Effects of dietary interventions on neonatal and infant outcomes: a systematic review and meta-analysis

Antenatal size, early childhood growth, and asthma within a cohort created by data linkage

INTRODUCTION

The gestation when small for gestational age (SGA) is first associated with asthma is not well understood. Here, we use routinely acquired data from 10 weeks gestation to up to 28 years of age to test the hypothesis that SGA before birth is associated with an increased risk for asthma in a large population born between 1987 and 2015.

METHODS

Databases were linked to produce a single database that held antenatal fetal ultrasound measurements; maternal characteristics; birth measurements; childhood anthropometric measurements at age 5 years; hospital admission data (1987-2015); and family doctor prescribing (2009-2015). Asthma admission and receipt of any asthma medications were the outcomes. Analyses related single and then multiple anthropometric measurements to asthma outcomes.

RESULTS

Outcome data were available for 63,930 individuals. Increased length in the first-trimester size was associated with a reduced odds ratio (OR) for asthma admission of 0.991 [0.983, 0.998] per mm increase and also a shorter time to first admission, with a hazard ratio risk of 0.987 [0.980, 0.994] per mm increase. Independent of all earlier measurements, increased height at 5 years (available in a subset of 15,760) was associated with reduced OR for an asthma admission, with OR of 0.874 [0.790, 0.967] per z score. Longitudinal measurements of weight were not related to asthma outcomes.

CONCLUSIONS

Longer first-trimester length is associated with more favorable asthma outcomes, and subsequently, increased height in childhood is also independently associated with more favorable asthma outcomes. Interventions that reduce SGA and encourage healthy postnatal growth might improve asthma outcomes.

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.

The Impact of Antenatal Balanced Plate Nutrition Education for Pregnant Women on Birth Weight: A Cluster Randomised Controlled Trial in Rural Bangladesh

Low birth weight (LBW) is a global public health problem with the highest prevalence in South Asia. It is strongly associated with maternal undernutrition. In South Asia, intra-household food distribution is inequitable, with lower dietary adequacy in women. Evidence that nutrition education improves diet during pregnancy and reduces LBW is weak. We assessed the impact of nutrition education for pregnant women on birth weight in rural Bangladesh. We conducted a parallel, two-arm, cluster-randomised controlled trial, with 36 clusters allocated equally to intervention (n = 445) or standard care (n = 448). From their first trimester until delivery, intervention participants received education about eating balanced meals to meet daily dietary requirements with diverse food groups. The primary outcome of mean birth weight was 127.5 g higher in the intervention compared to control women, and the intervention reduced the risk of LBW by 57%. Post hoc analyses showed a significantly higher birth weight and a greater reduction in LBW amongst adolescent mothers. The mean number of food groups consumed was significantly higher in the intervention from the third month of pregnancy than in the control. A community-based balanced plate nutrition education intervention effectively increased mean birth weight and reduced LBW, and improved dietary diversity in rural Bangladeshi women.

Gestational weight gain mediates the effects of energy intake on birth weight among singleton pregnancies in the Japan Environment and Children's Study

Background

Extra energy intake is commonly recommended for pregnant women to support fetal growth. However, relevant data regarding variations in energy intake and expenditure, body mass index and gestational weight gain (GWG) are frequently not considered. This study aimed to investigate how energy intake during pregnancy and gestational weight gain (GWG) are associated with birth weight.

Methods

Early pregnant women were recruited into a Japanese nationwide prospective birth cohort study between 2011 and 2014. We analysed data of 89,817 mother-child pairs of live-born non-anomalous singletons after excluding births before 28 weeks or after 42 weeks. Energy intake during pregnancy was estimated from self-administered food frequency questionnaires (FFQ) and was stratified into low, medium, and high. Participants completed the FFQ in mid-pregnancy (mean 27.9 weeks) by recalling food consumption at the beginning of pregnancy. Effects of energy intake on birth weight and mediation by GWG were estimated using the Karlson–Holm–Breen method; the method separates the impact of confounding in the comparison of conditional and unconditional parameter estimates in nonlinear probability models. Relative risks and risk differences for abnormal birth size were calculated.

Results

Mean daily energy intake, GWG, and birth weight were 1682.1 (533.6) kcal, 10.3 (4.0) kg, and 3032.3 (401.4) g, respectively. 6767 and 9010 women had small-for-gestational-age and large-for-gestational-age infants, respectively. Relative to low energy intake, moderate and high intakes increased adjusted birth weights by 13 g and 24 g, respectively: 58 and 69% of these effects, respectively, were mediated by GWG. Compared with the moderate energy intake group, the low energy intake group had seven more women per 1000 women with a small-for-gestational-age birth, whereas the high energy intake group had eight more women per 1000 women with a large-for-gestational-age birth.

Conclusion

GWG mediates the effect of energy intake on birth weight. All pregnant women should be given adequate nutritional guidance for optimal GWG and fetal growth.

Unintended consequences of welfare reform: Evidence from birthweight of Aboriginal children in Australia

In 2007, Australia introduced its most radical welfare reform in recent history, targeting Aboriginal communities with the aim of protecting children from harm. The 'income management' policy forced Aboriginal welfare recipients to spend at least half of their government transfers on essentials (e.g. food, housing), and less on non-essentials (e.g. alcohol, tobacco). By exploiting its staggered rollout, we estimate the impact of in utero exposure to the policy rollout on birthweight. We find that exposure to the income management policy reduced average birthweight robustly by 85 g and increased the risk of low birth weight by 3 percentage points. This finding is not explained by behavioral change (fertility, maternal risk behavior, access to care), or survival probabilities of at-risk fetuses. More likely, a lack of policy implementation planning and infrastructure led to acute income insecurity and stress during the rollout period, exacerbating the existing health inequalities it sought to address.

Folic acid supplementation during pregnancy alters behavior in male rat offspring: nitrative stress and neuroinflammatory implications

Pregnancy diet can impact offspring's neurodevelopment, metabolism, redox homeostasis, and inflammatory status. In pregnancy, folate demand is increased due to the requirement for one-carbon transfer reactions. The present study was proposed to investigate the effect of folic acid supplementation throughout pregnancy on a battery of behavior tests (olfactory preference, motor activity, exploratory capacity, habituation, memory, anxiety- and depression-like behavior). Redox homeostasis and neuroinflammatory status in cerebral cortex were also investigated. After pregnancy confirmation, the pregnant rats were randomly divided into two groups, according to the diet: group 1, (control) standard diet (2 mg/kg diet of folic acid) and group 2, supplemented diet with 4 mg/kg diet of folic acid. Throughout the gestational period, the pregnant rats received experimental diets. Results show that the supplemented diet with 4 mg/kg diet of folic acid throughout pregnancy impaired memory and motricity of the offspring when compared with control (standard diet). It was also observed an increase in anxiety- and depression-like behavior in this group. Nitrite levels increased in cerebral cortex of the offspring, when compared to control group. In contrast, iNOS expression and immunocontent were not altered. Moreover, we identify an increase in TNF-α, IL-1β, IL-6, IL-10, and MCP-1 gene expression in the cerebral cortex. In conclusion, our study showed that the supplemented diet with 4 mg/kg diet of folic acid throughout pregnancy may cause behavioral and biochemical changes in the male offspringGraphical abstract After pregnancy confirmation, the pregnant rats were randomly divided into two groups, according to the diet: group 1, (control) standard diet (2 mg/kg diet of folic acid) and group 2, supplemented diet with 4 mg/kg diet of folic acid. Throughout the gestational period, the pregnant rats received experimental diets. Results show that folic acid supplementation did not impair the mother-pup relationship. We showed that supplemented diet with 4 mg/kg diet of folic acid during pregnancy impairs memory and motricity of the offspring when compared with standard diet. It was also observed an increase in anxiety- and depression-like behavior in this group. Nitrative stress and neuroinflammation parameters were increased in the cerebral cortex of the offspring. ROS, reactive oxygen species.

