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Meetings, Planning & Dissemination Project

CIHR-Funded Reviews Kramer, M.S., & Kakuma, R. (2002). Optimal duration

of exclusive breastfeeding. Cochrane Database of Systematic Reviews,2002 (Issue 1), Art. No. CD003517. DOI: 10.1002/14651858.CD003517.

Kramer, M.S., Kakuma, R. (2003). Energy and protein intake in pregnancy. Cochrane Database of Systematic Reviews,2003 (Issue 4), Art. No.: CD000032. DOI: 10.1002/14651858.CD000032.

Summary Statement: Kramer (2002)

Overall Considerations

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Interpreting the Evidence

Growth among EBF infants for 6 months vs. EBF for 3-4 months and MBF thereafter through 6 months

What’s the evidence? Implications for practice & policy

Weight Gain (4 studies) • Weight gain at 3-8 months was significantly higher in

MBF compared to EBF infants (WMD – 12.45, 95% CI -23.46 to -1.44 g/mo).

Weight for age (2 studies)

• EBF infants had significantly lower scores for weight for age at six months (WMD -0.09, 95% CI -0.16 to -0.02), nine months (WMD -0.10, 95% CI -0.18 to -0.02), and 12 months (WMD -0.09, 95% CI -0.17 to -0.01) compared to MBF infants.

• Public health activities should acknowledge evidence indicating that MBF infants gain slightly more weight than EBF infants at 3-12 months, although there are no differences in weight gain at any other time points.

Weight Gain Weight gain at 3-8 months was significantly higher in MBF compared

to EBF infants (WMD – 12.45, 95% CI -23.46 to -1.44 g/mo).

Weight Gain No impact for EBF vs. MBF infants on weight gain at 8-12 months.

Interpreting the Evidence

Morbidity and mortality among infants EBF for 6 months vs. EBF for 3-4 months and MBF thereafter through 6 months

What’s the evidence? Implications for practice & policy

Gastrointestinal infections (1 study)

• EBF infants were 33% less likely to have GI infection in the first 12 months compared to MBF infants (RR 0.67, 95% CI 0.46 to 0.97).

• There was no reduction in risk of hospitalization

• Public health messages and programs should indicate that infants who are EBF are less likely to have gastrointestinal infections compared to MBF infants

Gastrointestinal Infections • EBF infants were 33% less likely to have GI infection in the first 12

months compared to MBF infants (RR 0.67, 95% CI 0.46 to 0.97).

Interpreting the Evidence

Morbidity and mortality among infants EBF for 6 months vs. EBF for 3-4 months and MBF thereafter through 6 months

What’s the evidence? Implications for practice & policy

Acute otitis media (ear infections) (2 studies)

• MBF infants were 28% more likely to have one or more episodes of otitis media compared to EBF infants (RR 1.28, 95% CI 1.04 to 1.57).

• Public health messages and programs should indicate that infants who are EBF are less likely to have otitis media compared to MBF infants;

Acute Otitis Media (ear infection)

• MBF infants were 28% more likely to have one or more episodes of otitis media compared to EBF infants (RR 1.28, 95% CI 1.04 to 1.57).

Overall Considerations

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Questions?

Summary Statement: Kramer (2003)

Overall Considerations

Considerations for Public Health Practice Conclusions from Health Evidence General Implications

This well done review is based on low quality studies. Balanced energy/protein supplementation • improves fetal growth • may reduce the risk of fetal and neonatal

death • equally likely to have a very minimal or

quite large impact on preterm birth • has no impact on gestational diabetes,

preeclampsia, and growth and development • may result in possible harms (e.g. reduced

fetal growth) *Note: The results presented are our own interpretation for increasing energy intake.

Public health programs should include: • nutritional advice to women (but not as a

sole strategy) • encourage balanced energy/protein

supplements Public health programs should not encourage: • isocaloric protein supplements for pregnant

women • high protein supplements for pregnant

women • energy/protein restriction for overweight

pregnant women The findings should be used cautiously given the low quality of the evidence.

Interpreting the Evidence

Nutritional advice to increase energy and protein intake

What’s the evidence? Implications for practice & policy

• Effective in reducing the risk of preterm birth (by 54% with the true risk reduced from 2-79%).

• Public health organizations should not include nutritional advice as a sole intervention.

• Public health messaging should emphasize that increased energy and protein intake is associated with a decreased risk of preterm birth.

Preterm birth • Effective in reducing the risk of preterm birth (by 54% with the true

risk reduced from 2-79%).

Interpreting the Evidence

High protein supplementation

What’s the evidence? Implications for practice & policy

• Increased risk of small for gestational age (by 58% with the true risk reduced from 3-141%).

• No impact on all other outcome

• Public health programs should not promote or provide high protein supplementation as it has no impact on most maternal, fetal, and infant health outcomes and may, in fact, have adverse outcomes.

Small-for-gestational Age • Increased risk of small for gestational age (by 58% with the true risk

reduced from 3-141%).

Interpreting the Evidence

Energy/protein restriction in women with overweight or high weight gain

What’s the evidence? Implications for practice & policy

• Resulted in small head circumference at birth (by 1cm with a range from 0.14 cm to 1.86 cm smaller).

• Public health programs should not include energy/protein restriction as a means of improving maternal, fetal, or infant health outcomes, since energy/protein restriction is not likely to be beneficial for maternal or infant health and may lead to smaller head circumference among infants.

Head Circumference • Resulted in small head circumference at birth (by 1cm with a range

from 0.14 cm to 1.86 cm smaller).

Overall Considerations

Considerations for Public Health Practice Conclusions from Health Evidence General Implications

This well done review is based on low quality studies. Balanced energy/protein supplementation • improves fetal growth • may reduce the risk of fetal and neonatal

death • equally likely to have a very minimal or

quite large impact on preterm birth • has no impact on gestational diabetes,

preeclampsia, and growth and development • may result in possible harms (e.g. reduced

fetal growth)

Public health programs should include: • nutritional advice to women (but not as a

sole strategy) • encourage balanced energy/protein

supplements Public health programs should not encourage: • isocaloric protein supplements for pregnant

women • high protein supplements for pregnant

women • energy/protein restriction for overweight

pregnant women The findings should be used cautiously given the low quality of the evidence.

Questions?

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