Evidence Report/Technology Assessment 

Number 118 

Effects of Omega-3 Fatty Acids on Child and 

Maternal Health 

Prepared for: 

Agency for Healthcare Research and Quality 

U.S. Department of Health and Human Services 

540 Gaither Road 

Rockville, MD 20850 

www.ahrq.gov 

Contract No. 290-02-0021 

Prepared by: 

University of Ottawa Evidence-based Practice Center at 

The University of Ottawa, Ottawa Canada 

David Moher, PhD 

Director 

Investigators:

Gabriela A Lewin, MD 

Howard M Schachter, PhD 

Doris Yuen, MD 

Pradeep Merchant, MD 

Vasil Mamaladze, MD 

Alexander Tsertsvadze, MD, MSc 

Tammy Clifford, PhD 

Kader Kourad MD, PhD 

David Barnes, MD 

Tanya Armour, PhD 

Fatemah Yazdi, MSc 

JoAnne MacNeil, RN, BScN 

AHRQ Publication No. 05-E025-2 

August 2005 

Candice McGahern, HRA 

Hope Senechal, BSc 

Manchun Fang, Msc 

Nicholas Barrowman, PhD 

Margaret Sampson, MLIS 

Andra Morrison, BSc 

Dominique Elien 

Marc Saint-Martin, BSc 

Aarathi Sambasivan 

Elizabeth Lowcock, BScH 

Yi Pan, MSc 

Brigitte Lemyre, MD 
This report is based on research conducted by the University of Ottawa Evidence-based 

Practice Center (EPC), under contract to the Agency for Healthcare Research and Quality 

(AHRQ), Rockville, MD (Contract No. 290-02-0021). The findings and conclusions in this 

document are those of the authors, who are responsible for its contents; the findings and 

conclusions do not necessarily represent the views of AHRQ. Therefore, no statement in this 

report should be construed as an official position of AHRQ or of the U.S. Department of 

Health and Human Services. 

The information in this report is intended to help health care decisionmakers, patients and 

clinicians, health system leaders, and policymakers make well-informed decisions and thereby 

improve the quality of health care services. This report is not intended to be a substitute for 

the application of clinical judgment. Anyone who makes decisions concerning the provision 

of clinical care should consider this report as they would any medical reference and in 

conjunction with all other pertinent information, i.e., in the context of available resources and 

circumstances presented by individual patients. 

This report may be used, in whole or in part, as the basis for development of clinical practice 

guidelines and other quality enhancement tools, or as a basis for reimbursement and coverage 

policies. Neither AHRQ’s nor the U.S. Department of Health and Human Services’ 

endorsement of such derivative products may be stated or implied. 
ii

This document is in the public domain and may be used and reprinted without permission except 

those copyrighted materials noted for which further reproduction is prohibited without the 

specific permission of copyright holders. 

Suggested Citation: 

Lewin GA, Schachter HM, Yuen D, Merchant P, Mamaladze V, Tsertsvadze A, et al. Effects of 

Omega-3 Fatty Acids on Child and Maternal Health. Evidence Report/Technology Assessment 

No. 118. (Prepared by the University of Ottawa Evidence-based Practice Center, under Contract 

No. 290-02-0021.) AHRQ Publication No. 05-E025-2. Rockville, MD: Agency for Healthcare 

Research and Quality. August 2005. 
iii

Preface 

 The Agency for Healthcare Research and Quality (AHRQ), through its Evidence-Based 

Practice Centers (EPCs), sponsors the development of evidence reports and technology 

assessments to assist public- and private-sector organizations in their efforts to improve the 

quality of health care in the United States. This report was requested and funded by the Office of 

Dietary Supplements, National Institutes of Health. The reports and assessments provide 

organizations with comprehensive, science-based information on common, costly medical 

conditions and new health care technologies. The EPCs systematically review the relevant 

scientific literature on topics assigned to them by AHRQ and conduct additional analyses when 

appropriate prior to developing their reports and assessments. 

 To bring the broadest range of experts into the development of evidence reports and health 

technology assessments, AHRQ encourages the EPCs to form partnerships and enter into 

collaborations with other medical and research organizations. The EPCs work with these partner 

organizations to ensure that the evidence reports and technology assessments they produce will 

become building blocks for health care quality improvement projects throughout the Nation. The 

reports undergo peer review prior to their release. 

 AHRQ expects that the EPC evidence reports and technology assessments will inform 

individual health plans, providers, and purchasers as well as the health care system as a whole by 

providing important information to help improve health care quality. 

 We welcome comments on this evidence report. They may be sent by mail to the Task Order 

Officer named below at: Agency for Healthcare Research and Quality, 540 Gaither Road, 

Rockville, MD 20850, or by email to epc@ahrq.gov. 

Carolyn M. Clancy, M.D. Jean Slutsky, P.A., M.S.P.H. 

Director Director 

Agency for Healthcare Research and Quality Center for Outcomes and Evidence 

 Agency for Healthcare Research and Quality 

Paul Coates, Ph.D. Kenneth S. Fink, M.D., M.G.A., M.P.H. 

Director Director, EPC Program 

Office of Dietary Supplements Agency for Healthcare Research and Quality 

National Institutes of Health 

Beth A. Collins-Sharp, R.N., Ph.D. 

EPC Program Task Order Officer 

Agency for Healthcare Research and Quality
iv

Acknowledgments 

The authors would like to thank numerous individuals for their support of the present project: our 

collaborators at SC-RAND and Tufts-NEMC EPCs; Isabella Steffensen and Christine Murray for 

their ability to convey with words, tables and figures what it is we did and found; for their expert 

and timely translation of articles; Herb Woolf for responding with substance to our request of 

industry for evidence; Peter O’Blenis for assuring that our software would adapt and grow as 

quickly as the project requirements shifted and expanded; Mary Fewtrell; Sjurdur Frodi Olsen; 

Maria Makrides; Eileen Birch; Susan Carlson for timely responded to our requests to clarify their 

research; Khai Tran and Maia Miguelez, PhD for providing input on the data abstraction forms; 

Nancy Santesso for helping on the development of the search strategy; Raymond Daniel for 

helping to retrieve the hard copies of the studies, Manijeh Hamifard for helping on the data 

abstraction and Chantelle Garritty for coordinating the project. 
v

Structured Abstract 

Context: The likely significance of omega-3 fatty acids for child and maternal health is 

therefore suggested by the observations that: the human brain and retina each contain 

considerable omega-3 fatty acid content; the child delivered at term receives an important supply 

of omega-3 fatty acids especially in the third trimester of pregnancy; and, due to a shortened 

gestational period, the child delivered prematurely receives less exposure to omega-3 fatty acid 

content than does the term child. This evidence is systematically reviewed here. 

Objectives: The purpose of this study was to conduct a systematic review of the scientific–

medical literature to identify, appraise and synthesize the evidence of omega-3 fatty acids in 

child and maternal health. Evidence was sought to investigate a series of questions regarding the 

influence of the omega-3 fatty acid intake (supplemented during pregnancy) on the duration of 

gestation, incidence of preeclampsia, eclapmsia or gestational hypertension (GHT), and 

incidence of infants small for gestational age (SGA), as well as the association between the 

maternal biomarkers during pregnancy and the pregnancy outcomes outlined above. The 

influence of the omega-3 fatty acid intake (supplemented or breast milk) on the developmental 

outcomes in preterm and term infants, such was growth, neurocognitive development and visual 

function, were also investigated, as well as the association between the maternal, fetal or child’s 

biomarkers and these clinical outcomes. The impact of effect modifiers was also examined, as 

well as the safety profile. The results will be used to inform a research agenda. 

Data Sources: A comprehensive search for citations was conducted using five electronic 

databases (MEDLINE®, PreMEDLINE®, EMBASE, Cochrane Central Register of Controlled 

Trials, and CAB Health). Searches were not restricted by language of publication, publication 

type, or study design, except with respect to the MeSH term “dietary fats,” which was limited by 

study design to increase its specificity. Search elements included scientific terms (with 

acronyms), generic and trade names relating to the exposure and its sources (e.g., 

eicosapentaenoic acid [EPA], fish oil), and relevant population terms (e.g., preterm, term, child 

development, etc). Additional published or unpublished literature was sought through manual 

searches of references lists of included studies and key review articles, and from the files of 

content experts. 

Study Selection: Studies were considered relevant if they described live human populations 

of healthy preterm (< 37 weeks of GA), term (> 37 weeks of GA) infants or healthy pregnant 

women, investigated the use of any supplements (formula, diet, etc.) known to contain omega-3 

fatty acids and/or human milk, and utilizing pertinent pregnancy and child developmental 

outcomes (e.g., growth, neurocognitive, visual). Studies examining the questions concerning the 

efficacy had to employ a controlled research design (i.e., RCTs), whereas, any type of design 

other than case-series or case-study was permitted to address the possible association between 

the content of biomarkers and the clinical outcomes. Three levels of screening for relevance, and 

two reviewers per level, were employed. Disagreements were resolved by consensus and, if 

necessary, third-party intervention. 
vi

Data Extraction: All data were extracted by one reviewer, then verified by a second one. 

Data included the characteristics of the report, study, population, intervention/exposure and 

comparator(s), cointerventions, discontinuations (with reasons), and outcomes (i.e., clinical, 

biomarkers, safety). Study quality (internal validity) and study applicability (external validity) 

were appraised. 

Data Synthesis: Question-specific qualitative synthesis of the evidence was derived. Metaanalysis was conducted with data concerning the supplemental influence on incidence of 

premature deliveries, GHT, birth weight, incidence of IUGR, growth patterns (i.e., weight, length 

and head circumference) in term and preterm infants, neurological and cognitive development in 

term infants, and visual function in both term and preterm infants. One hundred and seventeen 

reports, describing 89 studies, were deemed relevant for the systematic review, with many 

studies described in more that one question. 

Conclusions: Studies investigating the influence of omega-3 fatty acids on child and maternal 

health revealed the absence of a notable safety profile (i.e., moderate-to-severe AEs). Pregnancy 

outcomes were either unaffected by omega-3 fatty acid supplementation, or the results were 

inconclusive. Results suggested the absence of effects with respect to the impact of 

supplementation on the incidence of GHT, preeclampsia or eclampsia, as well as on infants being 

born SGA. However, regarding evaluations of the duration of gestation, some discrepancies 

were observed, although most of the studies failed to detect a statistically significant effect. 

Biomarker data failed to clarify patterns in pregnancy outcome data. 

Results concerning the impact of the intake of omega-3 fatty acids on the development of 

infants are primarily, although not uniformly, inconclusive. The inconsistencies in study results 

may be attributable to numerous factors. 

In addition, making clear sense of the absolute or relative effects of individual omega-3 fatty 

acids, or even omega-3 fatty acid combinations, on child outcomes is complicated or precluded 

by the following problem. Studies typically employed interventions that involved various 

cointerventional or background constituents (e.g., omega-6 fatty acids), yet whose metabolic 

interactions with the omega-3 fatty acid(s) were not taken into account in interpreting the results. 

The dynamic interplay among these fatty acid contents (e.g., competition for enzymes), and how 

this interplay may influence outcomes, may differ in important ways depending on whether DHA 

or olive oil is added to this combination of cointerventional or background constituents, 

particularly in the maternal population. This strategy prevented the isolation of the exact effects 

relating to the omega-3 fatty acid content. It is thus very difficult to reliably ascribe definite 

child outcome-related benefits, or the absence thereof, to specific omega-3 fatty acids. 

Biomarker data failed to clarify patterns in child outcome data. 

Future research should likely consider investigating the impact of specific omega-6/omega-3 

fatty acid intake ratios, in no small part to control for the possible metabolic interactions 

involving these types of fatty acids. To produce results that are applicable to the North 

American population, populations consuming high omega-6/omega-3 fatty acid intake ratios 

should likely be randomized into trials also exhibiting better control of confounding variables 

than was observed, especially in the present collection of studies of child outcomes. 
vii

Contents 

Chapter 1. Introduction ..............................................................................................................3 

 Metabolism and Biological Effects of Essential Fatty Acids ..............................................3 

 Metabolic Pathways of Omega-3 and Omega-6 Fatty Acids...............................................4 

 U.S. Population Intake of Omega-3 Fatty Acids .................................................................8 

 Dietary Sources of Omega-3 Fatty Acids ............................................................................9 

 Omega-3 Fatty Acids in Child and Maternal Health .........................................................11 

Chapter 2. Methods.................................................................................................................17 

 Overview............................................................................................................................17 

 Key Questions Addressed In This Report..........................................................................17 

 Analytic Framework ..........................................................................................................23

 Study Identification............................................................................................................27 

 Data Abstraction ................................................................................................................32 

 Summarizing the Evidence ................................................................................................32 

Chapter 3. Results ....................................................................................................................39 

 Results of Literature Search...............................................................................................39 

 Report and Study Design Characteristics of Included Studies ..........................................40 

 Pregnancy Outcomes .........................................................................................................42 

 Overview of relevant studies .......................................................................................42 

 Qualitative synthesis of relevant studies’ key characteristics......................................48 

 Qualitative synthesis of individual study results .........................................................52 

 Quantitative synthesis ..................................................................................................52 

 Impact of covariates and confounders .........................................................................54 

Overview of relevant studies .......................................................................................54 

Qualitative synthesis of relevant studies’ key characteristics......................................56 

Qualitative synthesis of individual study results .........................................................60 

Quantitative synthesis ..................................................................................................60 

Impact of covariates and confounders .........................................................................61 

Overview of Relevant Studies .....................................................................................61 

Qualitative synthesis of relevant studies’ key characteristics......................................64 

Qualitative synthesis of individual study results .........................................................68 

Quantitative synthesis ..................................................................................................68 

Impact of covariates and confounders .........................................................................70 

 Pregnancy Outcomes in Light of Biomarker Data.............................................................70 

Overview of relevant study characteristics and results................................................71 

Overview of relevant studies .......................................................................................74 

Qualitative synthesis of relevant studies’ key characteristics......................................76 

Qualitative synthesis of individual study results .........................................................78 

Overview of relevant studies .......................................................................................79 

Qualitative synthesis of relevant studies’ key characteristics......................................81 

Qualitative synthesis of individual study results .........................................................83 

 Growth Pattern Outcomes..................................................................................................83 

Overview of relevant study characteristics and results................................................84 
viii

Overview of relevant study characteristics and results................................................86 

Overview of relevant studies .......................................................................................88 

Qualitative synthesis of relevant studies’ key characteristics......................................97 

Qualitative synthesis of individual study results .......................................................102 

Quantitative synthesis ................................................................................................104 

Impact of covariates and confounders .......................................................................105 

 Overview of relevant studies .....................................................................................106 

Qualitative synthesis of relevant studies’ key characteristics....................................111 

Qualitative synthesis of individual study results .......................................................115 

Quantitative synthesis ................................................................................................116 

Impact of covariates and confounders .......................................................................119 

 Growth Pattern Outcomes in Light of Biomarker Data...................................................120 

 Overview of relevant study characteristics and results..............................................120 

 Neurological Development Outcomes.............................................................................122 

Overview of relevant study characteristics and results..............................................122 

Overview of relevant study characteristics and results..............................................123 

Overview of relevant studies .....................................................................................125 

Qualitative synthesis of relevant studies’ key characteristics....................................127 

Qualitative synthesis of individual study results .......................................................131 

Quantitative synthesis ................................................................................................132 

Impact of covariates and confounders .......................................................................133 

 Overview of relevant studies .....................................................................................133 

Qualitative synthesis of relevant studies’ key characteristics....................................135 

Qualitative synthesis of individual study results .......................................................139 

Quantitative synthesis ................................................................................................140 

Impact of covariates and confounders .......................................................................140 

 Neurological Development Outcomes in Light of Biomarker Data ................................141 

Overview of relevant study characteristics and results..............................................141 

Overview of relevant study characteristics and results..............................................143 

 Visual Function Outcomes...............................................................................................145 

Overview of relevant study characteristics and results..............................................145 

Overview of relevant study characteristics and results..............................................148 

Overview of relevant studies .....................................................................................153 

Qualitative synthesis of relevant studies’ key characteristics....................................155 

Qualitative synthesis of individual study results .......................................................159 

Quantitative synthesis ................................................................................................161 

Statistical analysis......................................................................................................162 

Impact of covariates and confounders .......................................................................166 

Overview of relevant studies .....................................................................................166 

Qualitative synthesis of relevant studies’ key characteristics....................................170 

Qualitative synthesis of individual study results .......................................................173 

Quantitative synthesis ................................................................................................176 

Impact of covariates and confounders .......................................................................182 

 Visual Function Outcomes in Light of Biomarker Data:.................................................183 

Overview of relevant studies .....................................................................................184 
ix

Qualitative synthesis of relevant studies’ key characteristics....................................187 

Qualitative synthesis of individual study results .......................................................190 

 Cognitive Development Outcomes:.................................................................................192 

Overview of relevant study characteristics and results..............................................192 

Overview of relevant study characteristics and results..............................................194 

Overview of relevant studies. ....................................................................................197 

Qualitative synthesis of relevant studies’ key characteristics....................................198 

Qualitative synthesis of individual study results .......................................................202 

Quantitative synthesis ................................................................................................203 

Impact of covariates and confounders .......................................................................203 

Overview of relevant studies. ....................................................................................204 

Qualitative synthesis of relevant studies’ key characteristics....................................205 

Qualitative synthesis of individual study results .......................................................209 

Quantitative synthesis ................................................................................................211 

Impact of covariates and confounders .......................................................................211 

 Cognitive Development Outcomes in Light of Biomarker Data .....................................212 

Overview of relevant study characteristics and results..............................................213 

 Safety Issues.....................................................................................................................215 

Chapter 4. Discussion ............................................................................................................219 

Overview..........................................................................................................................219 

Evidence Synthesis and Appraisal...................................................................................219 

Clinical Implications........................................................................................................237 

Research Implications and Directions .............................................................................240 

Limitations of the Review................................................................................................243 

Conclusion .......................................................................................................................244 

References and Included Studies ...........................................................................................247 

Abbreviations.........................................................................................................................263 

Appendixes 

Appendix A: Search Strategies 

Appendix B: Letter to Industry Representatives 

Appendix C: Data Assessment and Data Abstraction Forms 

Appendix D: Modified QUOROM Flow Chart 

Appendix E: Evidence Tables 

Appendix F: List of excluded studies (no RCTs) 

Appendix G: Interventional Formula’s Content 

Appendix H: Listing of Excluded Studies at Level 2 and 3 Screening 

Appendix I: Additional Acknowledgements 

Appendixes and Evidence Tables are provided electronically at 

http://www.ahrq.gov/clinic/tp/o3mchtp.htm
Introduction

The purpose of this study was to conduct a

systematic review of the scientific-medical

literature to identify, appraise, and synthesize the

human evidence for the effects of omega-3 fatty

acids on child and maternal health. The review

was requested and funded by the Office of

Dietary Supplements, National Institutes of

Health. It was undertaken as part of a

consortium involving three Evidence-based

Practice Centers (EPCs), which investigated the

value of omega-3 fatty acid supplementation

across eleven health/disease areas. The three

EPCs are Southern California-RAND, Tufts-New

England Medical Center, and the University of

Ottawa. To ensure consistency of approach, the

three EPCs collaborated on selected methodologic

elements, including literature search strategies,

rating of evidence, and data table design.

It has been posited that the accretion of

omega-3 fatty acids within the maternal biological

system has the potential to influence both

maternal health during pregnancy and fetal

health. Likewise, it has been hypothesized that

their accumulation within the post-delivery child’s

biological system can affect its development and

health. Birth weight is the most important factor

affecting neonatal morbidity and mortality, and is

thus an outcome worth monitoring.1 Moreover,

premature infants are at risk of injury to every

organ system in the newborn period. Of greatest

concern for infants who survive are the risks of

developing permanent neurocognitive deficits that

impact their lifelong health and functional

capacity.2-5

Results of studies conducted on residents of the

Faroe Islands6,7 suggest that marine diets, which

contain omega-3 fatty acids, increase birth weight

either by prolonging pregnancy8 or by increasing

the fetal growth rate.9,10 Additionally, it has been

hypothesized that marine oils may lower risks of

certain complications of pregnancy, in particular

preterm delivery, intrauterine growth retardation,

preeclampsia, and gestational hypertension,11

given that some of omega-3 fatty acids’ presumed

mechanisms of action overlap with those of

aspirin.12-14

Docosahexaenoic acid (DHA) and arachidonic

acid (AA) have been identified as important

structural components of the highly specialized

membrane lipids of the human central nervous

system, with phospholipids of brain gray matter

containing high proportions of DHA.15-17 DHA

has also been observed to be the major long-chain

polyunsaturated fatty acid (LC PUFA) in the

outer segments of the retina’s rods and cones.15

Based on observational studies, it has been

shown that human milk fed infants have

improved neurocognitive development compared

to formula fed infants; it was hypothesized that

one of the contributing factors may be the

availability of long-chain derivatives of linoleic

acid (LA) and alpha-linolenic acid (ALA) that is

present only in human milk.18,19 This difference

in fatty acids intake is reflected in lower

erythrocyte membrane phospholipid DHA in

Evidence Report/Technology Assessment

Number 118

Effects of Omega-3 Fatty Acids on Child and

Maternal Health

Summary

Authors: Lewin GA, Schachter HM, Yuen D, Merchant P, Mamaladze V, Tsertsvadze A, et al.

Agency for Healthcare Research and Quality

Advancing Excellence in Health Care • www.ahrq.gov

Agency for Healthcare Research and Quality Evidence-Based

Practice
2

infants fed formula.18 Until the recent availability of infant

formula with added omega-3 LC PUFAs, standard infant

formula was devoid of these fatty acids. 

The likely significance of omega-3 fatty acids for child health

is therefore suggested by the observations that (a) the human

brain and retina each contain considerable amounts of omega-3

fatty acids; (b) the children delivered at term receive an

important supply of omega-3 fatty acids, especially in the third

trimester of pregnancy; and (c) due to a shortened gestational

period, a child delivered prematurely receives less exposure to

omega-3 fatty acids content than does the term child. Not

surprisingly, the observation concerning preterm infants has

afforded considerable empirical study of the impact of omega-3

fatty acids on the health of such infants.

Key Questions 

The questions are organized by type of population (i.e.,

maternal/pregnancy versus child) and type of outcome data

(i.e., clinical/pregnancy versus clinical/child-developmental).

Maternal population, pregnancy outcomes/biomarkers

associations:

• What is the evidence that intake of omega-3 fatty acids

influences

- duration of gestation?

- incidence of preeclampsia, eclampsia or gestational

hypertension?

- incidence of births of human infants small for

gestational age (SGA)?

Child population, growth patterns, neurological, visual or

cognitive developmental outcomes/biomarkers

associations:

• What is the evidence that maternal intake of omega-3

fatty acids

- during pregnancy influences any of the clinical

outcomes in term or preterm human infants?

- within maternal breast milk, infant formula, both

and/or other sources (i.e., diet) influences any of the

clinical outcomes in term or preterm human infants?

• What is the evidence that term or preterm human infants’

clinical outcomes are associated with the omega-3 or

omega-6/omega-3 fatty acids content of

- maternal or fetal biomarkers during pregnancy?

- child biomarkers?

Adverse effects:

• What is the evidence for the risk, in pregnant or

breastfeeding women, term or preterm human infants, of

short- and long-term adverse events related to their intake

of omega-3 fatty acids during pregnancy or after birth?

Methods

A Technical Expert Panel (TEP) consisting of six members

was convened to provide advisory support to the project,

including refining the questions and highlighting key variables

requiring consideration in the evidence synthesis.

Study Identification

Several electronic databases were searched: MEDLINE®,

PreMEDLINE®, EMBASE, the Cochrane Library including

the Cochrane Central Register of Controlled Trials, and CAB

Health. Searches were not restricted by language of publication,

publication type, or study design, except with respect to the

MeSH term “dietary fats,” which was limited by study design

to increase its specificity. Search elements included scientific

terms, with acronyms, as well as generic and trade names

relating to the exposure and its sources (e.g., eicosapentaenoic

acid [EPA], omega-3 fatty acids, infant formula) and relevant

population terms (e.g., gestational hypertension). Reference

lists of included studies, book chapters, and narrative or

systematic reviews retrieved after having passed the first level of

relevance screening were manually searched to identify

additional unique references. Through contact with content

experts, attempts were made to identify both published and

unpublished studies. A final set of 2,049 unique references was

identified and posted to an internet-based software system for

review.

Studies were considered relevant if they described live,

otherwise “healthy” human populations of any age. The

generic term “child” was used to refer to infants (less than 12

months of age), toddlers, and children up to 18 years old.

Excluded were studies whose biomarker data were solely

obtained from aborted fetuses and which did not distinguish

between data obtained from term and preterm births. 

Interventional/exposure studies had to specifically investigate

foods or supplements known to contain omega-3 fatty acids of

any type, from any source, any serving size or dose, delivered in

any fashion and for any length of time. No restrictions were

placed on the types or doses of pre- or on-study

cointerventions. While omega-6 fatty acids appear to play a key

role in health and development, and their possible co-influence

on outcomes is thus assessed in our review, studies exclusively

investigating their impact on health outcomes were excluded. 

If at least two randomized controlled trials (RCTs) were

identified, no other types of design were required. Yet, if

insufficient numbers of RCTs were retrieved, non-RCT (i.e.,

controlled clinical trials, without random allocation) and
observational studies (i.e., cohort, case-control, or crosssectional studies) were included. Descriptive study designs

were also excluded.

Any and all child developmental outcomes reflecting the

four categories of the developmental arc were considered

relevant. As markers of omega-3 fatty acids metabolism, the

following fatty acids compositions or concentrations, from any

source (e.g., red blood cell [RBC] membranes, plasma

phospholipids) were considered relevant: EPA, DHA, AA/EPA,

AA/DHA, AA/EPA+DHA. 

Two initial levels of screening for relevance, and two

reviewers per level, were employed (directed at bibliographic

records, then full articles). A screening identified and excluded

uncontrolled studies. Calibration exercises preceded each step

of the screening process. The reasons for the unsuitability of

excluded studies were noted according to a modified

QUOROM format.20 Disagreements were resolved by

consensus and, when necessary, third-party intervention. 

Data Abstraction

Following a calibration exercise involving two studies, eleven

reviewers independently abstracted the contents of included

studies using an electronic data abstraction form. A second

reviewer then verified these data. Data abstracted included the

characteristics of the report (e.g., publication status), study

(e.g., sample size), population (e.g., preterm versus term status),

intervention/exposure (e.g., omega-3 fatty acids types), and

comparator(s), cointerventions (e.g., omega-6 fatty acids use),

withdrawals and dropouts, including reasons, clinical outcomes,

fatty acids content of biomarkers, and adverse events.

Data Synthesis

A summary table provided a question-specific overview of

included studies’ relevant data, which is presented in greater

detail in evidence tables. A question-specific summary matrix

described each study in terms of its quality and applicability

ratings. Question-specific qualitative syntheses of the evidence

were derived. Meta-analysis was performed if the following

criteria were met: at least two RCTs, same population

characteristics (mean age, health status, gender), same cointerventions, same intervention based on the type of omega-3

fatty acids supplemented (DHA+AA vs. DHA vs. DHA+EPA,

etc.) regardless of the daily dose in the child population, same

comparator based on source of placebo (e.g., olive oil,

unsupplemented formula), outcomes relevant to respond to the

key-questions: percentage (n) of premature deliveries, incidence

of gestational hypertension (GHT), pre-eclampsia or eclampsia,

incidence of IUGR or SGA infants, weight, length, and head

circumference of infants (means), neurological and cognitive

development measured by validated scales (e.g., Bayley’s

Developmental Scale score), and visual acuity or visual function

of infants measured by appropriate tests (Teller’s Card test,

etc.).

Results

Literature Search

Of the 2,049 records entered into the initial screening for

relevance, 1,579 were excluded. Of the 191 reports that made

it to this level of screening, 74 were excluded. Hence, in total,

117 reports, describing 89 unique studies, were deemed

relevant for the systematic review, with 20 studies each

described by more than one report and three reports describing

more than one unique study. There were 63 randomized

controlled trials (RCTs) and 26 observational studies across all

the key questions. Only one study required translation from

German to English.21 No studies were identified across all the

child outcomes (i.e., growth patterns, neurocognitive

development, and visual function) regarding the influence of

the intake of omega-3 fatty acids from sources other than

human milk, or infant formula, as well as the association

between omega-3 or omega-6/omega-3 fatty acids content of

fetal biomarkers and any of the clinical outcomes. Synopses of

evidence are presented according to the clinical outcomes by

population.

Safety Issues

Overall, omega-3 fatty acids supplementation in pregnant

women, breastfeeding mothers, and preterm and term infants,

was very well tolerated and did not generate any serious adverse

events across the included RCTs. The safety data was reported

in 21 RCTs. In pregnant women, the adverse events related to

the omega-3 fatty acids intake were mild and transient, with

nausea and gastrointestinal discomfort being the most

commonly reported.22,23 For both term and preterm

populations, change in number of stools and flatulence were

the most common adverse events related to the omega-3

supplemented formulas. However, most of the serious harms

were related to the fact that the infants were premature with

low birth weights, which increases the occurrence of necrotizing

enterocolitis (NEC), bleeding problems, infections and

respiratory failure, among others in the case of preterm

infants.24-43 None of the withdrawals were due to the

interventional formula.

Pregnancy Outcomes

Duration of gestation-intake during pregnancy: Fifteen

poor quality RCTs addressed this question.11,44-51,59 Seven trials

included otherwise healthy pregnant women,52-58 the remaining

eight studies included a high-risk population of pregnant

3
4

women. Ten studies did not find a significant difference

between intervention groups in the duration of gestation

measured as mean of gestational age at delivery.22,23,53-58 Four

poor quality studies observed that the omega-3 fatty acids

group had a significantly greater duration of gestation after

treatment compared with the unsupplemented group.22,52

Omega-3 fatty acids did not have a significant effect on the

proportion of premature deliveries in ten studies.11,23,52,55,59 Fish

consumption in the background diet was used as a covariate in

only one trial.52 Other covariates used to control the results

were: the compliance with the intervention,52 current smoking

status,23,55 maternal BMI, and number of prior pregnancies.55

The only variable that had an impact on the results was the

smoking status in Smuts et al.’s study.55 The duration of

gestation was significantly longer in the high-DHA group in

the nonsmokers.55

Meta-analysis of the incidence of premature deliveries was

performed from eight RCTs that used capsules containing

DHA+EPA (OR: 0.88 [95% CI: 0.62-1.25]),11,44,49 and two

trials using high DHA eggs (OR: 0.53 [95% CI: 0.13-2.29])47,50

or control group. There is inconsistent evidence of the use of

omega-3 fatty acids supplements during the second or third

trimester of pregnancy to reduce the incidence of premature

pregnancies in high- and low-risk populations. Nevertheless,

the overall effect does not show a significant difference between

study arms.

Duration of gestation-maternal biomarkers: Nothing

conclusive can be drawn from four studies that assessed this

association.55,60-62

Incidence of gestational hypertension (GHT),

preeclampsia, or eclampsia-intake during pregnancy: Of

eight RCTs with a quality score approaching good internal

validity,22,23,52,63,64 six trials compared the use of fish oil

supplements containing DHA and EPA with placebo. The

population included healthy or high-risk pregnant women (i.e.,

twin pregnancy).22,23,63,64 The incidence of GHT in these

populations, after the use of omega-3 fatty acids or placebo did

not differ in six studies.22,23,52,59,63 Regarding the incidence of

preeclampsia (hypertension, edema, and proteinuria), six

studies showed that compared with placebo, supplementation

with omega-3 fatty acids did not have a significant

effect.22,23,55,59,63 Meta-analysis of the incidence of gestational

hypertension from two studies revealed a nonsignificant

difference between groups (OR: 1.07, CI 95%: 0.75; 1.51).22,23

These findings were not adjusted for the potential covariates or

confounders, such as background diet, grade of risk for GHT

or preeclampsia in the current pregnancy, smoking status, and

age.

Incidence of preeclampsia-eclampsia or gestational

hypertension-maternal biomarkers: Five observational studies

were identified,21,65-68 of which four selected preeclamptic

women and normal pregnant women as controls.21,66-68 The

results are very inconsistent across the studies. 

Incidence of SGA infants- intake during pregnancy:

Fourteen poor quality score RCTs showed that in the majority

of the studies, the mean birth weight was not influenced by the

intervention. None of the trials adjusted their results for the

maternal background diet, which can be an important effect

modifier. 

Meta-analysis of the birth weight (mean) was combined in

two studies that were comparable in terms of type of

intervention and population (weight mean difference: -61.51,

CI 95%: -256.21; 133.18) showing a nonsignificantly

difference between groups.23 The incidence of infants with

IUGR showed a nonsignificant effect (OR: 1.14, CI 95%:

0.79; 1.64)22,23,59 of supplementation during pregnancy. 

Incidence of SGA infants-maternal biomarker: Six

studies addressed this question.58,60,61,69-71 de Groot et al.’s RCT

found a significantly positive correlation between the maternal

plasma and RBC DHA content and birth weight; however, this

relationship was nonsignificant when measured at delivery.58

Two observational studies found that the women with IUGR

fetuses had a significantly lower content of LA (omega-6) in the

plasma.69,71 The content of DHA, EPA, AA, total omega-3 and

omega-6 fatty acids, however, did not show a constant pattern

across the studies. Two observational studies did not observe a

correlation between maternal plasma biomarkers and birth

weight,61,69 consistent with the result in the RCT.58

Growth Pattern Outcomes

Maternal intake during pregnancy: One good quality

RCT addressed this question,54 showing no statistical difference

between infants (n=590 enrolled, 341 completers) from

mothers that were taking the supplementation with omega-3

and omega-6, or omega-6 fatty acids predominantly, on the

weight, length, and head circumference (HC) from birth to 12

months of age.54

Maternal breast milk: One good quality RCT evaluating

omega-3 supplementation in Norwegian mothers,54 one poor

quality RCT,72 and two observational studies were identified.73,74

Both RCTs showed no apparent effects of breast milk, with

maternal intake of omega-3 (DHA) or omega-6 fatty acids

(AA), on the growth patterns at any time point.54,72 The single

prospective cohort of Swedish mother/term infant pairs

showed a positive correlation between the maternal mother’s

breast milk content of AA/DHA and the infant’s rate of

increase of HC at 1 and 3 months of age.74 A cross-sectional
study from Africa showed that the differences in weight-for-age

and weight-for-height z-scores and weight gain (g) were

significantly lower in infants from Ouagadougou (low omega-3

fatty acids intake) compared with infants from Brazzaville (high

omega-3 intake).73

Formula intake, preterm infants: Twenty RCTs of poor

quality were identified,25-32,34,75-85 of which eighteen failed to find

an effect of the omega-3 supplementation in preterm formulas

on the growth parameters at any time point.25-30,32,34,75-84 The

outcomes measured were the mean (SD) and gain in weight,

length, and HC and the normalized z-score of weight. Two

trials found that the omega-3 fatty acids supplemented group

had a significantly lower weight from 6 to 18 months.31,85 The

results of the meta-analysis performed on the mean weight and

length measured at 4 months, from studies that compared the

use of formula supplemented with DHA+AA with control,

showed that the overall effect was nonstatistically significant

(weight: WMD: 0.04, CI 95%: -0.30; 0.38; length: WMD:

0.09, CI 95%: -0.62; 0.80).28,29

Formula intake, term infants: Eighteen good quality

RCTs were identified.35-43,86-93 The effects on the growth

outcomes were nonstatistically different between study arms.

Yet, some inconsistent differences were found across five trials

at certain timepoints and subgroup of patients.94-98 Metaanalysis demonstrated a nonstatistically significant overall effect

of formulas containing DHA+AA compared with control

formula at 4 or 12 months of age for the growth parameters 

(4 months: weight: WMD: -0.06, CI 95%: -0.45; 0.34;

length: WMD: -0.33, CI 95%: -1.07; 0.40; 12 months:

weight: WMD: -0.33, CI 95%: -0.87; 0.21; length: WMD: -

0.37, CI 95%: -1.26; 0.51; HC: WMD: 0.14, CI 95%: -0.83;

1.12) or DHA (4 months: weight: WMD: -0.12, CI 95%: -

0.44; 0.20; length: WMD: -0.43, CI 95%: -1.20; 0.34; HC:

WMD: 0.04, CI 95%: -0.37; 0.46. 12 months: weight:

WMD: -0.33, CI 95%: -0.87; 0.21; length: WMD: -0.71, CI

95%: -2.18; 0.76; HC: WMD: -0.04, CI 95%: -0.45; 0.38)

36,39 Only four trials adjusted the results for potential

confounders, such as gender, maternal education, parental

socioeconomic status and center, failing to find any change in

the results.39,41,43,88

Child biomarkers: Five were RCTs in preterm

infants,25,28,29,76,85 and five RCTs39,43,87,88,99 and a prospective single

cohort

100 in term infants. 

There is a negative correlation between weight and the

plasma or RBC content of DHA, and a positive correlation

between weight and the content of AA in plasma or RBC.

However, not all of the studies found this association. The

content of omega-6 fatty acids (AA) as a biomarker may be

related to weight gain in infants. The content of DHA seems

to be inversely related to weight gain, yet no significant clinical

outcomes were detected. 

Neurological Development Outcomes

Maternal intake during pregnancy: Helland et al. failed

to find a significant difference between groups in maturity as

evaluated from the EEGs, neither at day 1 of life nor at 

3 months of age.54

Maternal breast milk: Two studies, one RCT101 and one

single prospective cohort design102 showed that maternal breast

milk may not have an influence on the neurological outcome,

measured with the PDI scale of the Bayley’s Index.

Formula intake, preterm infants: Six good quality RCTs

were identified.28,30,31,34,82,103 For the Bayley’s PDI scale, two trials

did not observe a significant difference between the

supplemented and the control formula.31,34 Meta-analysis was

not possible for this outcome. Only Fewtrell et al. found that

there was no difference between groups in the neurological

impairment assessment at 9 and 18 months of corrected age

(CA), and in the Knobloch, Passamanick, and Sherrards’

Developmental Screening Inventory score.34 There is not

consistent evidence to suggest that the omega-3 fatty acids

supplementation of infant formula, with or without breast

milk, influences the neurological development in preterm

infants. 

Formula intake, term infants: Eight good quality RCTs,36-

39,42,43,104 of which seven failed to find a statistically significant

difference between diet groups at different follow-ups (6 to 24

months of age) in the Bayley’s PDI scale.36-39,42,43 One trial

showed a significantly better Brunet-Lézine test result in the LC

PUFAs supplemented group compared with control at 4

months of age (after exclusive formula intake) but not at 24

months.104 Meta-analysis of Bayley’s PDI score showed a

nonstatistically significant difference between groups using

formula supplemented with DHA+AA and control (WMD: -

2.80, CI 95%: -7.43; 1.82) at 12 months. 36,39,42

Maternal biomarkers: One cross-sectional study showed

that maternal DHA was negatively associated with active sleep

(AS), AS:QS (quiet sleep) and sleep-wake transition, and

positively associated with wakefulness (postpartum day 2).105

The ratio of n-6:n-3 in maternal plasma was positively

associated with AS, AS:QS and sleep-wake transition, and

negatively associated with wakefulness (day 2), suggesting a

greater CNS maturity. 

Child biomarkers: Three RCTs37,39,43 and a prospective

cohort study100 evaluated the association between the infant’s

plasma and RBC DHA content and the Bayley’s psychomotor

developmental index (PDI) score in healthy term infants. Two

RCTs found a significant positive correlation between the

5
plasma DHA and the PDI score.39,43 Two other studies

(including the observational study), did not find a significant

correlation between the PDI and the infant content of PUfatty

acids in plasma or RBC.37,100

Visual Function Outcomes

Maternal intake during pregnancy: One RCT failed to

find a significant effect of DHA supplementation during

pregnancy on the retinal sensitivity (ERG) measured at birth in

term infants.51 One cross-sectional study failed to find a

statistically significant difference in mean visual function values

between the exclusively breastfed group and the infants who

were also receiving formula.106

Maternal breast milk: Five studies found that the

correlation between the DHA content in breast milk and visual

function was not consistent with the clinical outcomes

measured in breastfed term infants of mothers who were or

were not taking supplements containing high DHA.72,101,106-108

Formula intake, preterm infants: Nine RCTs with a

quality score approaching good internal validity were

identified.25,26,28,29,76,77,82,85,103 Of five studies that measured visual

evoked potentials (VEP), two did not find a statistical

difference between feeding groups at any time point (from 1 to

12 months).82,103 Three studies found that compared with the

unsupplemented group, infants fed with LC PUFAssupplemented formula had a better or faster maturation of

visual function, in terms of significantly shorter waves in the

VEP.

25,28,77 Two studies found a significant difference between

groups in the Teller’s Acuity Card test.85 Meta-analysis of the

relevant visual outcomes comparing the studies by the type of

omega-3 fatty acids used in the supplemented formula (DHA

or DHA+AA) and control formula, and by the type of outcome

(VEP and Teller’s test of visual acuity) was done. For the VEP

visual acuity outcomes, only two studies were combined.25,28

O’Connor et al. found that the use of formulas with DHA+AA

resulted in a better VEP measurements compared with control

formula at 6 months of age yet not at 4 months.25,28

No significant effect of DHA-supplementation at 2, 4, 6, or

9 months of CA,29,76 or DHA+AA supplementation at 2, 3, 4,

or 6 months of CA was found in the visual acuity measured

with the Teller’s Card test.25,28,29,85,103

Formula intake, term infants: Thirteen RCTs, of average

good quality (Jadad: 3.61/5) were identified,36,37,39,41-43,88,89,91,93,109,110

of which five trials did not find a significant difference between

groups in the VEP at any age.36,39,41,43,89 Four trials found a

significantly better VEP in the LC PUFAs-supplemented group

compared with the control group at a number of time points,

from 1.5 to 13 months of age.37,87,91,93 The meta-analysis

performed on this outcome, by LC PUFAs content of DHA

alone (or with the addition of AA), versus control, showed that

the studies that compared DHA supplemented formula with

control formula did not have an overall significant effect at any

age.36,37,39 Conversely, in seven studies that compared the use of

DHA+AA formula with placebo, there was no difference

between groups at any age,36,37,39,87,89,91,93 with the exception of

four studies that found a significant difference at 12 months of

age.36,37,91,93

One trial that evaluated behavioral visual acuity with the

Teller’s test,110 found a significantly better acuity in the LC

PUFAs formula group compared with the control group at 2

months of age, yet not at 4, 6, 9, or 12 months. The

remaining four trials did not observe a significant difference

between groups in this outcome, at any time point.36,42,88 The

meta-analysis performed on this outcome showed that, in

studies comparing the use of DHA+AA with a control

intervention, acuity was only significantly better in the

DHA+AA group at 2 months of age,36,37,110 but not at 4, 6, 9, or

12 months of age.

Maternal biomarkers: One study measured the association

between the maternal content of biomarkers at 2 months

postpartum and the visual acuity (Teller’s Card Test) in term

infants at 2 months of age that failed to find a significant

correlation.106

Child biomarkers: Twenty-one studies assessed this

association. Of five studies in the preterm group, three were

RCTs,25,76,77 and two were cross-sectional studies.111,112 Of the 16

term infant studies, nine were RCTs,37,43,72,87-89,91,93,101 and seven

were observational studies.100,106,107,111,113-115 There was no pattern

of correlation between the infant’s biomarkers in blood and the

visual function outcomes across 21 studies that addressed this

issue.

Cognitive Development Outcomes

Maternal intake during pregnancy: One RCT addressed

this question.54 There were no differences between groups in

the novelty preference (Fagan Test of Infant Intelligence) at 6

and 9 months of age.54

Maternal breast milk: Two RCTs54,101 and one prospective

cohort

102 were identified. The study by Helland et al. was an

RCT described above,54 and Gibson et al. included mother of

term infants who intended to breastfeed.101 They were

randomized to receive five increasing doses of DHA (algal oil)

during the first 3 months postpartum. The mean Bayley’s

Mental Developmental Index (MDI) score did not differ

between groups at 1 or 2 years of age (underpowered).101

Formula intake preterm infants: Six good quality (Jadad:

4.4/5) RCTs were identified.28,30,31,34,76,103 Four of the five trials

6
did not find an effect on the Bayley’s MDI score from 3 to 24

months of age.28,31,34,116 Two studies found a significant

difference between the omega-3 fatty acids group and the

control group in the Fagan Test of Infant Intelligence.28,76

O’Connor et al. found that there was no significant differences

between groups in the Infant version of the MacArthur

Communicative Development Inventories at 9 months CA and

14 months CA.28 Meta-analysis was not possible given the

heterogeneity across the studies for each of the different

outcomes due to the intervention characteristics (meaning dose,

source of omega-3 fatty acids, duration of intervention),

cointerventions, different assessment tools, and timing of the

outcomes measures. 

Formula intake term infants: Six (of eight) good quality

RCTs36-39,42,43,92 did not find a significant difference between

groups (supplemented vs. control) in the Bayley’s MDI score

from 6 to 18 months of age.36-39,42,43 Birch et al. observed that

the DHA+AA group had a significantly higher score compared

with the control group at 18 months of age.37

The Knobloch, Passamanik, and Sherrards Development

Screening Inventory test (9 months),117 and the Fagan Test of

Infant Intelligence (6 and 9 months )98 did not differ between

groups. The IQ (Stanford-Binet), Receptive Vocabulary (PPVTR), Expressive Vocabulary, and Visual-Motor Index scores, as

well as the Problem-Solving scores, did not differ between

groups in two studies.36,92

A meta-analysis using the Bayley’s MDI score at 12 months

of age showed a nonstatistical difference between groups

(DHA+AA vs. control) from three trials (WMD: -0.80, CI

95%: -3.24; 1.63).36,39,42

Child biomarkers: Four good quality RCTs and two single

prospective cohort studies100,118 showed inconsistent results.

Discussion

Studies investigating the influence of omega-3 fatty acids on

child and maternal health revealed the absence of a notable

safety profile (i.e., moderate-to-severe adverse events).

Pregnancy outcomes were either unaffected by omega-3 fatty

acids supplementation, or the results were inconclusive. Results

suggested the absence of effects with respect to the impact of

supplementation on the incidence of GHT, preeclampsia or

eclampsia, as well as on infants being born SGA. However,

regarding evaluations of the duration of gestation, some

discrepancies were observed, although most of the studies failed

to detect a statistically significant effect. Biomarker data failed

to clarify patterns in pregnancy outcome data.

Results concerning the impact of the intake of omega-3 fatty

acids on the development of infants are primarily, although not

uniformly, inconclusive. The inconsistencies in study results

may be attributable to numerous factors. 

In addition, making clear sense of the absolute or relative

effects of individual omega-3 fatty acids, or even omega-3 fatty

acids combinations, on child outcomes is complicated or

precluded by the following problem. Studies typically

employed interventions that involved various cointerventional

or background constituents (e.g., omega-6 fatty acids), yet

whose metabolic interactions with the omega-3 fatty acids were

not taken into account in interpreting the results. The

dynamic interplay among these fatty acid contents (e.g.,

competition for enzymes), and how this interplay may

influence outcomes, may differ in important ways depending

on whether DHA or olive oil is added to this combination of

cointerventional or background constituents, particularly in the

maternal population. This strategy prevented the isolation of

the exact effects relating to the omega-3 fatty acids content. It

is thus very difficult to reliably ascribe definite child outcomerelated benefits, or the absence thereof, to specific omega-3

fatty acids. Biomarker data failed to clarify patterns in child

outcome data.

Future research should likely consider investigating the

impact of specific omega-6/omega-3 fatty acids intake ratios, in

no small part to control for the possible metabolic interactions

involving these types of fatty acids. To produce results that are

applicable to the North American population, populations

consuming high omega-6/omega-3 fatty acids intake ratios

should likely be randomized into trials also exhibiting better

control of confounding variables than was observed, especially

in the present collection of studies of child outcomes.

Availability of the Full Report

The full evidence report from which this summary was taken

was prepared for the Agency for Healthcare Research and

Quality (AHRQ) by the University of Ottawa Evidence-based

Practice Center under Contract No. 290-02-0021. It is

expected to be available in August 2005. At that time, printed

copies may be obtained free of charge from the AHRQ

Publications Clearinghouse by calling 800-358-9295.

Requesters should ask for Evidence Report/Technology

Assessment No. 118, Effects of Omega-3 Fatty Acids on Child

and Maternal Health. In addition, Internet users will be able to

access the report and this summary online through AHRQ’s

Web site at www.ahrq.gov.

Suggested Citation

Lewin GA, Schachter HM, Yuen D, Merchant P,

Mamaladze V, Tsertsvadze A, et al. Effects of Omega-3 Fatty

7
8

Acids on Child and Maternal Health. Summary, Evidence

Report/Technology Assessment No. 118. (Prepared by the

University of Ottawa Evidence-based Practice Center under

Contract No. 290-02-0021.) AHRQ Publication No. 05-E025-

1. Rockville, MD: Agency for Healthcare Research and Quality.

August 2005.

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essentiality of docosahexaenoic acid and arachidonic acid in the diet

of term infants. Pediatr Res 1998; 44(2):201-209.

38. Lucas A, Stafford M, Morley R, et al. Efficacy and safety of longchain polyunsaturated fatty acid supplementation of infant-formula

milk: a randomised trial.[comment]. Lancet 1999; 354(9194):1948-

1954.

39. Makrides M, Neumann MA, Simmer K, et al. Dietary long-chain

polyunsaturated fatty acids do not influence growth of term infants:

A randomized clinical trial. Pediatrics 1999; 104(3 Pt 1):468-475.

40. Morris G, Moorcraft J, Mountjoy A, et al. A novel infant formula

milk with added long-chain polyunsaturated fatty acids from singlecell sources: a study of growth, satisfaction and health. Eur J Clin

Nutr 2000; 54(12):883-886.

41. Makrides M, Neumann MA, Jeffrey B, et al. A randomized trial of

different ratios of linoleic to alpha-linolenic acid in the diet of term

infants: effects on visual function and growth.[comment]. Am J

Clin Nutr 2000; 71(1):120-129.

42. Auestad N, Halter R, Hall RT, et al. Growth and development in

term infants fed long-chain polyunsaturated fatty acids: a doublemasked, randomized, parallel, prospective, multivariate study.

Pediatrics 2001; 108(2):372-381.

43. Jensen CL, Prager TC, Fraley JK, et al. Effect of dietary

linoleic/alpha-linolenic acid ratio on growth and visual function of

term infants.[comment]. J Pediatr 1997; 131(2):200-209.

44. Olsen SF, Sorensen JD, Secher NJ, et al. Randomised controlled

trial of effect of fish-oil supplementation on pregnancy

duration.[comment]. Lancet 1992; 339(8800):1003-1007.

45. Helland IB, Saugstad OD, Smith L, et al. Similar effects on infants

of n-3 and n-6 fatty acids supplementation to pregnant and

lactating women. Pediatrics 2001; 108(5):E82.

46. Dunstan JA, Mori TA, Barden A, et al. Effects of n-3

polyunsaturated fatty acid supplementation in pregnancy on

maternal and fetal erythrocyte fatty composition. Eur J Clin Nutr

2004; 58(3):429-437.

47. Smuts CM, Borod E, Peeples JM, et al. High-DHA eggs: feasibility

as a means to enhance circulating DHA in mother and infant.

Lipids 2003; 38(4):407-414.

48. de Groot RH, Hornstra G, van Houwelingen AC, et al. Effect of

alpha-linolenic acid supplementation during pregnancy on maternal

and neonatal polyunsaturated fatty acid status and pregnancy

outcome. Am J Clin Nutr 2004; 79(2):251-260.

49. Onwude JL, Lilford RJ, Hjartardottir H, et al. A randomised

double blind placebo controlled trial of fish oil in high risk

pregnancy. Br J Obstet Gynaecol 1995; 102(2):95-100.

50. Smuts CM, Huang M, Mundy D, et al. A randomized trial of

docosahexaenoic acid supplementation during the third trimester of

pregnancy. Obstet Gynecol 2003; 101(3):469-479.

51. Malcolm CA, Hamilton R, McCulloch DL, et al. Scotopic

electroretinogram in term infants born of mothers supplemented

with docosahexaenoic acid during pregnancy. Invest Ophthalmol

Vis Sci 2003; 44(8):3685-3691.

52. Olsen SF, Sorensen JD, Secher NJ, et al. Randomised controlled

trial of effect of fish-oil supplementation on pregnancy

duration.[comment]. Lancet 1992; 339(8800):1003-1007.

53. Dunstan JA, Mori TA, Barden A, et al. Effects of n-3

polyunsaturated fatty acid supplementation in pregnancy on

maternal and fetal erythrocyte fatty composition. Eur J Clin Nutr

2004; 58(3):429-437.

54. Helland IB, Saugstad OD, Smith L, et al. Similar effects on infants

of n-3 and n-6 fatty acids supplementation to pregnant and

lactating women. Pediatrics 2001; 108(5):E82.

55. Smuts CM, Huang M, Mundy D, et al. A randomized trial of

docosahexaenoic acid supplementation during the third trimester of

pregnancy. Obstet Gynecol 2003; 101(3):469-479.

56. Malcolm CA, Hamilton R, McCulloch DL, et al. Scotopic

electroretinogram in term infants born of mothers supplemented

with docosahexaenoic acid during pregnancy. Invest Ophthalmol

Vis Sci 2003; 44(8):3685-3691.

57. Smuts CM, Borod E, Peeples JM, et al. High-DHA eggs: feasibility

as a means to enhance circulating DHA in mother and infant.

Lipids 2003; 38(4):407-414.

58. de Groot RH, Hornstra G, van Houwelingen AC, et al. Effect of

alpha-linolenic acid supplementation during pregnancy on maternal

and neonatal polyunsaturated fatty acid status and pregnancy

outcome. Am J Clin Nutr 2004; 79(2):251-260.

59. Bulstra-Ramakers MT, Huisjes HJ, Visser GH. The effects of 3g

eicosapentaenoic acid daily on recurrence of intrauterine growth

retardation and pregnancy induced hypertension. Br J Obstet

Gynaecol 1995; 102(2):123-126.

60. Elias SL, Innis SM. Infant plasma trans, n-6, and n-3 fatty acids and

conjugated linoleic acids are related to maternal plasma fatty acids,

length of gestation, and birth weight and length.[comment]. Am J

Clin Nutr 2001; 73(4):807-814.

61. Rump P, Mensink RP, Kester AD, et al. Essential fatty acid

composition of plasma phospholipids and birth weight: a study in

term neonates.[comment]. Am J Clin Nutr 2001; 73(4):797-806.

62. Reece MS, McGregor JA, Allen KG, et al. Maternal and perinatal

long-chain fatty acids: possible roles in preterm birth.[comment].

Am J Obstet Gynecol 1997; 176(4):907-914.

63. Laivuori H, Hovatta O, Viinikka L, et al. Dietary supplementation

with primrose oil or fish oil does not change urinary excretion of

9
prostacyclin and thromboxane metabolites in pre-eclamptic women.

Prostaglandins Leukot Essent Fatty Acids 1993; 49(3):691-694.

64. D’Almeida A, Carter JP, Anatol A, et al. Effects of a combination of

evening primrose oil (gamma linolenic acid) and fish oil

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versus placebo in preventing pre-eclampsia. Women Health 1992;

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65. Al MD, van Houwelingen AC, Badart-Smook A, et al. The essential

fatty acid status of mother and child in pregnancy-induced

hypertension: a prospective longitudinal study. Am J Obstet

Gynecol 1995; 172(5):1605-1614.

66. Craig-Schmidt MC, Carlson SE, Crocker L, et al. Plasma total

phospholipid arachidonic acid and eicosapentaenoic acid in normal

and hypertensive pregnancy. World Rev Nutr Diet 1994; 76:126-

129.

67. Shouk TA, Omar MN, Fayed ST. Essential fatty acids profile and

lipid peroxides in severe pre-eclampsia. Ann Clin Biochem 1999;

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68. Wang YP, Kay HH, Killam AP. Decreased levels of polyunsaturated

fatty acids in preeclampsia.[comment]. Am J Obstet Gynecol 1991;

164(3):812-818.

69. Vilbergsson G, Samsioe G, Wennergren M, et al. Essential fatty

acids in pregnancies complicated by intrauterine growth retardation.

Int J Gynaecol Obstet 1991; 36(4):277-286.

70. Matorras R, Perteagudo L, Nieto A, et al. Intrauterine growth

retardation and plasma fatty acids in the mother and the fetus. Eur J

Obstet Gynecol Reprod Biol 1994; 57(3):189-193.

71. Cetin I, Giovannini N, Alvino G, et al. Intrauterine growth

restriction is associated with changes in polyunsaturated fatty acid

fetal-maternal relationships. Pediatr Res 2002; 52(5):750-755.

72. Jensen CL, Prager TC, Zou Y, et al. Effects of maternal

docosahexaenoic acid supplementation on visual function and

growth of breast-fed term infants. Lipids 1999; 34(Suppl):S225.

73. Rocquelin G, Tapsoba S, Kiffer J, et al. Human milk fatty acids and

growth of infants in Brazzaville (The Congo) and Ouagadougou

(Burkina Faso). Public Health Nutr 2003; 6(3):241-248.

74. Xiang M, Alfven G, Blennow M, et al. Long-chain polyunsaturated

fatty acids in human milk and brain growth during early infancy.

Acta Paediatr 2000; 89(2):142-147.

75. Carlson SE, Rhodes PG, Rao VS, et al. Effect of fish oil

supplementation on the n-3 fatty acid content of red blood cell

membranes in preterm infants. Pediatr Res 1987; 21(5):507-510.

76. Carlson SE, Cooke RJ, Werkman SH, et al. First year growth of

preterm infants fed standard compared to marine oil n-3

supplemented formula. Lipids 1992; 27(11):901-907.

77. Faldella G, Govoni M, Alessandroni R, et al. Visual evoked

potentials and dietary long chain polyunsaturated fatty acids in

preterm infants. Arch Dis Child Fetal Neonatal Ed 1996;

75(2):F108-F112.

78. Lapillonne A, Picaud JC, Chirouze V, et al. Supplementation of

preterm formulas (PTF) with a low EPA fish oil: Effect on

polyunsaturated fatty acids(PUfatty acidsS) status and growth. J

Pediatr Gastroenterol Nutr 1997; 24(4).

79. Woltil HA, van Beusekom CM, Okken-Beukens M, et al.

Development of low-birthweight infants at 19 months of age

correlates with early intake and status of long-chain polyunsaturated

fatty acids. Prostaglandins Leukot Essent Fatty Acids 1999;

61(4):235-241.

80. Martinez FE, Santos MMd, Sieber VM, et al. Growth and nitrogen

balance in preterm infants fed formula with long chain

polyunsaturated fatty acids. Nutr Res 1999; 19(10):1497-1505.

81. Ghebremeskel K, Burns L, Costeloe K, et al. Plasma vitamin A and

E in preterm babies fed on breast milk or formula milk with or

without long-chain polyunsaturated fatty acids. Int J Vitam Nutr

Res 1999; 69(2):83-91.

82. Bougle D, Denise P, Vimard F, et al. Early neurological and

neuropsychological development of the preterm infant and

polyunsaturated fatty acids supply. Clin Neurophysiol 1999;

110(8):1363-1370.

83. Boue C, Combe N, Billeaud C, et al. Nutritional implications of

trans fatty acids during perinatal period, in French pregnant women.

Lipids, fats and oils: opportunities and responsibilities in the New

Century 2001; 8(1):68-72.

84. Groh-Wargo S, Moore JJ, Catalano P, et al. Docosahexaenoic acid

(DHA) and arachidonic acid (AA) supplementation does not change

body composition in preterm (PT) infants. Pediatr Res 2002;

51(4):380A.

85. Carlson SE, Werkman SH, Tolley EA. Effect of long-chain n-3 fatty

acid supplementation on visual acuity and growth of preterm infants

with and without bronchopulmonary dysplasia. Am J Clin Nutr

1996; 63(5):687-697.

86. Ponder DL, Innis SM, Benson JD, et al. Docosahexaenoic acid

status of term infants fed breast milk or infant formula containing

soy oil or corn oil. Pediatr Res 1992; 32(6):683-688.

87. Makrides M, Neumann M, Simmer K, et al. Are long-chain

polyunsaturated fatty acids essential nutrients in infancy?[comment].

Lancet 1995; 345(8963):1463-1468.

88. Innis SM, Akrabawi SS, Diersen-Schade DA, et al. Visual acuity

and blood lipids in term infants fed human milk or

formulae.[erratum appears in Lipids 1997 Apr;32(4):457]. Lipids

1997; 32(1):63-72.

89. Jorgensen MH, Holmer G, Lund P, et al. Effect of formula

supplemented with docosahexaenoic acid and gamma- linolenic acid

on fatty acid status and visual acuity in term infants. J Pediatr

Gastroenterol Nutr 1998; 26(4):412-421.

90. Lapillonne A. Erythrocyte fatty acid composition in term infants fed

human milk or a formula enriched with a low eicosapentanoic acid

fish oil for 4 months. Eur J Pediatr 2000; 159(1-2):49-53.

91. Birch EE, Hoffman DR, Castaneda YS, et al. A randomized

controlled trial of long-chain polyunsaturated fatty acid

supplementation of formula in term infants after weaning at 6 wk of

age. Am J Clin Nutr 2002; 75(3):570-580.

92. Willatts P, Forsyth JS, DiModugno MK, et al. Effect of long-chain

polyunsaturated fatty acids in infant formula on problem solving at

10 months of age. Lancet British edition 1998; 352(9129):688-691.

93. Hoffman DR, Birch EE, Castaneda YS, et al. Visual function in

breast-fed term infants weaned to formula with or without longchain polyunsaturates at 4 to 6 months: a randomized clinical trial. J

Pediatr 2003; 142(6):669-677.

94. Jensen CL, Prager TC, Fraley JK, et al. Effect of dietary

linoleic/alpha-linolenic acid ratio on growth and visual function of

term infants.[comment]. J Pediatr 1997; 131(2):200-209.

10
95. Makrides M, Neumann MA, Jeffrey B, et al. A randomized trial of

different ratios of linoleic to alpha-linolenic acid in the diet of term

infants: effects on visual function and growth.[comment]. Am J

Clin Nutr 2000; 71(1):120-129.

96. Lapillonne A. Erythrocyte fatty acid composition in term infants fed

human milk or a formula enriched with a low eicosapentanoic acid

fish oil for 4 months. Eur J Pediatr 2000; 159(1-2):49-53.

97. Morris G, Moorcraft J, Mountjoy A, et al. A novel infant formula

milk with added long-chain polyunsaturated fatty acids from singlecell sources: a study of growth, satisfaction and health. Eur J Clin

Nutr 2000; 54(12):883-886.

98. Auestad N, Halter R, Hall RT, et al. Growth and development in

term infants fed long-chain polyunsaturated fatty acids: a doublemasked, randomized, parallel, prospective, multivariate study.

Pediatrics 2001; 108(2):372-381.

99. Guesnet P. Blood lipid concentrations of docosahexaenoic and

arachidonic acids at birth determine their relative postnatal changes

in term infants fed breast milk or formula.[comment]. Am J Clin

Nutr 1999; 70(2):292-298.

100. Innis SM, Gilley J, Werker J. Are human milk long-chain

polyunsaturated fatty acids related to visual and neural development

in breast-fed term infants? J Pediatr 2001; 139(4):532-538.

101. Gibson RA, Neumann MA, Makrides M. Effect of increasing breast

milk docosahexaenoic acid on plasma and erythrocyte phospholipid

fatty acids and neural indices of exclusively breast fed infants. Eur J

Clin Nutr 1997; 51(9):578-584.

102. Agostoni C, Marangoni F, Giovannini M, et al. Prolonged breastfeeding (six months or more) and milk fat content at six months are

associated with higher developmental scores at one year of age

within a breast-fed population. Adv Exp Med Biol 2001; 501:137-

141.

103. Wezel-Meijler G, van der Knaap MS, Huisman J, et al. Dietary

supplementation of long-chain polyunsaturated fatty acids in

preterm infants: effects on cerebral maturation. Acta Paediatr 2002;

91(9):942-950.

104. Agostoni C, Trojan S, Bellu R, et al. Neurodevelopmental quotient

of healthy term infants at 4 months and feeding practice: the role of

long-chain polyunsaturated fatty acids. Pediatr Res 1995; 38(2):262-

266.

105. Cheruku SR, Montgomery-Downs HE, Farkas SL, et al. Higher

maternal plasma docosahexaenoic acid during pregnancy is

associated with more mature neonatal sleep-state patterning. Am J

Clin Nutr 2002; 76(3):608-613.

106. Krasevec JM, Jones PJ, Cabrera-Hernandez A, et al. Maternal and

infant essential fatty acid status in Havana, Cuba. Am J Clin Nutr

2002; 76(4):834-844.

107. Jorgensen MH, Hernell O, Hughes EL, et al. Is there a relation

between docosahexaenoic acid concentration in mothers’ milk and

visual development in term infants? J Pediatr Gastroenterol Nutr

2001; 32(3):293-296.

108. Williams C, Birch EE, Emmett PM, et al. Stereoacuity at age 3.5 y

in children born full-term is associated with prenatal and postnatal

dietary factors: a report from a population-based cohort study. Am J

Clin Nutr 2001; 73(2):316-322.

109. Baker PN. Possible dietary measures in the prevention of preeclampsia and eclampsia. [Review] [73 refs]. Baillieres Clin Obstet

Gynaecol 1995; 9(3):497-507.

110. Carlson SE, Ford AJ, Werkman SH, et al. Visual acuity and fatty

acid status of term infants fed human milk and formulas with and

without docosahexaenoate and arachidonate from egg yolk lecithin.

Pediatr Res 1996; 39(5):882-888.

111. Birch E, Birch D, Hoffman D, et al. Breast-feeding and optimal

visual development. J Pediatr Ophthalmol Strabismus 1993;

30(1):33-38.

112. Leaf A, Gosbell A, McKenzie L, et al. Long chain polyunsaturated

fatty acids and visual function in preterm infants. Early Hum Dev

1996; 45(1-2):35-53.

113. Makrides M, Simmer K, Goggin M, et al. Erythrocyte

docosahexaenoic acid correlates with the visual response of healthy,

term infants. Pediatr Res 1993; 33(4 Pt 1):425-427.

114. Innis SM, Nelson CM, Rioux MF, et al. Development of visual

acuity in relation to plasma and erythrocyte omega-6 and omega-3

fatty acids in healthy term gestation infants. Am J Clin Nutr 1994;

60(3):347-352.

115. Jorgensen MH, Hernell O, Lund P, et al. Visual acuity and

erythrocyte docosahexaenoic acid status in breast-fed and formulafed term infants during the first four months of life. Lipids 1996;

31(1):99-105.

116. Su HM, Huang MC, Saad NM, et al. Fetal baboons convert 18:3n3 to 22:6n-3 in vivo. A stable isotope tracer study. J Lipid Res 2001;

42(4):581-586.

117. Lucas A, Stafford M, Morley R, et al. Efficacy and safety of longchain polyunsaturated fatty acid supplementation of infant-formula

milk: a randomised trial.[comment]. Lancet 1999; 354(9194):1948-

1954.

118. Ghys A, Bakker E, Hornstra G, et al. Red blood cell and plasma

phospholipid arachidonic and docosahexaenoic acid levels at birth

and cognitive development at 4 years of age. Early Hum Dev 2002;

69(1-2):83-90.

11
www.ahrq.gov

AHRQ Pub. No. 05-E025-1

August 2005

ISSN 1530-440X
3

Chapter 1. Introduction 

This evidence report by the University of Ottawa’s Evidence-Based Practice Center (EPC) 

concerning the effects of omega-3 fatty acids on child and maternal health is one among several 

that address topics related to omega-3 fatty acids that were requested and funded by the Office of 

Dietary Supplements, National Institutes of Health (NIH), through the EPC program at the 

Agency for Healthcare Research and Quality (AHRQ). Three EPCs—the Tufts-New England 

Medical Center (Tufts-NEMC) EPC, the Southern California-RAND (SC-RAND) EPC, and the 

University of Ottawa EPC (UO-EPC)—each produced evidence reports. To ensure consistency 

of approach, the three EPCs collaborated on selected methodological elements, including 

literature search strategies, rating of evidence, and data table design. 

The aim of these reports is to summarize the current evidence concerning the health effects 

of omega-3 fatty acids on the following: cardiovascular diseases, cancer, child and maternal 

health, eye health, gastrointestinal/renal diseases, asthma, autoimmune diseases, immunemediated diseases, transplantation, mental health, and, neurological diseases and conditions. In 

addition to informing the research community and the public on the effects of omega-3 fatty 

acids on various health conditions, it is anticipated that the findings of the reports will also be 

used to help define the agenda for future research. 

The focus of this report is on child and maternal health outcomes in humans. In this chapter, 

the metabolism, physiological functions, and sources of omega-3 fatty acids are briefly 

discussed. This constitutes background material, putting in context the data presented in the 

evidence report. As well, the description of the U.S. population intake of omega-3 fatty acids is 

provided in response to a general question posed within the task order. This introductory 

material is then complemented by a brief review of the epidemiology and descriptions of the 

child and maternal health issues related to this intervention. The brief review is intended as an 

overview, rather than a comprehensive description. 

Chapter 2 describes the methods used to identify, review and synthesize the results from 

studies concerning omega-3 fatty acids and child and maternal health. Chapter 3 presents the 

findings of studies meeting eligibility criteria, with discussion points, including 

recommendations for future research completing the report in Chapter 4. 

Metabolism and Biological Effects of Essential Fatty Acids 

Dietary fat is an important source of energy for biological activities in human beings. It 

encompasses saturated fatty acids, which are usually solid at room temperature, and unsaturated 

fatty acids, which are liquid at room temperature. Unsaturated fatty acids can be further divided 

into monounsaturated and polyunsaturated fatty acids. Polyunsaturated fatty acids (or PUFAs) 

can be classified, on the basis of their chemical structure, into two groups: omega-3 (n-3) fatty 

acids and omega-6 (n-6) fatty acids. The omega-3 or n-3 notation means that the first double 

bond in this family of PUFAs is 3 carbons from the methyl end of the molecule. The same 
4

principle applies to the omega-6 or n-6 notation. Despite their differences in structure, all fats 

contain the same amount of energy (i.e., 9 kcal/g or 37 kJ/g). 

Of all fats found in food, two—alpha-linolenic acid (chemical abbreviation: ALA; 18:3 n-3) 

and linoleic acid (LA; 18:2 n-6)—cannot be synthesized in the human body, yet these are 

necessary for proper physiological functioning. These two fats are thus called “essential fatty 

acids.” The essential fatty acids can be converted in the liver to long-chain polyunsaturated fatty 

acids (LC PUFAs), which have a higher number of carbon atoms and double bonds. These LC 

PUFAs retain the omega type (n-3 or n-6) of the parent essential fatty acids. 

ALA and LA comprise the bulk of the total PUFAs consumed in a typical North American 

diet. Typically, LA comprises 89% of the total PUFAs consumed, while ALA comprises 9%. 

Smaller amounts of other PUFAs make up the remainder.1

 Both ALA and LA are present in a 

variety of foods. For example, LA is present in high concentrations in many commonly used 

oils, including safflower, sunflower, soy, and corn oil. ALA, which is consumed in smaller 

quantities, is present in leafy green vegetables and in some commonly used oils, including canola 

and soybean oil. Some novelty oils, such as flaxseed oil, contain relatively high concentrations 

of ALA, but these oils are not commonly found in the food supply. 

The Institute of Medicine (IOM) suggests that, for adults 19 and older, an adequate intake 

(AI) of ALA is 1.1-1.6 grams/day, and 11-17 grams/day for LA.2 Recommendations regarding 

AI differ by age and gender groups, and for special conditions such as pregnancy and lactation. 

As shown in Figure 1, eicosapentaenoic acid (EPA; 20:5 n-3) and docosahexaenoic acid 

(DHA; 22:6 n-3) can act as competitors for the same metabolic pathways as arachidonic acid 

(AA; 20:4 n-6). In human studies, the analyses of fatty-acid compositions in both blood 

phospholipids and adipose tissue have shown a similar competitive relationship between omega3 LC PUFAs and AA. General scientific agreement supports an increased consumption of 

omega-3 fatty acids and reduced intake of omega-6 fatty acids to promote good health. 

However, for omega-3 fatty acid intake, the specific quantitative recommendations vary widely 

among countries not only in terms of different units — ratio, grams, total energy intake — but 

also in quantity.3

Furthermore, there remain numerous questions relating to the inherent complexities 

concerning omega-3 and omega-6 fatty acid metabolism, in particular the relationships between 

the two fatty acids. For example, it remains unclear to what extent ALA is converted to EPA and 

DHA in humans, and to what extent the high intake of omega-6 fatty acids compromises any 

benefits of omega-3 fatty acid consumption. Without the resolution of these two fundamental 

questions, it remains difficult to study the importance of the omega-6/omega-3 fatty acid ratio. 

Metabolic Pathways of Omega-3 and Omega-6 Fatty Acids 

Omega-3 and omega-6 fatty acids share the same pools of enzymes and go through the same 

oxidation pathways while being metabolized (Figure 1). Once ingested, the parent of the omega3 fatty acids, ALA, and the parent of the omega-6 fatty acids, LA, can be elongated and 

desaturated into LC PUFAs. LA is converted into gamma-linolenic acid (GLA; 18:3 n-6), an 
5

omega-6 fatty acid that is a positional isomer of ALA. GLA, in turn, can be converted to the 

long-chain omega-6 fatty acid, AA, while ALA can be converted, to a lesser extent, to the longchain omega-3 fatty acids, EPA and DHA. However, the conversion from parent fatty acids into 

LC PUFAs occurs slowly in humans, and conversion rates are not well understood. Because of 

the slow rate of conversion, and the importance of LC PUFAs to many physiological processes, 

humans must augment their level of LC PUFAs by consuming foods rich in these important 

compounds. Meat is the primary food source of AA, and fish is the primary food source of EPA. 

The specific biological functions of fatty acids depend on the number and position of double 

bonds and the length of the acyl chain. Both EPA and AA are 20-carbon fatty acids and are 

precursors for the formation of prostaglandins (PGs), thromboxane (Tx), and leukotrienes 

(LTs)—hormone-like agents that are members of a larger family of substances called 

eicosanoids. Eicosanoids are localized tissue hormones that seem to be one of the fundamental 

regulatory classes of molecule in most higher forms of life. They do not travel in the blood, but 

are created in the cells to regulate a large number of processes, including the movement of 

calcium and other substances into and out of cells, dilation and contraction of muscles, inhibition 

and promotion of clotting, regulation of secretions including digestive juices and hormones, and, 

the control of fertility, cell division, and growth.4

 

As shown in Figure 1, the long-chain omega-6 fatty acid, AA, is the precursor of a group of 

eicosanoids including series-2 prostaglandins (PG2) and series-4 leukotrienes (LT4). The omega3 fatty acid, EPA, is the precursor to a group of eicosanoids including series-3 prostaglandins 

(PG3) and series-5 leukotrienes (LT5). The series-2 prostaglandins and series-4 leukotrienes 

derived from AA are involved in intense actions (such as accelerating platelet aggregation, and 

enhancing vasoconstriction and the synthesis of mediators of inflammation) in response to 

physiological stressors. The series-3 prostaglandins and series-5 leukotrienes derived from EPA 

are less physiologically potent than those derived from AA. More specifically, the series-3 

prostaglandins are formed at a slower rate and work to attenuate excessive series-2 

prostaglandins. Thus, adequate production of the series-3 prostaglandins, which are derived 

from the omega-3 fatty acid, EPA, may protect against heart attack and stroke as well as certain 

inflammatory diseases like arthritis, lupus, and asthma.4

 In addition, animal studies have 

demonstrated that omega-3 LC PUFAs, such as EPA and DHA, engage in multiple 

cytoprotective activities that may contribute to antiarrhythmic mechanisms.5

 Arrhythmias are 

thought to contribute to “sudden death” in heart disease. 

In addition to affecting eicosanoid production as described above, EPA also affects 

lipoprotein metabolism and decreases the production of other compounds—including cytokines, 

interleukin 1β (IL-1β), and tumor necrosis factor α (TNF-α)—which have pro-inflammatory 

effects. These compounds exert pro-inflammatory cellular actions that include stimulating the 

production of collagenase and increasing the expression of adhesion molecules necessary for 

leukocyte extravasation.6

 The mechanism responsible for the suppression of cytokine production 

by omega-3 LC PUFAs remains unknown, although suppression of eicosanoid production by 

omega-3 fatty acids may be involved. EPA can also be converted into the longer chain omega-3 

form of docosapentaenoic acid (DPA, 22:5 n-3), and then further elongated and oxygenated into 

DHA. EPA and DHA are frequently referred to as VLN-3FA—very long chain n-3 fatty acids. 

DHA, which is thought to be important for brain development and functioning, is present in 
6

significant amounts in a variety of food products, including fish, fish liver oils, fish eggs, and 

organ meats. Similarly, AA can convert into an omega-6 form of DPA. 

Studies have reported that omega-3 fatty acids decrease triglycerides (Tg) and very low 

density lipoprotein (VLDL) in hypertriglyceridemic subjects, concomitant with an increase in 

high density lipoprotein (HDL). However, they appear to increase or have no effect on low 

density lipoprotein (LDL). Omega-3 fatty acids apparently lower Tg by inhibiting VLDL and 

apolipoprotein B-100 synthesis, and decreasing post-prandial lipemia.7

 Omega-3 fatty acids, in 

conjunction with transcription factors (small proteins that bind to the regulatory domains of 

genes), target the genes governing cellular Tg production and those activating oxidation of 

excess fatty acids in the liver. Inhibition of fatty acid synthesis and increased fatty acid 

catabolism reduce the amount of substrate available for Tg production.8 

As noted earlier, omega-6 fatty acids are consumed in larger quantities (> 10 times) than 

omega-3 fatty acids. Maintaining a sufficient intake of omega-3 fatty acids is particularly 

important since many of the body’s physiologic properties depend upon their availability and 

metabolism. 
7

Docosahexaenoic acid

(DHA)

22:6 n-3

(Human milk, egg yolks,

fish liver oils, fish eggs, liver,

brain, other organ meats)

Omega-6

Eicosanoids

Linoleic acid (LA)

18:2 n-6

(Sunflower, soy, cottonseed,

safflower oils)

Alpha-Linolenic acid (ALA)

18:3 n-3

(Canola, Soybean, and

Flaxseed oils, grains, green

vegetables)

Octadecatetranenoic acid

18:4 n-3

Delta-6 Desaturase (D6D)

Delta-6 Desaturase (D6D)

Gamma-linolenic acid

(GLA)

18:3 n-6

(Evening primrose, borage,

black currant oils)

Eicosatetraenoic acid

20:4 n-3

Elongase

Elongase

Dihomo-gamma-linolenic

acid (DGLA)

20:3 n-6

(Liver & other organ meats)

Arachidonic acid (AA)

20:4 n-6

(Animal fats, brain, organ

meats, egg yolk)

Eicosapentaenoic acid

(EPA)

20:5 n-3

(Fish liver oils, fish eggs)

Adrenic acid

22:4 n-6

Docosapentaenoic acid

(DPA)

22:5 n-3

Docosapentaenoic acid

(DPA)

22:5 n-6

24:4 n-6 24:5 n-3

24:5 n-6 24:6 n-3

Polyunsaturated Fatty Acids (PUFAs)

Omega-3

 Minor intake

(0.3-0.4% dietary energy)*

*The dietary intake levels

are based on approximate

current levels in North

American diets Series-1

Prostaglandins:

TXA1

 PGE1 PGF1a

PGD1

Series-2

Prostaglandins:

TXA2

 PGE2 PGF2a

PGD2 PGH2 PGL2

Series-4 Leukotrienes

Series-3

Prostaglandins:

PGE3

 PGH3 PGI3 TXA3

Series-5 Leukotrienes

Thromboxanes (TX)

are important for:

- blood clotting

- constricting blood

vessels

- inflammatory

function of white

blood cells

Leukotrienes are

important for:

- inflammation

- lung function

Prostaglandins (PG)

are important for:

- pregnancy, birth

- stomach function

- kidney function

- maintaining blood

vessel patency

- preventing blood clots

- inflammation,

response to infection

suppress

Beta-oxidation

Cell

membrane

Adrenoceptors Endothelial and

smooth muscle cells

Extracellular

Ca2+

endoplasmic

reticulum

Intracellular

Ca2+

Delta-5 desaturase (D5D)

Elongase

Elongase

D6D

Beta-oxidation

DNA

Energy metabolic pathway Beta-oxidation

TNF-alpha

IL-1 beta

amino

acids

Lower VLDL,

Apo B-100, Tg

 Large intake

(7-8% dietary energy)*

Figure 1. Classical omega-3 and omega-6 fatty acid synthesis pathways and the role of omega-3 fatty acids 

in regulating health/disease markers 
8

U.S. Population Intake of Omega-3 Fatty Acids 

The major source of omega-3 fatty acids is dietary intake of fish, fish oil, vegetable oils 

(principally canola and soybean), some nuts such as walnuts, and, dietary supplements. Two 

population-based surveys, the third National Health and Nutrition Examination (NHANES III) 

1988-94, and the Continuing Survey of Food Intakes by Individuals 1994-98 (CSFII), are the 

main sources of dietary intake data for the U.S. population. NHANES III collected information 

on the U.S. population aged ≥2 months. Mexican Americans and non-Hispanic AfricanAmericans, children ≤5 years old, and adults ≥ 60 years old were over-sampled to produce more 

precise estimates for these population groups. There were no imputations for missing 24-hour 

dietary recall data. A total of 29,105 participants had complete and reliable dietary recall. 

The CSFII 1994-96, popularly known as the “What We Eat in America” survey, addressed 

the requirements of the National Nutrition Monitoring and Related Research Act of 1990 (Public 

Law 101-445) for continuous monitoring of the dietary status of the American population. The 

CSFII 1994-96 utilized an improved data-collection method for 24-hour recall known as the 

multiple-pass approach. Given the large variation in intake from day-to-day, multiple 24-hour 

recalls are considered to be best suited for most nutrition monitoring and will produce stable 

estimates of mean nutrient intake from groups of individuals.9

 In 1998, the Supplemental 

Children’s Survey, a survey of food and nutrient intake by children under the age of 10 years, 

was conducted as a supplement to the CSFII 1994-96. The CSFII 1994-96, 1998 surveyed 

20,607 people of all ages with over-sampling of low-income population (<130% of the poverty 

threshold). Dietary intake data from individuals of all ages were collected over 2 nonconsecutive 

days via two 1-day dietary recalls. 

Table 1 reports the NHANES III survey mean intake ± the standard error of the mean (SEM), 

in addition to the median and range for each omega-3 fatty acid. Distributions of EPA, DPA, 

and DHA were very skewed; therefore, the means and standard errors of the means should be 

used and interpreted with caution. Table 2 reports the CSFII survey mean and median intakes 

for each omega-3 fatty acid, along with SEMs, as reported in the Dietary Reference Intakes from 

the Institute of Medicine.2 

Table 1: Estimates of the mean±standard error of the mean (SEM) intake of linoleic acid (LA), alpha-linolenic 

acid (ALA), eicosapentaenoic acid (EPA), and docosahexaenoic acid (DHA) in the US population, based on 

analyses of a single 24-hour dietary recall of NHANES III data

Grams/day % Kcal/day

Mean±SEM Median (range)1

 Mean±SEM Median (range)1

LA (18:2 n-6) 14.1±0.2 9.9 (0 - 168) 5.79±0.05 5.30 (0 - 39.4) 

ALA (18:3 n-3) 1.33±0.02 0.90 (0 - 17) 0.55±0.004 0.48 (0 - 4.98) 

EPA (20:5 n-3) 0.04±0.003 0.00 (0 - 4.1) 0.02±0.001 0.00 (0 - 0.61) 

DHA (22:6 n-3) 0.07±0.004 0.00 (0 - 7.8) 0.03±0.002 0.00 (0 - 2.86) 1

The distributions are not adjusted for the over-sampling of Mexican-Americans, non-Hispanic African-Americans, 

children ≤5 years old, and adults ≥ 60 years old in the NHANES III dataset. 
9

Table 2: Mean, range, median, and standard error of the mean 

(SEM) of usual daily intakes of linoleic acid (LA), total omega-3 

fatty acids (n-3 FA), alpha-linolenic acid (ALA), eicosapentaenoic 

acid (EPA), docosapentaenoic acid (DPA) and docosahexaenoic 

acid (DHA) in the US population, based on CSFII data (1994-1996, 

1998) 

Grams/day

Mean±SEM Median±SEM 

LA (18:2 n-6) 13.0±0.1 12.0±0.1 

Total n-3 FA 1.40±0.01 1.30±0.01 

ALA (18:3 n-3) 1.30±0.01 1.21±0.01 

EPA (20:5 n-3) 0.028 0.004 

DPA (22:5 n-3) 0.013 0.005 

DHA (22:6 n-3) 0.057±0.018 0.046±0.013 

Dietary Sources of Omega-3 Fatty Acids 

Omega-3 fatty acids can be found in many different sources of food, including fish, 

shellfish, some nuts, and various plant oils. Selected from the USDA website, Table 3 lists the 

amount of omega-3 fatty acids in some commonly consumed fish, shellfish, nuts, and edible 

oils, selected from the USDA website.10
10

Table 3: The omega-3 fatty acid content, in grams per 100 g food serving, of a representative sample of 

commonly consumed fish, shellfish, fish oils, nuts and seeds, and plant oils that contain at least 5 g omega-3 

fatty acids per 100 g 

Food item EPA DHA ALA Food item EPA DHA ALA 

Fish (Rawa) Fish, continued 

Anchovy, European 0.6 0.9 - Tuna, Fresh, Yellowfin trace 0.2 trace 

Bass, Freshwater, Mixed Sp. 0.2 0.4 0.1 Tuna, Light, Canned in Oile trace 0.1 trace 

Bass, Striped 0.2 0.6 trace Tuna, Light, Canned in Watere trace 0.2 trace 

Bluefish 0.2 0.5 - Tuna, White, Canned in Oile trace 0.2 0.2 

Carp 0.2 0.1 0.3 Tuna, White, Canned in Watere 0.2 0.6 trace 

Catfish, Channel trace 0.2 0.1 Whitefish, Mixed Sp. 0.3 0.9 0.2 

Cod, Atlantic trace 0.1 trace Whitefish, Mixed Sp., Smoked trace 0.2 - 

Cod, Pacific trace 0.1 trace Wolffish, Atlantic 0.4 0.3 trace 

Eel, Mixed Sp. trace trace 0.4 

Flounder & Sole Sp. trace 0.1 trace 

Grouper, Mixed Sp. trace 0.2 trace Shellfish (Raw) 

Haddock trace 0.1 trace Abalone, Mixed Sp. trace - - 

Halibut, Atlantic and Pacific trace 0.3 trace Clam, Mixed Sp. trace trace trace 

Halibut, Greenland 0.5 0.4 trace Crab, Blue 0.2 0.2 - 

Herring, Atlantic 0.7 0.9 0.1 Crayfish, Mixed Sp., Farmed trace 0.1 trace 

Herring, Pacific 1.0 0.7 trace Lobster, Northern - - - 

Mackerel, Atlantic 0.9 1.4 0.2 Mussel, Blue 0.2 0.3 trace 

Mackerel, Pacific and Jack 0.6 0.9 trace Oyster, Eastern, Farmed 0.2 0.2 trace 

Mullet, Striped 0.2 0.1 trace Oyster, Eastern, Wild 0.3 0.3 trace 

Ocean Perch, Atlantic trace 0.2 trace Oyster, Pacific 0.4 0.3 trace 

Pike, Northern trace trace trace Scallop, Mixed Sp. trace 0.1 - 

Pike, Walleye trace 0.2 trace Shrimp, Mixed Sp. 0.3 0.2 trace 

Pollock, Atlantic trace 0.4 - Squid, Mixed Sp. 0.1 0.3 trace 

Pompano, Florida 0.2 0.4 - 

Roughy, Orange trace - trace 

Salmon, Atlantic, Farmed 0.6 1.3 trace Fish Oils 

Salmon, Atlantic, Wild 0.3 1.1 0.3 Cod Liver Oil 6.9 11.0 0.9 

Salmon, Chinook 1.0 0.9 trace Herring Oil 6.3 4.2 0.8 

Salmon, Chinook, Smokedb 0.2 0.3 - Menhaden Oil 13.2 8.6 1.5 

Salmon, Chum 0.2 0.4 trace Salmon Oil 13.0 18.2 1.1 

Salmon, Coho, Farmed 0.4 0.8 trace Sardine Oil 10.1 10.7 1.3 

Salmon, Coho, Wild 0.4 0.7 0.2 

Salmon, Pink 0.4 0.6 trace 

Salmon, Pink, Cannedc 0.9 0.8 trace Nuts and Seeds 

Salmon, Sockeye 0.6 0.7 trace Butternuts, Dried - - 8.7 

Sardine, Atlantic, Canned in Oild 0.5 0.5 0.5 Flaxseed 18.1 

Seabass, Mixed Sp. 0.2 0.4 - Walnuts, English - - 9.1 

Seatrout, Mixed Sp. 0.2 0.2 trace 

Shad, American 1.1 1.3 0.2 

Shark, Mixed Sp. 0.3 0.5 trace Plant Oils 

Snapper, Mixed Sp. trace 0.3 trace Canola (Rapeseed) - - 9.3 

Swordfish 0.1 0.5 0.2 Flaxseed Oil - - 53.3 

Trout, Mixed Sp. 0.2 0.5 0.2 Soybean Lecithin Oil - - 5.1 

Trout, Rainbow, Farmed 0.3 0.7 trace Soybean Oil - - 6.8 

Trout, Rainbow, Wild 0.2 0.4 0.1 Walnut Oil - - 10.4 

Tuna, Fresh, Bluefin 0.3 0.9 - Wheatgerm Oil - - 6.9 

Tuna, Fresh, Skipjack trace 0.2 - 

Trace = <0.1; - = 0 or no data; Sp. = species; aExcept as indicated; bLox.; cSolids with bone and liquid; dDrained 

solids with bone; eDrained solids. 
11

Omega-3 Fatty Acids in Child and Maternal Health 

The following description is intended only as an overview of the domain of inquiry in which 

it has been hypothesized that omega-3 fatty acid content, which includes both their intake and 

their levels in specific biomarkers, plays an important role in maternal pregnancy and child 

health outcomes in human subjects. This account serves exclusively to introduce the pertinence 

of this systematic review of the empirical evidence. 

Over the past 60 years, the influence of maternal nutrition on fetal growth and development 

has been extensively studied as part of attempts to understand the causes and consequences of 

protein-calorie malnutrition.11 This field of investigation has since expanded to encompass 

experimental, observational and descriptive studies designed to identify the specific roles of a 

broad range of sources and constituents of maternal nutrition. In addition, studies have also been 

conducted to evaluate the impact of maternal nutrition on maternal health during pregnancy and 

pregnancy outcomes. The following overview will focus on the the role played by omega-3 fatty 

acids in modulating the duration of pregnancy, incidence of pregnancy-induced hypertension, 

fetal growth and development, and infant (preterm and term) neurocognitive and visual 

development. The mechanisms by which omega-3 fatty acids or their eicosanoid derivatives 

impact the observed biological outcomes may include one or more of their identified functions in 

modulating the cell membrane microenviroment, signaling pathways, and gene expression.12,13

It has been posited that the accretion of omega-3 fatty acids within, and use by, the maternal 

biological system has the potential to influence both maternal health during pregnancy, and fetal 

health. Likewise, it has been hypothesized that their accumulation within, and use by, the postdelivery child’s biological system can affect their development and health. However, 

notwithstanding problems affecting their metabolism or availability, since EFAs must be 

“obtained” from “external sources” in order for their contents to accumulate and, in turn, 

potentially influence health, mothers and their fetuses/children require that omega-3 fatty acid 

content be “delivered” (i.e., via the placenta, breast milk, formula supplementation, food sources 

such as oily fish, or supplementation). 

Birth weight is the single most important factor affecting neonatal morbidity and 

mortality.14 Infants born with low birth weights (less than 2,500 grams by WHO criterion) may 

be the result of: 1. being constitutionally small; 2. intrauterine growth retardation (IUGR); or 3. 

preterm birth. In the United States, approximately 350,000 infants are born weighing less than 

2,500 grams.15

Preterm birth is a multifactorial condition that results in significant morbidity and 

mortality. Premature infants are at risk of injury to every organ system in the newborn period: 

intraventricular hemorrhage, retinopathy of prematurity, respiratory distress syndrome, chronic 

lung disease, necrotizing enterocolitis, growth failure, and infections. Of greatest concern for the 

infants who survive are the risks of developing permanent neurocognitive deficits (i.e., cerebral 

palsy, hearing and vision loss, cognitive deficits) that impact on their lifelong health and 

functional capacity.16-19 In addition, studies now suggest that premature infants are at higher risk 

for developing adult-onset chronic diseases including hypertension, cardiovascular disease, and 

diabetes, as a result of permanent physiologic changes induced by abnormal conditions during 

sensitive periods of human growth and development.20-22 There is an hypothesis that suboptimal 
12

n-3 and n-6 nutrititure during sensitive periods of fetal growth and development may result in 

permanent changes in neurocognitive and visual function and the development of adult-onset 

diseases such as hypertension. In the United States, preterm birth of low birth weight infants is 

6%-10% of all births, which is approximately 300,000 annually.23 In the United States, the cost 

of preterm births is estimated at several billion dollars annually, not including the costs of care 

for the associated-adult onset diseases.24 

Without exploring too deeply what was not, in fact, eligible for synthesis in our review—

because it failed to satisfy our eligibility criterion relating to research design—some evidence is 

introduced here merely to demonstrate that there can coexist more than one interpretation of how 

maternal intake of omega-3 fatty acids could influence a child outcome. Results of 

epidemiological studies conducted with residents of the Faroe Islands25,26 have been taken to 

suggest that marine diets, which contain omega-3 fatty acids, increase birth weight either by 

prolonging pregnancy.27 or increasing the fetal growth rate.28,29 Proposed mechanisms have 

included: a) the delayed timing of spontaneous delivery, which results from the altered balance 

among the PGs involved in the initiation of labor;27 or, b) an increased fetal growth rate, which 

results from enhanced placental blood flow associated with a decreased Tx/prostacyclin ratio28

and decreased blood viscosity.30 These observations might not be replicated in populations that 

regularly consume lesser amounts of omega-3 fatty acids from marine sources, however. With 

respect to maternal health during human pregnancy, it has been hypothesized that marine oils 

may lower risks of certain complications of pregnancy, in particular preterm delivery, 

intrauterine growth retardation, preeclampsia, and gestational hypertension.31 Given that some 

of their presumed mechanisms of action overlap with those of aspirin, it was thought that omega3 fatty acids might protect pregnant women against preeclampsia and gestational hypertension, 

for example.32-34 

Essential fatty acid derived eicosanoids play important roles as biochemical mediators in 

normal term labor that initiate uterine contractions, cervical maturation, and rupture of 

membranes.35,36 There is an elevation of omega-6 fatty acid eicosansoid series (PGE2 and 

PGF2alpha, LTC4, LTB4) in the maternal circulation prior to the onset of labor37 and inhibition 

of their synthesis with cyclooxygenase inhibitors stops the onset of labor.38 Women who deliver 

prematurely have higher erythrocyte total plasma lipid omega-6 fatty acids and lower omega-3 

fatty acids compared with women who delivered at term, suggesting that an imbalance in favor 

of omega-6 fatty acids and their eicosanoid derivatives contribute to the premature onset of 

labor.39,40 By altering the balance of omega-6 to omega-3 eicosanoids by diet supplementation 

with omega-3 fatty acids in human, rodent, and sheep, studies have been successful in increasing 

the duration of gestation.31,41-46 

In Western societies, placental insufficiency is the major cause of IUGR, with maternal 

hypertension having the most profound effect.47 Fetal adaptations that are required to 

compensate for poor placental function result in increased perinatal morbidity and mortality. Of 

greatest concern is the increased risk for permanent adverse effects on growth and 

development.47-51 Epidemiologic data suggests that the fetal adaptations may be associated with 

an increased risk for the development of adult-onset chronic diseases including hypertension, 

cardiovascular disease, obesity and diabetes.20-22 In keeping with these observations, animals 

studies on fetal growth restriction demonstrate metabolic, hormonal and end organ changes that 
13

predispose the animals to the development of hypertension, cardiovascular disease and 

diabetes.52-54

Hypertension in pregnancy of varying degrees of severity (chronic hypertension, 

preeclampsia, eclampsia) occurs in approximately 6%8% of pregnancies and is the second 

leading cause of maternal death in the United States.55 The pathophysiologic mechanisms of 

preeclampsia remain unclear but a consistent finding is endothelial dysfunction resulting in 

intense vasospasm due to increased endothelial sensitivity to pressors.56,57 It is thought, in part, 

that the enhanced vasoconstriction may be caused by increased synthesis of the potent omega-6 

fatty acid derived vasoconstrictor, thromboxane A2, that is found in maternal plasma and 

placental tissue of preeclamptic women.58-60 Non-pregnant hypertensive adults have been shown 

to have significantly lower plasma phospholipids levels of omega-3 fatty acids which results in 

decreased nitric oxide synthesis and increased aceylcholinesterase activity resulting in increased 

vascular tone.61,62 In contrast, populations with high marine oil intake or hypertensive patients 

supplemented with omega-3 fatty acids had higher plasma omega-3 fatty acid levels had lower 

blood pressures.62-66 Inuit women who ate a diet rich in marine foods were 2.6 times less likely 

to develop hypertension during pregnancy than Inuit women whose diets contained less marine 

foods.67 Supplementation with omega-3 fatty acids would correct an imbalance between 

prostacylin and thromboxane, reduce blood viscosity, reduce endogenous pressors, or alter 

baroreceptor function which may help to reduce the occurrence of hypertension in pregnancy.68-

73 

Normal placental blood flow is critical for adequate delivery of nutrients to the fetus to 

support normal growth and development. It has been proposed that the balance of omega-3 and 

omega-6 derived eicosanoids may play a key role in maintaining adequate placental blood flow 

and delivery of nutrient substrates to support normal fetal growth and development.74,75 Based 

on biochemical indices (decreased PGI2 synthesis and increased 20:5n-6 DPA content of 

umbilical artery endothelium), it appears that low birth weight infants are deficient in omega-3 

fatty acids.74 In addition, observational and interventional studies have demonstrated a direct 

association between fetal growth and maternal intake of omega-3 fatty acids.24,74-77

In keeping with other nutrients, the bulk of fatty acid delivery and storage in the fetus 

occurs in the last trimester. Infants born prematurely have lower total body content of omega-3 

LCPUFA.78-80 Omega-3 fatty acids accumulate in fetal fat stores, liver and neural tissues. The 

highest quantities are found in fat stores, but the relative proportion of omega-3 LCPUFA is 

highest in the retina and brain.79 It appears that the fetus is dependent on the maternal supply of 

omega-3 LCPUFA with levels in the umbilical plasma phosphoplipids that strongly correlate 

with maternal plasma phospholipids.81-84 

The fetus is capable of converting ALA (18:3n-3) to DHA, but it remains controversial as 

to whether the rate of conversion is adequate to meet their needs.85-87 Preformed DHA is 

preferentially transferred from the maternal circulation to the fetus, although the mechanism is 

unclear.74,88,89 Maternal stores of DHA are mobilized during pregnancy for transfer to the fetus 

since plasma DHA (g/ml or FA%) has been shown to be decreased in multiparous versus 

primiparous women. This finding correlated with the lower DHA FA% in cord tissue of higher 

birth order newborns. Taken together, these findings suggest that the current omega-3 fatty acid 

intake during pregnancy in Western countries is inadequate.90
14

Parallel to the high rates of fatty acid delivery and accretion in the fetus in the third 

trimester, is the rapid growth and development of neural tissues which continues for the first 18 

months after birth.81,91 During this period, the accretion of DHA in the brain is about 3 times 

greater than the relative increase in brain weight.92 DHA accretion in the human retinal begins in 

the third trimester and peaks at 36-40 weeks gestation.93 DHA and AA have been identified as 

important structural components of the highly specialized membrane lipids of the human central 

nervous system, with phospholipids of brain gray matter containing high proportions of DHA.94-

96 DHA has also been observed to be the major LCPUFA in the outer segments of the retina’s 

rods and cones.94 The functional roles of DHA were first shown in animals (fetus or newborn) 

deprived of DHA. Investigators have reported that the depletion of DHA from the developing 

retina and brain leads to abnormal electroretinograms (ERGs) and decreased VEP responses, in 

addition to altered learning behavior (e.g., performance in maze tasks, habituation, exploratory 

activity in novel environments, brightness discrimination, and olfactory-based learning tasks).97-

104 There is concern with findings that suggest that these changes in function may be irreversible 

despite correction of DHA status after deprivation of omega-3 fatty acids during critical periods 

of retinal development.105 As well, the dietary deficiency of ALA in developing animals has 

resulted in decreased DHA levels, with a reciprocal increase in omega-6 fatty acids, and 

especially DPA, observed in the retina, whole brain, isolated brain membranes, and specific 

brain regions.106-108 

Animal studies have suggested the value of providing omega-3 fatty acid supplementation 

as well. Recent studies have shown that omega-3 fatty acids alter the metabolism of dopamine 

and serotonin in the brain of rodents and piglets.109-114 Particular interest has been given to the 

dopaminergic system because of its role in the cognitive advances of early childhood, for 

example, as a modulator of attention and motivation, and in the visual pathways.115 Other recent 

studies have suggested that omega-3 fatty acids regulate the expression of genes involved in 

cytoskeleton and membrane association, signal transduction, ion channel formation, energy 

metabolism, synaptic plasticity, and the retinoid X receptor in the brain.116-119

Supplementation with DHA in human infants have shown variable results, with improved 

visual acuity demonstrated in premature infants120-123 and variable results in term infants.124-127 

In part, the variability was thought to be due to differences in study design, age and duration of 

intervention, method(s) of assessment. The different measures of visual function may reflect 

different neural processes, making the comparison of findings between studies problematic. For 

example, the Teller acuity card or forced choice preferential looking method evaluates an 

infant’s tendency to gaze at a pattern and assesses not only visual acuity but also an infant’s 

ability to respond which requires integration of motor and behavioral responses to the visual 

stimuli. Visual evoked potentials (VEP) directly measures the amplitude of electrical responses 

to visual stimuli that signal transduction from the eye to visual cortex and is not dependent on the 

infant’s behavioral state or motor abilities. 

Based on observational studies, it has been shown that human milk fed infants have 

improved neurocognitive development compared to formula fed infants, it was hypothesized that 

one of the contributing factors may be the availability of long chain derivatives of LA and ALA 

that is present only human milk82,128 This difference in fatty acid intake is reflected in lower 

erythrocyte membrane phospholipid DHA in infants fed formula.82 Until the recent availability 

infant formula with added omega-3 LCPUFA, standard infant formula was devoid of these fatty 
15

acids. Human milk contains DHA ranging from 0.2 to 0.4 FA% and varies considerably among 

different populations with differences in DHA intake.120,124 It is thought that the rate of 

conversion of ALA (18:3n-3) present in standard infant formula to DHA does not meet rates of 

accretion in the CNS that is seen in human milk fed infants.129-131 As with the DHA intervention 

trials in term infants on visual acuity, the effect of DHA supplementation on neurocognitive 

development is also inconsistent.127,132-134 Thevariability may, in part, be due to the use of 

different assessment tools.

While it could be hypothesized that the intake of omega-3 fatty acids might have a greater 

impact on preterm, than term, infants because the former have been exposed for a shorter period 

of time to what the latter likely received as significant contributors to their development, the 

present review was not planned to test this hypothesis. Even so, there may be considerable 

justification for giving omega-3 fatty acids to mothers who eventually deliver term babies as well 

as to these term infants post-delivery. Mothers of term infants may not exhibit uniform levels of 

omega-3 fatty acid content in their biomarkers, which are passed on to their children. 

For example, it has recently been observed that the human milk of North American women 

has significantly less DHA and AA content, when compared with milk obtained from women in 

China, Japan, or India.135,136 Furthermore, higher amounts of DHA in human milk have been 

associated with higher plasma and erythrocyte levels of DHA in breastfed infants;137-139 and, a 

significant association between DHA levels in human milk and visual evoked potential (VEP) 

acuity was recently reported in a cross-sectional study of breastfed infants in Denmark.140 

Related observations, which are reviewed in depth here, suggest the possible importance of the 

intake of omega-3 fatty acids by pregnant and lactating women for the health of their offspring. 

Moreover, when compared with women with lower plasma levels of AA and DHA during 

gestation, women with higher plasma levels gave birth to infants with higher levels of AA and 

DHA;137,141,142 and, higher levels of omega-6 and omega-3 fatty acid content in biomarkers at 

birth were found to be associated with higher blood levels of AA and DHA in the infant for 

several weeks after birth.138,140,143 Thus, individual differences in the levels of fatty acid content 

observed in mothers’ biomarkers, which appear to be paralleled by individual differences in the 

levels of fatty acid content in the biomarkers obtained from their children, might ultimately be 

found to account for differences in child development. DHA deficiency related to low maternal 

intake of omega-3 fatty acids during pregnancy, for example, might adversely impact child 

development. 

Direct measurement of tissue levels is not feasible for most tissues such as brain and 

retina. As such, fatty acid biomarkers are used as surrogate measures of tissue levels. How 

closely these biomarkers reflect tissue levels are not certain.131,144-147 Different measurements of 

the fatty acid content of different lipid pools reflect either the effects of short term (hours) or 

long term (days to months) dietary intake of fatty acids. 

The likely significance of omega-3 fatty acids for child health is therefore suggested by 

the observations that: a) the human brain and retina each contain considerable omega-3 fatty acid 

content; b) the child delivered at term receives an important supply of omega-3 fatty acids 

especially in the third trimester of pregnancy; and, c) due to a shortened gestational period, the 

child delivered prematurely receives less exposure to omega-3 fatty acid content than does the 

term child. Not surprisingly, the observation concerning preterm infants has afforded 
16

considerable empirical study of the impact of omega-3 fatty acids on their health. This evidence 

is systematically reviewed here. 

Given this overview, and the expected availability of empirical evidence, we aimed to 

evaluate the impact of omega-3 fatty acid content (i.e., intake; in biomarkers), from any and all 

sources (e.g., breast milk; formula), on the growth patterns, neurological development, visual 

development, and cognitive development of preterm and term children. We also planned to 

investigate the influence of omega-3 fatty acid content (i.e., intake; in biomarkers), from any and 

all sources (e.g., food; supplements), on specific pregnancy outcomes relating to offspring (i.e., 

preterm births; children born small for gestational age) and maternal health (i.e., preeclampsia; 

eclampsia; gestational hypertension). However, as pointed out in Chapter 2, not all of the 

relationships between the intake of omega-3 fatty acids, the fatty acid content of biomarkers, and 

clinical-developmental outcomes are investigated in either population (i.e., maternal; child). 

It should also be pointed out that, given the likely important role played by the omega-6 fatty 

acids—and AA in particular—in health and development, their co-influence on clinical and 

developmental outcomes are investigated, where possible. Finally, safety data (i.e., adverse 

effects) are evaluated. For example, concerns have been raised about the safety of fish oil 

supplementation in infants and pregnant women include, decreased platelet aggregation, 

immunosuppression, growth148,149 and environmental contaminants.26,132,148-151 However, the 

clinical significance of these potential risks need to be determined. 
17

Chapter 2. Methods 

Overview 

The UO-EPC’s evidence report on omega-3 fatty acids in child and maternal health is based 

on a systematic review of the scientific-medical literature to identify, and synthesize the results 

from, studies addressing key questions. Together with content experts, UO-EPC staff identified 

specific issues integral to the review. A Technical Expert Panel (TEP) helped refine the research 

questions as well as highlighted key variables requiring consideration in the evidence synthesis. 

Evidence tables presenting key study-related characteristics were developed and are found in the 

Appendices. In-text summary tables were derived from the evidence tables. The methodological 

quality and generalizability of the included studies was appraised, and individual study results 

were summarized. 

Key Questions Addressed In This Report 

The purpose of this evidence report was to synthesize information from relevant studies to 

address various questions. The questions are organized by the type of population (i.e., 

maternal/pregnancy versus child [e.g., term versus preterm delivery]) and the type of outcome 

data (i.e., clinical/pregnancy versus clinical/child-developmental capacity versus 

biological/biomarker status versus adverse effects): 

• Maternal population, clinical/pregnancy outcomes: 

o What is the evidence that intake of omega-3 fatty acids influences the duration of 

gestation in women with or without a history of a previous preterm birth (gestational 

duration less than 37 weeks)? 

o What is the evidence that maternal intake of omega-3 fatty acids influences the 

incidence of preeclampsia, eclampsia or gestational hypertension? 

o What is the evidence that maternal intake of omega-3 fatty acids influences the 

incidence of births of human infants small for gestational age? 

• Maternal population, biomarker data relating to clinical/pregnancy outcomes: 

o What is the evidence that the duration of gestation in women with or without a history 

of a previous preterm birth is associated with the omega-3 or omega-6/omega-3 fatty 

acid content of maternal biomarkers during pregnancy? 

o What is the evidence that the incidence of preeclampsia, eclampsia or gestational 

hypertension is associated with the omega-3 or omega-6/omega-3 fatty acid content 

of maternal biomarkers during pregnancy? 
18

o What is the evidence that the incidence of births of human infants small for 

gestational age is associated with the omega-3 or omega-6/omega-3 fatty acid content 

of maternal biomarkers during pregnancy? 

• Child population, growth pattern outcomes: 

o What is the evidence that maternal intake of omega-3 fatty acids during pregnancy 

influences growth patterns in term or preterm human infants? 

o What is the evidence that the omega-3 fatty acid content of maternal breast milk, with 

or without known maternal intake of omega-3 fatty acids, influences growth patterns 

in term or preterm human infants? 

o What is the evidence that the omega-3 fatty acid content of infant formula influences 

growth patterns in term or preterm human infants? 

o What is the evidence that the omega-3 fatty acid content of maternal breast milk, with 

or without known maternal intake of omega-3 fatty acids, and together with the 

omega-3 fatty acid content of infant formula, influences growth patterns in term or 

preterm human infants? 

o What is the evidence that intake of omega-3 fatty acids from sources other than 

maternal breast milk or infant formula supplemented with omega-3 fatty acids, by 

term or preterm human infants, influences growth patterns? 

• Child population, biomarker data relating to growth pattern outcomes: 

o What is the evidence that term or preterm human infants’ growth patterns are 

associated with the omega-3 or omega-6/omega-3 fatty acid content of maternal 

biomarkers during pregnancy? 

o What is the evidence that term or preterm human infants’ growth patterns are 

associated with the omega-3 or omega-6/omega-3 fatty acid content of fetal 

biomarkers during pregnancy? 

o What is the evidence that term or preterm human infants’ growth patterns are 

associated with the omega-3 or omega-6/omega-3 fatty acid content of child 

biomarkers? 

• Child population, neurological development outcomes: 

o What is the evidence that maternal intake of omega-3 fatty acids during pregnancy 

influences neurological development in term or preterm human infants? 

o What is the evidence that the omega-3 fatty acid content of maternal breast milk, with 

or without known maternal intake of omega-3 fatty acids, influences neurological 

development in term or preterm human infants? 

o What is the evidence that the omega-3 fatty acid content of infant formula influences 

neurological development in term or preterm human infants? 

o What is the evidence that the omega-3 fatty acid content of maternal breast milk, with 

or without known maternal intake of omega-3 fatty acids, and together with the 

omega-3 fatty acid content of infant formula, influences neurological development in 

term or preterm human infants? 
19

o What is the evidence that intake of omega-3 fatty acids from sources other than 

maternal breast milk or infant formula supplemented with omega-3 fatty acids, by 

term or preterm human infants, influences neurological development? 

• Child population, biomarker data relating to neurological development outcomes: 

o What is the evidence that term or preterm human infants’ neurological development is 

associated with the omega-3 or omega-6/omega-3 fatty acid content of maternal 

biomarkers during pregnancy? 

o What is the evidence that term or preterm human infants’ neurological development is 

associated with the omega-3 or omega-6/omega-3 fatty acid content of fetal 

biomarkers? 

o What is the evidence that term or preterm human infants’ neurological development is 

associated with the omega-3 or omega-6/omega-3 fatty acid content of child 

biomarkers? 

• Child population, visual function outcomes: 

o What is the evidence that maternal intake of omega-3 fatty acids during pregnancy 

influences visual function in term or preterm human infants? 

o What is the evidence that the omega-3 fatty acid content of maternal breast milk, with 

or without known maternal intake of omega-3 fatty acids, influences visual function 

in term or preterm human infants? 

o What is the evidence that the omega-3 fatty acid content of infant formula influences 

visual function in term or preterm human infants? 

o What is the evidence that the omega-3 fatty acid content of maternal breast milk, with 

or without known maternal intake of omega-3 fatty acids, and together with the 

omega-3 fatty acid content of infant formula, influences visual function in term or 

preterm human infants? 

o What is the evidence that intake of omega-3 fatty acids from sources other than 

maternal breast milk or infant formula supplemented with omega-3 fatty acids, by 

term or preterm human infants, influences visual function? 

• Child population, biomarker data relating to visual function outcomes: 

o What is the evidence that term or preterm human infants’ visual function is associated 

with the omega-3 or omega-6/omega-3 fatty acid content of maternal biomarkers 

during pregnancy? 

o What is the evidence that term or preterm human infants’ visual function is associated 

with the omega-3 or omega-6/omega-3 fatty acid content of fetal biomarkers? 

o What is the evidence that term or preterm human infants’ visual function is associated 

with the omega-3 or omega-6/omega-3 fatty acid content of child biomarkers? 

• Child population, cognitive development outcomes: 

o What is the evidence that maternal intake of omega-3 fatty acids during pregnancy 

influences cognitive development in term or preterm human infants?
20

o What is the evidence that the omega-3 fatty acid content of maternal breast milk, with 

or without known maternal intake of omega-3 fatty acids, influences cognitive 

development in term or preterm human infants?

o What is the evidence that the omega-3 fatty acid content of infant formula influences 

cognitive development in term or preterm human infants?

o What is the evidence that the omega-3 fatty acid content of maternal breast milk, with 

or without known maternal intake of omega-3 fatty acids, and together with the 

omega-3 fatty acid content of infant formula, influences cognitive development in 

term or preterm human infants?

o What is the evidence that intake of omega-3 fatty acids from sources other than 

maternal breast milk or infant formula supplemented with omega-3 fatty acids, by 

term or preterm human infants, influences cognitive development?

• Child population, biomarker data relating to cognitive development outcomes: 

o What is the evidence that term or preterm human infants’ cognitive development is 

associated with the omega-3 or omega-6/omega-3 fatty acid content of maternal 

biomarkers during pregnancy? 

o What is the evidence that term or preterm human infants’ cognitive development is 

associated with the omega-3 or omega-6/omega-3 fatty acid content of fetal 

biomarkers? 

o What is the evidence that term or preterm human infants’ cognitive development is 

associated with the omega-3 or omega-6/omega-3 fatty acid content of child 

biomarkers? 

• Maternal or child population, adverse effects: 

o What is the evidence for the risk, in pregnant women, of short and long-term adverse 

events related to their intake of omega-3 fatty acids?

o What is the evidence for the risk, in breastfeeding women, of short and long-term 

adverse events related to their intake of omega-3 fatty acids?

o What is the evidence for the risk, in term or preterm human infants, of short and longterm adverse events related to maternal intake of omega-3 fatty acids during 

pregnancy?

o What is the evidence for the risk, in term or preterm human infants, of short and longterm adverse events related to their intake of omega-3 fatty acids after birth (e.g., 

maternal breast milk, infant formula supplemented with omega-3 fatty acids)?

o What is the evidence that these adverse events, or any contraindications, are 

associated with the intake of specific sources (e.g., marine, plant), types (e.g., EPA, 

DHA, ALA) or doses of omega-3 fatty acids, including in specific populations such 

as diabetics? 
21

The overarching goal was to identify and systematically review whatever evidence exists 

within the eligibility boundaries established for this review in consultation with our TEP and in 

light of the topics being addressed by SC-RAND and Tufts-NEMC EPCs. These boundaries are 

delineated in the Eligibility Criteria section (below). At all times, data obtained from children 

delivered at term and preterm (i.e., gestational duration less than 37 weeks) were evaluated 

separately. More details concerning the questions are provided in conjunction with the 

description of the Analytic Frameworks (below). 

We were also guided collectively by ODS, our TEP and our UO-EPC review team content 

experts to examine, where data permitted, the possible influence on efficacy, association or 

safety evidence of the following potential effect modifiers: 

o intervention/exposure length; 

o timing of intervention/exposure period (e.g., beginning the 3rd day of life, for 4 months); 

o type(s) of omega-3 fatty acid (e.g., ALA, EPA, DHA); 

o source of the omega-3 fatty acids (e.g., marine, plant, nut), including the specific source (e.g., 

mackerel as an oily fish); 

o total caloric/energy intake; 

o delivery format (e.g., whole food servings, capsules, pourable or spreadable oils); 

o dose/serving size, including the precision/control of its delivery (e.g., per-day specific, 

minimum, maximum or range of numbers of capsules, whole food servings or bottlepourable litres); 

o type of processing used to purify the intervention/exposure and/or to maintain the 

experimental blind (e.g., ethyl esterification; adding an anti-oxidant to stabilize/preserve oils; 

adding flavor to oils; [vacuum] deodorization); 

o amount/dose of omega-6 fatty acid intake either added as a cointervention or identified as 

being present in the background diet, thereby establishing a specific, minimum, maximum or 

range of allowable or mandated on-study omega-6/omega-3 fatty acid intake; 

o the identity of the manufacturer and/or certain characteristics of their product(s) (i.e., purity; 

presence of other potentially active agents that have not been added intentionally: e.g., 

methylmercury content); 

o for questions relating to efficacy or association, the prestudy/baseline or on-study omega-3 or 

omega-6/omega-3 fatty acid content of blood lipid biomarkers; 

o absolute or relative omega-3 fatty acid content of the prestudy/baseline diet; 

o omega-6/omega-3 fatty acid content in the prestudy/baseline diet, with the study population’s 

country of origin as a possible surrogate measure of the omega-6/omega-3 fatty acid content 

of the background diet; and, 

o any study subpopulations (e.g., minority; ethnic; genetic, including diabetics). 

Furthermore, where data permitted, the following factors with the potential to influence child 

and maternal health outcomes were also investigated: 
22

o obstetric history (e.g., maternal age at conception and delivery; history of a previous and/or 

current preterm birth [length in weeks; etiology; spontaneous versus induced; history of 

preeclampsia, eclampsia or gestational hypertension; history of a previous birth of an infant 

small for gestational age); 

o gynecologic history (e.g., uterine abnormalities); 

o maternal general health history (e.g., medical and psychiatric), including maternal 

medication/treatment history (e.g., prescription and non-prescription drugs); 

o breastfeeding history; 

o setting (e.g., tertiary care hospital; community facility); 

o other sociodemographic/economic factors (e.g., marital status, education, income, 

employment status); 

o other maternal cointerventions (e.g., other supplement use [e.g., vitamins, minerals], 

psychological interventions, use of complementary/alternative [CAM] medicine/products); 

o maternal illicit drug use history; 

o history of domestic violence; 

o maternal smoker history; 

o history of maternal alcohol consumption; 

o prenatal history (e.g., delivery anomalies); 

o neonatal history (e.g., asphyxia; intracranial hemorrhage); 

o pediatric history (e.g., medications/treatments; supplement use [e.g., vitamins, minerals]; 

immunizations); and, 

o with respect to each child outcome in turn (e.g., cognitive development), the developmental 

capacity/status regarding the other child outcomes (i.e., growth patterns [e.g., weight, height 

and head circumference at birth]; neurological development; visual development). 

Parental smoking and alcohol consumption especially during pregnancy yet also postdelivery are particularly important effect modifiers in that they have been observed to influence 

both child or maternal health and essential fatty acid status, with levels of the latter potentially 

affecting the former.152 
23

Analytic Framework 

Two analytic frameworks were developed to make explicit the review’s specific links 

relating the populations and settings of interest (i.e., term versus preterm infants), the focal 

exposure or intervention (i.e., omega-3 fatty acids ingested as supplementation and/or from food 

sources), potential effect-modifying factors, key child and maternal health outcomes, and the 

possible role played by the omega-3 or omega-6/omega-3 fatty acid content of biomarkers in 

mediating the intake-outcome relationship. A first analytic framework (Figure 2) highlights 

maternal outcomes, whereas a second one focuses on child/developmental capacity outcomes 

(Figure 3). The possibility of adverse events (e.g., side effects) and contraindications is 

recognized in each framework. In short, the analytic frameworks outline the various lines of 

logic defining the review’s research questions. But, not all linkages in each analytic framework 

were investigated. 

One criterion established in this review is that each researchable question had to be clinically 

relevant. That is, irrespective of the population of interest, a question had to involve the 

investigation of at least one relevant clinical/pregnancy (i.e., maternal population: Figure 2) or 

developmental (i.e., child population: Figure 3) outcome. Likewise, to be eligible for inclusion 

in the review each study had to entail an investigation of at least one such outcome. Considering 

the purpose of the two-year task order is to afford a clinically-relevant research agenda, this 

decision was judged to be appropriate by both our TEP and our review team. Thus, excluded 

were studies whose sole focus was to examine the impact of omega-3 fatty acid interventions or 

exposures on the omega-3 or omega-6/omega-3 fatty acid content of biomarkers, even if the 

study populations met other eligibility criteria for the present review. 

The questions investigating maternal/pregnancy outcomes refer to clinical events whose 

likelihood might be influenced by the maternal intake of omega-3 fatty acids (i.e., from 

supplementation and/or the diet) and/or which might be associated with specific levels of omega3 fatty acid content (i.e., composition or concentrations) derived from any biomarker type 

obtained from pregnant women (e.g., red blood cells [RBCs]; plasma phospholipids) (Figure 2). 
24

Figure 2. Analytic Framework for omega-3 fatty acids in maternal health. Populations of interest in rectangles. 

Exposure in oval. Outcomes in rounded rectangles. Effect modifiers in hexagons. Solid connecting arrows indicate 

associations and effects reviewed in this report. 

The clinical events constitute the outcomes of interest, and include the shorter-than-term duration 

of gestation, the birth of an infant small for gestational age, or the maternal development of 

preeclampsia, eclampsia, or gestational hypertension. Otherwise “healthy” pregnant women, 

with or without a history of the following, constitute the study populations of interest: 

POPULATIONS OF INTEREST 

“Healthy” pregnant women with or without a history of: 

 a previous preterm birth or a birth of an infant small 

for gestational age, or 

 gestational hypertension, preeclampsia, or eclampsia 

 MATERNAL INTAKE OF OMEGA-3 FATTY ACIDS

 Route of delivery: supplementation and/or diet 

 Type (EPA, DHA, ALA), source (e.g., marine, plant) 

and amount (e.g., dose, serving size) of omega-3 

fatty acid content 

 Length of intervention/exposure 

FATTY ACID CONTENT OF BIOMARKERS 

 Source: mother’s blood 

 Type: e.g., red blood cells 

(erythrocytes), etc. 

 Fatty acid content: EPA, DHA, 

AA, AA/EPA, AA/DHA, 

AA/EPC+DHA

CLINICAL OUTCOMES 

 Duration of gestation 

 Infants born small for gestational age 

 Gestational hypertension, preeclampsia, or 

eclampsia 

 Adverse effects 

EFFECT 

MODIFIERS 

 e.g.,omega-6/omega-3

fatty acid content of

background diet 
25

• a previous preterm birth (i.e., gestational duration less than 37 weeks); 

• preeclampsia, eclampsia or gestational hypertension; or, 

• a previous birth of an infant small for gestational age. 

The questions investigating child outcomes refer to progress along four developmental arcs, 

which might be influenced by the term or preterm child’s intake of omega-3 fatty acids from 

various sources (i.e., mother via the placenta, breast milk, post-delivery formula 

supplementation, and/or from other food sources or supplementation) and/or which might be 

associated with specific levels of omega-3 fatty acid content (i.e., composition or concentrations) 

derived from any biomarker type (e.g., RBCs; plasma phospholipids) or source (i.e., mother; 

child) (Figure 3). 
26

C L IN IC A L O U T C O M E S

EFFECT

M O DIFIERS

P O P U L A T IO N S O F IN T E R E S T

y S o u rc e : m o th e r (e .g ., ve n o u s /u m b ilic a l c o rd ,

plac enta, blood), c hild (e.g., arterial/um bilic al c ord)

y Ty pe: e.g., red blood c ells (ery throc y tes ), etc .

y F atty ac id c ontent: E P A , D H A , A A , A A /E P A , A A /

DHA , A A /E P A +DHA

F A T T Y A C ID C O N T E N T O F B IO M A R K E R S

"H e a lth y " te rm o r p re te rm in fa n ts

C H IL D IN T A K E O F O M E G A -3 F A T T Y A C ID S

y G row th patterns

y N e u ro lo g ic a l d e ve lo p m e n t

y C o g n itive d e ve lo p m e n t

y V is u a l fu n c tio n

y A d ve rs e e ffe c ts

y Tim in g : d u rin g p re g n a n c y vs p o s t-d e live ry

y R o u te o f d e live ry : via u m b ilic a l c o rd & p la c e n ta , m o th e r’s

m ilk , c h ild ’s s u p p le m e n ta tio n (e .g ., fo rm u la ) & /o r d ie t

y Ty pe (E P A , D H A , A LA ), s ourc e (e.g., m other’s m ilk , m arine,

p la n t) a n d a m o u n t (e .g ., d o s e , s e rvin g s iz e ) o f o m e g a -3 fa tty

ac id c ontent

y L e n g th o f in te rve n tio n /e x p o s u re

3⁄4 W ith vs w ith o u t m o th e r’s in ta k e via d ie t & /o r s u p p le m e n ta tio n

d u rin g p re g n a n c y & /o r b re a s tfe e d in g

y e .g ., o m e g a -6 /o m e g a -3

fa tty a cid co n te n t o f

background diet

Figure 3. Analytic Framework for omega-3 fatty acids in child health. Populations of interest in rectangles. 

Exposure in oval. Outcomes in rounded rectangles. Effect modifiers in hexagons. Solid connecting arrows indicate 

associations and effects reviewed in this report. 

At the time they and their breast milk serve as the child’s source of omega-3 fatty acids, mothers 

may or may not have been receiving a supply of omega-3 fatty acids in their diet and/or from 

supplementation. The developmental arcs constitute the clinical-developmental outcomes of 

interest: growth patterns, neurological development, visual development, and cognitive 

development. The child populations of interest include otherwise “healthy” children delivered at 

term or preterm, with data from these populations investigated separately. 
27

Overall, questions pertaining to maternal populations center on the possible preventive, or 

protective, value of omega-3 fatty acid content (i.e., intake and/or in biomarkers) with respect to 

specific pregnancy outcomes. On the other hand, questions regarding child populations concern 

the possible value of omega-3 fatty acid content (i.e., intake and/or in biomarkers) in facilitating 

(e.g., “catching up to,” maintaining, or accelerating) expected or possible types or rates of 

development. Questions relating to adverse effects in both populations are investigated with data 

obtained from interventional/exposure studies meeting eligibility criteria. 

The possible influence of predefined effect modifiers is evaluated in relation to each of the 

questions. Where data permit, question-specific sections titled “Impact of Covariates and 

Confounders” elucidate a) those variables (e.g., intervention/exposure; population) that were 

consistently observed, across reviewed studies, to influence study outcomes as well as b) those 

variables (e.g., caloric/energy intake; smoker status; alcohol consumption), which having been 

controlled for either experimentally or analytically in reviewed studies, were observed to 

consistently influence, or consistently fail to influence, study outcomes. 

Study Identification 

Search Strategy 

The search strategy for this project was designed to be comprehensive and achieve the 

highest possible recall of relevant clinical studies. The electronic search strategy was developed 

by an information specialist in consultation with clinical content experts in child and maternal 

health. The child and maternal health search concept was combined with the core omega-3 fatty 

acids search strategy established in collaboration with the project librarians, biochemists, 

nutritionists, and clinicians from the three EPCs involved in the 2-year, Health Benefits of 

Omega-3 Fatty Acids task order. Consultation among these sources provided the biochemical 

names and abbreviations of omega-3 fatty acids, names of commercial omega-3 fatty acids 

products, and food sources of omega-3 fatty acids. 

The following electronic databases were searched: Medline (1966 - November Week 2 2003 

and updated to February Week 3 2004), Premedline (Dec 13 2003), Embase (1980 to 2003 Week 

50 and updated to 2004 Week 09), the Cochrane Library including the Cochrane Central Register 

of Controlled Trials (3rd Quarter 2003) and CAB Health (1973-Sept 2003). All databases were 

searched via the Ovid interface using Search Strategy 1 (Appendix A∗

), except CAB Health, 

which was searched through SilverPlatter using Search Strategy 2 (Appendix A). Searches were 

not restricted by language of publication, publication type, or study design, except with respect 

to the MeSH term “dietary fats,” which was limited by study design to increase its specificity. A 

total of 2,932 bibliographic records were downloaded, with duplicate records identified and 

removed using citation management software (Reference Manager®). 

Reference lists of included studies, book chapters, and narrative or systematic reviews 

retrieved after having passed the first level of relevance screening, were manually searched to 

identify additional unique references. Through contact with content experts, attempts were made 

 

∗

 Appendices and Evidence tables cited in this report are provided electronically at 

http://www.ahrq.gov/clinic/tp/o3mchtp.htm
28

to identify both published and unpublished studies. On behalf of the three EPCs investigating 

the evidence concerning the health benefits of omega-3 fatty acids, a letter was written to 

industry representatives to obtain additional evidence (Appendix B∗

). Investigators who 

frequently published study reports that were included in the review were contacted to clarify 

which of their reports were companion documents (i.e., multiple reports referring to the same 

study yet where each contains some unique outcome data or unique descriptions of the methods: 

e.g., additional follow-up data) or duplicate documents (i.e., a report which exclusively presents 

data published elsewhere). These informants were also asked to provide citations or copies of 

reports that our searches failed to detect and to identify the study each described. Investigators 

who responded with clarifying information included: Drs. Eileen Birch, Susan Carlson, Maria 

Makrides, Sjurdur Frodi Olsen, and Mary Fewtrell. All of these supplementary efforts to 

identify more evidence identified an additional 18 records that were entered into the collection 

for review. A final set of 2,049 unique references was identified. 

Eligibility Criteria 

Published and unpublished studies, written in any language, were eligible for inclusion. 

Excluding grey literature from systematic reviews of interventions can lead to the overestimation 

of effect sizes.153 Substantial bias in the results of a systematic review pertaining to a 

complementary/alternative medical (CAM) intervention can ensue from the exclusion of data 

from reports written in languages other than English.154 AHRQ and ODS consider omega-3 fatty 

acids to be a CAM exposure. 

To maximize their generalizability, clinical, developmental and biomarker data were required 

from live, otherwise “healthy” human study populations or subpopulations (e.g., genetic, 

minority, ethnic: e.g., diabetic) of any age. For sake of simplicity, we decided to use the generic 

term “child” when referring to infants (less than 12 months of age), toddlers and children up to 

18 years old. Excluded were studies whose biomarker data were solely obtained from aborted 

fetuses because the circumstances associated with or leading to spontaneous or elective abortions 

(e.g., chromosomal abnormalities; non-chromosomal congenital abnormalities) could influence 

the fatty acid status of biomarkers in ways that would preclude an interpretation of these 

observations that is meaningful for the purposes of the present review. Moreover, different types 

of abnormal fetus may exhibit different rates of omega-3 fatty acid accumulation in tissue and/or 

different patterns of tissue-specific omega-3 fatty acid accumulation during gestation, resulting 

in the limited generalizability of the respective data. 

Explicit affirmation of the health status of both the maternal and child populations, as well as 

the preterm/term status of the child populations, had to be provided in study reports. The 

concept of “child” was not predefined, and the impact on outcomes of any idiosyncratic 

definitions could not be evaluated post hoc. To allow the meaningful comparison of results from 

term and preterm infants, age was defined as postconceptional age. Also, if a study did not 

distinguish data obtained from term and preterm births, it was excluded from the review. 

Additional details concerning eligibility criteria (e.g., specific types of population required to 

 

∗

 Appendices and Evidence tables cited in this report are provided electronically at 

http://www.ahrq.gov/clinic/tp/o3mchtp.htm
29

address the research questions) have already been described with reference to the Analytic 

Frameworks, and are not repeated here. Excluded populations were those with peroxisomal 

(e.g., Zellweger’s) disorders since this topic was addressed in SC-RAND’s year-2 review of the 

evidence concerning omega-3 fatty acids in neurology. 

Ideal interventional/exposure studies of newborns might be expected to enroll and expose 

them to sources of omega-3 fatty acids immediately post-delivery so as to have, at least in 

theory, the greatest possible impact on development, and to minimize confounding from earlier 

exposure to other sources of nutrition,. However, neither the exact or requisite timing of the 

onset of the intervention/exposure nor the absence of an intervention/exposure to other sources 

of nutrition (e.g., parenteral feeding in preterm infants) prior to study entry constituted eligibility 

criteria. Plans were nevertheless made to explore, where data would permit, the possible impact 

of these factors on outcomes. 

No restrictions on the length or number of followups with respect to either study population 

were pre-established. Yet, given the dynamic nature of development, ideal studies of children 

might be thought to include multiple followups conducted at least according to expected 

developmental milestones specific to the four types of developmental arc of interest to the 

present review. 

Interventional/exposure studies had to specifically investigate foods or supplements known to 

contain omega-3 fatty acids of any type (e.g., EPA, ALA), from any source (e.g., mother’s milk, 

fish, walnuts, seed oil), any serving size or dose, delivered in any fashion (e.g., breastfeeding, 

capsules, liquid, LCPUFA-rich diet), and for any length of time. In all studies, some method had 

to have been employed to suggest the presence of omega-3 fatty acid content in the exposure, if 

not its actual amount (e.g., g/d). Studies investigating “PUFAs” or “ LC PUFAs,” or even types 

of diet one might presume would contain marine or land sources of omega-3 fatty acids (e.g., 

“Mediterranean diet”) at minimum had to highlight at least one source of the omega-3 fatty acid 

content (e.g., oily fish servings). No restrictions were placed on the types or doses of pre- or onstudy cointerventions (e.g., omega-6 fatty acid intake, other dietary supplements). While omega6 fatty acids appear to play a key role in health and development, and their possible co-influence 

on outcomes is thus assessed in our review, studies exclusively investigating their impact on 

health outcomes are excluded. A table placed at the end of this report summarizes the content of 

the fatty acids (and other constituents) in the various types of infant formula provided as 

supplementation in the included studies. 

Randomized controlled trials (RCTs) are the gold standard method to investigate questions of 

intervention efficacy or effectiveness.155 and were sought to address the research questions. If at 

least two RCTs were identified, no other types of design were required. Yet, if insufficient 

numbers of RCT were retrieved, non-RCT (i.e., controlled clinical trials, without random 

allocation) and observational studies were included. Excluded from this review were descriptive 

study designs, however (i.e., noncomparative case series; case studies). 

RCTs exhibit a greater inherent potential to deal with potentially serious biasing influences 

(e.g., selection bias) although a poorly designed or conducted RCT can produce results whose 

interpretability is no less complicated by the presence of confounding influences, for example, 

than observations derived from a well-constructed and conducted study employing a design with 

a lesser intrinsic capacity to control for these biases (e.g., non-RCT; prospective cohort study). 

For example, not all intervention RCTs succeed, either through an explicit experimental plan or 
30

the process of randomization per se, to equally distribute known confounding influences (e.g., 

background diet; energy/caloric intake from the intervention) across their respective study 

groups. 

That said, questions concerning the impact on child developmental outcomes of omega-3 

fatty acid intake via formula supplementational alone, or formula supplementation given in 

addition to breast milk, could be investigated exclusively by RCT evidence. Other questions 

required the inclusion of observational study evidence (e.g., maternal intake of omega-3 fatty 

acids, and child developmental outcomes; the role of biomarkers). The observational studies 

included cross-sectional designs, which by virtue of the lack of temporal separation in their 

assessments of exposure and outcome, constitute the weakest evidence when it comes to 

suggesting causal relationships. 

Any definition of control or comparator was permitted in the controlled studies (e.g., DHA 

versus olive oil placebo). However, not every control or comparator group constituted the most 

appropriate one. For example, with women in a study permitted to choose either to breast- or 

formula-feed their child, selection bias makes the analyzed comparison of the outcomes from 

these two groups difficult to interpret unequivocally. The breatfeeding group cannot be 

construed as the most appropriate control, even though some manufacturers of formula 

supplementation have attempted to match their fatty acid contents and other constituents to what 

is contained in human breast milk. 

Designs potentially affording less equivocal interpretations include women, having chosen 

not to breastfeed their children, being randomized to receive formula supplementation either with 

or without omega-3 fatty acid content. These data would be eligible for inclusion in one type of 

meta-analysis in our review. Often, as stated earlier, these designs can also include women who 

exclusively chose to breastfeed their children. However, data from the breastfed children in such 

studies are exclusively used here as a possible reference standard, or comparison group, yet 

whose data are not entered into possible meta-analysis as control observations. Another type of 

design potentially affording less equivocal interpretations involve women, having chosen to 

exclusively breastfeed their children, who are then randomized to receive formula 

supplementation either with or without omega-3 fatty acid content. These data would be eligible 

for an independent meta-analysis. 

The specific pregnancy outcomes were identified with reference to the Analytic Frameworks. 

Any and all child developmental outcomes reflecting the four categories of developmental arc 

were considered relevant. As markers of omega-3 fatty acid metabolism, the following fatty acid 

compositions or concentrations, from any source (e.g., red blood cell [RBC] membranes, plasma 

phospholipids), were considered relevant: EPA, DHA, AA/EPA, AA/DHA, AA/EPA+DHA. 

Studies exclusively evaluating the role of other biomarkers (e.g., cytokine production, eicosanoid 

levels), including preconditions (e.g., specific PG levels) often thought to be associated with our 

review-relevant clinical outcomes (i.e., the development of preeclampsia), were not included. 

These decisions were made with the assistance of our TEP. 
31

Study Selection Process 

The present review employed specific electronic functionality in the form of an internetbased software system, housed on a secure web site. It brings appreciable efficiencies to the 

systematic review process and the management of a systematic review team. Electronic yields of 

literature searches are posted to the system for review. Reviewers then submit all of their results 

of relevance screening, data appraisal or data abstraction directly to the system. The software 

system automatically conducts an internal comparison of multiple reviewers’ responses to 

screening questions, to determine the eligibility/relevance of a bibliographic record or a full 

report. As well, the software captures responses to specific requests to abstract pre-specified 

data (e.g., mean age of study participants; the assessment of a study’s internal validity) from 

pertinent reports. One large advantage associated with using this software is that review team 

members are able to complete their work from wherever they have internet access. 

Following a calibration exercise, which involved screening five sample records using an 

electronic form developed and tested especially for this review (Appendix C∗), two reviewers 

independently screened the title, abstract, and key words from each bibliographic record for 

relevance by liberally applying the eligibility criteria. A record was retained if it appeared to 

contain pertinent study information. If the reviewers did not agree in finding at least one 

unequivocal reason for excluding it, it was entered into the next phase of the review. The 

reasons for exclusion were noted using a modified QUOROM format (Appendix D).156 The 

screening process also aimed to identify the exact child and maternal health question a record 

addressed, in addition to determining whether it might also or instead pertain to any of the other 

topics being systematically reviewed by the three EPCs in year 2 of the omega-3 fatty acids 

project. 

Print or electronic copies of the full reports for those citations having passed level one 

screening were then retrieved. After completing a calibration exercise which involved 

evaluating five sample reports using the same eligibility criteria (Appendix C), the rest of the 

reports were independently assessed by two reviewers. Reports were not masked given the 

equivocal evidence regarding the benefits of this practice.157 To be considered relevant at this 

second level of screening, all eligibility criteria had to be met. A third level of dual-review 

screening aimed to exclude studies whose designs were not required to investigate the research 

questions (see Eligibility Criteria). All the levels of evidence were reviewed and when there 

were at least one study to address a given question, it was included regardless of the level of 

evidence. However, if there were at least two RCTs addressing the question, lower level of 

evidence reports were excluded (see list of excluded observational trials in Appendix F). 

Disagreements arising either at screening levels 2 or 3 were resolved by consensus and, if 

necessary, third party intervention. Excluded studies at each of these levels are noted as to the 

reason for their ineligibility in listings found at the end of this report. 

