Malaria, malnutrition, and birthweight: A meta-analysis using individual participant data.
Malaria, malnutrition, and birthweight: A meta-analysis using individual participant data.
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DOI：
10.1371/journal.pmed.1002373
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发表时间：
2017-08
期刊：
影响因子：
15.8
通讯作者：
Rogerson S
中科院分区：
文献类型：
--
作者：
Cates JE;Unger HW;Briand V;Fievet N;Valea I;Tinto H;D'Alessandro U;Landis SH;Adu-Afarwuah S;Dewey KG;Ter Kuile FO;Desai M;Dellicour S;Ouma P;Gutman J;Oneko M;Slutsker L;Terlouw DJ;Kariuki S;Ayisi J;Madanitsa M;Mwapasa V;Ashorn P;Maleta K;Mueller I;Stanisic D;Schmiegelow C;Lusingu JPA;van Eijk AM;Bauserman M;Adair L;Cole SR;Westreich D;Meshnick S;Rogerson S
先前的四项研究表明，怀孕期间感染疟疾对低出生体重风险的影响可能取决于母亲的营养状况。我们使用一个大的、多样化的研究人群进一步研究了这种依赖性。我们使用1996-2015年在非洲和西太平洋进行的13项研究（6项队列研究和7项随机对照试验）的14，633例妊娠的汇总数据，评估了孕产妇疟疾感染和孕产妇人体测量状态对LBW风险的相互作用。研究由孕产妇疟疾和营养不良（M3）倡议使用便利抽样方法确定，如果获得充分的伦理批准和基本变量的可用性，则有资格合并。使用治疗加权线性和对数二项回归模型的逆概率计算研究特定的校正效应估计值，并使用随机效应模型汇总。产前登记时感染疟疾的妇女分娩低出生体重婴儿的调整后风险为8.8%，而未感染疟疾的妇女为7.7（调整后的风险比[aRR] 1.14 [95%置信区间（CI）：0.91，1.42]; N = 13，613），在分娩时感染疟疾的妇女中为10.5%，而在未感染疟疾的妇女中为7.9%（aRR 1.32 [95% CI：1.08，1.62]; N = 11，826），入组时中上臂围较低（MUAC <23 cm）的女性为15.3%，而MUAC ≥ 23 cm的女性为9.5%（aRR 1.60 [95% CI：1.36，1.87]; N = 9，008）。在入组时患有疟疾感染和低MUAC的妇女中，分娩低出生体重婴儿的风险为17.8%，而在MUAC ≥ 23 cm的未感染妇女中为8.4%（联合aRR 2.13 [95% CI：1.21，3.73]; N = 8，152）。没有协同作用的证据（即，在乘法（p = 0.5）或加法（p = 0.9）量表上，疟疾感染和MUAC之间的相互作用导致的过度风险）。结果是相似的使用身体质量指数（BMI）作为人体测量指标的营养状况。荟萃回归结果表明，在非洲进行的研究中，入组时的疟疾感染和低MUAC之间可能存在乘法相互作用;然而，当考虑多重比较或使用疟疾和营养不良的其他定义时，这一发现在加法量表上并不一致。该研究的主要局限性包括仅有2项疟疾横断面测量，以及所有研究中评估早产和胎儿生长影响的基于超声的妊娠日期有限。与只有一个风险因素或没有风险因素的妇女相比，营养不良和疟疾感染的孕妇患低出生体重的风险增加，但疟疾和营养不良并不协同作用。在一项使用个体参与者数据的荟萃分析中，Jordan Cates及其同事探索了妊娠期间疟疾和营养之间的潜在相互作用及其与低出生体重的关系。每年有超过1.25亿孕妇在怀孕期间面临疟疾风险，对孕产妇、新生儿和婴儿健康产生有害影响。据估计，产妇营养不良每年造成80万新生儿死亡。先前来自4项小型研究的证据表明，疟疾对胎儿生长和出生体重（BW）的有害影响可能取决于母亲的常量营养素营养状况。如果疟疾和产妇营养不良对妊娠结果产生协同的负面影响，那么针对高危妇女的干预措施可能会带来巨大的公共利益。目前的研究提供了一个强大的评估潜在的疟疾营养相互作用在怀孕和克服规模和方法的限制早期探索性研究。我们对来自撒哈拉以南非洲和西太平洋地区的13项研究的个体参与者数据进行了大型汇总分析，这些研究调查了孕产妇疟疾感染和营养不良对低出生体重（LBW）和平均BW降低风险之间的相互作用。研究结果表明，感染疟疾和营养不良的妇女比未感染、营养良好的妇女有更大的低出生体重风险。然而，该研究没有发现两者之间相互作用的确凿证据，即，疟疾对BW的影响与母亲的常量营养素营养状况无关。亚组分析确实发现，仅在非洲进行的研究有轻微的相互作用证据，但这在所有分析中并不一致。虽然没有疟疾与营养相互作用的总体证据，但超过三分之一的孕妇患有疟疾和（或）营养不良，强调必须采取联合办法，减少孕产妇疟疾和改善营养，以尽量减少不良妊娠结果。
Four studies previously indicated that the effect of malaria infection during pregnancy on the risk of low birthweight (LBW; <2,500 g) may depend upon maternal nutritional status. We investigated this dependence further using a large, diverse study population. We evaluated the interaction between maternal malaria infection and maternal anthropometric status on the risk of LBW using pooled data from 14,633 pregnancies from 13 studies (6 cohort studies and 7 randomized controlled trials) conducted in Africa and the Western Pacific from 1996–2015. Studies were identified by the Maternal Malaria and Malnutrition (M3) initiative using a convenience sampling approach and were eligible for pooling given adequate ethical approval and availability of essential variables. Study-specific adjusted effect estimates were calculated using inverse probability of treatment-weighted linear and log-binomial regression models and pooled using a random-effects model. The adjusted risk of delivering a baby with LBW was 8.8% among women with malaria infection at antenatal enrollment compared to 7.7% among uninfected women (adjusted risk ratio [aRR] 1.14 [95% confidence interval (CI): 0.91, 1.42]; N = 13,613), 10.5% among women with malaria infection at delivery compared to 7.9% among uninfected women (aRR 1.32 [95% CI: 1.08, 1.62]; N = 11,826), and 15.3% among women with low mid-upper arm circumference (MUAC <23 cm) at enrollment compared to 9.5% among women with MUAC ≥ 23 cm (aRR 1.60 [95% CI: 1.36, 1.87]; N = 9,008). The risk of delivering a