Postpartum Maternal Vitamin Research Articles

Mapping the quality of prenatal and postnatal care and demographic differences on child mortality in 26 low to middle-income countries.

Closing the gap between child mortality in low- and middle-income countries (LMICs) and high-income countries is a priority set by the WHO in sustainable development goals (SDGs). We aimed to examine poor nutrition and prenatal and postnatal care that could increase the risk of child mortality in LMICs. The Demographic and Health Survey (DHS) was used to examine data from 26 countries to compare prenatal, postnatal, nutritional, and demographic factors across LMICs. Outcome of child death was classified into death before onemonth of age, between 1 to 11months, between one to two years, between three to fiveyears, and overall death before five years. Chi-square analyses identified differences in prenatal care, postnatal care, nutrition, and demographic factors between children who died and those who survived. Logistic regression identified factors that increased child mortality risk. The majority of deaths occurred before the ages of one month and one year. Considerably poorer quality of prenatal care, postnatal care, and nutrition were found in low-income and low-middle-income countries in the contemporary 2020s. High child mortality and poor quality of prenatal and postnatal care coincide with low income. Children in LMICs were exposed to less vitamin A-rich foods than children in higher-middle-income countries. The use of intestinal parasite drugs and the absence of postpartum maternal vitamin A supplementation significantly increased child mortality risk. Significant socio-demographic risk factors were associated with an increased mortality rate in children, including lack of education, maternal marital status, family wealth index, living rurally, and financial problems hindering access to healthcare. Poor nutrition remains a vital factor across all LMICs, with numerous children being exposed to foods low in iron and vitamin A. Significantly, most deaths occur in neonates and infants, indicating an urgent need to address risk factors associated with early child death.

Interrelationships Among Vitamin D Status and Body Composition in Mother-Infant Dyads

Abstract Objectives To explore the associations between postpartum maternal vitamin D status and body composition to neonatal serum 25-hydroxyvitamin D (25(OH)D) and body composition. Methods Healthy mothers and term-born infants of appropriate size for gestational age were recruited from Greater Montreal (March 2016 through March 2019). The present analysis includes data from mothers and infants (n = 144). Maternal characteristics and lifestyle factors were surveyed and newborn capillary blood samples were taken within 36 h of delivery to assess vitamin D status using total serum 25(OH)D (Liaison, Diasorin). Maternal and infant anthropometry and body composition (Dual-energy X-ray absorptiometry) and maternal serum 25(OH)D were measured within 1 mo postpartum. Mothers were classified into 2 groups (group 1: ≥50 nmol/L; group 2: <50 nmol/L). Data were analyzed descriptively (mean ± SD or n (%)) and using a mixed model with Tukey post hoc tests accounting for neonatal sex, gestational age, season, family income, maternal age, education, and race. Correlation tests were used to identify linear relationships between continuous variables. Results Neonates (85 males, 59 females) were 39.7 ± 1.0 wk GA and 3393 ± 363 g at birth. Mothers (32.1 ± 4.5 years) in group 1 had considerably higher serum 25(OH)D concentrations compared to mothers in group 2 (80.3 ± 22.0 n = 96 vs. 38.7 ± 9.0 n = 48, nmol/L, P < 0.0001). Moreover, maternal serum 25(OH)D concentrations were positively associated with their % whole body lean mass (r = 0.28, P = 0.0009) and inversely associated with their % whole body fat mass (r = −0.25, P = 0.003). At birth, infants of mothers in group 1 had higher serum 25(OH)D concentrations compared to infants in group 2 (51.0 ± 18.1 vs. 27.0 ± 12.0 nmol/L, P < 0.0001), and were correlated with maternal 25(OH)D (r = 0.74, P < 0.0001). Maternal lean body mass and lean mass index (LMI) (kg/m2) explained some positive variations in infant lean body mass and LMI (Estimate = 0.01, P = 0.004; Estimate = 27.7, P = 0.04). Conclusions Higher maternal vitamin D status is associated with higher neonatal vitamin D with possible implications to neonatal lean body mass. This study reinforces the importance of ensuring adequate maternal-fetal transfer of vitamin D. Funding Sources Canadian Institutes of Health Research.

