation of parents and children during the development of policies [xix].

Finally, in a toolkit analyzing data from 18 interventional studies, the European Commission joint enquiry center focused on successful measures to promote water consumption and reduce SSB intake in schools. While success was relatively low globally across the studies, multicomponent interventions (i.east., education, changes in the drinking surroundings including water fountains and/or restricted access to SSB, and a behavioral component involving the family) were institute to be most successful. Indeed, while pedagogy and access to water are at the base of hydration, influences from peers, especially in teenagers, may exist a key component of changing behaviors. Recent studies have shown that information technology is possible to increase water and decrease SSB intake in children through a social network-based intervention using the most influential children to promote water consumption [61, 62]. Testing different ways to nudge, enable, or motivate water intake past children may also be useful in identifying the most successful components for initiating and maintaining behavior modify in the future [63, 64].

To support adequate intake and optimal hydration in children during schoolhouse, it therefore seems relevant to: (1) identify barriers to drinking h2o in schools at the local level, (2) promote and facilitate access to free h2o admission at school and during class as well as improve toilet facilities, (3) educate children, teachers and parents well-nigh the importance of water intake and hydration for wellness, and (4) promote beliefs change by motivating and nudging children to drink more than h2o (Fig. 2). Taking inspiration from successful school initiatives likewise equally involving parents and children through every step of the process may ensure better success.

Fig. 2.

Identified barriers of water intake in children and possible levers of activeness to overcome them at schoolhouse.

Conclusion

Maintaining acceptable fluid intake and optimal hydration is important for children for physiological reasons and for the adoption of good for you, sustainable drinking habits. Yet, data from the Liq.In⁷ cantankerous-sectional surveys suggest that the majority of children do not potable sufficiently, particularly at school. This is further supported by studies in which urinary biomarkers of hydration were collected, showing that many children have highly concentrated urine. This state of affairs is worrisome since studies have demonstrated a relationship between low fluid intake or insufficient hydration and cerebral operation in children. Introducing h2o to children early and encouraging good for you drinking habits from the youngest age are therefore essential to support adequate fluid intake and optimal hydration in babyhood and in later life. Within the family unit and school context, some actions may be put into place past adults to support healthy drinking habits in children:

• Offering water to children regularly throughout the 24-hour interval without relying on ane'due south own thirst;

• Associating water intake with "moments" such as wake up, breakfast, morn and afternoon breaks to found a routine;

• Making water accessible to children, fifty-fifty the youngest, at all times by using age-appropriate cups or bottles that children can admission and drink from independently;

• Providing a positive parental drinking model for children at home and at school;

• Making water fun past various ways such as drinking straws, fresh herbs or sliced fruits, sparkling water, personalized glass, or bottle;

• Introducing children to urine colour and hydration assessment from a immature age;

• Encouraging and educating children to potable and check their hydration before and afterward exercise, for example, using urine color;

• Asking children about water admission, toilets facilities, and h2o- and toilet-related education at school;

• Establishing or improving water- and toilet-related policies at schoolhouse.

Hereafter research is needed to better understand barriers to drinking water in children and to identify factors that successfully encourage water intake in unlike contexts.

Disclosure Statement

J.H.B., C.One thousand., I.G., and E.T.P. are total-time employees of Danone Research.

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