The impact of gestational weight gain on fetal and neonatal outcomes: the Araraquara Cohort Study

BACKGROUND

Gestational weight gain (GWG) is an important indicator for monitoring maternal and fetal health.

OBJECTIVE

To evaluate the effect of GWG outside the recommendations of the Institute of Medicine (IOM) on fetal and neonatal outcomes.

STUDY DESIGN

A prospective cohort study with 1642 pregnant women selected from 2017 to 2023, with gestational age ≤ 18 weeks and followed until delivery in the city of Araraquara, Southeast Brazil. The relationship between IOM-recommended GWG and fetal outcomes (abdominal subcutaneous tissue thickness, arm and thigh subcutaneous tissue area and intrauterine growth restriction) and neonatal outcomes (percentage of fat mass, fat-free mass, birth weight and length, ponderal index, weight adequateness for gestational age by the Intergrowth curve, prematurity, and Apgar score) were investigated. Generalized Estimating Equations were used.

RESULTS

GWG below the IOM recommendations was associated with increased risks of intrauterine growth restriction (IUGR) (aOR 1.61; 95% CI: 1.14-2.27), low birth weight (aOR 2.44; 95% CI: 1.85-3.21), and prematurity (aOR 2.35; 95% CI: 1.81-3.05), and lower chance of being Large for Gestational Age (LGA) (aOR 0.38; 95% CI: 0.28-0.54), with smaller arm subcutaneous tissue area (AST) (-7.99 g; 95% CI: -8.97 to -7.02), birth length (-0.76 cm; 95% CI: -1.03 to -0.49), and neonatal fat mass percentage (-0.85%; 95% CI: -1.12 to -0.58). Conversely, exceeding GWG guidelines increased the likelihood of LGA (aOR 1.53; 95% CI: 1.20-1.96), with lower 5th-minute Apgar score (aOR 0.42; 95% CI: 0.20-0.87), and increased birth weight (90.14 g; 95% CI: 53.30 to 126.99).

CONCLUSION

Adherence to GWG recommendations is crucial, with deviations negatively impacting fetal health. Effective weight control strategies are imperative.

Predictors of nutritional recovery time in children aged 6-59 months with severe acute malnutrition in Sofala Province, Mozambique: survival analysis approach

BACKGROUND

Malnutrition is a public health problem that affects physical and psychosocial well-being. It manifests as a rapid deterioration in nutritional status and bilateral edema due to inadequate food intake or illness.

METHODS

This study is a retrospective cohort of 1208 children with severe acute malnutrition (SAM) in Sofala Province from 2018 to 2022. It includes hospitalized children aged 6-59 months with SAM and related complications. The dependent variable is recovery, and the independent variables include age, sex of the child, vomiting, dehydration, hypoglycemia, nutritional edema and anthropometry. Survival curves were plotted using the Kaplan-Meier method, and bivariable and multivariable Cox regression analyses were performed.

RESULTS

The crude analysis revealed significant factors for nutritional recovery in children with SAM, including age, weight, height, malaria, diarrhea and dehydration. Children under 24 months had a 28% lower likelihood of recovery. Weight below 6.16 kg decreased the likelihood by 2%, and height above 71.1 cm decreased it by 20%. Conversely, malaria, diarrhea and dehydration increased the likelihood of recovery. However, after adjustment, only diarrhea remained a significant predictor of nutritional recovery.

CONCLUSION

This study found that diarrhea is a predictor of nutritional recovery in children with SAM.

Predictors of nutritional recovery time in children aged 6–59 months with severe acute malnutrition in Sofala Province, Mozambique: survival analysis approach

Background

Malnutrition is a public health problem that affects physical and psychosocial well-being. It manifests as a rapid deterioration in nutritional status and bilateral edema due to inadequate food intake or illness.

Methods

This study is a retrospective cohort of 1208 children with severe acute malnutrition (SAM) in Sofala Province from 2018 to 2022. It includes hospitalized children aged 6–59 months with SAM and related complications. The dependent variable is recovery, and the independent variables include age, sex of the child, vomiting, dehydration, hypoglycemia, nutritional edema and anthropometry. Survival curves were plotted using the Kaplan–Meier method, and bivariable and multivariable Cox regression analyses were performed.

Results

The crude analysis revealed significant factors for nutritional recovery in children with SAM, including age, weight, height, malaria, diarrhea and dehydration. Children under 24 months had a 28% lower likelihood of recovery. Weight below 6.16 kg decreased the likelihood by 2%, and height above 71.1 cm decreased it by 20%. Conversely, malaria, diarrhea and dehydration increased the likelihood of recovery. However, after adjustment, only diarrhea remained a significant predictor of nutritional recovery.

