Antenatal dietary advice and supplementation to increase energy and protein intake
Abstract
Background
Gestational weight gain is positively associated with fetal growth, and observational studies of food supplementation in pregnancy have reported increases in gestational weight gain and fetal growth.
Objectives
To assess the effects of advice during pregnancy to increase energy and protein intake, or of actual energy and protein supplementation, on energy and protein intakes, and the effect on maternal and infant health outcomes.
Search methods
We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (22 July 2011) and contacted researchers in the field. We updated the search on 12 July 2012 and added the results to the awaiting classification section of the review.
Selection criteria
Randomised controlled trials of dietary advice to increase energy and protein intake, or of actual energy and protein supplementation, during pregnancy.
Data collection and analysis
Two review authors independently assessed trials for inclusion and assessed risk of bias. Two review authors independently extracted data and checked for accuracy. Extracted data were supplemented by additional information from the trialists we contacted.
Main results
We examined 110 reports corresponding to 46 trials. Of these trials, 15 were included, 30 were excluded, and one is ongoing. Overall, 15 trials involving 7410 women were included.
Nutritional advice (four trials, 790 women)
Women given nutritional advice had a lower relative risk of having a preterm birth (two trials, 449 women) (risk ratio (RR) 0.46, 95% CI 0.21 to 0.98 ), head circumference at birth was increased in one trial (389 women) (mean difference (MD) 0.99 cm, 95% CI 0.43 to 1.55) and protein intake increased (three trials, 632 women) (protein intake: MD +6.99 g/day, 95% CI 3.02 to 10.97). No significant differences were observed on any other outcomes.
Balanced energy and protein supplementation (11 trials, 5385 women)
Risk of stillbirth was significantly reduced for women given balanced energy and protein supplementation (RR 0.62, 95% CI 0.40 to 0.98, five trials, 3408 women), mean birthweight was significantly increased (random‐effects MD +40.96 g, 95% CI 4.66 to 77.26 , Tau2= 1744, I2 = 44%, 11 trials, 5385 women). There was also a significant reduction in the risk of small‐for‐gestational age (RR 0.79, 95% CI 0.69 to 0.90, I2 = 16%, seven trials, 4408 women). No significant effect was detected for preterm birth or neonatal death.
High‐protein supplementation (one trial, 1051 women)
High‐protein supplementation (one trial, 505 women), was associated with a significantly increased risk of small‐for‐gestational age babies (RR 1.58, 95% CI 1.03 to 2.41).
Isocaloric protein supplementation (two trials, 184 women)
Isocaloric protein supplementation (two trials,184 women) had no significant effect on birthweight and weekly gestational weight gain.
Authors' conclusions
This review provides encouraging evidence that antenatal nutritional advice with the aim of increasing energy and protein intake in the general obstetric population appears to be effective in reducing the risk of preterm birth, increasing head circumference at birth and increasing protein intake, there was no evidence of benefit or adverse effect for any other outcome reported.
Balanced energy and protein supplementation seems to improve fetal growth, and may reduce the risk of stillbirth and infants born small‐for‐gestational age. High‐protein supplementation does not seem to be beneficial and may be harmful to the fetus. Balanced‐protein supplementation alone had no significant effects on perinatal outcomes.
The results of this review should be interpreted with caution, the risk of bias was either unclear or high for at least one category examined in several of the included trials and the quality of the evidence was low for several important outcomes. Also the anthropometric characteristics of the general obstetric population is changing, therefore, those developing interventions aimed at altering energy and protein intake should ensure that only those women likely to benefit are included. Large, well designed randomised trials are needed to assess the effects of increasing energy and protein intake during pregnancy in women whose intake is below recommended levels.
PICOs
Plain language summary
Energy and protein intake in pregnancy
During pregnancy, a baby developing inside the womb receives all its nutrition from its mother. Therefore, advising women on their diet and providing food supplements in pregnancy may help babies to grow and thrive. This review of randomised controlled trials examined several aspects of dietary advice and supplementation and produced the following four findings.
(1) Providing nutritional advice resulted in an increase in the mother's protein intake, fewer preterm births in two trials involving 449 women and increases in birth head circumference in one trial involving 389 women.
(2) Giving the mothers balanced energy and/protein supplements was associated with clear increases in mean birthweight (11 trials, 5385 women) with fewer stillbirths (five trials, 3408 women) and fewer small‐for‐gestational age births (seven trials, 4408 women), but the impact on the long‐term health of the baby was uncertain, including among undernourished women.
(3) High‐protein supplementation: one trial involving 1051 women showed no benefit for women and potential harm for the baby.
(4) Isocaloric protein supplementations (i.e. balanced supplements in which the protein replaces an equal quantity of other nutrients, e.g. macronutrients, fat and carbohydrate): in two trials involving 184 women this intervention showed no benefit for women or their babies.
Providing nutritional advice or balanced energy and protein supplements to women during pregnancy may be beneficial; high‐protein supplements and Isocaloric protein supplements given in to women in pregnancy may be unhelpful or harmful.
