Author: Sophia Iacona

Multiple micronutrient supplements versus iron-folic acid supplements and maternal anemia outcomes: an iron dose analysis

Published: February 25, 2022

Publication: MMS in Pregnancy Technical Advisory Group, New York Academy of Sciences

Authors: Filomena Gomes, Rina Agustina, Robert E. Black, Parul Christian, Kathryn G. Dewey, Klaus Kraemer

Background

  • The World Health Organization currently recommends 30 to 60 mg of iron during pregnancy, with higher doses recommended in areas of high maternal anemia
    • Multiple micronutrient supplement (MMS) and iron folic acid (IFA) are both used to deliver iron during pregnancy
  • Comprehensive analysis was conducted examining 19 studies to address concerns related to 30mg of iron through MMS vs. 60mg of iron through IFA, with regard to maternal anemia outcomes in low- and middle-income countries (LMICs)

Summary

  • Of the 19 studies that were screened for inclusion, 11 were included and were part of the analyses of the three outcomes of interest:
    • Effect of MMS vs. IFA on maternal anemia in the third trimester
    • Effect of MMS vs. IFA on hemoglobin in the third trimester
    • Effect of MMS vs. IFA on iron deficiency anemia in the third trimester
  • When compared to 60 mg of IFA, MMS providing 30 mg of iron did not result in an increased risk of anemia, nor lower levels of hemoglobin, or increased risk of iron deficiency anemia
  • The included studies found that MMS with 30 mg of iron is comparable to IFA with 60 mg of iron with regard to these above-mentioned outcomes
  • MMS is known to have additional benefits in the risk of infant mortality at 6 months, low birthweight, preterm birth, born small-for-gestational age, and reduction of stillbirth. Greater reductions are found among anemic pregnant women so the data suggest that transitioning from IFA with 30 or 60 mg of iron to MMS with 30 mg of iron would not increase the risk of maternal anemia and has additional maternal/child health benefits.

Key Quotes

  • “Because MMS with 30 mg of iron influenced hemoglobin with clinically comparable results to IFA with 60 mg iron, and because MMS significantly improves fetal growth and survival, especially in anemic women, we suggest that policymakers in LMIC proceed with the transition from IFA to MMS.”

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Effect of multiple micronutrient supplements vs iron and folic acid supplements on neonatal mortality: a reanalysis by iron dose

Published: April 25, 2022

Publication: MMS in Pregnancy Technical Advisory Group, New York Academy of Sciences

Authors: Filomena Gomes, Rina Agustina, Robert E. Black, Parul Christian, Kathryn G. Dewey, Klaus Kraemer

Background

  • Multiple micronutrient supplements (MMS) are a cost-effective method of delivering iron to a mother and fetus, as well as reducing adverse pregnancy and birth outcomes, including anemia
  • However, there are concerns that MMS may increase the risk of neonatal mortality as compared to the use of iron and folic acid supplements (IFA), a similar prenatal vitamin

Summary

  • The study aimed to assess the effect of MMS vs. IFA on neonatal mortality stratified by iron dose in each supplement
  • The study authors updated the neonatal mortality analysis of the 2020 WHO guidelines to calculate the effects of MMS vs. IFA on neonatal mortality in subgroups that provided the same or different amounts of iron – varying amounts of MMS and IFA
  • The study found that there were no significant differences in neonatal mortality between MMS and IFA within any of the subgroups therefore, neonatal mortality did not differ between MMS and IFA regardless of iron dose in either supplement.

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Maternal and child undernutrition: consequences for adult health and human capital

Published: January 2008 

Publication: The Lancet 

Authors: Prof. Cesar G. Victora, M.D., Prof. Linda Adair, Ph.D., Prof. Caroline Fall, D.M., Pedro C Hallal, Ph.D., Prof. Reynaldo Martorell Ph.D., Prof. Linda Richter Ph.D., Prof. Harshpal Singh Sachdev, M.D., for the Maternal and Child Undernutrition Study Group 

Background

  • Previous studies have indicated that pre- and post-natal malnutrition can result in long term changes to the structure and functionality of the brain, impairing memory and learning in childhood and adolescence
    • There has been less emphasis on researching how malnutrition in the first year of life affects intellectual capacity across the lifespan
    • The “Barbados Nutrition Study” assessed IQ and academic skills in adults in Barbados who were born with a moderate birth rate, but experienced moderate to severe malnutrition in their first year of life
    • Individuals were enrolled in a nutritional health intervention program and monitored until they were at least 12 years of age to ensure they were in good health
    • The control group consisted of healthy individuals from the same neighborhoods and classrooms who did not experience malnourishment in their first year of life

Summary

  • Malnutrition in pregnancy and childhood can cause generational health problems 
  • Undernutrition in pregnant mothers and children was strongly associated with… 
    • Shorter adult height 
    • Less schooling 
    • Reduced economic productivity  
    • Lower offspring birthweight in women (birthweight is positively associated with lung function, the incidence of some cancers; undernutrition could be associated with mental illness) 
  • Lower weight and malnutrition in childhood followed by weight gain after two years of age was found to be risk factors for high glucose concentrations, elevated blood pressure and harmful lipid profiles once adult BMI and height were adjusted for, suggesting that rapid postnatal weight gain, after infancy, is linked to these conditions 

Key Quotes: 

  • “Poor fetal growth or stunting in the first 2 years of life leads to irreversible damage, including shorter adult height, lower attained schooling, reduced adult income, and decreased offspring birthweight.” 
  • “Children who are undernourished in the first 2 years of life and who put on weight rapidly later in childhood and in adolescence are at high risk of chronic diseases related to nutrition.” 
  • “We conclude that damage suffered in early life leads to permanent impairment, and might also affect future generations.” 

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Impaired IQ and academic skills in adults who experienced moderate to severe infantile malnutrition: a forty-year study

Published: Nov. 26, 2013

Publication: National Library of Medicine

Authors: Deborah P. Waber, Ph.D., Cyralene P. Bryce, M.D., Jonathan M. Girard, B.A., Miriam Zichlin, B.S., Garrett M. Fitzmaurice, Sc.D., and Janina R. Galler, M.D.

Background

  • Previous studies have indicated that pre- and post-natal malnutrition can result in long term changes to the structure and functionality of the brain, impairing memory and learning in childhood and adolescence
  • There has been less emphasis on researching how malnutrition in the first year of life affects intellectual capacity across the lifespan
  • The “Barbados Nutrition Study” assessed IQ and academic skills in adults in Barbados who were born with a moderate birth rate, but experienced moderate to severe malnutrition in their first year of life
  • Individuals were enrolled in a nutritional health intervention program and monitored until they were at least 12 years of age to ensure they were in good health
  • The control group consisted of healthy individuals from the same neighborhoods and classrooms who did not experience malnourishment in their first year of life

Summary

  • While previously malnourished individuals were able to catch up physically to their healthy peers, their cognitive and behavioral development lagged behind 
  • IQ scores in the intellectual disability range were 9 times more prevalent in the previously malnourished group 
  • Previously malnourished individuals had lower IQs, lower grades in school, and higher rates of attention problems. They also suffered from intellectual disabilities at a higher rate than their healthy peers. 
  • Malnutrition during the first year of life carries risk for significant lifelong functional morbidity.  

Key Facts: 

  • The estimated difference in IQ between the two groups was 15 points when tested as adolescents and 18 points when tested as adults 
  • 26.3 percent of individuals in the previously malnourished group had IQs indicating intellectual disabilities compared to only 3 percent in the control group 

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