The effect of balanced protein energy supplementation in undernourished pregnant women and child physical growth in low- and middle-income countries: a systematic review and meta-analysis

Perinatal intervention strategies providing food with micronutrients to pregnant and breastfeeding women in low- and middle-income countries: A scoping review

In resource-constrained settings, pregnant and breastfeeding women and girls (PBW/G) are particularly vulnerable to undernutrition. Micronutrient-fortified balanced energy protein (BEP) supplementation may be provided to boost maternal nutritional status and improve birth and infant outcomes. We conducted a scoping review of the published literature to determine the impact of BEP and other related nutrition interventions that provided fortified food or cash along with a minimum of 3 micronutrients on maternal, birth, and infant/child outcomes in low- and middle-income countries. We conducted a PubMed search using pre-defined keywords and controlled vocabulary search terms. All titles and abstracts were reviewed for eligibility by two independent reviewers, and data were extracted according to outcome type. We identified 149 eligible research articles that reported on a total of 21 trials and/or programme evaluations which assessed the health impact of one or more products (fortified lipid-based nutrient supplement [LNS, n = 12], fortified blended flours [n = 5], milk-based beverages [n = 2], and local food/snacks [n = 3]) that provided 118-750 kcal/day and varying levels of protein and micronutrients. Only one of these programme evaluations assessed the impact of the provision of cash and fortified food. Effects on maternal outcomes such as gestational weight gain and duration of gestation were promising but inconsistent. Birth outcomes were reported in 15 studies, and the effects on birthweight and birth length were generally positive. Seven studies demonstrated sustained benefits on infant and child growth out of the 15 studies that reported at least one of these outcomes, although data were sparse. Additional research is needed to investigate issues of dose, cost-effectiveness, and incorporation into multi-component interventions.

Evaluation of the Olo Prenatal Nutrition Follow-up Care for Vulnerable Pregnant Women

Olo nutritional follow-up care offers vulnerable pregnant women food vouchers, multivitamin supplements, tools, and nutritional counselling to support healthy pregnancy outcomes.Purpose: To evaluate the contribution of Olo follow-up care to nutritional intakes and eating practices, as well as to assess the programme-related experience of participants.Methods: Participants (n = 30) responded to questionnaires and web-based 24-hour dietary recalls and participated in a semi-structured interview (n = 10).Results: Olo follow-up care reduced the proportion of participants below the recommended intake for groups for many micronutrients, with the greatest reduction for folate (by 96.7%), vitamin D (by 93.3%), iron (by 70.0%), calcium (by 50.0%), and zinc (by 30.0%), mainly due to the prenatal multivitamin supplements. Most participants (96.7%) did not follow Olo's typical recommendations but, if they had, hypothetically they would have consumed an average of 746 additional calories per day and be above the recommendations for excessive intakes of folic acid and iron (100% and 33.3%, respectively). More than half of the participants were moderately to severely food insecure. Olo contributed to reducing the impact of isolation and increased food accessibility and budget flexibility among participants.Conclusion: Olo follow-up care helped reduce the proportion of women below the recommended intake for micronutrients, but revising the food offered and strategies to address food insecurity may be necessary.

Nutritious Supplemental Foods for Pregnant Women from Food Insecure Settings: Types, Nutritional Composition, and Relationships to Health Outcomes

There is growing evidence that the provision of nutritious supplemental foods to undernourished pregnant women can improve maternal and infant outcomes. However, comparing and synthesizing the evidence base is complicated by differences in interventions and products and the use of ambiguous terminology. We aimed to define 2 common types of nutritious supplemental foods used in pregnancy, balanced energy-protein (BEP) supplements and lipid-based nutrient supplements (LNS), and to review the evidence supporting each via a narrative review of systematic reviews and meta-analyses (SRMAs). Information about the nutritional composition of the food supplements and their effects on maternal and infant outcomes was abstracted. Five SRMAs (n = 20 trials) evaluated the effect of BEP compared with no BEP/control (comparison group commonly received iron and folic acid [IFA]). BEP foods/products ranged in calories (118-1017 kcals), protein (3-50 g), fat (6-57 g), and micronutrient content. Overall, maternal BEP improved birth weight and reduced the risk of stillbirth and small for gestational age when compared with no BEP/control in pregnancy. Three SRMAs (n = 5 trials) evaluated the effect of LNS compared with IFA or multiple micronutrients (MMNs). The LNS interventions comprised small- and large-quantity LNS that ranged in calories (118-746 kcals), protein (3-21 g), fat (10-53 g), and micronutrient content. LNS compared with IFA increased pregnancy duration, birth weight, and birth length and reduced the risk of small for gestational age and infant stunting; however, no beneficial effect of LNS was identified when compared with MMN. Despite heterogeneity in the nutritional composition of BEP supplements, the evidence suggests that in nutritionally at-risk populations, these products may improve birth outcomes in pregnant women. The evidence is limited but promising when LNS is compared with IFA in improving maternal and infant outcomes. Overall, BEP, compared with MMN or LNS, are key areas that have not been studied and deserve attention.

Is Maternal Carbohydrate Intake Having an Impact on Newborn Birth Weight? A Systematic Review

Glucose is a vital fuel for fetal growth, and carbohydrates are the primary source of glucose in the diet. The effects of carbohydrate intake during pregnancy on neonatal birth weight have not been fully investigated or systematically reviewed. Therefore, this systematic review aimed to collate the available evidence to determine whether carbohydrate intake during pregnancy impacts newborn birth weight. A literature search was performed from inception to March 2022 in Embase, Medline, and PsycInfo. Articles published in English were independently screened for the title and abstracts, and then for full texts. Out of 17 studies included, a significant relationship between the intake of maternal carbohydrate or its subcomponents and neonatal birth weight was reported in six studies. Of them, one study reported that higher carbohydrate intake in early pregnancy was associated with lower birth weight. The two other studies reported a positive correlation between maternal carbohydrate intake and neonatal birth weight regarding first- and second-trimester intake. Maternal carbohydrate intake may have an impact on birth weight, as suggested by the included studies in this systematic review. However, the overall review indicates contradictory findings concerning the relationship between carbohydrate intake and neonatal birth weight. Studies assessing the type of carbohydrate and the amount consumed with improved methodological quality are recommended.

Harmonization of maternal balanced energy-protein supplementation studies for individual participant data (IPD) meta-analyses - finding and creating similarities in variables and data collection

BACKGROUND

Public health and clinical recommendations are established from systematic reviews and retrospective meta-analyses combining effect sizes, traditionally, from aggregate data and more recently, using individual participant data (IPD) of published studies. However, trials often have outcomes and other meta-data that are not defined and collected in a standardized way, making meta-analysis problematic. IPD meta-analysis can only partially fix the limitations of traditional, retrospective, aggregate meta-analysis; prospective meta-analysis further reduces the problems.

METHODS

We developed an initiative including seven clinical intervention studies of balanced energy-protein (BEP) supplementation during pregnancy and/or lactation that are being conducted (or recently concluded) in Burkina Faso, Ethiopia, India, Nepal, and Pakistan to test the effect of BEP on infant and maternal outcomes. These studies were commissioned after an expert consultation that designed recommendations for a BEP product for use among pregnant and lactating women in low- and middle-income countries. The initiative goal is to harmonize variables across studies to facilitate IPD meta-analyses on closely aligned data, commonly called prospective meta-analysis. Our objective here is to describe the process of harmonizing variable definitions and prioritizing research questions. A two-day workshop of investigators, content experts, and advisors was held in February 2020 and harmonization activities continued thereafter. Efforts included a range of activities from examining protocols and data collection plans to discussing best practices within field constraints. Prior to harmonization, there were many similar outcomes and variables across studies, such as newborn anthropometry, gestational age, and stillbirth, however, definitions and protocols differed. As well, some measurements were being conducted in several but not all studies, such as food insecurity. Through the harmonization process, we came to consensus on important shared variables, particularly outcomes, added new measurements, and improved protocols across studies.

DISCUSSION

We have fostered extensive communication between investigators from different studies, and importantly, created a large set of harmonized variable definitions within a prospective meta-analysis framework. We expect this initiative will improve reporting within each study in addition to providing opportunities for a series of IPD meta-analyses.

Insights into Prevention of Health Complications in Small for Gestational Age (SGA) Births in Relation to Maternal Characteristics: A Narrative Review

Small for gestational age (SGA) births are a significant clinical and public health issue. The objective of this review was to summarize maternal biological and socio-demographic factors and preventive strategies used to reduce the risk of SGA births. A literature search encompassing data from the last 15 years was conducted using electronic databases MEDLINE/PubMed, Google Scholar and Scopus to review risk factors and preventive strategies for SGA. Current evidence shows that primiparity, previous stillbirths, maternal age ≤24 and ≥35 years, single motherhood, low socio-economic status, smoking and cannabis use during pregnancy confer a significant risk of SGA births. Studies on alcohol consumption during pregnancy and SGA birth weight are inconclusive. Beneficial and preventive factors include the "Mediterranean diet" and dietary intake of vegetables. Periconceptional folic acid supplementation, maternal 25-hydroxyvitamin D, zinc and iron levels are partly associated with birth weight. No significant associations between COVID-19 vaccinations and birthweight are reported. A midwifery-led model based on early and extensive prenatal care reduces the risk of SGA births in women with low socio-economic status. Major preventive measures relate to the awareness of modifiable and non-modifiable risk factors of SGA, leading to changes in parents' lifestyles. These data support that education, monitoring during pregnancy, and implementing preventive strategies are as important as biological determinants in risk reduction of SGA births.

Impact of a package of health, nutrition, psychosocial support, and WaSH interventions delivered during preconception, pregnancy, and early childhood periods on birth outcomes and on linear growth at 24 months of age: factorial, individually randomised controlled trial

OBJECTIVE

To determine the effect of integrated and concurrent delivery of health, nutrition, water, sanitation and hygiene (WaSH), and psychosocial care interventions during the preconception period alone, during pregnancy and early childhood, and throughout preconception, pregnancy, and early childhood on birth outcomes and linear growth at 24 months of age compared with routine care.

DESIGN

Individually randomised factorial trial.

SETTING

Low and middle income neighbourhoods of Delhi, India.

PARTICIPANTS

13 500 women were randomised to receive preconception interventions (n=6722) or routine care (n=6778). 2652 and 2269 pregnant women were randomised again to receive pregnancy and early childhood interventions or routine care. The analysis of birth outcomes included 1290 live births for the preconception, pregnancy, and early childhood interventions (group A), 1276 for the preconception intervention (group B), 1093 for the pregnancy and early childhood interventions (group C), and 1093 for the control (group D). Children aged 24 months by 30 June 2021 were included in the 24 month outcome analysis (453 in group A, 439 in B, 293 in C, and 271 in D).

INTERVENTIONS

Health, nutrition, psychosocial care and support, and WaSH interventions were delivered during preconception, pregnancy, and early childhood periods.

MAIN OUTCOME MEASURES

The primary outcomes were low birth weight, small for gestational age, preterm, and mean birth weight. At 24 months, the outcomes were mean length-for-age z scores and proportion stunted. Three prespecified comparisons were made: preconception intervention groups (A+B) versus no preconception intervention groups (C+D); pregnancy and early childhood intervention groups (A+C) versus routine care during pregnancy and early childhood (B+D) and preconception, pregnancy, and early childhood interventions groups (A) versus control group (D).

