Abstract
Prenatal supplementation with protein‐energy (PE) and/or multiple‐micronutrients (MMNs) may improve fetal growth, but trials of lipid‐based nutritional supplements (LNSs) have reported inconsistent results. We conducted a post‐hoc analysis of non‐primary outcomes in a trial in Gambia, with the aim to test the associations of LNS with fetal growth and explore how efficacy varies depending on nutritional status. The sample comprised 620 pregnant women in an individually randomized, partially blinded trial with four arms: (a) iron and folic acid (FeFol) tablet (usual care, referent group), (b) MMN tablet, (c) PE LNS, and (d) PE + MMN LNS. Analysis of variance examined unadjusted differences in fetal biometry z‐scores at 20 and 30 weeks and neonatal anthropometry z‐scores, while regression tested for modification of intervention‐outcome associations by season and maternal height, body mass index, and weight gain. Despite evidence of between‐arm differences in some fetal biometry, z‐scores at birth were not greater in the intervention arms than the FeFol arm (e.g., birth weight z‐scores: FeFol −0.71, MMN −0.63, PE −0.64, PE + MMN −0.62; group‐wise p = .796). In regression analyses, intervention associations with birth weight and head circumference were modified by maternal weight gain between booking and 30 weeks gestation (e.g., PE + MMN associations with birth weight were +0.462 z‐scores (95% CI [0.097, 0.826]) in the highest quartile of weight gain but –0.099 z‐scores (−0.459, 0.260) in the lowest). In conclusion, we found no strong evidence that a prenatal LNS intervention was associated with better fetal growth in the whole sample.
Highlights
In the 2013 Maternal and Child Nutrition series in the Lancet, Black et al (2013) estimated that undernutrition in the aggregate was responsible for 45% of child mortality, with fetal growth restriction alone accounting for 12% of deaths
The latter finding is in agreement with previous work from our group in rural Gambia, where we found that a daily high‐energy ground‐nut biscuit supplement providing approximately 1000 kcal/day of energy increased birth weight by 94 g (31, 157) for births occurring in the dry season but by 201 g (132, 270) for births occurring in the rainy season (Ceesay et al, 1997)
There was limited evidence that the supplements had affected fetal growth by 20 weeks of gestation, with the exception that fetal biometry measures were consistently greater in the PE arm compared to the other arms, with group‐wise comparisons for femur length (FL) and abdominal circumference (AC) being significant (e.g., FL z‐ scores: FeFol −0.29, MMN −0.28, PE +0.13, PE + MMN −0.22; group‐wise p = .012)
Summary
In the 2013 Maternal and Child Nutrition series in the Lancet, Black et al (2013) estimated that undernutrition in the aggregate was responsible for 45% of child mortality, with fetal growth restriction alone accounting for 12% of deaths This series included a comprehensive review of nutritional interventions which concluded, among other things, that balanced prenatal protein‐energy (PE) and multiple‐micronutrient (MMN) supplementation could potentially reduce fetal growth restriction and the risk of small‐for‐gestational age (SGA) birth (Bhutta et al, 2013). Developed lipid‐based nutritional supplements (LNSs), which are affordable, safe, can be produced locally, and have a long shelf‐life, have been shown to be a very effective option for the community‐based treatment of severe malnutrition if a high dose is given (Briend & Collins, 2010; Tekeste, Wondafrash, Azene, & Deribe, 2012; WHO, 2007) They may provide a route of MMN delivery that may be more preferable and efficacious than other products. The latter finding is in agreement with previous work from our group in rural Gambia, where we found that a daily high‐energy ground‐nut biscuit supplement providing approximately 1000 kcal/day of energy increased birth weight by 94 g (31, 157) for births occurring in the dry season but by 201 g (132, 270) for births occurring in the rainy season (Ceesay et al, 1997)
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