Neurodevelopment of Children Whose Mothers Were Randomized to Low-Dose Aspirin During Pregnancy

OBJECTIVE

Because low-dose aspirin is now commonly prescribed in pregnancy, we sought to assess the association between early antenatal exposure and child neurodevelopment.

METHODS

We performed a noninferiority, masked, neurodevelopmental follow-up study of children between age 33 and 39 months whose mothers had been randomized to daily low-dose aspirin (81 mg) or placebo between 6 0/7 and 13 6/7 weeks of gestation through 37 weeks. Neurodevelopment was assessed with the Bayley-III (Bayley Scales of Infant and Toddler Development, 3rd Edition) and the ASQ-3 (Ages and Stages Questionnaire, 3rd Edition). The primary outcome was the Bayley-III cognitive composite score with a difference within 4 points demonstrating noninferiority.

RESULTS

A total of 640 children (329 in the low-dose aspirin group, 311 in the placebo group) were evaluated between September 2021 and June 2022. The Bayley-III cognitive composite score was noninferior between the two groups (-1, adjusted mean -0.8, 95% CI, -2.2 to 0.60). Significant differences were not seen in the language composite score (difference 0.7, 95% CI, -0.8 to 2.1) or the motor composite score (difference -0.6, 95% CI, -2.5 to 1.2). The proportion of children who had any component of the Bayley-III score lower than 70 did not differ between the two groups. Similarly, the communication, gross motor, fine motor, problem-solving, and personal-social components of the ASQ-3 did not differ between groups. Maternal characteristics, delivery outcomes, breastfeeding rates, breastfeeding duration, and home environment as measured by the Family Care Indicators were similar.

CONCLUSION

Antenatal low-dose aspirin exposure was not associated with altered neurodevelopmental outcomes at age 3 years.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov , NCT04888377.

Neurodevelopment, vision and auditory outcomes at age 2 years in offspring of participants in the 'Women First' maternal preconception nutrition randomised controlled trial

BACKGROUND

Maternal nutrition in preconception and early pregnancy influences fetal growth. Evidence for effects of prenatal maternal nutrition on early child development (ECD) in low-income and middle-income countries is limited.

OBJECTIVES

To examine impact of maternal nutrition supplementation initiated prior to or during pregnancy on ECD, and to examine potential association of postnatal growth with ECD domains.

DESIGN

Secondary analysis regarding the offspring of participants of a maternal multicountry, individually randomised trial.

SETTING

Rural Democratic Republic of the Congo, Guatemala, India and Pakistan.

PARTICIPANTS

667 offspring of Women First trial participants, aged 24 months.

INTERVENTION

Maternal lipid-based nutrient supplement initiated preconceptionally (arm 1, n=217), 12 weeks gestation (arm 2, n=230) or not (arm 3, n=220); intervention stopped at delivery.

MAIN OUTCOME MEASURES

The INTERGROWTH-21st Neurodevelopment Assessment (INTER-NDA) cognitive, language, gross motor, fine motor, positive and negative behaviour scores; visual acuity and contrast sensitivity scores and auditory evoked response potentials (ERP). Anthropometric z-scores, family care indicators (FCI) and sociodemographic variables were examined as covariates.

RESULTS

No significant differences were detected among the intervention arms for any INTER-NDA scores across domains, vision scores or ERP potentials. After adjusting for covariates, length-for-age z-score at 24 months (LAZ24), socio-economic status, maternal education and FCI significantly predicted vision and INTER-NDA scores (R2=0.11-0.38, p<0.01).

CONCLUSIONS

Prenatal maternal nutrition supplementation was not associated with any neurodevelopmental outcomes at age 2 years. Maternal education, family environment and LAZ24 predicted ECD. Interventions addressing multiple components of the nurturing care model may offer greatest impact on children's developmental potential.

TRIAL REGISTRATION NUMBER

NCT01883193.

Women in Selected Communities of Punjab, India Have a High Prevalence of Iron, Zinc, Vitamin B12, and Folate Deficiencies: Implications for a Multiply-Fortified Salt Intervention

Dietary intake and biomarkers of micronutrient status of 100 non-pregnant women of reproductive age (NPWRA) were assessed to determine optimal levels of iron, zinc, vitamin B12, and folic acid to include in multiply-fortified salt (MFS) that will be evaluated in an upcoming trial. Weighed food records were obtained from participants to measure intake of micronutrients and discretionary salt, and to assess adequacy using Indian Nutrient Reference Values (NRVs). Statistical modeling was used to determine optimal fortification levels to reduce inadequate micronutrient intake while limiting intake above the upper limit. Fasting blood samples were obtained to assess iron, zinc, vitamin B12, and folate status. In usual diets, inadequate intake of iron (46%), zinc (95%), vitamin B12 (83%), and folate (36%) was high. Mean intake of discretionary salt was 4.7 g/day. Prevalence estimates of anemia (37%), iron deficiency (67%), zinc deficiency (34%), vitamin B12 insufficiency (37%), and folate insufficiency (70%) were also high. Simulating the addition of optimized MFS to usual diets resulted in percentage point (pp) reductions in inadequate intake by 29 pp for iron, 76 pp for zinc, 81 pp for vitamin B12, and 36 pp for folate. MFS holds potential to reduce the burden of micronutrient deficiencies in this setting.

Improving Calcium Status of Women: Results of a Study of Bio-Availability of Calcium From Slaked Lime Fortified Rice

BACKGROUND

Fortification of rice with slaked lime is an acceptable and inexpensive way to combat calcium (Ca) deficiency. However, bioavailability of calcium after intake of slaked lime fortified rice is yet to be investigated.

OBJECTIVE

To measure the fractional absorption of Ca (FAC) from slaked lime fortified cooked rice.

DESIGN

We conducted an experimental study using stable isotopes of Ca to measure FAC during a single morning test meal containing rice fortified with slaked lime. Participants (n = 22) were given slaked lime fortified rice 3 times a day for 4 days. On the morning of the fifth day, the participants were served the same amount of rice as previous the 4 days at the breakfast test meal with an accurately measured amount of ⁴⁴Ca stable isotope oral tracer followed by an intravenous injection of ⁴²Ca. Urine was collected over the next 24 hours in 3 consecutive 8-hour pools. Fractional absorption of Ca was calculated from the measurement of the relative enrichment of the of each administered tracer ⁴⁴Ca and ⁴²Ca using inductively coupled plasma mass spectrometry.

RESULTS

The mean Ca concentration in the test meal was 879.5 ± 152.9 µg/g with a coefficient of variance (CV) of 17.2%. Although Ca absorption efficiency decreases with higher calcium intake, the total amount of calcium absorbed from test meal using FAC = 0.391 calculated from the third 8-hour urine pool was 69.0 (CV of 15.6) mg.

CONCLUSIONS

We showed that one-fifth of daily calcium recommendation for women of reproductive age could be met by ingesting ∼200 g cooked slake fortified rice.

Quintuply-fortified salt for the improvement of micronutrient status among women of reproductive age and preschool-aged children in Punjab, India: protocol for a randomized, controlled, community-based trial

Background

Multiple micronutrient (MN) deficiencies remain highly prevalent among women of reproductive age (WRA) and preschool-aged children (PSC) in many areas within India. Salt is an attractive vehicle for MN fortification in this context, as it is universally consumed in fairly consistent amounts and coverage of iodized salt (IS) is 94%. The overall objective of this trial is to evaluate the nutritional impact of quintuply-fortified salt with iron in the form of encapsulated ferrous fumarate, zinc, vitamin B12, folic acid, and iodine (eFF-Q5S) vs. quintuply-fortified salt with iron in the form of ferric pyrophosphate plus EDTA, zinc, vitamin B12, folic acid, and iodine (FePP-Q5S) vs. IS for the improvement of MN status among non-pregnant WRA and PSC.

Methods

The study is a community-based, randomized, controlled trial that will be conducted in Punjab, India. 780 non-pregnant WRA 18–49 years old and 468 PSC 12–59 months old will be enrolled and assigned to one of three intervention groups. Salt will be provided to participants monthly for 12 months. Primary outcomes include changes in mean concentration of biomarkers of iron, zinc, vitamin B12, folate and iodine. Secondary outcomes include changes in the composition of the gut microbiome, and discretionary salt intake of PSC.

Discussion

If proven efficacious, multiply-fortified salt (MFS) has the potential to drastically reduce the burden of MN deficiencies in India, and around the world. Although effectiveness research will be needed to examine the impact of MFS under programmatic conditions, salt fortification will piggy-back on existing platforms to produce IS and doubly-fortified salt (DFS), making it possible to scale-up the intervention quickly.

Trial registration

Clinicaltrials.gov: NCT05166980; date of registration: December 22, 2021. Clinical Trials Registry-India: CTRI/2022/040332 and CTRI/2022/02/040333; date of registration: February 15, 2022.

Longitudinal Reduction in Diversity of Maternal Gut Microbiota During Pregnancy Is Observed in Multiple Low-Resource Settings: Results From the Women First Trial

Objective

To characterize the changes in gut microbiota during pregnancy and determine the effects of nutritional intervention on gut microbiota in women from sub-Saharan Africa (the Democratic Republic of the Congo, DRC), South Asia (India and Pakistan), and Central America (Guatemala).

Methods

Pregnant women in the Women First (WF) Preconception Maternal Nutrition Trial were included in this analysis. Participants were randomized to receive a lipid-based micronutrient supplement either ≥3 months before pregnancy (Arm 1); started the same intervention late in the first trimester (Arm 2); or received no nutrition supplements besides those self-administered or prescribed through local health services (Arm 3). Stool and blood samples were collected during the first and third trimesters. Findings presented here include fecal 16S rRNA gene-based profiling and systemic and intestinal inflammatory biomarkers, including alpha (1)-acid glycoprotein (AGP), C-reactive protein (CRP), fecal myeloperoxidase (MPO), and calprotectin.

