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Sherzai D, Moness R, Sherzai S, Sherzai A. A Systematic Review of Omega-3 Fatty Acid Consumption and Cognitive Outcomes in Neurodevelopment. Am J Lifestyle Med 2023; 17:649-685. [PMID: 37711355 PMCID: PMC10498982 DOI: 10.1177/15598276221116052] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/16/2023] Open
Abstract
INTRODUCTION This systematic review addresses the effects of n-3 long-chain polyunsaturated fatty acids consumption on human neurodevelopment. It evaluates articles published between 2000 and 2022 investigating the cognitive outcomes during the period of neurodevelopment: from fetal development to adolescence. For the purpose of this review the terms LC PUFA and omega-3 fatty acid will be used interchangeably. METHOD Data were sourced from several major databases including PubMed (MEDLINE), Web of Science, and ProQuest Central. Randomized controlled trials (RCTs), nonrandomized controlled trials, prospective or retrospective cohort studies, and observational studies investigating the effects of omega-3 fatty acid consumption from dietary supplements, multiple-nutrient supplement, or food questionnaire on neurodevelopment were considered. Study population was separated in three developmental phases: (1) in-utero, (2) lactation/infancy, and (3) childhood/adolescence. Each article was evaluated for several key factors such as study type, type/dosage of PUFAs, number of subjects, length of intervention, participant age range, population characteristics, outcome measure (both primary/cognitive and secondary/other), results, conclusion, and confounding variables/limitations. RESULTS A total of 88 articles were included in the review, 69 RCTs and 19 longitudinal or observational studies. The results indicate equivocal effect of intervention, with some short-term benefits observed in the areas of visual attention, working memory, executive function, and communication. Omega-3 supplement might have a short-term positive impact on neurodevelopment in all three phases. Supplementation is recommended throughout life, rather than only during the earliest developmental stage.
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Affiliation(s)
- Dean Sherzai
- Dept of Neurology, Brain Health and Alzheimer's Prevention Program, Loma Linda University, Loma Linda, CA, USA (AS, DS); Oak Ridge High School, El Dorado Hills, CA, USA (RM); California State University, Los Angeles, CA, USA (SS)
| | - Roman Moness
- Dept of Neurology, Brain Health and Alzheimer's Prevention Program, Loma Linda University, Loma Linda, CA, USA (AS, DS); Oak Ridge High School, El Dorado Hills, CA, USA (RM); California State University, Los Angeles, CA, USA (SS)
| | - Sophia Sherzai
- Dept of Neurology, Brain Health and Alzheimer's Prevention Program, Loma Linda University, Loma Linda, CA, USA (AS, DS); Oak Ridge High School, El Dorado Hills, CA, USA (RM); California State University, Los Angeles, CA, USA (SS)
| | - Ayesha Sherzai
- Dept of Neurology, Brain Health and Alzheimer's Prevention Program, Loma Linda University, Loma Linda, CA, USA (AS, DS); Oak Ridge High School, El Dorado Hills, CA, USA (RM); California State University, Los Angeles, CA, USA (SS)
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Heath RJ, Klevebro S, Wood TR. Maternal and Neonatal Polyunsaturated Fatty Acid Intake and Risk of Neurodevelopmental Impairment in Premature Infants. Int J Mol Sci 2022; 23:ijms23020700. [PMID: 35054885 PMCID: PMC8775484 DOI: 10.3390/ijms23020700] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 01/05/2022] [Accepted: 01/06/2022] [Indexed: 12/15/2022] Open
Abstract
The N3 and N6 long chain polyunsaturated fatty acids (LCPUFA) docosahexaenoic acid (DHA) and arachidonic acid (AA) are essential for proper neurodevelopment in early life. These fatty acids are passed from mother to infant via the placenta, accreting into fetal tissues such as brain and adipose tissue. Placental transfer of LCPUFA is highest in the final trimester, but this transfer is abruptly severed with premature birth. As such, efforts have been made to supplement the post-natal feed of premature infants with LCPUFA to improve neurodevelopmental outcomes. This narrative review analyzes the current body of evidence pertinent to neurodevelopmental outcomes after LCPUFA supplementation in prematurely born infants, which was identified via the reference lists of systematic and narrative reviews and PubMed search engine results. This review finds that, while the evidence is weakened by heterogeneity, it may be seen that feed comprising 0.3% DHA and 0.6% AA is associated with more positive neurodevelopmental outcomes than LCPUFA-deplete feed. While no new RCTs have been performed since the most recent Cochrane meta-analysis in 2016, this narrative review provides a wider commentary; the wider effects of LCPUFA supplementation in prematurely born infants, the physiology of LCPUFA accretion into preterm tissues, and the physiological effects of LCPUFA that affect neurodevelopment. We also discuss the roles of maternal LCPUFA status as a modifiable factor affecting the risk of preterm birth and infant neurodevelopmental outcomes. To better understand the role of LCPUFAs in infant neurodevelopment, future study designs must consider absolute and relative availabilities of all LCPUFA species and incorporate the LCPUFA status of both mother and infant in pre- and postnatal periods.