RESULTS

The proportion with low birth weight was lower in the preconception intervention groups (506/2235) than in the no preconception intervention groups (502/1889; incidence rate ratio 0.85, 98.3% confidence interval 0.75 to 0.97; absolute risk reduction -3.80%, 98.3% confidence interval -6.99% to -0.60%). The proportion with low birth weight was lower in the pregnancy intervention groups (502/2096) than in the no pregnancy intervention groups (506/2028) but the upper limit of the confidence interval crossed null effect (0.87, 0.76 to 1.01; -1.71%, -4.96% to 1.54%). There was a larger effect on proportion with low birth weight in the group that received interventions in the preconception and pregnancy periods (267/1141) compared with the control group (267/934; 0.76, 0.62 to 0.91; -5.59%, -10.32% to -0.85%). The proportion stunted at 24 months of age was substantially lower in the pregnancy and early childhood intervention groups (79/746) compared with the groups that did not receive these interventions (136/710; 0.51, 0.38 to 0.70; -8.32%, -12.31% to -4.32%), and in the group that received preconception, pregnancy, and early childhood interventions (47/453) compared with the control group (51/271; 0.49, 0.32 to 0.75; -7.98%, -14.24% to -1.71%). No effect on stunting at 24 months was observed in the preconception intervention groups (132/892) compared with the no preconception intervention groups (83/564).

CONCLUSIONS

An intervention package delivered during preconception, pregnancy, and early childhood substantially reduced low birth weight and stunting at 24 months. Pregnancy and early childhood interventions alone had lower but important effects on birth outcomes and 24 month outcomes. Preconception interventions alone had an important effect on birth outcomes but not on 24 month outcomes.

TRIAL REGISTRATION

Clinical Trial Registry-India CTRI/2017/06/008908.

Effectiveness of nutritional supplementation during the first 1000-days of life to reduce child undernutrition: A cluster randomized controlled trial in Pakistan

Background

Childhood stunting can start in the womb and continue for two years. Therefore, the first 1000 days of life between a woman's pregnancy and her child's 2nd birthday offer a unique window of opportunity to build healthier and more prosperous futures. Therefore, we aimed to assess the effectiveness of nutritional supplementation during the first 1000-days to reduce the prevalence of stunting in children at 24 months of age.

Methods

In this cluster randomized controlled trial, we enrolled women during their pregnancy from two rural districts of Sindh, Pakistan. A cluster was one union council with a population of ∼25000 residents. Out of 29 clusters, we randomly allocated 6 clusters to the intervention and control groups each. Pregnant women received a monthly supply of 5 kg (i.e., 165 grams/day) of wheat soya blend plus (WSB+) during pregnancy and the first six months of their lactation period. In addition, their children received lipid-based nutrient supplement - medium-quantity (LNS-MQ) between 6-23 months of age. The primary outcome was a reduction in the prevalence of stunting in children at 24 months of age. Analysis was an intention to treat. The trial is registered on ClinicalTrial.gov, number NCT02422953.

Findings

Two thousand thirty pregnant women (1017 in the intervention group and 1013 in the control group) were enrolled between August 30, 2014, and May 25, 2016. Monthly follow-ups were conducted between October 1, 2014, and October 25, 2018. At 24 months of age, we captured data from 699 (78%) of 892 live births in the intervention group and 653 (76%) of 853 live births in the control group. There was a significant difference in mean length (49.4 cm vs 48.9 cm, p =0.027), weight (3.1 kg vs 3.0 kg, p =0.013), length for age z-scores (-1.2 vs -1.5, p =0.004) and weight for age z-scores (-1.2 vs -1.5, p =0.015) among infants in the intervention compared to control group. At 24 months of age, a significant difference in the prevalence of stunting (absolute difference, 10.2%, 95% CI 18.2 to 2.3, p =0.017) and underweight (absolute difference, 13.7%, 95% CI 20.3 to 7.0, p =0.001) were observed in the intervention as compared to the control group. The prevalence of wasting was not significantly different between the intervention and control groups (absolute difference, 6.9%, 95% CI 14.1 to 0.3, p =0.057).

Interpretation

Provision of WSB+ and LNS-MQ during the first 1000-days of life improved child linear growth and reduced stunting in children at 24 months. This study can be scaled-up in similar settings to lower the prevalence of stunting in children under two years of age.

Funding

World Food Programme, Pakistan.

The effect of snakehead fish (Channa striata) cookies supplementation on fetal growth and birth outcomes: A randomized clinical trial

BACKGROUND: An estimated 15–20% of all births worldwide are low birth weight (LBW). In Indonesia, the LBW incidence reached more than 10% in 2013. Improved maternal nutrition is needed by providing high-calorie-protein supplementation for pregnant women to prevent intrauterine growth retardation and LBW. OBJECTIVES: To observe the effect of snakehead fish (Channa striata) cookies supplementation during pregnancy on fetal growth and birth outcomes. METHODS: A total of 50 pregnant women were included in this randomized controlled trial study and were randomly allocated into two groups: treatment and controls. Subjects in the treatment group received supplementation of snakehead fish cookies during pregnancy until giving birth as much as 75 g per day, while subjects in the control group received standard cookies. The snakehead fish cookies underwent a formulation process and were tested for nutrient content and microbial contamination to ensure safety before being given to the subjects. Fetal growth was monitored monthly using 2-dimensional ultrasonography. RESULTS: The average intake of cookies did not differ between the two groups (Control 69.6 (16.8)% vs Snakehead fish 64.6 (15.3)%, p = 0.278). There were no significant differences in fetal estimated fetal weight, biparietal diameter, abdominal circumference, femur length, birth weight, and birth length between the treatment and control groups (p >  0.05). However, the fetal growth measurements on the subjects who consumed snakehead fish cookies were practically higher than those who ate standard cookies. CONCLUSION: The snakehead fish cookies did improve the fetal growth measurements but the results were not significantly different when compared to standard cookies.

Acceptability of 11 fortified balanced energy-protein supplements for pregnant women in Nepal

Evidence suggests that multiple micronutrient and balanced energy protein (BEP) supplementation during pregnancy can decrease the risk of stillbirth and small-for-gestational-age births and increase birth weight. We conducted a mixed-methods formative research study to identify the most acceptable among a range of 11 candidates fortified BEP supplements for use in pregnancy and lactation in a rural district in Nepal. Forty pregnant women aged 15-40 years participated in a test meal tasting of 11 different sweet and savoury candidate BEP supplements. Each participant rated the products on organoleptic properties using a 7-point hedonic scale (1 = Dislike it very much to 7 = Like it very much), ranked her 'top 3' most liked supplements, and subsequently discussed each product with peers in focus group discussions (FGDs). Five supplements (sweet lipid-based nutrient supplement (LNS), savoury LNS, sweet vanilla biscuits, vanilla instant drinks and seasoned pillows) achieved the maximum overall median hedonic score of 7, with sweet LNS and seasoned pillows ranking as the top 2. This was consistent with the assessments in FGDs. Women in the FGDs expressed dislike of the smell and taste of the cocoa drink, savoury masala bar, sweet mango bar and savoury curry biscuit, which was consistent with the hedonic scale scores. This study provides valuable insights into our understanding of women's acceptance of different BEP supplements during pregnancy in rural Nepal and has helped identify the two most accepted BEP supplements to be used in a two-month home trial to assess utilisation and compliance in this setting.

Energy Intake and Food Restriction as Determinant Factors of Chronic Energy Deficiency among Pregnant Women in Rural Area of Sungai Sembilan, Riau, Indonesia

BACKGROUND OF THE STUDY: Maternal malnutrition is a major public health problem in Indonesia which is shown by high prevalence of chronic energy deficiency (CED) among pregnant women. CED was expressed by the measurement of Mid Upper Arm Circumference (MUAC) showing value less than 23.5 cm. AIM OF THE STUDY: This study aimed to identify the factors associated with chronic energy deficiency among pregnant women in rural area, Riau Province. METHODOLOGY: A community- based cross sectional study was conducted among 130 samples of pregnant women in Sungai Sembilan Community Health Center in June 2020. Data was collected using structured and field-study questionnaires. Mid Upper Arm Circumference (MUAC) was measured by MUAC tape. Energy and protein intake were assessed using 24-hour food recall. Multiple logistic regression was employed to analyse factors associated with CED by using SPSS version 20. RESULTS: The prevalence of CED among pregnant women was 64.9%. Age of mothers, food restriction, infection disease status, protein and energy intake were associated significantly with CED. Furthermore, energy intake and food restriction in pregnancy were risk factors of CED (AOR = 3.04, 95% CI: 1.1 – 8.3 and AOR = 6.73, 95% CI: 1.33 – 33.9, respectively). We found that proportion of energy intake below 80% RDA and mothers with food restriction were higher among CED group. CONCLUSION: High prevalence of chronic energy deficiency (CED) was found among pregnant women. Hence, innovative intervention was required to overcome this problem.

Compliance with and acceptability of two fortified balanced energy protein supplements among pregnant women in rural Nepal

Some evidence suggests that balanced energy protein (BEP) supplements taken during pregnancy and lactation can have positive effects on birth outcomes such as small‐for‐gestational age and birthweight, but more evidence is needed on the long‐term use and acceptability of such supplements. We conducted a mixed‐methods formative research study to assess and compare compliance with and acceptability of two BEP supplements, a lipid‐based peanut paste and a biscuit, to identify BEP supplements for subsequent inclusion in an efficacy trial. We conducted an 8‐week feeding trial of daily supplementation among two groups of 40 pregnant women each in rural Nepal. Compliance data were collected and supplements distributed at the weekly visits. Sensory properties of the supplements were assessed using a 7‐point Likert scale. In addition, in‐depth interviews with women (n = 16), family members (n = 6) and health workers (n = 6) and focus group discussions (FGDs) (n = 4) were conducted to explore themes related to general use and intention of future use of the supplement. Overall self‐reported compliance was high: medians of 91.1% in the lipid‐based peanut paste group and 96.4% in the biscuit group. Both supplements were rated highly on overall likability (median score 6/7) and sensory properties. Qualitative findings showed that sustained use of the supplements was attributed to expected health benefits, favourable sensory attributes, and family support. The FGDs suggested providing the option to choose between more than one type/flavour of supplements to improve compliance. Sharing was mostly evident in the first week with higher sharing reported in the biscuit group.

Both the lipid‐based peanut paste and the vanilla biscuit were well accepted by pregnant women in rural Nepal during an 8‐week home feeding trial.

The compliance measurements showed high overall compliance in both supplement groups with the reasons being the perceived health benefits to the mother and baby, favourable sensory properties, enabling environment at home for product consumption (privacy and family support) and ease of product use.

Before an efficacy trial of a nutritional food supplement, it is important to conduct a mixed‐methods feeding trial in the study population to understand the contextual factors that enable and prevent the use of supplements to inform ways to improve compliance with the supplements.