The Effect of High-Dose Postpartum Maternal Vitamin D Supplementation Alone Compared with Maternal Plus Infant Vitamin D Supplementation in Breastfeeding Infants in a High-Risk Population. A Randomized Controlled Trial.

In view of continuing reports of high prevalence of severe vitamin D deficiency and low rate of infant vitamin D supplementation, an alternative strategy for prevention of vitamin D deficiency in infants warrants further study. The aim of this randomized controlled trial among 95 exclusively breastfeeding mother–infant pairs with high prevalence of vitamin D deficiency was to compare the effect of six-month post-partum vitamin D3 maternal supplementation of 6000 IU/day alone with maternal supplementation of 600 IU/day plus infant supplementation of 400 IU/day on the vitamin D status of breastfeeding infants in Doha, Qatar. Serum calcium, parathyroid hormone, maternal urine calcium/creatinine ratio and breast milk vitamin D content were measured. At baseline, the mean serum 25-hydroxyvitamin D (25(OH)D) of mothers on 6000 IU and 600 IU (35.1 vs. 35.7 nmol/L) and in their infants (31.9 vs. 29.6) respectively were low but similar. At the end of the six month supplementation, mothers on 6000 IU achieved higher serum 25(OH)D mean ± SD of 98 ± 35 nmol/L than 52 ± 20 nmol/L in mothers on 600 IU (p < 0.0001). Of mothers on 6000 IU, 96% achieved adequate serum 25(OH)D (≥50 nmol/L) compared with 52%in mothers on 600 IU (p < 0.0001). Infants of mothers on 600 IU and also supplemented with 400 IU vitamin D3 had slightly higher serum 25(OH)D than infants of mothers on 6000 IU alone (109 vs. 92 nmol/L, p = 0.03); however, similar percentage of infants in both groups achieved adequate serum 25(OH)D ≥50 nmol/L (91% vs. 89%, p = 0.75). Mothers on 6000 IU vitamin D3/day also had higher human milk vitamin D content. Safety measurements, including serum calcium and urine calcium/creatinine ratios in the mother and serum calcium levels in the infants were similar in both groups. Maternal 6000 IU/day vitamin D3 supplementation alone safely optimizes maternal vitamin D status, improves milk vitamin D to maintain adequate infant serum 25(OH)D. It thus provides an alternative option to prevent the burden of vitamin D deficiency in exclusively breastfeeding infants in high-risk populations and warrants further study of the effective dose.

Does postpartum maternal vitamin D supplementation provide adequate supplementation for exclusively breastfed infants?

Martin Army Community Hospital FMR, Fort Benning, GA The authors declare no conflict of interests. The opinions and assertions contained herein are those of the authors and are not to be construed as official or as reflecting the views of the U.S. Army Medical Department, the Army at large or the Department of Defense.

The effect of neonatal vitamin A supplementation on morbidity and mortality at 12 months: a randomized trial.

