Tofail, F; (2006) Effect of food and micronutrient supplementation during pregnancy on subsequent development of infants in Bangladesh: a randomized trial. Doctoral thesis , UCL (University College London).

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Abstract

Background: The prevalence of low birth weight (LBW) is high in developing countries and is estimated to be 30% (UNICEF, 2001) in Bangladesh. Maternal under nutrition is an important cause of LBW is also highly prevalent in Bangladesh 50 % (March of Dimes, 2002). Public health programs of food-supplementation during pregnancy have been mounted to address the issue and it is important to determine the most effective way of providing the food. In addition it has been suggested that supplementation with multiple micronutrients may be more beneficial than supplementing with iron and folic acid alone, which is the present practise. Most studies of pregnancy supplementation have focused on the effect on birth outcomes whereas there is extremely little data on the effects on the offspring's' development. A large randomized-trial of the effect of 2 types of nutritional supplementation (food and micronutrients) in pregnant women on birth-outcomes was conducted in the Matlab field-site of ICDDR,B: Centre for Health and Population Research, Bangladesh. We took the opportunity to evaluate the effect of the supplements on children's development.;Aims: We aimed to determine the effect of giving pregnant women early (around 10 week of gestation) versus late (around 17 week of gestation) food-supplementation and multi-micronutrients or 30mg iron + 400 fig folate or 60mg iron + 400 fig folate on their infants' development.;Methods: A sub-sample of all singletons (n=2853) born between May 2002 and December 2003 in the main trial was selected to have developmental assessments at 7 months of age. The children were assessed using 2 problem-solving tests (cover and support), the Bayley motor-scale (PDI) and Wolke's behaviour ratings assessing approach, activity, emotionality, co-operation and vocalization during the test procedure. The children were also assessed for the age of attainment of motor milestones.;Intervention: 2 nutritional interventions were given: Food supplementation: Women were randomly assigned to begin the food supplementation program (a) immediately after diagnosis of pregnancy (early care) or (b) at the time of their choosing (usual care). Micronutrient supplementation: Within each food group, women were randomly assigned to receive a pill that contained (a) 30 mg iron and 400 Lig folate or (b) 60 mg iron and 400 Hg folate (usual care) or (c) 30 mg iron, 400 U-g folate and 13 additional micronutrients (UN1CEF/WHO/UNU, 1999 formulation of 15-micronutrients).;Results: There is no overall benefit of prenatal supplementation with early food or multiple-micronutrients compared with late food or iron and folate supplementation on any of the tests of children's development when assessed at 7 months of age. However infants of thin mothers (body mass index <18.5 kg/m ) showed a small but statistically significant benefit from both early food and multiple-micronutrients supplements whereas the children of better nourished mothers did not. Early food supplementation benefited children of malnourished mothers in the problem solving tests, support (BMI x early food p<0.03) and cover (BMI x early food p<0.05) and behaviour. The children were less fussy (BMI x early food p<0.04), more cooperative with the test situation (BMI x early food p<0.04) and vocalised more often (BMI x early food p<0.04) than children of similar mothers given late food supplementation. Small but significant benefits on motor development (BMI x micronutrients p=0.05) and activity (BMI x micronutrients p<0.05) were also observed among the infants of malnourished mothers who received multiple-micronutrient supplements. Mothers' BMI had an independent effect on children's development.;Conclusions: Early food and multiple micronutrient supplementation benefited development in children of undernourished mothers but not children of better nourished mothers. The findings support current practices in Bangladesh of targeting thin mothers and suggest that early food supplementation may be more beneficial than later supplementation. The findings also suggest that multiple micronutrients may be more beneficial to the child than iron and folate. However, the effect sizes were very small and their clinical and public health importance are not clear and can only be determined with longer follow-up. As there was no placebo group, the benefit of giving food supplementation throughout pregnancy could not be assessed. The relationship between mothers BMI and children's development emphasises the importance of maternal nutrition.

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