Cost-effectiveness of antenatal multiple micronutrients and balanced energy protein supplementation compared to iron and folic acid supplementation in India, Pakistan, Mali, and Tanzania: A dynamic microsimulation study

BACKGROUND

Malnutrition among women of childbearing age is especially prevalent in Asia and sub-Saharan Africa and can be harmful to the fetus during pregnancy. In the most recently available Demographic and Health Survey (DHS), approximately 10% to 20% of pregnant women in India, Pakistan, Mali, and Tanzania were undernourished (body mass index [BMI] <18.5 kg/m2), and according to the Global Burden of Disease (GBD) 2017 study, approximately 20% of babies were born with low birth weight (LBW; <2,500 g) in India, Pakistan, and Mali and 8% in Tanzania. Supplementing pregnant women with micro and macronutrients during the antenatal period can improve birth outcomes. Recently, the World Health Organization (WHO) recommended antenatal multiple micronutrient supplementation (MMS) that includes iron and folic acid (IFA) in the context of rigorous research. Additionally, WHO recommends balanced energy protein (BEP) for undernourished populations. However, few studies have compared the cost-effectiveness of different supplementation regimens. We compared the cost-effectiveness of MMS and BEP with IFA to quantify their benefits in 4 countries with considerable prevalence of maternal undernutrition.

METHODS AND FINDINGS

Using nationally representative estimates from the 2017 GBD study, we conducted an individual-based dynamic microsimulation of population cohorts from birth to 2 years of age in India, Pakistan, Mali, and Tanzania. We modeled the effect of maternal nutritional supplementation on infant birth weight, stunting and wasting using effect sizes from Cochrane systematic reviews and published literature. We used a payer's perspective and obtained costs of supplementation per pregnancy from the published literature. We compared disability-adjusted life years (DALYs) and incremental cost-effectiveness ratios (ICERs) in a baseline scenario with existing antenatal IFA coverage with scenarios where 90% of antenatal care (ANC) attendees receive either universal MMS, universal BEP, or MMS + targeted BEP (women with prepregnancy BMI <18.5 kg/m2 receive BEP containing MMS while women with BMI ≥18.5 kg/m2 receive MMS). We obtained 95% uncertainty intervals (UIs) for all outputs to represent parameter and stochastic uncertainty across 100 iterations of model runs. ICERs for all scenarios were lowest in Pakistan and greatest in Tanzania, in line with the baseline trend in prevalence of and attributable burden to LBW. MMS + targeted BEP averts more DALYs than universal MMS alone while remaining cost-effective. ICERs for universal MMS compared to baseline IFA were $52 (95% UI: $28 to $78) for Pakistan, $72 (95% UI: $37 to $118) for Mali, $70 (95% UI: $43 to $104) for India, and $253 (95% UI: $112 to $481) for Tanzania. ICERs for MMS + targeted BEP compared to baseline IFA were $54 (95% UI: $32 to $77) for Pakistan, $73 (95% UI: $40 to $104) for Mali, $83 (95% UI: $58 to $111) for India, and $245 (95% UI: $127 to $405) for Tanzania. Study limitations include generalizing experimental findings from the literature to our populations of interest and using population-level input parameters that may not reflect the heterogeneity of subpopulations. Additionally, our microsimulation fuses multiple sources of data and may be limited by data quality and availability.

CONCLUSIONS

In this study, we observed that MMS + targeted BEP averts more DALYs and remains cost-effective compared to universal MMS. As countries consider using MMS in alignment with recent WHO guidelines, offering targeted BEP is a cost-effective strategy that can be considered concurrently to maximize benefits and synergize program implementation.

Prenatal supplementation with multiple micronutrient supplements or medium-quantity lipid-based nutrient supplements has limited effects on child growth up to 24 months in rural Niger: a secondary analysis of a cluster randomized trial

BACKGROUND

Prenatal multiple micronutrient supplementation (MMS) and lipid-based nutrient supplementation (LNS) can improve birth outcomes relative to iron-folic acid supplementation (IFA); however, effects on child postnatal growth remain unclear.

OBJECTIVES

The aim was to compare the effect of prenatal MMS, medium-quantity LNS (MQ-LNS), and IFA on child growth up to 2 y of age.

METHODS

We conducted a cluster randomized controlled trial of prenatal nutritional supplementation in Madarounfa, Niger. Villages were randomly assigned for pregnant women to receive IFA (17 villages, 1105 women), MMS (18 villages, 1083 women) or MQ-LNS (18 villages, 1144 women). Pregnant women received nutritional supplements weekly until delivery, and children were followed up monthly from 6-8 wk to 24 mo of age. We assessed the effect of prenatal MMS and MQ-LNS compared with IFA and the effect of prenatal MMS compared with MQ-LNS on child length-for-age z scores (LAZ), weight-for-age z scores (WAZ), and weight-for-length z scores (WLZ) at 24 mo of age using generalized linear models. In secondary analyses, we used mixed-effects models to assess the trajectories of anthropometric z scores longitudinally from 6-8 wk to 24 mo.

RESULTS

Compared with IFA, MMS and MQ-LNS had no effect on child LAZ, WAZ, or WLZ at 24 mo of age (P > 0.05). Children in the MQ-LNS arm had significantly higher mid-upper arm circumference at 24 mo than children in the MMS arm: mean difference 0.50 cm (95% CI 0.10, 0.91 cm). WAZ and WLZ trajectories were more negative in the MQ-LNS arm compared with IFA and MMS, with lower z scores from 14 to 20 mo of age. However, WAZ and WLZ trajectories converged after 20 mo of age, and there were no differences by 24 mo of age.

CONCLUSIONS

Prenatal MMS and MQ-LNS had limited effect on anthropometric measures of child growth up to 24 mo of age as compared with IFA in rural Niger.

Fortified Balanced Energy-Protein Supplements Increase Nutrient Adequacy without Displacing Food Intake in Pregnant Women in Rural Burkina Faso

BACKGROUND

In many low- and middle-income countries, the prevalence of energy and nutrient deficiencies is high among pregnant women. Balanced energy-protein (BEP) supplements are a promising strategy to cover nutritional requirements during pregnancy and improve birth outcomes. However, the displacement of nutrient-dense foods by BEP might attenuate the efficacy of supplementation.

OBJECTIVE

This cross-sectional study of participants in a randomized controlled trial evaluated the difference in energy and macro- and micronutrient intakes, food groups, and nutrient adequacy between a control and intervention group receiving either a daily iron-folic acid (IFA) tablet or IFA and BEP supplement during pregnancy, respectively.

METHODS

We collected a single multiple-pass 24-h recall from 470 pregnant women from the MIcronutriments pour la SAnté de la Mère et de l'Enfant (MISAME) III study that investigates the efficacy of BEP supplementation on birth outcomes and infant growth. Dietary intake (median and IQR) and nutrient adequacy were assessed using individual recipes and preparation methods of mixed dishes for each participant. Linear regression models were fitted to compare energy and nutrient intakes.

RESULTS

Dietary energy, and macro- and micronutrient intakes were significantly higher among women in the intervention group when including BEP [2329 kcal/d (1855, 3008 kcal/d) compared with 1942 kcal/d (1575, 2405 kcal/d) in the control group (all P < 0.001)]. The difference in median energy intake (448 kcal/d; 95% CI: 291, 605 kcal/d) was approximately equivalent to a daily dose of the BEP supplement (393 kcal). Nutrient adequacy ratios for both groups were low for all micronutrients (between 0.02 and 0.66), when excluding BEP (except iron and folic acid, due to standard supplemental doses) from analysis. However, nutrient intakes increased to the Estimated Average Requirement for pregnant women when including BEP supplements.

CONCLUSIONS

BEP supplementation increases energy and macro- and micronutrient intakes among pregnant women and fills nutrient gaps without displacing food intake. This trial was registered at clinicaltrials.gov as NCT03533712 (https://clinicaltrials.gov/ct2/show/NCT03533712).

Maternal-focused interventions to improve infant growth and nutritional status in low-middle income countries: A systematic review of reviews

BACKGROUND

Small and nutritionally at-risk infants under 6 months (<6m) are a vulnerable group at increased risk of mortality, morbidity, poor growth and sub-optimal development. Current national and international (World Health Organization) management guidelines focus mainly on infants' needs, yet growing evidence suggests that maternal factors also influence infant outcomes. We aimed to inform future guidelines by exploring the impacts of maternal-focused interventions on infant feeding and growth.

METHODS

We conducted a systematic review of reviews published since 2008 (PROSPERO, register number CRD 42019141724). We explored five databases and a wide variety of maternal-focused interventions based in low- and middle-income countries. Infant outcomes of interest included anthropometric status, birthweight, infant mortality, breastfeeding and complementary feeding practices. Given heterogenous interventions, we present a narrative synthesis of the extracted data.

RESULTS

We included a total of 55 systematic reviews. Numerous maternal interventions were effective in improving infant growth or feeding outcomes. These included breastfeeding promotion, education, support and counselling interventions. Maternal mental health, while under-researched, showed potential to positively impact infant growth. There was also some evidence for a positive impact of: women's empowerment, m-health technologies, conditional cash transfers, water, sanitation and hygiene and agricultural interventions. Effectiveness was increased when implemented as part of a multi-sectoral program. Antenatal supplementation with macronutrient, multiple micronutrients, Vitamin D, zinc, iron folic acid and possibly calcium, iodine and B12 in deficient women, improved birth outcomes. In contrast, evidence for postnatal supplementation was limited as was evidence directly focusing on small and nutritionally at-risk infants; most reviews focused on the prevention of growth faltering.

CONCLUSION

Our findings suggest sufficient evidence to justify greater inclusion of mothers in more holistic packages of care for small and nutritionally at-risk infants aged <6m. Context specific approaches are likely needed to support mother-infant dyads and ensure infants survive and thrive.

Maternal Serum Albumin Redox State Is Associated with Infant Birth Weight in Japanese Pregnant Women

Background: Plasma albumin (ALB) reflects protein nutritional status in rats, but it is not clear whether it is associated with dietary protein insufficiency in pregnant women and/or their risk of low birth weight delivery. This study aimed to investigate whether maternal serum ALB redox state reflects maternal protein nutritional status and/or is associated with infant birth weights. Methods: The relationship between the serum reduced ALB ratio and infant birth weight was examined in an observational study of 229 Japanese pregnant women. A rat model simulating fetal growth restriction, induced by protein-energy restriction, was used to elucidate the relationship between maternal nutritional status, maternal serum ALB redox state, and birth weight of the offspring. Results: In the human study, serum reduced ALB ratio in the third trimester was significantly and positively correlated with infant birth weight. In the rat study, serum reduced ALB ratio and birth weight in the litter decreased as the degree of protein-energy restriction intensified, and a significant and positive correlation was observed between them in late pregnancy. Conclusions: Maternal serum reduced ALB ratio in the third trimester is positively associated with infant birth weight in Japanese pregnant women, which would be mediated by maternal protein nutritional status.

Mobilising evidence, data, and resources to achieve global maternal and child undernutrition targets and the Sustainable Development Goals: an agenda for action

As the world counts down to the 2025 World Health Assembly nutrition targets and the 2030 Sustainable Development Goals, millions of women, children, and adolescents worldwide remain undernourished (underweight, stunted, and deficient in micronutrients), despite evidence on effective interventions and increasing political commitment to, and financial investment in, nutrition. The COVID-19 pandemic has crippled health systems, exacerbated household food insecurity, and reversed economic growth, which together could set back improvements in undernutrition across low-income and middle-income countries. This paper highlights how the evidence base for nutrition, health, food systems, social protection, and water, sanitation, and hygiene interventions has evolved since the 2013 Lancet Series on maternal and child nutrition and identifies the priority actions needed to regain and accelerate progress within the next decade. Policies and interventions targeting the first 1000 days of life, including some newly identified since 2013, require renewed commitment, implementation research, and increased funding from both domestic and global actors. A new body of evidence from national and state-level success stories in stunting reduction reinforces the crucial importance of multisectoral actions to address the underlying determinants of undernutrition and identifies key features of enabling political environments. To support these actions, well-resourced nutrition data and information systems are essential. The paper concludes with a call to action for the 2021 Nutrition for Growth Summit to unite global and national nutrition stakeholders around common priorities to tackle a large, unfinished undernutrition agenda-now amplified by the COVID-19 crisis.