Background: Neonatal vitamin A supplementation (NVAS) is an intervention hypothesized to reduce infant morbidity and mortality. The objective of this study was to assess the efficacy of neonatal vitamin A supplementation in reducing infant morbidity and mortality and assess potential sources of heterogeneity of the effect of NVAS. Methods: We completed an individually randomized, double-blind, placebo-controlled trial in Tanzania. Infants were randomized within 3 days of birth to a single dose of vitamin A (50 000 IU) or placebo. We assessed infants at 1 and 3 days after supplementation, as well as 1, 3, 6 and 12 months after supplementation. We included all live births in the analysis and used relative risks (RR) and 95% confidence intervals (CI) to assess the risks of mortality and hospitalization by 12 months. We used general estimating equations to assess the incidence of morbidities during infancy. Results: A total of 31 999 infants were enrolled in the study between August 2010 and March 2013. At 12 months, vitamin A did not reduce all-cause infant mortality (RR 1.04; 95% CI 0.92-1.16), nor affect hospitalization (RR 1.09; 95% CI 0.97-1.22) or all-cause morbidity (RR 1.00; 95% CI 0.96-1.05). Postpartum maternal vitamin A supplementation modified the effect of neonatal vitamin A supplementation on mortality at 12 months (P-value, test for interaction = 0.04). Among infants born to women who received a mega-dose of vitamin A after delivery, NVAS appeared to increase the risk of death (RR 1.12; 95% CI 0.98-1.29), whereas the risk of death among infants born to women who did not receive a mega-dose was reduced (RR 0.86; 95% CI 0.70-1.06). We noted no modification of the effect of NVAS by infant gender, birthweight or maternal HIV status. Conclusion: NVAS did not affect the risk of death or incidence of common childhood morbidities. However, this study sheds light on potential sources of heterogeneity of the effect of neonatal vitamin A supplementation which should be further examined in a pooled analysis of all NVAS trials.

Low Vitamin B12 Intake during Pregnancy and Lactation and Low Breastmilk Vitamin B12 Content in Rural Kenyan Women Consuming Predominantly Maize Diets

Vitamin B12 deficiency during pregnancy and lactation may negatively affect fetal growth, brain development, pregnancy outcome, and breastmilk vitamin B12 content. To examine associations between pregnant and lactating women's vitamin B12 intake and pregnancy outcomes, breastmilk vitamin B12 concentration, and growth and development of breastfed infants from birth to 6 months. One hundred thirty-eight Kenyan women were followed during pregnancy, with 98 followed through 6 months of lactation and providing 294 randomly collected breastmilk samples. Maternal hematologic analyses were performed for erythrocyte morphology, erythrocyte size, and serum vitamin B12 concentration. Women's and infants'food intake was assessed. Breastmilk vitamin B12 was measured by a competitive binding isotope dilution technique. Infant anthropometric data and the Brazelton Neonatal Behavioral Assessment Scale (BNBAS) were assessed within 3 days after birth. The Infant Bayley Motor Scale was assessed at 6 months. Statistical analyses included simple regression and correlation analyses in relation to vitamin B12 status and gestational age. Intrauterine growth restriction and stillbirths were correlated with maternal macrocytic anemia and hypersegmented polymorphonuclear nuclei. Postpartum maternal vitamin B12 intake influenced breastmilk vitamin B12 levels 1 to 6 months postpartum. No associations were found between vitamin B12 intake during pregnancy or vitamin B12 levels in breastmilk and infant length, weight, or head circumference at birth or 6 months. Vitamin B12 intake during pregnancy was correlated with improved scores on infants' BNBAS reflex subscale (R = -0.19, p = .05) with adjustment for gestational age. Bayley Motor Scale results at 6 months were not significantly associated with breastmilk or supplemental feeding vitamin B12 content. Vitamin B12 deficiency may adversely affect pregnancy outcome, infant reflexes at birth, and breastmilk vitamin B12 content.

Cognitive and motor skills in school-aged children following maternal vitamin A supplementation during pregnancy in rural Nepal: a follow-up of a placebo-controlled, randomised cohort

ObjectiveTo determine the effects of maternal vitamin A supplementation from preconception through postpartum on cognitive and motor development of children at 10–13 years of age in rural Nepal.DesignFollow-up assessment of...

Comment on: 'Maternal postpartum vitamin A supplementation for the prevention of mortality and morbidity in infancy: a systematic review of randomised controlled trials'

Comment on: 'Maternal postpartum vitamin A supplementation for the prevention of mortality and morbidity in infancy: a systematic review of randomised controlled trials'

Effect of dietary fat supplementation during late pregnancy and first six months of lactation on maternal and infant vitamin A status in rural Bangladesh.