Results

Stool samples were collected from 640 women (DRC, n = 157; India, n = 102; Guatemala, n = 276; and Pakistan, n = 105). Gut microbial community structure did not differ by intervention arm but changed significantly during pregnancy. Richness, a measure of alpha-diversity, decreased over pregnancy. Community composition (beta-diversity) also showed a significant change from first to third trimester in all four sites. Of the top 10 most abundant genera, unclassified Lachnospiraceae significantly decreased in Guatemala and unclassified Ruminococcaceae significantly decreased in Guatemala and DRC. The change in the overall community structure at the genus level was associated with a decrease in the abundances of certain genera with low heterogeneity among the four sites. Intervention arms were not significantly associated with inflammatory biomarkers at 12 or 34 weeks. AGP significantly decreased from 12 to 34 weeks of pregnancy, whereas CRP, MPO, and calprotectin did not significantly change over time. None of these biomarkers were significantly associated with the gut microbiota diversity.

Conclusion

The longitudinal reduction of individual genera (both commensals and potential pathogens) and alpha-diversity among all sites were consistent and suggested that the effect of pregnancy on the maternal microbiota overrides other influencing factors, such as nutrition intervention, geographical location, diet, race, and other demographical variables.

Role of a Preconception Maternal Nutrition Supplement and Pre-pregnancy BMI on Amnion DNA Methylation at Birth in Guatemalan Mother-Infant Dyads: The Women First Trial

Objectives

Maternal nutrition can alter the offspring epigenome at birth. We sought to examine epigenome-wide DNA methylation (DNAme) from a subset of Guatemalan mother-infant dyads from the Women First Preconception Maternal Nutrition Trial (WF). Women were randomized to either: Arm 1) women consumed a daily maternal nutrition supplement (MNS) ≥ 3 months prior to conception until delivery; Arm 2) women consumed the same MNS starting at 12 weeks gestation until delivery; or Arm 3) no MNS. We tested if infant DNAme from amnion tissue at birth (N = 99) was associated with: 1) timing of exposure to maternal MNS; 2) pre-pregnancy body mass index (ppBMI); and 3) the interaction of maternal MNS and ppBMI.

Methods

Bisulfite-converted DNAme libraries were constructed using Roche NimbleGen SeqCap Epi CpGiant probes and were sequenced via 2 × 150 paired end reads. We assessed the relationship between Arm, ppBMI, and Arm x ppBMI interaction on CpG methylation. All statistical models adjusted for multiple testing using false discovery rate (FDR) and controlled for maternal age, infant sex, exposure to smoke, infant genetics, and cellular heterogeneity. Gene set enrichment analyses were performed via Enrichr.

Results

We identified 480 CpGs associated with Arm, 4 CpGs associated with ppBMI, and 22 CpGs associated with the interaction of Arm x ppBMI (FDR < 0.05). Further, we found that DNAme was changed between Arms (1 vs 2, 1 vs 3). There were 300 CpGs that were different between Arms 1 and 2 and 159 CpGs that were different between Arms 1 and 3 that annotated to genes and passed FDR < 0.05. These results suggest preconception consumption of maternal MNS elicits different epigenetic responses as compared to MNS commencing during gestation or not at all. In addition, CpGs that annotated to genes were enriched in pathways associated with growth, development, and metabolism that included circadian rhythm, TCA cycle, Wnt signaling, and melatonin metabolism.

Conclusions

Our findings indicate that maternal MNS was robustly associated with amnion DNAme at birth. More specifically, preconception MNS resulted in DNAme changes that differed from the other Arms in biologically relevant pathways suggesting timing of maternal nutrition impacts the fetal epigenome. Future studies will examine DNAme associated with birth outcomes.

Funding Sources

Bill & Melinda Gates Foundation and NIH NICHD/ODS.

Family Care Indices and Linear Growth Predict INTER-NDA Scores for Child Development at Age 2 Years: Findings From the “Women First” Trial

Objectives

Nutrition during fetal and early postnatal life impacts brain development, however evidence from randomized trials from low-and-middle-income countries (LMIC) is limited. We evaluated effects of maternal nutrition supplementation before and during pregnancy on neurodevelopment and vision in children from 4 LMIC with high rates of stunting, using a simplified assessment tool.

Methods

Women First was an individually randomized trial comparing the impact of maternal nutrition supplementation initiated preconception vs at ∼12 wk gestation vs no supplement; interventions were discontinued at delivery in trial sites in Democratic Republic of the Congo, Guatemala, India, and Pakistan. Neurodevelopment and visual acuity and visual contrast sensitivity were assessed at 24 mo using the INTER-NDA and the Cardiff tests, respectively, in a random sub-set, representing ∼1/3 of infants with valid birth measurements from the WF trial. Anthropometry and Family Care Indicators (FCI) were also obtained at 24 mo.

Results

667 and 634 children (91% and 86% of sub-set) were included in INTER-NDA and vision analyses. Arm-proportionate contribution was 32.2–32.8%. Overall, we observed the following percentage of children with delays: 66.6% cognitive; 87.4% fine motor; 91.3% gross motor; and 11.7% language; 25.9% had positive behavior problems; and 26.0% and 21.0% had low acuity and contrast sensitivity scores, respectively. WF intervention arm was not significant for INTER-NDA scores, rates of mild-to-moderate or severe delay (F = 0.004–1.518, p = 0.28–0.99; X² = 3.81–5.92, p = 0.18–0.42; X² = 3.81–6.33, p = 0.18–0.43); or for low acuity and contrast sensitivity (X² = 0.91, p = 0.63 and X² = 1.64, p = 0.44). LAZ_24mo was significantly associated with cognitive, motor, language, and behavior scores; maternal education predicted cognitive, language, and vision; and FCI was significantly associated with fine motor, language, and behavior after adjusting for other covariates (R² 0.33 cognitive; 0.40 language; 0.12 motor; 0.05 positive and 0.11 negative behavior; and 0.31–0.34 for vision models).

Conclusions

The findings highlight the association between child development, linear growth, and family environment.

Funding Sources

Thrasher Research Fund, Bill & Melinda Gates Foundation, NICHD, ODS.

Associations Between Ambient Temperature and Circulating Maternal One-carbon and Amino Acid Metabolites in Pregnancy

Objectives

Excessive ambient temperature closely linked to climate change is an imminent threat to the health of mothers and children globally. Recent studies have shown detrimental associations between high temperatures during pregnancy and birth outcomes. The goal of this study was to examine relationships between circulating metabolites in the mother and environmental temperature in a resource-limited setting.

Methods

The study was a secondary analysis employing data from the Women First (WF) trial conduced in Thatta, Pakistan. As part of the trial, women of child-bearing age either consumed a comprehensive maternal nutritional supplement (MNS) prior to conception until delivery (Arm 1), from 12 wk gestation until delivery (Arm 2); or were not supplemented with MNS Arm 3. Daily maximum air temperatures were acquired from the closest surface observation systems (n = 131). Average daily maximum temperatures (Tmax) for a 90-day window representing the 1st trimester of pregnancy was calculated for each participant. The number of days in this period when the Tmax was &gt; 39°C was computed to assess ‘heat stress days’. Maternal blood was collected on dried blood spot (DBS) cards at 34 wk gestation. A targeted metabolomics assay measuring concentrations of 23 metabolites was performed on DBS samples using LC-MS/MS.

Results

Linear regression was employed to assess the associations between ambient temperature in the 1st trimester and metabolite levels (z-scores). Models were adjusted for MNS supplementation. Significant associations between Tmax in the 1st trimester and 7 metabolites were observed (FDR p-values &lt; 0.05). Of these, maternal choline concentrations were negatively correlated with maximal temperature in the 1st trimester (β = −0.063, p = 4.3e-10). Concentrations of glutamine, histidine, arginine, symmetrical-dimethylarginine, methionine and cysteine were positively associated (p &lt; 0.05) with daily maximal temperature.

Conclusions

Collectively, the findings indicate that exposure to excessive heat stress in the first trimester is associated with lower choline levels and other metabolites important in blood pressure regulation. While the findings are associative, our results point to underlying mechanistic alterations in maternal circulation in concert with environmental heat stress.

Funding Sources

Bill & Melinda Gates Foundation; NIH/NICHD/ODS.

Comparison of Methods for Estimating Discretionary Salt Intake in Field Settings

Objectives

Accurate and precise estimates of discretionary salt (DS) intake are critical for designing salt fortification interventions and counseling on salt intake reduction. This study compared four methods of estimating DS intake among non-pregnant women of reproductive age (NPWRA) in northern India to inform the design of a trial of multiply-fortified salt.

Methods

Participants were NPWRA (18–49 y) in Punjab, India. Weighed food records (WFR), same-day duplicate diet (DD) composites, and samples of household (HH) salt were collected simultaneously from 100 women and repeated on a subset of 40. Sodium (Na) and iodine contents of the DD composites were analyzed using Inductively Coupled Plasma (ICP)-Optical Emission Spectrometry and ICP-Mass Spectrometry. HH salt samples were also analyzed for iodine. Methods for estimating DS intake included: 1) WFR: DS consumed from recipes or added at time of consumption were weighed; 2) HH salt disappearance (HHSD): total DS used by HH on the observation day divided by number of HH members; 3) Sodium estimation (NaE): Na content of 40 replicate DD composites prepared without DS were subtracted from the Na content of the corresponding original DD and difference multiplied by the molar mass of NaCl; 4) Iodine method (IM): analyzed iodine content of milk and milk products and commercial snacks were subtracted from DD iodine content, and difference divided by the iodine content of the HH's salt sample. The relations between methods were explored using Pearson correlation and Bland Altman analyses.

Results

Mean ± SD intake of DS according to the WFR, HHSD, and NaE methods were 4.7 ± 1.8 g/d, 5.8 ± 3.3 g/d, and 4.1 ± 2.1 g/d, respectively. Results of IM are pending. Pearson correlation coefficients for DS intake estimates obtained from WFR vs. NaE and WFR vs. HHSD were 0.82 (p < 0.001) and 0.48 (p < 0.001), respectively. Mean ± SD bias (limits of agreement) were 0.68 ± 1.25 g/d (−1.77, 3.13) for WFR vs. NaE, and 1.8 ± 2.93 g/d (−4.56, 6.92) for HHSD vs. WFR methods.

