Association of Early Interventions With Birth Outcomes and Child Linear Growth in Low-Income and Middle-Income Countries

Abstract

IMPORTANCE The first 1000 days of life represent a critical window for child development. Pregnancy, exclusive breastfeeding (EBF) period (0-6 months), and complementary feeding (CF) period (6-24 months) have different growth requirements, so separate considerations for intervention strategies are needed. No synthesis to date has attempted to quantify the associations of interventions under multiple domains of micronutrient and balanced energy protein and food supplements, deworming, maternal education, water sanitation, and hygiene across these 3 life periods with birth and growth outcomes. OBJECTIVE To determine the magnitude of association of interventions with birth and growth outcomes based on randomized clinical trials (RCTs) conducted in low-income and middle-income countries (LMICs) using Bayesian network meta-analyses. DATA SOURCES MEDLINE, Embase, and Cochrane databases were searched from their inception up to August 14, 2018. STUDY SELECTION Included were LMIC-based RCTs of interventions provided to pregnant women, infants (0-6 months), and children (6-24 months). DATA EXTRACTION AND SYNTHESIS Two independent reviewers used a standardized data extraction and quality assessment form. Random-effects network meta-analyses were performed for each life period. Effect sizes are reported as odds ratios (ORs) and mean differences (MeanDiffs) for dichotomous and continuous outcomes, with 95% credible intervals (CrIs). This study calculated probabilities of interventions being superior to standard of care by at least a minimal clinically important difference. MAIN OUTCOMES AND MEASURES The study compared ORs on preterm birth and MeanDiffs on birth weight for pregnancy, length for age (LAZ) for EBF, and height for age (HAZ) for CF. RESULTS Among 302 061 participants in 169 randomized clinical trials, the network meta-analyses found several nutritional interventions that demonstrated greater association with improved birth and growth outcomes compared with standard of care. For instance, compared with standard of care, maternal supplements of multiple micronutrients showed reduced odds for preterm birth (OR, 0.54; 95% CrI, 0.27-0.97) and improved mean birth weight (MeanDiff, 0.08 kg; 95% CrI, 0.00-0.17 kg) but not LAZ during EBF (MeanDiff, −0.02; 95% CrI, −0.18 to 0.14). Supplementing infants and children with multiple micronutrients showed improved LAZ (MeanDiff, 0.20; 95% CrI, 0.03-0.35) and HAZ (MeanDiff, 0.14; 95% CrI, 0.02-0.25). The study found that pregnancy interventions (continued) Key Points Question Which interventions under the domains of nutrition, deworming, maternal education, and water, sanitation, and hygiene can improve birth and linear growth outcomes during the first 1000 days of life in low-income and middle-income countries (LMICs)? Findings This study used Bayesian network meta-analyses of 169 randomized clinical trials including 302 061 participants and showed that several nutritional interventions demonstrating greater associations with improved outcomes compared with standard of care, whi...

Effects of Maternal Nutritional Supplements and Dietary Interventions on Placental Complications: An Umbrella Review, Meta-Analysis and Evidence Map

“…In total, 124 records were excluded at full-text review, including a mismatch in populations in a single study (i.e., supplementing infants), three in intervention (dietary interventions not reported separately), three in comparator (compared dosages, thus supplement given to both intervention and control), 12, which did not report outcomes of interest (i.e., infant mortality), 19 in study design (i.e., observational studies, commentary) and 48 duplicates and older versions of Cochrane reviews ( Table S3 ). Nineteen umbrella reviews [ 10 , 11 , 12 , 13 , 14 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 ] were excluded and 19 reviews that did not report meta-analyses of RCTs (narrative syntheses only, meta-analysis of observational studies or combined observational and RCTs) (vitamin A [ 35 , 36 , 37 ], vitamin B6 and/or 12 [ 35 , 38 ], vitamin C and/or E [ 35 , 38 , 39 ], vitamin D and/or calcium [ 35 , 37 , 40 , 41 , 42 ], iron and/or folic acid [ 35 , 37 , 41 , 43 , 44 ], magnesium [ 35 , 37 ], zinc [ 45 , 46 , 47 ], MMN […”

“…Calcium supplementation was evaluated in 19 meta-analyses [ 47 , 110 , 140 , 148 , 149 , 150 , 151 , 152 , 153 , 154 , 155 , 156 , 157 , 158 , 159 , 160 , 161 , 162 , 163 ], in which a majority were found to be protective against PE incidence, with the few reviews that reported no effects largely among subgroups, such as those with adequate baseline calcium intake [ 153 , 156 ] or featuring periconceptual supplementation [ 148 ]. A majority of reviews also reported significant beneficial effects of calcium supplementation on rates of PTB [ 47 , 140 , 149 , 150 , 160 , 161 ] but largely no effect on LBW or SGA. When outcomes were considered by baseline dietary calcium in a Cochrane review, only low calcium diet was significantly associated with lower rates of PE [ 140 ].…”

“…There were nine reviews that reported meta-analyses for iron and/or folic acid supplementation [ 47 , 152 , 187 , 188 , 189 , 190 , 191 , 192 , 193 ], which largely found no effect on outcomes of interest. A network meta-analysis found that iron was significantly attributed to lower rates of PTB [ 47 ] and another review found that iron with or without folic acid supplementation had a weak effect on reducing rates of LBW [ 188 ]. A Cochrane review examined iron alone and iron with folic acid supplementation by baseline anemia status and found that studies were largely conducted with women who were non-anemic at the start of supplementation when reported [ 189 ].…”

“…There were four reviews that reported meta-analyses for zinc supplementation [ 42 , 45 , 46 , 47 ], which found evidence of a beneficial effect on PTB [ 45 , 46 , 47 ], except among adolescent pregnancies [ 42 ]. A review covering a single trial found a significant effect on LBW among adolescent pregnancies [ 42 ], though two other reviews did not find a significant effect on LBW or SGA [ 45 , 46 ].…”

Severe Maternal Morbidity and Mortality

“…11 JAMA Network Open has published a number of important studies in this area, including studies on postpartum hemorrhage, 12 prevention of postpartum depression and anxiety, 13 Zika virus Downloaded From: https://jamanetwork.com/ on 10/03/2020 infection, 14 the association of age with severe maternal morbidity and mortality, 15 and interventions to improve outcomes of pregnant women in low-and middle-income countries. 16 JAMA Network Open is issuing a call for research studies on severe maternal morbidity and mortality. We are interested in studies that examine risk factors for this morbidity and mortality,…”