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Affiliation(s)
- Rory J. Heath
- Emergency Medicine Department, Derriford Hospital, University Hospitals Plymouth NHS Foundation Trust, Plymouth PL68DH, UK;
| | - Susanna Klevebro
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, 11883 Stockholm, Sweden;
| | - Thomas R. Wood
- Department of Pediatrics, University of Washington, Seattle, WA 98195, USA
- Center on Human Development and Disability, University of Washington, Seattle, WA 98195, USA
- Institute for Human and Machine Cognition, Pensacola, FL 32502, USA
- Correspondence:
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Nevins JEH, Donovan SM, Snetselaar L, Dewey KG, Novotny R, Stang J, Taveras EM, Kleinman RE, Bailey RL, Raghavan R, Scinto-Madonich SR, Venkatramanan S, Butera G, Terry N, Altman J, Adler M, Obbagy JE, Stoody EE, de Jesus J. Omega-3 Fatty Acid Dietary Supplements Consumed During Pregnancy and Lactation and Child Neurodevelopment: A Systematic Review. J Nutr 2021; 151:3483-3494. [PMID: 34383914 PMCID: PMC8764572 DOI: 10.1093/jn/nxab238] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 04/08/2021] [Accepted: 06/25/2021] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Maternal nutrition during pregnancy and lactation has profound effects on the development and lifelong health of the child. Long-chain PUFAs are particularly important for myelination and the development of vision during the perinatal period. OBJECTIVES We conducted a systematic review to examine the relationship between supplementation with omega-3 fatty acids during pregnancy and/or lactation and neurodevelopment in children, to inform the Scientific Report of the 2020 Dietary Guidelines Advisory Committee. METHODS We identified articles on omega-3 fatty acid supplementation in pregnant and lactating women that included measures of neurodevelopment in their children (0-18 y) by searching PubMed, CENTRAL, Embase, and CINAHL Plus. After dual screening articles for inclusion, we qualitatively synthesized and graded the strength of evidence using pre-established criteria for assessing risk of bias, consistency, directness, precision, and generalizability. RESULTS We included 33 articles from 15 randomized controlled trials (RCTs) and 1 prospective cohort study. Of the 8 RCTs that delivered omega-3 fatty acid dietary supplements during pregnancy alone (200-2200 mg/d DHA and 0-1100 mg/d EPA for approximately 20 wk), 5 studies reported ≥1 finding that supplementation improved measures of cognitive development in the infant or child by 6%-11% (P < 0.05), but all 8 studies also reported ≥1 nonsignificant (P > 0.05) result. There was inconsistent or insufficient evidence for other outcomes (language, social-emotional, physical, motor, or visual development; academic performance; risks of attention deficit disorder, attention-deficit/hyperactivity disorder, autism spectrum disorder, anxiety, or depression) and for supplementation during lactation or both pregnancy and lactation. Populations with a lower socioeconomic status and adolescents were underrepresented and studies lacked racial and ethnic diversity. CONCLUSIONS Limited evidence suggests that omega-3 fatty acid supplementation during pregnancy may result in favorable cognitive development in the child. There was insufficient evidence to evaluate the effects of omega-3 fatty acid supplementation during pregnancy and/or lactation on other developmental outcomes.