Conclusions

Discretionary salt intake from WFR and NaE showed good agreement and are feasible to implement in field settings.

Funding Sources

Bill & Melinda Gates Foundation.

Comparison of Toddler Crown Rump Length and Leg Length in Four Low- and Middle-Income Research Sites: The Women First trial

Objectives

Length at 2y of age is a strong indicator of adult height and potential for other adverse effects in adulthood; leg length (LL) is suggested to be the more nutritionally responsive component of height. These analyses examine body proportions- measured as linear crown rump length (CRL), LL, and CRL: LL- among 24 mo old children from four low- and middle-income settings with high stunting rates (average across 4 sites = 65%) participating in the Women First Preconception Maternal Nutrition Trial (WF).

Methods

The WF study is a nutrition intervention trial of maternal-child pairs in four diverse research sites (Democratic Republic of the Congo [DRC], Guatemala, India, and Pakistan). At 24 mo of age, toddler length and CRL were obtained and subsequently used to calculate LL (length-CRL). ANOVAs with post hoc Tukey HSD for each parameter were performed in JMP Pro 16.0.0.

Results

No statistical differences were seen by maternal intervention arm, thus anthropometric data from 2,157 children (DRC n = 488, Guatemala n = 540, India n = 531, Pakistan n = 598) were explored by site. While mean (±SD) CRL did not significantly differ between Guatemala and India (48.9 ± 2.18, 48.9 ± 2.30cm), Pakistan and DRC (47.7 ± 2.52, 45.8 ± 2.22cm) had significantly lower mean CRL (p < 0.001), with DRC having the lowest value. Mean LL did not differ significantly between Guatemala and Pakistan (30.6 ± 1.74, 30.5 ± 2.21), nor between DRC and India (32.6 ± 2.28, 32.3 ± 2.01cm); however, DRC and India had significantly longer mean LL vs Guatemala and Pakistan (p < 0.0001). Statistically significant differences in mean CRL: LL (p < 0.0001) were observed among all four sites, with Guatemala exhibiting the largest mean (1.60 ± 0.09), attributable to shorter LL.

Conclusions

CRL and LL are indicative of proportionality, a measure of impaired growth. These data highlight that among the four research sites in the WF trial, Guatemala, which exhibits the highest rate of maternal stunting, has the least favorable body proportions (largest CRL: LL). The difference in body proportions between sites despite nutritional intervention warrants further examination of genomic and environmental (including nutritional) factors that may have an effect on anthropometrics such as LL, CRL, and CRL: LL.

Funding Sources

Bill & Melinda Gates Foundation, NIH NICHD/ODS.

The Association Between Maternal Placenta Growth Factor Levels and Small-for-Gestational Age Infants: Findings From the Multi-Country Women First Study

Objectives

Examine the association between Placenta Growth Factor (PlGF) levels during pregnancy, maternal nutrition supplementation (MNS) and the prevalence of small-for-gestational age (SGA) infants in the Women First (WF) Study.

Methods

WF is a RCT of MNS consisting of a lipid-based micronutrient supplement ± a protein-energy supplement (for low maternal BMI or weight gain), provided to women daily until delivery starting either ≥ 3 months pre-conception (Arm 1), at the end of the first trimester (Arm 2) or not at all (control group, Arm 3). Serum samples were obtained at 12 (Arms 1 and 2) and 34 weeks (Arms 1, 2 and 3) gestation from a subset of women in three of the WF sites (Guatemala [Guat] (n = 257); India [Ind] (n = 171, Arms 1 & 2 only); and Pakistan [Pak](n = 279)). PlGF was measured using an ELISA. An ultrasound late in the 1^st trimester determined whether infants were SGA at birth (weight-for-age centile < 10, INTERGROWTH-21^st standards). PlGF levels were examined for arm, site and time point differences using ANOVA and post-hoc Tukey testing. The association between SGA and PlGF was analyzed by logistic regression adjusting for maternal height, age and education (STATA software v. 17.0).

Results

In participants with PlGF measurements, the prevalence of SGA infants is 23% in Guat, 44% in Ind and 34% in Pak. PlGF levels increased from 12 to 34 weeks gestation in Arms 1 and 2 in every site (Tukey's adjusted P < 0.0001). There are no differences in PlGF among sites at 12 weeks, whereas all sites are different at 34 weeks (Tukey's adjusted P < 0.0001). Regarding the association between SGA and PlGF (adjusting for maternal height, age and education), there are no differences by arm within each time point and site (arms were combined in subsequent analyses). PlGF is associated with SGA only in Guat at 34 weeks: odds of an infant being SGA decreases as PlGF increases (OR = 0.9989, 95% CI: 0.9981, 0.9998, unadjusted p = 0.015). For a 50 pg/mL increase in PlGF, the odds of the infant being SGA decreased by 0.948 (5.2%; OR 95% CI: 0.909, 0.990).

Conclusions

An association between PlGF and prevalence of SGA was found in Guatemala at 34 weeks: as PlGF increases, the odds of a SGA infant decreases. The MNS did not result in differences among arms.

Funding Sources

Bill & Melinda Gates Foundation, Eunice Kennedy Shriver NICHD and NIH ODS.

A Multi-country Association Analysis of Maternal Selenium (Se) Levels and Infant Birth Outcomes: Findings From the Women First Study

Objectives

Selenium (Se) soil content varies worldwide impacting population levels. Maternal Se deficiency may be related to preterm birth, small for gestational age (SGA), and low birth weight (LBW, < 2,500g) possibly through its roles in antioxidant and thyroid hormone function particularly during the first trimester. We examined associations of Se levels and birth outcomes in a multi-country nutritional intervention trial of pregnant women.

Methods

This is a secondary analysis of the Women First trial (NCT01883193), a randomized controlled study investigating timing of maternal multiple micronutrient (with 130 mcg Se) and protein-energy supplementation (MNS) on fetal growth. MNS was started 3 months prior to conception (Arm 1), at ∼12 wk of gestation (Arm 2), or not at all (Arm 3) in women in India, Guatemala, and Pakistan. Gestational age was determined by first trimester ultrasound. At 12 and 34 wk gestation, maternal serum Se was measured by ICP-MS (n = 143–325 per timepoint per site). TSH was measured by 1-step sandwich (Guatemala and Pakistan) or chemiluminescence immunoassay (India). We used t-test or ANOVA to test group differences and linear models to test association of Se with infant outcomes and TSH, adjusting for treatment arm and study site.

Results

Se levels were highest in Guatemalan women (mean ± SD, 12 wk: 102.1 ug/L ± 12.6; 34 wk: 103.9 ± 14.2) and lowest in Pakistani women (12 wk: 85.7 ± 14.5; 34 wk: 77.9 ± 14.8) at both timepoints (P < 0.0001). MNS supplementation before or during gestation increased serum Se levels at 34 wk in Guatemalan women only (p = 0.038). In Pakistan a negative association between maternal Se at 34 wk and LBW was seen in female (n = 153; p = 0.041) but not male (n = 143; p = 0.97) infants. Se levels were not associated with preterm birth or SGA status at any site. TSH levels did not differ by study arm but were lower in Pakistan at 12 and 34 wk compared to other sites. There was no association between TSH and Se levels at any timepoint at any site.

Conclusions

Maternal Se levels may impact fetal birth weight in vulnerable populations in a sexually dimorphic manner. Preconception Se supplementation as part of a comprehensive MNS did not increase Se levels in Pakistan where soil Se content is low. Although Se did not correlate with TSH levels in this study, future work will incorporate co-influence of iodine.

Funding Sources

Bill & Melinda Gates Foundation, NIH NICHD/ODS.

Neurodevelopment Scores at 24 Months Are Associated With Maternal Education, Home Environment, and Linear Growth in Offspring of the Women First Trial

Objectives

Healthy physical growth has been associated with better performance on neurodevelopmental testing in young children in low resource settings. We examined the relationship of growth indicators from 6 to 24 months of age to the sub-scales of the Bayley Scales of Infant Development-III (BSID-III) at 24 months in offspring of participants in the four-country preconception maternal nutrition trial, Women First (WF), which found the maternal intervention to benefit birth length, which was predictive of length and risk of stunting at 24 months.

Methods

With no post-delivery intervention, follow-up visits for anthropometry were obtained at 6-month intervals; BSID-III and Family Care Indicators (FCI) were completed at 24 months in a random sub-set of the WF offspring, representing 2/3 of infants with valid birth measurements. Multiple covariates (intervention arm, site, cluster within site, maternal education, age, SES, FCI subscales, LBW, and change in anthropometry Z-scores from 6 to 24 months, e.g., length-for-age, DLAZ6-24) were considered as confounders or predictors and were adjusted in a general linear model to predict adjusted mean differences (AMD) in BSID scores.

Results

1,386 infants (93% of those randomized to sub-set) were included in the analysis (n = 441,486, 459 for Arms 1, 2, 3, respectively). Four covariates were positively associated (p ≤ 0.01) with all 3 of the BSID subscales cognitive(C), motor(M), and social-emotional(SE) scales, respectively: maternal secondary education (+AMD 3.60(C), 3.35(M), 2.80(SE)); DLAZ6-24 (+AMD 1.98(C), 3.15(M), 2.06(SE)); BW &gt; 2500 g (+AMD 1.64(C), 2.20(M), 2.31(SE)); and FCI play materials (+AMD 1.46(C), 1.36(M), 1.72(SE)). No other anthropometric or maternal variables were consistently associated with BSID subscales.

Conclusions

The findings underscore the multiple critical components of nurturing care for early child development, including the caregiver, adequate birth weight, healthy linear growth, and opportunities for learning. Results suggest that the positive effects of maternal nutrition supplementation in the WF trial on birth length and postnatal linear growth may, in turn, have enduring downstream benefits for their children's neurodevelopment.

Funding Sources

The Bill & Melinda Gates Foundation, NICHD, ODS.

