Krauss‐Etschmann 2007.

Methods	RCT: NCT01180933 (NUHEAL Nutraceuticals for a Healthier Life); 2 x 2 factorial
Participants	315 women randomised (4 groups ‐ see below) Inclusion criteria: apparently healthy women < 20 weeks GA; singleton pregnancy, intention to give birth in 1 of the obstetric centres listed below; body weight from > 50 kg to 92 kg and > 18–41 years old Exclusion criteria: women with serious chronic illness (e.g. diabetes, hepatitis, or chronic enteric disease) or who used fish oil supplements since the beginning of pregnancy or folate or vitamin B‐12 supplements after gestation week 16 Setting: Departments of Obstetrics at Ludwig Maximilians University, Munich, Germany; the University of Granada, Granada, Spain; and the University of Pecs, Pecs, Hungary
Interventions	SUPPLEMENTATION + OTHER AGENTS: DHA + EPA versus DHA + EPA + folate versus folate versus placebo ‐ all in a milk base Group 1: DHA/EPA: 15 g milk‐based supplement with 500 mg DHA and 150 mg EPA daily: total number randomised: n = 77 Group 2: DHA/EPA/folate:15 g milk‐based supplement with 500 mg DHA and 150 mg EPA, 400 µg 5‐MTHF daily: total number randomised: n = 77 Group 3: folate:15 g of a milk‐based supplement with 400 µg 5‐MTHF daily: total number randomised: n = 80 Group 4: control: 15 g of a milk‐based supplement placebo: total number randomised: n = 81 Timing of supplementation: 20 weeks GA to birth (infant formula (see below) until 6 months of age if child not breastfed) All women: all sachets contained vitamins and minerals in amounts that met the recommended intakes during the second half of pregnancy for European women (minerals: 300 mg Ca, 240 mg P, 93 mg Mg, 3 mg Zn, 66 µg I; vitamins: 330 µg vitamin A, 1.5 µg vitamin D, 3 mg vitamin E, 0.36 mg thiamine, 1.5 mg riboflavin, 4.5 mg vitamin B‐3, 1.9 mg vitamin B‐6, 3.5 µg vitamin B‐12, 270 mg vitamin C). All women were encouraged to breastfeed. For infants who were not fully breastfed: if the newborns were born to fish oil‐supplemented women, they received an infant formula containing 0.5% of total fatty acids as DHA and 0.4% as AA, whereas children born to mothers in the placebo or 5‐MTHF groups received a formula virtually free of DHA and AA during the first 6 months of postnatal life. DHA + EPA dose/day: mid: 500 mg DHA + 150 mg EPA
Outcomes	Women/birth: length of gestation; maternal and cord plasma DHA and EPA; dietary data at gestation weeks 20 and 30 and at birth; indicators of pregnancy outcome, and fetal development; placental samples; proliferation cell nuclear antigen; mRNA expression of placental proteins; TLR2, TLR4 and CD14 mRNA (maternal blood, placenta, cord blood); GWG, mode of birth; preterm birth < 35 weeks; postnatal depression 8 weeks after birth (EPDS); proteinuria, BP, and eclampsia for gestation weeks 22 and 30 and at birth; blood loss at birth; birthweight, birth length; head circumference at birth (the previous 3 measurements reported for only a sample of babies); MTHFR C677T polymorphism; fatty acids. Babies/infants/children: Apgar score; umbilical pH; visually evoked potentials at 8 weeks (Germany and Spain); Bayley Mental Development Test at 6 months old (Spain); skin‐prick test at 6 months old (Spain); paediatric symptoms and illness questionnaire at birth, 8 and 24 weeks; Hempel examination at 4 years; Touwen examination at 5.5 years; minor neurological dysfunction, NOS; fluency score; cognitive development (Kaufman Assessment Battery) at 6.5 years; response conflict‐resolution ability; alerting, and spatial orienting of attention (Attention Network Test), ERPs, and sLORETA at 8.5 years; MTHFR C677T polymorphism
Notes	DHA and EPA provided by Pronova Biocare, Lysaker, Norway: Folate from BASF, Ludwigshafen, Germany Adherence: 89.5% of the women in the second trimester gestation and 87.4% in the 3rd trimester missed < 5 days of supplementation Funding: Commission of the European Research and Technological Development Programme “Quality of Life and Management of Living Resources” within the 5th Framework Programme (contract QLK1‐CT‐1999‐00888 (NUHEAL “Nutraceuticals for a Healthier Life”)) and the European Community’s 7th Framework Programme (FP7/2008‐2013) under grant agreement 212652 (NUTRIMENTHE Project “The Effect of Diet on the Mental Performance of Children”); the University Science Program of Ludwig Maximilians University; a Freedom to Discover Award from the Bristol Myers Squibb Foundation; Spanish Ministry of Economy and Competitiveness grant (State Secretariat for Research, Development, and Innovation; PSI2012‐39292); European Research Council advanced grant ERC‐2012‐AdG (no.322605 META‐GROWTH). Declarations of interest: "Disclosure of potential conflict of interest: The authors have received grant support from the Commission of the European Communities and the Danone Institute of Nutrition". No other potential or actual conflicts of interest declared.