Dietary fat intake is extremely low in most communities with vitamin A deficiency. However, its role in vitamin A status of pregnant and lactating women is poorly understood. The aim of the study was to examine the effect of supplementing women with fat from mid-/late pregnancy until six months postpartum on their vitamin A status and that of their infants. Women recruited at 5-7 months of gestation were supplemented daily with 20 mL of soybean-oil (n = 248) until six months postpartum or received no supplement (n = 251). Dietary fat intake was assessed by 24-hour dietary recall at enrollment and at 1, 3 and 6 months postpartum. Concentrations of maternal plasma retinol, beta-carotene, and lutein were measured at enrollment and at 1, 3 and 6 months postpartum, and those of infants at six months postpartum. Concentration of breastmilk retinol was measured at 1, 3 and 6 months postpartum. The change in concentration of plasma retinol at three months postpartum compared to pregnancy was significantly higher in the supplemented compared to the control women (+0.04 vs -0.07 micromol/L respectively; p < 0.05). Concentrations of plasma beta-carotene and lutein declined in both the groups during the postpartum period but the decline was significantly less in the supplemented than in the control women at one month (beta-carotene -0.07 vs -0.13 micromol/L, p < 0.05); lutein -0.26 vs -0.49 micromol/L, p < 0.05) and three months (beta-carotene -0.04 vs -0.08 micromol/L, p < 0.05; lutein -0.31 vs -0.47 micromol/L, p < 0.05). Concentration of breastmilk retinol was also significantly greater in the supplemented group at three months postpartum than in the controls (0.68 +/- 0.35 vs 0.55 +/- 0.34 micromol/L respectively, p < 0.03). Concentrations of infants' plasma retinol, beta-carotene, and lutein, measured at six months of age, did not differ between the groups. Fat supplementation during pregnancy and lactation in women with a very low intake of dietary fat has beneficial effects on maternal postpartum vitamin A status.

Commentary: Postpartum vitamin A supplementation and infant mortality

Maternal vitamin A deficiency during pregnancy and lactation continues to be a concern in many regions of the world. In this issue of IJE, Gogia and Sachdev report a systematic review and meta-analysis of the effect of maternal postpartum vitamin A supplementation on infant mortality and morbidity. A total of six trials from developing countries included in the meta-analysis revealed no impact on infant mortality [relative risk (RR)1⁄4 1.05, 95% confidence interval (CI)1⁄4 0.92–1.20]. Only one trial that reported morbidity found no effect on diarrhoea or respiratory infection. Out of the six postpartum vitamin A supplementation trials included in the meta-analysis, two large ones were cluster-randomized controlled trials that also included routine pre-conceptional and/or pre-natal supplementation using small weekly doses of vitamin A, representing a supplementation regimen that was restricted neither to the postpartum period nor to the large bolus dose as per the existing WHO guidelines for postpartum supplementation with 200 000 IU of vitamin A within 6 weeks. Additionally, for one of the trials in the meta-analysis, the authors selected infants from the placebo arm of a newborn vitamin A supplementation trial, which was nested within the maternal supplementation trial. Also, three other trials included in the meta-analysis had sample sizes of 300 or less per group. Although these trials reported mortality, they did not have this as a pre-specified outcome, nor were they designed or powered to assess mortality as an outcome. The one trial with the appropriate sample size and which used the currently recommended dose of 400 000 IU vitamin A was conducted in an HIV-infected population. Thus, it is evident that the meta-analysis was based on diverse data of limited utility for discerning a mortality impact. Additionally, it mixed different forms of maternal vitamin A dosing (single with routine) over varying periods of time (from pre-conceptional through postpartum) and therefore both cumulative and timing of dosages are variable. The primary motivation for the policy related to prophylactic postpartum dosing of vitamin A did not stem from reducing infant mortality; instead, the two primary goals for this approach were to improve maternal vitamin A status and the vitamin A status of infants <6 months of age via enhancing the vitamin A content of breast milk. Several previous trials of postpartum vitamin A supplementation, not included in the meta-analysis, have demonstrated improvements in biochemical indicators of vitamin A status in mothers and their breast-fed infants, including increased breast milk concentrations of vitamin A. Based on these studies, in 1997, the WHO, UNICEF and the International Vitamin A Consultative Group (IVACG) provided guidelines for postpartum vitamin A supplementation recommending a single dose of 200 000 IU soon after delivery. This recommendation was updated in 2002 to two doses of 200 000 IU (or 400 000 IU) based on an analysis of expected change and adequacy of infant vitamin A stores suggested to be suboptimal with a single 200 000 IU dose. The revised recommendation, however, has not been widely adopted in developing countries. Only two of the six trials included in the meta-analysis tested the revised 400 000 IU of vitamin A. In a parallel meta-analysis effort, these authors have also evaluated neonatal/early infancy dosing with 50 000 IU vitamin A using data from six trials and shown no impact on infant mortality. However, combining trials which provided vitamin A within 48 h of birth vs those in which infants were dosed later during the first month of life may have yielded the null findings. Limiting the analysis to the former studies, at least in the Asian context, has shown to have a beneficial impact. In a meta-regression analysis, it was shown that newborn vitamin A supplementation likely reduces infant mortality in regions where vitamin A deficiency is common. In contrast, studies from Africa, where vitamin A deficiency was not common, have shown an overall null effect, and a potential negative effect among girls. These apparently contradictory findings have resulted in three more trials of newborn vitamin A supplementation being commissioned by the WHO, Published by Oxford University Press on behalf of the International Epidemiological Association