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Affiliation(s)
- Julie E H Nevins
- Panum Group, Bethesda, MD, USA
- Nutrition Evidence Systematic Review team, Office of Nutrition Guidance and Analysis, Center for Nutrition Policy and Promotion, Food and Nutrition Service, USDA, Alexandria, VA, USA
| | - Sharon M Donovan
- Department of Food Science and Human Nutrition, University of Illinois, Urbana-Champaign, IL, USA
| | - Linda Snetselaar
- Department of Epidemiology, University of Iowa, Iowa City, IA, USA
| | - Kathryn G Dewey
- Department of Nutrition, University of California, Davis, CA, USA
| | - Rachel Novotny
- Department of Human Nutrition, Food and Animal Science, University of Hawaii at Manoa, Manoa, HI, USA
| | - Jamie Stang
- Division of Epidemiology and Community Health, University of Minnesota, Minneapolis, MN, USA
| | - Elsie M Taveras
- Department of Pediatrics, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Department of Nutrition, Harvard TH Chan School of Public Health, Boston, MA, USA
| | - Ronald E Kleinman
- Department of Pediatrics, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Regan L Bailey
- Department of Nutrition Science, Purdue University, West Lafayette, IN, USA
| | - Ramkripa Raghavan
- Panum Group, Bethesda, MD, USA
- Nutrition Evidence Systematic Review team, Office of Nutrition Guidance and Analysis, Center for Nutrition Policy and Promotion, Food and Nutrition Service, USDA, Alexandria, VA, USA
| | - Sara R Scinto-Madonich
- Panum Group, Bethesda, MD, USA
- Nutrition Evidence Systematic Review team, Office of Nutrition Guidance and Analysis, Center for Nutrition Policy and Promotion, Food and Nutrition Service, USDA, Alexandria, VA, USA
| | - Sudha Venkatramanan
- Panum Group, Bethesda, MD, USA
- Nutrition Evidence Systematic Review team, Office of Nutrition Guidance and Analysis, Center for Nutrition Policy and Promotion, Food and Nutrition Service, USDA, Alexandria, VA, USA
| | - Gisela Butera
- Panum Group, Bethesda, MD, USA
- Nutrition Evidence Systematic Review team, Office of Nutrition Guidance and Analysis, Center for Nutrition Policy and Promotion, Food and Nutrition Service, USDA, Alexandria, VA, USA
| | | | - Jean Altman
- Office of Nutrition Guidance and Analysis, Center for Nutrition Policy and Promotion, Food and Nutrition Service, USDA, Alexandria, VA, USA
| | - Meghan Adler
- Office of Nutrition Guidance and Analysis, Center for Nutrition Policy and Promotion, Food and Nutrition Service, USDA, Alexandria, VA, USA
| | - Julie E Obbagy
- Nutrition Evidence Systematic Review team, Office of Nutrition Guidance and Analysis, Center for Nutrition Policy and Promotion, Food and Nutrition Service, USDA, Alexandria, VA, USA
| | - Eve E Stoody
- Office of Nutrition Guidance and Analysis, Center for Nutrition Policy and Promotion, Food and Nutrition Service, USDA, Alexandria, VA, USA
| | - Janet de Jesus
- Office of Disease Prevention and Health Promotion, HHS, United States Department of Agriculture, Food and Nutrition Service, Center for Nutrition Policy and Promotion, Alexandria, VA, USA
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Cortés-Albornoz MC, García-Guáqueta DP, Velez-van-Meerbeke A, Talero-Gutiérrez C. Maternal Nutrition and Neurodevelopment: A Scoping Review. Nutrients 2021; 13:3530. [PMID: 34684531 PMCID: PMC8538181 DOI: 10.3390/nu13103530] [Citation(s) in RCA: 62] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 08/09/2021] [Accepted: 08/15/2021] [Indexed: 01/31/2023] Open
Abstract
In this scoping review, we examined the association between maternal nutrition during pregnancy and neurodevelopment in offspring. We searched the Pubmed and ScienceDirect databases for articles published from 2000 to 2020 on inadequate intake of vitamins (B12, folate, vitamin D, vitamin A, vitamin E, vitamin K), micronutrients (cooper, iron, creatine, choline, zinc, iodine), macronutrients (fatty acids, proteins), high fat diets, ketogenic diets, hypercaloric diets, and maternal undernutrition. Some older relevant articles were included. The search produced a total of 3590 articles, and 84 studies were included in the qualitative synthesis. Data were extracted and analyzed using charts and the frequency of terms used. We concluded that inadequate nutrient intake during pregnancy was associated with brain defects (diminished cerebral volume, spina bifida, alteration of hypothalamic and hippocampal pathways), an increased risk of abnormal behavior, neuropsychiatric disorders (ASD, ADHD, schizophrenia, anxiety, depression), altered cognition, visual impairment, and motor deficits. Future studies should establish and quantify the benefits of maternal nutrition during pregnancy on neurodevelopment and recommend adequate supplementation.