 

∗

 Appendices and Evidence tables cited in this report are provided electronically at 

http://www.ahrq.gov/clinic/tp/o3mchtp.htm
32

Data Abstraction 

Following a calibration exercise involving two studies, 11 reviewers independently 

abstracted the contents of included studies using an electronic Data Abstraction form developed 

especially for this review (Appendix C∗). A second reviewer then verified these data. Data 

abstracted included the characteristics of the: 

• report (e.g., publication status, language of publication, year of publication); 

• study (e.g., sample size; research design; number of study arms/groups, cohorts, or phases; 

funding source); 

• population (e.g., preterm versus term status); 

• intervention/exposure (e.g., omega-3 fatty acid types, sources, doses, and 

intervention/exposure length), and comparator(s); 

• cointerventions (e.g., omega-6 fatty acid use); 

• withdrawals and dropouts, including reasons; 

• clinical outcomes; 

• fatty acid content of biomarkers; and, 

• adverse events (e.g., side effects). 

Summarizing the Evidence 

Overview 

The evidence is presented in three ways. Evidence tables in the Appendices offer a detailed 

description of the included studies (e.g., study design, population characteristics, 

intervention/exposure characteristics [e.g., omega-3 fatty acid types and doses], cointervention 

[e.g., background diet]), with a study represented only once. These tables are organized by 

research design (Evidence Table 1: RCTs; Evidence Table 2: observational studies), with studies 

arranged alphabetically within each of the two table/design categories. 

Question-specific summary tables embedded in the text describe each study addressing a 

given question in abbreviated fashion, highlighting some key characteristics, including sample 

size (as measure of the “weight” of the evidence and possible precision of the results), dose and 

type of omega-3 fatty acids, and comparators’ (i.e., comparison groups’) specifications. This 

affords a comparison of all studies addressing a given question. A study can appear in more than 

one summary table since it can address more than one research question. Also question-specific 

is each summary matrix, situating each study in terms of its study quality and its applicability. 

 

∗

 Appendices and Evidence tables cited in this report are provided electronically at 

http://www.ahrq.gov/clinic/tp/o3mchtp.htm
33

Study Quality 

Study quality refers to the internal validity, or methodological soundness, of a study. A 

systematic review can be faced with great variability in the quality of its included studies. Our 

approach is not to use a minimal level of quality as an inclusion criterion since this precludes 

assessing the possible impact of study quality on study results. 

A study with low quality can make it difficult to clearly and meaningfully interpret its results, 

that is, to unequivocally attribute a significant observed benefit exclusively to an 

intervention/exposure (as opposed to other factors). Since definitions, or standards, of study 

quality can depend on the type of research design, different constructs were selected to evaluate, 

from study reports, the quality of RCTs and studies employing other types of research design. 

After a calibration exercise involving two studies with an RCT design, two assessors 

independently evaluated study quality. Disagreements were resolved via forced consensus. In 

the case of designs other than RCTs, a single quality assessor performed the evaluations. Time 

did not permit their dual assessment. 

Four fundamental quality constructs from two instruments were used to rate the internal 

validity of RCTs. These tools were chosen collectively by the three EPCs involved in the 2-year 

task order because they have been validated. The Jadad items158 assess the reporting of 

randomization, double blinding, and, withdrawals and dropouts (Appendix C∗). Total scores 

range from 0 to 5, with a score less than 3 indicating low quality. The reporting of the 

concealment of a trial’s allocation to treatment159 yields three grades (A = adequate; B = unclear; 

C = inadequate) (Appendix C). 

The assessment of the quality of studies using designs other than RCTs is complicated by the 

dearth of validated instruments and the variety of such designs (e.g., non-randomized controlled 

trials; uncontrolled studies). Nevertheless, a recent systematic review by Deeks et al. identified 

a number of “best tools” for use with these designs.160 Among them was a published instrument 

developed by Downs and Black161 and an unpublished albeit validated instrument derived by 

experts in Newcastle and Ottawa (NOS).162 The former validated both design-specific and 

design-neutral items. 

Where case-control studies were included in the review, the validated NOS was employed. 

Items applicable to cross-sectional designs were taken from the Downs and Black instrument; or, 

if the required constructs were not operationalized in this instrument, they were developed as 

modifications of existing NOS items (e.g., single prospective cohort studies).(Appendix C). 

It should be noted that the items defining the case-control assessment tool from the NOS 

were used as a whole, although specific guidelines as to which total score indicates either low or 

sound quality are unavailable. Likewise, no guidelines exist to mark low or sound study quality 

based on any subset of Downs and Black’s 27-item instrument. As already asserted, an Jadad 

total quality score of less than 3 indicates low quality. To permit the entry of these quality data 

into a summary matrix, cutpoints for each type of design were set somewhat arbitrarily to 

establish three levels of internal validity (see Summary Matrix). 

 

∗

 Appendices and Evidence tables cited in this report are provided electronically at 

http://www.ahrq.gov/clinic/tp/o3mchtp.htm
34

It was decided by our review team that, given the limitations of space, especially in printbased study reports, and the amount of detail that would likely be required to provide all of the 

details we needed to fully establish that only appropriate methods had been used to extract, 

prepare, store and analyze lipid content, it was reasonable to appraise these methods by focusing 

instead on identifying extant descriptions of inappropriate methods. On occasion, the 

inappropriateness of methods had to be determined by reference to standard protocols. 

Pilot-tested exclusively for their ease of use within the data abstraction form were questions 

designed to informally assess the successful control of study confounding from variables 

identified by content experts as potential threats to the internal validity of studies pertinent to the 

review. In their view, these variables required experimental or statistical control to permit an 

uncomplicated interpretation of study results (Appendix C∗

). The two major categories of threat 

in controlled designs came from having study groups vary in terms of key prestudy or baseline 

characteristics (e.g., background diet), or from having certain on-study changes (e.g., unexpected 

illness) unrelated to the exposure or intervention, occur unequally across study groups to produce 

confounding. Even RCTs are not immune to being influenced by these threats to internal 

validity. 

For example, if in a placebo-controlled RCT test of the supplemental treatment efficacy of 

omega-3 fatty acids, only certain treatment group members’ background diets changed 

appreciably from what was observed at baseline (e.g., decreased fish intake and thus an increased 

omega-6/omega-3 ratio in the background diet), at which point the two study groups’ baseline 

diets had been deemed comparable, then this on-study inequality could influence study 

outcomes. Because of this change in background diet, one study group might all of a sudden be 

receiving a different ratio of omega-6/omega-3 fatty acid intake than what had been set in the 

study protocol. This would amount to a change in the planned, on-study between-group 

difference in omega-6/omega-3 fatty acid intake; and, it is this intake ratio which could have the 

greatest influence on clinical outcomes. In general, contraventions of planned on-study betweengroup equivalences (e.g., caloric/energy intake; background diet; current smoker status; alcohol 

consumption) or of planned, on-study between-group differences (e.g., amount of omega-3 fatty 

acid intake) related to events other than the intervention/exposure (e.g., stressors, which can alter 

participants’ patterns of eating, smoking, and alcohol consumption), that is, in variables with the 

potential to affect child and maternal health outcomes (and biomarker levels), could either 

“mask” or incorrectly “reveal” clinical benefits of the intervention depending on the groups in 

which these unexpected changes occurred. Then, unless statistical adjustments are made, such a 

scenario will complicate the meaningful interpretation of outcomes. 

These informal assessment items were modified to assess single group studies since on-study 

changes involving the same key variables can also complicate the interpretation of their study 

results. However, no quality scores were derived from the data abstractors’ responses to these 

questions pertaining to controlled or uncontrolled studies. 

 

∗

 Appendices and Evidence tables cited in this report are provided electronically at 

http://www.ahrq.gov/clinic/tp/o3mchtp.htm
35

Study Applicability 

As specified in the scope of work for this series of evidence reports on the health benefits of 

omega-3 fatty acids, the primary focus is on the US population. Given the geographical location 

of the UO-EPC, however, the definition of study applicability was expanded slightly to include 

Canada as part of a larger North American context. This study’s reference point became the 

“typical” North American. 

Also known as external validity, or generalizability, the construct of applicability refers to 

the degree to which a given study’s sample population is sufficiently representative of the 

population to which one wishes to generalize its results. In the present review, two schemes 

operationally defined applicability (Appendix C∗). One assessed studies involving at least one 

otherwise “healthy” maternal population, with the other evaluating studies involving at least one 

otherwise “healthy” maternal population with a known elevated risk for a particular pregnancy 

and/or infant outcome. 

With regards to the highest level of applicability (Level I) in the first scheme, the broadest 

definition of the population of interest is the otherwise “healthy” North American (or similar 

individual), drawn from a somewhat broad socio-demographic spectrum (i.e., age, race), and 

who eats a diet “typical” of a broad spectrum North American population (e.g., with an estimated 

omega-6/omega-3 intake ratio of at least 15: see below for references). For Level I applicability 

in the second scheme, the broadest definition of the population of interest is the otherwise 

“healthy” North American (or similar individual), at known risk for a particular pregnancy 

and/or infant outcome perhaps because of a similar past occurrence, representing a somewhat 

broad socio-demographic spectrum (i.e., age, race), and eating a diet “typical” of a broad 

spectrum North American population (e.g., with an estimated omega-6/omega-3 intake ratio of at 

least 15). Together, these level I definitions represent the respective reference points, with 

applicability decreasing as the definition of the sample study population narrows in terms of the 

factors represented in the two schemes. 

Operationalized ideally in this review as the omega-6/omega-3 fatty acid ratio, background 

diet may be an important factor in assessing both types of study population (i.e., no known risk 

versus known risk). Given the competitive relationship between omega-3 and omega-6 fatty 

acids, both for enzymes to yield key metabolites with specific effects in the human biosystem 

(see Chapter 1) and for positions in cell membranes from which to have these and other possible 

influences (e.g., clinical prevention), the absolute and relative intake of omega-3 and omega-6 

fatty acids from all sources, and not just from the identified exposure, likely need to be taken into 

account when deciding whether populations assessed in different studies are comparable. The 

likelihood of biological and/or clinical effects in studies may turn out to vary depending on these 

absolute or relative intake values. A high background dietary omega-6/omega-3 fatty acid intake 

ratio—potentially reflected in a corresponding differential in these contents in cell membranes—

may make it harder for omega-3 fatty acid supplementation to make a clinically meaningful 

difference,163 although already having considerable omega-3 fatty acid content in the background 

diet and in cell membranes because of a low omega-6/omega-3 fatty acid intake ratio may make 

 

∗

 Appendices and Evidence tables cited in this report are provided electronically at 

http://www.ahrq.gov/clinic/tp/o3mchtp.htm
36

it difficult for typically small amounts of omega-3 fatty acid supplementation to make a 

clinically meaningful difference (see Discussion). 

Irrespective of which of these hypotheses may be eventually confirmed elsewhere, the fact 

that national, and sometimes regional, populations can vary in terms of their diet’s omega6/omega-3 fatty acid intake ratio strongly suggests that this potential confounding influence on 

study outcomes needs to be represented in the applicability schemes whereby the North 

American value is the reference point. The typical North American diet contains an omega6/omega-3 fatty acid intake ratio of at least 15, whereas urban India and Japan’s corresponding 

values are 38-50 and 4, respectively.152,164-175

UK populations represent somewhat of a special case in that, while they can exhibit sociodemographic pictures similarly broad to the ones seen in North American study populations, 

their somewhat different lifestyle and background diet recommended an applicability value of 

“II.” However, if participants were drawn from a narrower UK population, then a “III” was 

assigned. One assessor evaluated study applicability. 

Summary Matrix 

For a given research question, and where possible (e.g., more than one study addressing the 

question), a summary matrix situates the pertinent studies in terms of their respective study 

quality (internal validity) and applicability (external validity) values. The Jadad total quality 

score defined RCTs’ internal validity in summary matrices. A three-level format was derived 

from the range of possible RCT quality scores (A = Jadad total score of 4 or 5; B = Jadad total 

score of 3; C = Jadad total score of 0, 1 or 2). Given that allocation concealment scores have in 

the past tended to vary less widely than Jadad total scores, allocation concealment values were 

entered as superscripts in the summary matrices.163 A similar approach was taken for the studies 

employing other research designs. The following cutpoints were established, albeit without 

benefit of a validational exercise: 

• case-control study (NOS): A = 9-12; B = 5-8; C = 1-4; 

• (multiple-group) cross-sectional study: A = 8-11; B = 5-7; C = 1-4; and, 

• single prospective cohort study (Modified NOS): A = 8-10; B = 4-7; C = 1-3. 

The three-level applicability format was established by the 3 EPCs involved in the 2-year 

project for practical reasons, to permit the incorporation of quality scores within a summary 

matrix. Studies assigned an “X” (i.e., insufficient information to establish applicability) were 

excluded from summary matrices. 

Qualitative Data Synthesis 

An overarching qualitative synthesis describes the progress of each citation, then report, 

through the stages of the systematic review. It also highlights certain report and study design 

characteristics of included studies (e.g., distributions of research design by research question). 

Then, for each question, a separate qualitative synthesis is derived for included evidence, 
37

organized by broad categories of research design (i.e., RCTs vs observational studies). A brief 

study-by-study overview typically introduces the synthesis, followed by a narrative summary of 

the key defining features of relevant studies (e.g., inclusion/exclusion criteria), including their 

populations (e.g., diagnosis-related), intervention/exposures (e.g., types of omega-3 fatty acid), 

cointerventions (e.g., psychotropic medication), outcomes, study quality, applicability, and 

results. Whether or not data can be organized according to these subheadings depends on the 

number of studies addressing a given question and the amount or variety of detail available in the 

study reports. For example, having identified too few studies per research question that exhibit 

significant effects for a given clinical outcome can preclude determining the impact of 

covariables with the potential to modify or confound study results (e.g., type or dose of omega-3 

fatty acids). 

Juxtaposing, in turn, all pertinent studies’ parameters for a given research question has two 

key consequences. It allows us to identify the “gaps” in knowledge deemed crucial by content 

experts to understanding the clinical phenomenon (e.g., efficacy of omega-3 fatty acids). That is, 

data regarding possible confounders may be lacking, making it difficult to interpret study results 

with unfettered confidence. These gaps point to those variables requiring measurement and 

experimental or statistical control in future research. Second, it affords an understanding of the 

definition and extent of the included studies’ clinical homogeneity (i.e., population, intervention, 

cointervention, outcome), which can then inform decisions regarding the appropriateness of 

meta-analysis. Where strong clinical heterogeneity is observed, it may be important to forego 

meta-analysis because the “population” to which any point estimate, and its measure of 

precision, might be extrapolated may not exist per se; it, too, is synthetic (e.g., the “average” 

preterm infant). Subject to scrutiny in the evaluation of cross-study clinical homogeneity is the 

ability of each study to control for confounding influences and yield results that can be 

interpreted without serious question marks. The existence of statistical heterogeneity also plays 

a role in the decision to do without a quantitative synthesis. Whether or not meta-analysis is 

considered appropriate, an attempt is made to make sense of the possible influence of covariates 

and confounders within the context of the qualitative synthesis. 

Where eligibility criteria permit, evidence from research designs with a lesser inherent 

potential to control for biasing influences are used to see whether, collectively, they confirm the 

picture of efficacy, or association, derived from designs with a greater inherent potential to 

achieve this goal (e.g., RCTs: see Eligibility Criteria). For the purposes of interpreting results, 

greater emphasis is placed on the latter, with “greater emphasis” meaning that we assign greater 

interpretative, not numerical or statistical, weight to these intrinsically stronger designs. Factors 

other than study design also taken into account in interpreting results include study quality, the 

number of studies, and whether studies were sufficiently powered. 

Quantitative Data Synthesis 

Meta-analysis was conducted providing there was a clearly defined population to which to 

generalize the synthetic result (and its precision). Given its greater potential to control for 

possible confounding factors, only RCT evidence regarding the question of 

efficacy/effectiveness was considered for inclusion in meta-analysis. Details concerning certain 

study design requirements for entry into meta-analysis are presented in the Eligibility Criteria 
38

section (see above), and are not repeated here. All things being equal, it was also assumed that 

priority in meta-analysis should be given to clinical outcomes evaluated using validated 

measures pertinent to the present day practice of medicine (e.g., respective Bayley’s scales for 

neurological and cognitive development). 

The inclusion criteria to conduct meta-analysis were: 

1. at least two RCTs; 

2. same population characteristics (mean age, health status, gender); 

3. same co-interventions; 

4. same intervention based on the type of omega-3 FA supplemented (DHA+AA vs. DHA 

vs. DHA+EPA, etc.) regardless of the daily dose in the child population; 

5. same comparator based on source of placebo (e.g., olive oil, unsupplemented formula); 

6. outcomes relevant to respond the key-questions: percentage (n) of premature deliveries, 

incidence of GHT, pre-eclampsia or eclampsia, incidence of IUGR or SGA infants, 

weight, length and head circumference of infants (means), neurological and cognitive 

development measured by validated scales (e.g., Bayley’s Develomental Scale score), 

and visual acuity or visual function of infants measured by appropriate tests (Teller’s 

Card test, etc.). 

Insufficient numbers of study with comparable populations, interventions, interventioncomparator contrasts or outcomes precluded the conduct of a) many planned meta-analyses; b) 

planned subgroup analyses involving virtually all of the predefined covariables with the 

presumed potential to influence pertinent clinical-developmental outcomes (e.g., source, type or 

dose of omega-3 fatty acids); and c) planned sensitivity analyses investigating the possible 

impact of study quality and publication bias on clinical-developmental outcomes. 

Decisions regarding statistical models and related issues such as statistical heterogeneity are 

provided where results of meta-analysis are reported. 
39

Chapter 3. Results 

Results of Literature Search 

Regardless of its source, the progress of each bibliographic record through the stages of the 

systematic review is illustrated in the modified QUOROM flow chart (Appendix D∗). Ideally, a 

record included an abstract and key words, in addition to a citation. When a citation was 

discovered, for example, through a manual search of a reference list, its complete bibliographic 

record was sought (e.g., PubMed®) and then entered into the first level of relevance screening. 

Of the 2,049 records entered into the initial screening for relevance, 1,579 were excluded. 

Reflecting the specific eligibility criteria, the reasons for exclusion were: a. did not involve 

human participants (n=301); b. did not involve omega-3 FAs as an exposure/intervention 

(n=827); c. the purpose of the exposure/intervention was not for the assessment of child or 

maternal health outcomes (n=253); and, d. not a primary study (e.g., a review; n=198). All of the 

remaining 470 reports were then retrieved and subjected to a more detailed relevance assessment. 

The second relevance screening then excluded 279 reports for the following reasons: a. did not 

involve human participants (n=15); b. did not involve omega-3 FAs as an exposure/intervention 

(n=101); c. the purpose of the exposure/intervention did not concern maternal or childhood 

health outcomes (n=69); and, d. not a primary study (e.g., a review; n=76). There were an 

additional number of reports not retrieved at this level (n=18). The third relevance screening 

took into the account the level of evidence appropriate to answer each question. A list of 

excluded due to level of evidence (i.e., observational studies) studies for each topic is included in 

the Appendix F. Of the 191 reports that made it to this level of screening, 74 were excluded. 

Hence, in total, 117 reports, describing 89 unique studies, were deemed relevant for the 

systematic review, with 20 studies each described by more than one report and three reports 

describing more than one unique study. 

The 20 unique studies reported by more than one report were: Agostoni et al.176 (Agostoni et 

al.177,178), Al et al. 1995179(Al et al.180), Auestad et al.,104 (Scott et al.104, Auestad et al.181), Birch 

et al.182 (Birch et al.,183 Hoffman et al.184), Carlson et al.185 (Werkman et al.,186 Carlson et al.187-

190), Carlson et al.191 (Carlson et al.192), Clandinin et al.193 (secondary reports194,195), de Groot et 

al.,196 (de Groot et al.197), Faldella et al.198 (Faldella et al.199), Helland et al.,141(Helland et al.200), 

Innis et al.201 (Diersen-Schade et al.202), Jensen et al.203 (Voigt et al.204), Makrides et al.205

(secondary report206), O’Connor et al.207 (secondary report208), Olsen et al.209 (Olsen et al.,210

Salvig et al.211), Uauy et al.212 (Uauy et al.,213 Hoffman et al.,214,215 Birch et al.,216 Uauy et al.,217), 

Vanderhoof et al.218 (Vanderhoof et al.219,220), Vilbergsson et al.221 (secondary report222), Willatts 

et al.223 (secondary report224), Woltil et al.225 (secondary report226). 

Auestad et al.227 that included two uniques studies as well as Birch et al.228 Olsen et al. 

reported 6 unique trials.31 

 

∗

 Appendices and Evidence tables cited in this report are provided electronically at 

http://www.ahrq.gov/clinic/tp/o3mchtp.htm
40

Report and Study Design Characteristics of Included Studies 

Of the 117 relevant reports describing 89 unique studies, there were 63 randomized 

controlled trials (RCTs) and 26 observational studies across all the key questions. As an 

overview, the number of included studies investigating each question are described below, 

distinguishing the reports by population type (maternal, preterm or term infants), by intake of 

omega-3 FA supplements, or by research design. Since a given study may address more than 

one question, some studies may be described for more than one question. 

Only one study required translation from German to English.229

Fifteen uniques studies investigated the influence of omega-3 FAs during pregnancy on the 

duration of gestation.141,196,209,230,231,231-235 All reports were RCTs since we had decided to 

exclude other research designs if enough well-conducted RCTs were identified. Eight RCTs 

evaluated the question regarding the influence of maternal intake of omega-3 FA during 

pregnancy on the incidence of gestational hypertension (GHT), pre-eclampsia or 

eclampsia,209,230,234,236-238 whereas, 14 RCTs assessed the outcome of incidence of infants small 

for gestational age (SGA).141,196,209,230-236,238 

Regarding the question of the association between the duration of gestation in women with or 

without a history of a previous preterm birth with the omega-3 or omega-6/omega-3 FA content 

of maternal biomarkers during pregnancy, four studies were identified—one RCT,234 one casecontrol study,239 one single prospective cohort study,240 and one cross-sectional study.241 Five 

observational studies addressed the question of the association between maternal biomarkers and 

the incidence of GHT, pre-eclampsia or eclampsia—one was a prospective cohort study179 and 

four were of cross-sectional design.229,242-244 Whereas, one RCT,196 two case-control 

studies,245,246 one single prospective cohort study240 and two cross-sectional studies241,247 were 

identified that addressed the possible association between the incidence of SGA infants and the 

omega-3 or omega-6/omega-3 FA content of maternal biomarkers during pregnancy. 

No studies were identified across all the child outcomes (i.e., growth patterns, neurocognitive 

development and visual function) regarding the influence of the intake of omega-3 FA from 

sources other than human milk, or infant formula. 

Only one RCT was identified to answer the question of maternal intake of omega-3 FA 

during pregnancy and its influence of the growth pattern in term and preterm infants.141 One 

RCT,248 one prospective cohort study,249 and one cross-sectional study addressed the question of 

the influence of omega-3 FA content of human milk, with or without known maternal intake, on 

growth patterns in term infants. No studies were identified that addressed this question in the 

preterm population. Twenty RCTs investigated the influence of omega-3 FA content in formula, 

with or without human milk intake, on the growth patterns in preterm 

infants,185,193,198,201,207,212,218,225,250-259 whereas, 18 RCTs were conducted in term 

infants.104,182,203,205,223,227,260-270

No studies were identified regarding the association between the omega-3 or omega6/omega-3 FA content of maternal or fetal biomarkers during pregnancy and the growth patterns 

of term or preterm infants. However, a total of 12 studies addressed the question of child 

biomarkers, of which five RCTs included a preterm population of infants,185,191,201,207,212 and five 
41

RCTs143,203,205,262,263 and one prospective single cohort study271 included a term population of 

infants; the Woltil et al. study, which was deliberately described only in the preterm section of 

this question, selected a group of very low birth weight (VLBW) preterm and term infants.225

Only one RCT was identified to answer the question of maternal intake of omega-3 FA 

during pregnancy and its influence on the neurological development in term and preterm 

infants.141 One RCT138 and one prospective cohort study evaluated the influence of omega-3 FA 

content of human milk, with or without known maternal intake, on the neurological development 

in term infants. No studies were identified in the preterm population for this particular question. 

Six RCTs investigated the influence of omega-3 FA content in formula, with or without human 

milk intake, on the neurological development outcomes in preterm infants,193,207,254,270,272,273

whereas, eight RCTs were conducted in term infants.104,176,182,203,205,227,227,265

One cross-sectional study conducted in the United States assessed the association between 

maternal omega-3 FA content during pregnancy and the neurological development of the 

infants.274 No studies were identified to assess the association between the neurological 

develoment in term or preterm infants and the omega-3 or omega-6/omega-3 FA content of fetal 

biomarkers during pregnancy. However, four RCTs176,182,203,205 and one prospective cohort 

study271 investigated this association, but in child biomarkers. 

One RCT235 and one cross-sectional study275 evaluated the question of maternal intake of 

omega-3 FA during pregnancy and its influence on the visual function in term and preterm 

infants. Two RCTs,138,248 one prospective cohort276 and one cross-sectional study140 evaluated 

the influence of omega-3 FA content of human milk, with or without known maternal intake, on 

the visual function in term infants. No studies were identified in the preterm population for this 

particular question. Nine unique RCTs investigated the influence of omega-3 FA content in 

formula, with or without human milk intake, on visual function outcomes in preterm 

infants,185,191,198,201,207,212,251,254,272 whereas, 13 RCTs were conducted in term 

infants.104,182,203,205,227,262-264,266,269,270,277

One cross-sectional study assessed the association between maternal omega-3 FA content 

during pregnancy and the visual function of the infants.275 No studies were identified to assess 

the association between visual function in term or preterm infants and the omega-3 or omega6/omega-3 FA content of fetal biomarkers during pregnancy. However, 21 studies investigated 

this association in child biomarkers. Five studies included a preterm population,185,198,212,278,279

whereas, 16 studies included term infants. Of five studies in the preterm group, three were 

RCTs185,198,212 and two were cross-sectional studies.278,279 Of the 16 term infant studies, nine 

were RCTs138,182,203,248,262-264,269,270 and seven were observational studies.140,271,275,278,280-282 

One RCT283 evaluated the question of maternal intake of omega-3 FA during pregnancy and 

its influence on the cognitive development outcomes in term and preterm infants. One RCT138

and one single prospective cohort study284 evaluated the influence of omega-3 FA content of 

human milk, with or without known maternal intake, on the cognitive development of term 

infants. No studies evaluated this outcome in preterm infants. 

Six RCTs investigated the influence of omega-3 FA content in formula, with or without 

human milk intake, on the cognitive develoment in preterm infants,185,193,207,258,272,273 while eight 

RCTs were conducted in term infants.104,182,203,205,223,227,265 No studies were identified that 

evaluated the association between the omega-3 FA content of maternal or fetal biomarkers 
42

during pregnancy and the cognitive development outcomes. However, six studies addressed the 

question of child biomarkers. Four studies were RCTs138,182,203,205 and two were single 

prospective cohort studies.271,285

All of the RCT’s were evaluated for safety data. In addition, two other RCTs, although not 

providing efficacy data, did provide safety data and hence were also evaluated.286,287

The remainder of this chapter is organized by group of outcomes (pregnancy, growth, 

neurological, visual and cognitive), with the evidence addressing each of the key questions 

related to the type of intake, where at least one study was identified. Safety data is presented 

last. A table describing the composition of the interventional infant formulas used across the 

trials was added to Appendix G∗

. We begin with pregnancy outcomes. 

Pregnancy Outcomes 

What is the Evidence That Intake of Omega-3 Fatty Acids Influences 

the Duration of Gestation in Women With or Without a History of a 

Previous Preterm Birth (Gestational Duration Less Than 37 Weeks)? 

Fifteen RCTs met eligibility criteria for investigating a possible influence of maternal intake 

of omega-3 FA supplementation on the duration of gestation.141,196,209,230,231,231-235 The studies 

were published between 1992 and 2004 (see Summary Tables 1 to 3). 

Overview of relevant studies 

Olsen et al. investigated the effect of n-3 LCPUFA supplementation given as fish oil in 533 

women with singleton pregnancies in their 30th week of pregnancy (mean age=29 [18-44] years, 

smokers [31.2%], primiparae [59%]) on pregnancy duration.209 The women were randomally 

assigned to one of three three diet regimens: daily intake of four 1 g capsules of fish oil (Pikasol) 

containing EPA (32 % by weight [wt%]) and DHA (23wt%) corresponding to 2.7 g omega-3 FA 

daily intake; four 1 g capsules of olive oil daily each containing oleic acid (72wt%) and LA 

(12wt%); or, no supplement.209 (Summary Table 1) 

Bulstra-Ramakers et al. investigated the effect of dietary supplementation with EPA on the 

incidence rate of premature deliveries and GHT in 68 pregnant women (68 completed the study) 

with or without a previous history of prematurity or GHT.238 The intervention consisted of EPA 

capsules (each containing a mixture of 0.25 g EPA and DHA) in a daily dose of 3 g of EPA (four 

capsules three times per day). The placebo capsules, which were similar to the EPA capsules in 

appearance, smell, and taste, contained coconut oil. The interventions started between 12 and 14 

weeks of GA.238 (Summary Table 1) 

 

∗

 Appendices and Evidence tables cited in this report are provided electronically at 

http://www.ahrq.gov/clinic/tp/o3mchtp.htm
43

Onwude et al. conducted an intention-to-treat (ITT) RCT to evaluate the effect of omega-3 FA 

(EPA/DHA) on the occurrence of proteinuric and nonproteinuric gestational hypertension (GHT) 

and asymmetrical intrauterine growth retardation (IUGR) in 233 pregnant women (232 

completed the study; age range=16–40 years; mean gestational age (GA) at study entry=24 [18–

32] weeks) at high-risk for developing these disorders.233 GA was a secondary outcome measure 

for this study. The participants study were categorized as being multigravida, a history of one or 

more small babies (n=68), history of proteinuric or nonproteinuric GHT (n=76), history of 

unexplained stillbirth (n=16), and primigravida with abnormal uterine arcuate artery Doppler 

blood flow at 24 weeks GA (n=72). Participants were randomized to receive either 2.7 g 

MaxEpa daily containing 180 mg EPA and 120 mg DHA per capsule or matching air-filled 

capsules. The women were instructed to take nine capsules each day until the 38th week of 

pregnancy.233 (Summary Table 1) 

Summary Table 1: Omega-3 fatty acid influences on the duration of gestation in women with or without a 

history of a previous preterm birth 

Study groups1

 

Author, Year, 

Location: 

Length & 

Design 

Group 1 

(n)/ 

Group 4 

(n)

Group 2 

(n)/ 

Group 3 

(n)

Notable 

clinical 

effects Internal validity Applicability 

Olsen, 1992, 

Denmark: 

NR 

parallel 

RCT209

2.7g n-3 FAs fish 

oil (n=266) 

Olive oil 

(n=136)/ 

pb 

(n=131) 

SÏ GA in 

fish oil grp++ Jadad total: 2 

[Grade: C]; 

Schulz: Inadequate 

III 

BulstraRamakers, 

1994, 

Netherlands: 

27 wks 

parallel 

RCT238

n-3 FA-enriched 

capsules: 

EPA 3 g/d 

DHA NR 

(n=32) 

Control capsules: 

coconut oil (n=31) 

NS in % 

premature 

deliveries 

Jadad total: 5 

[Grade: A]; 

Schulz: Adequate 

III 

Onwude, 

1995, UK: 

NR 

parallel 

RCT233

DHA+EPA 

(1620mg 

EPA+1080mg 

DHA) 

(n=113) 

pb 

(n=119) 

NS in GA 

NS in % 

premature 

deliveries 

Jadad total: 5 

[Grade: A]; 

Schulz: Adequate 

II 

1

Proceeding from highest omega-3, or lowest omega-6/omega-3, fatty acid content of intervention/exposure; n-3 = 

omega-3 fatty acids; n-6 = omega-6 fatty acids; DHA = docosahexaenoic acid; EPA = eicosapentaenoic acid; 

Length = intervention length; Design = research design; n = sample size; pts = study participants; NR = not 

reported; S = statistically significantly different; NS = nonsignificant statistical difference; n/a = not applicable; pb = 

placebo; grp = group; wk = week(s); mo = month; FAs = fatty acids; GA = gestational age; ITT = intention-to-treat 

analysis; PP = per-protocol analysis (e.g., completers); +

p<.05 or significant with 95% confidence interval; ++p<.01; +++p<.001; ++++p<.0001; PP = per-protocol analysis (e.g., completers); Ï = increase(d)/higher; Ð = 

decrease(d)/reduction/lower 

Olsen et al.,230 in six multicenter RCTs including 19 hospitals, examined the preventative 

(prophylactic) and therapeutic effects of dietary n-3 FAs on pre-term delivery, IUGR and GHT 

in women with an increased risk for these clinical outcomes. Four prophylactic trials enrolled 

women after 16 weeks of GA with an uncomplicated pregnancy who had experienced previous 

pre-term delivery (n=232), IUGR (n=280), or GHT (n=386) and women who were currently 

pregnant with twins (n=579). 
44

The two therapeutic trials enrolled women with threatening preeclampsia (n=79) or suspected 

IUGR (n=63). Participants were randomly assigned to receive fish oil (Pikasol: EPA [32wt%] 

and DHA [23wt%]) or olive oil in identical-looking capsules from approximately 20 weeks 

(prophylactic trials) or 33 weeks (therapeutic trials) until delivery. Treatment with fish oil 

corresponded to 1.3 g EPA and 0.9 g DHA daily intake for the prophylactic group and 2.9 g/d 

EPA and 2.1 g/d DHA for the therapeutic group. (Summary Table 2 to 3) 

Summary Table 2: Omega-3 fatty acid influences on the duration of gestation in women with or without a 

history of a previous preterm birth 

Study groups1 Author, 

Year, 

Location: 

Length & 

Design 

Group 1 

(n)/ 

Group 4 

(n)

Group 2 

(n)/ 

Group 3 

(n)

Notable clinical 

effects Internal validity Applicability 

Olsen, 

2000a, 

multicenter: 

20 wks 

parallel 

RCT230

Earl-PD: Pikasol 

(fish oil) 0.9g 

DHA, 1.3g EPA 

capsules (n=110) 

Olive oil 

capsules 

(n=122) 

(ITT) SÏ GA in 

fish oil gp+ 

SÐ % Premature 

delivery in fish oil 

gp+ 

Jadad total: 2 

[Grade: C]; 

Schulz: Adequate 

III 

Olsen, 

2000b, 

multicenter: 

20 wks 

parallel 

RCT230

Earl-IUGR: 

Pikasol (fish oil) 

0.9g DHA, 1.3g 

EPA capsules 

(n=141) 

Olive oil 

capsules 

(n=139) 

(ITT) SÏ GA in 

fish oil gp+ Jadad total: 2 

[Grade: C]; 

Schulz: Adequate 

III 

Olsen, 

2000c, 

multicenter: 

20 wks 

parallel 

RCT230

Earl-PIH: Pikasol 

(fish oil) 0.9g 

DHA, 1.3g EPA 

capsules (n=184) 

Olive oil 

capsules 

(n=202) 

(ITT) NS in GA Jadad total: 2 

[Grade: C]; 

Schulz: Adequate 

III 

1

Proceeding from highest omega-3, or lowest omega-6/omega-3, fatty acid content of intervention/exposure; n-3 = 

omega-3 fatty acids; n-6 = omega-6 fatty acids; DHA = docosahexaenoic acid; EPA = eicosapentaenoic acid; 

Length = intervention length; Design = research design; n = sample size; pts = study participants; NR = not 

reported; S = statistically significantly different; NS = nonsignificant statistical difference; n/a = not applicable; pb = 

placebo; grp = group; wk = week(s); mo = month; FAs = fatty acids; GA = gestational age; ITT = intention-to-treat 

analysis; PP = per-protocol analysis (e.g., completers); +

p<.05 or significant with 95% confidence interval; ++p<.01; +++p<.001; ++++p<.0001; PP = per-protocol analysis (e.g., completers); Ï = increase(d)/higher; Ð = 

decrease(d)/reduction/lower; Earl-PD = pregnant women with antecedent of premature delivery; Earl-IUGR = 

pregnant women with antecedent of IUGR; Earl-PIH = pregnant women with antecedent of gestational 

hypertention in past pregnancies 
45

Summary Table 3: Omega-3 fatty acid influences on the duration of gestation in women with or without a 

history of a previous preterm birth 

Study groups1

 

Author, Year, 

Location: 

Length & 

Design 

Group 1 

(n)/ 

Group 4 

(n)

Group 2 

(n)/ 

Group 3 

(n)

Notable 

clinical effects Internal validity Applicability 

Olsen, 

2000d, 

multicenter: 

20 wks 

parallel 

RCT230

Twins trial: 

Pikasol (fish oil) 

0.9g DHA, 1.3g 

EPA capsules 

(n=289) 

Olive oil 

capsules 

(n=290) 

(ITT) NS in GA Jadad total: 2 

[Grade: C]; 

Schulz: Adequate 

III 

Olsen, 

2000e, 

multicenter: 

33 wks 

parallel 

RCT230

Threat-PE: 

Pikasol (fish oil) 

2.1g DHA, 2.9g 

EPA capsules 

(n=44) 

Olive oil 

capsules (n=35) 

(ITT) NS in GA Jadad total: 2 

[Grade: C]; 

Schulz: Adequate 

III 

Olsen, 2000f, 

multicenter: 

33 wks 

parallel 

RCT230

Susp-IUGR: 

Pikasol (fish oil) 

2.1g DHA, 2.9g 

EPA capsules 

(n=36) 

Olive oil 

capsules (n=27) 

(ITT) SÏ GA in 

fish oil gp+ Jadad total: 2 

[Grade: C]; 

Schulz: Adequate 

III 

1

Proceeding from highest omega-3, or lowest omega-6/omega-3, fatty acid content of intervention/exposure; n-3 

= omega-3 fatty acids; n-6 = omega-6 fatty acids; DHA = docosahexaenoic acid; EPA = eicosapentaenoic acid; 

Length = intervention length; Design = research design; n = sample size; pts = study participants; NR = not 

reported; S = statistically significantly different; NS = nonsignificant statistical difference; n/a = not applicable; pb 

= placebo; grp = group; wk = week(s); mo = month; FAs = fatty acids; GA = gestational age; ITT = intention-totreat analysis; PP = per-protocol analysis (e.g., completers); +

p<.05 or significant with 95% confidence interval; ++p<.01; +++p<.001; ++++p<.0001; PP = per-protocol analysis (e.g., completers); Ï = increase(d)/higher; Ð = 

decrease(d)/reduction/lower; Threat-PE = pregnant women with threatening preeclampsia; Susp-IUGR = 

pregnant women with suspected IUGR 

Helland et al. randomly assigned 590 (341 completers) healthy, nulli- or primiparous women 

in weeks 17 to 19 of pregnancy to receive either 10 mL/day of cod liver oil (containing 1,183 mg 

DHA, 112 mg EPA and 27.5 mg AA) or 10 mL/day of corn oil (containing only 8.3 mg DHA) 

until delivery.141 The study evaluated GA as a primary outcome.141 (Summary Table 4) 

Smuts et al. randomized 347 women in their third trimester of pregnancy (350 pregnancies; 

three women got pregnant twice during the study), who were supplied with DHA-enriched eggs 

(mean of 133±15 mg of DHA per egg) or ordinary eggs (mean of 33±11 mg of DHA per egg), 

and assessed GA and birth weight as primary outcomes (291 completed the study).234 The study 

also assessed the risk of preeclampsia/eclampsia. The mean number of consumed eggs was 

6.8±4.6 per week for the group consuming high-DHA eggs and 7.7±5.6 for the group consuming 

ordinary eggs.234 (Summary Table 4) 

The second Smuts et al. study monitored the safety of consuming high-DHA hen eggs 

compared with ordinary eggs with respect to pregnancy outcomes as well as infant 

anthropometric parameters.232 Fifty-two, mostly African-American women, in their third 

trimester of pregnancy were randomized to the two diet groups: 25 to the regular-egg group 

(mean daily DHA intake was 35.1±13.2 mg) and 27 to the high-DHA egg group (mean daily 

DHA intake was 183.9±71.4 mg). Another 21 pregnant women were not randomized and were 
46

not given supplementary eggs (low-egg intake group with a mean daily DHA intake 10.8±4.0 

mg).232 (Summary Table 4). 

Summary Table 4: Omega-3 fatty acid influence on the duration of gestation in women with or without a 

history of a previous preterm birth 

Study groups1 Author, 

Year, 

Location: 

Length & 

Design 

Group 1 

(n)/Group 4 (n)

Group 2 

(n)/ 

Group 3 

(n)

Notable 

clinical 

effects

Notable 

clinicalbiomarker2,3 

correlations 

Internal 

validity Applicability 

Helland, 

2001, 

Norway: 

8 mo 

parallel 

RCT141

CGA 1183 

mg/d DHA + 

803 mg/d EPA 

+ 27.5 mg/d AA 

(n=301) 

COG pb 

8.3mg/d DHA 

(n=289) 

NS in GA n/a Jadad total: 4 

[Grade: A]; 

Schulz: 

Unclear 

III 

Smuts, 

2003, US: 

13 wk 

parallel 

RCT232

High-DHA eggs 

(183.9 mg/d 

DHA) 

(n=18) 

Regular-DHA 

eggs (35.1 

mg/d DHA) 

(n=19) 

NS in GA 

High-DHA 

eggs Ð

PTDR than 

control (no 

p-value) 

n/a Jadad total: 2 

[Grade: C]; 

Schulz: 

Unclear 

II 

Smuts, 

2003, US: 

13 wk 

parallel 

RCT234

High-DHA eggs 

(133 mg/d 

DHA) 

(n=176) 

Regular-DHA 

eggs (33 

11mg/d DHA) 

(n=174) 

SÏ in GA in 

High-DHA 

vs RegularDHA+

NS in PTDR

S (+) 

correlation 

between 

infant RBC 

DHA & GA+

NS correlation 

between 

maternal RBC 

DHA & GA 

Jadad total: 3 

[Grade: B]; 

Schulz: 

Inadequate 

II 

1

Proceeding from highest omega-3, or lowest omega-6/omega-3 fatty acid content of intervention/exposure; 2

biomarker source; 3biomarkers = EPA, DHA, AA, AA/EPA, AA/DHA, AA/EPA+DHA; n-3 = omega-3 fatty acids; n-6 

= omega-6 fatty acids; DHA = docosahexaenoic acid; EPA = eicosapentaenoic acid; Length = intervention length; 

Design = research design; n = sample size; pts = study participants; NR = not reported; S = statistically significantly 

different; NS = nonsignificant statistical difference; n/a = not applicable; pb = placebo; grp = group; wk = week(s); mo 

= month; FAs = fatty acids; CGA = cod liver oil group; COG = corn oil group; GA = gestational age; PTDR = preterm 

delivery rate; RBC = red blood cells; ITT = intention-to-treat analysis; PP = per-protocol analysis (e.g., completers); +

p<.05 or significant with 95% confidence interval; ++p<.01; +++p<.001; ++++p<.0001; PP = per-protocol analysis (e.g., 

completers); Ï = increase(d)/higher; Ð = decrease(d)/reduction/lower 

Malcolm et al.235 investigated the duration of gestation in healthy pregnant women (ages 17-

36 years) that received fish oil capsule supplements from a mean of 15.4 wk gestation until 

delivery (Marinol D40, 100 mg DHA per capsule) compared with sunflower oil capsules.235 

(Summary Table 5) 

Dunstan et al. examined the effect of fish oil supplementation on maternal and neonatal FA 

status.231 The study also investigated if the fish oil supplementation to the diet of pregnant 

women had any effect on the duration of pregnancy and the size of their infants at birth (birth 

weight, length, and head circumference [HC]). The study recruited 98 healthy non-smoking 

pregnant women (83 completed the study); 58% of the women had a known history of allergic 

rhinitis and 40% had a history of asthma. Participants were randomly assigned to receive their 
47

usual diet supplemented with either 4 g/day fish oil (1.1 g EPA and 2.2 g DHA per day) or olive 

oil capsules, from GA of 20 weeks until delivery.231 (Summary Table 5) 

de Groot et al. conducted a double-blind RCT in 79 pregnant women (58 completed the 

study) who were randomly assigned to receive at least 25 g/day of either an ALA-enriched, highLA margarine (experimental group) or a high-LA margarine without ALA (control group), from 

week 14 of pregnancy until delivery. Subjects in the experimental group consumed 9.02 g LA 

and 2.82 g ALA daily, whereas, women in the control group received 10.94 g LA and 0.03 g 

ALA daily. One of the outcomes evaluated was the GA of the infant.196 (Summary Table 5) 

Summary Table 5: Omega-3 fatty acid influence on the duration of gestation in women with or without a 

history of a previous preterm birth 

Study groups1

 

Author, Year, 

Location: 

Length & 

Design 

Group 1 

(n)/ 

Group 4 

(n)

Group 2 

(n)/ 

Group 3 

(n)

Notable 

clinical 

effects

Notable 

clinicalbiomarker 

correlations 

Internal 

validity Applicability 

Malcolm , 2003, 

Denmark: 

15 wks 

parallel RCT235

Fish oil (DHA 

100 mg) 

capsules 

(n=50) 

pb 

(n=50) 

NS in GA NS 

correlation 

umbilical cord 

DHA & GA 

Jadad total: 

3 [Grade: 

B]; 

Schulz: 

Unclear 

II 

Dunstan, 2004, 

Australia: 

19 wk parallel 

RCT231

LCPUFA 

(2.2 g/d DHA 

+ 1.1 g/d EPA) 

(n=40) 

pb 

(n=43) 

NS in GA NS 

correlation 

between 

infant RBC 

DHA, EPA, 

AA & GA 

Jadad total: 

3 [Grade: 

B]; 

Schulz: 

Unclear 

III 

de Groot, 2004, 

Netherlands: 

24 wk 

parallel RCT196

LCPUFA 

(9.02 g/d 

LA+2.82 g/d 

ALA) 

(n=40) 

pb (10.94 

g/d LA+0.03 

g/d ALA) 

(n=39) 

NS in GA n/a Jadad total: 

3 [Grade: 

B]; 

Schulz: 

Unclear 

III 

1

Proceeding from highest omega-3, or lowest omega-6/omega-3, fatty acid content of intervention/exposure; 2

biomarker source; 3biomarkers = EPA, DHA, AA, AA/EPA, AA/DHA, AA/EPA+DHA; n-3 = omega-3 fatty acids; n-6 

= omega-6 fatty acids; DHA = docosahexaenoic acid; EPA = eicosapentaenoic acid; AA = arachidonic acid; Length 

= intervention length; Design = research design; n = sample size; pts = study participants; NR = not reported; S = 

statistically significantly different; NS = nonsignificant statistical difference; n/a = not applicable; pb = placebo; grp = 

group; wk = week(s); mo = month; FAs = fatty acids; GA = gestational age; RBC = red blood cells; ITT = intentionto-treat analysis; PP = per-protocol analysis (e.g., completers); +

p<.05 or significant with 95% confidence interval; ++p<.01; +++p<.001; ++++p<.0001; PP = per-protocol analysis (e.g., completers); Ï = increase(d)/higher; Ð = 

decrease(d)/reduction/lower; LA = linoleic acid; ALA = alpha-linolenic acid 
48

Qualitative synthesis of relevant studies’ key characteristics 

Study characteristics. Only the study of Olsen et al. had more than two study groups.209 

Countries where the studies were conducted included the United States,232,234 the United 

Kingdom,233,235 The Netherlands,196,238 Australia,231 Denmark209 and Norway.141 One 

multicenter study involved six trials conducted in 19 centers in Denmark, Scotland, Sweden, 

England, The Netherlands, Norway, Belgium and Russia.230 

Both of the studies by Smuts et al.232,234 were financially supported by Market Biosciences 

Boulder Corporation (former Omega Teach Inc.), Boulder, Colorado. The study by Onwude et 

al.233 was sponsored by Yorkshire Region Locally Organized Research, Glaxo (Leeds) and Seven 

Seas (Hull). Olsen et al.’s studies230 were funded by Conserted Action and PECO programmes 

of European Comission and the Danish National Research Foundation. The study of de Groot et 

al.196 was supported by Unilever Research and Development (Vlaardingen, Netherlands). 

Dunstan et al.’s231 was funded by the NH and MRC and Raine Medical Research Foundation, 

Australia. The other study by Olsen et al.209 was supported by the Danish Medical Research 

Council, Sygekassernes Helsefond, Weman’s Legat and Michaelsen Fonden. The study by 

Helland et al.141 was financed by Peter Moller, Avd. Orkla ASA and “Aktieselskabet Freia 

Chocoladefabriks Medicinske Fond.” Malcolm et al. was supported by the Chief Scientist’s 

Office, Scottish Office Health Department.235 Finally, Bulstra-Ramakers et al. failed to provide 

this information.238

Population characteristics. There was a total number of 3,686 pregnant women enrolled 

across the fifteen trials. The sample size varied from as low as 37232 to 590141 women. However, 

Helland et al. analysed only the patients who completed the study (n=341 of 590, 57%).288 The 

mean age-range of study participants across the eight studies was 19.9 (SD=4.1) years to 32.9 

(SD=14.6) years. Participants in both of the Smuts et al. trials232,234 tended to be younger (mean 

age range for high-DHA egg group=19.9 [SD=4.1] to 21.7 years; mean age range for placebo 

group=21.6 [SD=4.2] years to 24.8 [SD=7.8] years) than the participants in the rest of the studies 

(mean age range for treatment groups=27.6 [SD=3.2] years, and 32.9 [SD=14.6] years for the 

placebo groups).141,196,209,230,231,233 Two trials did not provide this information.235,238 

A thorough description of both inclusion and exclusion criteria were given in all trials. 

Information about racial/ethnic backgrounds were given in three of the 15 studies.196,232,234 Study 

participants in two trials were predominantly of African-American descent, comprising 79% and 

73% of participants in the ordinary egg groups, and 83% and 73% of participants in the highDHA egg groups, respectively.232,234 Only White participants were recruited in the Groot et al. 

study.196 

The exact duration of maternal dietary intervention during pregnancy and/or breastfeeding 

was reported in all but two studies,209,233 and ranged from 5 weeks230 to 8 months.141 In most of 

the studies, LCPUFA supplementation was prescribed in the second trimester of 

pregnancy.141,196,231,233,235,238 In three studies, PUFA supplementation was administered from the 

third trimester until delivery.209,232,234 There was no study where participants were randomized 

from the first trimester. In one of the studies of Olsen et al., four prophylactic groups of pregnant 

women were randomized from gestational week 20, whereas, in the therapeutic trials women 

were randomized around gestational week 33.230 Detailed information about the duration of the 
49

LCPUFA supplementation is provided in the Evidence Tables (Appendix E∗

). Maternal social 

status, defined as years of education, was determined in two studies.141,196 

Information regarding maternal smoking history and/or smoking during pregnancy was 

provided in eleven studies.141,196,209,230,233,234 Alcohol consumption at 14 weeks of pregnancy was 

reported in one study.196 

In the majority of RCTs, there was no evidence that randomization failed to produce 

comparable groups in terms of previous obstetric history, socioeconomic status, dietary intake of 

fish, smoking habits, alcohol intake, body mass index and GA.141,209,231,234,235,289 Onwude et al. 

showed that significantly more women were current smokers at enrollment in the treatment 

group than in the placebo group.233 Smuts et al. reported that women assigned to consume 

ordinary eggs were significantly older than those in the high-DHA egg group.232 Olsen et al. 

reported that in women with suspected IUGR, those in the placebo group had significantly higher 

GA after randomization.230

Intervention/exposure characteristics. Across the 15 studies, the sources of omega-3 

LCPUFA were identified as being either from natural feeding sources, such as eggs, fish and 

margarines, or from manufactured medical supplementations, such as capsules containing fish 

oil. Eggs as a source of omega-3 FA were used in two studies232,234 and margarine, containing 

different amounts of LA and ALA, was used in one study.196 

Gelatin capsules containing a fish oil were utilized in 11 studies. In most of the studies, 

LCPUFA supplementation was prescribed in the second trimester of pregnancy.141,196,231,233,235,238 

In three studies, PUFA supplementation was administered from the third trimester until 

delivery.209,232,234 There were no studies where participants were randomized from the first 

trimester. In one of the studies of Olsen et al., four prophylactic groups of pregnant women were 

randomized from gestational week 20, whereas, in the therapeutic trials women were randomized 

around gestational week 33.230 

Detailed information about the duration of the LCPUFA supplementation209,230,231,233,235,238 is 

provided in the Evidence Tables (Appendix E). Helland et al. failed to report the manner in 

which study participants received their oil supplementation;141 however, the investigators were 

the only ones to identify the exact sources of dietary FAs (i.e., cod liver oil and corn oil as the 

placebo). The daily amount of omega-3 LCPUFA intake, as well as the start and duration of 

intake, varied across the studies. 

Pregnant women in the Bulstra-Ramakers et al. study received four capsules containing 0.25 

mg EPA or placebo (coconut oil) three times daily. The EPA capsules contained a mixture of 3 

g EPA and DHA. Both capsules were similar in appearance, smell and taste.238

The two Smuts et al. studies232,234 used similar regimens of FA supplementation for the highDHA eggs and the ordinary egg groups. Daily DHA intake was reported to be 183.9 (SD=71.4) 

mg in the high-DHA diet and 35.1 (SD=13.2) mg for placebo in the one study232 and 133 

(SD=15) mg and 33 (SD=11) mg, respectively, in the other Smut et al. study.234 Women in both 

 

∗

 Appendices and Evidence tables cited in this report are provided electronically at 

http://www.ahrq.gov/clinic/tp/o3mchtp.htm
50

studies were randomized to the different dietary groups in their third trimester of pregnancy (24 

to 28 weeks), for a mean duration of supplementation of approximately 13 weeks.232,234 

de Groot et al. randomized a sample of women to receive margarine containing different 

amounts of LA and ALA from week 14 of GA until delivery.196 The experimental group 

received 9.02 g LA and 2.82 g ALA per day, whereas, the control group received 10.94 g LA 

and 0.03 g ALA daily.196 

Pregnant women in the Onwude et al. study were randomized to receive either fish oil or 

placebo.233 Women were allocated to treatment groups at a very wide range of GA, ranging from 

18 to 32 weeks (mean of 24 weeks). Hence, the time of exposure to the intervention was not 

equal for the study participants. Women in this study were instructed to take nine capsules daily, 

each containing either 180 mg EPA and 120 mg DHA (treatment group), or air (placebo group); 

timing of the intake of the nine capsules was left to the participants.233

The patients in the Olsen et al. study received fish oil (Pikasol containing EPA [32wt%] and 

DHA [23wt%]) or olive oil as placebo (oleic acid [72wt%] and ALA [12wt%]), provided in 1 g 

identical-looking gelatine capsules, but which were not identical in taste.230 In the four 

prophylactic trials, four capsules of either oil were given per day, while in the two therapeutic 

trials, nine capsules were given per day. In the prophylactic trials women were randomized 

around gestational week 20, whereas, in the therapeutic trials women were randomized around 

gestational week 33. The same sources of intervention with the same regimen were used in the 

other study of Olsen et al.209

The pregnant women in the study of Malcolm et al. received two fish oil capsules, rich in 

DHA (Marinol D40, 100 mg DHA per capsule, R.P. Scherer Ltd, Swindon, UK) per day or 

identical sunflower oil placebo capsules without DHA or ALA.235 Maternal diet, including fish 

intake, was assessed by interview at 15 and 28 weeks of pregnancy and delivery.235

The 98 women with a history of rhinitis or asthma in the Dunstan et al. study were 

randomized to receive either 4 g/day of fish oil or olive oil in capsules, as a supplement to their 

usual diet from 20 weeks gestation until delivery, when supplementation was ceased.231 Women 

in the fish oil group consumed about 1.1 g EPA and 2.2 g DHA daily. All capsules contained αtocopherol (3-4 mg/g oil) as an antioxidant.231

Helland et al. randomly assigned 590 study participants to either a treatment group (10 mL 

cod liver oil/day; Peter Moller, Avd Orkla, Oslo, Norway) or a placebo group (10 mL corn 

oil/day).141 Women in the cod liver oil group consumed 1,183 mg DHA, 803 mg EPA and 27.5 

mg AA daily compared with 8.3 mg DHA in the placebo group. Randomization started at 17 to 

19 weeks of gestation and supplementation continued until approximately 3 months after 

delivery, for a total of approximately 8 months of exposure.141

Dietary intake information was not well documented in all studies. There was no clear data 

to suggest that all eight studies were equally able to eliminate the possible confounding influence 

of having unequal amounts of calories (i.e., as energy) provided to their different study groups. 

Information about caloric balance of food intake among the study groups was reported in only 

one RCT.141 The daily energy intake (expressed as MJ/day) of participants in the Helland et al. 

study was similar among the two diet groups and varied from 8.2 (SD=2.0) MJ/day at week 18 of 

pregnancy to 8.7 (SD=2.3) MJ/day at week 35 of pregnancy.141 
51

None of the study investigators made an effort to deodorize the LCPUFA supplementation. 

In the study by Smuts et al., attempts were made to maintain blinding by conducting their own 

sensory test with clinic nurses who were blinded to the egg source. All of the nurses felt that the 

omega-3-fortified eggs looked and tasted like the non-enriched eggs.232

Attempts to optimize and assess the compliance of the study participants were made in 

twelve trials.141,196,209,230,232,233,235 In all of these studies, women were asked to fill a foodfrequency questionnaire indicating the exact amount of assigned dietary supplement consumed, 

followed by conversion of this information into dietary intake using either a computer 

program196 or simple percentage calculations.209,230,233 Smuts et al. utilized phone interviews 

with the women since few participants were compliant with the request to keep written records 

of their food intake.232

The manufacturer of the omega-3 intervention was reported in seven trials.141,196,209,231,232,235 

Purity data on the exposures used were not provided in any of the 15 studies. In five of seven 

studies that evaluated the FA content of biomarkers, appropriate methods to extract, prepare, 

store or analyze lipids were described.196,231,232,234 Helland et al. gave little information about the 

details of blood FA composition analysis.141 None of the trials reported details as to whether, or 

how, the presence of methylmercury was tested or eliminated from the omega-3 FA exposure 

when fish oil was the source.31,41,290 

Cointervention characteristics. Three studies reported the use and/or LCPUFA content of 

additional vitamin and mineral supplements taken by the pregnant participants.141,231,234 Smuts et 

al. reported that prenatal vitamin use in ordinary and high-DHA groups was 83.2% and 84.6%, 

respectively.234 Helland et al. reported that the amount of fat-soluble vitamins was identical 

between the two oil groups i.e., 117 μg/mL vitamin A; 1 μg/mL vitamin D; and, 1.4 μg/mL of dlά-tocopherol.141 Dunstan et al. used ά-tocopherol as an antioxidant to stabilize omega-3 FAs.231 

No studies reported the prestudy medication use by either pregnant or breastfeeding mothers. 

On-study antihypertensive therapy to treat GHT was used in one of the Olsen et al. studies.230 

Outcome characteristics. Fourteen studies addressed the question of whether or not omega3 FA supplementation affects the duration of gestation (gestational age as mean±SD). Preterm 

delivery rate was assessed in 11 trials.41,230,232,234,291,292 However, three more studies reported the 

number of premature deliveries excluded from the analysis (reported as dropouts).288,290,293 The 

use of ultrasound in the second trimester of pregnancy to determine GA was reported in four 

studies.209,230,233,234 If the ultrasound measurement was not available, the length of gestation was 

estimated from the date of last normal menstrual period.209,230 In seven studies, preterm delivery 

was defined as delivery at an estimated GA of less than 37 weeks.230,234

Study quality and applicability. The 15 RCTs received a mean Jadad total quality score of 

2.8, approaching a good internal validity (Summary Matrix 1). Two trials received a score of 

5,233,238 the trial of Helland et al. received a score of 4,141 four trials received a score of 

3,196,231,234,235 and eight reports received a score of 2.209,230,232 

Randomization method was not clearly reported in four trials,290,293-295 eight trials were not 

double-blinded,31,41,296 while double-bliniding method was not reported across five 

trials.288,290,293-295 Reasons for dropouts were not reported across eight trials.31,41,294
52

Summary Matrix 1: Study quality and applicability of evidence for the influence of LCPUFA on the duration of 

gestation 

Study Quality

A B C 

Author Year n Author Year n Author Year n I 

Author Year n Author Year n Author Year n

II OnwudeA 1995 233 SmutsI 

MalcolmU 2003 

2003 

350 

100 

SumtsU 2003 73 

Author Year n Author Year n Author Year n

Applicability 

III 

BulstraRamakersA 

HellandU 

1994 

2001 

68 

590 

DunstanU 

De GrootU 2004 

2004 

98 

79 

OlsenI 

OlsenA 1992 

2000 

533 

see 

below* 

n = number of allocated/selected participants; RCT = AAdequate vs UUnclear allocation concealment;I = Inadequate; *

Olsen 2000 6 trials: a) n=232; b)=280; c)n=579; d) n=386;e) n=79; f) n=63

Qualitative synthesis of individual study results 

Ten studies evaluating the influence of LCPUFA supplementation on the duration of 

gestation, did not find any beneficial effect of omega-3 FAs over their comparators.141,196,230-235 

Conversely, the other four studies found that dietary modifications by LCPUFA significantly 

prolonged the duration of gestation.209,230 However, the population characteristics, as well as the 

interventions, were different across these studies. The preterm delivery trial of Olsen et al. found 

a significantly increased mean duration of gestation in the treatment group (fish oil) of mothers 

with a preterm delivery in a previous pregnancy compared with mothers in the placebo group.230 

Preterm delivery rate was not affected by omega-3 FA supplementation during pregnancy and 

was not statistically different in randomized groups in ten trials that evaluated this 

outcome.31,209,233,234,238 Smuts et al. on the other hand, observed that 5.6% of women in the highDHA group had a premature delivery compared with 25% in the control group (no statistical 

significance was reported).232 

Dunstan et al. did not find any statistically significant relationship between GA and neonatal 

RBC DHA, EPA, and AA content.231 Contrary to these findings, Smuts et al.234 observed a 

statistically significant positive correlation between infant RBC DHA content at delivery and GA 

in the treatment group, whereas, maternal RBC phospholipid DHA content at the time of 

delivery was not significantly correlated with GA in either the treatment or placebo groups.231 

Malcolm et al. measured umbilical cord plasma DHA levels in infants of supplemented mothers 

and observed that the duration of gestation was significantly greater in infants in the upper 

quartile for cord blood DHA compared with infants in the lower quartile. However, gestational 

length did not differ based on quartiles of umbilical cord RBC DHA.235

Quantitative synthesis 

Meta-analysis was performed for incidence of premature deliveries, given that represents the 

most clinically relevant. Eleven of 15 trials reported this particular outcome. Eight of ten 

compared the use of DHA+EPA capsules intake with olive oil (control group).31,41,291 Olsen 

et al. 2000 reported the pooled data of six different RCTs, including pregnant women with 
53

different risk for prematurity.31 Five of eight trials provided the intervention from the second 

trimester (week 22) until delivery,31,291 and three trials from week 30-33 until delivery (3rd 

Trimester).31,41 Subgroup analysis (by risk of prematurity) was not possible for this outcome 

given the lack of individual data from Olsen et al. 2000.31 

Two studies by Smuts et al. comparing the use of eggs with high DHA content (mean 133 mg 

DHA per egg)296 or 12 high-DHA hen eggs (135 mg DHA/egg)294 with ordinary eggs (low DHA 

content: 18-33 mg DHA/egg)294,296 from the second trimester to delivery reported the incidence 

of premature delivery as an outcome. 

Two other studies compared the use of EPA alone292 or DHA+AA (from cod oil)288 with 

control, yet pooling was not possible due to the difference in omega-3 FA content. 

Meta-analyses for incidence of prematurity were performed by using a random effect model 

for odds ratio. 

Figure 1. Meta-analysis of studies comparing intake of DHA+EPA vs. control 

Review: N-3 child

Comparison: 01 DHA+EPA vs. control 

Outcome: 01 incidence premature birth 

Study Treatment Control OR (random) Weight OR (random)

or sub-category n/N n/N 95% CI % 95% CI

 Olsen 2000 116/460 135/480 65.50 0.86 [0.65, 1.15] 

 Onwude 1995 22/113 19/119 22.10 1.27 [0.65, 2.50] 

 Olsen 1992 9/266 9/136 12.40 0.49 [0.19, 1.28] 

Total (95% CI) 839 735 100.00 0.88 [0.62, 1.25]

Total events: 147 (Treatment), 163 (Control)

Test for heterogeneity: Chi2 = 2.58, df = 2 (P = 0.27), I2 = 22.6%

Test for overall effect: Z = 0.73 (P = 0.47)

 0.1 0.2 0.5 1 2 5 10

 Favours treatment Favours control

From eight RCTs, the incidence of premature deliveries did not differ significantly between 

groups, OR: 0.88 (95% CI: 0.62-1.25), p=0.47. 

Figure 2. Meta-analysis of studies comparing intake of DHA vs. control. 

Smuts et al 2003-1296 and Smuts et al. 2003-2.294

Review: N-3 child

Comparison: 03 DHA vs. control 

Outcome: 01 incidence premature birth 

Study Treatment Control OR (random) Weight OR (random)

or sub-category n/N n/N 95% CI % 95% CI

 Smuts 2003-1 14/142 17/149 71.80 0.85 [0.40, 1.79] 

 Smuts 2003-2 1/18 5/19 28.20 0.16 [0.02, 1.58] 

Total (95% CI) 160 168 100.00 0.53 [0.13, 2.29]

Total events: 15 (Treatment), 22 (Control)

Test for heterogeneity: Chi2 = 1.84, df = 1 (P = 0.17), I2 = 45.7%

Test for overall effect: Z = 0.84 (P = 0.40)

 0.1 0.2 0.5 1 2 5 10

 Favours treatment Favours control

From two RCTs,294,296 the incidence of premature deliveries did not differ significantly 

between groups, OR: 0.53 (95% CI: 0.13-2.29), p=0.40. 
54

Impact of covariates and confounders 

Olsen et al. adjusted the duration of gestation for fish consumption, as well as for compliance 

to the oil supplementation.209 Differences between groups in the average duration of gestation 

were significantly correlated with increasing fish consumption, with the mean length of gestation 

highest in the fish-oil group and lowest in the olive-oil group. The difference between fish oil 

and olive oil was nonstatistically significant between compliers and noncompliers.209 

Helland et al. adjusted the duration of gestation for the concentration of DHA in umbilical 

plasma phospholipids and reported that neonates with high concentration of DHA in umbilical 

plasma phospholipids (upper quartile) had longer gestational length than neonates with low 

concentration.141

Onwude et al. stratified the results by use of tobacco, failing to observe a difference between 

groups.233

Smuts et al. adjusted the results by smoking status, maternal BMI and number of prior 

pregnancies.234 The duration of gestation was significantly longer in the high-DHA egg group in 

the nonsmoking women, and when adjusted by maternal BMI and parity.234

The power analysis was reported in nine trials,31,288,292,296 while the intention-to –treat 

analysis approach was reported in six trials from the same author.31

What is the Evidence That Maternal Intake of Omega-3 Fatty Acids 

Influences the Incidence of Preeclampsia, Eclampsia or Gestational 

Hypertension? 

Eight unique studies met the eligibility criteria for investigating the effect of dietary 

supplementation of omega-3 FAs on the incidence of GHT, preeclampsia, or eclampsia, in 

pregnant women. All eight studies were parallel RCTs published between 1992 and 2003. 

Olsen et al.230 reported two unique trials relevant to this question—the “Twins trial” (twins in the 

current pregnancy) and “Earl-PIH” trial (women who had GHT in an earlier pregnancy). Of the 

eight RCTs, seven were double-blind.209,230,233,234,236,238 Of these, one trial was partially doubleblind.236 The overview of five trials was summarized in the question of duration of gestation (see 

key question: Duration of Gestation.). (Summary Tables 6-7) 

Overview of relevant studies

D’Almeida et al. evaluated the effect of dietary supplementation with fish oil in preventing 

preeclampsia in pregnant primiparous and multiparous women with GA of less than 4 months.236 

The study participants (n=150; age range: 14–40 years) were randomized to receive eight 

capsules per day of either a mixture of evening primrose oil and fish oil (containing gammalinolenic acid [GLA] 37 mg, EPA [18 mg] and DHA [10 mg]) or magnesium oxide (2 tablets/2 x 

500 mg/day) or placebo (olive oil), for 6 months. The main study outcome was the cumulative 

incidence rate of preeclampsia (complete triad of hypertension, edema, and proteinuria). Other 
55

study outcomes were individual cumulative incidence rates of GHT, edema, and proteinuria.236 

(Summary Table 6) 

The trial of Laivuori et al. investigated the influence of dietary supplementation with fish oil 

on the urinary excretion of antiaggregatory prostacyclin (PGI2) and proaggregatory thromboxane 

(TXA2) metabolites in women with preeclampsia. Of 18 women enrolled, 12 completed the 

study (mean age: 31 [range 23-40] years; parous: 50%; mean GA: 33 [range 26-37] weeks).237 

Changes in clinical signs of preeclampsia such as blood pressure (BP), proteinuria, and edema 

were also examined. Participants were randomized to receive 10 capsules per day of either 

Preglandin (containing 375 mg LA and 45 mg GLA), MaxEPA (containing 180 mg EPA, 120 

mg DHA and 680 mg of other fish oils) or placebo (containing 500 mg maize oil and 500 mg 

olive oil).237 (Summary Table 6) 

Summary Table 6: Influence of maternal intake of omega-3 fatty acids on the incidence of preeclampsia, 

eclampsia or gestational hypertension 

Study groups1

 

Author, Year, 

Location: 

Length & 

Design 

Group 1 

(n)/ 

Group 4 

(n)

Group 2 

(n)/ 

Group 3 

(n)

Notable clinical 

effects

Internal 

validity Applicability 

D’Almeida, 

1992, 

Angola: 

24 wk 

parallel 

RCT236

n-3 FA-enriched 

capsules: 

fish & primrose 

oil 

EPA 0.15 g/d 

DHA 0.08 g/d 

(n=50) 

Mg2+ oxide 

capsules: 1 g/d 

(n=50)/ 

olive oil capsules: 

(n=50) 

Rate of GHT Ï in 

grps 1-3 vs. grp 2 

(p = NR) 

Rate of 

preeclampsia/eclam

psia Ï in grp 3 vs. 

grps 1-2+++

Jadad total: 2 

[Grade: C]; 

Schulz: 

Inadequate 

III 

Laivuori, 

1993, 

Finland: 

8 wk parallel 

RCT237

n-3 FA-enriched 

capsules: 

fish oil 

EPA 1.80 g/d 

DHA 1.20 g/d 

(n=5) 

Primrose oil 

capsules: 

LA 3.75 g/d 

GLA 0.45 g/d 

(n=7)/ 

maize-olive oil 

capsules: 

10 g/d (n=6) 

NS BP, proteinuria, 

& rate of edema (grp 

1 vs. grps 2-3) 

Jadad total: 2 

[Grade: C]; 

Schulz: 

Adequate 

III 

BulstraRamakers, 

1995, 

Netherlands

27 wks 

parallel 

RCT238

n-3 FA-enriched 

capsules: 

EPA 3 g/d 

DHA NR 

(n=32) 

Control capsules: 

coconut oil (n=31) 

NS rate of GHT (grp 

1 vs. grp 2) 

Jadad total: 5 

[Grade: A]; 

Schulz: 

Adequate 

III 

1

Proceeding from highest omega-3, or lowest omega-6/omega-3, fatty acid content of intervention/exposure; n-3 

= omega-3 fatty acids; n-6 = omega-6 fatty acids; ALA = alpha linolenic acid; DHA = docosahexaenoic acid; EPA 

= eicosapentaenoic acid; AA = arachidonic acid; GLA = gamma-linolenic acid; Length = intervention length; 

Design = research design; n = sample size; pts = study participants; NR = not reported; S = statistically 

significantly different; NS = nonsignificant statistical difference; n/a = not applicable; pb = placebo; grp = group; 

wk = week(s); mo = month; wt = weight; RBC = red blood cells; PL = phospholipid; CPG = choline 

phosphoglycerides; +

p<.05 or significant with 95% confidence interval; ++p<.01; +++p<.001; ++++p<.0001; ITT = 

intention-to-treat analysis; PP = per-protocol analysis (e.g., completers); Ï = increase; Ð = decrease/reduction; 

GHT = gestational hypertension; BP = blood pressure; GHT = gestational hypertension 
56

Summary Table 7: Influence of maternal intake of omega-3 fatty acids on the incidence of preeclampsia, 

eclampsia or GHT 

Study groups1

 

Author, Year, 

Location: 

Length & 

Design 

Group 1 

(n)/ 

Group 4 

(n)

Group 2 

(n)/ 

Group 3 

(n)

Notable clinical 

effects

Internal 

validity Applicability 

Onwude, 1995, 

UK: 

14 wks 

parallel RCT233

n-3 FA-enriched 

capsules: 

fish oil 

EPA 1.62 g/d 

DHA 1.08 g/d 

(n=113) 

Control capsules: 

air-filled 

(n=119) 

NS rate of GHT (grp 1 

vs. grp 2) 

Jadad total: 5 

[Grade: A]; 

Schulz: 

Adequate 

II 

Olsen, 1992, 

Denmark: 

NR 

parallel RCT209

n-3 FA-enriched 

capsules: 

fish oil 

EPA 1.30 g/d 

DHA 0.90 g/d 

(n=266) 

Control capsules: 

olive oil 

4 g/d 

LA 12% 

(n=136)/ 

placebo 

capsules: 

no oil (n=131) 

NS in BP or rates of 

GHT & preeclampsia 

(grp 1 vs. grps 2-3) 

NS in BP (grp 1 vs. 

grps 2-3) 

Jadad total: 2 

[Grade: C]; 

Schulz: 

Inadequate 

III 

Olsen, 2000, 

multicenter* 

20 wks 

parallel RCT230

Twins trial: 

n-3 FA-enriched 

capsules: 

fish oil 

EPA 1.30 g/d 

DHA 0.90 g/d 

(n=289) 

Control capsules: 

olive oil 

4 g/d 

LA 12% 

(n=290) 

(ITT) NS in rates of 

GHT & preeclampsia 

(grp 1 vs. grp 2) 

NS BP (grp 1 vs. grp 

2) 

Jadad total: 2 

[Grade: C]; 

Schulz: 

Adequate 

III 

Olsen, 2000, 

multicenter* 

20 wks 

parallel RCT230

Earl-PIH: 

n-3 FA-enriched 

capsules: 

fish oil 

EPA 1.30 g/d 

DHA 0.90 g/d 

(n=184) 

Control capsules: 

olive oil 

4 g/d 

LA 12% 

(n=202) 

(ITT) NS in rates of 

GHT & preeclampsia 

(grp 1 vs. grp 2) 

NS in BP (grp 1 vs. grp 

2) 

Jadad total: 2 

[Grade: C]; 

Schulz: 

Adequate 

III 

Smuts, 2003, 

US: 

16 wks 

parallel RCT234

n-3 FA-enriched 

eggs: 

DHA 0.23 g/d 

(n=142) 

Control regular 

eggs: 

DHA 0.056 g/d 

(n=149) 

NS in rates 

preeclampsia (grp 1 

vs. grp 2) 

Jadad total: 3 

[Grade: B]; 

Schulz: 

Inadequate 

II 

1

Proceeding from highest omega-3, or lowest omega-6/omega-3, fatty acid content of intervention/exposure; n-3 = 

omega-3 fatty acids; n-6 = omega-6 fatty acids; ALA = alpha linolenic acid; DHA = docosahexaenoic acid; EPA = 

eicosapentaenoic acid; AA = arachidonic acid; GLA = gamma-linolenic acid; Length = intervention length; Design = 

research design; n = sample size; pts = study participants; NR = not reported; S = statistically significantly different; 

NS = nonsignificant statistical difference; n/a = not applicable; pb = placebo; grp = group; wk = week(s); mo = 

month; wt = weight; +

p<.05 or significant with 95% confidence interval; ++p<.01; +++p<.001; ++++p<.0001; ITT = 

intention-to-treat analysis; PP = per-protocol analysis (e.g., completers); Ï = increase; Ð = decrease/reduction; 

GHT = gestational hypertension; BP = blood pressure; * Denmark, Scotland, Sweden, UK, Italy, Netherlands, 

Norway, Russia, Belgium 

Qualitative synthesis of relevant studies’ key characteristics 

Study characteristics. Of the eight RCTs, seven were double-blinded 

studies209,230,233,234,236,238 of which, one was partially double-blind.236 For one study,237 it was not 

clear whether the study authors used a single or double-blind design. Authors of all eight trials 

reported inclusion criteria. Of the eight trials, two trials failed to report their exclusion 

criteria.236,237 Three trials209,236,237 had three arms and the remaining five trials230,233,234,238 had 

two arms. All arms in the three-arm trials were randomized. 
57

The studies were conducted in the following countries: the Republic of Angola,236 Finland,237

the Netherlands,230,238 England,230,233 Denmark,209,230Norway,230 Russia,230 and, the U.S.234 All 

but two studies237,238 reported their funding source. These included: Efamol, Ltd;236 Yorkshire 

Region Locally Organized Research, GLAXO (Leeds) and Seven Seas (Hull);233 Danish Medical 

Research, Sygekassernes Helsefond, Weiman’s Legat and Michaelsen Fonden;209 Concerted 

Action and PECO programmes of the European Commission and the Danish National Research 

Foundation;230 and, Martek Biosciences Boulder Corporation (formerly OmegaTech, Inc).234

Population characteristics. The total number of enrolled pregnant women across the 

included studies was 2,335 and ranged from 18237 to 579230 participants. 

In general, participants included in most of the trials were healthy, with uncomplicated 

pregnancies. Patients in the Laivuori et al. trial were diagnosed with preeclampsia (GHT and 

protein in urine >0.5 g/d).237 The study sample in another trial consisted of healthy women with 

previous history of anemia (27%), sickle-cell disease (34%), malaria (67%), or GHT (21%).236 

Four trials230,233,236,238 included pregnant women who had a history of GHT. In three 

trials,230,233,238 a previous episode of GHT was defined by a diastolic BP ≥90 mm Hg233,238 or 

>100 mm Hg.230 The proportion of women with a previous history of GHT in the four trials 

ranged from 21%236 to 100%230 of participants. The between-arm proportions of women with a 

previous history of GHT were not similar in the study of Bulstra-Ramakers et al. (75% vs 

48.4%).238 In another trial, the distribution of women with a previous history of GHT between 

the two randomized arms was more balanced (31.8% vs. 33.6%).233 

The age of the study participants was not reported in one study.238 In the remaining studies, 

the age ranged from 14 236 to 40 years.233,236,237 The approximate mean age values across the 

trials209,230,233,234,237 ranged from 26.5233 to 31.0 years,237 and were similarly distributed across the 

treatment groups. 

The women’s baseline mean diastolic BP across the trials209,230,233,234 ranged from 64234 to 74 

mm Hg.230 In these trials, the mean values of diastolic BP were similar across the randomized 

arms. The baseline mean (arm-specific) systolic BP was reported only in two studies,209,234 and 

ranged from 111234 to 124 mm Hg.209 In both trials, the randomized arms had similar mean 

values of systolic BP. 

All trials reported the GA of the study participants at enrollment, randomization and start of 

intervention. The women’s GA at enrollment and randomization across the trials, ranged from 

16209,236 to 37 weeks.237 The range of GA was reported in four trials.233,234,237,238 The armspecific mean GA (SD) was reported in five studies,230,233,234,237 which was distributed evenly 

across the randomized arms. Three trials included only parous women (those with previous live 

births).230,233,238 

The proportion of parous women across the remaining trials ranged from 48.5%230 to 

67.8%209 of participants and were similar across the study arms. Five studies reported on 

maternal tobacco smoking.209,230,233,234 The proportion of tobacco smokers ranged from 22%230to 

32%209,230,233 of participants. In three trials,209,230,234 the arm-specific distributions of smokers 

were more or less comparable. However, in two other trials,230,233 the proportions of smokers 

across the randomized arms were not as similar—in the Onwude et al. trial,233 42% of 

participants in the fish oil arm were smokers compared with 32% in the placebo arm; in the 
58

Olsen et al. “Earl-PIH” trial, 19.1% of participants in the fish oil arm were smokers compared 

with 24.2% in the placebo arm.230

The trials excluded subjects who had diabetes,230,233,234,238 systemic lupus 

erythematosus,234,238 chronic hypertension,233,234 placental abruption,209,230,233 asthma,233 severe 

fetal malformation,230 drug and/or alcohol abuse,230 regular intake of fish oil,196,209,230,231 allergy 

to fish oil,209 chronic illness (cardiovascular, cancer, renal, psychiatric, or neurological disorder) 

and a serious infectious disease (hepatitis).234 Regular users of prostaglandin inhibitors were also 

excluded.209

Intervention/exposure characteristics. In all but one study,234 the experimental 

intervention was dietary supplementation with omega-3 FA-enriched capsules. In the study by 

Smuts et al.,234 women were assigned to receive omega-3-enriched eggs. The daily number of 

assigned capsules across the trials varied from 4209,230 to 12.238 Five trials209,230,236,237 reported 

fish oil as a primary source of omega-3 FAs (i.e., ALA, LA EPA, DHA). The experimental 

intervention in most of the trials consisted of the combined supplementation with DHA and 

EPA.209,230,233,236-238 The enriched eggs in the trial of Smuts et al. provided DHA only.234 In 

three trials,209,230 the relative contents of DHA and EPA in each experimental capsule were 23% 

and 32%, respectively. In two trials,233,237 each experimental capsule contained 120 mg and 180 

mg of DHA and EPA, respectively. In two other trials,209,230 the absolute amounts of DHA and 

EPA were 225 mg and 325 mg per experimental capsule, respectively. In one trial, each capsule 

contained 250 mg of EPA.238 

The daily dose of DHA and EPA differed across the studies. The range of daily DHA intake 

was 0.08 g236 to 1.20 g237 and 0.15 g236 to 3.00 g238 for EPA. Three trials had a control arm with 

standard intervention such as magnesium oxide tablets (37 mg GLA),236 preglandin capsules (45 

mg GLA)237 or olive oil209, besides the experimental and placebo arms. In seven trials, 

intervention in the control/placebo arms consisted of capsules with an identical appearance and 

taste as the experimental capsules. In these trials, placebo capsules contained olive 

oil,209,230,236,237 maize oil,237 coconut oil,238 or no oil.233 In the trial conducted by Smuts et al., 

omega-3-enriched eggs contained a mean of 33 [range 22-51] mg of DHA.234

Information about patient compliance (numbers of partially- or non-compliant participants 

and/or reasons for non-compliance) were reported in six trials.209,230,233,234,238 The type of 

analysis performed (i.e., ITT) were reported in three trials.230,233 All three studies used ITT 

analyses. Two trials236,237 did not report any information on the rates and/or reasons of 

compliance. 

The manufacturers of the omega-3 FA-enriched supplemental products in the eight studies 

were: Efamol Research Institute and Efamol, Ltd (England);236 Orion OY (Finland);237 Lube Ltd. 

(Denmark);209,230 and, OmegaTech, Inc. (Bouldwer, CO)/Gold Circle Farms (U.S.).234 Two trials 

did not report the names of manufacturers who provided the omega-3 FA-enriched 

capsules.233,238 The trials had varying lengths of intervention (in weeks) i.e, 24,230,236 27,238 1 to 

8,237 14 to 16233,234 and 9.209 

Cointervention characteristics. Olsen et al.’s “Earl-PIH” and “Twins” trials allowed 2 mg 

tocopherol/mL in the fish oil capsules only.230 Only two studies assessed the background diet of 

participants during the study.209,236 Olsen et al. used a simple food-frequency questionnaire, 

reporting the amount of fish consumed before the trial: the low-fish intake group (at most one 
59

fish snack per month) to high fish intake (at least four fish meals per month). More than 50% of 

the women (n=327) were in the middle category of fish intake.209 D’Almeida et al. measured 

background diet with a 24-hour dietary recall questionnaire.236

Outcome characteristics. The incidence (or recurrence) rate of GHT was the primary 

outcome investigated in six trials.209,230,233,236,238 The definition of GHT varied slightly across the 

trials. Most trials defined GHT as diastolic BP above 90 mm Hg.209,230,233,238 These definitions 

were based on the number of measurements taken and the time-interval between measurements. 

One trial236 defined GHT as a rise in diastolic BP of >15 mm Hg, whereas, another study238

defined it as a rise in diastolic BP of >25 mm Hg. D’Almeida et al., defined GHT as a rise in 

systolic BP >30 mm Hg and/or a rise in diastolic BP >15 mm Hg.236 Since one of the trials of 

Olsen et al.230 included only pregnant females with a previous history of GHT (BP >100 mm 

Hg), the outcome of interest was the recurrence (not incidence) rate of GHT (BP >90 mm Hg). 

Note that, in this trial, the definitions for the previous/prevalent and incident GHT, differed. 

Five trials investigated the incidence of preeclampsia.209,230,234,236 Of these, four trials 

reported the definition of incident preeclampsia.209,230,236 D’Almeida et al. defined preeclampsia 

as the simultaneous occurrence of the clinical triad: GHT, proteinuria, and edema.236 However, 

in the remaining three trials,209,230 the definition was restricted to GHT accompanied only by 

proteinuria (proteins >0.3 g/L). Only D’Almeida et al.236 investigated the incidence of eclampsia 

which was defined by the simultaneous presence of GHT and two convulsive episodes. 

Systolic and/or diastolic BP (measured in mm Hg), as the outcome of interest was assessed in 

four studies.209,230,237 The cumulative incidence rates of proteinuria and edema were explored in 

two trials.236,237

Study quality and applicability. The eight RCTs received a mean Jadad total quality score 

of 2.9, approaching a good internal validity (Summary Matrix 2). The trials conducted by 

Bulstra-Ramakers et al. and Onwude et al. received a score of 5,233,238 Smuts et al. received a 

score of 3,234 and the remaining five reports received a score of 2.209,230,236,237 All reported an 

adequate randomization method. Six trials were not double-blinded,31,41,296-298 and five trials 

failed to report the reasons for dropouts.31,41,297,298

Summary Matrix 2: Study quality and applicability of evidence for the effect of LCPUFA supplementation on 

the incidence of gestational hypertension, preeclampsia and eclampsia 

Study Quality

A B C 

Author Year n Author Year n Author Year n 

I 

Author Year n Author Year n Author Year n

II OnwudeA 1995 233 SmutsI 2003 350 

Author Year n Author Year n Author Year n

Applicability 

III 

BulstraRamakersA 1994 68 D’AlmeidaI 

LaivuoriA 

OlsenA 

OlsenA 

OlsenI 

1992 

1993 

2000 

2000 

1992 

150 

18 

579* 

386** 

533 

n = number of allocated/selected participants; RCT = AAdequate vs UUnclear allocation concealment; I Inadequate 

*”Earl-PIH” trial; **”Twins” trial
60

Qualitative synthesis of individual study results 

Six trials investigating the effect of omega-3 FA-dietary supplementation on the incidence 

rate of GHT209,230,233,237,238 showed a nonstaistically significant difference between-groups in the 

incidence of GHT. In contrast, D’Almeida et al. observed that women randomized to receive the 

diet enriched with magnesium oxide had lower incidence rates of GHT compared with those 

participants in the omega-3 FA-supplemented and placebo groups (4% vs 18% and 26%, 

respectively; p-value NR).236 

Three trials demonstrated an effect of omega-3 FA-dietary supplementation in reducing risk 

of preeclampsia.209,230,234 The mean number of women who had developed preeclampsia in all 

study arms was 15 (range from five to 28 women). Although the proportion of women 

developing preeclampsia tended to be lower in the experimental/omega-3 FA-supplemented 

arms,209,230,234 the statistical power of these trials was too low to detect these differences. Only 

one trial236 was able to show that women in the fish oil arm had a lower rate of preeclampsia than 

those in the placebo and magnesium oxide groups. In the D’Almeida et al. study, none of the 

women in the fish oil and magnesium oxide groups developed severe eclampsia compared with 

3/50 (2.1%) patients in the placebo group.236 

The findings of Laivuori et al. suggested that dietary supplementation with fish oil did not 

have any effects on BP, proteinuria, and edema in women with preeclampsia in 12 of 18 women 

enrolled.237 Findings from trials that measured BP during the follow up,209,230 suggested that 

dietary supplementation with omega-3 FAs did not affect the BP of the women i.e., randomized 

groups had similar BP (systolic and diastolic) readings at follow up. 

The cumulative incidence rates of proteinuria and edema were measured in two studies.236,237 

D’Almeida et al. found similar incidence rates of proteinuria in the randomized groups. 

However, women in the placebo group had a significantly higher rate of edema than those in fish 

oil/primrose oil and magnesium oxide groups (58% vs 26% and 24%, respectively).236 Three 

studies reported data on dropouts and withdrawals with different detail.233,234,238 The number of 

non-completers across the trials ranged from 1233 to 57.234

Quantitative synthesis 

In total, seven studies were identified by our search that reported on incidence of preeclampsia or GHT. After examining the studies for source of oil and duration of 

supplementation, five studies209,230,233,236,237 were initially considered for meta-analysis. 

Upon further examination, three studies209,236,237 were excluded. Lavuiori et al. did not report 

quantitative outcome data.237 D’Almeida et al. included a population with unique comorbities in 

a developing-world population.236 Olsen et al. was carried out in a healthy population (i.e., 

women not at high risk of pre-eclampsia/GHT).209 Thus, two studies230,233 reporting on the 

incidence of GHT were available for meta-analysis. 
61

Figure 3. Gestational hypertension incidence. Meta-analysis was performed using a randomeffects model for odds ratios (n/N = number of patients with GHT/total sample in each arm). 

Review : N-3 CHILD

Comparison: 02 DHA + EPA vs Control 

Outcome: 01 Pregnancy induced hypertenion 

Study DHA + EPA Control OR (random) Weight OR (random)

or sub-category n/N n/N 95% CI % 95% CI

 Onw ude 1995 38/113 35/119 39.22 1.22 [0.70, 2.12] 

 Olsen 2000 55/167 61/183 60.78 0.98 [0.63, 1.53] 

Total (95% CI) 280 302 100.00 1.07 [0.75, 1.51]

Total events: 93 (DHA + EPA), 96 (Control)

Test for heterogeneity: Chi2 = 0.35, df = 1 (P = 0.56), I2 = 0%

Test for overall effect: Z = 0.37 (P = 0.71)

 0.1 0.2 0.5 1 2 5 10

 Favours treatment Favours control

In two studies,230,233, the overall size of the effect was nonstatistically significant between the 

DHA+EPA and the control groups in the incidence of GHT (OR: 1.07, CI 95%: 0.75; 1.51). 

Impact of covariates and confounders 

None of the included studies reported the use of multivariable techniques such as logistic or 

Cox regression modeling in order to adjust for the effects of dietary supplementation on the 

dichotomous outcomes (GHT, preeclampsia/eclampsia). Most of the studies reported having 

used a Chi-square or Fisher’s test. In one study,238 the randomized groups were not balanced 

with respect to the important prognostic/predictive factor such as a history of previous GHT (i.e., 

75% vs 48.4%). The trial conducted by D’Almeida et al.236 did not report the arm-specific 

proportions of women with a previous history of GHT. It is not clear whether the study authors 

adjusted the effect of interest for any between-group differences with respect to the proportion of 

women with GHT. 

The power calculation was reported in four trials,31,292,296 while the intention-to treat analysis 

approach was reported in two trials.31

What is the Evidence that Maternal Intake of Omega-3 Fatty Acids 

Influences the Incidence of Births of Human Infants Small for 

Gestational Age?

Fourteen unique studies were identified to answer this question. The studies were parallel 

RCTs, published between 1994 and 2004. Olsen et al.230 reported four unique trials: “Earl-PD” 

(women with history of premature delivery); “Earl-IUGR” (women who had IUGR in an earlier 

pregnancy); “Twins trial” (twins in the current pregnancy); and, “Susp-IUGR” (women 

suspected of having IUGR <10th percentile [PC] by ultrasonography in the current pregnancy). 

All the trials were already summarized above, therefore we only included the summary tables 

(see above key questions: Duration of Gestation. and Preeclampsia, Eclampsia or Gestational 

Hypertension) (Summary Table 8-10) 
62

Overview of Relevant Studies 

Summary Table 8: Maternal intake of omega-3 fatty acids and the incidence of births of human infants small 

for gestational age 

Study groups1

 

Author, Year, 

Location: 

Length & 

Design 

Group 1 

(n)/ 

Group 4 

(n)

Group 2 

(n)/ 

Group 3 

(n)

Notable 

clinical 

effects Internal validity Applicability 

D’Almeida, 

1992, Angola: 

24 wk parallel 

RCT236

n-3 FA-enriched 

capsules: 

fish & primrose oil 

EPA 0.15 g/d 

DHA 0.08 g/d 

(n=50) 

Mg2+ oxide 

capsules: 1 g/d 

(n=50)/ 

olive oil capsules: 

(n=50) 

% <2,000 g at 

birth: pb 3.3% 

vs. n-3: 1.3% 

vs. Mg2+: 4.7% 

(no p-value) 

Jadad total: 2 

[Grade: C]; 

Schulz: 

Inadequate 

III 

Olsen, 1992, 

Denmark: 

NR 

parallel 

RCT209

2.7g n-3 FAs fish 

oil (n=266) 

NR olive oil 

(n=136)/ 

pb 

(n=131) 

NS birth wt Jadad total: 2 

[Grade: C]; 

Schulz: 

Inadequate 

III 

BulstraRamakers, 

1994, 

Netherlands 

27 wks 

parallel 

RCT238

n-3 FA-enriched 

capsules: 

 EPA 3 g/d 

(n=32) 

Control capsules: 

coconut oil (n=31) 

NS in IUGR 

recurrence rate 

(grp 1 vs. grp 

2) 

Jadad total: 5 

[Grade: A]; 

Schulz: Adequate 

III 

Onwude, 

1995, UK: 

14 wks 

parallel 

RCT233

n-3 FA-enriched 

capsules: 

EPA 1.62 g/d 

DHA 1.08 g/d 

(n=113) 

Control capsules: 

air-filled 

(n=119) 

NS in birth wt 

& IUGR 

recurrence rate 

(grp 1 vs. grp 

2) 

Jadad total: 5 

[Grade: A]; 

Schulz: Adequate 

II 

Olsen, 2000a, 

multicenter: 

20 wks 

parallel 

RCT230

Earl-PD: Pikasol 

(fish oil) 0.9g 

DHA, 1.3g EPA 

capsules (n=110) 

Olive oil capsules 

(n=122) 

(ITT) SÏ birth 

wt in fish oil 

NS % IUGR 

Jadad total: 2 

[Grade: C]; 

Schulz: Adequate 

III 

1

Proceeding from highest omega-3, or lowest omega-6/omega-3, fatty acid content of intervention/exposure; n-3 = 

omega-3 fatty acids; n-6 = omega-6 fatty acids; ALA = alpha linolenic acid; DHA = docosahexaenoic acid; EPA = 

eicosapentaenoic acid; AA = arachidonic acid; Length = intervention length; Design = research design; n = sample 

size; pts = study participants; NR = not reported; S = statistically significant difference; NS = nonsignificant statistical 

difference; n/a = not applicable; pb = placebo; grp = group; wk = week(s); mo = month; wt = weight; +

p<.05 or 

significant with 95% confidence interval; ++p<.01; +++p<.001; ++++p<.0001; ITT = intention-to-treat analysis; PP = perprotocol analysis (e.g., completers); Ï = increase; Ð = decrease/reduction; GA = gestational age; IUGR = 

intrauterine growth retardation; FA = fatty acids; * Scotland, Sweden, UK, Italy, Netherlands, Norway, Russia, 

Belgium 
63

Summary Table 9: Maternal intake of omega-3 fatty acids and the incidence of births of human infants small 

for gestational age 

Study groups1

 

Author, Year, 

Location: 

Length & 

Design 

Group 1 

(n)/ 

Group 4 

(n)

Group 2 

(n)/ 

Group 3 

(n)

Notable clinical 

effects Internal validity Applicability 

Olsen, 2000b, 

multicenter* 

20 wks 

parallel 

RCT230

Earl-IUGR trial: 

n-3 FA-enriched 

capsules: 

fish oil 

EPA 1.30 g/d 

DHA 0.90 g/d 

(n=141) 

Control capsules: 

olive oil (n=139) 

(ITT) SÏ birth wt 

in olive oil 

NS % IUGR 

Jadad total: 2 

[Grade: C]; 

Schulz: 

Adequate 

III 

Olsen, 2000c, 

multicenter*: 

20 wks 

parallel 

RCT230

Twins trial: 

n-3 FA-enriched 

capsules: 

fish oil 

EPA 1.30 g/d 

DHA 0.90 g/d 

(n=289) 

Control capsules: 

olive oil (n=290) 

(ITT) NS in birth 

wt & % IUGR 

Jadad total: 2 

[Grade: C]; 

Schulz: 

Adequate 

III 

Olsen, 2000d, 

multicenter*: 

33 wks 

parallel 

RCT230

Susp-IUGR trial: 

n-3 FA-enriched 

capsules: 

fish oil 

EPA 2.9 g/d 

DHA 2.1 g/d 

(n=36) 

Control capsules: 

olive oil 

(n=27) 

(ITT) NS in birth 

wt & % IUGR 

Jadad total: 2 

[Grade: C]; 

Schulz: 

Adequate 

III 

Helland, 2001, 

Norway: 

23 wks 

parallel 

RCT141

Cod liver oil: 10 

mL/d 

EPA 0.80 g/d 

DHA 1.18 g/d 

(n=175) 

Corn oil: 10 mL/d 

(n=166) 

NS in birth wt, 

birth length, & 

HC (grp 1 vs. grp 

2) 

Jadad total: 4 

[Grade: A]; 

Schulz: Unclear 

III 

Malcolm , 

2003, 

Denmark: 

15 wks 

Parallel 

RCT235

Fish oil (DHA 100 

g) capsules (n=50) 

pb 

n=50) 

NS in birth wt, 

length & HC 

Jadad total: 3 

[Grade: B]; 

Schulz: Unclear 

II

1

Proceeding from highest omega-3, or lowest omega-6/omega-3, fatty acid content of intervention/exposure; 2

biomarker source; 3biomarkers = EPA, DHA, AA, AA/EPA, AA/DHA, AA/EPA+DHA; n-3 = omega-3 fatty acids; n-6 

= omega-6 fatty acids; ALA = alpha linolenic acid; DHA = docosahexaenoic acid; EPA = eicosapentaenoic acid; AA 

= arachidonic acid; Length = intervention length; Design = research design; n = sample size; pts = study 

participants; NR = not reported; S = statistically significant difference; NS = nonsignificant statistical difference; n/a = 

not applicable; pb = placebo; grp = group; wk = week(s); mo = month; wt = weight; +p<.05 or significant with 95% 

confidence interval; ++p<.01; +++p<.001; ++++p<.0001; ITT = intention-to-treat analysis; PP = per-protocol analysis 

(e.g., completers); Ï = increase; Ð = decrease/reduction; GA = gestational age; IUGR = intrauterine growth 

retardation; FA = fatty acids; HC = head circumference; * Scotland, Sweden, UK, Italy, Netherlands, Norway, 

Russia, Belgium 
64

Summary Table 10: Maternal intake of omega-3 fatty acids and the incidence of births of human infants small 

for gestational age 

Study groups1 Author, 

Year, 

Location: 

Length & 

Design 

Group 1 

(n)/ 

Group 4 

(n)

Group 2 

(n)/ 

Group 3 

(n)

Notable 

clinical effects

Notable 

clinicalbiomarker 

Correlations2,3

Internal 

validity Applicability 

Smuts, 

2003, US: 

16 wks 

parallel 

RCT232

n-3 FAenriched eggs: 

DHA 0.23 g/d 

(n=18) 

Control 

regular eggs 

(n=19)/ 

nonrandomized 

low eggs grp 

(n=16) 

Wt, length, & 

HC at birth Ï in 

grp 1 vs. grp 2 

(p-value: NR) 

rate of PD & 

LBW Ð in grp 1 

vs. grp 2 (pvalue: NR) 

n/a Jadad total: 

2 [Grade: 

C]; 

Schulz: 

Unclear 

II 

Smuts, 

2003, US: 

16 wks 

parallel 

RCT234

n-3 FAenriched eggs: 

DHA 0.23 g/d 

(n=142) 

Control 

regular eggs 

(n=149) 

NS in birth wt, 

birth length, 

HC, NS rate of 

LBW 

n/a Jadad total: 

3 

[Grade: B]; 

Schulz: 

Inadequate 

II 

de Groot, 

2004, 

Netherlan

ds: 

26 wks 

parallel 

RCT196

n-3 FAenriched 

margarine: 

25 g/d 

ALA 2.82 g/d 

LA 9.02 g/d 

(n=29) 

Control 

margarine: 

25 g/d 

ALA 0.03 g/d 

LA 10.94 g/d 

(n=29) 

Birth wt S Ï in 

ALA+LA vs. 

LA+

S (+) correlation 

maternal 

plasma & RBC 

DHA & birth wt 

S +correlation 

DHA intake & 

bith wt 

Jadad total: 

3 [Grade: 

B]; 

Schulz: 

Unclear 

III 

Dunstan, 

2004, 

Australia, 

UK: 

20 wks 

parallel 

RCT231

n-3 FAenriched 

capsules: 

fish oil 

EPA 1.10 g/d 

DHA 2.20 g/d 

(n=40) 

Control 

capsules: 

olive oil 

(n=43) 

NS in length, 

wt, & HC at 

birth 

n/a Jadad total: 

3 [Grade: 

B]; 

Schulz: 

Unclear 

III 

1

Proceeding from highest omega-3, or lowest omega-6/omega-3, fatty acid content of intervention/exposure; 2

biomarker source; 3biomarkers = EPA, DHA, AA, AA/EPA, AA/DHA, AA/EPA+DHA; n-3 = omega-3 fatty acids; n6 = omega-6 fatty acids; ALA = alpha linolenic acid; DHA = docosahexaenoic acid; EPA = eicosapentaenoic acid; 

AA = arachidonic acid; Length = intervention length; Design = research design; n = sample size; pts = study 

participants; NR = not reported; S = statistically significant difference; NS = nonsignificant statistical difference; n/a 

= not applicable; pb = placebo; grp = group; wk = week(s); mo = month; wt = weight; RBC = red blood cells; +p<.05 

or significant with 95% confidence interval; ++p<.01; +++p<.001; ++++p<.0001; ITT = intention-to-treat analysis; PP = 

per-protocol analysis (e.g., completers); Ï = increase; Ð = decrease/reduction; GA = gestational age; IUGR = 

intrauterine growth retardation; FA = fatty acids; PD = pre-term delivery (GA < 37 wks); LBW = low birth weight; 

HC = head circumference 

Qualitative synthesis of relevant studies’ key characteristics 

Study characteristics. All but one study236 were double-blind parallel RCTs. The study by 

D’Almeida et al. was partially blinded.236 All the included studies were published in English 

scientific journals. Eleven trials had two arms; two studies included a third study group.209,236 

The trials had been conducted in the following countries: South Africa,236 Denmark,209 The 

Netherlands,196,238 England,233,235 Norway,141 the U.S.,232,234 Australia and England.231 

Olsen et al. conducted the three hospital-based trials in Denmark, Scotland, Sweden, England, 

Italy, The Netherlands, Norway, Russia, and Belgium.230 All but one study238 reported their 

funding sources: Enfamol Ltd.,236 Danish Medical Research Council, Sygekassernes Helsefond, 
65

Weiman's Legat & Michaelsen Fonden,209 Yorkshire Region Locally Organized Research, 

GLAXO (Leeds) and Seven Seas (Hull);233 Concerted Action and PECO programmes of the 

European Commission and the Danish National Research Foundation;230 Peter Moller Grants, 

Avd. Orkla ASA and “Aktieselskabet Chocololadefabrils Medicinske Fond;141 Scottish Office 

Health Department;235 Martek Biosciences Boulder Corporation (formerly OmegaTech, 

Inc.);232,234 Unilever Research and Development (Vlaardingen, Netherlands);196 and, NH & 

MRC and Raine Medical Research Foundation (Australia).231 

Population characteristics. The total number of enrolled pregnant women across the 10 

trials was 3,404 and ranged from 60235 to 590141 participants. Helland et al. had a high rate of 

dropouts, leaving 341 women in the final analysis (57%).288

The age distribution of participants was reported in all but two trials.235,238 The age of 

women across these studies ranged from 14236 to 40 years.233 Smuts et al. studied the youngest 

population of women with about 50% of participants aged between 16 and 21 years.234 Whereas, 

in the study by Bulstra-Ramakers et al., more than 50% of the women were between 20 and 29 

years old.233 The age distribution across the study arms was not statistically different. However, 

in the Smuts et al. study,232 the experimental arm (omega-3 enriched eggs) consisted of 

significantly younger women than in the control arm (p <0.05).232

All but one study236 reported both inclusion and exclusion criteria. The 13 trials can be 

categorized into two groups—those trials investigating the effect of omega-3 dietary 

supplementation in pregnant women at risk of IUGR, due to a previous history of IUGR, twin 

pregnancy or history of premature delivery,230,233,238 and those trials that included only healthy 

pregnant women.141,196,209,231,232,232,234-236

The definition of a previous history of IUGR varied across the first group of studies. For 

example, Bulstra-Ramakers et al.238 defined IUGR as birth weight <10th PC, Onwude et al.233

defined it as birth weight <3rd PC, and Olsen et al.230 as a birth weight <5th PC. 

In the second group of studies, women were relatively healthy except in the Dunstan et al. 

study,231 who reported that 40% and 58% of the women had asthma and allergic rhinitis, 

respectively. The second group of trials studied multiparous, as well as nulliparous women. The 

corresponding data on parity were reported in five of the 9 trials.141,196,209,231,234 The proportion 

of multiparous women across the studies ranged from 43%234 to 60%196 and with the exception 

of Smuts et al.’s study (42% vs 32%), were evenly distributed between the study arms.141,196,231 

The trials excluded women with diabetes,230,233-235,238 gestational diabetes,232 systemic lupus 

erythematosus,234,238 chronic hypertension,196,233,234 GHT,232,235 placental abruption,209,230,233,235

asthma,233 severe fetal malformation,141,230 drug/alcohol abuse,230 regular intake of fish 

oil,196,209,230,231 chronic illness (cardiovascular, cancer, renal, psychiatric, or neurological 

disorder),196,232,234 preeclampsia,232,235 serious infectious disease (hepatitis),141,234 serious 

bleeding episodes,209,235 allergy to fish209,235 or use of prostaglandin inhibitors.209,235 Smuts et al. 

excluded women who had more than four pregnancies.232 Enrollment in one trial was restricted 

to non-smoking women.231 Malcolm et al also excluded twin pregnancies.235

Only three trials reported the racial composition of the study population.196,232,234 In two 

trials,232,234 the majority of women were Black (81.0 and 73.2%, respectively). The third trial 
66

included only White women.196 There was no statistically different racial distribution between 

the study arms among these trials. 

Ten studies reported on maternal tobacco smoking.141,196,209,230,231,233,234 The “Earl-IUGR” 

study by Olsen et al.230 had the highest prevalence of smokers (about 50%). In contrast, the 

lowest prevalence of smokers (about 19%) was in the study by Helland et al.141 In these trials, 

the arm-specific distributions of smokers were similar. In their trial, Dunstan et al. included only 

non-smokers.231

All trials reported the GA of the study participants at enrollment/intervention. In five 

trials,141,232-234,238 GA of women at the start of intervention ranged from 12 weeks238 to 32 

weeks.233 For the remaining six trials, the lowest reported value of GA at intervention start was 

16 weeks. The between-arm distribution of GA after randomization was reported as not different 

between-arms in nine trials.209,230,232-235 

Only three trials reported on alcohol use,196,231,234 and in all of them, the distribution of 

alcohol users was similar between the randomized arms. The years of maternal education was 

reported in only two trials.141,196

Intervention/exposure characteristics. In all 14 trials, the experimental intervention was 

the supplementation of the women’s usual diet with omega-3 FA-enriched products. In 10 

trials,209,230,231,233,235,236,238 the omega-3 FA supplementation was provided in capsules. The 

number of assigned capsules given to the women in these trials ranged from 4230 to 12 per day.238 

In two trials,232,234 women received omega-3 FA-enriched eggs. In 10 studies, the primary 

source of omega-3 FA supplementation was fish oil.141,209,230,231,233,235,236 In de Groot et al., the 

source of omega-3 FA supplementation was margarine.196 The experimental intervention in the 

majority of the trials consisted of the combined supplementation of DHA and 

EPA.141,209,230,231,233,238 Participants in the de Groot et al. trial received dietary supplementation 

with ALA and LA.196 The supplementation provided to participants in the two Smuts et al. trials 

was eggs enriched with only DHA.232,234 D’Almeida et al. used a mixture of evening primrose 

oil (GLA) and fish oil (DHA+EPA).236

The absolute amount of DHA ranged from 120233 to 135 mg per capsule (or per egg).232,234 

The study-defined daily dose (in grams) of DHA and EPA varied across the trials. The daily 

dose of DHA ranged from 0.20 g232 to 2.20 g.231 Whereas, the daily dose of EPA ranged from 

0.80 g141 to 3.0 g.238 In the study by de Groot et al., the daily doses of ALA and LA were 2.8 g 

and 9 g, respectively.196 

In most of the studies, intervention for the control group consisted of capsules,230,233,238

eggs,232,234 or margarine196, with similar appearance and/or taste as those for the experimental 

intervention. The participants in the control arms received olive oil,209,230,231 coconut oil,238 or 

corn oil.141 Onwude et al.’s control group received airfilled capsules.233

The duration of the intervention was, in general, until delivery. The manufacturers of the 

omega-3 FA-enriched supplemental products were reported in 12 studies: R P Scherer Ltd. 

(UK);235 Enfamol Ltd.;236 Lube Ltd. (Denmark);209,230 Peter Moller, Avd Orkla ASA 

(Norway);141 OmegaTech, Inc. (Bouldwer, CO)/Gold Circle Farms (U.S.);232,234 Unilever 

Research and Development (Vlaardingen, Netherlands);196 and, Ocean Nutrition (Nova Scotia, 

Canada).231 Two trials did not report the names of the manufacturers.233,238 
67

The data on compliance (numbers of non-compliant participants and reasons for noncompliance) and type of analysis performed (i.e., ITT) were reported in six trials.209,230,233 Five 

studies used ITT analyses.230,233 The numbers of non-compliant participants were reported in 

five studies.141,196,232,234,238 Dunstan et al. did not report well-documented compliance-related 

data.231

Cointervention characteristics. Six trials allowed 2 to 4 mg tocopherol/mL in the fish oil 

capsules.209,230,231 de Groot et al.’s margarines also contained vitamins (0.04%).196 In the 

Helland et al. study,141 the amount of fat-soluble vitamins was identical in the two oils provided 

to partipants (i.e., 117μg/mL of vitamin A, 1 μg/mL of vitamin D, and 1.4 mg/mL of tocopherol). 

Five studies assessed the background diet of participants during the study.141,209,232,235,236 The 

studies used either a food-frequency questionnaire or a 24 hour recall questionnaire.236

Outcome characteristics. Of the 14 studies, three looked at the recurrence rate (i.e., 

percentage, relative risk, or odds ratio) of IUGR.230,233,238 Olsen et al., in the “Earl-IUGR” trial, 

evaluated the incidence of IUGR (not recurrence).230 Twelve trials measured and compared 

mean birth weight values (in grams) between the randomized arms, adjusted for GA and 

sex.141,196,209,230-235 The rate of birth (i.e., percentage) of infants weighing <2,500 grams (LBW) 

was looked at in seven trials.230,232,234,236,238 The infants’ birth length and HC (in cm) between 

the randomized groups were compared in five trials.141,231,232,234,235

Study quality and applicability. The 14 RCTs received a mean Jadad total quality score of 

2.85, with an average poor internal validity (Summary Matrix 3). The trials conducted by 

Bulstra-Ramakers et al. and Onwude et al. received a score of 5,233,238 Helland et al. received a 

score of 4,141 four trials received a score of 3,196,231,234,235 seven reports received a score of 

2.209,230,236,294 Four trials failed to report the randomization method,290,293-295 seven trials were not 

double-blinded,31,41,296,297 while Smuts et al. did not provide the method of double-blinding.294

Seven trials did not report the reasons for dropouts.31,41,294,297

Summary Matrix 3: Study quality and applicability of the evidence for the effect of LCPUFA supplementation 

on the incidence of infants small for gestational age 

Study Quality

A B C 

Author Year n Author Year n Author Year n 

I 

Author Year n Author Year n Author Year n

II OnwudeA 

HellandU 1995 

2001 

233

590 

SmutsI 

MalcolmU 2003 

2003 

250 

100 

SmutsU 2003 73 

Author Year n Author Year n Author Year n

Applicability 

III 

BulstraRamakersA 1994 68 DunstanU 

de GrootU 2004 

2004 

98 

79 

OlsenI 

D’AlmeidaI 

OlsenA 

OlsenA 

OlsenA 

OlsenA

1992 

1992 

2000 

2000 

2000 

2000 

533 

150 

232* 

280** 

579*** 

63^ 

n = number of allocated/selected participants; RCT = AAdequate vs UUnclear allocation concealment; I Inadequate 

*”Earl-PD” trial; **”Earl-IUGR” trial; ***”Twins” trial;^”Susp-IUGR” trial
68

Qualitative synthesis of individual study results

The three studies investigating the effect of omega-3 FA dietary supplementation on pregnant 

women with a previous history of IUGR, concluded that the randomized groups did not differ 

with respect to the recurrence of IUGR (birth weight < 3rd and 10th PC adjusted for GA).230,233,238 

The between-group difference in the mean birth weight was not significantly different in 

eight of 12 studies.141,209,230,231,233-235 However, in three trials, the mean birth weight was 

significantly higher in the omega-3 FA-supplemented group compared with the group without 

supplementation.196,230,232 In contrast, the “Earl-IUGR” trial found a significantly higher mean 

birth weight in the olive oil group compared with the fish oil group.230 

Regarding birth length, three studies did not find a statistical difference between study 

arms.141,231,235 On the other hand, in the Smuts et al. trial, infants in the high-DHA egg group had 

a significantly higher birth length compared with those in the ordinary egg group.234 HC at birth 

was similar in both groups across four trials.141,231,234,235

Results of five trials showed that omega-3 FA supplementation did not influence the 

incidence rate of LBW infants from pregnant women with or without a history of previous 

IUGR.230,234,238 In the trial conducted by Smuts et al., no LBW infants were born to women 

receiving omega-3 FA supplementation, and the incidence rate of LBW infants born to women in 

the control arm was 26%.232 In D’Almeida et al., the percentage of infants born weighing 

<2,000 g was noticeable lower in the omega-3 FA supplemented group compared with the other 

two groups (placebo: 3.3%, magnesium: 4.7%, fish oil+primrose oil: 1.4%); however, no p-value 

was reported. 

Only one study evaluated the association between maternal biomarkers with this clinical 

outcome.196 de Groot et al. found a positive correlation between maternal plasma and RBC DHA 

and birth weight, when controlled for birth order. This difference was nonsignificant at delivery. 

There was also a statistically positive correlation between the total estimated DHA intake and 

birth weight. However, this study provided ALA and LA as supplementation.196

Seven studies reported data on dropouts/withdrawals, albeit with different 

detail.141,196,209,231,234,235,238 The most frequent reasons for study drop-out were: discomfort in 

consuming fish oil or margarine; lack of compliance; refusal to participate because it was time 

consuming; morning sickness; and/or, nausea. The number of non-completers across the trials 

ranged from 1233 to 57.234

Quantitative synthesis 

After examining the studies for source of oil and duration of supplementation, seven 

trials209,230,231,233,238 were initially considered for meta-analysis. For Olsen et al. data from only 

three of six trials was considered (DHA+EPA vs. control): prophylactic EARL-IUGR trial, 

therapeutic Susp-IUGR trial, and prophylactic Twins trial.230 Olsen et al.209 and Dunstan et al.231

were carried in a healthy population (i.e. women without previous history of high risk 

pregnancy). Thus five trials230,233,238 were considered for meta-analysis. 
69

For the birth weight outcome, data from the Susp-IUGR trial230 could not be included since it 

was reported as birth weight adjusted for GA, unlike the other studies. Bustra-Ramakers et al.238

did not report birth weight. Thus three trials230,233 were available for meta-analysis. 

For the intra-uterine growth retardation (IUGR) outcome, the therapeutic trial Susp-IUGR230

could not be included since it did not report IUGR outcomes. Thus four trials230,233,238 were 

available for meta-analysis. 

Figure 4. Birth weight (grams). Meta-analysis was performed using the random effects 

weighted mean difference. For the Onwude et al. study’233 the standard deviations in the two 

study groups were not reported, however, a 95% confidence interval for the difference in means 

was reported. We assumed the standard deviations were the same in both groups, and computed 

the standard deviation from the confidence interval. 

Review : N-3 CHILD

Comparison: 03 DHA + EPA vs Control 

Outcome: 01 Birthw eight (g) 

Study DHA + EPA Control WMD (random) Weight WMD (random)

or sub-category N Mean (SD) N Mean (SD) 95% CI % 95% CI

Onw ude 1995 113 3033.00(734.13) 119 2983.00(734.13) 44.24 50.00 [-139.00, 239.00] 

Olsen 2000 135 2910.00(604.50) 133 3060.00(514.00) 55.76 -150.00 [-284.27, -15.73] 

Total (95% CI) 248 252 100.00 -61.51 [-256.21, 133.18]

Test for heterogeneity: Chi2 = 2.86, df = 1 (P = 0.09), I2 = 65.0%

Test for overall effect: Z = 0.62 (P = 0.54)

 -1000 -500 0 500 1000

 Favours control Favours treatment

In two studies,230,233 the overall size of the effect in the mean birth weight did not reach 

statistical significance (weight mean difference: -61.51, CI 95%: -256.21; 133.18). 

Figure 5. Incidence of intra-uterine growth retardation (IUGR). Meta-analysis was 

performed using a random-effects model for odds ratios. 

Review : N-3 CHILD

Comparison: 04 Intrauterine Grow th Retardation (IUGR) 

Outcome: 01 DHA+EPA vs Control 

Study Treatment Control OR (random) Weight OR (random)

or sub-category n/N n/N 95% CI % 95% CI

 Bulstra-Ramakers1994 11/32 9/31 11.58 1.28 [0.44, 3.71] 

 Onw ude 1995 33/113 35/119 41.05 0.99 [0.56, 1.74] 

 Olsen 2000 43/131 37/132 47.37 1.25 [0.74, 2.12] 

Total (95% CI) 276 282 100.00 1.14 [0.79, 1.64]

Total events: 87 (Treatment), 81 (Control)

Test for heterogeneity: Chi2 = 0.41, df = 2 (P = 0.81), I2 = 0%

Test for overall effect: Z = 0.71 (P = 0.48)

 0.1 0.2 0.5 1 2 5 10

 Favours treatment Favours control

In three studies,230,233,238 the overall size of the effect on the incidence of IUGR between 

DHA+EPA and control groups was nonstatistically significant (OR: 1.14, CI 95%: 0.79; 1.64). 
70

Impact of covariates and confounders 

The observed between-group differences in birth weight in three studies,209,230,232 were 

adjusted for potential effect modifiers (i.e., duration of pregnancy, infant’s gender, placental 

weight, maternal age, other characteristics). 

Linear regression analysis revealed that the duration of pregnancy was an important predictor 

(potential confounder) of birth weight.230 The higher birth weight observed in the experimental 

group compared with the control group was partially due to the effect of duration of pregnancy, 

which was not evenly distributed between the randomized groups. Once this difference was 

accounted for, by adjusting for duration of pregnancy, the earlier observed difference in birth 

weight was attenuated.230 In another study,232 using ANOVA, it was found that birth order was 

an important predictor of birth weight and length. Smuts et al. used a multiple linear regression 

to account for effect modifiers by adjusting the effects of interest for race, the number of prior 

pregnancies, previous premature deliveries, smoking, maternal body mass index (BMI), age, 

alcohol use, and maternal RBC-DHA levels.234

In the study of Smuts et al., women randomized to receive the diet supplemented with 

omega-3 FAs (DHA-enriched eggs) were substantially younger compared with those women 

receiving the diet without this supplementation (regular eggs) (mean age: 19.9 vs 24.8 year, p 

<0.05).232 The authors did not report any attempt to adjust for the effect of age. 

In de Groot et al.,196 the observed difference in birth weight was adjusted for the duration of 

pregnancy. In their “Susp-IUGR” trial, Olsen et al. found that the mean birth weight adjusted for 

GA at delivery did not differ between the two randomized groups.230

The analysis revealed that the effect estimates for birth weight, length, and HC were strongly 

influenced by maternal BMI, race, smoking status, and number of pregnancies. The adjustment 

for the above-mentioned covariates attenuated the earlier observed crude differences in birth 

weight, length, and HC. In de Groot et al., duration of pregnancy was an influential covariate for 

the association between the allocation to the experimental intervention and birth weight.196 

In two studies,232,238 the randomized groups were not balanced with respect to the important 

prognostic/predictive factors such as GHT238 and age.232 

None of the studies adjusted the outcomes results for the maternal background diet. 

The power calculation was reported in seven trials,31,288,292,296 while the intention-to-treat 

analysis approach was reported in four trials.31

Pregnancy Outcomes in Light of Biomarker Data 

What is the Evidence That the Duration of Gestation in Women With 

or Without a History of a Previous Preterm Birth is Associated With 

the Omega-3 or Omega-6/Omega-3 Fatty Acid Content of Maternal 

Biomarkers During Pregnancy? 
71

Four studies were identified that answered this question.234,239-241 Smuts et al.’s RCT234 was 

described above; hence, only the three observational studies will be presented in this section.239-

241 The observational studies were published between 1997 to 2001 in English scientific 

journals. The study by Reece et al.239 was a case-control study, whereas, Elias and Innis was a 

single prospective cohort study240 and Rump et al. was a cross-sectional study.241 (Summary 

Table 11) 

Overview of relevant study characteristics and results 

Reece et al. compared blood LCPUFA content of 37 mother-infant pairs with preterm 

delivery (mean GA 34 weeks) with a group of 34 control full-term mother-infant pairs (mean GA 

40 weeks).239 The study was conducted in the U.S. and was supported by the Colorado 

Agricultural Experiment Station. The study included a sample of preterm and term cases based 

on the duration of gestation.239 “Preterm delivery” (n=37) was defined as GA of less than 37 

weeks, whereas, “term delivery” (n=34) was defined as GA of 37 or more weeks. The patients 

were excluded if they had a recognized cause of preterm birth (i.e., uterine abnormality, 

intrauterine infection, substance abuse, multiple gestation, pregnancy-onset hypertension). 

Exclusions for controls included recognized medical problems, multiple gestations, multiple 

parity, GHT, and substance abuse.239 Participants were enrolled at 18 weeks of GA and followed 

until delivery.239

In preterm cases, the maternal blood samples were obtained at delivery, while the control 

women were sampled at 34 weeks of GA and at delivery.239

The cases were well-matched with the controls in terms of marital status (50% married), race 

(82% white), financial support (80% public), pre-pregnancy body mass index, maternal infection 

detected (70% none), type of labor and maternal age.239 Both populations significantly differed 

in the duration of gestation (mean GA: 40.2 [SD=0.2] weeks vs 33.9 [SD=0.6] weeks), birth 

weight, length and HC (preterm infants had significantly lower growth parameters at birth than 

term infants).239

Reece et al. found that the RBC FA content (% total) of LA (omega-6), AA, and DHA was 

significantly higher in the preterm cases compared with the controls at 34 weeks GA and at 

term.239 The percent total EPA in RBC in controls at term was significantly higher than both 

preterm deliveries and 34-week controls. The maternal RBC omega-3/omega-6 ratio content 

was significantly higher in control term deliveries compared with preterm cases. The maternal 

plasma percent total LA (omega-6) was significantly increased in the 34-week control and 

preterm groups compared with the term control group. The plasma percent total LA, AA, EPA 

was significantly higher in preterm cases compared with term controls. The plasma AA content 

was increased in 70% of preterm cases compared with control cases at term.239

Elias and Innis determined the association between length of gestation and the maternal 

plasma concentration of AA and DHA in a cohort of pregnant women (n=84) at 35 weeks of 

GA.240 The study was conducted in Canada and was supported by the Molly Towell Perinatal 

Research Foundation and the National Science and Engineering Research Council of Canada.240 

The cohort included 60 women at 22 to 24 weeks of GA that were recruited from predelivery 

registration records and were followed until delivery. An additional 24 pregnant women were 
72

recruited from a low-risk delivery unit in Canada. Women with a history of surgical or medical 

problems that could influence the lipid metabolism or fetal growth were excluded from the study. 

These included women with more than one fetus, hyperemesis, psychological or social problems, 

illicit drug or alcohol use, cardiac or renal disease, diabetes, epilepsy, respiratory or rheumatoid 

conditions, cholestasis, high cholesterol or triglycerides before pregnancy, HIV infection, 

hepatitis, or tuberculosis.240 

The study measured the maternal intake, during pregnancy, of the different FAs through a 

food-frequency questionnaire designed to collect data on amounts and sources of fat, methods of 

food preparation, brand names and places of food purchase.240

The outcome measures were the maternal blood content of omega-3 and/or omega-6 FA 

during pregnancy and its relationship with the duration of gestation, as well as the infant FA 

blood content.240

Ellis and Innis did not find a significant association between the maternal plasma content of 

omega-3 and omega-6 FA and the duration of gestation, except for the maternal plasma 

triglyceride (TGL) AA content that was positively related to the length of gestation. However, 

this uncontrolled study did not provide the details regarding this association, as well as the fact 

that all the pregnancies reached term.240

Rump et al. was a cross-sectional study that included a sample of healthy pregnant woman 

and their term infants.241 It was conducted in the Netherlands and supported by a Hospital, and 

Nutricia Research. The blood samples were taken at 16 weeks and after delivery.241 

The cohort was separated by weight for gestational age groups, SGA (PC <10th), AGA (PC 

>10th and <90th) and LGA (PC >90th). The groups were comaparable in terms of maternal 

characteristics like age, height, weight, parity, smoking status, and mode of delivery.241

There was no correlation between the maternal content of PUFA and the birth weight.241
73

Summary Table 11: Association between duration of gestation in women with or without a history of a 

previous preterm birth and the the omega-3 or omega-6/omega-3 fatty acid content of maternal biomarkers 

during pregnancy (Observational studies) 

Study groups1 

Author, Year, 

Location: 

Design 

Group 1 

(n)/ 

Group 4 

(n)

Group 2 

(n)/ 

Group 3 

(n) Notable associations2,3 

Internal 

validity Applicability 

Reece, 1997, US: 

Case-control 

study239

Preterm 

births 

(n=37) 

Term 

deliveries 

controls 

(n=34) 

Maternal RBC LA, AA, DHA S 

Ï in preterm vs. 34-wk control+

& term+++ 

Maternal RBC EPA S Ïin term 

controls vs. both preterm & 34-

wk control++ 

Maternal RBC & plasma n-3/n6 ratio was SÏ in term controls 

vs. preterm++ 

NS Maternal RBC n-3/n6 

between preterm & 34-wk 

control 

Maternal plasma LA S Ï in 

preterm & 34-wk control vs. 

term control+ 

Maternal plasma LA, AA, EPA 

SÏ in preterm vs. term 

controls+

Quality 

score: 4 

[Grade C] 

III 

Elias, 2001, 

Canada: 

Single 

prospective 

cohort240

Healthy 

pregnant 

women 

(n=84) 

n/a Umbilical cord plasma TGL & 

CE AA S (+) associated with 

GA++ 

NS association between other 

maternal n-3 or n-6 BMK & GA 

Maternal plasma TGL AA S (+) 

correlated to GA++

Quality 

score: 6 

[Grade B] 

III 

Rump, 2001, 

Netherlands: 

Crosssectional241

Healthy 

pregnant 

womenterm 

infants 

(n=627) 

n/a NS correlation between 

maternal plasma FA at 11 (8) 

wk GA & at delivery & GA 

Quality 

score: 9 

[Grade A] 

III 

1

biomarkers = EPA, DHA, AA, AA/EPA, AA/DHA, AA/EPA+DHA; n-3 = omega-3 fatty acids; n-6 = omega-6 

fatty acids; ALA = alpha linolenic acid; DHA = docosahexaenoic acid; EPA = eicosapentaenoic acid; AA = 

arachidonic acid; LA = linoleic acid; n = sample size; pts = study participants; NR = not reported; S = 

statistically significant difference; NS = nonsignificant statistical difference; N/A = not applicable; pb = placebo; 

grp = group; wk = week(s); mo = month; BMK = biomarker; RBC = red blood cells; PL = phospholipid; CE = 

cholesteryl ester; TGL = triacylglycerol; GA = gestational age/duration of gestation; +

p<.05 or significant with 

95% confidence interval; ++p<.01; +++p<.001; ++++p<.0001; Ï = increase; Ð = decrease/reduction 

Study quality and applicability. Although they employed different research designs, all the 

studies were assigned a level III for applicability, and together they received a mean quality 

score of 6.3. 
74

Summary Matrix 4: Association between duration of gestation in women with or without a history of a 

previous preterm birth and the the omega-3 or omega-6/omega-3 fatty acid content of maternal biomarkers 

during pregnancy 

Study Quality

A B C 

Author Year n Author Year n Author Year n I 

Author Year n Author Year n Author Year n II 

Author Year n Author Year n Author Year n

Applicability 

III Rump 2001 627 Elias 2001 84 Reece 1997 71 

n = number of allocated/selected participants

What is the Evidence That the Incidence of Preeclampsia, Eclampsia 

or Gestational Hypertension is Associated With the Omega-3 or 

Omega-6/Omega-3 Fatty Acid Content of Maternal Biomarkers During 

Pregnancy? 

Five observational studies were identified that addressed this question.179,229,242-244 The 

studies were published between 1991 and 1999. The trials were included if they selected both 

preeclamptic and normal pregnant women, and blood samples were drawn before delivery. 

Three studies used blood samples taken after delivery and hence were excluded from the 

review.299-301 (Summary Table 12, 13) 

Four studies had a cross-sectional design,229,242-244 whereas, one was a nested case-control 

study derived from a prospective cohort.179

Overview of relevant studies 

Wang et al. assessed the association between the plasma levels of omega-6 FA (LA, AA) and 

omega-3 FA (ALA, EPA, DHA) in a sample of American nonpregnant, normal pregnant and 

preeclamptic patients (n=30).242 (Summary Table 12) 

Craig-Schmidt et al. evaluated the LCPUFA composition of plasma phospholipid in a small 

sample of American healthy pregnant women compared with women with GHT, preeclampsia 

and chronic hypertension (n=36).243 (Summary Table 12) 

Al et al.’s sample of Dutch healthy pregnant women were compared with pregnant women 

with GHT in a nested case-control study. The study assessed the plasma FA content during 

pregnancy in both groups (n=208).179 (Summary Table 12) 
75

Summary Table 12: Association between omega-3 or omega-6/omega-3 fatty acid content of biomarkers 

during pregnancy and incidence of preeclampsia, eclampsia or GHT 

Study groups1

 

Author, 

Year, 

Location: 

Design 

Group 1 

(n)/ 

Group 4 

(n)

Group 2 

(n)/ 

Group 3 

(n) Notable associations2,3

Internal 

validity Applicability 

Wang, 1991, 

US: 

Cross 

sectional 

study242

Preeclampsia 

(n=9)/ 

normal 

pregnant 

pts(n=11)/ 

nonpregnant 

women 

volunteers 

(n=10) 

Total PUFA, LA (n-6), ALA 

(n-3) & EPA plasma of 

normal pregnant women 

was S > preeclamptic pts+

NS between groups 

plasma AA & DHA 

S > EPA & DHA in normal 

pregnant women vs. 

nonpregnant++

Quality 

score: 5 

[Grade B] 

III 

CraigSchmidt, 

1994, US: 

Crosssectional 

study243

preeclampsia 

(n=10)/ 

normal 

pregnancy 

(n=10)

GHT (n=10)/ 

CHT (n=6) 

NS among groups in 

plasma saturated, 

monosaturated & PUFAs 

NS in n-6 or n-3 FA 

between normal 

pregnancies & GHT, 

preeclamsia or CHT 

CHT S Ï AA in plasma PL 

vs. other groups 

NS in plasma PL EPA 

among the groups 

NS in AA/EPA ratio & n6/n-3 ratio 

Quality 

score: 2 

[Grade C] 

III 

Al, 1995, 

Netherlands:

nested casecontrol 

study179

GHT women 

(n=52) 

Healthy 

pregnant 

controls 

(n=156) 

NS in absolute FA 

composition (mg/L) of 

maternal plasma PL 

(before 16, at 22 & 32 wks 

GA) 

Severe GHT women 

(n=17) mean GA & mean 

birth wt of their babies S Ð

than mild GHT 

During gestation & after 

delivery NS in maternal FA 

composition of the severe 

GHT vs. mild GHT 

Quality 

score: 11 

[Grade A] 

III 

1

Proceeding from highest omega-3, or lowest omega-6/omega-3, fatty acid content of intervention/exposure; 2

biomarker source; 3biomarkers = EPA, DHA, AA, AA/EPA, AA/DHA, AA/EPA+DHA; n-3 = omega-3 fatty 

acids; n-6 = omega-6 fatty acids; ALA = alpha linolenic acid; DHA = docosahexaenoic acid; EPA = 

eicosapentaenoic acid; AA = arachidonic acid; E-EPA = ethyl eicosapentaenoate; Length = intervention 

length; Design = research design; n = sample size; pts = study participants; NR = not reported; S = 

statistically significant difference; NS = nonsignificant statistical difference; n/a = not applicable; grp = group; 

wk = week(s); mo = month; PL = phospholipid; CPG = choline phosphoglycerides; EPG = ethanolamine 

phosphoglycerides; +

p<.05 or significant with 95% confidence interval; ++p<.01; +++p<.001; ++++p<.0001; ITT = 

intention-to-treat analysis; PP = per-protocol analysis (e.g., completers); Ï = increase; Ð = 

decrease/reduction; GHT = gestational hypertension; PL = phospholipids; CHT = chronic hypertension 

Hofmann et al. evaluated the LCPUFA composition of maternal blood in a small sample of 

German pregnant women with preeclampsia compared with healthy controls (n=30).229 

(Summary Table 13) 
76

Shouk et al. compared the LCPUFA plasma content in Egyptian women (mean age 29 

[SD=8.2] years, range: 20-40 years) with severe preeclampsia with healthy pregnant subjects 

during the third trimester.244 (Summary Table 13) 

Summary Table 13: Association between omega-3 or omega-6/omega-3 fatty acid content of biomarkers 

during pregnancy and incidence of preeclampsia, eclampsia or GHT 

Study groups1 Author, 

Year, 

Location: 

Length & 

Design 

Group 1 

(n)/ 

Group 4 

(n)

Group 2 

(n)/ 

Group 3 

(n) Notable associations2,3

Internal 

validity Applicability 

Hofmann, 

1998, 

Germany: 

Crosssectional 

study229

Preeclampsia 

(n=14) 

Healthy 

pregnant 

controls (n=16) 

Total FA in plasma TGL 

during pregnancy were S 

> in preeclamptic group 

vs. control+++

NS between groups in 

AA plasma TGL during 

pregnancy 

LA (n-6) & DHA (n-3) 

content in plasma TGL 

were S Ð in preeclamptic 

pts vs. controls+

NS between groups LA & 

AA (n-6) in plasma PL 

DHA plasma PL content 

was S Ð in preeclamptic 

women++ 

Quality 

score: 6 

[Grade B] 

III 

Shouk, 

1999, Egypt: 

Crosssectional 

study244

severe 

preeclampsia 

in 3rd

trimester 

(n=25) 

healthy 

pregnant 

controls (n=20)

AA in plasma was S > in 

preeclamptic women vs. 

control+++ 

NS between groups LA & 

ALA (n-3) content 

Quality 

score: 7 

[Grade B] 

III 

1

Proceeding from highest omega-3, or lowest omega-6/omega-3, fatty acid content of intervention/exposure; 2

biomarker source; 3biomarkers = EPA, DHA, AA, AA/EPA, AA/DHA, AA/EPA+DHA; n-3 = omega-3 fatty 

acids; n-6 = omega-6 fatty acids; ALA = alpha linolenic acid; DHA = docosahexaenoic acid; EPA = 

eicosapentaenoic acid; AA = arachidonic acid; E-EPA = ethyl eicosapentaenoate; Length = intervention 

length; Design = research design; n = sample size; pts = study participants; NR = not reported; S = 

statistically significant difference; NS = nonsignificant statistical difference; n/a = not applicable; pb = placebo; 

grp = group; wk = week(s); mo = month; PL = phospholipid; +

p<.05 or significant with 95% confidence 

interval; ++p<.01; +++p<.001; ++++p<.0001; ITT = intention-to-treat analysis; PP = per-protocol analysis (e.g., 

completers); Ï = increase; Ð = decrease/reduction; TGL = triglycerides 

Qualitative synthesis of relevant studies’ key characteristics 

Study characteristics. Of the five observational studies that met eligibility criteria, two 

studies were conducted in the U.S.,242,243 one was conducted in The Netherlands179, one in 

Germany229 and one in Egypt.244 Two studies compared the outcomes in more than two 

groups,242,243 whereas, three studies involved only three arms.179,229,244

Most studies were published in scientific journals in English, but one required translation 

from German.229 The funding source was reported in two of five studies. Wang et al. was 

supported by a pharmaceutical industry (Glaxo, Inc.),242 whereas, Al et al. was funded by 

Nutricia BV, Zoetermeer, The Netherlands.179
77

Population characteristics. There were 349 subjects included across the studies. The 

sample sizes ranged from 30 to 208 patients. Three studies reported the inclusion and exclusion 

criteria.179,229,244

Wang et al. selected three groups of women between 20 and 40 years, normal pregnant 

patients (n=11), preeclamptic patients (n=9) and nonpregnant female volunteers as controls. All 

were at term.242 Craig-Schmidt et al. included nulliparous pregnant women (mean age: 21 

[SD=6] years).243 The study groups were composed of women with normal pregnancy (n=10), 

GHT (n=10), preeclampsia (n=10), and chronic hypertension (n=6).243

Al et al. selected, from the prospective cohort of healthy pregnant women (GA <16 wks), a 

group of women with GHT and matched them with a group of healthy pregnant patients.179 

Hofmann et al.229 and Shouk et al.244 compared a group of women with preeclampsia with a 

healthy pregnant control group, although Shouk et al.’s patients had a severe preeclamsia in the 

third trimester. 

Shouk et al. did not provide a definition for preeclampsia.244 In general, preeclampsia was 

defined as as BP greater than 140/90 mm Hg measured on two occasions, 6 hours apart starting 

from the 20th week of GA. Proteinuria was defined as greater than 300 mg urinary protein per 24 

h; preeclampsia was the combination of hypertension and proteinuria with or without 

edema.179,229,242,243 

Wang et al.242 and Craig-Schmidt et al.243 failed to provide information about the betweengroup difference in terms of population characteristics (i.e., maternal age, GA, parity, education, 

smoking status, etc.) at baseline or before the study. Al et al. did not find a significant difference 

between groups in maternal age, number of nulliparous women, percentage of smoking women, 

or number of infants small for gestational age (SGA) at term.179 There was a significant 

difference between groups in diastolic BP at entry (GHT higher than control), maximum 

diastolic BP (GHT >control), GA at delivery (GHT < control), birth weight (GHT < control), and 

APGAR score at 5 min (GHT < control).179 Control of selection bias was achieved by measuring 

the FA content of pregnant women (at 16 weeks GA) who decided not to participate in the 

trial.179

Hofmann et al.’s study groups were well-matched for maternal age, BMI, GA, serum 

creatinine, blood glucose and hematocrit. Blood pressure was significantly higher in the 

preeclamptic women.229 Similarly, Shouk et al.’s patients were well-matched for age, parity and 

GA.244

Regarding the medications and/or treatments allowed before study entry, Wang et al.242 and 

Hofmann et al.’s229 preeclamptic women did not receive aspirin. The rest of the studies did not 

report the use of medication in their patients. 