Maternal postpartum vitamin A supplementation for the prevention of mortality and morbidity in infancy: a systematic review of randomized controlled trials

Maternal postpartum vitamin A supplementation (VAS) provides an opportunity to improve vitamin A nutriture of breast fed infants in developing countries and can possibly prevent infant mortality and morbidity attributable to vitamin A deficiency. To evaluate the effect of maternal postpartum VAS on infant mortality, morbidity and adverse effects. Systematic review, meta-analysis and meta-regression of randomized controlled trials. Electronic databases and abstracts and proceedings of micronutrient conferences. Randomized or quasi-randomized, placebo-controlled trials evaluating the effect of postpartum, maternal synthetic VAS on mortality or morbidity within infancy (<1 year), or adverse effects. The seven included trials were from developing countries. There was no evidence of a reduced risk of mortality during infancy [relative risk (RR) 1.05, 95% confidence interval (CI) 0.92-1.20, P = 0.438; I² = 0%, P = 0.940]. No variable emerged as a significant predictor of mortality but data for high-risk groups (high maternal night blindness prevalence and low birth weights) was restricted. Neonatal mortality data was available from a single study, (RR 1.09, 95% CI 0.88-1.35; P = 0.422). In two trials, there was no evidence of a reduced risk of cause-specific mortality. In one trial, there was no evidence of a decrease in either diarrhoea or acute respiratory infection. No adverse effects were reported in the single relevant trial. There is no evidence of a mortality or morbidity benefit to the infant following postpartum maternal VAS. Only prevention of infant morbidity or mortality would be sufficient justification for initiating this intervention in public health programmes.

Vitamin A deficiency in infants: Effects of postnatal maternal vitamin A supplementation on the growth and vitamin A status