Different Doses, Forms, and Frequencies of Zinc Supplementation for the Prevention of Diarrhea and Promotion of Linear Growth among Young Bangladeshi Children: A Six-Arm, Randomized, Community-Based Efficacy Trial

BACKGROUND

Children in resource-limited settings remain vulnerable to zinc deficiency and its consequences.

OBJECTIVES

To evaluate the effects of different doses, durations, and frequencies of zinc supplementation on the incidence of diarrhea and change in linear growth among young children.

METHODS

We conducted a randomized, partially double-blind, controlled, 6-arm, community-based efficacy trial in Dhaka, Bangladesh. Children aged 9-11 mo were randomly assigned to receive 1 of the following interventions for 24 wk: 1) standard micronutrient powder (MNP) containing 4.1 mg zinc and 10 mg iron, daily; 2) high-zinc (10 mg), low-iron (6 mg) (HiZn LoFe) MNP, daily; 3) HiZn (10 mg) LoFe (6 mg)/HiZn (10 mg), no-iron MNPs on alternating days; 4) dispersible zinc tablet (10 mg), daily; 5) dispersible zinc tablet (10 mg), daily for 2 wk at enrollment and 12 wk; 6) placebo powder, daily. Primary outcomes were incidence of diarrhea and change in length-for-age z-score (LAZ) over the 24-wk intervention period. Home visits were conducted twice weekly to assess diarrhea and other morbidity. Incidence and prevalence outcomes were compared among groups with Poisson regression; continuous outcomes were compared using ANCOVA.

RESULTS

A total of 2886 children were enrolled between February 2018 and July 2019. The mean incidence and prevalence of diarrhea among all participants was 1.21 episodes per 100 d and 3.76 d per 100 d, respectively. There were no differences in the incidence or prevalence of diarrhea across intervention groups. The decline in LAZ was slightly smaller among children in the daily HiZn LoFe MNP group compared with the placebo powder group (P < 0.05).

CONCLUSIONS

The dose of zinc in MNPs as well as the duration and frequency of supplementation evaluated in this trial were not effective in reducing diarrhea; however, the daily HiZn LoFe MNP formulation offered modest improvements in linear growth among young children. This trial was registered at clinicaltrials.gov as NCT03406793.

Reduced Fractional Absorption of Zinc in Children With Environmental Enteropathy in Zambia

OBJECTIVES

We measured fractional absorption of zinc (FAZ) in children with environmental enteropathy (EE) and carried out transcriptomic analysis of biopsies from these children in order to compare FAZ to histology of intestinal biopsies, expression of zinc transporter genes, and biomarkers of enteropathy.

METHODS

Fractional absorption of a standardized aqueous dose of zinc was measured by a dual isotope ratio technique in a cohort of children ages between 9 and 24 months in Lusaka, Zambia, who all had non-responsive stunting. Gene expression analysis was carried out on biopsies through RNA sequencing using an Illumina HiSeq2000 platform.

RESULTS

All 33 children had histological features of environmental enteropathy and plasma zinc concentrations below the lower limit of normal. Measured FAZ ranged from 0.18 to 0.93; all values >0.55 were observed in girls. FAZ was negatively correlated with faecal myeloperoxidase (MPO) (ρ = -0.51, n = 17; P = 0.04) and faecal calprotectin (ρ = -0.50, n = 16; P = 0.05), but not blood biomarkers. Of 41 genes with known roles in zinc metabolism, only three metallothionein genes were significantly correlated with FAZ.

CONCLUSIONS

Zinc homeostasis is impaired in children with environmental enteropathy, and was inversely correlated with mucosal inflammation. Reduced FAZ without specific changes in expression of most zinc transporter genes could be explained by reduced absorptive surface area due to villus/microvillus atrophy.

B-Vitamins and Choline in Human Milk Are Not Impacted by a Preconception Lipid-Based Nutrient Supplement, but Differ Among Three Low-to-Middle Income Settings-Findings From the Women First Trial

Introduction: Optimal human milk (HM) B-vitamin concentrations remain undefined, especially in areas where undernutrition is prevalent. The impact of supplementation pre-conception through pregnancy on HM B-vitamin composition remains unknown.

Methods: Human milk (HM) was collected at 2-weeks postpartum from 200 women in Guatemala, India, and Pakistan (the Women First Trial). The women were randomized to start a lipid-based nutrient supplement before conception, at end of the first trimester, or not at all; intervention continued until delivery. HM concentrations of eight B-vitamins and choline were assessed via ultra-performance liquid chromatography-tandem mass spectrometry. Maternal diet was assessed in early pregnancy, and infant growth followed through 6 months post-delivery.

Results: Despite supplement exposure averaging 15.7 (pre-conception arm) and 6.0 months (prenatal arm), HM B-vitamins did not differ between arms, but site differences were evident. Guatemala had higher HM concentrations of vitamin B3 than Pakistan and India. Pakistan had higher HM concentrations of thiamin and vitamin B6 than India and Guatemala. Cohort average HM vitamin B2 (162 ± 79 μg/L) and B6 (31.8 ± 24.6 μg/L) fell below values defined as deficient in 81.5 and 85.5% of samples, potentially reflecting sampling procedures and timing. Maternal dietary intakes of only vitamin B6 and choline were associated with the corresponding concentrations in HM (p < 0.005). No HM B-vitamin concentrations were associated with infant growth.

Conclusion: Prenatal supplementation for at least 6 months had no impact on HM B-vitamin concentrations at 2-weeks postpartum. Results suggest that the adequacy of HM composition was generally maintained, with potential exceptions of vitamin B2 and B6.

Zinc Supplementation with or without Additional Micronutrients Does Not Affect Peripheral Blood Gene Expression or Serum Cytokine Level in Bangladeshi Children

Preventive zinc supplementation provided as a stand-alone dispersible tablet, or via home fortification as multiple micronutrient powders (MNPs), has been considered a potential strategy to prevent zinc deficiency and improve health (including immune) outcomes among children in low- and middle-income countries. However, the impact of zinc supplementation on immune profiles has not been well characterized. We sought to define the effect of zinc supplementation on peripheral blood gene expression and cytokine levels among young children in Dhaka, Bangladesh. In a sub-study of a large randomized, controlled, community-based efficacy trial where children 9–11 months of age received one of the following interventions on a daily basis for 24 weeks: (1) MNPs containing 10 mg of zinc; (2) dispersible tablet containing 10 mg zinc; or (3) placebo powder, we used RNA sequencing to profile the peripheral blood gene expression, as well as highly sensitive multiplex assays to detect cytokine profiles. We profiled samples from 100 children enrolled in the parent trial (zinc MNPs 28, zinc tablets 39, placebo 33). We did not detect an effect from either zinc intervention on differential peripheral blood gene expression at the end of the intervention, or an effect from the intervention on changes in gene expression from baseline. We also did not detect an effect from either intervention on cytokine concentrations. Exploratory analysis did not identify an association between undernutrition (defined as stunting, underweight or wasting) and peripheral blood gene expression. Zinc interventions in children did not produce a gene expression or cytokine signature in the peripheral blood. However, this study demonstrates a proof of principle that sensitive multi-omic techniques can be applied to samples collected in field studies.

Infant Young Child Feeding Practices From 12 to 24 Months of Age of Offspring From the Women First Trial

Objectives

Evaluate infant young child feeding (IYCF) trends from 12 to 24 mo in four low middle-income countries: Democratic Republic of Congo (DRC); Guatemala; India; and Pakistan.

Methods

2413 children (570 DRC, 614 Guatemala, 589 India, and 640 Pakistan) born to women from the Women First Trial enrolled. Trained research health workers visited households and assessed children's feeding practices from 12 to 24 mo. Child feeding indicators including the prevalence and longitudinal trends of meeting minimum diet diversity (MDD), minimum meal frequency (MMF), and minimum acceptable diet (MAD) were analyzed using the 2018 IYCF definitions from 12 to 24 mo for all four sites individually and combined.

Results

MDD significantly increased from 16% at 12 mo to 29% at 24 mo for all sites combined (p &lt; 0.001); by site: 3 to 10 for DRC (p &lt; 0.001), 33 to 42 for Guatemala (p = 0.001), 28 to 63 for India (p &lt; 0.001), and 1 to 2 for Pakistan (not significant). MMF significantly increased from 49% at 12 mo to 68% at 24 mo for all sites (p &lt; 0.001); by site: 22 to 49 for DRC (p &lt; 0.001), 89 to 92 for Guatemala (not significant), 66 to 73 for India (0.012), and 18 to 58 for Pakistan (p &lt; 0.001). MAD significantly increased (p &lt; 0.001) for all sites, and by site for DRC and India only. Food groups least consumed at 24 mo for all sites were nuts/pulses (prevalence 20%), meats/fish/insects (21%), and vitamin A rich fruits & vegetables (38%); compared to grains/roots/tubers which were consumed by 98% of participants. For all sites, milk & dairy and eggs consumption significantly increased from 50 to 60% (p &lt; 0.001) and 26 to 50% (p &lt; 0.001), respectively. Breastfeeding decreased from 94% at 12 mo to 49% at 24 mo for all sites with the lowest prevalence of breastfeeding in Pakistan (23%), whereas the other sites were ∼50%.

Conclusions

For all sites, the prevalence of participants meeting IYCF recommendations for feeding indicators increased from 12 to 24 mo, but prevalence at 24 mo remained well below recommendations in all sites. Children with low IYCF scores are at risk for low intakes of vital nutrients, protein and vitamin A rich foods, which may negatively impact periods of rapid growth and development in these resource limited populations.

Funding Sources

Bill & Melinda Gates Foundation and Eunice Kennedy Shriver NICHD.

Heat Stress-Associated Growth Retardation in the First 1000 Days Is Mitigated by Preconception Nutritional Supplementation

Objectives

Understanding the interactions between nutrition and climate-driven health outcomes is increasingly necessary. Employing data from the Women First trial conducted in Thatta, Pakistan, we examined the interactions between maternal nutritional deficits and heat stress (HS) on birth outcomes.