Effect of balanced energy-protein supplementation during pregnancy and lactation on birth outcomes and infant growth in rural Burkina Faso: study protocol for a randomised controlled trial

INTRODUCTION

Adequate nutrition during pregnancy is crucial to both mother and child. Maternal malnutrition can be the cause of stillbirth or lead to poor birth outcomes such as preterm delivery and small-for-gestational-age newborns. There is a probable positive effect of providing pregnant women a balanced energy-protein (BEP) food supplement, but more evidence is needed. The MIcronutriments pour la SAnté de la Mère et de l'Enfant (MISAME) III project aims to improve birth outcomes and infant growth by testing a BEP supplement during pregnancy and lactation in rural Burkina Faso. This paper describes the study protocol.

METHODS AND ANALYSIS

MISAME-III is a four-arm individually randomised efficacy trial implemented in six rural health centre catchments areas in the district of Houndé. Eligible pregnant women, aged between 15 and 40 years old and living in the study areas, will be enrolled. Women will be randomly assigned to one of the four study groups: (1) prenatal intervention only, (2) postnatal intervention only, (3) prenatal and postnatal intervention or (4) no prenatal or postnatal intervention. The intervention group will receive the BEP supplement and iron/folic acid (IFA) tablets, while the control group will only receive the IFA tablets following the national health protocol. Consumption will be supervised by trained village women on a daily basis by means of home visits. The primary outcomes are small-for-gestational age at birth and length-for-age z-score at 6 months of age. Secondary outcomes will be measured at birth and during the first 6 months of the infants' life. Women will be enrolled from October 2019 until the total sample size is reached.

ETHICS AND DISSEMINATION

MISAME-III has been reviewed and approved by the University Hospital of Ghent and the ethics committee of Centre Muraz, Burkina Faso. Informed consent will be obtained. Results will be published in relevant journals and shared with other researchers and public health institutions.

TRIAL REGISTRATION NUMBER

NCT03533712.

Home consumption of two fortified balanced energy protein supplements by pregnant women in Burkina Faso

Balanced energy protein (BEP) supplementation for pregnant and lactating women in low‐ and middle‐income countries is a promising strategy to improve birth outcomes and child growth. The objective of this study was to assess and compare the acceptability of new formulations of two fortified BEP supplements, a lipid‐based peanut paste and a vanilla biscuit, among 80 pregnant women in rural Burkina Faso, prior to an efficacy trial. A 10‐week individually randomized cross‐over study was designed, in which women received a weekly supply of each supplement for 4 weeks, and a daily choice between the supplements in the last 2 weeks. Questionnaires to assess daily consumption and supplement acceptability (n = 80) and home observations (n = 20) were combined with focus group discussions (n = 6) and in‐depth interviews with women (n = 80) and stakeholders (n = 24). Results showed that the two supplements were well accepted. Quantitative findings indicated high compliance (>99.6%) and high overall appreciation (Likert score >6 out of 7) of both supplements. The assessment of preferred choice in Weeks 9 and 10 indicated a slight preference for the vanilla biscuit. Qualitative findings indicated that perceived health benefits, support from household members and educational messages from health professionals were important drivers for acceptance and compliance. Sharing was not often reported but was identified during interviews as a possible risk. We recommend that future studies use a combination of methods to identify appropriate food supplements and context‐specific factors that influence acceptability, compliance and subsequent impact of nutritious food supplements.

The Intergenerational Effects of Intimate Partner Violence in Pregnancy: Mediating Pathways and Implications for Prevention

Prenatal intimate partner violence (P-IPV) can have significant adverse impacts on both mother and fetus. Existing P-IPV interventions focus on the safety of the mother and on reducing revictimization; yet expanding these to address the adverse impact on the fetus has considerable potential for preventing long-term negative developmental outcomes. In this review, we draw together evidence on major pathways linking exposure to P-IPV and child outcomes, arguing that these pathways represent potential targets to improve P-IPV intervention efforts. Using a narrative review of 112 articles, we discuss candidate pathways linking P-IPV to child outcomes, as well as their implications for intervention. Articles were identified via key word searches of social science and medical databases and by inspection of reference lists of the most relevant articles, including recent reviews and meta-analyses. Articles were included if they addressed issues relevant to understanding the effects of P-IPV on child outcomes via six core pathways: maternal stress and mental illness, maternal-fetal attachment, maternal substance use, maternal nutritional intake, maternal antenatal health-care utilization, and infection. We also included articles relevant for linking these pathways to P-IPV interventions. We conclude that developing comprehensive P-IPV interventions that target immediate risk to the mother as well as long-term child outcomes via the candidate mediating pathways identified have significant potential to help reduce the global burden of P-IPV.

Mega-map of systematic reviews and evidence and gap maps on the interventions to improve child well-being in low- and middle-income countries

BACKGROUND

Despite a considerable reduction in child mortality, nearly six million children under the age of five die each year. Millions more are poorly nourished and in many parts of the world, the quality of education remains poor. Children are at risk from multiple violations of their rights, including child labour, early marriage, and sexual exploitation. Research plays a crucial role in helping to close the remaining gaps in child well-being, yet the global evidence base for interventions to meet these challenges is mostly weak, scattered and often unusable by policymakers and practitioners. This mega-map encourages the generation and use of rigorous evidence on effective ways to improve child well-being for policy and programming.

OBJECTIVES

The aim of this mega-map is to identify, map and provide an overview of the existing evidence synthesis on the interventions aimed at improving child well-being in low- and middle-income countries (LMICs).

METHODS

Campbell evidence and gap maps (EGMs) are based on a review of existing mapping standards (Saran & White, 2018) which drew in particular of the approach developed by 3ie (Snilstveit, Vojtkova, Bhavsar, & Gaarder, 2013). As defined in the Campbell EGM guidance paper; "Mega-map is a map of evidence synthesis, that is, systematic reviews, and does not include primary studies" (Campbell Collaboration, 2020). The mega-map on child well-being includes studies with participants aged 0-18 years, conducted in LMICs, and published from year 2000 onwards. The search followed strict inclusion criteria for interventions and outcomes in the domains of health, education, social work and welfare, social protection, environmental health, water supply and sanitation (WASH) and governance. Critical appraisal of included systematic reviews was conducted using "A Measurement Tool to Assess Systematic Reviews"-AMSTAR-2 rating scale (Shea, et al., 2017).

RESULTS

We identified 333 systematic reviews and 23 EGMs. The number of studies being published has increased year-on-year since 2000. However, the distribution of studies across World Bank regions, intervention and outcome categories are uneven. Most systematic reviews examine interventions pertaining to traditional areas of health and education. Systematic reviews in these traditional areas are also the most funded. There is limited evidence in social work and social protection. About 69% (231) of the reviews are assessed to be of low and medium quality. There are evidence gaps with respect to key vulnerable populations, including children with disabilities and those who belong to minority groups.

CONCLUSION

Although an increasing number of systematic reviews addressing child well-being topics are being published, some clear gaps in the evidence remain in terms of quality of reviews and some interventions and outcome areas. The clear gap is the small number of reviews focusing explicitly on either equity or programmes for disadvantaged groups and those who are discriminated against.

Interventions to improve birth outcomes of pregnant women living in low- and middle-income countries: a systematic review and network meta-analysis

Background: Improving the health of pregnant women is important to prevent adverse birth outcomes, such as preterm birth and low birthweight. We evaluated the comparative effectiveness of interventions under the domains of micronutrient, balanced energy protein, deworming, maternal education, and water sanitation and hygiene (WASH) for their effects on these adverse birth outcomes. Methods: For this network meta-analysis, we searched for randomized clinical trials (RCTs) of interventions provided to pregnant women in low- and middle-income countries (LMICs). We searched for reports published until September 17, 2019 and hand-searched bibliographies of existing reviews. We extracted data from eligible studies for study characteristics, interventions, participants' characteristics at baseline, and birth outcomes. We compared effects on preterm birth (<37 gestational week), low birthweight (LBW; <2500 g), and birthweight (continuous) using studies conducted in LMICs. Results: Our network meta-analyses were based on 101 RCTs (132 papers) pertaining to 206,531 participants. Several micronutrients and balanced energy food supplement interventions demonstrated effectiveness over standard-of-care. For instance, versus standard-of-care, micronutrient supplements for pregnant women, such as iron and calcium, decreased risks of preterm birth (iron: RR=0.70, 95% credible interval [Crl] 0.47, 1.01; calcium: RR=0.76, 95%Crl 0.56, 0.99). Daily intake of 1500kcal of local food decreased the risks of preterm birth (RR=0.36, 95%Crl 0.16, 0.77) and LBW (RR=0.17, 95%Crl 0.09, 0.29), respectively when compared to standard-of-care. Educational and deworming interventions did not show improvements in birth outcomes, and no WASH intervention trials reported on these adverse birth outcomes. Conclusion: We found several pregnancy interventions that improve birth outcomes. However, most clinical trials have only evaluated interventions under a single domain (e.g. micronutrients) even though the causes of adverse birth outcomes are multi-faceted. There is a need to combine interventions that of different domains as packages and test for their effectiveness. Registration: PROSPERO CRD42018110446; registered on 17 October 2018.

Effect of maternal prenatal food supplementation, gestational weight gain, and breast-feeding on infant growth during the first 24 months of life in rural Vietnam

Growth faltering among children during the first five years of life is a common problem among low and middle-income countries. The purpose of this study was to determine the effect of a nutrient-rich, food-based supplement given to Vietnamese rural women prior to and/or during pregnancy on the growth of their infants during first 24 months of life and to identify maternal and newborn factors associated with the infant’s growth. This prospective cohort study included 236 infants born to mothers who had received nutritional advice or a food supplement from pre-conception to term or from mid-gestation to term as part of a prior randomized controlled trial. Infant anthropometry and feeding information were monitored monthly and the infant weight for age Z-score (WAZ), length for age Z-score (LAZ), and weight for length Z-score (WLZ) were assessed at 6, 12, 18, and 24 months of age using mixed-effects regression modeling. Compared to the non-supplemented mothers, infants born to mothers receiving food supplementation from mid-gestation to term had significantly higher WLZ only at 18 months (p = 0.03) and did not differ in other outcomes. Supplementation from pre-conception to term did not affect infant growth at any time point during the first 24 months. In the entire study cohort, maternal height and gestational weight gain were positively associated with the infant’s WAZ and LAZ from 6 to 24 months of age. Programs designed to improve gestational weight gain among women performing demanding physical work throughout a reproductive cycle may improve postnatal infant growth.

Trial registration: Registered Clinical Trials.Gov: NCT01235767.

Effectiveness of wheat soya blend supplementation during pregnancy and lactation on pregnancy outcomes and nutritional status of their infants at 6 months of age in Thatta and Sujawal districts of Sindh, Pakistan: a cluster randomized-controlled trial

PURPOSE

We aimed to assess the effectiveness of wheat soya blend plus (WSBP) provided during pregnancy and lactation on weight gain during pregnancy, reduction of low birthweight (LBW), and improvement in nutritional status in infants at 6 months of age in Thatta and Sujawal districts of Sindh, Pakistan.