Association of Maternal Dietary Patterns With Birth Weight and the Mediation of Gestational Weight Gain: A Prospective Birth Cohort

The associations among maternal diet, birth weight, and gestational weight gain are still inconclusive. This study aimed to investigate the associations between maternal dietary patterns and birth weight, and further explore whether GWG mediates these associations. A total of 3,334 pregnant women who completed a validated semi-quantitative food frequency questionnaire from the Tongji Maternal and Child Health Cohort were included. Dietary patterns were extracted by using principal component analysis. Regression models and mediation analyses were performed to explore the associations between dietary patterns and birth weight and the effects of GWG on these associations. Five dietary patterns were identified: "Beans-vegetables," "Fish-meat-eggs," "Nuts-whole grains," "Organ-poultry-seafood" and "Rice-wheat-fruits." Only women following the "Beans-vegetables" pattern had heavier newborns (β = 47.39; 95% CI: 12.25, 82.54). Women following the "Beans-vegetables" pattern had significantly lower GWG (β = -0.7; 95% CI: -1.15, -0.25) and had a 16% lower risk of excessive GWG and 11% higher odd of adequate GWG. The association between the "Beans-vegetables" pattern and birth weight was negatively mediated by GWG. A dietary pattern enriched in beans and vegetables is beneficial for effectively controlling GWG and increasing birth weight. GWG serves. Clinical Trial Registry: This trial was registered at ClinicalTrials.gov (NCT03099837).

Short- and Long-Term Outcomes Associated with Large for Gestational Age Birth Weight

Large for gestational age birth weight is associated with adverse short- and long-term outcomes. Infants born with large for gestational age birth weight are at increased risk for neonatal intensive care unit admission, respiratory distress, neonatal metabolic abnormalities including hypoglycemia, birth trauma, and even stillbirth or neonatal death. The risk for many of these complications increases with higher birth weights. Individuals with large for gestational age birth weight also appear to be at subsequent increased risk for overweight/obesity, diabetes, cardiovascular disease, and even some childhood cancers. These data highlight the need for effective interventions to decrease risk across the lifespan.

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 Dietary Intake of Total Fat, Saturated Fat, and Added Sugar Is Associated with Infant Adiposity and Weight Status at 6 mo of Age

BACKGROUND

Whether current dietary guidelines are appropriate for pregnancy and lactation has not been well studied. Many women of reproductive age are not meeting recommendations for dietary components such as fat, added sugar, and fiber.

OBJECTIVES

To assess associations between maternal dietary components during pregnancy and lactation and infant growth and adiposity at 6 mo of age.

METHODS

Mother-infant dyads (n = 349) from the prospective, observational Mothers and Infants Linked for Healthy Growth study were included (100% fully breastfed for 1 mo; 75% to 6 mo). Daily intake of fat, fiber, and added sugar was obtained using the National Cancer Institute Diet History Questionnaire II during the third trimester of pregnancy and at 1 and 3 mo postpartum. Furthermore, intakes were categorized as meeting/exceeding 2015-2020 Dietary Guidelines for Americans. Multiple linear regression models adjusted for numerous potential confounders tested relations between dietary components and infant adiposity (via DXA) and growth parameters. Regression coefficients (β) for continuous variables were expressed per SD to allow for comparison of effect sizes.

RESULTS

Maternal intake of total fat and saturated fat was positively associated with infant percent body fat (%BF) (β: 0.84 per SD, P = 0.04; β: 0.96 per SD, P = 0.01, respectively). Added sugar intake was positively associated with infant weight-for-length z score (β: 0.16 per SD, P = 0.02), and excessive added sugar intake was positively associated with %BF at 6 mo (β: 0.75 per SD, P = 0.05).

CONCLUSIONS

In a predominantly fully breastfeeding cohort of women, maternal intake of fat and added sugar during pregnancy and lactation were associated with small increases in infant adiposity and relative weight at 6 mo. Additional research is needed to determine if these relations persist later in infancy and if such elevations in adiposity are important for long-term obesity risk.

Mediterranean-Style Diet and Birth Outcomes in an Urban, Multiethnic, and Low-Income US Population

Findings on the role of Mediterranean-style diet (MSD) on duration of pregnancy and birth weight have been inconsistent and based largely on Non-Hispanic white populations, making it unclear as to whether they could extend to African Americans who are at a higher risk of unfavorable birth outcomes. Our study addresses this gap using a large urban, multiethnic, predominantly low-income cohort of mother-infant dyads from Boston, MA, USA. Dietary information was obtained via food frequency questionnaires; health information including birth outcomes were extracted from medical records. A Mediterranean-style diet score (MSDS) was formulated based on intake history, and linear and log-binomial regressions were performed to assess its association with birth outcomes. After adjustment, the lowest MSDS quintile from the overall sample was found to be associated with an increased relative risk (RR) of overall preterm birth (RR 1.18; 95% CI: 1.06-1.31), spontaneous preterm birth (1.28; 1.11-1.49), late preterm birth (1.21; 1.05-1.39), and low birth weight (1.11; 1.01-1.22), compared to the highest quintile. The findings were similar for the African American sample. Our study adds to the current understanding of the diet's influence on birth outcomes by demonstrating that adherence to MSD may improve birth outcomes for African American women.

The Effectiveness of Smoking Cessation, Alcohol Reduction, Diet and Physical Activity Interventions in Improving Maternal and Infant Health Outcomes: A Systematic Review of Meta-Analyses

Diet, physical activity, smoking and alcohol behaviour-change interventions delivered in pregnancy aim to prevent adverse pregnancy outcomes. This review reports a synthesis of evidence from meta-analyses on the effectiveness of interventions at reducing risk of adverse health outcomes. Sixty-five systematic reviews (63 diet and physical activity; 2 smoking) reporting 602 meta-analyses, published since 2011, were identified; no data were identified for alcohol interventions. A wide range of outcomes were reported, including gestational weight gain, hypertensive disorders, gestational diabetes (GDM) and fetal growth. There was consistent evidence from diet and physical activity interventions for a significantly reduced mean gestational weight gain (ranging from -0.21 kg (95% confidence interval -0.34, -0.08) to -5.77 kg (95% CI -9.34, -2.21). There was evidence from larger diet and physical activity meta-analyses for a significant reduction in postnatal weight retention, caesarean delivery, preeclampsia, hypertension, GDM and preterm delivery, and for smoking interventions to significantly increase birth weight. There was no statistically significant evidence of interventions having an effect on low or high birthweight, neonatal intensive care unit admission, Apgar score or mortality outcomes. Priority areas for future research to capitalise on pregnancy as an opportunity to improve the lifelong wellbeing of women and their children are highlighted.

Association between preconception maternal stress and offspring birth weight: findings from an Australian longitudinal data linkage study

OBJECTIVE

Examine the relationship between preconception stress and offspring birth weight.

SETTING

Population-based cohort study linked with state-based administrative perinatal data.

PARTICIPANTS

6100 births from 3622 women from the 1973-1978 cohort of the Australian Longitudinal Study of Women's Health who (1) recorded a singleton birth between January 1997 and December 2011; (2) returned at least one follow-up survey within 3 years of conception; and (3) had complete data on perceived stress prior to conception.

PRIMARY OUTCOME MEASURES

Linear generalised estimating equations were used to examine the relationship between preconception stress and a continuous measure of birth weight, exploring differences based on birth order and stress chronicity. The minimal sufficient adjustment set of covariates was determined by a directed acyclic graph.

