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Nutrition during the early life cycle

Effect of fish-oil supplementation on breastmilk long-chain polyunsaturated fatty acid concentration: a randomized controlled trial in rural Ethiopia




For infants and young children in low-income settings, human milk (HM) is the main source of omega-3 (n-3) long-chain polyunsaturated fatty acids (LCPs), including docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA). However, the n-3 LCPs concentrations of HM show wide variability, largely depending on the maternal intake of marine foods. This may put children living far from coastal areas at risk of inadequate intake. We evaluated the efficacy of fish-oil (FO) supplementation of lactating mothers on HM n-3 LCPs concentrations in a rural setting from Ethiopia.


Mothers (n = 360) with children 6–12 months old were randomized to receive either intervention FO capsules (215 mg DHA + 285 mg EPA) or control corn-oil capsules (without n-3 LCPs). In a random subsample of 154 participants, we analyzed LCPs in HM and child capillary blood using gas chromatography.


Compared to the control, FO supplementation increased HM concentrations of DHA by 39.0% (95% CI: 20.6, 57.5%; P < 0.001) and EPA by 36.2% (95% CI: 16.0, 56.4%; P < 0.001), whereas the arachidonic acid (AA)/(DHA + EPA) ratio decreased by 53.5% (95% CI: −70.2, −36.7%; P < 0.001). We also found statistically significant association between the changes in (DHA + EPA)/AA ratio in HM and child capillary blood (P < 0.001). However, HM DHA concentrations remained lower than international norms after FO supplementation.


FO supplementation improves n-3 LCPs content of HM. Future studies should evaluate different doses of n-3 LCPs and consider potential effect modifiers such as genetic polymorphism and diet. This trial was registered at as NCT01817634.

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Fig. 1: Trial flowchart.
Fig. 2: HM LCP concentrations at baseline, midline and endline of intervention in the CO (---; n = 82) and FO (—; n = 72) groups.
Fig. 3: Relationship between the change in HM and child capillary blood (DHA + EPA)/AA ratios following the intervention.


  1. 1.

    Bazan N, Reddy T, Bazan H, Birkle D. Metabolism of arachidonic and docosahexaenoic acids in the retina. Prog Lipid Res. 1986;25:595–606.

    CAS  PubMed  Google Scholar 

  2. 2.

    Martinez M. Tissue levels of polyunsaturated fatty acids during early human development. J Pediatr. 1992;120:S129–38.

    CAS  PubMed  Google Scholar 

  3. 3.

    Martinez M, Mougan I. Fatty acid composition of human brain phospholipids during normal development. J Neurochem. 1998;71:2528–33.

    CAS  PubMed  Google Scholar 

  4. 4.

    Shulkin M, Pimpin L, Bellinger D, Kranz S, Fawzi W, Duggan C, et al. n–3 fatty acid supplementation in mothers, preterm infants, and term infants and childhood psychomotor and visual development: a systematic review and meta-analysis. J Nutr. 2018;148:409–18.

    PubMed  PubMed Central  Google Scholar 

  5. 5.

    Lapillonne A, Clarke SD, Heird WC. Polyunsaturated fatty acids and gene expression. Curr Opin Clin Nutr Metab Care. 2004;7:151–6.

    CAS  PubMed  Google Scholar 

  6. 6.

    Lapillonne A, Clarke SD, Heird WC. Plausible mechanisms for effects of long-chain polyunsaturated fatty acids on growth. J Pediatr. 2003;143:9–16.

    Google Scholar 

  7. 7.

    Calder PC. N-3 fatty acids, inflammation and immunity: new mechanisms to explain old actions. Proc Nutr Soc. 2013;72:326–36.

    CAS  PubMed  Google Scholar 

  8. 8.

    Gottrand F. Long-chain polyunsaturated fatty acids influence the immune system of infants. J Nutr. 2008;138:1807S–12S.

    CAS  PubMed  Google Scholar 

  9. 9.

    Echeverría F, Ortiz M, Valenzuela R, Videla LA. Long-chain polyunsaturated fatty acids regulation of PPARs, signaling: Relationship to tissue development and aging. Prostaglandins Leukot Ess Fat Acids. 2016;114:28–34.

    Google Scholar 

  10. 10.

    Forsyth S, Gautier S, Salem N. Dietary intakes of arachidonic acid and docosahexaenoic acid in early life - with a special focus on complementary feeding in developing countries. Ann Nutr Metab. 2017;70:217–27.

    CAS  PubMed  Google Scholar 

  11. 11.

    Michaelsen KF, Dewey KG, Perez-Exposito AB, Nurhasan M, Lauritzen L, Roos N. Food sources and intake of n-6 and n-3 fatty acids in low-income countries with emphasis on infants, young children (6-24 months), and pregnant and lactating women. Matern Child Nutr. 2011;7:124–40.

    PubMed  PubMed Central  Google Scholar 

  12. 12.