METHODS

A cluster randomized-controlled trial was conducted in Thatta and Sujawal districts in Pakistan from August 2014 to December 2016. A total of 2030 pregnant women were enrolled in the study. These women and their infants were followed during pregnancy and first 6 months of life. Pregnant women received a monthly ration of 5 kg (i.e., 165 g/day) of WSB + during pregnancy and the first 6 months of their lactation period.

RESULTS

There was no difference in weight gain during pregnancy between the intervention and control groups (n = 496, 326.7 g/week 95% CI 315.2-338.1 vs. (n = 507, 306.9 g/week, 95% CI 279.9-333.9 P = 0.192), after adjustment with different factors. The reduction in the prevalence of LBW was not different between intervention and control groups (n = 325, 34.0%, 95% CI 31.7-36.4, vs. (n = 127, 34.3%, 95% CI 27.2-41.5, P = 0.932). Significant reductions in risk of stunting (n = 1319 RR 0.85, 95% CI 0.73-0.99, P = 0.041), wasting (n = 1330 RR 0.77, 95% CI 0.65-0.91, P = 0.003), and underweight (n = 1295 RR 0.77, 95% CI 0.69-0.87, P < 0.001) were observed in infants at 6 months of age in the intervention as compared to the control group. However, no difference was noted on reduction in the risk of stunting among infants at 6 months of age in the intervention and control group (n = 1318 RR 0.91, 95% CI 0.78-1.07, P = 0.253) after adjustment. A significant reduction in anemia was noted (n = 1328 RR 0.94, 95% CI 0.91-0.98, P = 0.002) in infants at 6 months of age in the intervention as compared to the control group in adjusted analysis.

CONCLUSIONS

Provision of WSB + during pregnancy and the first 6 months of lactation is effective in reducing the risk of under nutrition and anemia in infants at 6 months of age. This study can potentially guide the government and donor agencies in investing in nutritional programmes, especially for pregnant and lactating women living in vulnerable settings.

Clinical Practice Guidelines for Childbearing Female Candidates for Bariatric Surgery, Pregnancy, and Post-partum Management After Bariatric Surgery

Emerging evidence suggests that bariatric surgery improves pregnancy outcomes of women with obesity by reducing the rates of gestational diabetes, pregnancy-induced hypertension, and macrosomia. However, it is associated with an increased risk of a small-for-gestational-age fetus and prematurity. Based on the work of a multidisciplinary task force, we propose clinical practice recommendations for pregnancy management following bariatric surgery. They are derived from a comprehensive review of the literature, existing guidelines, and expert opinion covering the preferred type of surgery for women of childbearing age, timing between surgery and pregnancy, contraception, systematic nutritional support and management of nutritional deficiencies, screening and management of gestational diabetes, weight gain during pregnancy, gastric banding management, surgical emergencies, obstetrical management, and specific care in the postpartum period and for newborns.

Identification of High-Risk Pregnancies in a Remote Setting Using Ambulatory Blood Pressure: The MINDI Cohort

Background: Ambulatory blood pressure is a potential tool for early detection of complications during pregnancy, but its utility in impoverished settings has not been assessed. This cross-sectional study aimed to determine whether maternal infections, nutrient deficiencies and inflammation (MINDI) were associated with four measures of maternal blood pressure (BP) and to determine their association with symphysis-fundal-height (SFH). Methods: Environmental and dietary factors, intake of iron and a multiple-nutrient supplement (MNS), markers of inflammation, protein, anemia, folate, vitamins B₁₂, A and D status, and urogenital, skin, oral and intestinal nematode infections were measured in indigenous pregnant Panamanian women. Stepwise multiple linear and logistic regression models explored determinants of systolic and diastolic blood pressure (SBP, DBP), hypotension (SBP < 100 and DBP < 60), mean arterial pressure (MAP), elevated MAP (eMAP), and pulse pressure (PP). Associations of BP with intestinal nematodes and with SFH Z scores (≥16 wk) were also explored. Results: Despite absence of high SBP or DBP, 11.2% of women had eMAP. Furthermore, 24.1% had hypotension. Linear regression showed that hookworm infection was associated with higher SBP (P = 0.049), DBP (P = 0.046), and MAP (P = 0.016), whereas Ascaris was associated with lower DBP (P = 0.018) and MAP (P = 0.028). Trichomonas was also associated with lower SBP (P < 0.0001) and MAP (P = 0.009). The presence of Trichuris (OR: 6.7, 95% CI 1.0-44.5) and folic acid deficiency (OR: 6.9, 95% CI 1.4-33.8) were associated with increased odds of eMAP. The odds of low BP was higher in the presence of Ascaris (OR: 3.63 ± 2.28, P = 0.040), but odds were lowered by MNS (OR: 0.35 ± 0.11, P = 0.001), more intake of animal-source foods/wk (OR: 0.7, 95% CI 0.5-0.9) and by higher concentrations of IL-17 (OR: 0.87 ± 0.05, P = 0.016). Conclusion: MINDI were bi-directionally associated with blood pressure indicators. In this MINDI cohort, infections, nutrients and cytokines both raised, and lowered BP indices. The presence of eMAP identified pregnant women at risk of hypertension whereas low PP was associated with lower SFH. Therefore, MAP and PP may help in detecting women at risk of adverse pregnancy outcomes in settings with limited access to technology.

Y, Westcott JE, Thorsten VR, Sridhar A, Das A, McClure E, Derman RJ, Goldenberg RL, Koso-Thomas M, Goudar SS, Krebs NF. Preconception nutrition intervention improved birth length and reduced stunting and wasting in newborns in South Asia: The Women First Randomized Controlled Trial

South Asia has >50% of the global burden of low birth weight (LBW). The objective was to determine the extent to which maternal nutrition interventions commenced before conception or in the 1st trimester improved fetal growth in this region. This was a secondary analysis of combined newborn anthropometric data for the South Asian sites (India and Pakistan) in the Women First Preconception Maternal Nutrition Trial. Participants were 972 newborn of mothers who were poor, rural, unselected on basis of nutritional status, and had been randomized to receive a daily lipid-based micronutrient supplement commencing ≥3 months prior to conception (Arm 1), in the 1st trimester (Arm 2), or not at all (Arm 3). An additional protein-energy supplement was provided if BMI <20 kg/m2 or gestational weight gain was less than guidelines. Gestational age was established in the 1st trimester and newborn anthropometry obtained <48-hours post-delivery. Mean differences at birth between Arm 1 vs. 3 were length +5.3mm and weight +89g. Effect sizes (ES) and relative risks (RR) with 95% CI for Arm 1 vs. 3 were: length-for-age Z-score (LAZ) +0.29 (0.11-0.46, p = 0.0011); weight-for-age Z-score (WAZ) +0.22 (0.07-0.37, p = 0.0043); weight-to-length-ratio-for-age Z-score (WLRAZ) +0.27 (0.06-0.48, p = 0.0133); LAZ<-2, 0.56 (0.38-0.82, p = 0.0032); WAZ <-2, 0.68 (0.53-0.88, p = 0.0028); WLRAZ <-2, 0.76 (0.64-0.89, p = 0.0011); small-for-gestational-age (SGA), 0.74 (0.66-0.83, p<0.0001); low birth weight 0.81 (0.66-1.00, p = 0.0461). For Arm 2 vs. 3, LAZ, 0.21 (0.04-0.38); WAZ <-2, 0.70 (0.53-0.92); and SGA, 0.88 (0.79-0.97) were only marginally different. ES or RR did not differ for preterm birth for either Arm 1 vs. 3 or 2 vs. 3. In conclusion, point estimates for both continuous and binary anthropometric outcomes were consistently more favorable when maternal nutrition supplements were commenced ≥3 months prior to conception indicating benefits to fetal growth of improving women's nutrition in this population.

Stunting: an overlooked problem in Myanmar – an economic evaluation

Objectives

Stunting increases a child's susceptibility to diseases, increases mortality, and is associated over long term with reduced cognitive abilities, educational achievement, and productivity. We aimed to assess the most effective public health nutritional intervention to reduce stunting in Myanmar.

Methods

We searched the literature and developed a conceptual framework for interventions known to reduce stunting. We focused on the highest impact and most feasible interventions to reduce stunting in Myanmar, described policies to implement them, and compared their costs and projected effect on stunting using data-based decision trees. We estimated costs from the government perspective and calculated total projected cases of stunting prevented and cost per case prevented (cost-effectiveness). All interventions were compared to projected cases of stunting resulting from the current situation (e.g., no additional interventions).

Results

Three new policy options were identified. Operational feasibility for all three options ranged from medium to high. Compared to the current situation, two were similarly cost-effective, at an additional USD 598 and USD 667 per case of stunting averted. The third option was much less cost-effective, at an additional USD 27,741 per case averted. However, if donor agencies were to expand their support in option three to the entire country, the prevalence of 22.5 percent would be reached by 2025 at an additional USD 667 per case averted.

Conclusions

A policy option involving immediate expansion of the current implementation of proven nutrition-specific interventions is feasible. It would have the highest impact on stunting and would approach the WHO 2025 target.

Maternal nutritional adequacy and gestational weight gain and their associations with birth outcomes among Vietnamese women

Background

During pregnancy, a mother’s nutritional needs increase to meet the added nutrient demands for fetal growth and development. An enhanced understanding of adequate nutrition and sufficient weight gain during pregnancy can guide development of policies and strategies for maternal nutrition care, actions that will ultimately promote better pregnancy outcomes. In a sample of pregnant women in Vietnam, this study characterized maternal nutrition status and gestational weight gain at a mid-pregnancy baseline, then examined the association of these variables with specific birth outcomes.

Methods

The study used baseline data from a randomized, controlled trial that compared pregnant Vietnamese women who received a nutritional intervention group with those who received only standard dietary counseling (control group). At baseline (26–29 weeks gestation), mothers’ dietary reports were collected, and intake of 10 macro- and micronutrients was estimated; data for baseline gestational weight gain was collected for all pregnant women enrolled into the study (n = 228). This analysis also used weights, lengths, and head circumferences at birth for infants of mothers in the control group.

Results

At baseline, 95% of the pregnant women had concurrent inadequacies for more than five nutrients, and nearly half had concurrent inadequacies for more than ten nutrients. Almost two-thirds of the pregnant women did not meet recommendations for gestational weight gain. We found a significant, inverse association between the number of nutrient inadequacies and gestational weight gain (overall p ≤ 0.045). After adjusting for potential confounders, gestational weight gain was positively associated with birth weight, length at birth, birth weight-for-age z-score and length-for-age z-score (all p ≤ 0.006).

Conclusions

Our findings raise concern over the high proportion of pregnant women in Vietnam who have multiple concurrent nutrient inadequacies and who fall short of meeting recommended gestational weight gain standards. To ensure better birth outcomes in this population, policies and strategies to improve the status of maternal nutrition are greatly needed.

Trial registration

The trial was retrospectively registered at clinicaltrials.gov on December 20, 2013, registration identifier: NCT02016586.