Risk of bias
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Unclear risk	Quote: “blockwise randomization”
Allocation concealment (selection bias)	Unclear risk	Quote: “envelopes containing cards with 1 of 4 numbers (1, 2, 3, or 4) according to the 4 intervention groups were mixed and put into a closed box. By drawing envelopes, intervention group numbers were consecutively assigned to subject identity numbers.”
Blinding of participants and personnel (performance bias) All outcomes	Low risk	Quote: "Neither the participating women nor the study personnel knew the content of the sachets"
Blinding of outcome assessment (detection bias) All outcomes	Low risk	Not specifically reported, but probably done.
Incomplete outcome data (attrition bias) All outcomes	High risk	45/315 (14.3%) did not complete the study at first follow‐up: Group 1: DHA/EPA 8/77 (10.4%) Group 2: DHA/EPA + folate 13/77 (16.9%) Group 3: folate 15/80 (18.8%) Group 4: placebo 9/81 (11.1%) There were 4 post randomisation exclusions: 2 women weighed > 92 kg, 1 of whom used commercial fish oil preparations; and 2 women regularly consumed fish oil preparations. Reasons for dropping out (n = 41) were noncompliance (n = 2), relocation (n = 1), aversion to or bad taste of the supplement (n = 9), and loss of contact (n = 2). In the remaining 17* cases, the reasons for dropping out were not known. Reasons were not reported by group and there were differential rates of loss between groups. *could be 27 Later follow‐up (4 and 5.5 years) 270 mother‐infant pairs were invited for neurological assessment; 175 complied with the request at the age of 4 years and 157 complied at 5.5 years of age. Dropout rates were a further 35.18% at the age of 4 years and 41.9% at the age of 5.5 years, with no differences in the dropout rates between groups. Main reasons for dropping out were relocation (n = 3), loss of contact (n = 65, n = 76), and unwillingness to continue in the study (n = 27, n = 34). 4 of the children examined at the age of 4 years and 5 of those examined at 5.5 years were born prematurely before week 35 of pregnancy and were therefore excluded from the analyses. Except for 1 child who was born with a congenital left side anophthalmus, no other serious congenital disorder was observed. In the health screening questionnaire at 4 years of age, 1 child was reported to have left side deafness, another had developed craniosynostosis and had surgery at the age of 6 months, and 1 child suffered from a developmental retardation of unknown etiology. These children were also excluded from the analyses, which left 167 and 148 children at the age of 4 and 5.5 years, respectively. 6.5 year follow‐up 161 children participated (exclusions: 4 children born < 35 weeks, 1 child was born with a congenital left‐side anophthalmus, 1 child developed craniosynostosis, and another was reported to have left‐side deafness). Dropout rates were similar between groups. Main reasons for dropping out were relocation (n = 3), loss of contact (n = 74), and unwillingness to continue (n = 30). There was a higher attrition of children whose fathers had a high educational level in the placebo and FO + 5‐MTHF groups, as well as differences in several outcomes (e.g. length of gestation, birth length) between children followed up and those lost to follow‐up. 8.5 year follow‐up 130 children participated; 37 FO, 27 folate; 32 placebo and 34 FO/folate (32 from Germany, 96 from Spain and 8 from Hungary; (exclusions: 4 children born < 35 weeks, 1 child was born with a congenital left‐side anophthalmus, 1 child developed craniosynostosis, and another was reported to have left‐side deafness). Dropout rates were similar between groups and had similar sociodemographic profiles. Main reasons for dropping out were relocation (n = 7), loss of contact (n = 75), and unwillingness to continue (n = 45).
Selective reporting (reporting bias)	Unclear risk	Preterm births treated as exclusions and not reported by group.
Other bias	Low risk	Similar baseline characteristics