RESULTS

For all births, there was no relationship between moderate/high acute or chronic stress and offspring birth weight in grams. Among first births only, there was a trend towards a relationship between moderate/high chronic stress and offspring birth weight. Offspring sex was associated with birth weight in all models, with female babies born lighter than male babies on average, after adjusting for covariates (p<0.0001).

CONCLUSIONS

Effects of preconception stress on birth weight was largely driven by time to conception. With the timing of stress critical to its impact on obstetrical outcomes, preconception care should involve not only reproductive life planning but the space to provide interventions at critical periods so that optimal outcomes are achieved.

Prenatal dietary diversity may influence underweight in infants in a Ugandan birth-cohort

Growth faltering in early childhood is prevalent in many low resource countries. Poor maternal dietary diversity during pregnancy has been linked with increased risk of fetal growth failure and adverse birth outcomes but may also influence subsequent infant growth. Our aim is to assess the role of prenatal maternal dietary diversity in infant growth in rural Uganda. Data from 3291 women and infant pairs enrolled in a birth cohort from 2014 to 2016 were analysed (NCT04233944). Maternal diets were assessed using dietary recall in the second or third trimesters of pregnancy. Maternal dietary diversity scores (DDS) were calculated using the FAO Minimum Dietary Diversity for Women (MDD‐W). Cox regression models were used to evaluate associations of the DDS with the incidence of underweight, stunting and wasting in infants from 3 to 12 months, adjusting for confounding factors. The median DDS for women was low, at 3.0 (interquartile range 3.0–4.0), relative to the threshold of consuming five or more food groups daily. Infants of women in highest quartile of DDS (diverse diets) were less likely to be underweight (adjusted hazard ratio: 0.70, 95% confidence interval: 0.61, 0.80) compared with infants of women in Quartile 1 (p for trend <0.001) in models controlling for maternal factors. There was no significant association between DDS and stunting or wasting. Our findings suggest a relationship between higher maternal dietary diversity and lower risk of underweight in infancy. These findings suggest that programmes to improve infant growth could additionally consider strengthening prenatal dietary diversity to improve child outcomes globally.

The Revised WIC Food Package and Child Development: A Quasi-Experimental Study

BACKGROUND AND OBJECTIVES

The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), one of the largest US safety net programs, was revised in 2009 to be more congruent with dietary guidelines. We hypothesize that this revision led to improvements in child development.

METHODS

Data were drawn from a cohort of women and children enrolled in the Conditions Affecting Neurocognitive Development and Learning in Early Childhood study from 2006 to 2011 (Shelby County, TN; N = 1222). Using quasi-experimental difference-in-differences analysis, we compared measures of growth, cognitive, and socioemotional development between WIC recipients and nonrecipients before and after the policy revision.

RESULTS

The revised WIC food package led to increased length-for-age z scores at 12 months among infants whose mothers received the revised food package during pregnancy (β = .33, 95% confidence interval: 0.05 to 0.61) and improved Bayley Scales of Infant Development cognitive composite scores at 24 months (β = 4.34, 95% confidence interval: 1.11 to 7.57). We observed no effects on growth at age 24 months or age 4 to 6 years or cognitive development at age 4 to 6 years.

CONCLUSIONS

This study provides some of the first evidence that children of mothers who received the revised WIC food package during pregnancy had improved developmental outcomes in the first 2 years of life. These findings highlight the value of WIC in improving early developmental outcomes among vulnerable children. The need to implement and expand policies supporting the health of marginalized groups has never been more salient, particularly given the nation's rising economic and social disparities.

Effects of Maternal Nutritional Supplements and Dietary Interventions on Placental Complications: An Umbrella Review, Meta-Analysis and Evidence Map

The placenta is a vital, multi-functional organ that acts as an interface between maternal and fetal circulation during pregnancy. Nutritional deficiencies during pregnancy alter placental development and function, leading to adverse pregnancy outcomes, such as pre-eclampsia, infants with small for gestational age and low birthweight, preterm birth, stillbirths and maternal mortality. Maternal nutritional supplementation may help to mitigate the risks, but the evidence base is difficult to navigate. The primary purpose of this umbrella review is to map the evidence on the effects of maternal nutritional supplements and dietary interventions on pregnancy outcomes related to placental disorders and maternal mortality. A systematic search was performed on seven electronic databases, the PROSPERO register and references lists of identified papers. The results were screened in a three-stage process based on title, abstract and full-text by two independent reviewers. Randomized controlled trial meta-analyses on the efficacy of maternal nutritional supplements or dietary interventions were included. There were 91 meta-analyses included, covering 23 types of supplements and three types of dietary interventions. We found evidence that supports supplementary vitamin D and/or calcium, omega-3, multiple micronutrients, lipid-based nutrients, and balanced protein energy in reducing the risks of adverse maternal and fetal health outcomes. However, these findings are limited by poor quality of evidence. Nutrient combinations show promise and support a paradigm shift to maternal dietary balance, rather than single micronutrient deficiencies, to improve maternal and fetal health. The review is registered at PROSPERO (CRD42020160887).

The impact of maternal stress on offspring birth weight and the mediating effect of dietary patterns: the Shanghai Maternal-Child Pairs Cohort study

BACKGROUND

Maternal stress and nutrition during pregnancy are two of the most commonly studied factors in the context of fetal development. However, few investigators have considered the combined effects of stress and diet in pregnant women and their offspring.

AIMS

To determine the impact of maternal stress on offspring birth weight, and the potential mediating role of maternal dietary patterns.

METHODS

A total of 3542 pregnant women and their singleton live births were recruited from Shanghai Maternal-Child Pairs Cohort (Shanghai MCPC). Maternal stress was assessed using the Life Event Scale for Pregnant Women (LESPW) in early and late pregnancy. Food frequency questionnaire (FFQ) was performed to evaluate maternal diet in late pregnancy. Multiple linear regression was conducted to estimate the associations between maternal stress and child birth weight. Logistic regression was performed to calculate the association between maternal stress and small for gestational age (SGA)/large for gestational age (LGA). The bootstrap method was used to investigate the mediating effects of maternal dietary patterns.

RESULTS

Maternal subjective events stress (β = 0.367) and total stress (β = 0.079) in early pregnancy, and positive objective life events stress (β = 0.275) in late pregnancy, were positively associated with birth weight. Maternal dietary pattern of "high-fat and sugar" mediated the associations between subjective events stress and total stress during early pregnancy and birth weight. An increased risk for LGA was observed among women exposed to relatively higher stress during early pregnancy (OR, 1.416; 95% CI, 1.035-1.937). No statistically significant associations were found between maternal stress during late pregnancy and child birth weight or SGA/LGA.

CONCLUSIONS

Maternal life events stress during early pregnancy significantly increases neonatal birth weight and risk for LGA, which may mediate by a "high-fat and sugar" dietary pattern.

LIMITATIONS

The lack of biological markers limits the explanation of the mechanism. The assessment of diet used food intake frequency to evaluate dietary characteristics, which may miss information of energy intake.

Engaging adolescents in changing behaviour (EACH-B): a study protocol for a cluster randomised controlled trial to improve dietary quality and physical activity

BACKGROUND

Poor diet and lack of physical activity are strongly linked to non-communicable disease risk, but modifying them is challenging. There is increasing recognition that adolescence is an important time to intervene; habits formed during this period tend to last, and physical and psychological changes during adolescence make it an important time to help individuals form healthier habits. Improving adolescents' health behaviours is important not only for their own health now and in adulthood, but also for the health of any future children. Building on LifeLab-an existing, purpose-built educational facility at the University of Southampton-we have developed a multi-component intervention for secondary school students called Engaging Adolescents in Changing Behaviour (EACH-B) that aims to motivate and support adolescents to eat better and be more physically active.