Interventions to improve birth outcomes of pregnant women living in low- and middle-income countries: a systematic review and network meta-analysis

Background: Improving the health of pregnant women is important to prevent adverse birth outcomes, such as preterm birth and low birthweight. We evaluated the comparative effectiveness of interventions under the domains of micronutrient, balanced energy protein, deworming, maternal education, and water sanitation and hygiene (WASH) for their effects on these adverse birth outcomes. Methods: For this network meta-analysis, we searched for randomized clinical trials (RCTs) of interventions provided to pregnant women in low- and middle-income countries (LMICs). We searched for reports published until September 17, 2019 and hand-searched bibliographies of existing reviews. We extracted data from eligible studies for study characteristics, interventions, participants' characteristics at baseline, and birth outcomes. We compared effects on preterm birth (<37 gestational week), low birthweight (LBW; <2500 g), and birthweight (continuous) using studies conducted in LMICs. Results: Our network meta-analyses were based on 101 RCTs (132 papers) pertaining to 206,531 participants. Several micronutrients and balanced energy food supplement interventions demonstrated effectiveness over standard-of-care. For instance, versus standard-of-care, micronutrient supplements for pregnant women, such as iron and calcium, decreased risks of preterm birth (iron: RR=0.70, 95% credible interval [Crl] 0.47, 1.01; calcium: RR=0.76, 95%Crl 0.56, 0.99). Daily intake of 1500kcal of local food decreased the risks of preterm birth (RR=0.36, 95%Crl 0.16, 0.77) and LBW (RR=0.17, 95%Crl 0.09, 0.29), respectively when compared to standard-of-care. Educational and deworming interventions did not show improvements in birth outcomes, and no WASH intervention trials reported on these adverse birth outcomes. Conclusion: We found several pregnancy interventions that improve birth outcomes. However, most clinical trials have only evaluated interventions under a single domain (e.g. micronutrients) even though the causes of adverse birth outcomes are multi-faceted. There is a need to combine interventions that of different domains as packages and test for their effectiveness. Registration: PROSPERO CRD42018110446; registered on 17 October 2018.

Maternal Characteristics Affect Fetal Growth Response in the Women First Preconception Nutrition Trial

The objective of this secondary analysis was to identify maternal characteristics that modified the effect of maternal supplements on newborn size. Participants included 1465 maternal-newborn dyads in Guatemala, India, and Pakistan. Supplementation commenced before conception (Arm 1) or late 1st trimester (Arm 2); Arm 3 received usual care. Characteristics included body mass index (BMI), stature, anemia, age, education, socio-economic status (SES), parity, and newborn sex. Newborn outcomes were z-scores for length (LAZ), weight (WAZ), and weight to length ratio-for-age (WLRAZ). Mixed-effect regression models included treatment arm, effect modifier, and arm * effect modifier interaction as predictors, controlling for site, characteristics, and sex. Parity (para-0 vs. para ≥1), anemia (anemia/no anemia), and sex were significant effect modifiers. Effect size (95% CI) for Arm 1 vs. 3 was larger for para-0 vs. ≥1 for all outcomes (LAZ 0.56 (0.28, 0.84, p < 0.001); WAZ 0.45 (0.20, 0.07, p < 0.001); WLRAZ 0.52 (0.17, 0.88, p < 0.01) but only length for Arm 2 vs. 3. Corresponding effects for para ≥1 were >0.02. Arm 3 z-scores were all very low for para-0, but not para ≥1. Para-0 and anemia effect sizes for Arm 1 were > Arm 2 for WAZ and WLRAZ, but not LAZ. Arm 1 and 2 had higher WAZ for newborn boys vs. girls. Maternal nulliparity and anemia were associated with impaired fetal growth that was substantially improved by nutrition intervention, especially when commenced prior to conception.

A life history approach to prenatal supplementation: Building a bridge from biological anthropology to public health and nutrition

While prenatal supplementation with protein, lipids, carbohydrates, and micronutrients has been used to improve infant outcomes in undernourished populations since the 1960s with inconsistent results, a flourishing body of literature within biological anthropology has used life history theory to explain why supplemental resources are often allocated to maternal survival and future reproduction and not to the current offspring. To date, however, public health and nutrition researchers have not adopted evolutionary perspectives in designing or analyzing prenatal supplementation studies. The result is a long series of supplementation trials with unpredictable and often disappointing outcomes for women and children, as well as serious lacunae in the understanding of long-term consequences of supplementation for women. The goal of this article is to open a tactical conversation about how to build a bridge between the evolutionary logic of biological anthropology and the evidentiary standards and methods of public health and nutrition with the aim of advancing knowledge about reproductive and metabolic physiology and improving women's health over the life course. The article reviews recent prenatal supplementation studies and proposes programmatic strategies by which biological anthropologists and public health and nutrition workers may collaborate to define different conditions of prenatal supplement resource allocation and to target more effective interventions.

Effects of animal protein supplementation of mothers, preterm infants, and term infants on growth outcomes in childhood: a systematic review and meta-analysis of randomized trials

BACKGROUND

Child stunting is a major public health problem, afflicting 155 million people worldwide. Lack of animal-source protein has been identified as a risk, but effects of animal protein supplementation are not well established.

OBJECTIVE

The aim of this study was to investigate effects of animal protein supplementation in mothers, preterm infants, and term infants/children on birth and growth outcomes.

METHODS

PubMed, EMBASE, Cochrane library, Web of Science, Cumulative Index of Nursing and Allied Health Literature, and Latin American and Caribbean Health Sciences Literature were searched for randomized controlled trials of animal protein supplementation in mothers or infants and children (≤age 5 y), evaluating measures of anthropometry (≤age 18 y). Main outcomes included birth weight, low birth weight, small for gestational age at birth; height, height-for-age, weight, weight-for-age, weight-for-length, stunting, and wasting ≤18 y of age. Data were extracted independently in duplicate, and findings pooled using inverse variance meta-analysis. Heterogeneity was explored using I2, stratified analysis, and meta-regression, and publication bias by funnel plots, Egger's test, and fill/trim methods.

RESULTS

Of 6808 unique abstracts and 357 full-text articles, 62 trials were included. The 62 trials comprised over 30,000 participants across 5 continents, including formula-based supplementation in infants and food-based supplementation in pregnancy and childhood. Maternal supplementation increased birth weight by 0.06 kg, and both formula and food-based supplementation in term infants/young children increased weight by ≤0.14 kg. Neither formula nor food-based supplementation for term infants/young children increased height, whereas the height-for-age z-score was increased in the food-based (+0.06 z-score) but not formula-based (-0.11 z-score) trials reporting this outcome. In term infants, the weight-for-length z-score was increased in trials of formula (+0.24 z-score) and food supplementation (+0.06 z-score), whereas food supplementation was also associated with reduced odds of stunting (-13%).

CONCLUSIONS

Supplementation of protein from animal-source foods generally increased weight and weight-for-length in children, but with more limited effects on other growth outcomes such as attained height.

Inadequate maternal weight gain in the third trimester increases the risk of intrauterine growth restriction in rural Bangladesh

OBJECTIVE

To estimate the effect of inadequate maternal weight gain in the third trimester on the risk of intrauterine growth restriction (IUGR) in rural Bangladesh.

METHODS

This study analyzed data from 1,463 mother-infant pairs in Matlab, Bangladesh which were available through the electronic databases of Matlab Health and Demographic Surveillance System and Matlab hospital of the International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b). All the mothers were admitted to Matlab hospital for childbirth from January 2012 to December 2014, and they had singleton live births at term. Third-trimester weight gain (kg) was calculated by subtracting the estimated weight at the end of the second trimester from the weight taken before childbirth. Inadequate third-trimester weight gain was defined as 4 kg or less irrespective of pre-gravid nutritional status. IUGR was defined as a birth weight below 2500 g in full-term newborns (LBW-Term), and a birth weight for gestational age and infant sex less than the 10th percentile (SGA-10th) and 2 standard deviations below the mean birth weight (SGA-2SD) based on the international newborn standards from the INTERGROWTH-21st project. Multivariable logistic regression models were fitted to determine the independent effect of inadequate weight gain in the third trimester on the risk of IUGR.

RESULTS

A total of 824 (56.3%) women experienced inadequate weight gain in the third trimester of pregnancy. In this study, 215 (14.7%), 573 (39.2%) and 220 (15.0%) infants were born as LBW-Term, SGA-10th and SGA-2SD, respectively. In the multivariable logistic regression models, compared to adequate weight gain in the third-trimester, the odds ratios (OR) for LBW-Term, SGA-10th and SGA-2SD for inadequate weight gain were 1.8 (95% CI: 1.3, 2.5; p < 0.001), 1.4 (95% CI: 1.1, 1.8; p = 0.002) and 1.8 (95% CI: 1.3, 2.4; p = 0.001), respectively.

CONCLUSIONS

Both inadequate third-trimester weight gain and IUGR are prevailing public health concerns in rural Bangladesh. Inadequate weight gain in the third trimester substantially increased the risk of IUGR. Public health programs focusing on the promotion of adequate weight gain in the third trimester of pregnancy with an ultimate aim to decrease IUGR should be implemented.

Severe malnutrition in infants aged <6 months-Outcomes and risk factors in Bangladesh: A prospective cohort study

Severe acute malnutrition (SAM) affects ~4 million infants under 6 months (u6m) worldwide, but evidence underpinning their care is "very low" quality. To inform future research and policy, the objectives of our study were to identify risk factors for infant u6m SAM and describe the clinical and anthropometric outcomes of treatment with current management strategies. We conducted a prospective cohort study in infants u6m in Barisal district, Bangladesh. One group of 77 infants had SAM (weight-for-length Z-score [WLZ] <-3 and/or bipedal oedema); 77 others were "non-SAM" (WLZ ≥-2 to <+2, no oedema, mid-upper-arm circumference ≥125 mm). All were enrolled at 4-8 weeks of age and followed up at 6 months. Maternal education and satisfaction with breastfeeding were among factors associated with SAM. Duration of exclusive breastfeeding was shorter at enrolment (3·9 ± 2.1 vs. 5.7 ± 2.2 weeks, P < 0.0001) and at age 6 months (13.2 ± 8.9 vs. 17.4 ± 7.9 weeks; P = 0.003) among SAM infants. Despite referral, only 13 (17%) reported for inpatient care, and at 6 months, 18 (23%) infants with SAM still had SAM, and 3 (3.9%) died. In the non-SAM group, one child developed SAM, and none died. We conclude that current treatment strategies have limited practical effectiveness: poor uptake of inpatient referral being the main reason. World Health Organization recommendations and other intervention strategies of outpatient-focused care for malnourished but clinically stable infants u6m need to be tested. Breastfeeding support is likely central to future treatment strategies but may be insufficient alone. Better case definitions of nutritionally at-risk infants are also needed.

Community-based supplementary feeding for food insecure, vulnerable and malnourished populations - an overview of systematic reviews

BACKGROUND

Supplementary feeding may help food insecure and vulnerable people by optimising the nutritional value and adequacy of the diet, improving quality of life and improving various health parameters of disadvantaged families. In low- and middle-income countries (LMIC), the problems supplementary feeding aims to address are entangled with poverty and deprivation, the programmes are expensive and delivery is complicated.

OBJECTIVES

1. To summarise the evidence from systematic reviews of supplementary feeding for food insecure, vulnerable and malnourished populations, including children under five years of age, school-aged children, pregnant and lactating women, people with HIV or tuberculosis (or both), and older populations.2. To describe and explore the effects of supplementary feeding given to people in these groups, and to describe the range of outcomes between reviews and range of effects in the different groups.