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Affiliation(s)
| | | | | | - Claudia Talero-Gutiérrez
- Neuroscience Research Group (NEUROS), Centro Neurovitae, School of Medicine and Health Sciences, Universidad del Rosario, Bogotá 111221, Colombia; (M.C.C.-A.); (D.P.G.-G.); (A.V.-v.-M.)
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Rasool A, Alvarado-Flores F, O'Tierney-Ginn P. Placental Impact of Dietary Supplements: More Than Micronutrients. Clin Ther 2020; 43:226-245. [PMID: 33358257 DOI: 10.1016/j.clinthera.2020.11.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 11/23/2020] [Accepted: 11/24/2020] [Indexed: 12/31/2022]
Abstract
PURPOSE Maternal nutrition is a key modifier of fetal growth and development. However, many maternal diets in the United States do not meet nutritional recommendations. Dietary supplementation is therefore necessary to meet nutritional goals. The effects of many supplements on placental development and function are poorly understood. In this review, we address the therapeutic potential of maternal dietary supplementation on placental development and function in both healthy and complicated pregnancies. METHODS This is a narrative review of original research articles published between February 1970 and July 2020 on dietary supplements consumed during pregnancy and placental outcomes (including nutrient uptake, metabolism and delivery, as well as growth and efficiency). Impacts of placental changes on fetal outcomes were also reviewed. Both human and animal studies were included. FINDINGS We found evidence of a potential therapeutic benefit of several supplements on maternal and fetal outcomes via their placental impacts. Our review supports a role for probiotics as a placental therapeutic, with effects that include improved inflammation and lipid metabolism, which may prevent preterm birth and poor placental efficiency. Supplementation with omega-3 fatty acids (as found in fish oil) during pregnancy tempers the negative effects of maternal obesity but may have little placental impact in healthy lean women. The beneficial effects of choline supplementation on maternal health and fetal growth are largely attributable to its placental impacts. l-arginine supplementation has a potent provascularization effect on the placenta, which may underlie its fetal growth-promoting properties. IMPLICATIONS The placenta is exquisitely sensitive to dietary supplements. Pregnant women should consult their health care practitioner before continuing or initiating use of a dietary supplement. Because little is known about impacts of many supplements on placental and long-term offspring health, more research is required before robust clinical recommendations can be made.
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Affiliation(s)
- Aisha Rasool
- Mother Infant Research Institute, Tufts Medical Center, Boston, MA, USA
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Gawlik NR, Makrides M, Kettler L, Yelland LN, Leemaqz S, Gould JF. The influence of DHA supplementation during pregnancy on language development across childhood: Follow-up of a randomised controlled trial. Prostaglandins Leukot Essent Fatty Acids 2020; 163:102207. [PMID: 33227646 DOI: 10.1016/j.plefa.2020.102207] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 10/02/2020] [Accepted: 11/07/2020] [Indexed: 12/17/2022]
Abstract
Numerous randomised controlled trials have explored the effect of docosahexaenoic acid (DHA) supplementation in early life on neurodevelopment, with some suggested positive effects on language. Australian women with a singleton pregnancy <21 weeks' gestation were randomised to receive 800 mg DHA/day or a placebo until birth. A sample of 726 children (all n=96 born preterm, random sample of n=630 born at term) were invited to undergo assessments of language, academic, and language-based cognitive abilities at 1.5, four and seven years of age. No group differences were detected for any group comparison. Exploratory analyses for sex by treatment interactions revealed a possible adverse effect of DHA supplementation on the language of females at 1.5 years but no effects on outcomes at four or seven years. Taken as a whole, evidence of an effect of prenatal DHA supplementation on language abilities across childhood is negligible and could be a chance finding.
