MATERNAL FOOD SUPPLEMENTATION AND SGA

Transcription

1 BORN TOO SMALL : 32 MILLION BABIES ARE BORN SMALL-FOR-GESTATIONAL AGE IN LMIC EFFECT OF MATERNAL MULTIPLE MICRONUTRIENT SUPPLEMENTATION ON BIRTH OUTCOMES Parul Christian, SPO-Women s Nutrition Nutrition Team Global Development Seminar on MIYCN ILSI SEA Region, Bangkok, Thailand July 24, Bill & Melinda Gates Foundation Anne CC et al; Lancet Global Health 2013 BACKGROUND: MATERNAL FOOD SUPPLEMENTATION AND BIRTH WEIGHT MATERNAL FOOD SUPPLEMENTATION AND SGA No impact on preterm birth Imdad & Bhutta, 2012 Imdad & Bhutta, 2012

2 % ILSI SEA Region Seminar on Maternal, Infant and Young Child Nutrition, July 24, 2017, Bangkok, Thailand ROUTINE IFA DURING PREGNANCY, ANEMIA, AND BIRTH OUTCOMES Haidar et al, BMJ 2013 MICRONUTRIENT REQUIREMENTS AND CHANGES IN CIRCULATING CONCENTRATIONS IN PREGNANCY IOM DRIs Females Pregnancy Change in levels during pregnancy Vitamin A (µg RE) None, but declines in malnourished popn. Vitamin D (IU) In late gestation Vitamin E (mg) Vitamin K (µg) Little data Folate (µg DFE) Decline maybe due to hemodilution Thiamine (mg) No change, few studies, but deficiency unlikely in Riboflavin (mg) healthy populations Niacin (mg) Vitamin B-12 (µg) By 25-50% due to hemodilution Vitamin B-6 (mg) Higher than that explained by hemodilution, due to hormonal factors Vitamin C (mg) Mainly due to hemodilution Iodine (µg) UI decreases; deficiency may occur Iron (mg) Due to hemodilution and deficiency Zinc (mg) 8 11 Due to hemodilution and deficiency Calcium until 34 wk and then a small until term MICRONUTRIENTS DEFICIENCIES IN EARLY PREGNANCY -NEPAL BACKGROUND: MATERNAL MULTIPLE MICRONUTRIENT DEFICIENCIES Common and co-occur in low and middle income countries Prenatal supplement use beyond IFA was uncommon SCN/UNICEF/WHO United Nations International Multiple Micronutrient Antenatal Preparation (UNIMAP) formulation conceived (1998) and tested RCTs and meta-analyses of trials (Jiang et al; J Nutr 2005)

3 MICRONUTRIENT SUPPLEMENT COMPOSITION 1 15 Vitamins and Minerals IOM RDA for Pregnancy/Lactation UNIMAP Formula UNICEF/WHO: Emergency Guidelines Vitamin A (μg RE) 750/ Vitamin D (μg) 5 (200 IU) 5 5 Vitamin E (mg) Folic Acid (μg DFE) Thiamin (mg) Riboflavin (mg) Niacin (mg) VitaminB-12 (μg) Vitamin B-6 (mg) Vitamin C (mg) 80/ Iron (mg) Zinc (mg) 12/ Iodine (μg) Copper (μg) Selenium (μg) DFE = dietary folate equivalent. POOLED AND META-ANALYSES OF MULTIPLE MICRONUTRIENT SUPPLEMENTATION (MMS) TRIALS Over 15 trials conducted from of MMS IFA as the SOC control. Or a true placebo was used with IFA ensured to all Amount of iron in the IFA supplement in some trials was 60 mg. In some trials this was compared vs. 30 mg iron in the MMS. One trial had 60 mg in the MMS as well. UNIMAP supplement was used in many trials but not all A majority had birth weight/low birth weight as the primary outcome. Two trials powered for mortality outcomes Pooled Analysis undertaken by WHO/UNICEF (FNB Supplement 2008); included 12 RCTs Systematic review and meta-analysis (Ramakrishnan et al 2012); included 15 RCTs Cochrane Systematic Review (Imdad & Bhutta 2015; revised 2017); included 15 RCTs Stratified IPD analysis (Smith et al; Submitted 2017); 17 RCTs including two of pregnancy lipid-based supplement; 10 MULTIPLE MICRONUTRIENT SUPPLEMENTATION AND BIRTH WEIGHT Smith et al; Submitted Ramakrishnan et al; Pediatr Peri Epi 2012

4 MULTIPLE MICRONUTRIENT SUPPLEMENTATION AND RISK OF SGA Ramakrishnan et al; Pediatr Peri Epi 2012 Haider & Bhutta, Cochrane Review COCHRANE SYSTEMATIC REVIEW: HAIDER & BHUTTA Haider & Bhutta, Cochrane Review

5 STRATIFIED ANALYSIS Haider & Bhutta, Cochrane Review Smith et al, 2017 Submitted 18 STRATIFIED ANALYSIS Dietary counseling Supplementation with Iron-Folic Acid Food (BEP) supplementation Calcium supplementation Multiple Micronutrient Supplementation Not Recommended but may be considered in some settings. Smith et al, 2017 Submitted 19 Bill & Melinda Gates Foundation 20

6 WHO ANC GUIDELINES SUMMARY Multiple micronutrient deficiencies are common in LMICs yet use of micronutrient supplements is low; women in HIC routinely use a one-a-day prenatal supplement during pregnancy There is robust evidence to show that MMS enhances birth outcomes over and above IFA, which itself improves fetal growth and reduces LBW Replacing IFA with MMS should be considered in contexts where appropriate given that WHO currently does not recommend its use Considerations include background levels of MN deficiencies as well as cost and supply chain In Southeast Asia, there are a number of settings where MMS use can benefit pregnant women and their offspring THANK YOU