Background: Malnutrition, including micronutrient deficiencies, remains one of the major public health challenges, particularly in low-to-middle-income countries. Micronutrient deficiencies affect people of all ages, but its effects appear more devastating in pregnant women and children. Poor maternal nutrition contributes to at least 20% of maternal deaths and increases the probability of poor pregnancy outcomes including intrauterine growth restriction, resulting in low birth weight, stunting, wasting and mortality. Key Messages: Several strategies have been employed to provide pregnant women with micronutrients. These strategies include education, dietary modification, food provision, agricultural interventions, supplementation and fortification either alone or in combination. Micronutrient supplementation is the most widely practiced intervention to prevent and manage single or multiple micronutrient deficiencies. Micronutrient supplementation either alone or in combination has shown to be effective in improving maternal, birth and child outcomes. Conclusions: There is a need to focus on maternal micronutrient status as a continuum from the periconceptional period throughout pregnancy to lactation. Given the wide prevalence of multiple micronutrient deficiencies in low-to-middle-income countries, the challenge is to implement intervention strategies that combine appropriate maternal and child health interventions with micronutrient interventions.

Keywords:
Multiple micronutrient supplementation, Pregnancy, Lactation, Low-to-middle-income countries, Malnutrition
1.
Guerrant RL, Lima AAM, Davidson F: Micronutrients and infection: interactions and implications with enteric and other infections and future priorities. J Infect Dis 2000;182 (suppl 1):S134-S138.
2.
Kapil U, Bhavna A: Adverse effects of poor micronutrient status during childhood and adolescence. Nutr Rev 2008;60:S84-S90.
3.
Bhaskaram P: Micronutrient malnutrition, infection and immunity: an overview. Nutr Rev 2002;60(pt 2):S40-S45.
4.
Black RE, Allen LH, Bhutta ZA, et al: Maternal and child undernutrition: global and regional exposures and health consequences. Lancet 2008;371:243-260.
5.
WHO: Severe malnutrition: report of a consultation to review current literature. Geneva, WHO, 2005.
6.
de Benoist, McLean E, Egli I, Cogswell M: Worldwide prevalence of anaemia 1993-2005: WHO global database on anaemia. Geneva, WHO, 2008.
7.
WHO, WFP, UNICEF: Preventing and controlling micronutrient deficiencies in populations affected by an emergency. 2006. http://www.unicef.org/nutrition/files/Joint_Statement_Micronutrients_March_2006.pdf.
8.
WHO: World health report, 2000. Geneva, WHO, 2000.
9.
Ramakrishnan U: Prevalence of micronutrient malnutrition worldwide. Nutr Rev 2002;60(pt 2):S46-S52.
10.
Morais MB, Ferrari AA, Fisberg M: Effect of oral iron therapy on physical growth. Rev Paul Med 1993;111:439-444.
11.
Olivares M, Walter T, Hertrampf E, Pizarro F: Anaemia and iron deficiency disease in children. Br Med Bull 1999;55:534-543.
12.
Black RE, Victora CG, Walker SP, et al: Maternal and child undernutrition and overweight in low-income and middle-income countries. Lancet 2013;382:427-451.
13.
Stevens GA, Finucane MM, De-Regil LM, et al: Global, regional, and national trends in haemoglobin concentration and prevalence of total and severe anaemia in children and pregnant and non-pregnant women for 1995-2011: a systematic analysis of population-representative data. Lancet Glob Health 2013;1:e16-e25.
14.
Allen LH: Biological mechanisms that might underlie iron's effects on fetal growth and preterm birth. J Nutr 2001;131:581S-589S.
15.
Haider BA, Olofin I, Wang M, Spiegelman D, Ezzati M, Fawzi WW: Anaemia, prenatal iron use, and risk of adverse pregnancy outcomes: systematic review and meta-analysis. BMJ 2013;346:f3443.
16.
Imdad A, Bhutta ZA: Routine iron/folate supplementation during pregnancy: effect on maternal anaemia and birth outcomes. Paediatr Perinat Epidemiol 2012;26(suppl 1):168-177.
17.
Murray-Kolb LE: Iron status and neuropsychological consequences in women of reproductive age: what do we know and where are we headed? J Nutr 2011;141:747S-755S.
18.
