Antenatal malaria prophylaxis plus iron and folic acid for child nutrition outcomes
This is a summary of the following paper: Godha D, Tharaney M, Nanama S et al. (2022) The association between iron and folic acid supplementation and malaria prophylaxis and linear growth among children and neonatal mortality in Sub-Saharan Africa – A pooled analysis. Nutrients, 14, 2296. https://pubmed.ncbi.nlm.nih.gov/36364759/
Many studies have highlighted a positive association of iron and folic acid (IFA) supplementation during pregnancy with foetal growth and birth weight. However, few have explored associations with a child's linear growth beyond birth. Moreover, much of the evidence base has been built in South Asia. In sub-Saharan Africa (SSA), malaria remains endemic, which complicates interventions. Malaria infection increases the risk of anaemia, while also reducing iron absorption, yet IFA supplementation increases malaria risk, with iron deficiency reducing it.
This study aimed to explore whether a combined antenatal regimen of IFA supplementation and malaria prophylaxis influences linear growth outcomes among children. A pooled analysis was conducted using recent Demographic and Health Survey data from 19 SSA countries. Four outcomes were analysed: severe stunting, stunting, height-for-age z scores (as a continuous variable), and neonatal mortality. In total, results from a sample size of 56,388 children (for severe stunting, stunting, height-for-age z-scores) and 90,503 (for neonatal mortality) were analysed.
A full breakdown of the methodology used and the specific results by country are beyond the scope of this summary. Both can be found in the original paper.
The odds of stunting were found to be 10% lower for children of mothers who received malaria prophylaxis (OR 0.90, p<0.05) after adjusting for multiple factors. No similar association was noted with severe stunting. After adjustment, neonatal mortality was reduced by almost 30% for children of mothers who received malaria prophylaxis (OR 0.72, p<0.01). Multivariate regression found that IFA supplementation for more than 90 days combined with malaria prophylaxis during pregnancy was the most favourable regimen – showing a weak yet significant (p<0.05) correlation with height-for-age z-scores.
After adjustment, no significant relationship was observed for either iron supplementation alone or IFA supplementation during pregnancy and child stunting. Moreover, after adjustment, no significant relationship was observed for iron supplementation and neonatal mortality.
These findings run contrary to those from Asian settings, where IFA supplementation is significantly correlated with linear growth and reduced neonatal mortality. Considering that malaria remains endemic across many parts of Africa, it is possible that any positive effects from supplementation were overridden by malaria infection.
This paper is complex in nature with multiple regression models and outcomes being considered, each with seemingly contrasting findings. Nevertheless, two practical lessons can be taken from the findings:
First, malaria prophylaxis during pregnancy remains important for reducing infant stunting and neonatal mortality in malaria-endemic regions.
Second, combining malaria prophylaxis with IFA supplementation appears to be effective in increasing linear growth, but it is important for health systems and practitioners to consider the complex relationship between these two strategies.
Although the study had its limitations, steps were taken to minimise bias and a large sample size was used for this analysis, which increases the reliability of these results. The authors present both adjusted and unadjusted regression models and, due to the scope of this summary, we have only presented the adjusted findings. We encourage readers to review the original paper to see how these regression models were created and confounders accounted for.
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Reference this page
Antenatal malaria prophylaxis plus iron and folic acid for child nutrition outcomes. Field Exchange 70, September 2023. p37. www.ennonline.net/fex/70/antenatal-malaria-prophylaxis-plus-iron-and-folic-acid-for-child-nutrition-outcomes
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