Methods

Women of child-bearing age either consumed a small quantity lipid-based nutrition supplement (sqLNS) prior to conception (Arm 1), from 12 wk of gestation until delivery (Arm 2); or were not supplemented with sqLNS (Arm 3). At the Pakistan site, samples sizes with birth outcomes obtained within 48 h of delivery for Arms 1, 2 and 3 were 157,150 and 138, respectively. Daily maximal air temperatures were used to were compute the average daily maximal temperatures (Tmax) for each infant over four 90-day windows representing each

trimester of gestation and 3 mo preconception. The number of days in each period when the Tmax was &gt; 39°C was computed to assess ‘heat stress days’.

Results

Linear regression models assessing the associations between heat exposure and outcome variables (gestational age adjusted Z-scores of birth length (LGAZ), birth weight (WGAZ) and head circumference (HCGAZ) revealed a striking negative association of both ambient temperature and HS days in the first trimester on birth length (LGAZ) and head circumference (HCGAZ) (p &lt; 0.005). For each 5°C increase in the Tmax in the first trimester, LGAZ decreased by 0.15 z-scores and HCGAZ decreased by 0.11 z-scores. Heat exposure (Tmax) in the second trimester also associated with HCGAZ (p = 0.02 and z-score of −0.11 for every 5°C) but not with birth length or birth weight. RNA-sequencing of placenta indicated a robust association of 1st trimester HS with genes involved in protein targeting to ER, protein biosynthesis, and cytoplasmic translation. Finally, while non-intervention groups (Arms 2 and 3) showed a robust negative association of excessive HS with LGAZ (p &lt; 0.05), preconception intervention with sqLNS (Arm 1) significantly mitigated heat-associated decreases in birth length.

Conclusions

These findings indicate that excessive HS in the first trimester is associated with decreased linear growth in utero. Importantly, sqLNS mitigated growth restriction in newborns implicating nutritional status as a driving force in resilience to HS.

Funding Sources

Supported by The BMGF and NICHD.

How birth outcomes among a cohort of Guatemalan women with a history of prior cesarean vary by mode or birth across different interpregnancy intervals

OBJECTIVES

Our objectives were to analyze how pregnancy outcomes varied by cesarean birth as compared to vaginal birth across varying interpregnancy intervals (IPI) and determine if IPI modified mode of birth.

METHODS

This secondary analysis used data from a prospective registry of home and hospital births in Chimaltenango, Guatemala from January 2017 through April 2020, through the Global Network for Women's and Children's Health Research. Bivariate comparisons and multivariable logistic regression were used to answer our study question, and the data was analyzed with STATA software v.15.1.

RESULTS

Of 26,465 Guatemalan women enrolled in the registry, 2794 (10.6%) had a history of prior cesarean. 560 (20.1%) women delivered by vaginal birth after cesarean with the remaining 2,233 (79.9%) delivered by repeat cesarean. Repeat cesarean reduced the risk of needing a dilation and curettage compared to vaginal birth after cesarean, but this association did not vary by IPI, all p-values > p = 0.05. Repeat cesarean delivery, as compared to vaginal birth after cesarean, significantly reduced the likelihood a woman breastfeeding within one hour of birth (AOR ranged from 0.009 to 0.10), but IPI was not associated with the outcome. Regarding stillbirth, repeat cesarean birth reduced the likelihood of stillbirth as compared to vaginal birth (AOR 0.2), but again IPI was not associated with the outcome.

CONCLUSION

Outcomes by mode of delivery among a Guatemalan cohort of women with a history of prior cesarean birth do not vary by IPI.

Preconceptional Lipid-Based Nutrient Supplementation in 2 Low-Resource Countries Results in Distinctly Different IGF-1/mTOR Placental Responses

BACKGROUND

Preconceptional maternal small-quantity lipid-based nutrient supplementation (SQLNS) improved intrauterine linear growth in low-resource countries as demonstrated by the Women First Preconception Maternal Nutrition Trial (WF). Fetal growth is dependent on nutrient availability and regulated by insulin-like growth factor 1 (IGF-1) through changes in placental transfer capacity, mediated by the mechanistic target of rapamycin (mTOR) pathway.

OBJECTIVES

Our objective was to evaluate the role of placental mTOR and IGF-1 signaling on fetal growth in women from 2 low-resource countries with high rates of stunting after they received preconceptional SQLNS.

METHODS

We studied 48 women from preconception through delivery who were from Guatemala and Pakistan and received SQLNS or not, as part of the WF study. Placental samples were obtained at delivery (control, n = 24; SQLNS, n = 24). Placental protein or mRNA expression of eukaryotic translation initiation factor binding protein-1 (4E-BP1), ribosomal protein S6 (rpS6), AMP-activated protein kinase α (AMPKA), IGF-1, insulin-like growth factor receptor (IGF-1R), and pregnancy associated plasma protein (PAPP)-A, and DNA methylation of the IGF1 promoter were determined. Maternal serum IGF-1, insulin-like growth factor binding protein (IGFBP)-3, IGFBP-4, IGFBP-5, PAPP-A, PAPP-A2, and zinc were measured.

RESULTS

Mean ± SEM maternal prepregnancy BMI differed between participants in Guatemala (26.5 ± 1.3) and Pakistan (19.8 ± 0.7) (P < 0.001). In Pakistani participants, SQLNS increased the placental rpS6(T37/46):rpS6 ratio (1.5-fold) and decreased the AMPKA(T172):AMPKA ratio. Placental IGF1 mRNA expression was positively correlated with birth length and birth weight z-scores. Placental PAPP-A (30-fold) and maternal serum zinc (1.2-fold) increased with SQLNS. In Guatemalan participants SQLNS did not influence placental mTOR signaling. Placental IGF-1R protein expression was positively associated with birth length and birth weight z-scores. SQLNS increased placental PAPP-A (40-fold) and maternal serum IGFBP-4 (1.6-fold).

CONCLUSIONS

In Pakistani pregnant women with poor nutritional status, preconceptional SQLNS activated placental mTOR and IGF-1 signaling and was associated with improved fetal growth. In contrast, in Guatemalan women SQLNS did not activate placental nutrient-sensing pathways. In populations experiencing childhood stunting, preconceptional SQLNS improves placental function and fetal growth only in the context of poor maternal nutrition. This trial was registered at clinicaltrials.gov as NCT01883193.

Bell Peppers Provide Consistent β-cryptoxanthin Content Independent of Organic Status, Fresh, or Cooked, North American Country of Origin and Season

Objectives

The carotenoid β-cryptoxanthin is a natural pigment that is both an antioxidant and a precursor to retinol. Research supports that β-cryptoxanthin has greater bioavailability than β-carotene in humans. Red bell peppers have more than double the amount of β-cryptoxanthin than any of the top seven consumed vegetables, as ranked by the USDA. To determine if the amounts of β-cryptoxanthin in bell peppers are dependent upon the organic status, color, cooking, season or location that the fruit was grown within North America, β-cryptoxanthin was measured and compared in green, red and yellow bell peppers.

Methods

An assortment of bell peppers were purchased in the greater Denver, CO region. Green, red and yellow peppers; organic and non-organic; and peppers grown in Canada, the US and Mexico during two different seasons were selected for analysis. The effects of lightly sautéing compared to fresh peppers and season of growth were compared. Samples (100 mg/1 mL) were freeze-dried, then prepared by liquid-liquid extraction for untargeted liquid chromatography mass spectrometry (LC-MS)-based metabolomics analysis. An accurate mass and retention time (AMRT) database was used to identify and quantify β-cryptoxanthin. Linear regression was used to assess the relationship between β-cryptoxanthin and pepper qualities.

Results

β-cryptoxanthin concentration was significantly higher in red bell peppers compared to green (11.8-fold) and yellow peppers (7.1-fold) (P = 1.624e-11). β-cryptoxanthin concentration does not appear to be influenced by organic status, season or geographic location. Likewise, the cooked peppers were similar in β-cryptoxanthin content compared to their fresh counterparts.

Conclusions

Our results suggest that the consumption of bell peppers as a source of β-cryptoxanthin is consistent across organic status, fresh, cooked, season and the location in which they were grown. While β-cryptoxanthin concentration in significantly higher in red bell peppers, more research is necessary in order to determine whether these differences result in any altered health outcomes.

Funding Sources

National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK).

Astaxanthin Levels Are Higher in Fresh Salmon Compared to Canned and Pouch Varieties

Objectives

Astaxanthin, a predominately marine-source carotenoid, is the subject of a large number of studies for its antioxidant and anti-inflammatory properties. Astaxanthin is not generally a primary carotenoid in human plasma due to relatively low dietary intake. Salmon is the one of the few dietary sources of astaxanthin in typical American diets and the concentration may vary by the source of salmon foods. A study was performed to 1) Compare astaxanthin concentration in various sources of salmon; 2) Compare astaxanthin plasma concentrations before and after salmon consumption.

Methods

An assortment of salmon types and forms was purchased in the greater Denver, CO region: wild Pacific, farmed Atlantic, canned and pouch. Plasma samples were collected from five participants prior to and after a five week Mediterranean diet intervention study, which included two servings of salmon per week. Salmon samples were freeze-dried, then both salmon (in triplicate) and plasma samples were prepared by liquid-liquid extraction for untargeted liquid chromatography-mass spectrometry analysis. An accurate mass and retention time database was used to identify and quantify astaxanthin. ANOVA with Tukey multiple testing corrections was used to assess the relationship between astaxanthin and the different salmon products, and paired t-tests for astaxanthin in plasma.

Results

Astaxanthin concentration was significantly higher in fresh salmon compared to pouch packaged (23.0-fold; P = 1.70e-04) and canned (34.9-fold; P = 1.23e-08). Interestingly, astaxanthin levels were similar between fresh wild Pacific and fresh farmed Atlantic salmon (0.91-fold, P = 0.82) and by mode of cooking (i.e., fresh, cooked, frozen; P = 0.81). Astaxanthin concentration in plasma was significantly increased after farmed Atlantic salmon consumption (1.98-fold, P = 6.16e-09).

Conclusions

Our data suggest that astaxanthin concentration varies among different processed salmon products compared to wild and farmed salmon. After salmon consumption, plasma astaxanthin concentration increased and may have potential as a biomarker of salmon consumption.