The effects of early postpartum maternal vitamin A supplementation (200,000 IU) on vitamin A status and growth of healthy breastfed infants were examined using a double blind controlled prospective study design. Vitamin A status during infancy was determined using a cross sectional study in infants. A retrospective analysis of case records of hospitalised children was used to define the extent of corneal lesions in infants. Serum vitamin A, retinol binding protein (RBP) and molar ratio of retinol to RBP in infants at birth, 6 wk, 3,6,9 & 12 months of age and vitamin A levels in breast milk were determined. Vitamin A status of infants at birth was low with mean serum retinol and RBP being 0.51 and 0.83 μmoles/L, respectively with a molar ratio of 0.59. Mean serum retinol was significantly increased in both the groups of infants by 6 wk of age (0.91 in the control and 0.82 μmoles L in the experimental group). Nevertheless, nearly 30% of infants continued to have serum retinol <0.70 μmoles/L in both the groups. Corneal lesions of malnourished children admitted during the last 10 years were significantly low during infancy, particularly below 6 months of age. Breast milk retinol levels were >1.05 μmoles/L upto 1 year of lactation in unsupplemented women. Supplemented mothers had significantly higher retinol content during the first 30 days of lactation. However, no impact of increased vitamin A intake could be observed on serum retinol levels and growth of their infants. In view of these data, the functional significance of low retinol levels among young infants and justification of supplementing lactating women with vitamin A to improve the vitamin A status of their newborns and young infants needs to be critically re-examined.

Evaluation of serum retinol, the modified-relative-dose-response ratio, and breast-milk vitamin A as indicators of response to postpartum maternal vitamin A supplementation

Conflicting results have been reported regarding the relative performance of serum retinol, the modified-relative-dose-response (MRDR) ratio, and breast-milk vitamin A concentrations in detecting changes in maternal vitamin A status. We used receiver operating characteristic analyses and standardized differences to compare the ability of these indicators to detect a response to postpartum vitamin A supplementation in lactating Bangladeshi women. At 2 wk postpartum, women were randomly assigned to receive either a single dose of vitamin A [200000 IU (60000 retinol equivalents); n = 74] or placebo (n = 73). Data from maternal serum and breast milk collected 3 mo postpartum and from infant serum collected 6 mo postpartum were used to examine the ability of serum retinol, the MRDR ratio, and breast-milk vitamin A to discriminate between individuals in the supplemented and unsupplemented groups. Breast milk was collected by expressing the entire contents of one breast that had not been used to feed an infant for > or =2 h (full samples) or without controlling the time since the last breast-feeding episode (casual samples). Casual breast-milk samples performed better than full breast-milk samples in detecting a response to maternal supplementation. The MRDR ratio performed better than serum retinol in both the women and their infants. Overall, the most responsive indicator was the measurement of breast-milk vitamin A per gram of fat in casual breast-milk samples. Breast-milk vitamin A and the MRDR ratio are responsive indicators of vitamin A status, especially in women with mild vitamin A deficiency.

Maternal Vitamin A or β-Carotene Supplementation in Lactating Bangladeshi Women Benefits Mothers and Infants but Does Not Prevent Subclinical Deficiency

The effects of maternal postpartum vitamin A or β-carotene supplementation on maternal and infant serum retinol concentrations, modified relative dose-response (MRDR) ratios and breast milk vitamin A concentrations were assessed during a community-based trial in Matlab, Bangladesh. At 1–3 wk postpartum, women were randomly assigned to receive either (1) a single dose of 200,000 international units [60,000 retinol equivalents (RE)] vitamin A followed by daily placebos (n = 74), (2) daily doses of β-carotene [7.8 mg (1300 RE)] (n = 73) or (3) daily placebos (n = 73) until 9 mo postpartum. Compared to placebos, vitamin A supplementation resulted in lower maternal MRDR ratios (i.e., increased liver stores) and higher milk vitamin A concentrations at 3 mo, but these improvements were not sustained. The β-carotene supplementation acted more slowly, resulting in milk vitamin A concentrations higher than the placebo group only at 9 mo. Irrespective of treatment group, over 50% of women produced milk with low vitamin A concentrations (≤1.05 μmol/L or ≤0.28 μmol/g fat) throughout the study. Overall, mean maternal serum retinol concentrations were not affected by supplementation. Compared to the placebo group, the mean MRDR ratio of 6-mo-old infants was higher in the vitamin A group. Infants (33%) had serum retinol concentrations <0.70 μmol/L and 88% had MRDR ratios ≥0.06. We conclude that while both interventions were beneficial, neither was sufficient to correct the underlying subclinical vitamin A deficiency in these women nor to bring their infants into adequate vitamin A status.