Abe Sarah K, Balogun Olukunmi O, Ota Erika, Takahashi Kenzo, Mori Rintaro
Department of Global Health Policy, Graduate School of Medicine, The University of Tokyo, Medical Building No. 3, Hongo Campus, 7-3-1 Hongo, Tokyo, Japan, 113-0033.
Cochrane Database Syst Rev. 2016 Feb 18;2(2):CD010647. doi: 10.1002/14651858.CD010647.pub2.
BACKGROUND: Globally, more than two billion people are estimated to be deficient in key vitamins and minerals, particularly iodine, iron and zinc. The majority of these people live in low-income settings and are typically deficient in more than one micronutrient. However, micronutrient deficiency among breastfeeding mothers and their infants also remains an issue in high-income settings, specifically among women who avoid meat and/or milk, women who may lack sufficient supplies of vitamin B12 and vitamin D, and/or women who are iron-deficient. Young children, pregnant and lactating women are particularly vulnerable to micronutrient deficiencies. They not only have a relatively greater need for vitamins and minerals because of their physiological state, but are also more susceptible to the harmful consequences of deficiencies. Multiple-micronutrient supplementation might be an option to solve these problems. OBJECTIVES: The objective of this review was to evaluate the effects of multiple-micronutrient supplementation in breastfeeding mothers on maternal and infant outcomes. SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 September 2015) and reference lists of retrieved studies. SELECTION CRITERIA: Randomised controlled trials of multiple-micronutrient supplementation of three or more micronutrients versus placebo, no supplementation or supplementation with two or fewer micronutrients, irrespective of dosage of micronutrients, in breastfeeding mothers. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. MAIN RESULTS: We found no studies that compared multiple-micronutrient supplementation (with three or more micronutrients) versus supplementation with two or fewer micronutrients.Two small studies (involving a total of 52 women) were included. One study compared multiple micronutrients with placebo and the other study compared multiple micronutrients with a group who received no supplementation. The studies were carried out in Brazil (36 adolescent mothers) and the USA (16 women) and included women with a low socioeconomic status. A lack of information in the study reports meant that risk of bias could not be adequately assessed (unclear risk of bias for many domains). There were no quantitative data for any of this review's outcomes so meta-analysis was not possible.Neither of the studies reported on the primary outcomes of interest in this review: maternal morbidity (febrile illness, respiratory tract infection, diarrhoea), adverse effects of micronutrients within three days of receiving the supplement, infant mortality (defined as a child dying before completing the first year of age).One study reported qualitatively on maternal anaemia (a secondary outcome of this review) - the study found that multiple-micronutrient supplementation was effective for recuperating from anaemia but there were no data for inclusion in our analyses. Maternal satisfaction was not reported in the included studies. Similarly, none of this review's infant secondary outcomes were reported in the included studies: clinical micronutrient deficiency; morbidity episodes (febrile illness, respiratory tract infection, diarrhoea, other), adverse effects of micronutrients within three days of receiving the supplement. AUTHORS' CONCLUSIONS: We found no evidence to quantitatively assess the effectiveness of multiple-micronutrient supplementation in improving health outcomes in mother and baby. The results of this review are limited by the small numbers of studies available, small sample sizes and the studies not reporting on the outcomes of interest in this review. There is no evidence to evaluate potential adverse effects of multiple-micronutrient supplements, particularly excess dosages.There is a need for high-quality studies to assess the effectiveness and safety of multiple-micronutrient supplementation for breastfeeding women for improving outcomes for the mother and her baby. Further research should focus on whether multiple-micronutrient supplementation during lactation compared with none, a placebo or supplementation with fewer than two micronutrients is beneficial to maternal and infant health outcomes. Future studies should collect data on outcomes beyond micronutrient concentrations, for example: maternal and infant morbidity, adverse effects, maternal satisfaction, the risks of excess supplementation, and potential adverse interactions between the micronutrients and the other outcomes. This would help to bridge the gap between research on intermediary outcomes and health outcomes in order to develop sound policy in this field. Future studies could more precisely assess a variety of multiple-micronutrient combinations and different dosages and look at how these affect maternal and infant health outcomes. Larger studies with longer follow-up would improve the quality of studies and provide stronger evidence. In most of the included studies, bias could not be adequately assessed due to lack of information, therefore attention should be given to adequate methods of randomisation and allocation concealment, adequate methods of blinding of the participants, providers and the outcome assessors to improve the methodological quality of studies in this field.
