Multiple Micronutrients Better Than Iron And Folic Acid Supplements Alone In Preventing Infant Death And Fetal Loss

Main Category: Pediatrics / Children's Health
Also Included In: Pregnancy / Obstetrics
Article Date: 21 Jan 2008 - 2:00 PST

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Multiple micronutrient supplementation (MMN) for pregnant women is more effective than iron and folic acid supplementation (IFA) alone at preventing early infant death and fetal loss. These are the conclusions of the Supplementation with Multiple Micronutrients Intervention Trial (SUMMIT) study group in an Article in this week's edition of The Lancet.

A number of previous studies have explored the effects of MMN, many using the United Nations international multiple micronutrient preparation (UNIMMAP). Whilst several studies have shown improvements in birth weight, gestational length and other factors, some have shown no advantages to MMN. A systematic review indicated that maternal MMN has tended to improve birthweight, but suggested more evidence was needed to establish the effects of MMN on infant and maternal health and mortality.

Dr Anuraj Shankar, SUMMIT Institute of Development, University of Mataram, Indonesia, and colleagues did a study of 31 290 of pregnant women in Indonesia, 15 486 of whom were randomised to receive IFA, and 15 804 to receive MMN. The IFA contained 30 mg iron and 400 μg folic acid. The MMN contained the exactly the same dose of iron and folic acid, plus vitamins A, C, D, E, B1, B2, B6, B12, niacin, zinc, copper, selenium, and iodine. Women were asked to take the supplements daily from enrolment to 90 days after giving birth.

The researchers found that infants of women consuming MMN had an 18% reduction in early infant mortality (deaths in the first 90 days after birth) compared with those given IFA (35•5 deaths per 1000 live births MMN, 43 per 1000 IFA). For mothers who were undernourished or anaemic, the effect of MMN was even greater, with reductions in early infant mortality of 25% and 38%, respectively, compared with IFA supplementation.

Reductions in combined fetal loss and early infant mortality were also greater for women given MMN compared with IFA-the average reduction was 11%, and again the reduction was greater in undernourished (15%) and anaemic (29%) women. The risk of lower birthweight was reduced by 14% in the MMN group compared with IFA-and by 33% if women were anaemic.

The authors conclude: "Our study suggests that maternal MMN supplementation, compared with IFA, reduced early infant mortality. This effect was seen predominantly after the first five days of life, and was most pronounced from days 29 to 90 after birth. Effects were greater in women consuming larger numbers of supplements and in those who were anaemic or undernourished at enrolment. MMN consumption also resulted in a significant reduction in overall fetal loss and neonatal death, and these effects also tended to be greater in poorly nourished women. Thus, the effects of maternal MMN on infant deaths might be dose and deficiency-dependent, and involve several mechanisms, resulting in perinatal and neonatal effects, and a larger postneonatal effect."

In an accompanying Comment, Professor Zulfiqar Bhutta and Dr Batool Haider, Department of Paediatrics & Child Health, Aga Khan University, Karachi, Pakistan, say that the SUMMIT findings provide a strong basis to pursue larger effectiveness trials of maternal multiple micronutrient supplementation. They say: "In view of the controversy surrounding these supplements and birth outcomes, these trials must be done in programmatic settings with strong monitoring and evaluation components."

The Lancet