Conclusion

This study found that diarrhea is a predictor of nutritional recovery in children with SAM.

Association between food environments and fetal growth in pregnant Brazilian women

Introduction

Birth weight is described as one of the main determinants of newborns’ chances of survival. Among the associated causes, or risk factors, the mother’s nutritional status strongly influences fetal growth and birth weight outcomes of the concept. This study evaluates the association between food deserts, small for gestational age (SGA), large for gestational age (LGA) and low birth weight (LBW) newborns.

Design

This is a cross-sectional population study, resulting from individual data from the Live Birth Information System (SINASC), and commune data from mapping food deserts (CAISAN) in Brazil. The newborn’s size was defined as follows: appropriate for gestational age (between 10 and 90th percentile), SGA (< 10th percentile), LGA (> 90th percentile), and low birth weight < 2,500 g. To characterize food environments, we used tertiles of the density of establishments which sell in natura and ultra-processed foods. Logistic regression modeling was conducted to investigate the associations of interest.

Results

We analyzed 2,632,314 live births in Brazil in 2016, after appropriate adjustments, women living in municipalities with limited availability of fresh foods had a higher chance of having newborns with SGA [OR2nd tertile: 1.06 (1.05–1.07)] and LBW [OR2nd tertile: 1.11 (1.09–1.12)]. Conversely, municipalities with greater availability of ultra-processed foods had a higher chance of having newborns with SGA [OR3rd tertile: 1.04 (1.02–1.06)] and LBW [OR2nd tertile: 1.13 (1.11–1.16)]. Stratification by race showed that Black and Mixed/Brown women had a higher chance of having newborns with SGA [OR3rd tertile: 1.09 (1.01–1.18)] and [OR3rd tertile: 1.06 (1.04–1.09)], respectively, while Mixed-race women also had a higher chance of having newborns with LBW [OR3rd tertile: 1.17 (1.14–1.20)]. Indigenous women were associated with LGA [OR3rd tertile: 1.20 (1.01–1.45)].

Conclusion

The study found that living in areas with limited access to healthy foods was associated with an increased risk of SGA and low birth weight among newborns, particularly among Black and Mixed/Brown women. Therefore, urgent initiatives aimed at reducing social inequalities and mitigating the impact of poor food environments are needed in Brazil.

Association between food environments and fetal growth in pregnant Brazilian women

INTRODUCTION

Birth weight is described as one of the main determinants of newborns' chances of survival. Among the associated causes, or risk factors, the mother's nutritional status strongly influences fetal growth and birth weight outcomes of the concept. This study evaluates the association between food deserts, small for gestational age (SGA), large for gestational age (LGA) and low birth weight (LBW) newborns.

DESIGN

This is a cross-sectional population study, resulting from individual data from the Live Birth Information System (SINASC), and commune data from mapping food deserts (CAISAN) in Brazil. The newborn's size was defined as follows: appropriate for gestational age (between 10 and 90th percentile), SGA (< 10th percentile), LGA (> 90th percentile), and low birth weight < 2,500 g. To characterize food environments, we used tertiles of the density of establishments which sell in natura and ultra-processed foods. Logistic regression modeling was conducted to investigate the associations of interest.

RESULTS

We analyzed 2,632,314 live births in Brazil in 2016, after appropriate adjustments, women living in municipalities with limited availability of fresh foods had a higher chance of having newborns with SGA [OR2nd tertile: 1.06 (1.05-1.07)] and LBW [OR2nd tertile: 1.11 (1.09-1.12)]. Conversely, municipalities with greater availability of ultra-processed foods had a higher chance of having newborns with SGA [OR3rd tertile: 1.04 (1.02-1.06)] and LBW [OR2nd tertile: 1.13 (1.11-1.16)]. Stratification by race showed that Black and Mixed/Brown women had a higher chance of having newborns with SGA [OR3rd tertile: 1.09 (1.01-1.18)] and [OR3rd tertile: 1.06 (1.04-1.09)], respectively, while Mixed-race women also had a higher chance of having newborns with LBW [OR3rd tertile: 1.17 (1.14-1.20)]. Indigenous women were associated with LGA [OR3rd tertile: 1.20 (1.01-1.45)].

CONCLUSION

The study found that living in areas with limited access to healthy foods was associated with an increased risk of SGA and low birth weight among newborns, particularly among Black and Mixed/Brown women. Therefore, urgent initiatives aimed at reducing social inequalities and mitigating the impact of poor food environments are needed in Brazil.

