Early and late preterm birth rates in participants adherent to randomly assigned high dose docosahexaenoic acid (DHA) supplementation in pregnancy

BACKGROUND

Intention-to-treat analyses do not address adherence. Per protocol analyses treat nonadherence as a protocol deviation and assess if the intervention is effective if followed.

OBJECTIVE

To determine the rate of early preterm birth (EPTB, <34 weeks gestation) and preterm birth (PTB, <37 weeks gestation) in participants who adhered to a randomly assigned docosahexaenoic acid (DHA) dose of 1000 mg/day.

STUDY DESIGN

Eleven hundred women with a singleton pregnancy were enrolled before 20-weeks' gestation, provided a capsule with 200 mg/day DHA and randomly assigned to two additional capsules containing a placebo or 800 mg of DHA. In the Bayesian Adaptive Design, new randomization schedules were determined at prespecified intervals. In each randomization, the group with the most EPTB was assigned fewer participants than the other group. Adherence was defined a priori as a postpartum red blood cell phospholipid DHA (RBC-PL-DHA) ≥5.5%.and post hoc as ≥8.0% RBC-PL-DHA, the latter after examination of postpartum RBC-PL-DHA. Bayesian mixture models were fitted for gestational age and dichotomized for EPTB and PTB as a function of baseline RBC-PL-DHA and dose-adherence. Bayesian hierarchical models were also fitted for EPTB by dose adherence and quartiles of baseline RBC-PL-DHA.

RESULTS

Adherence to the high dose using both RBC-PL-DHA cut points resulted in less EPTB compared to 200 mg [Bayesian posterior probability (pp) = 0.93 and 0.92, respectively]. For participants in the two lowest quartiles of baseline DHA status, adherence to the higher dose resulted in lower EPTB (≥5.5% RBC-PL-DHA, quartiles 1 and 2, pp = 0.95 and 0.96; ≥8% RBC-PL-DHA, quartiles 1 and 2, pp = 0.94 and 0.95). Using the Bayesian model, EPTB was reduced by 65%, from 3.45% to 1.2%, using both cut points. Adherence also reduced PTB before 35, 36 and 37 weeks using both cut points (pp ≥ 0.95). In general, performance of the nonadherent subgroup mirrored that of participants assigned to 200 mg.

CONCLUSION

Adherence to high dose DHA reduced EPTB and PTB. The largest effect of adherence on reducing EPTB was observed in women with low baseline DHA levels.

CLINICALTRIALS

gov (NCT02626299).

Docosahexaenoic acid (DHA) intake estimated from a 7-question survey identifies pregnancies most likely to benefit from high-dose DHA supplementation

BACKGROUND

Two randomized trials found women with low blood docosahexaenoic acid (DHA; an omega 3 fatty acid) had fewer early preterm births (<34 weeks gestation) if they were assigned to high dose DHA supplementation, however, there is currently no capacity for clinicians who care for pregnancies to obtain a blood assessment of DHA. Determining a way to identify women with low DHA intake whose risk could be lowered by high dose DHA supplementation is desired.

OBJECTIVE

To determine if assessing DHA intake can identify pregnancies that benefit from high dose DHA supplementation.

STUDY DESIGN

This secondary analysis used birth data from 1310 pregnant women who completed a 7-question food frequency questionnaire (DHA-FFQ) at 16.8 ± 2.5 weeks gestation that is validated to assess DHA status. They were then randomly assigned to a standard (200 mg/day) or high dose (800 or 1000 mg/day) DHA supplement for the remainder of pregnancy. Bayesian logistic regressions were fitted for early preterm birth and preterm birth as a function of DHA intake and assigned DHA dose.

RESULTS

Participants who consumed less than 150 mg/day DHA prior to 20 weeks' gestation (n = 810/1310, 58.1%) had a lower Bayesian posterior probability (pp) of early preterm birth if they were assigned to high dose DHA supplementation (1.4% vs 3.9%, pp = 0.99). The effect on preterm birth (<37 weeks) was also significant (11.3% vs 14.8%, pp = 0.97).

CONCLUSION

The DHA-FFQ can identify pregnancies that will benefit most from high dose DHA supplementation and reduce the risk of preterm birth. The DHA-FFQ is low burden to providers and patients and could be easily implemented in obstetrical practice.