Hofmann et al. and Shouk et al. included patients without other comorbid conditions.229,244 

The remainig three studies did not provide this information.179,242,243

Intervention/exposure characteristics. Groups in the study by Al et al. did not differ in 

their nutrient intake during pregnancy.179 None of the identified studies described the nature of 

the nutritional intake, including the use of supplements or any other substance that could alter the 

lipid content in maternal blood biomarkers. 
78

Outcome characteristics. All studies examined the omega-3 and omega-6 FA content in 

plasma of maternal blood from preeclamptic women compared with healthy controls. 

Study quality and applicability. The total quality score across the studies was 6.2, however 

the applicability level was III. 

Summary Matrix 5: Association between omega-3 or omega-6/omega-3 fatty acid content of biomarkers 

during pregnancy and incidence of preeclampsia, eclampsia or GHT 

Study Quality

A B C 

Author Year n Author Year n Author Year n I 

Author Year n Author Year n Author Year n II 

Author Year n Author Year n Author Year n

Applicability 

III Al 1995 208 Wang 

Hofmann 

Shouk 

1991 

1998 

1999 

30 

30 

45 

Craig-Schmidt 1994 36 

n = number of allocated/selected participants

Qualitative synthesis of individual study results 

Wang et al. found that the total PUFA, LA (omega-6), ALA (omega-3) and EPA content in 

plasma (mg/L, mean) of normal pregnant women was significantly higher than in the 

preeclamptic patients.242 There was a nonsignificant difference between groups in the content of 

AA and DHA in plasma. However, there was a significantly higher content of EPA and DHA in 

normal pregnant women compared with nonpregnant.242

Craig-Schmidt et al. did not observe a significant difference between groups in saturated, 

monosaturated and PUFAs, or in the content of omega-6 or omega-3 FA (mg/L and % of total 

FA) between women with normal pregnancies and women with GHT, preeclamsia or chronic 

hypertension.243 The women with chronic hypertension had a significantly greater AA in plasma 

phospholipid compared with the other three groups. There was a nonsignificant difference in 

plasma phospholipid EPA concentrations among the groups, as well as in the AA/EPA ratio or 

omega-6/omega-3 ratio at baseline.243

During pregnancy (before 16, at 22 and 32 weeks GA) no significant differences in the 

absolute FA composition (mg/L and % total FA) of maternal plasma phospholipid were observed 

between groups in the Al et al. study.179 After delivery, however, the amount of ALA (omega-3) 

was significantly lower in the GHT women compared with women who had normal pregnancies. 

After correction for differences in GA between groups, significantly higher levels of DHA were 

observed in umbilical plasma of the GHT compared with controls.179 When the GHT women 

were stratified by severity of hypertension, patients with severe GHT (diatolic BP >105 mmHg) 

(n=17), 12 of which had proteinuria, had a mean GA and mean infant birth weight that were 

significantly lower than those in the group with mild GHT (diastolic BP <105 mmHg). During 

gestation and after delivery, no significant differences were observed in the maternal FA 

composition of women with severe GHT compared with those with mild GHT.179 
79

Hofmann et al. found that the total amount of FA in plasma triglycerides during pregnancy 

were significantly higher in the preeclamptic group compared with the healthy control group. 

The difference disappeared on the 5th day after delivery.229 The AA content in plasma 

triglycerides did not differ between groups during pregnancy. On the other hand, the LA 

(omega-6) and DHA (omega-3) content in this blood fraction were significantly lower in the 

preeclamptic women compared with the controls. The LA and AA (omega-6) concentration in 

plasma phospholipid were not significantly different between groups, however, the DHA plasma 

phospholipid content was significantly lower in preeclamptic women.229

Shouk et al. observed that the AA in plasma (mcg/L) was significantly higher in preeclamptic 

women. LA and ALA (omega-3) content did not differ between groups.244

What is the Evidence That the Incidence of Births of Human Infants 

Small for Gestational Age is Associated With the Omega-3 or Omega6/Omega-3 Fatty Acid Content of Maternal Biomarkers During 

Pregnancy? 

Five observational studies were identified that addressed the possible association between the 

incidence of SGA infants and the omega-3 or omega-6/omega-3 FA content of maternal 

biomarkers during pregnancy.240,241,245-247 Two were cross-sectional studies,241,247 two were casecontrol studies245,246 and one was a single prospective cohort.240 Studies were published between 

1991 and 2002. (Summary Table 14, 15) 

Overview of relevant studies 

Vilbergsson et al. assessed the association between LCPUFAs of pregnant women considered 

to be at an increased risk for IUGR and the incidence of SGA deliveries.247 Investigators 

recruited 28 eligible women at week 33 or 34 of pregnancy who were considered as high risk for 

SGA delivery after thorough evaluation using a special risk scoring system, ultrasonographic 

measurements of fetuses’ growth parameters, nonstress test, and biophysical profile following 

regular monitoring. Twenty pregnant women with no risk factors were enrolled into the study as 

a control group.247 (Summary Table 14) 

Matorras et al., in a case-control intrapartum study, analyzed the relationship between 

maternal plasma LCPUFAs and IUGR in an apparently well-nourished population of pregnant 

women in the second stage of labor.245 

The study population consisted of 23 women in labor whose infants had prenatally-suspected 

IUGR and were at term delivery and 34 newborn control cases who whose size were appropriate 

for gestational age (AGA).245 (Summary Table 14) 
80

Summary Table 14: Incidence of births of SGA human infants and the association with the omega-3 or 

omega-6/omega-3 FA content of maternal biomarkers during pregnancy 

Study groups1

 

Author, Year, 

Location: 

Design 

Group 1 

(n)/ 

Group 4 

(n)

Group 2 

(n)/ 

Group 3 

(n) Notable associations2,3

Internal 

validity Applicability 

Vilbergson, 

1991, 

Sweden: 

Crosssectional247

SGA grp 

(n=13) 

Term AGA 

(control) 

(n=20) 

SÐ maternal plasma DHA 

& AA in SGA grp than in ctrl 

at 34 weeks GA & at 

delivery+

Quality score: 

7 [Grade B] 

III 

Matorras, 

1994, Spain: 

Casecontrol245

IUGR grp 

(n=23) 

AGA 

(control) 

(n=34) 

SÏ maternal plasma EPA 

in IUGR grp than in ctrl at 

delivery++

NS in maternal plasma DHA 

& AA at delivery 

Quality score: 

9 [Grade A] 

III 

1

Proceeding from highest omega-3, or lowest omega-6/omega-3, fatty acid content of intervention/exposure; 2

biomarker source; 3biomarkers = EPA, DHA, AA, AA/EPA, AA/DHA, AA/EPA+DHA; n-3 = omega-3 fatty acids; 

n-6 = omega-6 fatty acids; AGA = appropriate for gestational age; IUGR = intrauterine growth restriction; GA = 

gestational age; ct = control group; DHA = docosahexaenoic acid; EPA = eicosapentaenoic acid; AA = 

arachidonic acid; BW = birth weight; Fas = fatty acids; Length = intervention length; Design = research design; 

n = sample size; pts = study participants; NR = not reported; S = statistically significant difference; NS = 

nonsignificant statistical difference; n/a = not applicable; grp = group; wk = week(s); mo = month; +

p<.05 or 

significant with 95% confidence interval; ++p<.01; +++p<.001; ++++p<.0001; ITT = intention-to-treat analysis; PP 

= per-protocol analysis (e.g., completers); Ï = increase; Ð = decrease/reduction; SGA = small for gestational 

age; AGA = adequate for gestational age; IUGR = intrauterine growth retardation 

Elias and Innis determined the association between birth weight and length and the maternal 

plasma concentration of AA and DHA in a cohort of Canadian pregnant women (n=84) at 35 

weeks of GA.240 (Summary Table 15) 

Rump et al., in a cross-sectional study, evaluated the relationship between the incidence of 

term SGA births and observed changes in maternal plasma LCPUFA composition during 

pregnancy.241 The study population consisted of 81 SGA infants and 505 AGA infants. 

Maternal plasma FA analysis was performed at study entry (≤16 weeks GA), at delivery, and in 

cord plasma at birth. (Summary Table 15) 

Cetin et al.,246 in a case-control study, determined maternal FAs profiles in utero in 11 AGA 

and in 10 IUGR fetuses from 19 to 39 weeks of gestation and studied the relationship between 

maternal plasma LCPUFA status and the incidence of SGA. (Summary Table 15) 
81

Summary Table 15: Incidence of births of SGA human infants and the association with the omega-3 or 

omega-6/omega-3 FA content of maternal biomarkers during pregnancy 

Study groups1

 

Author, 

Year, 

Location: 

Design 

Group 1 

(n)/ 

Group 4 

(n)

Group 2 

(n)/ 

Group 3 

(n) Notable associations2,3

Internal 

validity Applicability 

Elias, 2001, 

Canada: 

Single 

prospective 

cohort240

Healthy 

pregnant 

women 

(n=84) 

n/a Maternal plasma TGL AA, 

S (+) correlated to infant 

birth wt & length++

Quality score: 

6 [Grade B] 

III 

Rump, 2001, 

Netherlands: 

Crosssectional241

Healthy 

pregnant 

women-term 

infants 

(n=627) 

n/a NS relation between 

maternal plasma FA at 11 

(8) wk GA & at delivery & 

infants BW 

Quality score: 

9 [Grade A] 

III 

Cetin, 2002, 

Italy: 

Casecontrol246

IUGR grp 

(n=10) 

AGA 

(control) 

(n=11) 

SÏ maternal plasma EPA 

in IUGR grp than in pb at 

≈28.2(8.0) wk GA+

NS in maternal plasma DHA 

& AA at ≈28.2 (8.0) wk GA 

Quality score: 

5 [Grade B] 

III 

1

Proceeding from highest omega-3, or lowest omega-6/omega-3, fatty acid content of intervention/exposure; 2

biomarker source; 3biomarkers = EPA, DHA, AA, AA/EPA, AA/DHA, AA/EPA+DHA; n-3 = omega-3 fatty acids; 

n-6 = omega-6 fatty acids; GA = gestational age; DHA = docosahexaenoic acid; EPA = eicosapentaenoic acid; 

AA = arachidonic acid; BW = birth weight; TGL = triacylglycerol; FAs = fatty acids; Length = intervention length; 

Design = research design; n = sample size; pts = study participants; NR = not reported; S = statistically 

significant difference; NS = nonsignificant statistical difference; n/a = not applicable; grp = group; wk = week(s); 

mo = month; wt = weight; +

p<.05 or significant with 95% confidence interval; ++p<.01; +++p<.001; ++++p<.0001; 

ITT = intention-to-treat analysis; PP = per-protocol analysis (e.g., completers); Ï = increase; Ð = 

decrease/reduction; SGA = small for gestational age; LGA = large for gestational age 

Qualitative synthesis of relevant studies’ key characteristics 

Study characteristics. The studies were conducted in different countries, including one 

from Canada,240 and one each from Sweden,247 Spain,245 Italy246 and The Netherlands.241 Four 

studies reported their funding sources and these included a professional society, university and 

foundation,240,247 and government.240,245,246

Population characteristics. Four studies selected a small number of participants, ranging 

from 21246 to 84.240 Only Rump et al. studied a large sample of infants (n=81 SGA, n=505 AGA, 

n=41 LGA).241 

Four studies presented clearly-defined inclusion and exclusion criteria240,241,245,247 and one 

study exclusively described exclusion criteria.246 Vilbergsson et al. included only singleton 

pregnancies and made an effort to equally distribute subjects to groups by age, parity, and dietary 

intake; maternal diabetes was an exclusion criterion.247 Matorras et al. included term SGA 

infants with no malformations and chromosomal abnormalities, delivered from a singleton 

pregnancy, with an accordance between GA (determined by last menstrual period and early 

ultrasound) and pediatric evaluation using the Dubowitz test.245 Elias and Innis included healthy 

pregnant women (GA 22-24 weeks), whereas, women with medical or surgical problems that 

could influence lipid metabolism were not eligible.240 In the study of Rump et al., selection 

criteria for inclusion/exclusion were GA <16 weeks at entry, diastolic BP <90 mmHg and no 
82

signs of cardiovascular, neurologic, renal, or metabolic disorders at the time of recruitment.241 

Cetin et al. set the following exclusion criteria for both normal and IUGR pregnancies: 

subsequent development of gestational diabetes or GHT; abnormal fetus caryotype; or, 

malformation at birth.246

The mean GA was reported in all of the five studies. The mean GA for the entire SGA group 

of infants ranged from 36247 to 40.6 weeks.241 Statistically significant differences in GA between 

the SGA/IUGR and AGA groups were reported in two studies.246,247 In the remaining three 

studies, the SGA/IUGR cohort and AGA controls were of similar age at birth.241,245,246 

Definition of IUGR and/or SGA was given in four studies.241,245-247 Cetin et al.246 and 

Matorras et al.245 established IUGR by performing ultrasonographic examination measuring fetal 

biparietal diameter and/or abdominal circumference, which had to be under the 10th PC of 

reference values for fetuses of a similar age. In the study of Cetin et al., growth retardation was 

confirmed at birth if the neonatal weight was below the 10th PC according to standards for birth 

and weight and GA.246 Rump et al.241 classified infants as SGA if their birth weight was ≤10th

PC of reference values, whereas Vilbergsson et al.247 defined SGA as an infant birth weight two 

standard deviations below the mean when compared with a standard growth chart. 

No authors explicitly stated the racial/ethnic background of the study participants, yet it is 

likely that Caucasian/Europeans were represented as a majority in all of these studies. 

Information regarding maternal smoking history and/or smoking during pregnancy was 

available in two studies and even though there was a higher proportion of smokers in the 

SGA/IUGR group than in control group, the difference did not reach statistical significance.241,245 

Vilbergsson et al reported that the control group contained no smokers and in the group at risk 

for IUGR, there were no differences between smokers and nonsmokers with respect to clinical 

characteristics or FAs results.247 Alcohol consumption during pregnancy was not reported in any 

of the five studies. 

None of the studies reported the use of medication and/or supplements before study entry or 

any comorbid conditions in newborn babies. Maternal characteristics such as parity, and age, 

height, weight at study entry, were similar between study groups in three studies.241,246,247 

However, in the study of Matorras et al.,245 IUGR mothers had lower height, pregestational 

weight and weight increase during pregnancy than mothers in the control group. 

Only one study reported the mean maternal energy intake during pregnancy, which was 

similar between control and IUGR groups.245 The same study evaluated socioeconomic levels of 

study population and reported that twice as many women with IUGR pregnancies belonged to 

low socioeconomic strata. The description of lipid extraction and biochemical analysis was 

adequate in all but one study.247

Outcome characteristics. The main outcome evaluated in these observational studies was 

incidence of births of SGA infants and its relation to either the absolute or relative amount of 

maternal plasma FA concentrations during pregnancy. Information regarding the timing of the 

maternal plasma LCPUFA analysis was reported in all but one study.247 

In the study of Vilbergsson et al., maternal blood samples were drawn in the 34th and 37th week 

of pregnancy, at delivery, and at 4 days postpartum. This study measured the plasma content in 

phospholipids (lecitin) of LCPUFA (mol %).247 Cetin et al. reported that maternal sample 
83

collection and analysis were done at 28.2±8.0 weeks GA in the AGA control group and at 

28.6±4.3 weeks GA in IUGR group. The plasma PUFA were measured in mcg/ml and % weight 

of total FA.246 In the study of Rump et al., maternal venous blood samples were collected at 

11±3 weeks GA. The plasma FA were measured in % weight of total FA.241 Matorras et al. 

obtained maternal blood samples during the second stage of labor. The plasma FA were 

measured in % weight of total FA 245 The correlation between maternal plasma FA composition 

and the main outcomes was calculated using Pearson’s correlation coefficient, following the 

standard criteria of applicability,245 linear regression analysis,246 and simple and multiple 

regression models.241,247 Elias and Innis assessed the association between maternal plasma 

PUFA and the birth weight and length of infants. The plasma FA were measured in % weight of 

total FA.240

Study quality and applicability. Although they employed different research designs, all the 

studies were assigned a level of applicability of III and together, received a mean quality score of 

7.2. 

Summary Matrix 6: Incidence of births of SGA human infants and the association with the omega-3 or 

omega-6/omega-3 FA content of maternal biomarkers during pregnancy 

Study Quality

A B C 

Author Year n Author Year n Author Year n I 

Author Year n Author Year n Author Year n II 

Author Year n Author Year n Author Year n

Applicability 

III Matorras 

Rump 

1994 

2001 

69 

627 

Vilbergson 

Elias 

Cetin 

1991 

2001 

2002 

33 

84 

21 

 

n = number of allocated/selected participants

Qualitative synthesis of individual study results 

Vibergsson et al.247 found that in a subgroup of SGA participants, maternal plasma DHA and 

AA concentrations were significantly lower than those in a control group at 34 weeks GA as well 

as at delivery. The study results of both Matorras et al.245 and Cetin et al.246 were similar. In the 

Spanish case-control study, Matorras et al. revealed that maternal plasma EPA concentrations 

expressed in percentage values of total amount of plasma FAs, were significantly increased in 

IUGR mothers compared with controls at delivery.245 Conversely, there were no differences in 

percentage values nor in absolute values in the other FAs analyzed in newborn infants.245 Cetin 

et al. observed significantly higher maternal plasma EPA in the IUGR group compared with the 

normal control group in the third trimester of pregnancy.246

Rump et al. found that observed changes in maternal plasma LCPUFA concentrations (% wt 

FA) were related to the size of the infants.241 Significantly bigger decreases in plasma 

concentrations of AA and DHA were noted in mothers of AGA control infants compared with 

mothers of the SGA group, whereas, the largest reduction in the fraction of linoleic acid was 

found in the mothers of SGA infants. No cross-sectional association was found between 
84

maternal FA concentrations and infant size at birth at study entry or at delivery, as well as 

between maternal plasma FA concentrations and the total duration of gestation. 

Elias and Innis observed that the maternal plasma TGL AA, but not phospholipid or 

cholesteryl ester AA, was positively related to infant birth weight and length (p<0.01). No other 

correlations were found between maternal plasma omega-3 or omega-6 FAs and these 

variables.240

Growth Pattern Outcomes

What is the Evidence That Maternal Intake of Omega-3 Fatty Acids 

During Pregnancy Influences Growth Patterns in Term or Preterm 

Human Infants? 

One RCT, published in 2002, was identified to answer this question.141 Helland et al.141,200

had two publications related to the same study population, yet this review will refer only to the 

earlier one.141 (Summary Table 16) 

Overview of relevant study characteristics and results 

Helland et al.,141 has been described in detail in the Pregnancy Outcomes section. A 

summary and the results relating to the current question are discussed here. 

Helland et al. assessed the gestational length, birth weight, and neurologic and cognitive 

outcomes in a sample of infants born of healthy pregnant women. Participants were randomized 

to receive either cod liver oil (1,183 mg/10 mL DHA, 803 mg EPA, 27.5 mg AA) or corn oil 

(LA and ALA) from week 18 of pregnancy to 3 months post delivery.141

The participants (n=590 enrolled) were included if they were healthy, with single 

pregnancies, between 19 and 35 years of age, and intended to breastfeed their infant. They 

should not have taken any supplements of omega-3 FA earlier in the pregnancy. The exclusion 

criteria were premature births, birth asphyxia, infections, and anomalies in the infants that 

required special attention.141 Infant growth patterns (i.e., weight, length and HC) were measured 

at birth, 6 weeks and 3, 6, 9 and 12 months. Helland et al. had a high rate of dropouts, leaving 

341 women in the final analysis (57%).288
85

Summary Table 16: Omega-3 fatty acids and its influence on growth patterns in infants after intake during 

pregnancy and breastfeeding 

Study groups1

 

Author, Year, 

Location: 

Design 

Group 1 

(n)/ 

Group 4 

(n)

Group 2 

(n)/ 

Group 3 

(n) Notable clinical effects

Internal 

validity Applicability 

Helland, 2001, 

Norway: 

34 wks 

parallel RCT141

Cod liver oil 

(DHA+AA+EPA) 

(n=301 

mothers; n=175 

infants) 

Corn oil 

(LA+ALA) 

(n=289 

mothers; 

n=166 infants) 

NS between groups in 

weight, length & head 

circumference at any 

point 

Jadad 

total: 4 

[Grade: A]; 

Schulz: 

Unclear 

III 

1

biomarkers = EPA, DHA, AA, AA/EPA, AA/DHA, AA/EPA+DHA; n-3 = omega-3 fatty acids; n-6 = omega-6 

fatty acids; ALA = alpha linolenic acid; DHA = docosahexaenoic acid; EPA = eicosapentaenoic acid; AA = 

arachidonic acid; E-EPA = ethyl eicosapentaenoate; n = sample size; pts = study participants; NR = not 

reported; NS = nonsignificant statistical difference; N/A = not applicable; pb = placebo; grp = group; wk = 

week(s); mo = month; RBC = red blood cells; PL = phospholipid; +

p<.05 or significant with 95% confidence 

interval; ++p<.01; +++p<.001; ++++p<.0001; Ï = increase; Ð = decrease/reduction 

The groups did not differ significantly in weight, length and HC at any time point during the 

study.141 

No correlation was found between these parameters and infant plasma biomarkers. 

Study quality and applicability. The Jadad total quality score was 4 (did not report doubleblinding method) and the allocation concealment was unclear in the report. The applicability 

level was III. 

Summary Matrix 7: Omega-3 fatty acids and its influence on growth patterns in infants after intake during 

pregnancy and breastfeeding 

Study Quality

A B C 

Author Year n Author Year n Author Year n I 

Author Year n Author Year n Author Year n II 

Author Year n Author Year n Author Year n

Applicability 

III HellandU 2001 590 

n = number of allocated/selected participants; RCT = AAdequate vs UUnclear allocation concealment

What is the Evidence That the Omega-3 Fatty Acid Content of 

Maternal Breast Milk, With or Without Known Maternal Intake 

of Omega-3 Fatty Acids, Influences Growth Patterns in Term 

or Preterm Human Infants? 

One RCT and two observational studies published between 1999 and 2003 met eligibility 

criteria regarding the influence of maternal milk intake on growth patterns.248,249,302 Jensen et al. 

was a double-blind RCT,248 Xiang et al. was a single prospective cohort study249 and Rocquelin 

et al. was a cross-sectional study.302 Helland et al.’s RCT (see above and Summary Table 16) 
86

also addressed this question since the mothers of the infants included in the study breastfed their 

infants while taking PUFA supplementation.141 

Overview of relevant study characteristics and results 

Jensen et al. investigated the effect of DHA supplementation in lactating women on the 

visual function and growth of their infants.248 Mothers were assigned randomily to receive 200 

to 250 mg DHA per day as either algal DHA (n=42), refined high-DHA fish oil (n=42) or 

placebo (n=42), for 120 days after delivery. Infant characteristics, as well as maternal 

characteristics, were not described in this abstract.248 The study showed no differences between 

the three diet groups in the weight, length or HC of the infants at 120 and 240 days.248

Xiang et al. evaluated the growth patterns in a random sample of healthy mother-term infant 

pairs (n=19) at 1 and 3 months of age. The infants were exclusively breastfed during the study 

period.249 Rocquelin et al. investigated the role of human milk LCPUFAs in term infant growth 

in two African suburban random samples of nursing mothers and their 5 month old infants.302

Xiang et al. was conducted in Sweden and was supported by the Wenner-Gren Centre 

Foundation.249 Rocquelin et al. was conducted in in The Congo and Burkina Faso (Africa), and 

supported partly by the Institut National de la Recherceh Agronomique.302

Xiang et al. did not report the inclusion and exclusion criteria, yet described the included 

sample as mother-infant pairs without acute or chronic conditions. The infants were exclusively 

breastfed during the 3 months of the study. The mothers registered the total intake of food and 

fluid, and a 3-day dietary record was obtained; however, the LCPUFA content was not 

measured. The maternal milk FA composition was measured at each visit.249 

Rocquelin et al. conducted a survey in two random samples of nursing mothers and their 5-

month old infants born at term—102 participants in Congo and 101 in Burkina Faso.302 The 

report failed to describe the inclusion and exclusion criteria. The dietary habits of the mothers 

was established using a Food-frequency questionnaire. The outcomes measured were the growth 

patterns (weight and height from birth to 5 months of age).302 The maternal age, height, BMI, 

and maternal occupation did not differ significantly between both locations, however, maternal 

education was significantly superior in participants in Congo compared with those in Burkina 

Faso. The characteristics of the participants’ homes (i.e., electricity, refrigerator, private water 

supply, private toilets, radio set, TV set) were significantly different between cities.302 

The feeding practices of the mothers were measured in each location. None of the infants 

were exclusively breastfed. All the infants in Burkina Faso were receiving extra fluids (e.g. 

water or juice) compared with 51% of Congo infants. However, the Burkina Faso infants had a 

significantly higher proportion of predominance of breast feeding and exclusion of solid foods. 

The LCPUFA content in breast milk and foods given to the infants were measured at both sites. 

The breast milk fat content was slightly lower in mothers in Congo. The content of omega-6 FA 

in the human milk of women in Burkina Faso was significantly higher than in Congo, yet it 

provided significantly lower (half) concentrations of omega-3 FA. Consequently, the LA 

omega-6/ALA omega-3 ratio and the LC omega-6/LC omega-3 ratio were 4.3 and 4.5 times 

higher, respectively, in Burkina Faso than in Congo. 
87

The fat and PUFA concentrations in flours fed as gruels were predominantly from corn and 

millet. In Burkina Faso, infants also received commercial infant formula (Cerelac) containing 

LA (800 mg/100g), ALA (29 mg/100g) (i.e., LA/ALA=28.0). In Congo, the FA content was LA 

1,080 mg/100g, ALA 73 g/100g (i.e., LA/ALA=14.8).302

Summary Table 17: Omega-3 fatty acid content of maternal breast milk, with or without known maternal 

intake of omega-3 fatty acids, influences growth patterns in term or preterm human infants 

Study groups1

Author, Year, 

Location: 

Design 

Group 1 

(n)/ 

Group 4 

(n)

Group 2 

(n)/ 

Group 3 

(n) Notable clinical effects

Internal 

validity Applicability 

Jensen, 1999, 

US: 

120 d 

parallel RCT248

DHA algal 

(n=42) 

High DHA 

fish oil 

(n=42)/ 

pb 

(n=42) 

NS in wt, length & HC at 4-8 mo Not 

assessed 

X 

Xiang, 2000, 

Sweden: 

Single 

prospective 

cohort249

Motherbreastfed 

term 

infants 

(n=19) 

n/a LA, ALA in maternal milk SÏ

during 3 mo 

DHA in maternal milk SÐ during 

3 mo 

AA/DHA in maternal milk S 

correlated with infants’ rate 

ÏHC at 1 & 3 mo++ 

AA/DHA in maternal milk S 

correlated with infants’ brain wt 

gain at 1 & 3 mo++ 

Quality 

score: 5 

[Grade B] 

III 

Rocquelin, 

2003, The 

Congo & 

Burkina Faso: 

Cross-sectional 

study302

Motherbreastfed 

term 

infants 

Congo 

(n=102) 

Motherbreastfed 

term 

infants 

Burkina 

Faso 

(n=101) 

SÐ wt-for-age & wt-for height zscores & wt gain (g) in Burkina 

Faso than in Congo++++ NS birth 

wt, age, weight gain of 

predominantly breastfed to 

complementary fed infants in 

Burkina Faso 

Quality 

score: 5 

[Grade B] 

III 

1

biomarkers = EPA, DHA, AA, AA/EPA, AA/DHA, AA/EPA+DHA; n-3 = omega-3 fatty acids; n-6 = omega-6 

fatty acids; ALA = alpha linolenic acid; DHA = docosahexaenoic acid; EPA = eicosapentaenoic acid; AA = 

arachidonic acid; E-EPA = ethyl eicosapentaenoate; n = sample size; pts = study participants; NR = not 

reported; S = statistically significant difference; NS = nonsignificant statistical difference; N/A = not applicable; 

grp = group; wk = week(s); mo = month; wt = weight; +

p<.05 or significant with 95% confidence interval; 

++p<.01; +++p<.001; ++++p<.0001; Ï = increase; Ð = decrease/reduction; HC = head circumference; 

In the Xiang et al. study, the LC PUFAs fraction (13.5% of total FA) in human milk (LA and 

ALA) increased significantly during the 3 months of lactation, whereas, DHA decreased 

significantly but not the EPA maternal milk content.249 The ratio of AA to DHA in the mother’s 

milk correlated positively with the infants’ rate of increase of HC at 1 month and 3 months of 

age, as well as with the gain in estimated brain weight at 1 and 3 months of age. No relations 

were found between HC or estimated brain weight and LA, ALA, AA or DHA content in human 

milk.249

Infants in Rocquelin et al.’s study did not differ in gender, percentage of LBW (<2,500 g), 

birth weight or length, between the two sites.302 However, the infants in Congo were 

significantly younger than in Burkina Faso. The weight-for-age and weight-for height z-scores 

and weight gain (in grams) were significantly lower in infants in Burkina Faso than in those in 

Congo. 
88

When comparing the anthropometric data (birth weight, age, weight gain) of predominantly 

breastfed to complementary fed infants in Burkina Faso, no differences between groups were 

detected. Since both populations were extremely different, the analysis of the relationship 

between the FA content in breast milk and anthropometric data between cities was excluded 

from the review.302

Study quality and applicability. Jensen et al. was not assessed by Jadad scale give that it was 

an abstract.248 Both observational studies had a mean total quality score of 5, and a level of 

applicability of III.249,302

Summary Matrix 8: Omega-3 fatty acid content of maternal breast milk, with or without known maternal intake 

of omega-3 fatty acids, influences growth patterns in term or preterm human infants 

Study Quality

A B C 

Author Year n Author Year n Author Year n I 

Author Year n Author Year n Author Year n II 

Author Year n Author Year n Author Year n

Applicability 

III Xiang 

Rocquelin 

2000 

2003 

19 

203 

 

n = number of allocated/selected participants; U = unclear allocation concealment

What is the Evidence That the Omega-3 Fatty Acid Content of Infant 

Formula Influences Growth Patterns in Term or Preterm Human 

Infants? 

What is the Evidence That the Omega-3 Fatty Acid Content of 

Maternal Breast Milk, With or Without Known Maternal Intake of 

Omega-3 Fatty Acids, and Together With the Omega-3 Fatty Acid 

Content of Infant Formula, Influences Growth Patterns in Term or 

Preterm Human Infants? 

Infant Formula Intake—Preterm Infants. 

Twenty double-blinded RCTs met eligibility criteria for investigating a possible effectiveness 

of omega-3 fatty acid content of infant formula on growth patterns in preterm infants. Studies 

were published between 1987 and 2004. (Summary Tables 18–21) 

Overview of relevant studies 

All of the included studies assessed the effect of omega-3 FA content of infant formula on 

growth patterns in preterm human infants. One study evaluated the effect of maternal 

breastfeeding together with the intake of omega-3 FA supplemented formula on growth patterns 
89

in preterm infants, as well as the effect of omega-3 FA content of infant formula on growth 

parameters.253 With the exception of the three Carlson et al. studies,185,191,250 as well as the 

studies of Clandinin et al.,193 Groh-Wargo et al.256 and Fewtrell et al.,258 all studies included a 

non-randomized group of breastfed infants that served as a reference standard. 

Carlson et al. conducted a study involving 61 preterm infants (<1500 g) with no major 

congenital abnormalities and major medical conditions.250 The infants were randomized to 

receive either preterm control formula (Similac Special care, or Enfamil Premature) or fish oil 

supplemented infant preterm formula for 4 weeks. (Summary Table 18) 

In another study by Carlson et al., 79 preterm, premature infants weighed less than 1400 g 

were randomly assigned to receive either control or marine oil-enriched preterm infant formulas 

(DHA [0.2wt%], EPA [0.3wt%]), followed by term placebo and experimental formulas (DHA 

[0.2wt%], EPA [0.3wt%]) for up to 57 weeks postconceptional age (PCA).185 (Summary Table 

18) 

Koletzko et al. compared LCPUFA supplemented preterm formula containing DHA 

(0.3wt%), EPA (0.03wt%) and AA (0.05wt%) with a control formula in a small study involving 

19 preterm babies with a weight less than 1850 g.251 Infants were followed for a period of 21 

days of full enteral feeding.251 (Summary Table 18) 

Uauy et al. randomized 60 preterm infants with a birth weight of 1,000 g to 1,500 g and no 

major neonatal morbidity by the tenth day of life, to receive one of three formulas for 6 

months.212 The feeding formulas differed only in the amounts and sources of LCPUFAs—two 

control formulas contained no added LCPUFAs and had different amount of 18:2 n-3 and 18:2 n6 FAs, whereas, the experimental formula contained additional LCPUFAs derived from marine 

oil (DHA [0.35wt%], EPA [0.65wt%] and AA [0.1wt%]). (Summary Table 18) 

Carlson et al. enrolled 59 preterm infants with or without bronchopulmonary dysplasia and 

randomly assigned them to receive standard preterm formula, which contained linolenic acid as 

2.5% of total FA (Similac Special Care) or a formula that provided n-3 LCPUFAs from marine 

oil (DHA [0.2wt%] and EPA [0.06wt%]) but did not differ otherwise from the standard 

formula.191 Randomization took place between 3 and 5 days of life and formula intake continued 

for up to 2 months PCA.191 (Summary Table 18) 

Faldella et al. recruited 46 preterm infants less than 33 weeks GA with no neurological, 

visual, acoustic, or gastrointestinal illnesses and randomly assigned them to a formula for 

preterm infants enriched with marine oil derived LCPUFAs (Preaptamil with Milupan) 

containing DHA (0.3wt%), EPA (0.05wt%), and AA (0.44wt%) or a traditional formula for 

preterm infants.198 Feeding regimens continued up to 52 weeks of PCA.198 (Summary Table 18) 
90

Summary Table 18: Omega-3 fatty acids and growth parameters of preterm infants 

Study groups1 Author, 

Year, 

Location: 

Length & 

Design 

Group 1 

(n)/ 

Group 4 

(n)

Group 2 

(n)/ 

Group 3 

(n)

Notable 

clinical 

effects

Notable clinicalbiomarker2,3 

correlations 

Internal 

validity 

Applicabili

ty 

Carlson, 

1987 US: 

4 wk 

parallel 

RCT250

MaxEPA 

preterm 

formula 

(n=30) 

Preterm 

formula 

(n=31) 

NS in ∆ wt at 

4 wks

n/a Jadad total: 

2 

[Grade: C]; 

Schulz: 

Unclear 

II 

Carlson, 

1992 

US: 

up to 57wk 

PCA 

parallel 

RCT185 

marine oil 

(DHA+AA) 

formula 

(n=31*) 

Control 

formula 

(n=34*) 

SÐ wt, L, 

HC in 

marine oil at 

40, 48, 57, 

68, 79, 93 

wks PCA+ 

wt & L z-scores 

correlated + with 

plasma & RBC AA at 

2,4,5,6,9, 12 mo 

HC correlated + 

plasma & RBC AA at 

2, 4 mo 

Jadad total: 

4 

[Grade: A]; 

Schulz: 

Adequate 

II 

Uauy, 1992 

US: 

6 mo 

parallel 

RCT212

Soy/ 

marine oil 

formula 

(n=22)/ 

HM 

(n=10) 

Soy oil 

formula 

(n=18)/ 

corn oil 

formula 

(n=20) 

NS in wt, L, 

HC, TST, 

SST at 3, 9, 

17, 26 wks

S correlation (-) 

between RBC AA at 

57 wk & length z 

score at 57 wks PCA 

Jadad total: 

2 

[Grade: C]; 

Schulz: 

Unclear 

II 

Koletzko, 

1994 

Germany: 

3 wk 

parallel 

RCT251

Egg lipids + 

primrose oil 

formula 

(DHA+EPA) 

(n=9) 

Control 

formula 

(n=10)/ 

HM 

(n=8) 

NS in wt, L, 

HC at 3 wks 

n/a Jadad total: 

2 

[Grade: C]; 

Schulz: 

Unclear 

III 

Carlson, 

1996, US: 

5 mo 

parallel 

RCT191 

Marine oil 

(DHA +EPA) 

formula 

(n=26) 

Control 

formula 

(n=33) 

SÐ wt, L, 

HC in 

LCPUFA at 

6+

, 9++ mo 

PT

S (-) correlation 

between wt-for-L & 

RBC PE DHA at 5 

mo 

S (+) correlation 

between L & RBC 

PC AA at 5 mo 

Jadad total: 

3 

[Grade: B]; 

Schulz: 

Unclear 

II 

Faldella, 

1996 Italy: 

up to 52 wk 

PCA 

parallel 

RCT198

DHA+EPA 

formula 

(n=23) 

Control 

formula 

(n=26)/ 

HM 

(n=17) 

NS in ∆ wt, 

∆L, ∆HC at 

52 wks PCA 

n/a Jadad total: 

1 

[Grade: C]; 

Schulz: 

Unclear 

III 

1

Proceeding from highest omega-3, or lowest omega-6/omega-3, fatty acid content of intervention/exposure; 2

biomarker source; 3biomarkers = EPA, DHA, AA, AA/EPA, AA/DHA, AA/EPA+DHA; n-3 = omega-3 fatty acids; n-6 

= omega-6 fatty acids; DHA = docosahexaenoic acid; EPA = eicosapentaenoic acid; AA = arachidonic acid; Length 

= intervention length; Design = research design; n = sample size; pts = study participants; NR = not reported; S = 

statistically significant difference; NS = nonsignificant statistical difference; n/a = not applicable; pb = placebo; grp = 

group; wk = week(s); mo = month; FAs = fatty acids; * = completed study; PCA = postconceptional age; ITT = 

intention to treat study; HM = human milk group; wt = weight; L = length; HC = head circumference; ∆ = change; 

RBC = red blood cells; +p<.05 or significant with 95% confidence interval; ++p<.01; +++p<.001; ++++p<.0001; PP = 

per-protocol analysis (e.g., completers); Ï = increase(d)/higher; Ð = decrease(d)/reduction/lower; PE: phosphatidyl 

ethanolamine; PC: phosphatidyl choline; TST = triceps skinfold thickness; SST = subscapular skinfold thickness 

Vanderhoof et al. conducted a double-blinded RCT of two formula-fed groups and a parallel 

reference group of breastfed infants. Medically-stable preterm infants with a birth weight 

ranging from 750 g to 2000 g were assigned to receive either control preterm formula (Preemie 
91

SMA®) or LCP-supplemented Preemie SMA (DHA [0.35wt%], AA [0.5wt%]) for up to 48 

weeks PCA.218 (Summary Table 19) 

Lapillone et al. evaluated 33 preterm infants appropriate for GA who were randomized to 

receive either standard preterm formula from inclusion to 40 weeks term corrected age (CA), 

then a standard term formula until 4 months CA, or preterm formula enriched with the fish oil 

containing DHA (0.37wt%) and EPA (0.05wt%) until 40 weeks CA and then a term formula 

supplemented with a fish oil containing DHA (0.45wt%) and EPA (0.09wt%) until 4 months 

CA.252 A reference group of 10 breastfed infants was also recruited for the trial.109 (Summary 

Table 19) 

Martinez et al. assessed 40 preterm infants (VLBW) who received in a double-blinded 

fashion either LCPUFA supplemented or control formula for 30 days. A group of 18 breastfed 

infants served as reference standard. The outcomes were the weight, length and head 

circumference at 30 days.120 (Summary Table 19) 

Woltil et al. conducted a double-blind RCT where preterm newborn babies were allocated to 

receive two experimental formulas supplemented with evening primrose oil and either a single 

(DHA [0.20wt%] and EPA [0.17wt%]; n=13) or double dosage (DHA [0.43wt%] and EPA 

[0.34wt%]; n=16) of purified fish oil, and three control formulas containing different amount of 

protein and ribonucleotides.225 Dietary intake took place for 6 weeks. Thirty-three infants 

received their mother’s own milk.225 (Summary Table 19) 

Ghebremeskel et al. randomized healthy preterm infants with no congenital malformations 

and metabolic disorders into four feeding groups: (1) breast milk and LCP-enriched formula 

(0.85±0.25wt% DHA); (2) breast milk and standard formula (0.55±0.25wt% DHA); (3) LCPsupplemented formula (0.30wt% DHA); or, (4) exclusively standard formula.253 Mean duration 

of an intervention was 11 weeks with a range of 7 to 15 weeks. Twenty exclusively breastfed 

infants formed a standard reference group. (Summary Table 19) 
92

Summary Table 19: Omega-3 fatty acids and growth parameters of preterm infants 

Study groups1 Author, 

Year, 

Location: 

Length & 

Design 

Group 1 

(n)/ 

Group 4 

(n)

Group 2 

(n)/ 

Group 3 

(n)

Notable clinical 

effects

Notable 

clinicalbiomarker2,3

correlations 

Internal 

validity Applicability 

Vanderhoof, 

1997, 

US: 

Up to 48 wk 

PCA 

parallel 

RCT218

 

Microbial 

fermentatio

n 

(DHA+AA) 

formula 

(n=77) 

Control 

formula 

(n=78)/ 

HM 

(n=133) 

SÏ wt, L, HC, 

MAC in LCP & 

control than in 

HM at 40 wk 

PCA+

NS in L, HC at 

48 wks PCA 

SÏ L, MAC in 

LCP than in HM 

at 48 wks PCA+

NS in wt, L, HC 

at 92 wks PCA

n/a Jadad total: 

4 

[Grade: A]; 

Schulz: 

Adequate 

I 

Lapillonne, 

1997, 

France: 

4 mo CA 

parallel 

RCT252

DHA+ 

EPA 

formula 

(n=11) 

Control 

formula 

(n=12)/ 

HM (n=10) 

NS in GP at 4 

mo CA

n/a Not 

assessed 

X 

Martinez, 

1999, Brazil 

30 d 

parallel 

RCT259

Egg-lipid + 

primrose oil 

(formula 

(n=20) 

Control 

formula 

(n=20)/ 

HM (n=18) 

NS in wt, L, HC 

at 30 d 

n/a Jadad total: 

1 

[Grade: C]; 

Schulz: 

Unclear 

III 

Woltil, 1999, 

Netherlands 

6 wks 

parallel 

RCT225

High-DHA 

formula 

(n=16)/ 

HM 

(n=33) 

Low-DHA 

formula 

(n=13) 

pb-1 

(n=13)/ 

pb-2 

(n=37)/ 

pb-3 

(n=31) 

NS in ∆ wt, ∆L, & 

∆HC between 

LCP-1, LCP-2 & 

pb at 1 mo 

SÏ ∆ wt, ∆L, ∆

brain wt, ∆HC in 

pb-1 than in pb-2 

& pb-3 at 1mo+ 

S (+) 

correlation 

between ∆wt, 

∆L, ∆HC & 

plasma & 

RBC DHA at 

1mo 

Jadad total: 

1 [Grade: 

C]; 

Schulz: 

Unclear 

III 

Ghebremes

kel1999, 

UK: 

11 wk 

parallel 

RCT253 

Egg-lipid+ 

primrose oil 

(DHA+AA) 

+HM 

(n=12)/ 

control 

formula 

(n=8) 

LCP 

formula 

(n=7)/ 

control 

formula+H

M/ (n=14)/ 

HM (n=20) 

NS in wt, L, HC 

at ≈11 wk among 

5 grps

n/a Jadad total: 

2 

[Grade: C]; 

Schulz: 

Unclear 

III 

1

Proceeding from highest omega-3, or lowest omega-6/omega-3, fatty acid content of intervention/exposure; 2

biomarker source; 3biomarkers = EPA, DHA, AA, AA/EPA, AA/DHA, AA/EPA+DHA; n-3 = omega-3 fatty acids; 

n-6 = omega-6 fatty acids; DHA = docosahexaenoic acid; EPA = eicosapentaenoic acid; AA = arachidonic acid; 

Length = intervention length; Design = research design; n = sample size; pts = study participants; NR = not 

reported; S = statistically significant difference; NS = nonsignificant statistical difference; n/a = not applicable; †

 

= mg/kg/day; pb = placebo; grp = group; wk = week(s); mo = month; FAs = fatty acids; PCA = post conceptional 

age; CA = corrected age; HM = human milk group; wt = weight; L = length; HC = head circumference; MAC = 

mid arm circumference; ∆ = change; GP = growth parameters; RBC = red blood cells; ITT = intention-to-treat 

analysis; PP = per-protocol analysis (e.g., completers); +

p<.05 or significant with 95% confidence interval; ++p<.01; +++p<.001; ++++p<.0001; PP = per-protocol analysis (e.g., completers); Ï = increase(d)/higher; Ð = 

decrease(d)/reduction/lower 
93

Bougle et al. conducted a small efficacy study involving healthy, AGA premature infants of 

less than 34 weeks postmenstrual age, who were randomized into two groups within the first 2 

days of enteral feeding—LCP-supplemented (DHA [0.6wt%], EPA [0.1wt%] and AA [0.1wt%]; 

n=14) or control formula without any LCPUFA supplementation (n=11).254 The end of the study 

occurred at the expected date of delivery, after babies were fed for at least 1 month on the study 

diet.254 (Summary Table 20) 

Field et al. conducted a double-blind RCT in which 44 medically-stable preterm newborn 

babies were allocated to receive either preterm formula (Preemie SMA) or the same formula 

manufactured to contain LCPUFAs (DHA [0.35wt%] and AA [0.49wt%]).303 Feeding of 

formulas began before day eight of postnatal life and continued until day 42. Seventeen 

exclusively breastfed infants were included as a reference group.303 (Summary Table 20) 

O’Connor et al. randomized 283 preterm infants of less than 33 weeks GA without any 

congenital abnormalities to one of three formula groups received in-hospital: (1) control; (2) 

treatment formula with supplemental LCPUFAs derived from fish/fungal oils (0.27±±0.04 

g/100g DHA, 0.08±0.01 g/100g EPA, and 0.43±0.02 g/100g AA); or (3) treatment formula with 

supplemental LCPUFAs derived from egg-triglycerides/fish oils (0.24±0.01 g/100g DHA and 

0.41±0.0 g/100g AA).207 After discharge, infants received postdischarge formulas with the same 

content of AA, but reduced amount of DHA (0.16±0.01 g/100g DHA in fish/fungal oil group and 

0.15±0.02 g/100g DHA in egg-triglycerides/fish oil group). The intervention lasted up to 12 

months PCA. (Summary Table 20) 

Fewtrell et al. recruited 195 preterm infants with no congenital malformations and 

randomized them to receive either preterm infant formula without additional LCPUFA (Prematil, 

Milupa) or a supplemented formula (Prematil with Milupan) containing DHA (0.17wt%) and 

EPA (0.04wt%) from egg lipids.273 All infants were fed and followed for up to 9 months PCA. 

A group of 88 breastfed infants formed a reference group.273 (Summary Table 20) 

Clandinin et al., in a double-blind multicenter RCT, randomized LBW infants to one of three 

feeding groups: (1) control (n=119); (2) LCP-1 (17mg/100kcal DHA and 34mg/100kcal AA, 

derived from single cell oils, n=112); or, (3) LCP-2 (17mg/100kcal DHA derived from fish oil 

and 34mg/100kcal AA, derived from single cell oils, n=130).193 Each group included three 

formula types: preterm, postdischarge, and term, which investigators chose based on infant 

needs. Formulas were the infant’s sole diet until 57 weeks PCA.193 (Summary Table 20) 
94

Summary Table 20: Omega-3 fatty acids and growth parameters of preterm infants 

Study groups1 

Author, Year, 

Location: 

Length & 

Design 

Group 1 

(n)/ 

Group 4 

(n)

Group 2 

(n)/ 

Group 3 

(n)

Notable clinical 

effects

Notable 

clinicalbiomarker2,3 

correlations 

Internal 

validity Applicability 

Bougle, 1999, 

France: 

1 mo 

parallel RCT254 

LCP 

formula 

(n=14) 

Control 

formula 

(n=11)/ 

HM 

(n=15) 

 

SÏ ∆ wt in LCP 

than in HM at 1 

mo+

NS in wt, L, HC, 

∆L, & ∆ HC at 1 

mo+

n/a Jadad total: 3 

[Grade: B]; 

Schulz: 

Unclear 

III 

Field, 2000 

Canada: 

5.5 wk parallel 

RCT303 

LCP 

formula 

(n=15) 

Control 

formula 

(n=12)/ 

HM 

(n=17) 

SÐ ∆ wt in HM 

than in LCP & pb 

at 28 d+ 

NS in L, HC at 35 

d+

n/a Jadad total: 1 

[Grade: C]; 

Schulz: 

Unclear 

II 

O’Connor, 

2001 US, UK, 

Chile: 

12 mo CA 

parallel RCT207

DHA+AA

(Fish/ 

fungal 

oil) 

formula 

(n=140) 

DHA+AA 

(Egg-TG/ 

fish oil) 

formula 

(n=143)/ 

control formula 

(n=144) 

(ITT) NS ∆ wt, 

∆L, ∆ HC at 8 wk, 

4 mo, 12 mo CA 

S (+) 

correlation rate 

wt gain & RBC 

PE AA at 28 d 

wt & L S 

correlated 

RBC PE AA at 

28 d 

Jadad total: 3 

[Grade: B]; 

Schulz: 

Unclear 

I 

Fewtrell, 2002 

UK: 

9 mo CA 

parallel RCT273

LCPUFA 

formula 

(n=95) 

Control 

formula 

(n=100)/ 

HM 

(n=88) 

(ITT) SÐ wt, L in 

LCPUFA than in 

pb at 9 , 18 mo 

CA+

NS in HC at 9, 18 

mo CA

n/a Jadad total: 5 

[Grade: A]; 

Schulz: 

Adequate 

II 

Clandinin 

2002 Canada: 

57 wk PMA 

parallel RCT193 

DHA+AA 

(SCO) 

(n=112) 

DHA+AA (fish 

oil) 

(n=130)/ 

control formula 

(n=119) 

NS in GP at 40, 

57 wks PMA 

SÏ wt in 

DHA+AA (SCO) 

than in control at 

66-118 wks 

PMA+ 

SÏ L in DHA+AA 

(SCO) than in 

other 2 formulas 

at 79, 92 wks 

PMA+ 

n/a Not assessed X 

1

Proceeding from highest omega-3, or lowest omega-6/omega-3, fatty acid content of intervention/exposure; 2

biomarker source; 3biomarkers = EPA, DHA, AA, AA/EPA, AA/DHA, AA/EPA+DHA; n-3 = omega-3 fatty acids; n-6 = 

omega-6 fatty acids; DHA = docosahexaenoic acid; EPA = eicosapentaenoic acid; AA = arachidonic acid; Length = 

intervention length; Design = research design; n = sample size; pts = study participants; NR = not reported; S = 

statistically significant difference; NS = nonsignificant statistical difference; n/a = not applicable; pb = placebo; grp = 

group; wk = week(s); mo = month; FAs = fatty acids; HM = human milk group;wt = weight; L = length; HC = head 

circumference; AC = arm circumference; ∆ = change; RBC = red blood cells; PE = phosphatidyl ethanolamine; PC = 

phosphatidylcholine; ITT = intention-to-treat analysis; PP = per-protocol analysis (e.g., completers); +

p<.05 or 

significant with 95% confidence interval; ++p<.01; +++p<.001; ++++p<.0001; PP = per-protocol analysis (e.g., 

completers); Ï = increase(d)/higher; Ð = decrease(d)/reduction/lower; PMA = postmenstrual age; GP = growth 

patterns;CA = corrected age; SCO = single cell oil; TG = tryglicerids 

Innis et al. conducted a double-blind, multicenter study of 194 healthy premature, VLBW 

(846 g-1560 g) infants who were randomized to receive either preterm formula with no DHA or 

AA (control, n=62), DHA (0.15wt% ; n=66) or DHA (0.14wt%) and AA (0.27wt%) (n=66) 
95

derived from single cell triglycerides, for at least 28 days and then fed term formula with no 

LCPUFA supplementations for up to 57 weeks postmenopausal age.201 Ninety breastfed infants 

served as a reference.201 (Summary Table 21) 

Groh-Wargo et al. evaluated the effect of feeding formula supplemented with DHA 

(0.42wt%) and AA (0.26wt%) derived from fish/fungal oils (LCP-1 group, n=18) or DHA 

(0.26wt%) and AA (0.26wt%) derived from egg phospholipid/fish oil (LCP-2 group, n=18) on 

growth parameters of preterm infants at 12 months of CA compared with infants fed 

unsupplemented formula (control group, n=21).256 Randomization of infants took place within 

72 hours of first enteral feeding. 256 (Summary Table 21) 

Koletzko et al. randomized 30 preterm infants with a stable medical condition and birth 

weight of less than 1800 g to receive either preterm control formula (n=15) or LCPsupplemented formula (DHA [0.57wt%], EPA [0.13wt%] and AA [0.1wt%]; n=15) within 3 

days of established full enteral feeding to 28 days post partum.257 Nineteen breastfed infants 

formed a reference group.257 (Summary Table 21) 

Fewtrell et al. randomly assigned preterm infants with a birth weight less than 2000 g and 

GA less than 35 weeks to unsupplemented (control group, n=116) or LCPUFA-supplemented 

formula (treatment group; DHA [0.5wt%], EPA [0.1wt%] and AA [0.04wt%]; n=122) until 9 

months PCA.258 (Summary Table 21) 
96

Summary Table 21: Omega-3 fatty acids and growth parameters of preterm infants 

Study groups1 Author, 

Year, 

Location: 

Length & 

Design 

Group 1 

(n)/ 

Group 4 

(n)

Group 2 

(n)/ 

Group 3 

(n)

Notable clinical 

effects

Notable clinicalbiomarker2,3 

correlations 

Internal 

validity Applicability 

Innis, 

2002, US, 

Canada: 

28 d 

multicenet

er 

 parallel 

RCT201

DHA+AA 

formula 

(n=66) 

DHA 

formula 

(n=66)/ 

control 

formula 

(n=62) 

SÏ ∆ wt in 

DHA+AA than in 

control at 40 wks 

PMA++ 

SÏ wt, L, wt-to-L in 

DHA+AA than in 

DHA at 48 wks 

PMA++

SÏ wt, wt-to-L in 

DHA+AA than in 

control at 48 wk 

PMA++

NS in HC at 48, 57 

wk PMA 

S (+) correlation 

between ∆ wt & 

RBC PE AA at 8 

wks 

S (+) correlation 

between wt, L & 

RBC PE AA at 8 

wks 

Jadad total: 

3 

[Grade: B]; 

Schulz: 

Unclear 

I 

GrohWargo, 

2002, 

Canada, 

US: 

12 mo CA 

parallel 

RCT256

LCP-1 

(n=18) 

LCP-2 

(n=18)/ 

control 

formula 

(n=21) 

NS in GP at 12 mo 

CA 

n/a Not 

assessed 

X 

Koletzko, 

2003 

Germany: 

28 days 

parallel 

RCT257

LCP 

formula 

(n=15) 

 

Control 

formula 

(n=15)/ 

HM 

(n=19) 

 

NS wt, L, HC at 28 

d 

n/a Jadad total: 

3 [Grade: 

B]; 

Schulz: 

Unclear 

III 

Fewtrell, 

2004 

UK: 

9 mo CA 

parallel 

RCT258

LCPUFA 

formula 

(n=122) 

Control 

formula 

(n=116) 

(ITT) SÏ ∆ wt, ∆L 

in LCPUFA than in 

control at 9 mo CA+

NS in HC at 9 mo 

CA 

NS in PG at 18 mo 

CA

n/a Jadad total: 

5 [Grade: 

A]; 

Schulz: 

Adequate 

II 

1

Proceeding from highest omega-3, or lowest omega-6/omega-3, fatty acid content of intervention/exposure; 2

biomarker source; 3biomarkers = EPA, DHA, AA, AA/EPA, AA/DHA, AA/EPA+DHA; n-3 = omega-3 fatty acids; n6 = omega-6 fatty acids; DHA = docosahexaenoic acid; EPA = eicosapentaenoic acid; AA = arachidonic acid; 

Length = intervention length; Design = research design; n = sample size; pts = study participants; NR = not 

reported; S = statistically significant difference; NS = nonsignificant statistical difference; n/a = not applicable; pb 

= placebo; grp = group; wk = week(s); mo = month; FAs = fatty acids; ITT = intention to treat; HM = human milk 

group; wt = weight; L = length; HC = head circumference; GP = growth parameters; PMA = post menstrual age; 

PT = post term; CA = corrected age; ∆ = change; RBC = red blood cells; ITT = intention-to-treat analysis; PP = 

per-protocol analysis (e.g., completers); +

p<.05 or significant with 95% confidence interval; ++p<.01; +++p<.001; ++++p<.0001; PP = per-protocol analysis (e.g., completers); Ï = increase(d)/higher; Ð = 

decrease(d)/reduction/lower 
97

Qualitative synthesis of relevant studies’ key characteristics 

Study characteristics. All studies were parallel RCTs with at least two groups, although the 

study of Ghebren et al. involved five feeding groups.253 

The inclusion/exclusion criteria were described by 11 of 20 

studies.198,201,207,212,218,250,251,253,257,259,303 Only inclusion criteria were reported in four 

studies225,254,258,273 and only exclusion criteria were reported in two studies.185,191 Three studies 

failed to report either inclusion or exclusion criteria.193,252,256 Three studies defined maternal 

substance abuse (cocaine and alcohol) history as exclusion criteria.191,207,218 The definition of a 

preterm infant (<37 weeks GA) was described in eight studies,198,251,253,254,258,259,273,303 although 

included preterm infants in these studies were at different GAs. Koletzko et al.251 and Fewtrell et 

al.273 included infants less than 37 weeks GA, whereas, Field et al.303 evaluated infants born at 

less than 36 weeks GA, Fewtrell et al.258 at less than 35 weeks GA, Bougle et al.254 at less than 

34 weeks GA, and Faldella et al.198 and Ghebremeskel et al.253 at less than 33 weeks GA. Eight 

studies were typically small, with a mean of 30 participants (range 19–41).251-254,256,257,259,303 The 

study duration ranged from 3 weeks to 12 months. 

The trials were conducted in various countries, with five undertaken in the 

U.S.,183,185,191,212,218,250 three in the U.K.253,258,273 and Canada,193,201,303 two in France252,254 and 

Germany,251,257 one in Italy,198 one in Brazil,259 and one in The Netherlands.225 One multicenter 

study was conducted in three countries—the U.S., U.K and Chile.207 Groh-Wargo et al. failed to 

indicate the country where their study was undertaken.256

The study of Carlson et al.250 was supported by Ross laboratories, Columbus, OH. Another 

Carlson et al. study was sponsored by Ross Laboratories, Columbus, OH, and the National Eye 

Institute.185 Koletzko et al. received a grant from Deutsche Forschungsgemeinschaft, Bonn, 

Germany and Milupa AG, Friedrichsdorf, Germany.251 Uauy et al.’s study was financially 

supported by the National Institute of Health.212 The Carlson et al. study191 was funded by the 

National Eye Institute, the National Institute of Child Health and Human Development, and Ross 

Products Division, Abbott Laboratories, Columbus, OH. Vanderhoof et al.’s study was 

supported by Wyeth Nutritionals International, Philadelphia, Pennsylvania, U.S.A.218 Martinez 

et al. was funded by the Brazilian Research Council and Milupa GmbH.259 Woltil et al.’s study 

was supported by grants from Friesland Nutrition, Leeuwarden, The Netherlands.225 The study 

of Ghebremeskel et al. was financed by The Christopher H.R. Reeves Charitable Trust and 

Milupa Plc.253 Field et al.’s study was supported by grants from the Natural Sciences and 

Engineering Research Council of Canada and the Medical Research Council of Canada, as well 

as Wyeth-Ayerst Research.303 Fewtrell et al.’s study was funded by Numico Research BV 

(Wageningen, The Netherlands).273 Clandinin et al.’s193 and Innis et al.’s201 studies were 

financed by grants from Mead Johnson & Company. The Groh-Wargo et al. study was 

supported by Abott Laboratoris, Columbus and GCRC NIH.256 Koletzko et al.’s study was 

sponsored by Deutsche Forschungsgemeinschaft, Bonn, Germany, Nestec S.A., Vevey, 

Switzerland and Nestle Alete GmbH, Munchen, Germany.257 Fewtrell et al.’s study was 

supported by grant from H.J. Heinz Company, Ltd, Hayes, Middlesex, U.K.258 Four trials did 

not provide information concerning their funding source.198,207,252,254
98

In general, six studies193,201,218,225,250,258 were granted only by pharmaceutical companies, six 

studies185,191,251,256,257,303 by both pharmaceutical and governmental fundings, two studies212,273 by 

only governmental sources, and one study253 partly by private and pharmaceutical sources. 

Pre-study sample size calculation to reach statistical significance and power was performed 

in seven studies.191,201,207,212,218,258,273

Population characteristics. A total of 2,650 preterm infants were enrolled across 20 RCTs. 

The total number of infants that completed the trials could not be calculated since six of the 

studies failed to report these data, providing only the number of infants who entered the 

trial.193,218,225,252,256,259

Eligibility criteria varied broadly across studies. Most importantly, body mass of recruited 

preterm infants, GA, and age at study enrollment, differed substantially from trial to trial. Some 

investigators randomized very small preterm infants (i.e., weighing less than 1,400 g to 1,500 

g),185,201,212,250,259 whereas, other authors broadened their criteria to include preterm infants with a 

birth weight ranging from 2,000 g to 2,500 g.218,225,258 Six studies failed to report predefined 

eligibility criteria regarding infant’s weight.191,198,253,254,256,303 

The gender distribution of randomized infants was reported in ten studies.191,207,212,218,225,257-

259,273,304 In eight of these studies, male infants constituted the majority of participants, although 

the gender ratio of infants among different diet groups were evenly distributed in all of these 

studies. 

The racial/ethnic background of study participants were described in only four 

trials.191,207,212,218 In two studies,191,212 the majority of infants were Black, accounting for 60% 

and 83% of study population, respectively. In the two other trials,207,218 White infants comprised 

the majority of study participants accounting for 58% and 70% of participants, respectively. 

Different variables were used to demonstrate family sociodemographic status in the studies 

(e.g., maternal education, social class, professional qualification, home inventory score, maternal 

WAIS-R raw vocabulary score). Maternal social status was determined in two studies,258,273

whereas, information about maternal education or maternal professional qualification was given 

in three trials.207,258,273 O'Connor et al. measured and compared the quality and quantity of 

stimulation and support available to a child in the home environment in different groups by 

means of a HOME inventory score. Maternal intelligence was assessed by administering a 

WAIS-R raw vocabulary score.207 There were no differences in sociodemographic variables 

among the study groups of randomized infants in all of these studies with the exception of 

HOME inventory scores, which were better in the control group than in both treatment groups.207 

Mothers of infants in the reference breastfed group had a more prestigious social score and 

attained a higher level of professional qualification compared with mothers of formula-fed 

infants.273

Only one study reported on maternal smoking during pregnancy and postnatal smoking in the 

home.207

Intervention/exposure characteristics. Only one of 20 reviewed studies reported the exact 

amount of supplementary LCPUFAs consumed per day by the preterm infants.225 Woltil et al.225

assigned preterm infants to two LCPUFA-supplemented feeding groups with different anounts of 

DHA—group LCP-1 consumed 23.3±9.9 mg/kg/day DHA, whereas group LCP-2 consumed 
99

13.3 to 41.8 mg/kg/day DHA. The rest of the studies failed to indicate daily consumption of 

omega-3 FAs by feeding infants. In all studies, formula-fed infants received preterm formula 

and depending on the ultimate interest of the research project, went to either post-discharge or 

term formula. In fourteen studies, the effect of only preterm formulas with supplemented 

LCPUFAs on growth indices of preterm infants were 

assessed.191,193,198,212,218,225,250,251,253,254,257,259,273,303 In six studies, infants continued to receive a 

formula designed for term infants (with or without LCP supplementation) according to their 

original assignments, and their effect on each child’s growth was further 

estimated.185,201,207,252,256,258 

Preterm infants were eligible to enter the study after they attained full enteral feeding without 

intravenous support. The minimum amount of formula-intake required in order to be considered 

fully enteral-fed differed across the trials. In two studies infants became eligible to enroll when 

they received at least 130 mL/kg/day of a preterm formula.251,257 Carlson et al. allowed preterm 

infants to enroll in the study after they had reached intakes of nutrient-enriched formula of at 

least 60 kcal/kg/day,250 whereas, Carlson et al. established criteria for enrollment of more than 

110 kcal/kg/day.185 Enteral feeding of at least 70 to 120 kcal/kg/day was required in the trial of 

Uauy et al.;212 Carlson et al. required an intake of at least 100 kcal/kg/day.191 Vanderhoof et al. 

specified an intake of 145 mL/kg/day,218 whereas, Woltil et al. required an intake of 80 

kcal/kg/day.225 In the Martinez et al. study, an intake of 112 kcal/kg/day was indicated259 and 

Innis et al. specified an intake of at least 90 kcal/kg/day.201 Eight studies failed to report a 

minimum daily food or caloric intake required for preterm infants.198,207,253,254,256,258,273,303 

Only two studies reported as part of the protocol that the volume of formula consumed, i.e., 

calculated as the difference in the volume of formula in the bottle at the start and end of the feed, 

was recorded.185,225 Daily intake of formula did not differ in the three feeding groups of Woltil et 

al. (171 [SD=21] mL/kg vs 172 [SD=17] mL/kg vs 176 [SD=17] mL/kg).225 In a study of 

Carlson et al.,185 all except one infant consumed at least 720 g of formula per day through 79 

weeks PCA. Duration of formula feeding ranged from 3 weeks251 to 12 months CA.207,256

The sources of omega-3 FA intervention varied across the RCTs. Three trials described the 

source of LCPUFA supplementation as purely fish oil.225,250,252 The specific type of fish from 

which fish oil exposures were derived was described in only one study.258 O’Connor et al.207 and 

Groh-Wargo et al.256 used a treatment formula with omega-3 FAs derived from fish and fungal 

oils, whereas, Fewtrell et al.258 supplemented a treatment formula with a combination of DHA 

derived from fish oil and AA derived from borage oil. The remaining studies employed either 

single cell sources of FAs,193,201,218,303 marine oils,185,191,212 egg phospholipids with primrose 

oil,253,259,273 or a combination of egg triglyceride and fish oil sources.207,256,257 The sources of 

supplemental LC PUFAs were not reported in three trials.198,251,254

The type of omega-3 FA employed in four studies included a combination of DHA and 

EPA;185,191,225,252 DHA alone was used in one trial.201 Supplementation of formulas with omega6 FA AA was reported in 12 studies.193,198,201,207,213,218,253,254,256,258,273,303

Seven studies failed to report the name of feeding formulas, although all of them indicated 

the manufacturers of the product.185,193,212,225,252,254,256 The brands of formulas employed in the 

rest of the studies were: Enfamil Premature (Mead Johnson Nutritionals, Evansville, Ind);201,250

Similac Special Care (Ross Laboratories, Columbus, OH);191,207,250 Prematil with Mipupan 
100

(Milupa, AG, Friedrichsdorf, Germany);198,251,253,259,273 SMA “Preemie” (Wyeth-Ayerst 

Laboratories, Randor, Philadelphia, PA);218,250,303 Alprem (Nestle, Vevey, Switzerland);257

OsterPrem with LCPUFA (Heinz Co, Ltd, Hayes, Middlesex, U.K.);258 NeoSure (Ross Product 

Division, Columbus, OH, USA);207 and, Farley’s PreCare with LCPUFA (Heinz Co, Ltd, Hayes, 

Middlesex, U.K.) were used as a term formulas after hospital discharge. Five studies indicated 

the manufacturer of at least one omega-3 FA product used in their study.201,212,218,250,303 In three 

of these trials supplemented LCPUFAs were manufactured and supplied by Market Biosciences 

Corporation (Columbia, MD, USA),201,218,303 whereas, in two other studies omega-3 FAs were 

produced by MaxEPA, R.P. Scherer, Troy, MI250 and Zapata-Haynie Co., Reedville, Va.212 Only 

one study reported on the purity of their omega-3 FA exposure.225 

Formula was the only source of alimentation in 14 studies and no solid foods were 

introduced during the entire trial period.185,191,193,198,201,218,225,250,251,253,254,257,259,303 Only one study 

reported the time of introduction of solid foods—Uauy et al.212 permitted cereals, fruit juices, or 

fruits at 4 months of CA in both study groups. Fewtrell et al.,273 Groh-Wargo et al.,256 Fewtrell 

et al.,258 and O’Connor et al.207 did not report of any solid food introduction to infants even 

though their study durations were up to 9 and 12 months CA. 

Information about caloric balance of feeding formulas was reported in eight 

RCTs.185,191,201,212,225,254,259,273 Nutritional and energy intake were similar between randomized 

groups throughout the study period in the majority of trials. However, Carlson et al. reported 

that the mean energy intake from formula was not affected by dietary assignment or gender at 48 

and 57 weeks PCA; however, at 68 weeks PCA, infants consuming the marine oil-supplemented 

formula had significantly higher energy intake from formula compared with infants fed standard 

formula.185

Only three RCTs212,258,273 mentioned that study treatment formulas were indistinguishable in 

appearance and odor. Uauy et al. also reported that supplemental marine oil was winterized and 

stabilized.212

Cointervention characteristics. Six studies reported the content of vitamin and mineral 

supplements of feeding formulas or multivitamin preparations taken by preterm 

infants.191,207,212,251,253,303 All of these formulas or oral vitamin supplements provided alphatocopherol ranging from 4.5 mg/day303 to 15 mg/day.253 Ghebremeskel et al. used a formula also 

supplemented with 0.22 μmol/100 mL vitamin A.253 The formula used by O’Connor et al.207

was supplemented with 0.60 mg/L vitamin A and 0.50 mg/L beta-carotene, and Field et al. added 

1200 U/day vitamin D to their infant formulas.303 

Due to the physical immaturity of LBW preterm infants, many of the newborns required preor on-study medical cointerventions, such as oxygen supply, mechanical ventilation, intravenous 

nutrition, blood or blood product transfusion, and corticosteroid treatment. The most frequently 

reported cointervention was oxygen supply or mechanical ventilation and measurements were 

provided in four studies.185,191,212,258 Carlson et al.191 allowed a significant subgroup of patients 

(n=23) who continued to require supplemental oxygen for 28 days and had lung changes on Xray characteristic of bronchopulmonary dysplasia, to remain in the study. Two studies reported 

use of blood or blood products.212,303 Uauy et al. described that only five preterm infants 

required blood transfusion after random assignment, and all transfusions were given at least 2 

weeks before blood sampling.212 
101

In the study of Field et al., two infants received an intravenous bolus of albumin on day 2 of 

life.303 Some investigators set strict inclusion criteria for infants requiring additional medical 

treatment. Vanderhoof et al., for example, excluded preterm infants with consistent requirements 

for oxygen at 36 weeks PCA and administration of more than a 5-day course of 

corticosteroids.218 In studies of Koletzko et al.251 and Koletzko et al.,257 infants requiring 

artificial ventilation or an oxygen supply with FiO2 >0.3 at the time of enrollment were excluded. 

Uauy et al. reported that no infants had used a ventilator after day 5 or for more than 3 days.212 

None of the participants received corticosteroids, red blood cells and plasma transfusions or 

intravenous lipid emulsions beyond day 8 of life in the Field et al. trial.303 However, none of 

these studies reported how many newborn babies received cointerventional measures below the 

set limit. 

Outcome characteristics. Of 20 trials, 12 assessed the growth parameters as primary 

outcomes123,150,305-314 while the remaining eight trials evaluated them as a secondary outcome or 

part of the safety profile. Thirteen included RCTs employed infants’ weight, length, and HC as 

main outcome measures for growth.185,191,193,201,212,218,251,253,254,257,259,273,303 Two trials (abstracts) 

did not specify the growth indices evaluated, rather they described changes in growth 

parameters.252,256 Carlson et al. evaluated only weight gain from birth to 4 weeks of study period 

in two randomized dietary groups.250 The rate of gain in weight, length and HC were assessed in 

five studies.198,207,225,254,258 Triceps skinfold thickness and subscapular skinfold thickness were 

measured in two RCTs.212,259 Another study evaluated mid-arm circumference,218 another 

measured weight-to-length ratio,201 and one study used estimated brain weight gain in preterm 

infants as one of the growth outcomes.225

Study quality and applicability. Seventeen (of twenty) RCTs received a mean Jadad total 

quality score of 2.64, indicating a poor internal validity (Summary Matrix 9). Three abstracts 

were not quality assessed.306,311,313 The trials conducted by Fewtrell et al. received a score of 

5,258,273 Carlson et al. and Vanderhoof et al. received a score of 4,185,218 five trials received a 

score of 3,191,201,207,254,257 four reports received a score of 2,212,250,251,253and four received a score 

of 1.198,225,259,303 Eleven trials failed to report the method of randomization,123,305,309,312,314-320

while one study reported an inappropriate method of randomization.308 Seven trials were 

unblinded,309,310,315-318,320 seven trials failed to report the double-blinding 

method,123,150,305,308,312,314,319 and six trials did not report the reasons for dropouts.305,307-309,317,320
102

Summary Matrix 9: Omega-3 fatty acids and growth parameters of preterm infants 

Study Quality

A B C 

Author Year n Author Year n Author Year n 

I VanderhoofA 1997 288 O’ConnorU 

InnisU 2001 

2002 

470 

194 

 

Author Year n Author Year n Author Year n

II 

CarlsonA 

FewtrellA 

FewtrellA 

1992 

2002 

2004 

79 

283 

238 

CarlsonU 1996 36 CarlsonU 

UauyU 

GhbremeskelU 

FieldU 

1987 

1992 

1999 

2000 

61 

81 

61 

44 

Applicability 

Author Year n Author Year n Author Year n

III 

 KoletzkoU

BougleU 2003 1999 

49 

40 

KoletzkoU 

FaldellaU 

WoltilU 

MartinezU 

1994 

1996 

1999 

1999 

27 

66 

143 

40 

n = number of allocated/selected participants; RCT = AAdequate vs UUnclear allocation concealment

Qualitative synthesis of individual study results 

The most frequently investigated outcomes across the reviewed studies were infant weight, 

length, and HC. Weight and/or weight gain was evaluated in all trials, and infant’s length and/or 

length gain was evaluated in all but one250 trial. The majority of the studies did not find any 

statistically significant difference between randomized groups regarding these two parameters at 

different time points. Carlson et al.,250 who randomized preterm infants to receive either preterm 

control formula or MaxEPA supplemented infant preterm formula for 4 weeks, did not find any 

better weight and length gain in the treatment group. Similar results were obtained at 3 weeks in 

the study of Koletzko et al.,251 at 3, 9, 17, and 26 weeks in the study of Uauy et al.,212 at 52 

weeks PCA in the Faldella et al. study,198 at 92 weeks PCA in the Vanderhoof et al. study,218 at 4 

months of CA according to Lapillonne et al.,252 a mean of 11 weeks according to Ghebremeskel 

et al.,253 at 1 month in three studies.,225,254,259, at 8 weeks, 4, and 12 months CA in the study of 

O’Connor et al.,207 at 40 and 57 weeks postmenstrual ages in Clandinin et al.,193 at 12 months 

CA according to Groh-Wargo et al.,256 and at 28 days of age in the study by Koletzko et al.257 

Three studies revealed statistically significant weight and length gain in LCPUFAsupplemented diet groups compared with placebo.193,201,258 

Clandinin et al. randomized LBW infants to one of three feeding groups: (1) control LCP-1 

(DHA [17mg/100kcal] and AA [34mg/100kcal] derived from single cell oils); (2) LCP-2 (DHA 

[17mg/100kcal] derived from fish oil); or, (3) AA (34mg/100kcal, derived from single cell 

oils).193 The study found a significantly higher weight in the LCP-1 group of infants compared 

with infants in in the placebo group at 66 weeks to 118 weeks postmenstrual ages. In addition, 

infants in the LCP-1 group were significantly longer than infants in the LCP-2 or placebo groups 

at 79 to 92 weeks postmenstrual ages.193 

Innis et al., who randomly assigned VLBW (846g-1560g) infants to receive either preterm 

control formula (no DHA or AA), preterm formula containing only DHA (0.15wt%; DHA 

group) or DHA+AA formula (DHA [0.14wt%] and AA [0.27wt%]; DHA+AA group), found 

significantly higher body weight, length and weight-to-length ratio in infants in the DHA+AA 
103

group compared with those in the DHA formula group, and significantly higher body weight and 

weight-to-length ratio in DHA+AA group compared with those in the control group at 48 weeks 

postmenstrual age.201 Moreover, infants fed the DHA+AA formula gained weight significantly 

faster during premature formula feeding than infants fed the control formula. The rate of weight 

gain of infants fed the formula with DHA was not different from that of infants fed the control 

formula or the formula with DHA+AA.201

The study of Fewtrell et al. involving preterm infants with a birth weight less than 2,000 g 

and GA less than 35 weeks, found a significantly greater increase in weight and length of infants 

in the LCPUFA-supplemented formula group (DHA [0.5wt%], EPA [0.1wt%], and AA 

[0.04wt%]) compared with infants fed unsupplemented control formula at 9 months CA.258

Contrary to these findings, three trials revealed statistically significant weight and length gain 

in infants in the placebo group compared with the LCPUFA-supplemented group, suggesting that 

omega-3 LCPUFA can have a negative effect on growth of very-low-birth infants.185,191,273 

The trial of Carlson et al.185 that compared growth parameters in preterm, premature infants 

weighed less than 1400 g fed marine oil-enriched preterm infant formula with infants in a 

placebo group, found that by 40 weeks and continuing throughout infancy (i.e., up to 93 weeks 

PCA), infants supplemented with marine oil had significantly lower normalized weight, length, 

HC and weight-to-length ratio than those receiving standard formula.185

Carlson et al. randomly assigned preterm infants with or without bronchopulmonary 

dysplasia to receive standard preterm formula, or a formula that provided n-3 LCPUFAs from 

marine oil (DHA [0.2wt%] and EPA [0.06wt%]).191 The investigators reported that n-3 

LCPUFA-supplemented infants weighed significantly less than placebo group babies both at 6 

and 9 months post term and had significantly lower weight-to-length ratios at 2, 6, 9, and 12 

months post term.191

Fewtrell et al observed that at 9 and 18 months CA, treatment formula infants were 

significantly lighter and shorter than control group babies. This weight difference was present in 

both boys and girls, and it remained significant at 18 months after adjusting for parental 

smoking, social class, and level of maternal education. 273

In the three studies where a weight and length gain benefit was observed in LCPUFA 

supplemented formula fed infants,193,201,258 investigators used experimental formulas containing 

AA. Conversely, in trials that showed a decrease in weight,185,191,273 length,185,191,273 and 

HC185,191 in infants fed LCPUFA-supplemented formula, the formula did not contain AA. It can 

be assumed that the growth benefit in preterm infants might be attributed to supplemented AA, 

and omega-3 FAs negatively affect infant weight gain. 

Infant HC and/or HC gain was evaluated in all but two trials.193,250 Most of the studies did 

not find any statistically significant difference between randomized groups regarding this 

parameter at different time point. Only two studies185,191 reported a significantly lower HC in the 

omega-3 FA supplemented group compared with the placebo group at 40 to 93 weeks PCA185

and at 6 and 9 months post term.191 None of the studies revealed any benefit of LCPUFA 

supplementation regarding the HC gain of premature infants. 

Other growth outcomes assessed were triceps skinfold thickness, subscapular skinfold 

thickness, and mid-arm circumference. Uauy et al. did not find any statistically significant 
104

difference in triceps skinfold thickness and subscapular skinfold thickness among the 

randomized study groups at 3, 9, 17, and 26 weeks.212 Martinez et al. had the same result at 30 

days.259 Vanderhoof et al. did not find a statistically significant difference in mid-arm 

circumference between study groups, although this parameter was significantly lower in the 

breastfed group.218

Carlson et al. found that the weight and length z-scores were positively correlated with the 

plasma and RBC AA content at 2, 4, 5, 6, 9, and 12 months of age. However, HC was positively 

correlated at 2 and 4 months of age only.185 Uauy et al. found that the length z-score at 57 weeks 

of PCA was negatively correlated with the RBC AA at 57 weeks PCA.212

The other Carlson et al. study reported a negative correlation between the weight-for-length 

z-score and the RBC PE DHA at 5 months of age, whereas, there was a positive correlation 

between length and RBC PC AA at 5 months.191 Innis et al. observed a positive correlation 

between the rate of weight gain and the RBC PE AA at 28 days (end of feeding), as well as the 

weight and length.201 Woltil et al. found a significantly positive correlation between the weight, 

length and HC gain and the plasma and RBC DHA content at 1 month of age.225

Finally, O’Connor et al. found a significantly postive correlation between the rate of weight 

gain, weight (mean) and length (mean) and the RBC AA at 1 month of age.207

Quantitative synthesis 

The outcomes considered for meta-analysis for growth development were weight, height and 

HC at 4 and 12 months. These end-points were selected given that the intervention with 

supplemented formula was exclusively administered until 4 months and 12 months (as a 

longterm followup measure), yet with the possible confounder factor of the background diet. 

Outcome results were available for more than one study at six different end-points in time: CA 4, 

6, 9, 11, 12, and 18 months in 19 studies. 

At 4 months CA, outcomes were available for four studies.185,191,201,207 Carlson et al.185

provided growth z-scores with standard deviation in a figure, and reported absolute growth data 

(by sex) in a table but without any measure of variability. In another report by Carlson et al.191

supplementation only continued to 2 months CA. Innis et al.201 did not report HC data on the 

grounds that results were not found to be statistically significant. We were thus able to combine 

weight and length results from Innis et al. and O'Connor et al.201,207 Both trials assessed these 

outcomes as primary outcomes. 

At 12 months CA, outcomes were available for three studies.185,191,207 Supplementation in 

Carlson et al.191 only continued until 2 months CA. 

Supplementation in Carlson et al.185 continued only until 9 months CA. In addition, Carlson 

et al.185 provided growth z-scores with SD in a figure, and absolute growth data (by sex and 

without any measure of variability) in a table. We were thus unable to combine any results. 
105

Figure 6. Child pre-term growth 4 months DHA+AA vs. control. Meta-analysis was performed using 

the random effects weighted mean difference. 

Review: preterm growth at 4 month (Version 01)

Comparison: 01 DHA+AA vs. control 

Outcome: 01 Weight 

Study Treatment Control WMD (random) Weight WMD (random)

or sub-category N Mean (SD) N Mean (SD) 95% CI % 95% CI

Innis 2002 55 6.31(0.96) 47 6.05(0.96) 38.67 0.26 [-0.11, 0.63] 

O'Connor 2001 247 6.30(0.85) 127 6.40(0.72) 61.33 -0.10 [-0.26, 0.06] 

Total (95% CI) 302 174 100.00 0.04 [-0.30, 0.38]

Test for heterogeneity: Chi2 = 2.99, df = 1 (P = 0.08), I2 = 66.5%

Test for overall effect: Z = 0.22 (P = 0.82)

 -1 -0.5 0 0.5 1

 Favours control Favours treatment

Review: preterm growth at 4 month (Version 01)

Comparison: 01 DHA+AA vs. control 

Outcome: 02 Length 

Study Treatment Control WMD (random) Weight WMD (random)

or sub-category N Mean (SD) N Mean (SD) 95% CI % 95% CI

Innis 2002 55 61.30(2.20) 47 60.70(2.74) 33.84 0.60 [-0.38, 1.58] 

O'Connor 2001 236 61.53(2.23) 120 61.70(2.05) 66.16 -0.17 [-0.63, 0.29] 

Total (95% CI) 291 167 100.00 0.09 [-0.62, 0.80]

Test for heterogeneity: Chi2 = 1.95, df = 1 (P = 0.16), I2 = 48.8%

Test for overall effect: Z = 0.25 (P = 0.80)

 -4 -2 0 2 4

 Favours control Favours treatment

The mean weight difference (WMD) in weight (kg) and length (cm) at 4 months (DHA+AA 

vs. control) in two studies201,207 were nonstatistically significant. For weight: WMD: 0.04, CI 

95%: -0.30; 0.38. For length: WMD: 0.09, CI 95%: -0.62; 0.80. 

Impact of covariates and confounders 

In the majority of the RCTs there was no evidence that randomization failed to produce 

comparable groups with the exception of scores on the HOME Inventory.268 In the study of 

O’Connor et al.,268 HOME Inventory scores were higher (better) in infants weighing less than 

1,250 g randomized to the control group than those randomized to the fish/fungal oil group. 

HOME Inventory scores were lower in infants in the more than 1,250 g birth weight stratum 

randomized to the egg-TG/fish oil group compared with scores in the control and fish/fungal oil 

groups.268

Carlson et al. used a multiple regression analysis to control for potential effect modifiers such 

as maternal height, marine oil supplementation, and birth order.185 Length achieved at 12 

months of age was positively associated with maternal height, but negatively associated with 

marine oil supplementation. Weight was negatively associated with both birth and marine oil 

supplementation.185

Fewtrell et al. controlled the growth changes for covariates like gender, center, parental smoking, 

social class and level of maternal education.273 

Differences in weight and length at 18 months post-term remained after adjusting for parental 

smoking, social class and level of maternal education.273 There were no differences in HC 

between groups. The growth differences were greater in one center than the other, however, 

there was no interaction between center and growth patterns.273 O’Connor et al. observed that 
106

the females in the DHA+AA (egg-TG/fish) group had a greater mean HC gain from day 1 to 

term CA compared with the females in the other groups.207

The power calculation was reported in eight trials,123,307,310,312,315,316,321,322 while the intentionto-treat analysis approach was reported in only three studies.310,321,322

Infant Formula Intake—Term Infants 

Eighteen double-blinded RCTs met eligibility criteria for addressing the question relating to 

the possible effectiveness of formula intake enriched with omega-3 FA on growth patterns in 

term infants.104,182,203,205,223,227,260-270 

Auestad et al. included two unique trials in one report.227 The studies were published 

between 1992 and 2004. (Summary Tables 22–24) 

Overview of relevant studies 

Ponder et al. conducted a small efficacy study involving 25 full-term, healthy infants who 

were randomized to receive either soy-based (Similac with Iron 20 ready-to-feed) or corn oilbased (Similac with Iron 20 powder) formulas for 8 weeks.260 None of the formulas contained 

either DHA, EPA, or AA supplementations and their FA composition differed primarily in the 

percentage of ALA (omega-3) and ratio of LA (omega-6)/ALA (omega-3) The outcomes were 

the mean weight, length and HC at 3 days, 4 and 8 weeks of age.260 (Summary Table 22) 

Decsi et al. randomly assigned 22 term infants to receive either conventional infant formula 

(Pre-Aptamil, placebo group) or the same formula enriched with egg lipids and evening primrose 

oil (Pre-Aptamil with Milupan, LCP-F group).261 All infants were fed ad libitum throughout the 

study but investigators failed to report the duration of interventions in both groups. The 

outcomes were the change in weight, length and HC at 4 months.261 (Summary Table 22) 

Makrides et al. compared fish oil and evening primrose oil derived LCPUFA-supplemented 

formula with placebo formula in a double-blinded RCT involving 89 healthy full-term infants.262 

Infants were fed for 30 weeks and growth parameters were measured and compared at 6, 16, and 

30 weeks.262 (Summary Table 22) 

Jensen et al. randomly assigned 80 healthy term infants to receive one of four formulas as 

his/her sole source of nutrition from birth to 120 days of age.203 LA comprised 15.6% to 17.6% 

of the total FAs of all formulas. The ALA content was 0.4%, 1%, 1.7%, and 3.2% of total FAs, 

and LA/ALA ratios were 44, 18.2, 9.7, and 4.8, respectively. 

The outcomes assessed were the growth patterns at 4 and 8 months of age and the correlation 

with infant biomarkers.203 (Summary Table 22) 

Innis et al. conducted a 3-month multicenter RCT at seven different centres in the U.S. and 

Canada involving 139 term infants who were randomized to receive one of two cow milk-protein 

based formulas (Mead Johnson Nutritionals), which differed only in FA composition and blend 

(18.0% LA, 1.9% ALA, with LA/ALA ratio of 9.5:1 vs 34.2% LA, 4.7% ALA, with an LA/ALA 

ratio of 7.3:1).263 Neither formula had any detectable DHA, EPA, or AA.263 (Summary Table 

22) 
107

Auestad et al. randomized 134 term, healthy infants to receive one of three formulas from 

less than 7 days of age to 12 months.104 The feeding formulas differed only in the amounts and 

sources of LCPUFAs: (1) the control formula contained no added LCP FAs; (2) formula 

containing AA (0.43wt%) and DHA (0.12wt%) from egg yolk phospholipids; and, (3) formula 

providing DHA (0.2wt%) from a high-DHA, low-EPA tuna fish oil with a ratio of DHA to EPA 

of 4:1.104(Summary Table 22) 

Summary Table 22: Omega-3 fatty acids and growth parameters of term infants 

Study groups1 Author, 

Year, 

Location: 

Length & 

Design 

Group 1 

(n)/ 

Group 4 

(n)

Group 2 

(n)/ 

Group 3 

(n)

Notable 

clinical effects

Notable clinicalbiomarker2,3 

correlations 

Internal 

validity Applicability 

Ponder, 

1992, US: 

8 wk 

parallel 

RCT260

Soy oil 

formula 

(n=11*) 

Corn oil 

formula 

(n=14*)/ 

HM (n=18*) 

NS in wt, L, HC 

at 3d, 4wk, 8wk

n/a Jadad total: 

1 [Grade: C]; 

Schulz: 

Unclear 

II 

Decsi, 

1995, 

Hungary: 

parallel 

RCT261

DHA+EPA

+AA 

formula 

(n=10) 

Control 

formula 

(n=12) 

NS in ∆ wt, ∆L, 

∆HC at 4 mo 

n/a Jadad total: 

1 [Grade: C]; 

Schulz: 

Unclear 

III 

Makrides, 

1995, 

Australia: 

30 wk 

parallel 

RCT262 

DHA+EPA

+AA fish 

oil formula 

(n=13*) 

Control 

formula 

(n=19*)/ 

HM 

(n=47*) 

NS in wt, L, HC 

at 6, 16, 30 wks

NS correlation of 

RBC LCPUFA & 

GP 

Jadad total: 

2 [Grade: C]; 

Schulz: 

Unclear 

II 

Jensen, 

1997, US: 

120 d 

parallel 

RCT203

F1 

(LA/ALA 

44) 

(n=20)/ 

F4 

(LA/ALA 

4.8) 

(n=20) 

F2 (LA/ALA 

18.2) 

(n=20)/ 

F3 (LA/ALA 

9.7) 

(n=20) 

SÐ wt in F4 

than in F1 at 4 

mo+

NS in L, HC, 

TST, & SST at 4 

& 8 mo

S (+) correlation 

between W at 4 

mo & plasma AA 

at 120d 

NS correlations 

between wt & 

plasma n-3 at 4 

mo 

Jadad total: 

2 [Grade: C]; 

Schulz: 

Unclear 

II 

Innis, 1997, 

US, 

Canada: 

3 mo 

MLT 

parallel 

RCT263

LA/ALA 

9.5 

(n=69) 

LA/ALA 7.3 

(n=70)/ 

HM 

(n=99) 

NS in wt, L, & 

HC at 3 mo 

NS correlations 

between GP & 

plasma & RBC AA 

Jadad total: 

2 [Grade: C]; 

Schulz: 

Unclear 

I 

Auestad, 

1997, US: 

12 mo 

parallel104

DHA+AA 

(n=46*)/ 

HM 

(n=63*) 

DHA 

(n=43*)/ 

control 

formula 

(n=45*) 

NS in wt, L, HC 

at 12 mo

n/a Jadad total: 

3 [Grade: B]; 

Schulz: 

Unclear 

I 
108

1

Proceeding from highest omega-3, or lowest omega-6/omega-3, fatty acid content of intervention/exposure; 2

biomarker source; 3biomarkers = EPA, DHA, AA, AA/EPA, AA/DHA, AA/EPA+DHA; n-3 = omega-3 fatty acids; n-6 

= omega-6 fatty acids; DHA = docosahexaenoic acid; EPA = eicosapentaenoic acid; AA = arachidonic acid; Length 

= intervention length; Design = research design; n = sample size; pts = study participants; NR = not reported; S = 

statistically significant difference; NS = nonsignificant statistical difference; n/a = not applicable; pb = placebo; grp = 

group; wk = week(s); mo = month; FAs = fatty acids; * = number of participants who completed study; HM = human 

milk group; BW = birth weight; BL = birth length; wt= weight; L = length; HC = head circumference; ∆ = change; 

RBC = red blood cells; GP = growth parameters; ITT = intention-to-treat analysis; PP = per-protocol analysis (e.g., 

completers); +

p<.05 or significant with 95% confidence interval; ++p<.01; +++p<.001; ++++p<.0001; PP = per-protocol 

analysis (e.g., completers); Ï = increase(d)/higher; Ð = decrease(d)/reduction/lower; HM = human milk; GP = 

growth parameters; TST = triceps skinfold thickness; SST = subscapular skinfold thickness 

Jorgensen et al. included 39 formula-fed infants randomized to receive one of the three 

formulas for at least 3 months: (1) formula with DHA (0.3wt%) and EPA (0.4wt%) derived from 

fish oil (DHAF group); (2) formula with DHA (0.3wt%) and EPA (0.4wt%) derived from fish 

oil, and GLA (0.5wt%) derived from borage oil (DHAGF group); and,(3) control formula with 

no supplemented LCPUFA. The outcomes were the growth patterns at 1, 2, and 4 months of 

age.264 (Summary Table 23) 

Birch et al. enrolled 79 exclusively formula-fed infants and randomized them to receive one 

of the three formulas from birth to 17 weeks of age. Study diets were Enfamil with iron (control 

group), Enfamil with iron supplemented with DHA (0.35wt%, DHA group), and Enfamil with 

iron supplemented with DHA (0.36wt%) and AA (0.72wt%).182 Treatment formulas contained 

single cell oils, specifically DHASCO® and ARASCO® (Market Biosciences, Columbia, MD). 

An exclusively breastfed reference group included 29 infants.182 (Summary Table 23) 

Willatts et al. randomized English term infants to receive LCPUFA (DHA 0.15-0.25 g/10 g 

fat + AA 0.30- 0.40 g/100 g fat) supplemented formula or standard formula during 4 months.223 

The outcome evaluated was the growth patterns at 3 months of age.223(Summary Table 23) 

Makrides et al. conducted a double-blinded RCT of three formula-fed groups and a parallel 

reference group of breastfed infants.205 The study formulas contained (1) DHA (0.34wt%) and 

AA (0.34wt%) from egg phospholipid (DHA+AA group, n=28): (2) DHA (0.35wt%) and EPA 

(0.10wt%) derived from tuna fish oil (DHA group, n=27), and (3) placebo formula (n=28) with 

no LCPUFA supplementation. Formulas were given to the infants for 12 months. A reference 

group of 33 breastfed infants was also recruited for the trial.205 (Summary Table 23) 

Lucas et al. evaluated the effect of feeding formula supplemented with DHA (0.32wt%), 

EPA (0.01wt%) and AA (0.30wt%) derived from purified egg phospholipid (LCPUFA group, 

n=154) compared with unsupplemented formula (control group, n=155) on growth parameters of 

infants at 18 months of age.265 Randomization of infants took place during the first week after 

delivery. One hundred and thirty-eight breastfed infants also were recruited as a reference 

group.265 (Summary Table 23) 

Makrides et al. conducted a double-blind RCT of newborn babies allocated to receive 

formula with an LA/ALA of either 10:1 (16.9/1.7, n=36) or 5:1 (16.3/3.3, n=37) from near birth 

to 34 weeks of age.266 Increased ALA was attained by replacing soy oil with low-erucic acid 

canola oil. A parallel group of 103 breastfed infants was also recruited.266 (Summary Table 23)
109

Summary Table 23: Omega-3 fatty acids and growth parameters of term infants 

Study groups1 Author, 

Year, 

Location: 

Length & 

Design 

Group 1 

(n)/ 

Group 4 

(n)

Group 2 

(n)/ 

Group 3 

(n)

Notable clinical 

effects

Notable clinicalbiomarker2,3 

correlations 

Internal 

validity Applicability 

Jorgensen

1997, 

Denmark: 

 3 mo 

parallel 

RCT264

DHA+GLA 

formula 

(n=12)/ 

HM 

(n=17) 

DHA formula 

(n=14)/ 

Control 

formula 

(n=11) 

NS in wt, L, HC, 

GV at 1, 2, & 4 mo

n/a Jadad 

total: 2 

[Grade: 

C]; 

Schulz: 

unclear 

III 

Birch, 

1998, US: 

17 wk 

parallel 

RCT182

DHA+AA 

(n=26)/ 

HM 

(n=29) 

DHA 

(n=26)/ 

control 

formula 

(n=26) 

NS in wt, L, HC, 

TST, SST at 17wk 

n/a Jadad 

total: 5 

[Grade: 

A]; 

Schulz: 

Adequate 

I 

Willatts, 

1998, UK: 

4 mo 

parallel 

RCT223

DHA + AA 

formula 

(n=20) 

Control 

formula 

(n=20) 

NS wt, L, HC at 3 

mo 

n/a Jadad 

total: 3 

[Grade: 

B]; 

Schulz: 

Unclear 

II 

Makrides, 

1999, 

Australia: 

12 mo 

parallel 

RCT205 

DHA+AA 

formula 

(n=28)/ 

HM 

(n=63) 

DHA formula 

(n=27)/ 

control 

formula 

(n=28) 

NS in wt, L, HC at 

6, 16, 34 wk, 12 

mo & 24 mo 

S (-) correlation 

of plasma DHA 

at 16 wks & wt at 

12 mo & 24 mo 

Jadad 

total: 5 

[Grade: 

A]; 

Schulz: 

Adequate 

III 

Lucas, 

1999, UK: 

6 mo 

parallel 

RCT265 

LCPUFA 

formula 

(n=154) 

control 

formula 

(n=155)/ 

HM 

(n=138) 

NS in wt, L, HC, 

MAC, SST at 6, 9, 

18 mo (ITT)

n/a Jadad 

total: 5 

[Grade: 

A]; Schulz: 

Adequate 

II 

Makrides, 

2000, 

Australia: 

34 wk 

parallel 

RCT266

LA/ALA 10 

formula 

(n=36) 

LA/ALA 5 

formula 

(n=37)/ 

HM 

(n=103) 

NS in ∆ wt, ∆L, ∆

HC between 10:1-

F & 5:1-F at 6, 16, 

34 wks 

SÏ wt at 6 wks & 

L at 16 wks in 5:1 

F+ 

n/a Jadad 

total: 5 

[Grade: 

A];Schulz: 

Adequate 

II 

1

Proceeding from highest omega-3, or lowest omega-6/omega-3, fatty acid content of intervention/exposure; 2

biomarker source; 3biomarkers = EPA, DHA, AA, AA/EPA, AA/DHA, AA/EPA+DHA; n-3 = omega-3 fatty acids; n-6 

= omega-6 fatty acids; DHA = docosahexaenoic acid; EPA = eicosapentaenoic acid; AA = arachidonic acid; Length 

= intervention length; Design = research design; n = sample size; pts = study participants; NR = not reported; S = 

statistically significant difference; NS = nonsignificant statistical difference; n/a = not applicable; pb = placebo; grp = 

group; wk = week(s); mo = month; FAs = fatty acids; HM = human milk group; wt = weight; L = length; HC = head 

circumference; RBC = red blood cells; GV = growth velocity; PC = phosphatidylcholine; PE = 

phosphatidylethanolamine; TST = triceps skinfold thickness; SST = subscapular skinfold thicknessITT = intentionto-treat analysis; PP = per-protocol analysis (e.g., completers); +

p<.05 or significant with 95% confidence interval; ++p<.01; +++p<.001; ++++p<.0001; PP = per-protocol analysis (e.g., completers); Ï = increase(d)/higher; Ð = 

decrease(d)/reduction/lower 

Lapillone et al.’s group of 24 infants were randomly assigned to received a placebo or a 

LCPUFA-enriched formula (DHA [0.31wt%], EPA [0.08wt%] and AA [0.03wt%] derived from 

high DHA/low EPA fish oil, ROPUFA® “30” n-3 INF oil, Roche, Basel, Switzerland) from the 
110

third day of life until 4 months of age.267 A non randomized group of 13 breastfed infants was 

also included.267 (Summary Table 24) 

Morris et al. randomized 140 healthy, full-term infants to receive either standard formula 

milk with no LCPUFA supplements (control group) or milk with added DHA (0.2wt%) and AA 

(0.4wt%) (trial group).268 Participants remained on these formulas for 12 weeks. Anthropometric 

measurements were taken at recruitment, 6 weeks, 3 months, 6 months, and 1 year.268 (Summary 

Table 24) 

Auestad et al.’s first trial compared the visual function of healthy term infants exclusively fed 

(1) formula with either DHA (0.14wt%) and AA (0.45wt%) derived from egg triglycerides, (2) 

formula with DHA (0.13wt%), EPA (<0.04wt%) and AA (0.46wt%), derived from fish and 

fungal oils, or (3) formula with no LCPUFAs (control group), from less than 9 days to 12 

months.227 (Summary Table 24) 

Auestad et al.’s second trial included a sample of healthy term infants who were exclusively 

breastfed for 3 months and then weaned to formula.227 Infants were randomized to receive a 

control formula and a DHA +AA supplemented formula derived from egg-triglycerides within 

11 days of birth and exclusively breastfed for 3 months. Study formulas were not provided nor 

fed until after 3 months of exclusive breastfeeding.227 (Summary Table 24) 

Birch et al. evaluated the effect of feeding DHA+AA supplemented formula (Enfamil with 

iron containing DHA [0.36 wt%] and AA [0.72 wt%], derived from single-cell oils, n=32) or 

unsupplemented formula (control formula, Enfamil with iron, n=33) from week 7 of life to 52 

weeks of age, on growth parameters measured at 6, 17, 26, and 52 weeks of age.269 (Summary 

Table 24) 

Hoffman et al. evaluated the effect of feeding previously breastfed infants with DHA+AA 

supplemented (DHA 0.36 wt%, AA 0.72 wt%) or unsupplemented formula from 4 to 6 months 

of age (after weaned from breastfeeding) to 12 months of age on growth patterns at 4, 6, 9 and 12 

months of age.270 (Summary Table 24)
111

Summary Table 24: Omega-3 fatty acids and growth parameters of term infants 

Study groups1 

Author, Year, 

Location: 

Length & 

Design 

Group 1 

(n)/ 

Group 4 

(n)

Group 2 

(n)/ 

Group 3 

(n)

Notable clinical 

effects

Internal 

validity Applicability 

Lapillonne, 

2000, 

France: 

4 mo parallel 

RCT267 

DHA(fish oil)- 

low EPA 

formula 

(n=12) 

Control formula 

(n=12)/ 

HM 

(n=13) 

SÏ HC in control 

than in LCPUFA & 

HM at 4mo+

NS in wt, L, at 2, 4 

mo

Jadad total: 1 

[Grade: C]; 

Schulz: 

Unclear 

III 

Morris, 2000, 

UK: 

12 wk 

parallel 

RCT268

DHA-TGL 

formula 

(n=54*) 

 

Control formula 

(n=55*) 

SÏ SST in DHA at 6 

wk & 3 mo+ NS at 6 

mo & 12 mo 

NS in wt, L, HC, 

MAC, TST at 6 wk, 12 

wk, 6 mo, 12 mo

Jadad total: 3 

[Grade: B]; 

Schulz: 

Unclear 

II 

Auestad, 

2001a, US: 

12 mo 

parallel 

RCT227 

DHA+ 

AA (egg-TG) 

formula (n=80) 

DHA+ AA 

(fish/fungal) 

formula (n=82)/ 

control formula 

(n=77) 

NS in wt, L, HC at 1, 

2, 4, 6, 9, & 12 mo 

SÏ wt gain in males 

in DHA+AA (egg) at 4 

mo

Jadad total: 5 

[Grade: A]; 

Schulz: 

Adequate 

I 

Auestad, 

2001b, US: 1 

y, 

parallel 

RCT227

DHA + AA 

formula + HM 

(n=83) 

Control formula + 

HM (n=82) 

NS in wt, L, HC at 1, 

2, 4, 6, 9, & 12 mo or 

in wt, L, HC gain 

Jadad total: 5 

[Grade: A]; 

Schulz: 

Adequate 

I 

Birch, 2002, 

US: 

46 wk 

parallel 

RCT269

LCP formula 

(n=32) 

Control formula 

(n=33) 

NS in wt, L, HC, TST 

& SST at 0,6,17,26 & 

52 wks 

Jadad total: 5 

[Grade: A]; 

Schulz: 

Adequate 

II 

Hoffman, 

2003 

US: 

7 mo 

Parallel 

RCT270

DHA+AA 

formula 

(n=30) 

Control formula 

(n=31) 

NS in wt, L, HC, wtfor-L at 4,6,9 & 12 mo Jadad total: 3 

[Grade:B]; 

Schulz: 

Adequate 

II 

1

Proceeding from highest omega-3, or lowest omega-6/omega-3, fatty acid content of intervention/exposure; n-3 = 

omega-3 fatty acids; n-6 = omega-6 fatty acids; DHA = docosahexaenoic acid; EPA = eicosapentaenoic acid; AA = 

arachidonic acid; Length = intervention length; Design = research design; n = sample size; pts = study participants; 

NR = not reported; S = statistically significant difference; NS = nonsignificant statistical difference; n/a = not 

applicable; pb = placebo; grp = group; wk = week(s); mo = month; FAs = fatty acids; * = number of participants who 

completed study; HM = human milk group; W = weight; L = length; HC = head circumference; MAC = mid-arm 

circumference; SST = sum of skinfold thickness; TST = triceps skinfold thickness; SST = subscapular skinfold 

thickness; ITT = intention-to-treat analysis; PP = per-protocol analysis (e.g., completers); +

p<.05 or significant with 

95% confidence interval; ++p<.01; +++p<.001; ++++p<.0001; PP = per-protocol analysis (e.g., completers); Ï = 

increase(d)/higher; Ð = decrease(d)/reduction/lower 

Qualitative synthesis of relevant studies’ key characteristics 

Study characteristics. All studies were parallel RCTs with at least two groups. All the 

studies evaluated the effect of omega-3 FA supplementations on infant growth. Auestad et al. 

also evaluated the effect of maternal breastfeeding together with omega-3 FA supplemented 

formula intake in term infants on growth pattern.227 Eleven of 18 studies also included a nonrandomized group of breastfed infants that served as a reference standard.104,182,205,227,260,262-267
112

The trials were conducted in various countries, with eight undertaken in the 

U.S.,104,182,203,227,260,269,270 three in Australia,205,262,266 three in the U.K.223,265,268 and one each in 

Denmark,264, France,267 and Hungary.261 The only multicenter study was conducted in the U.S. 

and Canada by Innis et al.263 Ponder et al.’s study was supported by Ross Laboratories, 

Columbus, OH.260 Decsi et al.’s study was sponsored by Deutsche Forschungsgemeinschaft, 

Bonn, Germany and Milupa Austria, Puch, Austria.261 Makrides et al. received grants from 

Channel 7 Children’s Medical Research Foundation, Nestle Australia, Scotia Pharmaceuticals, 

U.K. and the Flinders Medical Center Research Foundation.262 Jensen et al.’s study was 

financially supported by the U.S. Department of Agriculture, Agricultural Research Service, 

Mead-Johnson Nutritional Group, The Foundation Fighting Blindness, Research to Prevent 

Blindness, Inc. and Retina Research Foundation.203 The Innis et al. study was funded by Mead 

Johnson Research Center, Evansville, IN.263 Auestad et al.’s study was supported by Ross 

Products Division, Abbott Laboratories.104 Makrides et al.’s was supported by Wyeth 

Nutritionals International, USA the Australian National Health and Medical Research Council, 

and the MS McLeod Research Trust.266 The study by Birch et al. was financed by the National 

Institutes of Health and Mead Johnson Nutritionals Research, Evansville, IN.182 The second 

Makrides et al. study was funded by Nestec Ltd, Swirzerland and the Australian National Health 

and Medical Research Council.205 Jorgensen et al.’s study was supported by grants from the 

Food Technology Research and Development Program (FOTEK), BASF Health and Nutrition, 

Denmark, and the Swedish Medical Research Council.264 Lucas et al.’s was funded by Nestec 

Ltd (Switzerland).265 Both of Auestad et al.’s trials were supported by Ross Products Division, 

Abott Laboratoris, Columbus, OH.227 The Lappilonne et al. study was supported by Bledina sa., 

Villefranche, France.267 Birch et al. and Hoffman et al. were supported by the NIH.269,270 Only 

one trial conducted in U.K. did not provide information concerning its funding source.268 Willatts 

et al. was supported by Milupa Ltd.223 

In general, eight studies were funded by grants only from pharmaceutical 

companies,223,227,260,263,265,265,267 seven studies were funded by both pharmaceutical and 

governmental agencies,104,182,203,205,261,262,264 two trials were funded by governmental sources 

alone,269,270 and one study was funded partly by private, pharmaceutical and governmental 

sources.266

The pre-study sample size calculation to reach statistical significance and power was done in 

nine studies.182,205,223,227,262,265,269,270

Population characteristics. The total number of enrolled children across the 18 RCTs was 

not possible to calculate because two investigators104,260 failed to report this data providing only 

the number of infants who finished the study. The sample sizes ranged from 22261 to 447.265

The percentage of male randomized infants was reported in five studies205,264,265,269,323 and 

ranged from 42% to 64% of the infant cohort. The male/female ratio was reported in six 

studies.104,182,203,262,266,268 The gender ratio of infants among different diet groups was evenly 

distributed in all of these studies. 

In five studies most of the participants were White, accounting for 75% to 93% of the study 

population.104,182,227,269,270 Only one trial reported that Black infants comprised the majority of 

the study participants.203 Auestad et al.’s racial distribution of infants among the groups was not 

equal, for example, the breastfed group included significantly more White infants than the 
113

placebo group and the treatment groups.104 In two studies, participants were only White.205,266 

No information about the ethic/racial background of participants was provided in the remaining 

trials. 

The inclusion and exclusion criteria were described in twelve studies.104,182,205,227,262-

264,266,267,269,270 Only inclusion criteria were reported in one study.203 Four studies failed to report 

either inclusion or exclusion criteria.223,260,261,268 Lapillonne et al. defined maternal cocaine and 

alcohol abuse history as exclusion criteria.267 

The definition of a term infant (at least 37 weeks GA) was described in 11 studies 

104,223,227,260,262,263,265,266,269,270 The study duration ranged from 8 weeks to 24 months, with a 

mean interventional length of 27.5 weeks (range 8–52 weeks). Only one trial did not report the 

length of dietary intervention.261

Different variables were used to demonstrate the family socioconomic status across the 

studies (i.e., maternal education, paternal education, social score, social status of income earner, 

marital status). Maternal social status was determined in seven studies,205,227,262,265,268,270

whereas, information about maternal and/or paternal education and/or maternal marital status 

was given in six trials.182,205,227,265,269 Makrides et al. assessed parental education scores, as well 

as parental social scores in two randomized study groups.266 

There were no differences in sociodemographic variables among the study groups of 

randomized infants in all of these studies. Mothers of infants in the reference breastfed group 

had a more prestigious social score, and attained a higher level of education compared with 

mothers of formula-fed infants.205,227,262 Hoffman et al. found that maternal education was better 

in the LC PUFA supplemented group at baseline.270 There was missing data about maternal 

smoking history before and during pregnancy in eleven studies.104,182,203,223,262-265,267,269,270 In 

studies that reported information about maternal smoking history, there was a tendency for less 

maternal smoking during pregnancy and/or lactation among the mothers of breastfed infants 

compared with formula-fed groups.205,227,266

Intervention/exposure characteristics. Only four studies reported as part of the protocol 

that the volume of formula consumed, calculated as the difference in the volume of formula in 

the bottle at the start and end of the feed, was recorded.203,261,265,268 Nonetheless, most of the 

authors failed to report the daily amount of formulas consumed by infants in the different feeding 

groups. Only Decsi et al. reported that daily formula intakes were between 120 mL/kg and 150 

mL/kg and did not differ between the feeding groups.261

The duration of formula intake was not reported only in the study of Decsi et al.261 In the 

remaining trials, the formula intake duration ranged from 8 weeks260 to 12 months.104,205,227 

The sources of omega-3 FA intervention varied across the 18 RCTs. Six trials described the 

source as fish oil.104,205,227,264,267 Makrides et al. supplemented a standard formula with a 

combination of DHA derived from fish oil and AA derived from primrose oil.262 The specific 

type of fish from which the fish oil exposures were derived were described in two studies.104,205 

The remaining studies employed either single cell sources of FA,182,268-270 solely vegetable 

sources of FA,203,223,260,261,263,266 egg phospholipids,196,265 or at least one of the feeding formulas 

containing FA from vegetable or egg sources.104,205,227,264 Decsi et al. used a formula enriched 

with both egg lipids and primrose oil to achieve a higher levels of omega-3 and omega-6 FA.261 
114

In 10 studies, the type of omega-3 FA employed included a combination of DHA and 

EPA.205,223,227,261,262,264,265,267,270 In four trials DHA was used alone;104,182,268,269 ALA was used 

alone also in four trials.203,260,263,266 Supplementation of formulas with the omega-6 FA AA was 

reported in seven trials.104,182,205,227,265,269

Nine studies failed to report the name of the intervention formulas.104,205,227,264-268 In the rest 

of the studies, the brands of the employed formulas were: Enfamil (Mead Johnson Nutritionals, 

Evansville, Ind);182,203,263,269,270 Similac with iron (Ross Laboratories, Columbus, OH);260

Aptamil (Milupa Ltd.);223 and Pre-Aptamil (Puch/Salzburg, Austria).261 Eight trials indicated the 

manufacturer of at least one omega-3 FA product used in their study.182,223,227,265,267,269,270 None 

of the studies reported on the purity of their omega-3 FA exposure. 

Study infants were placed on the study formulas within the first week of life in most of the 

studies.104,182,205,223,260,261,265-268 Study formulas were started within the first month of life in four 

studies,203,227,263,264 from the beginning of week 7 in the Birch et al. study,269 1 month after 

delivery in the study of Jorgensen et al.,264 and in the second Auestad et al. trial, infants received 

the formula after 3 months of being exclusively breastfed.227 One trial failed to report 

information on the exact time of participants’ enrollment into the study.262 Hoffman et al.’ 

infants were breastfed for at least 4 to 6 months and then were randomized to the study formulas 

until 12 months of age.270

Formula was the only source of alimentation in three studies and no solid foods were 

introduced during the entire trial period.203,260,263 Innis et al. specified that an infant would be 

withdrawn from the study if more than 10% of dietary energy came from sources other than 

assigned formula for 5 days or more.263 Decsi et al. permitted fruit juices at 2 months of age and 

solid food beginning at 3 months of age in both study groups.261 In eight studies, introduction of 

solid foods was permitted after 4 months of age.104,205,227,262,266,267,270 Both Birch et al. trials did 

not permit the introduction of any solid food until 17 weeks of age.182,269 Lucas et al. reported 

that the mean age of first introduction of any solid food did not differ between those fed 

LCPUFA and those fed control formula.265 Two trials failed to report if any solid food was 

permitted at all.223,268

Information about caloric balance of feeding formulas was reported in seven 

RCTs.104,182,227,265,269,270 Only Auestad et al. mentioned that the study formulas were 

indistinguishable in appearance and odor.227

Cointervention characteristics. Three studies reported the content of vitamin and mineral 

supplements of feeding formulas and oils taken by pregnant or lactating women.182,261,264 In 

Ponder et al., no vitamins or mineral supplementations were given to the infants fed formula, 

whereas, breastfed infants received routine vitamin D supplementation.260 Only Jorgensen et al. 

reported about the use of preventive measures such as microencapsulation of fish and borage oils 

and addition of corn starch to avoid oxidation and to allow homogenization with the formula 

powder.264 Toxicology studies for supplemented oils were done only in one study.182 

Outcome characteristics. Nine (of 20) trials evaluated the growth parameters as primary 

outcomes,120,151,324-329 while the remaining 11 trials assessed these outcomes as secondary 

outcomes. All included RCTs employed the weight, length, and HC of infants as main outcome 

measures for growth. The rate of gains in weight, length and HC were assessed in three 

studies.261,264,266 Triceps skinfold thickness was measured in five RCTs182,203,223,268,269 
115

Subscapular skinfold thickness was assessed in five studies.182,203,265,268,269 Two studies 

evaluated mid-arm circumference as one of the growth outcomes.265,268 

Study quality and applicability. The 18 RCTs received a mean Jadad total quality score of 

3.2, with good internal validity (Summary Matrix 10). Seven trials received a score of 

5,182,205,265,266,269,329 four received a score of 3,104,223,268,270 four reports received a score of 2,203,262-

264 and three received a score of 1.260,261,267 Seven trials failed to report the randomization 

method,125,324,325,328,330-332 nine were unblinded,125,324-327,330,332-334 two failed to report the method 

of double-blinidng,328,331 and five trials did not describe the reasons for dropouts.324,326,330-332

Summary Matrix 10: Omega-3 fatty acids and growth parameters of term infants 

Study Quality

A B C 

Author Year n Author Year N Author Year n 

I AuestadA

AuestadA 2001 

2001 

239 

165 

AuestadU 1997 274 InnisU 1997 238 

Author Year n Author Year N Author Year n

II 

LucasA 

MakridesA

BirchA 

1999 

2000 

2002 

447 

176

65 

BirchU 

WillattsU 

MorrisU 

HoffmanA 

1999 

1998 

2000 

2003 

79 

40 

140 

68 

PonderU 

MakridesU 

JensenU 

1992 

1995 

1997 

43 

89 

80 

Applicability 

Author Year n Author Year N Author Year n

III MakridesA 1999 146 DecsiU 

JorgensenU 

LapilloneU 

1995 

1998 

2000 

22 

39 

24 

n = number of allocated/selected participants; RCT = AAdequate vs UUnclear allocation concealment; I Inadequate

Qualitative synthesis of individual study results 

The most frequently investigated outcomes across the included studies were infant weight, 

length, and HC, expressed as mean (SD), normalized z-score or gain over time. 

Most of the studies failed to find a statistical difference between groups in the growth 

patterns at any time point. However, some differences were detected in five trials. 

Only the study of Lapillonne et al. found that infants’ HC at 4 months in the placebo group 

was significantly larger than that in both breast and treatment formula groups.267 

Infant length and weight were not statistically different among the three feeding groups.267 

Makrides et al., who compared growth parameters among three randomized groups, did not find 

statistically significant differences in weight, length, or HC at any age up to 2 years, even after 

adjusting for gender, GA, and postnatal age at assessment.205 When growth parameters were 

compared between the two treatment formula and the breastfed infant groups, investigators 

found that breastfed babies were significantly shorter and lighter than infants in the DHA+AA 

and DHA+EPA groups at 34 weeks and 12 months of age. These differences did not reach 

statistical significance at 2 years of age.205 

Decsi et al., who randomized two groups of infants to receive either placebo or treatment 

formula, did not find a statistically significant difference between the groups regarding gain of 

weight, length, or HC at 4 months of age.261 
116

The Makrides et at. study, which compared growth parameters in two randomized groups 

receiving placebo and treatment formulas, did not find any statistically significant difference in 

weight, length, or HC at 30 weeks of age.262

Three out of four RCTs describing the use of ALA as a source of omega-3 FAs, failed to find 

any significant difference in growth parameters among the randomized groups receiving either 

placebo or treatment formula(s). The weight, length, and HC of infants were similar at 4 and 8 

weeks of age in the study of Ponder et al.,260 at 6, 16, and 34 weeks of age in the study of 

Makrides et al.266 and at 3 months of age in the Innis et al. study.263 Only one trial showed 

significantly lower weight at 120 days of age in the group of infants receiving the highest ALA 

intake, or the lowest LA/ALA ratio (LA [15.6wt%] and ALA [3.2wt%]), compared with the 

group receiving the lowest ALA, or highest LA/ALA ratio (LA [17.6wt%] and ALA 

[0.4wt%]).203 These results were obtained after adjusting for differences in birth weight, gender, 

and ethnicity. In Makrides et al.’s study, where newborn babies were randomized to receive 

formula with an LA:ALA of either 10:1 or 5:1, there were no significant differences in weight, 

length, and HC gain between the two groups, although breastfed infants had significantly lower 

weight and length gain at 16 and 34 weeks of age than infants in the two formula fed groups.266

Other growth outcomes assessed were triceps skinfold thickness, subscapular skinfold 

thickness, and mid-arm circumference. Five studies did not find a significant difference between 

groups in triceps skinfold thickness and subscapular skinfold thickness among the randomized 

study groups at any time point.182,203,223,265,269 Morris et al. randomized infants to receive either 

standard formula or the treatment formula with added DHA and found that subscapular skinfold 

thickness at 6 weeks and 3 months of age was significantly higher in the control group compared 

with the trial group, althought these differences were not evident at 6 months or at 1 year of 

age.268 

Four studies measured the correlation between the plasma or RBC PUFAs and growth 

outcomes.203,205,262,263 Two studies did not find a significant correlation between the omega-3 FA 

in plasma or RBC and the weight.203,262 However, Jensen et al. observed a significant positive 

correlation between weight at 4 months and the plasma AA content at the same time.203 Innis et 

al., on the contrary, did not find a correlation between growth patterns and the plasma and RBC 

AA content in term infants.263 

Makrides et al. found a significantly negative correlation between plasma DHA at 16 weeks 

and weight at 12 and 24 months of age.205

Quantitative synthesis

At 4 months of age, growth pattern outcomes were noted in 13 studies. However, only four 

studies included treatment groups of both DHA+AA and placebo.104,182,205,227 For Auestad et 

al.’s first study,227 data on weight, length, and HC could not be extracted; although partially 

reported in the text for statistically significant differences, the sample sizes were not given, and 

the weight gains were reported in grams/day. The figure provided growth data by sex at 

different follow-up times, but no sample sizes were indicated. For the Birch et al. 1998 study,182

standardized weight and length were reported in a boxplot figure using z-scores, thus it was not 
117

possible to obtain unstandardized growth measures. This left only two studies for metaanalysis.104,205 Both trials assessed the growth parameters as primary outcomes. 

Figure 7. Child term growth 4 months DHA+AA vs. control. Meta-analysis was performed using the 

random effects weighted mean difference. 

Review: term growth at 4 month

Comparison: 02 DHA+AA vs. control 

Outcome: 01 Weight 

Study Treatment Control WMD (random) Weight WMD (random)

or sub-category N Mean (SD) N Mean (SD) 95% CI % 95% CI

Auestad 1997 46 6.75(0.85) 45 7.00(0.80) 51.58 -0.25 [-0.59, 0.09] 

Makrides 1999 24 6.65(0.73) 22 6.50(0.53) 48.42 0.15 [-0.22, 0.52] 

Total (95% CI) 70 67 100.00 -0.06 [-0.45, 0.34]

Test for heterogeneity: Chi2 = 2.47, df = 1 (P = 0.12), I2 = 59.4%

Test for overall effect: Z = 0.28 (P = 0.78)

 -4 -2 0 2 4

 Favours control Favours treatment

Review: term growth at 4 month

Comparison: 02 DHA+AA vs. control 

Outcome: 02 Length 

Study Treatment Control WMD (random) Weight WMD (random)

or sub-category N Mean (SD) N Mean (SD) 95% CI % 95% CI

Auestad 1997 46 62.70(2.30) 45 63.15(1.85) 74.03 -0.45 [-1.31, 0.41] 

Makrides 1999 24 62.60(2.50) 22 62.60(2.50) 25.97 0.00 [-1.45, 1.45] 

Total (95% CI) 70 67 100.00 -0.33 [-1.07, 0.40]

Test for heterogeneity: Chi2 = 0.28, df = 1 (P = 0.60), I2 = 0%

Test for overall effect: Z = 0.89 (P = 0.38)

 -4 -2 0 2 4

 Favours control Favours treatment

The WMD in the weight (kg) and length (cm) (DHA+AA vs. control) in two studies104,205

was nonstatistically significant at 4 months. For weight: WMD: -0.06, CI 95%: -0.45; 0.34. For 

length: WMD: -0.33, CI 95%: -1.07; 0.40.

Figure 8. Meta-analysis: Child term growth 4 months DHA vs. control. Meta-analysis was performed 

using the random effects weighted mean difference. 

Review: term growth at 4 month

Comparison: 01 DHA vs. control 

Outcome: 01 Weight 

Study Treatment Control WMD (random) Weight WMD (random)

or sub-category N Mean (SD) N Mean (SD) 95% CI % 95% CI

Auestad 1997 43 6.70(1.00) 45 7.00(0.80) 45.71 -0.30 [-0.68, 0.08] 

Makrides 1999 25 6.53(0.65) 25 6.50(0.53) 54.29 0.03 [-0.30, 0.36] 

Total (95% CI) 68 70 100.00 -0.12 [-0.44, 0.20]

Test for heterogeneity: Chi2 = 1.66, df = 1 (P = 0.20), I2 = 39.7%

Test for overall effect: Z = 0.74 (P = 0.46)

 -4 -2 0 2 4

 Favours control Favours treatment

Review: term growth at 4 month

Comparison: 01 DHA vs. control 

Outcome: 02 Length 

Study Treatment Control WMD (random) Weight WMD (random)

or sub-category N Mean (SD) N Mean (SD) 95% CI % 95% CI

Auestad 1997 43 62.70(2.80) 45 63.15(1.85) 59.93 -0.45 [-1.45, 0.55] 

Makrides 1999 25 62.20(1.60) 22 62.60(2.50) 40.07 -0.40 [-1.62, 0.82] 

Total (95% CI) 68 67 100.00 -0.43 [-1.20, 0.34]

Test for heterogeneity: Chi2 = 0.00, df = 1 (P = 0.95), I2 = 0%

Test for overall effect: Z = 1.09 (P = 0.27)

 -4 -2 0 2 4

 Favours control Favours treatment
118

Review: term growth at 4 month

Comparison: 01 DHA vs. control 

Outcome: 03 Head circumference 

Study Treatment Control WMD (random) Weight WMD (random)

or sub-category N Mean (SD) N Mean (SD) 95% CI % 95% CI

Auestad 1997 43 41.87(1.03) 45 42.00(1.10) 59.69 -0.13 [-0.58, 0.32] 

Makrides 1999 25 41.80(0.90) 22 41.50(1.10) 40.31 0.30 [-0.28, 0.88] 

Total (95% CI) 68 67 100.00 0.04 [-0.37, 0.46]

Test for heterogeneity: Chi2 = 1.33, df = 1 (P = 0.25), I2 = 24.8%

Test for overall effect: Z = 0.21 (P = 0.84)

 -4 -2 0 2 4

 Favours control Favours treatment

The WMD in the weight (kg), length (cm) and HC (cm) (DHA vs. control) in two 

studies104,205 was nonstatistically significant at 4 months. For weight: WMD: -0.12, CI 95%: -

0.44; 0.20. For length: WMD: -0.43, CI 95%: -1.20; 0.34. For HC: WMD: 0.04, CI 95%: -0.37; 

0.46. 

Figure 9. Meta-analysis: Child term growth 12 months DHA+AA vs. control. Meta-analysis was 

performed using the random effects weighted mean difference

Review: term growth at 12 month

Comparison: 02 DHA+AA vs. control 

Outcome: 01 Weight 

Study Treatment Control WMD (random) Weight WMD (random)

or sub-category N Mean (SD) N Mean (SD) 95% CI % 95% CI

Auestad 1997 43 10.15(1.35) 45 10.25(0.75) 59.13 -0.10 [-0.56, 0.36] 

Makrides 1999 24 9.96(1.11) 21 10.62(1.13) 40.87 -0.66 [-1.32, 0.00] 

Total (95% CI) 67 66 100.00 -0.33 [-0.87, 0.21]

Test for heterogeneity: Chi2 = 1.88, df = 1 (P = 0.17), I2 = 46.7%

Test for overall effect: Z = 1.19 (P = 0.23)

 -4 -2 0 2 4

 Favours control Favours treatment

Review: term growth at 12 month

Comparison: 02 DHA+AA vs. control 

Outcome: 02 Length 

Study Treatment Control WMD (random) Weight WMD (random)

or sub-category N Mean (SD) N Mean (SD) 95% CI % 95% CI

Auestad 1997 46 75.20(2.50) 45 75.80(2.95) 62.49 -0.60 [-1.72, 0.52] 

Makrides 1999 21 77.00(2.40) 21 77.00(2.40) 37.51 0.00 [-1.45, 1.45] 

Total (95% CI) 67 66 100.00 -0.37 [-1.26, 0.51]

Test for heterogeneity: Chi2 = 0.41, df = 1 (P = 0.52), I2 = 0%

Test for overall effect: Z = 0.83 (P = 0.41)

 -4 -2 0 2 4

 Favours control Favours treatment

Review: term growth at 12 month

Comparison: 02 DHA+AA vs. control 

Outcome: 03 Head circumference 

Study Treatment Control WMD (random) Weight WMD (random)

or sub-category N Mean (SD) N Mean (SD) 95% CI % 95% CI

Auestad 1997 46 46.50(1.20) 45 46.80(1.20) 55.62 -0.30 [-0.79, 0.19] 

Makrides 1999 21 47.60(1.50) 21 46.90(1.20) 44.38 0.70 [-0.12, 1.52] 

Total (95% CI) 67 66 100.00 0.14 [-0.83, 1.12]

Test for heterogeneity: Chi2 = 4.18, df = 1 (P = 0.04), I2 = 76.1%

Test for overall effect: Z = 0.29 (P = 0.77)

 -4 -2 0 2 4

 Favours control Favours treatment

The WMD in the weight (kg), length (cm) and HC (cm) (DHA+AA vs. control) in two 

studies104,205 was nonstatistically significant at 12 months. For weight: WMD: -0.33, CI 95%: -

0.87; 0.21. For length: WMD: -0.37, CI 95%: -1.26; 0.51. For HC: WMD: 0.14, CI 95%: -0.83; 

1.12. 
119

Figure 10. Meta-analysis: Child term growth 12 months DHA vs. control. Meta-analysis was 

performed using the random effects weighted mean difference.

Review: term growth at 12 month

Comparison: 01 DHA vs. control 

Outcome: 01 Weight 

Study Treatment Control WMD (random) Weight WMD (random)

or sub-category N Mean (SD) N Mean (SD) 95% CI % 95% CI

Auestad 1997 43 10.15(1.35) 45 10.25(0.75) 59.13 -0.10 [-0.56, 0.36] 

Makrides 1999 24 9.96(1.11) 21 10.62(1.13) 40.87 -0.66 [-1.32, 0.00] 

Total (95% CI) 67 66 100.00 -0.33 [-0.87, 0.21]

Test for heterogeneity: Chi2 = 1.88, df = 1 (P = 0.17), I2 = 46.7%

Test for overall effect: Z = 1.19 (P = 0.23)

 -4 -2 0 2 4

 Favours control Favours treatment

Review: term growth at 12 month

Comparison: 01 DHA vs. control 

Outcome: 02 Length 

Study Treatment Control WMD (random) Weight WMD (random)

or sub-category N Mean (SD) N Mean (SD) 95% CI % 95% CI

Auestad 1997 46 75.80(2.95) 45 75.80(2.95) 52.49 0.00 [-1.21, 1.21] 

Makrides 1999 24 75.50(2.30) 21 77.00(2.40) 47.51 -1.50 [-2.88, -0.12] 

Total (95% CI) 70 66 100.00 -0.71 [-2.18, 0.76]

Test for heterogeneity: Chi2 = 2.56, df = 1 (P = 0.11), I2 = 61.0%

Test for overall effect: Z = 0.95 (P = 0.34)

 -4 -2 0 2 4

 Favours control Favours treatment

Review: term growth at 12 month

Comparison: 01 DHA vs. control 

Outcome: 03 Head circumference 

Study Treatment Control WMD (random) Weight WMD (random)

or sub-category N Mean (SD) N Mean (SD) 95% CI % 95% CI

Auestad 1997 43 46.80(1.30) 45 46.80(1.20) 62.53 0.00 [-0.52, 0.52] 

Makrides 1999 24 46.80(1.10) 21 46.90(1.20) 37.47 -0.10 [-0.78, 0.58] 

Total (95% CI) 67 66 100.00 -0.04 [-0.45, 0.38]

Test for heterogeneity: Chi2 = 0.05, df = 1 (P = 0.82), I2 = 0%

Test for overall effect: Z = 0.18 (P = 0.86)

 -4 -2 0 2 4

 Favours control Favours treatment

The WMD in the weight (kg), length (cm) and HC (cm) (DHA vs. control) in two 

studies104,205 was nonstatistically significant at 12 months. For weight: WMD: -0.33, CI 95%: -

0.87; 0.21. For length: WMD: -0.71, CI 95%: -2.18; 0.76. For HC: WMD: -0.04, CI 95%: -0.45; 

0.38. 

Impact of covariates and confounders 

In most of the RCTs there was no evidence that randomization failed to produce comparable 

groups, with the exception of HC.268 In the study of Morris et al., two randomized groups had 

similar characteristics at recruitment, except for a small difference in mean HC which just 

reached statistical significance.268 In the study of Jorgensen et al., within the formula groups 

there was a borderline statistical difference in birth weight in favor of the group supplemented 

with only DHA.264 Jorgensen et al.264 and Auestad et al.227 also reported that maternal age of 

infants assigned to breast milk was significantly higher than that in the randomized formula-fed 

groups. In the study of Auestad et al., infants in the breastfed group also had a higher GA, a 

smaller percentage of mothers having no postsecondary education, and a smaller prevalence of 

smoking exposures both in utero and in the houshold.227 

Four studies controlled the growth outcomes for potential confounders such as gender, 

maternal education, center, and socioeconomic status.203,205,263,266 No differences were found 

after adjusting for these covariates. 
120

The power calculation was reported in eleven trials,120,124,132,151,325,329,331,333-335 while the 

intention-to-treat analysis approach was reported in only one study.132

Growth Pattern Outcomes in Light of Biomarker Data 

What is the Evidence That Term or Preterm Human Infants’ Growth 

Patterns Are Associated With the Omega-3 or Omega-6/Omega-3 Fatty 

Acid Content of Child Biomarkers? 

A total of 12 studies were identified to address this question. The results of six RCTs of 

preterm infants were described previously in this section (see key question: Growth PatternsPreterm Infant Formula Intake),185,191,201,207,212,225 as well as the results of four RCTs that 

included a term population of infants (see key question: Growth Patterns-Term Infant Formula 

Intake).203,205,262,263 Therefore, two studies will be addressed here—the RCT of Guesnet et al.143

and the prospective single cohort study of Innis et al.271 The studies were published in 1999 and 

2001, respectively. A summary of the study characteristics and outcomes relating to the current 

question are described in this section. (Summary Table 25) 

Overview of relevant study characteristics and results 

Guesnet et al. assessed growth patterns and their correlation with the plasma and RBC PUFA 

content after the use of three different formulas. Healthy term infants (n=68) were randomized 

to receive one of three formulas, supplemented with either DHA and EPA (high dose), DHA and 

EPA (low dose) or unsupplemented, for 6 weeks.143 It also included a group of infants who 

where breastfed, yet were nonrandomized. The formulas were provided by Gallia 1 (Bledina-sa, 

Groupe Danone, Villefranche-sur-saone, France).143

This study was conducted in France and supported by the Bledina-sa, Groupe Danon Paris, 

French Ministry of Cooperation in Mauritius and the University of Mauritius. 

Blood samples were collected from umbilical cord at birth and venipuncture at 6 weeks of 

age. There was no difference between groups in the growth paramenters at 6 weeks of age.143 

Innis et al. selected a cohort of 83 term infants who were exclusively breastfed, with birth 

weights ranging from 2,500 g to 4,500 g.271 The objective of the study was to measure the infant 

RBC DHA content and its association with visual, neuro or cognitive development.271 Infants 

were enrolled within 2 weeks of age and to be eligible, their mothers were required to intend to 

exclusively breastfeed their infant without providing infant formula or cow’s milk for at least 3 

months and without introducing solid foods for at least the first 4 months after birth. The infants 

were excluded if they had evidence of metabolic or physical abnormality, or if their mothers had 

substance abuse, metabolic or physiologic problems, or communicable diseases.271

Only one mother reported taking FA supplements with LA and DHA. The maternal diet was 

not reported or controlled. Only five mothers reported being smokers during the study. Infant 

measures of weight, length and HC were correlated with the RBC DHA and AA content at birth, 

2, 4, 6, 9 and 12 months of age.271
121

Multiple linear regression analysis was used to determine the impact of the FA variables on 

the outcomes. The analysis controlled statistically for the duration of breastfeeding, maternal 

education, family income, gender, maternal smoking, birth order and birth weight, length and 

HC.271

Summary Table 25: Association between growth patterns and biomarker content in infants 

Study groups1

 

Author, Year, 

Location: 

Design 

Group 1 

(n)/ 

Group 4 

(n)

Group 2 

(n)/ 

Group 3 

(n) Notable associations2,3 

Internal 

validity Applicability 

Guesnet, 1999, 

France: 

6 wk parallel 

RCT143

High-EPA 

(n=23)/ 

HM 

(n=15) 

Low-EPA 

(n=24)/ 

pb 

(n=21) 

S (-) correlation between ∆ L & 

plasma & RBC EPA at birth 

Jadad 

total: 2 

[Grade: C]; 

Schulz: 

Unclear 

III 

Innis, 2001, 

Canada: 

prospective 

single cohort271

Term 

breastfed 

infants 

(n=83) 

n/a RBC CPG DHA++ & EPG DHA+

negative correlation with infant 

weight (6 mo); no correlation at 

12 mo; no correlation of blood 

AA & growth patterns at any 

age 

Quality 

score: 8 

[Grade A] 

III 

1

biomarkers = EPA, DHA, AA, AA/EPA, AA/DHA, AA/EPA+DHA; n-3 = omega-3 fatty acids; n-6 = omega-6 

fatty acids; ALA = alpha linolenic acid; DHA = docosahexaenoic acid; EPA = eicosapentaenoic acid; AA = 

arachidonic acid; n = sample size; pts = study participants; NR = not reported; S = statistically significant 

difference; NS = nonsignificant statistical difference; N/A = not applicable; pb = placebo; grp = group; wk = 

week(s); mo = month; RBC = red blood cells; PL = phospholipid; CPG = choline phosphoglycerides; EPG = 

ethanolamine phosphoglycerides; ∆ = change; L = length; +

p<.05 or significant with 95% confidence interval; ++p<.01; +++p<.001; ++++p<.0001; Ï = increase; Ð = decrease/reduction; HM = human milk; L = length 

Guesnet et al. observed a negative correlation between postnatal gains in length and the EPA 

concentration at birth in total plasma PL and in RBC PE. 

Innis et al. found that the RBC choline phosphoglyceride (CPG) DHA and the ethanolamine 

phosphoglycerides (EPG) DHA, but not the plasma DHA, were significantly inversely related to 

infant weight at 6 months of age, but not at 12 months. There was no significant relation 

between infant blood lipid concentrations of AA and growth at any age.271

Study quality and applicability. Guesnet et al. had a Jadad’s total score of 2 (did not report 

method of randomization and was unblinded) and an unclear allocation concealment.143 Innis et 

al. had a quality score of 8 and a level of applicability of III.271 (Summary Matrix 11) 

Summary Matrix 11: Association between growth patterns and biomarker content in infants

Study Quality

A B C 

I Author Year n Author Year N Author Year n 

Author Year n Author Year N Author Year n II 

Author Year n Author Year N Author Year n

Applicability 

III Innis 2001 83 GuesnetU 1999 68 

n = number of allocated/selected participants; U = unclear allocation concealment
122

Neurological Development Outcomes 

What is the Evidence That Maternal Intake of Omega-3 Fatty Acids 

During Pregnancy Influences Neurological Development in Term or 

Preterm Human Infants? 

One RCT, published in 2001, was identified to answer this question.141 Helland et al. had 

two publications related to the same study population.141,200 (Summary Table 26) 

Overview of relevant study characteristics and results 

Helland et al.,141 has been described in detail in the Pregnancy Outcomes and Growth Pattern 

Outcomes sections (see key questions: Duration of Gestation, Infants Small for Gestational Age, 

and Maternal Intake/Growth Patterns). A summary and the results relating to the current 

question are discussed here. 