Funding Sources

National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK).

Effect of Pooling Practices and Time Postpartum of Milk Donations on the Energy, Macronutrient, and Zinc Concentrations of Resultant Donor Human Milk Pools

OBJECTIVE

To characterize the macronutrient, energy, and zinc composition of pasteurized donor human milk pools and evaluate how composition varies based on pooling practices and "time postpartum" (ie, elapsed time from parturition to expression date) of individual milk donations.

STUDY DESIGN

The Mothers' Milk Bank (Arvada, Colorado) donated 128 donor human milk pools. Caloric density was assessed via mid-infrared spectroscopy, and zinc concentration was measured by atomic absorption spectroscopy. Pool time postpartum was calculated as the unweighted average of the time postpartum of all milk donations included in any given pool.

RESULTS

Time postpartum of donor human milk pools ranged from 3 days to 9.8 months. The majority (91%) of donor human milk pools included milk from either 1 donor or 2 donors. Pool energy density ranged from 14.7 to 23.1 kcal/oz, and protein ranged from 0.52 to 1.43 g/dL. Milk zinc concentrations were higher in preterm pools and were negatively correlated with pool time postpartum. We present an equation that estimates donor human milk pool zinc content based on time postpartum and explains 49% of the variability in zinc concentrations (P < .0001). Including more donors in donor human milk pools decreased the variability in protein, but not zinc, concentrations.

CONCLUSIONS

Donor human milk pools were lower in calories than is normally assumed in standard human milk fortification practices. Zinc concentrations were related to donor human milk time postpartum and were on average insufficient to meet preterm and term infants' needs without fortification or supplementation.

Differential DNA Methylation of Human Metastable Epialleles in Guatemalan Infants at Birth Due to Timing of a Maternal Lipid-Based Nutrition Supplement and Pre-Pregnancy BMI (P11-139-19)

Objectives

Human metastable epialleles (MEs) are specific regions that are systemically methylated (lack tissue specificity), stable over time, and variably expressed between individuals. DNA methylation (DNAme) of MEs have been previously reported to be altered by maternal nutritional status at the time of conception. Here, we examined DNAme of MEs from a subset of Guatemalan mother/infant dyads as part of the Women First study, an international RCT that tested whether timing of a daily lipid-based nutrition supplement (LNS) improved birth length. The 3 study arms are: women consumed LNS ≥ 3 months prior to conception until delivery (Arm 1, N = 45); women consumed the same LNS commencing at 12 weeks gestation until delivery (Arm 2, N = 45); or no LNS (Arm 3, N = 44). The purpose of this study was to test if the timing of maternal LNS and pre-pregnancy BMI (ppBMI, BMI range = 20.1 – 38.4 kg/m2) led to differential DNAme of MEs in infants at birth.

Methods

Bisulfite-converted DNAme libraries were constructed using NimbleGen SeqCap Epi CpGiant probes from amnion tissue collected at birth. Individuals were sequenced via 2 × 150 paired end reads using the Illumina NovaSeq sequencer. Subjects that passed quality control (131/142 subjects) were used in subsequent statistical analyses. A linear model was used to test for the interaction between maternal LNS and ppBMI on infant DNAme for each base pair site within 296 previously identified candidate ME regions. The number of methylated base pairs per region ranged from 1 – 737. A significance level adjusting for the 296 regions was set at P ≤ 0.000169.

Results

We identified 6 ME regions with significant interactions, demonstrating differential ME DNAme due to intervention arm was dependent on ppBMI values. Our analyses also identified 3 CpGs associated with ppBMI regardless of LNS status and 1 CpG associated with LNS regardless of ppBMI suggesting a role for independent effects of maternal LNS and ppBMI on ME DNAme.

Conclusions

Our findings indicate that timing of maternal LNS and ppBMI contribute to DNAme of candidate MEs in infants at birth, suggesting epigenetic influences due to in utero exposures. Future analyses will identify genes associated with changes in ME DNAme and the role of DNAme on infant growth.

Funding Sources

Bill & Melinda Gates Foundation and National Institutes of Health.

Maternal Characteristics Affect Fetal Growth Response to Maternal Supplements in the Women First Preconception Trial (WF) (P10-017-19)

Objectives

Determine if maternal characteristics modified newborn anthropometric outcomes in the WF trial (ClinicalTrials.gov NCT01883193).

Methods

Secondary analysis included combined data for all 1465 maternal infant dyads in WF sites in Guatemala, India, and Pakistan who had 1st trimester ultrasounds and newborn anthropometry with the three WF arms maintained: Arm 1 commenced a comprehensive nutrition supplement ≥3 months prior to conception; Arm 2 commenced the same supplement in the 1st trimester, and Arm 3 received no trial supplements. Maternal characteristics included were: baseline, BMI, hemoglobin, age, education, SES, and parity plus newborn sex. Newborn outcomes were Z-scores for length (LAZ), weight (WAZ), and weight-to-length ratio (WLRZ). Mixed effect regression models were fit for each outcome, including treatment arm, effect modifier, and treatment arm x effect modifier interaction as predictors and controlling for study site, maternal characteristics, and newborn sex.

Results

Parity, anemia and newborn sex were significant effect modifiers favoring para 0 vs para ≥1, anemia vs non anemia, and newborn male vs female. Effect of Arm 1 vs 3 was significantly larger for para 0 vs ≥1 women on length and weight (Table). Arm 2 vs 3 was not associated with improvements for para 0 in weight (P = 0.273) or WLRZ (P = 0.710). Arms 1 and 2 (vs 3) were associated with significantly higher length, weight, and WLRZ for anemic women.

For parity and anemia, effect sizes for Arm 1 were greater than for Arm 2 for WAZ and WLZ (P < 0.05), but not LAZ. Arm 1 and 2 were associated with significantly higher weight and WLRZ for male vs female newborn.

Conclusions

In diverse low resource populations, impaired fetal growth (weight and length) is substantially improved in nulliparous and in anemic women but minimally or not at all in parous and in non-anemic women. Correction of weight decrements is most pronounced with improvement in maternal nutrition commencing prior to conception.

Funding Sources

Bill & Melinda Gates Foundation; NIH, NICHD and ODS.

Supporting Tables, Images and/or Graphs

Differences in Birth Size Associated with Preconception Maternal Nutrition Intervention Persist in Postnatal Growth Through 6 Months (OR10-05-19)

Objectives

Newborn size, including length, has been associated with later growth. Preconception nutrition supplementation in Women First (WF) trial (clinicaltrials.gov NCT01883193) was associated with higher newborn length and lower rates of stunting. The objective was to examine postnatal growth outcomes through 6 mo in the WF offspring.

Methods

Subjects were 2450 infants from the WF sites in Democratic Republic of Congo (DRC), Guatemala, India, and Pakistan with the 3 WF arms maintained: Arm 1 started a lipid-based nutrition supplement ≥ 3 mo prior to conception; Arm 2 started same supplement at ∼11 wk gestation; and Arm 3 received no trial supplements. Maternal supplementation was discontinued at delivery. Anthropometric measurements were obtained at birth, 0.5, 1, 3, and 6 mo; Z-scores were calculated from WHO Child Growth Standards. Primary and secondary outcomes were analyzed using longitudinal generalized estimating equations accounting for the correlation of repeated measures over time and study cluster. Intervention effects were evaluated within each site as well as overall, adjusting for site and baseline maternal covariates that differed by arm. Statistical interaction between arm and infant sex was evaluated and included if significant.

Results

Longitudinal growth (length and weight) curves from 0–6 mo demonstrated differences by intervention arm, with Arms 1 and 2 more favorable compared to Arm 3 (Table + LAZ in Figure). Relative risks (RR) for stunting were significantly lower for Arms 1 and 2 (vs. Arm 3) (Table). Site-specific analyses revealed some site differences warranting further exploration.

Conclusions

Without any postnatal intervention, differences in fetal growth evident at birth persisted at 6 months.

Funding Sources

Bill & Melinda Gates Foundation; NIH, NICHD & ODS.

Supporting Tables, Images and/or Graphs

The Effect of a Preconception Nutrition Supplement on One Carbon Metabolites (P24-028-19)

Objectives

Studies in both animals and humans have shown that maternal dietary restriction and supplementation of one carbon (1C) metabolites (methyl donors), such as methionine and choline, can impact offspring growth, insulin resistance, and DNA methylation. However, there has been limited longitudinal research of 1C metabolite concentrations over the reproduction cycle of human pregnancy. The purpose of this study was to investigate if 1C metabolite concentrations change prior to and during pregnancy and if a preconception lipid-based nutrition supplement (LNS) influences such changes.

Methods

This study was a secondary analysis as part of the Women First study (clinicaltrials.gov, NCT01883193), a large, randomized controlled trial investigating whether the timing of maternal LNS initiation would impact fetal growth and development. The study arms were supplementation at least 3 months prior to conception (Arm 1), supplementation at ∼12 weeks of gestation (Arm 2), or no supplementation (Arm 3). Dried blood spot (DBS) cards were collected at study enrollment prior to conception, and at 12 and 34 weeks gestation. A targeted 1C metabolite assay (27 metabolites) was performed on a subset of DBS samples from Guatemalan women (n = 134) at each time point using liquid chromatography/tandem mass spectrometry. Longitudinal analyses were performed using linear mixed modeling to investigate the influence of time and LNS on these metabolites.

Results

The concentrations of two metabolites were changed by intervention status: asymmetric dimethylarginine (ADMA) and symmetric dimethylarginine (SDMA). Twenty-one of 27 metabolites significantly changed from preconception and across gestation after correcting for multiple testing using the Bonferroni correction (P < 0.00185).

Conclusions

Preconception LNS significantly decreased the level of ADMA, a metabolite which has been implicated in intrauterine growth restriction and preeclampsia. More work is needed to determine whether this intervention could influence development of these conditions.

Funding Sources

Bill & Melinda Gates Foundation, National Institutes of Health.

