klemm: the impact of maternal nutrition on the newborn

7/28/2019 Klemm: The Impact of Maternal Nutrition on the Newborn

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The impact of maternal

nutrition on the newborn

Rolf KlemmJ ohns Hopkins Bloomberg School of Public Health

Global Newborn HealthConference 2013:

South Africa


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We are born wet, naked andhungry. Then things get worse.

Chinese proverb

Every time achild is born,renews my faiththat God has not

given up onmen.Tagore


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Influence on life-long health

First 1000 days


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Poor maternal nutritional status & adversebirth outcome

Clear link from experimental animalstudies

Association in humans is more complex

Findings in human studies less consistentpartly due to differences in.

Baseline nutritional status

Socioeconomic status

Timing & dose of intervention

Measurement of outcome


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Adverse birth outcomes

Low birth weight (LBW)

Preterm birth

Intrauterine Growth Restriction (IUGR)


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Nutritional & health status ofwomen by region

S. Asia

%

SS Africa

%

US/Europe

%

Low Weight (


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Short stature: Risk factor for

caesarean delivery

60% increased need forassisted delivery

Is she sitting or standing?


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Pregnancyenergy, protein and micronutrient

needs; but lactation represents a greaternutritional burden than pregnancy

0

2040

60

80

100

120140

160

180

200

%RDA ofAdultFemale

Adult Female (non-preg, non-lact) Pregnant Lactating


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Evidence of

Intervention Impact


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Single MicronutrientSupplement (Iron, FA, Ca+)

Maternal Nutrition Intervention Strategies-Are they Effective? Safe?

Food Supplementation?

Multiple Micronutrient

Supplements?

Poverty Alleviation ProgramsGirls/Womens EducationWomens EmploymentWomens EmpowermentDietary ModificationAgricultural Production


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Food

Supplementation


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Food Supplementation

11 RCTs/quasi-RCTs

Balanced protein/energy

supplements Included milk supplements,

biscuits, skim milk+ bread+oil

Provided 300-800 kcal energy

Provided 15-40 g protein per

day


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Effect of balanced protein-energysupplementation during pregnancy

Outcome No.

Studie

s

Result Quality of

evidence

SGA1 6 31% SGA* Mod

Birth weight 13 60 grams*

Malnourished 8 75 grams*

Well-Nourished 5 27 gramsNeonatalmortality

3 35% Low

1 SGA=small for gestational age

Imdad and Bhutta, BMC Public Health, 2012

* Statistically significant @ p


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Food supplementation trial in the Gambia(Ceesay et al, BMJ 1997)

Birth wt g % LBW

All year 136 39

Harvest season 94 36

Hungry season 201 42

Perinatal mortality 44%

Daily food supplement (peanut biscuits) containing1000 kcal, 22 g protein, and 56g fat


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Conclusion-Food Supplementation

Balanced protein-energysupplementation effective inreducing IUGR/SGA.

This intervention should bescaled up in developingcountries especially among

malnourished women andfood insecure populations.

Imdad and Bhutta, BMC Public Health, 2012


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Iron

Iron+folic acidsupplementation in

pregnancy


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Iron Deficiency Anemia (IDA) in Pregnancy

42% of pregnant womenare anemic (McLean, Public Hlth Nutr,2008); 50% of which is dueto iron deficiency

Normal RBCs Anemic RBCs

IDA in pregnancy associations with risk ofLBW, perinatal, neonatal, post-neonatal& maternal mortality

Iron needs are high during pregnancy(due to RBC mass expansion & growth of

placental-fetal unit)


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Not all anemia is caused by iron

deficiency.