Krishnaswamy K, Lakshmi AV: Role of nutritional supplementation in reducing the levels of homocysteine. J Assoc Physicians India 2002;50(suppl):36-42.
19.
McLean E, de Benoist B, Allen LH: Review of the magnitude of folate and vitamin B12 deficiencies worldwide. Food Nutr Bull 2008;29(suppl 1):38-51.
20.
Vollset SE, Refsum H, Irgens LM, et al: Plasma total homocysteine, pregnancy complications, and adverse pregnancy outcomes: the Hordaland Homocysteine study. Am J Clin Nutr 2000;71:962-968.
21.
De-Regil LM, Fernandez-Gaxiola AC, Dowswell T, Pena-Rosas JP: Effects and safety of periconceptional folate supplementation for preventing birth defects. Cochrane Database Syst Rev 2010;10:CD007950.
22.
Lassi ZS, Salam RA, Haider BA, Bhutta ZA: Folic acid supplementation during pregnancy for maternal health and pregnancy outcomes. Cochrane Database Syst Rev 2013;3:CD006896.
23.
Vir SC: Current status of iodine deficiency disorders (IDD) and strategy for its control in India. Indian J Pediatr 2002;69:589-596.
24.
de Benoist B, Delange F: Iodine deficiency: current situation and future prospects (in French). Sante 2002;12:9-17.
25.
Andersson M, Karumbunathan V, Zimmermann MB: Global iodine status in 2011 and trends over the past decade. J Nutr 2012;142:744-750.
26.
Zimmermann MB, Andersson M: Assessment of iodine nutrition in populations: past, present, and future. Nutr Rev 2012;70:553-570.
27.
Pharoah POD, Buttfield IH, Hetzel BS: Neurological damage to the fetus resulting from severe iodine deficiency during pregnancy. Lancet 1971;297:308-310.
28.
Bleichrodt N, Born MP: A meta-analysis of research on iodine and its relationship to cognitive development; in Stanbury JB (ed): The Damaged Brain of Iodine Deficiency. New York, Cognizant Communication, 1994, pp 195-200.
29.
Qian M, Wang D, Watkins WE, et al: The effects of iodine on intelligence in children: a meta-analysis of studies conducted in China. Asia Pac J Clin Nutr 2005;14:32-42.
30.
Zimmermann MB: The effects of iodine deficiency in pregnancy and infancy. Paediatr Perinat Epidemiol 2012;26:108-117.
31.
Skeaff SA: Iodine deficiency in pregnancy: the effect on neurodevelopment in the child. Nutrients 2011;3:265-273.
32.
Wessells KR, Brown KH: Estimating the global prevalence of zinc deficiency: results based on zinc availability in national food supplies and the prevalence of stunting. PLoS One 2012;7:e50568.
33.
King JC: Determinants of maternal zinc status during pregnancy. Am J Clin Nutr 2000;71:1334s-1343s.
34.
Simmer K, Thompson RPH: Maternal zinc and intrauterine growth retardation. Clin Sci 1985;68:395-399.
35.
Stephenson LS, Latham MC, Ottesen EA: Global malnutrition. Parasitology 2000;121:5-22.
36.
Christian P, West KP, Khatry SK, et al: Maternal night blindness increases risk of mortality in the first 6 months of life among infants in Nepal. J Nutr 2001;131:1510-1512.
37.
West KP Jr, Katz J, Khatry SK, et al: Double blind, cluster randomised trial of low dose supplementation with vitamin A or β-carotene on mortality related to pregnancy in Nepal. The NNIPS-2 Study Group. BMJ 1999;318:570-575.
38.
Edmond K, Hurt L, Fenty J, et al: Effect of vitamin A supplementation in women of reproductive age on cause-specific early and late infant mortality in rural Ghana: ObaapaVitA double-blind, cluster-randomised, placebo-controlled trial. BMJ Open 2012;2:e000658.
39.
Christian P, Klemm R, Shamim AA, et al: Effects of vitamin A and β-carotene supplementation on birth size and length of gestation in rural Bangladesh: a cluster-randomized trial. Am J Clin Nutr 2013;97:188-194.
40.
Christian P, West KP, Khatry SK, et al: Vitamin A or β-carotene supplementation reduces but does not eliminate maternal night blindness in Nepal. J Nutr 1998;128:1458-1463.
