Transcript Document

Infant Mortality and Nutrition Primer
ASTPHND, MCH Nutrition Council
October 16, 2012
Jamie Stang, PhD, MPH, RD, LN
University of Minnesota School of Public Health
Associate Professor
Director of Leadership Education and Training Program in Maternal and Child
Health Nutrition,
Co-Director Midwest Center for Lifelong Learning in Public Health
Infant Mortality
• Infant mortality is defined as the probability of
dying between birth and one year of age
– Reported as rate per 1000 live births
• US ranks 31st in the world for infant mortality
– Ranking of US has decreased in past decades
• 2012 report by Congressional Research
Service provides an overview of factors
associated with infant mortality rates
Source: Adapted by CRS from Ariadi M. Minino, et al., National Vital Statics Reports: Deaths: Final Data for 2008,
National Center for Health Statistics, Vol. 59, No. 10, Hyattsville, MD, December 7, 2011.
Total and Preterm-Related Infant Mortality Rates
Leading Causes of Infant Mortality
• Birth defects
• Low birthweight including preterm birth and fetal
growth restriction
• Sudden Infant Death Syndrome
• Maternal complications of pregnancy
Causes of Infant Mortality
Causes of Infant Mortality by Race
Infant and Fetal Mortality by Gestational Age
Nutrition’s Role in Infant Mortality
“Every single cell, organ, and system inside a
newborn baby comes mostly from her mother’s food
intake before or during pregnancy.
Maternal nutrition is a critical determinant of infant
health; thus, it is not hard to see that poor maternal
nutrition can contribute, directly or indirectly, to
infant mortality.”
Nutrition and Infant Mortality
Good evidence for nutrition role in:
• Birth defects
• Preterm birth
• Fetal growth restriction
• Maternal complications of pregnancy such as
preeclampsia, anemia, infections / inflammation
Nutrition’s Role in Infant Mortality
Nutrition plays a key role in preventing
several leading causes of infant mortality,
but only as part of a long-term and
integrated strategy for improving maternal
and family health.
Birth Defects
 Folic acid status is associated with spina bifida,
anencephaly, and other neural tube defects
 B vitamins, vitamin K, magnesium, copper, and zinc
deficiencies have also been linked to other birth defects
 Vitamin A and other nutritional excesses can lead to
congenital anomalies
 Poorly controlled diabetes, prior to and early in pregnancy,
increases the risk cardiac and neural tube defects
 Dietary restrictions in women with PKU early in pregnancy
have shown to reduce the risk of congenital malformations
Prevalence of Pre-pregnancy Obesity
Diabetes
Second most frequently reported medical risk factor during
pregnancy
Pre-gestational Diabetes
• Fetal death and congenital anomalies if poorly controlled
• Poor control increases risk of cardiac defects
Gestational Diabetes
• Increased risk of fetal macrosomia, birth trauma, newborn hypoglycemia
and hyperbilirubinemia.
• May lead to insulin and leptin resistance in the fetus, and later greater
susceptibility to diabetes and obesity
Low Birthweight and Preterm Birth
• LBW and preterm birth are associated with prepregnancy
weight status and weight gain during pregnancy
• Most pregnant women in the U.S. enter pregnancy
overweight or underweight
• The majority of US women do not gain within the IOM
recommendations
• Maternal underweight and low weight gain during
pregnancy are declining
• Prepregnancy overweight/obesity and excessive weight gain
during pregnancy are increasing
Weight, Weight Gain and Pregnancy
• Low prepregnancy BMI and poor weight gain are associated
with increased risk for
– preterm birth
– fetal growth restriction
– important causes of infant mortality
• The lower a woman’s BMI, the more likely she is to be
undernourished.
• Underweight prior to pregnancy increases the risk of
congenital anomalies
– Cleft lip and palate
Weight, Weight Gain and Pregnancy
• High prepregnancy BMI and excessive weight gain are
associated with increased risk of
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gestational diabetes
preeclampsia
postpartum hemorrhage
fetal macrosomia and shoulder dystocia
• Maternal obesity has been linked to increased risk of
– neural tube defects and fetal death
– indicated preterm delivery secondary to pregnancy complications
• Excessive weight gain increases likelihood of excessive
postpartum weight retention
Nutrition and Maternal Complications
• Vitamin A, zinc and other micronutrients may
influence maternal infection rates
• Antioxidants may play a role in modulating
inflammation
• Fatty acid composition of diet may influence risk of
preterm birth
– Meta-analysis of studies of n-3 fatty acids showed
decreased risk of preterm birth (RR 0.61, CI 0.40-0.93)
• Gestational age was increased by 4.5 days
• Birthweight increased by 71 grams
Anemia
• Maternal anemia contributes to maternal and
fetal/infant morbidities and mortality associated with
obstetrical hemorrhage
• Deficiencies of iron, folate, and vitamin B12 are main
contributors to anemia
– Other nutrients such as vitamins A, C and B6 may also
contribute to anemia
• Strong evidence exists for an association between
maternal hemoglobin concentration and both
birthweight and preterm birth.
Other Associations
• Periconceptional nutrition may be important the
pathogenesis of preeclampsia
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Calcium
Other minerals (copper, zinc)
Anti-oxidants (vitamins C, E)
n-3 fatty acids
• Maternal nutrition can also mediate or modulate
several of the major pathways (e.g., inflammatory)
leading to spontaneous preterm birth
Dietary Patterns Among Pregnant Women
• Leading sources of energy from carbohydrates
include: soft drinks, fruit juices, biscuits, muffins,
white bread and other refined carbohydrates
• Leading sources of energy from fats include:
mayonnaise, salad dressings, whole milk, French fries
and fried potatoes
Dietary Patterns Among Pregnant Women
 Consume more protein, fat and trans-fat, and carbohydrates than
recommended.
 A substantial proportion of pregnant women do not meet their
recommended daily intake for iodine, calcium, magnesium, iron,
zinc, vitamins A, B1, B2, B3, B6, B12, and vitamin C from food
sources.
 Dietary intake of folate is inadequate for over 95 percent of women,
and that of vitamin E is inadequate for 25 percent of pregnant
women, which perhaps reflects low intakes of fruits and vegetables.
 1 in 4 women does not consume adequate amounts of folic acid
and vitamin E, even when multivitamins are included
 Fasting, pica, and fast food consumption are common among
pregnant women
PHN Role in Infant Mortality Reduction
 Encouraging women to reach and maintain healthy
body weight and waist circumference
 Supporting healthy eating patterns for women and
families
 Encouraging appropriate weight gain during pregnancy
 Offering preconception care for women considering
pregnancy
 healthy weight
 addressing chronic conditions and risk factors
PHN Role in Infant Mortality Reduction
 Supporting breastfeeding initiation and continuation
 Addressing hunger and food insecurity
 Monitoring and evaluating nutritional risk among women
 Engaging in program development, policy, systems and
environmental change activities to support the health of
women of reproductive age.
Suggested Readings
Maternal Nutrition and Infant Mortality in the Context of Relationality by
Michael C. Lu and Jessica S. Lu (2007) Joint Center for Political and Economic
Studies
The US Infant Mortality Rate: International Comparisons, Underlying
Factors, and Federal Programs by Elayne J. Heisler (April 4, 2012)
Congressional Research Service
MacDorman MF. Race and ethnic disparities in fetal mortality, preterm birth,
and infant mortality in the United States: an overview. Smein Perinatol.
2011;35:200-208
Slavig JD, Lamont RF. Evidence regarding and effect of marine n-3 fatty acids
on preterm birth: a systematic review and meta-analysis. Acta Obst Gynec.
2011;90:825-838