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The impact of maternal
nutrition on the newborn
Rolf KlemmJ ohns Hopkins Bloomberg School of Public Health
Global Newborn HealthConference 2013:
South Africa
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We are born wet, naked andhungry. Then things get worse.
Chinese proverb
Every time achild is born,renews my faiththat God has not
given up onmen.Tagore
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Influence on life-long health
First 1000 days
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Poor maternal nutritional status & adversebirth outcome
Clear link from experimental animalstudies
Association in humans is more complex
Findings in human studies less consistentpartly due to differences in.
Baseline nutritional status
Socioeconomic status
Timing & dose of intervention
Measurement of outcome
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Adverse birth outcomes
Low birth weight (LBW)
Preterm birth
Intrauterine Growth Restriction (IUGR)
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Nutritional & health status ofwomen by region
S. Asia
%
SS Africa
%
US/Europe
%
Low Weight (
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Short stature: Risk factor for
caesarean delivery
60% increased need forassisted delivery
Is she sitting or standing?
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Pregnancyenergy, protein and micronutrient
needs; but lactation represents a greaternutritional burden than pregnancy
0
2040
60
80
100
120140
160
180
200
%RDA ofAdultFemale
Adult Female (non-preg, non-lact) Pregnant Lactating
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Evidence of
Intervention Impact
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Single MicronutrientSupplement (Iron, FA, Ca+)
Maternal Nutrition Intervention Strategies-Are they Effective? Safe?
Food Supplementation?
Multiple Micronutrient
Supplements?
Poverty Alleviation ProgramsGirls/Womens EducationWomens EmploymentWomens EmpowermentDietary ModificationAgricultural Production
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Food
Supplementation
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Food Supplementation
11 RCTs/quasi-RCTs
Balanced protein/energy
supplements Included milk supplements,
biscuits, skim milk+ bread+oil
Provided 300-800 kcal energy
Provided 15-40 g protein per
day
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Effect of balanced protein-energysupplementation during pregnancy
Outcome No.
Studie
s
Result Quality of
evidence
SGA1 6 31% SGA* Mod
Birth weight 13 60 grams*
Malnourished 8 75 grams*
Well-Nourished 5 27 gramsNeonatalmortality
3 35% Low
1 SGA=small for gestational age
Imdad and Bhutta, BMC Public Health, 2012
* Statistically significant @ p
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Food supplementation trial in the Gambia(Ceesay et al, BMJ 1997)
Birth wt g % LBW
All year 136 39
Harvest season 94 36
Hungry season 201 42
Perinatal mortality 44%
Daily food supplement (peanut biscuits) containing1000 kcal, 22 g protein, and 56g fat
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Conclusion-Food Supplementation
Balanced protein-energysupplementation effective inreducing IUGR/SGA.
This intervention should bescaled up in developingcountries especially among
malnourished women andfood insecure populations.
Imdad and Bhutta, BMC Public Health, 2012
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Iron
Iron+folic acidsupplementation in
pregnancy
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Iron Deficiency Anemia (IDA) in Pregnancy
42% of pregnant womenare anemic (McLean, Public Hlth Nutr,2008); 50% of which is dueto iron deficiency
Normal RBCs Anemic RBCs
IDA in pregnancy associations with risk ofLBW, perinatal, neonatal, post-neonatal& maternal mortality
Iron needs are high during pregnancy(due to RBC mass expansion & growth of
placental-fetal unit)
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Not all anemia is caused by iron
deficiency.
But iron
Other vitamindeficiencies
Hookworm
Malaria
HIV/AIDS
InflammatoryConditions
Hemoglobin-
opathies
AnemiaIron
DeficiencyAnemia
IronDeficiency
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Overlapping causes of Anemia
Malaria Anemia Hookworm
Severe: 40%
Moderate: 20-39%
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Daily iron supplementation during pregnancy(Cochrane Review, 2012)
birth weight (31 g)
prevalence of LBW (19%)
of maternal anemia at term (70%)
of maternal iron deficiency at term (57%)
No evidence that Fe placental malaria
Based on 60 studies, >27,000 pregnant women
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Daily iron supplementation during pregnancy(Cochrane Review, 2012)
Preterm births: 13 studies (10,000 women)
RR: 0.88 (95% CI: 0.77, 1.01)
of preterm births (12%) but not statisticallysignificant
Neonatal mortality: 4 studies (7,500 participants)
RR: 0.90 (95% CI: 0.68, 1.19)
of neonatal mortality (10%) but not statisticallysignificant
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Recent RCTs FA-Fe in pregnancy
Baseline Levels
Place
(Study)
Anemia LBW ~N per
group
Control FA-Fe vs. Control
Nepal(BMJ 2003)
High High(44%)
~1,000 Control(VA)
BW (40 g) LBW (16%)SGA (9%)
USA-WIC(AJ CN, 2003)
None orLow
Med(17%)
135 FA BW (206 g) GA (0.6 wk)SGA (50%) Preterm LBW
W China(BMJ 2008)
Med Low/Med
(5%)
2,000 FA GA (0.23 wk)
Early preterm (
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Continuous risk relationship between Hb &maternal & perinatal mortality
0
500
10001500
2000
2500
3000
35004000
5 7 91
1
Hemoglobin (g/dL)
mo
rtality
Stoltzfus, et al, Comparative Quantification ofhealth risks: Global and regional burden ofdisease attributable to selected major riskfactors:, WHO, 2004
Risk reduction
associated with each 1
g/dL increase in
hemoglobin..Maternalmortality
20%
Perinatalmortality (Africa)
28%
Perinatalmortality (other)
16%
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Calcium
C l i l t ti (>1 /d) d i f
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Calcium supplementation (>1 g/d) during pregnancy forthe prevention of pre-eclampsia (Hofmeyr et al. Cochrane Review, 2012)
Hypertensive disorders account for40,000 maternal deaths annually
Outcome # studies RR 95% CI
High bloodpressure
12 0.65 0.53-0.81
Pre-eclampsia 13 0.36 0.20-0.65
Low Ca Intake 8 0.36 0.20-0.65
High risk 5 0.22 0.12-0.97
No evidence that Ca intake protective against LBW, IUGR orperinatal mortality
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Multiple
Micronutrient
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0
10
20
30
40
5060
70
80
PercentDeficient
Spring (Hot and dry) Summer (Hot and monsoon)
Fall (Post-monsoon) Winter (Cold and dry)
MN deficiencies in early pregnancy are
common, concurrent, & vary by season
in rural Nepali pregnant women
J iang et al, J Nutr 2005
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Cochrane Review (Haider & Bhutta, 2012): Multiple MicronutrientSupplementation (MMS) vs. Iron & folic acid (IFA) in pregnancy
Significant impact on. Effect of MMS
relative to IFALow birth weight 11%
Small for gestational age 13%
But NO significant impact on Preterm births, Perinatal mortality, Still births,
Neonatal mortality
21 trials comparing MMS vs. IFA~76,000 women
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Newborn Vitamin A
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Newborn Vitamin A
Asian Studies17% reduction
African StudiesNo reduction
Overall12% reduction
BMC Public Health, 2011
Single does (50,000 IU) in first 2 days of life
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Summary
Maternal nutrition before & duringpregnancy plays a crucial role ininfluencing fetal growth and birth outcomes
Recommendations: Food supplementation for food insecure
populations & undernourished women
Iron+folic acid in pregnancy (integrated withIPTp & deworming where appropriate)
Ca+ especially in populations with low intake &@ high risk for pre-eclampsia
Stay tuned: Multiple MNS and Newborn VA
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Thank You
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