41.
Tielsch JM, Rahmathullah L, Katz J, et al: Maternal night blindness during pregnancy is associated with low birthweight, morbidity, and poor growth in South India. J Nutr 2008;138:787-792.
42.
Prentice A: Maternal calcium requirements during pregnancy and lactation. Am J Clin Nutr 1994;59:477S-482S.
43.
Villar J, Belizan JM, Fischer PJ: Epidemiologic observations on the relationship between calcium intake and eclampsia. Int J Gynaecol Obstet 1983;21:271-278.
44.
Ortega RM, Martinez RM, Lopez-Sobaler AM, Andres P, Quintas ME: Influence of calcium intake on gestational hypertension. Ann Nutr Metab 1999;43:37-46.
45.
Hofmeyr GJ, Lawrie TA, Atallah AlN, Duley L: Calcium supplementation during pregnancy for preventing hypertensive disorders and related problems. Cochrane Database Syst Rev 2010;8:CD001059.
46.
Bucher HC, Cook RJ, Guyatt GH, et al: Effects of dietary calcium supplementation on blood pressure: a meta-analysis of randomized controlled trials. JAMA 1996;275:1016-1022.
47.
Imdad A, Bhutta ZA: Effects of calcium supplementation during pregnancy on maternal, fetal and birth outcomes. Paediatr Perinat Epidemiol 2012;26(suppl 1):138-152.
48.
WHO: World Health Organization recommendations for prevention and treatment of pre-eclampsia and eclampsia. Geneva, WHO, 2011.
49.
Bodnar LM, Catov JM, Simhan HN, Holick MF, Powers RW, Roberts JM: Maternal vitamin D deficiency increases the risk of preeclampsia. J Clin Endocrinol Metab 2007;92:3517-3522.
50.
Davis LM, Chang SC, Mancini J, Nathanson MS, Witter FR, O'Brien KO: Vitamin D insufficiency is prevalent among pregnant African American adolescents. J Pediatr Adolesc Gynecol 2010;23:45-52.
51.
Hypponen E, Boucher BJ: Avoidance of vitamin D deficiency in pregnancy in the United Kingdom: the case for a unified approach in National policy. Br J Nutr 2010;104:309-314.
52.
Dror DK: Vitamin D status during pregnancy: maternal, fetal, and postnatal outcomes. Curr Opin Obstet Gynecol 2011;23:422-426.
53.
De-Regil LM, Palacios C, Ansary A, Kulier R, Pena-Rosas JP: Vitamin D supplementation for women during pregnancy. Cochrane Database Syst Rev 2012;2:CD008873.
54.
de Onis M, Villar J, Gulmezoglu M: Nutritional interventions to prevent intrauterine growth retardation: evidence from randomized controlled trials. Eur J Clin Nutr 1998;52(suppl 1):S83-S93.
55.
Imdad A, Bhutta ZA: Maternal nutrition and birth outcomes: effect of balanced protein-energy supplementation. Paediatr Perinat Epidemiol 2012;26(suppl 1):178-190.
56.
Alnwick D: Weekly iodine supplements work. Am J Clin Nutr 1998;67:1103-1104.
57.
Haider BA, Bhutta ZA: Multiple-micronutrient supplementation for women during pregnancy. Cochrane Database Syst Rev 2012;11: CD004905.
58.
Bhutta ZA, Das JK, Rizvi A, et al: Evidence-based interventions for improvement of maternal and child nutrition: what can be done and at what cost? Lancet 2013;382:452-477.
59.
WHO: Use of multiple micronutrient powders for home fortification of foods consumed by infants and children 6-23 months of age. Geneva, WHO, 2011.
60.
Villar J, Bergsjø P: Scientific basis for the content of routine antenatal care. I. Philosophy, recent studies and power to eliminate or alleviate adverse maternal outcomes. Acta Obstet Gynecol Scand 1997;76:1-14.
61.
WHO, UNICEF, UNU: Iron deficiency anaemia: assessment, prevention, and control. Geneva, WHO, 2001.
62.
WHO: Intermittent iron supplementa- tion for menstruating women. 2011. http://whqlibdoc.who.int/publications/2011/9789241502023_eng.pdf (accessed April 7, 2012).