METHODS

A cluster randomised controlled trial is being conducted to evaluate the effectiveness of the EACH-B intervention. The primary outcomes of the intervention are self-reported dietary quality and objectively measured physical activity (PA) levels, both assessed at baseline and at 12-month follow-up. The EACH-B intervention consists of three linked elements: professional development for teachers including training in communication skills to support health behaviour change; the LifeLab educational module comprising in-school teaching of nine science lessons linked to the English National Curriculum and a practical day visit to the LifeLab facility; and a personalised digital intervention that involves social support and game features that promote eating better and being more active. Both the taught module and the LifeLab day are designed with a focus on the science behind the messages about positive health behaviours, such as diet and PA, for the adolescents now, in adulthood and their future offspring, with the aim of promoting personal plans for change. The EACH-B research trial aims to recruit approximately 2300 secondary school students aged 12-13 years from 50 schools (the clusters) from Hampshire and neighbouring counties. Participating schools will be randomised to either the control or intervention arm. The intervention will be run during two academic years, with continual recruitment of schools throughout the school year until the sample size is reached. The schools allocated to the control arm will receive normal schooling but will be offered the intervention after data collection for the trial is complete. An economic model will be developed to assess the cost-effectiveness of the EACH-B intervention compared with usual schooling.

DISCUSSION

Adolescents' health needs are often ignored and they can be difficult to engage in behaviour change. Building a cheap, sustainable way of engaging them in making healthier choices will benefit their long-term health and that of their future children.

TRIAL REGISTRATION

ISRCTN 74109264 . Registered on 30 August 2019. EACH-B is a cluster randomised controlled trial, funded by the National Institute for Health Research (RP-PG-0216-20004).

Regional variation in Black infant mortality: The contribution of contextual factors

BACKGROUND

Compared to other racial/ethnic groups, infant mortality rates (IMR) are persistently highestamong Black infants in the United States, yet there is considerable regional variation. We examined state and county-level contextual factors that may explain regional differences in Black IMR and identified potential strategies for improvement.

METHODS AND FINDINGS

Black infant mortality data are from the Linked Birth/Infant Death files for 2009-2011. State and county contextual factors within social, economic, environmental, and health domains were compiled from various Census databases, the Food Environment Atlas, and the Area Health Resource File. Region was defined by the nine Census Divisions. We examined contextual associations with Black IMR using aggregated county-level Poisson regression with standard errors adjusted for clustering by state. Overall, Black IMR varied 1.5-fold across regions, ranging from 8.78 per 1,000 in New England to 13.77 per 1,000 in the Midwest. In adjusted models, the following factors were protective for Black IMR: higher state-level Black-White marriage rate (rate ratio (RR) per standard deviation (SD) increase = 0.81, 95% confidence interval (CI):0.70-0.95), higher state maternal and child health budget per capita (RR per SD = 0.96, 95% CI:0.92-0.99), and higher county-level Black index of concentration at the extremes (RR per SD = 0.85, 95% CI:0.81-0.90). Modeled variables accounted for 35% of the regional variation in Black IMR.

CONCLUSIONS

These findings are broadly supportive of ongoing public policy efforts to enhance social integration across races, support health and social welfare program spending, and improve economic prosperity. Although contextual factors accounted for about a third of regional variation, further research is needed to more fully understand regional variation in Black IMR disparities.

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.

Maternal profile according to Mediterranean diet adherence and small for gestational age and preterm newborn outcomes

OBJECTIVE

The objective was to evaluate maternal Mediterranean diet (MD) pattern adherence during pregnancy and its association with small for gestational age (SGA) and preterm birth. A secondary objective of the current study was to describe the sociodemographic, lifestyle and obstetric profile of the mothers studied as well as the most relevant paternal and newborn characteristics.

DESIGN

The current study is a two-phase retrospective population-based study of maternal dietary habits during pregnancy and their effect on newborn size and prematurity. The descriptive first phase examined maternal dietary habits during pregnancy along with the maternal sociodemographic, lifestyle and obstetric profile in a cross-sectional period study. In the second phase, newborn outcomes were evaluated in a nested case-control study. Adherence to MD during pregnancy was measured with the Spanish version of Kidmed index.

SETTING

Obstetrics ward of the La Fe Hospital in Valencia.

PARTICIPANTS

All mother-child pairs admitted after delivery during a 12-month period starting from January 2018 were assessed for eligibility. A total of 1118 provided complete outcome data after signing informed consent.

RESULTS

14·5 % met the criteria of poor adherence (PA); 34·8 %, medium adherence (MA); and 50·7 %, optimal adherence (OA). Medium adherence to MD was associated in the adjusted scenarios with a higher risk of giving birth to a preterm newborn. No association was found between MD adherence and SGA.

CONCLUSIONS

Early intervention programmes geared towards pregnant women, where women were aided in reaching OA to MD, might reduce the risk of preterm newborn.

Impact of economic crises on offspring health and the developmental origins of health and disease concept

There is emerging evidence that economic crises may impact long-term health. Furthermore, adversity experienced by women and their offspring might be transmitted to next generations. The Developmental Origins of Health and Disease (DOHaD) approach emphasises the importance of early life events for the state of health and risk for disease later in life. In this review, we discuss current evidence on the possible impact of economic crises on offspring health through the DOHaD framework and highlight the importance of critical periods of development for future disease risk. Therefore, successful interventions should prioritise strategies that address early life risk factors.

The Maternal Nutritional Buffering Model: an evolutionary framework for pregnancy nutritional intervention

Evidence that fetal nutrition influences adult health has heightened interest in nutritional interventions targeting pregnancy. However, as is true for other placental mammals, human females have evolved mechanisms that help buffer the fetus against short-term fluctuations in maternal diet and energy status. In this review, we first discuss the evolution of increasingly elaborate vertebrate strategies of buffering offspring from environmental fluctuations during development, including the important innovation of the eutherian placenta. We then present the Maternal Nutritional Buffering Model, which argues that, in contrast to many micronutrients that must be derived from dietary sources, the effects of short-term changes in maternal macronutrient intake during pregnancy, whether due to a deficit or supplementation, will be minimized by internal buffering mechanisms that work to ensure a stable supply of essential resources. In contrast to the minimal effects of brief macronutrient supplementation, there is growing evidence that sustained improvements in early life and adult pre-pregnancy nutrition could improve birth outcomes in offspring. Building on these and other observations, we propose that strategies to improve fetal macronutrient delivery will be most effective if they modify the pregnancy metabolism of mothers by targeting nutrition prior to conception and even during early development, as a complement to the conventional focus on bolstering macronutrient intake during pregnancy itself. Our model leads to the prediction that birth weight will be more strongly influenced by the mother’s chronic pre-pregnancy nutrition than by pregnancy diet, and highlights the need for policy solutions aimed at optimizing future, intergenerational health outcomes.

Lay summary: We propose that strategies to improve fetal macronutrient delivery will be most effective if they modify the pregnancy metabolism of mothers by targeting nutrition prior to conception and even during early development, as a complement to the conventional focus on bolstering macronutrient intake during pregnancy itself.

