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Reproductive Health
Program Planning:
What’s the evidence?
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The Health Evidence Team
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Meetings, Planning &
Dissemination Project

CIHR-Funded Reviews
 Kramer, M.S., & Kakuma, R. (2002). Optimal duration
of exclusive breastfeeding. Cochrane Database of
Systematic Reviews,2002 (Issue 1), Art. No. CD003517.
DOI: 10.1002/14651858.CD003517.
 Kramer, M.S., Kakuma, R. (2003). Energy and protein
intake in pregnancy. Cochrane Database of Systematic
Reviews,2003 (Issue 4), Art. No.: CD000032. DOI:
10.1002/14651858.CD000032.

Summary Statement:
Kramer (2002)

Overall Considerations
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Interpreting the Evidence
Growth among EBF infants for 6 months vs. EBF for 3-4
months and MBF thereafter through 6 months
What’s the evidence? Implications for practice &
policy
Weight Gain (4 studies) • Public health activities should
• Weight gain at 3-8 months was significantly higher in acknowledge evidence indicating that
MBF compared to EBF infants (WMD – 12.45, 95% MBF infants gain slightly more weight
CI -23.46 to -1.44 g/mo). than EBF infants at 3-12 months,
although there are no differences in
Weight for age (2 studies) weight gain at any other time points.
• EBF infants had significantly lower scores for weight
for age at six months (WMD -0.09, 95% CI -0.16 to
-0.02), nine months (WMD -0.10, 95% CI -0.18 to -
0.02), and 12 months (WMD -0.09, 95% CI -0.17 to
-0.01) compared to MBF infants.

Weight Gain
 Weight gain at 3-8 months was significantly higher in MBF compared
to EBF infants (WMD – 12.45, 95% CI -23.46 to -1.44 g/mo).

Weight Gain
 No impact for EBF vs. MBF infants on weight gain at 8-12 months.

Interpreting the Evidence
Morbidity and mortality among infants EBF for 6 months vs.
EBF for 3-4 months and MBF thereafter through 6 months
What’s the evidence? Implications for practice & policy
Gastrointestinal infections (1 study) • Public health messages and programs
should indicate that infants who are EBF
• EBF infants were 33% less likely to have GI infection are less likely to have gastrointestinal
in the first 12 months compared to MBF infants infections compared to MBF infants
(RR 0.67, 95% CI 0.46 to 0.97).
• There was no reduction in risk of hospitalization

Gastrointestinal Infections
• EBF infants were 33% less likely to have GI infection in the first 12
months compared to MBF infants (RR 0.67, 95% CI 0.46 to 0.97).

Interpreting the Evidence
Morbidity and mortality among infants EBF for 6 months vs.
EBF for 3-4 months and MBF thereafter through 6 months
What’s the evidence? Implications for practice & policy
Acute otitis media (ear infections) (2 studies) • Public health messages and programs
should indicate that infants who are EBF
• MBF infants were 28% more likely to have one or are less likely to have otitis media
more episodes of otitis media compared to EBF compared to MBF infants;
infants (RR 1.28, 95% CI 1.04 to 1.57).

Acute Otitis Media (ear infection)
• MBF infants were 28% more likely to have one or more episodes of
otitis media compared to EBF infants (RR 1.28, 95% CI 1.04 to 1.57).

Overall Considerations
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Questions?

Summary Statement:
Kramer (2003)

Overall Considerations
Considerations for Public Health Practice
Conclusions from Health Evidence General Implications
This well done review is based on low quality Public health programs should include:
studies. • nutritional advice to women (but not as a
sole strategy)
Balanced energy/protein supplementation • encourage balanced energy/protein
• improves fetal growth supplements
• may reduce the risk of fetal and neonatal Public health programs should not encourage:
death • isocaloric protein supplements for pregnant
• equally likely to have a very minimal or women
quite large impact on preterm birth • high protein supplements for pregnant
• has no impact on gestational diabetes, women
preeclampsia, and growth and development • energy/protein restriction for overweight
• may result in possible harms (e.g. reduced pregnant women
fetal growth) The findings should be used cautiously given the
low quality of the evidence.
*Note: The results presented are our own
interpretation for increasing energy intake.

Interpreting the Evidence
Nutritional advice to increase energy and protein intake
What’s the evidence? Implications for practice & policy
• Effective in reducing the risk of preterm • Public health organizations should not
birth (by 54% with the true risk reduced include nutritional advice as a sole
from 2-79%). intervention.
• Public health messaging should emphasize
that increased energy and protein intake is
associated with a decreased risk of preterm
birth.

Preterm birth
• Effective in reducing the risk of preterm birth (by 54% with the true
risk reduced from 2-79%).

Interpreting the Evidence
High protein supplementation
What’s the evidence? Implications for practice & policy
• Increased risk of small for gestational age • Public health programs should not promote
(by 58% with the true risk reduced from 3- or provide high protein supplementation as
141%). it has no impact on most maternal, fetal, and
• No impact on all other outcome infant health outcomes and may, in fact, have
adverse outcomes.

Small-for-gestational Age
• Increased risk of small for gestational age (by 58% with the true risk
reduced from 3-141%).

Interpreting the Evidence
Energy/protein restriction in women with overweight or high
weight gain
What’s the evidence? Implications for practice & policy
• Resulted in small head circumference at • Public health programs should not include
birth (by 1cm with a range from 0.14 cm to energy/protein restriction as a means of
1.86 cm smaller). improving maternal, fetal, or infant health
outcomes, since energy/protein restriction
is not likely to be beneficial for maternal or
infant health and may lead to smaller head
circumference among infants.

Head Circumference
• Resulted in small head circumference at birth (by 1cm with a range
from 0.14 cm to 1.86 cm smaller).

Overall Considerations
Considerations for Public Health Practice
Conclusions from Health Evidence General Implications
This well done review is based on low quality Public health programs should include:
studies. • nutritional advice to women (but not as a
sole strategy)
Balanced energy/protein supplementation • encourage balanced energy/protein
• improves fetal growth supplements
• may reduce the risk of fetal and neonatal Public health programs should not encourage:
death • isocaloric protein supplements for pregnant
• equally likely to have a very minimal or women
quite large impact on preterm birth • high protein supplements for pregnant
• has no impact on gestational diabetes, women
preeclampsia, and growth and development • energy/protein restriction for overweight
• may result in possible harms (e.g. reduced pregnant women
fetal growth) The findings should be used cautiously given the
low quality of the evidence.

Questions?

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