Global Newborn Health Conference 2013: South Africa

The impact of maternal nutrition on the newborn

Rolf Klemm Johns Hopkins Bloomberg School of Public Health

Every time a child is born, renews my faith that God has not given up on men. Tagore

We are born wet, naked and hungry. Then things get worse.
Chinese proverb

Early life nutrition Influence on life-long health

First 1000 days

Poor maternal nutritional status & adverse birth outcome

Clear link from experimental animal studies Association in humans is more complex Findings in human studies less consistent partly due to differences in. Baseline nutritional status Socioeconomic status Timing & dose of intervention Measurement of outcome

Adverse birth outcomes

Low birth weight (LBW) Preterm birth Intrauterine Growth Restriction (IUGR)

Nutritional & health status of women by region

S. Asia SS Africa US/Europe % % % 63 10xs 23 4xs 5-6 21 6xs 6 2xs 3-4 34 9xs 18 4.5xs 4 42 3.5xs 56 5xs 12 10 3-4 -

Low Weight (<45kg/99 lbs) Short Height (<145 cm /47) Low BMI (<18.5) Anemia (preg) Maternal XN
XN=Night blindness

UNICEF, SOWC, 2009; McClean Pub Hlth Nut, 2008 Christian P, Access presentation, 2006

Is she sitting or standing?

Short stature: Risk factor for caesarean delivery 60% increased need for assisted delivery

Pregnancy energy, protein and micronutrient needs; but lactation represents a greater nutritional burden than pregnancy
Adult Female (non-preg, non-lact) 200 180 160 140 Pregnant Lactating

%RDA of 120 Adult 100 Female 80

60 40 20 0

Evidence of Intervention Impact

Maternal Nutrition Intervention StrategiesAre they Effective? Safe?

Food Supplementation?

Single Micronutrient Supplement (Iron, FA, Ca+)

Poverty Alleviation Programs Girls/Womens Education Womens Employment Womens Empowerment Dietary Modification Agricultural Production

Multiple Micronutrient Supplements?

Food Supplementation

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

Effect of balanced protein-energy supplementation during pregnancy

No. Studie s 6 SGA1 Birth weight 13 Malnourished 8 Well-Nourished 5 Neonatal 3 mortality * Statistically significant @ p<0.05 Outcome Result Quality of evidence Mod

31% SGA* 60 grams* 75 grams* 27 grams 35%

1

Low

SGA=small for gestational age

Imdad and Bhutta, BMC Public Health, 2012

Food supplementation trial in the Gambia (Ceesay et al, BMJ 1997)

Daily food supplement (peanut biscuits) containing 1000 kcal, 22 g protein, and 56g fat

Birth wt g All year Harvest season Hungry season Perinatal mortality 136 94 201 44%

% LBW 39 36 42

Conclusion-Food Supplementation
Balanced protein-energy supplementation effective in reducing IUGR/SGA. This intervention should be scaled up in developing countries especially among malnourished women and food insecure populations.
Imdad and Bhutta, BMC Public Health, 2012

Iron Iron+folic acid supplementation in pregnancy

Iron Deficiency Anemia (IDA) in Pregnancy

42% of pregnant women are anemic (McLean, Public Hlth Nutr, 2008); 50% of which is due to iron deficiency
Normal RBCs Anemic RBCs

Iron needs are high during pregnancy

(due to RBC mass expansion & growth of placental-fetal unit)

IDA in pregnancy associations with risk of LBW, perinatal, neonatal, post-neonatal & maternal mortality

Not all anemia is caused by iron deficiency. But iron

Hookworm Other vitamin deficiencies Malaria

Anemia
HIV/AIDS Inflammatory Conditions

Iron Deficiency Anemia

Iron Deficiency

Hemoglobinopathies

Overlapping causes of Anemia

Malaria

Anemia

Hookworm

Severe: 40%

Moderate: 20-39%

Daily iron supplementation during pregnancy

(Cochrane Review, 2012) Based on 60 studies, >27,000 pregnant women

birth weight (31 g) prevalence of LBW (19%) of maternal anemia at term (70%) of maternal iron deficiency at term (57%) No evidence th at Fe placental malaria

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 statistically significant

Neonatal mortality: 4 studies (7,500 participants)

RR: 0.90 (95% CI: 0.68, 1.19) of neonatal mortality (10%) but not statistically significant

Recent RCTs FA-Fe in pregnancy

Baseline Levels Place (Study) Nepal
(BMJ 2003)

Anemia High

LBW High

~N per group

Control

FA-Fe vs. Control

Context matters! ~1,000 Control BW (40 g)

(VA)

(44%)

USA-WIC
(AJCN, 2003)

None or Low

BW (206 g) (17%) GA (0.6 wk) Environmental factors SGA (50%) Baseline nutritional status Preterm LBW Med Low/Med (5%)

SESFA 135

LBW (16%) SGA (9%)

W China
(BMJ 2008)

Med

Diet FA 2,000

N China
(JAMA Int Med, 2013)

Low

Underlying risks for Interpregnancy interval Low 6,000 FA No effect on birth weight, birth Others (2%) length, perinatal mortality

GA (0.23 wk) Early preterm (<34 wk) outcomes Early neonatal morality(54%)

Continuous risk relationship between Hb & maternal & perinatal mortality

4000 3500 3000 2500 2000 1500 1000 500 0 Hemoglobin (g/dL)
Stoltzfus, et al, Comparative Quantification of health risks: Global and regional burden of disease attributable to selected major risk factors:, WHO, 2004

Risk reduction associated with each 1 g/dL increase in hemoglobin.. Maternal 20% mortality Perinatal mortality (Africa) Perinatal mortality (other)
11 7 9

mortality

28% 16%

Calcium

Calcium supplementation (>1 g/d) during pregnancy for the prevention of pre-eclampsia (Hofmeyr et al. Cochrane Review, 2012)

Hypertensive disorders account for 40,000 maternal deaths annually

Outcome # studies RR 95% CI

High blood pressure Pre-eclampsia Low Ca Intake High risk

12 13 8 5

0.65 0.53-0.81 0.36 0.20-0.65 0.36 0.20-0.65 0.22 0.12-0.97

No evidence that Ca intake protective against LBW, IUGR or perinatal mortality

Multiple Micronutrient

MN deficiencies in early pregnancy are common, concurrent, & vary by season in rural Nepali pregnant women
Spring (Hot and dry) Fall (Post-monsoon)
80 70 60 50 Percent 40 Deficient 30 20 10 0

Summer (Hot and monsoon) Winter (Cold and dry)

Jiang et al, J Nutr 2005

Cochrane Review (Haider & Bhutta, 2012): Multiple Micronutrient Supplementation (MMS) vs. Iron & folic acid (IFA) in pregnancy

21 trials comparing MMS vs. IFA ~76,000 women

Significant impact on. Low birth weight Small for gestational age Effect of MMS relative to IFA 11% 13%

But NO significant impact on Preterm births, Perinatal mortality, Still births, Neonatal mortality

Newborn Vitamin A

Newborn Vitamin A
Single does (50,000 IU) in first 2 days of life

Asian Studies 17% reduction African Studies No reduction Overall 12% reduction
BMC Public Health, 2011

Summary Maternal nutrition before & during pregnancy plays a crucial role in influencing fetal growth and birth outcomes Recommendations:
Food supplementation for food insecure populations & undernourished women Iron+folic acid in pregnancy (integrated with IPTp & deworming where appropriate) Ca+ especially in populations with low intake & @ high risk for pre-eclampsia Stay tuned: Multiple MNS and Newborn VA

Thank You