Computer-based tailored dietary counselling improves the nutrient adequacy of the diet of French pregnant women: a randomised controlled trial

During pregnancy, mothers-to-be should adapt their diet to meet increases in nutrient requirements. Pregnant women appear to be keener to adopt healthier diets, but are not always successful. The objective of the present study was to determine whether a guided, stepwise and tailored dietary counselling programme, designed using an optimisation algorithm, could improve the nutrient adequacy of the diet of pregnant women, beyond generic guidelines. Pregnant women (n 80) who attended Notre-Dame-de-Bon-Secours Maternity Clinic were randomly allocated to the control or intervention arm. Dietary data were obtained twice from an online 3-d dietary record. The nutrient adequacy of the diet was calculated using the PANDiet score, a 100-point diet quality index adapted to the specific nutrient requirements for pregnancy. Women were supplied with generic dietary guidelines in a reference booklet. In the intervention arm, they also received nine sets of tailored dietary advice identified by an optimisation algorithm as best improving their PANDiet score. Pregnant women (n 78) completed the 12-week dietary follow-up. Initial PANDiet scores were similar in the control and intervention arms (60·4 (sd 7·3) v. 60·3 (sd 7·3), P = 0·92). The PANDiet score increased in the intervention arm (+3·6 (sd 9·3), P = 0·02) but not in the control arm (-0·3 (sd 7·3), P = 0·77), and these changes differed between arms (P = 0·04). In the intervention arm, there were improvements in the probabilities of adequacy for α-linolenic acid, thiamin, folate and cholesterol intakes (P < 0·05). Tailored dietary counselling using a computer-based algorithm is more effective than generic dietary counselling alone in improving the nutrient adequacy of the diet of French women in mid-pregnancy.

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.

The relationship between early pregnancy dietary intakes and subsequent birthweight and neonatal adiposity

Background

Maternal nutrition intakes may influence neonatal birthweight and adiposity; however, inconsistencies within the literature exist. The relationships between maternal dietary intakes in early pregnancy and both birthweight and neonatal adiposity requires elucidation. This study examined the relationship between early pregnancy dietary intakes and subsequent birthweight and neonatal adiposity.

Methods

Women were recruited at their convenience after sonographic confirmation of a singleton pregnancy. Women completed a Willet food frequency questionnaire evaluating habitual food and nutrient intakes at their first antenatal visit. Neonatal body composition was measured using air-displacement plethysmography.

Results

Of the 385 mother-neonate dyads, mean maternal age was 30.8 ± 5.3 years, mean Body Mass Index (BMI) was 24.5 ± 4.8 kg/m2 and 41.8% (n = 161) were nulliparous. There were no relationships between maternal food intakes and birthweight (P > 0.05) (n = 385). On multivariable analysis there was a positive relationship between polyunsaturated fat and neonatal fat mass index (FMI) (beta = 0.015, 95% CI = 0.002-0.028, P = 0.04) (n = 80).

Conclusion

Dietary intakes of polyunsaturated fat in early pregnancy are positively associated with neonatal FMI at birth on multivariable analysis. Further longitudinal studies need to explore this association and the long-term implications for the neonate.

Burden and determinants of malnutrition among pregnant women in Africa: A systematic review and meta-analysis

BACKGROUND

Malnutrition in pregnancy remains unacceptably high across all regions of Africa though promising progresses have been made globally. Primary studies might not be sufficient to portrait a comprehensive picture of malnutrition during pregnancy and its main risk factors. Therefore, we intended to review the burden of malnutrition, for this specific review implies to protein energy malnutrition, during pregnancy in Africa to present its magnitude and determinant factors.

METHODS

We did a systematic review of observational studies published from January 1/2008 to January 31/2018. The CINAHL(EBSCO), MEDLINE (via Ovid), Emcare, PubMed databases and Google scholar were searched. Articles quality was assessed using the Newcastle-Ottawa Scale and studies with fair to good quality were included. We pooled malnutrition prevalence and an odds ratio estimates for risk factors after checking for heterogeneity and publication bias. This review has been registered in Prospero with a protocol number CRD42018114949.

RESULT

23 studies involving 20,672 pregnant women were included. Using a random effect model, the overall pooled prevalence of malnutrition among pregnant women in Africa was 23.5% (95%CI: 17.72-29.32; I2 = 98.5%). Based on the current review pooled odds ratio finding; rural residency (POR = 2.6%; 95%CI: 1.48-4.65; I2 = 0%), low educational status of partners (POR = 1.7%; 95%CI: 1.19-2.53; I2 = 54.8%), multiple pregnancy (POR = 2.15%; 95%CI: 1.27-3.64; I2 = 0%) and poor nutritional indicators (POR = 2.03%; 95%CI: 1.72-2.4, I2 = 0%) were positively determine maternal malnutrition. On contrary, better household economic status (POR = 0.47%; 95%CI: 0.36-0.62; I2 = 24.2%) negatively determine maternal malnutrition.

CONCLUSION

A significant number of the pregnant population in Africa are suffering of malnutrition, above 10% of the standard acceptable malnutrition rate. Thus, efforts should be renewed to ensure a proper and widespread implementation of programs that would address issues identified in the current review to reduce the burden of malnutrition.

Healthy Life Trajectories Initiative: Summary of the evidence base for pregnancy-related interventions to prevent overweight and obesity in children

This overview of systematic reviews (SRs) aimed to identify dietary and lifestyle interventions in pregnant women that reduce the prevalence of overweight, obesity, and/or risk factors thereof, in their children. Following identification of eligible SRs, a matrix of all included studies identified overlap between SRs. The most recent, comprehensive, high-quality SRs were selected for further dissagregation. We developed a Grading of Recommendations, Assessment, Development and Evaluations (GRADE)-based effectiveness matrix incorporating effect size and study quality to prioritise interventions as (1) beneficial or harmful, (2) possibly beneficial or possibly harmful, (3) no effect, (4) possibly no effect, or (5) uncertain effect. Of the 27 SRs identified, 16 SRs were excluded due to overlap. From 11 remaining SRs, five discrete interventions were ranked "beneficial" or "possibly beneficial" for reducing risk factors for childhood obesity: (1) balanced energy/protein supplements, (2) dietary counseling alone, (3) low glycemic index dietary advice, (4) diet and exercise counseling, (5) diet counseling and supervised exercise. High protein supplementation was ranked "harmful" as it increased the risk of small-for-gestational age (SGA) infants in normal-weight pregnant women. Evidence of the impact of pregnancy-related diet or lifestyle interventions, on childhood obesity was limited. Five dietary interventions, alone or in combination with exercise, showed beneficial effects on the risk factors for childhood obesity.

A systematic review of associations between maternal exposures during pregnancy other than smoking and antenatal fetal measurements

BACKGROUND

Reduced birth weight is associated with many maternal environmental exposures during pregnancy, but the gestational age at onset of this association is unknown. We have previously reported associations between maternal smoking and fetal size.

OBJECTIVE

To report on our systematic review of the literature describing associations between antenatal size and growth and maternal exposures during pregnancy.

DATA SOURCES

Electronic databases (OVID and EMBASE) and web sites for cohort studies were searched. Studies were eligible if they examined associations between maternal environmental exposures (including ambient air exposure, diet and alcohol) and antenatal fetal ultrasound measurements. The Navigation Guide was used to assess the strength of evidence.

RESULTS

There were 451 abstracts identified and 36 papers were included of which maternal diet was the exposure of interest in 15, maternal ambient air exposure in 10, maternal alcohol in 3 and other exposures in 8. The first paper was published in 2006. Associations were present between exposures and fetal measurements in 18% of comparisons with second trimester measurements and in 46% of comparisons with third trimester measurements. In the third trimester, when an association was present, reduced head size was most commonly (58%) associated with current or previous maternal exposure, with reduced length being least commonly (32%) associated and reduced weight being intermediate (52%). In the third trimester, increased maternal nitrogen dioxide exposure was associated with reduced head size was associated with in all seven studies identified and reduced fetal weight in five out of six studies.

CONCLUSION

There is sufficient evidence of toxicity in the context of maternal exposure to nitrogen dioxide and reduced third trimester fetal head size. There is currently insufficient evidence of toxicity with regard to maternal exposures to dietary factors, alcohol and environmental chemicals and reduced fetal size.