    Fu Y, Liu X, Zhou B, Jiang AC, Chai L. An updated review of worldwide levels of docosahexaenoic and arachidonic acid in human breast milk by region. Public Health Nutr. 2016;19:2675–87.

    PubMed  Google Scholar 

  13. 13.

    Brenna JT, Varamini B, Jensen RG, Diersen-schade DA, Boettcher JA, Arterburn LM. Docosahexaenoic and arachidonic acid concentrations in human breast milk worldwide. Am J Clin Nutr. 2007;85:1457–64.

    CAS  PubMed  Google Scholar 

  14. 14.

    Yuhas R, Pramuk K, Lien EL. Human milk fatty acid composition from nine countries varies most in DHA. Lipids 2006;41:851–8.

    CAS  PubMed  Google Scholar 

  15. 15.

    Koletzko B, Cetin I, Thomas Brenna J, Alvino G, von Berlepsch J, Biesalski HK, et al. Dietary fat intakes for pregnant and lactating women. Br J Nutr. 2007;98:873–7.

    CAS  PubMed  Google Scholar 

  16. 16.

    Brenna JT, Lapillonne A. Background paper on fat and fatty acid requirements during pregnancy and lactation. Ann Nutr Metab. 2009;55:97–122.

    CAS  PubMed  Google Scholar 

  17. 17.

    Forsyth S, Gautier S, Salem N. Global estimates of dietary intake of docosahexaenoic acid and arachidonic acid in developing and developed countries. Ann Nutr Metab. 2016;68:258–67.

    CAS  PubMed  Google Scholar 

  18. 18.

    Argaw A, Wondafrash M, Bouckaert KP, Kolsteren P, Lachat C, Belachew T, et al. Effect of n-3 long-chain PUFA supplementation to lactating mothers and their breastfed children on child growth & morbidity: a 2 X 2 factorial randomized controlled trial in rural Ethiopia. Am J Clin Nutr. 2018;107:454–64.

    PubMed  Google Scholar 

  19. 19.

    Argaw A, Huybregts L, Wondafrash M, Kolsteren P, Belachew T, Worku BN, et al. Neither n–3 long-chain PUFA supplementation of mothers through lactation nor of offspring in a complementary food affects child overall or social-emotional development: a 2 × 2 factorial randomized controlled trial in rural Ethiopia. J Nutr. 2019;149:505–12.

    PubMed  Google Scholar 

  20. 20.

    Ichihara K, Waku K, Yamaguchi C, Saito K, Shibahara A, Miyatani S, et al. A convenient method for determination of the C20-22 PUFA composition of glycerolipids in blood and breast milk. Lipids. 2002;37:523–6.

    CAS  Google Scholar 

  21. 21.

    Bligh E, Dyer W. A rapid method of total lipid extraction and purification. Can J Biochem Physiol. 1959;37:911–7.

    CAS  PubMed  PubMed Central  Google Scholar 

  22. 22.

    Hall E, Flores S, De, Jesús V. Influence of hematocrit and total-spot volume on performance characteristics of dried blood spots for newborn screening. Int J Neonatal Screen. 2015;1:69–78.

    PubMed  PubMed Central  Google Scholar 

  23. 23.

    Bailey-Hall E, Nelson E, Ryan A. Validation of a rapid measure of blood PUFA levels in humans. Lipids 2008;43:181–6.

    CAS  PubMed  Google Scholar 

  24. 24.

    Fidler N, Sauerwald T, Pohl A, Demmelmair H, Koletzko B. Docosahexaenoic acid transfer into human milk after dietary supplementation: a randomized clinical trial. J Lipid Res. 2000;41:1376–83.

    CAS  PubMed  Google Scholar 

  25. 25.

    Makrides M, Neumann M, Gibson R. Effect of maternal docosahexaenoic acid (DHA) supplementation on breast milk composition. Eur J Clin Nutr. 1996;50:352–35.

    CAS  PubMed  Google Scholar 

  26. 26.

    Jensen C, Maude M, Anderson R, Heird W. Effect of docosahexaenoic acid supplementation of lactating women on the fatty acid composition of breast milk lipids and maternal and infant plasma phospholipids. Am J Clin Nutr. 2000;4(71(Suppl)):292S–9S.

    Google Scholar 

  27. 27.

    Otto S, Houwelingen AC, Van Badart-Smook A, Hornstra G. Comparison of the peripartum and postpartum phospholipid polyunsaturated fatty acid profiles of lactating and nonlactating women. Am J Clin Nutr. 2001;73:1074–9.

    CAS  PubMed  Google Scholar 

  28. 28.

    van Goor S, Dijck-brouwer D, Hadders-algra M, Doornbos B, Jaap J, Erwich H, et al. Human milk arachidonic acid and docosahexaenoic acid contents increase following supplementation during pregnancy and lactation. Prostaglandins, Leukot Ess Fat Acids. 2009;80:65–9.

    Google Scholar 

  29. 29.

    Michalski M, Briard V, Michel F, Tasson F, Poulain P. Size distribution of fat globules in human colostrum, breast milk, and infant formula. J Dairy Sci. 2005;88:1927–40.