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Affiliation(s)
- N R Gawlik
- Discipline of Paediatrics, Faculty of Health and Medical Sciences, The University of Adelaide, North Terrace Adelaide, South Australia, 5000.
| | - M Makrides
- Discipline of Paediatrics, Faculty of Health and Medical Sciences, The University of Adelaide, North Terrace Adelaide, South Australia, 5000; Women and Kids, South Australian Health and Medical Research Institute, 72 King William Road, North Adelaide, South Australia, 5006.
| | - L Kettler
- Trinity College Gawler Inc, Alexander Avenue, Evanston South SA 5116; School of Psychology, The University of Adelaide, North Terrace Adelaide, South Australia, 5000.
| | - L N Yelland
- Women and Kids, South Australian Health and Medical Research Institute, 72 King William Road, North Adelaide, South Australia, 5006; School of Public Health, Faculty of Health and Medical Sciences, The University of Adelaide, North Terrace Adelaide, South Australia, 5000.
| | - S Leemaqz
- Women and Kids, South Australian Health and Medical Research Institute, 72 King William Road, North Adelaide, South Australia, 5006.
| | - J F Gould
- Women and Kids, South Australian Health and Medical Research Institute, 72 King William Road, North Adelaide, South Australia, 5006; School of Psychology & Discipline of Paediatrics, Faculty of Health and Medical Sciences, The University of Adelaide, North Terrace Adelaide, South Australia, 5000.
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Gawlik NR, Anderson AJ, Makrides M, Kettler L, Gould JF. The Influence of DHA on Language Development: A Review of Randomized Controlled Trials of DHA Supplementation in Pregnancy, the Neonatal Period, and Infancy. Nutrients 2020; 12:E3106. [PMID: 33053714 PMCID: PMC7599780 DOI: 10.3390/nu12103106] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 10/02/2020] [Accepted: 10/07/2020] [Indexed: 12/25/2022] Open
Abstract
This review summarizes randomized controlled trials (RCTs) assessing the effect of docosahexaenoic acid (DHA) supplementation in the first 1000 days on child language. Six databases were searched and RCTs were included if they involved supplementation with DHA during pregnancy, to preterm infants, or during the postpartum period, included a placebo group with less or no DHA, and reported a language outcome. We included 29 RCTs involving n = 10,405 participants from 49 publications. There was a total of 84 language measures at ages ranging from 3 months to 12 years. Of the 84 assessments, there were 4 instances where the DHA group had improved scores, and 2 instances where the DHA group had worse scores (with the majority of these significant effects found within one RCT). The remaining comparisons were null. A few RCTs that included subgroup analyses reported (inconsistent) effects. There was limited evidence that DHA supplementation had any effect on language development, although there were some rare instances of both possible positive and adverse effects, particularly within population subgroups. It is important that any subgroup effects are verified in future trials that are adequately powered to confirm such effects.
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Affiliation(s)
- Nicola R. Gawlik
- Discipline of Paediatrics, Faculty of Health and Medical Sciences, The University of Adelaide, North Terrace, Adelaide 5000, Australia; (N.R.G.); (A.J.A.); (M.M.)
| | - Amanda J. Anderson
- Discipline of Paediatrics, Faculty of Health and Medical Sciences, The University of Adelaide, North Terrace, Adelaide 5000, Australia; (N.R.G.); (A.J.A.); (M.M.)