Nutrition and the Use of Supplements in Women During Pregnancy: A Cross-Sectional Survey

OBJECTIVE

A healthy diet during pregnancy is essential to ensure optimal fetal growth and development. Women's awareness of dietary guidelines may assist them in following a healthy diet for themselves and their unborn babies. The Institute of Medicine and the American College of Obstetrics and Gynecology have published recommendations concerning the nutrition of pregnant/nursing women. The Israeli Ministry of Health has adopted these recommendations in revised guidelines published in 2015. The aim of this study was to describe the dietary habits among pregnant/nursing women in Israel and to assess the correlation between socioeconomic parameters and adherence to those guidelines.

METHODS

We performed a cross-sectional survey by interviewing pregnant/lactating women attending family health centers (FHC) in different areas of Tel Aviv, Israel.

RESULTS

One-half of the 239 recruited women reported having been informed of the guidelines for dietary changes during and after pregnancy, 30% by a professional source. Women in a lower socioeconomic status (SES) consumed more undercooked (rare) beef, raw fish, and caffeine compared to women in a higher SES (P = 0.03 and P = 0.003, respectively). The former was less compliant with the recommendation for folic acid supplementation (155 [(88.1]) vs 47 [(77]), P = 0.05) and less likely to use other dietary supplements during pregnancy, e.g., multivitamins and omega 3, than the latter (P = 0.01 and P < 0.001, respectively).

CONCLUSION

This survey revealed deficiencies in adherence to the implementation of medical guidelines to nutrition during and after pregnancy, as well as gaps between women of different SESs, mostly in the use of dietary supplements.

Development of a novel Periconceptual Nutrition Score (PENS) to examine the relationship between maternal dietary quality and fetal growth

BACKGROUND

Maternal nutrition may influence intrauterine fetal development. To date, the relationship between contemporary European dietary guidelines and fetal growth has not been examined.

AIMS

To develop a novel Periconceptual Nutrition Score (PENS) to assess maternal dietary quality in early pregnancy and examine its relationship with fetal growth.

STUDY DESIGN

Women were recruited conveniently at their first clinic visit and completed a supervised four day retrospective diet history. The PENS was developed using European Food Safety Authority recommended dietary intakes for pregnancy. The relationship between PENS and fetal growth was examined.

SUBJECTS

Women with a singleton pregnancy.

OUTCOME MEASURES

Birthweight, small for gestational age (SGA), neonatal head circumference.

RESULTS AND CONCLUSIONS

Of the 202 women, the mean age was 32.2 ± 5.0 years and 44.6% were nulliparas. The mean PENS was 9.4 ± 3.1. On multivariable regression, there was a positive relationship between the PENS and birthweight (beta = 45.3, 95%CI 14.8-75.9, P = 0.002) and neonatal head circumference (beta = 0.12, 95%CI 0.01-0.23, P = 0.03). Compared with the lowest PENS quartile, the mean birthweight was increased in the highest quartile (Mean difference 328 g, P = 0.02). The incidence of SGA was 16.4% (n = 10/61) in the lowest PENS quartile compared to 6.5% (n = 9/139) in the top three quartiles (P = 0.03). Thus, higher maternal dietary quality was associated with increased intrauterine fetal growth. The PENS is potentially useful in identifying those women before or during pregnancy who may benefit from dietary interventions that may optimise fetal growth. It may also be useful in tracking maternal dietary quality during pregnancy.

A multivariate discrete failure time model for the analysis of infant motor development

We develop a multivariate discrete failure time model for the analysis of infant motor development. We use the model to jointly evaluate the time (in months) to achievement of three well-established motor milestones: sitting up, crawling, and walking. The model includes a subject-specific latent factor that reflects underlying heterogeneity in the population and accounts for within-subject dependence across the milestones. The factor loadings and covariate effects are allowed to vary flexibly across milestones, and the milestones are permitted to have unique at-risk intervals corresponding to different developmental windows. We adopt a Bayesian inferential approach and develop a convenient data-augmented Gibbs sampler for posterior computation. We conduct simulation studies to illustrate key features of the model and use the model to analyze data from the Nurture study, a birth cohort examining infant health and development during the first year of life.

Effects of high-fat diets on fetal growth in rodents: a systematic review

BACKGROUND

Maternal nutrition during pregnancy has life-long consequences for offspring. However, the effects of maternal overnutrition and/ or obesity on fetal growth remain poorly understood, e.g., it is not clear why birthweight is increased in some obese pregnancies but not in others. Maternal obesity is frequently studied using rodents on high-fat diets, but effects on fetal growth are inconsistent. The purpose of this review is to identify factors that contribute to reduced or increased fetal growth in rodent models of maternal overnutrition.

METHODS

We searched Web of Science and screened 2173 abstracts and 328 full texts for studies that fed mice or rats diets providing ~ 45% or ~ 60% calories from fat for 3 weeks or more prior to pregnancy. We identified 36 papers matching the search criteria that reported birthweight or fetal weight.

RESULTS

Studies that fed 45% fat diets to mice or 60% fat diets to rats generally did not show effects on fetal growth. Feeding a 45% fat diet to rats generally reduced birth and fetal weight. Feeding mice a 60% fat diet for 4-9 weeks prior to pregnancy tended to increase in fetal growth, whereas feeding this diet for a longer period tended to reduce fetal growth.

CONCLUSIONS

The high-fat diets used most often with rodents do not closely match Western diets and frequently reduce fetal growth, which is not a typical feature of obese human pregnancies. Adoption of standard protocols that more accurately mimic effects on fetal growth observed in obese human pregnancies will improve translational impact in this field.

The effect of portable HEPA filter air cleaner use during pregnancy on fetal growth: The UGAAR randomized controlled trial

BACKGROUND

Fine particulate matter (PM_2.5) exposure may impair fetal growth.

AIMS/OBJECTIVES

Our aim was to assess the effect of portable high efficiency particulate air (HEPA) filter air cleaner use during pregnancy on fetal growth.

METHODS

The Ulaanbaatar Gestation and Air Pollution Research (UGAAR) study is a single-blind randomized controlled trial conducted in Ulaanbaatar, Mongolia. Non-smoking pregnant women recruited at ≤18 weeks gestation were randomized to an intervention (1-2 air cleaners in homes from early pregnancy until childbirth) or control (no air cleaners) group. Participants were not blinded to their intervention status. Demographic, health, and birth outcome data were obtained via questionnaires and clinic records. We used unadjusted linear and logistic regression and time-to-event analysis to evaluate the intervention. Our primary outcome was birth weight. Secondary outcomes were gestational age-adjusted birth weight, birth length, head circumference, gestational age at birth, and small for gestational age. The study is registered at ClinicalTrials.gov (NCT01741051).

RESULTS

We recruited 540 participants (272 control and 268 intervention) from January 9, 2014 to May 1, 2015. There were 465 live births and 28 losses to follow up. We previously reported a 29% (95% CI: 21, 37%) reduction in indoor PM_2.5 concentrations with portable HEPA filter air cleaner use. The median (25th, 75th percentile) birth weights for control and intervention participants were 3450 g (3150, 3800 g) and 3550 g (3200, 3800 g), respectively (p = 0.34). The intervention was not associated with birth weight (18 g; 95% CI: -84, 120 g), but in a pre-specified subgroup analysis of 429 term births the intervention was associated with an 85 g (95% CI: 3, 167 g) increase in mean birth weight.

CONCLUSIONS

HEPA filter air cleaner use in a high pollution setting was associated with greater birth weight only among babies born at term.

Exploring the views of young women and their healthcare professionals on dietary habits and supplementation practices in adolescent pregnancy: a qualitative study

Background

Nutrition is a modifiable factor affecting foetal growth and pregnancy outcomes. Inadequate nutrition is of particular concern in adolescent pregnancies with poor quality diet and competing demands for nutrients. The aim of this study was to explore knowledge and understanding of nutrition advice during adolescent pregnancy, and identify barriers and facilitators to dietary change and supplementation use in this vulnerable population.

