Folic Acid Supplementation for the Prevention of Neural Tube Defects: An Updated Evidence Report and Systematic Review for the US Preventive Services Task Force

Red blood cell folate and benign prostatic hyperplasia: results from the NHANES 2001-2008

BACKGROUND

Benign prostatic hyperplasia (BPH) affects 30% of men worldwide, folate is essential for life. However, few studies have investigated the relationship between folate levels and BPH. The present study aims to explore the relationship between red blood cell (RBC) folate, a better indicator of long-term folate intake, and BPH in United States (US) men.

METHODS

We used statistics from four cycles of the "National Health and Nutrition Examination Survey" (NHANES2001-2008), RBC folate data come from laboratory data and BPH date come from questionnaire data. A multivariate conditional logistic regression model and subgroup analysis were using to assess the association between RBC folate and BPH.

RESULTS

647 males from four survey cycles in the NHANES2001-2008, of which, 574 men (88.7%) had BPH. After adjusting for potential confounders, a considerable correlation was observed between RBC folate and BPH; With the first quintiles of RBC folate as the reference, multivariable-adjusted odds ratios (ORs) and confidence intervals (95% CIs) of the second, third, fourth, and the highest quintiles were 1.19 (0.58 ∼ 2.44), 1.39 (0.65 ∼ 2.97), 2.27 (0.96 ∼ 5.39), 2.26 (1.35 ∼ 3.76) and 5.37 (1.85 ∼ 15.59), respectively.

CONCLUSIONS

Individuals with high levels of RBC folate were associated with an increased risk of self-reported benign prostatic hyperplasia of US men.

Explorative case control study on the associations of serum vitamin D3, folic acid and vitamin B12 levels on Kawasaki disease and coronary artery lesions

Background

Kawasaki Disease (KD) is a pediatric vasculitic disorder characterized by systemic small vasculitis, notably coronary arteritis, with unclear pathogenesis. This explorative case-control study investigated the association between folic acid (FA), vitamin D3 (VD3), and vitamin B12 (VB12) levels and the different types of Kawasaki Disease, as well as the incidence of coronary artery lesions (CALs).

Methods

In this explorative case control study, 365 KD children admitted to our hospital from January 1, 2022 to June 30, 2023 were included as the KD group. Simultaneously, 365 healthy children who received physical examination during the same period were included as the control group. The KD group was divided into typical KD group and incomplete KD group (IKD group), CALs group and non-CALS group, and IVIG sensitive group and IVIG resistant group. The children with CALs were divided into small tumor group, medium tumor group and large tumor group. Serum levels of FA, VB12, and VD3 were compared across all groups.

Results

Serum levels of FA and VD3 were significantly decreased in both the KD and CALs groups (p < 0.05), and both factors were identified as independent risk factors for KD and CALs. Similarly, reduced serum VD3 levels were observed in the IKD and IVIG-resistant groups (p < 0.05), with VD3 also being an independent risk factor for both IKD and IVIG resistance. Additionally, lower serum FA levels were noted in the group with large aneurysms (p < 0.05), establishing FA as an independent risk factor for aneurysm size.

Conclusion

Serum levels of folic FA and vitamin VD3 were significantly reduced in children with KD. Furthermore, these reductions were more pronounced in children with IKD and CALs. This pattern suggests that lower FA and VD3 levels may increase the risk of more severe coronary lesions in KD patients. Therefore, monitoring these biomarkers could provide valuable insights for early clinical diagnosis and intervention.

Potential Micronutrient Deficiencies in the First 1000 Days of Life: The Pediatrician on the Side of the Weakest

PURPOSE OF REVIEW

This study is to examine potential micronutrient deficiencies and any need for supplementation in children following specific diet plans in the first 1000 days of life.

RECENT FINDINGS

Optimal nutrition in the first 1000 days of life has a lifelong positive impact on child development. Specific intrauterine and perinatal factors, pathological conditions, and dietary restrictions can represent potential risk factors for micronutrient deficiencies in the first 1000 days of life, which can have negative systemic consequences. Preterm and low-birth-weight infants are intrinsically at risk because of immature body systems. Children affected by cystic fibrosis are prone to malnutrition because of intestinal malabsorption. The risk of micronutrient deficiency can increase in various situations, including but not limited to children following selective dietary regimens (vegetarian and vegan diets and children affected by specific neuropsychiatric conditions) or specific dietary therapies (children affected by food allergies or specific metabolic disorders and children following restricted diet as a part of therapeutic approach, i.e., ketogenic diet for epilepsy). In light of this situation, the micronutrient status in these categories of children should be investigated in order to tailor strategies specific to the individual's metabolic needs, with a particular focus on deficiencies which can impair or delay the physical and cognitive development of children, namely, vitamin B12, vitamin D and folic acid, as well as oligo-elements such as iron, zinc, calcium, sodium, magnesium, and phosphorus, and essential fatty acids such as omega-3. Identification of micronutrient deficiency in the first 1000 days of life and timely supplementation proves essential to prevent their long-term consequences.

Preconception Care Interventions for Adolescents and Young Adults to Prevent Adverse Maternal and Child Health Outcomes: Protocol for an Evidence Gap Map

BACKGROUND

Preconception is the period before a young woman or woman conceives, which draws attention to understanding how her health condition and certain risk factors affect her and her baby's health once she becomes pregnant. Adolescence and youth represent a life-course continuum between childhood and adulthood, in which the prepregnancy phase lacks sufficient research.

OBJECTIVE

The aim of the study is to identify, map, and describe existing empirical evidence on preconception interventions that enhance health outcomes for adolescents, young adults, and their offspring.

