Recommendation

For pregnant women with high daily caffeine intake (more than 300 mg per day), lowering daily caffeine intake during pregnancy is recommended to reduce the risk of pregnancy loss and low-birth-weight neonates

(Context-specific recommendation)

 

Publication history

First published: November 2016

Updated: No update planned

Assessed as up-to-date: November 2016

 

Remarks

• Pregnant women should be informed that a high daily caffeine intake (> 300 mg per day) is probably associated with a higher risk of pregnancy loss and low birth weight.
• Caffeine is a stimulant found in tea, coffee, soft-drinks, chocolate, kola nuts and some over-the-counter medicines. Coffee is probably the most common source of high caffeine intake. A cup of instant coffee can contain about 60 mg of caffeine; however, some commercially brewed coffee brands contain more than 150 mg of caffeine per serving.
• Caffeine-containing teas (black tea and green tea) and soft drinks (colas and iced tea) usually contain less than 50 mg per 250 mL serving.
• Caffeine intake includes any product, beverage or food containing caffeine (i.e. brewed coffee, tea, cola-type soft drinks, caffeinated energy drinks, chocolate, caffeine tablets).

 

Background

Pregnancy requires a healthy diet that includes an adequate intake of energy, protein, vitamins and minerals to meet maternal and fetal needs. However, for many pregnant women, dietary intake of vegetables, meat, dairy products and fruit is often insufficient to meet these needs, particularly in low and middle-income countries (LMICs) where multiple nutritional deficiencies often co-exist. In resource poor countries in sub-Saharan Africa, south-central and south-east Asia, maternal undernutrition is highly prevalent and is recognized as a key determinant of poor perinatal outcomes (1). However, obesity and overweight is also associated with poor pregnancy outcomes and many women in a variety of settings gain excessive weight during pregnancy. While obesity has historically been a condition associated with affluence, there is some evidence to suggest a shift in the burden of overweight and obesity from advantaged to disadvantaged populations (2).

Caffeine is possibly the most widely used psychoactive substance in the world (3), and the GDG also evaluated evidence on the impact, if any, of caffeine restriction during pregnancy.

 

Methods

The ANC recommendations are intended to inform the development of relevant health-care policies and clinical protocols. These recommendations were developed in accordance with the methods described in the WHO handbook for guideline development (4). In summary, the process included: identification of priority questions and outcomes, retrieval of evidence, assessment and synthesis of the evidence, formulation of recommendations, and planning for the implementation, dissemination, impact evaluation and updating of the guideline.

The quality of the scientific evidence underpinning the recommendations was graded using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) (5) and Confidence in the Evidence from Reviews of Qualitative research (GRADE-CERQual) (6) approaches, for quantitative and qualitative evidence, respectively. Up-to-date systematic reviews were used to prepare evidence profiles for priority questions. The DECIDE (Developing and Evaluating Communication Strategies to support Informed Decisions and Practice based on Evidence) (7) framework, an evidence-to-decision tool that includes intervention effects, values, resources, equity, acceptability and feasibility criteria, was used to guide the formulation and approval of recommendations by the Guideline Development Group (GDG) – an international group of experts assembled for the purpose of developing this guideline – at three Technical Consultations between October 2015 and March 2016.

To ensure that each recommendation is correctly understood and applied in practice, the context of all context-specific recommendations is clearly stated within each recommendation, and the contributing experts provided additional remarks where needed.

In accordance with WHO guideline development standards, these recommendations will be reviewed and updated following the identification of new evidence, with major reviews and updates at least every five years.

Further information on procedures for developing this recommendation are available here.

 

Recommendation question

For this recommendation, we aimed to answer the following question:

• For pregnant women (P), does restricting caffeine intake (I) compared with not restricting caffeine intake (C) improve maternal and perinatal outcomes (O)?

 

Evidence summary

a) Effects of decaffeinated coffee versus caffeinated coffee (RCT evidence)

Some evidence on the effects of caffeine intake was derived from a Cochrane review that included two RCTs (3). Only one of the trials, conducted in Denmark, contributed evidence. In this trial, 1207 pregnant women drinking more than three cups of coffee a day were randomized to receive instant decaffeinated coffee (intervention group) versus instant caffeinated coffee (control group) in order to assess the effect of caffeine reduction during pregnancy. In this trial, a cup of caffeinated coffee was estimated to contain 65 mg caffeine. Other sources of caffeine, such as cola, tea and chocolate were not restricted. Mean daily caffeine intake in the decaffeinated coffee group was 117 mg per day (interquartile range [IQR]: 56–228 mg) compared with 317 mg per day (IQR: 229–461 mg) in the caffeinated coffee group.