Term Offspring of Nulliparous Women Have Lower Weight-for-age Z-scores Than Multiparous Women in Chimaltenango, Guatemala (P11-065-19)

Objectives

Women´s parity may be associated with their current offspring growth outcomes. We aimed to determine the association between parity and birthweight among Guatemalan women.

Methods

We analyzed 50,987 term births that occurred between 2014 and 2016 in the Chimaltenango, Guatemala site of the Global Network for Women and Children's Health Maternal Neonatal Health Registry. Gestational age was determined by ultrasound or last menstrual period. Birthweight was obtained within the first 48 hours of life with up to 10 grams of accuracy and converted to z-scores using INTERGROWTH-21st with quality control. The means of birthweight z-scores were computed by ANOVA; adjusting for maternal age and height did not change the results. P-values < 0.05 were considered significant.

Results

Nulliparous women had offspring of lower birthweight than women with parity 1–3 and 4 or more.

Conclusions

These results may have implications for the targeting of nutritional interventions aimed to improve pregnancy outcomes.

Funding Sources

Grant from National Institute of Child Health and Human Development.

Supporting Tables, Images and/or Graphs

Exchangeable Zinc Pool (EZP) Size in Bangladeshi Toddlers at Risk of Environmental Enteric Dysfunction (EED) Is Not Influenced by Inflammation (OR07-03-19)

Objectives

The effect of infection and inflammation on EZP size, a putative biomarker of Zn status, is unknown. We sought to evaluate the relationship of EZP to systemic inflammation in a group of toddlers with high risk of Zn deficiency and EED.

Methods

Subjects were 112 children from an urban slum area in Dhaka, Bangladesh, aged 18–24 months, at risk of EED and who participated in stable isotope studies of Zn homeostasis while on habitual diets. All children underwent screening for EED, using L: M ratio, and multiple markers of systemic and intestinal inflammation were obtained. EZP size was measured from intravenously administered stable isotope of Zn, with urine collections obtained over 4 days, starting 3 days after isotope administration. The size of EZP was calculated by dividing the mass (mg) of intravenous isotope dose (67 Zn or 68 Zn) by the enrichment value at the y intercept of the linear regression: EZP (mg) = IV dose/y-intercept. The intercept is estimated from linear regression of a semi-log plot of urine enrichment data. Multiple regression analysis was applied to examine relationships among child size, serum Zn, markers of systemic and intestinal inflammation and EZP. EZP was also compared to previously published evaluation of EZP from multiple studies (Miller LV, J Nutr, 2016).

Results

Mean (± SD) age of subjects was 19 ± 2 months; mean weight 9.1 ± 1.0 kg; mean dietary Zn was 2.7 mg/d. Mean EZP was 3.7 ± 0.5 mg/kg, compared to an expected value of 4.1 mg/kg based on the previous published analysis of all child data; all data points were within the 90% prediction interval from those data (Figure). Compared to existing child data, these children weighed less and had smaller EZP. EZP/kg was directly associated with serum Zn concentration, and inversely associated with hemoglobin and dietary Zn (best model R2 = 0.24). The analyses indicated no evidence of an association of EZP/kg with any biomarkers of inflammation.

Conclusions

The apparent absence of an effect of inflammation on EZP size may provide some advantage over serum Zn. The inverse relationship with dietary Zn suggests redistribution of Zn pools in chronic marginal Zn status. Evaluation of utility of EZP as a biomarker of Zn status will require measurement during controlled interventions.

Funding Sources

Bill & Melinda Gates Foundation.

Supporting Tables, Images and/or Graphs

The use of Zinc Stable Isotopes in the Study of Iron-Zinc Interactions in Chilean Women

The objective of this study was to compare the fractional zinc absorption (FAZ) and the size of the rapidly exchangeable zinc pool (EZP) after three months of iron supplementation in women consuming ferrous sulfate between meals. Twenty-one non-anemic apparently healthy women received on average 55.1 ± 18.5 mg elemental iron per day as ferrous sulfate, and five received no supplemental iron. Fractional absorption of zinc was determined before and three days after finishing the third month of iron supplementation by using an extrinsic labeling with zinc stable isotopes and a dual isotope enrichment method in urine. EZP was determined from urine enrichment following intravenous administration of 70Zn. Results of selected zinc-related variables in the iron supplemented women were (before vs. after iron supplementation): FAZ with meal 0.22 vs. 0.24, p = .23; FAZ in fasting state 0.58 vs. 0.69, p = .005; EZP 177 mg vs. 160 mg, p = .058; plasma zinc 90.6 vs. 86.1 μg/dl, p = .065. The control group remained unchanged. The capacity to absorb zinc was increased three days after terminating a period of iron supplementation as compared with the pre-iron period. This may be attributable to impairment of zinc status by the iron supplements as evidenced by a trend for lower plasma zinc and EZP.

Study Protocol for a Randomized, Double-Blind, Community-Based Efficacy Trial of Various Doses of Zinc in Micronutrient Powders or Tablets in Young Bangladeshi Children

Zinc is essential to supporting growth in young children especially for tissues undergoing rapid cellular differentiation and turnover, such as those in the immune system and gastrointestinal tract. Therapeutic zinc supplementation has been initiated in low-income countries as part of diarrhea treatment programs to support these needs for young children, but the effects of preventive supplemental zinc as a tablet or as a multiple micronutrient powder (MNP) on child growth and diarrheal disease are mixed and pose programmatic uncertainties. Thus, a randomized, double-blind community-based efficacy trial of five different doses, forms, and frequencies of preventive zinc supplementation vs. a placebo was designed for a study in children aged 9–11 months in an urban community in Dhaka, Bangladesh. The primary outcomes of this 24-week study are incidence of diarrheal disease and linear growth. Study workers will conduct in-home morbidity checks twice weekly; anthropometry will be measured at baseline, 12 weeks and 24 weeks. Serum zinc and other related biomarkers will be measured in a subsample along with an estimate of the exchangeable zinc pool size using stable isotope techniques in a subgroup. Therapeutic zinc will be provided as part of diarrhea treatment, in accordance with Bangladesh’s national policy. Therefore, the proposed study will determine the additional benefit of a preventive zinc supplementation intervention. The protocol has been approved by the Institutional Review Boards (IRBs) of icddr,b and Children’s Hospital Oakland Research Institute (CHORI). The IRB review process is underway at the University of Colorado Denver as well.

Upregulation of Zinc Absorption Matches Increases in Physiologic Requirements for Zinc in Women Consuming High- or Moderate-Phytate Diets during Late Pregnancy and Early Lactation

Background: Estimated physiologic requirements (PRs) for zinc increase in late pregnancy and early lactation, but the effect on dietary zinc requirements is uncertain.Objective: The aim of this study was to determine changes in daily fractional absorbed zinc and total absorbed zinc (TAZ) from ad libitum diets of differing phytate contents in relation to physiologic zinc requirements during pregnancy and lactation.Methods: This was a prospective observational study of zinc absorption at 8 (phase 1) and 34 (phase 2) wk of gestation and 2 (phase 3) and 6 (phase 4) mo of lactation. Participants were indigenous Guatemalan women of childbearing age whose major food staple was maize and who had been randomly assigned in a larger study to either of 2 ad libitum feeding groups: low-phytate maize (LP; 1.6 mg/g; n = 14) or control maize (C; 7.1 mg/g; n = 8). Total dietary zinc (milligrams per day, TDZ) and phytate (milligrams per day) were determined from duplicate diets and fractional absorption (FAZ) by dual isotope ratio technique (TAZ = TDZ × FAZ). All variables were examined longitudinally and by group and compared with PRs. TAZ values at later phases were compared with phase 1. Measured TAZ was compared with predicted TAZ for nonpregnant, nonlactating (NPNL) women.Results: TAZ was greater in the LP group than in the C group at all phases. All variables increased from phase 1 to phases 2 and 3 and declined at phase 4. TAZ increased by 1.25 mg/d (P = 0.045) in the C group and by 0.81 mg/d (P = 0.058) in the LP group at phase 2. At phase 3, the increases were 2.66 mg/d (P = 0.002) in the C group and 2.28 mg/d (P = 0.0004) in the LP group, compared with a 1.37-mg/d increase in PR. Measured TAZ was greater than predicted values in phases 2-4.Conclusions: Upregulation of zinc absorption in late pregnancy and early lactation matches increases in PRs of pregnant and lactating women, regardless of dietary phytate, which has implications for dietary zinc requirements of pregnant and lactating women.

Resistant starch does not affect zinc homeostasis in rural Malawian children

OBJECTIVE

This study tested the hypothesis that Malawian children at risk for zinc deficiency will have reduced endogenous fecal zinc (EFZ) and increased net absorbed zinc (NAZ) following the addition of high amylose maize resistant starch (RS) to their diet.

METHODS

This was a small controlled clinical trial to determine the effects of added dietary RS on zinc homeostasis among 17 stunted children, aged 3-5 years consuming a plant-based diet and at risk for perturbed zinc homeostasis. Dual zinc stable isotope studies were performed before and after 28 d of intervention with RS, so that each child served as their own control. The RS was incorporated into fried wheat flour dough and given under direct observation twice daily for 28 d. Changes in zinc homeostatic measures were compared using paired Student's t-tests and linear regression analysis.

RESULTS

Children had a mean height-for-age Z-score of -3.3, and consumed animal source foods ≤twice per month. Their habitual diet contained a phytate:zinc molar ratio of 34:1. Children avidly consumed the RS without complaints. EFZ was 0.8±0.4mg/d (mean±SD) both before and after the intervention. Fractional absorption of zinc was 0.38±0.08 and 0.35±0.06 before and after the RS intervention respectively. NAZ was 1.1±0.5 and 0.6±0.7 before and after the RS intervention. This reduction of NAZ corresponded with diminished dietary zinc intake on the study day following intervention with RS. Regression analysis indicated no change in zinc absorption relative to dietary intake as a result of the RS intervention.

CONCLUSION

Consumption of RS did not improve zinc homeostasis in rural African children without zinc deficiency. RS was well tolerated in this setting.