Helland et al. assessed the gestational length, birth weight, and neurologic and cognitive 

outcomes in a sample of 590 healthy pregnant women. They were randomized to receive 10 ml 

of cod liver oil (1,183 mg DHA, 803 mg EPA) or corn oil (LA and ALA) from week 18 of 

pregnancy to 3 months post delivery.141 They should not have taken any supplements of omega3 FA earlier during the pregnancy. The exclusion criteria were premature births, birth asphyxia, 

infections, and anomalies in the infants that required special attention.141 The neurological 

outcomes assessed was the electroencephalogram (EEG) recordings of the included infants to 

evaluate brain maturity. EEGs were performed at 1 day of life and repeated at 3 months of 

age.141 Helland et al. had a high rate of dropouts, leaving 341 women in the final analysis 

(57%).288

Summary Table 26: Influence of omega-3 fatty acids intake during pregnancy on neurological development of 

their infants 

Study groups1 

Author, Year, 

Location: 

Design 

Group 1 

(n)/ 

Group 4 

(n)

Group 2 

(n)/ 

Group 3 

(n) Notable clinical effects

Internal 

validity Applicability 

Helland, 2001, 

Norway: 

34 wks 

parallel RCT141

Cod liver 

oil 

DHA+EPA 

(n=301) 

Corn oil 

LA+ALA 

(n=289) 

NS EEGs scores between 

groups (3 mo) 

Jadad total: 

4 [Grade: 

A]; 

Schulz: 

Unclear 

III 

1

biomarkers = EPA, DHA, AA, AA/EPA, AA/DHA, AA/EPA+DHA; n-3 = omega-3 fatty acids; n-6 = omega-6 

fatty acids; ALA = alpha linolenic acid; DHA = docosahexaenoic acid; EPA = eicosapentaenoic acid; AA = 

arachidonic acid; E-EPA = ethyl eicosapentaenoate; n = sample size; pts = study participants; NR = not 

reported; NS = nonsignificant statistical difference; N/A = not applicable; grp = group; wk = week(s); mo = 

month; RBC = red blood cells; PL = phospholipid; +

p<.05 or significant with 95% confidence interval; ++p<.01; 

+++p<.001; ++++p<.0001; Ï = increase; Ð = decrease/reduction; EEG = electroencephalogram 

There were no differences between groups in maturity as evaluated from the EEGs, neither at 

day 1 of life nor at 3 months of age.141
123

Between neonates with mature (score 1; n=70) and immature EEG scores (score 2 and 3; 

n=51), there were significant differences in umbilical plasma phospholipid levels of EPA, DPA 

and DHA at the 2nd day of life. At 3 months, there were no significant differences in plasma 

phospholipid levels between those with mature and immature EEGs.141

Study quality and applicability. Helland et al. received a Jadad total quality score of 4 (did 

not report method of double-blinding), indicating good internal validity. However, the allocation 

concealment was unclear. The applicability was scored with III, since the Norwegian population 

has a significantly higher intake of LCPUFA from marine sources compared to the Nort 

American population. 

Summary Matrix 12: Influence of omega-3 fatty acids intake during pregnancy on neurological development 

of their infants 

Study Quality

A B C 

Author Year n Author Year N Author Year n I 

Author Year n Author Year N Author Year n II 

Author Year n Author Year N Author Year n

Applicability 

III HellandU 2001 590 

n = number of allocated/selected participants; RCT = AAdequate vs UUnclear allocation concealment

What is the Evidence That the Omega-3 Fatty Acid Content of 

Maternal Breast Milk, With or Without Known Maternal Intake of 

Omega-3 Fatty Acids, Influences Neurological Development in Term 

or Preterm Human Infants? 

One RCT and one single prospective cohort study were identified.138,284 They were 

published between 1997 and 2001. (Summary Table 27) 

Overview of relevant study characteristics and results 

Gibson et al. was a double-blind RCT that investigated the effect of maternal intake of 

omega-3 FAs on breastfed infant’s neurological and visual function outcomes in Australia.138 

This study included mothers of term infants (>37 weeks of GA) who intended to breast feed for 

at least 12 weeks (n=52, means age: 30 [SD=4] years). These mothers were randomized to 

receive one of five doses of a DHA-rich algal oil (0, 0.2, 0.4, 0.9, 1.3 g DHA/day; DHASCO, 

Market Biosciences, MD, U.S.) between day 5 and week 12 postpartum. The oil contained 43% 

DHA, 1% omega-6 PUFA, 38% saturates and 18% monosaturates. Infants who were exclusively 

breastfed for 12 weeks were assessed. Infants (n=20) were healthy, appropriate weight for GA, 

and had Apgar scores greater than 7 at 5 minutes.138 

Infant’s visual function was assessed using visual evoked potentials (VEP) (logMAR) at 12 

and 16 weeks of life.138 Global development (Bayley’s Scales of Infant development) was 

assessed at 1 and 2 years of age. From Bayley Scales of Infant Development, the psychomotor 
124

developmental index (PDI) was derived. PDI assesses the control of gross and fine muscle 

groups, including walking, running, jumping, comprehension, use of writing implements, and 

imitation of hand movements. Mothers were from middle class families and completed year 12 

of education. The five groups were compared in terms of maternal age, maternal BMI, GA, 

infant gender, birth weight, birth length, birth HC, Apgar score, siblings, maternal social score, 

smoking, education, home stimulation, and length of breast feeding, at baseline. There was a 

predominance of boys in the group that received the highest dose of DHA.138 

Agostoni et al. evaluated the neurodevelopmental indices at 1 year of age in a single 

prospective cohort of term infants (n=44; 54.5% males) who were exclusively breastfed for at 

least 3 months in Italy.284 The children received breast milk for at least 3 months, after which 

weaning foods were introduced to all infants. Infants underwent clinical examination at 0, 1, 3, 

6, 9 and 12 months of age.284 

The mother’s milk lipid composition was determined at each time-point. The day before, the 

control pooled milk was collected from all feedings over 24 hours. There was a progressive 

reduction of the number of breastfed infants to n=29 at 6 months, n=17 at 9 months and n=10 at 

1 year.284 

Summary Table 27: Omega-3 fatty acid content of maternal breast milk, with or without known maternal 

intake of omega-3 fatty acids, influences neurological development in term or preterm human infants 

Study groups1 

Author, Year, 

Location: 

Design 

Group 1 

(n)/ 

Group 4 

(n)

Group 2 

(n)/ 

Group 3 

(n) Notable clinical effects

Internal 

validity Applicability 

Gibson, 1997, 

Australia: 

12 wk parallel 

RCT138

1.3 g/d 

DHA 

(n=8)/ 

0.2 g/d 

DHA 

(n=10) 

0.9 g/d 

DHA 

(n=10)/ 

0.4 g/d 

DHA 

(n=12)/ 

pb 

(n=12) 

NS in PDI at 12 mo and 24 mo 

No correlation of 

sociodemographics & PDI at 1 y 

Positive correlation between 

level of education of partner & 

PDI+ 

Jadad total: 

3 [Grade: 

B]; 

Schulz: 

Unclear 

II 

Agostoni, 2001, 

Italy: 

Single 

prospective 

cohort284

Term 

breastfed 

infants at 

1 y-old 

(n=44) 

n/a NS correlation between Bayley’s 

PDI & length of BF 

NS correlation between Bayley’s 

PDI & milk FA content 

Quality 

score: 8 

[Grade A] 

III 

1

biomarkers = EPA, DHA, AA, AA/EPA, AA/DHA, AA/EPA+DHA; n-3 = omega-3 fatty acids; n-6 = omega-6 

fatty acids; ALA = alpha linolenic acid; DHA = docosahexaenoic acid; EPA = eicosapentaenoic acid; AA = 

arachidonic acid; E-EPA = ethyl eicosapentaenoate; n = sample size; pts = study participants; NR = not 

reported; NS = nonsignificant statistical difference; N/A = not applicable; grp = group; wk = week(s); mo = 

month; RBC = red blood cells; PL = phospholipid; PDI = psychomotor developmental index; +

p<.05 or 

significant with 95% confidence interval; ++p<.01; +++p<.001; ++++p<.0001; Ï = increase; Ð = 

decrease/reduction; BF = breast feeding; PDI = Bayley’s psychomotor scale 

The mean PDI score was similar in infants between dietary groups at 1 and 2 years of age in 

Gibson et al. study.138 There were no associations with any sociodemographic variables at 1 

year. The only association at 2 years of age was between PDI and the level of education of the 

partner (r

2

=0.10; adjusted r

2

=0.08, p<0.05).138
125

In Agostoni et al., the mean PDI in 1-year old infants, was 92 (SD=11.3).284 After correcting 

for potential confounders such us parity and mother’s characteristics (i.e., age, education, 

smoking habits), breast feeding for 6 months or longer was not significantly correlated to the 

mean PDI result compared with subjects breastfed for 3 to 6 months (n=15).284 Associations 

between PDI and milk fat content and composition were measured with a multiple regression 

analysis. There was no correlation between PDI and the milk fat content at any time-point.284

Study quality and applicability. Gibson et al. obtained a Jadad total quality score of 3 (did 

not report methods of randomization and double-blinding), indicating sound internal validity.336 

However, the allocation concealment was unclear. The applicability level was II for Gibson et al. 

and III for Agostoni et al.337

Summary Matrix 13: Omega-3 fatty acid content of maternal breast milk, with or without known maternal 

intake of omega-3 fatty acids, influences neurological development in term or preterm human infants

Study Quality

A B C 

Author Year n Author Year N Author Year n I 

Author Year n Author Year N Author Year n II 

 GibsonU 1997 52 

Author Year n Author Year N Author Year n

Applicability 

III Agostoni 2001 44 

n = number of allocated/selected participants; RCT = AAdequate vs UUnclear allocation concealment

What is the Evidence That the Omega-3 Fatty Acid Content of Infant 

Formula Influences Neurological Development in Term or Preterm 

Human Infants? 

What is the Evidence That the Omega-3 Fatty Acid Content of 

Maternal Breast Milk, With or Without Known Maternal Intake of 

Omega-3 Fatty Acids, and Together With the Omega-3 Fatty Acid 

Content of Infant Formula, Influences Neurological Development in 

Term or Preterm Human Infants? 

Infant Formula Intake—Preterm Infants 

Six RCTs, published between 1999 and 2004, met eligibility criteria.193,207,254,258,272,273 Five 

trials were summarized in the Growth Pattern Outcomes section (see key question: Growth 

Patterns-Preterm Infants Formula Intake).310,311,319,321,322 (Summary Table 28) 

Overview of relevant studies 

van Wezel-Meijler et al. studied the influence of supplemented formula with DHA and AA 

on brain maturation in preterm infants and investigated parameters of functional brain 

development, including cognitive development.272 (Summary Table 36) 
126

Summary Table 28: Omega-3 fatty acids and its influence on neurological development in preterm infants 

Study groups1 Author, 

Year, 

Location: 

Length & 

Design 

Group 1 

(n)/ 

Group 4 

(n)

Group 2 

(n)/ 

Group 3 

(n) Notable clinical effects

Internal 

validity Applicability 

Bougle, 

1999, 

France: 

30 d 

parallel 

RCT254

AA+EPA+ 

DHA formula 

(n=14) 

LA (n-6)+ ALA 

(n-3) formula 

(n=11)/ HM 

(n=15) 

NS LAEP between d 0 & 

30d 

SÏ ∆ motor NCT (m/s) in 

DHA/EPA/AA 

supplemented formula & 

HM from d0-30+

NS ∆ sensory (m/s) test

Jadad total: 3 

[Grade: B]; 

Schulz: Unclear 

III 

O’Connor, 

2001, US, 

UK, Chile: 

12 mo 

parallel 

RCT207

DHA+AA 

(fish/fungal) 

(n=140)/ HM 

(n=43) 

DHA+AA (eggTG/fish) 

(n=143)/ 

Control 

formula 

(n=144) 

(ITT) SÏ PDI score in 

<1250 g birth wt fed 

AA+DHA (egg-TG/fish) 

than control infants++ NS 

score control or AA+DHA 

(fish/fungal) groups 

Jadad total: 3 

[Grade: B]; 

Schulz: Unclear 

I 

van WezelMeijler,

2002, The 

Netherlands: 

6 mo, 

parallel 

RCT272

AA+DHA 

preterm formula 

(n=22) 

Control 

formula (n=20) 

SÏ PDI score 

unsupplemented group 

vs. supplemented 

formula at 3, 6, 12 & 24 

mo+ 

Jadad total: 5 

[Grade: A]; 

Schulz: 

Adequate 

III 

Fewtrell, 

2002, UK: 

33 d 

parallel 

RCT273

AA+DHA+EPA 

preterm formula 

(n=95)

Control 

formula 

(n=100)/ HM 

(n=88) 

(ITT) NS PDI score 

between formula gps at 

18 mo S Ï PDI in the 

HM group vs. both 

formula gps 

NS between formula gps 

in KPSDSI at 9 mo; HM 

S Ï quotient vs. 

formulas 

Jadad total: 5 

[Grade: A]; 

Schulz: 

Adequate 

II 

Clandinin, 

2002, 

Canada: 

92 wks 

parallel 

RCT193

DAS (DHA+AA 

from SCO) 

(n=72)/ HM 

(n=105)

DAF (DHA 

from fish 

oils+AA from 

SCO) (n=90)/ 

Control 

formula (n=83) 

SÏ PDI score formula 

gps (DAS, DAF) vs. 

control gp 

Not assessed X 

Fewtrell, 

2004, UK: 

9 mo 

parallel 

RCT258

GLA+ DHA 

formula (n=122)

Control 

formula 

(n=116) 

(ITT) NS formula groups 

in Bayley’s PDI scores at 

18 mo 

Jadad total: 5 

[Grade: A]; 

Schulz: 

Adequate 

II 

1

Proceeding from highest omega-3, or lowest omega-6/omega-3, fatty acid content of intervention/exposure; n-3 = 

omega-3 fatty acids; n-6 = omega-6 fatty acids; ALA = alpha linolenic acid; DHA = docosahexaenoic acid; EPA = 

eicosapentaenoic acid; AA = arachidonic acidLength = intervention length; Design = research design; n = sample size; 

pts = study participants; NR = not reported; S = statistically significant difference; NS = nonsignificant statistical 

difference; n/a = not applicable; grp = group; wk = week(s); mo = month; wt = weight; +

p<.05 or significant with 95% 

confidence interval; ++p<.01; +++p<.001; ++++p<.0001; ITT = intention-to-treat analysis; PP = per-protocol analysis (e.g., 

completers); Ï = increase; Ð = decrease/reduction; NCT = nerve conduction test; LAEP = latency auditory evoked 

potentials; SCO = single-cell oil; HM = human milk; TG = triglycerides 
127

Qualitative synthesis of relevant studies’ key characteristics

Study characteristics. Six parallel RCTs involving preterm infants were identified to 

address these questions.193,207,254,258,272,273 Five of the studies were published in English 

scientific journals, while one was published as an abstract.193 Bougle et al.’s study was 

conducted in France,254 both Fewtrell et al.’s studies were conducted in the U.K.,258,273 the 

van Wezel-Meijler et al. study was located in the Netherlands,272 Clandinin et al.’s study was 

conducted in Canada,193 and the O’Connor et al. study took place in the United States, United 

Kingdom and Chile.207 

Three studies involved three study arms comparing the use of supplemented and 

unsupplemented infant formula with the addition of a fourth reference standard group (i.e., 

human milk).193,207,254 Two RCTs compared only two study groups (i.e., formula with or without 

LCPUFA),258,272 whereas, another study also included a group using human milk as a reference 

standard.273

van Wezel-Meijler et al.272 and Fewtrell et al. (2002)273 were supported by a private source 

(Numico Research). Clandinin et al. was funded by Mead Johnson & Company 

(pharmaceutical-nutritional company),193 whereas, Fewtrell et al. (2004)258 was supported by 

H.J. Heinz Company (food company). O’Connor et al. and Bougle et al. did not report their 

funding source.207,254

Population characteristics. There were 1,228 preterm infants enrolled across the included 

studies that were randomized to receive the supplemented or control formulas. The sample sizes 

ranged from 25 to 470 participants. The mean age of the infants at randomization was not 

significantly different between study groups across five RCTs.207,254,258,272,273 Clandinin et 

al. did not report the age of their infants.193 The GA of the preterm infants was below 37 weeks 

across five studies,207,254,258,272,273 except for Clandinin et al. that also included VLBW 

term infants.193 The between-group difference in GA was not significant across the studies. 

In four studies, the proportion of male participants did not differ significantly between 

randomized groups,207,258,272,273 although two studies did not mention this information in their 

report.193,254 The range of males varied between 35%272 to 56%.207

O’Connor et al. was the only one to describe the racial composition of their participants, 

which was predominantly White.207 The rest of the studies failed to provide the race and/or 

ethnicity of their subjects. 

Other variables like birth weight, proportion of SGA infants, percentage from multiple 

pregnancies, and Apgar score at birth, were nonstatistically different between groups in 

O’Connor et al.207 van Wezel-Meijler et al. matched their population by birth weight and 

proportion of SGA at baseline.272 Infants in both of Fewtrell et al.’s studies were well matched 

by birth weight and length, proportion of SGA, proportion from multiple pregnancies, and 

delivery by C-section at baseline.258,273 

Three of six studies analyzed the between-group difference of maternal covariates. 

O’Connor et al. matched their study groups by maternal age, education, smoking status during 

pregnancy and in the home, prenatal care, the HOME inventory score and maternal intelligence 

measured with WAIS-R Raw vocabulary score.207 The HOME Inventory Score was statistically 

different depending of the birth weight group—in infants <1,250 g, the control group had a 
128

higher score than infants in the AA+DHA (fish/fungal) group and in infants >1,250 g, the control 

group had a higher score than the AA+DHA (egg-TG/fish) group. Finally, the infants with a 

birth weight higher than 1,250 g in the AA+DHA (fish/fungal) group had a higher score than 

those in the AA+ DHA (egg-TG/fish) group.207

The inclusion criteria were described in every included study, however, exclusion criteria 

were not reported in two studies.193,273

The studies included mostly healthy preterm infants with a defined range of weight drawn 

from neonatal intensive care units (NICU). Bougle et al. included healthy preterm infants (<34 

weeks GA) free of respiratory, metabolic or neurological disease.254 O’Connor et al. selected 

preterm infants (<33 weeks GA) with a birth weight ranging from 750 g to 1,805 g, including 

singleton and twin births as well as SGA subjects, that could initiate enteral feeding by the 28th

day of life.207 van Wezel-Meijler et al. included premature infants (<34 weeks GA) with birth 

weight of <1,750 g, normal neurological examination throughout the neonatal period, normal 

repeated brain ultrasound or showing minor abnormalities such as isolated subependymal 

haemorrhage and subventricle, with no ventricular dilation, transient periventricular 

echodensities, without evolution into cysts or any combination of previous findings.272 Infants in 

the Fewtrell et al. (2002) trial had a GA below 37 weeks and a birth weight of <1,750 g, were 

free of congenital malformations known to affect neurodevelopment, and whose mothers decided 

not to breastfeed at 10 days of age.273 Fewtrell et al.’s (2004) preterm infants (GA <35 weeks) 

with birth weight ≤2,000 g received at least one of their enteral feeds as formula milk during 

their hospital stay.258 On the other hand, Clandinin et al. included VLBW term and preterm 

infants after their feeding reached 30 mL/kg/day.193

Three studies excluded infants with serious congenial abnormalities affecting growth and 

development, major surgery before randomization, perivenricular or intraventricular hemorrhage, 

maternal incapacity, liquid ventilation asphyxia resulting in severe and permanent neurologic 

damage, or uncontrolled systemic infection at the time of enrollment.207,258,272

The baseline characteristics of the patients in the Bougle et al. study were nonstatistically 

significant for the electrophysiological studies (i.e., motor and sensory nerve conduction studies, 

auditory evoked potentials).254

Only three trials measured the blood content of FAs at baseline.207,272 O’Connor et al. found 

a nonsignificant difference between groups in the plasma or RBC (lipid fractions) levels of AA 

and DHA.207 van Wezel-Meijler et al. observed the same finding.272 Bougle et al.’s plasma 

phospolipid composition of EPA was significantly lower in the low LCPUFA supplemented 

formula than in the DHA/EPA/AA supplemented formula and human milk.254 However, the 

RBC content of omega-3 and omega-6 did not differ between groups. The Bougle et al. study 

was the only one to describe the FA content in human milk i.e., 0.5% (SD 0.1) total FA DHA 

and ALA (omega-3) plus 0.9% (SD 0.2) total FA AA.254

None of the studies reported the presence of concurrent conditions in the study population 

and/or the use of medications. However, van Wezel-Meijler et al. reported that 13 patients were 

excluded from the analyses for the following reasons: necrotizing enterocolitis (n=2, 1 each 

group); chronic lung disease (n=3; n=2 DHA-AA vs n=1 control); grade 4 retinopathy of 

prematurity (n=1 AA+DHA); cystic periventricular leucomalacia (n=1 control); and, duration of 

artificial ventilation at baseline.272 No differences were found between groups.272 None of the 
129

studies included information regarding maternal concurrent conditions, medications or 

background diet, that could be relevant for the infants consuming breast milk. 

No other pre-study medications or treatments were mentioned in the included studies. The 

infants in the O’Connor et al. study were formula and/or human milk fed before study entry,207

whereas, van Wezel-Meijler et al.’s infants received parenteral nutrition using 

glucose/Vaminolact 6.75%/Intralipid 20% (Kabi-Fresenius, Stockohlm, Sweden) for an average 

of 12 to 17 days, from 24 hours after birth.272 This parenteral nutrition contained negligible 

amounts of LCPUFA. Three to 7 days after birth, enteral feeding was introduced using preterm 

formula (without LCPUFA). Total enteral nutrition was usually achieved within 2 to 3 weeks 

after birth.272

Intervention/exposure characteristics. The intervention groups in each trial received 

different types of supplemented infant formula, therefore, each study will be discussed 

separately. 

Bougle et al.’s small sample were randomized to receive a formula with 17.7% total FA of 

LA (omega-6), AA (0.1%), ALA (omega-3: 1.2%), EPA (0.1%) and DHA (0.6%), for at least 30 

days.254 

O’Connor et al. randomized their participants to receive one of three study formulas with or 

without the addition of LCPUFA until term CA. The intra-hospital preterm formula was a 

modified version of Similac Special Care ready-to-feed (Ross Products Division, Columbus, OH, 

U.S.) with or without AA- and DHA-enriched oils. At term CA, postdischarge nutrient-enriched 

formula (modified version of NeoSure powder) with and without the same sources of AA+DHA 

and/or human milk was given to the infants until 12 months CA.207 The first group received a 

supplemented formula with fungal and low-EPA fish oil (DHA/EPA ratio: 3.5/1) providing 0.27 

g DHA, 0.08 g EPA and 0.43 g AA (per 100 mL) in the Similac Special Care formula and 0.16 g 

DHA and 0.43 g AA in the NeoSure formula. In the other group, egg-tryglyceride (TG) and 

low-EPA fish oil provided 0.24 g DHA and 0.41 g AA to the Similac formula, but 0.15 g DHA 

to NeoSure. The purveyors of the fish, fungal and egg-TG oils were Mochida International 

(Japan), Suntory Ltd. (Japan) and Eastman Chemicals Co (U.S.), respectively. The duration of 

the treatment was until 12 months CA.207

In van Wezel-Meijler et al., the neonates were randomized to receive preterm liquid formula 

supplemented with (4.4 g/100mL fat) a 2/1 ratio of DHA (0.015 g/100mL [0.34% fat]) as 

DHASCO® oil produced by microalgae (Martek Inc., Columbia, U.S.) and AA (0.031 g/100 mL 

[0.68% fat] as ARASCO® oil produced by fungi (Martek Inc.). The formula was continued 

from enrollment until a weight of 3000 g was reached. Subsequently, this group continued with 

a supplemented term formula (3.5 g/100 mL fat) with a reduced absolute amount of DHA (0.012 

g/100 mL; 0.34% fat) and AA (0.025 g/100 mL; 0.70 % fat) until 6 months CA.272

Fewtrell et al. used a LCPUFA-supplemented preterm formula (n=95) (Prematil, Milupan) 

with fat blended from vegetable oils (palm coconut, soya, sunflower) and milk fat with derivates 

of LA and ALA sourced from evening primrose oil (GLA) and egg-lipids (AA [0.31 g/100 mL, 

DHA [017 g/100 mL], EPA [0.04 g/100mL]). Formula was provided as a ready-to-feed form for 

a mean of 31 days until neonatal unit care discharge.273
130

Clandinin et al. included two interventional groups. The first group (DAS group) received 17 

mg DHA plus 34 mg AA/100 Kcal from single cell oils (SCO) (n=72) as preterm formula (24 

Kcal oz), discharge formula (22 Kcal oz) and term formula (20 Kcal oz). The second group 

(DAF group) received the same formula as the DAS group but with 17 mg DHA/100 Kcal from 

fish oil and 34 mg AA/100 Kcal from single cell oils (n=90).193

Fewtrell et al.’s study 2004 study used a preterm infant formula supplemented with LCPUFA 

(OsterPrem with LCPUFA) until the infants were discharged from the NICU. Afterwards, a 

nutrient-enriched postdischarge formula was used (Farley’s PremCare with LCPUFA). The fat 

was a blend of vegetable oils (high oleic sunflower oil, palmolein, palm kernel oil, and canola 

oil). LCPUFAs were sourced from borage (starflower) oil (GLA [omega-6] 0.9 g/100 mL) and 

tuna fish oil (high DHA/EPA ratio: DHA 0.5 g/100 mL, EPA 0.1 g/100 mL, AA: 0.04 g/100 

mL). Formula was provided in ready-to-feed form during the hospital stay and in powdered 

form after discharge up to 9 months after CA.258

The studies compared the interventional formulas with unsupplemented infant formulas that 

were identical in appearance and smell,258,273 contained the same proportion of monosaturated 

and saturated FAs, and given to the infants during the same period of time as the intervention 

group. Bougle et al. compared the supplemented formula with a LA (omega-6) and ALA 

(omega-3) enriched formula.254

The studies did not provide information regarding background diet, when introduced, and the 

purity data the omega-3 supplements. No study report included details as to whether, or how, the 

presence of methylmercury was tested for, or eliminated from, the omega-3 FA exposure. 

Cointervention characteristics. Human milk was the reference standard group, either as a 

separate arm193,258,273 or as part of the formula groups that did not comply with the 

intervention.207 Bougle et al permitted the use of supplements, which contained dextrines, 

proteins and minerals during the study period. The patients received daily supplementation with 

1,200 IU of vitamin D and 4.5 mg of vitamin E (Uvesterol ADEC).254 Infant preterm and term 

formulas in the O’Connor et al. study contained beta-carotene and natural vitamin E.207 

Participants in both of Fewtrell et al.’s studies received an identical proportion of minerals and 

vitamins (A,D,E,K) in their formulas.258,273 

Outcome characteristics. Only one study performed electrophysiological studies at 

baseline and after treatment.254 This study measured the latencies of auditory evoked potentials 

(BAEP test), motor and sensory nerve conduction studies on the posterior tibial nerve and the 

flexor hallucis brevis muscle.254 

The Bayley’s PDI was assessed in five of six studies.193,207,258,272,273 O’Connor et al.’s 

average percent of agreement on scoring between site testers and central testers was 93% (range: 

73%-100%).207

The first Fewtrell et al. study utilized the Knobloch, Passamanick and Sherrard’s 

Developmental Screening Inventory (five subscales: adaptative, gross motor, fine motor, 

language and personal–social) to assess neurodevelopment at 9 months, as well as neurologic 

impairement at 9 and 18 months of followup (diagnosed by examining pediatrician).273

Study quality and applicability. Five RCTs received a mean Jadad total quality score of 

4.2, indicating a good internal validity (Summary Matrix 6). One abstract was not assessed.311 
131

Three trials received a score of 5,258,272,273 Bougle et al. and O’Connor et al. each received a 

score of 3.207,254 Bougle et al. failed to report the method of randomization and doubleblinding,319 while O’Connor et al. was unblinded.310 

Summary Matrix 14: Study quality and applicability of evidence for the effect of LCPUFA supplementation on 

the neurological development in preterm infants 

Study Quality

A B C 

Author Year n Author Year n Author Year n I O’ConnorU 2001 470 

Author Year n Author Year n Author Year n

II FewtrellA

FewtrellA 2002 2004 

283 

238 

Author Year n Author Year n Author Year n

Applicability 

III van WezelMeijlerA 2002 55 BougleU 1999 40 

n = number of allocated/selected participants; RCT = AAdequate vs UUnclear allocation concealment

Qualitative synthesis of individual study results 

The latencies of auditory evoked potentials (i.e., Wave I, Wave III, Wave V and I-V 

interpeak latency) difference between day 0 and day 30 were not significant in the study of 

Bougle et al.254 The change in the motor nerve conduction test (m/s) was significantly higher in 

the group receiving the DHA/EPA/AA-supplemented formula and in the human milk groups, 

from day 0 to day 30. However, the change in the sensory test (m/s) was nonsignificant during 

the same period.254

Five studies evaluated Bayley’s PDI after the administration of supplemented formula, 

unsupplemented formula, and/or human milk only (reference standard).193,207,258,272,273 In 

O’Connor et al., a statistically significantfeeding by birth weight stratum interaction was 

observed for Bayley PDI (p=0.005) among infants who consumed >80% of their feeding as study 

formula and/or human milk.207 

van Wezel-Meijler et al. observed a statistically significant higher PDI score for the 

unsupplemented group compared with supplemented formula group, at 3, 6, 12 and 24 

months.272 The first Fewtrell et al. study did not find a statistical difference between formula 

groups at 18 months. Although the human milk group was not randomized, since it was used as 

reference standard, the PDI was significantly higher in the breastfed group compared with both 

formula groups.273

Clandinin et al., using ANOVA analysis, found that the control group had a significantly 

lower PDI score than the formula groups (DAS, DAF) and the human milk group (reference 

standard).193 The second Fewtrell et al. study showed that there was a nonstatistical diference in 

Bayley’s PDI scores between formula groups at 18 months.258

Fewtrell et al. found that The Knobloch, Passamanick and Sherrard’s Developmental 

Screening Inventory scores (quotient) at 9 months did not differ significantly between the 

formula groups, whereas, the breastfed group had a significantly higher quotient compared with 
132

the formula groups.273 This study also failed to find a difference in neurological impairment 

between formula groups, at 9 and 18 months of followup.273

Bougle et al.’s cohort of healthy preterm infants had seven dropouts during the study. The 

main reasons were NEC (n=1) in the human milk group, hydrocephalus in the control formula 

group (n=5), and transfer to their referring hospital (n=3 human milk group, n=1 control, n=1 

supplemented formula group).254

O’Connor et al.’s had 94 withdrawals (80%) at 12 months CA.207 There was no statistical 

difference in the number of withdrawals between groups. The main reason for withdrawals was 

symptoms related to feeding intolerance. During the study 6 infants in the control group, 3 in the 

AA+DHA (fish/fungal) group, 6 in the AA+ DHA (egg-TG/fish) group, and none in the human 

milk groups, died. None of the infant deaths were related to study feedings.207

There were 13 dropouts in the van Wezel-Meijler et al. study.272 Reasons for withdrawal 

were: necrotizing enterocolitis; chronic lung disease; grade 4 retinopathy of prematurity; cystic 

periventricular leucomalacia; change from formula feeding to mother’s expressed milk; and, 

home-to-hospital distance. There were no losses to followup.272

In the first Fewtrell et al. study, six patients randomized to the control formula withdrew 

from the trial before 3 weeks for the following reasons: early discharge (<3 weeks of age; n=3); 

necrotizing enterocolitis (n=1); intolerance of feeds (n=1); and, breastfed (n=1).273 Fourteen 

infants withdrew in the supplemented formula group. Reasons for withdrawal were: early 

discharge (n=2); necrotizing enterocolitis (n=5); maternal concern (n=2); and, death(n=2).273 

There were 14 lost to follow up at 9 months in the control group, whereas, only one infant 

withdrew in the supplemented formula group and three in the human milk group. There were 

two deaths in the supplemented formula group and three in the human milk group.273 Clandinin 

et al. failed to report the dropouts.193 Fewtrell et al.’s reasons for dropouts were: in the control 

group—abdominal distention (n=1); death due to bronchopulmonary dysplasia at 25 days of age 

(n=1); and lost to follow up at 18 months (n=21).258 In the supplemented formula group, the 

reasons for dropouts were: necrotizing enterocolitis (n=1); and, lost to follow up at 18 months 

(n=15).258

Quantitative synthesis 

The inclusion criteria for meta-analysis in this population were: 1. Formula with same 

content of omega-3 FA supplements (e.g., DHA+ AA or DHA alone) compared with a control 

formula without omega-3 FA; 2. same outcome measure; 3. same follow-up period or timepoint 

of outcome measure; 4. at least two trials. Only five studies measured the Bayley’s 

Developmental Index (PDI). This outcome was chosen to evaluate the possibility of metaanalysis. However, outcome results were only available for more than one study at two followup times: CA 12 months and 18 months. At 12 months CA, outcomes were available for two 

studies.207,272 In Wezel-Meijler et al.,272 the experimental group received supplemented formula 

from the first enteral feeding time until 6 months CA. In O'Connor et al.,207 however, 

supplemented formula was used until 12 months CA. We would have combined data at 6 

months follow-up, however, this data was not available in O'Connor et al.207 Thus, metaanalysis was not possible for this outcome. 
133

Impact of covariates and confounders 

O’ Connor et al.’s Bayley’s PDI score in <1,250 g birth weight infants who strictly followed 

the feeding protocol was greater in infants fed AA+DHA (egg-TG/fish) than control infants, 

even after adjusting for a number of covariates including the HOME inventory, maternal WAISR, and human milk intake.207 The score did not differ statistically from either the control or 

AA+DHA (fish/fungal) groups. In an ITT and subgroup population analysis, the percentage of 

participants who had a significantly delayed motor performance did not differ statistically by 

study formula group.207 

In van Wezel-Meijler et al., after adjusting for birth weight and number of SGA infants, there 

was no difference in PDI between the groups.272

To explore the possible influence of maturity on the response to LCPUFA supplementation, 

the first Fewtrell et al. study stratified the cohort by GA (<30 weeks). Infants who had a GA <30 

weeks and received LCPUFA supplemented formula, had a Bayley PDI of 5.8 points higher than 

the control group, although the difference was nonsignificant.273 There were no differences in 

Bayleys PDI between supplemented and control groups with a GA >30 weeks.273 In this study, 

there was no significant interaction between formula and duration or volume of formula 

consumed on later outcome. At 18 months of age, breastfed infants had a significantly higher 

PDI score than formula groups. This result persisted after adjusting for effect modifiers (social 

class, level of maternal education, birth order and marital status).273

The second Fewtrell et al. study did not find a significant difference between groups when 

the PDI scores were adjusted by gender, GA and birth weight.258

The remaining studies did not report on the control for effect modifiers. 

The power calculation was reported in three trials,310,321,322 while the intention-to-treat 

analysis approach was reported in both Fewtrell et al.’s trials.321,322

Infant Formula Intake—Term Infants 

Eight unique parallel design RCTs met eligibility criteria. These trials were published 

between 1995 and 2003. Seven trials were described in the Growth Pattern Outcomes section 

(see key question: Growth Patterns-Term Infant Formula Intake).124,132,151,325,327,329 (Summary 

Tables 29-30) 

Overview of relevant studies 

All of the included studies evaluated the influence of supplemental omega-3 FA intake on 

neurological function of term infants. All but two studies—Birch et al.182 and Jensen et al.,203—

included a non-randomized group of breastfed infants that served as a reference standard. 

Agostoni et al. randomized Italian healthy term infants to receive LCPUFA-(AA+DHA+EPA) 

supplemented formula or a control formula. The main outcomes were the Brunet-Lézine test 

(Italian edition) of the graded psychomotor developmental test at 4 months, and the FA 

composition of venous blood (plasma and RBC PL composition).176 (Summary Table 29) 
134

Summary Table 29: Omega-3 fatty acids and its influence on neurological development in term infants 

Study groups1 Author, 

Year, 

Location: 

Length & 

Design 

Group 1 

(n)/ 

Group 4 

(n)

Group 2 

(n)/ 

Group 3 

(n)

Notable 

clinical 

effects

Notable 

clinicalbiomarker2,3 

correlations 

Internal 

validity Applicability 

Agostoni, 

1995, Italy: 

4 mo 

Parallel 

RCT176

DHA+ 

EPA+ 

AA formula 

(n=27) 

Control 

formula 

(n=29)/ HM 

(n=30) 

S better 

score in 

DHA+EPA 

in BrunetLezine test 

(DQ) at 4++ 

NS at 24 mo 

RBC DHA at 4 

mo S + 

correlation with 

DQ at 4 mo 

NS at 24 mo 

Jadad total: 

4 [Grade: A]; 

Schulz: 

Unclear 

II 

Auestad, 

1997, US: 

12 mo 

parallel 

RCT104

Formula 

DHA+AA 

(n=46)/ 

HM (n=63) 

Formula 

DHA 

(n=43)/ 

control 

formula 

(n=45) 

S better in 

control gp 

vs. DHA+AA 

in PDI at 12 

mo 

NS among 3 

gps

n/a Jadad total: 

3 [Grade: B]; 

Schulz: 

Unclear 

I 

Lucas, 

1999, UK: 

6 mo 

parallel 

RCT265

Formula 

LCPUFA 

(n=154) 

control 

formula 

(n=155)/ 

HM 

(n=138) 

NS in PDI at 

18 mo; NS 

in KPS at 9 

mo (ITT) 

n/a Jadad total: 

5 [Grade: A]; 

Schulz: 

Adequate 

II 

Birch, 1998, 

US: 

17 wk 

parallel 

RCT182 

Formula 

DHA+AA 

(n=27) 

Formula 

DHA 

(n=26)/ 

NR pb 

(n=26) 

NS in PDI at 

18 mo; NS 

in BRS at 18 

mo

NS correlation of 

PDI & BRS at 18 

mo and plasma 

& RBC LA, ALA, 

AA, EPA, or 

DHA at 4 mo & 

12 mo 

Jadad total: 

5 [Grade: A]; 

Schulz: 

Unclear 

I 

1

Proceeding from highest omega-3, or lowest omega-6/omega-3, fatty acid content of intervention/exposure; 2

biomarker source; 3biomarkers = EPA, DHA, AA, AA/EPA, AA/DHA, AA/EPA+DHA; n-3 = omega-3 fatty acids; n6 = omega-6 fatty acids; ALA = linolenic acid; LA = alpha linoleic acid; DHA = docosahexaenoic acid; EPA = 

eicosapentaenoic acid; AA = arachidonic acid; HM = human milk group; Length = intervention length; Design = 

research design; n = sample size; pts = study participants; NR = not reported; S = statistically significant 

difference; NS = nonsignificant statistical difference; n/a = not applicable; pb = placebo; grp = group; wk = week(s); 

mo = month; wt = weight; PDI = psychomotor developmental index, Bayley scale; KPS = Knobloch, Passmark, and 

Sherrard’s test; BRS = behavioral rating scales; RBC = red blood cells; ITT = intention-to-treat analysis; PP = perprotocol analysis (e.g., completers); DQ = developmental quotien; +

p<.05 or significant with 95% confidence 

interval; ++p<.01; +++p<.001; ++++p<.0001 
135

Summary Table 30: Omega-3 fatty acids and its influence on neurological development in term infants 

Study groups1 Author, 

Year, 

Location: 

Length & 

Design 

Group 1 

(n)/ 

Group 4 

(n)

Group 2 

(n)/ 

Group 3 

(n)

Notable 

clinical 

effects

Notable 

clinicalbiomarker2,3

correlations 

Internal 

validity Applicability 

Makrides, 

1999, 

Australia: 

12 mo 

parallel 

RCT205

Formula 

DHA+AA 

(n=28)/ 

NR HM (n=63) 

Formula 

DHA 

(n=27)/ 

NR pb 

(n=28) 

NS in PDI at 

12 & 24 mo

S correlation 

between PDI 

at 12 mo & 

plasma AA 

levels at 12 

mo 

Jadad 

total: 5 

[Grade: A]; 

Schulz: 

Adequate 

III 

Auestad, 

2001a, US: 

12 mo 

parallel 

RCT227 

DHA+ 

AA (egg-TG) 

formula (n=80) 

DHA+ AA 

(fish/fungal) 

formula 

(n=82)/ 

control 

formula 

(n=77) 

NS in PDI at 6 

& 12 mo

n/a Jadad 

total: 5 

[Grade: A]; 

Schulz: 

Adequate 

I 

Auestad, 

2001b, US: 

1 y, 

parallel 

RCT227

DHA + AA 

formula/ HM 

(n=83) 

Control 

formula/ 

HM 

(n=82) 

NS in PDI at 6 

& 12 mo

n/a Jadad 

total: 5 

[Grade: A]; 

Schulz: 

Adequate 

I 

Jensen, 

1997, US: 

120 d 

parallel 

RCT203

Formula 1

LA/ALA 

44/1 

(n=20)/ 

F 3 LA/ALA 

9.7/1 

(n=20) 

Formula 2

LA/ALA 

18.2/1 

(n=20)/ 

F 4 LA/ALA 

4.7/1 

(n=20) 

NS in PDI at 

12 mo 

S Ð score 

(Gross motor 

DQ) in F 1 & 

F 3 vs. F2 & 4+ 

S correlation 

between 

plasma DHA 

& PDI 

NS 

correlation 

between 

RBC DHA & 

PDI 

Jadad 

total: 2 

[Grade: C]; 

Schulz: 

Unclear 

II 

1

Proceeding from highest omega-3, or lowest omega-6/omega-3, fatty acid content of intervention/exposure; 2

biomarker source; 3biomarkers = EPA, DHA, AA, AA/EPA, AA/DHA, AA/EPA+DHA; n-3 = omega-3 fatty acids; n6 = omega-6 fatty acids; LA = linolenic acid; ALA = alpha linolenic acid; DHA = docosahexaenoic acid; EPA = 

eicosapentaenoic acid; AA = arachidonic acid; HM = human milk group; Length = intervention length; Design = 

research design; n = sample size; pts = study participants; NR = not reported; S = significant statistical difference; 

NS = nonsignificant statistical difference; n/a = not applicable; pb = placebo; grp = group; wk = week(s); mo = 

month; PDI = psychomotor developmental index, Bayley scale; CLOG = cod liver oil group; COG = corn oil group; 

RBC = red blood cells; +

p<.05 or significant with 95% confidence interval; ++p<.01; +++p<.001; ++++p<.0001; ITT = 

intention-to-treat analysis; PP = per-protocol analysis (e.g., completers); Ï = increase(d)/higher; Ð = 

decrease(d)/reduction/lower; DQ = developmental quotien 

Qualitative synthesis of relevant studies’ key characteristics 

Study characteristics. All studies were parallel RCTs with at least two arms. Countries 

where the studies were conducted included the United States,104,182,203,227 Italy,176 

Australia,205 and the U.K.265 

Agostoni et al. did not report their funding source.176 Auestad et al.’s104 study was supported 

by Ross Products Division, Abott Laboratoris, Columbus, OH and the U.S. Maternal and Child 

Health Bereau, Rockville, MD. Lucas et al.’s study was funded by Nestec Ltd (Switzerland).265 

The study of Birch et al. was supported by an NIH grant and Mead Johnson Nutritional Center 

(Evansville, IN).183 Makrides et al.’s study was sponsored by Nestec Ltd (Switzerland), the MS 
136

McLeod Research Trust and the Australian National Health and Medical Research Council.205 

Both of Auestad et al.’s trials were supported by Ross Products Division, Abott Laboratoris, 

Columbus, OH.227 The study of Jensen et al. was sponsored by federal funds from the U.S. 

Department of Agriculture, Agricultural Research Service.203 

Population characteristics. Maternal and infant characteristics were analyzed separately. 

Across the seven RCTs, sample sizes ranged from 60176 to 447265 infants. The maternal 

sample size was provided in only one study.265 

The definition of a term infant (at least 37 weeks GA) was described in seven 

studies.104,176,182,205,227,265 

Of eight RCTs, the mean GA of randomized infants was reported in six studies and ranged 

from 39 to 40.3 weeks).176,203,205,227 The percentage of males of randomized infants was reported 

in five studies and ranged from 46.4% to 52.5% of infants.176,182,205,227

The gender ratio of the infants, among the different diet groups, was evenly distributed in 

four studies;176,182,227 however, in the study of Makrides et al., there was a tendency for 

proportionally more boys to be enrolled in the group that received the highest dose of DHA.205 

The mean age of the infant’s mothers across the eight trials was impossible to determine 

given that the full sample size was not reported in four of the trials.104,182,203,205 Excluding the 

studies failing to report the mean maternal age, the mean age of participants in the other four 

studies ranged from 27.0 (SD=5.12) to 32.4 (SD=5.7) years.176,227,265 Auestad et al. did not 

report the age, gender distribution, or racial/ethnic background of either participating women or 

their children.104 

Four studies failed to report the racial/ethnic background of the trial population,176,203,205,265 

In four studies, most of the participants were White, accounting for 68.4% to 90.2% of the study 

population and the distribution of race/ethnicity between the study groups of randomized infants 

was closely matched 104,182,227 Different variables were used to demonstrate family 

sociodemographic status in these studies (i.e., parental education, social score, smoking, marital 

status, birth order, number of siblings, HOME screening questionnaire score).104,182,227 

Maternal social status was reported in five studies,182,205,227,265 as well as information about 

maternal and/or paternal education and/or maternal marital status. There were no differences in 

sociodemographic variables among the study groups of randomized infants in all these studies. 

Five studies failed to provide the maternal smoking history before and during 

pregnancy.104,176,182,203,265 The studies that provided information about maternal smoking history, 

there was a tendency for less maternal smoking during pregnancy among the breastfed infants 

compared with the formula-fed groups.205,227 

The inclusion/exclusion criteria were described in four of eight studies.104,205,227 Only 

exclusion criteria were reported in two studies.104,265 All the studies included only healthy term 

infants. 

Intervention/exposure characteristics. Lucas et al. reported that by the protocol, the 

volume of formula consumed, calculated as the difference in amounts in the bottle at the start 

and end of the feed, was recorded.265 
137

The duration of formula feeding was reported in all studies and ranged from 3 months203 to 

12 months.104,205,227 Three studies104,227 failed to report the name of the infant formulas. Seven 

trials reported the manufacturer of the omega-3 FA intervention.176,182,203,205,265 Agostoni et al. 

used Aptamil with Milupan supplied by Milupa od Friedrichsdorf, Germany.176 Lucas et al.265

and Makrides et al.205 used Nestec formula (Nestec Ltd, Switzerland), and both Birch et al.182

and Jensen et al.203 administered Enfamil, by Mead Johnson Nutritional Center (Evansville, IN). 

Both Auestad et al. trials used fish oil provided by Mochida International Co, Ltd, Tokyo, Japan 

and fungal oil by Suntory Ltd., Osaka, Japan; egg-derived trigycerides was provided by Eastman 

Chemical Co, Kingsport, TN.227

The duration of the intervention in children in four studies104,205,227 was 12 months, at least 6 

months in Lucas et al.,265 and 4 months in three studies.176,182,203 

In many of the studies, information regarding the time of introduction of solid food, caloric 

composition of formulas, source of omega-3 FA, micronutrient and vitamin content of formulas 

as well as presence of omega-3 FA stabilizing antioxidants, and attempts to deodorize any odor, 

were not clearly reported. Only five studies reported about the time of solid food 

introduction.104,182,227,265 All the Auestad et al. studies permitted solid foods in all study groups 

beginning at 4 months of age.104,227 Birch et al. did not introduce any solid food until 17 weeks 

of age.182 Lucas et al. reported that the mean age of first introduction of any solid food did not 

differ between those fed LCPUFA and control formula (12.5 [SD=0.4] vs 11.8 [SD=0.4] 

weeks).265 Information about caloric balance of feeding formulas was reported in five 

RCTs.176,182,227,265 Infant formulas provided 670 kcal/L, 2805kJ/L and 670 to 694 kcal/L energy, 

respectively. 

The source of omega-3 FA varied across the trials. Agostoni et al.’s fat blend was derived 

from palm oil, coconut and palm kernel fats, soybean oil, sunflower oil (parents PUFA), evening 

primrose oil (GLA) and egg lipids (LCPUFA PL and TGL).176 The content of AA was 0.44 

g/100 g fat; EPA 0.05 g and DHA 0.30 g.176 However, the control formula also contained LA 

(omega-6) and GLA (omega-6).176 Auestad et al.104 described the source of DHA as fish oil in 

one of the formulas (DHA group) and the source of DHA and AA as egg-derived phospholipids 

in another formula (DHA+AA group). Not only the sources but the content of the omega-3 FAs 

were different in this trial: the DHA group contained 0.2wt% of DHA, while the DHA+AA 

group contained 0.12wt% DHA and 0.43wt% AA.104 Lucas et al. reported the source of 

LCPUFAs as egg-derived phospholipids and triglyceride fractions (0.32wt% DHA, 0.3wt% AA 

and 0.01wt% EPA).265

Birch et al. compared two DHA-supplemented (0.35wt% DHA) and DHA+AAsupplemented formulas (0.36wt% DHA and 0.72wt% AA), containing single-cell oils 

(DHASCO® and ARASCO®; Market Biosciences, Columbia, MD, USA) with a control, 

LCPUFA-unsupplemented formula.183 Makrides et al.‘s study formula contained either no 

LCPUFAs (placebo) or 0.35wt% DHA from tuna oil or 0.34wt% DHA and 0.34% AA from egg 

phospholipids fraction.205 

The first Auestad et al. trial227 randomized infants to receive a control formula or one of two 

formulas supplemented with DHA and AA: 1) fish oil and fungal oil containing DHA 

(0.13wt%), AA (0.46wt%) and EPA (0.04wt%) or 2) egg-derived triglyceride, containing DHA 

(0.14wt%) and AA (0.45wt%). Only this study mentioned that study formulas were 
138

indistinguishable in appearance and odor.227 The second Auestad et al. trial227 randomized the 

breastfed infants to receive a control formula or the AA+DHA (egg-TG) formula for 12 months. 

The infants were allowed water ad libitum, solid foods after 4 months and alternate formulas for 

up to 5 days.227 

Jensen et al. randomly and blindly assigned each infant to receive one of four formulas from 

birth to 120 days of age.203 There were no significant differences among formulas in the content 

of FAs other than ALA, which ranged from 0.4wt% to 3.2wt%. The LA:ALA ratio ranged from 

44 to 4.8. No information was provided by the investigators regarding the delivery method of 

omega-3 FA exposure or attempts to deodorize the oil supplements. 

Cointervention characteristics. Only one study265 reported the content of vitamin and 

mineral supplements of feeding formulas and oils taken by women. No studies reported the prestudy or on-study medication use by either pregnant or breast feeding mothers or infants. 

Outcome characteristics. The most frequently employed outcome assessing infants 

neurological development was the Bayley Scales of Infant Development, from which were 

derived a PDI. Two trials104,205 used Bayley I Scales (1st edition) and five studies employed 

Bayley II Scales (2nd edition).182,203,227,265 Lucas et al.265 administered two tests to assess infant 

neurological development: as a primary outcome measure they used Bayley Scales, 2nd edition 

and as a secondary outcome measure–Knobloch, Passamanik and Sherrards Developmental 

Screening Inventory at 9 months. The latter test comprises of five scales: adaptive, gross motor, 

fine motor, language, and personal-social. Agostoni et al. used the Italian edition of the graded 

psychomotor developmental test by O. Brunet and I. Lezine for French children to rate the global 

neurodevelopment at 4 and 24 months of age. It explores four developmental areas: posture and 

gross notor function, adaptation and fine motor function, social reactions and language. This test 

was statistically validated.176

As for infants neurological development outcome assessment four studies evaluated these 

indices at 12 months203,227,327, two studies at 18 months,182,265 whereas in two other studies the 

assessment has been done at 12 and 24 months.205 

Study quality and applicability. The eight RCTs received a mean Jadad total quality score 

of 4.25, indicating a good internal validity (Summary Matrix 15). Five trials received a score of 

5,124,205,265,329 Agostoni et al. received a score of 4,176 Auestad et al. received a score of 3,104 and 

Jensen et al. received a score of 2.203 Jensen et al. failed to report the method of 

randomization,325 Auestad et al. 1997 was unblinded,327 and Agostoni et al. did not report the 

method of double-blinding.134
139

Summary Matrix 15: Omega-3 fatty acids and its influence on neurological development in term infants. 

Study Quality

A B C 

Author Year n Author Year n Author Year n 

I BirchU

AuestadA 

AuestadA

1998 

2001 

2001 

79 

239

165 

AuestadU 1997 274 

Author Year n Author Year n Author Year n

II AgostoniU 

LucasA 1995 

1999 

60 

447 

 JensenU 1997 80 

Author Year n Author Year n Author Year n

Applicability 

III MakridesA 1999 146 

n = number of allocated/selected participants; RCT = AAdequate vs UUnclear allocation concealment

Qualitative synthesis of individual study results 

All but one study addressing the issue of child neurological development used Bayley’s 

Developmental Scales (PDI) as a primary outcome measure.104,182,203,205,227,265 The included 

studies did not find a statistically significant difference in PDI between the formula groups at 6, 

12, 18 and 24 months of age. Makrides et al. (1997) reported a nonsignificantly difference 

among the 3 formula arms,327 however when we compared the scores (PDI) between the 

DHA+AA group versus control formula (see Figure 11 below) the score was favouring 

significantly the control group. Lucas et al. did not find a significant difference in Bayley PDI at 

18 months or in Klobloch, Passamanick and Sherrard’s test performance at 9 months between 

control and LCPUFA groups.265 Birch et al. also measured the developmental ages on the 

cognitive, language and motor subscales.182 The cognitive and motor subscales were 

significantly poorer in the control group compared with both supplemented formula groups 

(DHA+AA and DHA).182 No significant differences were found among diet groups on the 

language subscale.182 The Behavioral Rating Scale (BRS) did not differ significantly among diet 

groups at 18 months of age.182 Both of the Auestad et al. trials, with and without human milk, 

failed to find a significant difference in the BRS among diet groups at 6 and 12 months of age.227

Jensen et al found a statistically significant difference among the study groups in gross motor 

developmental quotient (GM DQ) index at 12 months of age.203 Group 1 (i.e., lowest ALA 

intake) and Group 3 (LA/ALA ratio 9.7) had significantly lower mean GM DQ than Group 2 

(LA/ALA ratio 18.2) and Group 3 (LA/ALA ratio 4.8).203

Agostoni et al. found that the Brunet Lezine test DQ was significantly higher in the 

supplemented group compared with the control group at 4 months of age; the difference was, 

however, not statistically significant at 24 months.176

Four investigators tried to find a correlation between different covariates as well as plasma 

and/or RBC phospholipid content of omega-3 and omeda-6 LCPUFAs and each 

neurodevelopmental index.176,182,203,205 Agostoni et al. found that the RBC DHA content at 4 

months was positively correlated with the DQ at 4 months but not at 24 months.176

Birch et al. found that PDI and BRS scores at 18 months of age were not significantly 

correlated with plasma or RBC LA, ALA, AA, EPA, or DHA at 4 months or at 12 months of 

age.182 The PDI score was negatively correlated with VEP acuity at 4 months of age, i.e. better 
140

visual acuity was associated with a better PDI score.182 There was no significant correlation 

between PDI score at 18 months and FPL acuity at 4 months of age.182 PDI score at 18 months 

was not correlated with normalized height, weight, or weight-for-length z scores at 4 months. 

Jensen et al. found a positive correlation between both PDI and GM DQ scores and the 

plasma, but not the RBC, phospholipid content of DHA at 120 days of age.203 

In the study performed by Makrides et al., the only FA variable to significantly influence the 

PDI was plasma AA at 1 year of age.205 The same study established significant environmental 

variables that influenced PDI scores at 1 year—i.e., the assessor, maternal education, number of 

siblings, and the infant’s age at testing. HC, number of siblings, and maternal smoking predicted 

PDI at 2 years of age, and PDI at 1 year was correlated with PDI at 2 years.205

Quantitative synthesis 

The outcome measure selected to conduct meta-analysis was the Bayley’s Developmental 

Index at 4 and 12 months of age. All the infants that were followed-up at 12 months, were 

exclusively breastfed until 4 months of age. At 12 months, outcomes were noted in three studies 

that were using the same comparators—DHA+AA versus unsupplemented formula.104,205,227 

Figure 11. Bayley’s Developmental Index (PDI). Meta-analysis was performed using the 

random effects weighted mean difference (WMD). 

Review : N-3 CHILD

Comparison: 01 DHA + AA vs Control 

Outcome: 01 Psychomotor Developmental Index 

Study DHA + AA Control WMD (random) Weight WMD (random)

or sub-category N Mean (SD) N Mean (SD) 95% CI % 95% CI

Auestad 1997 46 98.00(14.00) 45 105.00(15.00) 36.07 -7.00 [-12.96, -1.04] 

Auestad 2001 117 93.80(13.20) 48 94.60(12.50) 50.96 -0.80 [-5.07, 3.47] 

Makrides 1999 21 103.00(22.00) 21 102.00(17.00) 12.96 1.00 [-10.89, 12.89] 

Total (95% CI) 184 114 100.00 -2.80 [-7.43, 1.82]

Test for heterogeneity: Chi2 = 3.13, df = 2 (P = 0.21), I2 = 36.0%

Test for overall effect: Z = 1.19 (P = 0.24)

 -10 -5 0 5 10

 Favours control Favours treatment

The WMD in the Bayley’s PDI score at 12 months was nonstatistically significant (WMD: -

2.80, CI 95%: -7.43; 1.82).104,205,227

Impact of covariates and confounders 

Most of the RCTs did not reveal enough evidence regarding the comparability of the study 

groups in terms of infant gender, ethnic/racial distribution, birth characteristics, parental 

socioeconomic background, education or maternal and/or paternal smoking. Only one study 

failed to report the baseline characteristics of randomized groups so it was impossible to estimate 

the impact of potential covariates and confounders on the study results.182 Differences in some 

characteristics at enrollment were noted between breastfed and formula fed infant groups only. 

In the Makrides et al. study, breastfed infants had parents who were less likely to smoke, had 

attained a higher level of education and had more prestigious social scores compared with 

formula fed infants.205 Bayley’s PDI scores at 12 and 24 months were adjusted for different 

covariates. The only variables that significantly influenced (regression model) the PDI scores at 
141

12 months were the assessor, maternal education, number of siblings and the infant’s age at 

testing. At 24 months, HC, number of siblings and maternal smoking predicted the PDI.205 

Auestad et al.227 reported that maternal age and GA in a breastfed infant group were significantly 

higher than that in the randomized formula-fed groups. In the same study, infants assigned to 

breast milk also had a significantly smaller percentage of mothers having no postsecondary 

education and smaller prevalence of smoking exposures both in utero and in the household.227 In 

Lucas et al., the results were unaffected when Bayley’s score was adjusted for center or 

observer.265

Jensen et al. used a multiple regression model to adjust the scores for effect modifiers such as 

birth weight, weight at 120 days of age, chronological age on the assessment day.203 However, 

none of these variables seemed to affect the results. 

The power calculation was reported in seven trials,124,132,134,151,325,329 while the intention-totreat analysis approach was reported in only one study.132

Neurological Development Outcomes in Light of 

Biomarker Data 

What is the Evidence That Term or Preterm Human Infants’ 

Neurological Development is Associated With the Omega-3 or Omega6/Omega-3 Fatty Acid Content of Maternal Biomarkers During 

Pregnancy? 

One cross-sectional study was identified to answer this question. Cheruku et al. was 

conducted in the United States and founded by the National Institutes of Health, the US 

Department of Agriculture, the Donaghue Medical Research Foundation, and the University of 

Conneticut Research Foundation.274 This study was published in 2002.274 (Summary Table 31) 

Overview of relevant study characteristics and results 

Cheruku et al. assessed the association between the content of LCPUFA in maternal blood 

and the Central Nervous System (CNS) integrity of their newborns.274

Healthy pregnant women (n=17) were included after their admission for delivery. The 

exclusion criteria were: women with a history of chronic hypertension, hyperlipidemia, renal or 

liver disease, heart disease, thyroid disorders, multiple gestations, pregnancy-induced 

complications (e.g., hypertension, preterm labor, or premature rupture of membranes), treatment 

during labor with drugs that affect respiration of newborns, or any infant with lower than 4 hours 

of crib time in the first and second days postpartum.274

The maternal blood samples to measure the plasma FA content were taken at delivery. The 

CNS integrity was measured using the Motility Monitoring System to record the sleep patterns 

(i.e., quiet sleep, active sleep, sleep-wake transition, wakefulness, time spent out of the crib) on 

postpartum day 1 and postpartum day 2.274 Infant sleep patterns are an expression of central 
142

integrative control. Multiple mechanisms involving both neural and humoral processes in various 

regions of the brain interact to produce sleep and wakefulness. Changes in the sleep architecture 

may be associated with neurologic changes during development and that deviant sleep patterns 

may be associated with neuroogic deficits.338

Summary Table 31: Association of neurological development outcomes and biomarkers content in infants 

(observational study) 

Study groups1

 

Author, Year, 

Location: 

Design 

Group 1 

(n)/ 

Group 4 

(n)

Group 2 

(n)/ 

Group 3 

(n) Notable associations2,3 

Internal 

validity Applicability 

Cheruku, 2002, 

US: 

Crosssectional274

Healthy 

pregnant 

women 

high DHA 

(n=10) 

Healthy 

pregnant 

women low 

DHA 

(n=7) 

Maternal DHA was (-) 

associated with AS, AS:QS & 

sleep-wake transition+ (d 2) 

Maternal DHA (+) associated 

with wakefulness+ (D2) 

n-6:n-3 ratio in maternal plasma 

was (+) associated with AS, 

AS:QS &sleep-wake transition+

(d 1)

n-6:n-3 ratio in maternal plasma 

was (-) associated to 

wakefulness+ (d 1) 

Quality 

score: 6 

[Grade B] 

I 

1

biomarkers = EPA, DHA, AA, AA/EPA, AA/DHA, AA/EPA+DHA; n-3 = omega-3 fatty acids; n-6 = omega-6 

fatty acids; ALA = alpha linolenic acid; DHA = docosahexaenoic acid; EPA = eicosapentaenoic acid; AA = 

arachidonic acid; E-EPA = ethyl eicosapentaenoate; n = sample size; pts = study participants; NR = not 

reported; NS = nonsignificant statistical difference; N/A = not applicable; pb = placebo; grp = group; wk = 

week(s); mo = month; +p<.05 or significant with 95% confidence interval; ++p<.01; +++p<.001; ++++p<.0001; Ï = 

increase; Ð = decrease/reduction; AS = active sleep; QS = quiet sleep 

Regression analysis used to describe the associations of maternal plasma PL FA 

concentrations with infant sleep and wake states indicated that, among the omega-6 and omega-3 

LCPUFAs, only the omega-3 FAs specially DHA, and the n-6:n-3 ratio showed strong 

correlations on both postpartum days 1 and 2.274 The following correlations were the most 

significant among all the statistically significant correlations for this population. On postpartum 

day 2, maternal DHA was negatively associated with active sleep (AS), AS:QS (quiet sleep) and 

sleep-wake transition, and positively associated with wakefulness.274 On postpartum day 2, the 

ratio of n-6:n-3 LCPUFAs in maternal plasma was positively associated with AS, AS:QS and 

sleep-wake transition and negatively associated to wakefulness.274

On postpartum day 1, the ratio of n-6:n-3 LCPUFAs in maternal plasma was negatively 

associated with QS and positively associated with arousals in QS. 

When the cohort was analyzed by maternal DHA plasma concentration, the high DHA group 

(>3.0% by wt of total FAs) did not differ significantly from the low DHA group (≤3.0% by wt of 

total FAs) in terms of maternal age, race, parity, duration of gestation, maternal education, infant 

birth weight and length, infant HC and Apgar score at 1 and 5 minutes.274 However, infants from 

mother with high DHA concentrations had significantly less AS and had a lower AS:QS 

compared with infants of mothers with low DHA concentrations. Furthermore, infants in the 

high DHA group had significantly less sleep-wake transition and more wakefulness than did 

infants in the low DHA group on postpartum day 2.274
143

Study quality and applicability. The quality score was 6 and the applicability level was III. 

Summary Matrix 16: Association of neurological development outcomes and biomarkers content in infants 

Study Quality

A B C 

Author Year n Author Year n Author Year n I Cheruku 2002 17 

Author Year n Author Year n Author Year n II 

Author Year n Author Year n Author Year n

Applicability 

III 

n = number of allocated/selected participants

What is the Evidence That Term or Preterm Human Infants’ 

Neurological Development is Associated With the Omega-3 or Omega6/Omega-3 Fatty Acid Content of Child Biomarkers? 

Five studies were identified to answer this question, including four RCTs that were described 

in the Growth Pattern Outcomes and Neurological Development Outcomes sections (see key 

questions: Growth Patterns & Neurological Development-Term Infant Formula 

Intake),176,182,203,205 and a prospective single cohort study published in 2001.271 (Summary Table 

32) 

Overview of relevant study characteristics and results

Innis et al. selected a cohort of 83 Canadian term infants who were exclusively breastfed, 

with birth weights in the range of 2,500 g to 4,500 g.271 The objective of the study was to 

measure the infant RBC DHA content and its association with the visual, neurological or 

cognitive development.271

Innis et al. was funded by the Medical Research Council (MRC) of Canada and Ross 

Laboratories, OH.271

The infants were enrolled within 2 weeks of age and to be eligible, their mothers were 

required to intend to breastfeed their infant without providing infant formula or cow’s milk for at 

least 3 months and without introducing solid foods for at least the first 4 months after birth. The 

infants were excluded if their mothers had substance abuse, metabolic or physiologic problems, 

communicable diseases, and infants with evidence of metabolic or physical abnormality.271

Only one mother was taking FA supplements with LA and DHA. The maternal diet was not 

reported or controlled. Only five mothers were smokers during the study.271

The outcome assessed included the Bayley’s PDI at 6 and 12 months and its correlation with the 

RBC DHA and AA content in infants. 
144

Multiple linear regression analysis was used to determine the impact of the FA variables on 

the outcomes. The analysis controlled statistically for the duration of breast-feeding, maternal 

education, family income, gender, maternal smoking, birth order and birth weight, length and 

HC. 

Summary Table 32: Association of neurological development outcomes and biomarkers content in infants 

(observational study) 

Study groups1

 

Author, Year, 

Location: 

Design 

Group 1 

(n)/ 

Group 4 

(n)

Group 2 

(n)/ 

Group 3 

(n) Notable associations2,3 

Internal 

validity Applicability 

Innis, 2001, 

Canada: 

Prospective 

single cohort271

Term 

breastfed 

infants 

(n=83) 

n/a NS RBC DHA or AA at 2 mo & 

Bayley’s PDI score (6-12 mo) 

Quality 

score: 8 

[Grade A] 

II 

1

biomarkers = EPA, DHA, AA, AA/EPA, AA/DHA, AA/EPA+DHA; n-3 = omega-3 fatty acids; n-6 = omega-6 

fatty acids; ALA = alpha linolenic acid; DHA = docosahexaenoic acid; EPA = eicosapentaenoic acid; AA = 

arachidonic acid; E-EPA = ethyl eicosapentaenoate; n = sample size; pts = study participants; NR = not 

reported; NS = nonsignificant statistical difference; N/A = not applicable; pb = placebo; grp = group; wk = 

week(s); mo = month; RBC = red blood cells; +

p<.05 or significant with 95% confidence interval; ++p<.01; +++p<.001; ++++p<.0001; Ï = increase; Ð = decrease/reduction 

No statistically significant relation was found between the infant DHA or AA status (RBC) at 

2 months of age and the Bayley’s PDI score at 6 and 12 months of age.271 

There were 31 dropouts at 12 months due to different reasons, like lost to follow up, fed with 

formula before 3 months of age, or lack of blood samples. 

Study quality and applicability. This study had a quality score of 8 and a level of 

applicability of II. 

Summary Matrix 17: Association of neurological development outcomes and biomarkers content in infants 

Study Quality

A B C 

Author Year n Author Year n Author Year n I 

Author Year n Author Year n Author Year n II Innis 2001 83 

Author Year n Author Year n Author Year n

Applicability 

III 

n = number of allocated/selected participants
145

Visual Function Outcomes 

What is the Evidence That Maternal Intake of Omega-3 Fatty Acids 

During Pregnancy Influences Visual Function in Term or Preterm 

Human Infants? 

Overview of relevant study characteristics and results 

One double-blinded RCT235 and one cross-sectional study275 evaluated the influence of 

maternal intake of omega-3 FAs during pregnancy on the visual function. The RCT was 

conducted in the United Kingdom and was funded by the Scottish Office Health Dept.235 The 

cross-sectional study was conducted in Cuba and was funded by Canadian International 

Development Agency.275 (Summary Table 33) 

Malcolm et al.235 investigated the photoreceptor function of healthy term infants (mean 279.7 

[SD:9.5] days; males 52%) at approximately 1 week of age, whose mothers (ages 17-36 years) 

received fish oil capsule supplements from a mean of 15.4 wk gestation until delivery (Marinol 

D40, 100 mg DHA per capsule, R.P. Scherer Ltd, Swindon, UK) compared with infants (279.6 

[SD:8.5] days; males 37.9%) whose mothers received sunflower oil capsules from the same time 

point. Women were excluded if they had had a twin pregnancy, placental abruption, postpartum 

hemorrhage, allergy to fish products, a thrombophilic tendency, or receiving drugs affecting 

thrombocyte function. Healthy full-term infants with an Apgar score above 7 and with no visual, 

medical or developmental disorders were included. The tests used to measure photoreceptor 

function were intensity-series electroretinogram (ERG) (rod photoreceptor function) and 

standard maximum combined ERG (mixed rod and cone function). In addition, the b wave 

amplitudes were fitted to the Naka-Rushton function as another assessment of rod photoreceptor 

function and the derived log δ  was used as a measure of retinal sensitivity.235
146

Summary Table 33: Omega-3 fatty acids intake during pregnancy and its influence on visual function in term 

infants 

Study groups1 

Author, 

Year, 

Location: 

Length & 

Design 

Group 1 

(n)/ 

Group 4 

(n) 

Group 2 

(n)/ 

Group 3 

(n) 

Group 5

Notable 

clinical 

effects

Notable 

clinicalbiomarker2,3 

correlations 

Internal 

validity Applicability 

Malcolm , 

2003, 

Denmark: 

15 wks 

Parallel 

RCT235

DHA (fish 

oil) capsules 

(n=50)/ 

term infants 

(n=31) 

Pb capsules 

(oleic 

sunflower 

oil) (n=50)/ 

term infants 

(n=29) 

NS in b 

wave implicit 

time 

NS in NakaRushton 

function 

NS in log δ

NS in 

maximium 

combined 

ERG

NS correlation 

of max 

combined ERG 

& cord blood 

DHA 

NS (-) 

correlation of 

log δ & cord 

blood AA 

S (+) 

correlation of 

log δ & cord 

RBC proportion 

DHA+

 & total 

n-3 FA + , n-6/n3+

S correlation of 

log δ & cord 

RBC quartiles 

of DHA+++, AA+

, 

total n-3 

LCPUFAs +

Jadad total: 

3 [Grade: B]; 

Schulz: 

Unclear 

II 

Krasevec, 

2002, Cuba: 

crosssectional275

Healthy 

pregnant 

women 

(n=56) 

 Breastfed 

infants 

(n=56) 

HM + 

formula 

infants 

Visual acuity 

scores 99% 

prediction for 

2.5 mo old 

infants 

NS Mean 

values for 

visual acuity 

between 

HM vs. HM 

+ formula 

infants 

NS correlation 

visual acuity & 

any individual 

PUFA 

concentration, 

ratio of PUFA 

concentrations 

or 

concentrations 

of groups of 

PUFAs in infant 

tissues 

Quality 

score: 7 

[Grade B] 

III 

1

biomarkers = EPA, DHA, AA, AA/EPA, AA/DHA, AA/EPA+DHA; n-3 = omega-3 fatty acids; n-6 = omega-6 fatty 

acids; ALA = alpha linolenic acid; DHA = docosahexaenoic acid; EPA = eicosapentaenoic acid; AA = arachidonic 

acid; n = sample size; pts = study participants; NR = not reported; S = statistically significant difference; NS = 

nonsignificant statistical difference; N/A = not applicable; pb = placebo; grp = group; wk = week(s); mo = month;

RBC = red blood cells; PL = phospholipid; +p<.05 or significant with 95% confidence interval; ++p<.01; +++p<.001; ++++p<.0001; Ï = increase; Ð = decrease/reduction; HM = human milk 

Malcolm et al. showed that maternal fish oil supplementation during pregnancy, from a mean 

of 15.4 weeks gestation to delivery, had no significant effect on retinal function (rod 

photoreceptor function, rod and cone photoreceptor function, or retinal sensitivity) assessed 

within the first week of life in healthy term infants.235 There were no differences between the 

fish oil and placebo groups in the maternal self-selected diets, fish intake, or consumption of 

DHA-containing dietary supplements at study entry, or in the time period between study entry 

and delivery (assessed by interview at 15 and 28 weeks gestation, and at delivery). 
147

In addition, the groups did not differ significantly in age, previous obstetric history, 

socioeconomic status, smoking habits, alcohol intake and exercise patterns. Satisfactory 

intensity-series ERGs were recorded in 41/60 infants (fish oil, n=22, placebo, n=19), and 

maximum combined ERGs were recorded in 44/60 infants (fish oil, n=25, placebo, n=19). 

Regardless of mother’s supplementation group, significant correlations were found between 

retinal sensitivity and cord RBC levels of DHA, AA, omega-6/omega-3 FA and total omega-3 

FAs.235 

Krasevec et al. evaluated the visual acuity in 2-month old term infants (mean age:40.4 

[SD:1.5] weeks; males NR) born to Cuban mothers (mean age 26.8 [SD:4.0] years) who had 

received a high fat fish diet during pregnancy and breast feeding.275 Included were pregnant 

women with a history of normal pregnancy, no medical risks affecting FA metabolism (i.e. heart, 

kidney, hypertensive, gallbladder, or thyroid diseases and gestational or other diabetes), resident 

of Havana, and a range of age from 17 to 36 years; exclusion criteria were not reported for the 

mothers. Neither inclusion or exclusion criteria were reported for the infants.275 

All Cubans received 227 g of a high fat fish every week through the ration system before and 

during pregnancy, and a higher amount during breast feeding. Infants were exclusively breastfed 

(55%), fed a combination breastmilk and bottle-feeding (39%), or not fed any breastmilk (5%). 

Supplemental milks were fed for an average of 2 to 4 weeks before the 2-month study. 

Binocular visual acuity was assessed at 2 months of age using the Teller Acuity Cards with 

acceptable reliability.

Krasevec et al.275 observed that there were no significant correlations between visual acuity 

and any individual PUFA concentration, ratio of PUFA concentrations or concentrations of 

groups of PUFAs in the infants’ plasma and RBCs, in term infants born to Cuban women who 

received high fat fish during pregnancy and breast feeding. Fatty acid composition was analyzed 

in 31/56 infants’s plasma and 33/56 infants’ RBCs. Infant RBC PUFA contents were compared 

with values reported in the literature without statistical evaluation. Visual acuity was tested in 

54/56 infants. The visual acuity scores for all tested infants were within the 99% prediction 

limits for 2.5 month old infants. The group mean visual acuity score was within a range of data 

obtained from full-term, normally developing infants. Mean values for visual acuity were not 

significantly different between the exclusively breastfed or not exclusively breastfed infants. 

Study quality and applicability. Malcom et al.’s Jadad total quality score was 3 (failed to 

report methods of randomization and double-blinding), indicating a good internal validity.235 

The allocation concealment was unclear. Krasevec et al. quality score was of 7.

Summary Matrix 18: Association of maternal intake of omega-3 fatty acids during pregnancy with full-term 

infant visual function 

Study Quality

A B C 

Author Year n Author Year n Author Year n I 

Author Year n Author Year n Author Year n II MalcolmU 2003 100 

Author Year n Author Year n Author Year n

Applicability 

III Krasevec 2002 56 

n = number of allocated/selected participants; RCT = AAdequate vs UUnclear allocation concealment
148

What is the Evidence That the Omega-3 Fatty Acid Content of 

Maternal Breast Milk, With or Without Known Maternal Intake of 

Omega-3 Fatty Acids, Influences Visual Function in Term or Preterm 

Human Infants? 

Two RCTs and two observational studies published from 1997 to 2001 met eligibility criteria 

regarding the influence of maternal breast milk intake in term infants.138,140,248,276 Krasevec et 

al.275 also addressed the issue of maternal intake during breastfeeding and visual function in term 

infants, and is fully described above (see key question: Maternal Intake/Visual Function).275 No 

reports were identified in the preterm population. (Summary Table 34, 35)

Overview of relevant study characteristics and results 

Gibson et al. was a double-blind RCT that investigated the maternal intake effect on 

breastfed infant’s neurological and visual function outcomes in Australia.138 This study included 

mothers of term infants (>37 weeks of GA) who intended to breast feed for at least 12 weeks 

(n=52, means age: 30 [SD=4] years). These mothers were randomized to receive one of five 

doses (0, 0.2, 0.4, 0.9, or 1.3 g DHA/day) of a DHA-rich algal oil (DHASCO, Market 

Biosciences, MD, US) between day 5 and week 12 postpartum. The oil contained 43% DHA, 

1% omega-6 PUFA, 38% saturates and 18% monosaturates. Infants who were exclusively 

breastfed for 12 weeks were assessed. Infants (n=20) were healthy, appropriate weight for GA, 

Apgar scores greater than 7 at 5 minutes.138 

Infant’s visual function using VEP (logMAR) was assessed at 12 and 16 weeks of life, and 

for global development (Bayley’s Scales of Infant development) at 1 and 2 years of age. 

Mothers were from middle class families and completed year 12 education. The five groups 

were compared in terms of maternal age, maternal BMI, GA, infant’s gender, birth weight, birth 

length, birth HC, Apgar score, siblings, maternal social score, smoking, education, home 

stimulation, and length of breast feeding, at baseline. There was a predominance of boys in the 

group that received the highest dose of DHA.138

Jensen et al. investigated the effect of DHA supplementation in lactating women on the 

visual function and growth of their infants.248 

Mothers were randomaly assigned to receive 200 to 250 mg DHA per day as either algal DHA 

(n=42), refined high-DHA fish oil (n=42) or placebo (n=42), for 120 days after delivery. Infant 

characteristics, as well as the maternal characteristics, were not described in this abstract.248
149

Summary Table 34: Omega-3 fatty acid content of maternal breast milk, with or without known maternal 

intake of omega-3 fatty acids, influences visual function in term or preterm human infants

Study groups1 

Author, 

Year, 

Location: 

Length & 

Design 

Group 1 

(n)/ 

Group 4 

(n) 

Group 2 

(n)/ 

Group 3 

(n) 

Group 5

Notable 

clinical 

effects

Notable 

clinicalbiomarker2,3 

correlations 

Internal 

validity Applicability 

Gibson, 

1997, 

Australia: 

12 wk 

 parallel 

RCT138

1.3g/d DHA 

(n=8)/ 

0.2g/d DHA 

(n=10) 

0.9g/d DHA 

(n=10)/ 

0.4g/d DHA 

(n=12)/ 

pb 

(n=12) 

NS VEP 

acuity 

between 

dietary 

groups at 12 

& 16 wks

No correlation 

VEP & DHA 

HM, infant 

plasma or RBC 

LCPUFA 

Jadad total: 

3 [Grade: B]; 

Schulz: 

Unclear 

II 

Jensen, 

1999, US: 

12 mo 

 parallel 

RCT 248

Algal DHA 

(n=42) 

Fish oil DHA 

(n=42)/ 

Placebo 

(n=42) 

NS VEP 

latency, 

sweep VEP 

acuity or 

Teller Card 

Acuity at 120 

or 240 d 

NS correlation 

visual function 

& infant plasma 

PL DHA at 120 

d 

Not 

assessed 

X 

1

biomarkers = EPA, DHA, AA, AA/EPA, AA/DHA, AA/EPA+DHA; n-3 = omega-3 fatty acids; n-6 = omega-6 fatty 

acids; ALA = alpha linolenic acid; DHA = docosahexaenoic acid; EPA = eicosapentaenoic acid; AA = arachidonic 

acid; E-EPA = ethyl eicosapentaenoate; n = sample size; pts = study participants; NR = not reported; ; S = 

statistically significant difference; NS = nonsignificant statistical difference; N/A = not applicable; pb = placebo; 

grp = group; wk = week(s); mo = month; RBC = red blood cells; PL = phospholipid; +p<.05 or significant with 95% 

confidence interval; ++p<.01; +++p<.001; ++++p<.0001; Ï = increase; Ð = decrease/reduction; BF = breast 

feeding; VEP = visual evoked potentials; HM = human milk 

Jorgensen et al. investigated, in a cross-sectional study, whether the variation in milk DHA 

content between Danish mothers is large enough to cause differences in visual acuity in their 

healthy term 4-month-old infants, and to evaluate the influence of frequency of fish intake on the 

DHA level of milk.140 The study included term infants (GA 37-42 weeks) with normal birth 

weight for GA; uncomplicated pregnancy, delivery, and neonatal period; Apgar score > 8 after 5 

minutes; fully breastfed at the time of the examination (i.e., no energy drinks and < 100 mL of 

formula per day). Infants were excluded if they were SGA (< 10th PC of birth weight), had 

strabismus, or operation of pyloric stenosis. Seventy infants were enrolled, of which 39 

completed the study (mean age: 17.4 [SD=0.7] months; 51% males).140 The study was 

conducted in Denmark and was supported by the Danish Research and Development Programme 

for Food Technology (FOTEK), and BASF Health and Nutrition A/S.140

The study by Williams et al. was a population-based cohort study that compared the 

stereoacuity at age 3.5 years in healthy term children who were breastfed with similar children 

who had not been breastfed after adjustement for socioeconomic status and maternal diet.276 The 

study included a random selected subset of children born in the last 6 months of the Avon 

Longitudinal Study of Pregnancy and Childhood (ALSPAC) enrollment period. 

The ALSPAC was a prospective population birth cohorth study.339 Infants were excluded if 

they had strabismus, reduced vision, high refractive error, preterm infants (GA <37 weeks).276 

Williams et al. enrolled 641 children aged a mean of 43.2 (SD=0.6) months (i.e., 3.5 years), of 

which 435 completed the study period (52.1% males).276 The study was based in the United 

Kingdom, and was funded by the Medical Reseach Council, the Wellcome Trust, Ministry of 
150

Agriculture, Foods and Fisheries, the Departments of Health and Enviroment, the South West 

Regional Health Authority, the National Eye Research Centre, Cow and Gate, and Milupa.276

Jorgensen et al.’s infants were exclusively breastfed until 14 weeks of age. The median 

DHA content of the milk was 0.31 wt% of total FAs (range: 0.12-1.20 wt%), AA was 0.30 

(SD=0.07) wt% and the content of EPA was 0.39 (SD=0.07) wt%. The study described the 

details regarding the maternal age, weight gain during pregnancy, Apgar score at 5 minutes, 

gender, GA, birth weight, length at birth and HC, as well as growth parameters at the time of the 

examination.140 Jorgensen et al.’ mothers did not take any fish oil supplements regularly, 

however one of the ninemothers that ate fish the day before the milk sample was taken, ate lean 

fish while the remaining ate fatty fish.140 Outcomes measures were visual acuity, using VEP 

acuity (expressed in LogMar) in the 4-month infants, and the correlation with the LCPUFA 

content of maternal breast milk and/or maternal fish intake.140

Williams et al. used different questionnaires to collect information related to the infant’s 

feeding practices from 4 weeks to 6 months of age and at 36 months (3.5 years), as well as other 

information like socioeconomic status, smoking status, and housing.276 During the study period, 

no formula milks supplemented with DHA were commercially available in the United 

Kingdom.276 This study did not report the DHA/AA/EPA FA content in human milk. Williams 

et al. measured the stereoacuity (peripheral or poor; macular or moderate; foveal or adult) in the 

3.5 year-old children. They also measured the possible correlation with the percentage of DHA 

content of the maternal RBC PL during pregnancy, as well as with the mother’s intake of fish 

oil.276

Both Jorgensen et al.’s and Williams et al.’s studies collected the maternal diet intake using a 

food-frequency questionnaire, including questions regarding fish intake.140,276
151

Summary Table 35: Omega-3 fatty acid content of maternal breast milk, with or without known maternal 

intake of omega-3 fatty acids, influences visual function in term or preterm human infants

Study groups1 

Author, 

Year, 

Location: 

Length & 

Design 

Group 1 

(n)/ 

Group 4 

(n) 

Group 2 

(n)/ 

Group 3 

(n) 

Group 5

Notable 

clinical 

effects

Notable 

clinicalbiomarker2,3 

correlations 

Internal 

validity Applicability 

Jorgensen, 

2001, 

Denmark: 

Crosssectional140

Term infants 

HM (BF) 

(n=39) 

n/a S 

association 

between 

visual acuity 

(VEP) at 4 

mo & 

mother’s 

milk DHA+ 

NS association 

between AA, 

EPA, LA & ALA 

(n-3) with visual 

acuity 

Quality 

score: 9 

[Grade A] 

III 

Williams, 

2001, UK: 

Prospective 

cohort276

Term infants 

HM (BF) 

(n=334) 

Term infants 

never 

breastfed 

(n=101) 

BF was S 

correlated to 

foveal (adult) 

stereacuity 

Maternal oily 

fish intake 

during 

pregnancy 

was S 

correlated 

with foveal 

stereoacuity

S correlation 

between child’s 

stereoacuity at 

3.5 y & 

antenatal 

mother’s RBC 

DHA content 

Quality 

score: 9 

[Grade A] 

III 

1

biomarkers = EPA, DHA, AA, AA/EPA, AA/DHA, AA/EPA+DHA; n-3 = omega-3 fatty acids; n-6 = omega-6 fatty 

acids; ALA = alpha linolenic acid; DHA = docosahexaenoic acid; EPA = eicosapentaenoic acid; AA = arachidonic 

acid; E-EPA = ethyl eicosapentaenoate; n = sample size; pts = study participants; NR = not reported; S = 

statistically significant difference; NS = nonsignificant statistical difference; N/A = not applicable; pb = placebo; 

grp = group; wk = week(s); mo = month; RBC = red blood cells; +p<.05 or significant with 95% confidence 

interval; ++p<.01; +++p<.001; ++++p<.0001; Ï = increase; Ð = decrease/reduction; BF = breast feeding; VEP = 

visual evoked potentials; HM = human milk 

Gibson et al.’s VEP acuity did not differ significantly between the dietary DHA groups at 

either 12 or 16 weeks of age, although numbers were limited in each treatment group. VEP 

acuity (n=19) significantly improved with age (0.83 [SD=0.13 logMAR at 12 weeks vs. 0.73 

[SD=0.09] log MAR at 16 weeks, p<0.01). There was no association between VEP acuity and 

the level of DHA in the breast milk, infant plasma or RBC as well as with any sociodemographic variables.138

Jensen et al. failed to find a statistical difference among groups in VEP latency, sweep VEP 

acuity or Teller Card acuity at 120 or 240 days of age in term infants. However, transient VEP 

amplitude was lower in infants of mothers who received the algal DHA supplement than infants 

in the other two groups at 120 days but not at 240 days of age. There were no significant 

correlations betweeb the visual function and the milk DHA or infant plasma PL DHA content at 

120 days of age.248

Jorgensen et al. observed a significant association between visual acuity of the infant at 4 

months of age and the mother’s milk DHA.140, controlling for intake of fatty fish the day before 

sampling. The visual acuity of infants of mothers who ate fish the day before sampling did not 

differ from the rest of the group. Neither did AA, EPA, LA and ALA (omega-3) correlate with 
152

visual acuity, nor did any of the antropometric data (i.e., GA or age at examination). No 

association was found between educational level of the mother and visual acuity or educational 

level and milk DHA.140 In a general linear model, including frequency of consumption of lean 

and fatty fish, and fatty fish intake the day before sampling, all three variables were associated 

positively with milk DHA.140 

Williams et al., in an univariate analysis, found that breast feeding, greater maternal age, and 

consumption of oily fish by the mother antenatally or by the child up to the age of 3.5 years were 

all associated with an increased likelihood of the child having foveal (adult) stereacuity.276 As 

these variables were interrelated, a multiple logistic regression analysis was used to determine 

which factors might be independently associated with the child’s stereoacuity. The variable most 

associated with an increased likelihood of foveal as opposed to worse-than-foveal stereoacuity 

was breast feeding.276 This result was consistent even when it was stratified by age (< or >4 

months), compared with a diet without breast milk. A second variable was the mother’s intake 

of oily fish. The mothers who ate oily fish at least once every 2 weeks during pregnancy were 

more likely to have children who achieved foveal stereoacuity than were the mothers who never 

ate oily fish (adjusted OR: 1.57; 95%CI: 1.00-2.45). There was no statistical evidence of 

interaction between the effects on stereoacuity and whether or not the mother ate oily fish, or for 

breast feeding compared with formula feeding. When only the children whose mothers never 

breastfed (n=101) were selected, foveal stereoacuity in the children (n=20) was still more likely 

if the mothers ate oily fish during pregnancy than if they did not, however, the difference was not 

significant. The correlation between maternal age and children eating oily fish did not reach 

statistical significance using the multiple regression model.276 There was a correlation between 

the child’s stereoacuity and the antenatal mother’s RBC DHA content. 

None of the RCTs reported the power calculation or intention-to-treat approach.336,340

Study quality and applicability. Gibson et al. had a total quality score of 3 (did not report the 

randomization and double-blind method), indicating a good internal validity.336 However, 

Jensen et al. could not be assessed given it was an abstract.340 The allocation concealment was 

unclear in both. The observational studies had a mean quality score of 9. 

Summary Matrix 19: Omega-3 fatty acid content of maternal breast milk, with or without known maternal 

intake of omega-3 fatty acids, influences visual function in term or preterm human infants 

Study Quality

A B C 

Author Year n Author Year n Author Year n I 

Author Year n Author Year n Author Year n II GibsonU 1997 52 

Author Year n Author Year n Author Year n

Applicability 

III Jorgensen 

Williams 

2001 

2001 

39 

435 

 

n = number of allocated/selected participants; RCT = AAdequate vs UUnclear allocation concealment
153

What is the Evidence That the Omega-3 Fatty Acid Content of Infant 

Formula Influences Visual Function in Term or Preterm Human 

Infants? 

What is the Evidence That the Omega-3 Fatty Acid Content of 

Maternal Breast Milk, With or Without Known Maternal Intake of 

Omega-3 Fatty Acids, and Together with the Omega-3 Fatty Acid 

Content of Infant Formula, Influences Visual Function in Term or 

Preterm Human Infants? 

Infant Formula Intake - Preterm Infants 

Nine unique studies met the eligibility criteria in investigating the effect of omega-3 FAs on 

visual function in preterm infants. All these studies were parallel design RCTs published 

between 1992 and 2003. All the studies were summarized in the Growth Pattern Outcomes and 

Neurological Development Outcomes sections (see key questions Growth Patterns & 

Neurological Development-Preterm Infant Formula Intake). (Summary Tables 36, 37) 

Overview of relevant studies 

All the included studies evaluated the influence of intake of infant formula, supplemented 

with omega-3 FAs on visual function (i.e., visual acuity, retinal development, visual behavior 

and attention) in preterm infants. The effect on visual function in the groups receiving omega-3 

FA-supplemented formulas, were compared with the effect in the groups (control) receiving 

standard infant formulas (without omega-3 FA supplementation) and/or human milk. In five of 

the nine studies, visual function measured in infants receiving formulas with or without omega-3 

FA supplementation was compared with visual function in infants receiving breast 

milk.198,207,212,251,254 In all these studies, the breastfed arms were non-randomized and 

served as reference groups. 
154

Summary Table 36: Omega-3 fatty acids intake associated with the visual function in preterm infants 

Study groups1 Author, 

Year, 

Location: 

Length & 

Design 

Group 1 

(n)/ 

Group 4 

(n)

Group 2 

(n)/ 

Group 3 

(n)

Notable clinical 

effects

Notable 

clinicalbiomarker2,3 

correlations

Internal 

validity Applicability 

Birch, 1992, 

US: 

6 mo 

parallel 

RCT212

Soy/marine 

oil: 

EPA+ DHA 

(n=26)/ 

HM (n=8) 

Soy oil: 

ALA 

(n=22)/ 

Corn oil 

(n=18) 

SÐ in VEP for 

all grps at 57 

wks 

S Ð VEP in 

DHA+EPA vs. 

grps 2-3 at 36-

57 wks+ 

NS b-Rod ERG 

at 36-57 wks 

S correlation 

between: RBCDHA/DPA & 

VEP+++

RBC-DHA/DPA 

& FPL+ at 57 

wks 

Jadad total: 2 

[Grade: C]; 

Schulz: Unclear 

II 

Carlson, 

1992, US: 

12 mo 

parallel 

RCT185

Marine oil: 

DHA + EPA 

(n=33) 

Control: 

LA 

(n=34) 

S Ï resolution 

acuity in DHA 

+EPA vs. control 

at 2 & 4 mo +++

S correlation (+) 

RBC DHA at 2 

mo with visual 

acuity at 2,4 mo 

Jadad total: 4 

[Grade: A]; 

Schulz: 

Adequate 

II 

Koletzko, 

1995, 

Germany: 

21 d 

parallel 

RCT251

LCPUFAenriched: 

DHA + 

EPA + ALA 

(n=9) 

Control: 

(n=10)/ 

HM 

(n=8) 

NS difference in 

visual acuity 

across at 21 d 

n/a Jadad total: 2 

[Grade: C]; 

Schulz: Unclear 

III 

Carlson, 

1996, US: 

4 mo 

parallel 

RCT191

Marine oil: 

DHA +EPA 

(n=26) 

Control 

ALA 

(n=23) 

SÏ higher 

acuity in 

DHA+EPA vs. 

control at 2 mo+ 

NS at 4-12 mo 

n/a Jadad total: 3 

[Grade: B]; 

Schulz: Unclear 

II 

Faldella, 

1996, Italy: 

5 mo 

parallel 

RCT198

LCPUFAenriched: 

DHA +EPA+ 

ALA 

(n=21) 

Control 

EPA + ALA 

(n=25)/ 

HM 

(n=12) 

S shorter wave 

(N4 & P4) 

latencies VEP in 

DHA+EPA vs. 

control at 52 

wks PCA++

NS in BAEP & 

ERG (a & b) 

latencies) 

across grps1-3 

At 52 wks PCA, 

inverse 

correlation 

between: 

RBC-DHA & N4 

wave latency +

& RBC-DHA & 

P4 wave 

latency++

Jadad total: 1 

[Grade: C]; 

Schulz: Unclear 

III 

Bougle, 

1999, 

France: 

30 d 

parallel 

RCT254

LCPUFAenriched: 

DHA + EPA 

+ ALA 

(n=14) 

Control 

(n=11)/ 

HM 

(n=15) 

NS in VEP (N1 

wave latency) at 

30 d 

n/a Jadad total: 3 

[Grade: B]; 

Schulz: Unclear 

III 

1

Proceeding from highest omega-3, or lowest omega-6/omega-3, fatty acid content of intervention/exposure; 2

biomarker source; 3biomarkers = EPA, DHA, AA, AA/EPA, AA/DHA, AA/EPA+DHA; n-3 = omega-3 fatty acids; n-6 = 

omega-6 fatty acids; ALA = alpha linolenic acid; DHA = docosahexaenoic acid; EPA = eicosapentaenoic acid; AA = 

arachidonic acid; Length = intervention length; Design = research design; n = sample size; pts = study participants; 

NR = not reported; S = statistically significant difference; NS = nonsignificant statistical difference; n/a = not 

applicable; pb = placebo; grp = group; wk = week(s); mo = month; wt = weight; RBC = red blood cells; PL = 

phospholipid; +

p<.05 or significant with 95% confidence interval; ++p<.01; +++p<.001; ++++p<.0001; ITT = intention-totreat analysis; PP = per-protocol analysis (e.g., completers); Ï = increase; Ð = decrease/reduction; HM = human 

milk; GA = gestational age; PCA = postconception age; CA = corrected age; ERG = electroretinogram; BAEP = 

brainstem acoustic evoked potential 
155

Summary Table 37: Omega-3 fatty acids intake associated with the visual function in preterm infants 

Study groups1 

Author, Year, 

Location: 

Length & Design 

Group 1 

(n)/ 

Group 4 

(n)

Group 2 

(n)/ 

Group 3 

(n)

Notable clinical 

effects

Internal 

validity Applicability 

O’Connor, 2001, 

US, UK, Chile: 

14 mo parallel 

RCT207

Fish/fungal oil: 

DHA 0.27% 

EPA 0.08% 

ALA 2.60% 

(n=140)/ 

HM 

(n=43) 

Egg-TG/fish oil: 

DHA 0.24% 

ALA 2.50% 

(n=143)/ 

Control 

ALA 2.4% 

(n=144) 

(ITT) NS in VEP/FPL 

acuity at 4 mo CA 

S ÏVEP acuity in 

grps1-2 vs. grp3 at 6 

mo CA ++

NS VEP acuity 

across both 

DHA+AA grps 

Jadad total: 3 

[Grade: B]; 

Schulz: 

Unclear 

I 

van WezelMeijler, 2002, 

Netherlands: 

8 mo 

parallel RCT272

LCPUFAenriched: 

DHA 0.34% 

AA 0.70% 

(n=22) 

Control 

(n=20) 

NS in VEP (P200 & 

N300) wave 

latencies at 3 & 12 

mo CA 

NS mean visual 

acuity at 3,6,12 mo 

CA 

Jadad total: 5 

[Grade: A]; 

Schulz: 

Adequate 

III 

Innis, 

2002, US, 

Canada: 

28 d parallel 

RCT201

LCPUFAenriched: 

DHA 0.33% 

AA 0.60% 

(n=66)/ 

HM 

(n=90) 

LCPUFAenriched: 

DHA 0.34% 

 (n=66)/ 

Control 

(n=62) 

NS in FPL visual 

acuity at 48 & 57 

wks PCA 

SÏ visual acuity in 

HM than grps1-3 at 

57 wks PCA +

Jadad total: 3 

[Grade: B]; 

Schulz: 

Unclear 

I 

1

Proceeding from highest omega-3, or lowest omega-6/omega-3, fatty acid content of intervention/exposure; n-3 = 

omega-3 fatty acids; n-6 = omega-6 fatty acids; ALA = alpha linolenic acid; DHA = docosahexaenoic acid; EPA = 

eicosapentaenoic acid; AA = arachidonic acid; E-EPA = ethyl eicosapentaenoate; Length = intervention length; 

Design = research design; n = sample size; pts = study participants; NR = not reported; NS = nonsignificant statistical 

difference; n/a = not applicable; pb = placebo; grp = group; wk = week(s); mo = month; wt = weight; +p<.05 or 

significant with 95% confidence interval; ++p<.01; +++p<.001; ++++p<.0001; ITT = intention-to-treat analysis; PP = perprotocol analysis (e.g., completers); Ï = increase; Ð = decrease/reduction; GA = gestational age; PCA = 

postconception age; CA = corrected age; ERG = electroretinogram; VEP = visual evoked potential; FPL = forcedchoice preferential looking using Teller’s card test 

Qualitative synthesis of relevant studies’ key characteristics 

Study characteristics. All nine studies had at least two randomized groups. Three studies 

involved three randomized groups.201,207,212 Of the nine trials, five used non-randomized groups 

of infants receiving human milk (reference standard).198,207,212,251,254 

The trials had been conducted in the following countries: the United States,185,191,212the 

Netherlands,272 France,254 Italy,198 and Germany.251 Two trials201,207were conducted 

multinationally in different centers in the United States, United Kingdom, and Chile,207 and in 

Canada and United States.207 The Birch et al. study was funded by National Eye Institute, 

National Institute of Child Health and Development, United Cerebral Palsy Research 

Foundation, and Pediatric Subunit United States Public Health Service grants.212 The Carlson et 

al. study was supported by National Eye Institute and Ross Laboratories, Columbus, OH.185 

Koletzko et al. was funded by Deutsche Forschungsgemeinschaft and Milupa AG, Germany.251 

Carlson et al. was supported by National Eye Institute, Ross Products Division, National Institute 

of Child Health and Development, and Abbott Laboratories.191 O’Connor et al. was supported 

by Ross Products Division and Abbott Labs.207 van Wezel-Meijler et al. was funded by Numico 
156

Research.272 Innis et al. was supported by Mead Johnson Nutritionals.201 Faldella et al.and 

Bougle et al. did not report their funding source.198,254 

Population characteristics. The total number of enrolled infants, including reference nonrandomized breastfed infants, across the nine trials was 1,171 with a range from 27251to 

470207infants. 

All nine trials reported the infants’ study arm-specific means of GA. The range of study armspecific mean GA across all trials was 27.0191 to 33.9 weeks.254 In all nine trials, the GA was 

relatively evenly distributed amongst the study arms. Four studies did not report the percentage 

of males (or females) across study groups (randomized as well as 

reference/breastfed).198,212,251,254 The total percentage of males across the remaining five studies 

was from 35.5%272 to 53.4%.207 In four studies, the percentage of male infants across the 

randomized groups was similar. One study failed to report the study arm-specific distribution of 

sex.191

Racial/ethnical composition was reported only in three studies,185,191,207 of which two 

reported arm-specific percentages of White/Black185and White/Black/Hispanic/Other infants.207 

The race distribution across the randomized groups in these studies was more or less balanced. 

The remaining one trial reported the race percentage (%White/Black) of the total study 

sample.191 In two studies by Carlson et al., the majority of participants belonged to the Black 

race.185,191 All studies reported the birth weight of the infants. 

Six studies reported ranges of birth weight for the entire sample, as well as the arm-specific 

means of birth weight.185,201,207,212,251,272 Two studies reported only arm-specific means of birth 

weight.198,254 Birth weight, across the majority of the studies ranged from 750 to 1,850 

grams.185,201,207,212,251,272 In six studies, birth weight was similarly and evenly distributed across 

the randomized study arms.185,201,207,212,251,272 

Of the nine studies, six described both the inclusion and exclusion criteria with enough 

detail.185,201,207,212,251,272 Two trials reported only inclusion or exclusion criteria.191,254 One trial 

reported neither inclusion nor exclusion criteria.198

The infants in most of these studies were healthy preterm infants (< 37 weeks GA), free of 

respiratory or neurological disease, able to receive enteral feeding, had no severe intrauterine 

growth retardation, and did not require long-term mechanical ventilation or gastrointestinal 

surgery after birth. The studies excluded infants with risk factors for visual development, 

congenital abnormalities, retinopathy (> stage 2), intraventricular or periventricular hemorrhage 

(> grade 2), metabolic abnormalities, or history of maternal drug abuse. The study sample of one 

trial consisted of 49% infants suffering from bronchopulmonary dysplasia.191 

Only three studies reported parental education.185,191,207 O’Connor et al. presented only 

maternal education (in years and earned degrees).207 In this study, randomized formula groups 

had similar mean duration of maternal education. However, the breastfed arm had a higher mean 

maternal education compared with the formula groups (breastfed group:15.1 years vs. formula 

groups:12.9, 13.1, and 12.8 years). In two other trials, years of parental (mother’s and father’s) 

education were balanced across the randomized study arms,185,191 and the number of years of 

education in these trials ranged from 11.4 to 12.2. Only one study reported percentage of 

maternal smoking during pregnancy.207 The formula (randomized) groups had strikingly high 
157

rates of maternal smoking during pregnancy compared with the breastfed group (formula groups: 

28%, 25.4%, 29.3% vs. breastfed group: 4.7%).

Intervention/exposure characteristics. In all nine trials, the study intervention was the 

assignment of dietary standard infant formulas (preterm/term) with or without the supplemental 

omega-3 and/or omega-6 LCPUFAs. In six trials, breast milk was the study exposure aside from 

the randomly assigned intervention (infant formula: with or without the supplementation of 

omega-3 and/or omega-6 LCPUFA).198,201,207,212,251,254 

Some of these studies defined breastfed infants as those whose dietary intake of human milk 

accounted for 75% to 85% of their total dietary intake.198,201,207,212 The amount/content (i.e., 

mean g/100 g, % of total FAs), type (i.e., ALA, LA, DHA, AA, EPA), and source (i.e., egg-TG, 

corn-, soy-, marine-, fish-, and/or fungal-oil) of omega-3 and/or omega-6 LCPUFA 

supplementation differed slightly across the studies. The formula content of DHA 

supplementation in the experimental arms across the trials ranged from 0.14%201 to 0.60%.254 

For the majority of trials, the content of DHA supplementation was confined between 0.20% and 

0.35% inclusively.185,191,198,207,212,251 

Of the nine studies, two did not report the formula content/amount (%) of EPA 

supplementation in the experimental arms.201,272 Across the remaining seven trials, the formula 

content/amount (%) of EPA supplementation in the experimental arms, ranged from 0.03%251to 

0.65%.212 Mostly, the EPA formula content was confined between 0.03% to 0.1%.191,198,207,251,254 

The formula content/amount (%) of ALA supplementation in the experimental arms was 

reported in seven trials,185,191,198,207,212,251,254and ranged from 0.20%251 to 3.10%.185 Amongst the 

studies, the most common source of omega-3 and/or omega-6 LCPUFA supplementation was 

marine oil.185,191,341

In three trials, the sources used for omega-3 and/or omega-6 LCPUFA supplementation were 

oils derived from the alga and fungus.201,207,272 One study used egg-derived triglyceride (eggTG).207 Two trials did not report the source of omega-3 and/or omega-6 LCPUFA 

supplementation.198,254 Birch et al. used corn and soy oils as sources of FA supplementation.212 

In almost all studies, the infants were enrolled and assigned to the interventions within ten 

days after their birth. Only one study reported the rate of formula intake (at least 0.72 L 

formula/day through 79 weeks PCA.185 The duration of preterm formula intake varied between 

the studies, ranging from 21 days251to 12 months.207 Upon reaching the weight of 1,800 g, the 

infants were switched from preterm to term formulas with or without LCPUFA 

supplements.185,207 In one study, standard and supplemented formulas differed from their 

commercial versions in that the former contained nucleotides, β-carotene, lactose, and αtocopherol.207 

Two studies reported that the assigned study formulas had nutritionally similar content 

(except for fat composition), and the only difference between them was the composition of 

omega-3/omega-6 FAs.191,212 In two trials, the manufacturer of the study formula (Enfamil) was 

Mead-Johnson Nutritional Group, Evansville, Indiana.201,212 In other trials, the manufacturer of 

the study formulas included Milupa AG, Friedrichsdorf, Germany (Preaptamil with 

Milupan),198,251 Ross Products Division, Columbus, OH (Similac Special Care),191 and Nutricia, 
158

Zoetermeer, The Netherlands (product name not reported).272 None of the studies reported welldocumented data on compliance. 

The study protocol in the trial by O’Connor et al. did not limit the amount or duration of 

human milk feeding. Whenever the study infants were being weaned from human milk, the 

protocol required that the infant be fed the assigned study formula unless there was a medical 

indication to do otherwise.207 

Cointervention characteristics. None of the studies described how the dietary formula 

intake and background diet was monitored. Three studies reported vitamin intake.212,251,254 For 

example, one trial reported that the study groups were given a daily supplementation of 1,200 IU 

of vitamin D and 4.5 mg of vitamin E.254 Another trial reported that all infants in the study were 

given daily multivitamin drops (A, C, and D) and vitamin E (25 IU per day) for 14 days, after 

feeding was well tolerated.212 In the trial by Koletzko et al., the infants received oral vitamin 

supplement providing 0.8 mg α-tocopherolacetate/kg body weight.251 

Outcome characteristics. Visual acuity parameters (FPL and/or VEP) were evaluated in all 

the trials. In these studies, FPL was measured by Teller Acuity Card 

Procedure.185,191,201,207,212,251,272 The FPL values were expressed as means of Log10 (cycles/cm) 

[SD] and were derived from threshold of the finest grating size identified (cycles/cm), based on 

the infant’s behavior, and the distance between the infant and visual stimulus. 

The SD was expressed in octaves (SD of log acuity score/0.301). The VEP values were 

measured in five studies.198,207,212,254,272 For the VEP responses, peak-to-peak amplitude (in 

mvolts) and latency (in msec) for each check size were determined. The VEP acuity (in 

logMAR) was obtained from linear functions relating amplitude to the logarithm of each check 

size. Lower LogMAR values indicate better visual acuity. 

Two trials reported ERGs.198,212 The ERGs were reported as latencies and rod/cone ERG 

amplitudes (Naka-Rushton parameters: log threshold, LogVmax, and log k). 

Study quality and applicability. The nine RCTs received a mean Jadad total quality score 

of 2.9, approaching a good internal validity (Summary Matrix 20). van Wezel-Meijler et al. 

received a score of 5,272 Carlson et al. received a score of 4,185 four reports received a score of 

3,191,201,207,254 two reports received a score of 2,212,251 and Faldella et al. received a score of 1.198 

Six trials failed to report the method of randomization,123,305,312,316,317,319 three were 

unblinded,310,316,317 five trials did not decribe the method of double-blinding,123,150,305,312,319 and 

two did not report the reasons for dropouts.305,317

Summary Matrix 20: Omega-3 fatty acid intake associated with the visual function in preterm infants 

Study Quality

A B C 

Author Year n Author Year n Author Year n 

I O’ConnorU 

InnisU 2001 

2002 

470 

194 

 

Author Year n Author Year n Author Year n II CarlonA 1992 79 CarlsonU 1996 36 UauyU 1992 81 

Author Year n Author Year n Author Year n

Applicability 

III van MezelMeijlerA 2002 55 BougleU 1999 40 KoletzkoU 

FaldellaU 1994 

1996 

27 

66 

n = number of allocated/selected participants; RCT = AAdequate vs UUnclear allocation concealment
159

Qualitative synthesis of individual study results 

The study results regarding the effects of LCPUFA supplementation on visual acuity in 

healthy preterm infants are not consistent. Five studies observed that preterm infant formula 

supplemented with LCPUFA is associated with better FLP and/or VEP acuity.185,191,198,207,212 In 

contrast, the remaining studies did not observe any relationships between LCPUFA 

supplementation and the development of visual acuity (FLP and/or VEP).201,251,254,272 In two 

studies, ERG responses were not statistically significantly different across the formula groups at 

52 to 57 weeks postconceptional age (PCA).198,212 

According to study results obtained by Birch et al.,212 the soy/marine oil-supplemented 

formula (DHA+EPA: 1.0 g/100 g) group had a better VEP acuity than the corn oil-based formula 

(LA: 24.2, ALA: 0.5 g/100g) group at 36 weeks PCA. At 57 weeks PCA, the soy/marine oilsupplemented formula group had a statistically significantly better VEP acuity than the corn oiland soy-based formula groups. The soy/marine oil-supplemented formula group had a better 

FPL acuity (of borderline statistical significance) than the corn oil-supplemented formula group 

at 57 weeks PCA. Statistically significant differences were observed for rod threshold at 36 

weeks PCA between the study arms (higher in corn-oil supplemented formula group vs. human 

milk, soy- or soy/marine-oil supplemented formula groups). The rod ERG responses between 

the groups were not statistically significantly different at 57 weeks PCA. There was no 

statistically significant differences for cone ERG parameters between the groups at 36 and 57 

weeks postconception.212

Carlson et al.185 found a statistically significant effect of marine-oil supplementation on 

visual acuity at the age of 2 and 4 months. Specifically, infants fed with marine oilsupplemented formula (DHA: 0.2 and EPA: 0.3 g/100 g) had a better visual acuity than those fed 

with standard formula (ALA: 3 g/100 g) group. 

The study by Koletzko et al. did not demonstrate any statistically significant effect of 

LCPUFA supplementation on visual acuity.251 

The results obtained by Carlson et al.191 demonstrated that healthy infants (i.e., those without 

bronchopulmonary dysplasia) who were fed LCPUFA supplemented formula had a better visual 

acuity at 2 months of age than those infants who were fed formula with no supplementation (2.90 

vs. 2.15 cycles/degree, p< 0.05). In contrast, there was no difference in visual acuity between the 

formula groups at 4 months. The study authors detected an interaction between 

bronchopulmonary dysplasia and diet at 0 and 2 months (p<0.03 and p<0.005, respectively). 

Namely, in infants without bronchopulmonary dysplasia the LCPUFA supplementation was 

related to an improved visual acuity. In contrast, this supplementation in infants with 

bronchopulmonary dysplasia was related to poorer visual acuity. 

Faldella et al. found that the mean latencies of flash VEP (N4 and P4 waves) at 52 weeks 

PCA were significantly shorter in infants from LCPUFA supplemented formula (DHA: 0.23% 

and EPA: 0.08%) and breast milk groups compared with infants from standard/control formula 

groups.198 No significant differences were observed across the study groups (control formula vs. 

LCPUFA-supplemented formula vs. human milk) in ERG and BAEP parameters (latencies a and 

b) measured at 52 weeks postconception.198
160

Bougle et al. did not find any difference amongst the breastfed and the formula (with and 

without LCPUFA supplement) fed groups in VEP responses (latency of wave N1) after 30 days 

of diet.254

Results in the trial by O’Connor et al. suggested that study diet did not have any significant 

effect on FPL and VEP acuity at 4 months CA.207 However, at 6 months CA, infants randomized 

to either fish/fungal oil-supplemented or egg-TG/fish oil-supplemented formula had higher mean 

VEP acuity than infants in the control formula group. Infants in the fish/fungal oil- and eggTG/fish oil-supplemented formula groups had similar VEP acuity at 4 and 6 months CA. There 

was no difference with respect to FPL acuity between the study groups at 6 months CA.207 

van Wezel-Meijler et al. did not reveal any statistically significant differences in flash VEP 

latencies (P200 and N300) and FLP acuity responses at any stage of follow up (at 3 and 12 

months of age) between the supplemented and non-supplemented formula groups.272 The 

authors reported that VEP responses could not be obtained from three infants at 3 months of age 

for technical reasons, and because of lack of parents’ permission. 

According to Innis et al., three randomized groups of infants had similar mean FLP values of 

visual acuity at 48 and 57 weeks PCA (differences were not statistically significant).201 At 57 

weeks PCA, breastfed term infants had a significantly higher visual acuity than preterm infants 

randomized to receive either control (without LCPUFA supplement) or LCPUFA supplemented 

formulas.201

In Birch et al, the LCPUFA content of RBC-DHA/DPA ratio correlated with both FPL and 

VEP at 57 weeks PCA.212 Based on ANOVA, there was a statistically significant correlation 

between RBC-PE-DHA at 2 months and visual acuity at 2 and 4 months in Carlson et al.185

Faldella et al. found a negative correlation between the RBC DHA and the N4 and P4 wave 

latency of the VEP at 52 wks PCA.198

The study by Birch et al.212 reported the number (n=2) and reasons (medical complications) 

of dropouts/withdrawals. Carlson et al.185 reported that of the 79 infants, there were ten noncompleters (reasons for not completing the study not given) who eventually were replaced. At 

the end of the study, the authors also excluded four infants who had received enteral nutrition. 

Carlson et al.191 reported that of the 94 enrolled infants, 35 were lost at 2-month follow up. Of 

those, 19 infants were lost for their intolerance to enteral feeding leading to sepsis and 

necrotizing enterocolitis, and an additional 14 infants dropped out of the study because their 

parents moved or refused any further participation in the study. 

The study authors stated that the reasons for non-participation were not related to the type of 

study diet. Although Faldella et al. reported that eight infants could not complete the follow up, 

they failed to provide information on the reasons for the loss/withdrawal of infants.198 In their 

study, Bougle et al. presented the data and reasons for dropouts: necrotizing enterocolitis (n=1), 

hydrocephalus (n=1), and transfer to referring hospital (n=5).254 

According to O’Connor et al., the percentage of study completers at 12 months of 

observation was about 80%.207 van Wezel-Meijler et al. reported that of the 55 enrolled infants, 

13 were excluded due to different reasons such as necrotizing enterocoloitis (n=2), chronic lung 

disease (n=3), grade 4 retinopathy of prematurity (n=1), cystic periventricular leucomalacia (1), 

practical reasons (n=4), and change from formula feeding to mother’s expressed milk (n=2).272 
161

According to Innis et al., 21 infants did not complete the pre-term diet protocol due to 

necrotizing enterocolitis or other gastrointestinal disease, complications unrelated to the study, 

formula intolerance, receiving oxygen at discharge, and protocol violation.201

Quantitative synthesis 

Visual acuity was measured both through behavioral and electrophysiologic tests. For the 

behaviorally-based tests, we extracted data from the studies using the Teller Acuity Card 

Procedure (ACP) or the Forced Choice Preferential Looking Procedure (FPL). For all of the 

behaviorally-based tests, stimuli were high-contrast square-ware grating of two discrete 

luminance presented in equal duty cycles. Grating acuity can be expressed in units of cycles per 

degree (cy/degree) of visual angle. Higher values of cy/degree indicate better visual acuity. For 

electrophysiologic tests, we extracted data from studies using steady-state or transient VEP tests. 

Visual acuity was expressed as the minimal angle of resolution (MAR). Opposite to cy/degree, 

the lower the MAR value, the better the visual acuity. In this systematic review, visual acuity 

was measured at age 0, 2, 3, 4, 6, 7, 8, 9, 12, 24, and 39 months. In visual acuity research, 

measures of dispersion, such as the standard error of the mean are commonly represented in units 

of octaves. A one octaves change represents a doubling or a halving of the stimulus spatial 

frequency (or a thinning of the width of the individual stimulus lines by one half). In the studies 

included in this systematic review, visual acuity data were reported in cy/degree, MAR, log 

cy/degree, and log MAR. Most of the standard deviations of the visual acuity are in these units 

as well, although some are in octaves. For standardization, all the data has been converted into 

octaves. 

Almost all of the studies included in this review only reported the mean of the visual acuity 

for each dietary group, not the difference of visual acuity between the groups. Thus, the visual 

acuity difference between groups consuming a source of DHA and groups not consuming a 

source of DHA needed to be calculated from individual values. Due to the different meanings of 

the magnitude of cy/degree and MAR, when the unit of the visual acuity is cy/degree, the visual 

acuity difference was calculated by subtracting the mean of visual acuity of the no-DHA intake 

group from the mean of visual acuity of the DHA intake group; however, if the unit was MAR, 

the reverse was done. Finally, these results (mean visual acuity difference with the standard 

error) were recorded into the database as the outcome data for each trial. Some studies did not 

report the actual data, but a graph. In these cases, data were extracted from the graph. The visual 

acuity development is very sensitive to the age of the infants. One of the complexities of this 

systematic review was that each included study started at different ages, for example, some 

visual acuity data were tested at the very beginning of the study. Since this data is actually 

baseline information, it was excluded from the final analyses since the data would confound 

observed treatment effects. For example, in the Hoffman 2003 study, there were two 

measurements, one obtained from 4 to 6 months, and the other at 12 months. However, the 

treatment was introduced from 4 to 6 months. This means that visual acuity data obtained at 4 to 

6 months was actually baseline information. If we combine this data with data obtained from the 

other studies at the same age, the treatment effectiveness would be confounded by this baseline 

information. 
162

Since the durations of the supplementation differed across trials, some studies tested visual 

acuity after the supplement was stopped. In order to separate “during”, and “post”supplement 

effectiveness, the data were split into two sets according to the duration of the supplementation 

reported in each trial. The effectiveness of the supplement was evaluated by using the database 

for “during” supplement. 

Statistical analysis 

 It was not reasonable to combine the results of visual acuity difference obtained from 

fullterm infants and preterm infants, or from different test ages, or from different visual acuity 

tests (behaviorally-based or electrophysiological-based), or from different study components 

(randomized and non-randomized components). One meta-analysis is required for each 

subgroup in which all the factors are the same across the studies. Therefore, the number of 

different combinations of these factors determined the number of meta-analyses needed for this 

systematic review. 

Although all the included studies have a common interest, i.e., the effectiveness of omega-3 

on child visual acuity, most of the studies (73%) included more than two dietary groups. 

The fixed effect model was used to obtain combined estimates of visual acuity differences 

and their standard errors within each category in some meta-analyses. The weights of each study 

were taken by using the reciprocal of the variance of the visual acuity difference of each study. 

When heterogeneity was present between studies, a Dersimonian and Laird random-effect 

method was used instead to get the pooled estimates of the visual acuity difference across the 

studies. However, it is notable that in some meta-analyses that only included a small number of 

studies, the test for heterogeneity should be interpreted carefully. 

The median of the number of dietary groups in a single study was 3.5. The dietary groups 

could be classified into 4 major groups—no-DHA intake, DHA intake, DHA+AA intake and 

human milk (HM) groups. Thus, the comparisons conducted were: DHA vs no-DHA intake and 

DHA+AA vs no-DHA. These were two randomized comparisons, whereas, a non-randomized 

comparison of HM vs no-DHA intake was also conducted as a reference. 

DHA vs no-DHA 

Meta-analysis for behaviorally-based test at 0, 2, 4, 6, and 9 months (Table 4, Figure 12). 

There was no statistically significant difference in visual acuity between DHA intake and 

placebo groups for preterm infants based on the behavioral test at age 0, 2, 4, 6, and 9 months. 

Table 4. Meta-analysis of visual acuity difference (DHA vs. no-DHA) for preterm infants based on behavioral 

test

Age Studies Heterotest Point estimate 95% C.I. P-value 

0 1Carlson 1992 - 0.20 (-0.11, 0.51) 0.21 

2 1Carlson 1992, 2Innis 2002 0.07 0.27 (-0.18, 0.71) 0.24 

4 1Carlson 1992, 2Innis 2002 0.02 0.15 (-0.23, 0.52) 0.44 

6 1Carlson 1992 - 0.19 (-0.03, 0.41) 0.08 

9 1Carlson 1992 - 0.20 (-0.02, 0.42) 0.07 

Age: in months; Studies: superscripts correspond to the report number in the graphs; Heterotest: Pvalue for the heterogeneity test; Point estimate: (in octaves); positive value means the point estimate 

favors DHA intake over no-DHA intake; P-value: P-value for the effectiveness–only one study in this 

meta-analysis. 
163

Difference in Visual Acuity (octaves)

Corrected Age (months)

0

2

4

6

9

1

2, 1

2, 1

1

1

← Favours no-DHA Favours DHA →

RefID

-0.2 0.0 0.2 0.4 0.6

Figure 12. Meta-analysis of visual acuity difference (DHA vs. no-DHA) in preterm infants based on the 

behavioral test. Shaded circles represent the pooled estimates of visual acuity difference from the meta-analysis of 

randomized comparisons (formula fed DHA vs formula fed no-DHA) tested at certain ages. The open symbols 

represent the pooled estimates of visual acuity difference from the meta-analysis of nonrandomized comparisons 

(human milk vs formula without DHA). 

DHA+AA vs no-DHA 

Meta-analysis for behaviorally-based test at 0, 2, 3, 4 and 6months (Table 5, Figure 13). 

There is no statistically significant difference on visual acuity between DHA+AA intake and 

placebo groups for preterm infants based on the behavioral test at age 0, 2, 4, 6, and 9 months. 
164

Table 5. Meta-analysis of visual acuity difference (DHA+AA vs. no-DHA) for preterm infants based on 

behavioral test 

Age Studies Heterotest Point estimate 95% CI P-value 

0 6Carlson 1996 - 0.24 (-0.37, 0.85) 0.44 

2 

2

Innis 2002, 4O’Connor 

2001, 6

Carlson 1996 0.12 0.12 (-0.08, 0.33) 0.24 

3 3Wezel-Meijl 2002 - 0.30 (-0.03, 0.63) 0.08 

4 

2

Innis 2002, 4O’Connor, 5

Birch 1992 <0.01 0.10 (-0.18, 0.38) 0.50 

6 

3

Wezel-Meijl 2002,

4

O’Connor 0.20 0.06 (-0.11, 0.23) 0.46 

Age: in months; Studies: superscripts correspond to the report number in the graphs; Heterotest: P-value for the 

heterogeneity test; Point estimate: (in octaves); positive value means the point estimate favors DHA intake over noDHA intake; P-value: P-value for the effectiveness–only one study in this meta-analysis. 

Difference in Visual Acuity (octaves)

Corrected Age (months)

0

2

3

4

6

6

2, 4, 6

3

2, 4, 5

3, 4

← Favours no-DHA Favours DHA+AA → RefID

-0.4 -0.2 0.0 0.2 0.4 0.6

Figure 13. Difference in visual acuity (DHA+AA vs no-DHA)in preterm infants based on the behavioral based 

test. Shaded circles represent the pooled estimates of visual acuity difference from the meta-analysis of randomized 

comparisons (formula fed DHA vs. formula fed no-DHA) tested at certain ages. The open symbols represent the 

pooled estimates of visual acuity difference from the meta-analysis of nonrandomized comparisons (human milk vs. 

formula without DHA). 
165

Meta-analysis for Electrophysiologically based test at 0, 4 and 6 months (Table 6, Figure 

14). Except for the results at 4 month, the results show that at 0 and 6 month, DHA+AA intake 

group show better visual acuity than the placebo group. Notably, there is only 1 study at each 

month support the results. 

Table 6. Meta-analysis of visual acuity difference (DHA+AA vs. no-DHA) for preterm infants based on 

electrophysiological test 

Age Studies Heterotest Point estimate 95% CI P-value 

0 5Birch 1992 - 0.3 (0.16, 0.44) <0.01 

4 4O’Connor, 5Birch 1992 <0.01 0.44 (-0.41, 1.28) 0.31 

6 4O’Connor - 0.51 (0.22, 0.8,) <0.01 

Age: in months; Studies: superscripts correspond to the report number in the graphs; Heterotest: Pvalue for the heterogeneity test; Point estimate: (in octaves); positive value means the point estimate 

favors DHA intake over no-DHA intake; P-value: P-value for the effectiveness–only one study in this 

meta-analysis. 

Difference in Visual Acuity (octaves)

Corrected Age (months)

0

4

6

5

4, 5

4

← Favours no-DHA Favours DHA+AA → RefID

-0.4 0.0 0.4 0.8 1.2

Figure 14. Difference in visual acuity (DHA+AA vs. no-DHA) in fullterm infants based on Electrophysiological 

test. Shaded circles represent the pooled estimates of visual acuity difference from the meta-analysis of randomized 

comparisons (formula fed DHA vs. formula fed no-DHA) tested at certain ages. The open symbols represent the 

pooled estimates of visual acuity difference from the meta-analysis of nonrandomized comparisons (Human milk vs. 

formula without DHA). 
166

Human Milk vs no-DHA 

Meta-analysis for Behaviorally based and Electrophysiologically based test at 0, 2, 4 and 6 

months (Table 7). 

Table 7. Meta-analysis of visual acuity difference (HM vs no-DHA) in preterm infants based on the behavioral 

and electrophysiological tests 

Test Age Heterotest Point estimate 95% CI P-value 

B 2 0.71 -0.01 (-0.2, 0.17) 0.9 

B 4 0.02 0.26 (0.04, 0.49) 0.02 

B 6 - 0 (-0.31, 0.31) 1 

E 0 - 0.6 (0.46, 0.74) <0.01 

E 4 0.03 0.3 (-0.25, 0.84) 0.29 

E 6 - 0.85 (0.46, 1.24) <0.01 

B: Behavioral test. E: Electrophysiological test; Age: in months; Heterotest: P-value for the heterogeneity test; 

Point estimate: of meta-analysis of certain age (in octaves); The positive value means the point estimate favors 

DHA intake over no-DHA intake; P-value: P-value for the effectiveness; only one study in this meta-analysis 

Impact of covariates and confounders 

Carlson et al. controlled the results for potential independent variables related to visual 

function such as birth weight, gestational age, oxygen supplementation, enrollment weight, RBC 

DHA at 2 months, and sex. Oxygen supplementation was negatively related to visual acuity at 

term in the whole population, whereas, birth weight and gestational age were derectly associated 

with visual acuity.185 In a second trial, Carlson et al. used a regression analysis and correlations 

among neonatal and perinatal characteristics and 4 months grating acuity.191 Variables were 

mechanical ventilation, birth weight, age and RBC DHA in infants, among others. Total hours 

of mechanical ventilation, volume of packed RBCs and days required to reach enteral intake of 

418 kj/kg/d were significantly negatively correlated with visual acuity at 4 months of CA. Birth 

weight was positively correlated with a higher visual acuity at 4 months.191

The power calculation was reported in four trials,123,310,312,316 while the intention-to-treat 

analysis approach was reported in only one study.310

Infant Formula Intake - Term Infants 

Thirteen unique parallel design RCTs met eligibility criteria. These studies were published 

between 1995 and 2003. All but one trial126 were summarized in the Growth Pattern Outcomes 

section (see key question: Growth Patterns-Term Infant Formula Intake). (Summary Tables 38-

40) 

Overview of relevant studies 

Carlson et al evaluated the effect of feeding DHA + AA (0.1 wt% and 0.43 wt%, 

respectively) supplemented formula compared with unsupplemented formula from birth to 12 

months of age on visual acuity using the Teller Acuity Card protocol at 2, 4, 6, 9 and 12 months 

of age.277(Summary Table 38) 
167

Summary Table 38: Omega-3 fatty acids intake associated with visual function in term infants 

Study groups1 

Author, Year, 

Location: 

Length & 

Design 

Group 1 

(n)/ 

Group 4 

(n)

Group 2 

(n)/ 

Group 3 

(n)

Notable clinical 

effects

Notable 

clinicalbiomarker 

correlations 

Internal 

validity Applicability 

Makrides, 1995 

Australia: 

30 wk 

parallel RCT262

DHA+GLA 

(n=13) 

control 

(n=19) 

S improved VA of 

DHA+GLA infants 

at 16 wk+++ & 30 

wk++

S Ï % of 

DHA+GLA infants 

were able to 

evoke cortical 

responses to the 

smallest 

checkerboard 

pattern+++

S correlation 

RBC DHA & 

VEP acuity at 

16 wk+++ & 30 

wk++ of age 

Jadad 

total: 2 

[Grade: C]; 

Schulz: 

Unclear 

II 

Carlson, 1996, 

US: 

12 mo 

parallel RCT277

DHA+AA 

(n=19) 

Control 

(n=20) 

S better VA with 

DHA+AA at 2 mo 

of age ++

n/a Jadad 

total: 3 

[Grade: B]; 

Schulz: 

unclear 

II 

Jorgensen, 

1998, 

Denmark: 

4 mo parallel 

RCT264 

DHA+EPA 

(n=12) 

DHA+EPA+

GLA 

(n=14)/ 

control 

(n=11) 

NS effect of DHA 

on VA 

NS VA at 4 mo 

& RBC DHA, 

EPA, or AA 

S negative 

correlation VA 

& RBC CPG 

LA+

Jadad 

total: 2 

[Grade: C]; 

Schulz: 

Unclear 

III 

Auestad, 1997, 

US: 

12 mo 

parallel RCT104 

DHA 0.01% 

fa 

(n=43) 

DHA+AA 

(n=46)/ 

control 

(n=45) 

NS acuity 

thresholds at 

2,4,6,9 or 12 mo 

of age using either 

VA method 

NS FPL at 2,4,6,9, 

12 or 39 mo of 

age 

n/a Jadad 

total: 3 

[Grade: B]; 

Schulz: 

Unclear 

I 

Innis,1997, 

US, Canada: 

90 d 

parallel RCT 263

LA/ALA 

9.5/1 

(n=59) 

LA/ALA 

7.3/1 

(n=57) 

NS FPL at 90 d of 

age 

NS VA & 

plasma & RBC 

CPG DHA 

Jadad 

total: 2 

[Grade: C] 

Schulz: 

Unclear 

I 

1

Proceeding from highest omega-3, or lowest omega-6/omega-3, fatty acid content of intervention/exposure; 2

biomarker source; 3biomarkers = EPA, DHA, AA, AA/EPA, AA/DHA, AA/EPA+DHA; n-3 = omega-3 fatty acids; n-6 

= omega-6 fatty acids; ALA = alpha linolenic acid; DHA = docosahexaenoic acid; EPA = eicosapentaenoic acid; AA 

= arachidonic acid; Length = intervention length; Design = research design; n = sample size; pts = study 

participants; NR = not reported; S = statistically significant difference; NS = nonsignificant statistical difference; n/a = 

not applicable; pb = placebo; grp = group; wk = week(s); mo = month; wt = weight; RBC = red blood cells; PL = 

phospholipid; CPG = choline phosphoglycerides; EPG = ethanolamine phosphoglycerides; +

p<.05 or significant with 

95% confidence interval; ++p<.01; +++p<.001; ++++p<.0001; ITT = intention-to-treat analysis; PP = per-protocol 

analysis (e.g., completers); Ï = increase; Ð = decrease/reduction; VA = visual acuity; PL = phospholipids; d = 

day(s); GLA = γ-linolenic acid; FPL = forced-choice preferential looking using Teller’s card test 
168

Summary Table 39: Omega-3 fatty acids intake associated with visual function in term infants 

Study groups1 Author, 

Year, 

Location: 

Length & 

Design 

Group 1 

(n)/ 

Group 4 

(n)

Group 2 

(n)/ 

Group 3 

(n)

Notable clinical 

effects

Notable 

clinicalbiomarker 

correlations 

Internal 

validity Applicability 

Jensen,1997, 

US: 

120 d 

parallel 

RCT203 

F1 

(LA/ALA 

44) 

(n=20)/ 

F4 

(LA/ALA 

4.8) 

(n=20) 

F2 (LA/ALA 

18.2) 

(n=20)/ 

F3 (LA/ALA 

9.7) 

(n=20) 

NS latency VEP 

among gps at 120 & 

240 d 

NS amplitude VEP 

among gps at 120 & 

240 d 

NS plasma & 

RBC PL DHA 

& amplitude at 

120 & 240 d 

Jadad total: 

2 [Grade: 

C]; 

Schulz: 

Unclear 

II 

Birch, 1998, 

US: 

4 mo 

parallel 

RCT182

DHA 

(n=20) 

DHA + AA 

(n=19)/ 

control 

(n=21) 

S poorer sweep VEP 

acuity in control than 

DHA+++ or DHA+

AA +++ at 6 wk; DHA++ or 

DHA+

AA+ at 17 wks; 

DHA++ or DHA+

AA++

at 52 wks 

NS diet on FPL 

acuity 

S better ERG & DHA 

or DHA+

AA at 6 wk+

S RBC DHA 

17 wks & 

better sweep 

VEP acuity at 

6 wk+++, 17 

wk++ & 52 

wk+++

S 6 wk sweep 

VEP acuity & 

17 wk RBC n3/n-6 

LCPUFA+++

S 17 wk RBC 

n-3/n-6 

LCPUFA & 

sweep VEP at 

6 wk+++, 17 

wk+, 52 wk+++

S log k & RBC 

CPG DHA at 6 

wk+

Jadad total: 

5 [Grade: 

A]; 

Schulz: 

Adequate 

I 

Auestad, 

2001a, US: 

4 mo 

parallel 

RCT227

DHA+ 

AA (eggTG) 

formula 

(n=80) 

DHA+ AA 

(fish/fungal) 

formula 

(n=82)/ 

control 

formula 

(n=77) 

NS FPL at 2,4,6 & 12 

mo of age 

n/a Jadad total: 

5 [Grade: 

A]; 

Schulz: 

Adequate 

I 

Auestad, 

2001b, US: 

4 mo 

parallel 

RCT227 

DHA + 

AA 

formula/ 

HM 

(n=83) 

Control 

formula/ 

HM 

(n=82) 

NS VA between 

groups

n/a Jadad total: 

5 [Grade: 

A]; 

Schulz: 

Adequate 

I 

1

Proceeding from highest omega-3, or lowest omega-6/omega-3, fatty acid content of intervention/exposure; 2

biomarker source; 3biomarkers = EPA, DHA, AA, AA/EPA, AA/DHA, AA/EPA+DHA; n-3 = omega-3 fatty acids; n-6 

= omega-6 fatty acids; ALA = alpha linolenic acid; DHA = docosahexaenoic acid; EPA = eicosapentaenoic acid; AA 

= arachidonic acid; Length = intervention length; Design = research design; n = sample size; pts = study 

participants; NR = not reported; S = statistically significant difference; NS = nonsignificant statistical difference; n/a = 

not applicable; pb = placebo; grp = group; wk = week(s); mo = month; wt = weight; RBC = red blood cells; PL = 

phospholipid; CPG = choline phosphoglycerides; EPG = ethanolamine phosphoglycerides; +

p<.05 or significant with 

95% confidence interval; ++p<.01; +++p<.001; ++++p<.0001; ITT = intention-to-treat analysis; PP = per-protocol 

analysis (e.g., completers); Ï = increase; Ð = decrease/reduction; VA = visual acuity; PL = phospholipids; d = 

day(s); FPL = forced-choice preferential looking using Teller’s card test; HM = human milk; VEP = visual evoked 

potential; F = formula; ERG = electroretinogram 
169

Summary Table 40: Omega-3 fatty acids intake associated with visual function in term infants 

Study groups1 

Author, Year, 

Location: 

Length & 

Design 

Group 1 

(n)/ 

Group 4 

(n)

Group 2 

(n)/ 

Group 3 

(n)

Notable clinical 

effects

Notable clinicalbiomarker 

correlations 

Internal 

validity Applicability 

Makrides, 

1999, 

Australia: 

1 y 

Parallel 

RCT205 

DHA 

(n=22) 

DHA+AA 

(n=19)/ 

control 

(n=19) 

NS VEP acuity 

at 16 or 34 wk 

n/a Jadad total: 

5 [Grade: A]; 

Schulz: 

Adequate 

III 

Makrides, 

2000, 

Australia: 

34 wk 

Parallel 

RCT266

LA/ALA 

10/1 

(n=30) 

LA/ALA 

5/1 

(n=28) 

NS VEP acuity 

at 16 & 34 wk 

n/a Jadad total: 

5 [Grade: A]; 

Schulz: 

Adequate 

II 

Birch, 2002 

US: 

46 wk 

Parallel 

RCT269

DHA+AA 

(n=30) 

Control 

(n=28) 

NS DHA+

AA on 

sweep VEP at 6 

wk 

S DHA+

AA & 

better sweep 

VEP 17++, 26+++

& 

52 wk +++

S DHA+AA & 

better FPL at 

17++

S better sweep VEP 

& plasma AA at 17++, 

52+++ wk & 

plasma DHA at 17+++, 

52+++ wk 

S better sweep VEP 

& RBC AA at 

52 wk++ & RBC DHA 

at 17++ & 52+++ wk 

NS sweep VEP & 

plasma or RBC LA or 

ALA at 17 or 52 wk 

S better FPL & 

plasma DHA at 17 

wk++ or RBC LA at 17 

wk+++

NS FPL & plasma or 

RBC ALA, AA, 

plasma LA, or RBC 

DHA

Jadad total: 

5 [Grade: A]; 

Schulz: 

Adequate 

II 

Hoffman, 

2003 

US: 

7 mo 

Parallel 

RCT270

DHA+AA 

(n=30) 

Control 

(n=31) 

S better sweep 

VEP & DHA+AA 

at 12 mo+++

NS DHA+AA & 

FPL at 4,6,9, & 

12 mo 

S better sweep VEP 

at 12 mo & RBC 

DHA+++, 

Σ n-3 LCPUFAs+++, 

n-3/n-6 LCPUFAs++, 

DHA/DPA++, n-6 

unsaturation index++

S poorer sweep VEP 

at 12 mo & RBC 

LA++, AA++

NS FPL & RBC n-3 

or n-6 FA

Jadad total: 

3 [Grade:B]; 

Schulz: 

Adequate 

II 

1

Proceeding from highest omega-3, or lowest omega-6/omega-3, fatty acid content of intervention/exposure; 2

biomarker source; 3biomarkers = EPA, DHA, AA, AA/EPA, AA/DHA, AA/EPA+DHA; n-3 = omega-3 fatty acids; n-6 

= omega-6 fatty acids; ALA = alpha linolenic acid; DHA = docosahexaenoic acid; EPA = eicosapentaenoic acid; AA 

= arachidonic acid; Length = intervention length; Design = research design; n = sample size; pts = study 

participants; NR = not reported; S = statistically significant difference; NS = nonsignificant statistical difference; n/a = 

not applicable; pb = placebo; grp = group; wk = week(s); mo = month; wt = weight; RBC = red blood cells; PL = 

phospholipid; CPG = choline phosphoglycerides; EPG = ethanolamine phosphoglycerides; +

p<.05 or significant with 

95% confidence interval; ++p<.01; +++p<.001; ++++p<.0001; ITT = intention-to-treat analysis; PP = per-protocol 

analysis (e.g., completers); Ï = increase; Ð = decrease/reduction; VA = visual acuity; PL = phospholipids; d = 

day(s); FPL = forced-choice preferential looking using Teller’s card test; VEP = visual evoked potentials 
170

Qualitative synthesis of relevant studies’ key characteristics 

Study characteristics. All studies were parallel RCTs with at least two groups. Countries 

where the studies were conducted included Australia,205,262,266 United 

States,104,182,203,227,263,269,277,342 Denmark,264 and Canada.263 Makrides et al.’s study was funded by 

grants-in-aid from Channel 7 Children's Medical Research Foundation, Nestle Australia, Scotia 

Pharmaceuticals UK and Flinders Medical Research Foundation.262 Jorgensen et al’s study was 

funded by Food Technology Research and Development Program (FOTEK), DanoChemo AS, 

BASF Health & Nutrition (Denmark), Swedish Medical Research Council, and Semper AB 

supplied infant formula.264 Carlson et al.’s study was funded by the National Institute of Child 

Health and Human Development Grant and infant formula supplied by Ross Products Division, 

Abbott Lab.277 Auestad et al.’s 1997 study and the secondary report by Austed et al. were 

funded by Ross Products Division, Abbott Laboratories and a US Maternal & Child Health 

Bureau grant.104 Innis et al.’s study was funded by the Mead Johnson Research Center.263 

Jensen et al.’s study was funded by Federal funds from the US dept of Agriculture, Agriculture 

Research Services, Mead-Johnson Nutritional Group, the Foundation Fighting Blindness, 

Research to Prevent Blindness Inc., and the Retina Research Foundation.203 Formulas for this 

study was provided by Mead-Johnson Nutrition Group and weaning foods were provided by 

Gerber Products Co.203 Birch et al. was funded by an NIH grant and Mead Johnson Nutritional 

Research.182 Both of Auestad et al.’s 2001 studies were funded by Ross Products Division, 

Abbott Laboratories.227 Makrides et al.’s study was funded by Nestec Ltd, the MS McLeod 

Research Trust, and the Australian National Health & Medical Research Council.205 Makrides et 

al.’s study was funded by Wyeth Nutritionals International, the Australian National Health and 

Medical Research Council, and the MS McLeod Research Trust.266 Birch et al.’s study was 

funded by an NIH grant and Mead Johnson Nutritional Group.269 Hoffman et al.’s study was 

funded by NIH.270

Population characteristics. The range of sample sizes were from 33 to 274 infants across 

the included studies. 