Methods

Semi-structured interviews were conducted with young women and key antenatal healthcare providers: midwives, family nurses and obstetricians. Doncaster, Manchester and London were chosen as sites offering different models of midwifery care alongside referral to the Family Nurse Partnership programme.

Results

A total of 34 young women (adolescents aged 16–19 years) and 20 health professionals were interviewed. Young women made small changes to their dietary intake despite limited knowledge and social constraints. Supplementation use varied; the tablet format was identified by few participants as a barrier but forgetting to take them was the main reason for poor adherence. Health professionals provided nutrition information but often lack the time and resources to tailor this appropriately. Young women’s prime motivator was a desire to have a healthy baby; they wanted to understand the benefits of supplementation and dietary change in those terms.

Conclusion

Pregnancy is a window of opportunity for improving nutrition but often constrained by social circumstances. Health professionals should be supported in their role to access education, training and resources which build their self-efficacy to facilitate change in this vulnerable population group beyond the routine care they provide.

Electronic supplementary material

The online version of this article (10.1186/s40795-018-0254-7) contains supplementary material, which is available to authorized users.

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.

Maternal dietary patterns and risk of adverse pregnancy (hypertensive disorders of pregnancy and gestational diabetes mellitus) and birth (preterm birth and low birth weight) outcomes: a systematic review and meta-analysis

OBJECTIVE

Epidemiological studies have indicated that dietary patterns during pregnancy are associated with adverse pregnancy and birth outcomes such as hypertensive disorders of pregnancy (HDP), gestational diabetes mellitus (GDM), preterm birth (PTB) and low birth weight (LBW). However, the results of these studies are varied and inconsistent. The present study aimed to assess the association between dietary patterns and the risk of adverse pregnancy and birth outcomes.

DESIGN

Systematic review and meta-analysis. Seven databases were searched for articles. Two reviewers performed the study selection and data extraction. A random-effects model was used to estimate pooled effect sizes of eligible studies.

SETTING

Studies conducted all over the world were incorporated.

SUBJECTS

The review focused on pregnant women.

RESULTS

A total of twenty-one studies were identified. Adherence to a healthy dietary pattern (intake of vegetables, fruits, legumes, whole grains) was significantly associated with lower odds (OR; 95 % CI) of pre-eclampsia (0·78; 0·70, 0·86; I2=39·0 %, P=0·178), GDM (0·78; 0·56, 0·99; I2=68·6 %, P=0·013) and PTB (0·75; 0·57, 0·93; I2=89·6 %, P=0·0001).

CONCLUSIONS

Our review suggests that dietary patterns with a higher intake of fruits, vegetables, legumes, whole grains and fish are associated with a decreased likelihood of adverse pregnancy and birth outcomes. Further research should be conducted in low-income countries to understand the impact of limited resources on dietary intake and adverse pregnancy and birth outcomes.

Effectiveness of maternal dietary interventions for improving mother and infant health outcomes: an umbrella review protocol

REVIEW QUESTION/OBJECTIVE

The objective of this umbrella review is to determine the characteristics of dietary interventions delivered any time before, during or after pregnancy for women living in developed countries, identified in quantitative systematic reviews as effective for improving mother and infant health outcomes and feasible for translation into practice.Specifically, the review will address the following questions:For the purpose of this overview, dietary interventions encompass the broad scope of dietary manipulations, including the direct provision of food and/or nutrients to participants, nutrition education, nutrition counseling, nutrition care teams, or any combination of these four intervention types.Both a narrative and quantitative summary on the effect of maternal dietary interventions on maternal and infant health outcomes as compared with usual care will be provided. The quantitative summary of the maternal and infant outcomes will be supported by an appraisal of the certainty of evidence of the effects and the strength of the recommendations using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) framework.

Effect of Adherence to a Mediterranean Diet and Olive Oil Intake during Pregnancy on Risk of Small for Gestational Age Infants

To quantify the effect of a Mediterranean dietary pattern, as well as the consumption of olive oil (OO), on the risk of having a small for gestational age infants (SGA), a matched case-control study was conducted in Spain. Dietary intake during pregnancy was assessed using a validated food frequency questionnaire. Three indices were used to evaluate the adherence to Mediterranean diet (MD) (Predimed, Trichopoulou and Panagiotakos). Crude odds ratios (cOR) and adjusted odds ratios (aOR) and their 95% confidence intervals (CI) were estimated using conditional logistic regression models. Results were stratified by severity of SGA: moderate (percentiles 6–10), and severe (percentiles ≤5). For moderate, four or more points in the Predimed´s index was associated with a 41% reduction of having SGA compared with women with a score ≤3, aOR = 0.59 (95% CI 0.38–0.98); for severe, the reduction in risk was not statistically significant. Similar results were found when the other MD indexes were used. An intake of OO above 5 g/day was associated with a lower risk of SGA (aOR = 0.53, 95% CI 0.34–0.85); statistical significance was observed for moderate SGA (aOR = 0.53, 95% CI 0.30–0.96), but not for severe SGA (aOR = 0.51, 95% CI 0.24–1.07), although the magnitude of ORs were quite similar. Adherence to a MD and OO intake is associated with a reduced risk of SGA.

A Retrospective Cross-Sectional Population-Based Study on Prenatal Levels of Adherence to the Mediterranean Diet: Maternal Profile and Effects on the Newborn

The Mediterranean diet (MD) is a dietary pattern with important benefits. The objectives of this study were to assess the adherence to the MD among pregnant women in Valencia (Spain) and characterize the pregnant women according to their level of adherence. Finally, we aimed to examine the role of MD adherence during pregnancy in the anthropometric development of the newborn. The study included 492 pregnant women who were followed at La Fe Hospital in 2017. The self-administered "Kidmed" questionnaire for data collection on dietary information evaluation was used and a clinical history review of mothers and newborns was performed. Two groups of mothers were identified: those with low adherence (LA) and optimal adherence (OA). The study revealed that 40.2% of the women showed LA to the MD. The newborns born to these women presented a higher risk of being small for gestational age (SGA) {adjusted odds ratio (aOR) = 1.68; 95% confidence interval (CI) 1.02⁻5.46} when adjusting for parental body mass index (BMI) and multiple gestation, but not when adjusting for all significant possible confounders (aOR = 2.32; 95% CI 0.69⁻7.78). The association between MD and SGA was not significantly affected by the use of iron and folic acid supplements (aOR = 2.65; 95% CI 0.66⁻10.65). The profile of the pregnant woman with LA is that of a young smoker, with a low level of education and a low daily intake of dairy products. These results suggest that LA to the MD is not associated with a higher risk of giving birth to a SGA newborn.

Estado nutricional materno e sua associação com o peso ao nascer em gestações de alto risco

Resumo O estado clínico e o nutricional da gestante representam importantes variáveis para o risco de inadequações de peso ao nascer. Assim, o presente estudo visou avaliar o estado nutricional de gestantes de alto risco e sua associação com o peso ao nascer de seus conceptos. Estudo transversal com gestantes de alto risco assistidas no Hospital Universitário de Maceió-AL e seus recém-nascidos. O estado nutricional das gestantes e de seus conceptos foi avaliado segundo o Índice de Massa Corporal para a idade gestacional e o peso ao nascer, respectivamente. A associação entre fatores maternos (comorbidades e estado nutricional) e o peso ao nascer foram realizadas pelos testes de qui-quadrado e correlação de Pearson, adotando um nível de confiança de 95% (α = 0,05). Foram estudadas 149 gestantes, com 19,7% delas com baixo peso; 32,0% eutróficas e 48,3% com excesso de peso. Entre os recém-nascidos, 39,6% eram pequenos para idade gestacional (PIG); 26,8% adequados para a idade gestacional (AIG) e 33,6% grandes para a idade gestacional (GIG). O excesso de peso gestacional e a presença de comorbidades metabólicas se associaram com o nascimento de recém-nascidos GIG e o ganho ponderal gestacional insuficiente com o nascimento de recém-nascidos PIG, sendo fundamentais intervenções para redução desses desfechos.

