Rapid Review Alert April 22, 2011
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 In EPA & DHA Research
Abstract Details

Objective: To determine whether supplementation of pregnant women with DHA-rich fish oil improved the visual acuity of infants at 4 months. 

Experimental Design: In a blinded assessment of a subset of healthy, full-term infants born to women enrolled in a double-blind, randomized controlled trial called the DHA for Maternal and Infant Outcomes (DOMInO) trial, women were randomly assigned to consume (from mid pregnancy to delivery) either DHA-rich fish oil capsules (800mg DHA + 100mg EPA per day in the treatment group) or vegetable oil capsules (control group). NOTE: Infants were not supplemented.

Outcome Measurements: The primary outcome was the sweep visual evoked potential (VEP) acuity at 4 months. The VEP latency at 4 months was a secondary outcome.   

Results: Neither VEP acuity nor VEP latencies differed between the treatment and control groups. Irrespective of the group, maternal smoking in pregnancy was independently associated with poorer VEP acuity in the infant.   

Authors' Conclusions: DHA supplementation in women with singleton pregnancies does not enhance infant visual acuity in infants at 4 months of age. Visual acuity in infancy is adversely associated with maternal smoking in pregnancy. 
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Long-Chain Omega-3s and Infant Visual Development

Review of:
Smithers LG Gibson RA and Makrides M (2011). Maternal supplementation with docosahexaenoic acid during pregnancy does not affect early visual development in the infant: a randomized controlled trial. Am J Clin Nutr doi: 10:3945/ajcn.110.009647. 

What You Need To Know

The benefits of DHA for a healthy pregnancy are well established and the results of the present research do not change the large body of scientific evidence in support of DHA supplementation during pregnancy. Many organizations and government agencies recommend long-chain omega-3 supplementation for pregnant women, including:  

  • ISSFAL (International Society for the Study of Fatty Acids and Lipids): at least 200 mg/day DHA
  • EFSA (European Food Safety Authority): 100-200mg/day DHA for pregnant women in addition to the general recommendation of 250mg/day EPA + DHA
  • ANSES (French Agency for Food, Environmental and Occupational Health and Safety)(formerly AFSSA: Agence Francais de Securite Santaire des Ailments): 500 mg/day EPA + DHA with at least 250 mg from DHA
  • Joint FAO/WHO Expert Consultation on Fats and Fatty Acids in Human Nutrition: 300 mg/day EPA + DHA of which at least 200mg should be DHA
  • Perinatal Lipid Intake Working Group: at least 200 mg/day DHA
  • Australia New Zealand National Health and Medical Research Council: 110 – 115mg/day EPA + DHA + DPA 

A large body of scientific evidence supports a role of DHA in normal visual development of infants. EFSA has reviewed the science and provided a positive opinion on the following claim, “Docosahexaenoic acid (DHA) intake contributes to the normal visual development of infants up to 12 months of age.” 

Study Limitations
  • Study sample involved a subgroup of infants from the larger DOMInO trial.
  • Supplementation was only from mid-pregnancy to delivery; therefore, the period of supplementation may have been too short.
  • During pregnancy, DHA conversion is up-regulated and DHA is preferentially transported to the fetus. Thus said, in all likelihood, a highly DHA-deficient group of mothers would have been needed to demonstrate a significant benefit.  
  • The observation that “…higher DHA concentrations in the milk of treatment-group mothers were not due to supplements because the milk DHA concentrations were higher even when mothers who consumed DHA supplements during lactation were excluded from the analysis” suggests that DHA levels of the mothers were sufficient enough to ensure optimal growth of the fetus, with no additional benefit being obtained with further supplementation.
  • EPA & DHA red blood cell levels were not measured. If levels were similar between the two groups of mothers then this would likely translate to no difference in levels between the two groups of infants, thus explaining no differences in infant visual acuity (Makrides et al., 1995).  
  • Given the importance of post-natal DHA status to infant visual acuity (Makrides et al., 1995), it’s important to know if DHA status differed between the groups. If it didn’t, this may account for the lack of an effect.
  • The authors did not do a more sophisticated analysis similar to Innis and Friesen, 2008, who reported an increased risk of low visual acuity among infants of mothers following their usual diet when compared with infants of women considered at low risk of inadequate DHA due to DHA supplementation.   
  • Post-natal exposure of the mothers and infants to LCPUFAs was uncontrolled, with almost a third consuming DHA supplemented formula. This may have negated any potential differences in infant visual acuity.
  • No food intake records were collected in either group during pregnancy to determine baseline long-chain omega-3 intake. 

Noteworthy, Yet Underreported 

  • The study corroborated the safety of fish oil supplements, 900mg/day (800mg DHA + 100mg EPA), during pregnancy.

Suggested Citation

Global Organization for EPA and DHA Omega-3s (2011). Long-Chain Omega-3s and Infant Visual Development [Peer commentary on the paper “Maternal supplementation with docosahexaenoic acid during pregnancy does not affect early visual development in the infant: a randomized controlled trial” by Smithers LG Gibson RA and Makrides M. Am J Clin Nutr doi: 10:3945/ajcn.110.009647.]. 


AFFSA (France). Avis de l'Agence française de sécurité sanitaire des aliments relatif à l'actualisation des apports nutritionnels conseillés pour les acides gras. March 1, 2010. http://www.afssa.fr/cgi-bin/countdocs.cgi?Documents/NUT2006sa0359EN.pdf Accessed April 20, 2011.
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Scientific Opinion of the Panel on Dietetic Products, Nutrition and Allergies on a request from Mead Johnson Nutritionals on DHA and ARA and visual development. EFSA Journal (2009) 941, 1‐14.  
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