- Women and Kids, South Australian Health and Medical Research Institute, 72 King William Road, North Adelaide 5006, Australia
| | - Maria Makrides
- Discipline of Paediatrics, Faculty of Health and Medical Sciences, The University of Adelaide, North Terrace, Adelaide 5000, Australia; (N.R.G.); (A.J.A.); (M.M.)
- Women and Kids, South Australian Health and Medical Research Institute, 72 King William Road, North Adelaide 5006, Australia
| | - Lisa Kettler
- Trinity College Gawler Inc., Alexander Avenue, Evanston South 5116, Australia;
| | - Jacqueline F. Gould
- Women and Kids, South Australian Health and Medical Research Institute, 72 King William Road, North Adelaide 5006, Australia
- School of Psychology & Discipline of Paediatrics, Faculty of Health and Medical Sciences, The University of Adelaide, North Terrace, Adelaide 5000, Australia
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Martins BP, Bandarra NM, Figueiredo-Braga M. The role of marine omega-3 in human neurodevelopment, including Autism Spectrum Disorders and Attention-Deficit/Hyperactivity Disorder – a review. Crit Rev Food Sci Nutr 2019; 60:1431-1446. [DOI: 10.1080/10408398.2019.1573800] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Affiliation(s)
- Bárbara P. Martins
- Department of Clinical Neurosciences and Mental Health, Medical Psychology, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Narcisa M. Bandarra
- Department of Sea and Marine Resources, Portuguese Institute for the Sea and Atmosphere (IPMA, IP), Lisbon, Portugal
| | - Margarida Figueiredo-Braga
- Department of Clinical Neurosciences and Mental Health, Medical Psychology, Faculty of Medicine, University of Porto, Porto, Portugal
- Research Group: Metabolism, Nutrition & Endocrinology, i3S Instituto de Investigação e Inovação em Saúde, Porto, Portugal
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Klevebro S, Juul SE, Wood TR. A More Comprehensive Approach to the Neuroprotective Potential of Long-Chain Polyunsaturated Fatty Acids in Preterm Infants Is Needed-Should We Consider Maternal Diet and the n-6:n-3 Fatty Acid Ratio? Front Pediatr 2019; 7:533. [PMID: 31998669 PMCID: PMC6965147 DOI: 10.3389/fped.2019.00533] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Accepted: 12/09/2019] [Indexed: 12/16/2022] Open
Abstract
There is growing evidence that long-chain polyunsaturated fatty acids (LCPUFAs) are of importance for normal brain development. Adequate supply of LCPUFAs may be particularly important for preterm infants, because the third trimester is an important period of brain growth and accumulation of arachidonic acid (n-6 LCPUFA) and docosahexaenoic acid (n-3 LCPUFA). Fatty acids from the n-6 and n-3 series, particularly, have important functions in the brain as well as in the immune system, and their absolute and relative intakes may alter both the risk of impaired neurodevelopment and response to injury. This narrative review focuses on the potential importance of the n-6:n-3 fatty acid ratio in preterm brain development. Randomized trials of post-natal LCPUFA supplementation in preterm infants are presented. Pre-clinical evidence, results from observational studies in preterm infants as well as studies in term infants and evidence related to maternal diet during pregnancy, focusing on the n-6:n-3 fatty acid ratio, are also summarized. Two randomized trials in preterm infants have compared different ratios of arachidonic acid and docosahexaenoic acid intakes. Most of the other studies in preterm infants have compared formula supplemented with arachidonic acid and docosahexaenoic acid to un-supplemented formula. No trial has had a comprehensive approach to differences in total intake of both n-6 and n-3 fatty acids during a longer period of neurodevelopment. The results from preclinical and clinical studies indicate that intake of LCPUFAs during pregnancy and post-natal development is of importance for neurodevelopment and neuroprotection in preterm infants, but the interplay between fatty acids and their metabolites is complex. The best clinical approach to LCPUFA supplementation and n-6 to n-3 fatty acid ratio is still far from evident, and requires in-depth future studies that investigate specific fatty acid supplementation in the context of other fatty acids in the diet.