Maternal outcomes

None of the maternal outcomes addressed in the ANC guideline were reported in the review.

Fetal and neonatal outcomes

Low-certainty evidence from one trial shows that restricting caffeine intake (replacing caffeinated coffee with decaffeinated coffee) may have little or no effect on SGA (1150 neonates; RR: 0.97, 95% CI: 0.57–1.64), mean birth weight (1197 neonates; MD: 20.00, 95% CI: –48.68 to 88.68) and preterm birth (1153 neonates; RR: 0.81, 95% CI: 0.48–1.37). No data were available on congenital anomalies or perinatal mortality.

 

b) Effects of high caffeine intake versus moderate, low or no caffeine intake (nonrandomized study evidence)

The GDG considered the evidence from RCTs to be insufficient to make a recommendation on caffeine restriction and additional evidence from reviews of non-randomized studies (NRSs) was thus evaluated. Two NRS reviews asked the question, “Is there an association between maternal caffeine intake and the risk of low birth weight?” (8, 9), and two reviews asked the question “Is there an association between maternal caffeine intake and the risk of pregnancy loss?” (10,11). In these reviews, low caffeine intake was defined as less than 150 mg caffeine per day, and high caffeine intake was defined as more than 300 mg or more than 350 mg per day. All four reviews adjusted data for smoking and other variables, and performed dose–response meta-analyses.

Fetal and neonatal outcomes: low birth weight

Moderate-certainty evidence from one review shows that high caffeine intake (more than 300 mg) is probably associated with a greater risk of low birth weight than low or no caffeine intake (12 studies; odds ratio [OR]: 1.38, 95% CI: 1.10–1.73) (9). Very low- to moderate-certainty evidence from the other review was stratified according to dose and shows that very low caffeine intake may be associated with fewer low-birth-weight neonates than low (5 studies; RR: 1.13, 95% CI: 1.06–1.21), moderate (7 studies; RR: 1.38, 95% CI: 1.18–1.62) or high caffeine intake (8 studies; RR: 1.60, 95% CI: 1.24–2.08) (8).

Fetal and neonatal outcomes: stillbirths

The reviews reported “pregnancy loss”, a composite outcome comprising stillbirths and miscarriages. Moderate-certainty evidence from one review (11) shows that any caffeine intake probably increases pregnancy loss compared with controls (no exposure) (18 studies; OR: 1.32, 95% CI: 1.24–1.40). However, pregnancy loss is probably more  common among pregnant women with moderate caffeine intake (18 studies; OR: 1.28, 95% CI: 1.16–1.42) and high caffeine intake (17 studies, OR: 1.60, 1.46–1.76), but not more common with low caffeine intake (13 studies; OR: 1.04, 95% CI: 0.94–1.15) compared with controls. This NRS evidence was upgraded to “moderate-certainty” due to the presence of a dose–response relationship. A dose–response relationship was also observed in the other review but the evidence was less certain (10).

Resources

Communicating with pregnant women about the probable risks of high caffeine intake during pregnancy is a relatively low-cost intervention.

Equity

Interventions to restrict coffee intake during pregnancy are unlikely to impact health inequalities as coffee consumption tends to be associated with affluence. However, it is unclear whether the consumption of caffeine through other sources might be a problem for pregnant women in disadvantaged populations.

Acceptability

Qualitative evidence indicates that women in a variety of settings generally appreciate any advice (including dietary or nutritional) that may lead to a healthy baby and a positive pregnancy experience (high confidence in the evidence) (12). Evidence on health-care providers’ views on ANC suggests that they may be keen to offer general health-careadvice and specific pregnancy-related information (low confidence in the evidence) but they sometimes feel they do not have the appropriate training and lack the resources and time to deliver the service in the informative, supportive and caring manner that women want (high confidence in the evidence) (13).

Feasibility

A lack of suitably trained staff to deliver health promotion interventions may limit implementation (high confidence in the evidence) (13).