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.

Evaluating LINE-1 methylation in cleft lip tissues and its association with early pregnancy exposures

Aim: To pilot investigation of methylation of long interspersed nucleotide element-1 in lip tissues from infants with nonsyndromic cleft lip, and its association with maternal periconceptional exposures. Methods: The lateral and medial sides of the cleft lips of 23 affected infants were analyzed for long interspersed nucleotide element-1 methylation by bisulfite conversion and pyrosequencing. Results: The medial side showed 1.8% higher methylation compared with the lateral side; p = 0.031, particularly in male infants (2.7% difference; p = 0.011) or when the mothers did not take folic acid during periconceptional period (2.4% difference; p = 0.011). These results were not statistically significant when Bonferroni adjustment was used. Conclusion: The observed differences in DNA methylation, although nonsignificant after correction for multiple comparisons, suggest that differential regulation of the two sides may impact lip fusion and warrant larger-scale replication.

Periconceptional maternal 'high fish and olive oil, low meat' dietary pattern is associated with increased embryonic growth: The Rotterdam Periconceptional Cohort (Predict) Study

OBJECTIVE

To investigate the association between periconceptional maternal dietary pattern and first-trimester embryonic growth.

METHODS

This was a prospective cohort study of 228 women with a singleton ongoing pregnancy, of which 135 were strictly dated spontaneous pregnancies and 93 were pregnancies achieved after in-vitro fertilization or intracytoplasmatic sperm injection (IVF/ICSI). All women underwent serial transvaginal three-dimensional ultrasound (3D-US) examinations from 6 + 0 to 13 + 0 weeks' gestation. Crown-rump length (CRL) and embryonic volume (EV) measurements were performed using a virtual reality system. Information on periconceptional maternal dietary intake was collected via food frequency questionnaires. Principal component analysis was performed to identify dietary patterns. Associations between dietary patterns and CRL and EV trajectories were investigated using linear mixed models adjusted for potential confounders.

RESULTS

A median of five (range, one to seven) 3D-US scans per pregnancy were performed. Of 1162 datasets, quality was sufficient to perform CRL measurements in 991 (85.3%) and EV measurements in 899 (77.4%). A dietary pattern comprising high intake of fish and olive oil and a very low intake of meat was identified as beneficial for embryonic growth. In strictly dated spontaneous pregnancies, strong adherence to the 'high fish and olive oil, low meat' dietary pattern was associated with a 1.9 mm (95% CI, 0.1-3.63 mm) increase in CRL (+14.6%) at 7 weeks and a 3.4 mm (95% CI, 0.2-7.81 mm) increase (+6.9%) at 11 weeks, whereas EV increased by 0.06 cm³ (95% CI, 0.01-0.13 cm³ ) (+20.4%) at 7 weeks and 1.43 cm³ (95% CI, 0.99-1.87 cm³ ) (+14.4%) at 11 weeks. No significant association was observed in the total study population or in the IVF/ICSI subgroup.

CONCLUSION

Periconceptional maternal adherence to a high fish and olive oil, low meat dietary pattern is positively associated with embryonic growth in spontaneously conceived pregnancies. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Obesity and gynaecological and obstetric conditions: umbrella review of the literature

Objective To study the strength and validity of associations between adiposity and risk of any type of obstetric or gynaecological conditions.Design An umbrella review of meta-analyses.Data sources PubMed, Cochrane database of systematic reviews, manual screening of references for systematic reviews or meta-analyses of observational and interventional studies evaluating the association between adiposity and risk of any obstetrical or gynaecological outcome.Main outcomes Meta-analyses of cohort studies on associations between indices of adiposity and obstetric and gynaecological outcomes.Data synthesis Evidence from observational studies was graded into strong, highly suggestive, suggestive, or weak based on the significance of the random effects summary estimate and the largest study in the included meta-analysis, the number of cases, heterogeneity between studies, 95% prediction intervals, small study effects, excess significance bias, and sensitivity analysis with credibility ceilings. Interventional meta-analyses were assessed separately.Results 156 meta-analyses of observational studies were included, investigating associations between adiposity and risk of 84 obstetric or gynaecological outcomes. Of the 144 meta-analyses that included cohort studies, only 11 (8%) had strong evidence for eight outcomes: adiposity was associated with a higher risk of endometrial cancer, ovarian cancer, antenatal depression, total and emergency caesarean section, pre-eclampsia, fetal macrosomia, and low Apgar score. The summary effect estimates ranged from 1.21 (95% confidence interval 1.13 to 1.29) for an association between a 0.1 unit increase in waist to hip ratio and risk endometrial cancer up to 4.14 (3.61 to 4.75) for risk of pre-eclampsia for BMI >35 compared with <25. Only three out of these eight outcomes were also assessed in meta-analyses of trials evaluating weight loss interventions. These interventions significantly reduced the risk of caesarean section and pre-eclampsia, whereas there was no evidence of association with fetal macrosomia.Conclusions Although the associations between adiposity and obstetric and gynaecological outcomes have been extensively studied, only a minority were considered strong and without hints of bias.

Trial of ready-to-use supplemental food and corn-soy blend in pregnant Malawian women with moderate malnutrition: a randomized controlled clinical trial

Background

Malnutrition during pregnancy in sub-Saharan Africa is associated with poor birth outcomes.

Objective

This study compared maternal and offspring anthropometry for moderately malnourished pregnant women receiving ready-to-use supplemental food (RUSF), a fortified corn-soy blend (CSB+) with a daily multiple micronutrient antenatal supplement [United Nations International Multiple Micronutrient Preparation (UNIMMAP)], or standard of care comprising CSB+ and iron and folic acid (IFA).

Design

A single-blind randomized controlled clinical trial was conducted in southern Malawi among 1828 pregnant women with moderate malnutrition, defined as a midupper arm circumference (MUAC) ≥20.6 and ≤23.0 cm. Women received 1 of 3 dietary treatment regimens that provided ∼900 kcal/d and 33-36 g protein/d. Maternal and infant anthropometry were followed until the child was 3 mo old.

Results

Newborns had a mean length-for-age z score of -1.3 ± 1.2 and 22% were stunted at birth. Mothers receiving RUSF had the highest weight gain during supplementation (3.4 ± 2.6, 3.0 ± 2.2, and 3.2 ± 2.4 kg for the RUSF, CSB+ with UNIMMAP, and CSB+ with IFA groups, respectively; P = 0.03). Newborn birth weights and lengths were similar across intervention groups, but the incidence of newborns with a birth weight <2.4 kg (weight-for-age z score <-2) was higher in the CSB+ with UNIMMAP group than the other groups (17%, 18%, and 24% for the CSB+ with IFA, RUSF, and CSB+ with UNIMMAP groups, respectively; P = 0.02). At birth, HIV-exposed newborns had a similar length and weight as newborns without HIV exposure, but their head circumference was smaller (34.0 ± 1.5 and 34.3 ± 1.6 cm, respectively; P = 0.02). At 3 mo of age, HIV-exposed infants had smaller weights, lengths, and head and arm circumferences than infants without HIV exposure.

Conclusions

RUSF improved maternal weight gain compared with CSB+ with UNIMMAP. The large amount of food given and the modest effect on linear growth in newborns suggests that stunting in utero is unlikely to be reduced by supplemental food alone. This trial was registered at clinicaltrials.gov as NCT02120599.