The inclusion criteria were described by all of the included term infant studies. The 

definition of a term infant (range: 37-43 weeks GA) was described in ten studies.104,182,205,227,262-

264,269,277 

All but one study described the exclusion criteria.203 Enough detail was provided for the 

selection of healthy infants in nine studies.104,182,205,227,264,266,269,270

Opthalmologic examination criteria for the exclusion of infants from visual acuity 

assessments after enrolment were described in four studies.104,262,266,277 These infants 

participated in all the other assessments of the studies. 

Exclusion of infants at risk for lipid metabolic abnormalities based on maternal risk factors 

was described in six studies.104,182,262,266,269,270

In the RCTs, the mean GA of randomized infants (range:39.0 - 40.3 weeks) was reported in 

nine studies.104,203,205,227,262,264,266,277 The GA was not reported in four studies.182,263,269,270 The 

percentage of males of randomized infants was reported in ten studies and ranged from 37.5% to 

69.2%.182,203,205,227,262,264,266,270,277 This information was not reported in three studies.263,269,270 

Ten of the RCTs reported the race and/or ethnicity data.104,182,203,205,227,266,269,270,277 Randomized 
171

infants were matched for GA at birth in nine studies,104,203,205,227,262,264,266,277 and not reported in 

four studies.182,263,269,270 The proportion of male to female randomized study infants was evenly 

distributed in four trials,182,227,277 not reported in two studies,263,266 and reported for all study 

infants but not for each study group in one study.270 

There was a disproportionately higher percentage of males in the control formula group in 

two studies104,269 and in one of the supplemented formula groups in three studies.205,262,264 There 

was a disproportionately lower percentage of males in one of the supplemented formula groups 

in one study.203 The race and/or ethnicity of the randomized infants was reported in ten 

studies,104,182,203,205,227,266,269,270,277 The majority of randomized infants were White in eight 

studies,104,182,205,227,266,269,270 and Black/Hispanic in two studies.203,277 The distribution of 

race/ethnicity among the study groups of randomized infants for these studies was closely 

matched in three studies,205,266,269 somewhat matched four in studies,104,182,227 discrepant in two 

studies,203,277 and not reported in one study.270 

Parental sociodemographic factors were reported in nine studies.182,205,227,262,266,269,270,277 

Different variables were used to demonstrate family sociodemographic status in the various 

studies (parental education, social score, income, adults in household, children in household, 

smoking, marital status, birth order, HOME screening questionnaire score). There were no 

differences in sociodemographic variables among the study groups of randomized infants in five 

trials,227,262,269,277 significantly different parental post-secondary education (p < 0.005) in one 

study270 and reported but not analysed in three trials.205,266,343 Two of these studies took the 

sociodemographic factors into account in comparing VEP acuity between randomized formula 

groups with analysis by covariance 205,266 and multiple linear regression.266

Intervention/exposure characteristics. Randomized infants in all studies were fed ad 

libitum with a standard cow’s milk based infant formula with or without the addition of omega-3 

and/or omega-6 LCPUFA,104,182,205,227,262,264,269,270,277 ALA and/or LA,203,263,266 and/or GLA.262,264 

The sources of DHA in the studies included fish oil,104,205,227,248,262,264 or single cell oils 

(DHASCO®).182,269,270 The sources of DHA and AA included egg PL,104,205,227,277 and sources of 

AA in the studies included single cell oils (ARASCO®)182,269,270 and fungal lipid.227 Sources of 

ALA included canola oil,203,266 and sources of GLA included evening oil,262 and borage oil.264

The source of ALA and AA were not reported in one study.263 Only one study monitored the 

volume of formula intake of the groups of study patients and found no difference.203 Study 

infants were placed on the study formulas within the first week of life in the majority of the 

studies.104,182,203,205,227,262,263,266,277 The second Auestad et al. study randomized the infants at 11 

days of life, but had them begin formula feeding after 3 months of being exclusively breastfed.227 

Study formulas were started within the first month of life in Jorgensen et al’s study,264from the 

beginning of week 7 in Birch et al’s study,269 and after weaning from breast feeding at 4 to 6 

months of age in Hoffman et al’s study.344 

The introduction of solid foods, usually starting with cereals, will not contribute to the 

omega-3 and omega-6 FA intake, and thus would have very little impact on the study diets. 

However, if a significant proportion of the diet is from supplementary foods and beverages other 

than the study formula, this may contribute to decreased study formula intake. Dietary intake 

information was not well documented in all the studies. Five studies in which study formula was 
172

initiated within the first week of life, supplementary foods and beverages were discouraged for 

varying durations during the intervention phase.104,182,203,262,266 

Innis et al.263 specified that an infant would be withdrawn if more than 10% of dietary energy 

came from sources other than assigned formula for 5 days or more. Jorgensen et al.’s study 

documented that no supplementary food was consumed.264 Infants were started on the study 

formulas from the beginning of week 7 of life in Birch et al’s study, and it was documented that 

none of the infants consumed solid food before 17 weeks and most had no solid food other than 

cereal until 26 weeks of age.269 In Hoffman et al’s study, study formula started at 4 to 6 months 

of age and the diet was not controlled.270 Criteria for inclusion/exclusion of supplementary foods 

or beverages was not stated in two studies.205,277

Cointervention characteristics. Only two studies reported the use of tocopherol (vitamin 

E) in their formulas.182,264 Auestad et al. also allowed the use of breast millk as a 

cointervention.227

Outcome characteristics. Assessment of visual acuity was evaluated using the following 

methods: FPL with Teller Acuity Cards104,182,227,263,277 or infant random dot stereocards,269,270

VEP,203,205,262,266 and sweep VEP.104,182,264,269,270 Some studies employed more than one method 

for the assessment of visual acuity.182,269,270 Birch et al. also employed electroretinography 

(ERG) to assess maturity of retinal function.182 FPL using Teller Acuity Cards is reported as 1) 

threshold—the finest gating at which the tester can locate the grating based on the infant’s 

behaviour, and 2) Log10 acuity score—represents the log transformed acuity based on the 

conversion of the finest grating recognized (cycles/cm) and the distance of the subject from the 

visual stimulus. The SD of Log10 acuity score is expressed in octaves (SD log acuity 

scores/0.301). A difference between groups of 1.0 octave means that the smallest stripe detected 

by one group is twice as large as the smallest stripe detected by the other. Only tests with 

confidence ratings of 3 to 5 (1-5, low to high) and good inter-rater reliability were included in the 

analyses. 

Random dot stereoacuity by FPL using the infant random dot stereocards is reported as log10 

s—log of the minimum detectable binocular disparity. VEP responses to a pattern-reversal 

stimulus at 2 hertz are reported as 1) latency—time between stimulus and maximal electrical 

response of the occipital cortex (msec), 2) amplitude—maximal height of the electrical response 

of the occipital cortex (mvolts), amd 3) logMAR (log10 minimal angle of resolution)—peak to 

peak amplitude of the VEP response is plotted against log of the angle subtended by each check 

size and the linear portion of the plot is extrapolated to 0 to give the theoretical value that would 

just elicit a response (valid only if there were at least three points and r2 was > 0.8 and p < 0.05). 

Sweep VEP responses to sine-wave gratings are reported as logMAR—the log10 transformed 

data of the extrapolation of the VEP amplitude versus spatial frequency function to zero 

amplitude. Some studies specified that only the trials that met a 3:1 signal-to-noise and phase 

coherence criteria were used in the estimates of logMAR. Lower values of logMAR represent 

better visual acuity. ERG responses are reported as 1) maximum response amplitude (Vmax), 

rod thresholds (light required to generate a 2 mV response), and 2) semisaturation constant (log 

k). Maturation = higher Vmax, lower rod threshold & log k. 

Study quality and applicability. The 13 RCTs received a mean Jadad total quality score of 

3.61, with a good internal validity (Summary Matrix 21). Six trials received a score of 
173

5,182,205,266,269,329 three studies received a score of 3,104,270,277 and four reports received a score of 

2.203,262-264

Summary Matrix 21: Omega-3 fatty acids intake associated with the visual function in term infants 

Study Quality

A B C 

Author Year n Author Year n Author Year n 

I BirchU

AuestadA 

AuestadA

1998 

2001 

2001 

79 

239 

165 

AuestadU 1997 274 InnisU 1997 238 

Author Year n Author Year n Author Year n

II MakridesA 

BirchA 2000 

2002 

176 

65 

CarlsonU 

HoffmanA 1996 

2003 

94 

68 

MakridesU 

JensenU 1995 

1997 

89 

80 

Author Year n Author Year n Author Year n

Applicability 

III MakridesA 1999 146 JorgensenU 1998 39 

n = number of allocated/selected participants; RCT = AAdequate vs UUnclear allocation concealment

Qualitative synthesis of individual study results 

The 13 relevant unique trials that were reviewed reported their results on the effect of 

LCPUFA on visual function in term infants. These trials employed different methods for 

measuring the development of visual acuity. Therefore, the qualitative synthesis of the results 

will be presented in a stratified manner with respect to the types of visual acuity (i.e., VEP, 

Teller’s visual acuity, random dot stereo-acuity, FPL). 

Of the 13 unique trials, five104,182,264,269,270 reported their results on the effect of LCPUFA 

supplementation on the development of sweep VEP measured in cycles/degrees or log MAR. Of 

the five trials, similar mean sweep VEP values between the randomized groups of infants were 

found in four trials104,182,264,269 at 1.5,269 2,104 4,104,264 6,104 6.5,182and 9104months of age 

(differences were statistically non-significant). 

In contrast, the findings of the same two trials182,269 and another trial270 suggested that infants in 

the LCPUFA-supplemented formula groups had a lower sweep VEP log MAR values, meaning a 

significantly better visual acuity than those in the control formula groups at 1.5,182 4,182,269 6.5,269

12,270 and 13182,269 months of age. 

Five trials,182,203,205,262,266 reported the effect of LCPUFA supplementation on the VEP), 

measured in log MAR. Of these, three203,205,266 did not find any between-arm differences in VEP 

values at 4 and 8 months of age, i.e., the mean VEP values of the infants in the LCPUFA 

supplemented and control groups were not statistically significantly different. However, findings 

from the remaining two trials indicated that infants at 4182,262 and 13182 months of age, who had 

been fed with breast milk and LCPUFA supplemented formula, had lower mean log MAR 

values, i.e., better visual acuity, compared with those fed with control formula without the 

LCPUFA supplementation. In both studies,182,262 the breastfed and LCPUFA groups of infants 

had very similar VEP acuities. 

Teller’s visual acuity, as an outcome measured in cycles/degrees, was explored in five 

trials.104,227,263,277 In all but one,277 the observed values of Teller’s visual acuity in the LCPUFAsupplemented and control groups of infants did not differ statistically between groups at 2104,227
174

3,263 4,104 6,104 10,104 and 12227 months of age. In the trial by Carlson et al.,277 breastfed infants 

and those randomized to receive the LCPUFA supplemented formula, had on average a 

significantly higher visual acuity score (i.e., better Teller’s visual acuity) than those randomized 

to receive the control formula at 2 months of age. In the same trial,277 the observed effect of 

LCPUFA supplementation at 2 months of age was transient and was no longer present at 4, 6, 9, 

and 12 months of age. 

Two trials269,270 investigated the effect of supplementary LCPUFA on the random dot 

stereoacuity in term infants, measured in log seconds. The results of both trials indicated that 

stereoacuity did not differ statistically significantly across the randomized groups of infants at 8, 

9, 12, and 13 months of age. Note that Hoffman et al.270 found a trend for better stereoacuity in 

the infants receiving LCPUFA-enriched formula at 9 and 12 months of age. However, none of 

the observed differences was statistically significant at 9 and 12 months. Results of these two 

trials were less consistent for the effect of LCPUFA in the infants at 4 months of age. 

Specifically, Birch et al.269 found that the infants randomized to receive LCPUFA-enriched 

formula had a better stereoacuity at 4 months of age than those randomized to receive the control 

formula (numerical data was not given). Whereas in the other trial, Hoffman et al.270 suggested 

that the measures of stereoacuity did not differ across the randomized groups of infants receiving 

either LCPUFA-enriched or control formula at 4 months of age. 

Of the 13 trials, only one trial182 assessed the effect of LCPUFA supplementation on FPL 

acuity. In this trial, the mean FPL acuity, measured in log MAR at 1.5, 4, 6.5, and 13 months of 

age, did not differ across the groups of infants fed breast milk, LCPUFA-supplemented formula 

or control formula. 

The effect of LCPUFA (DHA and AA) supplementation on the maturity of retinal function as 

measured by Naka-Rushton parameters (log k, log Vmax, and rod threshold) in term infants was 

only investigated in one trial.182 The evaluation of the retinal function maturity was based ERG 

responses determined by electroretinography. 

The results of this trial indicated that at 1.5 months of age, the log k (semisaturation constant) 

was statistically significantly lower (i.e., more mature ERG response) in the infants receiving 

DHA + AA supplemented formula, compared with those receiving DHA supplemented formula 

or control formula. This effect was no longer present at 4 months of age. Other two NakaRushton parameters, log Vmax and rod threshold, were not statistically significantly different 

across the diet groups at either 1.5 or 4 months of age.182 

Of the 13 trials, six104,205,227,266,277 did not report any information regarding the associations 

(i.e., correlation, linear regression) between maternal/infant blood biomarkers (i.e., plasma-, 

RBC-LCPUFA content) and the measures of visual acuity (i.e., VEP, FLP, Teller’s acuity) or 

ERG responses in infants. Seven trials182,203,262-264,269,270 reported some information concerning 

the above-mentioned associations. 

Of the seven trials, four182,264,269,270 reported associations between milk or blood biomarkers 

(plasma/RBC-DHA and/or –AA content) and the sweep VEP acuity measures. Of these trials, 

three182,269,270 found statistically significant negative linear regression coefficients indicating that 

higher RBC-DHA content was associated with a better sweep VEP acuity in infants at 1.5, 

4,182,269 6.5,182 12,270 and 13182,269 months of age. Results of the remaining study264 suggested 

that milk- or RBC-DHA content was not associated with the measured sweep VEP acuity at 4 
175

months of age. The results of both trials182,264 that looked at the RBC-EPA and RBC-AA content 

in relation to the measure of sweep VEP acuity, indicated that neither RBC-AA nor RBC-EPA 

content was associated with the sweep VEP acuity during the first year of the infants’ life. One 

study,269 that investigated the relationship between infant’s plasma-DHA and -AA content, found 

that higher plasma contents of both DHA and AA were associated with better sweep VEP acuity 

at 4 and 13 months of age. 

The relationship between human milk or the infants’ blood biomarkers (plasma/RBC-DHA 

and/or -AA content) and the measures of infant VEP acuity were reported in two trials.203,262 

Both trials suggested that RBC-DHA correlated negatively with the amplitude of VEP acuity (in 

log MAR), measured at 4203,262 and 7.5262 months of age (i.e., infants at 4 and 7.5 months of age 

who on average had a higher RBC-DHA content, tended to have a lower log MAR or better VEP 

acuity). The squared correlation coefficients for the association between RBC-DHA and the 

amplitude of VEP acuity, measured at 4 and 7.5 months of age were 0.23 (p < 0.001) and 0.12 (p 

< 0.005), respectively.262 The former trial203 also showed that there was no correlation between 

either plasma- or RBC-DHA content at 4 months of age, and the latency measure of VEP acuity 

obtained at either 4 or 8 months of age. The same trial,203 however, found a statistically 

significant negative correlation between plasma-DHA content and the amplitude of VEP acuity 

both measured at 4 months of age. 

Of the reviewed trials, only one263 reported the association(s) for human milk and/or the 

infants’ blood lipid composition (plasma-DHA and/or RBC-DHA content) in relation to the 

measure of Teller’s visual acuity. The plasma-DHA content did not correlate with the Teller’s 

acuity, measured at 3263months of age. Similarly, the associations relating the infants’ RBCDHA263 content to Teller’s visual acuity did not reach the traditional level of statistical 

significance. 

Only two trials reported the associations between the infants’ RBC-DHA content and their 

stereoacuity (in log seconds) measured at 4269 and 12270 months of age. Both trials found that 

there was no association/correlation between the two factors. For example, in one trial,269 the 

reported linear regression coefficient estimate was β = -0.31 (p > 0.05). In the same trial, the 

infants’ plasma-DHA content was negatively correlated with their stereoacuity at 4 months of 

age, meaning that, on average, infants with higher plasma-DHA content tended to have a better 

stereoacuity. 

The relationship (correlation) between blood lipid content (plasma- and RBC-DHA) and 

ERG parameters (measured by Naka-Rushton indicators) in infants was reported in one trial.182 

None of the Naka-Rushton parameters except for log k (in scotopic troland seconds) was 

statistically significantly correlated with plasma- or RBC-DHA content at either 1.5 or 4 months 

of age. There was a statistically significant negative correlation between the RBC-DHA content 

and log k in the infants at 1.5 months of age. 

All the trials reported some information on the losses to follow up/noncompleters/withdrawn. The trial that failed to report this information was presented in a form of 

an abstract. The most common reported reasons for the non-completion/withdrawal of study 

protocol were: intolerance to lactose or cow’s milk/dietary hypersensitivity, poor compliance to 

the study regimen, early cessation of breast feeding, illness (cataract, meningitis, pyloric 

stenosis, allergic asthma, and phenylketonuria), declined to participate in the trial, and relocation. 
176

The number of non-completers/drop-outs varied across the trials ranging from two264 to 116.104 

Across majority of the trials,182,203,205,262-264,266,269,270,277 the number of non-completers ranged 

from two264 to 47263, with a mean of 20 per trial. 

Carlson et al.277 reported one infant was withdrawn for an abnormal ophthalmologic 

examination. It should be noted that in all studies, that not all infants who completed the study 

feeding protocol were successfully assessed for visual acuity. It was not always reported as to 

which study group the unsuccessful visual acuity assessments were in. 

In the Makrides et al. study, there were 66 of 79 of all infants who completed the feeding 

study who had successful VEP assessments at 16 weeks, and 60 who has successful feeding 

assessments at 30 weeks;262 the sample size calculation was not reported. In the Jorgensen et al. 

study,264 there were 26 of 37 formula study infants with successful sweep VEP (DHAGF:18, 

STF:8). Auestad et al.104 withdrew two from the control group, nine from the DHA + AA group, 

and four from the DHA group, due to abnormal ophthalmologic examination; one from the DHA 

group was excluded from the acuity card procedure. Some studies reported the exclusion of 

values from visual acuity assessments due to low tester confidence.104

In Makrides et al.,205 one infant in the formula group was withdrawn due to cataracts. This 

resulted in smaller sample sizes that were determined a priori. Hoffman et al.270 reported that 16 

were lost to follow up or had unsuccessful stereoacuity testing, however, information regarding 

which group these participants belonged to was not specified, so it is unknown if the sample 

sizes were too small based on a priori sample size calculations.182 

Quantitative synthesis 

Quantitative analysis of visual acuity was as described previously for pre-term infants (see 

above). 

DHA vs. no-DHA.

Meta-analysis for behaviorally based test (Teller’s Card test) at age 2, 4, 6, 9 and 12 

months (Table 8, Figure 15). There is no statistically significant difference on visual acuity 

between DHA intake and placebo groups for term infants based on the behavioral test at age 2, 4, 

6, 9 and 12 months. 

Table 8. Meta-analysis of visual acuity difference (DHA vs. no-DHA) for term infants based on behavioral test 

Age Studies Heterotest Point estimate 95% CI P-value 

2 1Auestad 1997, 2Birch 1998 0.72 0.20 (-0.1, 0.51) 0.19 

4 1Auestad 1997, 2Birch 1998 0.38 -0.14 (-0.37, 0.10) 0.25 

6 1Auestad 1997, 2Birch 1998 0.96 -0.07 (-0.27, 0.12) 0.45 

9 1Auestad 1997 - -0.18 (-0.42, 0.06) 0.13 

12 1Auestad 1997, 2Birch 1998 0.97 -0.19 (-0.38, 0) 0.05 

Age: in months; Studies: superscripts correspond to the report number in the graphs; Heterotest: P-value for 

the heterogeneity test; Point estimate: (in octaves); positive value means the point estimate favors DHA intake 

over no-DHA intake; P-value: P-value for the effectiveness–only one study in this meta-analysis. 
177

Difference in Visual Acuity (octaves)

Age (months)

2

3

4

6

9

12

1, 2

1, 2

1, 2

1

1, 2

← Favours no-DHA Favours DHA →

Report

-0.4 -0.2 0.0 0.2 0.4 0.6

Figure 15. Meta-analysis of visual acuity difference (DHA vs no-DHA) in term infants based on behavior test 

Shaded circles represent the pooled estimates of visual acuity difference from the meta-analysis of randomized 

comparisons (formula fed DHA vs. formula fed no-DHA) tested at certain ages. The open symbols represent the 

pooled estimates of visual acuity difference from the meta-analysis of nonrandomized comparisons (Human milk vs. 

formula without DHA). 

Meta-analysis for electrophysiologically-based test (VEP) at 2, 4, 6, 9 and 12 months

(Table 9, Figure 16). There is no statistically significant difference on visual acuity between 

DHA intake and placebo groups for term infants based on the Electrophysiologically based test 

at age 2, 4, 6, 8, 9 and 12 months. 
178

Table 9. Meta-analysis of visual acuity difference (DHA vs. no-DHA) for term infants based on 

electrophysiological test 

Age Studies Heterotest 

Point 

estimate 95% CI P-value 

2 1Auestad 1997, 2Birch 1998 0.01 0.25 (-0.36, 0.86) 0.42 

4 

1

Auestad 1997, 2Birch 1998, 3

Makrides 1999 0.04 -0.01 (-0.25, 0.24) 0.96 

6 1Auestad 1997, 2Birch 1998 0.07 -0.02 (-0.36, 0.32) 0.91 

8 3Makrides 1999 - -0.27 (-0.64, 0.1) 0.16 

9 1Auestad 1997 - -0.11 (-0.33, 0.11) 0.32 

12 1Auestad 1997, 2Birch 1998 <0.01 0.12 (-0.45, 0.69) 0.68 

Age: in months; Studies: superscripts correspond to the report number in the graphs; Heterotest: P-value 

for the heterogeneity test; Point estimate: (in octaves); positive value means the point estimate favors DHA 

intake over no-DHA intake; P-value: P-value for the effectiveness–only one study in this meta-analysis. 

Difference in Visual Acuity (octaves)

Age (months)

2

4

6

8

9

12

1, 2

3, 1, 2

1, 2

3

1

1, 2

← Favours no-DHA Favours DHA →

RefID

-0.4 0.0 0.4 0.8

Figure 16. Meta-analysis of visual acuity difference (DHA vs. no-DHA) in term infants based on 

electrophysiological test. Shaded circles represent the pooled estimates of visual acuity difference from the metaanalysis of randomized comparisons (formula fed DHA vs. formula fed no-DHA) tested at certain ages. The open 

symbols represent the pooled estimates of visual acuity difference from the meta-analysis of nonrandomized 

comparisons (Human milk vs. formula without DHA). 
179

DHA+AA vs no-DHA 

Meta-analysis for Behaviorally based test (Teller’s Card test) at 2, 4, 6, 9 and 12 month

(Table 10, Figure 17). Except for results at 2 months, there is no statistically significant 

difference in visual acuity between DHA + AA intake and placebo groups for term infants based 

on the behavioral test at age 4, 6, and 9 and 12 months. 

Table 10. Meta-analysis of visual acuity difference (DHA+AA vs. no-DHA) for term infants based on 

behavioral test 

Age Studies Heterotest 

Point 

estimate 95% C.I. P-value 

2 

1

Auestad 1997, 4Carlson 1996, 2Birch 

1998 0.32 0.37 (0.15, 0.6) <0.01 

4 

1

Auestad 1997, 4Carlson 1996, 2Birch 

1998 0.55 -0.14 (-0.33, 0.05) 0.16 

6 1Auestad 1997, 2Birch 1998 0.29 0.07 (-0.16, 0.3) 0.57 

9 1Auestad 1997 - -0.04 (-0.31, 0.23) 0.78 

12 1Auestad 1997, 2Birch 1998 0.63 -0.04 (-0.26, 0.17) 0.7 

Age: in months; Studies: superscripts correspond to the report number in the graphs; Heterotest: P-value for the 

heterogeneity test; Point estimate: (in octaves); positive value means the point estimate favors DHA intake over 

no-DHA intake; P-value: P-value for the effectiveness–only one study in this meta-analysis. 
180

Difference in Visual Acuity (octaves)

Age (months)

2

3

4

6

9

12

1, 4, 2

1, 4, 2

1, 2

1

1, 2

← Favours no-DHA Favours DHA+AA →

Report

-0.2 0.0 0.2 0.4 0.6

Figure 17. Meta-analysis of in visual acuity difference (DHA+AA vs no-DHA) in term infants based on 

behavior test. Shaded circles represent the pooled estimates of visual acuity difference from the meta-analysis of 

randomized comparisons (formula fed DHA+AA vs. formula fed no-DHA) tested at certain ages. The open symbols 

represent the pooled estimates of visual acuity difference from the meta-analysis of nonrandomized comparisons 

(human milk vs. formula without DHA). 

Meta-analysis for Electrophysiologically based test (VEP) at 2, 4, 6, 7, 9 and 12 months

(Table 11, Figure 18).Except results at 12 month, there is no statistically significant difference on 

visual acuity between DHA +AA intake and placebo groups for term infants based on the 

Electrophysiologically based test at age 2, 4, 6, 8, and 9 months. 
181

Table 11. Meta-analysis of visual acuity difference (DHA+AA vs. no-DHA) for term infants based on 

electrophysiological test

Age Studies Heterotest Point estimate 95% CI P-value 

2 1Auestad 1997, 2Birch 1998 <0.01 0.29 (-0.32, 0.91) 0.35 

4 

5

Birch 2002, 3Makrides 1999, 1

Auestad 1997, 7Makrides 1995, 8

Jorgensen 1997, 2Birch 1997 <0.01 0.17 (-0.01, 0.36) 0.07 

6 

5

Birch 2002, 1Auestad 1997, 2

Birch 1998 <0.01 0.16 (-0.13, 0.45) 0.28 

8 3Makrides 1999 - 0 (-0.35, 0.35) 1 

9 1Auestad 1997 - -0.12 (-0.32, 0.08) 0.23 

12 

5

Birch 2002, 1Auestad 1997, 2

Birch 1998, 6Hoffman 2003 <0.01 0.32 (0.09, 0.56) 0.01 

Age: in months; Studies: superscripts correspond to the report number in the graphs; Heterotest: P-value for 

the heterogeneity test; Point estimate: (in octaves); positive value means the point estimate favors DHA intake 

over no-DHA intake; P-value: P-value for the effectiveness–only one study in this meta-analysis. 

Difference in Visual Acuity (octaves)

Age (months)

2

4

6

8

9

12

1, 2

5, 3, 1, 7, 8, 2

5, 1, 2

3

1

5, 1, 2, 6

← Favours no-DHA Favours DHA+AA →

RefID

-0.4 0.0 0.4 0.8

Figure 18. Difference in visual acuity (DHA+AA vs. no-DHA) in term infants based on electrophysiological test 

Shaded circles represent the pooled estimates of visual acuity difference from the meta-analysis of randomized 

comparisons (formula fed DHA vs. formula fed no-DHA) tested at certain ages. The open symbols represent the 

pooled estimates of visual acuity difference from the meta-analysis of nonrandomized comparisons (human milk vs. 

formula without DHA). 
182

Human milk vs no-DHA 

Here are listed the combined results of visual acuity difference between HM and no-DHA 

groups based on behavioral- and electrophysiological-based tests at different ages as references. 

Table 12. Meta-analysis of visual acuity difference (HM vs. no-DHA) in term infant based on behavioral and 

electrophysiological test

Test Age Heterotest Point estimate 95% CI P-value 

B 2 0.38 0.5 (0.29, 0.7) 0 

B 3 - 0.12 (-0.13, 0.37) 0.36 

B 4 0.94 0.02 (-0.17, 0.2) 0.87 

B 6 0.48 0.07 (-0.12, 0.26) 0.47 

B 9 - 0.03 (-0.17, 0.23) 0.76 

B 12 0.93 -0.05 (-0.21, 0.11) 0.57 

E 2 <0.01 0.17 (-0.6, 0.93) 0.67 

E 4 0<0.01 0.24 (0.02, 0.47) 0.03 

E 6 0.01 -0.03 (-0.49, 0.43) 0.89 

E 8 0.06 0.13 (-0.3, 0.56) 0.56 

E 9 - -0.12 (-0.34, 0.1) 0.28 

E 12 <0.01 0.23 (-0.33, 0.79) 0.42 

B: Behavioral test. E: Electrophysiological test; Age: in months; Heterotest: P-value for the heterogeneity 

test; Point estimate: of meta-analysis of certain age (in octaves); The positive value means the point 

estimate favors DHA intake over no-DHA intake; Standard error: of pooled estimates from meta-analysis 

(in octaves); P-value: P-value for the effectiveness; only one study in this meta-analysis 

Impact of covariates and confounders 

Of the 13 reviewed trials, 12 reported some information on statistical techniques/methods 

used to estimate the effect of LCPUFA formula supplementation on visual acuity development in 

term infants. In 11 trials, the effect of interest was estimated using analysis of variance with 

repeated measures (ANOVA) alone,262,263 ANOVA and analysis of co-variance 

(ANCOVA),104,203,227 ANCOVA and multiple linear regression (MLR),205,266or ANOVA and 

MLR.182,264,269,270 In one trial,277 ANOVA together with generalized linear model was used. 

Five trials reported that the analyses (ANOVA/ANCOVA/MLR) were adjusted for age 

only.182,262,263,269,277 The analyses in other trials were reported to be adjusted for some additional 

covariates such as birth weight,203,205,264,266 length at birth,203,205,264 HC at birth,266 sex,203,205,270

ethnicity,203 maternal smoking,205,266 blood lipid (DHA) composition,203,266,270 duration of breast 

feeding,264 GA,205,264 maternal education,205,266 birth order,205 and social score.205,266 Three 

trials104,227 reported that the adjustment in the analysis was done for the study site. 

Several trials reported that the randomized formula study groups at baseline were not wellbalanced (statistically significant differences) for the following factors: sex,205 parental 

education,270 ethnicity,182 maternal smoking,104,266 and birth weight.263,264 For example, in one 

trial,104 the percentage of infants whose mothers had been smokers were 26, 17, and 11 in the 

DHA + AA, DHA, and control formula groups, respectively (chi-square test based p < 0.05). 

The authors of this trial reported that the association between the diet and visual acuity was only 

adjusted for the study site. In the other trial,266 a baseline distribution of the randomized infants 

whose mothers were smokers across the two ALA-enriched and LA-enriched formula groups 

was 51% and 39%, respectively. Furthermore, there was a higher proportion of smoker noncompleters in the ALA-enriched than LA-enriched formula group (8% vs. 2%). These factors 
183

had been controlled for, as reported, in three trials.205,264,266 It is not clear whether the trials 

reporting to have controlled only for age,182,262,263,269,277 or site,104,227 adjusted for additional 

factors such as maternal smoking, the infants’ ethnicity, sex, and size, or other potentially 

important covariates. 

Across the trials, mothers whose infants had been breastfed, tended to be more 

educated,104,205,262,277 to have a higher social class,205 to be non-smokers,104,205,266 and of White 

race,104,182,277 than those in the formula arms.104,277

Most trials reported that infant sex,182,264,269,270 maternal education,104,182,227,266,269 maternal 

social score,262,266,270 maternal age,182,227,264,269,270 infant length and HC at birth,104,227,248,262-264,270

GA,104,262,264,277 and duration of breast feeding264 amongst the randomized formula groups were 

evenly distributed (statistically non-significant differences). 

Four trials reported those covariates that influenced the outcome (visual function). These 

covariates were as follows: sex,205 birth weight,205,264 duration of breast feeding,264 maternal 

smoking,205,266 anthropometrical measures at birth,266 partner’s social score,266 and RBC-DHA 

content.270 In these trials, female gender,205 lower rates of maternal/partner smoking,205,266

higher birth weight,205,264 greater HC,264,266 and longer duration of breast feeding264 were 

independently related with better visual acuity (p < 0.05). 

In most trials, the analyzed main effect of age was statistically significant. It correlated with 

better visual functioning. The statistically significant interaction between age and diet was 

detected in two trials,269,270 meaning that the effect of diet was not uniform with respect to the 

infants’ age. 

The power calculation was reported in ten trials,120,124,126,151,325,329,331,334,335 while the 

intention-to-treat analysis approach was reported in only one study.120

Visual Function Outcomes in Light of Biomarker Data 

What is the Evidence That Term or Preterm Human Infants’ Visual 

Function is Associated With the Omega-3 or Omega-6/Omega-3 Fatty 

Acid Content of Maternal Biomarkers During Pregnancy? 

One cross-sectional study was identified to respond this question. Krasevec et al.’s275 study 

was described in the Visual Function Outcomes questions (see key question: Maternal 

Intake/Visual Function). 

What is the Evidence That Term or Preterm Human Infants’ Visual 

Function is Associated With the Omega-3 or Omega-6/Omega-3 Fatty 

Acid Content of Child Biomarkers? 

There were a total of 21 studies that addressed this question. Eight cross-sectional studies, 

included in seven reports, published between 1993 and 2002, met the eligibility criteria. Since 

these were observational studies, and in order to respond to this particular question, the cross-
184

sectional data was abstracted from three prospective cohort studies.271,281,282 Krasevec et al.275

was described above (see key question: Maternal Intake/Visual Function.). There were also nine 

RCT’s described in the term population138,182,203,248,262-264,269,270 and three RCTs in the preterm 

population (see above).185,198,212. (Summary Tables 38-40 and 41-43) 

Overview of relevant studies 

The studies that included preterm infants will be described separately from the term infant 

studies. Birch et al. assessed the association between LCPUFA RBC content of omega-3 FAs 

and the visual function development after dietary supply of LCPUFA (breast milk) in American 

infants. This report included two different study populations, one of healthy preterm infants and 

another of full-term infants. The outcomes were measured at 4 months CA and, for the term 

infants, also at 36 months CA.278 (Summary Table 41) 

Makrides et al. studied the FA profiles of Australian term infants (5 months of age) fed breast 

milk and infant formula, and its association with VEP acuity.280(Summary Table 41)

Summary Table 41: Association between omega-3 or omega-6/omega-3 fatty acid content of biomarkers and 

visual function development in term and preterm infants 

Study groups1

 

Author, 

Year, 

Location: 

Design 

Group 1 

(n)/ 

Group 4 

(n)

Group 2 

(n)/ 

Group 3 

(n) Notable associations2,3

Internal 

validity Applicability 

Birch, 

1993a, US: 

Crosssectional278

Preterm 

infants 

breastfed 

(n=15) 

Preterm 

infants corn 

oil formula 

(n=15) 

LogMAR acuity was S 

correlated with the ratio 

[DHA n-3/DPA n-6] in total 

RBC lipids+++ 

FPL acuity LogMAR was S 

correlated with the ratio 

DHA n-3/DPA n-6++ 

RBC ratio was S Ï in HM 

than in formula fed++++

Quality score: 

4 [Grade B] 

III 

Birch, 

1993b, US: 

Crosssectional 278

Term infants 

4 mo CA 

breastfed 

(n=NR) / 

Term infants 

36 mo CA 

corn oil 

formula 

(n=NR) 

Term infants 

4 mo CA 

corn oil 

formula 

(n=NR) / 

Term infants 

36 mo CA 

breastfed 

(n=NR) 

Mean VEP & FPL acuities 

better in HM than in formula 

(4 mo)+ 

Mean RBC DHA/DPA in 

total RBC lipids was S 

Ï++++ HM than in formula 

group & stereo acuity was S 

correlated with the endproduct ratio+

Letter matching (36 mo) 

was S correlated with ratio, 

RBC DHA/DPA (4 mo)+

Quality score: 

4 [Grade B] 

III 

Makrides, 

1993, 

Australia: 

Crosssectional 280

Term infants 

breastfed 

(n=8) 

Term infants 

formula fed 

(n=8) 

HM group S Ð logMAR 

(i.e., better VEP acuity) than 

formula-fed (5 mo) 

S correlation between 

logMAR (VEP acuity) & % 

DHA+

 & LA+ in RBC PL 

Quality score: 

4 [Grade B] 

III 
185

1

Proceeding from highest omega-3, or lowest omega-6/omega-3, fatty acid content of intervention/exposure; 2

biomarker source; 3biomarkers = EPA, DHA, AA, AA/EPA, AA/DHA, AA/EPA+DHA; n-3 = omega-3 fatty acids; 

n-6 = omega-6 fatty acids; ALA = alpha linolenic acid; DHA = docosahexaenoic acid; EPA = eicosapentaenoic 

acid; AA = arachidonic acid; E-EPA = ethyl eicosapentaenoate; Length = intervention length; Design = 

research design; n = sample size; pts = study participants; NR = not reported; S = statistically significant 

difference; NS = nonsignificant statistical difference; n/a = not applicable; grp = group; wk = week(s); mo = 

month; wt = weight; RBC = red blood cells; PL = phospholipid; CPG = choline phosphoglycerides; EPG = 

ethanolamine phosphoglycerides; +

p<.05 or significant with 95% confidence interval; ++p<.01; +++p<.001; ++++p<.0001; ITT = intention-to-treat analysis; PP = per-protocol analysis (e.g., completers); Ï = increase; Ð = 

decrease/reduction; LBM = low breast milk; HBM = high breast milk; FPL = forced-choice preferential looking; 

HM = human milk; CA = corrected age; ERG = electroretinogram; VEP = visual evoked potential 

Innis et al. studied the development of preferential looking acuity in exlusively breastfed or 

formula-fed Canadian term infants. The goal was to measure the possible association between 

this outcome and the omega-3 and/or omega-6 FA content of RBC and plasma of the infants at 

14 days and 3 months of age.281(Summary Table 42) 

Leaf et al. evaluated the correlation between the FA composition of RBC and plasma in 

Australian preterm infants of 40 weeks of PCA and the development of visual function, using 

ERG and the Teller Acuity Card Procedure. The exposure was low breast-milk diet or high 

breast-milk diet, besides the use of total parenteral nutrition (TPN) until reaching 2,000 g of 

weight.279(Summary Table 42) 

The aim of Jorgensen et al.’s study was to establish an association between the FA 

composition of RBC and plasma of term infants and their visual acuity, using the Teller Acuity 

Card Procedure at 4 months of life.282 A small sample of Danish term infants were receiving 

either breast milk or formula without LCPUFA supplementation.282(Summary Table 42) 

Summary Table 42: Association between omega-3 or omega-6/omega-3 fatty acid content of biomarkers and 

visual function development in term and preterm infants

Study groups1 Author, 

Year, 

Location: 

Length & 

Design 

Group 1 

(n)/ 

Group 4 

(n)

Group 2 

(n)/ 

Group 3 

(n) Notable associations2,3

Internal 

validity Applicability 

Innis, 1994, 

Canada: 

Crosssectional 281

Term 

infants 

breastfed 

(n=17) 

Term 

infants 

formula 

fed 

(n=18) 

NS between groups in visual 

acuity test (14 d & 3 mo) 

Visual acuity NS to diet or 

plasma PL, RBC PC or PE 

concentrations of DHA on 

entire group of infants or within 

the breastfed or formula-fed 

group of infants 

Quality 

score: 5 

[Grade B] 

III 

Leaf, 1996, 

Australia: 

Crosssectional 279

Preterm 

infants 

HBM 

(n=9) 

Preterm 

infants 

LBM 

(n=9) 

S (+) correlation between 

scotopic b wave implicit time & 

% DHA in plasma+++ & RBC 

PL+

, total n-3 LCPUFA in 

plasma++ & RBC PL++ 

(+) correlation between RBC 

AA+ & total n-6 LCPUFA+

 & 

scotopic a-b amplitude 

NS relationships were seen 

between photopic ERGs & 

plasma or RBC LCPUFAs 

Quality 

score: 6 

[Grade B] 

III 
186

Jorgensen, 

1996, 

Denmark: 

Crosssectional 282

Term 

infants 

breastfed 

(n=17) 

Term 

infants 

formula 

fed 

(n=16) 

Visual acuity Ï overtime in 

both feeding groups+++, S Ï

increase in HM group+++ 

NS correlation between RBC 

DHA & visual between groups 

(4 mo) 

NS correlation between AA 

levels & visual acuity 

Quality 

score: 5 

[Grade B] 

III 

1

Proceeding from highest omega-3, or lowest omega-6/omega-3, fatty acid content of 

intervention/exposure; 2

biomarker source; 3biomarkers = EPA, DHA, AA, AA/EPA, AA/DHA, AA/EPA+DHA; 

n-3 = omega-3 fatty acids; n-6 = omega-6 fatty acids; ALA = alpha linolenic acid; DHA = docosahexaenoic 

acid; EPA = eicosapentaenoic acid; AA = arachidonic acid; Length = intervention length; Design = research 

design; n = sample size; pts = study participants; NR = not reported; S = statistically significant difference; 

NS = nonsignificant statistical difference; n/a = not applicable; pb = placebo; grp = group; wk = week(s); mo 

= month; wt = weight; RBC = red blood cells; PL = phospholipid; CPG = choline phosphoglycerides; EPG = 

ethanolamine phosphoglycerides; +

p<.05 or significant with 95% confidence interval; ++p<.01; +++p<.001; ++++p<.0001; ITT = intention-to-treat analysis; PP = per-protocol analysis (e.g., completers); Ï = increase; 

Ð = decrease/reduction 

Innis et al. included a sample of Canadian term infants exclusively breastfed for at least 3 

months since birth. The aim of the study was to determine the association between the RBC 

DHA content at 2 months of age and visual and neural development. The visual acuity was 

measured using the Teller Acuity Card Procedure at 2, 4, 6 and 12 months.271(Summary Table 

43) 

Krasevec et al. measured the LCPUFA content in maternal and infant’s blood at 2 months of 

age and its correlation with the visual acuity using the Teller Acuity Card Procedure. The Cuban 

term infants were either breastfed or formula fed.275(Summary Table 43) 

Summary Table 43: Association between omega-3 or omega-6/omega-3 fatty acid content of biomarkers and 

visual function development in term and preterm infants

Study groups1 Author, 

Year, 

Location: 

Length & 

Design 

Group 1 

(n)/ 

Group 4 

(n)

Group 2 

(n)/ 

Group 3 

(n) Notable associations2,3

Internal 

validity 

Applicabilit

y 

Innis, 2001, 

Canada: 

Crosssectional 271

Term infants 

breastfed 

(n=83) 

n/a RBC PE DHA (2 mo) was S (+) 

correlated to visual acuity at 2 

mo++ & 12 mo+

 

NS at 4 & 6 mo 

Infants with RBC PE DHA 

<8.53g/100g had S Ð visual 

acuity at 2 & 12 mo than infants 

with > 10.78g/100g FA+

Quality 

score: 8 

[Grade A] 

III 
187

Krasevec, 

2002, Cuba: 

Crosssectional 275

Mother/term 

infants 

breastfed 

(n=31) 

Mother/term 

infants 

formula fed 

(n=23) 

NS correlations between visual 

acuity & EFA concentration, 

ratio of EFA, or group of PUFA 

in infant tissues 

NS correlation for full sample & 

each feeding group (i.e., 

exclusively breast milk vs. not 

exclusively breastfed) 

NS correlation between PUFA 

profiles of maternal tissues for 

exclusively breastfed infants & 

visual acuity 

Quality 

score: 7 

[Grade B] 

III 

1

Proceeding from highest omega-3, or lowest omega-6/omega-3, fatty acid content of intervention/exposure; 2

biomarker source; 3biomarkers = EPA, DHA, AA, AA/EPA, AA/DHA, AA/EPA+DHA; n-3 = omega-3 fatty acids; 

n-6 = omega-6 fatty acids; ALA = alpha linolenic acid; DHA = docosahexaenoic acid; EPA = eicosapentaenoic 

acid; AA = arachidonic acid; E-EPA = ethyl eicosapentaenoate; Length = intervention length; Design = 

research design; n = sample size; pts = study participants; NR = not reported; S = statistically significant 

difference; NS = nonsignificant statistical difference; n/a = not applicable; pb = placebo; grp = group; wk = 

week(s); mo = month; wt = weight; RBC = red blood cells; PL = phospholipid; CPG = choline 

phosphoglycerides; EPG = ethanolamine phosphoglycerides; +

p<.05 or significant with 95% confidence 

interval; ++p<.01; +++p<.001; ++++p<.0001; ITT = intention-to-treat analysis; PP = per-protocol analysis (e.g., 

completers); Ï = increase; Ð = decrease/reduction 

Qualitative synthesis of relevant studies’ key characteristics

Study characteristics. Eight unique cross-sectional studies were deemed relevant for the 

review.271,275,278-282 One report included two unique studies, with preterm and full-term 

infants. Birch et al. and Leaf et al. included preterm infants,278,279 whereas the remaining six 

studies selected full-term infants.271,275,278,280-282 Two studies were conducted in the 

US,278 two in Australia,279,280 two in Canada,271,281 one in Denmark,282 and one in 

Cuba.275 

Leaf et al.279 did not provide the funding source. Both Birch et al. studies were supported by 

the National institutes of Health, Delta Gamma Foundation of Dallas, Pediatric Subunit, and the 

United Cerebral Palsy Foundation.278 Makrides et al. was funded by Scotia Pharmaceuticals and 

Nestle Australia,280 whereas Jorgensen et al. received funds from Food Technology Research and 

Development Program, DanoChemo A/S, and the Swedish Medical Research Council.282 The 

first Innis et al. study was supported by the British Columbia Children’s Hospital 

Investigatorship,281 and the second271 by the Medical Research Council of Canada and Ross 

Laboratories. Finally, Krasevec et al.275 was funded by a CIDA Award for Canadians. 

Population characteristics. All the studies included healthy preterm278,279 or term 

infants. The elegibility criteria was adequately described in six of eight studies. The preterm 

infant’s studies included 48 patients (sample size range: 18-30), while the term infants’ studies 

selected 296 subjects (sample size range: 16-83). 

The preterm infants were included if they were healthy, and born before 32 and 33 weeks of 

GA; Birch et al. also included infants with birth weights of 1,000 g to 1,500 g and an appropriate 

weight for GA.278,279 Birch et al. included two samples of healthy full-term infants, one was 

composed of 30 infants born at 39 to 41 weeks of GA and tested at 4 months of PCA, and the 

other was composed of 43 term infants tested at 36 months of age.278 Makrides et al.’ infants 

were selected at approximately 5 months of age, with an appropriate weight for GA at birth 
188

recorded from immunizations and/or postnatal clinics.280 The first sample of infants from Innis 

et al.’s study had an appropriate weight for GA and their mothers had to choose to breast feed or 

formula feed for at least 3 months.281 Yet, the second sample of term infants from Innis et al.’s 

study271 had a birth weight 2,500 g to 4,500 g and were enrolled within 2 weeks of birth. Their 

mothers were required to intend to breast feed them without providing infant formula or cow’s 

milk for at least 3 months, and without introducing solid foods for at least the first 4 months after 

birth. Jorgensen et al.s elected healthy children with birth weights between 2,700g and 4,500g 

and an Apgar score > 7 after 5 min. Finally, Krasevec et al.275 was the only study that included 

healthy Cuban women who experienced a normal pregnancy and their infants at 2 months 

postpartum. 

The preterm infants were excluded if they experienced a major congenital anomaly, severe 

intra/peri ventricular hemorrhage, 5-min Apgar score below 5,279 were unable to tolerate enteral 

feeds by day 10 of life, with respirator treatment for more than 7 days, congenital infection or 

malformation, retinopathy of prematurity, or grade 3 or 4 intraventricular hemorrhage.278 Term 

infants were excluded if they had a known eye disorder, family history of eye disorder, a 

neurological disorder, or neonatal morbidity.278,280 Innis et al.271 also excluded mothers with 

substance abuse, communicable diseases, metabolic or physiologic problems, infections likely to 

influence fetal growth, or multiple births and infants with evidence of metabolic or physical 

abnormality. Three studies did not provide the exclusion criteria.275,281,282

None of the studies reported the use of medication and/or supplements before study entry. 

For both studies that included a preterm population, the weight and length at the time of the 

evaluation,278,279 as well as the GA at birth,279 were comparable between feeding groups. 

The studies that evaluated term infants had a between-group nonstatistically difference in 

terms of birth weight,271,281,282 GA,281,282 current weight, length,278 age, parity, social status,280

pregnancy weight gain, maternal age, percentage of cesarians and percentage of males.282

Only Leaf et al.279 reported the comorbid condition of their preterm infants during the study 

period. The conditions were: subependymal intraventricular hemorrhage (n=4), mild ventricular 

dilatation (n=1), stage 1 retinopathy of prematurity (n=1) and stage 2 (n=1). 

Intervention/exposure characteristics. The exposure desciption will be made separately 

for preterm and term infants. The preterm infants were fed according to nursery protocol and 

their parent’s wishes in Leaf et al.’s study.279 TPN was commenced in those with birth weight < 

1,500 g (Vitamin-N, Pharmacia Ltd.) along with Intralipid 20% (Pharmacia Ltd.), which 

provided a source of lipids (receiving in 15 mL/kg/day approx. 6.4 mg/kg/day of AA and 5.8 

mg/kg/day of DHA from egg-phospholipid). Enteral feed were started as soon as possible by 

intermittent gavage. Breast milk was given if available. If not, infants were commenced on 

Premature Enfalac formula until 2,000 g, and then standard on Enfalac, which contains vegetable 

oils as a source of lipids. No LCPUFAs were found in the formula milks. For breast milk, 150 

mL/kg/day provided 32 mg/kg/day of AA and 17 mg/kg/day of DHA. The low breast-milk 

(LBM) and high breast-milk (HBM) groups did not differ in the amount of TPN and intralipid 

intake (less AA and DHA than breast milk). In Birch et al.’s study, preterm infants were fed 

with breast milk or a corn oil-based formula.278 

The term infant groups in Birch et al.’s study were either breastfed or fed corn oil-based 

formula. The diets were regulated until 12 months of age to maintain cholesterol and FA profiles 
189

consistent with the two dietary regimes. The breastfed group was provided with a monosaturated 

FA formula, with high oleic acid supplement and by feeding egg yolk as a solid food (LC 

PUFA). For the formula-fed group, a high LA supplement was provided and solid foods were 

selected to maintain a low cholesterol and omega-3 LCPUFA supply.278

Makrides et al.’s formula-fed infants (n=8) received one of three infant formulas, each of 

which had a similar FA composition. LA ranged from 12% to 15% and ALA ranged from 1% to 

1.6% of total FAs. The LA:ALA ratios were similar and ranged from 9.4 to 11.3. Both groups 

were receiving solid foods, like rice cereal and stewed fruit. None of the infants were receiving 

detectable quantities of DHA or AA from solids.280 The first term formula group in Innis et al.’s 

study (no LCPUFA) (n=18) were fed with ready-to-feed Enfalac (by Mead Johnson Nutritionals) 

from 14 (SD=2) days of age. Enfalac is a whey protein based term formula with 17.9% LA 

(omega-6) and 2.1% ALA (omega-3). The breast milk was composed of 13.4 % LA, 1.5 % 

ALA, 0.1% EPA and 0.2 % DHA. This group was also provided with a daily supplement of 

vitamin D, A and C, while the formula-fed group did not receive supplements (vitamins or 

minerals). The duration of the intervention was 3 months.281 

In the second Innis et al. study, the infants were exclusively breastfed for 3 months, and the 

majority were exclusively breastfed for more than 3 months.271 The mother’s breast milk had 

0.26 g DHA, 0.4 g AA, 12.5 g LA (per 100 g of milk FAs).271

Jorgensen et al.’s breast feeding infants (n=17) received between 0.44% to 0.56%wt of AA, 

0.13% to 0.23%wt of EPA and 0.43% to0.53%wt of DHA, while the formula-fed infants (n=16) 

received 14.4%wt LA and 1.7% wt of ALA (omega-3). The omega6/omega-3 ratio was 

comparable between groups. Small amounts of supplementary food (vegetable mashes and 

cereal-based gruel, one meal per day) were introduced to one breastfed and nine formula-fed 

infants from the age of 3 months.282

Krasevec et al.275 included data regarding the infant’s feeding practices collected at 2 months 

of age. They were exclusively breastfed (n=31), fed with a combination of breast milk and 

bottle-feeding (n=22), or not fed any breast milk (n=3). The most common supplemental milk 

fed to these infants was a cow milk formulation made with skim milk powder and vegetable oil, 

as well as evaporated milk and yogurt. Supplemental milks had been fed for an average of 2 to 4 

weeks before the 2-month study visit. Their mothers were receiving 454 g/week of a high fat 

fish (Trachurus mediterraneous) while breast feeding (source of LCPUFA).275

Outcome characteristics. All but one of the studies280 evaluated the visual function with 

the same test. The FPL was measured with the Teller Acuity Card Procedure. The retinal 

maturity was measured with an ERG in one study.279 Visual acuity was also assessed using 

VEP acuity in three studies.278,280 Finally, both Birch et al.’s term and preterm studies 

evaluated the visual function using the operant FPL acuity, stereo acuity, recognition acuity, 

color vision, letter matching, picture naming, orthopic exam at 36 months of age. All acuities 

were expressed in a common unit of measurement, which is independent of the technique, log 

MAR (log minutes of arc resolution).278 

All of the studies drew blood samples from the infants, and in one case from the mothers.275 

The description of the lipid extraction was adequate. The correlation between the RBC or 

plasma FA composition and the visual function outcomes was calculated. 
190

Study quality and applicability. Although the studies employed different reseach designs, 

the mean quality score was 5.3 and the applicability assigned was level III. 

Summary Matrix 22: Association between omega-3 or omega-6/omega-3 fatty acid content of biomarkers and 

visual function development in term and preterm infants 

Study Quality

A B C 

Author Year n Author Year n Author Year n I 

Author Year n Author Year n Author Year n II 

Author Year n Author Year n Author Year n

Applicability 

III 

Innis 2001 83 Birch 

Birch 

Makrides 

Innis 

Leaf 

Jorgensen 

Krasevec 

1993 

1993 

1993 

1994 

1996 

1996 

2002 

30 

73 

16 

35 

18 

33 

56 

 

n = number of allocated/selected participants

Qualitative synthesis of individual study results 

The results will be analyzed separately for preterm and term infants. 

Both preterm studies reported different clinical outcomes related to visual function, thus they 

will be depicted independently. Birch et al. found that the breastfed infants had a significantly 

better VEP acuity than the formula-fed infants at 4 months of age. LogMAR acuity was 

significantly correlated with the end-product ratio [DHA n-3/DPA n-6] in total RBC lipids. For 

FPL acuity, the results were the same for both the breastfed and formula-fed groups. For the 

mean RBC end-product ratio, DHA/DPA was significantly higher in the human milk-fed infants 

compared with the formula-fed infants, and the LogMAR was significantly correlated with this 

ratio.278 

Leaf et al. analyzed the ERG (retinal function measure) at 40 weeks PCA in relation to 

dietary intake and to plasma and RBC LCPUFA content, and also to infant variables such as GA 

and age at recording, as possible effect modifiers.279 The infant group was separated by the 

predominance of breast milk intake (nine infants had a high breast milk intake [mean 74% of 

total diet] and nine had a low breast milk intake [mean 17.5% of total diet]) in order to make 

comparisons. Scotopic and photopic ERG results were analyzed in relation to plasma and RBC 

FAs: AA and DHA, total omega-6 LCPUFA and total omega-3 LCPUFA as continuous 

variables. There was a positive correlation between scotopic b wave implicit time and 

percentage composition of DHA in both plasma and RBC PL. A similar relationship was seen 

with total n-3 LCPUFA in both plasma and RBC PL. There was a positive correlation between 

both RBC AA and total n-6 LCPUFA and scotopic a-b amplitude. No significant relationships 

were seen between photopic ERGs and either plasma or RBC LCPUFAs. The correlation 

between the Teller Card visual acuity test and blood biomarkers was not measured. 
191

For the term population, since the exposure characteristics as well as the population 

characteristics were so different across the studies, the outcome measures will be described 

separately for each study. 

Birch et al.’s mean VEP and FPL acuities were better in human milk-fed infants than in the 

formula-fed infants at 4 months of age. No correlation with RBC FA content was measured.278 

However, the 36-month evaluation of the full-term infant group showed that there was no 

statistical differences between groups (human milk vs. formula fed) in terms of mean OPL 

grating acuities, near recognition acuity and distance recognition. Human milk-fed infants had 

significantly better OPL stereoacuity than the formula-fed group at 36 months. The mean RBC 

end-product ratio, DHA/DPA in total RBC lipids, was significantly higher in the human milk 

group compared with the formula group, and stereo acuity was significantly correlated with the 

end-product ratio. The human milk group was significantly better in letter matching than the 

formula group. Performance on this outcome at 36 months was significantly correlated with the 

end-product ratio, DHA/DPA in total RBC lipids at 4 months. No significant differences were 

found between the two diet groups in picture naming or color vision.278

Makrides et al.’s breastfed infants had a significantly smalled logMAR (i.e., better VEP 

acuity) than those who had been formula-fed at 5 months of age. There was no correlation 

between postnatal age and VEP acuity. Infants fed with breast milk had a greater proportion of 

RBC DHA and less RBC LA relative to those who had received infant formula. There was a 

significant correlation between logMAR (VEP acuity) and the proportion of DHA and LA (p < 

0.01) in RBC PL.280

The Innis et al.’s first study, the covariates used in the analysis were age (14 days of age vs. 3 

months) and diet (human milk vs. formula). There was a nonsignificant difference between 

groups in visual acuity test at 14 days and at 3 months. Regression analysis indicated that visual 

acuity was not related to dietary intake or to plasma PL, RBC PC or PE concentrations of DHA, 

when tested for the entire group of infants, or just within the breastfed or formula-fed group of 

infants.281

In the second Innis et al. study, the RBC PE DHA at 2 months was significantly and 

positively correlated to visual acuity at 2 and 12 months, but not at 4 and 6 months of age. 

Infants with an RBC PE DHA concentration < 8.53 g/100 g had significantly lower visual acuity 

at 2 and 12 months than infants with an RBC PE DHA > 10.78 g/100 g FAs.271

Jorgensen et al.infant’s visual acuity increased over time in both feeding groups, with a 

significantly higher increase in the breastfed group. There was no significant correlation 

between RBC DHA and visual acuity within the two feeding groups at 4 months. However, 

when the two groups were combined, the correlation became significant. There was no 

significant correlation between AA levels and visual acuity.282 Finally, Krasevec et al.’s study 

did not find significant correlations between visual acuity scores and any individual EFA 

concentration, ratio of EFA concentrations, or group of EFA in infant tissues. The same results 

were obtained when the correlation was measured in the entire sample, and when assessing each 

feeding group (i.e., exclusively breast milk vs. not exclusively breastfed) separately. There were 

no relations between EFA profiles of maternal tissues for exclusively breastfed infants and visual 

acuity.275 The mean visual acuity scores did not differ between feeding groups. 
192

Cognitive Development Outcomes: 

What is the Evidence That Maternal Intake of Omega-3 Fatty Acids 

During Pregnancy Influences Cognitive Development in Term or 

Preterm Human Infants? 

One RCT published in 2001 was identified which answered this question.141 This study also 

answered the question regarding cognitive outcomes in breastfed infants whose mothers received 

the LCPUFA intervention. (Summary Table 44) 

Overview of relevant study characteristics and results 

Helland et al. assessed the gestational length, birth weight, and neurologic and cognitive 

outcomes in a sample of healthy pregnant women. They were randomized to receive cod liver oil 

(1183 mg/10 mL DHA, 803 mg EPA) or corn oil (LA and ALA) from week 18 of pregnancy to 3 

months post delivery.141

Helland et al. was conducted in Norway and funded by Peter Moller, Avd. Orkla ASA, and 

“Aktieselskabet Freia Chocoladefrabriks Medicinske Fond.” 

The participants (n=590 enrolled) were included if they were healthy women with single 

pregnancies between 19 and 35 years of age, and intended to breastfeed their infant. They 

should not have taken any supplements of omega-3 FAs earlier during the pregnancy. The 

exclusion criteria were premature births, birth asphyxia, infections, and anomalies in the infants 

that required special attention.141 Helland et al. had a high rate of dropouts, leaving 341 women 

in the final analysis (57%).288

There was no difference between groups in body mass index before pregnancy and at birth, 

parity, smoking, or maternal and paternal education at baseline.141 The mean age of mothers 

receiving cod liver oil was significantly higher than the age of mothers receiving corn oil. 

The subjects were randomly assigned to either 10 mL/day of cod liver oil (Peter Moller, Avd 

Orkla ASA, Oslo, Norway), or identical 10 mL/day of corn oil from 18 week of pregnancy to 3 

months after delivery.141 The cod liver oil contaned 1,183 mg/10 mL DHA, 803 mg/10 mL of 

EPA. The corn oil contained 4,747 mg/10 mL LA (omega-6) and 92 mg/10 mL ALA (omega-3). 

The amount of fat-soluble vitamins was identical in both oils. There was no significant 

difference between groups in the maternal dietary intake of nutrients at baseline.141 There was 

no significant difference in maternal plasma PL concentration of DHA before entering the study. 

The cognitive outcomes were assessed using the Fagan test of Infant Intelligence at 27 and 

39 weeks of age (6-9 months). A subpopulation analysis (n=90) was performed at 4 years of 

age, assessing the children’s intelligence using the Kaufman Assessement Battery for Children 

(K-ABC).141
193

Summary Table 44: Omega-3 fatty acids and its influence on cognitive development in infants after intake 

during pregnancy and breast feeding 

Study groups1

 

Author, Year, 

Location: 

Design 

Group 1 

(n)/ 

Group 4 

(n)

Group 2 

(n)/ 

Group 3 

(n) Notable clinical effects

Internal 

validity Applicability 

Helland, 2001, 

Norway: 

34 wks 

parallel RCT141

Cod liver oil 

(DHA+EPA) 

(n=301) 

Corn oil 

(LA+ALA) 

(n=289) 

NS novelty preference (Fagan 

test) at 6 & 9 mo 

NS correlation between level 

DHA & novelty preference (6 & 

9 mo) 

Cod liver oil > Mental 

Processing K-ABC score than 

corn oil (4 y)+

Jadad 

total: 4 

[Grade: A]; 

Schulz: 

Unclear 

III 

1

biomarkers = EPA, DHA, AA, AA/EPA, AA/DHA, AA/EPA+DHA; n-3 = omega-3 fatty acids; n-6 = omega-6 

fatty acids; ALA = alpha linolenic acid; DHA = docosahexaenoic acid; EPA = eicosapentaenoic acid; AA = 

arachidonic acid; E-EPA = ethyl eicosapentaenoate; n = sample size; pts = study participants; NR = not 

reported; S = statistically significant difference; NS = nonsignificant statistical difference; N/A = not applicable; 

grp = group; wk = week(s); mo = month; RBC = red blood cells; PL = phospholipid; +

p<.05 or significant with 

95% confidence interval; ++p<.01; +++p<.001; ++++p<.0001; Ï = increase; Ð = decrease/reduction 

Helland et al. did not observe a significant difference between groups in the novelty 

preference at 6 or 9 months of age. When the score from 6 and 9 months of age were combined, 

there still was no difference between the two groups.141 When infants with high DHA 

concentration in umbilical plasma PL were compared with infants with low DHA concentration, 

there were no differences in novelty preference. Neither did they find differences in DHA 

concentrations between infants with high and low novelty preference.141

Children in the cod liver oil group had significantly higher scores than the corn oil group on 

Mental Processing Composite of the K-ABC test at 4 years of age. There was nonsignificant 

difference between groups in the rest of the test composites (simultaneous processing scale and 

nonverbal scale). The Mental Processing Composite correlated significantly with HC at birth, 

but not with birth weight or gestational length.141 No correlation was found between LCPUFA 

content in umbilical plasma PL and intelligence scores. Yet intelligence scores at 4 years 

correlated with plasma PL concentrations of DPA (omega-3) and DHA at 4 weeks of age. 

Mental processing skills of the children correlated significantly with maternal intake of EPA and 

DHA during pregnancy.141

There were 153 withdrawals from randomization to the second Fagan test assessment. The 

reasons were congenital anomalies, infections in the mothers or infants, miscarriages, premature 

births, and before giving birth (lack of compliance, discomfort taking the oil).141

Study quality and applicability. Helland’s Jadad total quality score was 4, indicating good 

internal validity, yet with an unclear allocation concealment. 
194

Summary Matrix 23: Omega-3 fatty acids and its influence on cognitive development in infants after intake 

during pregnancy and breast feeding 

Study Quality

A B C 

Author Year n Author Year n Author Year n I 

Author Year n Author Year n Author Year n II 

Author Year n Author Year n Author Year n

Applicability 

III HellandU 2001 590 

n = number of allocated/selected participants

What is the Evidence That the Omega-3 Fatty Acid Content of 

Maternal Breast Milk, With or Without Known Maternal Intake of 

Omega-3 Fatty Acids, Influences Cognitive Development in Term or 

Preterm Human Infants? 

One RCT and a single prospective cohort study published between 1997 and 2001 were 

identified to answer this question.138,284 Helland et al. also addressed this question, which was 

described above (see key question: Maternal Intake/Cognitive Development). (Summary Table 

44 and 45) 

Overview of relevant study characteristics and results 

Gibson et al. was a double-blind RCT that investigated the maternal intake effect on 

breastfed infant’s neurological and visual function outcomes in Australia.138 This study included 

mothers of term infants (> 37 weeks of GA) who intended to breast feed for at least 12 weeks 

(n=52, means age: 30 [SD=4] years). These mothers were randomized to receive one of five 

doses (0, 0.2, 0.4, 0.9, or 1.3 g DHA/day) of a DHA-rich algal oil (DHASCO, Market 

Biosciences, MD, US) between day 5 and week 12 postpartum. The oil contained 43% DHA, 

1% omega-6 FA, 38% saturates and 18% monosaturates. Infants who were exclusively breastfed 

for 12 weeks were assessed. Infants (n=20) were healthy, with appropriate weight for GA and 

Apgar scores greater than 7 at 5 minutes.138 (Summary Table 45) 

Infant’s visual function using VEP (logMAR) was assessed at 12 and 16 weeks of life, and 

for global development (Bayley’s Scales of Infant development) at 1 and 2 years of age. Blood 

was drawn for biomarker analysis in infants at 12 weeks of age. Mothers were from middle class 

families and completed year 12 education. The five groups were compared in terms of maternal 

age, maternal BMI, GA, infant’s gender, birth weight, birth length, birth HC, Apgar score, 

siblings, maternal social score, smoking, education, home stimulation, and length of breast 

feeding, at baseline. There was a predominance of boys in the group that received the highest 

dose of DHA.138

Agostoni et al. evaluated the neurodevelopmental indices at 1 year of age in a single 

prospective cohort of term infants (n=44; 54.5% males) who were exclusively breastfed for at 

least 3 months in Italy.284 (Summary Table 45) 
195

The children received breast milk for at least 3 months, after which weaning foods were 

introduced in all subjects. They underwent clinical examination at 0, 1, 3, 6, 9 and 12 months. 

The mother’s milk lipid composition was determined at each time-point. The day before, the 

control pooled milk was collected from all feedings over 24 hours. There was a progressive 

reduction of the number of breastfed infants to n=29 (at 6 months), n=17 (n=9 months) and n=10 

(at 1 year). 

Summary Table 45: Omega-3 fatty acid content of maternal breast milk, with or without known maternal 

intake of omega-3 fatty acids, influences cognitive development in term or preterm human infants 

Study groups1 

Author, Year, 

Location: 

Design 

Group 1 

(n)/ 

Group 4 

(n)

Group 2 

(n)/ 

Group 3 

(n) Notable clinical effects

Internal 

validity Applicability 

Gibson, 1997, 

Australia: 

12 wk 

 parallel RCT138

1.3g/d 

DHA 

(n=8)/ 

0.2g/d 

DHA 

(n=10) 

0.9g/d 

DHA 

(n=10)/ 

0.4g/d 

DHA 

(n=12)/ 

pb 

(n=12) 

S correlation between MDI & 

DHA in infants’s diet & status 

(RBC & plasma at 12 wks) at 1 

y

+ 

NS at 2 y 

S correlation MDI & length of BF 

at 1 y+ 

NS at 2 y

Jadad total: 

3 [Grade: 

B]; 

Schulz: 

Unclear 

II 

Agostoni, 2001, 

Italy: 

Single 

prospective 

cohort284

Term 

breastfed 

infants at 

1 y-old 

(n=44) 

n/a S correlation between Bayley’s 

MDI & milk total fat content at 6 

mo++, but NS at 12 mo 

NS AA, DHA milk content 

correlation with MDI at 12 mo

Quality 

score: 8 

[Grade A] 

III 

1

biomarkers = EPA, DHA, AA, AA/EPA, AA/DHA, AA/EPA+DHA; n-3 = omega-3 fatty acids; n-6 = omega-6 

fatty acids; ALA = alpha linolenic acid; DHA = docosahexaenoic acid; EPA = eicosapentaenoic acid; AA = 

arachidonic acid; E-EPA = ethyl eicosapentaenoate; n = sample size; pts = study participants; NR = not 

reported; NS = nonsignificant statistical difference; N/A = not applicable; grp = group; wk = week(s); mo = 

month; RBC = red blood cells; PL = phospholipid; MDI = Mental Developmental Index; +

p<.05 or significant with 

95% confidence interval; ++p<.01; +++p<.001; ++++p<.0001; Ï = increase; Ð = decrease/reduction; BF = 

breast feeding 

Gibson et al.’s mean Bayley’s Mental Developmental Index (MDI) score did not differ 

between groups at 1 or 2 years of age.138 Bayley’s MDI score at 1 year of age (n=51) was found 

to correlate with DHA indices in the infant’s diet and status, although no association was found 

at 2 years (n=49). Length of breast feeding was also significantly correlated with MDI at 1 year, 

but not at 2 years. Length of breast feeding was collinear with indices of social status, education 

and home stimulation.138 All these factors were consistent predictors of Bayleys MDI at both 

ages. Whether the partner smoked was also related to Bayley’s MDI at 1 year, but not at 2 years. 

In a post hoc analysis, it was observed that at 1 year, home stimulation and RBC DHA were the 

only significant predictors of Bayley’s MDI score. By 2 years of age, the model only included 

gender plus the social score of the oartner as predictors of Bayley’s MDI.138

The Bayley’s MDI at 1 year old was 93.39 (SD=8.1). After correcting for potential 

confounders such us parity and mother’s characteristics (i.e., age, education, smoking habits), 

breast-feeding for 6 months or longer was not significantly correlated to the mean MDI result 

compared with subjects who were breastfed for 3 to 6 months (n=15).284 Associations between 

MDI and the milk fat content and composition were measured with a multiple regression 
196

analysis. There was a positive correlation between MDI and the milk total fat content at 6 

months, but not at 12 months. There was no correlation between the AA and DHA FA content of 

breast milk and the MDI result at 12 months.284

Study quality and applicability. Gibson et al.’s Jadad total quality score was 3, indicating a 

sound internal validity. However, the allocation concealment was unclear.138 Agostoni et al. 

had a quality score of 8.284 

Summary Matrix 24: Omega-3 fatty acid content of maternal breast milk, with or without known maternal 

intake of omega-3 fatty acids, influences cognitive development in term or preterm human infants 

Study Quality

A B C 

Author Year n Author Year n Author Year n 

I 

Author Year n Author Year n Author Year n II GibsonU 1997 52 

Author Year n Author Year n Author Year n

Applicability 

III Agostoni 2001 44 

n = number of allocated/selected participants

What is the Evidence That the Omega-3 Fatty Acid Content of Infant 

Formula Influences Cognitive Development in Term or Preterm 

Human Infants? 

What is the Evidence That the Omega-3 Fatty Acid Content of 

Maternal Breast Milk, With or Without Known Maternal Intake of 

Omega-3 Fatty Acids, and Together With the Omega-3 Fatty Acid 

Content of Infant Formula, Influences Cognitive Development in Term 

or Preterm Human Infants? 

Infant Formula Intake - Preterm infants 

Six RCTs met the eligibility criteria. They were published between 1992 and 2004. All the 

studies were summarized in the Growth Pattern Outcomes and Neurological Development 

Outcomes sections (see key questions: Growth Patterns & Neurological Development-Preterm 

Infants). (Summary table 46) 
197

Overview of relevant studies 

Summary Table 46: Omega-3 fatty acids and its influence on cognitive development in preterm infants 

Study groups1 Author, 

Year, 

Location: 

Length & 

Design 

Group 1 

(n)/ 

Group 4 

(n)

Group 2 

(n)/ 

Group 3 

(n)

Notable clinical 

effects

Internal 

validity Applicability 

Carlson, 

1992, US: 

6 mo 

parallel 

RCT185

Supplemented 

formula (marine 

oil) (n=31) 

control formula 

(n=34) 

DHA-supplemented 

infants had a S Ð

novelty preference 

vs. control group 

Jadad total: 

4 [Grade: 

A]; 

Schulz: 

Adequate 

II 

O’Connor, 

2001, US, 

UK, Chile: 

12 mo 

parallel 

RCT207

DHA+AA 

(fish/fungal) 

(n=140)/ Human 

milk (reference 

standard) (n=43) 

DHA+AA (eggTG/fish) 

(n=143)/ 

Control formula 

(n=144) 

(ITT) NS Bayley’s 

MDI (12 mo)

M novelty 

preference look 

(Fagan test) 

AA+DHA (eggTG/fish) > control 

& AA+DHA 

(fish/fungal) (6 

mo)++ 

Jadad total: 

3 [Grade: 

B]; 

Schulz: 

Unclear 

I 

van WezelMeijler,

2002, The 

Netherlands: 

6 mo, 

parallel 

RCT272

 AA+DHA 

preterm formula 

(n=22) 

Control formula 

(n=20) 

NS Bayley’s MDI 

(3, 6, 12 & 24 mo) 

Jadad total: 

5 [Grade: 

A]; 

Schulz: 

Adequate 

III 

Fewtrell, 

2002, UK: 

33 d 

parallel 

RCT273

AA+DHA+EPA 

preterm formula 

(n=95)

Control formula 

(n=100)/ human 

milk (n=88) 

(ITT) NS Bayley’s 

MDI (18 mo)

Jadad total: 

5 [Grade: 

A]; 

Schulz: 

Adequate 

II 

Clandinin, 

2002, 

Canada: 

92 wks 

parallel 

RCT193

DAS (DHA+AA 

from SCO) 

(n=72)/ human 

milk (n=105)

DAF (DHA from 

fish oils+AA 

from SCO) 

(n=90)/ Control 

formula (n=83) 

Bayley’s MDI: DAS 

& DAF formulas 

had > scores than 

control formula+

. 

HM had > scores 

than the other 

groups (118 wks 

PMA)+

Not 

assessed 

X 

Fewtrell, 

2004, UK: 

9 mo 

parallel 

RCT258

GLA+ DHA 

formula (n=122)

Control formula 

(n=116) 

(ITT) NS Bayley’s 

MDI (18 mo). Boys 

in formula > score 

vs. control+

Jadad total: 

5 [Grade: 

A]; 

Schulz: 

Adequate 

II 

1

Proceeding from highest omega-3, or lowest omega-6/omega-3, fatty acid content of 

intervention/exposure; n-3 = omega-3 fatty acids; n-6 = omega-6 fatty acids; ALA = alpha linolenic acid; 

DHA = docosahexaenoic acid; EPA = eicosapentaenoic acid; AA = arachidonic acid; Length = intervention 

length; Design = research design; n = sample size; pts = study participants; NR = not reported; S = 

statistically significant difference; NS = nonsignificant statistical difference; n/a = not applicable; grp = 

group; wk = week(s); mo = month; wt = weight; MDI = Mental Developmental Index; +

p<.05 or significant 

with 95% confidence interval; ++p<.01; +++p<.001; ++++p<.0001; ITT = intention-to-treat analysis; PP = perprotocol analysis (e.g., completers); Ï = increase; Ð = decrease/reduction; SCO = single-cell oil 
198

Qualitative synthesis of relevant studies’ key characteristics

Study characteristics. Six parallel RCTs involving preterm infants were identified to 

address these questions.193,207,258,272,273 Five of them were published in English scientific 

journals, while one was published as an abstract.193 Carlson et al. was conducted in the United 

States.185 Both Fewtrell et al.’s studies were conducted in the UK,258,273 van Wezel-Meijler 

et al.was located in the Netherlands,225,272 Clandinin et al. was conducted in Canada,193 and 

O’Connor et al. was sited in the US, UK and Chile.207 

Two studies involved three arms comparing the use of supplemented and unsupplemented 

infant formula with the addition of a fourth reference standard group (i.e., human milk).193,207 

Three RCTs compared only two study groups of formula with or without LCPUFA,185,258,272

while another study also used a group using human milk as a reference standard.273 Carlson et 

al. was supported by the National Eye Institute and Ross Laboratories.185 van Wezel-Meijler et 

al. and Fewtrell et al.’s 2002 studies were supported by a private source, Numico Research.272,273 

Clandinin et al. was funded by Mead Johnson & Company (pharmaceutical-nutritional 

company),193 while Fewtrell et al.’s 2004 study was supported by H.J. Heinz Company (food 

company).258 O’Connor et al. did not report the funding source.207

Population characteristics. There were 1,486 preterm infants enrolled across the included 

studies that were randomized to receive the supplemented or control formulas. The sample sizes 

ranged from 55 to 470 participants. The mean age of the infants at randomization was 

nonsignificantly different between study groups across the four RCTs. One study did not report 

the age of their infants.193 The GA of the preterm infants was below 37 weeks across four 

studies, except for one study that also included VLBW term infants.193 The between-group 

difference on the GA was not significant across the studies. 

In five studies, the proportion of male participants did not differ significantly between 

randomized groups, although two studies did not mention this information or the between-group 

difference.185,193 The range of percentage of males was from 35% to 56%. 

Carlson et al. and O’Connor et al. described the racial composition of their participants.185,207 

Carlson et al. included 86.5% of Black infants,185 while O’Connor included predominatly White 

subjects.207 The rest of the studies failed to provide the race and/or ethnicity of their subjects. 

Variables like birth weight, proportion of SGA patients, percentage from multiple 

pregnancies, Apgar score at birth were nonstatistically different between groups in two 

studies.185,207 van Wezel-Meijler et al. matched their population by birth weight and proportion 

of SGA at baseline.272 Both Fewtrell et al.’s infants were well matched by birth weight and 

length, proportion of SGA, proportion from multiple pregnancies, and delivered by C-section, at 

baseline.258,273 

Four of six studies analyzed the between-group difference of maternal covariates. Carlson et 

al.’s sample did not differ in maternal age and parental education.185 O’Connor et al. matched 

their study groups by maternal age, education, smoking status during pregnancy and in the home, 

prenatal care, the HOME inventory score and the maternal intelligence measured with WAIS-R 

Raw vocabulary score.207 Statistically siginificant differences in the HOME Inventory Score 

were observed between the following birth weight groups: 1) Infants with < 1,250 g, the control 

group had a higher score than infants in the AA + DHA (fish/fungal) group; 2) Infants > 1,250 g, 
199

the control group had a higher score than those in the AA + DHA (egg-TG/fish) group; and 3) 

Infants with a birth weight higher than 1,250 g in the AA + DHA (fish/fungal) group had a 

higher score than those in the AA + DHA (egg-TG/fish) group.207

The inclusion criteria were described in every included study, however the exclusion criteria 

were not reported in two studies.193,273

The studies included mostly healthy preterm infants with a defined weight range, drawn from 

neonatal intensive care units (NICU). Carlson et al. included VLBW (between 748 g and 1,390 

g) preterm infants.185 O’Connor et al. selected preterm infants (< 33 weeks of GA) with a birth 

weight range of 750 g to 1,805 g in NICU that could initiate enteral feeding by 28th day of life, 

including singleton and twin births, as well as SGA subjects.207 van Wezel-Meijler et al. 

included premature infants (< 34 weeks of GA), with birth weight of < 1,750 g, normal 

neurological examination throughout the neonatal period, normal repeated brain ultrasound or 

showing minor abnormalities such as isolated subependymal haemorrhage and subventricle, with 

no ventricular dilation, transient periventricular echodensities, without evolution into cysts or 

any combination of previous findings.272 Infants in Fewtrell et al.’s 2002 study had a GA below 

37 weeks and a birth weight of < 1,750 g, free of congenital malformations known to affect 

neurodevelopment, whose mothers decided not to breastfeed at 10 days of age.273 Preterm 

infants (GA < 35 weeks) in Fewtrell et al.’s study had a birth weight ≤ 2,000 g, and had received 

at least one of their enteral feeds as formula milk during their hospital stay.258 Clandinin et al. 

included VLBW term and preterm infants after their feeding reached 30 mL/kg/day.193 

Four studies excluded infants with serious congenial abnormalities affecting growth and 

development, major surgery before randomization, periventricular or intraventricular 

hemorrhage, maternal incapacity, liquid ventilation asphyxia resulting in severe and permanent 

neurologic damage, or uncontrolled systemic infection at the time of enrollment.185,207,258,272

Three RCT measured the blood content of FAs at baseline.185,207,272 O’Connor et al. and van 

Wezel-Meijler et al. found a nonsignificant difference between groups in the plasma or PE or PC 

fractions of RBC levels of AA and DHA.207,272 None of the studies measured the FA content of 

human milk. 

Only two studies reported the presence of concurrent conditions in the study population 

and/or the use of medications.185,272 Carlson et al.’s preterm infants had VLBW, and some were 

in mechanical ventilation and IV nutrition at randomization.185 van Wezel-Meijler et al.’s study 

reported that 13 patients were excluded from the analyses for the following reasons: necrotizing 

enterocolitis (n=2, 1 each group), chronic lung disease (n=3, n=2 DHA-AA vs. n=1 control), 

grade 4 retinopathy of prematurity (n=1, AA + DHA), cystic periventricular leucomalacia (n=1, 

control), and the duration of artificial ventilation of their patients at baseline. No differences 

were found between groups.272 None of the studies included information related to maternal 

concurrent conditions or medications, which could be relevant to patients taking human milk. 

No other prestudy medications or treatments were mentioned in the included studies. 

O’Connor et al.’s infants were formula and/or human milk fed before study entry,207 whereas 

van Wezel-Meijler et al.’s study used parenteral nutrition with glucose/Vaminolact 

6.75%/Intralipid 20% (Kabi-Fresenius, Stockohlm, Sweden) being administered for an average 

of 12 to 17 days, starting 24 hours after birth. This parenteral nutrition contained negligible 
200

amounts of LCPUFA. Three to 7 days after birth, enteral feeding was introduced using preterm 

formula (without LCPUFA). Total enteral nutrition was usually achieved within 2 to 3 weeks 

after birth.272

Intervention/exposure characteristics. The intervention groups in each trial received 

different types of supplemented infant formula, thus each study will be discussed separately. 

Carlson et al.’s patients received either a marine oil-supplemented formula with 0.3 g EPA 

and 0.2 g DHA as preterm formula until discharge (1,800 g), then term formula until 79 weeks of 

age.185 The manufactured was Ross Laboratories. 

O’Connor et al.’s study randomized its participants to receive one of three study formulas, 

with or without the addition of LCPUFA and/or human milk: intrahospital preterm formula 

(modified version of Similac Special Care [SSC]; ready-to-feed by Ross Products Division, 

Columbus, OH, US) with AA or DHA enriched oils until term CA; and at term CA, 

postdischarge nutrient-enriched formula (modified version of NeoSure powder) AA and DHA 

and/or human milk until 12 months of CA.207 The first group received a supplemented formula 

with fungal and low-EPA fish oil (DHA/EPA ratio: 3.5/1) providing 0.27 g DHA, 0.08 g EPA 

and 0.43 g AA (per 100 mL) in the SSC formula and 0.16 g DHA and 0.43 g AA in the NeoSure 

formula. In the other group, egg- TG and low-EPA fish oil provided 0.24 g DHA and 0.41 g AA 

in SSC, but 0.15 g DHA in NeoSure. The purveyors of the fish, fungal and egg-TG oils were 

Mochida International (Japan), Suntory Ltd. (Japan) and Eastman Chemicals Co (US), 

respectively. The duration of the treatment was until 12 months of CA.207

In van Wezel-Meijler et al., the neonates were randomized to receive preterm liquid formula 

supplemented with (4.4 g/100mL fat) a 2/1 ratio of DHA (0.015 g/100 mL [0.34% fat]) as 

DHASCO® oil produced by microalgae (Martek Inc., Columbia, US) and AA (0.031 g/100 mL 

[0.68% fat] as ARASCO® oil produced by fungi (Martek Inc.). The formula was continued 

from enrollment until a weight of 3,000 g was reached. Subsequently, this group continued with 

a supplemented term formula (3.5 g/100 mL fat) with a reduced absolute amount of DHA (0.012 

g/100 mL; 0.34% fat) and AA (0.025 g/100 mL; 0.70 % fat) until 6 months of CA.272

Fewtrell et al. used a LCPUFA-supplemented preterm formula (n=95) (Prematil, Milupan) 

fat blended with vegetable oils (palm coconut, soya, sunflower) and milk fat, with derivates of 

LA, and ALA sourced from evening primrose oil (GLA) and egg-lipids (AA 0.31 g; DHA: 017 

g; EPA: 0.04 g [per 100mL]). Formula was provided as ready-to-feed form for a mean of 31 

days until neonatal unit care discharge.273

Clandinin et al. included two interventional groups. The intervention for the first group 

(DAS) was 17 mg DHA plus 34 mg AA/100 Kcal from single cell oils (SCO) (n=72) as preterm 

formula (24 Kcal oz), discharge formula (22 Kcal oz) and term formula (20 Kcal oz). The 

intervention for the second group (DAF) was the same as for DAS but with 17 mg DHA/100 

Kcal from fish oil and 34 mg AA/100 Kcal from SCO (n=90).193

Fewtrell et al.’s study used a preterm infant formula supplemented with LCPUFA 

(OsterPrem with LCPUFA) until the infants were discharged from NICU. Afterwards, a 

nutrient-enriched postdischarge formula was used (Farley’s PremCare with LCPUFA). The fat 

was a blend of vegetable oils (high oleic sunflower oil, palmolein, palm kernel oil, and canola 

oil). LCPUFA were sourced from borage (starflower) oil (GLA: n-6 0.9g/100 mL) and tuna fish 
201

oil (high DHA/EPA ratio: DHA 0.5 g/100 mL, EPA: 0.1 g/100 mL, AA: 0.04 g/100 mL). 

Formula was provided in ready-to-feed form during the hospital stay and in powdered form after 

discharge up to 9 months after term.258

The studies compared interventional formulas with identical appearance and smell,185,258,273

and unsupplemented infant formulas containing the same proportion of monosaturated and 

saturated FAs, over the same time period as the intervention group. 

The studies did not provide information regarding the background diet, when introduced, and 

the purity data for the omega-3 supplements. No study report included details as to whether, or 

how, the presence of methylmercury was tested or eliminated from the omega-3 FA exposure. 

Cointervention characteristics. Human milk was the reference standard group, either as a 

separate arm,193,258,273 or as part of the formula groups that did not comply with the 

intervention.207 O’Connor et al.’s infant preterm and term formulas contained beta-carotene 

and natural vitamin E.207 Both Fewtrell et al.’s subjects received and identical proportion of 

minerals and vitamins (A, D, E, and K) in their formulas.258,273 

Outcome characteristics. The instruments used to measure the cognitive development 

in the preterm infants were the Bayley’s Scale of Infant Development 

(MDI),193,207,258,272,273 the Fagan Test of Infant Intelligence (Infantest), novelty preference 

(a measure of visual recognition memory) by determining the percentage of total looking time 

spent looking at a novel versus familiar face stimuli during the test phase, mean duration of 

individual looks (measure of efficiency of information processing),185 and the vocabulary 

checklist from the infant version of the MacArthur Communicative Development Inventories (a 

standardized parent-report instrument.207 O’Connor et al.’s average percent of agreement on 

scoring between site testers and central testers was 91% (range: 71%-100%) for the Bayley’s 

MDI.207 

Study quality and applicability. The six RCTs received a mean Jadad total quality score of 

4.4, indicating a good internal validity (Summary Matrix 25). Three trials received a score of 

5,258,272,273 Carlson et al. received a score of 4,185 and O’Connor received a score of 3.207 

O’Connor et al. was unblinded,310 and Carlson et al. failed to report the method of doubleblinding.150 

Summary Matrix 25: Omega-3 fatty acids and its influence on cognitive development in preterm infants 

Study Quality

A B C 

Author Year n Author Year n Author Year n I O’ConnorU 2002 470 

Author Year n Author Year n Author Year n

II CarlsonA 

FewtrellA 

FewtrellA 

1992 

2002 

2004 

79 

283 

238 

 

Applicability 

Author Year n Author Year n Author Year n

III Van WezelMeijlerA

 

2002 55 

n = number of allocated/selected participants; RCT = AAdequate vs UUnclear allocation concealment; I Inadequate
202

Qualitative synthesis of individual study results 

O’Connor et al. did not find a statistical difference in the Bayley’s MDI score between 

groups at 12 months CA.207 van Wezel-Meijler et al. and both Fewtrell et al.’s studies failed to 

observe a statistically different MDI score between groups at any follow up.258,272,273 Clandinin 

et al.193 showed that term infants had higher MDI scores than preterm infants (data not shown). 

Infants in the DAA and DAF formula groups had significantly higher scores than infants in the 

control formula group, whereas infants in the human milk group had significantly higher scores 

than infants from the other groups at 118 weeks of postmenstrual age. 

Carlson et al. and O’Connor et al. measured the Fagan Test of Infant Intelligence (Infantest) 

at 6, 9 and 12 months of CA.185,207 Carlson et al. observed that, during novelty tests, both diet 

groups had a significant preference for novelty (i.e., longer looking time viewing the novel 

stimuli).185 However, at 12 months DHA-supplemented group had a significantly lower novelty 

preference compared to control group. Diet influenced the number of discrete looks during the 

novelty test: the DHA group had more total (novel and familiar) discrete looks compared with 

the control group, as well as a shorter average look duration.185 O’Connor et al. found that the 

mean novelty preference look was significantly greater in AA + DHA (egg-TG/fish) formula 

group than in the control and AA + DHA (fish/fungal) groups at 6 months.207 Novelty 

preference has been interpreted as an early measure of information processing capability and it 

has validity for performance on standardized intelligent tests in childhood.345 Shorter visual 

fixation look duration in infancy has also been shown to be related to superior performance in 

infancy and childhood. Shorter look duration has been interpreted as evidence of more efficient 

information processing or enhanced ability to disengage from attended stimuli.345 However, 

there was a nonstatistically different result between groups in the Infant version of the 

MacArthur Communicative Development Inventories (a standardized parent-report instrument) 

at 9 months CA and 14 months CA.207 

Although the correlation between the FA content in blood and clinical outcomes was not 

measured, the level of AA and DHA was significantly higher at hospital discharge (mean time: 

41 days) in the supplemented groups compared with the control group in the O’Connor et al. 

study.207 With the exception of AA levels in RBC PE at 4 and 12 months CA, infants fed the AA 

+ DHA supplemented formulas had higher levels of AA and DHA in plasma and RBC PL than 

those infants fed the control formulas. Infants fed AA + DHA (fish/fungal) but not AA + DHA 

(egg-TG/fish), had higher levels of AA in RBC PE than infants fed the control formulas (p < 

0.02). 

van Wezel-Meijler et al. did not find a statistically difference in AA levels in RBC between 

groups at 2 to 3 weeks.272 DHA levels were significantly lower in the control group compared 

with the group receiving supplemented formula.272

O’Connor et al.’s had 94 withdrawals (80%) at 12 months of CA. There were 

nonstatistically significant differences between groups. The main reason of the withdrawals was 

symptoms related to feeding intolerance. During the study, the following infant deaths were 

reported: six infants from the control group, three infants from the AA + DHA (fish/fungal) 

group, and six infants from the AA + DHA (egg-TG/fish) group; none of the infants from the 

human milk groups died. No infants deaths were related to study feedings.207
203

There were 13 dropouts in van Wezel-Meijler et al.’s study.272 The reasons were: necrotizing 

enterocolitis (NEC), chronic lung disease, grade 4 retinopathy of prematurity, cystic 

periventricular leucomalacia, change from formula feeding to mother’s expressed milk and home 

to hospital distance. There were no losses to follow up.272

In the first Fewtrell et al.’s study,273 six patients randomized to the control formula withdrew 

from the trial before 3 weeks for the following reasons: early discharge (< 3 weeks of age) (n=3); 

NEC (n=1); intolerance of feeds (n=1); and breastfed (n=1). Fourteen infants withdrew from the 

supplemented formula group for the following reasons: early discharge (n=2); NEC (n=5); 

maternal concern (n=2); and death (n=2). There were 14 infants lost to follow up at 9 months in 

the control group, one was lost to follow up in the supplemented formula group, and three were 

lost to follow up in the human milk groups. There were two deaths in the supplemented formula 

group and three were lost to follow up in the human milk groups.273 Clandinin et al. failed to 

report the dropouts.193 In Fewtrell et al.’s study, reasons for dropout in the control group 

included: abdominal distention (n=1), death due to bronchopulmonary dysplasia at 25 days of 

age (n=1), and lost to follow up(n=21). In the supplemented formula group, reasons for dropout 

included: NEC (n=1), and lost to follow up at 18 months (n=15).258

Quantitative synthesis 

Only five studies measured the Bayley’s MDI. This outcome was chosen to evaluate the 

possibility of meta-analysis. Yet, outcome results were only available for more than one study at 

two follow-up times: CA 12 months and 18 months. At CA 12 months, outcomes were available 

for two studies.207,272 In van Wezel-Meijler et al.,272 the experimental group received 

supplemented formula from the first enteral feeding time until 6 months CA. In O'Connor et 

al.,207 however, supplemented formula was used until 12 months CA. We would have combined 

data at 6 months follow-up, but it was not available in O'Connor et al.207 Thus, meta-analysis 

was not possible for this outcome. 

Impact of covariates and confounders 

Carlson et al. adjusted (ANOVA) the novelty test results in both groups for diet and study 

age and failed to find an change in the results; however, at 12 months, the DHA-supplemented 

group had a significantly lower novelty prederence compared with the control group.185 

In an intention-to-treat analysis using ANCOVA and taking into consideration covariates like 

site, gender, birth-weight stratum, feeding per gender, feeding per birth-weight stratum, HOME, 

maternal WAIS-R raw vocabulary score, GA, human milk intake, birth order, and the first 

language of the biological mother, O’Connor et al. did not find a statistical difference between 

groups at 12 months CA in the Bayley’s MDI score.207

The second Fewtrell et al. study, in a subgroup analysis, observed that the boys in the 

supplemented formula group had a significantly higher score than those in the control group at 

18 months, and there was a significant interaction between diet and sex on the MDI score. These 

differences were maintained after adjusting for effect modifiers, such as maternal education and 

social class.258
204

The power calculation and the intention-to-treat analysis approach was reported in three 

trials.310,321,322 

Infant Formula Intake - Term Infants 

Eight unique studies published between 1997 and 2002 were identified that addressed this set 

of questions. All the trials were summarized in the Growth Pattern Outcomes section (see key 

question: Growth Patterns-Term Infant Formula Intake). (Summary Table 47) 

Overview of relevant studies 

Summary Table 47: Omega-3 fatty acids as supplemental treatment for cognitive development in term infants 

Study groups1 Author, 

Year, 

Location: 

Length & 

Design 

Group 1 

(n)/ 

Group 4 

(n)

Group 2 

(n)/ 

Group 3 

(n)

Notable clinical 

effects

Notable clinicalbiomarker 

correlations 

Internal 

validity 

Applicabili

ty 

Auestad, 

1997, US: 

4 mo 

parallel 

RCT104

AA+DHA 

formula 

(n=46)/ 

HM 

(n=63) 

DHA 

formula 

(n=43)/ 

Control 

formula 

(n=45) 

NS Bayley’s MDI 

between grps at 

12 mo

n/a Jadad total: 3 

[Grade: B]; 

Schulz: 

Unclear 

I 

Birch, 

1998, US: 

17 wk 

parallel 

RCT182 

DHA+AA 

formula 

(n=27) 

DHA 

formula 

(n=26)/ 

Control 

formula 

(n=26) 

MDI S better in 

n-3 formulas vs. 

control at 18 mo 

MDI score at 18 

mo correlated (+) 

with plasma & 

RBC DHA at 4 

mo 

RBC-LA & ALA 

correlated (-) with 

MDI at 18 mo 

Jadad total: 5 

[Grade: A]; 

Schulz: 

Unclear 

I 

Willatts, 

1998, UK: 

4 mo 

parallel 

RCT223

DHA + 

AA 

formula 

(n=20) 

Control 

formula 

(n=20) 

NS problemsolving scores, 

intention score & 

number of 

solutions at 3 mo 

n/a Jadad total: 3 

[Grade: B]; 

Schulz: 

Unclear 

II 

Lucas, 

1999, UK: 

6 mo, 

parallel 

RCT265

LCPUFA 

formula 

(n=154) 

Control 

formula 

(n=155)/ 

HM 

(n=138) 

NS Bayley’s MDI 

between grps at 

18 mo (ITT)

n/a Jadad total: 5 

[Grade: A]; 

Schulz: 

Adequate 

II 

Makrides, 

1999, 

Australia: 

1 y 

parallel 

RCT205

DHA+ 

AA 

formula 

(n=24)/ 

HM 

(n=46) 

DHA 

formula 

(n=23)/ pb 

(n=21) 

NS Bayley’s MDI 

between groups 

at 1 or 2 y

NS FA variables 

correlated MDI 

scores at 1 or 2 y 

Jadad total: 5 

[Grade: A]; 

Schulz: 

Adequate 

III 

Auestad, 

2001a, US: 

1 y, 

parallel 

RCT227

DHA+ 

AA (eggTG) 

formula 

(n=80) 

DHA+ AA 

(fish/funga

l) formula 

(n=82)/ 

control 

formula 

(n=77) 

NS Bayley’s MDI 

between groups 

at 6 &12 mo 

n/a Jadad total: 5 

[Grade: A]; 

Schulz: 

Adequate 

I 
205

Auestad, 

2001b, US: 

1 y, 

parallel 

RCT227

DHA + 

AA 

formula/ 

HM 

(n=83) 

Control 

formula/ 

HM (n=82) 

NS Bayley’s MDI 

between grps at 

6 & 12 mo

n/a Jadad total: 5 

[Grade: A]; 

Schulz: 

Adequate 

I 

Jensen, 

2002, US: 

120 d 

parallel 

RCT203

ÏÏ ALA 

formula 

(n=20)/ 

ÐÐ ALA 

formula 

(n=20) 

Ï ALA 

formula 

(n=20)/ Ð

ALA 

formula 

(n=20) 

NS Bayley’s MDI 

between grps at 

12 mo

NS correlations, 

CAT/CLAMS DQ 

& plasma or RBC 

PL n-3 or n-6 at 

120 d CLAMS 

DQ correlated (+) 

with RBC PL 

EPA, not with 

plasma or RBC 

PL DHA 

CAT DQ 

correlated + with 

plasma PL LA (n6) at 120 d 

Jadad total: 2 

[Grade: C]; 

Schulz: 

Unclear 

II 

1

Proceeding from highest omega-3, or lowest omega-6/omega-3, fatty acid content of intervention/exposure; 2

biomarker source; 3biomarkers = EPA, DHA, AA, AA/EPA, AA/DHA, AA/EPA+DHA; n-3 = omega-3 fatty acids; 

n-6 = omega-6 fatty acids; ALA = alpha linolenic acid; DHA = docosahexaenoic acid; EPA = eicosapentaenoic 

acid; AA = arachidonic acidLength = intervention length; Design = research design; n = sample size; pts = 

study participants; NR = not reported; S = statistically significant difference; NS = nonsignificant statistical 

difference; n/a = not applicable; grp = group; wk = week(s); mo = month; wt = weight; RBC = red blood cells; 

PL = phospholipid; MDI = Mental Developmental Index; +

p<.05 or significant with 95% confidence interval; ++p<.01; +++p<.001; ++++p<.0001; ITT = intention-to-treat analysis; PP = per-protocol analysis (e.g., completers); 

Ï = increase; Ð = decrease/reduction; HM = human milk; CAT/CLAMS = Clinical Adaptative Test/Clinical 

Linguistic and Auditory Milestone Scale; DQ = developmental quotien 

Qualitative synthesis of relevant studies’ key characteristics 

Study characteristics. Eight parallel RCTs involving term infants were identified. All of 

them were published in English scientific journals. Four studies were conducted in the United 

States,104,203,227 whereas, two studies were located in the United Kingdom223,265 and one in 

Australia.205

Four studies involved two arms which compared formulas with or without LCPUFA,223,227,265

however, Lucas et al. also had a reference standard group (i.e., human milk).265 Three studies 

randomized their patients to three study groups, comparing the use of two different LCPUFA 

supplemented formulas with a standard formula,104,205,227 yet two of them also included a 

breastfed group as a reference standard.104,205 Finally, patients in Jensen et al.’s study received 

four different formulas with increasing amounts of ALA (omega-3), and decreasing amounts of 

LA (omega-6) and omega-6/omega-3 ratios.203

Jensen et al. was supported by the U.S. Department of Agriculture, Agricultural Research 

Service, Mead-Johnson Nutritional Group, the Foundation Fighting Blindness, Research to 

Prevent Blindness, Inc. and the Retina Research Foundation.203 Auestad et al. (1997 and 

2001ab) were funded by Ross Products Division, Abbot Laboratories,104,227 whereas, Lucas et 

al.265and Makrides et al.205 were financially supported by Nestec Ltd., Switzerland. Willatts et 

al. was supported by Milupa Ltd., UK.223 

Population characteristics. There were 1,470 term infants enrolled across the included 

studies of infants randomized to receive LCPUFA supplemented formula or control formula. 
206

The sample sizes ranged from 40 to 447 participants. Most studies performed the randomization 

since birth or from the time when the infant could tolerate enteral feeding (mean time= 7 days of 

life). The mean age at randomization was only reported in two studies.104,203 Three studies 

reported that the mean age of their participants was nonsignificantly different between groups, 

either at baseline or at the time of the assessment.104,203,223 Four studies did not provide this 

information.205,227,265 Six studies reported that the between-group difference in terms of gender 

or percentage of males was nonsignificant.104,205,223,227,265 Jensen et al. did not provide the 

difference between study arms.203

Makrides et al. only selected White participants.205 Jensen et al.’s racial composition was: 

Black (62%), Hispanic (28.5%), and White (9.5%) at 120 days, yet statistical differences among 

groups was not reported.203 Auestad et al. 1997’s subjects were predominantly White among the 

groups, but this group was significantly larger in the nonrandomized breastfed group compared 

with the formula groups.104 Auestad et al. 2001ab’s studies included about 80% of European 

American infants, but the study groups did not differ significantly.227 Two studies failed to 

provide the racial and/or ethnical composition of their participants.223,265 

Birth weight, GA, length and HC at birth, birth order, triceps skinfold thickness at birth, and 

Apgar score at 5 minutes were measured in most studies. The GA did not differ between groups 

in the four studies,104,227,265 however, in Willatts et al.’s study, infants in the LCPUFA formula 

group had a significantly longer GA than infants in the control group.223 Seven studies did not 

find a statistical difference between groups for birth weight.104,203,205,223,227,265 None of the 

studies provided information regarding the maternal clinical history and/or medications that 

could have some influence on the FA composition of the breast milk. 

The inclusion and exclusion criteria were reported in five studies.104,205,227,265 The exclusion 

criteria were not reported in two studies.203,223

The studies included healthy term infants (at least 37 weeks of GA) with appropriate weight 

for the GA (2,500 g - 4,000 g). Two studies also included babies whose Apgar score was > 7 (at 

5 minutes).227 To receive formula, their mothers had to decide to not breastfeed and viceversa. 

The patients were excluded if they had congenital abnormalities,104,205,227,265 Apgar score < 7104, 

significant illness,104,227 IV lipid infusion, blood transfusion,104 and maternal medical history 

known to have proven adverse events on the fetus.227

The maternal socioeconomic status was not reported in one trial.203 Seven studies did not 

observe a statistically different status between group, in terms of maternal education, marital 

status, housing, and family size. Only Makrides et al.’s breastfed infants (reference standard 

group) had parents who were less likely to smoke, had attained a higher level of education, and 

had more prestigious social scores compared with formula-fed infants.205

None of the studies reported the use of medications and/or treatments as well as concurrent 

conditions, at baseline, in the eligible infants or their mothers. The smoking status during 

pregnancy and at birth (in household) was significantly higher in mothers in the AA + DHA 

formula group compared with the other groups in Auestad et al. 1997’s study.104 In Makrides et 

al.’s study, the proportion of smokers in the DHA formula group was higher than in the other 

groups.205 Both of Auestad et al. 2001’s studies227 did not reveal a significant difference 

between groups for maternal smoking status.227
207

The prestudy diet characteristics in the mothers were not reported. Two studies mentioned 

that their infants received standard formula since birth until enrollment, yet not description was 

made.227,265 One study mentioned that their infants were breastfed since birth and during the 

whole study.227

None of the studies measured the biomarkers status in either plasma or RBC PL at baseline, 

in infants or their mothers. 

Intervention/exposure characteristics. The intervention with formula was heterogeneous 

across the included studies, thus the description will be done separately for each trial. 

Auestad et al. 1997 randomized their patients to receive two different liquid ready-to-feed 

formulas supplemented with LCPUFA. One of them contained AA (0.43 wt% total FAs) and 

DHA (0.12 wt%) from egg yolk PL (AA + DHA formula). T he second (DHA formula) provided 

DHA (0.2 wt%) from high DHA, low EPA fish (tuna) oil with a ration of DHA/EPA of ~4:1. 

The formulas contained the same amount of protein, carbohydrate, fat and energy (670-694 kcal) 

per liter. The oil blend consisted of high oleic safflower, coconut, and soy oils with or without 

PL or TG sources of LPUFA. The control formula contained the same amount of nutrients, but 

without the addition of DHA, EPA or AA. These formulas were provided as the sole source of 

nutrition for a minimum of 4 months.104 In the reference standard group, the human milk 

contained similar amounts of AA and DHA than the supplemented formulas. 

The infants were exclusively breastfed for at least 3 months, after which supplementation with 

commercial formula SW1 was permitted.104

Birch et al. compared the use of three different infant formulas: Enfamil with iron; Enfamil 

with iron supplemented with 0.35% DHA (of total FA); or Enfamil with iron supplemented with 

0.36% DHA and 0.72% AA.182 All formulas provided LA and ALA. The source of the PUFA 

was single cell oils (DHASCO® and ARASCO®, Martek Biosciences, Columbia, US). All 

formulas were provided in ready-to-feed cans. The duration of intervention was from a mean of 

2.1 days of life until 17 weeks (4 months).182

Willatts et al. compared the use of LCPUFA supplemented formula with an unsupplemented 

formula. The standard formula was the Aptamil brand without DHA and AA. The 

supplemented formula was ready-to-feed Aptamil/Milupan manufactured by Milupa Ltd., 

Trowbridge, UK). The fat blend was derived from milk fat, vegetable oils, and egg lipids. 

While the omega-3 content was 0.15 g to 0.25 g/100 mL of DHA and 0.60 g to 0.65 g/100 mL of 

ALA, the omega-6 content was 11.5 g to 12.8 g/100 mL of LA and 0.30 g to 0.40g of AA. The 

intervention length was until 4 months of age. The total amount of formula intake during the 

trial did not differ between groups.223

Lucas et al. compared the use of a supplemented formula (Nestec Ltd, Vevey, Switzerland) 

that contained 0.30% AA and 0.32% DHA from purified egg PL and TG fractions (Lipid Teknic, 

Norway), with an identical unsupplemented formula.265 The duration of the intervention was 

until the age of 6 months.265 The reference standard group (n=138) received only breast milk for 

at least 6 weeks.265

In the Makrides et al. study, the LCPUFA supplemented formula (provided by Nestec Ltd., 

Konolfingen, Switzerland) contained 0.35% DHA as total FAs from tuna oil in one formula, and 

0.34% DHA and 0.34% AA from an egg PL fraction in the second formula.205 The control 
208

formula did not contain LCPUFA, yet the protein, fat and carbohydrate composition of all the 

formulas was identical, as well as the packaging.205 The reference standard group’s breast milk 

contained (n=33) 0.9 % EPA, 0.20 % DHA and 0.39% AA.205

Auestad et al. 2001’s reported trials had different intervention characteristics. The Auestad 

et al. 2001a compared the use of three formulas, two of them were supplemented with 

DHA+AA, one derived from fish oil and fungal oil, and the other derived from egg- TG.227 All 

were liquid ready-to-use formulas with similar amount of protein, carbohydrate, fat and calories. 

The fat blend consisted of high-oleic safflower, coconut, and soy oils. They were 

indistinguishable in appearance and odor. All contained ALA and LA. The DHA+AA 

(fish/fungal) formula contained (per 100 mL) 0.46g AA, <0.04g EPA and 0.13g DHA, while the 

DHA+AA (egg-TG) contained (per 100 mL) 0.45g AA and 0.14g DHA. The duration of the 

intervention was from less than 9 days of life to 12 months of age. The formulas were 

exclusively administered during the first 4 months, then as sole milk beverage up to 12 

months.227 In Auestad et al. 2001b,227 breast feeding was supplemented with a DHA+AA 

(human milk/egg-TG) formula, containing the same amount of DHA and AA described above in 

one group and a control formula and human milk as the comparator (human milk/control). The 

breast milk contained (per 100 mL) 0.51g AA, 0.05g EPA and 0.12g DHA. The duration of the 

breast feeding was exclusively until 3 months, after which only the formula was administered as 

the milk source.227

Jensen et al. compared the use of four formulas with different content of LA (omega-6) and 

ALA (omega-3). The content of ALA and LA in each formula (from lowest to highest content of 

omega-3) was 0.4%, 0.95%, 1.7% and 3.2% of total FAs, for ALA, and 17.6%, 17.3%, 16.5% 

and 15.6% of total FAs, for LA, respectively. The PUFA’s were abstracted from canola, 

safflower, high oleic sunflower and coconut oil. The amount of protein, total fat, energy, 

carbohydrate, vitamin and minerals were similar to those of Enfamil brand. The formulas were 

manufactured by Mead Johnson Nutritionals (Evansville, Ind.). The duration of the intervention 

was from day 1 of life to 120 days of life.203

Cointervention characteristics. The background diet during the study period was not 

reported in two studies.205,223 In Jensen et al.’s study, infants were exclusively formula-fed for 

120 days, after which the diet intake was neither controlled nor monitored.203 In Auestad et 

al.1997’s study, supplementation with solid foods was permitted for all infants since 4 months of 

age.104 The mean age of the first introduction of any solid food did not differ between groups in 

Lucas et al’s study.265 In both of Auestad et al. 2001’s studies, infants were allowed to drink 

water and solid foods after 4 months of age.227 

Regarding the cointervention characteristics, three studies failed to provide this 

information.205,223,227 Jensen et al. did not allow any medication during the study.203 Auestad et 

al. 1997 only stated that there was a nonstatistically significant difference between groups in 

terms of cointerventions, yet did not provide details.104 Lucas et al.’s LCPUFA group was 

prescribed more antibiotics (OR 1.3) and had more visits from a medical practitioner (OR 1.8) 

during the study period, but the differences were not significant compared with the control 

group.265 Finally, since the infants in Auestad et al. 2001b227 received breast milk besides the 

interventional formula, the former would be considered the cointervention.227
209

Outcome characteristics. Seven studies used the Bayley’s MDI scale.104,182,203,205,227,265 

Three studies utilized the MacArthur Communicative Development Inventories (a standardized 

parent-report instrument that evaluates the early word production, language comprehension, and 

gesture communication).104,227

Jensen et al. also used the DQ for language development (CLAMS DQ), visual problem 

solving ability (CAT DQ) and overall cognition (mean of CLAMS and CAT DQ).203 To assess 

the cognitive and language development at 39 months, the Stanford-Binet Intelligence Scale 

Form L-M, the Peabody Picture Vocabulary Test Revised (PPVT-R), and the Beery VisualMotor Index test were used after standardization procedures in the Auestad et al. 1997.104 

Willatts et al.223 used a problem-solving assessment in two steps, at 3 and 9 months of age. 

Lucas et al. also utilized the Knobloch, Passamanik, and Sherrards Developmental Screening 

Inventory at 9 months (as DQ).265 Both of Auestad et al.2001’s studies also assessed the 

cognitive development with the Fagan test of Infant Intelligence (Infantest) at 6 and 9 months.227

Study quality and applicability. The eight RCTs received a mean Jadad total quality score 

of 4.1, indicating a good internal validity (Summary Matrix 26). Five trials received a score of 

5,124,205,227,265 Auestad et al. 1997 and Willatts et al. received a score of 3,104,223 and one report 

received a score of 2.203 Jensen et al. failed to report the method of randomization,325 and three 

trials were unblinded.325,327,333

Summary Matrix 26: Omega-3 fatty acids as supplemental treatment for cognitive development in term 

infants 

Study Quality

A B C 

Author Year n Author Year n Author Year n 

I BirchU

AuestadA 

AuestadA

1998 

2001a 

2001b 

79 

239 

165 

AuestadU 1997 274 

Author Year n Author Year n Author Year n II LucasA 1999 447 WillattsU 1998 40 JensenU 1997 80 

Applicability 

Author Year n Author Year n Author Year n

III MakridesA 1999 146 

n = number of allocated/selected participants; RCT = AAdequate vs UUnclear allocation concealment

Qualitative synthesis of individual study results 

The Bayley’s MDI scale was assessed in seven of eight studies. None of these studies but 

one observed a between-group significant difference at any follow up point.104,203,205,227,265 Birch 

et al. found that the group supplemented with omega-3 FA for 4 months had a significantly 

higher score compared with the control group at 18 months of age.182 Jensen et al. recognized 

that the groups were too small to detect an among-group difference in the neurodevelopmental 

indices.203 The purpose of this study was to determine the correlation between the plasma and/or 

the RBC PL content of any omega-3 FAs, total omega-3 and/omega-6 FAs at 120 days, and 

neurodevelopmental indices at 1 year of age.203 
210

In Makrides et al.’s study, there was no difference when the scores were compared between 

the human milk with the formula groups at 1 year. There was a significant decrease in MDI 

scores of formula-fed infants between 1 and 2 years of age that was independent of the diet.205

In relation to the Knobloch, Passamanik, and Sherrards Developmental Screening Inventory, 

Lucas et al. did not reveal a significant difference between study groups at 9 months, including 

the comparison with the reference standard group.265

Only Auestad et al. 2001 evaluated the Fagan Test of Infant Intelligence (Infantest) in both 

study populations, failing to detect a significant difference between groups at 6 and 9 months.227 

The Infant version of the MacArthur Communicative Development Inventories (a standardized 

parent-report instrument) was measured in three studies.104,227 At 14 months, two statistically 

significant differences were found in the components of this test in Auestad et al. 1997.104 

Vocabulary comprehension was significantly lower in the DHA group than in the human milk 

group.104 Vocabulary production in the DHA group was marginally lower than that in the 

control formula group (p=0.052). The DHA + AA group did not differ from the human milk 

group. When the comparison is made only among the three formula groups, there was a 

significantly lower Vocabulary Production Score in the DHA group compared with the control 

group.104 Both of Auestad et al. 2001’s studies had a nonsignificantly different result between 

groups at 9 months. However, at 14 months, infants fed the DHA + AA (fish/fungal) formula 

had a slightly significantly higher vocabulary expression score than those fed the DHA + AA 

(egg-TG) formula.227

Auestad et al. 1997 did not find a significant difference between groups for the IQ (StanfordBinet), Receptive Vocabulary (PPVT-R), Expressive Vocabulary and Visual-Motor Index 

Score.104

Regarding the problem-solving scores, Willatts et al. observed a nonsignificant difference 

between groups in the intention score and number of solutions at 3 months.223 

Jensen et al. did not find a correlation between the blood content of omega-3 and/or omega-6 

FAs and the Bayley’s MDI score at 1 year.203 There were no statistical correlations, in a multiple 

regression analysis, between CAT/CLAMS DQ and the plasma or RBC PL content of any 

omega-3 or omega-6 LCPUFA at 120 days of age. CLAMS DQ (and index of the language 

development) correlated positively with the RBC PL content of EPA, but not with the plasma or 

RBC PL content of DHA. The CAT DQ (an index of visual problem solving ability) correlated 

positively with the plasma PL content of LA (omega-6) at 120 days. Finally, Makrides et al.’s 

regression analysis found that no FA variables significantly predicted MDI scores at either 1 or 2 

years.205

Birch et al. found that the MDI score at 18 months was positively correlated with plasma and 

RBC DHA at 4 months of age. None of the other plasma biomarkers (LA, AA, ALA, EPA) were 

correlated with the MDI at 18 months, although the RBC-LA and RBC ALA were negatively 

correlated with the MDI at 18 months of age.182 None of the biomarkers measured at 12 months 

of age were correlated with the MDI at 18 months of age.182 
211

Quantitative synthesis 

The outcome assessed was Bayley’s MDI at age 4 and 12 months given that at these ages, the 

diet was exclusively formula (4 months) or a 12-month followup. At 4 months of age, the 

outcomes were not available in any of the studies. At age 12 months, outcomes were noted in 

three studies that were using the same comparators, i.e., DHA+AA versus unsupplemented 

formula.104,205,227

Meta-analysis was performed using the random effects weighted mean difference 

(WMD).

Review : N-3 CHILD

Comparison: 01 DHA + AA vs Control 

Outcome: 02 Mental Development Index 

Study DHA + AA Control WMD (random) Weight WMD (random)

or sub-category N Mean (SD) N Mean (SD) 95% CI % 95% CI

Auestad 1997 46 105.00(12.00) 45 105.00(14.00) 20.57 0.00 [-5.36, 5.36] 

Auestad 2001 117 96.90(9.20) 48 97.80(8.30) 71.34 -0.90 [-3.78, 1.98] 

Makrides 1999 21 108.00(16.00) 21 110.00(12.00) 8.09 -2.00 [-10.55, 6.55] 

Total (95% CI) 184 114 100.00 -0.80 [-3.24, 1.63]

Test for heterogeneity: Chi2 = 0.17, df = 2 (P = 0.92), I2 = 0%

Test for overall effect: Z = 0.65 (P = 0.52)

 -10 -5 0 5 10

 Favours control Favours treatment

The WMD for the Bayley’s MDI score at 12 months of age in three studies (DHA+AA vs. 

control) was nonstatistically significant (WMD: -0.80, CI 95%: -3.24; 1.63).104,205,227

Impact of covariates and confounders 

The effect modifiers that could be influencing the results were controlled in all the studies. 

Variables like GA, gender, birth weight, length at birth, maternal age, and socioeconomic status 

were detected in most of the studies. Jensen et al.’s groups were comparable in terms of the 

study formula’s intake.203 The CAT DQ (an index of visual problem solving ability) correlated 

positively with weight at 120 days of age.203

Auestad et al. 1997 observed that female sex was positively associated with IQ, receptive 

vocabulary, and visual-motor ability at 39 months.104 Maternal education was positively 

associated with IQ and receptive vocabulary, when either all four feeding groups or only the 

formula groups were included in the regression model. The variable selection model identified 

which of 22 potentially influential variables contributed significantly to the variance for IQ and 

expressive language. Approximately one third of the variance for IQ was explained by four 

factors: sex, years of maternal education, number of siblings, and exposure to cigarette smoke. 

Positive associations were found for female sex and maternal education, and negative 

associations were found for the other two variables previously described. Expressive language 

was positively associated with maternal education, but negatively associated with average hours 

in childcare per week and hospitalizations since birth, but only when the breastfed group was 

included in the analysis.104 At 14 months, there was a significant association between 

vocabulary production and comprehension. At 39 months, there was a significant association 

between receptive (PPVT-R) and expressive (MLU) language and between expressive language 
212

(MLU) and IQ. However, no significant associations between vocabulary production at 14 

months and expressive language (MLU) at 39 months were found.104 

In the early peak-fixation infants, none of the covariables was significantly related to number 

of intentional solutions in Willatts et al.223 In the late peak-fixation infants, only diet and birth 

weight were significantly related to the number of intentional solutions. ANCOVA on the 

intention scores for the effects of diet and peak fixation showed no significant main effects, and 

diet per peak interaction was not significant.223 Regarding the problem-solving scores, Willatts 

et al. observed a nonsignificant difference between groups in the intention score and number of 

solutions at 3 months.223 When adjusted by GA, the differences were still nonsignificant. 

ANCOVA on number of intentional solutions for the effects of diet and peak fixation, covariated 

with GA and birth weight, showed a significant diet per peak fixation interaction. Simple-effects 

analysis showed that the number of intentional solutions did not differ significantly between the 

early-peak fixation infants receiving LCPUFA. In contrast, the number of intentional solutions 

was significantly reduced in the late peak-fixation infants receiving the standard formula.223

In Lucas et al.’s study, the results did not change after adjusting by center or observer (see 

above).265 A multiple linear regression with adjustement for possible confounding factors and 

imbalance at baseline was made between the formula groups and the human milk reference 

standard group.265 It did not observe a significant difference between formula groups and 

breastfed infants, even after adjusting by effect modifiers (sex, center, maternal age, maternal 

education, maternal marital status, and social class).265 In relation to the Knobloch, Passamanik, 

and Sherrards Developmental Screening Inventory, Lucas et al. did not reveal a significant 

difference between study groups at 9 months, including the comparison with the reference 

standard group, which was maintained after adjusting by effect modifiers.265

Makrides et al. found that the feeding mode was the only nutritional variable to predict MDI 

with formula feeding resulting in lower MDI scores.205 Although environmental variables such 

as parental education, occupational prestige, and Home Screening Questionnaire scores were 

associated with Bayley’s MDI at 1 and 2 years of age, only weight (at 1 year) and birth order, 

feeding mode, and gender (at 2 years) significantly predicted MDI.205 At 2 years the MDI scores 

of breastfed infants were higher than those of the formula-fed group, even after adjusting for the 

significant covariates of gender and number of siblings (95% CI: 4.4-21.7).205 

The power calculation was reported in seven trials,124,132,151,325,329,333 while the intention-totreat analysis approach was reported in only one study.132

Cognitive Development Outcomes in Light of Biomarker Data 

What is the Evidence that Term or Preterm Human Infants’ Cognitive 

Development is Associated With the Omega-3 or Omega-6/Omega-3 

Fatty Acid Content of Child Biomarkers? 

Six studies were identified to answer this question. Two were RCTs and were described 

above (see key questions: Growth Patterns-Term Infant Formula Intake, and Maternal 
213

Intake/Visual Function).138,182,203,205 Innis et al. and Ghys et al. were prospective single cohort 

studies published between 2001 and 2002.271,285 (Summary Tables 45, 47 and 48) 

Overview of relevant study characteristics and results 

Innis et al. selected a cohort of 83 Canadian term infants who were exclusively breastfed, 

with birth weights in the range of 2,500 g to 4,500 g.271 The objective of the study was to 

measure the infant RBC DHA content and its association with the visual, neuro or cognitive 

development.271

Ghys et al. evaluated the association between the AA and DHA status at birth and the 

cognitive development at 4 years of age in a full-term infant cohort.285

Innis et al. was funded by the Medical Research Council (MRC) of Canada and Ross 

Laboratories, OH.271 Ghys et al. failed to report the funding source.285

Innis et al. enrolled infant (n=83) with less than 2 weeks of age and to be eligible, their 

mothers were required to intend to breastfeed their infant without providing infant formula or 

cow’s milk for at least 3 months, and without introducing solid foods for at least the first 4 

months after birth. The infants were excluded if their mothers had substance abuse, metabolic or 

physiologic problems, communicable diseases, and infants with evidence of metabolic or 

physical abnormality.271

Ghys et al. included full-term newborns (n=246) from healthy Caucasian women born 

between 1994 and 1995. A total of 128 (mean age 47 [SD=1.3] months, 55% males) infants 

were assessed for cognitive development outcomes at 4 years of age.285

Only one mother was taking FA supplements with LA and DHA in Innis et al. The maternal 

diet was not reported or controlled. Only five mothers were smokers during the study.271

In Ghys et al.’s study, 84% of infants were first born and none had suffered any 

neurologically damaging disorder or event, and 5% of the families lived on social security.285

Innis et al. used the Bayley’s MDI at 6 and 12 months to assess the cognitive development 

and its correlation with the RBC DHA and AA content in infants.271 Another test used for this 

outcome, was Novelty preference with the Fagan Test of Infant Intelligence (Infantest) at 6 and 9 

month of age.271 Ghys et al. used the Dutch version of the Kaufman Assessement Battery for 

Children (K-ABC), and the Groningen Developmental Scale (GOS) for children between 2.5 and 

4.5 years of age.285

Multiple linear regression analysis was used to determine the impact of the FA variables on 

the outcomes in both studies.271,285 In Innis et al.’s study, the analysis controlled statistically for 

the duration of breast feeding, maternal education, family income, gender, maternal smoking, 

birth order and birth weight, length and HC.271

The covariables used in Ghys et al. were birth weight, breast feeding, maternal intelligence 

(IQ) and parental educational attainment, which are associated with cognitive development in 

infants.285
214

Summary Table 48: Association of cognitive development outcomes and biomarkers content in infants 

(observational study) 

Study groups1

 

Author, Year, 

Location: 

Design 

Group 1 

(n)/ 

Group 4 

(n)

Group 2 

(n)/ 

Group 3 

(n) Notable associations2,3 

Internal 

validity Applicability 

Innis, 2001, 

Canada: 

Prospective 

single cohort271

Term 

breastfed 

infants 

(n=83) 

n/a No correlation between RBC 

DHA & AA status & Bayley’s 

MDI (6,12 mo), novelty 

preference (6,9 mo) 

Quality 

score: 8 

[Grade A] 

III 

Ghys, 2002, the 

Netherlands: 

Prospective 

single cohort285

Term 

infants 

(n=128) 

n/a No correlation between plasma 

or RBC DHA & AA & cognitive 

development (4 y)

Quality 

score: 8 

[Grade A] 

III 

1

biomarkers = EPA, DHA, AA, AA/EPA, AA/DHA, AA/EPA+DHA; n-3 = omega-3 fatty acids; n-6 = omega-6 

fatty acids; ALA = alpha linolenic acid; DHA = docosahexaenoic acid; EPA = eicosapentaenoic acid; AA = 

arachidonic acid; n = sample size; pts = study participants; NR = not reported; S = statistically significant 

difference; NS = nonsignificant statistical difference; N/A = not applicable; pb = placebo; grp = group; wk = 

week(s); mo = month; RBC = red blood cells; MDI = Mental developmental scale; y = year(s) 

Innis et al. did not find a statistically significant relation between the infant DHA or AA 

status (RBC) at 2 months of age and the Bayley’s MDI score at 6 and 12 months of age, as well 

as the Novelty Preference at 6 and 9 months.271

In a bivariate analysis, Ghys et al. did not observe a correlation between the DHA and AA 

concentration in infant’s plasma or RBC and the cognitive development at 4 years of age. Small 

but significant associations occurred with maternal IQ, birth weight, duration of breast feeding, 

maternal smoking during pregnancy, and paternal educational attainment. 

Study quality and applicability. Both studies had a mean total quality score of 8 and a level 

of applicability of III. 

Summary Matrix 27: Association of cognitive development outcomes and biomarkers content in infants 

Study Quality

A B C 

Author Year n Author Year n Author Year n 

I 

Author Year n Author Year n Author Year n II 

Author Year n Author Year n Author Year n

Applicability 

III Innis 

Ghys 

2001 

2002 

83 

128 

 

n = number of allocated/selected participants
215

Safety Issues 

What is the Evidence for the Risk, in Pregnant Women, of Short and 

Long-Term Adverse Events Related to Their Intake of Omega-3 Fatty 

Acids? 

What is the Evidence for the Risk, in Breast Feeding Women, of Short 

and Long-Term Adverse Events Related to Their Intake of Omega-3 

Fatty Acids? 

All nine unique relevant trials,196,230,232,233 that were reviewed, reported some information on 

safety and/or adverse events (e.g., complications, intolerance) (See Summary Tables in 

Appendix E∗). In one report, Olsen et al.230 presented pregnancy-related adverse 

events/outcomes aggregated across six unique trials, four of which were preventive and two of 

which were therapeutic.230 In seven of the nine trials, the experimental intervention consisted of 

LCPUFA enriched (fish oil) capsules.230,233 The remaining two trials studied LCPUFA-enriched 

eggs232 or margarine.196 Control intervention in the nine trials consisted of the capsules, eggs, 

and margarine without the LCPUFA-supplementation, respectively. 

In seven trials,230,233 women in the experimental arms reported belching and unpleasant taste 

more often than those in the control arms. Two of eight studies reported the occurrence of 

nausea,196,230 finding similar between-arm rates of nausea as opposed to another trial,233 which 

showed that women in the LCPUFA supplementation arm experienced nausea more frequently 

than those allocated to the regimen of standard intervention (9.7% vs 2.9%). Note that the daily 

dose of EPA/DHA intake in this trial233 was greater than that in other trials.196,230 

In the trial by Onwude et al.,233 the proportion of women who had had stomach pain was 

higher in the experimental arm compared with the control arm (4.8% vs. 0%). The aggregated 

results of six trials230 showed the rates of stillbirths, stay at hospital after delivery, vaginal 

bleeding, macrosomia, anaemia, vomiting, constipation, diarrhoea, and nose bleeding were 

similar between the experimental and control arms. In their trial, Smuts et al.232observed fewer 

adverse events for the omega-3 supplemented than for the control arm (birth of infant with LBW: 

0% vs. 26%, preterm delivery: 5.6% vs. 26%, C-section: 11% vs 32%, gestational diabetes: 0% 

vs. 16% ). De Groot et al.196 observed similar rates of long-term hospitalization, diabetes 

mellitus, still birth, and postpartum depression in the two randomized groups. In this trial, six 

women were withdrawn/lost to follow up for the following reasons: morning sickness (n=2), 

long-term hospitalization (n=2), diabetes mellitus (n=1), and stillbirth (n=1). Of the nine trials, 

only Smuts et al.’s232 explicitly reported their opinion on the underlying reasons (breech, preterm 

delivery, maternal gestational diabetes and chorioamnionitis) for the observed adverse events 

(admission to intensive care unit). 

 

∗

 Appendices and Evidence tables cited in this report are provided electronically at 

http://www.ahrq.gov/clinic/tp/o3mchtp.htm
216

What is the Evidence for the Risk, in Term or Preterm Human Infants, 

of Short and Long-Term Adverse Events Related to Maternal Intake of 

Omega-3 Fatty Acids During Pregnancy? 

What is the Evidence for the Risk, in Term or Preterm Human Infants, 

of Short and Long-Term Adverse Events Related to Their Intake of 

Omega-3 Fatty Acids After Birth (e.g., Maternal Breast Milk, Infant 

Formula Supplemented With Omega-3 Fatty Acids)? 

What is the Evidence That These Adverse Events, or any 

Contraindications, are Associated With the Intake of Specific Sources 

(e.g., Marine, Plant), Types (e.g., EPA, DHA, ALA) or Doses of Omega3 Fatty Acids, Including in Specific Populations Such as Diabetics? 

Preterm infants 

All the eleven relevant trials193,201,207,212,218,251,257,258,273,286,287 that were reviewed, reported 

some information on safety/adverse events (e.g., complications, intolerance) (See Summary 

Tables in Appendix E∗). The trials reported explicitly that the study infants had experienced 

similar arm-specific rates of the following adverse events (ascribed or not ascribed to the study 

participation): neonatal morbidity,193,212 bleeding time,212 gastric residuals,251,257,286

spitting/abdominal distention,251,258,273 respiratory effects (pharyngitis, rhinitis, bronchiolitis, 

pneumonia, and increased cough),218,273 cardiovascular (bradycardia, cardiovascular event), 

gastrointestinal (increased abdomen, vomiting, diarrhoea, infection), haemic (anemia, hypoxia), 

lymphatic, urogenital, flatulence, otitis media, apnea,billirubinemia,218 eczema,258,273

death,201,207,218,258,273 chronic lung disease,207 systemic infection,207,258,273 hospital 

readmission,207,273 feeding intolerance,207,258,273 retinopathy of prematurity,201,273intra-ventricular 

haemorrhage (IVH),201,273 pulmonary haemorrhage,273 necrotizing enterocolitis (NEC),201,258,273

sepsis,201,273 vomiting,257 bradycardia,286 and stool frequency.257,258 

The difference in the frequency of adverse events between the study arms was found only in 

three trials.218,258,273 Specifically, in one trial218 at 48 weeks of post-conception age (after 17 

weeks of feeding), infants in the omega-3 supplemented arm had a higher rate of diarrhoea (vs. 

human milk arm) and flatulence (vs. control formula and human milk arms), but lower rates of 

milk intolerance and anaemia (vs. control formula). 

Note that in the same trial,218 but at 92 weeks post-conception age (after 60 weeks of 

feeding), the omega-3 FA-supplemented and control dietary arms had similar rates of flatulence, 

anaemia, and diarrhoea. In another trial, infants in the omega-3 FA-supplemented arm were 

found to have a lower mean number of stools per day, compared with those in the control arm 

(1.96 vs. 2.12).273 In the trial by Fewtrell et al.,258 infants in the supplemented arm required the 

use of ventilation and umbilical catheters for a longer period of time than those in the control 

 

∗

 Appendices and Evidence tables cited in this report are provided electronically at 

http://www.ahrq.gov/clinic/tp/o3mchtp.htm
217

formula arm (median days ventilated: 4 [3-8] vs. 2 [2-5] and median days with umbilical 

catheters: 4 [3-6] vs. 3 [2-5]). 

Information on the consequences (i.e., withdrawals, death) of adverse effects/intolerance was 

reported in six trials.201,207,218,258,273,287 McClead et al.,287 reported that two infants who had 

developed tachycardia and tachypnea subsequently recovered. In the trial conducted by 

Vanderhoof et al.,218 the majority of those who were withdrawn, had cow’s milk intolerance 

(n=8), vomiting (n=5), diarrhoea (n=3), ileus (n=3), enlarged abdomen (n=2), and NEC (n=2). 

Other more rare events leading to the infant’s withdrawal were oesophageal reflux (n=1), 

constipation (n=1), rash (n=1), and cerebral necrosis (n=1). In another trial,207 the formula 

feeding intolerance resulted in 51 (12% of the total number of randomized infants) withdrawals. 

Innis et al.201 reported that amongst the 21 infants who were withdrawn from the feeding 

protocol, three infants had had NEC (n=2) and formula feeding intolerance (n=1). In the trial by 

Fewtrell et al.,273 ten infants were withdrawn for the following reasons: death (n=3; had chronic 

pulmonary disease requiring ventilation), NEC (n=6), and formula feeding intolerance (n=1). In 

another trial,258 three infants, each of whom had developed bronchopulmonary dysplasia 

resulting in death, NEC, and abdominal distension, were withdrawn from the feeding protocol. 

Most commonly reported reasons for death were SIDS (n=4; totalled across studies),201,218

NEC (n=2; totalled across studies),218,273 and pulmonary disease requiring ventilation (n=4; 

totalled across studies).258,273 Only six trials reported explicitly that the adverse events and/or 

death occurring in these trials could not have been ascribed to the feeding diets.207,212,218,251,273,287

Term infants 

Of the twelve unique relevant trials that were reviewed, eleven reported some information on 

safety and/or adverse events (e.g., complications, intolerance).104,182,203,205,227,261,265,266,268,287 (See 

Summary Tables in Appendix E) The authors of one trial263 failed to report any relevant data on 

the above-mentioned outcome of interest. Given the information provided by the study authors, 

in general, the experimental regimens had been well tolerated and the trial authors observed 

either no or very few serious adverse events occurring to the infants. In addition, even if certain 

adverse events were observed, none of the between-group differences with respect to their 

occurrence reached the traditional level of statistical significance, regardless of the timing of 

observation. 

For example, six trials104,205,227,265,266,268 reported that the infants had experienced similar armspecific rates of the following adverse events (ascribed or not ascribed to the experimental diet): 

cataracts,104 viral meningitis,104 pyloric stenosis,104,265 phenylketonuria,104, ≥1 

hospitalization,104,268 prescribed antibiotics,104,265 otitis media,104 respiratory infections,265,268

gastroenteritis,265,268 eczema,265 asthma,265 visit to medical practitioner,265,268

vomiting,205,227,265,266 constipation,205,265,266 diarrhoea,205,266 stool consistency,227,268 and 

allergy.268 

The inability to find the between-group statistically significant differences in the proportions of 

infants with adverse events, could have been partially due to the small numbers of these events 

across these trials and/or insufficient sample size. For example, in one study,104 the between-arm 

differences in the number of used prescriptions for antibiotics could not reach the statistically 
218

significant result (formula with [DHA]: 57% vs. formula with [DHA+AA]: 46% vs. breastfed 

group: 66%). Another study,265 found that the formula with [DHA+EPA] supplementation group 

was prescribed more antibiotics (OR = 1.3, 95% CI: 0.8, 2.2) and had more visits to medical 

practitioner (OR = 1.8, 95% CI: 0.8, 4.2) than the control formula group, but neither of these 

differences was statistically significant. Of the remaining four trials,182,203,261,287 three 

trials182,261,287 reported explicitly that the experimental regimens had been well tolerated (i.e., 

trial authors observed either no or very few adverse events in the infants). These adverse events 

were: tachycardia and tachypnea,287 diaper dermatitis,261 unspecified illness unrelated to the diet 

and lactose intolerance,182 and dietary protein hypersensitivity.203 In the trial by Jensen et al.,203

it was not clear if the study infants had or had not experienced any adverse events (the authors 

did not state this explicitly). Note that these four trials,182,203,261,287 on average, had a shorter 

length of intervention (range: 1-17 weeks) and smaller total sample size (range: 20-108 infants) 

than the six trials104,205,227,265,266,268(range: 12-48 weeks and 109-447 infants, respectively) that 

observed the greater number of adverse events (though with similar arm-specific rates of adverse 

events). 

