Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, MA.
Bill & Melinda Gates Foundation, Seattle, WA.
J Nutr. 2019 Mar 1;149(3):359-361. doi: 10.1093/jn/nxy279.
Recent data from an individual patient data (IPD) meta-analysis of 17 randomized control trials including >100,000 women living in low- and middle-income countries found that multiple micronutrient supplementation (MMS) in pregnancy reduced the risk of low birth weight, preterm birth, and being born small for gestational age. Further, MMS reduced the risk of neonatal and infant mortality for females, and there was no evidence of increased risk among the 26 subgroups examined. The 2016 WHO antenatal care guidelines, which were released before the IPD meta-analysis, did not universally recommend MMS, noting: "There is some evidence of additional benefit … but there is also some evidence of risk." The guidelines suggest that MMS may increase the risk of neonatal mortality based on an exploratory subgroup analysis of 6 randomized trials. However, we identified several issues with this subgroup analysis. In this report we correct and update the subgroup analysis and show that there is no evidence that MMS increases the risk of neonatal mortality. There is growing scientific consensus that MMS containing iron and folic acid (IFA) is superior to IFA alone. The WHO guidelines currently state that "policy-makers in populations with a high prevalence of nutritional deficiencies might consider the benefits of MMN [multiple micronutrient] supplements on maternal health to outweigh the disadvantages, and may choose to give MMN supplements that include iron and folic acid." This equivocal guidance has created confusion about the best course of action for public health programs in low- and middle-income countries. Given the new evidence, WHO should review their statements regarding the potential neonatal mortality risks and re-evaluate the overall potential benefits of implementing MMS as a public health program.
最近一项包含超过 10 万名生活在中低收入国家的妇女的个体患者数据（IPD）荟萃分析的研究结果显示，妊娠期间补充多种微量营养素（MMS）可降低低出生体重、早产和出生体重小于胎龄儿的风险。此外，MMS 降低了女性新生儿和婴儿死亡率的风险，在检查的 26 个亚组中没有证据表明风险增加。2016 年发布的世卫组织产前保健指南在 IPD 荟萃分析之前没有普遍推荐 MMS，指出：“有一些额外益处的证据……但也有一些风险的证据。”该指南表明，MMS 可能会增加新生儿死亡的风险，这是基于对 6 项随机试验的探索性亚组分析得出的。然而，我们发现该亚组分析存在一些问题。在本报告中，我们纠正并更新了该亚组分析，并表明没有证据表明 MMS 会增加新生儿死亡的风险。越来越多的科学共识认为，含有铁和叶酸的 MMS（IFA）优于单独的 IFA。世卫组织目前的指南指出，“在营养缺乏症高发的人群中，政策制定者可能会考虑 MMN（多种微量营养素）补充剂对产妇健康的益处超过其缺点，并可能选择给予包含铁和叶酸的 MMN 补充剂。”这种模棱两可的指导意见造成了对中低收入国家公共卫生计划的最佳行动方案的困惑。鉴于新的证据，世卫组织应重新审查其关于潜在新生儿死亡风险的声明，并重新评估实施 MMS 作为公共卫生计划的总体潜在益处。
