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HomeResearch AfricaSugar-free gum in pregnancy associated with lower preterm birth rates – Malawi study

Sugar-free gum in pregnancy associated with lower preterm birth rates – Malawi study

Women who chewed sugar-free gum daily in early pregnancy had a significantly lower risk of preterm birth at a cost of approximately $700 to prevent one preterm birth, according to a multicentre study from Malawi.

The research showed that the rate of preterm births was significantly lower among those who chewed xylitol twice a day during preconception or at less than 20 weeks’ gestation, compared with those who did not, said Dr Kjersti Aagaard of Texas Children’s Hospital and Baylor College of Medicine in Houston.

There were also fewer babies born with low birth weight versus those who did not chew the gum, which was largely attributable to reducing late preterm birth, Aagaard said during a presentation at the Society for Maternal-Fetal Medicine virtual meeting on 3 February.

Among more than 4,200 women who were compliant with dental visits, xylitol gum use was also associated with lower rates of maternal periodontitis, which has been linked to both preterm birth and low birth weight in previous studies, she noted.

“The global burden of preterm birth is staggering,” Aagaard said. There are 12m to 14m preterm births annually, and low-resourced settings such as Malawi are disproportionately affected. Xylitol chewing gum may be a cost-effective strategy to reduce preterm birth rates, Aagaard added, with a cost of approximately $700 to prevent one preterm birth.

The cluster randomised Prevention of Prematurity and Xylitol (PPaX) trial was conducted across eight centres in Malawi over 10 years. Women were followed for 28 days postpartum. Four centres were randomised to group perinatal and oral health education plus daily xylitol chewing gum use, and the other four centres were randomised to education only. The study authors compared rates of preterm birth, low birth weight (defined as below 2,500g), and oral health outcomes between the two groups.

Overall, there were more than 10,000 women enrolled in the trial (4,549 in the intervention group and 5,520 in the control group), and 9,670 outcomes were available at follow-up. There were no significant differences in loss to follow-up or pregnancy rates between the two groups.

Aagaard acknowledged that cluster randomised trials might result in baseline characteristic differences between groups, which could limit the findings. The researchers also did not assess for long-term infant or childhood outcomes. In addition, these findings may not be generalisable to other populations or clinical settings.

Study details

Cluster randomised trial of xylitol chewing gum on prevention of preterm birth in Malawi

Kjersti Aagaard, Gregory Valentine, Kathleen Anthony, Rose Chirwa, Mary Dumba, Saukani Petro, Deborah Nanthuru, Cynthia Shope, Jesse Mlotha-Namarika, Jeffrey Wilkinson, Joshua Aagaard, Ellen Aagaard, Martin Seferovic, Judy Levison, Haleh Sangi-Haghpeykar.

Presented at Society for Maternal-Fetal Medicine virtual meeting on 3 February 2022

Objective
Studies have shown an association between maternal periodontal disease and preterm birth (PTB), but randomised trials of dental scaling/planing in pregnancy have not demonstrated preventative benefit. Xylitol chewing gum reduces dental caries, but its effect on improving periodontal health and reducing PTB is unknown. Hypothesising that daily xylitol gum use starting periconception would reduce periodontitis and PTB, we undertook a cluster randomised trial in Malawi, the country with the highest known PTB rate (22%).

Study Design
This was a multicenter, open label, cluster randomised trial enrolling subjects from eight health centers spanning a 79km urban-rural region in Lilongwe, Malawi, over six years with follow up of 28 days postpartum. Subjects were consented & enrolled pre-pregnancy or < 20 weeks gestation. Four centres were randomised to group perinatal and oral health education plus daily xylitol chewing gum use (intervention), and compared to four centres randomised to only education (control). Analysis of significant impact on the primary outcomes delivery < 37 weeks and/or < 2500 grams was by group allocation (xylitol vs control) following adjustment for confounders.

Results
A total of 10,069 women were enrolled (4,549 intervention & 5,520 control) with 9,670 outcomes available at follow-up. Perinatal xylitol chewing gum use resulted in a significant PTB reduction (12.6% vs. 16.5%; aRR 0.76, 95% CI 0.59-0.99) and fewer < 2500g neonates (8.9% vs 12.9%; aRR 0.70, 95% CI 0.49-0.99), largely attributable to reducing late PTB (34-36 6/7 weeks; 9.9% vs 13.5%, aRR 0.73, 95% CI 0.53-0.99. Among n=4220 subjects compliant with dental visits, a significant reduction in periodontitis occurred with xylitol gum use (p=0.03 vs p=0.29).

Conclusion
In a cluster randomised trial in Malawi, periconception initiation and use of xylitol chewing gum resulted in a reduced incidence of PTB and < 2500g newborns, predominately due to significantly fewer late PTBs and in association with less periodontitis. To prevent a case of PTB, 26 patients would need to chew daily xylitol gum at an estimated retail cost of $1,087.

Abstract presented at Society for Maternal-Fetal Medicine virtual meeting (Open access)

 

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