63.
WHO: Daily iron and folic acid supplementation in pregnant women. Geneva, WHO, 2011.
64.
WHO: Intermittent iron supplementation in preschool and school age children. Geneva, WHO, 2011.
65.
WHO: Intermittent iron and folic acid supplementation in non-anaemic pregnant women. Geneva, WHO, 2011.
66.
WHO: Vitamin A supplementation in infants and children 6-59 months of age. Geneva, WHO, 2011.
67.
Allen L, de Benoist B, Dary O, Hurrell R: Guidelines on food fortification with micronutrients. Geneva, WHO/FAO, 2006.
68.
Das JK, Salam RA, Kumar R, Bhutta ZA: Micronutrient fortification of food and its impact on woman and child health: a systematic review. Syst Rev 2013;2:67.
69.
Harvey PWJ, Dary O: Governments and academic institutions play vital roles in food fortification: iron as an example. Public Health Nutr 2012;1:1-5.
70.
Salam RA, MacPhail C, Das JK, Bhutta ZA: Effectiveness of micronutrient powders (MNP) in women and children. BMC Public Health 2013;13(suppl 3):S22.
71.
WFP: Micronutrient powder (MixMe™) Program for under-fives and pregnant and lactating women affected by cyclone Sidr in Bangladesh (ASIA). 2009. http://www.dsm.com/content/dam/dsm/nip/en_US/documents/mnp-brief-bangladesh.pdf.
72.
Hotz C, McClafferty B: From harvest to health: challenges for developing biofortified staple foods and determining their impact on micronutrient status. Food Nutr Bull 2007;28:S271-S279.
73.
Olney D, Rawat R, Ruel M: Identifying potential programs and platforms to deliver multiple micronutrient interventions. J Nutr 2012;142:178S-185S.
74.
Lim SS, et al: A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 2012;380:2224-2260.
75.
Black R: Micronutrients in pregnancy. Br J Nutr 2001;85(suppl 2):S193-S197.
76.
Alderman H, Horton S: The economics of addressing nutritional anemia; in Kraemer K, Zimmermann MB (eds): Nutritional Anemia. Basel, Sight and Life, 2007, pp 19-35.
77.
Zimmermann M, Hurrell R: Nutritional iron deficiency. Lancet 2007;370:511-520.
78.
Baltussen R, Knai C, Sharan M: Iron fortification and iron supplementation are cost-effective interventions to reduce iron deficiency in four subregions of the world. J Nutr 2004;134:2678-2684.
79.
Ruel MT, Alderman H: Nutrition-sensitive interventions and programmes: how can they help to accelerate progress in improving maternal and child nutrition? Lancet 2013;382:536-551.
80.
Shroff M, Griffiths P, Adair L, Suchindran C, Bentley M: Maternal autonomy is inversely related to child stunting in Andhra Pradesh, India. Matern Child Nutr 2009;5:64-74.
81.
Nube M: Relationships between undernutrition prevalence among children and adult women at national and subnational level. Eur J Clin Nutr 2005;59:1112-1120.
82.
Milton AH, Smith W, Rahman B, et al: Prevalence and determinants of malnutrition among reproductive aged women of rural Bangladesh. Asia Pac J Public Health 2010;22:110-117.
83.
Subramanian SV, Smith GD: Patterns, distribution, and determinants of under- and overnutrition: a population-based study of women in India. Am J Clin Nutr 2006;84:633-640.
84.
Strobino DM, Ensminger ME, Kim YJ, Nanda J: Mechanisms for maternal age differences in birth weight. Am J Epidemiol 1995;142:504-514.
85.
Hediger ML, Scholl TO, Schall JI: Implications of the Camden Study of adolescent pregnancy: interactions among maternal growth, nutritional status, and body composition. Ann NY Acad Sci 1997;817:281-291.
86.
Stevens-Simon C, McAnarney ER: Adolescent maternal weight gain and low birth weight: a multifactorial model. Am J Clin Nutr 1988;47:948-953.
87.
Allen LH: Multiple micronutrients in pregnancy and lactation: an overview. Am J Clin Nutr 2005;81:1206S-1212S.
© 2014 S. Karger AG, Basel
2014
Copyright / Drug Dosage / Disclaimer
Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.
You do not currently have access to this content.