In seven trials,104,203,205,227,265,266,268 it was explicitly reported that the infants who had had 

adverse events were withdrawn/non-completers. Three trials,104,182,266 explicitly stated that some 

of the observed adverse events (viral meningitis, pyloric stenosis, cataracts, phenylketonuria, 

sudden infant death syndrome, and unspecified illness) were not related to the experimental 

formula feeding. 
219 

Chapter 4. Discussion 

Overview 

A total of 117 reports, describing 89 unique studies, investigated questions pertinent to this 

systematic review of the evidence concerning the effects of omega-3 fatty acids on child and 

maternal health. The questions regarding the influence of the intake of omega-3 fatty acids on 

pregnancy outcomes, such as duration of gestation, preeclampsia, eclampsia or gestational 

hypertension and infants SGA were address separately, since RCTs were identified that 

answered each of these questions separately. 

The questions regarding the child’s outcomes, such as growth patterns, neurological 

development, cognitive development and visual function are divided in a series of questions: one 

question is related to the maternal intake of omega-3 fatty acids for each outcome; another 

question is associated with the infant’s intake of human milk; two questions have been lumped 

together regarding the infant’s intake of formula, with or without breast milk; a separate question 

addressed the infant’s intake of omega-3 fatty acids from other sources (diet, supplements); and, 

a final set of questions relate to biomarkers in maternal, fetal or infant’s blood, and the 

association with the clinical outcomes. 

For each group of outcomes, we present a synthesis of the key findings with respect to each 

question. This includes a critical appraisal of the group of trials from which results are drawn. 

The broader implications of these findings, including potential future research, are highlighted. 

We begin with the safety issues concerning all the included studies. 

Evidence Synthesis and Appraisal 

Adverse events, contraindications, and intolerance are often under-reported in human 

experimental studies. Many studies do not report any data on adverse events, and so it is 

frequently not clear whether or not an adverse event had actually occurred in these studies. 

Furthermore, even if a study reports an adverse event, the study authors do not always state 

explicitly if this adverse event was related to the study intervention or some other factor(s). An 

additional problem that aggravates the assessment of adverse event data, is that some authors do 

not clarify whether the number of adverse events reflects the total number of event occurrences 

across all patients (i.e., a single patient may experience more than one adverse event during the 

study period), or the number of patients who had experienced at least one adverse event. This 

information should be reported in order to distinguish between the two scenarios. 

Overall, omega-3 fatty acids supplementation in pregnant women, breastfeeding mothers and 

preterm and term infants, was very well tolerated and did not generate any serious adverse events 

across the included RCTs. The safety data was reported in 21 RCTs. 

In pregnant women, the adverse events related to the omega-3 fatty acids intake were mild 

and transient, with nausea and gastrointestinal discomfort being the most commonly 

reported.230,233 
220

For both the term and preterm population, change in number of stools and flatulence were the 

most common adverse events related to the omega-3 supplemented formulas. However, most of 

the serious adverse events were related to the fact that the infants were premature with low birth 

weights, which increases the occurrence of necrotizing enterocolitis (NEC), bleeding problems, 

infections and respiratory failure, among others in the case of preterm 

infants.104,182,193,201,203,205,207,212,218,227,251,257,258,261,265,266,268,273,286,287 In general, none of the 

withdrawals were due to the interventional formula. 

Fifteen average poor quality (Jadad: 2.8/5) RCTs addressed the question of the influence of 

omega-3 fatty acids intake during pregnancy on the duration of gestation.

31,41,288,290,291,293-

295,295,296 Seven trials included otherwise healthy pregnant women,141,196,209,231,232,234,235 the 

remaining eight studies included a high-risk population of pregnant women, yet with different 

types of risk factors (i.e., IUGR, premature delivery, preeclampsia, etc). Ten studies did not find 

a significant difference between intervention groups in the duration of gestation measured as 

mean of gestational age at delivery.141,196,230-235 However, four average poor quality (Jadad score 

2/5) studies observed that the omega-3 fatty acid group had a significantly greater duration of 

gestation after treatment compared with the unsupplemented group.209,230

Omega-3 fatty acids did not have a significant effect on the proportion of premature 

deliveries in ten studies.31,209,233,234,238 Only Smuts et al. observed a noticeable lower percentage 

of premature deliveries in mothers taking omega-3 fatty acid supplements, yet this study was 

underpowered (small sample) to measure the statistical significance of such observation.232 

Other variables, such as length of the intervention and background diet, were different among 

the identified trials. Most studies began the treatment during the second trimester of 

pregnancy,141,196,230,231,233,235,238 while the remaining trials enrolled their subjects during the third 

trimester. Fish consumption in the background diet, one of the most important effect modifiers, 

was used as a covariate in only one trial.209 After adjusting for this effect modifier, the results 

did not change, and the fish oil group still had a longer duration of gestation than the olive oil 

group.209

Other covariates used to control the results were the compliance with the intervention,209

current smoking status,233,234 as well as maternal BMI and number of prior pregnancies.234 The 

only variable that had an impact on the results was the smoking status in Smuts et al’s study.234 

The duration of gestation was significantly longer in the high-DHA group in the nonsmokers.234 

Meta-analysis of the incidence of premature deliveries was performed pooling the data of 

eight RCTs that compared the use of capsules containing DHA+EPA,31,41,291 and two trials using 

high DHA eggs294,296 with control group. Both meta-analysis failed to find a statistical 

difference between groups. The limitation of combining the studies using DHA+EPA versus 

control, is that the population of pregnant women included in seven trials was high risk for 

premature delivery in different ways (twin pregnancy,31 antecedent of premature delivery,31

antecedent of GHT and IUGR,31,291 and threatening pre-eclampsia31). Only one study included 

healthy Danish women.41 Subgroup analysis was not possible given the lack of individual data 

for each of the six RCTs included in Olsen et al. 2000.31 Another limitation of this approach is 

the length of intervention. While five trials started in the second trimester of pregnancy,31,291

three began the intervention during the third trimester (shorter period of time and likely not 

meaningful to see a significant effect).31,41
221

These findings suggest that there is inconsistent evidence of the use of omega-3 fatty acids 

supplements during the second or third trimester of pregnancy to reduce the incidence of 

premature pregnancies in high and low risk populations. Nevertheless, the overall effect does 

not show a significant difference between study arms. 

The association between the maternal biomarkers during pregnancy and the duration of 

gestation was assessed in four studies.234,239-241 The study by Smuts et al. was an RCT that 

compared the use of DHA-enriched eggs intake with ordinary eggs in healthy pregnant 

women.234 This study did not observe a significant correlation between the maternal RBC 

content of DHA and the duration of gestation, however, the study found a significantly positive 

correlation between the infant RBC DHA at birth and this pregnancy outcome.234

Three observational trials,239,240 found a significantly positive association between the 

maternal plasma content of AA (at 34-35 weeks of GA) and the duration of gestation, whereas, 

Rump et al.’s cross-sectional study did not find any correlation between maternal biomarker 

content and duration of gestation.241 The study by Elias and Innis was a single prospective 

cohort of pregnant women that reached a term delivery,240 and the study by Reece et al.239 was a 

case-control study that compared the maternal content of RBC omega-3 and omega-6 fatty acid 

biomarkers at 34 weeks of gestation and at delivery in preterm and term pregnancies. This study 

found that the preterm deliveries had a significantly higher content of AA (omega-6) and DPA 

(omega-6), reflecting a relative reduction in the omega-3 fatty acids. The omega-6/omega-3 

ratio was higher in preterm deliveries or in 34-week pregnant women, compared with samples 

taken after term deliveries.239

These findings suggest that there is an uncertain association between the maternal biomarkers 

during pregnancy and the duration of gestation, independently of the maternal intake. 

Eight RCTs addressing the question concerning the influence of maternal intake of omega-3 

fatty acids during pregnancy in the incidence of gestational hypertension (GHT), preeclampsia 

or eclampsia were identified with a quality score approaching good internal validity (Jadad: 

2.9/5).209,230,233,236,237 Six studies compared the use of fish oil supplements containing DHA and 

EPA with placebo (generally olive oil). The population characteristics of these studies were very 

diverse, since one of them included healthy Danish pregnant women,209 while the others included 

high-risk pregnant women (i.e., preeclamptic, twin pregnancies, IUGR or preeclampsia in 

previous pregnancies, etc).230,233,236,237 The incidence of GHT in these populations, after the use 

of omega-3 fatty acids or placebo did not differ in six of seven studies.209,230,233,237,238 The study 

by D’Almeida et al. was the only poor quality trial conducted in South Africa that observed a 

reduction of the incidence of GHT in the magnesium oxide group, compared to the omega-3 FA 

supplemetation and the placebo groupsa (no significance assessed).236 Regarding the incidence of 

preeclampsia (triad of hypertension, edema and proteinuria), six studies showed that compared 

with placebo, supplementation with omega-3 fatty acids did not have a significant 

effect.230,233,234,237,238

Only one study conducted in South Africa observed a statistically significant difference 

between groups, showing that the fish oil group had a lower incidence of preeclampsia compared 

with placebo and magnesium oxide.236 

Meta-analysis was possible for the outcome related to the incidence of gestational 

hypertension. Two studies were included in the analysis,230,233 which selected a population of 
222

women at high risk of developing GHT. The overall effect size was nonsignificant between 

groups. 

It appears that there is some evidence to suggest that supplementation with omega-3 fatty 

acids during the second or third trimester of pregnancy does not reduce the incidence of 

gestational hypertension, preeclampsia or eclampsia in healthy or high-risk pregnant women. 

However, the results were not adjusted for the potential covariates or confounders, such as 

background diet, grade of risk for GHT or preeclampsia in the current pregnancy, smoking 

status, and age, among others. 

No RCTs were identified to investigate the association between the omega-3 or omega6/omega-3 ratio content of maternal biomarkers and the incidence of preeclampsia-eclampsia or 

gestational hypertension. We identified five observational trials that addressed this question, yet 

the incidence of preeclampsia could not be assessed given the study designs.179,229,242-244 Four 

studies selected preeclamptic women and normal pregnant women as controls.229,242-244 Al et al. 

selected women with GHT and healthy pregnant women as controls,179 and Craig-Smith et al. 

also included women with GHT and chronic hypertension.243 Wang et al. and Hofmann et al. 

found that the maternal plasma content of AA did not differ significantly between preeclamptic 

and normal pregnant women.229,242 On the other hand, Craig-Smith et al. observed that the 

women with chronic hypertension had a significantly higher plasma content of AA compared 

with women with preeclampsia, GHT or normal pregnant women.243 Shouk et al. observed that 

the women with preeclampsia had a significantly higher AA content compared with normal 

women, although the plasma measurement was different from the other studies (mcg/L).244 

Results regarding total PUFA content, total omega-3 fatty acids, total omega-6 fatty acids, DHA, 

EPA and other PUFAs did not follow a consistent pattern across the studies. The results are very 

inconsistent among the studies. 

These discrepancies across the studies can be explained given the differences in the study 

designs, case ascertainment, severity of preeclampsia, appropriate technique of lipid extraction 

and manipulation, measurements of FA in plasma (% weight of total FA, mcg/L or mol/L) 

background diet, age, gestational age, and other variables like alcohol intake, tobacco use and 

supplements that were not assessed. 

Regarding the influence of omega-3 fatty acids supplementation during pregnancy on the 

incidence of SGA infants, fourteen average poor quality scores (Jadad: 2.85/5) RCTs with 

addressed this question. The definition of SGA was diverse across the included studies, using 

the smaller percentile (PC) as the upper limit (i.e., PC < 3 or PC < 5 or PC < 10 for gestational 

age). Most of the studies evaluated the mean birth weight, instead of the incidence of SGA 

infants. In the majority of the studies, mean birth weight was not influenced by the intervention. 

Despite the fact that the selected populations in the trials were so different (e.g., high risk vs. 

healthy women), the results seem to be very consistent across the studies. None of the trials 

adjusted their results for the maternal background diet, which can be an important effect 

modifier. 

Meta-analysis was performed for two different variables. The birth weight (mean value) was 

combined in two studies that were comparable in terms of type of intervention and population. 

The overall size of the effect was nonsignificantly different between groups (supplemented vs. 

unsupplemented).230,233 The other outcome was the incidence of infants with IUGR in three 
223

studies,230,233,238 with a nonsignificant overall effect of supplementation during pregnancy. These 

findings are consistent with the results of the remaining included studies. 

Six studies addressed the question regarding the association between the omega-3 or omega6/omega-3 ratio content of maternal biomarkers and the incidence of SGA infants.

196,240,241,245-247 

de Groot et al.’s RCT found a significantly positive correlation between the maternal plasma and 

RBC DHA content and birth weight, however, this relationship was nonsignificant when 

measured at delivery.196 Among the observational studies, three investigators compared the 

maternal biomarker content in women at risk of IUGR with healthy controls.245-247 Two of them 

found that the women with IUGR fetuses had a significantly lower content of LA (omega-6) in 

the plasma.246,247 The content of DHA, EPA, AA, total omega-3 and omega-6 fatty acids, 

however, did not show a constant pattern across the studies. Two observational studies did not 

observe a correlation between maternal plasma biomarkers and birth weight,241,247 consistent 

with the result in the RCT.196 Elias and Innis did not define the birth weight for GA, so their 

results are difficult to interpret in the context of correlation of maternal PUFA with SGA 

infants.346

These discrepancies in the study results may be due to many variables that play a relevant 

role in the lipid profile, such as population characteristics (healthy pregnant women, high risk of 

IUGR, women with IUGR), background diet, lipid extraction and manipulation, lipid fraction 

(TGL, PL, CE), and timing of drawing the blood samples. 

No studies were identified to address the question of the influence of the omega-3 fatty acids 

from sources other than formula or human milk, and any of the child’s clinical outcomes (e.g., 

growth patterns, neurological and cognitive development, and visual function). 

One good quality RCT addressed the question of the influence of maternal omega-3 fatty 

acids intake during pregnancy on the growth patterns outcomes.

141 There was no statistical 

differences between infants from mothers that were taking the supplementation with omega-3 

and omega-6, or omega-6 fatty acids predominantly, on the weight, length and head 

circumference (HC) from birth to 12 months of age.141 The infants were also breastfed 

exclusively during the first three months of life, and their mothers were still taking the 

interventional oils. Thus, these results also apply to the question of the maternal breast milk 

content of omega-3 fatty acids and growth patterns. 

Helland et al. included a large sample (n=590) of healthy pregnant women from Norway, yet 

this study only used the completers in the analysis (n=341) given the large number of 

dropouts.141 The fact that only 57% of the included women were included in the analysis, makes 

the results more difficult to interpret. The intake of marine omega-3 fatty acids is relatively high 

in Norway compared with other countries.347,348 The pregnant and lactating women have high 

concentration of DHA in plasma phospholipids and breast milk, and a great majority of 

Norwegian mothers also breastfeed their infants up to at least 3 months after giving birth, thus 

providing their infants with preformed DHA.141

One good quality RCT evaluating omega-3 supplementation in Norwegian mothers,141 one 

poor quality RCT,248 and two observational studies were identified to answer the question related 

to the influence of omega-3 fatty acid content of maternal breast milk on the growth patterns in 

term infants.

249,302 No studies were identified to answer this question for the preterm population. 
224

The two RCTs showed no apparent effects of breast milk, with maternal intake of omega-3 

(DHA) or omega-6 fatty acids (AA), on the growth patterns at any time point.141,248 The single 

prospective cohort of a small sample of Swedish mother/term infant pairs, where the infants were 

receiving almost exclusively breast milk for 3 months, showed a positive correlation between the 

maternal mother’s breast milk content of AA/DHA and the infant’s rate of increase of HC at 1 

and 3 months of age.249 No associations were found between the HC and LA or ALA, or 

between HC and AA or DHA in breast milk.249

On the other hand, a cross-sectional study that included two different cohorts of term infants 

from Africa (two different cities with different intakes of PUFAs) was identified.302 Despite the 

limitations of including a study with this type of research design, the differences in weight-forage and weight-for-height z-scores and weight gain (g) were significantly lower in infants from 

Ouagadougou (low omega-3 fatty acids intake) compared with infants from Brazzaville (high 

omega-3 intake).302 There are several problems with the interpretation of these results, such as 

the fact that the included cohorts corresponded to a completely different population (location, 

maternal education, home characteristics, feeding practices, maternal diet, etc.). Thus, the 

differences in the growth patterns could be due to all these baseline discrepancies rather than a 

real statistical difference. The conflicting findings across the studies demonstrate the need for 

further appropriate research on this association. 

Twenty RCTs, with an overall mean quality score of 2.64/5 (i.e., poor quality), addressed the 

question of the influence of omega-3 fatty acid supplement of infant formula on the growth 

patterns in preterm infants.

185,191,193,198,201,207,212,218,225,250-259,273 Eighteen studies failed to find an 

effect of the omega-3 and omega-6 fatty acids supplementation in preterm formulas on the 

growth parameters at several time points.185,193,198,201,207,212,218,225,250-259 The growth outcomes 

measured were the mean (SD) weight, length and head circumference, the normalized z-score of 

weight, length and HC and the weight, length and HC gain. 

Two studies found that the omega-3 fatty acids supplemented group had a significantly lower 

weight at 6, 9 and 18 months of CA.191,273 Both studies included healthy preterm infants and 

provided formulas containing DHA+EPA, as well as a control formula for comparison. The 

duration of the supplementation was different across the 19 trials (range from 3 weeks to 12 

months CA). Interestingly enough, two studies by the same author (Fewtrell et al.) showed 

opposite effects in the growth pattern outcomes.321,322 The results were different probably due to 

the different length of intervention (33 days vs. 9 months), dose of DHA and EPA (DHA 0.17 

g/100 ml vs. 0.5 g/100 ml) and source of PUFAs (egg-TGL vs. fish oil). 

Meta-analysis was performed for two different growth outcomes—weight and length at 4 

months of CA. The results of the meta-analysis performed on the mean weight and length 

measured at 4 months, in the studies that compared the use of formula supplemented with 

DHA+AA with control formula,201,207 showed that the overall effect was nonstatistically 

significant. No other combinations were possible, given the differences in the intervention 

length, measuring points and type of growth parameter (mean, z-score, mean change). Overall, 

there is some evidence from 20 RCTs that the omega-3 fatty acids supplementation may not have 

an impact on the growth parameters. This findings are consistent with the meta-analysis done by 

Simmer and Patole in 2003.349 
225

Eighteen average good quality (Jadad: 3.2/5) RCTs addressed the question of the influence of 

omega-3 fatty acid supplement of infant formula on the growth patterns in term 

infants.

104,182,203,205,223,227,260-270

The effects across these studies on the growth outcomes, such as weight, length and head 

circumference, were nonstatistically different between study arms. Yet, some inconsistent 

differences were found across five trials at certain timepoints and subgroup of 

patients.120,325,328,329,332 The supplementation with omega-3 and/or omega-6 fatty acids has not 

demonstrated any benefit regarding the growth of term infants across these trials. 

The studies were rather diverse in terms of intervention characteristics (type of formula, 

content of PUFA, duration of intervention, cointerventions), as well as the timing of the outcome 

measures (e.g., 2, 4, 6, 9, 12 months of age). 

Meta-analysis was only possible for two studies that had the same intervention as well as the 

timing of the outcomes.104,205 We decided to measure only two time points that corresponded to 

the background diet as a potential confounder. Consequently, 4 and 12 months of age were the 

time points selected. Four months of age is when the infants were exclusively fed with the 

formula, after which they began solid foods that were not controlled in any of the trials. The 

overall effect of formulas containing DHA+AA or DHA compared with control formula was 

nonstatistically significant at 4 or 12 months of age for any of the growth parameters (weight, 

length or HC in mean (SD)). This is consistent with the rest of the included studies and with a 

meta-analysis prepared by Simmer in 2003.350

Only four trials adjusted the results for potential confounders, such as gender, maternal 

education, parental socioeconomic status and center, failing to find any change in the 

results.203,205,263,266 

Regarding the association between the growth patterns in preterm and term infants and the 

omega-3 or omega-6/omega-3 fatty acid content of maternal or fetal biomarkers, no studies were 

identified to answer these questions. 

A total of 12 studies addressed the question of the association between growth patterns in 

preterm and term infants and the omega-3 or omega-6/omega-3 fatty acid content of child 

biomarkers. Five RCTs included a preterm population of infants,185,191,201,207,212 five 

RCTs143,203,205,262,263 and a prospective single cohort271 included a term population of infants and 

Woltil et al., which was consciously described only in the preterm section of this question, 

selected a group of VLBW preterm and term infants.225

All the RCTs that included a preterm population, assessed the correlation between the 

infant’s plasma and RBC content of AA and the growth outcomes, such as weight (mean, gain), 

length and HC.185,191,201,207,212 Carlson et al. found a significantly positive correlation between 

the weight and length z-scores from 2 to 12 months of CA and the plasma and RBC AA.185 

However, Uauy et al. observed a negative correlation between the RBC AA content and the 

length z-score at 57 weeks (PCA).212 Two studies found a positive correlation between the RBC 

AA and the weight and length at 1 month CA207 and at 2 months CA.201 These two studies also 

found a significantly positive correlation between the same biomarker and weight gain.201,207 

Only Carlson et al. detected a positive correlation between the plasma and RBC AA and the HC 

at 2 and 4 months.185
226

Carlson et al., in another study, found a negative correlation between the weight-for-length zscore and the RBC DHA at 5 months of age.191 Woltil et al. found a positive correlation between 

the weight, length and HC gains, and the plasma and RBC DHA content in preterm and term 

infants.225

Five RCTs measured the correlation between the plasma or RBC PUFAs and growth 

outcomes in term infants.143,203,205,262,263 Two studies did not find a significant correlation 

between the omega-3 fatty acids in plasma or RBC and weight.203,262 However, Jensen et al. 

observed a significant positive correlation between the weight at 4 months and the plasma AA 

content at the same time point.203 Innis et al., on the contrary, did not find a significant 

correlation between growth patterns and the plasma and RBC AA content in term infants.263 

Makrides et al. found a significantly negative correlation between plasma DHA at 16 weeks 

and weight at 12 and 24 months of age.205 Consistent with the findings in Innis et al.’s cohort of 

term infants, with a negative correlation of RBC and plasma DHA and infant’s weight at 6 

months of age, yet not at 12 months.271 Guesnet et al. also found a negative correlation between 

the plasma and RBC EPA at birth and the length gain over 6 weeks.143

It appears to be a negative correlation between weight and the plasma or RBC content of 

DHA, and a positive correlation between weight and the content of AA in plasma or RBC. 

However, not all of the studies found this association. The content of omega-6 fatty acids (AA) 

as a biomarker may be related to weight gain in infants. The content of DHA seems to be 

inversely related to weight gain, yet no significant clinical outcomes were detected. 

There was one good quality RCT that addressed the question of the influence of omega-3 

fatty acids intake during pregnancy and the neurological development outcomes.

141 Helland et 

al. randomized a sample of pregnant women to receive either cod liver oil (DHA + EPA) or corn 

oil (LA +ALA) until 3 month post-delivery. This study failed to find a significant difference 

between groups in maturity as evaluated from the EEGs, neither at day 1 of life nor at 3 months 

of age.141

Two studies, one RCT138 and one single prospective cohort design,284 addressed the question 

of the omega-3 fatty acid content of maternal breast milk, with or without known maternal intake 

of omega-3 fatty acids, influence on the neurological development in term or preterm human 

infants.

138,284 Gibson et al. randomized healthy mothers of term infants who intended to 

breastfed with increasing doses of DHA-rich algal oil. The infants were exclusively breastfed 

for 3 months. There was no difference between groups in the Bayley’s Developmental Index 

(PDI score) at 12 and 24 months of age, however, none of the groups were acting as a control 

group (no omega-3 fatty acids).138 Another issue with the interpretation of these results is that 

the infants were only exclusively breastfed for the first 3 months of life, which introduces 

potential confounding factors, such as the background diet of the infants after this age. Other 

potential confounders were controlled in a post-hoc analysis, which found that there were no 

associations with any sociodemographic variables at 1 year. The only association at 2 years of 

age was between PDI and the level of education of the partner.138

Agostoni et al. evaluated the neurodevelopmental indices at 1 year of age in a single 

prospective cohort of term infants who were exclusively breastfed for at least 3 months in 

Italy.284 After correcting for potential confounders such us parity and mother’s characteristics 

(i.e., age, education, smoking habits), breastfeeding for 6 months or longer was not significantly 
227

correlated to the mean PDI result compared with subjects breastfed for 3 to 6 months (n=15).284 

There was no correlation between PDI and the milk fat content at any time point. 

The results of these two different design studies showed that maternal breast milk might not 

have an influence on the neurological outcome, measured with the PDI scale of the Bayley’s 

Index. 

Six average good quality (Jadad: 4.2/5) RCTs were identified to assess the neurological 

development of preterm infants (< 37 weeks of GA) supplemented with omega-3 fatty acids in 

infant formula with or without breast milk intake.

193,207,254,258,272,273 The outcomes assessed were 

the PDI scale of the Bayley’s Developmental Index, the Knobloch, Passamanick and Sherrards’ 

Developmental Screening Inventory (five subscales), the neurological impairment evaluated by a 

pediatrician, BAEP, and NCV studies. 

The results showed that, for the PDI scale, two of five studies did not observe a significant 

difference between the supplemented and the control formula.258,273 Two studies found that the 

supplemented formula groups had a significantly higher score (better) than the control 

group.193,207 However, O’Connor et al. only observed this difference in the group of infants that 

consumed > 80% infant formula and whose weight at birth were <1,250 g.207 On the other hand, 

van Wezel-Meijler et al. found a significantly better PDI score in the control group compared 

with the supplemented group at 3, 6 and 24 months, yet this difference did not reach statistical 

significance when adjusted for birth weight and number of SGA infants.272 Only Fewtrell et al. 

found that there was no difference between groups in the neurological impairment assessment at 

9 and 18 months CA, and in the Knobloch, Passamanick and Sherrards’ Developmental 

Screening Inventory score.258

For the studies that measured the Bayley’s PDI score, we could not combine them for metaanalysis given the lack of information at certain time points (i.e, 4 or 12 months of age). Two 

studies included patients who were also breastfed,207,258 which could have introduced bias given 

the content of PUFAs in human milk. In some cases, the duration of supplementation was 

different than the time to outcome measure, or endpoint (e.g., intervention lasted 6 months and 

PDI was measured at 24 months). Infants that tolerated enteral feeding began their solid food at 

around 4 months of age. This background diet added to the formulas was not controlled in the 

trials, which can modify the effect of the intervention. Other factors, such as maternal diet, 

second hand smoking, and socioeconomic status are potential confounders, as well as parental 

stimulation at home. 

Four studies used a non-randomized reference standard group of mothers who decided to 

breastfeed exclusively.193,207,254,273 

Overall, there is not consistent evidence to suggest that the omega-3 fatty acids 

supplementation of infant formula, with or without breast milk, influences the neurological 

development in preterm infants. These findings also corresponds with the meta-analysis done by 

Simmer and Patole.349

Eight average good quality (Jadad: 4.25/5) RCTs addressed the question regarding the 

influence of omega-3 fatty acids supplement in infant formula, with or without human milk, on 

the neurological development of term infants.

104,176,182,203,205,227,227,265 The main outcome 

measured was the Bayley’s Developmental Score system, the PDI. None of the seven studies 
228

that assessed this outcome found a statistically significant difference between diet groups at 

different follow-ups.104,182,203,205,227,265 The endpoints were measured at 6, 12, 18 and 24 months 

of age. 

There were other type of outcomes measured, like the Brunet-Lézine test in an Italian trial,176

which showed a significantly better result in the LCPUFA supplemented group compared with 

the control group at 4 months of age (after exclusive formula intake). However, this result was 

not significant at 24 months of age, possibly due to the potential covariates and confounders after 

20 months of lack of intake.176 

All the studies included healthy term infants, although the sources and type of omega-3 fatty 

acids supplementation, as well as the duration of the intervention, were different across the 

studies. Other potential confounders that were not assessed in the analysis were the lack of 

information regarding the background diet from 4 months of age until the time of assessment, 

and the absolute and relative amount of omega-3 and omega-6 fatty acids intake that was 

associated with the infant formulas. This last piece of information was not provided in any of the 

included trials. Jensen et al. was the only trial that compared the use of LCPUFA precursors 

such as LA (omega-6) and ALA (omega-3) in different ratios.203 The remaining studies used 

DHA and AA as type of LCPUFA, yet from completely different sources (egg lipids, vegetable 

oils, fish oil). 

We did not include the comparisons made with the reference standard group, breastfed 

infants, given that those infants were not randomized and belonged to a different population. 

Only one study included human milk as a cointervention of the infant formulas.227 This study 

did not find differences between groups in any of the neurological outcomes (i.e., Bayley’s PDI, 

and BRS at 6 and 12 months).227

Meta-analysis of the outcome measured with the Bayley’s PDI was conducted in three RCTs 

that compared the use of formula supplemented with DHA+AA with control formula.104,205,227 

The overall effect size at 12 months was nonstatistically significant between groups. No other 

time points could be combined. These conclusions are consistent with the meta-analysis done by 

Simmer in 2003.350

One cross-sectional study conducted in the United States assessed the association of 

maternal LCPUFA content (DHA) in plasma and RBC at delivery and the neurological status of 

their newborns.

274 Maternal DHA was negatively associated with active sleep (AS), AS:QS 

(quiet sleep) and sleep-wake transition, and positively associated with wakefulness (postpartum 

day 2).274 The ratio of n-6:n-3 in maternal plasma was positively associated with AS, AS:QS and 

sleep-wake transition, and negatively associated with wakefulness (day 2). On day 1, the ratio of 

n-6:n-3 in maternal plasma was negatively associated with QS and positively associated with 

arousals in QS.274 These results mean that lower amounts of AS and the greater amounts of QS 

observed in the infants exposed prenatally to higher DHA concentrations suggest greater CNS 

maturity. Furthermore, the lower AS:QS observed in the infants in the high-DHA group shows 

that their sleep organization soon after birth was approaching that of normal, older infants.338 

When the cohort was analyzed by maternal DHA plasma concentration, the high DHA group 

(>3.0% by wt of total fatty acids) did not significantly differ from the low DHA group (≤3.0% by 

wt of total fatty acids) in terms of maternal age, race, parity, duration of gestation, maternal 

education, infant birth weight and length, infant HC and Apgar score at 1 and 5 minutes.274 
229

However, infants from mothers with high plasma DHA concentrations had significantly less AS 

and had a lower AS:QS compared with infants of mothers with low plasma DHA concentrations. 

Furthermore, infants in the high DHA group had significantly less sleep-wake transition and 

more wakefulness than did infants in the low DHA group on postpartum day 2.274 

The difficulty with the interpretation of these results lies in the research design. Crosssectional studies are appropriate to measure prevalence, yet not appropriate for measuring the 

etiological association between two variables, such as maternal biomarkers at delivery and 

neurological development in the infant. The outcomes assessed in this study are related to sleep 

patterns rather than other neurological functions such as motor, sensation and brain development, 

which can be associated with the CNS maturity of the infant at birth. 

No studies were identified to answer the question about the association with fetal biomarkers. 

Four RCTs176,182,203,205 and one observational study271 addressed the question regarding the 

association of the child content of omega-3 and/or omega-6 and the neurological outcomes. 

Three RCTs182,203,205 and a prospective cohort study271 evaluated the association between the 

infant’s plasma and RBC DHA content and the Bayley’s PDI score in term infants. All these 

studies assessed this association in healthy term infants. Two RCTs found a significant positive 

correlation between the plasma DHA and the PDI score.203,205 However, the timing of 

assessment was different for both studies. Makrides et al. measured both the blood content of 

biomarkers and the PDI at 12 months of age,205 while Jensen et al. measured the plasma and 

RBC content of PUFA at 120 days of age and the PDI at 12 months.203 The formula intake was 

also different in both trials. Two other studies (including the observational study), did not find a 

significant correlation between the PDI and the infant content of PUFA in plasma or RBC.182,271

Innis et al. did not find a statistically significant relation between the infant RBC DHA or AA 

status at 2 months of age and the Bayley’s PDI score at 6 and 12 months of age.271 But given the 

research design of this study, the interpretation of the results is very limited. Bias could have 

been introduced due to several potential effect modifiers that could underestimate results, such as 

maternal diet of the breastfed infants, child’s background diet after 3 months of age, as well as 

other environmental factors that can influence the content of LCPUFAs and the neurological 

development in infants. The results, across the studies, are not consistent enough to draw any 

conclusions. 

Two studies addressed the question of the influence of omega-3 fatty acids intake during 

pregnancy and the visual function in term infants.

235,275 There were no studies identified that 

included a preterm population. 

The first study was a double-blinded RCT that assessed the retinal function of term infants of 

mothers that were or were not taking DHA during pregnancy.235 This trial failed to find a 

significant effect of DHA supplementation during pregnancy on the retinal sensitivity (ERG) 

measured at birth in term infants. The cross-sectional study was conducted in Cuba and 

measured the visual function of a cohort of term infants from mothers who had a high intake of 

high-fat fish during pregnancy and breastfeeding.275 This study failed to find a statistically 

significant difference in mean visual function values between the exclusively breastfed group 

and the infants who were also receiving formula.275 However, the purpose of this study was to 

evaluate the correlation between the visual function at 2 month of age and their blood LCPUFA 

biomarkers; and, no correlations were found.275 The interpretation of such research design on 
230

the clinical outcomes is very difficult given the lack of an appropriate comparator, 

randomization, blinding and other variables necessary to produce more accurate results. 

These findings suggest that maternal intake of omega-3 fatty acids supplements may not 

effect visual function outcomes in term infants. Yet, better-conducted studies are required to 

support this conclusion. 

Five studies addressed the question regarding the influence of human milk content of omega3 or omega-6/omega-3 fatty acids on the visual function of term infants.

138,140,248,275,276 Two were 

RCTs,138,248 one was a prospective cohort study,276 and two were cross-sectional studies.140,275 

The RCTs did not detect a statistical difference in the VEP acuity among infants of mother who 

were or were not receiving DHA at any age (from 12 weeks to 8 months of age).138,248 No studies 

were identified in the preterm population. 

Two observational studies found a significant association between the DHA content of breast 

milk and visual function in term infants at 4 months of age,140 and at 3.5 years old.276 The Cuban 

cross-sectional study, on the other hand, did not observe this correlation at 2 months of age.275

The correlation between the DHA content in breast milk and visual function was not 

consistent with the clinical outcomes measured in breastfed term infants of mothers who were or 

were not taking supplements containing high DHA. 

The influence of omega-3 fatty acids supplementation of infant formula, with or without 

maternal breast milk, on the visual function in preterm infants was evaluated in nine RCTs with 

an average quality score approaching good internal validity (Jadad: 

2.9/5).185,191,198,201,207,212,251,254,272 Five studies used the VEP as the main outcome 

measure,198,207,212,254,272 while six trials measured the visual acuity with the Teller’s Acuity Card 

Procedure for binocular vision.185,191,201,207,251,272 Only two trials measured the ERG to evaluate 

the retinal function of the infants, and did not detect a significant effect with LCPUFA 

supplementation compared with control formula.198,212 

Of the five studies that measured VEP, two did not find a statistical difference between 

feeding groups at any time point (1, 3, 4, 12 months of CA).254,272 Three studies found that 

compared with the unsupplemented group, infants fed with LCPUFA-supplemented formula had 

a better or faster maturation of visual function, in terms of significantly shorter waves in the 

VEP.198,207,212 O’Connor et al., however, only detected this positive effect at 6 months, but not at 

4 months of CA.207 Uauy et al. included VLBW preterm infants (60% Black),212 whereas 

Faldella et al.198 and O’Connor et al.207 included healthy preterm infants with an appropriate 

weight for GA. 

Among the studies that evaluated the visual acuity using the Teller’s Acuity Card test, only 

two studies found a significant difference between groups.185,191 Carlson et al. observed a higher 

acuity in the LCPUFA group compared with the control group at 2 months of CA, but not at 4 

and 12 months.191 The same significant difference favoring the supplemented group was seen in 

the other Carlson et al. study at 2 and 4 months of CA, but not from 6.5 to 12 months of CA.185 

A meta-analysis of the relevant visual outcomes was performed, comparing the studies by the 

type of omega-3 fatty acids used in the supplemented formula (DHA or DHA+AA) and control 

formula, and by the type of outcome (VEP and Teller’s test of visual acuity). For the VEP visual 

acuity outcomes, only two studies were combined.207,212 O’Connor et al. found that the use of 
231

formulas with DHA+AA resulted in a better VEP measurements compared with control formula, 

but only at 6 months of age. At 4 months of CA, none of the interventions showed a significant 

difference.207,212

Regarding the behavioral visual acuity measured with the Teller’s Card test, compared with 

controls, there was no significant effect of DHA-supplementation at 2,4,6 or 9 months of 

CA,185,201 or DHA+AA supplementation at 2, 3, 4 or 6 months of CA.191,201,207,212,272

Only O’Connor et al. allowed their infants to receive breast milk besides the formula.207 The 

results were controlled for the amount of formula taken (>80%) in contrast with the breast milk, 

and the differences were still not significant for both outcomes (VEP and Teller).207

The differences across the trials were mostly related to the intervention characteristics 

(amount of formula, type of supplementation, duration of intervention) and some population 

characteristics, such as birth weight (VLBW, AGA), race/ethnicity distribution, and 

socioeconomic status, among others. These differences could explain the discrepancies in the 

results. These findings are consistent with the meta-analysis done by Simmer and Patole.349 

However, the conclusions of another meta-analysis conducted by SanGiovanni et al.351 were 

somewhat different. Their meta-analysis of four studies showed that at 2 and 4 months of age 

there was a statistically significant difference between the DHA and control groups in the visual 

resolution acuity (behavioral test) .351 They did not observe a significant overall effect after 4 

months of age. In SanGiovanni et al., the comparisons used in the meta-analysis were taken 

from the same trial that included more than two dietary groups (corn oil vs. soy/marine oil, soy 

vs. soy/marine oil, human milk vs. corn oil and human milk vs. soy oil). We did not use this 

approach given that we considered more appropriate to combine the dietary groups without 

omega-3 FA as control group and the intervention groups discriminated by content of DHA+AA 

or DHA alone. Therefore, their approach to do meta-analysis is different from ours and that 

could be the result of the discrepancies between them. 

Thirteen RCTs, of average good quality (Jadad: 3.61/5), addressed the question of the 

influence of the omega-3 fatty acids supplementation of infant formula, with or without breast 

milk intake, on the visual function outcomes in term infants.

104,182,203,205,227,263,264,266,269,270,277,352

The outcomes assessed were the VEP in nine trials,104,182,203,205,264,266,269,270,352 visual acuity 

(binocular vision) using the Teller’s Card test (behavioral visual function) in five 

studies,104,227,263,277 retinal function using the ERG in one study,182 and stereoacuity using the 

FPL in three studies.182,269,270

Five of nine studies did not find a significant difference between groups in the VEP at any 

age.104,203,205,264,266 Whereas, the other four trials did find a significantly better VEP in the 

LCPUFA-supplemented group compared with the control group at a number of time points, from 

1.5 to 13 months of age.182,262,269,270 The meta-analysis performed on this particular outcome, by 

LCPUFA content of DHA alone (or with the addition of AA), versus control, showed that the 

studies that compared DHA supplemented formula with control formula did not have an overall 

significant effect at any age.104,182,205 Conversely, in seven studies that compared the use of 

DHA+AA formula with placebo, there was no difference between groups at any 

age,104,182,205,262,264,269,270 with the exception of four studies that found a significant difference at 

12 months of age.104,182,269,270 
232

One of five studies that evaluated behavioral visual acuity with the Teller’s test,277 found a 

significantly better acuity in the LCPUFA formula group compared with the control group at 2 

months of age, yet not at 4, 6, 9 or 12 months. The remaining four studies did not observe a 

significant difference between groups in this outcome, at any time point.104,227,263 The metaanalysis performed on this outcome showed that, in studies comparing the use of DHA+AA with 

a control intervention, acuity was only significantly better in the DHA+AA group at 2 months of 

age,104,182,277 but not at 4, 6, 9 or 12 months of age. 

These findings suggest that there are conflicting results across the trials regarding the 

efficacy of the omega-3 fatty acids supplementation of infant formula on the visual function 

outcomes. These conclusions are consistent with the meta-analysis done by Simmer in 2003.350 

Another meta-analysis performed by SanGiovanni et al., also showed that there was a 

significantly better visual acuity (Teller’s Card test) in the DHA supplemented group compared 

with the control group at 2 months of age, yet this effect was not seen at any other age. This 

result is also consistent with our findings.353

One study measured the association between the maternal content of biomarkers at 2 months 

postpartum and the visual acuity (Teller’s Card Test) in term infants at 2 months of age. This 

study failed to find a significant correlation.275 No studies were identified to assess the 

association of the omega-3 fatty acids content in fetal biomarkers and the visual function 

outcomes. However, 21 studies assessed the question of the association between child’s omega3 or omega6/omega-3 fatty acids biomarkers and the visual function outcomes. Five studies 

included a preterm population,185,198,212,278,279 while 16 included term infants. Of the five studies 

in the preterm group, three were RCTs,185,198,212 and two were cross-sectional studies.278,279 Of 

the 16 term infant studies, nine were RCTs,138,182,203,248,262-264,269,270 and seven were observational 

studies.140,271,275,278,280-282 

In all the preterm RCTs, the results were conflicting. In the study by Birch et al, the 

LCPUFA content of RBC DHA/DPA ratio correlated with both FPL and VEP at 57 weeks 

PCA.212 Based on ANOVA, there was a statistically significant correlation between RBC DHA 

at 2 months and visual acuity at 2 and 4 months, in the Carlson et al. study.185 Faldella et al. 

found a negative correlation between the RBC DHA and the N4 and P4 wave latency of the VEP 

at 52 weeks PCA.198

In two preterm cross-sectional studies, the results also were divergent.278,279 Birch et al. 

found that the LogMAR (VEP) acuity was significantly associated with the end-product ratio 

[DHA n-3/DPA n-6] in total RBC lipids. For FPL acuity, the results were the same for both the 

breastfed and formula-fed groups.278 Whereas, Leaf et al. observed a positive correlation 

between scotopic b wave (ERG) implicit time and percentage composition of DHA in both 

plasma and RBC PL. A similar relationship was seen with total omega-3 LCPUFA in both 

plasma and RBC PL. There was a positive correlation between both RBC AA and total omega-6 

LCPUFA and scotopic a-b amplitude. No significant relationships were seen between photopic 

ERGs and either plasma or RBC LCPUFAs.279

Given the different designs and interventions (human milk or formula), it is very challenging 

to draw a conclusion in the preterm population. 

In the term population, of the seven RCTs that had an infant intake, four182,264,269,270 reported 

associations between milk or blood biomarkers (plasma/RBC DHA and/or AA content) and the 
233

sweep VEP acuity measures. Of these trials, three182,269,270 found statistically significant negative 

linear regression coefficients indicating that higher RBC DHA content was associated with a 

better sweep VEP acuity in infants at different age time points. The remaining study264

suggested that the RBC DHA content was not associated with the measured sweep VEP acuity at 

4 months of age. The results of both trials182,264 that looked at the RBC EPA and AA content in 

relation to the measure of sweep VEP acuity, indicated that neither RBC AA nor EPA content 

was associated with the sweep VEP acuity during the first year of the infants’ life. One study,269

that investigated the relationship between infant’s plasma DHA and AA content, found that 

higher plasma contents of both DHA and AA were associated with better sweep VEP acuity at 4 

and 13 months of age. 

The relationship between the infants’ blood biomarkers and the measures of infant amplitude 

of VEP acuity were reported in two trials.203,262 Both trials suggested that RBC DHA correlated 

negatively with the amplitude of VEP acuity (in log MAR), measured at 4203,262 and 7.5262

months of age (i.e., infants at 4 and 7.5 months of age who on average had a higher RBC DHA 

content, tended to have a lower log MAR or better VEP acuity). The former trial203 also showed 

that there was no correlation between either plasma or RBC DHA content at 4 months of age, 

and the latency measure of VEP acuity obtained at either 4 or 8 months of age. The same trial,203

however, found a statistically significant negative correlation between plasma-DHA content and 

the amplitude of VEP acuity both measured at 4 months of age. 

One study reported the association(s) of the plasma DHA or RBC DHA content in relation to 

the measure of Teller’s visual acuity.263 The plasma or RBC DHA content did not correlate with 

the Teller’s acuity, measured at 3 months of age. 

Only two trials reported the associations between the infants’ RBC DHA content and their 

stereoacuity (in log seconds) measured at 4269 and 12270 months of age. Both trials found that 

there was no association between the two factors. 

The correlation between plasma- and RBC DHA and ERG parameters in infants was reported 

in one trial.182 None of the Naka-Rushton parameters except for log k (in scotopic troland 

seconds) was significantly correlated with plasma or RBC DHA content at either 1.5 or 4 months 

of age. There was a statistically significant negative correlation between the RBC DHA content 

and log k in the infants at 1.5 months of age. 

None of the RCTs that measured the association of the infant’s biomarkers after exclusive 

breast milk intake and the visual acuity outcomes found any significant correlation.138,248

The seven observational studies were very heterogeneous in term of exposure characteristics 

and population, as well as outcomes. Most of them used breast milk as the main exposure, as 

well as formula. However, the overall association was that in four cross-sectional studies there 

was a nonsignificant correlation between infant’s biomarkers and the visual acuity at any 

age.140,275,281,282 In three studies, there was significant correlation between the biomarkers and 

the visual acuity.271,278,280 Yet, the biomarkers and the outcomes were different in each. Birch et 

al. found that there was a positive correlation between the infant’s RBC DHA/DPA ratio and the 

stereoacuity,278 whereas, Makrides et al. observed a positive correlation between the RBC DHA 

and LA and the VEP (logMAR).280 Finally, Innis et al. also detected a positive association 

between the RBC DHA at 2 months and the visual acuity (Teller’s test) at 2 and 12 months of 

age, but not at 4 and 6 months of age.271
234

Overall, there was a lack of pattern of correlation between the infant’s biomarkers in blood 

and the visual function outcomes across 21 studies that addressed this issue. 

One RCT addressed the question regarding the influence of maternal intake of omega-3 fatty 

acids during pregnancy on the cognitive development in infants.

141 This study measured the 

cognitive development using the Fagan Test of Infant Intelligence at 6 and 9 months of age in the 

infants of mother who had taken either cod liver oil (DHA+EPA) or corn oil (LA+ALA) during 

pregnancy and lactation. There was no differences between groups in the novelty preference at 

both time points.141 There was a follow-up study at 4 years of age that measured the Kaufman 

Assessment Battery for Children (K-ABC), which is a measurement of intelligence and 

achievement designed for children between 2.5 years and 12.5 years old.354 The supplemented 

group (DHA+EPA) had significantly higher scores than children in the corn oil group (mothers) 

on the Mental Processing Composite of the K-ABC at 4 years old. However, the scores in the 

Sequential Processing Scale, the Simultaneous Processing Scale and the Nonverbal Scale among 

children who were born to mothers who were given cod liver oil were non statistically different 

from the control group.141

The latter relationship may be relevant, although the clinical importance of this result has yet 

to be determined. The potential confounders such as infant’s diet after the exclusive 

breastfeeding, medications, supplements and other variables that could affect the results, were 

not measured at the time of the outcome (4 years of age). 

Three studies were identified to respond to the question of the influence of maternal content 

of omega-3 fatty acids in breast milk influences the cognitive development in infants.

138,141,284 

Two were RCTs138,141 and one was a prospective cohort.284 The study by Helland et al. was an 

RCT described above,141 and the study by Gibson et al. was a double-blind RCT that included 

mother of term infants who intended to breastfeed.138 They were randomized to receive five 

increasing doses of DHA (algal oil) during the first 3 months postpartum. The mean Bayley’s 

MDI score did not differ between groups at 1 or 2 years of age.138 The environmental factors 

that were associated with the Bayley’s MDI at 1 year of age were the home stimulation test, 

partner smoking status, length of breastfeeding and the 3-month DHA status of breast milk and 

infant blood. The only one that was still correlated to the Bayley’s MDI at 2 years was the home 

stimulation test.138 

This study was underpowered to detect a significant difference between groups in the MDI 

scores, which makes it very difficult to draw a conclusion. There was no comparator without 

omega-3 fatty acids. The infants were fed solid foods before the measurements (Bayley’s score), 

which can be a potential effect modifier.

Six average good quality (Jadad: 4.4/5) RCTs addressed the question of the influence of 

formula intake, with or without breast milk, on the cognitive development of preterm 

infants.

185,193,207,258,272,273 The main outcome measured was the Bayley’s MDI score, at different 

time points in the five RCTs.193,207,258,273,355 Overall, four of the five trials did not find that the 

supplementation of infant formula with omega-3 fatty acids had an effect on this particular 

outcome at 3, 6, 12, 18 and 24 months of age. This remained true even after controlling for 

potential effect modifiers such as site, gender, birth weight, maternal education, gestational age, 

and human milk intake, among others.207 Except for one trial which found that sex was an 

important covariate, males in the supplemented formula group had a significantly higher score 
235

than those in the control group at 18 months.258 Only one study, which included preterm and 

term infants, found that the supplemented groups had greater scores than the control group at 118 

weeks PMA, and the term infants had higher scores than the preterm infants.193

Regarding the Fagan test of Infant Intelligence outcome, two studies found a significant 

difference between the omega-3 fatty acids group and the control group.185,207 Carlson et al. 

observed that the DHA group had significantly more discrete looks in the novelty test,185

however, at 12 months the DHA-supplemented group had a significantly lower novelty 

preference compared with the control group. Whereas, O’Connor found that the DHA+AA (eggTGL/fish) group had a significantly greater mean novelty preference look compared with the 

DHA+AA (fish/fungal) formula and the control group at 6 months.207

O’Connor et al. also found that there was no significant differences between groups in the 

Infant version of the MacArthur Communicative Development Inventories (a standardized 

parent-report instrument) at 9 months CA and 14 months CA.207 

Meta-analysis was not possible given the heterogeneity across the studies for each of the 

different outcomes. This heterogeneity was observed in the intervention characteristics (meaning 

dose, source of omega-3 fatty acids, duration of intervention), cointerventions, and timing of the 

outcomes measures. Other potential confounding factors can be associated with the 

discrepancies in the study results such as background diet, breast milk intake, and environmental 

factors (parental education, stimulus at home, smoking status at home, etc), as well as the use of 

different assessment tools. It is thought that global measures of cognitive development (Griffith, 

Bayley, Brunet-Lezine scales) may not be sensitive enough to detect differences in normal 

infants supplemented with or without DHA. It is likely that specific functional tests (Fagan’s 

test, Means-end problem solving test) would be more sensitive and specific in detecting these 

differences in assessing the adequacy of DHA intake on optimizing neurocognitive development. 

The more specific tests used during infancy have been shown to have a better correlation with 

testing later in childhood than the global infant tests.356,357

Overall, most of the studies did not find a significant effect of the omega-3 fatty acids 

supplementation in preterm infants on the cognitive developmental outcomes using the Bayley’s 

MDI scale. Nonetheless, a question remains as to which would be the best instrument to 

measure this particular outcome. These conclusions are consistent with the meta-analysis done 

by Simmer and Patole.349

Eight good quality RCTs were identified to address the question of the influence of omega-3 

fatty acids supplementation of infant formula, with or without breast milk intake, on the cognitive 

development in term infants.

104,182,203,205,223,227,265 The mean outcome that was measured across 

seven RCTs was the Bayley’s MDI score at different time points.104,182,203,205,227,265 All but one 

of the studies did not find a significant difference between groups (supplemented vs. control) in 

this outcome at 6, 12 and 18 months of age. Only Birch et al. observed that the DHA+AA group 

had a significantly higher score compared with the control group at 18 months of age.182 

There were five other different cognitive outcomes measured across the trials. The 

Knobloch, Passamanik, and Sherrards Development Screening Inventory test, performed at 9 

months of age in the study by Lucas et al., and the Fagan Test of Infant Intelligence, performed 

at 6 and 9 months of age in two other trials by Auestad et al., did not reveal an effect with 

omega-3 fatty acids supplementation.227,265 The IQ (Stanford-Binet), Receptive Vocabulary 
236

(PPVT-R), Expressive Vocabulary, and Visual-Motor Index scores, as well as the ProblemSolving scores, did not differ between groups in two studies.104,223

Regarding the Infant version of the MacArthur Communicative Development Inventories, 

Auestad et al. found that the DHA group had a significantly lower vocabulary production score 

compared with the control group at 14 months of age.104 Yet, the other Auestad et al. study 

found that at 14 months, the DHA+AA (fish/fungal) group had a significantly higher vocabulary 

expression score than those fed with DHA+AA (egg-TG) supplemented formula.227 Both 

Auestad et al. studies did not reveal a between-group significant difference at 9 months.227

A meta-analysis of the main outcome used across the trials, the Bayley’s MDI score at 12 

months of age, was performed. Three studies were identified to be appropriately comparable in 

terms of type of supplementation (DHA+AA) and population characteristics (healthy term 

infants).104,205,227 The overall size of the effect was nonstatistically different between study 

groups. 

Overall, it appears that the supplementation with omega-3 fatty acids does not have an effect 

on the cognitive development outcomes. These conclusions are consistent with the metaanalysis done by Simmer in 2004.350 Although the design of the studies is very appropriate, they 

have some limitations. The studies did not measure the total dose of omega-3 or omega-6 fatty 

acids contained in the formulas, since they failed to account for the total amount of formula 

intake per day. They also were unsuccessful in controlling for background diet, in the infants 

(from 4 months of age) and the mothers (breastfed infants). There were also discrepancies in the 

intervention length and the outcome measures (e.g., formula given until 4 months of age and 

Bayley’s MDI measured at 12 months of age) within each trial and across all the included 

studies. 

An attempt to control for potential confounders was appropriately done in almost all the 

studies. However, none of them use the omega-3 fatty acids dose as a covariate. Instead, they 

used the plasma or RBC DHA content, or the type of diet. 

Only one study allowed the infants to be breastfed as a cointervention.227 Nevertheless, the 

use of both supplemented formula and breast milk, did not show an effect on the cognitive 

development when compared with breast milk alone (control formula). 

No studies were identified to answer the questions of the association of omega-3 or omega6/omega-3 fatty acids content of maternal or fetal biomarkers and the cognitive development in 

term or preterm infants. 

Six studies addressed the question of the association of omega-3 or omega-6/omega-3 fatty 

acids content of child biomarkers and the cognitive development in term infants.

138,182,203,205,271,285 

Four of them were good quality RCTs,138,182,203,205 and two were single prospective cohort 

studies.271,285 There were no studies identified to address the same question in preterm children. 

Gibson et al found that the infants were exclusively breastfed for 3 months. There was a 

significant correlation between the Bayley’s MDI score at 1 year old and DHA indices in plasma 

and RBC at 12 weeks of age, yet this correlation was not seen at 2 years of age.138

Birch et al. found that the MDI score at 18 months was positively correlated with plasma and 

RBC DHA at 4 months of age. None of the other plasma biomarkers (LA, AA, ALA, EPA) were 
237

correlated with the MDI at 18 months, however the RBC-LA and RBC ALA were negatively 

correlated with the MDI at 18 months of age.182 None of the biomarkers measured at 12 months 

of age were correlated with the MDI at 18 months of age.182

Jensen et al. and Makrides et al. did not observe a significant correlation between the PUFA 

content in infant’s plasma and RBC, and the Bayley’s MDI at 1 and 2 years of age.203,205 

However, these studies used a different type of intervention—Jensen et al. used increasing ratios 

of LA/ALA in four groups,203 whereas, Makrides et al. used three formulas with LCPUFAs 

(DHA+AA vs. DHA alone vs. control).205 

Finally, both observational studies failed to find a significant correlation between the 

biomarkers and the cognitive outcomes.271,285 Innis et al. did not find a statistically significant 

relation between the infant RBC DHA or AA status at 2 months of age and the Bayley’s MDI 

score at 6 and 12 months of age, as well as the Novelty Preference at 6 and 9 months.271 Ghys et 

al. did not observe a correlation between the DHA and AA concentration in infant’s plasma or 

RBC and the cognitive development at 4 years of age. Small but significant associations 

occurred with maternal IQ, birth weight, duration of breast-feeding, maternal smoking during 

pregnancy, and paternal educational attainment. 

Meta-analysis of these associations was not possible given the differences in the intervention 

characteristics, as well as in the timing of the blood samples and the cognitive outcomes 

measures. In general, there are discrepancies in the results related to the association between the 

child’s biomarkers and the cognitive developmental outcomes. 

Clinical Implications 

The intake of omega-3 fatty acids in the present review’s collection of interventional studies 

by maternal and child populations did not appear to be associated with moderate or severe 

adverse events. Supplementation studies enrolling pregnant women typically utilized controlled, 

capsule delivery of relatively simple interventions (e.g., fish oil, containing DHA); and, 

supplementation appeared to be well tolerated, with some mild, mostly gastrointestinal events 

occurring occasionally. A similar pattern was observed in supplementation studies with child 

populations. However, a few factors make it very difficult to identify the specific or collective 

safety profiles of the individual omega-3 fatty acids in studies investigating their influence on 

child outcomes. 

First, there was a wide variety of types of omega-3 fatty acid employed in these studies. 

Second, more than just a single omega-3 fatty acid was typically employed in these pediatric 

trials. The latter observation likely has strong implications for what can be understood as the 

meaningfulness of possible differences or similarities in the adverse event profiles associated 

with the respective study groups (i.e., “intervention,” “control”), even in RCTs considered wellcontrolled in other ways (e.g., allocation concealment; blinding). 

In a study comparing the effects of DHA and an olive oil placebo (i.e., “no-DHA”), for 

example, typically added to the active and placebo formulations are the exact same constituents 

(e.g., other omega-3 fatty acids; omega-6 fatty acids; iron; anti-oxidants). However, the 

possibility that individually or collectively these cointerventional or background elements could 
238

“interact”—metabolically speaking—differently with DHA and olive oil to potentially produce 

different “synergistic” influences on clinical outcomes suggests that, in these studies: a) what is 

meant by the “intervention” and “control” is more complicated than a simple distinction between 

“DHA present” and “DHA absent;” and b) the exact absolute and relative influences of DHA on 

clinical outcomes in this example cannot be readily isolated. Especially problematic for 

interpretation are those interventional studies whose specific cointerventional or background 

constituents included various other omega-3, omega-6 or omega-9 fatty acids, which constitute 

various metabolites along the metabolic pathway (from the parent EFAs, LA and ALA). In 

short, the dynamic interplay among these fatty acid contents (e.g., competition for enzymes), and 

how this interplay may influence outcomes, may differ in important ways depending on whether 

DHA or olive oil is added to this combination of cointerventional or background constituents. 

Thus, the ability to reliably associate the presence, or absence, of specific adverse effects 

with specific omega-3 fatty acids may be impeded by the inclusion of background constituents 

within studies of formula supplementation. At best, inferences may be drawn with respect to 

often very complex combinations of constituents. This research strategy adds considerable 

“noise” to studies, which precludes the identification of clear “signals” regarding the adverse 

effects associated with specific omega-3 fatty acids. Moreover, definitions of interventions in 

the different studies were often diverged, even though they appeared to share the same key active 

ingredient, such as “DHA.” This clinical heterogeneity complicated attempts to compare studies. 

The evidence pertaining to the possible impact of supplementation with omega-3 fatty acids 

on predefined pregnancy outcomes showed either evidence of no effect, or the results were 

inconclusive. Results suggested the absence of effects with respect to the impact of 

supplementation on the incidence of GHT, preeclampsia or eclampsia, as well as on infants being 

born SGA (measured via birth weight and incidence of IUGR). However, regarding evaluations 

of the duration of gestation, some discrepancies were observed, although most of the studies 

failed to detect a statistically significant effect. 

Regarding the questions of the biomarker content during pregnancy, and its possible 

association with pregnancy outcomes, nothing conclusive can be asserted. There was 

considerable heterogeneity in the research designs (i.e., experimental versus observational), the 

types of biomarker that were evaluated, the timing of these measurements, and the types of 

intervention given to study participants (i.e., source of omega-3 fatty acids; omega-6 fatty acids; 

omega-6/omega-3 ratio intake). 

Overall, results concerning the impact of the intake of omega-3 fatty acids on the 

development of infants are primarily, although not uniformly, inconclusive. The inconsistencies 

in study results may be due to differences in the: a) definitions of the type and source of omega-3 

fatty acids; b) omega-6/omega-3 fatty acid intake ratio in the intervention, the background diet, 

or both; c) absolute and/or daily amounts of formula supplementation received by the children; 

or, d) duration of the intervention. Most of the studies did not control for the absolute or daily 

amounts of formula ingested by the child populations, which lessens our ability to draw 

unequivocal inferences about the value of this supplementation. Moreover, making clear sense 

of the absolute or relative effects of individual omega-3 fatty acids, or even omega-3 fatty acid 

combinations, on child outcomes is complicated by the same problem of “noise” described with 
239

respect to the safety evidence in child supplementation studies. It is very difficult to reliably 

ascribe definite benefits, or the absence thereof, to specific omega-3 fatty acids. 

Looking at specific categories of child outcome, growth patterns were not affected by the 

intake of omega-3 fatty acids via human milk or formula supplementation in either term or 

preterm infants. With biomarker data obtained exclusively from infant population sources, 

results across the different studies concerning the association between child biomarker content 

and growth outcomes were inconsistent, and thus inconclusive. 

The neurological development outcomes were influenced somewhat by the omega-3 fatty 

acids supplementation of infant formula in preterm infants,193,207 although not all of the studies 

found evidence for a benefit. Overall, however, the results must be considered inconclusive for 

preterm offspring. On the other hand, term infants did not receive any benefit from the 

intervention in the short- or longterm. A reliable association between infant biomarker content 

and neurological outcomes for both term and preterm infants was not supported, because of the 

lack of consistency in the results across the studies. 

Visual function outcomes provided the most inconsistent data in both the preterm and term 

infant populations. This suggests an inconclusive response to the question of the value of 

omega-3 fatty acid intake for visual development. This same observation characterizes the 

results concerning the association between biomarker content and visual outcomes. 

In the preterm population, the only type of clinical outcome that showed a significant 

favorable effect related to the intake of omega-3 fatty acids was the Fagan test of Infant 

Intelligence (i.e., “novelty preference looks”) at 6 and 12 months of age.185,207 It assesses 

cognitive function. However, the scores on the Bayley’s Developmental Index (MDI) were not 

influenced by infant supplementation at any age.185,207,258,273 In most of these studies, the 

intervention was stopped months before the final cognitive assessment was performed (i.e., 12 or 

18 months). This observation suggests a likely problem in interpreting the results. Between the 

end of the intervention period and the final cognitive evaluation, dietary intake was not measured 

and controlled for analytically. This factor may have contributed to what was observed at the 

final outcome evaluation. Other factors that could have influenced the outcomes included child 

illnesses, perceptual-cognitive stimulation, smoking, and parental education. 

In the term population, while there was some disagreement in results across the trials, most 

of them reported a lack of effect using the Bayley’s MDI. The association between biomarker 

content and cognitive outcomes has yet to be determined. 

In summary, definitions of the maternal population in studies of pregnancy outcomes varied 

considerably, yet no conclusive evidence for benefit was identified. Results based on both term 

and preterm study populations were also inconclusive, although these studies typically entailed 

interventions of the complex nature discussed earlier. Thus, when it came to the set of child 

developmental/health questions investigated in our review, it must be asked whether or not the 

included studies could have been expected to provide unequivocal evidence regarding the value 

of all, or individual, omega-3 fatty acids in influencing child health? Could these studies have 

been expected to permit the isolation of the impact of the omega-3 fatty acids in these 

populations? That said, had the results been conclusive one way or the other, much of the 

included research studies lacked strong applicability to the North American population. 
240

What, then, are the research implications? 

Research Implications and Directions 

Questions for which no evidence was identified clearly require empirical studies. The studies 

enrolling child populations typically exhibited sound quality, defined in terms of Jadad total 

scores. However, these investigators typically failed to design studies where the specific effects 

of omega-3 fatty acids could be isolated. While this outcome may have been necessary, given 

the expectation that all of the constituents were likely important for child health, the results were 

difficult to interpret. Biomarkers measure the content of specific fatty acids of different lipid 

fractions in plasma (individual fatty acids or content in triglycerides, cholesterol esters or 

phospholipids), cell membranes (red blood cells, platelets) or tissues (such as adipose, umbilical 

cord). These biomarkers are used to reflect dietary intake or as a surrogate measurement of the 

fatty acid content of various tisses that are not readily available for measurement. The essential 

n-3 and n-6 fatty acids content of these biomarkers reflect the exogenous intake of these fatty 

acids within hours to years. The inherent difficulty with using membrane and accessible tissue 

biomarkers as surrogate measurements of the fatty acid content of for example, the brain or 

retina, is the difference in preferential deposition of these fatty acids in different membranes and 

tissues and the rate of turnover. For example, DHA is preferentially accumulated in the brain 

and retina but not in the red cell membrane. As well, once DHA is deposited in the brain and 

retina, the amount is relatively resistant to turnover even with subsequent dietary n-3 fatty acid 

or DHA deficiency, whereas RBC membrane levels would decrease. 

During different stages in life there are changes fatty acid metabolism, storage and turnover 

that affect the fatty acid profile of the various biomarkers. The choice of biomarker is dependent 

on the intervention and outcome of interest. For example, during pregnancy there are significant 

changes in lipid metabolism with increased fat storage in the early stages and mobilization in the 

later stages. If the outcome of interest is the effect of maternal intake of n-3 fatty acids on 

pregnancy outcomes, then markers that reflect shorter term dietary intake should be used (plasma 

lipid fractions, RBC membranes). During periods of growth and development in infancy, there 

is rapid accumulation of n-3 fatty acids that are preferentially deposited in neurologic tissues, 

which may not be reflected in the available biomarkers. Again, it is likely that RBC membrane 

fatty acid content more closely reflects the content in neurologic tissue than from plasma or 

adipose tissue. It is clear that further research is required to establish the predictive value of 

available biomarkers or the development of new biomarkers of n-3 fatty acid status on clinical 

outcomes. 

One key implication is that the most likely question that the included child outcome studies 

might have been able to address is whether formula supplementation “cocktails,” which included 

at least one type of omega-3 fatty acid content, could provide a benefit to child health. The 

overarching question concerning the role of omega-3 fatty acids in child health that we aimed to 

address with this review might have been too narrow especially in light of: a) expectations that 

the omega-6 fatty acids alone (e.g., AA), or possibly in combination with the omega-3 fatty 

acids, might substantially influence child health; and b) knowledge that the available, relevant 

studies invariably employed interventions including elements other than the omega-3 fatty acids. 
241

Thus, one key contribution of our review may be that we have now raised an additional question: 

can questions concerning the possible impact of any of the EFAs on child health be conceived 

without concurrently considering the (e.g., interactive) roles of both the omega-3 and omega-6 

fatty acids? 

That said, one possible strategy for research entails defining interventions according to 

specific omega-6/omega-3 fatty acid intake ratios, which would be achieved via the comodification of the intake of omega-3 and omega-6 fatty acids. While the ideal design with 

which to test questions of efficacy is the RCT, pilot work using less complex designs would need 

to be done first. These would help establish intake ratios with some potential to benefit child 

outcomes. It might then be observed that different intake ratios positively influence different 

developmental outcomes, or yield different safety profiles. 

Decisions as to the “appropriate” or “reasonable” intake ratios for use as interventions in 

RCTs could then be made based on what is considered an acceptable benefit/safety profile and/or 

what are the most important outcomes—and the timing of their assessment—requiring 

modification. It may turn out that in a preliminary cohort study, exposure to EFAs is most 

beneficial for early neurodevelopment. 

Evidence concerning the metabolic interplay of the fatty acid contents in biomarkers might 

also help shape the “appropriate” or “reasonable” intake ratio. This preliminary work could 

demonstrate that certain combinations of fatty acids actually produce antagonistic, rather than 

synergistic, effects, metabolically speaking. In this way the optimal combinations of EFA (e.g., 

DHA+AA), and sources thereof (e.g., marine, plant) could be identified, including circumstances 

where it is an antagonistic metabolic dynamic that is desired, since it appears to produce 

important clinical effects. Work with biomarker data could thus be helpful in designing studies 

and not just as a means to predict clinical outcomes, or to make sense of relationships between 

patterns of EFA intake and clinical outcomes. Nevertheless, to produce readily interpretable 

results, at least two additional strategies would be helpful. 

First, the nutrients obtained via the background diet would also need to be factored into the 

definition of the intake ratios. Second, to control for the possibility that it is the volume of intake 

of supplementation that positively influences child outcomes, daily or weekly amounts of intake 

should be measured, and the corresponding data are entered into covariate analysis. For ethical 

reasons, this approach would likely be preferable to one whereby a minimum or maximum 

volume of intake is established. 

These strategies would complement the other, typically necessary research-design elements, 

and maximize the meaningful interpretability of even RCT results (e.g., control for 

caloric/energy intake across study groups). Data regarding the maternal preconceptional and 

perinatal diets should be retrieved before a study begins.353 Data concerning the maternal diet 

during pregnancy or breastfeeding may help explain (the lack of) beneficial effects with respect 

to child outcomes. Likewise, data regarding the dietary intake of children following the 

termination of the intervention period (e.g., at 4 months), yet preceding a longer term followup 

(e.g., at 12 months), need to be collected to help explain (the lack of) beneficial effects on child 

outcomes. 

Many of these variables were not assessed in the studies focusing on child outcomes in our 

review. Failure to control for these or other variables, either experimentally or analytically, 
242

complicate or preclude the meaningful interpretation of results. Also very important is the need 

to take into account the possible influences of key confounders, such as mother’s smoking or 

alcohol consumption. If it is assumed that EFA content in mother’s biomarkers may be 

associated with child outcomes, then these and other factors with the ability to negatively 

influence the fatty acid content of biomarkers need to be evaluated. These factors are likewise 

important when trying to make sense of maternal outcome data. 

Future child outcome trials will always be faced with the problem of selection bias inherent 

in appropriately giving women the choice of whether or not to breastfeed, and then excluding 

those who decide to breastfeed from being randomized to study groups varying in terms of the 

constituents defining formula supplementation. As we did in this review, data from children of 

mothers who breastfed can be used as a reference point from which to understand results 

produced by supplementation. That said, it must also be appreciated that the choice not to 

breastfeed could also influence child outcomes in ways that are as yet unclear. 

The relevance of the instruments chosen by the investigators to measure the neurological 

development, cognitive development and visual function are perhaps open to debate. Future 

research might benefit from the work of a panel to establish the most important outcome 

constructs as well as the most reliable and valid instruments. Candidate outcomes and 

instruments should include, yet without being restricted to, those instruments utilized in studies 

included in our review (e.g., Bayley’s Developmental Index, Fagan test of Infant Intelligence, 

EEG). 

Regarding pregnancy outcomes, the issue of the length of the omega-3 fatty acid intervention 

may be an important one. Most of the studies initiated the intervention during the second or third 

trimester of pregnancy. Almost none provided it before, or at the beginning of, the pregnancy. 

One empirical question is whether or not ingesting omega-3 fatty acids for a longer period of 

time might increase their contents in maternal stores, which in turn could have a beneficial 

impact on maternal or child outcomes. 

Most of the interventions given to maternal populations identified in our review were 

relatively simple, in that they did not contain the myriad constituents such as those received in 

formula supplementation studies. However, while the problem of “noise” discussed above with 

respect to child outcome studies typically did not characterize the maternal outcome 

investigations, studies relating to pregnancy outcomes might consider concurrently modifying 

the intake of both omega-3 and omega-6 fatty acid contents for the purposes of evaluating the 

possible beneficial impact of specific omega-6/omega-3 fatty acid intake ratios. 

In preparing such intake ratio interventions, the exact source, type and doses of fatty acids 

will require definition in pilot work. As with interventions given to child populations, the 

efficacy and safety of those provided to maternal populations needs to be balanced. Moreover, 

the possible interactions of fatty acid contents and other types of supplementation routinely taken 

during pregnancy (e.g., vitamins, iron) should likely be fully understood to assure that positive 

clinical outcomes are afforded. 

In the studies of pregnancy outcomes per se, a number of factors need to be controlled either 

experimentally (e.g., stratification) or analytically, which will permit meaningful inferences to be 

drawn from results. These variables include the maternal background diet, smoking, alcohol 
243

consumption, obstetric history, other supplementation, medication, and socioeconomic status. 

Most of the included studies did not control for maternal background diet, for example. 

Future studies hoping to investigate the possible role played by biomarker data—obtained 

from the mother, fetus or child—in understanding the relationship between the intake of specific 

nutrients and clinical-developmental outcomes should likely be undertaken as an integral part of 

RCTs evaluating this relationship. Observational studies lack the types of controls required to 

best minimize bias from known and unknown confounders. The timing of the measurement of 

biomarker data is also very important. If an argument can be made to conduct followup 

assessments of clinical-developmental outcomes at specific time points, or according to specific 

milestones, then it might be reasonable to evaluate the fatty acid content of biomarkers at these 

same times. If there is no concurrence in the measurement of these two classes of outcomes, 

then it may be difficult to detect the most meaningful parallels in the respective patterns of 

results. 

Finally, in order to maximize the applicability of the evidence to the reference standard 

established in our review—the North American population—it would be helpful to conduct more 

research in North America. Furthermore, evidence concerning otherwise healthy populations 

should likely be obtained, before attempts are made to understand the interrelationships among 

intake, biomarkers, and clinical-developmental outcomes in populations with specific disorders 

or problems (e.g., celiac disease; malnutrition). 

Limitations of the Review 

One of the main limitations was that we did not investigate studies assessing the possible 

impact of the intake of omega-3 fatty acids on the fatty acid content of biomarkers. While it 

might be assumed that omega-3 fatty acids, when ingested, eventually find their way into 

pertinent biomarkers, it may be the case that it is actually the failure to become incorporated in 

pertinent biomarkers that prevents (some or all of) the fatty acid contents from positively 

influencing clinical-developmental outcomes. Thus, problems complicating or preventing their 

accretion should likely be understood before interpretations can be accepted that omega-3 fatty 

acids have no effect on clinical-developmental outcomes in various populations. 

Another limitation is the difficulties that we were faced to identify studies that addressed 

some of the questions, specially the association between fetal biomarkers and clinical outcomes 

and the influence of other sources of omega-3 fatty acids on the child’s clinical outcomes. 

Safety data obtained from RCTs are typically under-reported. Thus, the exclusive focus on 

RCT evidence for certain questions in our review may have allowed us to miss key adverse 

effects data contained in reports of studies employing less inherently rigorous types of study 

design. 

The quality assessment of observational studies was conducted using items we modified from 

existing instruments. A design-specific, total quality score was then generated for each study, 

from which a single summary value was derived. (i.e., A, B, C). This simplification permitted 

the entry of these values into summary matrices. However, the design-specific cutpoints used to 

assign these values were established without any validational basis, and so their value is likely 
244

extremely limited. The modified instruments themselves were also never subjected to a 

validational exercise. The applicability indices, while continuing the work we did when we 

systematically reviewed the evidence for the health effects of omega-3 fatty acids on asthma,163

likewise did not receive validational support. 

We recognize that the issue of investigating the possible impact of the background diet’s 

omega-6/omega-3 fatty acid intake ratio within studies evaluating the health effects of omega-3 

fatty acids is a very complex one. There are many ways to produce the same ratio, for example. 

Ratios of 30:2 and 15:1 are equivalent, yet the absolute amounts may also need to be taken into 

consideration when appreciating the possible benefits of omega-3 fatty acid supplementation. 

Moreover, there are multiple definitions of each of these classes of fatty acid (i.e., omega-3 vs 

omega-6 fatty acids), and the types of dynamic metabolic interaction between fatty acids appears 

to depend greatly on which fatty acids are involved. One likely needs to distinguish the absolute 

and relative amounts of the short- versus long-chain fatty acids, for example. EPA and DHA 

(i.e., long-chain omega-3 fatty acids) have markedly different metabolic properties than ALA 

(i.e., short-chain omega-3 fatty acid). The same may be said about LA (i.e., short-chain omega-6 

fatty acid) when compared with AA (i.e., long-chain omega-6 fatty acid). The interaction of 

EPA and AA is different from the interaction of DHA and AA. Moreover, AA and DHA do not 

compete for positions in cell membrane phospholipids: AA may be found in PI, while DHA is 

contained in PS and PE. That said, future research might end up concluding that especially in 

the North American diet—where much more omega-6 fatty acid content is consumed when 

compared with omega-3 fatty acid content—the best way to alter the omega-6/omega-3 fatty acid 

intake ratio is to focus exclusively on increasing the intake of (especially long-chain) omega-3 

fatty acids. 

Finally, time constraints made it impossible to perform additional meta-analysis of other time 

points relating to the neurological and cognitive outcomes. 

Conclusion 

Studies investigating the influence of omega-3 fatty acids on child and maternal health 

revealed the absence of a notable safety profile (i.e., moderate-to-severe AEs). Pregnancy 

outcomes were either unaffected by omega-3 fatty acid supplementation, or the results were 

inconclusive. Results suggested the absence of effects with respect to the impact of 

supplementation on the incidence of GHT, preeclampsia or eclampsia, as well as on infants being 

born small for gestational age. However, regarding evaluations of the duration of gestation, 

some discrepancies were observed, although most of the studies failed to detect a statistically 

significant effect. Biomarker data failed to clarify patterns in pregnancy outcome data. 

Results concerning the impact of the intake of omega-3 fatty acids on the development of 

infants are primarily, although not uniformly, inconclusive. The inconsistencies in study results 

may be attributable to numerous factors. 

In addition, making clear sense of the absolute or relative effects of individual omega-3 fatty 

acids, or even omega-3 fatty acid combinations, on child outcomes is complicated or precluded 

by the following problem. Studies typically employed interventions that involved various 
245

cointerventional or background constituents (e.g., omega-6 fatty acids), yet whose metabolic 

interactions with the omega-3 fatty acid(s) were not taken into account in interpreting the results. 

The dynamic interplay among these fatty acid contents (e.g., competition for enzymes), and how 

this interplay may influence outcomes, may differ in important ways depending on whether DHA 

or olive oil is added to this combination of cointerventional or background constituents, 

particularly in the maternal population. This strategy prevented the isolation of the exact effects 

relating to the omega-3 fatty acid content. It is thus very difficult to reliably ascribe definite 

child outcome-related benefits, or the absence thereof, to specific omega-3 fatty acids. 

Biomarker data failed to clarify patterns in child outcome data. 

Future research should likely consider investigating the impact of specific omega-6/omega-3 

fatty acid intake ratios, in no small part to control for the possible metabolic interactions 

involving these types of fatty acid. To produce results that are applicable to the North American 

population, populations consuming high omega-6/omega-3 fatty acid intake ratios should likely 

be randomized into trials also exhibiting better control of confounding variables than was 

observed, especially in the present collection of studies of child outcomes. 
247

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 273 . Fewtrell MS, Morley R, Abbott RA et al. 

Double-blind, randomized trial of long-chain 

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 274 . Cheruku SR, Montgomery-Downs HE, Farkas SL 

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 275 . Krasevec JM, Jones PJ, Cabrera-Hernandez A et 

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 276 . Williams C, Birch EE, Emmett PM et al. 

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 277 . Carlson SE, Ford AJ, Werkman SH et al. Visual 

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 278 . Birch E, Birch D, Hoffman D et al. Breastfeeding and optimal visual development. J 

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 279 . Leaf A, Gosbell A, McKenzie L et al. Long chain 

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 280 . Makrides M, Simmer K, Goggin M et al. 

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260

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 325 . Jensen CL, Prager TC, Fraley JK et al. Effect of 

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 326 . Innis SM, Akrabawi SS, Diersen-Schade DA et 

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 327 . Auestad N, Montalto MB, Hall RT et al. Visual 

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 330 . Ponder DL, Innis SM, Benson JD et al. 

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 331 . Jorgensen MH, Holmer G, Lund P et al. Effect of 

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 333 . Willatts P, Forsyth JS, DiModugno MK et al. 

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 334 . Hoffman DR, Birch EE, Castaneda YS et al. 

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 335 . Birch EE, Hoffman DR, Castaneda YS et al. A 

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 337 . Agostoni C, Marangoni F, Giovannini M et al. 

Prolonged breast-feeding (six months or more) 

and milk fat content at six months are associated 

with higher developmental scores at one year of 

age within a breast-fed population. Adv Exp Med 

Biol 2001; 501:137-141. 

 338 . Cheruku SR, Montgomery-Downs HE, Farkas SL 

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265

Abbreviations 

AA (20:4 n-6) Arachidonic acid 

ACP Teller Acuity Card Procedure 

AE adverse effects 

AGA Adequate for gestational age 

AHRQ Agency for Healthcare Research Quality 

AI Adequate Intake 

ALA (18:3 n-3) Alpha linolenic acid 

ALSPAC Avon Longitudinal Study of Pregnancy and Childhood

ANCOVA analysis of co-variance 

ANOVA analysis of variance 

AS active sleep 

BAEP Brainstem auditory evoked potentials 

BAEP test brainstem auditory evoked potential 

BMI body mass index 

BP Blood pressure 

BRS Behavioral Rating Scale 

C5a Complement fragment 5a 

CA corrected age 

CAM complementary alernative medicine 

cAMP Cyclic adenosine monophosphate 

CNS central nervous system 

COX Cyclooxygenase 

CSFII Continuing Survey of Food Intakes by Individuals 

DHA (22:6 n-3) Docosahexaenoic acid 

DPA docosapentaenoic acid 

DQ developmental quotient 

DTS Dense tubular system 

EAR Estimated Average Requirement 

EEG Electroencephalogram 

EFA Essential fatty acid 

EPA (20:5 n-3) Eicosapentaenoic acid 

ERG Electroretinogram 

ERG electroretinogram 

FA fatty acids 

FLP Forced Choice Preferential Looking Procedure 

GA Gestational age 

GHT Gestational hypertension 

GLA (18:3 n-6) Gamma linolenic acid 
266

GM DQ gross motor developmental quotient 

GOS Groningen Developmental Scale 

HC Head circumference 

HDL High density lipoprotein 

HM Human milk 

IFN Interferon 

IgE Immunoglobulin E 

IL Interleukin 

ITT intention-to-treat 

IUGR Intra-uterine growth retardation 

K-ABC Kaufman Assessment Battery for Children 

LA (18:2 n-6) Linoleic acid 

LBW low birth weight 

LC PUFA Long-chain polyunsaturated fatty acid 

LDL Low density lipoprotein 

LGA large for gestational age 

LT Leukotriene 

MAR Minimal angle of resolution 

MDI Mental developmental index 

MDI 

Mental Developmental Index (Bayley Scales of Infant 

Development) 

MJ/day daily energy intake 

MLR multiple linear regression 

MLU Mean length of utterance 

MRC Medical Research Council 

NCV Nerve conduction velocity 

NEC Necrotizing enterocolitis 

NEC Necrotizing enterocolitis 

NHANES III National Health and Nutrition Examination (NHANES 

III) 

NICU neonatal intensive care unit 

NIH National Institutes of Health 

NOS Newcastle and Ottawa Scale 

ODS Office of Dietary Supplements 

OPL Operant preferential looking 

PC phosphatidyl choline 

PCA post conceptional age 

PDI Psychomotor developmental index 

PDI psychomotor developmental index 

PE phosphatidyl ethanolamine 

PG Prostaglandin 
267

PGI2 antiaggregatory prostacyclin 

PL Phospholipids 

PPAR Peroxisome proliferator activated receptor 

PPVT-R 

Peabody Picture Vocabulary Test - Receptive 

Vocabulary 

PUFA Polyunsaturated fatty acid 

QS quiet sleep 

QUORUM Quality of the reporting of meta-analysis 

RBC red blood cells 

RCT Randomized Controlled Trial 

RDA Recommended Dietary Allowances 

SCN special care nursery 

SCO single cell oils 

SD standard deviation 

SEMs standard errors of the means 

SGA Small for gestational age 

SIDS sudden infant death syndrome 

Sp species 

SREBP Sterol regulatory element binding protein 

TEP technical expert panel 

Tg Triglycerides 

TGL triglyceride 

TNF Tumor necrosis factor 

TPN Total parenteral nutrition 

Tx Thromboxane 

TXA2 proaggregatory thromboxane 

UK United Kingdom 

USDA United States Department of Agriculture 

VEP Visual evoked potentials 

VLBW Very low birth weight 

VLDL Very low density lipoprotein 

VLN-3FA very long chain n-3 fatty acids 

WAIS-R Wechsler Adult Intelligence Scale - Revised 

WMD weighted mean difference 
A – 1 

Appendix A. Search Strategies 

Search Strategy 1 

Ovid interface for Medline, MEDLINE(R) In-Process & Other Non-Indexed Citations, Embase, 

Cochrane Central Register of Controlled Trials, CDSR, DARE 

1. exp growth/ 

2. exp child development/ 

3. Gestational Age/ 

4. (Gestat$ and (age$ or durat$ or week$)).tw. 

5. Infant, Premature/ 

6. exp Infant, Low Birth Weight/ 

7. (Prematur$ or preterm or pre-term).mp. 

8. ((Infant$ or baby) adj3 (low adj3 (birthweight or weight))).mp. 

9. ((Infant$ or baby or birth) adj3 (prematur$ or gestational age)).mp. 

10. (newborn or neonatal).mp. 

11. Retinopathy of Prematurity/ 

12. retrolental fibroplasia$.mp. 

13. Retinopathy of Prematurity.tw. 

14. or/1-13 

15. Fetal Growth Retardation/ 

16. exp "Embryo and Fetal Development"/ 

17. exp Fetus/ 

18. ((fetal or fetus or intrauterine) adj3 (growth or develop$)).mp. 

19. or/15-18 

20. Pre-Eclampsia/ 

21. Preeclamp$.mp. 

22. (Pregnan$ adj10 Toxemia$).mp. 

23. ((Gestation$ or pregnan$) and (hypertens$ or toxemia$)).mp. 

24. gestat$.mp. 

25. 24 and (child$ or newborn$ or infan$ or neonat$ or baby or babies or pediatr$ or 

paediatr$).tw. 

26. or/20-23,25 

27. exp fatty acids, omega-3/ 

28. fatty acids, essential/ 

29. Dietary Fats, Unsaturated/ 

30. linolenic acids/ 

31. exp fish oils/ 

32. (n 3 fatty acid$ or omega 3).tw. 

33. docosahexa?noic.tw,hw,rw. 

34. eicosapenta?noic.tw,hw,rw. 

35. alpha linolenic.tw,hw,rw. 

36. (linolenate or cervonic or timnodonic).tw,hw,rw. 

37. menhaden oil$.tw,hw,rw. 

38. (mediterranean adj diet$).tw. 
A – 2 

39. ((flax or flaxseed or flax seed or linseed or rape seed or rapeseed or canola or soy or 

soybean or walnut or mustard seed) adj2 oil$).tw. 

40. (walnut$ or butternut$ or soybean$ or pumpkin seed$).tw. 

41. (fish adj2 oil$).tw. 

42. (cod liver oil$ or marine oil$ or marine fat$).tw. 

43. (salmon or mackerel or herring or tuna or halibut or seal or seaweed or anchov$).tw. 

44. (fish consumption or fish intake or (fish adj2 diet$)).tw. 

45. diet$ fatty acid$.tw. 

46. or/27-45 

47. dietary fats/ 

48. (randomized controlled trial or clinical trial or controlled clinical trial or evaluation studies 

or multicenter study).pt. 

49. random$.tw. 

50. exp clinical trials/ or evaluation studies/ 

51. follow-up studies/ or prospective studies/ 

52. or/48-51 

53. 47 and 52 

54. (Ropufa or MaxEPA or Omacor or Efamed or ResQ or Epagis or Almarin or Coromega).tw. 

55. (omega 3 or n 3).mp. 

56. (polyunsaturated fat$ or pufa or dha or epa or long chain or longchain or lc$).mp. 

57. 55 and 56 

58. 46 or 53 or 54 or 57 

59. 14 and 58 

60. limit 59 to all child <0 to 18 years> 

61. 19 and 58 

62. limit 61 to human 

63. 26 and 58 

64. limit 63 to human 

65. or/60,62,64 

Search Strategy 2 

CAB Health on Silverplatter 

#1 growth in SU 

#2 "postnatal-development" in SU 

#3 "cognitive-development" in SU 

#4 child* develop* in ti,ab,id 

#5 psychomotor develop* in ti,ab,id 

#6 (Gestat* and (age* or durat* or week*)) in ti,ab,id 

#7 premature infants in SU 

#8 low birth weight infants in SU 

#9 (Prematur* or preterm or pre-term) in ti,ab,id 

#10 (newborn* or neonatal*) in ti,ab,id 

#11 ((Infant* or baby or babies or birth*) near3 (prematur* or gestational age)) in ti,ab,id 
A – 3 

#12 ((Infant* or baby or babies) near3 (low near3 (birthweight or weight))) in ti,ab,id 

#13 retinopathy in SU 

#14 Retinopathy of Prematurity in ti,ab,id 

#15 retrolental fibroplasia* in ti,ab,id 

#16 #1 or #2 or #3 or #4 or #5 or #6 or #7 or #8 or #9 or #10 or #11 or #12 or #13 or #14 or 

#1535419 

#17 fetal growth in SU 

#18 gestation period in SU 

#19 explode embryonic development in SU 

#20 explode fetus in SU 

#21 ((fetal or fetus or intrauterine) near3 (growth or develop*)) in ti,ab,id 

#22 #17 or #18 or #19 or #20 or #214221 

#23 Preeclampsia in SU 

#24 pregnancy toxaemia in SU 

#25 Preeclamp* in ti,ab,id 

#26 Pre-eclamp* in ti,ab,id 

#27 Toxemia*in ti,ab,id 

#28 ((Gestation* or pregnan*) and hypertens*) in ti,ab,id 

#29 pregnancy-induced hypertens* in ti,ab,id 

#30 (gestat* in ti,ab,id) and ((child* or newborn* or infan* or neonat* or baby or babies or 

pediatr* or paediatr* or human) in ti,ab,id)+A71 

#31 #23 or #24 or #25 or #26 or #27 or #28 or #29 or #304754 

#32 baby* or babies* or newborn* or infan* or neonat* or preschool* or pre-school* or 

child*115761 

#33 (#22 or #31 or (#16 and #32)) and (man in od)16359 

#34 omega 31043 

#35 ("essential-fatty-acids" in SU) or ("linolenic-acid" in SU)1895 

#36 ("docosahexaenoic-acid" in SU) or ("eicosapentaenoic-acid" in SU)1440 

#37 explode "plant-oils" in SU 

#38 explode "fish-oils" in SU 

#39 "fish-consumption" in SU 

#40 "polyenoic-fatty-acids" in SU 

#41 "polyunsaturated-fats" in SU 

#42 "dietary-fat" in SU 

#43 (n 3 fatty acid* or omega 3) in ti,ab,id 

#44 (docosahexanoic or docosahexaenoic) in ti,ab,id 

#45 (eicosapentanoic or eicosapentaenoic) in ti,ab,id 

#46 (alpha linolenic)in ti,ab,id 

#47 (linolenate or cervonic or timnodonic) in ti,ab,id 

#48 (mediterranean diet) in ti,ab,id 

#49 ((flax or flaxseed or flax seed or linseed or rape seed or rapeseed or canola or soy or 

soybean or walnut or mustard seed or menhaden) and oil*) in ti,ab,id 

#50 (walnut* or butternut* or soybean* or pumpkin seed*) in ti,ab,id 

#51 (fish oil* or cod liver oil* or marine oil* or marine fat*) in ti,ab,id 

#52 (salmon or mackerel or herring or tuna or halibut or seal or seaweed or anchov*) in ti,ab,id 

#53 (fish consumption or fish intake) in ti,ab,id 
A – 4 

#54 (diet* fatty acid*) in ti,ab,id 

#55 (ropufa or maxepa or omacor or efamed or resq or epagis or almarin or coromega) in 

ti,ab,id 

#56 ((omega 3 or n 3) and (polyunsaturated fat* or pufa or dha or epa or long chain or 

longchain or lc*)) in ti,ab,id 

#57 "long-chain-fatty-acids" in SU 

#58 (fish and diet) in ti,ab,id 

#59 (explode "essential-oils" in SU) or (explode "olive-oil" in SU) or (explode "palm-oils" in 

SU) or (explode "plant-oils" in SU) or (explode "seed-oils" in SU)7742 

#60 explode "fish-liver-oils" in SU 

#61 ("long-chain-fatty-acids" in SU) or (((omega 3 or n 3) and (polyunsaturated fat* or pufa or 

dha or epa or long chain or longchain or lc*)) in ti,ab,id) or ((ropufa or maxepa or omacor 

or efamed or resq or epagis or almarin or coromega) in ti,ab,id) or ((diet* fatty acid*) in 

ti,ab,id) or ((n 3 fatty acid* or omega 3) in ti,ab,id) or ("dietary-fat" in SU) or 

("polyunsaturated-fats" in SU) or ("polyenoic-fatty-acids" in SU) or ("fish-consumption" in 

SU) or (explode "fish-oils" in SU) or (explode "plant-oils" in SU) or (("docosahexaenoicacid" in SU) or ("eicosapentaenoic-acid" in SU)) or (("essential-fatty-acids" in SU) or 

("linolenic-acid" in SU)) or (omega 3) or ((fish consumption or fish intake) in ti,ab,id) or 

((salmon or mackerel or herring or tuna or halibut or seal or seaweed or anchov*) in 

ti,ab,id) or ((fish oil* or cod liver oil* or marine oil* or marine fat*) in ti,ab,id) or 

((walnut* or butternut* or soybean* or pumpkin seed*) in ti,ab,id) or (((flax or flaxseed or 

flax seed or linseed or rape seed or rapeseed or canola or soy or soybean or walnut or 

mustard seed or menhaden) and oil*) in ti,ab,id) or ((mediterranean diet) in ti,ab,id) or 

((linolenate or cervonic or timnodonic) in ti,ab,id) or ((alpha linolenic)in ti,ab,id) or 

((eicosapentanoic or eicosapentaenoic) in ti,ab,id) or ((docosahexanoic or 

docosahexaenoic) in ti,ab,id) or (explode "fish-liver-oils" in SU) or ((explode "essentialoils" in SU) or (explode "olive-oil" in SU) or (explode "palm-oils" in SU) or (explode 

"plant-oils" in SU) or (explode "seed-oils" in SU)) or ((fish and diet) in ti,ab,id) 

#62 ((explode "almond-oil" in SU) or (explode "castor-oil" in SU) or (explode "coconut-oil" in 

SU) or (explode "cottonseed-oil" in SU) or (explode "groundnut-oil" in SU) or (explode 

"jojoba-oil" in SU) or (explode "linseed-oil" in SU) or (explode "maize-oil" in SU) or 

(explode "melon-seed-oil" in SU) or (explode "mustard-oil" in SU) or (explode "palmkernel-oil" in SU) or (explode "rapeseed-oil" in SU) or (explode "rice-oil" in SU) or 

(explode "safflower-oil" in SU) or (explode "sesame-oil" in SU) or (explode "soyabean-oil" 

in SU) or (explode "sunflower-oil" in SU) or (explode "tung-oil" in SU) or (explode 

"wheat-germ-oil" in SU)) or (("cod-liver-oil" in SU) or ("menhaden-oil" in SU)) 

#63 #61 or #62 

#64 #33 and #63 
B – 1 

Appendix B. Letter to Industry Representatives 

Letter to Industry Representatives from the Three EPCs Investigating 

the Health Benefits of Omega-3 Fatty Acids 

May 2, 2003 

Dear _________, 

I am writing on behalf of the Evidence Based Practice Centers at RAND, New England 

Medical Center and the University of Ottawa. We are conducting a systematic review of 

the efficacy and toxicity of omega-3 fatty acids in the prevention and treatment of a 

number of different diseases/conditions. This review is being conducted under a contract 

from the Agency for Healthcare Research and Quality (AHRQ). 

We are contacting you to see if there is any evidence, including unpublished evidence, 

that you want considered. Our focus is on clinical trials of omega-3 fatty acids in 

humans, so animal and chemical studies are not necessary. 

The specific questions that all the EPCs will address are detailed in the attachment to this 

letter. 

Please contact me with any information that you might have. I will be out of town next 

week and will respond to any questions when I get back. If you have any questions that 

you would like addressed before I return, please contact Donna Mead at the address 

above. 

Best regards, 

Catherine MacLean, M.D., Ph.D. 

RAND1700 Main Street, M 23-C 

Santa Monica, CA 90407-2138 

Voice: 310 393-0411, x6364 

Fax: 310-451-6930 

maclean@rand.org
C – 1 

Appendix C. Data Assessment and Data Abstraction 

Forms 

Relevance Assessment Form 

Please respond to each question.* Use the comments box to identify duplicate reports, a key 

review whose references should be checked, anomalies, etc. 

a. Inclusion criteria: 

1. Does this report describe a study involving human participants? 

 YES Can’t Tell NO 

2. Does this study evaluate the role of: a. omega-3 fatty acid intake (diet and/or 

supplementation) as an intervention/exposure; or b. omega-3 or omega-6/omega-3 fatty 

acid content of biomarkers? 

 YES Can’t Tell NO 

3. Is the purpose of the study to investigate the effect (e.g., efficacy, effectiveness, adverse 

events) of maternal or child intake (via diet, supplementation, or human milk) of omega-3 

fatty acids on, or the association of the omega-3 or omega-6/omega-3 fatty acid content 

of maternal, child or placental biomarkers with: a. visual function, cognitive 

development, neurological development, or growth patterns in (preterm* or term) infants; 

b. the incidence of retinopathy of prematurity in preterm infants; c. the duration of 

gestation in women with or without a history of preterm birth; d. the incidence of 

preeclampsia (gestational hypertension); or e. the incidence of births of infants small for 

gestational age? 

 YES Can’t Tell NO 

b. Exclusion criterion: 

5. If this is a narrative or systematic review, opinion piece or editorial, letter, guideline or 

policy paper, etc., does it exclusively describe studies already reported elsewhere (i.e., it 

does not present any empirical evidence published for the first time)? 

YES Can’t Tell NO 

c. Context: 

6. The study appears to also or instead concern omega-3 fatty acids as an 

intervention/exposure associated with the following human health/disease domains 

(select at least one option; click on all that apply): 

__transplantation __neurology 

__cancer __eye health 

__mental health __none of the above 
C – 2 

7. Is this report written in English? 

YES NO 

8. Comments (write "only biomarkers" if it exclusively investigates "the omega-3 or omega6/omega-3 fatty acid content in biomarkers"): BOX 

Note: *Preterm = gestational duration less than 37 weeks 

Level of Evidence Assessment 

1. Is this a Randomized Controlled Trial (for efficacy questions only) or an observational 

study (i.e., prospective cohort, case-control study, cross-sectional) for Biomarkers 

association questions? 

YES NO 

Data Abstraction Form 

Instructions: Please answer each question. Selecting response options means clicking on them. 

A text box (“BOX”) requires that you provide specific data, and allows you to provide 

clarification, as needed (e.g., when the available data are not straightforward). When data are not 

reported (= NR), the question does not apply (= N/A), you cannot tell what/where the data are in 

the report (= CT), the data are not broken down (= NBD) to permit the required abstraction (e.g., 

by study group), or you have no comment to make (= NC), type the code in the BOX. 

 ‘Participants’ refers to study participants. ‘Group’ refers to a study group, arm or cohort or, in 

a crossover design, a study phase. Often, you will be asked to abstract ‘full’ sample data as well 

as by group. If requested group data are not available, abstract full sample data and label it as 

such. 

 If more than one report describes this study, draw on each to abstract study data. This means 

that, for question 2, record all of the relevant report Refid#s, and for question 3, record all of the 

relevant reports’ data. When you are abstracting data from multiple reports for a given study, 

point out any inconsistencies. 

 If the research report describes more than one unique study, answer in this eForm all the 

questions for the first reported study while immediately notifying the review manager that 

another data abstraction form is required. 

BOX = single box at end of list 

All abstractors access each level, for verification possibilities. 

Each abstractor assigned level(s), and Refids

1. Initials of reviewer: BOX 

2. Reference identification #s (Refid#s) of all report(s) referring to this study, including duplicate 

reports, data-splitting reports, additional follow-ups, re-analyses, etc.: BOX 
C – 3 

3. First author’s last name, year of publication, country(s) in which study conducted (from each 

relevant report), [# study sites] (e.g., Smith, 1988, Canada [1 site]): BOX 

4. Number of unique, review-relevant studies that this report describes (if more than one, notify 

review manager): BOX 

Publication status, per report/Refid# referring to this study (e.g., Refid 3000=journal publication, 

Refid 6=conference abstract): 

 Peer-reviewed journal publication 

Journal publication 

 Conference abstract/poster 

Book 

 Book chapter 

 HTA/technical report 

 Thesis 

 Unpublished document 

Study sponsor’s internal report 

Internet document/material 

Other 

BOX 

Identity of funding source(s), including category per source (e.g., government, industry, 

private/non-industry, hospital), and what each provided: BOX 

 

Question(s) addressed (select all that apply): 

Pregnancy question(s), with clinical outcomes, investigated (select all that apply): 

What is the evidence that intake of omega-3 fatty acids influences the duration of 

gestation in women with or without a history of a previous preterm birth (gestational duration 

less than 37 weeks)? 

What is the evidence that maternal intake of omega-3 fatty acids influences the incidence 

of preeclampsia, eclampsia or gestational hypertension? 

What is the evidence that maternal intake of omega-3 fatty acids influences the incidence 

of births of human infants small for gestational age? 

None of the above 

Pregnancy question(s), with biomarker outcomes, investigated (select all that apply):

What is the evidence that the duration of gestation in women with or without a history of 

a previous preterm birth is associated with the omega-3 or omega-6/omega-3 fatty acid content 

of maternal biomarkers during pregnancy? 
C – 4 

What is the evidence that the incidence of preeclampsia, eclampsia or gestational 

hypertension is associated with the omega-3 or omega-6/omega-3 fatty acid content of maternal 

biomarkers during pregnancy? 

What is the evidence that the incidence of births of human infants small for gestational 

age is associated with the omega-3 or omega-6/omega-3 fatty acid content of maternal 

biomarkers during pregnancy? 

None of the above 

Growth patterns question(s), with clinical outcomes, investigated (select all that apply): 

What is the evidence that maternal intake of omega-3 fatty acids during pregnancy 

influences growth patterns in term or preterm human infants? 

What is the evidence that the omega-3 fatty acid content of maternal breast milk, with or 

without known maternal intake of omega-3 fatty acids, influences growth patterns in term or 

preterm human infants? 

What is the evidence that the omega-3 fatty acid content of infant formula influences 

growth patterns in term or preterm human infants?

What is the evidence that the omega-3 fatty acid content of maternal breast milk, with or 

without known maternal intake of omega-3 fatty acids, and together with the omega-3 fatty acid 

content of infant formula, influences growth patterns in term or preterm human infants?

What is the evidence that intake of omega-3 fatty acids from sources other than maternal 

breast milk or infant formula supplemented with omega-3 fatty acids, by term or preterm human 

infants, influences growth patterns? 

None of the above

Growth patterns question(s), with biomarker outcomes, investigated (select all that apply): 

What is the evidence that term or preterm human infants’ growth patterns are associated 

with the omega-3 or omega-6/omega-3 fatty acid content of maternal biomarkers during 

pregnancy? 

What is the evidence that term or preterm human infants’ growth patterns are associated 

with the omega-3 or omega-6/omega-3 fatty acid content of fetal biomarkers during pregnancy? 

What is the evidence that term or preterm human infants’ growth patterns are associated 

with the omega-3 or omega-6/omega-3 fatty acid content of child biomarkers? 

None of the above

Neurological development question(s), with clinical outcomes, investigated (select all that 

apply): 

What is the evidence that maternal intake of omega-3 fatty acids during pregnancy 

influences neurological development in term or preterm human infants? 
C – 5 

What is the evidence that the omega-3 fatty acid content of maternal breast milk, with or 

without known maternal intake of omega-3 fatty acids, influences neurological development in 

term or preterm human infants? 

What is the evidence that the omega-3 fatty acid content of infant formula influences 

neurological development in term or preterm human infants?

What is the evidence that the omega-3 fatty acid content of maternal breast milk, with or 

without known maternal intake of omega-3 fatty acids, and together with the omega-3 fatty acid 

content of infant formula, influences neurological development in term or preterm human 

infants?

What is the evidence that intake of omega-3 fatty acids from sources other than maternal 

breast milk or infant formula supplemented with omega-3 fatty acids, by term or preterm human 

infants, influences neurological development? 

None of the above

Neurological development question(s), with biomarker outcomes, investigated (select all 

that apply): 

What is the evidence that term or preterm human infants’ neurological development is 

associated with the omega-3 or omega-6/omega-3 fatty acid content of maternal biomarkers 

during pregnancy?

What is the evidence that term or preterm human infants’ neurological development is 

associated with the omega-3 or omega-6/omega-3 fatty acid content of fetal biomarkers? 

What is the evidence that term or preterm human infants’ neurological development is 

associated with the omega-3 or omega-6/omega-3 fatty acid content of child biomarkers?

None of the above

Visual function question(s), with clinical outcomes, investigated (select all that apply): 

What is the evidence that maternal intake of omega-3 fatty acids during pregnancy 

influences visual function in term or preterm human infants? 

What is the evidence that the omega-3 fatty acid content of maternal breast milk, with or 

without known maternal intake of omega-3 fatty acids, influences visual function in term or 

preterm human infants? 

What is the evidence that the omega-3 fatty acid content of infant formula influences 

visual function in term or preterm human infants?

What is the evidence that the omega-3 fatty acid content of maternal breast milk, with or 

without known maternal intake of omega-3 fatty acids, and together with the omega-3 fatty acid 

content of infant formula, influences visual function in term or preterm human infants?

What is the evidence that intake of omega-3 fatty acids from sources other than maternal 

breast milk or infant formula supplemented with omega-3 fatty acids, by term or preterm human 

infants, influences visual function? 

None of the above
C – 6 

Visual function question(s), with biomarker outcomes, investigated (select all that apply): 

What is the evidence that term or preterm human infants’ visual function is associated 

with the omega-3 or omega-6/omega-3 fatty acid content of maternal biomarkers during 

pregnancy?

What is the evidence that term or preterm human infants’ visual function is associated 

with the omega-3 or omega-6/omega-3 fatty acid content of fetal biomarkers? 

What is the evidence that term or preterm human infants’ visual function is associated 

with the omega-3 or omega-6/omega-3 fatty acid content of child biomarkers? 

None of the above

Cognitive development question(s), with clinical outcomes, investigated (select all that 

apply): 

What is the evidence that maternal intake of omega-3 fatty acids during pregnancy 

influences cognitive development in term or preterm human infants? 

What is the evidence that the omega-3 fatty acid content of maternal breast milk, with or 

without known maternal intake of omega-3 fatty acids, influences cognitive development in term 

or preterm human infants? 

What is the evidence that the omega-3 fatty acid content of infant formula influences 

cognitive development in term or preterm human infants?

What is the evidence that the omega-3 fatty acid content of maternal breast milk, with or 

without known maternal intake of omega-3 fatty acids, and together with the omega-3 fatty acid 

content of infant formula, influences cognitive development in term or preterm human infants?

What is the evidence that intake of omega-3 fatty acids from sources other than maternal 

breast milk or infant formula supplemented with omega-3 fatty acids, by term or preterm human 

infants, influences cognitive development? 

None of the above

Cognitive development question(s), with biomarker outcomes, investigated (select all that 

apply): 

What is the evidence that term or preterm human infants’ cognitive development is 

associated with the omega-3 or omega-6/omega-3 fatty acid content of maternal biomarkers 

during pregnancy? 

What is the evidence that term or preterm human infants’ cognitive development is 

associated with the omega-3 or omega-6/omega-3 fatty acid content of fetal biomarkers? 

What is the evidence that term or preterm human infants’ cognitive development is 

associated with the omega-3 or omega-6/omega-3 fatty acid content of child biomarkers?

None of the above
C – 7 

Adverse events question(s) investigated (select all that apply): 

What is the evidence for the risk, in pregnant women, of short and long-term adverse 

events related to their intake of omega-3 fatty acids? 

What is the evidence for the risk, in breastfeeding women, of short and long-term adverse 

events related to their intake of omega-3 fatty acids? 

What is the evidence for the risk, in term or preterm human infants, of short and longterm adverse events related to maternal intake of omega-3 fatty acids during pregnancy? 

What is the evidence for the risk, in term or preterm human infants, of short and longterm adverse events related to their intake of omega-3 fatty acids after birth (e.g., maternal breast 

milk, infant formula supplemented with omega-3 fatty acids)? 

What is the evidence that these adverse events, or any contraindications, are associated 

with the intake of specific sources (e.g., marine, plant), types (e.g., EPA, DHA, ALA) or doses of 

omega-3 fatty acids, including in specific populations such as diabetics? 

None of the above

Study design (select one): 

a. RCT parallel design

b. RCT crossover design 

c. RCT factorial design 

d. Controlled clinical trial (non-RCT) 

e. Multiple prospective cohorts 

f. At least one prospective cohort and one retrospective cohort 

g. Case-control 

h. Cross-sectional 

i. Before-after (pre-post) 

j. Single prospective cohort 

k. Single retrospective cohort 

l. Case series (noncomparative) 

m. Case study 

n. Sequential 

o. Cross-national ecological analysis 

p. Other: BOX 

Any notable details (e.g., restricted randomization; blocking size) or problems (i.e., no or 

inappropriate run-in or washout procedures or durations; study stopped prematurely): BOX 

Full sample eligibility criteria (e.g., population [e.g., pregnant women and/or children; permitted 

vs mandated/required characteristics/experiences/histories, including health status, 

complications, medications, etc.) (complete both): 

Inclusion criteria: BOX

Exclusion criteria: BOX

Were the same eligibility criteria employed with reference to each study group? (select one) 

a. Yes 
C – 8 

b. No 

c. Unclear 

d. Not reported 

e. Not applicable (e.g., a single group study) 

Adequacy of reporting of eligibility criteria (select one): 

a. Likely adequate (= not inadequate) 

b. Likely inadequate (= missing, incomplete or conflicting data) 

Adequacy of eligibility criteria: 

a. Likely adequate (= not inadequate) 

b. Likely inadequate (e.g., the inclusion criteria will not lead to the study of the target 

population the investigators intend to study; populations with 

characteristics/experiences/histories outside the investigators’ intended scope, yet 

who show the same characteristics/experiences/histories as the target population, have 

not been identified as requiring exclusion) 

Sample sizes (by population, if appropriate) (complete all): 

Total # individuals screened: BOX

# selected/allocated participants (full [e.g., n=12]; by group [e.g., group 1 n=5; group 2 

n=7]): BOX

# completers (= final followup)/total (full; per group) (e.g., group 1: n=4/5; group 2: 

n=6/7): BOX 

Settings (complete both):

Type(s) of setting (e.g., tertiary care hospital vs. community facility) (full; by group): 

BOX

Proportion of participants in relatively controlled (e.g., inpatients) settings during study 

(full; by group): BOX 

Study period (complete all): 

Intervention length (d, wk, mo, y) (by group only if it varies): BOX 

Timing of intervention (e.g., beginning the 3rd day of life, for 4 mo; beginning the 5th wk 

of pregnancy, until delivery): BOX

Study duration, including units (h, d, wk, mo) (includes intervention length + run-in 

period duration, washout duration[s], etc.): BOX 

Run-in duration/protocol: BOX 

Washout duration/protocol: BOX 

Did participants in each study group receive the intervention/exposure for the same length of 

time? (select one) 

a. Yes 

b. No 

c. Unclear 

d. Not reported 

e. Not applicable (e.g., a cross-sectional survey) 
C – 9 

Was the same study procedure employed with reference to each study group? (select one) 

a. Yes 

b. No 

c. Unclear 

d. Not reported 

e. Not applicable

Were participants in each study group assessed at the same number of followups, and with the 

same timing, during the study (select one)? 

a. Yes 

b. No 

c. Unclear 

d. Not reported 

e. Not applicable (e.g., a cross-sectional survey) 

Number and timing of followups (i.e., specify corrected age [mos] and/or actual mos of age), and 

any definition of the ‘length of followup required to observe an/no impact of the 

exposure/intervention:’ BOX

Adverse events, and losses to followup (complete both): 

# withdrawals vs. # dropouts, with reasons (full; by group): BOX 

Adverse events/side effects and contraindications (full; by group): BOX 

Basic population characteristics (maternal and/or children) (complete all):

Mean age (mean (range) y) of all relevant participants at study onset (full; by group, by 

population): BOX 

Percentage of male children (full; by group): BOX 

Maternal racial composition (proportions: full; by group) (e.g., Caucasian 50%, Asian 

50% per group) BOX 

Children’s racial composition (proportions: full; by group) (e.g., Caucasian 50%, Asian 

50% per group) BOX 

Maternal socioeconomic status (i.e., employment status, income, marital status, 

education) (full; by group): BOX 

Maternal health history prior to current pregnancy (complete all) (if this study does not 

specifically investigate a maternal population, click here): 

Gynecologic history (e.g., STD, uterine anomalies, cervical incompetence) (full, by 

group): BOX 

Obstetric history (i.e., n gestations, deliveries, abortions, live births, premature births, 

multiple gestations; complications, pre/eclampsia, gestational hypertension or gestational 

diabetes in previous pregnancies) (full, by group): BOX 

Medical conditions (full, by group): BOX 

Medications/treatments (full, by group): BOX 

Breastfeeding history, including difficulties (full; by group): BOX 
C – 10 

Alcohol (ab)use, especially during previous pregnancies/breastfeeding (full, by group): 

BOX 

Smoking tobacco use or exposure, especially during previous pregnancies/breastfeeding 

(full, by group): BOX 

Illicit drug use, especially during previous pregnancies/breastfeeding (full, by group): 

BOX 

Other (e.g., domestic violence) (full, by group): BOX 

Maternal health status of current pregnancy/breastfeeding (complete all): 

 Age at conception AND at delivery (specify) (full, by group): BOX 

 Obstetric history of current pregnancy (full, by group): BOX 

 Medical conditions, including psychiatric conditions (full, by group): BOX

 All medication/treatments (e.g., prescription and non-prescription) (dose/frequency) (full, 

by group): BOX 

 Supplement use (vitamins, minerals) and/or CAM therapies prior to study onset: BOX 

 Alcohol (ab)use (full, by group): BOX 

 Smoking tobacco use or exposure (full, by group): BOX 

 Illicit drug use (full, by group): BOX 

 Other (e.g., domestic violence) (full, by group): BOX 

Child’s pre-study health history (complete all) (if this study does not specifically investigate a 

child population, click here):

Prenatal history (i.e., GA, complications during pregnancy, delivery and/or labor 

anomalies, etc) (full, by group): BOX 

Neonatal history (e.g., asphyxia, intracranial hemorrhage, kernicterus, TORCH, 

hydrocephalus, congenital cataracts, coriorretinitis) (full, by group): BOX 

 Pediatric history (i.e., medical conditions, immunizations, etc.) (full, by group): BOX 

 Weight (W), height (H) and head circumference (HC) at birth, with percentiles (Pc) (full; 

by group): BOX 

 Medications/treatments (with dose/frequency) (full, by group): BOX 

 Other (e.g., exposure to toxic material) (full, by group): BOX 

Child’s health status at study baseline (complete all): 

 Current weight (Pc) (full, by group): BOX

 Current height (Pc) (full, by group): BOX

 Current head circumference (Pc) (full, by group): BOX 

 Growth patterns (percentile pattern, to study baseline) (full, by group): BOX

 Visual function (full, by group): BOX 

 Cognitive developmental status (e.g., language) (full, by group): BOX 

 Neurodevelopmental status (full, by group): BOX 

 Medical conditions (full, by group): BOX 

 Medications/treatments (e.g., prescription and non-prescription drugs), with dose/frequency 

(full, by group): BOX 

 Supplement use (vitamins, minerals) and/or CAM therapies prior to study onset: BOX

 Other (full, by group): BOX 
C – 11 

Describe the method(s)/test(s) used to assess the child’s visual development (full, by group; at 

each evaluation) (e.g., visual acuity, electroretinogram, etc): BOX 

Describe the method(s)/test(s) used to assess the child’s cognitive developmental status (full, by 

group; at each evaluation) [e.g., Bayley’s mental developmental index (<2 years of age), 

Weschler (WPPSI, > 2 years of age), and WISC (> 7 years of age)]: BOX

Describe the method(s)/test(s) used to assess the child’s neurological development status (full, by 

group; at each evaluation) [e.g., Bayley's motor developmental index (< 2 years of age), 

Peabody (>2 years of age)]: BOX

Maternal n-3 intake (pre-study/baseline) (complete all): 

Pre-study/baseline total maternal (daily, weekly or monthly) n-3 intake via diet and/or 

supplementation, with amount per n-3 type (EPA, DHA, ALA), and source (e.g., fish servings; 

walnuts; flaxseed oil) (by group) (e.g., group 1: 1.8g/d EPA, 1.2g/d DHA, from 3 fish oil 

capsules/d; and, NR [likely EPA &/or DHA], from 1-2 fish servings/wk; group 2: 0g/d EPA, 

0g/d DHA, water placebo; and, NR, 0 fish servings/wk): BOX 

Pre-study/baseline total (daily, weekly or monthly) maternal dietary n-6/n-3 intake (by group) 

(e.g., group 1: 15/1; group 2: 10/1): BOX 

Pre-study/baseline % (daily, weekly or monthly) maternal caloric/energy intake from fat (by 

group): BOX 

Absolute and relative n-3 fatty acid content of the pre-study/baseline maternal diet (full; by 

group): BOX 

Types of pre-study/baseline maternal diet (proportion of participants on each diet: in full; by 

group): 

High fish diet 

Fish-vegetarian diet 

Low fish diet 

Low fat diet 

High fat diet 

Mediterranean diet 

Other 

Unclear 

Not reported 

BOX

How was the pre-study maternal dietary intake of n-3, n-6 and n-6/n-3 evaluated/estimated 

(select all that apply)? 

Nutritionist-administered quantitative food-frequency survey(s) 

Nutritionist-administered semi-quantitative food-frequency survey(s) 

Self-administered quantitative food-frequency survey(s) 

Self-administered semi-quantitative food-frequency survey(s) 
C – 12 

Parent-administered quantitative food-frequency survey(s) 

Parent-administered semi-quantitative food-frequency survey(s) 

Direct measurement(s) of food intake 

Survey(s) (e.g., 24-hour recall): BOX

Survey(s), yet no details provided 

Other: BOX 

Unclear 

Not reported 

Not applicable 

Maternal total amount of dietary n-3 intake (complete all): 

 Significant (e.g., p-value; stated result of statistical test) pre-study/baseline betweengroup difference(s) (specify direction of difference(s): e.g., n-3 > pb): BOX 

Significant (e.g., p-value; stated result of statistical test) between-group difference(s) in 

within-group changes from baseline, to each followup (specify nature of change(s), by followup: 

e.g., final followup = n-3 > pb): BOX 

Specify whether any significant between-group differences at pre-study/baseline or 

regarding within-group changes from baseline, to each followup, were taken into consideration 

in the study analysis: BOX

Total amount of maternal n-3 intake from supplementation (complete all): 

 Significant (e.g., p-value; stated result of statistical test) pre-study/baseline betweengroup difference(s) (specify direction of difference(s): e.g., n-3 > pb): BOX 

Significant (e.g., p-value; stated result of statistical test) between-group difference(s) in 

within-group changes from baseline, to each followup (specify nature of change(s), by followup: 

e.g., final followup = n-3 > pb): BOX 

Specify whether any significant between-group differences at pre-study/baseline or 

regarding within-group changes from baseline, to each followup, were taken into consideration 

in the study analysis: BOX 

Total amount of maternal n-3 intake from diet and supplementation (complete all): 

 Significant (e.g., p-value; stated result of statistical test) pre-study/baseline betweengroup difference(s) (specify direction of difference(s): e.g., n-3 > pb): BOX 

Significant (e.g., p-value; stated result of statistical test) between-group difference(s) in 

within-group changes from baseline, to each followup (specify nature of change(s), by followup: 

e.g., final followup = n-3 > pb): BOX 

Specify whether any significant between-group differences at pre-study/baseline or 

regarding within-group changes from baseline, to each followup, were taken into consideration 

in the study analysis: BOX 

Maternal dietary n-6/n-3 intake (complete all): 

 Significant (e.g., p-value; stated result of statistical test) pre-study/baseline betweengroup difference(s) (specify direction of difference(s): e.g., n-3 > pb): BOX 

Significant (e.g., p-value; stated result of statistical test) between-group difference(s) in 

within-group changes from baseline, to each followup (specify nature of change(s), by followup: 

e.g., final followup = n-3 > pb): BOX 
C – 13 

Specify whether any significant between-group differences at pre-study/baseline or 

regarding within-group changes from baseline, to each followup, were taken into consideration 

in the study analysis: BOX 

% Maternal caloric/energy intake (complete all): 

 Significant (e.g., p-value; stated result of statistical test) pre-study/baseline betweengroup difference(s) (specify direction of difference(s): e.g., n-3 > pb): BOX 

Significant (e.g., p-value; stated result of statistical test) between-group difference(s) in 

within-group changes from baseline, to each followup (specify nature of change(s), by followup: 

e.g., final followup = n-3 > pb): BOX 

Specify whether any significant between-group differences at pre-study/baseline or 

regarding within-group changes from baseline, to each followup, were taken into consideration 

in the study analysis: BOX 

Child’s n-3 intake (pre-study/baseline) (complete all): 

Pre-study/baseline child’s total (daily, weekly or monthly) n-3 intake via breast milk, diet 

(source) and/or formula/supplementation, with amount per n-3 type (EPA, DHA, ALA) (by 

group): BOX 

Pre-study/baseline child’s total (daily, weekly or monthly) dietary n-6/n-3 intake (by group) 

(e.g., group 1: 15/1; group 2: 10/1): BOX 

Pre-study/baseline % (daily, weekly or monthly) child’s caloric/energy intake from fat (by 

group): BOX 

Child’s types of pre-study/baseline diet (proportion of participants on each diet: in full; by 

group): 

High fish diet 

Fish-vegetarian diet 

Low fish diet 

Low fat diet 

High fat diet 

Mediterranean diet 

Other 

Unclear 

Not reported 

BOX

Absolute and relative n-3 fatty acid content of the pre-study/baseline child’s diet (full; by group): 

BOX

How was the pre-study child’s dietary intake of n-3, n-6 and n-6/n-3 evaluated/estimated (select 

all that apply)? 

Nutritionist-administered quantitative food-frequency survey(s) 

Nutritionist-administered semi-quantitative food-frequency survey(s) 
C – 14 

Self-administered quantitative food-frequency survey(s) 

Self-administered semi-quantitative food-frequency survey(s) 

Parent-administered quantitative food-frequency survey(s) 

Parent-administered semi-quantitative food-frequency survey(s) 

Direct measurement(s) of food intake 

Survey(s) (e.g., 24-hour recall): BOX

Survey(s), yet no details provided 

Other: BOX 

Unclear 

Not reported 

Not applicable

BOX 

Total amount of child’s n-3 intake via breast milk (complete all): 

 Significant (e.g., p-value; stated result of statistical test) pre-study/baseline betweengroup difference(s) (specify direction of difference(s): e.g., n-3 > pb): BOX 

Specify whether any significant between-group differences at pre-study/baseline or 

regarding within-group changes from baseline, to each followup, were taken into consideration 

in the study analysis: BOX 

Child’s total amount of dietary n-3 intake (complete all): 

 Significant (e.g., p-value; stated result of statistical test) pre-study/baseline betweengroup difference(s) (specify direction of difference(s): e.g., n-3 > pb): BOX 

Specify whether any significant between-group differences at pre-study/baseline or 

regarding within-group changes from baseline, to each followup, were taken into consideration 

in the study analysis: BOX 

Child’s total amount of n-3 intake from supplementation/formula (complete all): 

 Significant (e.g., p-value; stated result of statistical test) pre-study/baseline betweengroup difference(s) (specify direction of difference(s): e.g., n-3 > pb): BOX 

Specify whether any significant between-group differences at pre-study/baseline or 

regarding within-group changes from baseline, to each followup, were taken into consideration 

in the study analysis: BOX 

Total amount of child’s n-3 intake from breast milk, diet and supplementation/formula (complete 

all): 

 Significant (e.g., p-value; stated result of statistical test) pre-study/baseline betweengroup difference(s) (specify direction of difference(s): e.g., n-3 > pb): BOX 

Specify whether any significant between-group differences at pre-study/baseline or 

regarding within-group changes from baseline, to each followup, were taken into consideration 

in the study analysis: BOX 

Child’s total dietary n-6/n-3 intake (complete all): 

 Significant (e.g., p-value; stated result of statistical test) pre-study/baseline betweengroup difference(s) (specify direction of difference(s): e.g., n-3 > pb): BOX 
C – 15 

Specify whether any significant between-group differences at pre-study/baseline or 

regarding within-group changes from baseline, to each followup, were taken into consideration 

in the study analysis: BOX 

Child’s (daily, weekly or monthly) % caloric/energy intake from fat (complete all): 

 Significant (e.g., p-value; stated result of statistical test) pre-study/baseline betweengroup difference(s) (specify direction of difference(s): e.g., n-3 > pb): BOX 

Specify whether any significant between-group differences at pre-study/baseline or 

regarding within-group changes from baseline, to each followup, were taken into consideration 

in the study analysis: BOX 

Pre-study/baseline maternal biomarkers data (by biomarker: e.g., breast milk, placental blood, 

RBCs; for DHA, EPA, AA, AA/EPA, AA/DHA, AA/EPA+DHA levels, with units (e.g., % total 

fatty acids; absolute amount) (full; by group): BOX 

Maternal DHA status (per biomarker) (complete all): 

 Significant (e.g., p-value; stated result of statistical test) pre-study/baseline betweengroup difference(s) (specify direction of difference(s): e.g., n-3 > pb): BOX 

Significant (e.g., p-value; stated result of statistical test) between-group difference(s) in 

within-group changes from baseline, to each followup (specify nature of change(s), by followup: 

e.g., final followup = n-3 > pb): BOX 

Specify whether any significant between-group differences at pre-study/baseline or 

regarding within-group changes from baseline, to each followup, were taken into consideration 

in the study analysis: BOX 

Maternal EPA status (per biomarker) (complete all): 

 Significant (e.g., p-value; stated result of statistical test) pre-study/baseline betweengroup difference(s) (specify direction of difference(s): e.g., n-3 > pb): BOX 

Significant (e.g., p-value; stated result of statistical test) between-group difference(s) in 

within-group changes from baseline, to each followup (specify nature of change(s), by followup: 

e.g., final followup = n-3 > pb): BOX 

Specify whether any significant between-group differences at pre-study/baseline or 

regarding within-group changes from baseline, to each followup, were taken into consideration 

in the study analysis: BOX 

Maternal EPA+DHA status (per biomarker) (complete all): 

 Significant (e.g., p-value; stated result of statistical test) pre-study/baseline betweengroup difference(s) (specify direction of difference(s): e.g., n-3 > pb): BOX 

Significant (e.g., p-value; stated result of statistical test) between-group difference(s) in 

within-group changes from baseline, to each followup (specify nature of change(s), by followup: 

e.g., final followup = n-3 > pb): BOX 

Specify whether any significant between-group differences at pre-study/baseline or 

regarding within-group changes from baseline, to each followup, were taken into consideration 

in the study analysis: BOX 

Maternal AA status (per biomarker) (complete all): 
C – 16 

 Significant (e.g., p-value; stated result of statistical test) pre-study/baseline betweengroup difference(s) (specify direction of difference(s): e.g., n-3 > pb): BOX 

Significant (e.g., p-value; stated result of statistical test) between-group difference(s) in 

within-group changes from baseline, to each followup (specify nature of change(s), by followup: 

e.g., final followup = n-3 > pb): BOX 

Specify whether any significant between-group differences at pre-study/baseline or 

regarding within-group changes from baseline, to each followup, were taken into consideration 

in the study analysis: BOX 

Maternal AA/DHA status (per biomarker) (complete all): 

 Significant (e.g., p-value; stated result of statistical test) pre-study/baseline betweengroup difference(s) (specify direction of difference(s): e.g., n-3 > pb): BOX 

Significant (e.g., p-value; stated result of statistical test) between-group difference(s) in 

within-group changes from baseline, to each followup (specify nature of change(s), by followup: 

e.g., final followup = n-3 > pb): BOX 

Specify whether any significant between-group differences at pre-study/baseline or 

regarding within-group changes from baseline, to each followup, were taken into consideration 

in the study analysis: BOX 

Maternal AA/EPA status (per biomarker) (complete all): 

 Significant (e.g., p-value; stated result of statistical test) pre-study/baseline betweengroup difference(s) (specify direction of difference(s): e.g., n-3 > pb): BOX 

Significant (e.g., p-value; stated result of statistical test) between-group difference(s) in 

within-group changes from baseline, to each followup (specify nature of change(s), by followup: 

e.g., final followup = n-3 > pb): BOX 

Specify whether any significant between-group differences at pre-study/baseline or 

regarding within-group changes from baseline, to each followup, were taken into consideration 

in the study analysis: BOX 

Maternal AA/EPA+DHA status (per biomarker) (complete all): 

 Significant (e.g., p-value; stated result of statistical test) pre-study/baseline betweengroup difference(s) (specify direction of difference(s): e.g., n-3 > pb): BOX 

Significant (e.g., p-value; stated result of statistical test) between-group difference(s) in 

within-group changes from baseline, to each followup (specify nature of change(s), by followup: 

e.g., final followup = n-3 > pb): BOX 

Specify whether any significant between-group differences at pre-study/baseline or 

regarding within-group changes from baseline, to each followup, were taken into consideration 

in the study analysis: BOX 

Pre-study/baseline child’s biomarkers data (by biomarker: e.g., cord blood, RBCs; for DHA, 

EPA, AA, AA/EPA, AA/DHA, AA/EPA+DHA levels, with units (e.g., % total fatty acids; 

absolute amount) (full; by group): BOX 

Child’s DHA status (per biomarker) (complete all): 
C – 17 

 Significant (e.g., p-value; stated result of statistical test) pre-study/baseline betweengroup difference(s) (specify direction of difference(s): e.g., n-3 > pb): BOX 

Significant (e.g., p-value; stated result of statistical test) between-group difference(s) in 

within-group changes from baseline, to each followup (specify nature of change(s), by followup: 

e.g., final followup = n-3 > pb): BOX 

Specify whether any significant between-group differences at pre-study/baseline or 

regarding within-group changes from baseline, to each followup, were taken into consideration 

in the study analysis: BOX 

Child’s EPA status (per biomarker) (complete all): 

 Significant (e.g., p-value; stated result of statistical test) pre-study/baseline betweengroup difference(s) (specify direction of difference(s): e.g., n-3 > pb): BOX 

Significant (e.g., p-value; stated result of statistical test) between-group difference(s) in 

within-group changes from baseline, to each followup (specify nature of change(s), by followup: 

e.g., final followup = n-3 > pb): BOX 

Specify whether any significant between-group differences at pre-study/baseline or 

regarding within-group changes from baseline, to each followup, were taken into consideration 

in the study analysis: BOX 

Child’s EPA+DHA status (per biomarker) (complete all): 

 Significant (e.g., p-value; stated result of statistical test) pre-study/baseline betweengroup difference(s) (specify direction of difference(s): e.g., n-3 > pb): BOX 

Significant (e.g., p-value; stated result of statistical test) between-group difference(s) in 

within-group changes from baseline, to each followup (specify nature of change(s), by followup: 

e.g., final followup = n-3 > pb): BOX 

Specify whether any significant between-group differences at pre-study/baseline or 

regarding within-group changes from baseline, to each followup, were taken into consideration 

in the study analysis: BOX 

Child’s AA status (per biomarker) (complete all): 

 Significant (e.g., p-value; stated result of statistical test) pre-study/baseline betweengroup difference(s) (specify direction of difference(s): e.g., n-3 > pb): BOX 

Significant (e.g., p-value; stated result of statistical test) between-group difference(s) in 

within-group changes from baseline, to each followup (specify nature of change(s), by followup: 

e.g., final followup = n-3 > pb): BOX 

Specify whether any significant between-group differences at pre-study/baseline or 

regarding within-group changes from baseline, to each followup, were taken into consideration 

in the study analysis: BOX

Child’s AA/DHA status (per biomarker) (complete all): 

 Significant (e.g., p-value; stated result of statistical test) pre-study/baseline betweengroup difference(s) (specify direction of difference(s): e.g., n-3 > pb): BOX 

Significant (e.g., p-value; stated result of statistical test) between-group difference(s) in 

within-group changes from baseline, to each followup (specify nature of change(s), by followup: 

e.g., final followup = n-3 > pb): BOX 
C – 18 

Specify whether any significant between-group differences at pre-study/baseline or 

regarding within-group changes from baseline, to each followup, were taken into consideration 

in the study analysis: BOX 

Child’s AA/EPA status (per biomarker) (complete all): 

 Significant (e.g., p-value; stated result of statistical test) pre-study/baseline betweengroup difference(s) (specify direction of difference(s): e.g., n-3 > pb): BOX 

Significant (e.g., p-value; stated result of statistical test) between-group difference(s) in 

within-group changes from baseline, to each followup (specify nature of change(s), by followup: 

e.g., final followup = n-3 > pb): BOX 

Specify whether any significant between-group differences at pre-study/baseline or 

regarding within-group changes from baseline, to each followup, were taken into consideration 

in the study analysis: BOX

Child’s AA/EPA+DHA status (per biomarker) (complete all): 

 Significant (e.g., p-value; stated result of statistical test) pre-study/baseline betweengroup difference(s) (specify direction of difference(s): e.g., n-3 > pb): BOX 

Significant (e.g., p-value; stated result of statistical test) between-group difference(s) in 

within-group changes from baseline, to each followup (specify nature of change(s), by followup: 

e.g., final followup = n-3 > pb): BOX 

Specify whether any significant between-group differences at pre-study/baseline or 

regarding within-group changes from baseline, to each followup, were taken into consideration 

in the study analysis: BOX 

ON-STUDY 

How was maternal on-study dietary intake of n-3 or n-6/n-3 evaluated/estimated (select all that 

apply)? 

Nutritionist-administered quantitative food-frequency survey(s) 

Nutritionist-administered semi-quantitative food-frequency survey(s) 

Self-administered quantitative food-frequency survey(s) 

Self-administered semi-quantitative food-frequency survey(s) 

Parent-administered quantitative food-frequency survey(s) 

Parent-administered semi-quantitative food-frequency survey(s) 

Direct measurement(s) of food intake 

Survey(s) (e.g., 24-hour recall): BOX

Survey(s), yet no details provided 

Other: BOX 

Unclear 

Not reported 

Not applicable 

How was child’s on-study dietary intake of n-3 or n-6/n-3 evaluated/estimated (select all that 

apply)? 