METHODS

In January 2017, we searched the Cochrane Database of Systematic Reviews, MEDLINE, Embase and nine other databases. We included systematic reviews evaluating community-based supplementary feeding, and concerning food insecure, vulnerable and malnourished populations. Two review authors independently undertook selection of systematic reviews, data extraction and 'Risk of bias' assessment. We assessed review quality using the AMSTAR tool, and used GRADEpro 'Summary of findings' tables from each review to indicate the certainty of the evidence for the main comparisons. We summarised review findings in the text and reported the data for each outcome in additional tables. We also used forest plots to display results graphically.

MAIN RESULTS

This overview included eight systematic reviews (with last search dates between May 2006 and February 2016). Seven were Cochrane Reviews evaluating interventions in pregnant women; children (aged from birth to five years) from LMIC; disadvantaged infants and young children (aged three months to five years); children with moderate acute malnutrition (MAM); disadvantaged school children; adults and children who were HIV positive or with active tuberculosis (with or without HIV). One was a non-Cochrane systematic review in older people with Alzheimer's disease. These reviews included 95 trials relevant to this overview, with the majority (74%) of participants from LMIC.The number of included participants varied between 91 and 7940 adults, and 271 and more than 12,595 children. Trials included a wide array of nutritional interventions that varied in duration, frequency and format, with micronutrients often reported as cointerventions. Follow-up ranged from six weeks to two years; three trials investigated outcomes at four to 17 years of age. All reviews were rated as high quality (AMSTAR score between eight and 11). The GRADE certainty ratings ranged from very low to moderate for individual comparisons, with the evidence often comprising only one or two small trials, thereby resulting in many underpowered analyses (too small to detect small but important differences). The main outcome categories reported across reviews were death, anthropometry (adults and children) and other markers of nutritional status, disease-related outcomes, neurocognitive development and psychosocial outcomes, and adverse events.Mortality data were limited and underpowered in meta-analysis in all populations (children with MAM, in children with HIV, and in adults with tuberculosis) with the exception of balanced energy and protein supplementation in pregnancy, which may have reduced the risk of stillbirth (risk ratio (RR) 0.60, 95% confidence interval (CI) 0.39 to 0.94; 5 trials, 3408 women). Supplementation in pregnancy also improved infant birth weight (mean difference (MD) 40.96 g, 95% CI 4.66 to 77.26; 11 trials, 5385 participants) and reduced risk of infants born small-for-gestational age (RR 0.79, 95% CI 0.69 to 0.90; 7 trials, 4408 participants). These effects did not translate into demonstrable long-term benefits for children in terms of growth and neurocognitive development in the one to two trials reporting on longer-term outcomes. In one study (505 participants), high-protein supplementation was associated with increased risk of small-for-gestational age babies.Effects on growth in children were mixed. In children under five years of age from LMIC, one review found that supplementary feeding had a little or no effect on child growth; however, a more recent review in a similar population found that those who received food supplementation gained an average of 0.12 kg more in weight (MD 0.12 kg, 95% CI 0.05 to 0.18; 9 trials, 1057 participants) and 0.27 cm more in height (MD 0.27 cm, 95% CI 0.07 to 0.48; 9 trials, 1463 participants) than those who were not supplemented. Supplementary food was generally more effective for younger children (younger than two years of age) and for those who were poorer or less well-nourished. In children with MAM, the provision of specially formulated food improved their weight, weight-for-height z scores and other key outcomes such as recovery rate (by 29%), as well as reducing the number of participants dropping out (by 70%). In LMIC, school meals seemed to lead to small benefits for children, including improvements in weight z scores, especially in children from lower-income countries, height z scores, cognition or intelligence quotient tests, and maths and spelling performance.Supplementary feeding in adults who were HIV positive increased the daily energy and protein intake compared to nutritional counselling alone. Supplementation led to an initial improvement in weight gain or body mass index but did not seem to confer long-term benefit.In adults with tuberculosis, one small trial found a significant benefit on treatment completion and sputum conversion rate. There were also significant but modest benefits in terms of weight gain (up to 2.60 kg) during active tuberculosis.The one study included in the Alzheimer's disease review found that three months of daily oral nutritional supplements improved nutritional outcomes in the intervention group.There was little or no evidence regarding people's quality of life, adherence to treatment, attendance at clinic or the costs of supplementary feeding programmes.

AUTHORS' CONCLUSIONS

Considering the current evidence base included, supplementary food effects are modest at best, with inconsistent and limited mortality evidence. The trials reflected in the reviews mostly reported on short-term outcomes and across the whole of the supplementation trial literature it appears important outcomes, such as quality of life and cost of programmes, are not systematically reported or summarised.

Optimal protein intake during pregnancy for reducing the risk of fetal growth restriction: the Japan Environment and Children's Study

Clinical trials show that protein supplement increases infant size in malnourished populations; however, epidemiological studies in high-income countries have reported mixed results. Although these findings suggest a non-linear relationship between maternal macronutrient intake and fetal growth, this relationship has not been closely examined. We assessed the association between maternal protein intake and fetal growth among 91 637 Japanese women with singletons in a nation-wide cohort study using validated FFQ. The respondents answered the FFQ twice, once during early pregnancy (FFQ1; 16·3 (sd 6·0) weeks), and second during mid-pregnancy (FFQ2, 28·1 (sd 4·1) weeks). Daily energy intake and percentage energy from protein, fats and carbohydrates were 7477 (sd 2577) kJ and 13·5 (sd 2·0), 29·5 (sd 6·5) and 55·3 (sd 7·8) %, respectively, for FFQ1, and 7184 (sd 2506) kJ and 13·6 (sd 2·1), 29·8 (sd 6·6) and 55·3 (sd 7·9) %, respectively, for FFQ2. The average birth weight was 3028 (sd 406) g, and 6350 infants (6·9 %) were small for gestational age (SGA). In both phases of the survey, birth weight was highest and the risk of SGA was lowest when the percentage energy from protein was 12 %, regardless of whether isoenergetic replacement was with fat or carbohydrates. Furthermore, when protein density in the maternal diet was held constant, birth weight was highest when 25 % of energy intake came from fat and 61 % came from carbohydrates during early pregnancy. We found maternal protein intake to have an inverse U-curve relationship with fetal growth. Our results strongly suggest that the effect of protein on birth weight is non-linear, and that a balanced diet fulfilling the minimum requirement for all macronutrients was ideal for avoiding fetal growth restriction.

A village-matched evaluation of providing a local supplemental food during pregnancy in rural Bangladesh: a preliminary study

BACKGROUND

Prenatal balanced protein energy supplementation consumed by undernourished women improves mid-upper arm circumference in early infancy. This study aimed to identify whether locally produced maternal food-based supplementation improved anthropometric measures at birth and early infancy.

METHODS

A village-matched evaluation, applying principles of a cluster randomised controlled trial, of a locally produced supplemental food to 87 undernourished pregnant women. 12 villages (intervention: n = 8; control: n = 4) in Pirganj sub-district, Rangpur District, northern Bangladesh. Daily supplements were provided.

RESULTS

Anthropometric data at birth were available for 77 mother-infant dyads and longer-term infant growth data for 75 infants. Mid-upper arm circumference (MUAC) was significantly larger in infants of mothers in the intervention group compared with the control group at 6 months (p < 0.05). The mean birth weight in babies of supplemented mothers (mean: 2·91 kg; SD: 0·19) was higher than in babies of mothers in the control group (mean: 2·72 kg; SD: 0·13), and these changes persisted until 6 months. Also, the proportion of low birth weight babies in the intervention group was much lower (event rate = 0.04) than in the control group (event rate = 0.16). However, none of these differences were statistically significant (p > 0·05; most likely due to small sample size). The intervention reduced the risk of wasting at 6 months by 63.38% (RRR = 0.6338), and of low birth weight by 88·58% (RRR = 0.8858), with NNT of 2.22 and 6.32, respectively. Only three pregnant women require this intervention in order to prevent wasting at 6 months in one child, and seven need the intervention to prevent low birth weight of one child.

CONCLUSIONS

Locally produced food-based balanced protein energy supplementation in undernourished pregnant women in northern Bangladesh resulted in larger MUAC in infants at 6 months. Further research, with larger sample sizes, is required to confirm the role of locally produced supplementation for undernourished pregnant women on weight and linear growth in newborns and infants.

TRIAL REGISTRATION

This research was registered with the ISRCTN registry (ISRCTN97447076). This project had human research ethical approval from the James Cook University (Australia) Ethics committee (H4498) and the Bangladesh Medical Research Council (BMRC/NREC/2010-2013/58).

Intergenerational Transmission of Birth Weight Across 3 Generations

While previous studies have shown intergenerational transmission of birth weight from mother to child, whether the continuity persists across 3 generations has rarely been assessed. We used the Aberdeen Maternity and Neonatal Databank (United Kingdom) to examine the intergenerational correlations of birth weight, birth weight adjusted for gestational age and sex, and small- and large-for-gestational-age births across 3 generations among 1,457 grandmother-mother-child triads. All participants were born between 1950 and 2015. The intergenerational transmission was examined with linear regression analyses. We found that grandmaternal birth weight was associated with grandchild birth weight, independently of prenatal and sociodemographic covariates and maternal birth weight (B = 0.12 standard deviation units, 95% confidence interval: 0.07, 0.18). Similar intergenerational continuity was found for birth weight adjusted for sex and gestational age as well as for small-for-gestational-age births. In conclusion, birth weight and fetal growth showed intergenerational continuity across 3 generations. This supports the hypothesis that the developmental origins of birth weight and hence later health and disease are already present in earlier generations.

Impact on birth weight and child growth of Participatory Learning and Action women's groups with and without transfers of food or cash during pregnancy: Findings of the low birth weight South Asia cluster-randomised controlled trial (LBWSAT) in Nepal

BACKGROUND

Undernutrition during pregnancy leads to low birthweight, poor growth and inter-generational undernutrition. We did a non-blinded cluster-randomised controlled trial in the plains districts of Dhanusha and Mahottari, Nepal to assess the impact on birthweight and weight-for-age z-scores among children aged 0-16 months of community-based participatory learning and action (PLA) women's groups, with and without food or cash transfers to pregnant women.

METHODS

We randomly allocated 20 clusters per arm to four arms (average population/cluster = 6150). All consenting married women aged 10-49 years, who had not had tubal ligation and whose husbands had not had vasectomy, were monitored for missed menses. Between 29 Dec 2013 and 28 Feb 2015 we recruited 25,092 pregnant women to surveillance and interventions: PLA alone (n = 5626); PLA plus food (10 kg/month of fortified wheat-soya 'Super Cereal', n = 6884); PLA plus cash (NPR750≈US$7.5/month, n = 7272); control (existing government programmes, n = 5310). 539 PLA groups discussed and implemented strategies to improve low birthweight, nutrition in pregnancy and hand washing. Primary outcomes were birthweight within 72 hours of delivery and weight-for-age z-scores at endline (age 0-16 months). Only children born to permanent residents between 4 June 2014 and 20 June 2015 were eligible for intention to treat analyses (n = 10936), while in-migrating women and children born before interventions had been running for 16 weeks were excluded. Trial status: completed.