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Affiliation(s)
- Susanna Klevebro
- Department of Clinical Science and Education, Stockholm South General Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Sandra E Juul
- Division of Neonatology, Department of Pediatrics, University of Washington, Seattle, WA, United States
| | - Thomas R Wood
- Division of Neonatology, Department of Pediatrics, University of Washington, Seattle, WA, United States
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Middleton P, Gomersall JC, Gould JF, Shepherd E, Olsen SF, Makrides M. Omega-3 fatty acid addition during pregnancy. Cochrane Database Syst Rev 2018; 11:CD003402. [PMID: 30480773 PMCID: PMC6516961 DOI: 10.1002/14651858.cd003402.pub3] [Citation(s) in RCA: 132] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Higher intakes of foods containing omega-3 long-chain polyunsaturated fatty acids (LCPUFA), such as fish, during pregnancy have been associated with longer gestations and improved perinatal outcomes. This is an update of a review that was first published in 2006. OBJECTIVES To assess the effects of omega-3 LCPUFA, as supplements or as dietary additions, during pregnancy on maternal, perinatal, and neonatal outcomes and longer-term outcomes for mother and child. SEARCH METHODS For this update, we searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (16 August 2018), and reference lists of retrieved studies. SELECTION CRITERIA Randomised controlled trials (RCTs) comparing omega-3 fatty acids (as supplements or as foods, stand-alone interventions, or with a co-intervention) during pregnancy with placebo or no omega-3, and studies or study arms directly comparing omega-3 LCPUFA doses or types. Trials published in abstract form were eligible for inclusion. DATA COLLECTION AND ANALYSIS Two review authors independently assessed study eligibility, extracted data, assessed risk of bias in trials and assessed quality of evidence for prespecified birth/infant, maternal, child/adult and health service outcomes using the GRADE approach. MAIN RESULTS In this update, we included 70 RCTs (involving 19,927 women at low, mixed or high risk of poor pregnancy outcomes) which compared omega-3 LCPUFA interventions (supplements and food) compared with placebo or no omega-3. Overall study-level risk of bias was mixed, with selection and performance bias mostly at low risk, but there was high risk of attrition bias in some trials. Most trials were conducted in upper-middle or high-income countries; and nearly half the trials included women at increased/high risk for factors which might increase the risk of adverse maternal and birth outcomes.Preterm birth < 37 weeks (13.4% versus 11.9%; risk ratio (RR) 0.89, 95% confidence interval (CI) 0.81 to 0.97; 26 RCTs, 10,304 participants; high-quality evidence) and early preterm birth < 34 weeks (4.6% versus 2.7%; RR 0.58, 95% CI 0.44 to 0.77; 9 RCTs, 5204 participants; high-quality evidence) were both lower in women who received omega-3 LCPUFA compared with no omega-3. Prolonged gestation > 42 weeks was probably increased from 1.6% to 2.6% in women who received omega-3 LCPUFA compared with no omega-3 (RR 1.61 95% CI 1.11 to 2.33; 5141 participants; 6 RCTs; moderate-quality evidence).For infants, there was a possibly reduced risk of perinatal death (RR 0.75, 95% CI 0.54 to 1.03; 10 RCTs, 7416 participants; moderate-quality evidence: 62/3715 versus 83/3701 infants) and possibly fewer neonatal care admissions (RR 0.92, 95% CI 0.83 to 1.03; 9 RCTs, 6920 participants; moderate-quality evidence - 483/3475 infants versus 519/3445 infants). There was a reduced risk of low birthweight (LBW) babies (15.6% versus 14%; RR 0.90, 95% CI 0.82 to 0.99; 15 trials, 8449 participants; high-quality evidence); but a possible small increase in large-for-gestational age (LGA) babies (RR 1.15, 95% CI 0.97 to 1.36; 6 RCTs, 3722 participants; moderate-quality evidence, for omega-3 LCPUFA compared with no omega-3. Little or no difference in small-for-gestational age or intrauterine growth restriction (RR 1.01, 95% CI 0.90 to 1.13; 8 RCTs, 6907 participants; moderate-quality evidence) was seen.For the maternal outcomes, there is insufficient evidence to determine the effects of omega-3 on induction post-term (average RR 0.82, 95% CI 0.22 to 2.98; 3 trials, 2900 participants; low-quality evidence), maternal serious adverse events (RR 1.04, 95% CI 0.40 to 2.72; 2 trials, 2690 participants; low-quality evidence), maternal admission to intensive care (RR 0.56, 95% CI 0.12 to 2.63; 2 trials, 2458 participants; low-quality evidence), or postnatal depression (average RR 0.99, 95% CI 0.56 to 1.77; 2 trials, 2431 participants; low-quality evidence). Mean gestational length was greater in women who received omega-3 LCPUFA (mean difference (MD) 1.67 days, 95% CI 0.95 to 2.39; 41 trials, 12,517 participants; moderate-quality evidence), and pre-eclampsia may possibly be reduced with omega-3 LCPUFA (RR 0.84, 95% CI 0.69 to 1.01; 20 trials, 8306 participants; low-quality evidence).For the child/adult outcomes, very few differences between antenatal omega-3 LCPUFA supplementation and no omega-3 were observed in cognition, IQ, vision, other neurodevelopment and growth outcomes, language and behaviour (mostly low-quality to very low-quality evidence). The effect of omega-3 LCPUFA on body mass index at 19 years (MD 0, 95% CI -0.83 to 0.83; 1 trial, 243 participants; very low-quality evidence) was uncertain. No data were reported for development of diabetes in the children of study participants. AUTHORS' CONCLUSIONS In the overall analysis, preterm birth < 37 weeks and early preterm birth < 34 weeks were reduced in women receiving omega-3 LCPUFA compared with no omega-3. There was a possibly reduced risk of perinatal death and of neonatal care admission, a reduced risk of LBW babies; and possibly a small increased risk of LGA babies with omega-3 LCPUFA.For our GRADE quality assessments, we assessed most of the important perinatal outcomes as high-quality (e.g. preterm birth) or moderate-quality evidence (e.g. perinatal death). For the other outcome domains (maternal, child/adult and health service outcomes) GRADE ratings ranged from moderate to very low, with over half rated as low. Reasons for downgrading across the domain were mostly due to design limitations and imprecision.Omega-3 LCPUFA supplementation during pregnancy is an effective strategy for reducing the incidence of preterm birth, although it probably increases the incidence of post-term pregnancies. More studies comparing omega-3 LCPUFA and placebo (to establish causality in relation to preterm birth) are not needed at this stage. A further 23 ongoing trials are still to report on over 5000 women, so no more RCTs are needed that compare omega-3 LCPUFA against placebo or no intervention. However, further follow-up of completed trials is needed to assess longer-term outcomes for mother and child, to improve understanding of metabolic, growth and neurodevelopment pathways in particular, and to establish if, and how, outcomes vary by different types of omega-3 LCPUFA, timing and doses; or by characteristics of women.
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Affiliation(s)
- Philippa Middleton
- Healthy Mothers, Babies and Children, South Australian Health and Medical Research InstituteWomen's and Children's Hospital72 King William RoadAdelaideSouth AustraliaAustralia5006
| | - Judith C Gomersall
- Healthy Mothers, Babies and Children, South Australian Health and Medical Research InstituteWomen's and Children's Hospital72 King William RoadAdelaideSouth AustraliaAustralia5006
| | - Jacqueline F Gould
- The University of AdelaideSchool of PsychologyNorth Terrace, AdelaideAdelaideSouth AustraliaAustralia5001
| | - Emily Shepherd
- The University of AdelaideARCH: Australian Research Centre for Health of Women and Babies, Robinson Research Institute, Discipline of Obstetrics and GynaecologyAdelaideSouth AustraliaAustralia5006
| | - Sjurdur F Olsen
- Statens Serum InstitutCentre for Fetal Programming, Department of EpidemiologyCopenhagenDenmark
| | - Maria Makrides
- Healthy Mothers, Babies and Children, South Australian Health and Medical Research InstituteWomen's and Children's Hospital72 King William RoadAdelaideSouth AustraliaAustralia5006
- The University of AdelaideSchool of Paediatrics and Reproductive HealthAdelaideAustraliaAustralia
- Women's and Children's Health Research InstituteNorth AdelaideAustralia
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