    CAS  PubMed  Google Scholar 

  30. 30.

    Harzer G, Haug M, Dieterich I, Gentner P. Changing patterns of human milk lipids in the course of the lactation and during the day. Am J Clin Nutr. 1983;37:612–21.

    CAS  PubMed  Google Scholar 

  31. 31.

    Dunstan J, Mitoulas L, Dixon G, Doherty D, Hartmann P, Simmer K, et al. The Effects of Fish Oil Supplementation in Pregnancy on Breast Milk Fatty Acid Composition Over the Course of Lactation: A Randomized Controlled Trial. Pediatr Res. 2007;62:689–94.

    CAS  PubMed  Google Scholar 

  32. 32.

    Barrera C, Valenzuela R, Chamorro R, Bascuñ K, Sandoval J, Sabag N, et al. The impact of maternal diet during pregnancy and lactation on the fatty acid composition of erythrocytes and breast milk of chilean women. Nutrients. 2018;10.

  33. 33.

    Sherry C, Oliver J, Marriage B. Essential Fatty Acids Docosahexaenoic acid supplementation in lactating women increases breast milk and plasma docosahexaenoic acid concentrations and alters infant omega 6: 3 fatty acid ratio. Prostaglandins Leukot Ess Fat Acids. 2015;95:63–9.

    CAS  Google Scholar 

  34. 34.

    Gibson RA, Muhlhausler B, Makrides M. Conversion of linoleic acid and alpha-linolenic acid to long-chain polyunsaturated fatty acids (LCPUFAs), with a focus on pregnancy, lactation and the first 2 years of life. Matern Child Nutr. 2011;7:17–26.

    PubMed  PubMed Central  Google Scholar 

  35. 35.

    Innis S. Human milk: maternal dietary lipids and infant development. Proc Nutr Soc. 2007;66:397–404.

    CAS  PubMed  Google Scholar 

  36. 36.

    Del PradoM, Villalpando S, Elizondo A, Demmelmair H, Koletzko B. Contribution of dietary and newly formed arachidonic acid to human milk lipids in women eating a low-fat diet. Am J Clin Nutr. 2001;74:242–7.

    Google Scholar 

  37. 37.

    Martin J, Bougnoux P, Fignon A, Theret V, Antoine J, Lamisse F, et al. Dependence of human milk essential fatty acids on adipose stores during lactation. Am J Clin Nutr. 1993;58:653–9.

    CAS  PubMed  Google Scholar 

  38. 38.

    Molto-Puigmartı C, Plat J, Mensink R, Muller A, Jansen E, Zeegers M, et al. FADS1 FADS2 gene variants modify the association between fish intake and the docosahexaenoic acid proportions in human milk. Am J Clin Nutr. 2010;91:1368–76.

    PubMed  Google Scholar 

  39. 39.

    Lauritzen L, Carlson SE. Maternal fatty acid status during pregnancy and lactation and relation to newborn and infant status. Matern Child Nutr. 2011;7:41–58.

    PubMed  PubMed Central  Google Scholar 

  40. 40.

    Henderson R, Jensen R, Lammi-keefe C, Ferris A, Dardick K. Effect of Fish Oil on the Fatty Acid Composition of Human Milk and Maternal and Infant Erythrocytes. Lipids 1992;27:863–9.

    CAS  PubMed  Google Scholar 

  41. 41.

    Innis S. Impact of maternal diet on human milk composition and neurological development of infants. Am J Clin Nutr. 2014;99:734–41.

    Google Scholar 

  42. 42.

    Central Statistical Agency (CSA) [Ethiopia] and ICF. Ethiopia demographic and health survey 2016. Addis Ababa, Ethiopia, and Rockville, Maryland, USA: CSA and ICF; 2016.

    Google Scholar 

  43. 43.

    do Amaral Y, Marano D, da Silva L, Guimarães A, Moreira M. Are there changes in the fatty acid profile of breast milk with supplementation of Omega-3 Sources? A systematic review. Rev Bras Ginecol Obs. 2017;39:128–41.

    Google Scholar 

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This study was funded by the Institutional University Collaboration Programme of the Flemish Interuniversity Council with Jimma University, Nutrition Third World, the Nutricia Research Foundation, Michiels Fabrieken NV, and Fortitech Inc. The funders had no role in the design, analyses and interpretation results.

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KPB, LH, PK, and MW conceived the study. AA, KPB, MW, and LH implemented the study. BDM performed the laboratory analysis. AA and KPB analyzed the data and wrote the manuscript with support from all authors. All authors read and approved the final manuscript.

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Correspondence to Alemayehu Argaw.

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Argaw, A., Bouckaert, K.P., Wondafrash, M. et al. Effect of fish-oil supplementation on breastmilk long-chain polyunsaturated fatty acid concentration: a randomized controlled trial in rural Ethiopia. Eur J Clin Nutr 75, 809–816 (2021).

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