Editorial

See corresponding article on page 86.

Starting life right: birth length matters

Parul Christian

Center for Human Nutrition, Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA

Attention on the prenatal and intrauterine period has increased 2 years of life. This was also previously shown in a publication
over the past 2 decades as part of the first thousand days of on findings of a 6-month follow-up by these investigators (3).
life initiative (https://thousanddays.org/). Increasingly, however, They also show that a low LAZ at birth was the strongest
it is recognized that preconception nutrition may set the stage predictor of the LAZ at 24 months of age. Both findings are of
for intrauterine growth and development trajectories, in addition significance. The “prenatal origins” of postnatal linear growth
to the need for nutritional support during pregnancy. In this have been examined previously in extant birth cohort data from
issue of the American Journal of Clinical Nutrition, the Women 19 longitudinal studies involving over 44,000 children followed
First trial, which was designed to examine preconception through up at 12–60 months of age. In this meta-analysis, childhood
prenatal nutrition impacts on birth outcomes, reports the longer- stunting was linked to birth size and gestational age (4, 5).
term effects on postnatal growth (1). This multisite trial was Relative to an adequate weight for gestational age and term birth
done among women individually randomized to either receive as the referent category, the odds of child stunting associated
a micronutrient-fortified, small-quantity, lipid-based nutritional with preterm and small for gestational age (SGA) infants were
supplement (SQ-LNS) daily for at least 3 months prior to 1.93 and 2.43, respectively, whereas being both preterm and SGA
conception throughout pregnancy (in arm 1); receive an SQ-LNS increased the odds to 4.51. More importantly, the population-
daily from the late first trimester throughout pregnancy (arm 2); attributable risks for overall SGAs for outcomes of child stunting
or receive no intervention (arm 3) (2). In all groups, women and wasting were high, at 20% and 30%, respectively. The study
with a low BMI and inadequate gestational weight gain were by Krebs et al. (1) provides causal evidence that this previous
also provided an extra protein-energy supplement until delivery. observational data (4, 5) could not establish, by demonstrating
The primary study findings, published previously, demonstrated that nutritional intervention starting either before or during
improvements in birth length-for-age z-scores (LAZs) by 0.20 pregnancy is causally associated with improvement in postnatal
in both intervention arms, with no difference between arms by linear growth.
onset of supplementation (2). A 2-year postnatal follow-up, with Increasing evidence is emerging on the importance of the early
anthropometric assessments every 6 months in the offspring postnatal (the first 6 months) period as critical for growth. An
of the women who participated in the trial, is presented as a analysis using longitudinal anthropometric data from close to
secondary analysis of treatment effects on growth in the first 100,000 children examined the incidence of stunting from birth
2 years of life (1). Growth deceleration was seen right from over the first 2 years of life and found that the incidence rates
birth in all 3 arms, with the mean LAZ reaching below −2 and were highest at birth and in the first 3 months of life (https://www.
stunting prevalence of ∼65% by 24 months of age in all 3 arms. medrxiv.org/content/10.1101/2020.06.09.20127001v2). Also, in
Intriguingly, significant differences were observed in the linear high-prevalence contexts for stunting, such as Bangladesh (6)
growth velocities of children between the supplemented arms and Malawi (7), over 50% of the total burden of stunting is
compared with the control arm. Mean LAZ changes over 24 found to already exist by 6 months of age, half of which is
months were higher by 0.19 and 0.17 in the preconception and already present at birth, indicating the importance of pregnancy-
pregnancy arms, respectively, compared with the control arm, related and early life infant nutrition. Interventions using social
after adjusting for multiple other predictors of linear growth, and behavioral change communication approaches in the first
including maternal height and pre-pregnancy BMI. As with the 6 months of life that have focused on the promotion of exclusive
trial’s primary outcome of birth length, starting supplementation breastfeeding and complementary feeding from 6–24 months of
prior to conception compared with in early pregnancy did not age have failed to show an impact on stunting (8). More research
affect postnatal growth differentially. is needed to better support maternal lactation and interventions
This study may be unique in showing a preconception or to prevent early infant growth faltering. Beyond 6 months of age,
prenatal intervention effect on linear growth, mediated in part
by improved early linear growth in utero and in length at birth. The author reported no funding received for this study.
The difference in growth in the first 6 months appears to be the Address correspondence to PC (e-mail: [email protected]).
highest, as shown in Figure 1 of Krebs et al. (1), explaining First published online June 9, 2022; doi: https://doi.org/10.1093/ajcn/
most of the overall difference in the growth trajectory in the first nqac076.

Am J Clin Nutr 2022;116:1–2. Printed in USA. © The Author(s) 2022. Published by Oxford University Press on behalf of the American Society for Nutrition.
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2 Editorial