Vitamin A and neonatal anthropometry

Low levels of vitamin A have a major impact on growth, development, and immunity. The aim of this study was to determine the relationship between cord concentrations of vitamin A and neonatal anthropometry in 711 babies born at term in Brazil. Gestational age of the babies was evaluated by the Capurro method. Vitamin A was measured by high performance liquid chromatography. Concentrations of vitamin A in cord blood correlated significantly (p < 0.001) with birthweight (r = 0.24), length (r = 0.20), chest circumference (r = 0.24), mid-upper arm circumference (r = 0.23), triceps skinfold thickness (r = 0.26), and head circumference (r = 0.12) of the babies. The anthropometric measurements of the babies were sorted by the vitamin A concentrations (means and standard deviations) and divided into quartiles. Differences between the quartiles were tested by analysis of variance. Babies in the bottom length, head circumference and triceps skinfold thickness quartiles had lower mean vitamin A concentrations than those of quartiles two, three and four. Babies in the bottom birthweight, chest and mid-upper arm circumferences quartiles had lower mean vitamin A concentrations than those of quartiles three and four (p < 0.003). These data shows that smaller/shorter babies had lower concentrations of vitamin A than heavier/longer babies, probably reflecting the important role of this micronutrient on growth.

[Parameters for the assessment of iron status]

The assessment of iron status at individual and populational levels has been the target of many studies because some issues still need to be defined. A Medline, Lilacs and Dedalus literature review was carried out for the period of 1972 to 1998 and scientific publications in both English and Portuguese relating hematological and biochemical parameters were used in the assessment of iron status. The parameters reflect the three different stages of iron storage deficiency, which occur in a gradual and progressive way leading to the development of anaemia. In general, when used alone, these parameters are neither sensitive nor specific for detecting iron deficiency anaemia. Moreover, some advantages and limitations should be taken into consideration for the choice of the appropriate parameter. To improve both sensitivity and specificity, different parameters have been used in association and their specific contribution is determined according to the characteristics of the study population, methodological issues and the costs involved in the process.

Maternal and neonatal anthropometry

Anthropometric measurements were assessed in 434 Brazilian mother-baby pairs (263 appropriate-for-gestational-age [AGA] and 171 intrauterine growth-retarded [IUGR]) to compare their distribution and to evaluate associations in AGA and IUGR pairs. Mothers who delivered IUGR babies were thinner and shorter than mothers of AGA babies; the cut-off points of risk for delivering an IUGR baby were 50 kg for weight (OR = 3.8, p < 0.001) and 150 cm for height (OR = 3.6, p < 0.001). IUGR mothers also tended to gain less weight in pregnancy than AGA mothers, presenting a risk 6.1 times higher for weight gain < or = 7 kg (p < 0.001). There were weak though statistically significant correlations between AGA mother-baby pairs, and a few weak correlations between IUGR mother-baby pairs. The larger number of statistically significant correlations between anthropometric measurements in AGA mother-baby pairs than in IUGR pairs shows that in this region of the country, where maternal malnutrition has a low prevalence, probably other factors are associated with IUGR. It seems that the influence of maternal nutrition on a baby's size at birth is more important in populations with moderate-to-severe malnutrition. In Brazil, as in some other developing countries, overweight is becoming an important issue and the prevalence of malnutrition has decreased. In this study, there were few mothers (n = 17) with a body mass index (BMI) < or = 20. On the other hand, there were many (n = 209) overweight (BMI 25-30) and obese (BMI > 30) mothers. We advise further large epidemiological studies to assess the diet of pregnant women and its relationship to maternal weight, weight gain and low birthweight (particularly IUGR) in countries with a considerable prevalence of maternal undernutrition and maternal overweight/obesity.

Vitamin A status of pregnant women assessed by a biochemical indicator and a simplified Food Frequency Questionnaire