Zinc absorption from micronutrient powder is low but is not affected by iron in Kenyan infants

Interference with zinc absorption is a proposed explanation for adverse effects of supplemental iron in iron-replete children in malaria endemic settings. We examined the effects of iron in micronutrient powder (MNP) on zinc absorption after three months of home fortification with MNP in maize-based diets in rural Kenyan infants. In a double blind design, six-month-old, non-anemic infants were randomized to MNP containing 5 mg zinc, with or without 12.5 mg of iron (MNP + Fe and MNP − Fe, respectively); a control (C) group received placebo powder. After three months, duplicate diet collections and zinc stable isotopes were used to measure intake from MNP + non-breast milk foods and fractional absorption of zinc (FAZ) by dual isotope ratio method; total absorbed zinc (TAZ, mg/day) was calculated from intake × FAZ. Mean (SEM) TAZ was not different between MNP + Fe (n = 10) and MNP - Fe (n = 9) groups: 0.85 (0.22) and 0.72 (0.19), respectively, but both were higher than C (n = 9): 0.24 (0.03) (p = 0.04). Iron in MNP did not significantly alter zinc absorption, but despite intakes over double estimated dietary requirement, both MNP groups' mean TAZ barely approximated the physiologic requirement for age. Impaired zinc absorption may dictate need for higher zinc doses in vulnerable populations.

Absorbed zinc and exchangeable zinc pool size are greater in Pakistani infants receiving traditional complementary foods with zinc-fortified micronutrient powder

Adequacy of zinc intake from breast milk alone becomes marginal in relation to infant requirements by around 6 mo of age. Simple and cost-effective strategies are needed at the population level to ensure adequate intakes of zinc in infants and toddlers in populations at risk of zinc deficiency. We determined the amount of absorbed zinc (AZ) from a micronutrient powder (MNP) without and with 10 mg of zinc (MNP+Zn) added to local complementary foods used in Pakistan and the impact on the exchangeable zinc pool (EZP) size. As a nested study within a large, prospective, cluster randomized trial, 6-mo-old infants were randomly assigned to receive MNP or MNP+Zn. Stable isotope methodology was applied after ∼3 and 9 mo of use to measure AZ from MNP-fortified test meals of rice-lentils (khitchri) and EZP. Nineteen infants per group completed the first metabolic studies and 14 and 17 infants in the MNP and MNP+Zn groups, respectively, completed the follow-up studies. AZs were (mean ± SD) 0.1 ± 0.1 and 1.2 ± 0.5 mg at the first point for the MNP and MNP+Zn groups, respectively (P < 0.001); results were nearly identical at the follow-up measurement. EZP did not differ between groups at the first measurement but was less in the MNP group (3.7 ± 0.6 mg/kg) than in the MNP+Zn group (4.5 ± 1.0 mg/kg) at the second measurement (P = 0.01). These data confirm that the MNP+Zn in khitchri were well absorbed and after 1 y of home fortification, zinc status assessed by EZP was significantly better for the MNP+Zn group. Additional field studies may be necessary to ascertain the adequacy of this dose for infants at high risk of deficiency. This trial was registered at ClinicalTrials.gov as NCT00705445.

Newborn length predicts early infant linear growth retardation and disproportionately high weight gain in a low-income population

BACKGROUND

Stunting is prevalent by the age of 6 months in the indigenous population of the Western Highlands of Guatemala.

AIM

The objective of this study was to determine the time course and predictors of linear growth failure and weight-for-age in early infancy.

STUDY DESIGN AND SUBJECTS

One hundred and forty eight term newborns had measurements of length and weight in their homes, repeated at 3 and 6 months. Maternal measurements were also obtained.

RESULTS

Mean ± SD length-for-age Z-score (LAZ) declined from newborn -1.0 ± 1.01 to -2.20 ± 1.05 and -2.26 ± 1.01 at 3 and 6 months respectively. Stunting rates for newborn, 3 and 6 months were 47%, 53% and 56% respectively. A multiple regression model (R(2) = 0.64) demonstrated that the major predictor of LAZ at 3 months was newborn LAZ with the other predictors being newborn weight-for-age Z-score (WAZ), gender and maternal education∗maternal age interaction. Because WAZ remained essentially constant and LAZ declined during the same period, weight-for-length Z-score (WLZ) increased from -0.44 to +1.28 from birth to 3 months. The more severe the linear growth failure, the greater WAZ was in proportion to the LAZ.

CONCLUSION

The primary conclusion is that impaired fetal linear growth is the major predictor of early infant linear growth failure indicating that prevention needs to start with maternal interventions.

Effects of different complementary feeding regimens on iron status and enteric microbiota in breastfed infants

OBJECTIVE

To compare iron status in breastfed infants randomized to groups receiving complementary feeding regimens that provided iron from fortified infant cereals or meats, and to examine the development of the enteric microbiota in these groups.

STUDY DESIGN

Forty-five exclusively breastfed 5-month-old infants were randomized to 1 of 3 feeding groups (FGs)-commercially available pureed meats, iron- and zinc-fortified infant cereals, or iron-only fortified infant cereals-as the first and primary complementary food through 9-10 months of age. Dietary iron was determined by monthly 3-day diet records. Iron status was assessed at the end of the study by measurements of hemoglobin, serum ferritin, and soluble transferrin receptor levels. In a subsample of 14 infants, enteric microbiota were profiled in monthly stool samples (5-9 months) by 16S ribosomal RNA gene pyrosequencing.

RESULTS

Infants in the 2 cereal FGs had 2- to 3-fold greater daily iron intakes versus the meat FG (P < .0001). More than one-quarter (27%) of the infants had a low serum ferritin level, and 36% were mildly anemic, with no significant differences by FG; more infants in the meat FG had a high soluble transferrin receptor value (P = .03). Sequence analysis identified differences by time and FG in the abundances of several bacterial groups, including significantly more abundant butyrate-producing Clostridium group XIVa in the meat FG (P = .01) CONCLUSION: A high percentage of healthy infants who were breastfed-only were iron-deficient, and complementary feeding, including iron exposure, influenced the development of the enteric microbiota. If these findings are confirmed, then reconsideration of strategies to both meet infants' iron requirements and optimize the developing microbiome may be warranted.

Randomized controlled trial of meat compared with multimicronutrient-fortified cereal in infants and toddlers with high stunting rates in diverse settings

BACKGROUND

Improved complementary feeding is cited as a critical factor for reducing stunting. Consumption of meats has been advocated, but its efficacy in low-resource settings has not been tested.

OBJECTIVE

The objective was to test the hypothesis that daily intake of 30 to 45 g meat from 6 to 18 mo of age would result in greater linear growth velocity and improved micronutrient status in comparison with an equicaloric multimicronutrient-fortified cereal.

DESIGN

This was a cluster randomized efficacy trial conducted in the Democratic Republic of Congo, Zambia, Guatemala, and Pakistan. Individual daily portions of study foods and education messages to enhance complementary feeding were delivered to participants. Blood tests were obtained at trial completion.

RESULTS

A total of 532 (86.1%) and 530 (85.8%) participants from the meat and cereal arms, respectively, completed the study. Linear growth velocity did not differ between treatment groups: 1.00 (95% CI: 0.99, 1.02) and 1.02 (95% CI: 1.00, 1.04) cm/mo for the meat and cereal groups, respectively (P = 0.39). From baseline to 18 mo, stunting [length-for-age z score (LAZ) <-2.0] rates increased from ~33% to nearly 50%. Years of maternal education and maternal height were positively associated with linear growth velocity (P = 0.0006 and 0.003, respectively); LAZ at 6 mo was negatively associated (P < 0.0001). Anemia rates did not differ by group; iron deficiency was significantly lower in the cereal group.

CONCLUSION

The high rate of stunting at baseline and the lack of effect of either the meat or multiple micronutrient-fortified cereal intervention to reverse its progression argue for multifaceted interventions beginning in the pre- and early postnatal periods.

Evaluation of meat as a first complementary food for breastfed infants: impact on iron intake

The rationale for promoting the availability of local, affordable, non-fortified food sources of bioavailable iron in developing countries is considered in this review. Intake of iron from the regular consumption of meat from the age of 6 months is evaluated with respect to physiological requirements. Two major randomized controlled trials evaluating meat as a first and regular complementary food are described in this article. These trials are presently in progress in poor communities in Guatemala, Pakistan, Zambia, Democratic Republic of the Congo, and China.

Complementary feeding: a Global Network cluster randomized controlled trial

Background

Inadequate and inappropriate complementary feeding are major factors contributing to excess morbidity and mortality in young children in low resource settings. Animal source foods in particular are cited as essential to achieve micronutrient requirements. The efficacy of the recommendation for regular meat consumption, however, has not been systematically evaluated.

Methods/Design

A cluster randomized efficacy trial was designed to test the hypothesis that 12 months of daily intake of beef added as a complementary food would result in greater linear growth velocity than a micronutrient fortified equi-caloric rice-soy cereal supplement. The study is being conducted in 4 sites of the Global Network for Women's and Children's Health Research located in Guatemala, Pakistan, Democratic Republic of the Congo (DRC) and Zambia in communities with toddler stunting rates of at least 20%. Five clusters per country were randomized to each of the food arms, with 30 infants in each cluster. The daily meat or cereal supplement was delivered to the home by community coordinators, starting when the infants were 6 months of age and continuing through 18 months. All participating mothers received nutrition education messages to enhance complementary feeding practices delivered by study coordinators and through posters at the local health center. Outcome measures, obtained at 6, 9, 12, and 18 months by a separate assessment team, included anthropometry; dietary variety and diversity scores; biomarkers of iron, zinc and Vitamin B₁₂ status (18 months); neurocognitive development (12 and 18 months); and incidence of infectious morbidity throughout the trial. The trial was supervised by a trial steering committee, and an independent data monitoring committee provided oversight for the safety and conduct of the trial.

Discussion

Findings from this trial will test the efficacy of daily intake of meat commencing at age 6 months and, if beneficial, will provide a strong rationale for global efforts to enhance local supplies of meat as a complementary food for young children.

Trial registration

NCT01084109