Nutritionist-administered quantitative food-frequency survey(s) 

Nutritionist-administered semi-quantitative food-frequency survey(s) 
C – 19 

Self-administered quantitative food-frequency survey(s) 

Self-administered semi-quantitative food-frequency survey(s) 

Parent-administered quantitative food-frequency survey(s) 

Parent-administered semi-quantitative food-frequency survey(s) 

Direct measurement(s) of food intake 

Survey(s) (e.g., 24-hour recall): BOX

Survey(s), yet no details provided 

Other: BOX 

Unclear 

Not reported 

Not applicable 

On-study GROUP 1 (highest dose n-3 [or lowest n-6/n-3 ratio if both n-3 and n-6 are modified] 

study first, active comparator next (e.g., n-6), placebo control last) (complete all): 

total (daily, weekly or monthly) maternal n-3 dose via supplementation during 

pregnancy and/or breastfeeding, with amount per n-3 type; source, frequency and timing of 

delivery; other active ingredients (e.g., pregnancy = 1.8g/d EPA, 1.2g/d DHA, from 3 [1g vegan 

outer] fish oil capsules/d, with breakfast, NR): BOX 

total (daily, weekly or monthly) maternal n-3 exposure via diet during pregnancy and/or 

breastfeeding, with amount per n-3 type, source, frequency and timing of delivery (e.g., 

breastfeeding = NR, likely EPA or DHA, from 2 0.5oz oily fish servings/wk, as dinner; e.g., 

pregnancy = NR, likely ALA, from 8-10oz/wk flaxseed oil as salad dressing, NR): BOX 

total (daily, weekly or monthly) maternal n-3 exposure via all sources 

(diet+supplementation) during pregnancy and/or breastfeeding, per n-3 type (e.g., pregnancy = 

NR, at least 3g/d EPA+DHA): BOX 

total (daily, weekly or monthly) maternal n-6 and/or n-6/n-3 intake from 

diet+supplementation during pregnancy and/or breastfeeding: BOX

type, source and total (daily, weekly or monthly) maternal intake of other mandated or 

permitted exposures during pregnancy and/or breastfeeding (e.g., vitamins, minerals), with 

dose/serving/frequency: BOX 

n allocated-selected/ n completed (maternal) (e.g., n=24/21): BOX 

total (daily, weekly or monthly) child’s n-3 intake amount via breast milk, with amount 

per n-3 type; source, frequency and timing of delivery: BOX 

total (daily, weekly or monthly) child’s n-3 dose via supplementation/formula, with 

amount per n-3 type; source, frequency and timing of delivery; other active ingredients: BOX 

total (daily, weekly or monthly) child’s n-3 exposure via diet, with amount per n-3 type, 

source, frequency and timing of delivery (e.g., NR, likely EPA or DHA, from 2 0.5oz oily fish 
C – 20 

servings/wk, as dinner; e.g., NR, likely ALA, from 8-10oz/wk flaxseed oil as salad dressing, 

NR): BOX 

total (daily, weekly or monthly) child’s n-3 exposure via all sources 

(diet+supplementation), per n-3 type (e.g., NR, at least 3g/d EPA+DHA): BOX 

total (daily, weekly or monthly) child’s n-6 and/or n-6/n-3 intake from 

diet+supplementation: BOX

type, source and total (daily, weekly or monthly) child’s intake of other mandated or 

permitted exposures (e.g., vitamins, minerals), with dose/serving/frequency: BOX 

n allocated-selected/ n completed (child) (e.g., n=24/21): BOX 

On-study GROUP 2 (next highest dose n-3 [or lowest n-6/n-3 ratio if both n-3 and n-6 are 

modified] study first, active comparator next (e.g., n-6), placebo control last) (complete all; click 

here if there are no more study groups): 

total (daily, weekly or monthly) maternal n-3 dose via supplementation during 

pregnancy and/or breastfeeding, with amount per n-3 type; source, frequency and timing of 

delivery; other active ingredients (e.g., pregnancy = 1.8g/d EPA, 1.2g/d DHA, from 3 [1g vegan 

outer] fish oil capsules/d, with breakfast, NR): BOX 

total (daily, weekly or monthly) maternal n-3 exposure via diet during pregnancy and/or 

breastfeeding, with amount per n-3 type, source, frequency and timing of delivery (e.g., 

breastfeeding = NR, likely EPA or DHA, from 2 0.5oz oily fish servings/wk, as dinner; e.g., 

pregnancy = NR, likely ALA, from 8-10oz/wk flaxseed oil as salad dressing, NR): BOX 

total (daily, weekly or monthly) maternal n-3 exposure via all sources 

(diet+supplementation) during pregnancy and/or breastfeeding, per n-3 type (e.g., pregnancy = 

NR, at least 3g/d EPA+DHA): BOX 

total (daily, weekly or monthly) maternal n-6 and/or n-6/n-3 intake from 

diet+supplementation during pregnancy and/or breastfeeding: BOX

type, source and total (daily, weekly or monthly) maternal intake of other mandated or 

permitted exposures during pregnancy and/or breastfeeding (e.g., vitamins, minerals), with 

dose/serving/frequency: BOX 

n allocated-selected/ n completed (maternal) (e.g., n=24/21): BOX 

total (daily, weekly or monthly) child’s n-3 intake amount via breast milk, with amount 

per n-3 type; source, frequency and timing of delivery: BOX 

total (daily, weekly or monthly) child’s n-3 dose via supplementation/formula, with 

amount per n-3 type; source, frequency and timing of delivery; other active ingredients: BOX 
C – 21 

total (daily, weekly or monthly) child’s n-3 exposure via diet, with amount per n-3 type, 

source, frequency and timing of delivery (e.g., NR, likely EPA or DHA, from 2 0.5oz oily fish 

servings/wk, as dinner; e.g., NR, likely ALA, from 8-10oz/wk flaxseed oil as salad dressing, 

NR): BOX 

total (daily, weekly or monthly) child’s n-3 exposure via all sources 

(diet+supplementation), per n-3 type (e.g., NR, at least 3g/d EPA+DHA): BOX 

total (daily, weekly or monthly) child’s n-6 and/or n-6/n-3 intake from 

diet+supplementation: BOX

type, source and total (daily, weekly or monthly) child’s intake of other mandated or 

permitted exposures (e.g., vitamins, minerals), with dose/serving/frequency: BOX 

n allocated-selected/ n completed (child) (e.g., n=24/21): BOX 

On-study GROUP 3 (next highest dose n-3 [or lowest n-6/n-3 ratio if both n-3 and n-6 are 

modified] study first, active comparator next (e.g., n-6), placebo control last) (complete all; click 

here if there are no more study groups): 

total (daily, weekly or monthly) maternal n-3 dose via supplementation during 

pregnancy and/or breastfeeding, with amount per n-3 type; source, frequency and timing of 

delivery; other active ingredients (e.g., pregnancy = 1.8g/d EPA, 1.2g/d DHA, from 3 [1g vegan 

outer] fish oil capsules/d, with breakfast, NR): BOX 

total (daily, weekly or monthly) maternal n-3 exposure via diet during pregnancy and/or 

breastfeeding, with amount per n-3 type, source, frequency and timing of delivery (e.g., 

breastfeeding = NR, likely EPA or DHA, from 2 0.5oz oily fish servings/wk, as dinner; e.g., 

pregnancy = NR, likely ALA, from 8-10oz/wk flaxseed oil as salad dressing, NR): BOX 

total (daily, weekly or monthly) maternal n-3 exposure via all sources 

(diet+supplementation) during pregnancy and/or breastfeeding, per n-3 type (e.g., pregnancy = 

NR, at least 3g/d EPA+DHA): BOX 

total (daily, weekly or monthly) maternal n-6 and/or n-6/n-3 intake from 

diet+supplementation during pregnancy and/or breastfeeding: BOX

type, source and total (daily, weekly or monthly) maternal intake of other mandated or 

permitted exposures during pregnancy and/or breastfeeding (e.g., vitamins, minerals), with 

dose/serving/frequency: BOX 

n allocated-selected/ n completed (maternal) (e.g., n=24/21): BOX 

total (daily, weekly or monthly) child’s n-3 intake amount via breast milk, with amount 

per n-3 type; source, frequency and timing of delivery: BOX 
C – 22 

total (daily, weekly or monthly) child’s n-3 dose via supplementation/formula, with 

amount per n-3 type; source, frequency and timing of delivery; other active ingredients: BOX 

total (daily, weekly or monthly) child’s n-3 exposure via diet, with amount per n-3 type, 

source, frequency and timing of delivery (e.g., NR, likely EPA or DHA, from 2 0.5oz oily fish 

servings/wk, as dinner; e.g., NR, likely ALA, from 8-10oz/wk flaxseed oil as salad dressing, 

NR): BOX 

total (daily, weekly or monthly) child’s n-3 exposure via all sources 

(diet+supplementation), per n-3 type (e.g., NR, at least 3g/d EPA+DHA): BOX 

total (daily, weekly or monthly) child’s n-6 and/or n-6/n-3 intake from 

diet+supplementation: BOX

type, source and total (daily, weekly or monthly) child’s intake of other mandated or 

permitted exposures (e.g., vitamins, minerals), with dose/serving/frequency: BOX 

n allocated-selected/ n completed (child) (e.g., n=24/21): BOX 

On-study GROUP 4 (next highest dose n-3 [or lowest n-6/n-3 ratio if both n-3 and n-6 are 

modified] study first, active comparator next (e.g., n-6), placebo control last) (complete all; click 

here if there are no more study groups): 

total (daily, weekly or monthly) maternal n-3 dose via supplementation during 

pregnancy and/or breastfeeding, with amount per n-3 type; source, frequency and timing of 

delivery; other active ingredients (e.g., pregnancy = 1.8g/d EPA, 1.2g/d DHA, from 3 [1g vegan 

outer] fish oil capsules/d, with breakfast, NR): BOX 

total (daily, weekly or monthly) maternal n-3 exposure via diet during pregnancy and/or 

breastfeeding, with amount per n-3 type, source, frequency and timing of delivery (e.g., 

breastfeeding = NR, likely EPA or DHA, from 2 0.5oz oily fish servings/wk, as dinner; e.g., 

pregnancy = NR, likely ALA, from 8-10oz/wk flaxseed oil as salad dressing, NR): BOX 

total (daily, weekly or monthly) maternal n-3 exposure via all sources 

(diet+supplementation) during pregnancy and/or breastfeeding, per n-3 type (e.g., pregnancy = 

NR, at least 3g/d EPA+DHA): BOX 

total (daily, weekly or monthly) maternal n-6 and/or n-6/n-3 intake from 

diet+supplementation during pregnancy and/or breastfeeding: BOX

type, source and total (daily, weekly or monthly) maternal intake of other mandated or 

permitted exposures during pregnancy and/or breastfeeding (e.g., vitamins, minerals), with 

dose/serving/frequency: BOX 

n allocated-selected/ n completed (maternal) (e.g., n=24/21): BOX 
C – 23 

total (daily, weekly or monthly) child’s n-3 intake amount via breast milk, with amount 

per n-3 type; source, frequency and timing of delivery: BOX 

total (daily, weekly or monthly) child’s n-3 dose via supplementation/formula, with 

amount per n-3 type; source, frequency and timing of delivery; other active ingredients: BOX 

total (daily, weekly or monthly) child’s n-3 exposure via diet, with amount per n-3 type, 

source, frequency and timing of delivery (e.g., NR, likely EPA or DHA, from 2 0.5oz oily fish 

servings/wk, as dinner; e.g., NR, likely ALA, from 8-10oz/wk flaxseed oil as salad dressing, 

NR): BOX 

total (daily, weekly or monthly) child’s n-3 exposure via all sources 

(diet+supplementation), per n-3 type (e.g., NR, at least 3g/d EPA+DHA): BOX 

total (daily, weekly or monthly) child’s n-6 and/or n-6/n-3 intake from 

diet+supplementation: BOX

type, source and total (daily, weekly or monthly) child’s intake of other mandated or 

permitted exposures (e.g., vitamins, minerals), with dose/serving/frequency: BOX 

n allocated-selected/ n completed (child) (e.g., n=24/21): BOX 

On-study GROUP 5 (next highest dose n-3 [or lowest n-6/n-3 ratio if both n-3 and n-6 are 

modified] study first, active comparator next (e.g., n-6), placebo control last) (complete all; click 

here if there are no more study groups): 

total (daily, weekly or monthly) maternal n-3 dose via supplementation during 

pregnancy and/or breastfeeding, with amount per n-3 type; source, frequency and timing of 

delivery; other active ingredients (e.g., pregnancy = 1.8g/d EPA, 1.2g/d DHA, from 3 [1g vegan 

outer] fish oil capsules/d, with breakfast, NR): BOX 

total (daily, weekly or monthly) maternal n-3 exposure via diet during pregnancy and/or 

breastfeeding, with amount per n-3 type, source, frequency and timing of delivery (e.g., 

breastfeeding = NR, likely EPA or DHA, from 2 0.5oz oily fish servings/wk, as dinner; e.g., 

pregnancy = NR, likely ALA, from 8-10oz/wk flaxseed oil as salad dressing, NR): BOX 

total (daily, weekly or monthly) maternal n-3 exposure via all sources 

(diet+supplementation) during pregnancy and/or breastfeeding, per n-3 type (e.g., pregnancy = 

NR, at least 3g/d EPA+DHA): BOX 

total (daily, weekly or monthly) maternal n-6 and/or n-6/n-3 intake from 

diet+supplementation during pregnancy and/or breastfeeding: BOX
C – 24 

type, source and total (daily, weekly or monthly) maternal intake of other mandated or 

permitted exposures during pregnancy and/or breastfeeding (e.g., vitamins, minerals), with 

dose/serving/frequency: BOX 

n allocated-selected/ n completed (maternal) (e.g., n=24/21): BOX 

total (daily, weekly or monthly) child’s n-3 intake amount via breast milk, with amount 

per n-3 type; source, frequency and timing of delivery: BOX 

total (daily, weekly or monthly) child’s n-3 dose via supplementation/formula, with 

amount per n-3 type; source, frequency and timing of delivery; other active ingredients: BOX 

total (daily, weekly or monthly) child’s n-3 exposure via diet, with amount per n-3 type, 

source, frequency and timing of delivery (e.g., NR, likely EPA or DHA, from 2 0.5oz oily fish 

servings/wk, as dinner; e.g., NR, likely ALA, from 8-10oz/wk flaxseed oil as salad dressing, 

NR): BOX 

total (daily, weekly or monthly) child’s n-3 exposure via all sources 

(diet+supplementation), per n-3 type (e.g., NR, at least 3g/d EPA+DHA): BOX 

total (daily, weekly or monthly) child’s n-6 and/or n-6/n-3 intake from 

diet+supplementation: BOX

type, source and total (daily, weekly or monthly) child’s intake of other mandated or 

permitted exposures (e.g., vitamins, minerals), with dose/serving/frequency: BOX 

n allocated-selected/ n completed (child) (e.g., n=24/21): BOX 

On-study GROUP 6 (next highest dose n-3 [or lowest n-6/n-3 ratio if both n-3 and n-6 are 

modified] study first, active comparator next (e.g., n-6), placebo control last) (complete all; click 

here if there are no more study groups): 

total (daily, weekly or monthly) maternal n-3 dose via supplementation during 

pregnancy and/or breastfeeding, with amount per n-3 type; source, frequency and timing of 

delivery; other active ingredients (e.g., pregnancy = 1.8g/d EPA, 1.2g/d DHA, from 3 [1g vegan 

outer] fish oil capsules/d, with breakfast, NR): BOX 

total (daily, weekly or monthly) maternal n-3 exposure via diet during pregnancy and/or 

breastfeeding, with amount per n-3 type, source, frequency and timing of delivery (e.g., 

breastfeeding = NR, likely EPA or DHA, from 2 0.5oz oily fish servings/wk, as dinner; e.g., 

pregnancy = NR, likely ALA, from 8-10oz/wk flaxseed oil as salad dressing, NR): BOX 

total (daily, weekly or monthly) maternal n-3 exposure via all sources 

(diet+supplementation) during pregnancy and/or breastfeeding, per n-3 type (e.g., pregnancy = 

NR, at least 3g/d EPA+DHA): BOX 
C – 25 

total (daily, weekly or monthly) maternal n-6 and/or n-6/n-3 intake from 

diet+supplementation during pregnancy and/or breastfeeding: BOX

type, source and total (daily, weekly or monthly) maternal intake of other mandated or 

permitted exposures during pregnancy and/or breastfeeding (e.g., vitamins, minerals), with 

dose/serving/frequency: BOX 

n allocated-selected/ n completed (maternal) (e.g., n=24/21): BOX 

total (daily, weekly or monthly) child’s n-3 intake amount via breast milk, with amount 

per n-3 type; source, frequency and timing of delivery: BOX 

total (daily, weekly or monthly) child’s n-3 dose via supplementation/formula, with 

amount per n-3 type; source, frequency and timing of delivery; other active ingredients: BOX 

total (daily, weekly or monthly) child’s n-3 exposure via diet, with amount per n-3 type, 

source, frequency and timing of delivery (e.g., NR, likely EPA or DHA, from 2 0.5oz oily fish 

servings/wk, as dinner; e.g., NR, likely ALA, from 8-10oz/wk flaxseed oil as salad dressing, 

NR): BOX 

total (daily, weekly or monthly) child’s n-3 exposure via all sources 

(diet+supplementation), per n-3 type (e.g., NR, at least 3g/d EPA+DHA): BOX 

total (daily, weekly or monthly) child’s n-6 and/or n-6/n-3 intake from 

diet+supplementation: BOX

type, source and total (daily, weekly or monthly) child’s intake of other mandated or 

permitted exposures (e.g., vitamins, minerals), with dose/serving/frequency: BOX 

n allocated-selected/ n completed (child) (e.g., n=24/21): BOX 

protocol (e.g., what is mandated vs. permitted), with method and target values, to modify daily, 

weekly or monthly n-6 or n-6/n-3 maternal intake (e.g., increase daily n-3 intake to Y% of total 

daily fat intake, decrease daily n-6 intake to X% of total daily fat intake; e.g., none, participants 

told to maintain background diet) (by population, by group): BOX 

protocol (e.g., what is mandated vs. permitted), with method and target values, to modify daily, 

weekly or monthly child’s n-6 or n-6/n-3 intake (e.g., increase daily n-3 intake to Y% of total 

daily fat intake, decrease daily n-6 intake to X% of total daily fat intake; e.g., none, participants 

told to maintain background diet) (by population, by group): BOX

Briefly describe whether there was a clearly planned and instituted difference, between study 

groups, in their (daily, weekly or monthly) total-gram n-3 and/or n-6/n-3 intake (by population): 

BOX 
C – 26 

Briefly describe whether there was a clearly planned and instituted equivalence, across study 

groups, of (daily, weekly or monthly) caloric/energy intake from study-relevant 

exposures/interventions (by population): BOX 

Briefly describe any problems with compliance whereby notable deviations (e.g., decreases) 

from the planned amounts of intake (e.g., frequency of breastfeeding, formula, servings) in one 

or more of the study groups violated the difference(s) established a priori between study groups 

for n-3 and/or n-6/n-3 intake or the equivalence established a priori across study groups for 

caloric/energy intake (full; by group; by population): BOX 

Briefly describe whether, and which, study groups/participants were asked to maintain their (prestudy/baseline) background diet while on-study (full; by group; by population): BOX 

Briefly describe whether, and how, without specific instruction to do so, or with specific 

instruction not to do so, participants’ (pre-study/baseline) background diet was altered while onstudy (full; by group): BOX

Briefly describe whether, and which, study groups/participants were asked to maintain their (prestudy/baseline) therapies/medications while on-study (full; by group): BOX 

n-3: Briefly describe whether, and how, without specific instruction to do so, or with specific 

instruction not to do so, participants’ (pre-study/baseline) therapies/medication were altered 

while on-study (full; by group): BOX 

Briefly describe any evidence of selection bias: BOX 

Child’s prenatal history (complete all): 

 Significant (e.g., p-value; stated result of statistical test) pre-study/baseline betweengroup difference(s) (specify direction of difference(s): e.g., n-3 > pb): BOX 

Significant (e.g., p-value; stated result of statistical test) between-group difference(s) in 

within-group changes from baseline, to each followup (specify nature of change(s), by followup: 

e.g., final followup = n-3 > pb): BOX 

Specify whether any significant between-group differences at pre-study/baseline or 

regarding within-group changes from baseline, to each followup, were taken into consideration 

in the study analysis: BOX 

Child’s neonatal history (up to 28 days of age) (complete all): 

 Significant (e.g., p-value; stated result of statistical test) pre-study/baseline betweengroup difference(s) (specify direction of difference(s): e.g., n-3 > pb): BOX 

Significant (e.g., p-value; stated result of statistical test) between-group difference(s) in 

within-group changes from baseline, to each followup (specify nature of change(s), by followup: 

e.g., final followup = n-3 > pb): BOX 

Specify whether any significant between-group differences at pre-study/baseline or 

regarding within-group changes from baseline, to each followup, were taken into consideration 

in the study analysis: BOX 
C – 27 

Child’s pediatric history (complete all): 

 Significant (e.g., p-value; stated result of statistical test) pre-study/baseline betweengroup difference(s) (specify direction of difference(s): e.g., n-3 > pb): BOX 

Significant (e.g., p-value; stated result of statistical test) between-group difference(s) in 

within-group changes from baseline, to each followup (specify nature of change(s), by followup: 

e.g., final followup = n-3 > pb): BOX 

Specify whether any significant between-group differences at pre-study/baseline or 

regarding within-group changes from baseline, to each followup, were taken into consideration 

in the study analysis: BOX 

Child’s weight (Pc) (complete all): 

 Significant (e.g., p-value; stated result of statistical test) baseline between-group 

difference(s) (specify direction of difference(s): e.g., n-3 > pb): BOX 

Significant (e.g., p-value; stated result of statistical test) between-group difference(s) in 

within-group changes from baseline, to each followup (specify nature of change(s), by followup: 

e.g., final followup = n-3 > pb): BOX 

Specify whether any significant between-group differences at pre-study/baseline or 

regarding within-group changes from baseline, to each followup, were taken into consideration 

in the study analysis: BOX 

Child’s height (Pc) (complete all): 

 Significant (e.g., p-value; stated result of statistical test) baseline between-group 

difference(s) (specify direction of difference(s): e.g., n-3 > pb): BOX 

Significant (e.g., p-value; stated result of statistical test) between-group difference(s) in 

within-group changes from baseline, to each followup (specify nature of change(s), by followup: 

e.g., final followup = n-3 > pb): BOX 

Specify whether any significant between-group differences at pre-study/baseline or 

regarding within-group changes from baseline, to each followup, were taken into consideration 

in the study analysis: BOX 

Child’s head circumference (Pc) (complete all): 

 Significant (e.g., p-value; stated result of statistical test) baseline between-group 

difference(s) (specify direction of difference(s): e.g., n-3 > pb): BOX 

Significant (e.g., p-value; stated result of statistical test) between-group difference(s) in 

within-group changes from baseline, to each followup (specify nature of change(s), by followup: 

e.g., final followup = n-3 > pb): BOX 

Specify whether any significant between-group differences at pre-study/baseline or 

regarding within-group changes from baseline, to each followup, were taken into consideration 

in the study analysis: BOX 

Child’s growth patterns (percentile’s profile) (complete all): 

 Significant (e.g., p-value; stated result of statistical test) pre-study/baseline betweengroup difference(s) (specify direction of difference(s): e.g., n-3 > pb): BOX 

Significant (e.g., p-value; stated result of statistical test) between-group difference(s) in 

within-group changes from baseline, to each followup (specify nature of change(s), by followup: 

e.g., final followup = n-3 > pb): BOX 
C – 28 

Specify whether any significant between-group differences at pre-study/baseline or 

regarding within-group changes from baseline, to each followup, were taken into consideration 

in the study analysis: BOX 

Child’s medications/treatments: (complete all): 

 Significant (e.g., p-value; stated result of statistical test) baseline between-group 

difference(s) (specify direction of difference(s): e.g., n-3 > pb): BOX 

Significant (e.g., p-value; stated result of statistical test) between-group difference(s) in 

within-group changes from baseline, to each followup (specify nature of change(s), by followup: 

e.g., final followup = n-3 > pb): BOX 

Specify whether any significant between-group differences at pre-study/baseline or 

regarding within-group changes from baseline, to each followup, were taken into consideration 

in the study analysis: BOX 

Child’s visual function (complete all): 

 Significant (e.g., p-value; stated result of statistical test) baseline between-group 

difference(s) (specify direction of difference(s): e.g., n-3 > pb): BOX 

Significant (e.g., p-value; stated result of statistical test) between-group difference(s) in 

within-group changes from baseline, to each followup (specify nature of change(s), by followup: 

e.g., final followup = n-3 > pb): BOX 

Specify whether any significant between-group differences at pre-study/baseline or 

regarding within-group changes from baseline, to each followup, were taken into consideration 

in the study analysis: BOX 

Child’s cognitive developmental history and/or status (complete all): 

 Significant (e.g., p-value; stated result of statistical test) baseline between-group 

difference(s) (specify direction of difference(s): e.g., n-3 > pb): BOX 

Significant (e.g., p-value; stated result of statistical test) between-group difference(s) in 

within-group changes from baseline, to each followup (specify nature of change(s), by followup: 

e.g., final followup = n-3 > pb): BOX 

Specify whether any significant between-group differences at pre-study/baseline or 

regarding within-group changes from baseline, to each followup, were taken into consideration 

in the study analysis: BOX 

Child’s neurodevelopmental history and/or status (complete all): 

 Significant (e.g., p-value; stated result of statistical test) baseline between-group 

difference(s) (specify direction of difference(s): e.g., n-3 > pb): BOX 

Significant (e.g., p-value; stated result of statistical test) between-group difference(s) in 

within-group changes from baseline, to each followup (specify nature of change(s), by followup: 

e.g., final followup = n-3 > pb): BOX 

Specify whether any significant between-group differences at pre-study/baseline or 

regarding within-group changes from baseline, to each followup, were taken into consideration 

in the study analysis: BOX 

Child’s use of other licit (prescription and non-prescription) drugs, supplements (e.g., vitamins, 

minerals) and/or complementary/alternative therapies (specify) (complete all): 
C – 29 

 Significant (e.g., p-value; stated result of statistical test) baseline between-group 

difference(s) (specify direction of difference(s): e.g., n-3 > pb): BOX 

Significant (e.g., p-value; stated result of statistical test) between-group difference(s) in 

within-group changes from baseline, to each followup (specify nature of change(s), by followup: 

e.g., final followup = n-3 > pb): BOX 

Specify whether any significant between-group differences at pre-study/baseline or 

regarding within-group changes from baseline, to each followup, were taken into consideration 

in the study analysis: BOX 

Maternal age at conception and at delivery (complete all): 

 Significant (e.g., p-value; stated result of statistical test) baseline between-group 

difference(s) (specify direction of difference(s): e.g., n-3 > pb): BOX 

Specify whether any significant between-group differences at pre-study/baseline were 

taken into consideration in the study analysis: BOX 

Maternal gynaecologic history (complete all): 

 Significant (e.g., p-value; stated result of statistical test) pre-study/baseline betweengroup difference(s) (specify direction of difference(s): e.g., n-3 > pb): BOX 

Significant (e.g., p-value; stated result of statistical test) between-group difference(s) in 

within-group changes from baseline, to each followup (specify nature of change(s), by followup: 

e.g., final followup = n-3 > pb): BOX 

Specify whether any significant between-group differences at pre-study/baseline or 

regarding within-group changes from baseline, to each followup, were taken into consideration 

in the study analysis: BOX 

Number of premature deliveries: (complete all): 

 Significant (e.g., p-value; stated result of statistical test) pre-study/baseline betweengroup difference(s) (specify direction of difference(s): e.g., n-3 > pb): BOX 

Significant (e.g., p-value; stated result of statistical test) between-group difference(s) in 

within-group changes from baseline, to each followup (specify nature of change(s), by followup: 

e.g., final followup = n-3 > pb): BOX 

Specify whether any significant between-group differences at pre-study/baseline or 

regarding within-group changes from baseline, to each followup, were taken into consideration 

in the study analysis: BOX 

History of eclampsia/preeclampsia (complete all): 

 Significant (e.g., p-value; stated result of statistical test) pre-study/baseline betweengroup difference(s) (specify direction of difference(s): e.g., n-3 > pb): BOX 

Significant (e.g., p-value; stated result of statistical test) between-group difference(s) in 

within-group changes from baseline, to each followup (specify nature of change(s), by followup: 

e.g., final followup = n-3 > pb): BOX 

Specify whether any significant between-group differences at pre-study/baseline or 

regarding within-group changes from baseline, to each followup, were taken into consideration 

in the study analysis: BOX 

History of gestational hypertension (complete all): 
C – 30 

 Significant (e.g., p-value; stated result of statistical test) pre-study/baseline betweengroup difference(s) (specify direction of difference(s): e.g., n-3 > pb): BOX 

Significant (e.g., p-value; stated result of statistical test) between-group difference(s) in 

within-group changes from baseline, to each followup (specify nature of change(s), by followup: 

e.g., final followup = n-3 > pb): BOX 

Specify whether any significant between-group differences at pre-study/baseline or 

regarding within-group changes from baseline, to each followup, were taken into consideration 

in the study analysis: BOX 

Maternal obstetric history (complete all): 

 Significant (e.g., p-value; stated result of statistical test) pre-study/baseline betweengroup difference(s) (specify direction of difference(s): e.g., n-3 > pb): BOX 

Specify whether any significant between-group differences at pre-study/baseline were 

taken into consideration in the study analysis: BOX 

Maternal obstetric history of current pregnancy (complete all): 

 Significant (e.g., p-value; stated result of statistical test) pre-study/baseline betweengroup difference(s) (specify direction of difference(s): e.g., n-3 > pb): BOX 

Significant (e.g., p-value; stated result of statistical test) between-group difference(s) in 

within-group changes from baseline, to each followup (specify nature of change(s), by followup: 

e.g., final followup = n-3 > pb): BOX 

Specify whether any significant between-group differences at pre-study/baseline or 

regarding within-group changes from baseline, to each followup, were taken into consideration 

in the study analysis: BOX 

Maternal medical status (complete all): 

 Significant (e.g., p-value; stated result of statistical test) pre-study/baseline betweengroup difference(s) (specify direction of difference(s): e.g., n-3 > pb): BOX 

Significant (e.g., p-value; stated result of statistical test) between-group difference(s) in 

within-group changes from baseline, to each followup (specify nature of change(s), by followup: 

e.g., final followup = n-3 > pb): BOX 

Specify whether any significant between-group differences at pre-study/baseline or 

regarding within-group changes from baseline, to each followup, were taken into consideration 

in the study analysis: BOX 

Maternal medication and/or treatment types and doses during pregnancy and/or breast-feeding 

(clarify) (complete all): 

 Significant (e.g., p-value; stated result of statistical test) baseline between-group 

difference(s) (specify direction of difference(s): e.g., n-3 > pb): BOX 

Significant (e.g., p-value; stated result of statistical test) between-group difference(s) in 

within-group changes from baseline, to each followup (specify nature of change(s), by followup: 

e.g., final followup = n-3 > pb): BOX 

Specify whether any significant between-group differences at pre-study/baseline or 

regarding within-group changes from baseline, to each followup, were taken into consideration 

in the study analysis: BOX 
C – 31 

Maternal use of other licit (prescription and non-prescription) drugs, supplements (e.g., vitamins, 

minerals) and/or complementary/alternative therapies during current pregnancy and/or 

breastfeeding (complete all): 

 Significant (e.g., p-value; stated result of statistical test) pre-study/baseline betweengroup difference(s) (specify direction of difference(s): e.g., n-3 > pb): BOX 

Significant (e.g., p-value; stated result of statistical test) between-group difference(s) in 

within-group changes from baseline, to each followup (specify nature of change(s), by followup: 

e.g., final followup = n-3 > pb): BOX 

Specify whether any significant between-group differences at pre-study/baseline or 

regarding within-group changes from baseline, to each followup, were taken into consideration 

in the study analysis: BOX 

Maternal (ab)use of alcohol, illicit drugs and/or use or exposure to smoking tobacco during 

current pregnancy and/or breastfeeding (complete all): 

 Significant (e.g., p-value; stated result of statistical test) pre-study/baseline betweengroup difference(s) (specify direction of difference(s): e.g., n-3 > pb): BOX 

Significant (e.g., p-value; stated result of statistical test) between-group difference(s) in 

within-group changes from baseline, to each followup (specify nature of change(s), by followup: 

e.g., final followup = n-3 > pb): BOX 

Specify whether any significant between-group differences at pre-study/baseline or 

regarding within-group changes from baseline, to each followup, were taken into consideration 

in the study analysis: BOX 

Maternal socioeconomic status (i.e., employment status, income, marital status, and education) 

(specify) (complete all): 

 Significant (e.g., p-value; stated result of statistical test) pre-study/baseline betweengroup difference(s) (specify direction of difference(s): e.g., n-3 > pb): BOX 

Significant (e.g., p-value; stated result of statistical test) between-group difference(s) in 

within-group changes from baseline, to each followup (specify nature of change(s), by followup: 

e.g., final followup = n-3 > pb): BOX 

Specify whether any significant between-group differences at pre-study/baseline or 

regarding within-group changes from baseline, to each followup, were taken into consideration 

in the study analysis: BOX 

 

Name of n-3(-containing) product (e.g., Almarin, Coromega, Eiconol; Efamed, Epagis, 

MaxEPA, Menhaden oil, ResQ, Omacor, Ropufa, Similac, Enfalac, Isomil, etc.): BOX

Manufacturer (per product): BOX

Purity data (per product): BOX

Presence of other, potentially active agents in n-3 product (per product): BOX

n-3 composition (%) of the exposure (e.g., 18% EPA, 12% DHA in each fish oil capsule) 

(per product): BOX

Reported method(s) to maintain the freshness (i.e., preclude rancidity) of n-3 

exposures/interventions (e.g., added anti-oxidants to capsules, with fish oil exposure, to 

minimize oxidation): BOX
C – 32 

Reported method(s) to eliminate methylmercury from fish or its products/derivatives: BOX 

 

Note any descriptions of inappropriate methods of lipid extraction/preparation (e.g., failure to 

extract blood after a [overnight] fasting period; failure to collect blood in EDTA- or EGTAcontaining vials): BOX

Note any descriptions of inappropriate methods of lipid storage (e.g., failure to store samples at –

70 to –80 degrees C if not analyzed immediately): BOX 

Note any descriptions of inappropriate methods of lipid analysis (e.g., failure to conduct lab 

measurements on coded samples by technicians blinded to participants’ identity and allocation; 

failure to use a standard protocol [e.g., Bligh & Dyer] requiring, for example, purging samples 

with nitrogen, or using thin-layer chromatography or gas liquid chromatography): BOX

Adequacy of method to deodorize smell of especially fish oil exposure (select one): 

Adequate = reported that study participants could not reliably guess which exposure they 

received 

Inadequate = reported that participants could reliably guess which exposure they received 

Unclear = incomplete or conflicting data reported 

Not reported = no method reported, or method reported but no data reported 

Not applicable = did not use an exposure requiring or permitting such a method (e.g., 

flaxseed; full fish servings)

If this is a controlled study, briefly describe whether clinical outcome data from all study groups 

(e.g., active vs placebo) were simultaneously entered into data analysis: BOX

If this is a controlled study, briefly describe whether biomarker data from all study groups (e.g., 

active vs placebo) were simultaneously entered into data analysis: BOX

Data were analyzed according to which criterion (select one)? 

Intention-to-treat (all randomized/enrolled) 

Those receiving at least one dose/serving 

Those completing the study (i.e., with final follow-up data) 

Unclear 

Other: BOX

Was the study adequately powered to detect a difference? BOX

Any further comments about the study: BOX 
C – 33 

Quality Assessment Form—Randomized Controlled Trials 

1. Randomization: Was the study described as randomized (i.e. including words such as 

randomly, random, randomization)? Yes = 1 No = 0 =___ 

A trial reporting that it is ‘randomized’ is to receive one point. Trials describing an appropriate 

method of randomization (table of random numbers, computer generated) receive an additional 

point. Appropriate = 1 Not appropriate = 0 = ___ 

However, if the report describes the trial as randomized and uses an inappropriate method of 

randomization (e.g. date of birth, hospital numbers), a point is deducted. 

TOTAL POINTS: 0 1 2 SCORE = __

2. Double-blinding: Was the study described as double-blind? Yes = 1 No = 0 =___

A trial reporting that it is ‘double-blind’ is to receive one point. Trials that describe an 

appropriate method of double-blinding (identical placebo: color, shape, taste) are to receive an 

additional point. Yes = 1 No = 0 = ___

However, if the report describes the trial as double-blind and uses an inappropriate method (e.g. 

comparison of tablets vs. injection with no dummy), a point is deducted. 

TOTAL POINTS: 0 1 2 SCORE = ___

3. Withdrawals and dropouts: Was there a description of withdrawals and dropouts? 

Yes = 1 No = 0 SCORE = ___

A trial reporting the number of and reasons for withdrawals or dropouts is to receive one point. If 

there is no description, no point is given. 

 JADAD TOTAL SCORE = ___

4. Adequacy of Allocation Concealment: (select one):

-Central randomization; numbered or coded bottles or containers; drugs prepared by a pharmacy, 

serially numbered, opaque, sealed envelopes, 

etc..................................................................................... ADEQUATE

-Alternation; reference to case record # or date of birth, 

etc.................................................................................. INADEQUATE

-Allocation concealment is not reported, or, fits neither 

category..................................................... ........................... UNCLEAR
C – 34 

Quality Assessment (Internal Validity) Forms—Designs Other than an 

RCT 

Controlled Study Designs 

DESIGN: CASE-CONTROL STUDY (Newcastle-Ottawa, with assessment of an additional 

confounder) 

1. Is the case definition adequate? 

a. yes, with independent validation (e.g., clinical/research diagnostic criteria) (1 point) 

b. yes: e.g., record linkage or based on reports 

c. no description 

2. Representativeness of the cases 

a. consecutive or obviously representative series of cases (1 point) 

b. potential for selection biases, or not stated 

3. Selection of controls 

a. community controls (1 point) 

b. hospital controls 

c. no description 

4. Definition of controls 

a. no history of disease (requires clinical/research diagnostic criteria to determine this) (1 point) 

b. no description of source 

5. Comparability of cases and controls on the basis of the design or analysis: 

a. study controls for maternal background diet (omega-6/omega-3 fatty acid intake) at baseline 

and in possible changes during “intervening period” (1 point) 

b. study fails to control for this confounding influence 

6. Comparability of cases and controls on the basis of the design or analysis: 

a. study controls for age and sex (only child) at baseline (1 point) 

b. study fails to control for this confounding influence 

7. Comparability of cases and controls on the basis of the design or analysis: 

a. study controls for maternal obstetric history (e.g., Gestational age) or child’s health status (at 

birth) at baseline and in possible changes during “intervening period” (1 point) 

b. study fails to control for this confounding influence 

8. Comparability of cases and controls on the basis of the design or analysis: 
C – 35 

a. study controls for child’s pre/term status and/or maternal socieconomic status at baseline (1 

point) 

b. study fails to control for this confounding influence 

9. Comparability of cases and controls on the basis of the design or analysis: 

a. study controls for maternal smoking status at baseline and in possible changes during 

“intervening period” (1 point) 

b. study fails to control for this confounding influence 

10. Ascertainment of exposure 

a. validated method used to extract, prepare, store and analyze lipid data where appropriate in 

cases/controls (1 point) 

b. Inappropriate method 

c. no description 

11. Same method of ascertainment for cases and controls 

a. yes (1 point) 

b. no 

12. Non-response rate (blood samples analyzed) 

a. same rate for both groups (1 point) 

b. non respondents described 

c. rate different and no designation 

DESIGN: (MULTIPLE-GROUP) CROSS-SECTIONAL STUDY 

1. Control for selection bias 

a. Yes = 1 

b. No = 0 

c. Unable to determine = 0 

2. Description of the same validated method to distinguish the study populations (i.e., to confirm 

pre/term status, presence or absence of pre-eclampsia, etc.) 

a. Yes = 1 

b. No = 0 

c. Unable to determine = 0 

3. Homogeneity of the target population 

a. Yes = 1 

b. No = 0 

c. Unable to determine = 0 
C – 36 

4. Comparability of study groups on the basis of the design or analysis: age and sex (only child) 

a. Yes = 1 

b. No = 0 

c. Unable to determine = 0 

5. Comparability of study groups on the basis of the design or analysis: omega-3 fatty acid intake 

in recent (last 6 months) background diet (maternal) 

a. Yes = 1 

b. No = 0 

c. Unable to determine = 0 

6. Comparability of study groups on the basis of the design or analysis: omega-6 fatty acid 

intake, or omega-6/omega-3 fatty acid intake ratio, in recent (last 6 months) background diet 

(maternal) 

a. Yes = 1 

b. No = 0 

c. Unable to determine = 0 

7. Comparability of study groups on the basis of the design or analysis: current smoker status 

(maternal) 

a. Yes = 1 

b. No = 0 

c. Unable to determine = 0 

8. Comparability of study groups on the basis of the design or analysis: Gestational age 

(maternal) 

a. Yes = 1 

b. No = 0 

c. Unable to determine = 0 

9. Comparability of study groups on the basis of the design or analysis: pre/term status (child) 

a. Yes = 1 

b. No = 0 

c. Unable to determine = 0

10. Description of a validated primary clinical outcome measure(s) 

a. Yes = 1 

b. No = 0 

c. Unable to determine = 0 
C – 37 

11. Description of the same appropriate methods used to extract, prepare, store and analyze lipid 

data from all study populations 

a. No inappropriate descriptions = 1 

b. At least one inappropriate description = 0 

c. Different methods used for different study groups = 0 

d. Unable to determine for one or more of the methods = 0 

Uncontrolled Study Designs 

DESIGN: SINGLE PROSPECTIVE COHORT STUDY (Modified Newcastle-Ottawa) 

1. Representativeness of the exposed cohort 

a. Truly or somewhat representative of the average individual at no (or elevated) risk/potential 

for a given outcome (defined by the report) in the community = 1 

b. Selected group of users e.g., nurses, volunteers = 0 

c. No description of the derivation of the cohort = 0 

2. Ascertainment of exposure 

a. Validated dietary assessment questionnaire or structured interview = 1 

b. Written self-report = 0 

c. No description = 0 

3. Demonstration that outcome of interest was not present at start of study 

a. Yes = 1 

b. No = 0 

c. Unable to determine = 0 

4. Description of a validated method to quantify the amount, per type, of omega-3 fatty acids 

a. Yes = 1 

b. No = 0 

c. Unable to determine = 0

5. Assessment of outcome 

a. Independent blind assessment = 1 

b. Record linkage = 1 

c. Self-report = 0 

d. No description = 0 

6. Was followup long enough for outcomes to occur? 

a. Yes (maternal: until delivery) = 1 

b. No = 0 
C – 38 

c. Unable to determine = 0 

7. Adequacy of followup of cohort 

a. Complete followup, all subjects accounted for = 1 

b. Subjects lost to followup unlikely to introduce bias, small number lost, at least 90% followup, 

or description provided of those lost = 1 

c. Followup rate of less than 90% and no description of those lost = 0 

8. Analytic control for confounding: age and sex (child) 

a. Yes = 1 

b. No = 0 

c. Unable to determine = 0

9. Analytic control for confounding: omega-6 fatty acid intake or omega-6/omega-3 fatty acid 

intake ratio 

a. Yes = 1 

b. No = 0 

c. Unable to determine = 0

10. Analytic control for confounding: smoking history (maternal) 

a. Yes = 1 

b. No = 0 

c. Unable to determine = 0
C – 39 

Applicability Indices 

For studies involving at least one target maternal population.

Assign ‘I’ to a target study population of otherwise “healthy” North American (or similar) pregnant 

women or mothers of preterm or term infants representing a somewhat broad socio-demographic 

spectrum (i.e., age, race), and eating a diet “typical” of a broad spectrum North American population 

(e.g., with an estimated omega-6/omega-3 intake ratio of at least 15). 

Assign ‘II’ to a target study population of otherwise ‘healthy’ North American (or similar) of pregnant 

women or mothers of preterm or term infants, yet representing a more circumscribed socio-demographic 

picture (e.g., Asian-American/Canadian), and likely eating a diet “somewhat different” from that of a 

broad spectrum North American population (e.g., with an estimated omega-6/omega-3 intake ratio 

notably less than 15, yet likely not reaching a value of 4, such as observed in Japan). 

Assign ‘III’ to a target study population of pregnant women or mothers of preterm or term infants 

representing a population whose socio-demographic characteristics are notably “atypical” of a broad 

spectrum North American population, and eating a diet that is “notably different” from that of a broad 

spectrum North American population (e.g., with an estimated omega-6/omega-3 intake ratio perhaps 

reaching a value of 4, such as observed in Japan, or 38-50, as observed in urban India). 

Assign ‘X’ when applicability cannot be ascertained due to incomplete or conflicting reporting of the 

details concerning the target study population, particularly relating to the background diet. 
C – 40 

For studies involving a target population with or without a known elevated risk for a particular 

pregnancy and/or infant outcome 

Assign ‘I’ to a target study population of otherwise “healthy” North American (or similar) of pregnant 

women or mothers of preterm or term infants, with or without a known elevated risk for pregnancy or 

child’s outcomes (e.g., IUGR), representing a somewhat broad socio-demographic spectrum (i.e., age, 

race), and eating a diet “typical” of a broad spectrum North American population (e.g., with an omega6/omega-3 intake ratio of at least 15). 

Assign ‘II’ to a target study population of otherwise “healthy” North American (or similar) of pregnant 

women or mothers of preterm or term infants, with or without a known elevated risk for pregnancy or 

child’s outcomes (e.g., IUGR), yet representing a more circumscribed socio-demographic picture (e.g., 

Asian-American/Canadian), and likely eating a diet “somewhat different” from that of a broad spectrum 

North American population (e.g., with an omega-6/omega-3 intake ratio notably less than 15, yet likely 

not reaching a value of 4, as observed in Japan). 

Assign ‘III’ to a target study population of otherwise “healthy” of pregnant women or mothers of preterm 

or term infants, with or without a known elevated risk for pregnancy or child’s outcomes (e.g., IUGR), yet

representing a very circumscribed population whose socio-demographic characteristics are “notably 

atypical” of a broad spectrum North American population, and eating a diet that is “notably different” 

from that of a broad spectrum North American population (e.g., with an omega-6/omega-3 intake ratio 

perhaps reaching a value of 4, such as observed in Japan, or 38-50, as observed in urban India). 

Assign ‘X’ when applicability cannot be ascertained due to incomplete or conflicting reporting of the 

details concerning the target study population, particularly relating to the background diet.
D – 1 

Appendix D. Modified QUOROM Flow Chart 

Potentially relevant citations identified and screened for possible retrieval (n = 2049)

Citations excluded via screening of bibliographic records, with reasons (n = 1579):

a. not involving human participants (n = 301);

b. no omega-3 fatty acid focus (intervention/exposure or biomarkers) (n = 827);

c. not related to predefined child or maternal outcomes (n = 253); &,

d. not a first publication of empirical evidence (e.g., review) (n = 198)

Reports retrieved for more detailed assessment of relevance (n = 470)

Reports excluded via Level 2 relevance assessment, with reasons (n = 279):

a. not involving human participants (n = 15);

b. no omega-3 fatty acid focus (intervention/exposure or biomarkers) (n = 101);

c. not related to predefined child or maternal outcomes (n = 69)

d. not a first publication of empirical evidence (e.g., review) (n = 76); &,

e. not obtained (n = 18)

Reports excluded via Level 3 relevance assessment, with reasons (n = 74)

a. not level of evidence appropriate for a given question (n = 74)

Reports (n = 117) describing unique studies (n = 89) entered into qualitative synthesis

and, eligible for inclusion in meta-analysis

Meta-analysis conducted for studies investigating:

a. pre-eclampsia-gestational hypertension (n = 2)

b. small for GA (n=3)

c. growth patterns preterm infants (n=2)

d. growth patterns term infants (n=2)

e. neurological development term infants (n=3)

f. visual function preterm infants (n=6)

g. visual function term infants (n=8)

h. cognitive development term infants (n=3)
E – 1 

Appendix E. Evidence Tables Table 1: Randomized controlled trial evidence for omega-3 fatty acids in child and maternal health 

Author, 

Year, 

Location Study Design 

Population 

Characteristics 

Intervention/ 

comparators 

Timing & Dose of 

intervention (if 

appropriate) 

Clinical 

Re

Agostoni, 

1995, 

Italy 

{2940,359,467} 

 RCT 

Parallel Double-blind 

 Jadad 

total: 4 [Grade: A] 

 Schulz: 

Unclear 

Inclusion criteria: Healthy term infants of both sexes born between Sept. 1992-Aug. 1993; GA end of 37 wk-42 wk, AGA; Apgar >7 @ 5min & absence of diseaseExclusion criteria: NREnrolled/Completed: n=90/86 

Mean Age:• Child: F1 39.0 (1.3) wks GA; 

F2: 39.4 (1.4); BF 39.0 (1.1) 

LCPUFA formula (palm, coconut, soybean, sunflower, evening primrose oils, egglipids) (n=29) vs. crtl formula (n=31) vs. HM (RS) (n=30) 

LCPUFA formula (0.44 wt% AA+ 0.05 wt% EPA + 0.30 wt% DHA) within d 3 of life to 4 mo of age 

• Br

psychomodevelopmbetter scoDHA+EPA Lezine tesNS at 24 m

• PU

PC & PE (DHA at 4 correlation mo; NS at 

Auestad, 

1997, US 

{380,298,6} 

 RCT 

Parallel 

 Jadad 

total: 3 [Grade: B] 

 Schulz: 

Unclear 

Inclusion criteria: Healthy term infants ≥ 37 wk AGA.Exclusion criteria: Apgar <7 @ 5 min, physical or metabolic defects, receipt of lipid or blood transfusion, infants born to mothers with hx diabetes, hyperlipidemia, or perinatal infection Enrolled/Completed: n=274/173 

Mean Age: • Child: (d) HM: 3.6 ± 2.3; F 

crtl: 3.2 ± 2.5; F DHA+AA: 2.8 ± 1.9; F DHA n= 2.6 ± 1.9 

DHA+AA formula (from egg yolk phospholipids) (n=68) vs. DHA+EPA formula (from high-DHA, low-EPA tuna oil) (n=65) vs. Crtl formula (n=65) vs. HM (RS) (n=76) 

Dose NR; all formulas at least 4 mo 

• G

patterns: S

than in F1 in L, HC, T4 & 8 mo 

• Ba

MDI: S bevs. DHA+A12 mo; NS gps 

• Sw

NS acuity 2, 4, 6, 9 o

• Ac

procedure2,4,6,9, 12 age 

d = day(s); ERG = electroretinogram; g = gram(s); HM = human milk; mo = month; n = number of participants; NR = not reported; RCT = 

reference standard; TG = triglycerides; UK = United Kingdom; US = United States; VEP = visual evoked potential; wk(s) = week(s); LCP

polyunsaturated fatty acids; GLA = gammalinolenic acid; DHA = docosahexaenoic acid; AA = arachidonic acid; EPA = eicosapentanoic a

linolenic acid; GA = gestational age; AGA = weight appropriate for gestational age; F = feeding formula; GP = growth parameters; TST = 

= subscapular skinfold thickness; PDI = psychomotor developmental index; MDI = Mental developmental index; S = statistically significanonsignificant statistical difference; DQ = developmental quotien; RBC = red blood cells; PE = phosphatidyl ethanolamine; HC = head c

length; gp(s) = group(s); ctrl(s) = control(s) 
E – 2 

Table 1: Randomized controlled trial evidence for omega-3 fatty acids in child and maternal health 

Author, 

Year, 

Location Study Design 

Population 

Characteristics 

Intervention/ 

comparators 

Timing & Dose of 

intervention (if 

appropriate) Clinical Outco

Auestad, 

2001a 

US 

{125} 

 RCT 

Parallel 

Double-blind 

 Jadad 

total: 5 [Grade: A] 

 Schul

z: Adequate 

Inclusion criteria: Healthy term infants fed formula (GA 37-42 wk) Exclusion criteria: Evidence of S cardiac, respiratory, ophthalmologic, gastrointestinal, hematologic, or metabolic disease; milk-protein allergy; or maternal medical hx with proven adverse effects on the fetus, tuberculosis, human immunodeficiency virus infection, prenatal infections or substance abuse Enrolled/Completed: n=239/165 

Mean Age: • Maternal: NR • Child: FF crtl = 39.4 ± 

1.2 wk; FF egg-DTG = 39.0 ±1.3 wk, FF fish/fungal = 39.3 ± 1.2 wk 

DHA+AA formula (derived from eggTG) (n=80) vs. DHA+EPA+AA formula (LCPUFAs derived from fish and fungal oils) (n=82) vs. Crtl formula (n=77) vs. HM (n=165) 

LCPUFA 

formulas (0.13-0.14 wt% DHA & 0.45 wt% AA & <0.04 wt% EPA) for 12 mo 

• Telle

Procedure: N12 mo of age 

• Grow

NS in wt, L, H6, 9, & 12 moin males in Dat 4 mo 

• Faga

6, 9 mo 

• Bayle

in PDI & MD

• MacA

CommunicatDevelopmenNS at 9 mo; vocabulary escore in DHA(fish/fungal) (egg-TG) at 

g = gram(s); h = hour(s); d = day(s); wk(s) = week(s); mo = month; y = year; n = number of participants; NR = not reported; hx = history; 

age; FF = formula fed; BF = breast fed; HM = human milk ; S = significant; PMA = postmenstrual age; ERG = electroretinogram; RCT = reference standard; TG = triglycerides; UK = United Kingdom; US = United States; LCPUFA = long chain poly unsaturated fatty acids; GDHA = docosahexaenoic acid; AA = arachidonic acid; EPA = eicosapentanoic acid; LA = linoleic acid; ALA = α-linolenic acid; S = statistinonsignificant statistical difference; gp(s) = group(s); PDI = psychomotor developmental index; MDI = Mental developmental index; HC = weight; L = length; ctrl(s) = control(s) 
E – 3 

Table 1: Randomized controlled trial evidence for omega-3 fatty acids in child and maternal health (cont’d) 

Author, 

Year, 

Location Study Design 

Population 

Characteristics 

Intervention/ 

comparators 

Timing & Dose 

of intervention 

(if appropriate) Clinical Outcome

Auestad, 

2001b 

US 

{125} 

 RCT 

Parallel Double-blind 

 Jadad 

total: 5 [Grade: A] 

 Schul

z: Adequate 

Inclusion criteria: Healthy term infants breast-fed (gestational age 37-42 wk) Exclusion criteria: Evidence of significant cardiac, respiratory, ophthalmologic, gastrointestinal, hematologic, or metabolic disease; milk-protein allergy; or maternal medical hx with proven adverse effects on the fetus, tuberculosis, human immunodeficiency virus infection, prenatal infections or substance abuse Enrolled/Completed: NR Mean Age: • Maternal: NR • Child: NR 

HM/DHA+AA formula (derived from egg-TG) (n=83) vs. HM/Crtl formula (n=82) 

LCPUFA formulas (0.13-0.14 wt% DHA & 0.45 wt% AA) from 3 mo of age to 12 mo 

• Teller Acuit

Procedure: NS at 2of age 

• Growth patt

wt, L, HC at 1, 2, 4, or in wt, L, HC gain 

• Fagan Test

mo 

• Bayley Sca

& MDI at 6 & 12 mo 

• MacArthur 

Communicative DevInventories: NS at 9 vocabulary expressDHA+AA (fish/fungaDHA+AA (egg-TG) 

g = gram(s); h = hour(s); d = day(s); wk(s) = week(s); mo = month; y = year; n = number of participants; NR = not reported; hx = history; 

age; FF = formula fed; BF = breast fed; HM = human milk ; RCT = randomized control trial; RS = reference standard; TG = triglycerides; 

United States; LCPUFA = long chain polyunsaturated fatty acids; NIH = National Institute of health; BAEP = brainstem auditory evoked p

docosahexaenoic acid; AA = arachidonic acid; EPA = eicosapentanoic acid; LA = linoleic acid; ALA = α-linolenic acid; S = statistically signonsignificant statistical difference; gp(s) = group(s); PDI = psychomotor developmental index; MDI = Mental developmental index; HC = weight; L = length; ctrl(s) = control(s) 
E – 4 

Table 1: Randomized controlled trial evidence for omega-3 fatty acids in child and maternal health (cont’d) 

Author, 

Year, 

Location Study Design 

Population 

Characteristics 

Intervention/ 

comparators 

Timing & Dose 

of intervention 

(if appropriate) Clinical Outcome

Birch, 

1992, 

US 

{603,672,59

8,235,534,5

61} 

 RCT 

Parallel 

 Jadad: 

total: 2 [Grade: C] 

 Schulz: 

Unclear 

Inclusion criteria: VLBW infants with birth weight of 1000-1500 g appropriate for GA, able to receive enteral feedings (70-120 kcal/g) & free of major neonatal morbidity by d 10 Exclusion criteria: S respirator tx > 7 d, congenital infection, gross congenital malformation, Grade III or IV intracranial hemorrhage, & > Grade 2 retinopathy of prematurity Enrolled/Completed: n=81/52 Mean Age: • Materanl: NR • Child: Intrauterine = 

35.0 wk (0); VLBW gp = 30.4 wk (1.5)

Soy/marine oil (DHA+EPA+AA) formula (n=26) vs. soy oil formula (n=22) vs. corn oil formula (low n-3) (n=18) vs. HM (RS) (n=10) 

LCPUFA formula (1.4 g AA, 0.65 g EPA, 0.35 g DHA in 100 ml) for 6 mo 

• VEP: SÐ in 

grps at 57 wks; S Ð 

DHA+EPA vs. grps wks 

• Full-field ER

ERG at 36-57 wks 

• FPL acuity: 

had a better FPL acborderline statisticavs. corn oil at 57 wk

• Growth para

in wt, L, HC, TST, S17, 26 wks 

• BMK: S cor

between RBC AA alength z score at 57 correlation between DHA/DPA & VEP; RDHA/DPA & FPL at 

g = gram(s); h = hour(s); d = day(s); wk(s) = week(s); mo = month; y = year; n = number of participants; NR = not reported; hx = history; 

age; FF = formula fed; BF = breast fed; HM = human milk ; S = significant; PMA = postmenstrual age; ERG = electroretinogram; RCT = reference standard; TG = triglycerides; US = United States; VEP = visual evoked potential; LCPUFA = long chain polyunsaturated fatty ahealth; VLBW = very low birth weight; FPL = forced-choice preferential looking; BMK = biomarkers in blood or other tissues; DHA = docoarachidonic acid; EPA = eicosapentanoic acid; LA = linoleic acid; ALA = α-linolenic acid; TST = triceps skinfold thickness; SST = subscastatistically significant difference; NS = nonsignificant statistical difference; gp(s) = group(s); HC = head circumference; wt = weight; L = age; RBC = red blood cells; ctrl(s) = control(s) 
E – 5 

Table 1: Randomized controlled trial evidence for omega-3 fatty acids in child and maternal health (cont’d) 

Author, 

Year, 

Location Study Design 

Population 

Characteristics 

Intervention/ 

comparators 

Timing & Dose of 

intervention (if 

appropriate) Clinical Outcom

Birch, 

1998, US 

{2301,198,164} 

 RCT 

Parallel Double-blind 

 Jadad 

total: 5 [Grade: A] 

 Schul

z: Adequate 

Inclusion criteria: Term infants (37-40 wk) singleton, appropriate weight for GA Exlusion criteria: Family hx of mild protein allergy, genetic or familial eye disease, vegetarian or vegan maternal dietary patterns, maternal metabolic disease, anemia, or infection, presence of congenital malformation or infection, jaundice, perinatal asphyxiameconium aspiraton, & any perinatal event leading to NICU admission Enrolled/Completed: n=108/80 Mean Age: • Maternal: 29.1 (4.8) 

y 

• Child: NR

DHA+AA formula (derived from SCO) (n=27) vs. DHA formula (derived from SCO) (n=26) vs. Crtl formula (n=26) vs. HM (n=29) 

DHA+AA formula (0.36 wt% DHA, 0.72wt% AA, 14.9wt% LA, 1.53 wt% ALA); DHA formula (0.35 wt% DHA, 0.02 wt% AA, 15.1 wt% LA, 1.54 wt% ALA); Crtl formula (14.6 wt% LA, 1.49 wt% ALA) for 17 wk 

• Sweep V

sweep VEP acuitDHA or DHA+AA DHA or DHA+AA DHA or DHA+AA 

• ERG: S b

DHA or DHA+AA 

• FPL acuit

FPL acuity 

• Growth p

wt, L, HC, TST, S

• Neurolog

development: NS mo; NS in BRS a

• Cognitive

in n-3 formulas vsmo 

• BMK: NS 

PDI & BRS at 18 plasma & RBC LAEPA, or DHA at 4 MDI score at 18 m(+) with plasma & 4 mo; RBC-LA & correlated (-) with mo 

g = gram(s); h = hour(s); d = day(s); wk(s) = week(s); mo = month; y = year; n = number of participants; NR = not reported; hx = history; 

age; FF = formula fed; BF = breast fed; HM = human milk ; S = significant; PMA = postmenstrual age; ERG = electroretinogram; RCT = reference standard; TG = triglycerides; US = United States; VEP = visual evoked potential; LCPUFA = long chain polyunsaturated fatty ahealth; FPL = forced-choice preferential looking; BMK = biomarkers in blood or other tissues; NICU = neonatal intensive care unit; GLA = 

docosahexaenoic acid; AA = arachidonic acid; EPA = eicosapentanoic acid; LA = linoleic acid; ALA = α-linolenic acid; BRS = behavioral electroretinogram; MDI = mental developmental index; PDI = psychomotor developmental index; S = statistically significant difference; Ndifference; gp(s) = group(s); RBC = red blood cells; ctrl(s) = control(s) 
E – 6 

Table 1: Randomized controlled trial evidence for omega-3 fatty acids in child and maternal health (cont’d) 

Author, 

Year, 

Location Study Design 

Population 

Characteristics 

Intervention/ 

comparators 

Timing & Dose of 

intervention (if 

appropriate) Clinical Outcom

Birch, 

2002, 

US 

{87} 

 RCT 

Parallel 

 Jadad 

total: 5 [Grade: A] 

 Schul

z: Adequate 

Inclusion criteria: Healthy term infants 6 wks age born at 37-40 wk PMA, singleton births, BW appropriate for GA. Exclusion criteria: Family hx of milk protein allergy; genetic or familial eye disease; vegetarian or vegan maternal dietary patterns; maternal metabolic disease, anemia or infection; presence of a congenital malformation or infection; jaundice; perinatal asphyxia; meconiumaspiration; & any perinatal event that resulted in NICU admission Enrolled/Completed: n=65/58 Mean Age • Maternal: NR • Child: 5.1± 1.2 wks 

DHA+AA formula (derived from SCO) (n=32) vs. Crtl formula (n=33) 

DHA+AA formula (0.36 wt% DHA, 0.72wt% AA, 14.9wt% LA, 1.53 wt% ALA); Crtl formula (14.6 wt% LA, 1.49 wt% ALA) from 7 to 52 wk 

• Cortical V

DHA+AA on swewks; S DHA+AA sweep VEP 17, 2

• FPL: S D

better FPL at 17 w

• Growth p

wt, L, HC, TST & 0,6,17,26 & 52 w

• BMK: S b

VEP & plasma AA wks & plasma DHwks; S better sweRBC AA at 52 wkDHA at 17 & 52 wsweep VEP & plaLA or ALA at 17 obetter FPL & plas17 wks or RBC LNS FPL & plasma ALA, AA, plasma DHA 

g = gram(s); h = hour(s); d = day(s); wk(s) = week(s); mo = month; y = year; n = number of participants; NR = not reported; hx = history; 

age; PMA = postmenstrual age; BW = birth weight; US = United States; VEP = visual evoked potential; LCPUFA = long chain polyunsatuNational Institute of health; GLA = gammalinolenic acid; DHA = docosahexaenoic acid; AA = arachidonic acid; EPA = eicosapentanoic a

linolenic acid; TST = triceps skinfold thickness; SST = subscapular skinfold thickness; S = statistically significant difference; NS = nonsiggp(s) = group(s); RBC = red blood cells; ctrl(s) = control(s); SCO = single cell oil; NICU = neonatal intensive unit care; HC = head circum

length; FPL = forced-choice preferential looking 
E – 7 

Table 1: Randomized controlled trial evidence for omega-3 fatty acids in child and maternal health (cont’d) 

Author, 

Year, 

Location Study Design 

Population 

Characteristics 

Intervention/ 

comparators 

Timing & Dose of 

intervention (if 

appropriate) Clinical Outcom

Bougle, 1999, 

France 

{233} 

 RCT 

Parallel Double-blind 

 Jadad 

total: 3 [Grade: B] 

 Schul

z: Unclear 

Inclusion criteria: Premature, healthy, appropriate for GA infants (<34 wk postmenstrual age); free of respiratory, metabilic or neurological disease, of malformation, & of infection; fed by digestive route within the first 7 d of life, no hx of intrauterine asphyxia Exclusion criteria: Stop or change of study diet for > 2 d; any neurological event; haemorrhage of > 2 in cerebral ultrasound Enrolled/Completed: 40/33 Mean Age: • Maternal: NR • Child: BF GA = 33.1 

(1.5) wk; FF gp A GA = 32.2 (1.1) wk; FF gp B GA = 33.9 (1.0) wk 

LCPUFA-enriched formula (DHA, EPA, ALA) (n=14) vs. Crtl formula (n=11)/ HM: DHA 0.5%; EPA 0.5%; ALA 0.4% (n=15) 

Dose: NR during 30 d (from 1st d of 

enteral feeding) 

• Growth: N

HC, ∆ L, & ∆ HC 

• Electroph

studies of peripheNS LAEP betweeSÏ ∆ motor NCT DHA/EPA/AA supformula & HM fro∆ sensory (m/s) t

• VEP: NS 

wave latency) at 

g = gram(s); h = hour(s); d = day(s); wk(s) = week(s); mo = month; y = year; n = number of participants; NR = not reported;; hx = history; formula fed; BF = breast fed; HM = human milk ; VEP = visual evoked potential; LCPUFA = long chain polyunsaturated fatty acids; LAEP potentials; GLA = gammalinolenic acid; DHA = docosahexaenoic acid; AA = arachidonic acid; EPA = eicosapentanoic acid; LA = linoleic 

= statistically significant difference; NS = nonsignificant statistical difference; gp(s) = group(s); ctrl(s) = control(s); NCT = nerve conductiocircumference; wt = weight; L = length 
E – 8 

Table 1: Randomized controlled trial evidence for omega-3 fatty acids in child and maternal health (cont’d) 

Author, 

Year, 

Location Study Design 

Population 

Characteristics 

Intervention/ 

comparators 

Timing & Dose of 

intervention (if 

appropriate) 

Clinical 

Re

BulstraRamakers, 

1994, 

Netherlands 

{481} 

RCT Parallel Double-blind Jadad total: 5 [Grade: A]; Schulz: Adequate 

Inclusion criteria: BW < the 10th PC corrected for 

gestational age, parity & sex in association with GHT; BW < the 10th

PC in association with chronic renal disease; BW < the 10th PC & placental 

abnormalities suggestive of impaired uterplacental circulation Exclusion criteria: Women with diabetes, systemic lupus erythematosus or other connective tissue disease; women on low dose aspirin for tx with obstetric hx Enrolled/Completed: n=68/63 Mean Age: • Maternal: NR • Child: NR 

EPA + DHA capsules (n=32) vs. placebo (coconut oil) (n=31) 

4 capsules, 025 mg EPA +DHA, 3 x d (3g/d); from 12-14 wks PMA unitl delivery 

• In

IUGR: NS recurrence vs. grp 2) 

• In

NS rate of vs. grp 2) 

• Du

gestation: premature 

Carlson, 1987, 

US 

{736} 

RCT parallel Double-blind Jadad total: 2 [Grade: C]; Schulz: Unclear 

Inclusion criteria: Healthy LBW infants < 1,500g Exclusion criteria: Free of major congenital malformations & had no major disease process such as bronchopulmonary dysplasia Enrolled/Completed: n=61/39 Mean Age: • Maternal: NR • Child: crtl = 28 ± 14 d, fish 

oil = 26 ± 10 d; age for subgroup of n=19 (completing 6 wk f/u) crtl = 29 ± 18 d, fish oil = 27 ± 11 d 

MaxEPA preterm formula (fish oil) (n=30) vs. preterm formula (n=31) 

MaxEPA 750 mg/kg/d 1/d by orogastric tube during 4 wks 

• W

NS in ∆ w

g = gram(s); h = hour(s); d = day(s); wk(s) = week(s); mo = month; y = year; n = number of participants; NR = not reported; hx = history; 

age; FF = formula fed; BF = breast fed; HM = human milk ; S = significant; PMA = postmenstrual age; ERG = electroretinogram; RCT = reference standard; TG = triglycerides; US = United States; LCPUFA = long chain polyunsaturated fatty acids; NIH = National Institute of 

birth weight); PC = percentile; GHT = gestational hypertension; f/u = follow-up; DHA = docosahexaenoic acid; AA = arachidonic acid; EP

statistically significant difference; NS = nonsignificant statistical difference; gp(s) = group(s); ctrl(s) = control(s); IUGR = intrauterine grow
E – 9 

Table 1: Randomized controlled trial evidence for omega-3 fatty acids in child and maternal health (cont’d) 

Author, 

Year, 

Location Study Design 

Population 

Characteristics (enrolled/evaluated) 

Intervention/ 

comparators 

Timing & Dose of 

intervention (if 

appropriate) 

Clinical 

Re

Carlson, 

1992, 

US 

{581,555,423,6

34,573,2950} 

 RCT 

Parallel 

 Jadad 

total: 4 [Grade: A] 

 Schul

z: Adequate 

Inclusion criteria: VLBW premature infants, tolerating enteral intakes > 462 kJ.kg body wt -1 for 5-7 d if at that time they did not require 1) mechanical ventilation, 2) have intraventricular hemorrhage > grade 2, 3) have ROP > stage 2, 4) require surgical intervention for necrotizing enterocolitis, 5) have severe intrauterine growth retardation defined as BW < 5th PC for GA, or 6) have a hx of maternal substance abuse Exclusion criteria: Risk factors for poor growth other than prematuritly, severely growth retarded in utero (weight < the 5th PC for their 

GA), long tx of mechanical ventilation or GI surgery; risk factors for cognitive & visual development: intraventricular/ periventricular hemorrhage > grade 2, ROP > stage 2, hx of maternal cocaine use Enrolled/Completed: n=79/65 Mean Age: • Maternal: NR • Child: crtl = 25 (10) d; 

marine FF = 22 (8) d 

Supplemented formula (marine oil) (n=31) vs. crtl formula (n=34) 

Preterm formula (0.3 g EPA, 0.2 g DHA) until discharge (1,800g), then term formula until 79 wks 

• G

patterns: S

in marine 57, 68, 79

• Te

Card: S Ï acuity in Dvs. crtl at 

• Fa

Infant InteDHA-suppinfants ha

novelty prcrtl gp 

• BM

scores coplasma & 2,4,5,6,9, correlated RBC AA acorrelation DHA at 2 acuity at 2 

g = gram(s); h = hour(s); d = day(s); wk(s) = week(s); mo = month; y = year; n = number of participants; NR = not reported; hx = history; 

age; FF = formula fed; BF = breast fed; HM = human milk ; S = significant; PMA = postmenstrual age; ERG = electroretinogram; RCT = reference standard; TG = triglycerides; US = United States; VEP = visual evoked potential; LCPUFA = long chain polyunsaturated fatty ahealth; V(LBW) = very (low birth weight); FPL = forced-choice preferential looking; BMK = biomarkers in blood or other tissues; GI = gastROP = retinopathy of prematurity; GLA = gammalinolenic acid; DHA = docosahexaenoic acid; AA = arachidonic acid; EPA = eicosapenta

significant difference; NS = nonsignificant statistical difference; gp(s) = group(s); RBC = red blood cells; ctrl(s) = control(s); PCA = postcocircumference; wt = weight; L = length 
E – 10 

Table 1: Randomized controlled trial evidence for omega-3 fatty acids in child and maternal health (cont’d) 

Author, 

Year, 

Location Study Design 

Population 

Characteristics (enrolled/evaluated) 

Intervention/ 

comparators 

Timing & Dose of 

intervention (if 

appropriate) 

Clinical 

Re

Carlson, 1996, 

US 

{415} 

 RCT 

Parallel Double-blind 

 Jadad 

total: 3 [Grade: B] 

 Schul

z: unclear 

Inclusion criteria: Full term healthy infants (37-43 wk PMA) Exclusion criteria: IUGR; medical problems that may influence long-term growth & development Enrolled/Completed: n=94/58 

Mean Age: • Maternal: NR • Child: BF GA = 39.5 ± 1.3 

wk; Crtl FF GA = 40.3 ± 0.9 wk; Experimental FF GA = 39.8 ± 1.2 wk

DHA+AA formula (LCPUFAs derived from egg-TG) (n=28) vs. Crtl formula (n=31) vs. HM (n=35) 

LCPUFA formula (0.1 wt% DHA, 0.43 wt% AA) for at least 4 mo 

• Bi

acuity: S bacuity with 2 mo of ag

Carlson, 

1996, 

US 

{434,424} 

 RCT 

Parallel Double-blind 

 Jadad 

total: 3 [Grade: B] 

 Schul

z: Unclear 

Inclusion criteria: Healthy preterm infants who acheived full enteral feeding of 418 kJ (200 kcal). kg-1 by 6 wk of age & tolerated enteral feeding thereafter were allowed to remain in the study Exclusion criteria: Intraventricular or perventricular hemorrhage > grade 2, hx of maternal cocaine or alcohol abuse, congenital anomalies affecting long-term growth & development, or intrauterine growth retardation (wt < the 5th PC for GA) 

Enrolled/Completed: n=94/59 Mean Age: • Maternal: NR • Child: Ctrl no BPD = 28.6 

(1.3) wk, BPD =27.5 (1.6) wk; FF (marine) no BPD = 28.5 (1.2) wk, BPD = 27.0 (1.1) wk

LCPUFA formula (marine oil) (n=18) vs. crtl formula (n=18) 

Similac Special Care 0.2%DHA, 0.06%EPA, vitamin E from 3-5 d age to 2 mo CA 

• Te

Card: SÏ in DHA+E2 mo; NS 

• G

patterns: S

in LCPUF

• BM

correlation for-L & RB5 mo; S (+between L AA at 5 m

h = hour(s); d = day(s); wk(s) = week(s); mo = month; y = year; n = number of participants; NR = not reported; hx = history; tx = treatmenformula fed; BF = breast fed; HM = human milk ; RCT = randomized control trial; TG = triglycerides; US = United States; LCPUFA = long acids; PC = percentile; CA = corrected age; DHA = docosahexaenoic acid; AA = arachidonic acid; EPA = eicosapentanoic acid; S = statiNS = nonsignificant statistical difference; gp(s) = group(s); RBC = red blood cells; ctrl(s) = control(s); IUGR = intrauterine growth retardatPE = phosphatidyl ethanolamine; BPD = bronchopulmonary dysplasia; PC = phosphatidylcholyne; HC = head circumference; wt = weig
E – 11 

Table 1: Randomized controlled trial evidence for omega-3 fatty acids in child and maternal health (cont’d) 

Author, 

Year, 

Location Study Design 

Population 

Characteristics 

Intervention/ 

comparators 

Timing & Dose of 

intervention (if 

appropriate) Clinical Outcom

Clandinin, 

2002, 

Canada 

{1553,1552, 

1565}

 RCT 

Parallel Double Blind 

 Abstr

act 

Inclusion criteria: VLBW term & preterm infants Exclusion criteria: NR Enrolled/Completed: n=361/NR Mean Age: • Maternal: NR • Child: NR 

DAS (DHA+AA from SCO) (n=72) vs. DAF (DHA from fish oils+AA from SCO) (n=90) vs. Crtl formula (n=83) vs. HM (RS) (n=105)

Preterm, discharge & term formulas until 57 wks PMA, then beikost until 92 wks PMA 

• Bayley

MDI: DAS & DAhad S > scores formula (118 w

PDI score formDAF) vs. crtl gp 

• Growth 

in GP at 40, 57 SÏ wt in DHA+

than in crtl at 6PMA; SÏ L in 

(SCO) than in oformulas at 79, 

D'Almeida, 

1992, South 

Africa 

{580} 

 RCT 

parallel Partially double-blind 

 Jadad 

total: 2 [Grade: C] 

 Schul

z: Inadequate 

Inclusion criteria: Primiparous & multiparous women in the first 4 mo of pregnancy Exclusion criteria: NR Enrolled/Completed:n=150/NR Mean Age: • Maternal: 14-40 y

GLA+EPA+DHA (primrose + fish oil) (n=50) vs. magnesium oxide (n=50) vs. placebo (olive oil + vitamin E) (n=50) 

GLA+EPA+DHA & placebo: 240 capsules (8 x d); Magnesium oxide: 60 tablets x mo (2 tablets x d; 500 mg) 

• Inciden

preeclampsia & during pregnanGHT Ï in grps 

(p = NR); rate opreeclampsia/ein grp 3 vs. grp

g = gram(s); h = hour(s); d = day(s); wk(s) = week(s); mo = month; y = year; n = number of participants; NR = not reported; hx = hist

gestational age; FF = formula fed; BF = breast fed; HM = human milk ; S = significant; PMA = postmenstrual age; ERG = electroretinogratrial; RS = reference standard; TG = triglycerides; LCPUFA = long chain polyunsaturated fatty acids; V(LBW) = very (low birth weight); G

↑ = increase/greater; GLA = gammalinolenic acid; DHA = docosahexaenoic acid; AA = arachidonic acid; EPA = eicosapentanoic acid; LA 

linolenic acid; S = statistically significant difference; NS = nonsignificant statistical difference; gp(s) = group(s); ctrl(s) = control(s); MDI & Psychomotor Indexes; SCO = single cell oil; GP = growth patterns 
E – 12 

Table 1: Randomized controlled trial evidence for omega-3 fatty acids in child and maternal health (cont’d) 

Author, 

Year, 

Location Study Design 

Population 

Characteristics 

Intervention/ 

comparators 

Timing & Dose of 

intervention (if 

appropriate) Clinical Outcom

de Groot, 

2003, 

Netherlands 

{2907,2935} 

 RCT 

parallel Double-blind 

 Jadad 

total: 3 [Grade: B] 

 Schul

z: Unclear 

Inclusion criteria: Healthy white pregnant women GA < 14 wk; normal health; fish consumption of < 2 /wk Exclusion criteria: Diastolic BP >90mmHg, multiple pregnancy, use of medication, use of LCPUFA rich supplements Enrolled/Completed: n=79/58 Mean Age: • Maternal: Crtl = 

29.2 ± 3.8 y; Experimental = 30.0 ± 3.3 y 

• Child: Crtl GA = 

276.5 ± 12.2 d; Experimental GA = 281.0 ± 7.4 d

ALA enriched, Ï LA margarine (n=29) vs. crtl gp (n=29) 

25 g margarine/d: 45.4% LA + 14.2% ALA (n-3) of total FA from wk 14 GA until delivery 

• Duratio

gestation: NS i

• Birth w

ALA+LA vs. LA 

• BMK: S 

correlation mat& RBC DHA & correlation DHA 

g = gram(s); h = hour(s); d = day(s); wk(s) = week(s); mo = month; y = year; n = number of participants; NR = not reported; hx = hist

gestational age; FF = formula fed; BF = breast fed; HM = human milk ; S = significant; PMA = postmenstrual age; ERG = electroretinogratrialTG = triglycerides; LCPUFA = long chain polyunsaturated fatty acids; GHT = gestational hypertension;; ↑ = increase/greater; GLA = docosahexaenoic acid; LA = linoleic acid; ALA = α-linolenic acid; S = statistically significant difference; NS = nonsignificant statistical diff

red blood cells; ctrl(s) = control(s); BW = birth weight 
E – 13 

Table 1: Randomized controlled trial evidence for omega-3 fatty acids in child and maternal health (cont’d) 

Author, 

Year, 

Location Study Design 

Population 

Characteristics 

Intervention/ 

comparators 

Timing & Dose of 

intervention (if 

appropriate) 

Clinical 

Re

Decsi, 1995, 

Hungary 

{460} 

 RCT 

Parallel 

 Jadad 

total: 1 [Grade: C] 

 Schul

z: Unclear 

Inclusion criteria: FF full term infants appropriate for GA Exclusion criteria: NR Enrolled/Completed: n=22/NR 

Mean Age: • Maternal: NR • Child: FF gp = 39.4 ± 1.3 

wk; LCPUFA-F gp = 38.9 ± 1.1 wk

Pre-Aptamil with Milupan (egg lipids, primrose oil) (n=12) vs. PreAptamil without LCPUFA (n=10) 

120-150 ml/kg/d 0.5% AA + 0.03% EPA + 0.3% DHA + vitamin E formula ad libitum for 4 mo 

• G

patterns: NHC at 6, 1

• BM

correlation LCPUFA & 

Dunstan, 

2004, 

Australia 

{2917} 

 RCT 

Parallel Double-blind 

 Jadad 

total: 3 [Grade: B] 

 Schulz: 

Unclear 

Inclusion criteria: Pregnant women with hx of allergic rhinitis or asthma but otherwise healthy Exclusion criteria: Smokers; high risk pregnancy; ate fish more than once/week Enrolled/Completed: n=98/83 Mean Age: • Maternal: crtl: 32.4 ±0.5 y; 

fish Oil: 31.1 ± 0.6 y 

• Child: NR 

Capsules with LCPUFAs (derived from fish oil, treatment gp) (n=40*) vs. Capsules with olive oil (Crtl grp) (n=43*) 

2.2 g/day DHA, 1.1 g/day EPA in capsules for 19 wk 

• Du

gestation: 

• G

at birth: NHC at birth 

g = gram(s); h = hour(s); d = day(s); wk(s) = week(s); mo = month(s); y = year(s); n = number of participants; NR = not reported; hx = his

gestational age; FF = formula fed; BF = breast fed; HM = human milk ; S = significant; PMA = postmenstrual age; ERG = electroretinograRS = reference standard; TG = triglycerides; LCPUFA = long chain polyunsaturated fatty acids; BMK = biomarkers in blood or other tissu

acid; DHA = docosahexaenoic acid; AA = arachidonic acid; EPA = eicosapentanoic acid; LA = linoleic acid; ALA = α-linolenic acid; S = s

NS = nonsignificant statistical difference; gp(s) = group(s); RBC = red blood cells; ctrl(s) = control(s):; GP = growth patterns; HC = head length 
E – 14 

Table 1: Randomized controlled trial evidence for omega-3 fatty acids in child and maternal health (cont’d) 

Author, 

Year, 

Location Study Design 

Population 

Characteristics 

Intervention/ 

comparators 

Timing & Dose of 

intervention (if 

appropriate) 

Clinica

R

Faldella, 1996, 

Italy 

{390,2375} 

 RCT 

Parallel 

 Jadad 

total: 1 [Grade: C] 

 Schul

z: Unclear 

Inclusion criteria: Healthy preterm infants < 33 wk GA, of appropriate weight, no malformation interfering with somatic &/ or psychomotor development, no neurological, visual, acoustic or gastroenterological illnesses, no hx of perinatal asphyxia, normal fundus oculi, & by 10 d age all received at least 50% of calorie requirement through enteral feeding Exclusion criteria: NR Enrolled/Completed: n=66/58 

Mean Age • Maternal: NR • Child: BF = 31.8 wk, FF 

LCPUFA = 31.1 wk, FF Crtl = 31.3 wk 

LCPUFAenriched formula (Milupan) (n=23) vs. Crtl formula (n=26)/ HM (RS) (n=17)

LCPUFA formula (DHA 0.23%; EPA 0.08%;ALA 0.40%) until 52 wks PCA 

• 

wave (Nlatencies DHA+EPwks PCA 

• 

in BAEP 

• 

ERG (a across g

• 

NS in ∆ 

52 wks P

• 

PCA, invbetweenN4 wave DHA & P

g = gram(s); h = hour(s); d = day(s); wk(s) = week(s); mo = month(s); y = year(s); n = number of participants; NR = not reported; hx = his

gestational age; FF = formula fed; BF = breast fed; HM = human milk ; ERG = electroretinogram; RCT = randomized control trial; RS = rtriglycerides; VEP = visual evoked potential; LCPUFA = long chain polyunsaturated fatty acids; BAEP = brainstem auditory evoked potenblood or other tissues; PCA = postconceptional age; GLA = gammalinolenic acid; DHA = docosahexaenoic acid; AA = arachidonic acid; 

= linoleic acid; ALA = α-linolenic acid; S = statistically significant difference; NS = nonsignificant statistical difference; gp(s) = group(s); Rcontrol(s); HC = head circumference; wt = weight; L = length 
E – 15 

Table 1: Randomized controlled trial evidence for omega-3 fatty acids in child and maternal health (cont’d) 

Author, 

Year, 

Location Study Design 

Population 

Characteristics 

Intervention/ 

comparators 

Timing & Dose of 

intervention (if 

appropriate) 

Clinica

R

Fewtrell, 

2002, UK 

{2129} 

 RCT 

Parallel Double-blind 

 Jadad 

total: 5 [Grade: A] 

 Schul

z: Adequate 

Inclusion criteria: Preterm infants < 1,750 g; GA < 37 wk; free of congenital malformations known to affect neurodevelopment; mothers decided not to BF by 10 d of age; tolerant of enteral feeding at the time of enrolment Exclusion criteria: NR Enrolled/Completed: n=283/240 

Mean Age • Maternal: NR • Child: BF crtl = 30.3 (2.4) wk; 

FF Crtl = 30.3 (2.0) wk; FF LCPUFA = 30.4 (2.3) wk

Supplemented preterm formula (egg-lipids) (n=95) vs. crtl preterm formula (n=95) vs. HM (RS) (n=88)

NR dose; mean 33 (SD=17) d in crtl gp vs. mean 31 (SD=21) d in supplemented formula 

• 

PDI: NS between 18 mo 

• 

PassamSherrardDevelopScreeninbetween 9 mo 

• 

L in LCPat 9 & 18 HC at 9, 

g = gram(s); h = hour(s); d = day(s); wk(s) = week(s); mo = month; y = year; n = number of participants; NR = not reported; hx = history; 

age; FF = formula fed; BF = breast fed; HM = human milk ; S = significant; PMA = postmenstrual age; RCT = randomized control trial; RLCPUFA = long chain polyunsaturated fatty acids; VLBW = very low birth weight; UK = United Kingdom; ↑ = increase/greater; PCA = po

= Bayley’s Mental and Psychomotor Indexes; S = statistically significant difference; NS = nonsignificant statistical difference; gp(s) = gro

head circumference; wt = weight; L = length; SD = standard deviation; CA = corrected age 
E – 16 

Table 1: Randomized controlled trial evidence for omega-3 fatty acids in child and maternal health (cont’d) 

Author, 

Year, 

Location Study Design 

Population 

Characteristics 

Intervention/ 

comparators 

Timing & Dose of 

intervention (if 

appropriate) 

Clinical 

Re

Fewtrell, 

2004, 

UK 

{2938} 

 RCT 

Parallel Double-blind 

 Jadad 

total: 5 [Grade: A] 

 Schul

z: Adequate 

Inclusion criteria: Healthy preterm infants with BW ≤ 2,500g, 

GA < 35 wks, receiving at least some of their enteral feeds as formula milk during NICU stay Exclusion criteria: Congenital malformations known to affect growth or neurodevelopment Enrolled/Completed: n=238/199 Mean Age: • Maternal: crtl = 28.5 (5.7) y; 

LCPUFA= 29.0 (4.6) y 

• Child: crtl= 13.9 (10.4) d; 

LCPUFA 14.3 (9.6) d 

↑ DHA/EPA (borage, tuna fish oil) formula (n=122) vs. Crtl formula (n=116)

Preterm formula until 2 kg or discharge, then postdischarge formula until 9 mo after term 

• 

& PDI: Ngps in M18 mo 

• 

patterns

in LCPUat 9 mo; 9 mo; Nmo 

Field, 2000, 

Canada, 

{2191} 

 RCT 

Parallel 

 Jadad 

total: 1 [Grade: C] 

 Schul

z: Unclear 

Inclusion criteria Preterm infants GAs between 27 & 36 wks size appropriate for GA & receive 100% of daily fluid & energy requirements enterally by d 14 of life Exclusion criteria: Infants with major congenital malformation, documented systemic or congenital infection, significant neonatal morbidity or acute illness that precludes oral feeding; mixed feeding; corticosteroid use; RBC & plasma transfusion; or IV lipid emulsion beyond d 8 Enrolled/Completed: n=44/44 Mean Age: • Maternal: NR • Child: BF = 32 ± 2wk; Ctrl F = 31 

± 2 wk; F + LCPUFA = 32 ± 2 wk 

Supplemented preterm formula (DHA+AA derived from SCO) (n=15) vs. Crtl preterm formula (n=12) vs. HM (RS) (n=17) 

LCPUFA formula (0.35 wt% DHA, 0.49 wt% AA) from 8 to 42 d of age; 

• 

patternsHM than & pb at 2HC at 35 

g = gram(s); h = hour(s); d = day(s); wk(s) = week(s); mo = month; y = year; n = number of participants; NR = not reported; hx = history; 

age; FF = formula fed; BF = breast fed; HM = human milk ; RCT = randomized control trial; RS = reference standard; LCPUFA = long ch

UK = United Kingdom; MDI & PDI = Bayley’s Mental and Psychomotor Indexes; NICU = neonatal intensive care unit; DHA = docosahexaacid; EPA = eicosapentanoic acid; S = statistically significant difference; NS = nonsignificant statistical difference; gp(s) = group(s); RBC control(s); HC = head circumference; wt = weight; L = length; GP = growth patterns 
E – 17 

Table 1: Randomized controlled trial evidence for omega-3 fatty acids in child and maternal health (cont’d) 

Author, 

Year, 

Location Study Design 

Population 

Characteristics 

Intervention/ 

comparators 

Timing & Dose of 

intervention (if 

appropriate) 

Clinical 

Re

Ghebremeske

l, 1999, UK 

{2262} 

 RCT 

Parallel 

 Jadad 

total: 2 [Grade: C] 

 Schul

z: Unclear 

Inclusion criteria: Healthy preterm infants Exclusion criteria: Congenital malformations; metabolic disorders Enrolled/Completed: n=61/35 Mean Age: • Maternal: NR • Child: GA = 29.5 wks ± 2.4 

wks

LCPUFA preterm formula (DHA+AA derived from eggTG) (n=7) vs. LCPUFA formula+HM (n=14) vs. Crtl preterm formula (n=8) vs. Crtl formula+ HM (n=12) vs. HM (RS) (n=20) 

LCPUFA formula+HM (0.85+-0.25wt% DHA); Crtl formula+HM 0.55+-0.25wt% DHA); LCPUFA formula (0.30wt% DHA) for a mean of 11 wk (range 7-15 wk) 

• G

patterns: NHC at ≈11 grps 

Gibson, 1997, 

Australia 

{2959} 

 RCT 

Parallel Double-blind 

 Jadad 

total: 3 [Grade: B] 

 Schul

z: Unclear 

Inclusion criteria: Mothers of term infants (> 37 wks GA), who intended to BF for ≥ 12 wks; 

infants were healthy, AGA, apgar > 7 @ 5 min Exclusion criteria: NR Enrolled/Completed: n=52/50Mean Age: • Maternal: 30 ± 4 y • Child: GA = 39 – 40 ± 1 wks 

DHASCO (DHArich algal oil) 5 different doses (n=12 vs. n=10 vs. n=12 vs. n=10 vs. n=8) 

Maternal DHA doses: 0 gvs. 0.2 g vs. 0.4 gvs. 0.9 g vs. 1.3 g). HM (DHA content: 0.21% vs. 0.35% vs. 0.46% vs. 0.86% vs. 1.13% of FA) 

• VE

at 12 & 16 

• Ba

PDI: NS in mo & 24 mcorrelation MDI & DHdiet at 1 y

• BM

correlation HM, infant RBC LCPcorrelation MDI & DH(RBC & plwks) at 1 y 

 h = hour(s); d = day(s); wk(s) = week(s); mo = month; y = year; n = number of participants; NR = not reported; hx = history; tx = treatme

formula fed; BF = breast fed; HM = human milk ; S = significant; PMA = postmenstrual age; RCT = randomized control trial; RS = referen

VEP = visual evoked potential; LCPUFA = long chain polyunsaturated fatty acids; NIH = National Institute of health; BAEP = brainstem aVLBW = very low birth weight; BMK = biomarkers in blood or other tissues; UK = United Kingdom; MDI & PDI = Bayley’s Mental and Psy

docosahexaenoic acid; AA = arachidonic acid; EPA = eicosapentanoic acid; LA = linoleic acid; ALA = α-linolenic acid; S = statistically sig

nonsignificant statistical difference; gp(s) = group(s); RBC = red blood cells; ctrl(s) = control(s); HC = head circumference; wt = weight; L 
E – 18 

Table 1: Randomized controlled trial evidence for omega-3 fatty acids in child and maternal health (cont’d) 

Author, 

Year, 

Location Study Design 

Population 

Characteristics 

Intervention/ 

comparators 

Timing & Dose of 

intervention (if 

appropriate) 

Clinical 

Re

Gobel, 2003 

Germany 

{1516}

 RCT 

Parallel 

 Jadad 

total: 2 [Grade: C] 

 Schul

z: Unclear

Inclusion criteria: Healthy preterm infants, GA between 28 wk + 0 d & 36 wk + 6 d, admission to the intensive care nursery of the study centers within 24 h of birth, & expected requirment for parental nutrition providing at least 80% of total energy intake from the duration of study Exclusion criteria: Severe malformation of visceral organs, kidneys, lung, or brain or inborn errors of metabolism Enrolled/Completed: n=45/33 Mean Age: • Maternal: NR • Child: gp O GA = 220 d 

±16.5 d, gp S GA = 224 d ±12.8 d

Olive/soybean oil emulsion (DHA + ALA) (n=24) vs. Soybean oil emulsion (DHA + ALA) (n=21) 

IV lipid infusion olive/soybean oil emulsion (DHA 0.23% + ALA 2.0%); IV lipid infusion soybean oil emulsion (DHA 0.34% & ALA 6.99%) for 7 d 

• Sa

Groh-Wargo, 

2002, US, 

Canada 

{1538} 

 RCT 

Parallel 

 Abstr

act 

Inclusion criteria: FF preterm infants, 750-1,800g < 33 wk gestation Exclusion criteria: NR Enrolled/Completed: n=57/NR Mean Age: • Maternal: NR • Child: NR 

Supplemented preterm formula (DHA+AA derived from egg-TG) (n=18) vs. Supplemented preterm formula (DHA+AA derived from fish oil) (n=18) vs. Crtl preterm formula (n=21) 

Preterm formula (0.26 wt% DHA, 0.42 wt% AA) until term, then postdischarge formula until 1 y CA 

• G

patterns: N12 mo CA 

 h = hour(s); d = day(s); wk(s) = week(s); mo = month; y = year; n = number of participants; NR = not reported; hx = history; tx = treatme

formula fed; BF = breast fed; HM = human milk ; S = significant; ERG = electroretinogram; RCT = randomized control trial; RS = referencLCPUFA = long chain polyunsaturated fatty acids; NIH = National Institute of health; US = United States; DHA = docosahexaenoic acid; eicosapentanoic acid; LA = linoleic acid; ALA = α-linolenic acid; S = statistically significant difference; NS = nonsignificant statistical diffecontrol(s); IV = intravenous; GP = growth patterns; CA = corrected age 
E – 19 

Table 1: Randomized controlled trial evidence for omega-3 fatty acids in child and maternal health (cont’d) 

Author, 

Year, 

Location Study Design 

Population 

Characteristics 

Intervention/ 

comparators 

Timing & Dose of 

intervention (if 

appropriate) 

Clinical 

Re

Guesnet, 

1999, France 

{1650} 

 RCT 

Parallel 

 Jadad 

total: 2 [Grade: C] 

 Schul

z: Unclear

Inclusion criteria: Singleton healthy term infants (between 37-42 weeks gestation), appropriate weight for GA after a healthy pregnancy Exclusion criteria: NR Enrolled/Completed: n=98/83 Mean Age: • Maternal: NR • Child: NR 

Supplemented formula (DHA+high EPA) (n=23) vs. supplemented (DHA +low EPA) (n=24) vs. crtl formula (n=22) vs. HM (RS) (n=15) 

DHA 0.45%, EPA 0.35%, AA 0.05% vs. DHA 0.45% vs. EPA 0.10%, AA 0.05% vs. no DHA or EPA or AA for 6 wks 

• RB

PUFAs cogrowth: S between ∆ 

& RBC EP

Helland, 2001 

Norway 

{111,39} 

 RCT 

Parallel Double-blind 

 Jadad 

total: 4 [Grade: A] 

 Schul

z: Unclear 

Inclusion criteria: Healthy women with single pregnancies between 19 to 35 y of age, & nulli or primipara who intended to BF their infants & none have taken any supplements of n-3 fatty acids earlier during the pregnancy Exclusion criteria: Premature births, birth asphyxia, infections & anomalies in the infants requiring special attention Enrolled/Completed: n=590/341 Mean Age • Maternal: cod liver oil SD = 

28.6 (3.4) y, corn oil SD = 27.6 (3.2) y; 

• Child: cod liver oil GA SD = 

279.6 (9.2) d; corn oil SD = 279.2 (9.3) d 

Cod liver oil (n=301) vs. corn oil (n=289) 

10 mL/d oil (1183 mg DHA, 803 mg EPA, 27.5 mg AA /10 ml) from entry to 3 mo after delivery 

• Du

gestation: 

• Bi

HC: NS in L, & HC (g2) 

• G

patterns: Ngps in wt, wks & 3, 6

• Fa

novelty pr(Fagan temo 

• EE

scores bemo) 

• K-

liver oil > Processinscore than 

h = hour(s); d = day(s); wk(s) = week(s); mo = month; y = year; n = number of participants; NR = not reported; hx = history; tx = treatmenformula fed; BF = breast fed; HM = human milk ; PMA = postmenstrual age; ERG = electroretinogram; RCT = randomized control trial; R

triglycerides; LCPUFA = long chain polyunsaturated fatty acids; BMK = biomarkers in blood or other tissues; US = United States; PCA = 

gammalinolenic acid; DHA = docosahexaenoic acid; AA = arachidonic acid; EPA = eicosapentanoic acid; K-ABC = Kaufman assessmenphosphatidylcholine; PE = Phosphatidylethanolamine; HC = head circumference; EEG = electroencephalogram; S = statistically significanonsignificant statistical difference; gp(s) = group(s); RBC = red blood cells; ctrl(s) = control(s); HC = head circumference; wt = weight; L 
E – 20 

Table 1: Randomized controlled trial evidence for omega-3 fatty acids in child and maternal health (cont’d) 

Author, 

Year, 

Location Study Design 

Population 

Characteristics 

Intervention/ 

comparators 

Timing & Dose 

of intervention 

(if appropriate) Clinical Outcom

Hoffman, 

2003, 

US 

{2958} 

 RCT 

Parallel 

 Jada

d total: 3 [Grade:B] 

 Schu

lz: Adequate 

Inclusion criteria: Singleton term infants & infants with BW appropriate for GA Exclusion criteria: Family hx of milk-protein allergy, genetic or familial eye disease, vegetarian or vegan maternal diet, maternal metabolic disease, maternal anemia, maternal infection, congenital malformation or infection, & any perinatal event that resulted in NICU Enrolled/Completed: n=68/61 

Mean Age: • Maternal: NR • Child: 4-6 mo

Supplemented formula (DHA+AA derived from SCO) (n=33) vs. crtl formula (n=35) 

LCPUFA formula (0.36 wt% DHA, 0.72 wt% AA) after weaning at 4-6 mo to 12 mo of age 

• VEP: S b

VEP & DHA+AA 

• Acuity ca

NS DHA+AA & F12 mo 

• Growth p

wt, L, HC, wt-for-mo 

• BMK: S b

VEP at 12 mo & R3, n-3/n-6, DHA/Dunsaturation indesweep VEP at 12 AA; NS FPL & RB

Innis, 

1997, 

US, Canada 

{374} 

 RCT 

Parallel 

 Jada

d total: 2 [Grade: C] 

 Schu

lz: Unclear 

Inclusion criteria: Full term healthy infants (37-41 wk), with a BW > 2,500g to< 4500g, < 14 d old, mother had chosen to either exclusively BF or FF for 3 mo Exclusion criteria: BF infants recieving formula later than 6 d after birth; infants with congenital problems or disease considered likely to interfere with normal feeding or nutrient metabolism; with feeding intolerance; poor milk or formula intake; or with abnormal eye exam (as judged by infant's physician) Enrolled/Completed: n=238/191 

Mean Age: • Maternal: NR • Child: NR

Formula 1 (cow milkprotein based) (n=69) vs. Formula 2 (cow milkprotein based) (n=70) vs. HM (n=99) 

Formula 1 (18.0% LA, 1.9% ALA, with LA/ALA ratio of 9.5:1) & Formula 2 (34.2% LA, 4.7% ALA, with an LA/ALA ratio of 7.3:1) for 3 mo 

• Acuity ca

FPL at 90 d of ag

• Growth p

wt, L, & HC at 3 m

• BMK: NS 

plasma & RBC C

h = hour(s); d = day(s); wk(s) = week(s); mo = month; y = year; n = number of participants; NR = not reported; hx = history; tx = treatmenformula fed; BF = breast fed; HM = human milk ; S = significant; PMA = postmenstrual age; ERG = electroretinogram; RCT = randomize

standard; TG = triglycerides; VEP = visual evoked potential; LCPUFA = long chain polyunsaturated fatty acids; NIH = National Institute opreferential looking; BMK = biomarkers in blood or other tissues; US = United States; DHA = docosahexaenoic acid; AA = arachidonic ac

acid; LA = linoleic acid; ALA = 

α-linolenic acid; SCO = single cell oil; NIC = neonatal intensive care; S = statistically significant difference

difference; gp(s) = group(s); RBC = red blood cells; ctrl(s) = control(s); HC = head circumference; wt = weight; L = length; NICU = neonabirth weight 
E – 21 

Table 1: Randomized controlled trial evidence for omega-3 fatty acids in child and maternal health (cont’d) 

Author, 

Year, 

Location Study Design 

Population 

Characteristics 

Intervention/ 

comparators 

Timing & Dose 

of intervention 

(if appropriate) Clinical Outcome

Innis, 

2002, 

Canada, 

US 

{80,2279} 

 RCT 

Parallel Double-blind 

 Jadad 

total: 3 [Grade: B] 

 Schul

z: Unclear 

Inclusion criteria: Healthy VLBW (846-1,560g) FF preterm infants Exclusion criteria: Preterm infants SGA, >24 days postnatal age when full enteral feeds ≥375 kJ/kg/day achieved, had necrotizing enterocolitis or other gastrointestinal disease, impaired visual or ocular status, or a hx of underlying disease or congenital malformation that could interfere with growth Enrolled/Completed: n=194/121

Mean Age: • Maternal: NR • Child: NR 

DHA+AA formula (SCO) (n=66) vs. DHA formula (n=66) vs. crtl fornula (n=62) 

LCPUFA formula (0.14% DHA + 0.27%AA or 0.15% DHA) for at least 28 d, then unsupplemented term formula to 57 wks PMA 

• Growth patt

in DHA+AA than in PMA; SÏ wt, L, wt-

DHA+AA than in DHPMA; SÏ wt, wt-to-

than in crtl at 48 wk HC at 48, 57 wks P

• Teller acuity 

procedure: NS in FPacuity at 48 & 57 w

• BMK: S (+) 

between ∆ wt & RB

wks; S (+) correlatiowt, L & RBC PE AA 

h = hour(s); d = day(s); wk(s) = week(s); mo = month; y = year; n = number of participants; NR = not reported; hx = history; tx = treatmenformula fed; BF = breast fed; HM = human milk ; S = significant; PMA = postmenstrual age; RCT = randomized control trial; LCPUFA = l

acids; VLBW = very low birth weight; US = United States; DHA = docosahexaenoic acid; AA = arachidonic acid; EPA = eicosapentanoic 

PMA = postmenstrual age; S = statistically significant difference; NS = nonsignificant statistical difference; gp(s) = group(s); RBC = red b

HC = head circumference; wt = weight; L = length; SGA = small for gestational age; PE = Phosphatidylethanolamine; FPL = forced-choi
E – 22 

Table 1: Randomized controlled trial evidence for omega-3 fatty acids in child and maternal health (cont’d) 

Author, 

Year, 

Location Study Design 

Population 

Characteristics 

Intervention/ 

comparators 

Timing & Dose 

of intervention 

(if appropriate) Clinical Outcome

Jensen, 

1997, 

US 

{350,82} 

 RCT 

Parallel 

 Jadad 

total: 2 [Grade: C] 

 Schul

z: Unclear 

Inclusion criteria: Healthy full term infants whose mothers had elected not to breast feed Exclusion criteria: NR Enrolled/Completed: n=80/63 

Mean Age: • Maternal: NR • Child: Formula 1 GA = 39.8 ± 

1.4 wk; Formula 2 GA = 39.6 ± 1.8 wk; Formula 3 GA = 39.6 ± 2.0 wk; Formula 4 GA = 39.6 ± 1.5 wk; BF GA = 40.2 ± 1.2 wk

Formula 1 (CSHPCo) (n=20) vs. Formula 2 (CSHPCo) (n=20) vs. Formula 3 (CSHPCo) (n=20) vs. Formula 4 (CSHPCo) (n=20) 

Formula 1 (15.6% -17.6% LA, 0.4% ALA); Formula 2 (15.6% -17.6% LA, 1% ALA); Formula 3 (15.6% -17.6% LA, 1.7% ALA); Formula 4 (15.6% -17.6% LA, 3.2% ALA) for 4 mo 

• Growth patt

in F4 than in F1 at 4 HC, TST, & SST at 

• VEP: NS la

among gps at 120 & amplitude VEP amo& 240 d 

• BMK: S (+) 

between wt at 4 mo at 120d; NS correlawt & plasma n-3 at correlation between & PDI; NS correlatioRBC DHA & PDI; NRBC PL DHA & am& 240 d 

• Bayley’s: N

MDI at 12 mo 

h = hour(s); d = day(s); wk(s) = week(s); mo = month; y = year; n = number of participants; hx = history; tx = treatment; GA = gestational 

human milk ; S = significant; RCT = randomized control trial; VEP = visual evoked potential; LCPUFA = long chain polyunsaturated fatty weight; US = United States; DHA = docosahexaenoic acid; AA = arachidonic acid; EPA = eicosapentanoic acid; PMA = postmenstrual aSafflower, High oleic sunflower, Palm starin, Coconut oils; LA = linoleic acid; ALA = α-linolenic acid; GI = gastrointestinal; S = statistically 

nonsignificant statistical difference; gp(s) = group(s); RBC = red blood cells; ctrl(s) = control(s); HC = head circumference; wt = weight; L developmental index; PDI = psychomotor developmental index 
E – 23 

Table 1: Randomized controlled trial evidence for omega-3 fatty acids in child and maternal health (cont’d) 

Author, 

Year, 

Location Study Design 

Population 

Characteristics 

Intervention/ 

comparators 

Timing & Dose of 

intervention (if 

appropriate) 

Clinical 

Re

Jensen, 1999, 

US 

{240} 

 RCT 

Parallel 

 Abstr

act 

Inclusion criteria: Healthy full term infants Exclusion criteria: NR Enrolled/Completed: n=126/NR Mean Age: • Maternal: NR • Child: NR 

algal DHA (n=42) vs. fish oil derived DHA (n=42) vs. Crtl grp. (n=42) 

Breast-feeding maternal intake of 200-250 mg DHA/d for 4 mo after delivery 

• Tr

(120 & 24delivery): latency & acuity 

• Te

Card Proc

• G

patterns: NHC at 4-8 

• BM

correlation function & PL DHA a

Jorgensen, 

1996, 1998, 

Denmark 

{1159} 

 RCT 

Parallel 

 Jadad 

total: 2 [Grade: C] 

 Schul

z: unclear 

Inclusion criteria: For FF & BF infants; uncomplicated pregnancy, term delivery (GA 37-42 weeks); BW between 2700 & 4500g; Apgar score >7 after 5 min & no neonatal diseases. For FF infants, termination of BF prior to 30 days of age without using a DHA supplemented formula. Exclusion criteria: Infant hospitalization; serious illness during the study period; formula intolerance (vomiting/diarrhea) Enrolled/Completed: n=39/37 Mean Age: • Maternal: NR • Child: Gp 1 (DHAGF) = 25.8 

d; Gp 2 (DHAF) = 23.8 d; gp 3 (STF) = 22.5 d 

Formula 1 (DHA+EPA -fish oil) (n=15) vs. Formula 2 (DHA+EPA, -fish oil, & GLA - borage oil) (n=13) vs. Crtl formula (n=11) vs. HM (RS) (n=17) 

Formula 1 (0.3wt% DHA, 0.4wt% EPA); Formula 2 (0.3wt% DHA, 0.4wt% EPA, 0.5wt% GLA) for 3 mo 

• S

NS effect visual acu

• G

patterns: NHC, GV at 

• BM

acuity at 4 DHA, EPAcorrelation & RBC CP

NRICGP = National Research Initiative Competitive Grants Program; h = hour(s); d = day(s); wk(s) = week(s); mo = month; y = year; n = 

not reported; hx = history; tx = treatment; GA = gestational age; FF = formula fed; BF = breast fed; HM = human milk ; S = significant; PMrandomized control trial; VEP = visual evoked potential; LCPUFA = long chain polyunsaturated fatty acids; BW = birth weight; US = Unitegammalinolenic acid; DHA = docosahexaenoic acid; AA = arachidonic acid; EPA = eicosapentanoic acid; SCO = single cell oil; PMA = pacid; ALA = α-linolenic acid; GI = gastrointestinal; S = statistically significant difference; NS = nonsignificant statistical difference; gp(s) = cells; ctrl(s) = control(s); HC = head circumference; wt = weight; L = length; BMK = biomarkers correlations 
E – 24 

Table 1: Randomized controlled trial evidence for omega-3 fatty acids in child and maternal health (cont’d) 

Author, 

Year, 

Location Study Design 

Population 

Characteristics 

Intervention/ 

comparators 

Timing & Dose of 

intervention (if 

appropriate) 

Clinical 

Re

Koletzko, 

1995, 

Germany 

{455} 

 RCT 

Parallel Double-blind 

 Jadad 

total: 2 [Grade: C] 

 Schul

z: Unclear 

Inclusion criteria: Healthy preterm infants with BW ≤1850 a /= 130 ml milk/ Kg /day Exclusion criteria: Need for artificial ventilation or an oxygen supply with FiO2 > 0.30 at the time of enrollment or during the study; apparent GI, hepatic, & metabolic abnormalities; & septicemia Enrolled/Completed: n=27/27 

Mean Age: • Maternal: NR • Child: BF SD GA = 32.6 wk 

(1.9); FF no LCPUFA SD GA = 34.2 wk (2.3); FF+ LCPUFA SD GA = 33.8 wk (1.9)

LCPUFA Prematil (Milupa) formula (egg-lipid, evening primrose oil) (n=9) vs. Crtl formula (n=10) vs. HM (RS) (n=8) 

LCPUFA formula (0.5 % AA, 0.03% EPA, 0.3% DHA, vitamin E 20 mg/L) for 3 wks 

• G

patterns: NHC at 3 w

• Vi

Teller’s tedifference acuity acr

Koletzko, 

2003, 

Germany 

{940} 

 RCT 

Parallel Double-blind 

 Jadad 

total: 3 [Grade: B] 

 Schul

z: Unclear 

Inclusion criteria: Preterm infants in stable condition with BW < 1800g Exclusion criteria: Artificial ventilation or oxygen supply with FiO2 > 0.3 at time of enrollment & presence of genetic GI or metabolic disorders. Enrolled/Completed: n=49/33 Mean Age: • Maternal: NR • Child: full PCA = 35 ± 2 wk; 

crtl BF = 26±14 d; FF 39 ± 22 d; F + LCPUFA-F = 39 ± 24 d

LCPUFA formula (egg, black currant seed oil, low EPA fish oil) (n=15) vs. crtl formula (n=15) vs. HM (RS) (n=19) 

0.57 mol DHA+ 0.1 mol AA formula + vitamin E during 28 d 

• G

patterns: Nat 28 d 

NRICGP = National Research Initiative Competitive Grants Program; h = hour(s); d = day(s); wk(s) = week(s); mo = month; y = year; n = 

not reported; hx = history; tx = treatment; GA = gestational age; FF = formula fed; BF = breast fed; HM = human milk; RCT = randomized chain polyunsaturated fatty acids; BW = birth weight; DHA = docosahexaenoic acid; AA = arachidonic acid; EPA = eicosapentanoic acid= linoleic acid; GI = gastrointestinal; S = statistically significant difference; NS = nonsignificant statistical difference; gp(s) = group(s); ctrl

circumference; wt = weight; L = length; RS = reference standard; PCA = postconceptional age 
E – 25 

Table 1: Randomized controlled trials evidence for omega-3 fatty acids in child and maternal health (cont’d) 

Author, 

Year, 

Location Study Design 

Population 

Characteristics 

Intervention/ 

comparators 

Timing & Dose of 

intervention (if 

appropriate) 

Clinical 

Re

Laivuori, 

1993, Finland 

{547} 

 RCT 

parallel design 

 Jadad 

total: 2 [Grade: C] 

 Schulz: 

Adequate 

Inclusion criteria: Preeclamptic women admitted to hospital between 26 & 37 wks of gestation Exclusion criteria: NR Enrolled/Completed: n=18/12 Mean Age: • Maternal: Primerose oil = 32 

y (23-40), Fish oil = 30.3 y (24-40), Placebo = 30.2 y (26-32) 

• Child: NR

MaxEPA (fish oil) (n=3) vs. Preglandin (primrose oil) (n=4) vs. placebo (maize oil, olive oil) (n=5) 

Max EPA (180 mg EPA, 120 mg DHA, 680 mg fish oils), Preglandin (375 mg LA, 45 mg GLA), placebo (500 mg each oil); 10 capsules 

• Ef

proteinuria NS (grp 1 

Lapillone, 

1997, France 

{1760} 

 RCT Parallel 

 Abstr

act 

Inclusion criteria: Preterm infants appropriate for GA, (29.3 wk) Exclusion criteria: NR Enrolled/Completed: n=33/NR Mean Age: • Maternal: NR • Child: GA = 29.3 ±1.6 wk

LCPUFA formula (DHA+AA derived from fish oil) (n=16) vs. Crtl formula (n=17) 

LCPUFA preterm formula (0.37wt% DHA, 0.05wt% EPA) until 40 wk CA, then LCPUFA term formula (0.45wt% DHA, 0.09wt% EPA) until 4 mo CA 

• G

patterns: Nmo CA 

Lapillonne, 

2000, 

France 

{1621} 

 RCT 

Parallel 

 Jada

d total: 1 [Grade: C] 

 Schu

lz: Unclear 

Inclusion criteria: Term infants appropriate for GA & born with a BW of > 2800g; free of neonatal morbidity Exclusion criteria: Hx of maternal cocaine or alcohol abuse, or born to mothers with a hx of diabetes, hyperlipidaemia, abnormal dietary pattern (strict vegetarian or vegan) Enrolled/Completed: n=NR/24 Mean Age • Maternal: NR • Child: GA = 40.1 ± 0.8 wk; 

LCPUFA formula (DHA+EPA+AA derived from fish oil) (n=12) vs. Crtl formula (n=12) 

LCPUFA formula (0.31wt% DHA, 0.08wt% EPA, 0.03wt% AA) from 3 d to 4 mo of age 

• G

patterns: S

than in LCat 4mo; N2, 4 mo 

 h = hour(s); d = day(s); wk(s) = week(s); mo = month; y = year; n = number of participants; NR = not reported; hx = history; tx = treatme

formula fed; BF = breast fed; HM = human milk ; RCT = randomized control trial; LCPUFA = long chain polyunsaturated fatty acids; BW docosahexaenoic acid; AA = arachidonic acid; EPA = eicosapentanoic acid; CA = corrected age; S = statistically significant difference; Ndifference; gp(s) = group(s); ctrl(s) = control(s); HC = head circumference; wt = weight; L = length; GP = growth patterns 
E – 26 

Table 1: Randomized controlled trials evidence for omega-3 fatty acids in child and maternal health (cont’d) 

Author, 

Year, 

Location Study Design 

Population 

Characteristics 

Intervention/ 

comparators 

Timing & Dose of 

intervention (if 

appropriate) 

Clinical 

Re

Lucas, 

1999, 

UK & 

Australia 

{270} 

 RCT 

Parallel Double-blind 

 Jada

d total: 5 [Grade: A] 

 Schu

lz: Adequate

Inclusion criteria: FF gp: women giving birth to healthy singletons of appropriate size for GA & of at least 37 wk gestation, mothers who decided on FF after birth; BF crtl gp: plan to BF for at least 6 wk Exclusion criteria: Congenital abnormalities affecting development; BF pts were excluded from analysis if BF< 6 mo Enrolled/Completed: n=447/354 Mean Age: • Maternal: FF Crtl = 27.5 ± 

5.23 y; FF LCPUFA = 27.0 ± 5.12 y; BF=30.6 ± 4.34 y 

• Child: NR 

LCPUFA (egg lipids) formula (n=154) vs. crtl formula (n=155) vs. HM (RS) (n=138) 

0.30% AA + 0.32% DHA formula from 1st wk age until 6 

mo 

• Ba

PDI: NS a

• Kn

PassamanSherrard’s KPS at 9 m

• G

patterns: NHC, MAC18 mo 

Makrides, 

1995, 

Australia 

{477} 

 RCT 

Parallel 

 Jadad 

total: 2 [Grade: C] 

 Schul

z: Unclear 

Inclusion criteria: Healthy infants of 37-42 weeks gestation, appropriate weight for gestation Exclusion criteria: Mothers with hx of lipid metabolism disorders, IDDM, drug or ETOH abuse Enrolled/Completed: n=89/79 Mean Age: • Maternal: NR • Child: fully BF GA = 39.8 wk; 

Partially BF GA = 39.7 wk; pb FF GA = 39.6 wk; Supplemented FF GA = 39.1wk

Supplemented formula (DHA+ EPA, derived from fish oil, and AA derived from primrose oil) (n=13*) vs. Crtl formula (n=19*) vs. HM (n=47*) 

LCPUFA formula (0.36 wt% DHA+0.58 wt% EPA+0.01 wt% AA); 

• G

patterns: NHC at 6, 1

• VE

improved of DHA+Gwk 

• BM

correlation LCPUFA & correlation VEP acuitwks of age 

h = hour(s); d = day(s); wk(s) = week(s); mo = month; y = year; n = number of participants; NR = not reported; hx = history; tx = treatmenformula fed; BF = breast fed; HM = human milk ; S = significant; PMA = postmenstrual age; RCT = randomized control trial; VEP = visua

long chain polyunsaturated fatty acids; GLA = gammalinolenic acid; DHA = docosahexaenoic acid; AA = arachidonic acid; EPA = eicosa

developmental index; PDI = psychomotor developmental index; S = statistically significant difference; NS = nonsignificant statistical differed blood cells; ctrl(s) = control(s); HC = head circumference; wt = weight; L = length; MAC = mid arm circumference; KPS = Knobloch, ETOH = alcohol abuse 
E – 27 

Table 1: Randomized controlled trials evidence for omega-3 fatty acids in child and maternal health (cont’d) 

Author, 

Year, 

Location Study Design 

Population 

Characteristics 

Intervention/ 

comparators 

Timing & Dose of 

intervention (if 

appropriate) 

Clinical 

Re

Makrides, 

1999, 

Australia {229,213} 

 RCT 

Parallel double-blind 

 Jadad 

total: 5 [Grade: A] 

 Schul

z: Adequate 

Inclusion criteria: Healthy white term infants Exclusion criteria: SGA, evidence of congenital disease, mother had IDDM or hx of drug or ETOH abuse Enrolled/Completed: n=146/114 • Mean Age:

• Maternal: NR • Child: PB formula GA = 39.6 

± 1.5 wk; DHA formula GA = 39.6 ± 1.1 wk; DHA+ AA formula GA = 39.8 ± 1.3 wk; BF GA = 39.3 ± 1.4 wk

DHA + AA formula (tuna oil, egg-PL) (n=28) vs. DHA formula (n=27) vs. crtl formula (n=28) vs. HM (RS) (n=63) 

DHA+AA formula (0.34%DHA + 0.34%); DHA formula (0.35% DHA) during 12 mo; 

• G

patterns: NHC at 6, 1& 24 mo 

• BM

correlation DHA at 16 12 mo & 2correlation at 12 mo & levels at 1with MDI 

• VE

acuity at 1

• Ba

MDI & PDmo 

Makrides, 

2000, 

Australia {220,109} 

 RCT 

Parallel 

 Jadad 

total: 5 [Grade: A] 

 Schul

z: Adequate 

Inclusion criteria: White term infants Exclusion criteria: SGA; evidence of congenital disease; mother had diabetes requiring insulin; or a hx of drug or ETOH abuse Enrolled/Completed: n=176/145 Mean Age: • Maternal: NR • Child: full NBD (formula LA : 

ALA) 10:1 GA = 39.4 ± 1.2 wks; 5:1 GA = 39.2 ± 1.3 wk; BF GA = 39.5 ± 1.1 wk

Formula 10:1 (FAs from CSHPCo) (n=36) vs. Formula 5:1 (FAs from CSHPCo) (n=37) vs. HM (n=103) 

Formula 10:1 (16.9 wt% LA, 1.7 wt% ALA); Formula 5:1 (16.6 wt% LA, 3.3 wt% ALA) from 4-6 d to 34 wk of age; 

• G

patterns: N

L, ∆ HC b

& 5:1-F at wks; SÏ w

L at 16 wk

• VE

acuity at 1

h = hour(s); d = day(s); wk(s) = week(s); mo = month; y = year; n = number of participants; NR = not reported; hx = history; GA = gestatio

human milk ; S = significant; PMA = postmenstrual age; RCT = randomized control trial; VEP = visual evoked potential; LCPUFA = long 

acids; DHA = docosahexaenoic acid; AA = arachidonic acid; LA = linoleic acid; ALA = α-linolenic acid; PL = phospholipids; CSHPCo = C

sunflower, Palm starin, Coconut oils; MDI = mental developmental index; PDI = psychomotor developmental index; IDDM = insulin depe

= alcohol abuse; S = statistically significant difference; NS = nonsignificant statistical difference; gp(s) = group(s); ctrl(s) = control(s); HC 

weight; L = length 
E – 28 

Table 1: Randomized controlled trial evidence for omega-3 fatty acids in child and maternal health (cont’d) 

Author, 

Year, 

Location Study Design 

Population 

Characteristics 

Intervention/ 

comparators 

Timing & Dose of 

intervention (if 

appropriate) 

Clinical 

Re

Malcolm, 

2003, 

UK 

{12} 

 RCT 

Parallel Double-blind 

 Jadad 

total: 3 [Grade: B] 

 Schul

z: Unclear 

Inclusion criteria: Mothers: women at approximately 15 wk of pregnancy; infants: healthy born > 36 wk gestation, with Apgar score of >7 at 5 m &with no visual, medical or developmental disorders Exclusion criteria: Mothers: diabetes, twin pregnancies, k pre-eclampsic toxemia, hx of abruption or postpartum hemorrhage, allergy to fish products, or a thrombophilic tendency or those receiving drugs affecting thrombocyte function Enrolled/Completed: • Mothers: n=100/63 • Child: n=60/56 Mean Age:• Maternal: NR • Child: fish oil = 279.7 (9.5) d, 

pb = 279.6 (8.5) d

Maternal LCPUFA supplementation capsules (from fish oil) (n=50) vs. Placebo capsules (n=50) 

LCPUFA capsules (40.4 wt% DHA, 7.2 wt% EPA) from 15 wk of pregnancy until delivery 

• Du

gestation: 

• G

patternss: wt, L & HC 

• ER

in b wave NS in Nakfunction; N

NS in maxcombined 

• BM

correlation combined blood DHAcorrelation cord blood correlation 

cord RBC DHA & tot6/n-3; S clog δ & coquartiles ototal n-3 L

h = hour(s); d = day(s); wk(s) = week(s); mo = month; y = year; n = number of participants; NR = not reported; hx = history; tx = treatmenelectroretinogram; RCT = randomized control trial; LCPUFA = long chain polyunsaturated fatty acids; UK = United Kingdom; GLA = gam

docosahexaenoic acid; AA = arachidonic acid; EPA = eicosapentanoic acid; LA = linoleic acid; ALA = α-linolenic acid; GI = gastrointestinstatistically significant difference; NS = nonsignificant statistical difference; gp(s) = group(s); RBC = red blood cells; ctrl(s) = control(s); H

weight; L = length 
E – 29 

Table 1: Randomized controlled trial evidence for omega-3 fatty acids in child and maternal health (cont’d) 

Author, 

Year, 

Location Study Design 

Population 

Characteristics 

Intervention/ 

comparators 

Timing & Dose of 

intervention (if 

appropriate) 

Clinical 

Re

Martinez, 

1999, Brazil 

{2258} 

 RCT 

Parallel 

 Jadad 

total: 1 [Grade: C] 

 Schul

z: Unclear 

Inclusion criteria: GA betweeen 28 & 34 weeks BW between 900g- 1500g, on enteral feeding for 2 days before the beginning of the study Exclusion criteria: Congenital anomalies; requirements of special care such as sepsis, hyaline membrane disease, patent ductus arteriosus, need for ventilatory support or O2 supplementation

Enrolled/Completed: n=58/NR Mean Age: • Maternal: NR • Child: BF = 15.8 ± 1.2 d; FF 

= 18.0 ± 2.1 d; FF+ LCPUFA = 12.8 ± 1.0 d

LCPUFA formula (Egg-TG & primrose oil) (n=20) vs. crtl formula (n=20) vs. HM (n=18) 

LCPUFA formula (NR) for 1 mo 

• G

patterns: NHC at 30 d 

McClead, 

1985, US 

{2550} 

 RCT 

Parallel 

 Jadad 

total: 3 [Grade: B] 

 Schul

z: Unclear 

Inclusion criteria: Infants in NICU requiring TPN for at least 7 days Exclusion criteria: Medical conditions that precluded IV fat therapy (e.g. severe hyperbilirubinemia, respiratory distress, thrombocytopenia) Enrolled/Completed: n=23/20 

Mean Age: • Marternal: NR • Child: NR 

Modified Liposyn 20% (high ALA) (n=10) vs. Liposyn 20% (low ALA) (n=10) 

IV ALA 3 (SD: 1.5)% safflower oil emulsion vs. IV ALA 0.1% safflower oil emulsion for 13 d 

• Sa

h = hour(s); d = day(s); wk(s) = week(s); mo = month; y = year; n = number of participants; NR = not reported; hx = history; tx = treatmenformula fed; BF = breast fed; HM = human milk ; S = significant; PMA = postmenstrual age; RCT = randomized control trial; LCPUFA = l

acids; BW = birth weight; US = United States; GLA = gammalinolenic acid; DHA = docosahexaenoic acid; AA = arachidonic acid; EPA = linoleic acid; ALA = α-linolenic acid; IV = intravenous; NICU = neonatal intensive care unit; TPN = total parental nutrition; S = statistically 

nonsignificant statistical difference; gp(s) = group(s); ctrl(s) = control(s); HC = head circumference; wt = weight; L = length; SD = standa
E – 30 

Table 1: Randomized controlled trial evidence for omega-3 fatty acids in child and maternal health (cont’d) 

Author, 

Year, 

Location Study Design 

Population 

Characteristics 

Intervention/ 

comparators 

Timing & 

Dose of 

intervention 

(if 

appropriate) Clinical Outcomes 

Morris, 2000, 

UK 

{2231} 

 RCT 

Parallel Double-blind 

 Jadad 

total: 3 [Grade: B] 

 Schul

z: Unclear 

Inclusion criteria: Term infants whose mothers had decided to bottle feed with BW between 2.5-4.5 kg up to age 72 h Exclusion criteria: Major congenital abnormalities & infants from multiple pregnancies Enrolled/Completed: n=140/109 

Mean Age: • Maternal: NR • Child: NR

LCPUFA formula (DHA+AA, from Egg-TG) (n=55*) vs. Crtl formula (n=54*) 

LCPUFA formula (0.2 wt% DHA, 0.4 wt% AA) for 12 wk 

• Growth patter

in DHA at 6 wk & 3 mmo & 12 mo; NS in wtTST at 6 & 12 wk, 6 & 

h = hour(s); d = day(s); wk(s) = week(s); mo = month; y = year; n = number of participants; NR = not reported; hx = history; tx = treatmenformula fed; BF = breast fed; HM = human milk ; S = significant; RCT = randomized control trial; LCPUFA = long chain polyunsaturated f

Kingdom; GLA = gammalinolenic acid; DHA = docosahexaenoic acid; AA = arachidonic acid; EPA = eicosapentanoic acid; LA = linoleic a

NICU = neonatal intensive care unit; * = completers; S = statistically significant difference; NS = nonsignificant statistical difference; gp(s

HC = head circumference; wt = weight; L = length; MAC = mid arm circumference; SST = subscapular skinfold thickness; TG = triglycer
E – 31 

Table 1: Randomized controlled trial evidence for omega-3 fatty acids in child and maternal health (cont’d) 

Author, 

Year, 

Location Study Design 

Population 

Characteristics 

Intervention/ 

comparators 

Timing & Dose 

of intervention 

(if appropriate) Clinical Outcome

O'Connor, 

2001, 2003, 

US, UK, Chile 

{126,1507} 

 RCT 

Parallel Doublemasked 

 Jadad 

total: 3 [Grade: B]; 

 Schul

z: Unclear 

Inclusion criteria: Initiation of enteral feeding by 28th d 

of life; singleton & twin births, SGA Exclusion criteria: Serious congenial abnormalities affecting growth & development; major surgery before randomization; perivenricular/ intraventricular hemorrhage > Grade II; maternal incapacity; liquid ventilation’ asphyxia resulting in severe & permanent neurologic damage, or uncrtlled systemic infection at the time of enrollment Enrolled/Completed: n=470/376 Mean Age: • Maternal: FF-crtl = 27.2 y, 

FF-fish/fungal = 27.0 y, FF-eggTG/fish = 27.0 y, HM = 29.7 y 

• Child: GA wk (postnatal 

age d): FF-crtl = 29.6 wk (5.5 d), FF-fish/fungal = 29.8 wk (5.0 d), FF-egg-TG/fish = 29.7 (4.6 d), HM = 29.7 (5.5 d)

DHA+AA (fish/fungal) (n=140)/ vs. DHA+AA (egg-TG/fish) (n=143)/ vs. Crtl formula (n=144) vs. HM (RS) (n=43) 

NR dose, Inhospital preterm formula until discharge, then postdischarge formula until 12 mo CA 

• Growth patt

wt, ∆ L, ∆ HC at 8 w

mo CA 

• Teller Acuit

Procedure: NS in Fmo CA 

• VEP: S ÏV

grps1-2 vs. grp3 at VEP acuity across bgrps 

• Bayley’s: S

in <1,250 g birth wt (egg-TG/fish) than cscore crtl or AA+DH(fish/fungal) gps; NS MDI (12 mo) 

• Fagan: M n

preference look (FaAA+DHA (egg-TG/fAA+DHA (fish/funga

• MacArthur 

Communicative DevInventories (9, 14 m

• BMK: S (+) 

rate wt gain & RBC d; wt & L S correlateAA at 28 d 

h = hour(s); d = day(s); wk(s) = week(s); mo = month; y = year; n = number of participants; NR = not reported; hx = history; tx = treatmenformula fed; BF = breast fed; HM = human milk ; RCT = randomized control trial; LCPUFA = long chain polyunsaturated fatty acids; UK = docosahexaenoic acid; AA = arachidonic acid; S = statistically significant difference; NS = nonsignificant statistical difference; gp(s) = gro

ctrl(s) = control(s); HC = head circumference; wt = weight; L = length; MDI = mental developmental index; PDI = psychomotor developm

standard 
E – 32 

Table 1: Randomized controlled trial evidence for omega-3 fatty acids in child and maternal health (cont’d) 

Author, 

Year, 

Location Study Design 

Population 

Characteristics 

Intervention/ 

comparators 

Timing & Dose of 

intervention (if 

appropriate) 

Clinical Ou

Resu

Olsen, 1992, 

Dalby Salvig, 

1996, 

Denmark 

{614,425,531} 

 RCT 

Parallel Double-blind 

 Jada

d total: 2 [Grade: C] 

 Schul

z: Inadequate 

Inclusion criteria: All women scheduled to attend for a routine wk 30 GA midwife assessment Exclusion criteria: Hx of placental abruption in previous pregnancy; seroius bleeding episode in the present pregnancy; regular use of prostaglandin inhibitors; multiple pregnancy; allergy to fish & regular intake of fish oil Enrolled/Completed: n=533/402 Mean Age: • Maternal: fish oil=29.4 y 

(4.4); olive oil= 29.7 y (4.3); ctrl=29.1 y (4.1) 

• Chid: NR

Fish oil (n=266) vs. placebo (olive oil) (n=136) vs. no oil (n=131) 

4 capsules/d of 1 g gelatine capsules with fish oil (Pikasol fish oil: 32% EPA, 23% DHA, 2 mg vit E); 2.7 g n-3 FA/d until delivery 

• Du

of gestatio

GA in fish 

• Bi

weight: NS wt 

• BP 

(baseline; 37, 39 & wdelivery): BP or rateGHT & preeclamp1 vs. grps in BP (grp grps 2-3) 

GCRC = General Clinical Research Centers; h = hour(s); d = day(s); wk(s) = week(s); mo = month; y = year; n = number of participants; tx = treatment; GA = gestational age; FF = formula fed; BF = breast fed; HM = human milk ; S = significant; RCT = randomized control trpolyunsaturated fatty acids; GLA = gammalinolenic acid; DHA = docosahexaenoic acid; AA = arachidonic acid; EPA = eicosapentanoic a

linolenic acid; BP = blood pressure; S = statistically significant difference; NS = nonsignificant statistical difference; gp(s) = group(s); ctrl(
E – 33 

Table 1: Randomized controlled trial evidence for omega-3 fatty acids in child and maternal health (cont’d) 

Author, 

Year, 

Location Study Design 

Population 

Characteristics 

Intervention/ 

comparators 

Timing & Dose of 

intervention (if 

appropriate) 

Clinical Ou

Resu

Olsen, 2000, 

Denmark* 

{66} 

 RCT 

Parallel Design 

 Jada

d total: 2 [Grade: C] 

 Schu

lz: Adequate 

Inclusion criteria: Women > 16 wk of gestation with an uncomplicated pregnancy, hx preterm delivery (< 259 d of gestation) Exclusion criteria: Diabetes mellitus in or before pregnancy; diagnosed severe fetal malformation or hydrops in current pregnancy; suspicion in current pregnancy, or occurrence in an earlier pregnancy, of placental abruption; drug or alcohol abuse; regular intake of fish oil or of nonsteroidal antiinflammatory agents or other drugs affecting thrombocyte function or eicosanoid metabolism; allergy to fish products. In the therapeutic trials also high probability of delivering soon after randomization (estimated within one wk) Enrolled/Completed: n=232/228 Mean Age: • Maternal: fish oil = 29.3 y 

(4.87); olive oil = 30.0 y (6.22) 

• Child: GA = 131.8 d (24.6); 

GA = 130.5 d (27.7)

Fish oil (Pikasol) (n=110) vs. placebo (Olive oil) (n=122) 

4 gelatine capsules/d, 32% EPA, 23% DHA, 2mg vit E; 2.7 g of LCPUFA/d 

• Pr

delivery: S

in fish oil g% prematdeliveries oil gp 

• Bi

weight: SÏ 

wt in fish oIUGR

GCRC = General Clinical Research Centers; h = hour(s); d = day(s); wk(s) = week(s); mo = month; y = year; n = number of participants; tx = treatment; GA = gestational age; FF = formula fed; BF = breast fed; HM = human milk ; S = significant; RCT = randomized control trpolyunsaturated fatty acids; GLA = gammalinolenic acid; DHA = docosahexaenoic acid; AA = arachidonic acid; EPA = eicosapentanoic a

linolenic acid; BP = blood pressure; * Scotland, Sweden, UK, Italy, The Netherlands, Norway, Belgium & Russia; S = statistically significa

nonsignificant statistical difference; gp(s) = group(s); ctrl(s) = control(s); IUGR = intrauterine growth retardation 
E – 34 

Table 1: Randomized controlled trial evidence for omega-3 fatty acids in child and maternal health (cont’d) 

Author, 

Year, 

Location Study Design 

Population 

Characteristics 

Intervention/ 

comparators 

Timing & Dose of 

intervention (if 

appropriate) 

Clinical Ou

Resu

Olsen, 2000, 

Denmark* 

{66} 

 RCT 

Parallel Design 

 Jada

d total: 2 [Grade: C] 

 Schu

lz: Adequate 

Inclusion criteria: Women > 16 wk of gestation with an uncomplicated pregnancy, hx IUGR (<5th PC) Exclusion criteria: NR Enrolled/Completed: n=280/263 Mean Age: • Maternal: NR • Child: NR

Fish oil (Pikasol) (n=141) vs. placebo (Olive oil) (n=139)

4 gelatine capsules/d, 32% EPA, 23% DHA, 2mg vit E; 2.7 g of LCPUFA/d

• Du

of gestatio

GA in fish 

• Re

e of IUGRweight: SÏ 

wt in olive % IUGR 

Olsen, 2000, 

Denmark* 

{66} 

 RCT 

Parallel Design 

 Jada

d total: 2 [Grade: C] 

 Schu

lz: Adequate 

Inclusion criteria: Women > 16 wk of gestation with hx GHT Exclusion criteria: NR Enrolled/Completed: n=386/350 

Mean Age: • Maternal: NR • Child: NR

Fish oil (Pikasol) (n=184) vs. placebo (Olive oil) (n=202)

4 gelatine capsules/d, 32% EPA, 23% DHA, 2mg vit E; 2.7 g of LCPUFA/d

• Du

of gestatioGA 

• Re

e GHT, preeclampin rates of preeclamp1 vs. grp 2BP (grp 1 2) 

Olsen, 2000, 

Denmark* 

{66} 

 RCT 

Parallel Design 

 Jada

d total: 2 [Grade: C] 

 Schu

lz: Adequate 

Inclusion criteria: Women > 16 wk of gestation with current twin pregnancy Exclusion criteria: NR Enrolled/Completed: n=579/569 Mean Age: • Maternal: NR • Child: NR

Fish oil (Pikasol) (n=289) vs. placebo (Olive oil) (n=290)

4 gelatine capsules/d, 32% EPA, 23% DHA, 2mg vit E; 2.7 g of LCPUFA/d

• Du

of gestatioGA 

• G

preeclampin rates of preeclamp1 vs. grp 2BP (grp 1 2) 

• IU

in birth wt IUGR 

GCRC = General Clinical Research Centers; h = hour(s); d = day(s); wk(s) = week(s); mo = month; y = year; n = number of participants; tx = treatment; GA = gestational age; FF = formula fed; BF = breast fed; HM = human milk ; S = significant; RCT = randomized control trpolyunsaturated fatty acids; GLA = gammalinolenic acid; DHA = docosahexaenoic acid; AA = arachidonic acid; EPA = eicosapentanoic a

linolenic acid; BP = blood pressure; * Scotland, Sweden, UK, Italy, The Netherlands, Norway, Belgium & Russia; PC = percentile; IUGR retardation; S = statistically significant difference; NS = nonsignificant statistical difference; gp(s) = group(s); ctrl(s) = control(s); GHT = g
E – 35 

Table 1: Randomized controlled trial evidence for omega-3 fatty acids in child and maternal health (cont’d) 

Author, 

Year, 

Location Study Design 

Population 

Characteristics (enrolled/evaluated) 

Intervention/ 

comparators 

Timing & Dose of 

intervention (if 

appropriate) 

Clinical Ou

Resu

Olsen, 2000, 

Denmark* 

{66} 

 RCT 

Prallel Design 

 Jada

d total: 2 [Grade: C] 

 Schu

lz: Adequate 

Inclusion criteria: Women > 16 wk of gestation, threatening preeclampsia current pregnancy Exclusion criteria: NR Enrolled/Completed: n=79/NR 

Mean Age: • Maternal: NR • Child: NR

Fish oil (Pikasol) (n=44) vs. placebo (Olive oil) (n=35) 

9 gelatine capsules/d, 32% EPA, 23% DHA, 2mg vit E; 6.1 g of LCPUFA/d

• Du

of gestatioGA 

Olsen, 2000, 

Denmark* 

{66} 

 RCT 

Parallel Design 

 Jada

d total: 2 [Grade: C] 

 Schulz: 

Adequate 

Inclusion criteria: Women > 16 wk of gestation, suspected IUGR (<10th PC in U/S) 

Exclusion criteria: NR Enrolled/Completed: n=63/NR Mean Age: • Maternal: NR • Child: NR

Fish oil (Pikasol) (n=36) vs. placebo (Olive oil) (n=27)

9 gelatine capsules/d, 32% EPA, 23% DHA, 2mg vit E; 6.1 g of LCPUFA/d

• Du

of gestatio

GA in fish 

• IU

birth weigbirth wt & 

Onwude, 1995, UK 

{480} 

 RCT 

Prallel Double-blind 

 Jada

d total: 5 [Grade: A] 

 Schu

lz: Adequate 

Inclusion criteria: Primigravida with abnormal Doppler at 24 wks GA; multigravida with hx of small babies (<PC 3), proteinuric or non-poteinuric GHT or unexplained stillbirth Exclusion criteria: Hx of diabetes, chronic hypertension, asthma, use of anticoagulants Enrolled/Completed: n=233/230 Mean Age: • Maternal: Fish Oil =26.8 y; 

pb =26.1 y 

• Child: NR 

Max EPA (EPA+ DHA form fish oil) (n=113) vs. placebo (olive oil)(n=119) 

2.7 g/d (EPA 180 mg, DHA 120 mg), 9 capsules/d until 38 wk GA 

• Du

of gestatioGA; NS in premature deliveries 

• Pr

or non-potGHT: NS GHT (grp 2) 

• IU

birth weigbirth wt & recurrence (grp 1 vs. 