Validation of an abbreviated food frequency questionnaire for estimating DHA intake of pregnant women in the United States

Docosahexaenoic acid (DHA) intake was estimated in pregnant women between 12- and 20-weeks' gestation using the National Cancer Institute's (NCI) Diet History Questionnaire-II (DHQ-II) and a 7-question screener designed to capture DHA intake (DHA Food Frequency Questionnaire, DHA-FFQ). Results from both methods were compared to red blood cell phospholipid DHA (RBC-DHA) weight percent of total fatty acids. DHA intake from the DHA-FFQ was more highly correlated with RBC-DHA (r_s=0.528) than the DHQ-II (r_s=0.352). Moreover, the DHA-FFQ allowed us to obtain reliable intake data from 1355 of 1400 participants. The DHQ-II provided reliable intake for only 847 of 1400, because many participants only partially completed it and it was not validated for Hispanic participants. Maternal age, parity, and socioeconomic status (SES) were also significant predictors of RBC-DHA. When included with estimated intake from the DHA-FFQ, the model accounted for 36% of the variation in RBC-DHA.

A Randomized Trial of Maternal Docosahexaenoic Acid Supplementation to Reduce Inflammation in Extremely Preterm Infants

Maternal supplementation with 1000 mg/day docosahexaenoic acid (DHA) provides third trimester DHA accretion levels in breast milk for the preterm infant. We hypothesized that DHA supplementation to mothers providing breastmilk for extremely preterm infants would result in decreased inflammatory markers, in the infant. Mother/infant dyads (n = 27) were enrolled at birth and mothers were assigned to receive 200 or 1000 mg/day of DHA. Milk and plasma samples were analyzed for fatty acids and inflammatory markers. Decreases in inflammation were observed in both maternal and infant plasma and correlated with red blood cell (RBC) DHA levels. The fact that maternal DHA supplementation decreases infant markers of inflammation implies that DHA, delivered through breastmilk, has the potential to decrease inflammation in the infant.

Effects of hepatotoxic doses of acetaminophen and furosemide on tissue concentrations of CoASH and CoASSG in vivo

The effects of hepatotoxic doses of acetaminophen on tissue concentrations of CoA in the thiol form (CoASH) and as the corresponding mixed disulfide with GSH (CoASSG) were determined to test the hypotheses that early oxidant effects of acetaminophen are expressed principally in the mitochondrial compartment and that oxidative shifts in this redox couple could be employed as biomarkers of mitochondrially compartmentalized oxidant stresses. Administration of 400 mg of acetaminophen/kg to male ICR mice did not change CoASSG concentrations at 2, 4, or 6 h, but CoASH levels were lower than in saline-treated control animals at 2 and 4 h (77 +/- 8 vs 124 +/- 14 nmol/g of liver and 66 +/- 9 vs 142 +/- 7 nmol/g of liver, respectively). HPLC analyses of acid supernatants from livers of mice treated with acetaminophen in vivo showed a peak that coeluted with an adduct generated in vitro by reaction of CoASH with N-acetyl-p-benzoquinone imine, but extensive efforts to characterize further the putative product formed in vivo have been unsuccessful. Decreases in CoASH levels were not observed in mice given comparably hepatotoxic doses of furosemide, which diminishes the concern that the decreases in CoASH levels observed in the acetaminophen-treated mice were simply secondary to injury. Hepatic CoASSG concentrations were elevated 10-20-fold 2 h after administration of 400 or 500 mg of furosemide/kg, but were not different than in saline-treated control mice at 4 or 6 h. Increases in hepatic concentrations of GSSG were observed after 6 h in both the acetaminophen-treated and the furosemide-treated mice, suggesting that these changes may be more reflective of oxidant responses to hepatic necrosis than of thiol oxidation mechanisms involved in mediating the injury. The results presented here are not consistent with oxidant stress mechanisms in initiation of hepatic necrosis by acetaminophen in vivo, but the data suggest possible roles for mitochondrially compartmentalized oxidant effects of furosemide.

Skin-to-skin holding in the neonatal intensive care unit influences maternal milk volume

OBJECTIVES

To evaluate the effect of early initiation of skin-to-skin (STS) holding on lactation, we compared 24-hour milk volumes of mothers of ventilated low birth weight infants in an STS group to mothers in a non-STS control group.

STUDY DESIGN

Mean 24-hour milk volumes at 2, 3, and 4 weeks after delivery of mothers participating in STS holding were compared with those of a retrospective control group from the 12-month period immediately preceding the introduction of STS holding in the neonatal intensive care unit. A repeated-measures analysis of variance adjusting for baseline volumes (1 week after delivery) was used to evaluate the difference in milk volumes between STS and control groups.

RESULTS

Sixteen mothers initiated STS holding during the 2-month study period. Eight mothers met study criteria by initiating STS holding during the first 4 weeks after delivery. During a 2-week period the study group had a strong linear increase in milk volume in contrast to no indicative change of the control group's milk volume.

CONCLUSION

STS holding of low birth weight infants initiated in the early intensive care phase can result in a significant increase in maternal milk volume, thereby overcoming the frequently seen insufficient lactation experienced by these mothers.