baby with LBW was 17.8% among women with both malaria infection and low MUAC at enrollment compared to 8.4% among uninfected women with MUAC ≥ 23 cm (joint aRR 2.13 [95% CI: 1.21, 3.73]; N = 8,152). There was no evidence of synergism (i.e., excess risk due to interaction) between malaria infection and MUAC on the multiplicative (p = 0.5) or additive scale (p = 0.9). Results were similar using body mass index (BMI) as an anthropometric indicator of nutritional status. Meta-regression results indicated that there may be multiplicative interaction between malaria infection at enrollment and low MUAC within studies conducted in Africa; however, this finding was not consistent on the additive scale, when accounting for multiple comparisons, or when using other definitions of malaria and malnutrition. The major limitations of the study included availability of only 2 cross-sectional measurements of malaria and the limited availability of ultrasound-based pregnancy dating to assess impacts on preterm birth and fetal growth in all studies. Pregnant women with malnutrition and malaria infection are at increased risk of LBW compared to women with only 1 risk factor or none, but malaria and malnutrition do not act synergistically. In a meta-analysis using individual participant data, Jordan Cates and colleagues explore potential interactions between malaria and nutrition during pregnancy and their associations with low birthweight. More than 125 million pregnant women are at risk of malaria in pregnancy annually, producing detrimental effects on maternal, newborn, and infant health. Maternal undernutrition is estimated to be responsible for 800,000 newborn deaths annually. Prior evidence from 4 small studies indicated that the harmful impact of malaria on fetal growth and birthweight (BW) may depend upon the macronutrient nutritional status of the mother. If malaria and maternal undernutrition have synergistic negative impacts on pregnancy outcomes, interventions targeted to high-risk women might provide substantial public benefit. The present study provides a robust assessment of potential malaria–nutrition interactions in pregnancy and overcomes size and methodological limitations of earlier exploratory studies. We present a large, pooled analysis of individual participant data from 13 studies conducted in sub-Saharan Africa and the Western Pacific investigating the interaction between maternal malaria infection and malnutrition on the risk of low birthweight (LBW) and reduced mean BW. The findings suggest that women who are both infected with malaria and malnourished are at greater risk of LBW than their uninfected, well-nourished counterparts. However, the study found no conclusive evidence of interaction between the 2, i.e., the impact of malaria on BW was independent of the macronutrient nutritional status of the mother. Subgroup analyses did find that studies conducted just in Africa had slight evidence of interaction, but this was not consistent throughout all analyses. Although there was no overall evidence of malaria–nutrition interactions, more than 1 in 3 pregnant women suffered from malaria and/or undernutrition, emphasizing the importance of joint approaches to decrease maternal malaria and improve nutrition to minimize adverse pregnancy outcomes.
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DOI：
10.4269/ajtmh.2010.10-0264
发表时间：
2010-12-01
影响因子：
3.3
作者：
Luntamo, Mari;Kulmala, Teija;Ashorn, Per
通讯作者：
Ashorn, Per
影响因子：
3
作者：
Bich-Tram Huynh;Fievet, Nadine;Cot, Michel
通讯作者：
Cot, Michel
影响因子：
2.9
作者：
Mombo-Ngoma, Ghyslain;Mackanga, Jean Rodolphe;Ramharter, Michael
通讯作者：
Ramharter, Michael
影响因子：
6.3
作者：
Downs, SH;Black, N
通讯作者：
Black, N
DOI：
10.1016/0197-2456(86)90046-2
发表时间：
1986-09-01
期刊：
CONTROLLED CLINICAL TRIALS
影响因子：
--
作者：
DERSIMONIAN, R;LAIRD, N
通讯作者：
LAIRD, N