The aim of this study was to compare plasma concentrations of vitamin A in 710 women after delivery, with a simplified Food Frequency Questionnaire (FFQ). Vitamin A was determined in plasma, by HPLC. The FFQ included 55 foods, and was based on the typical diet of the low socioeconomic families in the Southeast of Brazil. For calculation purposes, first were identified all potential sources of retinol and carotenoids; the portion sizes being assigned to each food item on the basis of a previous study in the same area. Daily, weekly and monthly frequencies of consumption of foods with high, moderate and low concentrations of vitamin A were grouped according to the IVACG recommendations (1) in usual pattern of food consumption (UPF) scores. Pregnant women were allocated by these scores in 3 different categories (high, moderate and low) according to their risk of developing vitamin A deficiency. The categories of risk were based on the safe level of vitamin A intake of 800 RE/day (5600 RE/week) (7) and the basal requirement of 370 RE/day for pregnant women (8). 1.3% of the women had plasma concentrations of vitamin A < or = 0.70 mumol/l, 10.2% between 0.71-1.05 mumol/l and 88.5% > 1.05 mumol/l. According to the score categories, 49.5% of the women were at low risk for vitamin A deficiency, and 50.5% were at moderate risk. There was a weak statistically significant correlation between the plasma concentrations of vitamin A and the score categories (r = 0.11; p = 0.005). Our results indicate that the FFQ does not provide a very precise information on vitamin A status, probably because of the day to day variation in vitamin A intake, and the insensitivity of plasma concentrations to consumption of vitamin A. However, by using a simple score based on the FFQ, we were able to predict that the majority of the mothers were not at high risk for vitamin A deficiency.

Maternal iron status and intrauterine growth retardation

The objective of this study was to compare the iron status of 356 mother-baby pairs who had intrauterine growth retardation (IUGR) with 356 mother-baby pairs who had appropriate weight for gestational age (AGA). Mothers were selected in 1991/92 from 4 hospitals in Campinas city, Brazil, where 95% of deliveries take place. Gestational age of the newborns was determined by the Capurro method. Newborns were classified as having IUGR according to the Lubchenco birthweight for gestational age standard. Haemoglobin (Hb), haematocrit (Ht) and ferritin were determined, respectively, by the cyanmethaemoglobin method, an haematocrit centrifuge, and an immunoenzymetric assay. Mean levels of Hb and Ht were higher in IUGR (16.4 g/dL; 51.7%) than in AGA babies (15.7 g/dL; 49.7%) (P < 0.001), as a consequence of intrauterine hypoxia. Higher maternal levels of ferritin (> 50 micrograms/L) were more common in IUGR than in AGA mothers (P < 0.001). Forty-seven percent (335/712) of the IUGR and AGA mothers were anaemic (Hb < or = 11.0 g/dL), but only 4.4% (31/356) of them had low levels of ferritin (< or = 10 micrograms/L). We advise further large epidemiological studies involving IUGR and AGA mother-baby pairs, elucidating the mechanisms underlying the plasma-volume changes in pregnancy, and the prevalence of iron-deficiency anaemia assessed by different indicators, in view of the fact that ferritin can be affected by inflammation and infection, important risk factors for IUGR in developing countries.

Weight, length, ponderal index, and intrauterine growth retardation in Brazil

The objective of this study was to classify intrauterine growth-retarded (IUGR) newborn babies from an urban region in Brazil into four different subtypes, according to their weight, length, and ponderal index (PI). Three hundred and fifty-six (356) babies were differentiated by this classification into IUGR subtypes A (short length and adequate PI), B (adequate length and low PI), C (short length and low PI), and D (adequate length and adequate PI), by the Lubchenco weight, length, and PI for gestational age standards. Gestational age of the babies was determined by the Capurro method. Anthropometric measurements were taken according to the Jelliffe and Jelliffe recommendations. Ninety-eight per cent of the IUGR babies included in the study were type I (proportional): 48 per cent of them were subtype A and 50 per cent subtype D (slightly thin). Subtypes B and C comprised 1.4 per cent and 0.6 per cent of the babies respectively. This classification of IUGR is of great importance, considering that these four subtypes probably reflect the stages of pregnancy at which the babies were affected by adverse growth and development factors. The risk factors for the different subtypes of IUGR, and examination of their predictive value for subsequent morbidity, growth, development, and mortality, will be of interest.

[Vitamin A and intrauterine growth retardation]

OBJECTIVES

Compare the levels of vitamin A in cord and maternal blood of 356 mothers who had intrauterine growth retarded babies (IUGR) and 356 mothers who had adequate for gestational age (AGA) babies, identify a possible relationship between vitamin A and IUGR, and evaluate the correlation between maternal and blood levels of vitamin A.

MATERIAL AND METHODS

Mothers were recruited from 4 hospitals in Campinas, where an average of 1350 babies are born every month. Newborns were classified as being IUGR according to the Lubchenco classification. Gestational age of the newborns was evaluated by the Capurro method. Vitamin A was measured by high performance liquid chromatography (HPLC).

RESULTS

More IUGR babies - 188/356 (33.1%) than AGA babies - 52/356 (14.6%) had low levels of vitamin A (<or= 0.70umol/l) in cord blood. However, the percentages of IUGR mothers (1.1%) with low levels of vitamin A were similar to AGA mothers (1.4%).