GCRC = General Clinical Research Centers; h = hour(s); d = day(s); wk(s) = week(s); mo = month; y = year; n = number of participants; tx = treatment; GA = gestational age; FF = formula fed; BF = breast fed; HM = human milk ; S = significant; RCT = randomized control trpolyunsaturated fatty acids; GLA = gammalinolenic acid; DHA = docosahexaenoic acid; AA = arachidonic acid; EPA = eicosapentanoic a

linolenic acid; BP = blood pressure; * Scotland, Sweden, UK, Italy, The Netherlands, Norway, Belgium & Russia; PC = percentile; pb = psignificant difference; NS = nonsignificant statistical difference; gp(s) = group(s); ctrl(s) = control(s); IUGR = intrauterine growth retardatio
E – 36 

Table 1: Randomized controlled trial evidence for omega-3 fatty acids in child and maternal health (cont’d) 

Author, 

Year, 

Location Study Design 

Population 

Characteristics 

Intervention/ 

comparators 

Timing & Dose of 

intervention (if 

appropriate) 

Clinical 

Re

Ponder, 1992, 

US 

{1354} 

 RCT 

Parallel 

 Jadad 

total: 1 [Grade: C] 

 Schul

z: Unclear 

Inclusion criteria: Healthy term infants, 37-42 wk gestation, wt, L & HC btw 5-95th PC 

Exclusion criteria: NR Enrolled/Completed: n=NR/43 Mean Age: • Maternal: NR • Child: 3 d

Similac (soy) formula (n=11) vs. Similac (corn) formula (n=14) vs. HM (RS) (n=18) 

101-125 kcal/kg/d Soy: 4.8g ALA (n-3) vs. Corn: 0.8g ALA during 8 wks 

• G

patterns: NHC at 3d, 

Smuts, 2003, 

US 

{2896} 

 RCT 

Parallel 

 Jadad 

total: 2 [Grade: C] 

 Schul

z: Unclear 

Inclusion criteria: Between 24-28 wk pregnant; between ages of 16-35 yr at time of enrollment; were accessible by phone & planned to deliver at study hospital Exclusion criteria: Chronic illness, pregnancy induced hypertension, pre-eclampsia, pregnancy induced diabetes, or more than 4 prior pregnancies Enrolled/Completeed: n=73/53 Mean Age: • Maternal: low = 21.3 ± 4.8 y; 

regular = 24.8 ± 7.8 y; high 19.9 ± 4.1 y 

• Child: NR 

DHA-enriched eggs (n=18) vs. ordinary eggs (n=19) vs. placebo 

DHA-enriched eggs (135mg DHA/egg); ordinary eggs (18mg DHA/egg) from wk 24-28 until delivery 

• Du

gestation: high-DHA premature crtl (no p-v

• Bi

SGA: Wt, birth Ï in 2 (p-value

in grp 1 vsvalue: NR

h = hour(s); d = day(s); wk(s) = week(s); mo = month; y = year; n = number of participants; NR = not reported; hx = history; tx = treatmenformula fed; BF = breast fed; HM = human milk ; S = significant; RCT = randomized control trial; LCPUFA = long chain polyunsaturated f

gammalinolenic acid; DHA = docosahexaenoic acid; AA = arachidonic acid; EPA = eicosapentanoic acid; LA = linoleic acid; ALA = α-lino

PC = percentile; pb = placebo; HC = head circumference; S = statistically significant difference; NS = nonsignificant statistical difference

control(s); LBW = low birth weight 
E – 37 

Table 1: Randomized controlled trial evidence for omega-3 fatty acids in child and maternal health (cont’d) 

Author, 

Year, 

Location Study Design 

Population 

Characteristics 

Intervention/ 

comparators 

Timing & Dose of 

intervention (if 

appropriate) 

Clinical 

Re

Smuts, 

2003, 

US 

{31} 

 RCT 

Parallel Double-blind Jadad total: 3 [Grade: B] 

 Schul

z: Inadequate 

Inclusion criteria: Pregnant women 16-36 y of age, 24-28 wk of gestation at enrollment, able & willing to consume eggs, access to refrigeration, plan to deliver at Truman Medical Center, singleton gestation Exclusion criteria: <16 or >36 y of age, weight > 240 lb at baseline, serious illness such as cancer, lupus, hepatitis, serious infectious disease, diabetes or gestational diabetes at baseline, high BP attributed to any cause Enrolled/Completed: n=350/291 Mean Age: • Maternal: Ordinary eggs = 

21.6 y (4.2); High-DHA eggs = 21.y Y(4.3) 

• Child: Ordinary eggs = 271.6 

d (15.6); DHA eggs = 274.1 d (13.5)

DHA-enriched eggs (n=176) vs. ordinary eggs (n=174) 

 12 DHA-eggs (133 mg DHA) per wk until birth 

• Du

GestationHigh-DHA DHA; NS delivery ra

• Bi

at birth: NLBW 

• In

preeclamp1 vs. grp 2

• BM

correlation infant RBC NS correlamaternal RGA 

h = hour(s); d = day(s); wk(s) = week(s); mo = month; y = year; n = number of participants; NR = not reported; hx = history; tx = treatmenformula fed; BF = breast fed; HM = human milk ; S = significant; RCT = randomized control trial; LCPUFA = long chain polyunsaturated f

gammalinolenic acid; DHA = docosahexaenoic acid; AA = arachidonic acid; EPA = eicosapentanoic acid; LA = linoleic acid; ALA = α-lino

pb = placebo; S = statistically significant difference; NS = nonsignificant statistical difference; gp(s) = group(s); RBC = red blood cells; ctr

circumference; wt = weight; L = length; LBW = low birth weight 
E – 38 

Table 1: Randomized controlled trial evidence for omega-3 fatty acids in child and maternal health (cont’d) 

Author, 

Year, 

Location Study Design 

Population 

Characteristics 

Intervention/ 

comparators 

Timing & Dose of 

intervention (if 

appropriate) 

Clinical 

Re

Vanderhoof, 

2000, 

US 

{2143,182,175

2} 

 RCT 

Parallel Double-Blind 

 Jadad 

total: 4 [Grade: A] 

 Schul

z: Adequate 

Inclusion criteria: Premature infants 0-28 d of age, medically stable, BW between 750-2,000g appropriate for GA, had received enteral feedings < 24 h Exclusion criteria: Significant acute or chronic illnesses, systemic infections, documented major congenital infections, intraventricular hemorrhage more than grade 2, periventricular leukomalacia, neonatal seizures, neonatal meningitis, or maternal substance abuse, BF infants whose mothers were vegans or had hx of metabolic disease that would affect essential fatty acid status were excluded Enrolled/Completed: n=288/153 Mean Age: • Maternal: NR • Child: PCA at enrollment: 

LCPUFA formula = 31.2 ± 2.3 wk; Ctrl Formula = 30.9 ± 2.6 wk; HM = 30.5 ± 2.4 wk 

LCPUFA formula (microbial fermentation) (n=77) vs. crtl formula (n=78) vs. HM (RS) (n=133) 

Preterm formula 0.5% AA + 0.35% DHA until 48 wks PCA, then term formula until 92 wks PCA, ad libitum 

• G

patterns: S

MAC in LCthan in HM PCA; NS wks PCA; 

in LCPUFat 48 wks wt, L, HC PCA 

h = hour(s); d = day(s); wk(s) = week(s); mo = month; y = year; n = number of participants; NR = not reported; hx = history; tx = treatmenformula fed; BF = breast fed; HM = human milk ; S = significant; RCT = randomized control trial; LCPUFA = long chain polyunsaturated f

docosahexaenoic acid; AA = arachidonic acid; PCA = postconceptual age; S = statistically significant difference; NS = nonsignificant sta

group(s); ctrl(s) = control(s); HC = head circumference; wt = weight; L = length; MAC = mid arm circumference; BW = birth weight 
E – 39 

Table 1: Randomized controlled trial evidence for omega-3 fatty acids in child and maternal health (cont’d) 

Author, 

Year, 

Location Study Design 

Population 

Characteristics 

Intervention/ 

comparators 

Timing & Dose of 

intervention (if 

appropriate) 

Clinical 

Re

van WezelMeijler, 2002, 

Netherlands 

{40} 

 RCT 

Parallel Double-blind 

 Jadad 

total: 5 [Grade: A] 

 Schul

z: Adequate 

Inclusion criteria: Premature infants with gestational age < 34 wk, BW of < 1750 g, normal neurological examination throughout the neonatal period; normal repeated brain ultrasound or showing minor abnormalities such as isolated subependymal haemorrhage & subventricle, with no ventricular dilation; transient periventricular echodensities, without evolution into cysts; any combination of previous findings Exclusion criteria: Abnormalities of the CNS (excluding items on inclusion criteria), either congenital or acquired; abnormal neurologic examination; seizure; any systemic disease with potential negative influence on future growth or development (chronic lung disease, congenital abnormalities of other organs than the brain; metabolic disease; congenital infections & endocrine dysfunction; serious nutritional or GI problems preventing initiation of enteral feeding after the first wk of life or complete enteral 

feeding after the 3rd wk of life 

Enrolled/Completed: n=55/42 Mean Age: • Maternal: • Child: FF control = 30.4 wks 

LC PUFA supplemented formula (microalgae, fungi)  (n=22) vs. Control formula (n=20)

Preterm formula: from 2-3 wks of age to 3,000g wt, then Term formula until 6 mo CA 

• Ba

MDI: SÏ unsupplemsupplemeat 3, 6, 12 Bayley’s M& 24 mo 

• VE

VEP (P20wave laten12 mo CA 

• Te

NS mean at 3,6,12 m

h = hour(s); d = day(s); wk(s) = week(s); mo = month; y = year; n = number of participants; NR = not reported; hx = history; tx = treatmenformula fed; RCT = randomized control trial; LCPUFA = long chain polyunsaturated fatty acids; GLA = gammalinolenic acid; DHA = docoarachidonic acid; EPA = eicosapentanoic acid; CNS = central nervous system; GI = gastrointestinal; S = statistically significant difference

difference; gp(s) = group(s); ctrl(s) = control(s); BW = birth weight; MDI = mental developmental index; PDI = psychomotor developmentapotentials; CA = corrected age 
E – 40 

Table 1: Randomized controlled trial evidence for omega-3 fatty acids in child and maternal health (cont’d) 

Author, 

Year, 

Location Study Design 

Population 

Characteristics 

Intervention/ 

comparators 

Timing & Dose of 

intervention (if 

appropriate) 

Clinical 

Re

Willatts, 1998, 

UK 

{2307,2293} 

 RCT 

Parallel 

 Jadad 

total: 3 [Grade: B] 

 Schul

z: Unclear 

Inclusion criteria: Healthy term infants weight 2,500-4,000 g; gestation 37-42 wk Exclusion criteria: NR Enrolled/Completed: n=58/40 Mean Age: • Maternal: Gp 1= 26.2 ± 4.2 

y; Gp 2 = 27.7 ± 4.6 y 

• Child: Gp 1 = 274.2 ± 2.7 d, 

Gp 2 = 275.2 ± 5.0 d 

LCPUFA formula (DHA+AA derived from Egg-TG) (n=27) vs. Crtl formula (n=31) 

LCPUFA formula (0.15-0.25 wt% DHA, 0.30-0.40 wt% AA) for 4 mo; 

• G

patterns: Nat 3 mo 

• Co

function amo): NS 

• Pr

assessme

Woltil, 

1999, 

Netherlands 

{275,329} 

 RCT 

Parallel 

 Jadad 

total: 2 [Grade: C] 

 Schul

z: Unclear 

Inclusion criteria: LBW (< 2500g) either solely BF or solely FF Exclusion criteria: Blood transfusions; blood products; or parenteral lipids. Enrolled/Completed: n=143/128 

Mean Age: • Maternal: NR • Child: Formula without 

LCPUFA = 36 wk; Formula with LCPUFA = 37 wk; HM = 35 wk

LCPUFA preterm formula Ï n-3 fish oil (n=13) vs. LCPUFA formula Ð

n-3 fish oil (n=13) vs. crtl formula (n=75) vs. HM (RS) (n=27) 

Ïfish oil (EPA 0.34 mol; DPA 0.03 mol; DHA 0.43 mol vs.Ðfish oil (per 100 mol: EPA 0.17 mol; DPA 0.02 mol; DHA 0.20 mol) until d 42 life 

• G

patterns: N

∆L, & ∆HC 

LCPUFA-& pb at 1 

∆ L, ∆ bra

pb-1 than 3 at 1mo 

• BM

correlation ∆wt, ∆L, ∆

- RBC DH

h = hour(s); d = day(s); wk(s) = week(s); mo = month; y = year; n = number of participants; NR = not reported; hx = history; tx = treatmenformula fed; BF = breast fed; HM = human milk ; S = significant; RCT = randomized control trial; LCPUFA = long chain polyunsaturated f

gammalinolenic acid; DHA = docosahexaenoic acid; AA = arachidonic acid; EPA = eicosapentanoic acid; LA = linoleic acid; ALA = α-lino

CA = corrected age; UK = United Kingdom, Ï = increase; Ð = decrease; S = statistically significant difference; NS = nonsignificant statis

group(s); RBC = red blood cells; ctrl(s) = control(s); HC = head circumference; wt = weight; L = length; BMK = biomarkers correlations; 
E – 41 

Table 2: Evidence from observational studies for omega-3 fatty acids in child and maternal health 

Author, 

Year, 

Location Study Design 

Population 

Characteristics Exposure 

Timing & Dose 

of exposure (if 

appropriate) Clinical Outcom

Agostini, 

2001, 

Italy 

{98} 

 Single 

prospective cohort 

 Qualit

y score: 8 [Grade A] 

Inclusion criteria: Healthy term infants, exclusively BF for at least 3 mo Exclusion criteria: NR Enrolled: n=44 Mean Age: 

 Maternal: NR  Child: NR 

HM HM (FA 

composition NR) for ≥6 mo vs. HM 

for <6 mo 

 Bayley’s 

at 12 mo: NS cbetween Baylelength of BF; Nbetween Baylemilk FA contencorrelation betBayley’s MDI & content at 6 m12 mo; NS AAcontent correlaat 12 mo 

Al, 

1995, 

The 

Netherlands 

{55,504} 

 Neste

d casecontrol study 

 Qualit

y score: 11 [Grade A] 

Inclusion criteria: Pregnant women < 16 wk gestation, cardiovascular, neurologic, renal or metabolic disease at the beginning of pregnancy; women with no hypertension (controls),or with pregnancy induced hypertension (cases) , matched for parity and hospital with three crtls Exclusion criteria: Multiple pregnancy Enrolled: n=208 Mean Age: 

 Maternal: NR  Child: NP GA =279.9 d 

(0.59), PIH GA = 273.3 d (2.18)

N/A N/A  BMK: N

FA compositiomaternal plasm16, at 22 & 32 severe GHT wmean GA & mtheir babies wmild GHT; dur& after delivery maternal FA cthe severe GHGHT 

N/A = not applicable; US = United States; n = number of participants; y = years; mo= month(s); wk(s) = week (s); d= day (s); hr (s) = hou

= (appropriate for) gestational age; GA = gestational age; IUGR = intrauterine growth retardation; PIH = pregnancy induced hypertension

preterm; FT = full term; RBC = red blood cells; FA = fatty acids; PL = phospholipids; n-3 = omega-3 fatty acids; n-6 = omega-6 fatty acidalpha-linolenic acid; EPA = eicosapentaenoic acid; DHA = docosahexaenoic acid; AA = arachidonic acid; DGLA = dihomo-gama-linoleni

significant difference; NS = nonsignificant statistical difference; gp(s) = group(s); ctrl(s) = control(s) 
E – 42 

Table 2: Evidence from observational studies for omega-3 fatty acids in child and maternal health 

Author, 

Year, 

Location Study Design 

Population 

Characteristics Exposure 

Timing & Dose of 

exposure (if 

appropriate) Clinical Outco

Birch, 

1993a, 

US 

{567} 

 Cross

-sectional 

 Qualit

y score: 4 [Grade B] 

Inclusion criteria: Healthy pre-term infants born at 27-33 wk postconception with wirth BW of 1000-1500 g; AGA. Exclusion criteria: Inability to accept enteral feeds by d 10 of life, respiratory tx > 7 d, congenital infection or malformation, retinopathy of prematurity, or grade 3 or 4 intraventricular hemorrhage Enrolled: n=30 Mean Age: 

 Maternal: NR  Child: 27-33 wk

HM/corn-oil based formula 

NR  BMK-

LogMAR accorrelated w[DHA n-3/DPtotal RBC lipacuity LogMcorrelated wDHA n-3/DPratio was S in formula fe

Birch, 

1993b, 

US 

{567} 

 Cross

-sectional 

 Qualit

y score: 4 [Grade B] 

Inclusion criteria: Healthy term infants, AGA Exclusion criteria: Inability to accept enteral feeds by d 10 of life, respiratory tx > 7 d, congenital infection or malformation, retinopathy of prematurity, or grade 3 or 4 intraventricular hemorrhageEnrolled: Gp 1, n=30; Gp 2, n=43 Mean Age: • Maternal: NR• Child: 27-33 wk

HM/corn-oil based formula 

NR  BMK-

VEP & FPL in HM than imo); mean RDHA/DPA in lipids was S 

formula gp & acuity was S with the endletter matchwas S correratio, RBC Dmo) 

N/A = not applicable; US = United States; n = number of participants; y = years; mo= month(s); wk(s) = week (s); d= day (s); hr (s) = hou

= (appropriate for) gestational age; GA = gestational age; IUGR = intrauterine growth retardation; PIH = pregnancy induced hypertension

preterm; FT = full term; RBC = red blood cells; FA = fatty acids; PL = phospholipids; n-3 = omega-3 fatty acids; n-6 = omega-6 fatty acidalpha-linolenic acid; EPA = eicosapentaenoic acid; DHA = docosahexaenoic acid; AA = arachidonic acid; DGLA = dihomo-gama-linoleni

treatment; S = statistically significant difference; NS = nonsignificant statistical difference; gp(s) = group(s); RBC = red blood cells; ctrl(s) 
E – 43 

Table 2: Evidence from observational studies for omega-3 fatty acids in child and maternal health (cont’d) 

Author, 

Year, 

Location Study Design 

Population 

Characteristics Exposure 

Timing & Dose 

of exposure (if 

appropriate) Outcomes 

Cetin, 2002, 

Italy 

{33} 

 Casecontrol  Qualit

y score: 5 [Grade B] 

Inclusion criteria: Pregnancies with AGA & IUGR fetuses Exclusion criteria: Gestational diabetes; pregnancyinduced hypertension Enrolled: n=21 Mean Age: 

 Maternal: gp 1 AGA = 28.2 y; 

gp 2: IUGR = 29.6 y 

 Child: NR 

N/A N/A  Materna

EPA, DHA & Awk of gestatio

maternal plasIUGR grp tha≈28.2(8.0) wk maternal plasAA at ≈28.2 (8

Cheruku, 2002, 

US 

{73} 

 Cross 

sectional 

 Qualit

y score: 6 [Grade B] 

Inclusion criteria: Healthy pregnant women & infants (n=17) Exclusion criteria: Hx of chronic hypertension, hyperlipidemia, renal or liver, heart, thyroid disease, multiple gestations, or pregnancy-induced complications, pts under tx with drugs during labor affecting respiration of new borns such as magnesium sulfate, & butorphanal, any infants with <4 h of crib time in the 1st & 2nd d postpartum Enrolled: n=17 Mean Age 

 Maternal: High-DHA = 29.20 

(5.2) y; low-DH A= 24.28 (5.12) y 

 Child: High-DHA = 40.4 

(0.96) wk; low-DHA = 39.0 (1.86) wk 

N/A N/A  Infant sl

pattern –mate(postpartum d Maternal DHA associated wi& sleep-wake 2); maternal Dassociated wiwakefulness (ratio in maternwas (+) assocAS:QS &sleeptransition (d 1ratio in maternwas (-) assocwakefulness (

N/A = not applicable; US = United States; n = number of participants; y = years; mo= month(s); wk(s) = week (s); d= day (s); g = grams; N

applicable; AGW = infants with appropriate gestational weight; GA = gestational age; HM = Human milk; (B)W = (birth) weight; (B)L = (bir

cells; (LC)PUFA = (long chain) polyunsaturated fatty acids; PE = phosphatidylethanolamine; FA = fatty acids; LA = linoleic Acid; ALA = aleicosapentaenoic acid; DHA = docosahexaenoic acid; AA = arachidonic acid; DGLA = dihomo-gama-linolenic acid; tx = treatment; IUGR retardation; S = statistically significant difference; NS = nonsignificant statistical difference; gp(s) = group(s); ctrl(s) = control(s) 
E – 44 

Table 2: Evidence from observational studies for omega-3 fatty acids in child and maternal health (cont’d) 

Author, 

Year, 

Location Study Design 

Population 

Characteristics Exposure 

Timing & Dose of 

exposure (if 

appropriate) Outcomes 

CraigSchmidt, 

1994, 

US 

{503} 

 Cross 

sectional 

 Qualit

y score: 2 [Grade C] 

Inclusion criteria: Healthy nulliparous women Exclusion criteria: NR Enrolled: n=36 Mean Age: 

 Maternal: 21 ± 6 y  Child: NR 

N/A N/A  BMK: 

gps in plasmmonosaturaPUFAs; NS FA between pregnanciepreeclamsia CHT S Ï A

PL vs. otheplasma PL the gps; NS ratio & n-6/

Elias, 

2000, Canada 

{143} 

 Single 

prospective cohort 

 Qualit

y score: 6 [Grade B] 

Inclusion criteria: Healthy pregnant women (from 22-24 wk gestation until delivery) & infants Exclusion criteria: Medical or surgical problems influencing lipid metabolism or fetal growth, communicable disease; > 1 fetus, hypermesis, psychological or social problems, illicit drug or alcohol use, cardiac or renal disease, diabetes, epilepsy, respiratory or rheumatoid conditions, cholestasis, hx of high blood cholesterol or tricylglycerol concentrations before pregnancy, HIV infection or AIDS, hepatitis, or tuberculosis Enrolled: n=84 Mean Age: 

 Maternal: NR  Child: GA = 40.0 wk 

Maternal intake of LCPUFAs during pregnancy 

13.6+-0.9 g/d LCPUFAs at 28 wk of gestation; 12.1±0.6 g/d LCPUFAs at 35 wk gestation; 

 BMK: 

plasma TGcorrelated twt & L 

N/A = not applicable; US = United States; n = number of participants; y = years; mo= month(s); wk(s) = week (s); d= day (s); g = grams; 

applicable; AGW = infants with appropriate gestational weight; GA = gestational age; HM = Human milk; (B)W = (birth) weight; (B)L = (bi

chain) polyunsaturated fatty acids; PE = phosphatidylethanolamine; FA = fatty acids; LA = linoleic Acid; ALA = alpha-linolenic acid; EPA 

= docosahexaenoic acid; AA = arachidonic acid; DGLA = dihomo-gama-linolenic acid; hx = history; HIV = human immuno-deficiency virudeficiency syndrome; S = statistically significant difference; NS = nonsignificant statistical difference; gp(s) = group(s); ctrl(s) = control(s) 
E – 45 

Table 2: Evidence from observational studies for omega-3 fatty acids in child and maternal health (cont’d) 

Author, 

Year, 

Location Study Design 

Population 

Characteristics Exposure 

Timing & Dose 

of exposure (if 

appropriate) Outcomes R

Ghys, 2002 

Netherlands 

{38} 

 Prosp

ective single cohort 

 Qualit

y score: 8 [Grade A] 

Inclusion criteria: Full-term neonates Exclusion criteria: NR Enrolled: n=128 Mean Age: 

 Maternal: NR  Chid: 47 (1.3) mo 

N/A N/A  BMK: No c

between plasma & AA & cognitive (4 y) 

Hofmann, 

1998, 

Germany 

{1145} 

 Cross 

sectional 

 Qualit

y score: 6 [Grade B] 

Inclusion criteria: Pregnant women with preeclampsia (BP at rest > 140/90 beyond the 20th wk gestation) & healthy pregant women Exclusion criteria: Endocrionological sx affecting the lipide metabolism Enrolled: PE n=14; ctrl n=16 Mean Age: 

 Maternal: PE = 27 y (17-38); 

ctrl = 28 y (20-39) 

 Child: PE GA = 36 wk (32-

40); ctrl GA = 37 wk (34-40) 

N/A N/A  BMK: Tota

plasma TGL durwere S > in preevs. crtl; NS betwplasma TGL durpregnancy; LA (n(n-3) content in pwere S Ð in preevs. crtls; NS betw& AA (n-6) in plaplasma PL contepreeclamptic wo

Innis, 

1994, Canada 

{521} 

 Cross 

sectional 

 Qualit

y score: 5 [Grade B] 

Inclusion criteria: Full term infants (> 37 wk GA at birth), AGA, & if mother decided to BF or FF for >/= 3 mo Exclusion criteria: NR Enrolled: n=35 Mean Age: 

 Maternal: NR  Child: BF GA = 39.5 ± 1.0 wk, 

FF GA = 39.1 ± 1.0 wk 

HM (n=17) vs. CF (n=18) 

HM (0.2+-0.02 wt% DHA, 0.1± 0.01 wt% EPA, 0.5± 0.03 wt% AA) from 14± 2 d to ≥3 mo 

 Visual acu

between gps in vtest (14 d & 3 mo

 BMK: Visu

to diet or plasma or PE concentraon entire gp of inwithin the breastformula-fed gp o

N/A = not applicable; n = number of participants; y = years; mo= month(s); wk(s) = week (s); d= day (s); hr (s) = hour (s); g = grams; NR 

(appropriate for) gestational age; GA = gestational age; PCA = post-conceptual age; HM = human milk; PT = preterm; BF = breast fed; F

formula; FT = full term; CA = corrected age; RBC = red blood cells; n-3 = omega-3 fatty acids; n-6 = omega-6 fatty acids; (LC)PUFA = (lo

acids; FA = fatty acids; DHA = docosahexaenoic acid; AA = arachidonic acid; DPA = docosapentaenoic acid; HC = head circumference; statistically significant difference; NS = nonsignificant statistical difference; gp(s) = group(s); RBC = red blood cells; ctrl(s) = control(s); A

age 
E – 46 

Table 2: Evidence from observational studies for omega-3 fatty acids in child and maternal health (cont’d) 

Author, 

Year, 

Location Study Design 

Population 

Characteristics Exposure 

Timing & Dose of 

exposure (if 

appropriate) Outcomes 

Innis, 

2001, Canada 

{112} 

 Prosp

ective single cohort 

 Qualit

y score: 8 [Grade A] 

Inclusion criteria: Mothers who committed to only BF heatlhy term infants (no formula or cow's milk) from at least 3 mo, no solid food for at least 1st 4 mo after birth 

Exclusion criteria: Mothers with substance abuse, metabolic or physiologic problems, infections likely to influence fetal growth , or multiple births & infants with evidence of metabolic or physical abnormality Enrolled: n=83 Mean Age: 

 Maternal: 32.2 y  Child: NR 

HM HM for at least 3 

mo 

 BMK: 

DHA (2 mo) correlated to at 2 & 12 momo; Infants DHA <8.53gÐ visual acumo than infa10.78g/100g correlation bplasma or RAA & cognitdevelopmen

Jorgensen, 

1996, Sweden 

{422} 

 Cross 

sectional 

 Qualit

y score: 5 [Grade B] 

Inclusion criteria: Healthy term AGA BF & FF infants; age: 37-42 wk (n=33) Exclusion criteria: Major congenital anomaly, severe intra/peri venticular haemorrhage or 5-min APGAR score < 5 Enrolled: n=33 Mean Age: 

 Maternal: NR  Child: LBM gp = 28.4 wk; HBM = 

28.5 wk

HM (n=17) vs. CF (n=16) 

HM (0.49+-0.20 to 0.53+-0.56 wt% DHA; 0.13+-0.07 to 0.23+-0.35 wt% EPA; 0.56+-0.12 to 0.44+-0.09 wt% AA) for 4 mo 

 BMK: 

correlation bDHA & visuagps (4 mo); correlation blevels & visu

 Visua

mo: Visual aovertime in gps, S Ï inc

grp 

N/A = not applicable; n = number of participants; y = years; mo= month(s); wk(s) = week (s); d= day (s); hr (s) = hour (s); g = grams; NR 

(appropriate for) gestational age; HM = breast milk; BF = breast fed; FF = formula fed; (B)W = (birth) weight; L = length; HC = head circu

= red blood cells; n-3 = omega-3 fatty acids; n-6 = omega-6 fatty acids; PC = phosphatidylcholine; PE = phosphatidylethanolamine; (LC)

polyunsaturated fatty acids; FA = fatty acids; PL = phospholipids; DHA = docosahexaenoic acid; LA = linoleic Acid; EPA = eicosapentae

docosahexaenoic acid; AA = arachidonic acid; DGLA = dihomo-gama-linolenic acid; S = statistically significant difference; NS = nonsigni

gp(s) = group(s); RBC = red blood cells; ctrl(s) = control(s) 
E – 47 

Table 2: Evidence from observational studies for omega-3 fatty acids in child and maternal health (cont’d) 

Author, 

Year, 

Location Study Design 

Population 

Characteristics Exposure 

Timing & Dose of 

exposure (if 

appropriate) Outcomes 

Jorgensen, 

2001, 

Denmark 

{2207} 

 Cross

-sectional study 

 Qualit

y score: 9 [Grade A] 

Inclusion criteria: Term delivery (37-42 wk); normal BW for GA; uncomplicated pregnancy, delivery, & neonatal period; Apgar score > 8 after 5 min; & fully BF at time of examination (no energy drinks & < 100 mL fromula /d) Exclusion criteria: SGA (< 10th PC of BW); strabismus, operation of pyloric stenosis Enrolled: n=39 Mean Age: 

 Maternal: 30.5 (3.9) y  Child: 39.8 (1.2) wk 

HM HM (0.35+-0.20 

wt% DHA, 0.39+-0.07 wt% EPA, 0.30+-0.07 wt% AA) for ≥14 wk; 

 BMK: NS as

between AA, EALA (n-3) with 

 HM LA, ALA

DHA & correlavisual acuity: S between visuaat 4 mo & mothDHA 

Krasevec, 

2002, Cuba 

{72} 

 Cross 

sectional 

 Qualit

y score: 7 [Grade B] 

Inclusion criteria: Normal pregnancy, with no medical risks affecting fatty acid metabolism, including heart disease, kidney disease, gestational or other diabetes, hypertension, gallbladder disease, or thyroid disease; resident of Central or Old Havana; ages or 17 to 36 y Exclusion criteria: NR Enrolled: n=56 Mean Age: 

 Maternal: f/u gp = 26.8 (4.0) y; 

ot-f/u gp = 26.9 (5.3) y 

 Child: f/u gp GA = 40.4 (1.5) wk; 

not-f/u gp GA = 40.2 (1.1) wk 

High-fat fish maternal intake during pregnancy; HM (n=31), Formula+HM (n=22), Formula (n=3) 

454 g/wk maternal fish intake 

 Visual acuity 

prediction for 2infants; NS Mevisual acuity bevs. HM + formu

 BMK: NS co

visual acuity & concentration, or gps of PUFAtissues; NS cofull sample & egp (i.e., exclusmilk vs. not excbreastfed); NS between PUFA maternal tissueexclusively bre& visual acuity 

N/A = not applicable; US = United States; n = number of participants; y = years; mo= month(s); wk(s) = week (s); d= day (s); hr (s) = hou

socioeconomic class; NR = not reported; (A)GA = (appropriate for) gestational age; IUGR = intrauterine growth retardation; CF = control induced hypertension; HM = breast milk; BF = breast fed; FF = formula fed; (B)W = (birth) weight; L = length; HC = head circumference; fatty acids; n-6 = omega-6 fatty acids; PC = phosphatidylcholine; PE = phosphatidylethanolamine; (LC)PUFA = (long chain) polyunsatura

PL = phospholipids; DHA = docosahexaenoic acid; LA = linoleic Acid; EPA = eicosapentaenoic acid; DHA = docosahexaenoic acid; AA dihomo-gama-linolenic acid; PC = percentile; f/u = follow-up; S = statistically significant difference; NS = nonsignificant statistical differencontrol(s) 
E – 48 

Table 2: Evidence from observational studies for omega-3 fatty acids in child and maternal health (cont’d) 

Author, 

Year, 

Location Study Design 

Population 

Characteristics Exposure 

Timing & Dose of 

exposure (if 

appropriate) Outcomes 

Leaf, 1996, 

Australia 

{402} 

 Cross 

sectional 

 Qualit

y score: 6 [Grade B] 

Inclusion criteria: Healthy preterm infants < 32 wk GA Exclusion criteria: Major congenital anomaly, severe intra/peri venticular haemorrhage or 5-min apgar score < 5 Enrolled: n=18 

Mean Age: 

 Maternal: NR  Child: LBM = 28.4 wk; HBM = 28.5 

wk 

HHM (n=9) vs. LHM (n=9) 

HM (32 mg/kg/d AA, 17 mg/kg/d DHA) ± “Intralipid 20%” (6.4 mg/kg/d AA, 5.8 mg/kg/d DHA) from birth up to 40 wk PCA 

 BMK: 

correlation scotopic b wtime & % D& RBC PL, plasma & Rcorrelation AA & total nscotopic a-NS relationseen betweERGs & plaLCPUFAs 

Makrides, 

1993, 

Australia 

{560} 

 Cross 

sectional 

 Quality 

score: 4 [Grade B] 

Inclusion criteria: Healthy infants born at term with appropriate weight for GA & were approximately 5 mos of age. Exclusion criteria: NR Enrolled: n=16 Mean Age: 

 Maternal: NR  Child: BF = 22.4 (±3.7) wk; 

FF= 22.3 (± 4.3) wk 

HM (n=8) vs. CF (>70% nutrition from formula)+HM (n=8) 

NR  Visua

gp S Ð log

better VEP formula-fed 

 BMK: 

between loacuity) & % RBC PL 

N/A = not applicable; n = number of participants; y = years; mo= month(s); wk(s) = week (s); d= day (s); hr (s) = hour (s); g = grams; NR 

milk; BF = breast fed; FF = formula fed; (B)W = (birth) weight; (B)L = (birth) length; HC = head circumference; ∆ = change; RBC = red b

linoleic Acid; ALA = alpha-linolenic acid; EPA = eicosapentaenoic acid; DHA = docosahexaenoic acid; AA = arachidonic acid; PL = phossignificant difference; NS = nonsignificant statistical difference; gp(s) = group(s); RBC = red blood cells; ctrl(s) = control(s); ERG = electrevoked potential; HHM = high intake of human milk; LHM = low intake of human milk 
E – 49 

Table 2: Evidence from observational studies for omega-3 fatty acids in child and maternal health (cont’d) 

Author, 

Year, 

Location Study Design 

Population 

Characteristics Exposure 

Timing & Dose of 

exposure (if 

appropriate) Outcomes 

Matorras, 

1994, 

Spain 

{494} 

 Casecontrol  Qualit

y score: 9 [Grade A] 

Inclusion criteria: Healthy women at labor with term IUGR & their singleton infants; no malformations or chromosomal abnormalities; no antepartum death; accordancy of GA & pediatric evaluation by means of Dubowitz test & neonatal weight < 10th PC for GA for 

geographic area (cases); healthy women at labor with term AGA births, neonatal weight > 10th PC (control) 

Exclusion criteria: NR Enrolled: Mother n=69; infants n=51 Mean Age: 

 Maternal: IUGR = 28.4 ±6.4 y 

Ctrl = 26.2 ± 6.2 yr 

 Child: IUGR GA = 39.1 ±1.4 

wk; Ctrl GA = 39.4 ±1.3 wk 

N/A N/A  BMK: 

plasma EPA than in pb ain maternal & AA at del

N/A = not applicable; n = number of participants; y = years; mo= month(s); wk(s) = week (s); d= day (s); hr (s) = hour (s); g = grams; NR 

(appropriate for) gestational age; IUGR = intrauterine growth retardation; RBC = red blood cells; EPA = eicosapentaenoic acid; DHA = darachidonic acid; PL = phospholipids; PC = percentile; IUGR = intrauterine growth retardation; S = statistically significant difference; NS 

difference; gp(s) = group(s); ctrl(s) = control(s) 
E – 50 

Table 2: Evidence from observational studies for omega-3 fatty acids in child and maternal health (cont’d) 

Author, 

Year, 

Location Study Design 

Population 

Characteristics Exposure 

Timing & Dose of 

exposure (if 

appropriate) Outcomes 

Reece, 1997 

US 

{53} 

 Casecontrol  Qualit

y score: 4 [Grade C] 

Inclusion criteria: Healthy preterm infants; mean GA 33.9±0.6 wk, (cases); term infants; mean GA 40.2±0.2 wk (control) Exclusion criteria: Cases (preterm): recognised causes of preterm birth, including uterine abnormalities, intrauterine infection, substance abuse, multiple gestations, pregnancy-onset hypertension, or other medical disorders; Controls (term): recognized medical problems, multiple gestations, multiple parity, pregnancy-onset hypertension, recognized substance abuse Enrolled: n=71 

Mean Age: 

 Maternal: Cases = 22 y; 

Controls = 24 y 

 Child: Cases GA = 40.2 wk; 

Controls GA = 33.9 wk 

N/A N/A  Mater

RBC LA, AA

preterm vs. control+ & tEPA S Ïin vs. both precontrol; RBC 3/n-6 ratio wterm controNS RBC n-3preterm & 3plasma LA preterm & 3term crtl; plaEPA SÏ in term crtls 

Rocquelin, 

2003, Congo, 

Burkina Faso 

{3} 

 Cross

-national 

 Qualit

y score: 5 [Grade B] 

Inclusion criteria: Healthy term infants from Congo & healthy term infants from Burkina faso Exclusion criteria: NR Enrolled: Congo n=102; Burkina faso 

n=101 Mean Age: 

 Maternal: NR  Child: Congo = 4.9 (± 0.3) 

mo; Burkina faso = 5.1 (± 0.2) mo 

HM HM from Congo 

(0.15+-0.07 wt% DHA, 0.12+-0.06 wt% AA) vs. HM from Burkina Faso (0.08+-0.05 wt% DHA, 0.21+-0.08 wt% AA) for 5 mo 

 Growt

SÐ wt-for-a

height z-sco(g) in Burkinin Congo; Nage, wt gain predominanto compleminfants in B

N/A = not applicable; n = number of participants; y = years; mo= month(s); wk(s) = week (s); d= day (s); hr (s) = hour (s); g = grams; NR 

(appropriate for) gestational age; SGA = small for gestational age; IUGR = intrauterine growth retardation; HM = human milk; BF = breas

(birth) weight; (B)L = (birth) length; HC = head circumference; BRW = brain weight; ∆ = change; GP = growth parameters; RBC = red blodevelopmental index; MDI = mental developmental index; FA = fatty acids; GLA = gammalinolenic acid; LA = linoleic Acid; ALA = alpha-

eicosapentaenoic acid; DHA = docosahexaenoic acid; AA = arachidonic acid; PL = phospholipids; S = statistically significant difference; 

difference; gp(s) = group(s); ctrl(s) = control(s) 
E – 51 

Table 2: Evidence from observational studies for omega-3 fatty acids in child and maternal health (cont’d) 

Author, 

Year, 

Location Study Design 

Population 

Characteristics) Exposure 

Timing & Dose 

of exposure (if 

appropriate) Outcomes 

Rump, 2001, 

Netherlands 

{144}

 Cross

-sectional 

 Qualit

y score: 9 [Grade A] 

Inclusion criteria: Healthy singleton term infants, GA of< 16 wk at entry, a diastolic BP < 90mm Hg, & no signs of cardiovascular, neurologic, renal or metabolic disorders at the time of recruitment Exclusion criteria: Infants with unknown gestational age or BW, born prematurely, or who died & of mothers with diabetes or pregnancyinduced hypertension. Enrolled: n=627 Mean Age: 

 Maternal: SGA: 28.9 (± 4.1) y; 

AGA 10-25 PC: 28.9 (± 4.6) y; 25-75 PC: 29.5 (± 4.2); 75-90 PC: 29.3 (± 4.2y); LGA: 29.4 (± 3.9) y 

 Child: SGA: 40.1 (± 1.3) wk; AGA 

10-25 PC: 40.0 (±1.0) wk; AGA 25-75 PC: 40.1 (± 1.2) wk; AGA 75-90 PC: 40.6 (± 1.2) wk; LGA: 40.4 (± 1.3) wk 

N/A N/A  BMK: 

correlation maternal pl11 (8) wk Gdelivery & G

Shouk, 1999, 

Egypt 

{243} 

 Casecontrol  Qualit

y score: 7 [Grade B] 

Inclusion criteria: Pregnant women with severe preeclampsia in 3rd T; healthy pregnant women without proteinuria or hx of renal disease, not on medications & no hx of obstetric complications Exclusion criteria: NR Enrolled: n=45 Mean Age: 

 Maternal: Preeclampsia gp: 29 

(20-40) y 

N/A N/A  BMK: 

was S > in women vs. between gp(n-3) conten

N/A = not applicable; n = number of participants; y = years; mo= month(s); wk(s) = week (s); d= day (s); hr (s) = hour (s); g = grams; WG 

weight-for-age Z-score; WFH Z-score = weight-for-height Z-score; HFA Z-score = height-for-age Z-score; GA = gestational age; NR = n

(appropriate for) gestational age; GP = growth parameters; IUGR = intrauterine growth retardation; HM = human milk; CF = control form

= fatty acids; LA = linoleic Acid; DHA = docosahexaenoic acid; AA = arachidonic acid; BP = blood pressure; hx = history; S = statistically nonsignificant statistical difference; gp(s) = group(s); ctrl(s) = control(s) 
E – 52 

Table 2: Evidence from observational studies for omega-3 fatty acids in child and maternal health (cont’d) 

Author, 

Year, 

Location Study Design 

Population 

Characteristics) Exposure 

Timing & Dose of 

exposure (if 

appropriate) Outcom

Vilbergsson, 

1991, Sweden 

{633,505} 

 Cross 

sectional 

 Qualit

y score: 7 [Grade B] 

Inclusion criteria: Healthy pregnant women at risk of IUGR (cases); healthy pregnant women at no risk of IUGR (crtl) Exclusion criteria: Diabetics Enrolled: n=48 Mean Age: 

 Maternal: NR 

N/A N/A  BM

maternal & AA in Sin crtl at & at deliv

Wang, 

1991, 

US 

{59} 

 Cross 

sectional 

 Qualit

y score: 5 [Grade B] 

Inclusion criteria: Healthy normal & preeclamptic pregnant women (not on a regimen of aspirin tx) at term & nonpregnant women Exclusion criteria: NR Enrolled: n=30 

Mean Age: 

 Maternal: NR 

N/A N/A  BM

PUFA, L(n-3) & Enormal pwomen wpreeclambetween AA & DHDHA in npregnant nonpregn

N/A = not applicable; US = United States; n = number of participants; y = years; mo= month(s); wk(s) = week (s); d= day (s); hr (s) = hou

not applicable; HM = human milk; PT = preterm; FT = full term; RBC = red blood cells; HM = human milk; n-3 = omega-3 fatty acids; n-6 

(LU)PUFA = (long chain) polyunsaturated fatty acids; LA = linoleic Acid; ALA = alpha-linolenic acid; EPA = eicosapentaenoic acid; DHA 

arachidonic acid; DGLA = dihomo-gama-linolenic acid; GLA = gamma-liolenic acid; BRW = brain weight; tx = treatment; IUGR = intraute

statistically significant difference; NS = nonsignificant statistical difference; gp(s) = group(s); ctrl(s) = control(s) 
E – 53 

Table 2: Evidence from observational studies for omega-3 fatty acids in child and maternal health (cont’d) 

Author, 

Year, 

Location Study Design 

Population 

Characteristics) Exposure 

Timing & Dose 

of exposure (if 

appropriate) Outcomes R

Williams, 

2001, UK 

{153} 

 Prosp

ective cohort 

 Qualit

y score: 9 [Grade A] 

Inclusion criteria: Healthy full-term BF infants; term infants never BF Exclusion criteria: Strabilsmus, reduced vision, high refractive error, missing dietary data, GA < 37 wk Enrolled: BF n=101; non-BF n=101 Mean Age: • Maternal: NR

• Child: NR

N/A N/A  Stereoacu

BF was S correlafoveal (adult) stematernal oily fish during pregnanccorrelated with fostereoacuity 

 BMK: S co

between child’s sat 3.5 y & antenamother’s RBC D

Xiang, 

2000, 

Sweden 

{202} 

 Single 

prospective cohort 

 Qualit

y score: 5 [Grade B] 

Inclusion criteria: Healthy mother-infant pairs Exclusion criteria: NR Enrolled: n=19 

Mean Age: 

 Maternal: 29.5 y  Child: 40.1 wk

HM NR  BMK: LA, 

maternal milk SÏ 

mo; DHA in mateSÐ during 3 mo; maternal milk S with infants’ rate 

& 3 mo; AA/DHA maternal milk S with infants’ brai1 & 3 mo 

N/A = not applicable; US = United States; n = number of participants; y = years; mo= month(s); wk(s) = week (s); d= day (s); hr (s) = hou

not applicable; HM = human milk; PT = preterm; FT = full term; RBC = red blood cells; HM = human milk; n-3 = omega-3 fatty acids; n-6 

(LU)PUFA = (long chain) polyunsaturated fatty acids; LA = linoleic Acid; ALA = alpha-linolenic acid; EPA = eicosapentaenoic acid; DHA 

arachidonic acid; DGLA = dihomo-gama-linolenic acid; GLA = gamma-liolenic acid; BRW = brain weight; S = statistically significant differ

statistical difference; gp(s) = group(s); RBC = red blood cells; ctrl(s) = control(s); HC = head circumference; wt = weight; L = length 
E – 54

Safety Profile Tables 

Preterm Infants 

Summary Table 1: Studies reporting adverse events (e.g., side effects) and contraindications in relation to 

dietary intake of omega-3 fatty acids 

Study groups1

Author, 

Year, 

Location: 

Length & 

Design 

Group 1 

(n)/ 

Group 4 

(n)

Group 2 

(n)/ 

Group 3 

(n) Safety data 

Preterm infants 

McClead, 

1985, US: 

1-3 wks 

parallel 

RCT 287

Safflower oil 

emulsion 

‘high ALA’ 

(n=10)φ

Safflower oil 

emulsion 

‘low ALA’ 

(n=10) 

ALA 3 (SD: 1.5)% safflower oil emulsion (high ALA)

No adverse events/effects 

ALA 0.1% safflower oil emulsion (low ALA)

Tachycardia: n=1, tachycardia and tachypnea (secondary 

to presumed sepsis): n=1 

Birch, 1992 

US: 

6 mo 

parallel 

RCT 212

n-3 FAenriched F 

soy/marine oil 

(n=22)/ 

Nonrandomized 

HM(n=10) 

Control F 

soy oil 

(n=20)/ 

Control F 

corn oil 

(n=18) 

NS diet-induced differences in neonatal morbidity, 

bleeding time, growth of the LBW infants, or other AE

Koletzko, 

1995, 

Germany: 

3 wks 

parallel 

RCT 251

n-3 FAenriched F 

primrose oil 

(n=9) 

Control F 

(n=10)/Nonrandomized HM 

(n=8) 

NS between-arm differences in gastric residuals, spitting & 

abdominal distention (rare occurrence), or other adverse 

events ascribable to feeding

1

Proceeding from highest omega-3, or lowest omega-6/omega-3, fatty acid content of intervention/exposure; n-3 

= omega-3 fatty acids; n-6 = omega-6 fatty acids; ALA = alpha linolenic acid; DHA = docosahexaenoic acid; EPA 

= eicosapentaenoic acid; AA = arachidonic acid; Length = intervention length; Design = research design; n = 

sample size; pts = study participants; NR = not reported; NS = nonsignificant statistical difference; n/a = not 

applicable; pb = placebo; grp = group; wk = week(s); mo = month; wt = weight; +p<.05 or significant with 95% 

confidence interval; ++p<.01; +++p<.001; ++++p<.0001; FA = fatty acids; PD = preterm delivery; LBW = low birth 

weight; ICU = intensive care unit; SCN = special care nursery; GD = gestational diabetes; HM = human milk; 

NEC = necrotizing enterocolitis; F = formula ; IVH = Intra-ventricular haemorrhage; PCA: post-conception age; 

SIDS = sudden infant death syndrome; TG = triglyceride; φ = completed (otherwise enrolled); AE = adverse 

events 
E – 55

Summary Table 2: Studies reporting adverse events (e.g., side effects) and contraindications in relation to 

dietary intake of omega-3 fatty acids 

Study groups1

Author, 

Year, 

Location: 

Length & 

Design 

Group 1 

(n)/ 

Group 4 

(n)

Group 2 

(n)/ 

Group 3 

(n) Safety data 

Preterm infants 

Vanderhoof, 

1999, US, 

Canada: 

17 wks 

parallel 

RCT218

n-3 FAenriched F 

triglycerides 

derived from 

microbial 

fermentation 

(n=77) 

Control F 

(source NR) 

(n=78)/Nonrandomized 

HM: (n=133) 

F (DHA 0.35%) vs. F(control) vs. HM (grp 1 vs. grp 2 vs. grp 3)

Events at 48 wks PCA (17 wks of feeding)

Death (due to SIDS & NEC): n=1 vs. n=1 vs. n=0 (NS) 

Diarrhea: n=10 vs. n=8 vs. n=4; S (grp 1 vs. grp 3)+

Flatulence: n=12 vs. n=3 vs. n=7; S (grp 1 vs. grps 2-3)+

Jaundice: n=5 vs. n=1 vs. n=13; S (grp 2 vs. grp 3)+

Milk intolerance: n=0 vs. n=3 vs. n=0; S (grp 2 vs. grps 1,3)+

Anemia: n=12 vs. n=25 vs. n=28; S (grp 1 vs. grps 2-3)+

Events leading to discontinuation at 48 wks PCA

All: n=11 vs. n=11 vs. n=8 (NS) 

Diarrhea: n=1 (grp 1 vs. grp 2 vs. grp 3) 

Vomiting n=1 (grps 1-2) vs. n=3 

NEC: n=2 (grps 1-2) vs. vs. n=0 

Abdominal pain: n=1 vs. n=0 vs. n=1 

Ileus: n=2 vs. n=0 vs. n=1 

Infections: n=0 vs. n=1 (grps 2-3) 

Milk intolerance: n=2 vs. n=5 vs. n=1 

Cerebral necrosis or hemorrhage: n=0 (grps 1-2) vs. n=1 

Rash: n=0 vs. n=1 vs. n=0 

Constipation: n=1 vs. n=0 (grps 2-3) 

Esophageal reflux: n=1 vs. n=0 (grps 2-3) 

NS between-arm differences in respiratory, cardiovascular, 

gastrointestinal, hemic, lymphatic, or urogenital system 

events; n=2 deaths due to SIDS & NEC not diet related 

At 92 wks PCA (60 weeks of feeding)

≥ 1 AE: 96.1% vs. 93.6% vs. 86.5% 

Bradycardia: 40.3% vs. 33.3% vs. 37.6% 

Apnea: 36.4% vs. 24.4% vs. 32.3% 

Infection: 32.5% vs. 35.9% vs. 23.3% 

Pharyngitis: 23.4% vs. 20.5% vs. 17.3% 

Otitis media: 23.4% vs. 19.2% vs. 12.0% 

Bilirubinemia: 22.1% vs. 11.5% vs. 13.5% 

Anemia: 19.5% vs. 32.1% vs. 21.8% 

Flatulence: 16.9% vs. 5.1% vs. 5.3% 

Vomiting: 15.6% vs. 16.7% vs. 6.8% 

Hypoxia: 15.6% vs. 11.5% vs. 13.5% 

Bronchiolitis: 15.6% vs. 7.7% vs. 7.5% 

Ileus: 14.3% vs. 10.3% vs. 9.8% 

Oral moniliasis: 14.3% vs. 7.7% vs. 6.0% 

Diarrhea: 13.0% vs. 15.4% vs. 5.3% 

Rhinitis: 13.0% vs. 12.8% vs. 6.0% 

Rash: 13.0% vs. 10.3% vs. 11.3% 

Cardiovascular event: 11.7% vs. 16.7% vs. 7.5% 

Enlarged abdomen: 11.7% vs. 10.3% vs. 13.5% 

Irritability: 11.7% vs. 10.3% vs. 9.8% 

Increased cough: 11.7% vs. 1.3% vs. 4.5% 

Pneumonia: 9.1% vs. 14.1% vs. 7.5% 
E – 56

1

Proceeding from highest omega-3, or lowest omega-6/omega-3, fatty acid content of intervention/exposure; n-3 

= omega-3 fatty acids; n-6 = omega-6 fatty acids; ALA = alpha linolenic acid; DHA = docosahexaenoic acid; EPA 

= eicosapentaenoic acid; AA = arachidonic acid; Length = intervention length; Design = research design; n = 

sample size; pts = study participants; NR = not reported; NS = nonsignificant statistical difference; n/a = not 

applicable; pb = placebo; grp = group; wk = week(s); mo = month; wt = weight; +

p<.05 or significant with 95% 

confidence interval; ++p<.01; +++p<.001; ++++p<.0001; FA = fatty acids; PD = preterm delivery; LBW = low birth 

weight; ICU = intensive care unit; SCN = special care nursery; GD = gestational diabetes; HM = human milk; 

NEC = necrotizing enterocolitis; F = formula ; IVH = Intra-ventricular haemorrhage; PCA: post-conception age; 

SIDS = sudden infant death syndrome; TG = triglyceride; φ = completed (otherwise enrolled); AE = adverse 

events 
E – 57

Summary Table 3: Studies reporting adverse events (e.g., side effects) and contraindications in relation to 

dietary intake of omega-3 fatty acids 

Study groups1

Author, 

Year, 

Location: 

Length & 

Design 

Group 1 

(n)/ 

Group 4 

(n)

Group 2 

(n)/ 

Group 3 

(n) Safety data 

Preterm infants 

O’Connor, 

2001, 

US, UK, 

Chile: 

14 mo 

 parallel 

RCT 207

n-3 FA-enriched F 

fish/fungal oil 

(n=140) 

n-3 FA-enriched F 

egg-TG/fish oil 

(n=143)/ 

Control F 

coconut/safflower oil 

(n=144)

Between-arm differences in death, chronic lung 

disease, systemic infection, hospital readmission, 

and feeding intolerance: NS 

F with fish/fungal oil (DHA 0.27% + EPA 0.08%)

Symptoms of feeding intolerance leading to 

withdrawal: 14%,died: n=3, serious adverse event 

(n ≥ 1): 46%, hospital readmission (n ≥ 1): 39% 

F with egg-TG/fish oil (DHA 0.24% + EPA 0%)

Symptoms of feeding intolerance leading to 

withdrawal: 8%, died: n=6, serious adverse event 

(n ≥ 1): 47%, hospital readmission (n ≥ 1): 43% 

Control F with coconut/safflower oil (no DHA or 

EPA)

Symptoms of feeding intolerance leading to 

withdrawal: 13%, died: n=6, serious adverse event 

(n ≥ 1): 44%, hospital readmission (n ≥ 1): 38% 

Innis, 2002, 

US, 

Canada: 

4 wks 

 parallel 

RCT 201

n-3 FA-enriched F 

alga/fungal oil 

(n=66) 

n-3 FA-enriched F 

 alga oil 

(n=66)/ 

Control F 

(source NR) 

(n=62) 

Between-arm differences in SAE, retinopathy of 

prematurity, IVH, NEC, or sepsis: NS 

F with alga/fungal oil (DHA 0.33% + AA 0.60%)

NEC: n=0, sepsis: n=24, SAE: n=4 

F with alga oil (DHA 0.34%)

NEC: n=2, sepsis: n=31, SAE: n=3, death: n=1 

(due to SIDS) 

Control F (source: NR; no DHA, EPA, or AA)

NEC: n=1, sepsis: n=24, SAE: n=4, death: n=1 

(due to SIDS) 

Clandinin, 

2002, 

Canada, 

US: 

20 wks 

 parallel 

RCT 193

n-3 FA-enriched F 

fish/single-cell oil 

(n=130) 

n-3 FA-enriched F 

single-cell oil 

(n=112)/ 

Control F 

(source NR) 

(n=119) 

NS between-arm differences in adverse events or 

concomitant medical conditions 

Well tolerated, although > infants had gas in grp 2 

vs. grp 3 at 40-44 wks PCA, but not at 48-57 wks 

PCA

1

Proceeding from highest omega-3, or lowest omega-6/omega-3, fatty acid content of intervention/exposure; n-3 

= omega-3 fatty acids; n-6 = omega-6 fatty acids; ALA = alpha linolenic acid; DHA = docosahexaenoic acid; EPA 

= eicosapentaenoic acid; AA = arachidonic acid; Length = intervention length; Design = research design; n = 

sample size; pts = study participants; NR = not reported; NS = nonsignificant statistical difference; n/a = not 

applicable; pb = placebo; grp = group; wk = week(s); mo = month; wt = weight; +

p<.05 or significant with 95% 

confidence interval; ++p<.01; +++p<.001; ++++p<.0001; FA = fatty acids; PD = preterm delivery; LBW = low birth 

weight; ICU = intensive care unit; SCN = special care nursery; GD = gestational diabetes; HM = human milk; TG 

= triglyceride; NEC = necrotizing enterocolitis; F = formula ; IVH = Intra-ventricular haemorrhage; PCA: postconception age; SIDS = sudden infant death syndrome; AE = adverse events; SAE = serious adverse events 

φ = completed (otherwise enrolled) 
E – 58

Summary Table 4: Studies reporting adverse events (e.g., side effects) and contraindications in relation to 

dietary intake of omega-3 fatty acids 

Study groups1

Author, 

Year, 

Location: 

Length & 

Design 

Group 1 

(n)/ 

Group 4 

(n)

Group 2 

(n)/ 

Group 3 

(n) Safety data 

Preterm infants 

Fewtrell, 

2002, UK: 

4 wks 

 parallel 

RCT 273

n-3 FA enriched 

F 

primrose oil/egg 

lipids 

(n=95) 

Control F 

(source NR) 

(n=100)/Nonrandomized 

HM (n=88) 

n-3 FA-enriched F vs. control F vs. HM 

Death: 4.2% vs. 0% vs. 2.3% (NS) 

NEC: 5.3% vs. 2% vs. 0% (NS; withdrew before 3 wks) 

Systemic infection: 5.3% vs. 7% vs. 2.3% (NS) 

Skin sepsis: 13% vs. 8% vs. 8% (NS) 

IVH: 8.4% vs. 3% vs. 9.9% (NS) 

Pulmonary haemorrhage: 2.1% vs. 1% vs. 0% (NS) 

N ventilated: 51% vs. 50% vs. 48% (NS) 

Periventricular leukomalacia: 3.1% vs. 4% vs. 3.7% (NS) 

Patent ductus arteriosus: 6.3% vs. 7% vs. 2.5% (NS) 

Retrolental fibroplasia: 2.1% vs. 3% vs. 0% (NS) 

Retinopathy of prematurity: NR (NS) 

Mean n of d abdominal distension: NR (NS) 

Mean n of d nappy rash reported: NR (NS) 

Mean n of stools per d (grp 1 vs. grp 2): 1.96 vs. 2.12; S+

 

4 deaths in n-3 FA-enriched F 

n=1 early death due to NEC(d 9), and n=3 late deaths (d 

46-135) due to chronic lung disease 

Follow-up data on AE

NS Between-arm differences in the incidence of respiratory 

tract infections and eczema, n of doctor visits and hospital 

admissions, between discharge and 18 mo follow-up: NR 

Koletzko, 

2003, 

Germany: 

4 wks 

 parallel 

RCT 257

n-3 FA enriched 

F black currant 

seed oil/fish 

oil/egg 

lipids 

(n=15) 

Control F 

(source NR) 

(n=15)/Nonrandomized 

HM 

 (n=19) 

Frequency of gastric residuals, vomiting, or stools: NR (NS) 

1

Proceeding from highest omega-3, or lowest omega-6/omega-3, fatty acid content of intervention/exposure; n3 = omega-3 fatty acids; n-6 = omega-6 fatty acids; ALA = alpha linolenic acid; DHA = docosahexaenoic acid; 

EPA = eicosapentaenoic acid; AA = arachidonic acid; Length = intervention length; Design = research design; n 

= sample size; pts = study participants; NR = not reported; NS = nonsignificant statistical difference; n/a = not 

applicable; pb = placebo; grp = group; wk = week(s); mo = month; wt = weight; +p<.05 or significant with 95% 

confidence interval; ++p<.01; +++p<.001; ++++p<.0001; FA = fatty acids; PD = preterm delivery; LBW = low birth 

weight; ICU = intensive care unit; SCN = special care nursery; GD = gestational diabetes; HM = human milk; 

NEC = necrotizing enterocolitis; F = formula ; IVH = Intra-ventricular haemorrhage; PCA: post-conception age; 

SIDS = sudden infant death syndrome; TG = triglyceride; AE = adverse events; SAE = serious adverse events 

φ = completed (otherwise enrolled) 
E – 59

Summary Table 5: Studies reporting adverse events (e.g., side effects) and contraindications in relation to 

dietary intake of omega-3 fatty acids 

Study groups1

Author, 

Year, 

Location: 

Length & 

Design 

Group 1 

(n)/ 

Group 4 

(n)

Group 2 

(n)/ 

Group 3 

(n) Safety data 

Preterm infants 

Gobel, 

2003, 

Germany: 

1 wk 

 parallel 

RCT 286

Olive/soybean 

oil emulsion 

(n=24) 

Soybean oil 

emulsion 

(n=21) 

No SAE 

NS between-arm differences in AE 

Olive/soybean oil emulsion (DHA 0.23% + ALA 2.0%)

Bradycardia: n = 7 (29%) 

Gastroesophageal reflux: n = 7 (29%) 

Hyperbilirubinemia: n = 5 (20.8%) 

Apnea: n = 4 (16.7%) 

Soybean oil emulsion (DHA 0.34% and ALA 6.99%)

Bradycardia: n = 6 (28.6%) 

Gastroesophageal reflux: n = 5 (23.8%) 

Hyperbilirubinemia: n = 3 (14.3%) 

Apnea: n = 2 (9.6%) 

Fewtrell, 

2004, UK: 

42 wks 

 parallel 

RCT 258

n-3 FA 

enriched F 

starflower and 

tuna fish oil 

(n=122) 

Control F 

Sunflower/can

ola oil 

(n=116) 

n-3 FA-enriched F (grp 1) vs. control F (grp 2) 

Death: 0% vs. 1%; NS 

NEC: 4% vs. 2%; NS 

Systemic infection: 9% vs. 7%; NS 

Skin infections: NR; NS 

IVH: 7% vs. 8%; NS 

Pulmonary haemorrhage: 0% vs. 1%; NS 

n ventilated: 38% vs. 38%; NS 

Median d ventilated: 4 (3-8) vs. 2 (2-5); S+

Periventricular leukomalacia: NR; NS 

Patent ductus arteriosus: NR; NS 

Retinopathy of prematurity: NR; NS 

Required respiratory assistance: 8% vs. 5%; NS 

Median d with umbilical catheters: 4 (3-6) vs. 3 (2-5); S+

Mean n of stools per d: 3 vs. 3; NS 

Mean n of d abdominal distension reported: NR; NS 

Follow-up data on AE

Between-arm differences in the incidence of respiratory tract 

infections & eczema, n of doctor visits & hospital 

admissions, between discharge & 18 mo follow-up: NR (NS) 

Stool frequency & consistency between the arms were 

similar 1

Proceeding from highest omega-3, or lowest omega-6/omega-3, fatty acid content of intervention/exposure; n3 = omega-3 fatty acids; n-6 = omega-6 fatty acids; ALA = alpha linolenic acid; DHA = docosahexaenoic acid; 

EPA = eicosapentaenoic acid; AA = arachidonic acid; Length = intervention length; Design = research design; n 

= sample size; pts = study participants; NR = not reported; NS = nonsignificant statistical difference; n/a = not 

applicable; pb = placebo; grp = group; wk = week(s); mo = month; wt = weight; +

p<.05 or significant with 95% 

confidence interval; ++p<.01; +++p<.001; ++++p<.0001; FA = fatty acids; PD = preterm delivery; LBW = low birth 

weight; ICU = intensive care unit; SCN = special care nursery; GD = gestational diabetes; HM = human milk; 

NEC = necrotizing enterocolitis; F = formula ; IVH = Intra-ventricular haemorrhage; PCA: post-conception age; 

SIDS = sudden infant death syndrome; TG = triglyceride; φ = completed (otherwise enrolled); AE = adverse 

events; SAE = serious adverse events 
E – 60

Term Infants 

Summary Table 6: Studies reporting adverse events (e.g., side effects) and contraindications in relation to 

dietary intake of omega-3 fatty acids 

Study groups1

Author, 

Year, 

Location: 

Length & 

Design 

Group 1 

(n)/ 

Group 4 

(n)

Group 2 

(n)/ 

Group 3 

(n) Safety data 

Term infants 

McClead, 

1985, US: 

1-3 wks 

parallel 

RCT 287

Safflower oil 

emulsion 

‘high ALA’ 

(n=10)φ

Safflower oil 

emulsion 

‘low ALA’ 

(n=10) 

ALA 3 (SD: 1.5)% safflower oil emulsion (high ALA)

No AE 

ALA 0.1% safflower oil emulsion (low ALA)

Tachycardia & tachypnea (2nd to fluid overload): n=1 

Decsi, 

1995, 

Germany: 

12 wks 

parallel 

RCT 261

n-3 FA 

enriched F 

egg lipids 

evening 

primrose oil 

(n=12)φ

Control F 

(n=10) 

F-s well tolerated & no serious adverse events reported 

except for minor dermatological symptoms such as 

seborrhoeic & diaper dermatitis 

Auestad, 

1997, US: 

16-48 wks 

parallel 

RCT 104

n-3 FA 

enriched F 

fish oil 

(n=43)/Nonrandomized 

HM 

 (n=63)φ

n-3 FA enriched 

F 

egg lipids 

(n=46)/ 

Control F 

Oil blend: 

coconut 

safflower & soy 

(n=45) 

aT 12 mo (cataracts, viral meningitis, pyloric stenosis, 

phenylketonuria, anisometropia) were not related to F intake 

At 39 mo, NS between-arm differences in the % of those 

with ≥ 1 hospitalization, pressure equalization tubes for 

chronic otitis media, and ≥ 3 prescriptions for antibiotics 

F (fish oil: DHA 0.23%)

SIDS: n=1 (unrelated to study participation), F-intolerance: 

n=4, ≥ 3 prescriptions for antibiotics: 57%, pressure 

equalization tubes for chronic otitis media: 6%, ≥1 

hospitalization: 12% 

F (egg lipids: DHA 0.12% + AA 0.43%)

Cataracts: n=1, F-intolerance: n=9, ≥3 prescriptions for 

antibiotics: 46%, pressure equalization tubes for chronic 

otitis media: 11%, ≥1 hospitalization: 29% 

F (coconut, safflower, & soy oils; no DHA or AA)

Viral meningitis: n=1, pyloric stenosis: n=1, 

F-intolerance: n=2, ≥3 prescriptions for antibiotics: 62%, 

pressure equalization tubes for chronic otitis media: 8%, 

≥ 1 hospitalization: 19% 

HM

Phenylketonuria: n=1, anisometropia: n=1, 

≥3 prescriptions for antibiotics: 66%, pressure equalization 

tubes for chronic otitis media: 4%, ≥ 1 hospitalization: 14% 1

Proceeding from highest omega-3, or lowest omega-6/omega-3, fatty acid content of intervention/exposure; n-3 

= omega-3 fatty acids; n-6 = omega-6 fatty acids; ALA = alpha linolenic acid; DHA = docosahexaenoic acid; EPA 

= eicosapentaenoic acid; AA = arachidonic acid; E-EPA = ethyl eicosapentaenoate; Length = intervention length; 

Design = research design; n = sample size; pts = study participants; NR = not reported; NS = nonsignificant 

statistical difference; n/a = not applicable; pb = placebo; grp = group; wk = week(s); mo = month; wt = weight; +

p<.05 or significant with 95% confidence interval; ++p<.01; +++p<.001; ++++p<.0001; FA = fatty acids; PD = 

preterm delivery; LBW = low birth weight; ICU = intensive care unit; SCN = special care nursery; GD = 

gestational diabetes; HM = human milk; NEC = necrotizing enterocolitis; F = formula; IVH = intra-ventricular 

haemorrhage; PL = phospholipid; TG = triglyceride; SIDS = sudden infant death syndrome; AE = adverse 

events; SAE = serious adverse events; φ = completed (otherwise enrolled) 
E – 61

Summary Table 7: Studies reporting adverse events (e.g., side effects) and contraindications in relation to 

dietary intake of omega-3 fatty acids 

Study groups1

Author, 

Year, 

Location: 

Length & 

Design 

Group 1 

(n)/ 

Group 4 

(n)

Group 2 

(n)/ 

Group 3 

(n) Safety data 

Term infants 

Birch, 

1998, US: 

17 wks 

parallel 

RCT 182

n-3 FA enriched F 

single-cell oils 

(n=27)/Nonrandomized HM 

(n=29) 

n-3 FA enriched F 

single-cell oils 

(n=26)/Control F 

(n=26) 

F (grp 1) vs. F (grp 2) vs. F (grp 3) vs. HM (grp 4)

Illness unrelated to protocol: 

At 6 wks: n=0 vs. n=1 vs. n=0 vs. n=1 

At 17 wks: n=1 vs. n=0 (grps 2-4) 

At 52 wks: n=2 vs. n=0 (grps 2-4) 

Signs of lactose intolerance 

At 6 wks: n=1 vs. n=2 vs. n=3 vs. n=2 

Lucas, 

1999, UK: 

6-24 wks 

parallel 

RCT 265

n-3 FA enriched F 

egg PL-TG 

fractions 

(n=154) 

Control F 

(source NR) 

(n=155)/Nonrandomized HM 

(n=138) 

F (DHA 0.32% + AA 0.30%) vs. F (control; no DHA or 

EPA) 

By 9 mo of follow-up 

Withdrawals due to AE: n=17 vs. n=19; NS 

Mild AE: n=5 vs. n=8; NS 

Moderate AE: n=12 vs. n=8; NS 

Severe AE: n=0 vs. n=3; NS 

Constipation: n=1 vs. n=0; NS 

Gastroenteritis: n=1 vs. n=0; NS 

Pyloric stenosis: n=1 vs. n=0; NS 

Vomiting: n=7 vs. n=7; NS 

Median crying time (min/day): 53 vs. 40; NS 

Odds of having an event (grp 1 relative to grp 2) by 9 mo 

Prescribed antibiotics: OR=1.3, 95% CI: 0.8, 2.2 (NS) 

Respiratory infections: OR=1.1, 95% CI: 0.5, 2.4 (NS) 

Gastroenteritis: OR=0.8, 95% CI: 0.5, 1.5 (NS) 

Visit to medical practitioner: OR=1.8, 95% CI: 0.8, 4.2 

(NS) 

Eczema: OR=1.2, 95% CI: 0.7, 2.1 (NS) 

Asthma: OR=0.8, 95% CI: 0.3, 2.5 (NS) 

Wheeze: OR=1.1, 95% CI: 0.6, 1.8 (NS) 

Makrides, 

1999, 

Australia: 

16 wks 

parallel 

RCT 205

n-3 FA enriched F 

tuna oil 

(n=27)/Nonrandomized HM 

 (n=63) 

n-3 FA enriched F 

egg-PL fraction 

(n=28)/ 

Control F 

(n=28) 

At 6 &16 wks of feeding: NS between-arm % of infants 

with restlessness, rash, vomiting, diarrhea, & constipation 

NR (NS) 

Of the 32 withdrawn infants (formula-fed: 15 and HM: 17), 

n=2 AE; n=11 cataracts (HM) & n=1 (DHA 0.35% or grp 1) 

- unrelated unspecified medical problem 1

Proceeding from highest omega-3, or lowest omega-6/omega-3, fatty acid content of intervention/exposure; n-3 = 

omega-3 fatty acids; n-6 = omega-6 fatty acids; ALA = alpha linolenic acid; DHA = docosahexaenoic acid; EPA = 

eicosapentaenoic acid; AA = arachidonic acid; E-EPA = ethyl eicosapentaenoate; Length = intervention length; Design 

= research design; n = sample size; pts = study participants; NR = not reported; NS = nonsignificant statistical 

difference; n/a = not applicable; pb = placebo; grp = group; wk = week(s); mo = month; wt = weight; +p<.05 or 

significant with 95% confidence interval; ++p<.01; +++p<.001; ++++p<.0001; FA = fatty acids; PD = preterm delivery; LBW 

= low birth weight; ICU = intensive care unit; SCN = special care nursery; GD = gestational diabetes; HM = human 

milk; NEC = necrotizing enterocolitis; F = formula; IVH = intra-ventricular haemorrhage; PL = phospholipid; TG = 

triglyceride; φ = completed (otherwise enrolled); AE = adverse events; SAE = serious adverse events 
E – 62

Summary Table 8: Studies reporting adverse events (e.g., side effects) and contraindications in relation to 

dietary intake of omega-3 fatty acids 

Study groups1

Author, 

Year, 

Location: 

Length & 

Design 

Group 1 

(n)/ 

Group 4 

(n)

Group 2 

(n)/ 

Group 3 

(n) Safety data 

Term infants 

Morris, 

2000, UK: 

12 wks 

parallel 

RCT 268

n-3 FA 

enriched F 

TG-form 

(n=54)φ

Control F 

(source NR) 

(n=55) 

At 6 wks 

n-3 FA enriched F (DHA 0.20%)

n=2 (‘vomiting’) 

n=2 (‘slow to feed’ and ‘hungry’) 

Control F

n=3 (‘hungry’, ‘not satisfied’, and ‘erratic’) 

At 12 wks 

n-3 FA enriched F (DHA 0.20%)

n=1 (‘not satisifed’) 

Control F

n=1 (‘colic’) 

NS between-arm difference in stool consistency 

NS between-arm difference in frequency of consultations 

with primary care team, hospital admissions, 

gastrointestinal disturbances, stools, upper respiratory 

infections, & allergic reactions 

Makrides, 

2000, 

Australia: 

34 wks 

parallel 

RCT 266

High ‘ALA’ F 

Palm, canola, 

coconut, & 

soy oils 

(n=37) 

Low ’ALA’ F 

Oleic, coconut, 

soy, & safflower 

oils (n=36)/Nonrandomized HM 

(n=103) 

At 6 & 16 wks of age 

NS in reported frequency of infant restlessness, rash, 

vomiting, diarrhea, or constipation 

In HM: n=4 infants had recurrent illnesses unrelated to the 

trial & withdrew 

Auestad, 

2001, US: 

48 wks 

2 parallel 

RCT 227

n-3 FAenriched F 

fish/fungal 

(n=82)/Nonrandomized 

HM 

(n=165) 

n-3 FA-enriched F 

egg-TG 

(n=80)/ 

Control F coconut, 

soy, & safflower 

oils (n=77) 

F intolerance by 48 wks of age 

NS frequency of spitting up, vomiting, &consistency of 

stools 

F intolerance leading to withdrawals: 

n=14 (fish/fungal F arm) 

n=13 (egg-TG F arm) 

n=16 (control F) 

Jensen, 

2002, US: 

16 wks 

parallel 

RCT 203

F1 canola, 

palm, coconut 

oils (n=20)/F4 

palm, 

coconut, 

safflower oils 

(n=20) 

F2 palm, coconut, 

canola oils (n=20)/ 

F3 sunflower, 

palm, coconut oil 

(n=20) 

Dietary protein hypersensitivity 

n=2 (F3: ALA 0.95% arm) 

1

Proceeding from highest omega-3, or lowest omega-6/omega-3, fatty acid content of intervention/exposure; n-3 = 

omega-3 fatty acids; n-6 = omega-6 fatty acids; ALA = alpha linolenic acid; DHA = docosahexaenoic acid; EPA = 

eicosapentaenoic acid; AA = arachidonic acid; E-EPA = ethyl eicosapentaenoate; Length = intervention length; 

Design = research design; n = sample size; pts = study participants; NR = not reported; NS = nonsignificant 

statistical difference; n/a = not applicable; pb = placebo; grp = group; wk = week(s); mo = month; wt = weight; +

p<.05 

or significant with 95% confidence interval; ++p<.01; +++p<.001; ++++p<.0001; FA = fatty acids; PD = preterm delivery; 

LBW = low birth weight; ICU = intensive care unit; SCN = special care nursery; GD = gestational diabetes; HM = 

human milk; NEC = necrotizing enterocolitis; F = formula; IVH = intra-ventricular haemorrhage; ; PL = phospholipid; 

TG = triglyceride; φ = completed (otherwise enrolled); AE = adverse events; SAE = serious adverse events 
E – 63

Listing of Included Studies 

Agostoni C, Marangoni F, Giovannini M, Galli C, 

Riva E. Prolonged breast-feeding (six months or 

more) and milk fat content at six months are 

associated with higher developmental scores at one 

year of age within a breast-fed population. Adv 

Exp Med Biol 2001; 501:137-141. 

Agostoni C, Riva E, Trojan S, Bellu R, Giovannini 

M. Docosahexaenoic acid status and 

developmental quotient of healthy term 

infants.[comment]. Lancet 1995; 346(8975):638. 

Agostoni C, Trojan S, Bellu R, Riva E, Giovannini 

M. Neurodevelopmental quotient of healthy term 

infants at 4 months and feeding practice: the role 

of long-chain polyunsaturated fatty acids. Pediatr 

Res 1995; 38(2):262-266. 

Agostoni C, Trojan S, Bellu R, Riva E, Bruzzese 

MG, Giovannini M. Developmental quotient at 24 

months and fatty acid composition of diet in early 

infancy: a follow up study. Arch Dis Child 1997; 

76(5):421-424. 

Al MD, von Houwelingen AC, Hasaart TH, 

Hornstra G. The relationship between the essential 

fatty acid status of mother and child and the 

occurrence of pregnancy-induced hypertension. 

Intermediate results of a prospective longitudinal 

study. World Rev Nutr Diet 1994; 76:110-113. 

Al MD, van Houwelingen AC, Badart-Smook A, 

Hasaart TH, Roumen FJ, Hornstra G. The essential 

fatty acid status of mother and child in pregnancyinduced hypertension: a prospective longitudinal 

study. Am J Obstet Gynecol 1995; 172(5):1605-

1614. 

Auestad N, Halter R, Hall RT, Blatter M, Bogle 

ML, Burks W et al. Growth and development in 

term infants fed long-chain polyunsaturated fatty 

acids: a double-masked, randomized, parallel, 

prospective, multivariate study. Pediatrics 2001; 

108(2):372-381. 

Auestad N, Montalto MB, Hall RT, Fitzgerald 

KM, Wheeler RE, Connor WE et al. Visual acuity, 

erythrocyte fatty acid composition, and growth in 

term infants fed formulas with long chain 

polyunsaturated fatty acids for one year. Ross 

Pediatric Lipid Study. Pediatr Res 1997; 41(1):1-

10. 

Auestad N, Scott DT, Janowsky JS, Jacobsen C, 

Carroll RE, Montalto MB et al. Visual, cognitive, 

and language assessments at 39 months: a followup study of children fed formulas containing longchain polyunsaturated fatty acids to 1 year of age. 

Pediatrics 2003; 112(3 Pt 1):e177-e183. 

Birch E, Birch D, Hoffman D, Hale L, Everett M, 

Uauy R. Breast-feeding and optimal visual 

development. J Pediatr 

Ophthalmol Strabismus 1993; 30(1):33-38. 

Birch DG, Birch EE, Hoffman DR, Uauy RD. 

Retinal development in very-low-birth-weight 

infants fed diets differing in omega-3 fatty acids. 

Invest Ophthalmol Vis Sci 1992; 33(8):2365-2376. 

Birch EE, Birch DG, Hoffman DR, Uauy R. 

Dietary essential fatty acid supply and visual 

acuity development. Invest Ophthalmol Vis Sci 

1992; 33(11):3242-3253. 

Birch EE, Garfield S, Hoffman DR, Uauy R, Birch 

DG. A randomized controlled trial of early dietary 

supply of long-chain polyunsaturated fatty acids 

and mental development in term infants. Dev Med 

Child Neurol 2000; 42(3):174-181. 

Birch EE, Hoffman DR, Castaneda YS, Fawcett 

SL, Birch DG, Uauy RD. A randomized controlled 

trial of long-chain polyunsaturated fatty acid 

supplementation of formula in term infants after 

weaning at 6 wk of age. Am J Clin Nutr 2002; 

75(3):570-580. 

Birch EE, Hoffman DR, Uauy R, Birch DG, 

Prestidge C. Visual acuity and the essentiality of 

docosahexaenoic acid and arachidonic acid in the 

diet of term infants. Pediatr Res 1998; 44(2):201-

209. 

Bougle D, Denise P, Vimard F, Nouvelot A, 

Penneillo MJ, Guillois B. Early neurological and 

neuropsychological development of the preterm 

infant and polyunsaturated fatty acids supply. Clin 

Neurophysiol 1999; 110(8):1363-1370. 

Bulstra-Ramakers MT, Huisjes HJ, Visser GH. 

The effects of 3g eicosapentaenoic acid daily on 

recurrence of intrauterine growth retardation and 

pregnancy induced hypertension. Br J Obstet 

Gynaecol 1995; 102(2):123-126. 

Carlson SE, Cooke RJ, Rhodes PG, Peeples JM, 

Werkman SH, Tolley EA. Long-term feeding of 

formulas high in linolenic acid and marine oil to 

very low birth weight infants: phospholipid fatty 

acids. Pediatr Res 1991; 30(5):404-412. 
E – 64

Carlson SE, Cooke RJ, Werkman SH, Tolley EA. 

First year growth of preterm infants fed standard 

compared to marine oil n-3 supplemented formula. 

Lipids 1992; 27(11):901-907. 

Carlson SE, Ford AJ, Werkman SH, Peeples JM, 

Koo WW. Visual acuity and fatty acid status of 

term infants fed human milk and formulas with 

and without docosahexaenoate and arachidonate 

from egg yolk lecithin. Pediatr Res 1996; 

39(5):882-888. 

Carlson SE, Rhodes PG, Rao VS, Goldgar DE. 

Effect of fish oil supplementation on the n-3 fatty 

acid content of red blood cell membranes in 

preterm infants. Pediatr Res 1987; 21(5):507-510. 

Carlson SE, Werkman SH. A randomized trial of 

visual attention of preterm infants fed 

docosahexaenoic acid until two months. Lipids 

1996; 31(1):85-90. 

Carlson SE, Werkman SH, Cooke RJ, Peeples JM, 

Tolley EA. Docosahexaenoate (DHA) and 

eicosapentaenoate (EPA) status of preterm infants: 

relationship to the Fagantest of Infant Intelligence 

and the Bayley Scale of Mental Development. 

FASEB Journal 1990; 4:A1156. 

Carlson SE, Werkman SH, Peeples JM, Cooke RJ, 

Tolley EA. Arachidonic acid status correlates with 

first year growth in preterm infants. Proc Natl 

Acad Sci U S A 1993; 90(3):1073-1077. 

Carlson SE, Werkman SH, Rhodes PG, Tolley EA. 

Visual-acuity development in healthy preterm 

infants: effect of marine-oil supplementation. Am 

J Clin Nutr 1993; 58(1):35-42. 

Carlson SE, Werkman SH, Tolley EA. Effect of 

long-chain n-3 fatty acid supplementation on 

visual acuity and growth of preterm infants with 

and without bronchopulmonary dysplasia. Am J 

Clin Nutr 1996; 63(5):687-697. 

Cetin I, Giovannini N, Alvino G, Agostoni C, Riva 

E, Giovannini M et al. Intrauterine growth 

restriction is associated with changes in 

polyunsaturated fatty acid fetal-maternal 

relationships. Pediatr Res 2002; 52(5):750-755. 

Cheruku SR, Montgomery-Downs HE, Farkas SL, 

Thoman EB, Lammi-Keefe CJ. Higher maternal 

plasma docosahexaenoic acid during pregnancy is 

associated with more mature neonatal sleep-state 

patterning. Am J Clin Nutr 2002; 76(3):608-613. 

Clandinin MTV. Safety of formulas with 

docosahexaenoic acid (DHA) and arachidonic acid 

(ARA) from single-cell and marine sources for 

low-birth-weight infants (LBW). J Pediatr 

Gastroenterol Nutr 2002; 34(4):484. 

Clandinin MTV. Growth and development of 

very-low-birth-weight infants (VLBW) is 

enhanced by formulas supplemented with 

docosahexaenoic acid (DHA) and arachidonic acid 

(ARA). J Pediatr Gastroenterol Nutr 2002; 

34(4):479. 

Craig-Schmidt MC, Carlson SE, Crocker L, Sibai 

BM. Plasma total phospholipid arachidonic acid 

and eicosapentaenoic acid in normal and 

hypertensive pregnancy. World Rev Nutr Diet 

1994; 76:126-129. 

D'Almeida A, Carter JP, Anatol A, Prost C. 

Effects of a combination of evening primrose oil 

(gamma linolenic acid) and fish oil 

(eicosapentaenoic + docahexaenoic acid) versus 

magnesium, and versus placebo in preventing preeclampsia. Women Health 1992; 19(2-3):117-131. 

de Groot RH, Hornstra G, van Houwelingen AC, 

Roumen F. Effect of alpha-linolenic acid 

supplementation during pregnancy on maternal 

and neonatal polyunsaturated fatty acid status and 

pregnancy outcome. Am J Clin Nutr 2004; 

79(2):251-260. 

De Groot RHM, Adam J, Jolles J, Hornstra. 

Alpha-linolenic acid supplementation during 

human pregnancy does not effect cognitive 

functioning. Prostaglandins Leukot Essent Fatty 

Acids 2004; 70(1):41-47. 

Decsi T, Koletzko B. Growth, fatty acid 

composition of plasma lipid classes, and plasma 

retinol and alpha-tocopherol concentrations in fullterm infants fed formula enriched with omega-6 

and omega-3 long-chain polyunsaturated fatty 

acids. Acta Paediatr 1995; 84(7):725-732. 

Dunstan JA, Mori TA, Barden A, Beilin LJ, Holt 

PG, Calder PC et al. Effects of n-3 polyunsaturated 

fatty acid supplementation in pregnancy on 

maternal and fetal erythrocyte fatty composition. 

Eur J Clin Nutr 2004; 58(3):429-437. 

Elias SL, Innis SM. Infant plasma trans, n-6, and 

n-3 fatty acids and conjugated linoleic acids are 

related to maternal plasma fatty acids, length of 

gestation, and birth weight and length.[comment]. 

Am J Clin Nutr 2001; 73(4):807-814. 

Faldella G, Govoni M, Alessandroni R, Marchiani 

E, Salvioli GP, Biagi PL et al. Maturation of the 

visual cortex in relation to dietary intake of 
E – 65

polyenoic fatty acids in preterm infants. Bambini e 

Nutrizione 1995; 2(3):116-120. 

Faldella G, Govoni M, Alessandroni R, Marchiani 

E, Salvioli GP, Biagi PL et al. Visual evoked 

potentials and dietary long chain polyunsaturated 

fatty acids in preterm infants. Arch Dis Child Fetal 

Neonatal Ed 1996; 75(2):F108-F112. 

Fewtrell MS, Morley R, Abbott RA, Singhal A, 

Isaacs EB, Stephenson T et al. Double-blind, 

randomized trial of long-chain polyunsaturated 

fatty acid supplementation in formula fed to 

preterm infants. Pediatrics 2002; 110(1):73-82. 

Fewtrell MS, Abbott RA, Kennedy K, Singhal A, 

Morley R, Caine E et al. Randomized, doubleblind trial of long-chain polyunsaturated fatty acid 

supplementation with fish oil and borage oil in 

preterm infants. J Pediatr 2004; 144(4):471-479. 

Field CJ, Thomson CA, Aerde Jv, Parrott A, Euler 

A, Lien E et al. Lower proportion of CD45R0+ 

cells and deficient interleukin-10 production by 

formula-fed infants, compared with human-fed, is 

corrected with supplementation of long-chain 

polyunsaturated fatty acids. J Pediatr Gastroenterol 

Nutr 2000; 31(3):291-299. 

Ghebremeskel K, Burns L, Costeloe K, Burden TJ, 

Harbige L, Thomas B et al. Plasma vitamin A and 

E in preterm babies fed on breast milk or formula 

milk with or without long-chain polyunsaturated 

fatty acids. Int J Vitam Nutr Res 1999; 69(2):83-

91. 

Ghys A, Bakker E, Hornstra G, van den HM. Red 

blood cell and plasma phospholipid arachidonic 

and docosahexaenoic acid levels at birth and 

cognitive development at 4 years of age. Early 

Hum Dev 2002; 69(1-2):83-90. 

Gibson RA, Neumann MA, Makrides M. Effect of 

increasing breast milk docosahexaenoic acid on 

plasma and erythrocyte phospholipid fatty acids 

and neural indices of exclusively breast fed 

infants. Eur J Clin Nutr 1997; 51(9):578-584. 

Gobel Y, Koletzko B, Bohles HJ, Engelsberger I, 

Forget D, Le Brun A et al. Parenteral fat emulsions 

based on olive and soybean oils: a randomized 

clinical trial in preterm infants. J Pediatr 

Gastroenterol Nutr 2003; 37(2):161-167. 

Groh-Wargo S, Moore JJ, Catalano P, Thomas A, 

O'Connor DL, Lerner E. Docosahexaenoic acid 

(DHA) and arachidonic acid (AA) 

supplementation does not change body 

composition in preterm (PT) infants. Pediatr Res 

2002; 51(4):380A. 

Guesnet P. Blood lipid concentrations of 

docosahexaenoic and arachidonic acids at birth 

determine their relative postnatal changes in term 

infants fed breast milk or formula.[comment]. Am 

J Clin Nutr 1999; 70(2):292-298. 

Helland IB, Saugstad OD, Smith L, Saarem K, 

Solvoll K, Ganes T et al. Similar effects on infants 

of n-3 and n-6 fatty acids supplementation to 

pregnant and lactating women. Pediatrics 2001; 

108(5):E82. 

Helland IB, Smith L, Saarem K, Saugstad OD, 

Drevon CA. Maternal supplementation with verylong-chain n-3 fatty acids during pregnancy and 

lactation augments children's IQ at 4 years of age. 

Pediatrics 2003; 111(1):e39-e44. 

Hoffman DR, Birch EE, Birch DG, Uauy RD. 

Effects of supplementation with omega 3 longchain polyunsaturated fatty acids on retinal and 

cortical development in premature infants. Am J 

Clin Nutr 1993; 57(5 Suppl):807S-812S. 

Hoffman DR, Birch EE, Birch DG, Uauy R. Fatty 

acid profile of buccal cheek cell phospholipids as 

an index for dietary intake of docosahexaenoic 

acid in preterm infants. Lipids 1999; 34(4):337-

342. 

Hoffman DR, Birch EE, Birch DG, Uauy R, 

Castaneda YS, Lapus MG et al. Impact of early 

dietary intake and blood lipid composition of longchain polyunsaturated fatty acids on later visual 

development. J Pediatr Gastroenterol Nutr 2000; 

31(5):540-553. 

Hoffman DR, Birch EE, Castaneda YS, Fawcett 

SL, Wheaton DH, Birch DG et al. Visual function 

in breast-fed term infants weaned to formula with 

or without long-chain polyunsaturates at 4 to 6 

months: a randomized clinical trial. J Pediatr 2003; 

142(6):669-677. 

Hofmann M, Bahlmann F, Pollow K, Brockerhoff 

P. Phospholipid and triglycerid composition in 

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polyunsaturated fatty acids. Geburtshilfe 

Frauenheilkd 1998; 58(9). 

Innis SM, Adamkin DH, Hall RT, Kalhan SC, Lair 

C, Lim M et al. Docosahexaenoic acid and 

arachidonic acid enhance growth with no adverse 

effects in preterm infants fed formula. J Pediatr 

2002; 140(5):547-554. 

Innis SM, Akrabawi SS, Diersen-Schade DA, 

Dobson MV, Guy DG. Visual acuity and blood 

lipids in term infants fed human milk or 
E – 66

formulae.[erratum appears in Lipids 1997 

Apr;32(4):457]. Lipids 1997; 32(1):63-72. 

Innis SM, Gilley J, Werker J. Are human milk 

long-chain polyunsaturated fatty acids related to 

visual and neural development in breast-fed term 

infants? J Pediatr 2001; 139(4):532-538. 

Innis SM, Nelson CM, Rioux MF, King DJ. 

Development of visual acuity in relation to plasma 

and erythrocyte omega-6 and omega-3 fatty acids 

in healthy term gestation infants. Am J Clin Nutr 

1994; 60(3):347-352. 

Jensen CL, Prager TC, Fraley JK, Chen H, 

Anderson RE, Heird WC. Effect of dietary 

linoleic/alpha-linolenic acid ratio on growth and 

visual function of term infants.[comment]. J 

Pediatr 1997; 131(2):200-209. 

Jensen CL, Prager TC, Zou Y, Fraley JK, Maude 

M, Anderson RE et al. Effects of maternal 

docosahexaenoic acid supplementation on visual 

function and growth of breast-fed term infants. 

Lipids 1999; 34(Suppl):S225. 

Jorgensen MH, Hernell O, Hughes EL, Michaelsen 

KF. Is there a relation between docosahexaenoic 

acid concentration in mothers' milk and visual 

development in term infants? J Pediatr 

Gastroenterol Nutr 2001; 32(3):293-296. 

Jorgensen MH, Hernell O, Lund P, Holmer G, 

Michaelsen KF. Visual acuity and erythrocyte 

docosahexaenoic acid status in breast-fed and 

formula-fed term infants during the first four 

months of life. Lipids 1996; 31(1):99-105. 

Jorgensen MH, Holmer G, Lund P, Hernell O, 

Michaelsen KF. Effect of formula supplemented 

with docosahexaenoic acid and gamma- linolenic 

acid on fatty acid status and visual acuity in term 

infants. J Pediatr Gastroenterol Nutr 1998; 

26(4):412-421. 

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F – 1 

Appendix F. List of excluded studies (no RCTs) 

1.. Pregnancy outcomes 

1a. Duration of gestation 

1. Olsen, S. F., Hansen, H. S., Sommer, S., 

Jensen, B., Sorensen, T. I., Secher, N. J., and 

Zachariassen, P., Gestational age in relation 

to marine n-3 fatty acids in maternal 

erythrocytes: a study of women in the Faroe 

Islands and Denmark, Am J Obstet Gynecol, 

164( 5 Pt 1), 1991, p.1203 – 1209 

2. Grandjean, P., Bjerve, K. S., Weihe, P., and 

Steuerwald, U., Birthweight in a fishing 

community: significance of essential fatty 

acids and marine food 

contaminants.[comment], Int J Epidemiol, 

30( 6), 2001, p.1272 – 1278 

3. Velzing-Aarts, F. V., van der Klis, F. R., van 

der Dijs, F. P., and Muskiet, F. A., 

Umbilical vessels of preeclamptic women 

have low contents of both n-3 and n-6 longchain polyunsaturated fatty acids, Am J Clin 

Nutr, 69( 2), 1999, p.293 – 298 

4. Araya, Araya J., Rojas, Garcia M., 

Fernandez, Fraile P., and Mateluna, 

Acevedo A., [Differences in percent 

composition of long chain polyunsaturated 

fatty acids in maternal-fetal erythrocytes in 

term and preterm infants]. [Spanish], Arch 

Latinoam Nutr, 48( 3), 1998, p.210 – 215 

5. Araya, J., Rojas, M., Fernandez, P., and 

Mateluna, A., [Essential fatty acid content of 

maternal erythrocyte phospholipids. A study 

in preterm and full-term human newborns]. 

[Spanish], Rev Med Chil, 126( 4), 1998, 

p.391 - 396 

6. Wang, J. and Zhang, Y., Effect of the long 

chain polyunsaturated fatty acids levels in 

mothers on fetuses. [Chinese], Chung-Hua 

Fu Chan Ko Tsa Chih [Chinese Journal of 

Obstetrics & Gynecology], 33( 12), 1998, 

p.722 – 723 

7. Kesmodel, U., Olsen, S. F., and Salvig, J. 

D., Marine n-3 fatty acid and calcium intake 

in relation to pregnancy induced 

hypertension, intrauterine growth 

retardation, and preterm delivery. A casecontrol study, Acta Obstet Gynecol Scand, 

76( 1), 1997, p.38 – 44 

8. Foreman-van Drongelen, M. M., Al, M. D., 

van Houwelingen, A. C., Blanco, C. E., and 

Hornstra, G., Comparison between the 

essential fatty acid status of preterm and 

full-term infants, measured in umbilical 

vessel walls, Early Hum Dev, 42( 3), 18-8-

1995, p.241 – 251 

9. Olsen, S. F., Hansen, H. S., Secher, N. J., 

Jensen, B., and Sandstrom, B., Gestation 

length and birth weight in relation to intake 

of marine n-3 fatty acids, Br J Nutr, 73( 3), 

1995, p.397 – 404 

10. Vizek, K., Mourek, J., Base, J., Smidova, L., 

Mikova, M., and Cechova, I., [Serum fatty 

acids in premature neonates]. [Czech], Sb 

Lek, 94( 1), 1993, p.19 - 24 

11. Olsen, S. F., Grandjean, P., Weihe, P., and 

Videro, T., Frequency of seafood intake in 

pregnancy as a determinant of birth weight: 

evidence for a dose dependent relationship, J 

Epidemiol Community Health, 47( 6), 1993, 

p.436 – 440 

12. Leaf, A. A., Leighfield, M. J., Costeloe, K. 

L., and Crawford, M. A., Long chain 

polyunsaturated fatty acids and fetal growth, 

Early Hum Dev, 30( 3), 1992, p.183-191. 

13. Leaf, A. A., Leighfield, M. J., Costeloe, K. 

L., and Crawford, M. A., Factors affecting 

long-chain polyunsaturated fatty acid 

composition of plasma choline 

phosphoglycerides in preterm infants, J 

Pediatr Gastroenterol Nutr, 14( 3), 1992, 

p.300 – 308 

14. Olsen, S. F., Olsen, J., and Frische, G., Does 

fish consumption during pregnancy increase 

fetal growth? A study of the size of the 

newborn, placental weight and gestational 

age in relation to fish consumption during 

pregnancy, Int J Epidemiol, 19( 4), 1990, 

p.971 – 977 

15. Olsen, S. F. and Secher, N. J., A possible 

preventive effect of low-dose fish oil on 

early delivery and pre-eclampsia: indications 

from a 50-year-old controlled trial, Br J 

Nutr, 64( 3), 1990, p.599 – 609 

16. Olsen, S. F., Hansen, H. S., Jensen, B., and 

Sorensen, T. I., Pregnancy duration and the 

ratio of long-chain n-3 fatty acids to 

arachidonic acid in erythrocytes from 
F – 2 

Faroese women, J Intern Med Suppl, 225( 

731), 1989, p.185 – 189 

17. Olsen, S. F., Hansen, H. S., Sorensen, T. I., 

Jensen, B., Secher, N. J., Sommer, S., and 

Knudsen, L. B., Intake of marine fat, rich in 

(n-3)-polyunsaturated fatty acids, may 

increase birthweight by prolonging 

gestation, Lancet, 2( 8503), 16-8-1986, 

p.367 – 369 

18. Olsen, S. F. and Secher, N. J., Low 

consumption of seafood in early pregnancy 

as a risk factor for preterm delivery: 

Prospective cohort study, Br Med J, 324( 

7335), 23-2-2002, p.23 

1b. Gestational hypertension, preeclampsia and eclampsia 

1. Clausen, T., Slott, M., Solvoll, K., Drevon, 

C. A., Vollset, S. E., and Henriksen, T., 

High intake of energy, sucrose, and 

polyunsaturated fatty acids is associated 

with increased risk of preeclampsia, Am J 

Obstet Gynecol, 185( 2), 2001, p.451 - 458 

2. Velzing-Aarts, F. V., van der Klis, F. R., van 

der Dijs, F. P., and Muskiet, F. A., 

Umbilical vessels of preeclamptic women 

have low contents of both n-3 and n-6 longchain polyunsaturated fatty acids, Am J Clin 

Nutr, 69( 2), 1999, p.293 – 298 

3. Kesmodel, U., Olsen, S. F., and Salvig, J. 

D., Marine n-3 fatty acid and calcium intake 

in relation to pregnancy induced 

hypertension, intrauterine growth 

retardation, and preterm delivery. A casecontrol study, Acta Obstet Gynecol Scand, 

76( 1), 1997, p.38 – 44 

4. Williams, M. A., Zingheim, R. W., King, I. 

B., and Zebelman, A. M., Omega-3 fatty 

acids in maternal erythrocytes and risk of 

preeclampsia, Epidemiology, 6( 3), 1995, 

p.232 – 237 

5. Gerrard, J., Popeski, D., Ebbeling, L., 

Brown, P., and Hornstra, G., Dietary omega 

3 fatty acids and gestational hypertension in 

the Inuit, Arctic Med Res, Suppl, 1991, 

p.763 – 767 

6. Popeski, D., Ebbeling, L. R., Brown, P. B., 

Hornstra, G., and Gerrard, J. M., Blood 

pressure during pregnancy in Canadian 

Inuit: community differences related to diet, 

CMAJ, 145( 5), 1-9-1991, p.445 – 454 

7. van der Schouw, Y. T., Al, M. D., Hornstra, 

G., Bulstra-Ramakers, M. T., and Huisjes, 

H. J., Fatty acid composition of serum lipids 

of mothers and their babies after normal and 

hypertensive pregnancies, Prostaglandins 

Leukot Essent Fatty Acids, 44( 4), 1991, 

p.247 – 252 

8. Olsen, S. F. and Secher, N. J., A possible 

preventive effect of low-dose fish oil on 

early delivery and pre-eclampsia: indications 

from a 50-year-old controlled trial, Br J 

Nutr, 64( 3), 1990, p.599 – 609 

1c. Small for Gestational Age 

1. Grandjean, P., Bjerve, K. S., Weihe, P., and 

Steuerwald, U., Birthweight in a fishing 

community: significance of essential fatty 

acids and marine food 

contaminants.[comment], Int J Epidemiol, 

30( 6), 2001, p.1272 – 1278 

2. Velzing-Aarts, F. V., van der Klis, F. R., van 

der Dijs, F. P., and Muskiet, F. A., 

Umbilical vessels of preeclamptic women 

have low contents of both n-3 and n-6 longchain polyunsaturated fatty acids, Am J Clin 

Nutr, 69( 2), 1999, p.293 – 298 

3. Wang, J. and Zhang, Y., Effect of the long 

chain polyunsaturated fatty acids levels in 

mothers on fetuses. [Chinese], Chung-Hua 

Fu Chan Ko Tsa Chih [Chinese Journal of 

Obstetrics & Gynecology], 33( 12), 1998, 

p.722 – 723 

4. Zhang, L., The effects of essential fatty 

acids preparation in the treatment of 

intrauterine growth retardation, Am J 

Perinatol, 14( 9), 1997, p.535 – 537 

5. Badart-Smook, A., van Houwelingen, A. C., 

Al, M. D., Kester, A. D., and Hornstra, G., 

Fetal growth is associated positively with 

maternal intake of riboflavin and negatively 

with maternal intake of linoleic acid, J Am 

Diet Assoc, 97( 8), 1997, p.867 – 870 

6. Kesmodel, U., Olsen, S. F., and Salvig, J. 

D., Marine n-3 fatty acid and calcium intake 

in relation to pregnancy induced 

hypertension, intrauterine growth 

retardation, and preterm delivery. A casecontrol study, Acta Obstet Gynecol Scand, 

76( 1), 1997, p.38 – 44 

7. Mourek, J. and Dohnalova, A., Relationship 

between birth weight of newborns and 

unsaturated fatty acid(n-3) proportions in 
F – 3 

their blood serum, Physiol Res, 45( 2), 1996, 

p.165 – 168 

8. Foreman-van Drongelen, M. M., Al, M. D., 

van Houwelingen, A. C., Blanco, C. E., and 

Hornstra, G., Comparison between the 

essential fatty acid status of preterm and 

full-term infants, measured in umbilical 

vessel walls, Early Hum Dev, 42( 3), 18-8-

1995, p.241 – 251 

9. Olsen, S. F., Hansen, H. S., Secher, N. J., 

Jensen, B., and Sandstrom, B., Gestation 

length and birth weight in relation to intake 

of marine n-3 fatty acids, Br J Nutr, 73( 3), 

1995, p.397 – 404 

10. Foreman-van Drongelen, M. M., van 

Houwelingen, A. C., Kester, A. D., Hasaart, 

T. H., Blanco, C. E., and Hornstra, G., 

Long-chain polyunsaturated fatty acids in 

preterm infants: status at birth and its 

influence on postnatal levels, J Pediatr, 126( 

4), 1995, p.611 – 618 

11. Felton, C. V., Chang, T. C., Crook, D., 

Marsh, M., Robson, S. C., and Spencer, J. 

A., Umbilical vessel wall fatty acids after 

normal and retarded fetal growth, Arch Dis 

Child Fetal Neonatal Ed, 70( 1), 1994, p.F36 

- F39 

12. Olsen, S. F., Grandjean, P., Weihe, P., and 

Videro, T., Frequency of seafood intake in 

pregnancy as a determinant of birth weight: 

evidence for a dose dependent relationship, J 

Epidemiol Community Health, 47( 6), 1993, 

p.436 – 440 

13. Leaf, A. A., Leighfield, M. J., Costeloe, K. 

L., and Crawford, M. A., Long chain 

polyunsaturated fatty acids and fetal growth, 

Early Hum Dev, 30( 3), 1992, p.183 – 191 

14. Leaf, A. A., Leighfield, M. J., Costeloe, K. 

L., and Crawford, M. A., Factors affecting 

long-chain polyunsaturated fatty acid 

composition of plasma choline 

phosphoglycerides in preterm infants, J 

Pediatr Gastroenterol Nutr, 14( 3), 1992, 

p.300 – 308 

15. Koletzko, B. and Braun, M., Arachidonic 

acid and early human growth: is there a 

relation?, Ann Nutr Metab, 35( 3), 1991, 

p.128 – 131 

16. Harper, V., MacInnes, R., Campbell, D., and 

Hall, M., Increased birth weight in northerly 

islands: is fish consumption a red herring?, 

BMJ, 303( 6795), 20-7-1991, p.166 

17. Olsen, S. F., Olsen, J., and Frische, G., Does 

fish consumption during pregnancy increase 

fetal growth? A study of the size of the 

newborn, placental weight and gestational 

age in relation to fish consumption during 

pregnancy, Int J Epidemiol, 19( 4), 1990, 

p.971 – 977 

18. Crawford, M. A., Costeloe, K., Doyle, W., 

Leighfield, M. J., Lennon, E. A., and 

Meadows, N., Potential diagnostic value of 

the umbilical artery as a definition of neural 

fatty acid status of the fetus during its 

growth: the umbilical artery as a diagnostic 

tool, Biochem Soc Trans, 18( 5), 1990, 

p.761 – 766 

19. Crawford, M. A., Doyle, W., Drury, P., 

Lennon, A., Costeloe, K., and Leighfield, 

M., n-6 and n-3 fatty acids during early 

human development, J Intern Med Suppl, 

225( 731), 1989, p.159 – 169 

20. Olsen, S. F. and Secher, N. J., A possible 

preventive effect of low-dose fish oil on 

early delivery and pre-eclampsia: indications 

from a 50-year-old controlled trial, Br J 

Nutr, 64( 3), 1990, p.599 – 609 

21. Hansen, I. B., Friis-Hansen, B., and Clausen, 

J., The fatty acid composition of umbilical 

cord serum, infant serum and maternal 

serum and its relation to the diet, Z 

Ernahrungswiss, 9( 4), 1969, p.352 – 363 

22. Olsen, S. F. and Secher, N. J., Low 

consumption of seafood in early pregnancy 

as a risk factor for preterm delivery: 

Prospective cohort study, Br Med J, 324( 

7335), 23-2-2002, p.23 

23. Matorras, R., De Larrucea, A. L., Sanjurjo, 

P., Ruiz, J. I., Echevarria, Y., Nieto, A., 

Perteagudo, L., and Aldamiz-Echvarria, J. 

L., Increased tissue concentrations of 

arachidonic acid in umbilical artery and 

placenta in fetal growth retardation, Acta 

Obstet Gynecol Scand, 80( 9), 2001 

2. Growth Pattern Outcomes 

1. Foreman-van Drongelen, M. M., van 

Houwelingen, A. C., Kester, A. D., Hasaart, 

T. H., Blanco, C. E., and Hornstra, G., 

Long-chain polyunsaturated fatty acids in 

preterm infants: status at birth and its 

influence on postnatal levels, J Pediatr, 126( 

4), 1995, p.611 – 618 

2. Guldan, G. S., Zhang, M. Y., Zhang, Y. P., 

Hong, J. R., Zhang, H. X., Fu, S. Y., and Fu, 
F – 4 

N. S., Weaning practices and growth in rural 

Sichuan infants: a positive deviance study, J 

Trop Pediatr, 39( 3), 1993, p.168 – 175 

3. Olsen, S. F., Olsen, J., and Frische, G., Does 

fish consumption during pregnancy increase 

fetal growth? A study of the size of the 

newborn, placental weight and gestational 

age in relation to fish consumption during 

pregnancy, Int J Epidemiol, 19( 4), 1990, 

p.971 – 977 

4. Fomon, S. J., Thomas, L. N., Filer, L. J., Jr., 

Ziegler, E. E., and Leonard, M. T., Food 

consumption and growth of normal infants 

fed milk-based formulas, Acta Paediatr 

Scand Suppl, 223, 1971, p.1 – 36 

5. Decsi, T., Kelemen, B., Minda, H., Burus, I., 

and Kohn, G., Effect of type of early infant 

feeding on fatty acid composition of plasma 

lipid classes in full-term infants during the 

second 6 months of life, J Pediatr 

Gastroenterol Nutr, 30( 5), 2000 

6. Clandinin, M. T., Aerde, JE van, Parrott, A., 

Field, C. J., Euler, A. R., Lien, E., and Van 

Aerde, J. E., Assessment of feeding different 

amounts of arachidonic and 

docosahexaenoic acids in preterm infant 

formulas on the fatty acid content of 

lipoprotein lipids, Acta Paediatr, 88( 8), 

1999, p.890 – 896 

7. Clandinin, M. T., Aerde, JE van, Parrott, A., 

Field, C. J., Euler, A. R., Lien, E. L., and 

Van Aerde, J. E., Assessment of the 

efficacious dose of arachidonic and 

docosahexaenoic acids in preterm infant 

formulas: fatty acid composition of 

erythrocyte membrane lipids, Pediatr Res, 

42( 6), 1997, p.819 – 825 

8. Tichelaar, H. Y., Steyn, N. P., Nel, J. H., 

Smuts, C. M., Jaarsveld, PJ van, Prinsloo, J. 

F., Rooyen, J. van, Lombard, C. J., Dhansay, 

M. A., Benade, A. J. S., van Jaarsveld, P. J., 

and van Rooyen, J., Effect of catfish 

supplementation on the fatty acid status and 

growth of undernourished rural preschool 

children under 6 years of age: an 

intervention trial in Lebowa, South Africa, 

Asia Pac J Clin Nutr, 8( 2), 1999, p.96 – 105 

9. Courage ML, McCloy UR, Herzberg GR, 

Andrews WL, Simmons BS, McDonald AC, 

Mercer CN, Friel JK., Visual acuity 

development and fatty acid composition of 

erythrocytes in full-term infants fed breast 

milk, commercial formula, or evaporated 

milk., J Dev Behav Pediatr, 19(1), 1998, p.9 

– 17 

3. Neurological outcomes 

1. Vik, T., Bjerve, K., and Andersson, H., 

Psychomotor development at one year of 

age in very low birth weight infants and 

omega-3 fatty acid status, Pediatr Res, 29, 

1991, p.305a 

2. Bjerve, K. S., Brubakk, A. M., Fougner, K. 

J., Johnsen, H., Midthjell, K., and Vik, T., 

Omega-3 fatty acids: essential fatty acids 

with important biological effects, and serum 

phospholipid fatty acids as markers of 

dietary omega 3-fatty acid intake, Am J Clin 

Nutr, 57( 5 Suppl), 1993, p.801S - 805S 

3. Bjerve, K. S., Thoresen, L., Bonaa, K., Vik, 

T., Johnsen, H., and Brubakk, A. M., 

Clinical studies with alpha-linolenic acid 

and long-chain n-3 fatty acids, Nutrition, 8( 

2), 1992, p.130 – 132 

4. Agostoni, C., Marangoni, F., Giovannini, 

M., Galli, C., and Riva, E., Prolonged 

breast-feeding (six months or more) and 

milk fat content at six months are associated 

with higher developmental scores at one 

year of age within a breast-fed population, 

Adv Exp Med Biol, 501, 2001, p.137 – 141 

5. Agostoni, C., Verduci, E., Massetto, N., 

Radaelli, G., Riva, E., and Giovannini, M., 

Plasma long-chain polyunsaturated fatty 

acids and neurodevelopment through the 

first 12 months of life in phenylketonuria, 

Dev Med Child Neurol, 45( 4), 2003, p.257 

– 261 

6. Cheruku, S. R., Montgomery-Downs, H. E., 

Farkas, S. L., Thoman, E. B., and LammiKeefe, C. J., Higher maternal plasma 

docosahexaenoic acid during pregnancy is 

associated with more mature neonatal sleepstate patterning, Am J Clin Nutr, 76( 3), 

2002, p.608 – 613 

4. Cognitive Outcomes 

1. Bakker, E. C., Ghys, A. J., Kester, A. 

D., Vles, J. S., Dubas, J. S., Blanco, C. 

E., and Hornstra, G., Long-chain 

polyunsaturated fatty acids at birth and 

cognitive function at 7 y of age, Eur J 

Clin Nutr, 57( 1), 2003, p.89 – 95 

2. Santiago, Burruchaga M., Ruiz-Sanz, J. 

I., Pijoan-Zubizarreta, J. I., Benito, 

Fernandez J., and Sanjurjo, Crespo P., 

Intellectual development in the second 

year of life in healthy breast-fed 
F – 5 

children vs. formula-fed children, An 

Esp Pediatr, 52( 6), 2000, p.530 – 536 

5. Visual outcomes 

1. Werkman, S. H. and Carlson, S. E., A 

randomized trial of visual attention of 

preterm infants fed docosahexaenoic acid 

until nine months, Lipids, 31( 1), 1996, p.91 

– 97 

2. Carlson, S. E. and Werkman, S. H., A 

randomized trial of visual attention of 

preterm infants fed docosahexaenoic acid 

until two months, Lipids, 31( 1), 1996, p.85 

– 90 

3. Carlson, S. E., Werkman, S. H., Rhodes, P. 

G., and Tolley, E. A., Visual-acuity 

development in healthy preterm infants: 

effect of marine-oil supplementation, Am J 

Clin Nutr, 58( 1), 1993, p.35 – 42 

4. Birch, E. E., Birch, D. G., Hoffman, D. R., 

and Uauy, R., Dietary essential fatty acid 

supply and visual acuity development, 

Invest Ophthalmol Vis Sci, 33( 11), 1992, 

p.3242 – 3253 

5. Agostoni, C., Verduci, E., Massetto, N., 

Radaelli, G., Riva, E., and Giovannini, M., 

Plasma long-chain polyunsaturated fatty 

acids and neurodevelopment through the 

first 12 months of life in phenylketonuria, 

Dev Med Child Neurol, 45( 4), 2003, p.257 

– 261 

6. Innis, S. M., Nelson, C. M., Lwanga, D., 

Rioux, F. M., and Waslen, P., Feeding 

formula without arachidonic acid and 

docosahexaenoic acid has no effect on 

preferential looking acuity or recognition 

memory in healthy full-term infants at 9 mo 

of age, Am J Clin Nutr, 64( 1), 1996, p.40 – 

46 

7. Courage ML, McCloy UR, Herzberg GR, 

Andrews WL, Simmons BS, McDonald AC, 

Mercer CN, Friel JK., Visual acuity 

development and fatty acid composition of 

erythrocytes in full-term infants fed breast 

milk, commercial formula, or evaporated 

milk., J Dev Behav Pediatr, 19(1), 1998, p.9 

– 17 

8. Carlson SE, Peeples JM, and Werkman SH, 

Docosahexaenoate (DHA) and 

eicosapentaenoate (EPA) status of preterm 

infants: relationship to the Fagantest of 

Infant intelligence and the Bayley scale of 

mental development, FASEB J, 4, 1990, 

p.A1156 

9. Carlson, SE, Cooke, RJ, and Peeples, JM, 

Docosahexaenoate (DHA) and 

eicosapentaenoate (EPA) status of preterm 

infants: relationship to visual acuity in n-3 

supplemented and unsupplemented infants, 

Pediatr Res, 25, 1989, p.285a 
G – 1 

Appendix G. Interventional Formula’s Content 

 Interventional Study Formula Content 

Formula DHA EPA ALA LA AA GLA DPA DGLA Mono

Algal + DHA (%) 0.37 Algal oil (%) 48. 18.0 Aptamil + Milupan 0.15-0.25 0.60-0.65 11.5-12.8 0.30-

0.40 

 

Borage oil (%) 0.32 0.37 1.17 12.67 0.06 0.54 0.10 0.16 Borage oil (g/100g) 0.5 0.1 1.5 12.3 0.9 43 Cod liver oil (mg/10ml) 1183 803 75 160 27.5 112 Corn oil (g/100g) 0.8 31.4 17.1 Corn oil (mg/10ml) 8.3 92 4747 Egg phospholipids (%) 

.34 1.0 16.6 .34 31.0 

Egg phospholipids (%) 

0.34 1.02 16.56 0.34 0.13 31.03 

Egg yolk (g/100g) 0.12 1.9 21.7 0.43 42.1 Egg yolk Lecithin (g/100g) 

0.1 2.0 21.8 0.43 

Egg-derived triglyceride/fish oil (%) 

0.26 0.42 

Egg-DTG (g/100g) 0.14 22.4 0.45 2.5 41.0 Egg-TG/Fish* (g/100g) 0.24 2.5 17.5 0.41 9.8 Egg-TG/Fish** (g/100g) 

0.15 2.4 20.3 0.41 29.8 

Enfamil + LCPUFA(%) 0.36 1.53 14.9 0.72 0.05 29.2 
G – 2 

Enfamil - 0.4% ALA 0.4 17.6 Enfamil - 1% ALA 0.95 17.3 Enfamil (%) 1.9 18 Enfamil (%) 4.7 34.2 Enfamil + DHA (%) 0.34 3.1 22.0 Enfamil + DHA +ARA (%) 

0.33 3.0 21.0 0.60 

Enfamil + LCPUFA (g/L) 

0.21 0.86 8.37 0.42 0.01 16.42 

Enfamil -1.7% ALA 1.7 16.5 Enfamil -3.2% ALA 3.2 15.6 Enfamil iron DHA+AA (%) 

0.36 1.53 14.9 0.72 29.2 

Enfamil iron+ DHA (%) 0.35 1.54 15.1 0.02 30.3 EPA (g) 3.0 Fish oil 0.31 0.08 1.07 17.62 0.03 Fish oil – DD (mol/100ml) 

0.43 0.34 1.05 11.40 0.03 0.32 0.01 0.01 

Fish oil - high EPA (%) 0.45 0.35 0.85 17.8 0.05 33.8 Fish oil - low EPA (%) 0.45 0.10 1.10 17.7 0.05 34.0 Fish oil – PT (%) 0.37 0.05 Fish oil – SD (mol/100ml) 

0.20 0.17 1.06 11.22 0.02 0.31 0.02 
G – 3 

Fish oil – term (%) 0.45 0.09 Fish oil (%) 0.36 0.58 1.52 17.44 0.01 0.27 0.07 30.75 Fish oil (%) 40.4 7.2 0.8 1.2 4.1 Fish oil (%) 56.0 27.7 0.3 1.8 7.1 Fish oil (%) 0.32 0.39 1.20 11.95 0.06 0.07 0.16 Fish oil (%) 0.39 Fish oil (%) 23.0 32.0 Fish oil (%) 23.0 32.0 Fish oil (g) 1.08 1.62 Fish oil (mg/100kcal) 17 34 Fish/Fungal (g/100g) 0.13 <0.04 21.0 0.46 2.4 40.0 Fish/fungal ** (g/100g) 0.16 2.4 19.5 0.43 27.9 Fish/fungal oil (%) 0.26 0.42 Fish/fungal* (g/100g) 

0.27 0.08 2.6 16.8 0.43 8.4 

Fish oil + GLA (mg) 10 18 37 Formula + LCPUFA (%) 

0.32 0.01 1.4 15.9 0.30 

Formula A (%) 1.3 14.1 Formula B (%) 0.6 0.1 1.2 17.7 0.1 0.4 Formula LCPUFA-F (%) 

0.57 0.13 1.2 17.7 0.1 0.4 26.9 
G – 4 

Formula+LCPUFA (%) 0.2 2.3 11.6 0.4 0.2 High-DHA eggs (g/100g) 

5.45 

LA:ALA 10:1 (%) 1.7 16.9 35.8 LA:ALA 5:1 (%) 3.3 16.6 36.7 Margarine + ALA 14.18 45.36 17.41 Marine oil - PT (g/100g) 

0.2 0.3 3.1 18.7 

Marine oil - term (g/100g) 

0.2 0.3 4.9 32.6 

Marine oil (%) 0.20 0.06 2.4 21.2 MaxEPA (mg) 120 180 Microalgae & fungi 0.34 0.70 Pre-Aptamil Milupan LCPUFA-F (%) 

0.3 0.03 1.0 13.8 0.5 0.2 34.4 

Preemie SMA + LCPUFA (%) 

0.35 1.5 12.1 0.50 

Preemie SMA+LCPUFA (%) 

0.35 1.5 12.1 0.49 

Preglandin (mg) 375. 45. Prematil + LCPUFA (%) 

0.3 0.03 0.8 13.8 0.5 0.2 0.1 

Prematil Milupan (g/100g) 

0.17 0.04 0.6 12.0 0.31 0.4 

Prematil Milupan + LCPUFA (%) 

0.30 0.05 0.73 10.85 0.44 0.30 0.07 0.12 

Single cell oils (mg/100kcal) 

17 34 

Soy oil (g/100g) 4.8 34.2 17.3 Soy/Marine oil (g/100g) 

0.35 0.65 1.4 20.4 0.1 10.7 
G – 5 

Tuna fish oil (g/100g) 0.5 0.1 1.5 12.3 0.9 43 Tuna oil (%) .35 .10 1.2 16.8 31.9 Tuna oil (%) 0.35 0.10 1.22 16.76 0.12 31.85 Tuna oil (g/100g) 0.23 0.07 1.9 20.7 40.2 * = in-hospital; ** = post discharge; PT = preterm; SD = single dose; DD = double dose; DHA = docosahexaenoic acid; EPA = eicosapentanoic 

acid; LA = linoleic acid; AA = arachidonic acid; GLA = gammalinolenic acid; DGLA = dihomo-gama-linolenic acid 
H – 1 

Appendix H. Listing of Excluded Studies at Level 

2 and 3 Screening 

Level 2 

Adair C D, Sanchez-Ramos L, Briones D L et al. 

The effect of high dietary n-3 fatty acid 

supplementation on angiotensin II pressor 

response in human pregnancy. American Journal 

of Obstetrics & Gynecology 1996;175( 3 Pt 

1):688-691. Not related to predefined child or 

maternal health outcomes. 

Agostoni C. Breast-feeding, human milk, longchain polyunsaturated fatty acids and 

development. Developmental Medicine & Child 

Neurology 2001;43( SUPPL. 86). Not a first 

publication of empirical evidence (e.g., review). 

Agostoni C. Effects of diet on the lipid and fatty 

acid status of full-term infants at 4 

months.[comment]. J Am Coll Nutr 1994;13( 

6):658-664. Not related to predefined child or 

maternal health outcomes. 

Agostoni C, Giovannini M. Cognitive and visual 

development: influence of differences in breast 

and formula fed infants. Nutr Health 2001;15( 3-

4):183-188. Not a first publication of empirical 

evidence (e.g., review). 

Agradi E, Galli C. Requirement and role of 

essential fatty acids during brain development. 

[Review] [28 refs]. Beitr Infusionther Klin 

Ernahr 1988;19128-139. Not a first publication of 

empirical evidence (e.g., review). 

Alexander S. On the prevention of preeclampsia: 

nutritional factors back in the 

spotlight?[comment]. Am J Epidemiol 2002;13( 

4):382-383. Not a first publication of empirical 

evidence (e.g., review). 

Amadi B. Role of food antigen elimination in 

treating children with persistent diarrhea and 

malnutrition in Zambia. Journal of Pediatric 

Gastroenterology & Nutrition 2002;34 Suppl 

1S54-S56. No omega-3 fatty acid focus 

(intervention/exposure or biomarkers). 

Arnold R W, Kesler K, Avila E. Susceptibility to 

retinopathy of prematurity in Alaskan natives. 

Journal of Pediatric Ophthalmology & 

Strabismus 1994;31( 3). No omega-3 fatty acid 

focus (intervention/exposure or biomarkers). 

Asch M J, Sperling M, Fiser R et al. Metabolic 

and hormonal studies comparing three parenteral 

nutrition regimens in infants. Ann Surg 

1975;182( 1):62-65. No omega-3 fatty acid focus 

(intervention/exposure or biomarkers). 

Ashwell M. Infant brain lipids and 

diet.[comment]. Lancet 31-10-1992;340( 

8827):1093. Not related to predefined child or 

maternal health outcomes. 

Baker P, Broughton Pipkin F. Fish-oil and preeclampsia.[comment]. British Journal of 

Obstetrics & Gynaecology 1991;98( 5):499-500. 

Not a first publication of empirical evidence (e.g., 

review). 

Bang H O, Dyerberg J. Urinary thromboxane 

metabolites in pre-eclampsia (II). Lancet 

1990;335( 8698). Not involving human 

participants. 

Baryshkov IuA. [The level of higher unsaturated 

fatty acids in the blood serum of infants during 

the 1st months of life]. [Russian]. Vopr Okhr 

Materin Det 1967;12( 1):25-27. Not related to 

predefined child or maternal health outcomes. 

Bell J D, Margen S, Calloway D H. Ketosis, 

weight loss, uric acid, and nitrogen balance in 

obese women fed single nutrients at low caloric 

levels. Metabolism: Clinical & Experimental 

1969;18( 3):193-208. No omega-3 fatty acid 

focus (intervention/exposure or biomarkers). 

Berry C, Montgomery C, Sattar N et al. Fatty 

acid status of women of reproductive age. Eur J 

Clin Nutr 2001;55( 7):518-524. No omega-3 fatty 

acid focus (intervention/exposure or biomarkers). 

Bistrian B R. Clinical aspects of essential fatty 

acid metabolism: Jonathan Rhoads Lecture. 

[Review] [68 refs]. Jpen: Journal of Parenteral & 

Enteral Nutrition 2003;27( 3):168-175. No 

omega-3 fatty acid focus (intervention/exposure 

or biomarkers). 

Bjerve K S, Thoresen L, Borsting S. Linseed and 

cod liver oil induce rapid growth in a 7-year-old 

girl with N-3 fatty acid deficiency. JPEN J 

Parenter Enteral Nutr 1988;12( 5):521-525. Not 

related to predefined child or maternal health 

outcomes. 

Black D D. Intestinal lipoprotein metabolism. 

Journal of Pediatric Gastroenterology & Nutrition 

1995;20( 2). Not involving human participants. 

Bottai F, Franchini F, Cocchi C et al. EFA's 
H – 2 

effects on child's health: Recent advances about a 

therapeutic, prophylactic and dietetic tool. Pediatr 

Med Chir 1994;16( 2). Not a first publication of 

empirical evidence (e.g., review). 

Boue C, Combe N, Billeaud C et al. Nutritional 

implications of trans fatty acids during perinatal 

period, in French pregnant women. Lipids, fats 

and oils: opportunities and responsibilities in the 

New Century 2001;Wurzburg, Germany, 8-10 

October, 2000. OCL -Oleagineux,-Corps-Gras,-

Lipides. 2001, 8( 1):68-72. No omega-3 fatty acid 

focus (intervention/exposure or biomarkers). 

Bougle D. Red blood cell vitamin E in the 

premature effect of an alpha-linolenic acid 

supplementation [abstract]. Am J Clin Nutr 

1995;14( Suppl 2):26. Not related to predefined 

child or maternal health outcomes. 

Brenna J T. Efficiency of conversion of alphalinolenic acid to long chain n-3 fatty acids in 

man. Curr Opin Clin Nutr Metab Care 2002;5( 

2):127-132. Not a first publication of empirical 

evidence (e.g., review). 

Broughton Pipkin F, McCormack M J, 

Constantine G et al. Fish-oil and pre-eclampsia 

[1]. British Journal of Obstetrics & Gynaecology 

1991;98( 7). Not a first publication of empirical 

evidence (e.g., review). 

Bruce A. Skeletal muscle lipids. 3. Changes in 

fatty acid composition of individual 

phosphoglycerides in man from fetal to middle 

age. J Lipid Res 1974;15( 2):109-113. Not 

involving human participants. 

Bruce, A., Svennerholm, L. Skeletal muscle lipids. 

I. Changes in fatty acid composition of lecithin in 

man during growth. Biochimica et Biophysica 

Acta 1971;239( 3):393 – 400. Not involving 

human participants. 

Carlson S E. Functional effects of increasing 

omega-3 fatty acid intake.[comment]. Eur J 

Pediatr 1997;131( 2):173-175. Not a first 

publication of empirical evidence (e.g., review). 

Carlson S E. Docosahexaenoic acid and 

arachidonic acid in infant development. Semin 

Neonatol 2001;6( 5):437-449. Not a first 

publication of empirical evidence (e.g., review). 

Carlson S E, Montalto M B, Ponder D L et al. 

Lower incidence of necrotizing enterocolitis in 

infants fed a preterm formula with egg 

phospholipids. Pediatr Res 1998;44( 4):491-498. 

No omega-3 fatty acid focus 

(intervention/exposure or biomarkers). 

Carroll. Essential fatty acids: what level in the diet 

is most desirable?. Advances in Experimental 

Medicine & Biology 1977;83535-546. Not related 

to predefined child or maternal health outcomes. 

Carruth B R, Nevling W, Skinner J D. 

Developmental and food profiles of infants born to 

adolescent and adult mothers. J Adolesc Health 

1997;20( 6):434-441. No omega-3 fatty acid focus 

(intervention/exposure or biomarkers). 

Cicmanec J L. Comparison of four human studies 

of perinatal exposure to methylmercury for use in 

risk assessment. Toxicology 1996;111( 1-3). No 

omega-3 fatty acid focus (intervention/exposure or 

biomarkers). 

Clandinin M T, VanAerde J. Formula 

supplementation and growth.[comment]. 

Pediatrics 2003;112( 6 Pt 1):1456-1458. Not a first 

publication of empirical evidence (e.g., review). 

Clandinin M T, Chappell J E, Heim T. Do low 

weight infants require nutrition with chain 

elongation-desaturation products of essential fatty 

acids?. Prog Lipid Res 1981;20901-904. Not 

involving human participants. 

Crawford M A. Is there a common denominator 

between fetal growth retardation and 

cardiovascular disease?. Acta Cardiol 1989;44( 

6):449-453. No omega-3 fatty acid focus 

(intervention/exposure or biomarkers). 

Crawford M A. Essential fatty acids and 

neurodevelopmental disorder. Advances in 

Experimental Medicine & Biology 1992;318( pp 

307-314). Not a first publication of empirical 

evidence (e.g., review). 

Crawford M A. Aspirin in pregnancy.[comment]. 

Lancet 20-3-1993;341( 8847):753-754. Not a first 

publication of empirical evidence (e.g., review). 

Crawford M A, Ghebremeskel K, Phylactos A. 

The biochemistry of unsaturated fatty acids and 

development of preterm infants. Br J Clin Pract 

1995;49( SUPPL. 80). Not a first publication of 

empirical evidence (e.g., review). 

Crawford M A, Hassam A G, Hall B M. 

Metabolism of essential fatty acids in the human 

fetus and neonate. Ann Nutr Metab 1977;21 Suppl 

1187-188. No omega-3 fatty acid focus 

(intervention/exposure or biomarkers). 

Cunnane S C, Crawford M A. Survival of the 

fattest: fat babies were the key to evolution of the 

large human brain. [Review] [39 refs]. 

Comparative Biochemistry & Physiology 

2003;Part A, Molecular & Integrative Physiology. 

136( 1):17-26. No omega-3 fatty acid focus 

(intervention/exposure or biomarkers). 
H – 3 

Cunnane S C, Francescutti V. Fatty acid profiles 

of maternal adipose tissue in relation to infant 

development. Br J Nutr 1999;82( 4):253-254. Not 

a first publication of empirical evidence (e.g., 

review). 

Cunnane S C, Francescutti V, Brenna J T. 

Docosahexaenoate requirement and infant 

development.[comment]. Adv Nutr Res 1999;15( 

10):801-802. Not a first publication of empirical 

evidence (e.g., review). 

Davidson M, Levine S Z, Bauer C H et al. Feeding 

studies in low-birth-weight infants. I. 

Relationships of dietary protein, fat, and 

electrolyte to rates of weight gain, clinical courses, 

and serum chemical concentrations. Eur J Pediatr 

1967;70( 5):695-713. No omega-3 fatty acid focus 

(intervention/exposure or biomarkers). 

Davis K C. Vitamin E: adequacy of infant diets. 

Am J Clin Nutr 1972;25( 9):933-938. No omega-3 

fatty acid focus (intervention/exposure or 

biomarkers). 

De Lucchi C, Pita M L, Faus M J et al. Influences 

of diet and postnatal age on the lipid composition 

of red blood cell membrane in newborn infants. 

Ann Nutr Metab 1988;32( 4):231-239. Not related 

to predefined child or maternal health outcomes. 

Deckelbaum R J, Williams C L. Fat intake in 

children: is there a need for revised 

recommendations?[comment]. Eur J Pediatr 

2000;136( 1):7-9. No omega-3 fatty acid focus 

(intervention/exposure or biomarkers). 

Decsi T. Plasma lipid and apolipoprotein 

concentrations in full term infants fed formula 

supplemented with long-chain polyunsaturated 

fatty acids and cholesterol. Eur J Pediatr 

1997;156( 5):397-400. Not related to predefined 

child or maternal health outcomes. 

Decsi T, Boehm G, Tjoonk H M R et al. Trans 

isomeric octadecenoic acids are related inversely 

to arachidonic acid and DHA and positively 

related to mead acid in umbilical vessel wall 

lipids. Lipids 1-10-2002;37( 10):01. Not related to 

predefined child or maternal health outcomes. 

de Swiet, M. Pre-eclampsia. III: The role of 

aspirin in prevention. Modern Midwife 1994;4( 

12):20 – 22. Not a first publication of empirical 

evidence (e.g., review). 

Diener UC, Fink M M, Demmelmair H. 

Docosahexaenoic acid intake affects alphalinolenic acid metabolism in preterm infants 

[abstract]. Am J Clin Nutr 1999;18( Suppl 1):55. 

Not related to predefined child or maternal health 

outcomes. 

Diener U. Effect of docosahexaenoic acid 

supplementation on conversion of linoleic and alinolenic acid in preterm infants. J 

1999;Pediatr.Gastroenterol.Nutr 28( 05):589. Not 

related to predefined child or maternal health 

outcomes. 

Drane D L, Logemann J. An explanation for the 

association between specific language impairment 

and toxemia. Med Hypotheses 1-8-2003;61( 2):01. 

No omega-3 fatty acid focus 

(intervention/exposure or biomarkers). 

Drongelen M M H P, Zeijdner E E, Houwelingen 

A C V et al. Essential fatty acid status measured in 

umbilical vessel walls of infants born after a 

multiple pregnancy. Early Hum Dev 1996;46( 

3):205-215. No omega-3 fatty acid focus 

(intervention/exposure or biomarkers). 

Duchen K, Yu G, Bjorksten B. Polyunsaturated 

fatty acids in breast milk in relation to atopy in the 

mother and her child. International Archives of 

Allergy & Immunology 1999;118( 2-4). Not 

related to predefined child or maternal health 

outcomes. 

Duhamel J F, Travert G, Briere S et al. 

[Nutritional management of neonates and infants 

with cystic fibrosis of the pancreas detected at 

birth]. [French]. Arch Fr Pediatr 1986;43( 4):229-

233. No omega-3 fatty acid focus 

(intervention/exposure or biomarkers). 

Dunstan J A, Mori T A, Barden A. Fish oil 

supplementation in pregnancy modifies neonatal 

allergen-specific immune responses and clinical 

outcomes in infants at high risk of atopy: A 

randomized, controlled trial. Journal of Allergy & 

Clinical Immunology 2003;112( 6):1178-1184. 

Not related to predefined child or maternal health 

outcomes. 

Dyerberg J, Bang H O. Pre-eclampsia and 

prostaglandins. Lancet 1985;1( 8440). Not a first 

publication of empirical evidence (e.g., review). 

Elswyk ME, van Hatch S D, Stella G G et al. Eggs 

as a functional food alternative to fish and 

supplements for the consumption of DHA. Egg 

nutrition and biotechnology 1999;121-133; 25 ref. 

Not related to predefined child or maternal health 

outcomes. 

Fairey A K, Butte N F, Mehta N et al. Nutrient 

accretion in preterm infants fed formula with 

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H – 5 

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No omega-3 fatty acid focus 

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King K C, Adam P A, Laskowski D E et al. 

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[Review] [29 refs]. World Review of Nutrition & 

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Kohn G. Long-chain polyunsaturated fatty acids in 

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Eur J Clin Nutr 1992;46 Suppl 1S51-S62. Not a 

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Koletzko B, Schmidt E, Bremer H J et al. Dietary 
H – 7 

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[Polish]. Medycyna Wieku Rozwojowego 2000;4( 

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Langer J W. [Drug information. Fish oils can 

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Lapinleimu H, Jokinen E, Myyrinmaa A et al. 

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Lapinleimu H, Viikari J, Jokinen E et al. 

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Laube H. [Effect of nutritional factors on the 

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[German]. Dtsch Med Wochenschr 22-6-1973;98( 

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Luepker R V, Perry C L, McKinlay S M et al. 

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Luukkainen P, Salo M K, Janas M et al. Fatty acid 

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H – 8 

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Martinez, M., Conde, C., and Ballabriga, A., Some 

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No omega-3 fatty acid focus 

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Mendy F, Hirtz J, Berret R et al. [Variation of the 

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Scandinavian Journal of 

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Lancet 4-4-1998;351( 9108):04. No omega-3 fatty 

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1994, 199-205; 45 ref.Spain, 7-Spain,10. Not 

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Muskiet F A J, van Beusekom C M, Boersma E R 

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Water, Air, & Soil Pollution 1997;97( 1-2):53-61. 

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fatty acid focus (intervention/exposure or 

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maternal health outcomes. 

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Lancet 30-5-1992;339( 8805):1327-1328. Not a 

first publication of empirical evidence (e.g., 

review). 

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Not a first publication of empirical evidence (e.g., 

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NutraCos 2002;1( 5):34-35. Not a first publication 

of empirical evidence (e.g., review). 

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O'Brien P M, Morrison R, Broughton Pipkin F. 

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H – 16 

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Fomon SJ, Thomas LN, Filer LJ, Jr., Ziegler EE, 

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Foreman-van Drongelen MM, van Houwelingen 

AC, Kester AD, Hasaart TH, Blanco CE, Hornstra 

G. Long-chain polyunsaturated fatty acids in 

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Houwelingen AC, Blanco CE, Hornstra G. 

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maternal and neonatal blood.[comment]. Eur J 

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Guldan GS, Zhang MY, Zhang YP, Hong JR, 

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level of evidence. 

Harper V, MacInnes R, Campbell D, Hall M. 

Increased birth weight in northerly islands: is fish 

consumption a red herring? BMJ 1991; 

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Hayes KC, Pronczuk A, Wood RA, Guy DG. 

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H – 17 

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[German]. Wien Med Wochenschr 1967; 

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formulas having a varying fat content]. [Russian]. 

Pediatriia 1985;(4):10-13. Not level of evidence. 

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MA. Factors affecting long-chain polyunsaturated 

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Leaf AA, Leighfield MJ, Costeloe KL, Crawford 

MA. Long chain polyunsaturated fatty acids and 

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Not level of evidence. 

Matorras R, De Larrucea AL, Sanjurjo P, Ruiz JI, 

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Acta Obstet Gynecol Scand 2001; 80(9). Not level 

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Mourek J, Dohnalova A. Relationship between 

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56(9-10):477-483. Not level of evidence. 

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Pregnancy duration and the ratio of long-chain n-3 

fatty acids to arachidonic acid in erythrocytes from 

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164(5 Pt 1):1203-1209. Not level of evidence. 

Olsen SF, Grandjean P, Weihe P, Videro T. 

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Petridou E, Koussouri M, Toupadaki N, 

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[Spanish]. An Esp Pediatr 1984; 21(3):215-221. 

Not level of evidence. 

Popeski D, Ebbeling LR, Brown PB, Hornstra G, 

Gerrard JM. Blood pressure during pregnancy in 
H – 18 

Canadian Inuit: community differences related to 

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AM. Psychomotor development at one year of age 

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fetuses. [Chinese]. Chung Hua Fu Chan Ko Tsa 

Chih 1998; 33(12):722-723. Not level of 

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AM. Omega-3 fatty acids in maternal erythrocytes 

and risk of preeclampsia. Epidemiology 1995; 

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I – 1 

Appendix I. Additional Acknowledgements 

The UO-EPC gratefully acknowledges the following individuals who served on our Technical 

Expert Panel (TEP). Acknowledgement does not reflect endorsement of this report. 

Bruce Holub PhD 

Professor, Department of Human Biology and Nutritional Sciences 

University of Guelph 

Guelph, ON 

(Industry representative) 

Bill Harris PhD 

Co-director, Lipid and Diabetes Research Center 

Saint Luke’s 

Kansas City, MO 

James Friel PhD 

Professor, Dept. of Human Nutritional Sciences 

Faculty of Human Ecology 

University of Manitoba 

Winnipeg, MB 

Catherine Spong, MD 

Chief of NICHD's Pregnancy and Perinatology Branch 

National Institutes of Health 

Arlington, VA 

Ralph Hale, M.D. 

Executive Vice President 

The American College of Obstetricians and Gynecologists 

Washington, D.C

Eileen Birch, PhD 

Retina Foundation of the Southwest 

Dallas, TX 
I – 2 

The UO-EPC gratefully acknowledges the following individuals who reviewed the initial draft of 

this evidence report, and provided constructive feedback. Acknowledgement does not reflect 

endorsement of this report. 

Bill Harris PhD 

Co-director, Lipid and Diabetes Research Center 

Saint Luke’s 

Kansas City, MO 

James Friel PhD 

Professor, Dept. of Human Nutritional Sciences 

Faculty of Human Ecology 

University of Manitoba 

Winnipeg, MB 

Ralph Hale, M.D. 

Executive Vice President 

The American College of Obstetricians and 

Gynecologists 

Washington, D.C

Dr. Guttorm Haugen 

Head 

Division of Fetal Medicine 

Department of Obstetrics and 

Gynaecology 

Rikshospitalet University Hospital 

Oslo, Norway 

K.S. Joseph MD, PhD 

Associate Professor 

Depts. of Obstetrics & Gynaecology and 

Pediatrics 

Dalhousie University and the IWK Health 

Halifax 

David Atkins, MD 

Chief Medical Officer, 

Agency for Healthcare Researcy and Quality 

(AHRQ) 

Rockville, MD 

 

Linda Dodds, PhD 

Associate Professor 

Departments of Obstetrics & Gynecology & 

Pediatrics at Dalhousie University; 

IWK Health Centre, Perinatal Epidemiology 

Research Unit, 5980 University Ave, Halifax 

Halifax, NS 

 

Karen Simmer, MD 

Professor, Neonatal Medicine 

Director, Neonatal Clinical Care Unit 

King Edward Memorial Hospital 

Subiaco, Western Australia 

 

Mary Frances Picciano, Ph.D. 

Senior Nutrition Research Scientist 

Office of Dietary Supplements 

National Institutes of Health 

Bethesda, MD 

 

Dr. Sheila M. Innis, PhD 

Professor, Dept. of Pediatrics , 

University of British Columbia ; 

BC Research Institute for Children's & Women's 

Hea lth 

Vancouver, BC