RESULTS

In PLA plus food/cash arms, 94-97% of pregnant women attended groups and received a mean of four transfers over their pregnancies. In the PLA only arm, 49% of pregnant women attended groups. Due to unrest, the response rate for birthweight was low at 22% (n = 2087), but response rate for endline nutritional and dietary measures exceeded 83% (n = 9242). Compared to the control arm (n = 464), mean birthweight was significantly higher in the PLA plus food arm by 78·0 g (95% CI 13·9, 142·0; n = 626) and not significantly higher in PLA only and PLA plus cash arms by 28·9 g (95% CI -37·7, 95·4; n = 488) and 50·5 g (95% CI -15·0, 116·1; n = 509) respectively. Mean weight-for-age z-scores of children aged 0-16 months (average age 9 months) sampled cross-sectionally at endpoint, were not significantly different from those in the control arm (n = 2091). Differences in weight for-age z-score were as follows: PLA only -0·026 (95% CI -0·117, 0·065; n = 2095); PLA plus cash -0·045 (95% CI -0·133, 0·044; n = 2545); PLA plus food -0·033 (95% CI -0·121, 0·056; n = 2507). Amongst many secondary outcomes tested, compared with control, more institutional deliveries (OR: 1.46 95% CI 1.03, 2.06; n = 2651) and less colostrum discarding (OR:0.71 95% CI 0.54, 0.93; n = 2548) were found in the PLA plus food arm but not in PLA alone or in PLA plus cash arms.

INTERPRETATION

Food supplements in pregnancy with PLA women's groups increased birthweight more than PLA plus cash or PLA alone but differences were not sustained. Nutrition interventions throughout the thousand-day period are recommended.

TRIAL REGISTRATION

ISRCTN75964374.

Expanding the population coverage of evidence-based interventions with community health workers to save the lives of mothers and children: an analysis of potential global impact using the Lives Saved Tool (LiST)

Background

Evidence has been accumulating that community health workers (CHWs) providing evidence–based interventions as part of community–based primary health care (CBPHC) can lead to reductions in maternal, neonatal and child mortality. However, investments to strengthen and scale–up CHW programs still remain modest.

Methods

We used the Lives Saved Tool (LiST) to estimate the number of maternal, neonatal and child deaths and stillbirths that could be prevented if 73 countries effectively scaled up the population coverage of 30 evidence–based interventions that CHWs can deliver in these high–burden countries. We set population coverage targets at 50%, 70%, and 90% and summed the country–level results by region and by all 73 high–burden countries combined. We also estimated which specific interventions would save the most lives.

Findings

LiST estimates that a total of 3.0 (sensitivity bounds 1.8–4.0), 4.9 (3.1–6.3) and 6.9 (3.7–8.7) million deaths would be prevented between 2016 and 2020 if CBPHC is gradually scaled up during this period and if coverage of key interventions reaches 50%, 70%, and 90% respectively. There would be 14%, 23%, and 32% fewer deaths in the final year compared to a scenario assuming no intervention coverage scale up. The Africa Region would receive the most benefit by far: 58% of the lives saved at 90% coverage would be in this region. The interventions contributing the greatest impact are nutritional interventions during pregnancy, treatment of malaria with artemisinin compounds, oral rehydration solution for childhood diarrhea, hand washing with soap, and oral antibiotics for pneumonia.

Conclusions

Scaling up CHW programming to increase population–level coverage of life–saving interventions represents a very promising strategy to achieve universal health coverage and end preventable maternal and child deaths by 2030. Numerous practical challenges must be overcome, but there is no better alternative at present. Expanding the coverage of key interventions for maternal nutrition and treatment of childhood illnesses, in particular, may produce the greatest gains. Recognizing the millions of lives of mothers and their young offspring that could be achieved by expanding coverage of evidence–based interventions provided by CHWs and strengthening the CBPHC systems that support them underscores the pressing need for commitment from governments and donors over the next 15 years to prioritize funding, so that robust CHW platforms can be refined, strengthened, and expanded.

Teenage pregnancy and mental health beyond the postpartum period: a systematic review

Background

Teenage mothers are at increased risk for adverse social outcomes and short-term health problems, but long-term impacts on mental health are poorly understood. The aims of our systematic review were to determine the association between teenage pregnancy and mental health beyond the postpartum period, critically appraise the literature’s quality and guide future research.

Methods

We systematically searched MEDLINE, Embase, PsycINFO, CINAHL, Scopus and Web of Science from inception to June 2017 for peer-reviewed articles written in English or French. Data were collected using a modified Cochrane Data Extraction Form. Study quality was assessed using the Effective Public Health Practice Project critical appraisal tool. Heterogeneity of studies permitted only a qualitative synthesis.

Results

Nine quantitative studies comprising the results from analyses of 11 cohorts met our criteria and were rated as strong (n=5), moderate (n=2) or weak (n=2). Three cohorts found a statistically significant association between teenage pregnancy and poor long-term mental health after adjustment, three found a statistically significant association before but not after adjustment and five did not find a statistically significant association. Studies observed varying degrees of attenuation after considering social context. Studies with statistically significant findings tended to comprise earlier cohorts, with outcomes measured at older ages.

Conclusions

The association between teenage pregnancy and mental health beyond the postpartum period remains unclear. Future studies should employ age–period–cohort frameworks to disentangle effects of normative patterns and stress accumulation. Social factors are important in determining long-term mental health of teenage mothers and should be prioritised in prevention and intervention strategies.

Importance of maternal diet in the training of the infant's immune system during gestation and lactation

Latest forecasts predict that half of the European population will be allergic within the coming 15 years, with food allergies contributing substantially to the total burden; preventive measures are urgently needed. Unfortunately, all attempted alimentary strategies for primary prevention of allergic diseases through allergen avoidance so far have failed. This also holds true for the prevention of food allergies in breastfed infants by the common practice of excluding certain foods with allergenic potential from the maternal diet. As a preventive measure, therefore, exclusion diets should be discouraged. They can exhaust nursing mothers and negatively impact both their nutritional status as well as their motivation to breastfeed. A prolonged exclusion diet may be indicated solely in cases of doctor-diagnosed food allergy following rigid medical tests (e.g. double-blind placebo-controlled food challenges). Indicated cases usually involve exclusion of only a few food items. Continued breastfeeding is generally important for many aspects of the infant's health, including the training of the infant's immune responses to foreign compounds and avoidance of overshooting inflammatory responses. Recent studies suggest that the presence of maternal dietary proteins in amniotic fluid, cord blood, and human milk might support the induction of tolerance towards solid foods in infants. These are exactly the same species of proteins or remnants thereof that, in comparatively few cases, trigger allergic responses. However, the insight that the proteins of maternal dietary origin in human milk are more likely to be cure (or, more precise, directing prevention) than curse has still largely evaded the attention of health care professionals consulted by worried breastfeeding mothers. In this paper, we summarize recent literature on the importance of exposure to dietary proteins in the establishment of immunological tolerance and hence prevention of allergic disease. Multiple organizations have used the scientific knowledge to build (local) guidelines (e.g. AAAAI, EAACI, BSACI) that can support health care professionals to provide the best strategy to prevent the onset of allergic diseases. We thus hope to clarify existing confusion about the allergenic propensities of dietary proteins during early life, which has contributed to exaggerated fears around the diet of pregnant and breastfeeding mothers.

Prenatal food restriction induces neurobehavioral abnormalities in adult female offspring rats and alters intrauterine programming

The higher risk of adult neuropsychiatric diseases in individuals with low fetal birth weight may be related to brain-derived neurotrophic factor (BDNF) signaling pathway inhibition. Here, we investigated whether prenatal food restriction (PFR) induces neurobehavioral alterations in adult female offspring and explored the underlying intrauterine programming mechanism. Pregnant Wistar rats in the PFR group were fed 50% of the daily food intake of control rats from gestational day (GD) 11 to 20; some pregnant rats were sacrificed at GD20, and the remaining female pups had normal delivery and were fed a post-weaning high-fat diet (HFD) and half of them were exposed to an unpredictable chronic stress (UCS) from postnatal week (PW) 21. All adult female offspring were sacrificed at PW24. At GD20, PFR altered fetal hippocampal structure and function, increased glucocorticoid receptor (GR) expression, and decreased mineralocorticoid receptor (MR), BDNF and synaptic plasticity-related gene expressions. At PW24, PFR induced depression-like behavioral abnormalities in adult rat offspring fed an HFD. These rats exhibited depression- and anxiety-like behavioral changes after HFD/UCS. Furthermore, the hippocampal morphology of the PFR group showed abnormal changes in adult offspring fed an HFD and more serious damage after HFD/UCS. These changes were accompanied by increased serum corticosterone levels, elevated GR expression, and reduced expression of the BDNF signaling pathway and synaptic plasticity-related genes in the hippocampus. In conclusion, PFR may induce neurobehavioral abnormalities in adult offspring, especially those exposed to UCS, through high levels of glucocorticoids, which increase hippocampal GR expression and decrease BDNF expression.

Is dietary macronutrient composition during pregnancy associated with offspring birth weight? An observational study

There is lack of evidence on the differential impact of maternal macronutrient consumption: carbohydrates (CHO), fats and protein on birth weight. We investigated the association between maternal dietary macronutrient intakes and their sub-components such as saccharides and fatty acids and birth weight. This analyses included 1,196 women with singleton pregnancies who were part of the CAffeine and REproductive health study in Leeds, UK between 2003 and 2006. Women were interviewed in each trimester. Dietary information was collected twice using a 24-h dietary recall about 8–12 weeks and 13–27 weeks of gestation. Multiple linear regression models adjusted for alcohol and smoking in trimester 1, showed that each additional 10 g/d CHO consumption was associated with an increase of 4 g (95 % CI 1, 7;P=0·003) in birth weight. Conversely, an additional 10 g/d fat intake was associated with a lower birth weight of 8 g (95 % CI 0, 16;P=0·04) when we accounted for energy contributing macronutrients in each model, and maternal height, weight, parity, ethnicity, gestational age at delivery and sex of the baby. There was no evidence of an association between protein intake and birth weight. Maternal diet in trimester 2 suggested that higher intakes of glucose (10 g/d) and lactose (1 g/d) were both associated with higher birth weight of 52 g (95 % CI 4, 100;P=0·03) and 5 g (95 % CI 2, 7;P<0·001) respectively. These results show that dietary macronutrient composition during pregnancy is associated with birth weight outcomes. An appropriately balanced intake of dietary CHO and fat during pregnancy could support optimum birth weight.

Adolescent pregnancy and nutrition: a subgroup analysis from the Mamachiponde study in Malawi

Young age at childbearing (≤19 years) is common and associated with poor birth outcomes. A trial among Malawian pregnant women with moderate malnutrition was used to determine outcomes of young adolescents (≤18 years), older adolescents (18-20 years), and adults (>20 years). Women received one of three supplementary foods that provided ∼900 kcal/day and 33-36 g protein/day and returned every 2 weeks. Newborn/maternal measurements were taken at delivery and after 6 and 12 weeks. Upon enrollment, adolescents had greater body mass index than adults (19.9 ± 1.3 versus 19.5 ± 1.4 kg/m2 , P < 0.001). Young adolescents received more rations of food and enrolled and delivered with a lower fundal height than adults (21.7 ± 5.2 versus 23.0 ± 5.6, P = 0.00 enrollment; 30.2 ± 3.1 versus 31.0 ± 2.8, P < 0.001 delivery). Among newborns, length for age was lowest in young adolescents, greater in older adolescents, and greatest in adults (Z-scores -1.7 ± 1.2, -1.4 ± 1.2, and -1.1 ± 1.1, respectively; P < 0.001). These differences persisted in length for age at 6 and 12 weeks of age for infants. Adolescents enrolled earlier in pregnancy and appeared more nutritionally adequate than adults; adolescent outcomes were inferior to those of adults, suggesting that they were subject to more physiologic stressors and/or different nutritional needs.