CONCLUSION

The results suggest that vitamin A is the result of being born small rather than vice-versa. The explanations for the lower cord levels of vitamin A in IUGR babies compared to AGA babies are: inadequate supply of vitamin A by the mother to the foetus, poor foetal binding, increased utilization of vitamin A by the foetus, and poor storage by the foetus.

The influence of maternal nutritional factors on intrauterine growth retardation in Brazil

A case-control study of 712 Brazilian mother-baby pairs was performed to assess maternal nutritional factors, more specifically low or marginal concentrations of vitamin A, folate and iron, as risk factors for intrauterine growth retardation (IUGR). Newborns were classified as being IUGR according to the Lubchenco classification. The gestational age of the newborns was evaluated by the Capurro method. Vitamin A, folate, ferritin and haemoglobin were measured by high-performance liquid chromatography, radioimmunoassay, immunoenzymetric assay and by the cyanmethaemoglobin method respectively. The relationship between maternal nutritional status and IUGR was investigated using stratification and logistic regression. According to the final logistic regression model, the risk factors for IUGR were: maternal body weight, per capita income, cigarette smoking, maternal weight gain, prior history of low birthweight, high maternal ferritin, beer intake and coffee intake. Specific interventions likely to have the major short-term impact in this region are not directly related to nutritional factors, but to efforts to reduce or eliminate toxic exposures. Over the long term, improvement in maternal nutritional status and socioeconomic conditions would be expected to produce important benefits.

Coffee consumption and intrauterine growth retardation in Brazil

OBJECTIVE

To examine the association between coffee consumption in pregnancy and foetal growth.

DESIGN

Retrospective unmatched case-control study.

SETTING

Maternidade de Campinas, Universidade Estadual de Campinas, Pontificia Universidade Católica de Campinas, Hospital Albert Sabin.

SUBJECTS

356 mother/baby pairs who had interauterine growth retardation (IUGR) and 356 mother/baby pairs who were appropriate for gestational age (AGA).

INTERVENTIONS

Newborns were classified as being IUGR according to the Lubchenco classification. Gestational age of the newborns was evaluated by the Capurro method. Coffee consumption in pregnancy was assessed by a food frequency questionnaire. Coffee consumption and a range of risk factors for IUGR were stratified and entered into a logistic regression model. The final results were expressed by the attributable risk percent (AR%).

RESULTS

More IUGR mothers (85.4%) than AGA mothers (70.5%) ingested coffee in pregnancy (OR = 2.45; P < 0.001). The proportion of mothers who delivered IUGR babies increased as the average consumption of coffee increased (test for trend = 31.76; P < 0.001). The tendency for heavy coffee drinkers to deliver IUGR babies remained after controlling for alcohol intake and cigarette smoking (P < 0.001). According to the logistic regression model and to the attributable risk percent (AR% = 28.0%), coffee consumption, (independent of average coffee consumption) was an important preventable cause of IUGR in this Brazilian population.

CONCLUSIONS

We recommend moderation in the consumption of coffee in pregnancy, since intrauterine growth retardation increases the risk of perinatal and neonatal morbidity and mortality. Further large prospective studies evaluating the content of caffeine in the coffee consumed by this population is advised.

Chest circumference as an indicator of intrauterine growth retardation

Three hundred and fifty six intrauterine growth retarded (IUGR) and 356 appropriate birth weight (ABW) babies were studied for a range of different anthropometric measurements. Birth weights was highly correlated with chest circumference (r = 0.64, P < 0.001; r = 0.76, P < 0.001), length (r = 0.71, P < 0.001; r = 0.68, P < 0.001), and head circumference (r = 0.49, P < 0.001; r = 0.53, P < 0.001) either in IUGR and ABW babies, respectively. There were weak statistically significant correlations between birth weight and mid-upper arm circumference (MUAC) (r = 0.65, P < 0.001; r = 0.15, P < 0.001), MUAC/head circumference (r = 0.43, P < 0.001; r = 0.13, P < 0.001), triceps skinfold thickness (r = 0.31, P < 0.001; r = 0.14, P < 0.001), and ponderal index (r = 0.23, P < 0.001, r = 0.33, P < 0.001) in IUGR and ABW babies. All anthropometric measurements had a statistically significant sensitivity and specificity for identifying intrauterine growth retardation (IUGR). However, chest circumference < or = 29.0 cm; length < or = 47.5 cm; and head circumference < or = 33.0 cm has the highest sensitivity, specificity and predictive power. Chest circumference seems to be the easiest, cheapest and most reliable anthropometric measurement to assess IUGR.