背景:据估计,全球有超过20亿人缺乏关键维生素和矿物质,尤其是碘、铁和锌。这些人中的大多数生活在低收入环境中,通常缺乏不止一种微量营养素。然而,在高收入环境中,母乳喂养的母亲及其婴儿中的微量营养素缺乏问题仍然存在,特别是在那些不吃肉和/或不喝牛奶的女性、可能缺乏足够维生素B12和维生素D的女性,以及/或者缺铁的女性中。幼儿、孕妇和哺乳期妇女尤其容易出现微量营养素缺乏。由于她们的生理状态,她们不仅对维生素和矿物质的需求相对更大,而且也更容易受到缺乏症有害后果的影响。补充多种微量营养素可能是解决这些问题的一个选择。 目的:本综述的目的是评估母乳喂养母亲补充多种微量营养素对母婴结局的影响。 检索方法:我们检索了Cochrane妊娠与分娩组试验注册库(2015年9月30日)以及检索到的研究的参考文献列表。 入选标准:对母乳喂养母亲补充三种或更多微量营养素与安慰剂、不补充或补充两种或更少微量营养素进行比较的随机对照试验,无论微量营养素的剂量如何。 数据收集与分析:两位综述作者独立评估试验是否纳入及偏倚风险,提取数据并检查其准确性。 主要结果:我们未找到比较补充三种或更多微量营养素与补充两种或更少微量营养素的研究。纳入了两项小型研究(共涉及52名女性)。一项研究将多种微量营养素与安慰剂进行比较,另一项研究将多种微量营养素与未补充的一组进行比较。这些研究在巴西(36名青少年母亲)和美国(16名女性)进行,纳入的女性社会经济地位较低。研究报告中缺乏信息意味着无法充分评估偏倚风险(许多领域的偏倚风险不明确)。对于本综述的任何结局均无定量数据,因此无法进行荟萃分析。两项研究均未报告本综述感兴趣的主要结局:母亲发病率(发热性疾病、呼吸道感染、腹泻)、补充剂服用后三天内微量营养素的不良反应、婴儿死亡率(定义为在一岁前死亡的儿童)。一项研究定性报告了母亲贫血(本综述的次要结局)——该研究发现补充多种微量营养素对从贫血中恢复有效,但无数据纳入我们分析。纳入研究中未报告母亲满意度。同样,纳入研究中也未报告本综述的任何婴儿次要结局:临床微量营养素缺乏;发病情况(发热性疾病、呼吸道感染、腹泻、其他)、补充剂服用后三天内微量营养素的不良反应。 作者结论:我们没有证据定量评估补充多种微量营养素对改善母婴健康结局的有效性。本综述的结果受到现有研究数量少、样本量小以及研究未报告本综述感兴趣结局的限制。没有证据评估多种微量营养素补充剂的潜在不良反应,尤其是过量剂量。需要高质量的研究来评估母乳喂养女性补充多种微量营养素对改善母婴结局的有效性和安全性因素。进一步的研究应关注哺乳期补充多种微量营养素与不补充、安慰剂或补充少于两种微量营养素相比是否有利于母婴健康结局。未来的研究应收集微量营养素浓度以外结局的数据,例如:母婴发病率、不良反应、母亲满意度、过量补充的风险以及微量营养素与其他结局之间潜在的不良相互作用。这将有助于弥合中间结局研究与健康结局研究之间的差距,以便在该领域制定合理的政策。未来的研究可以更精确地评估多种微量营养素组合和不同剂量,并研究它们如何影响母婴健康结局。进行更长随访期的更大规模研究将提高研究质量并提供更有力的证据。在大多数纳入研究中,由于缺乏信息无法充分评估偏倚,因此应注意采用适当的随机化和分配隐藏方法、对参与者、提供者和结局评估者进行适当的盲法,以提高该领域研究的方法学质量。
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