 

Further information and considerations related to this recommendation can be found in the WHO guidelines, available at:

http://apps.who.int/iris/bitstream/10665/250796/8/9789241549912-websupplement-eng.pdf?ua=1

 

Implementation considerations

• The successful introduction of evidence-based policies related to antenatal care into national programmes and health care services depends on well-planned and participatory consensus-driven processes of adaptation and implementation. These processes may include the development or revision of national guidelines or protocols based on this recommendation.
• The recommendation should be adapted into locally-appropriate documents and tools that are able to meet the specific needs of each country and health service. Modifications to the recommendation, where necessary, should be justified in an explicit and transparent manner.
• An enabling environment should be created for the use of this recommendation, including changes in the behaviour of health care practitioners to enable the use of evidence-based practices.
• Local professional societies may play important roles in this process and an all-inclusive and participatory process should be encouraged.
• Antenatal care models with a minimum of eight contacts are recommended to reduce perinatal mortality and improve women’s experience of care. Taking this as a foundation, the GDG reviewed how ANC should be delivered in terms of both the timing and content of each of the ANC contacts, and arrived at a new model – the 2016 WHO ANC model – which replaces the previous four-visit focused ANC (FANC) model. For the purpose of developing this new ANC model, the ANC recommendations were mapped to the eight contacts based on the evidence supporting each recommendation and the optimal timing of delivery of the recommended interventions to achieve maximal impact.

 

Research implications

The GDG did not identify any priority question related to this recommendation

 

Related links

WHO recommendations on antenatal care for a positive pregnancy experience

(2016) - full document and evidence tables

Managing Complications in Pregnancy and Childbirth: A guide for midwives and doctors

Pregnancy, Childbirth, Postpartum and Newborn Care: A guide for essential practice

WHO Programmes: Sexual and Reproductive health

WHO Programmes: Department of Nutrition for Health and Development

Maternal Health

 

References

1. Tang AM, Chung M, Dong K, Terrin N, Edmonds A, Assefa N et al. Determining a global midupper arm circumference cutoff to assess malnutrition in pregnant women. Washington (DC): FHI 360/Food and Nutrition Technical Assistance III Project (FANTA); 2016 (http:// www.fantaproject.org/sites/default/files/ resources/FANTA-MUAC-cutoffs-pregnantwomen-June2016.pdf, accessed 26 September 2016).
2. Popkin S, Slining MM. New dynamics in global obesity facing low- and middle-income countries. Obes Rev. 2013;14(2):11–20. doi:10.1111/obr.12102.
3. Jahanfar S, Jaafar SH. Effects of restricted caffeine intake by mother on fetal, neonatal andpregnancy outcomes. Cochrane Database Syst Rev.2015;(6):CD006965.
4. WHO handbook for guideline development, 2nd edition. Geneva: World Health Organization; 2014 (http://www.who.int/kms/handbook_2nd_ ed.pdf, accessed 6 October 2016).
5. GRADE [website]. The GRADE Working Group; 2016 (http://gradeworkinggroup.org/, accessed 27 October 2016).
6. GRADE-CERQual [website]. The GRADECERQual Project Group; 2016 (https://cerqual. org/, accessed 27 October 2016).
7. The DECIDE Project; 2016 (http://www.decide-collaboration.eu/, accessed 27 October 2016).
8. Chen LW, Wu Y, Neelakantan N, Chong MF, Pan A, van Dam RM. Maternal caffeine intake during pregnancy is associated with risk of low birth weight: a systematic review and dose response meta-analysis. BMC Med. 2014;12:174.
9. Rhee J, Kim R, Kim Y, Tam M, Lai Y, Keum N, Oldenburg CE. Maternal caffeine consumption during pregnancy and risk of low birth weight: a dose-response meta-analysis of observational studies. PLoS One. 2015;10(7):e0132334.doi:10.1371/journal.pone.0132334.
10. Chen LW, Wu Y, Neelakantan N, Chong MF, Pan A, van Dam RM. Maternal caffeine intake during pregnancy and risk of pregnancy loss: a categorical and dose-response metaanalysis of prospective studies. Public Health Nutr. 2016:19(7):1233–44. doi:10.1017/S1368980015002463.
11. Li J, Zhao H, Song JM, Zhang J, Tang YL, Xin CM. A meta-analysis of risk of pregnancy loss and caffeine and coffee consumption during pregnancy. Int J Gynaecol Obstet. 2015;130(2):116-22. doi:10.1016/j.ijgo.2015.03.033.
12. Downe S, Finlayson K, Tunçalp Ö, Gülmezoglu AM. Factors that influence the use of routine antenatal services by pregnant women: a qualitative evidence synthesis. Cochrane Database Syst Rev. 2016;(10):CD012392
13. Downe S, Finlayson K, Tunçalp Ö, Gülmezoglu AM. Factors that influence the provision of good quality routine antenatal care services by health staff: a qualitative evidence synthesis. Cochrane Database Syst Rev. 2016

 

Citation: WHO Reproductive Health Library. WHO recommendation on caffeine intake during pregnancy. (November 2016). The WHO Reproductive Health Library; Geneva: World Health Organization.