promising interventions, such as SQ-LNS as complementary food References

supplements, have been shown to significantly reduce postnatal 1. Krebs NF, Hambidge KM, Westcott J, Garces AL, Figueroa L, Tshefu
stunting, wasting, and anemia (9), as well as to potentially reduce AK, Lokangaka AL, Goudar SS, Dhaded SM, Saleem S, et al. Birth
child mortality (10). Such products need to be delivered at scale length is the strongest predictor of linear growth status and stunting
in the first 2 years of life after a preconception maternal nutrition
to further reduce stunting in low- and middle-income settings. intervention: The children of the Women First trial. Am J Clin Nutr
The maternal SQ-LNS product used in the Women First trial 2022;116(1):86–96.
contained few calories (118 kcal) and limited protein (2.6 g); thus, 2. Hambidge KM, Westcott JE, Garcés A, Figueroa L, Goudar SS,
the effects seen on infant growth rates may be attributed to the Dhaded SM, Pasha O, Ali SA, Tshefu A, Lokangaka A, et al. A
multicountry randomized controlled trial of comprehensive maternal
product’s micronutrient content, which provided an approximate nutrition supplementation initiated before conception: the Women First
RDA of about 15 nutrients. However, where undernutrition (low trial. Am J Clin Nutr 2019;109(2):457–69.
BMI) among women is high, balanced energy and protein (BEP) 3. Krebs NF, Hambidge KM, Westcott JL, Garcés AL, Figueroa L, Tsefu
supplements are needed and recommended by the WHO (11). In AK, Lokangaka AL, Goudar SS, Dhaded SM, Saleem S, et al. Growth
from birth through six months for infants of mothers in the “Women
the Women First trial (2), in 3 of the 4 countries (Democratic First” preconception maternal nutrition trial. J Pediatr 2021;229:199–
Republic of Congo, India, and Pakistan) over 90% of the women 206.e4.
had a low BMI or inadequate gestational weight gain and were 4. Christian P, Lee SE, Angel MD, Adair LS, Arifeen SE, Ashorn P,
provided food supplements containing additional calories and Barros FC, Fall CHD, Fawzi WW, Ma WH, et al. Risk of childhood
undernutrition related to small-for-gestational age and preterm birth
protein. Efforts are underway in several countries to test the in low and middle income countries. Int J Epidemiol. 2013;42:
effects of ready-to-use, fortified BEP supplements using the 1340–55.
consensus-derived specifications for macro- and micronutrients 5. Christian P. Fetal growth restriction and preterm as determinants of
by an expert group (12), which may be appropriate in contexts child growth in the first two years and potential interventions. In:
Singhal A, Uauy R, Black RE,editors. International nutrition: achieving
where maternal undernutrition is high, with targeting as done in millennium goals. Nestle Nutrition Workshop Series Vol 78. Vevey
the Women First study (1). The current WHO recommendation (Switzerland): Nestec Ltd; 2014. pp. 81–91.
for BEP supplement use during pregnancy in undernourished 6. Christian P, Shaikh S, Shamim AA, Mehra S, Wu L, Mitra M,
settings (defined as those in which over 20% of maternal BMIs Ali A, Merrill RD, Choudhury N, Parveen M, et al. Effect of
fortified complementary food supplementation on child growth in rural
are low) does not recommend screening and targeting, and at the Bangladesh–a cluster-randomized trial. Int J Epidemiol. 2015;44:1862–
national level this recommendation applies only to 2 countries 76.
(Bangladesh and India), despite the identified geographic “hot 7. Christian P, Hurley KM, Phuka J, Kang Y, Ruel-Bergeron J, Buckland
spots” throughout South Asia and sub-Saharan Africa (13). AJ, Mitra M, Wu L, Klemm R, West KP. Impact evaluation of a
comprehensive nutrition program for reducing stunting in children aged
Research is needed to better understand the value of targeting 6–23 months in rural Malawi. J Nutr 2020;150(11):3024–32.
using pre- and early pregnancy low BMIs and inadequate weight 8. Victora CG, Bahl R, Barros AJ, França GV, Horton S, Krasevec J, et al.
gain in pregnancy, for which data are limited. Breastfeeding in the 21st century: epidemiology, mechanisms,
The Women First trial was unable to show discernable and lifelong effect. Lancet North Am Ed 2016;387(10017):
475–90.
differences between starting supplementation preconceptionally 9. Das JK, Salam RA, Hadi YB, Sadiq Sheikh S, Bhutta AZ, Weise Prinzo
or in early pregnancy, the main comparison of interest. This Z, Bhutta ZA. Preventive lipid-based nutrient supplements given with
has programmatic implications, as preconception interventions complementary foods to infants and young children 6 to 23 months
would require additional resources and new delivery platforms of age for health, nutrition, and developmental outcomes. Cochrane
Database Syst Rev 2019;5(5):CD012611.
to reach women prior to pregnancy. Furthermore, questions 10. Stewart CP, Wessells KR, Arnold CD, Huybregts L, Ashorn P, Becquey
remain about whether a 3-month duration was sufficient for E, Humphrey JH, Dewey KG. Lipid-based nutrient supplements and
optimizing the pre-pregnancy status, as well as whether higher all-cause mortality in children 6–24 months of age: a meta-analysis of
amounts of calories and proteins, at least in some settings, were randomized controlled trials. Am J Clin Nutr 2020;111:207–18.
11. WHO. WHO recommendations on antenatal care for a positive
needed. The Women First study adds much to our understanding pregnancy experience. Geneva (Switzerland): World Health
of the importance of preconception nutrition. Similar studies Organization; 2016.
with larger sample sizes, perhaps longer durations of exposure, 12. Members of an Expert Consultation on Nutritious Food Supplements for
and carefully designed nutrition interventions are needed to Pregnant and Lactating Women. Framework and specifications for the
nutritional composition of a food supplement for pregnant and lactating
advance our understanding of preconception and, by extension, women (PLW) in undernourished and low income settings. [version 1;
of adolescent nutrition. not peer reviewed]. Gates Open Res 2019;3:1498.
13. Victora CG, Christian P, Vidaletti LP, Gatica-Dominiquez G, Menon P,
Author disclosures: PC is an Associate Editor of the American Journal Black RE. Revisiting maternal and child undernutrition in low-income
of Clinical Nutrition and played no role in the editorial handling of this and middle-income countries: variable progress towards and unfinished
agenda. Lancet North Am Ed 2021;397(10282):1388–99.
manuscript.