But iron

Other vitamindeficiencies

Hookworm

Malaria

HIV/AIDS

InflammatoryConditions

Hemoglobin-

opathies

AnemiaIron

DeficiencyAnemia

IronDeficiency


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Overlapping causes of Anemia

Malaria Anemia Hookworm

Severe: 40%

Moderate: 20-39%


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Daily iron supplementation during pregnancy(Cochrane Review, 2012)

birth weight (31 g)

prevalence of LBW (19%)

of maternal anemia at term (70%)

of maternal iron deficiency at term (57%)

No evidence that Fe placental malaria

Based on 60 studies, >27,000 pregnant women


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Daily iron supplementation during pregnancy(Cochrane Review, 2012)

Preterm births: 13 studies (10,000 women)

RR: 0.88 (95% CI: 0.77, 1.01)

of preterm births (12%) but not statisticallysignificant

Neonatal mortality: 4 studies (7,500 participants)

RR: 0.90 (95% CI: 0.68, 1.19)

of neonatal mortality (10%) but not statisticallysignificant


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Recent RCTs FA-Fe in pregnancy

Baseline Levels

Place

(Study)

Anemia LBW ~N per

group

Control FA-Fe vs. Control

Nepal(BMJ 2003)

High High(44%)

~1,000 Control(VA)

BW (40 g) LBW (16%)SGA (9%)

USA-WIC(AJ CN, 2003)

None orLow

Med(17%)

135 FA BW (206 g) GA (0.6 wk)SGA (50%) Preterm LBW

W China(BMJ 2008)

Med Low/Med

(5%)

2,000 FA GA (0.23 wk)

Early preterm (


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Continuous risk relationship between Hb &maternal & perinatal mortality

0

500

10001500

2000

2500

3000

35004000

5 7 91

1

Hemoglobin (g/dL)

mo

rtality

Stoltzfus, et al, Comparative Quantification ofhealth risks: Global and regional burden ofdisease attributable to selected major riskfactors:, WHO, 2004

Risk reduction

associated with each 1

g/dL increase in

hemoglobin..Maternalmortality

20%

Perinatalmortality (Africa)

28%

Perinatalmortality (other)

16%


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Calcium

C l i l t ti (>1 /d) d i f


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Calcium supplementation (>1 g/d) during pregnancy forthe prevention of pre-eclampsia (Hofmeyr et al. Cochrane Review, 2012)

Hypertensive disorders account for40,000 maternal deaths annually

Outcome # studies RR 95% CI

High bloodpressure

12 0.65 0.53-0.81

Pre-eclampsia 13 0.36 0.20-0.65

Low Ca Intake 8 0.36 0.20-0.65

High risk 5 0.22 0.12-0.97

No evidence that Ca intake protective against LBW, IUGR orperinatal mortality


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Multiple

Micronutrient


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0

10

20

30

40

5060

70

80

PercentDeficient

Spring (Hot and dry) Summer (Hot and monsoon)

Fall (Post-monsoon) Winter (Cold and dry)

MN deficiencies in early pregnancy are

common, concurrent, & vary by season

in rural Nepali pregnant women

J iang et al, J Nutr 2005


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Cochrane Review (Haider & Bhutta, 2012): Multiple MicronutrientSupplementation (MMS) vs. Iron & folic acid (IFA) in pregnancy

Significant impact on. Effect of MMS

relative to IFALow birth weight 11%

Small for gestational age 13%

But NO significant impact on Preterm births, Perinatal mortality, Still births,

Neonatal mortality

21 trials comparing MMS vs. IFA~76,000 women


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Newborn Vitamin A


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Newborn Vitamin A

Asian Studies17% reduction

African StudiesNo reduction

Overall12% reduction

BMC Public Health, 2011

Single does (50,000 IU) in first 2 days of life


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Summary

Maternal nutrition before & duringpregnancy plays a crucial role ininfluencing fetal growth and birth outcomes

Recommendations: Food supplementation for food insecure

populations & undernourished women

Iron+folic acid in pregnancy (integrated withIPTp & deworming where appropriate)

Ca+ especially in populations with low intake &@ high risk for pre-eclampsia

Stay tuned: Multiple MNS and Newborn VA


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Thank You

klemm: the impact of maternal nutrition on the newborn

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