METHODS

We will conduct an evidence gap map (EGM) activity following the Campbell guidelines by populating searches identified from electronic databases such as MEDLINE, Embase, CINAHL, and Cochrane Library. We will include interventional studies and reviews of interventional studies that report the impact of preconception interventions for adolescents and young adults (aged 10 to 25 years) on adverse maternal, perinatal, and child health outcomes. All studies will undergo title or abstract and full-text screening on Covidence software (Veritas Health Innovation). All included studies will be coded using the Evidence for Policy and Practice Information (EPPI) Reviewer software (EPPI Centre, UCL Social Research Institute, University College London). Cochrane Risk of Bias tool 2.0 and Assessing the Methodological Quality of Systematic Reviews-2 (AMSTAR-2) tool will be used to assess the quality of the included trials and reviews. A 2D graphical EGM will be developed using the EPPI Mapper software (version 2.2.4; EPPI Centre, UCL Social Research Institute, University College London).

RESULTS

This EGM exercise began in July 2023. Through electronic search, 131,031 publications were identified after deduplication, and after the full-text screening, 18 studies (124 papers) were included in the review. We plan to submit the paper to a peer-reviewed journal once it is finalized, with an expected completion date in May 2024.

CONCLUSIONS

This study will facilitate the prioritization of future research and allocation of funding while also suggesting interventions that may improve maternal, perinatal, and child health outcomes.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/56052.

Hispanic Women's Perceptions of Neural Tube Defects and Folic Acid Supplementation: A Qualitative Study

INTRODUCTION

In the United States, the prevalence of neural tube defects (NTDs) is higher among infants born to Hispanic women compared with those born to non-Hispanic women. The purpose of this study is to investigate perceptions of NTDs and the use of folic acid and folate as a preventive measure among Hispanic women.

METHODS

Purposive sampling was used to recruit Hispanic women from a prenatal clinic in a Northeastern metropolitan city. In-depth interviews were conducted by native Spanish-speaking researchers using a semistructured interview guide. Thematic analysis was used to develop themes related to a priori domains.

FINDINGS

The study sample consisted of 26 Hispanic women representing nine countries of origin. Four themes were revealed: dietary sources of folic acid, awareness of folic acid supplementation and fortification, preferences for receiving health information, and factors in decision-making concerning an NTD diagnosis.

CONCLUSIONS

This study highlights the importance of early and targeted educational interventions sensitive to the cultural needs of this population. Results suggest that current NTD health education efforts may not be sufficient to increase our participants' knowledge of NTD. Additionally, the disparity may be multimodal, potentially influenced by insufficient understanding of prenatal folic acid use and the role of religiosity in decision-making during pregnancy. If Hispanic women are more likely to continue pregnancies affected by NTDs, this factor could be a part of NTD disparities. Exploring factors beyond supplementation and fortification that might influence rates of NTDs at birth in the U.S. Hispanic population can help to inform prevention efforts.

Preconception folic acid supplementation for the prevention of birth defects: a prospective, population-based cohort study in mainland China

BACKGROUND

Folic acid supplementation is recommended for reducing the risk of birth defects. We aimed to assess the protective association of periconception folic acid supplements with birth defects in real-world setting.

METHODS

This prospective, population-based cohort study utilized national preconception registered data of married Chinese couples planning a pregnancy within 6 months between 2010 and 2012 in Mainland China. Participated women are freely provided folic acid starting 3 months before conception till 3 months after conception. Birth defects were self-reported at 42 days postpartumn followup. R software (v4.0.2) was applied for statistical analyses.

RESULTS

Complete data of 567,547 couples with pregnancy outcomes and folic acid supplementation were extracted for final analysis. A total of 74.7% women were with folic acid supplementation, and 599 birth defects were self-reported. The odd of birth defects was lower among women taking folic acid compared to their counterparts not taking (0.102% vs 0.116%, P < 0.001). In the multiple logistic regression analyses, the odd of birth defects was lower among couples with maternal folic acid supplementation (OR = 0.78, 95%CI: 0.66-0.95, P = 0.011), especially decreased odd of neural tube defects (NTDs) (OR = 0.56, 95%CI: 0.39-0.82, P = 0.003). This association was confirmed by 1:4 and 1:10 case control analysis. Odds of birth defects were significantly lower among women with folic acid supplementation more than 3 months before pregnancy (P < 0.001), and moreover, the odds of cleft (P = 0.007) and NTDs (P = 0.007) were of notable decrease.

CONCLUSION

This retrospective case cohort study provides programmatic evidence for public health strategy-making to for reducing the risk of NTDs and clefts.

Folic acid supplementation use during the peri-conceptional period among professionals of a hospital in France

Folic acid insufficiency is an important risk factor for congenital neural tube defects. Despite recommendations and national campaigns, the proportion of women taking folic acid in the peri-conceptional period remains insufficient worldwide. We describe in this study the proportion of peri-conceptional folic acid supplementation use and its determinants among a population of hospital workers during the course of a prevention campaign. We performed a single-center cross sectional study in a university hospital in France. Data were collected during 2 months in 2019 by an online questionnaire sent to all professionals. We collected information about folic acid supplementation use, its modalities (form, period, frequency and dosage) and reason for initiating or not supplementation. Response rate was 11.4 % (n = 1,075/9,447). Among the 748 women who reported at least one pregnancy, 72.7 % (95 % CI: 69.4-76.0 %) reported taking folic acid during their last pregnancy. Main reason for initiating supplementation was information given by a health professional (87.8 %), especially by gynaecologists-obstetricians. Principal factors associated with folic acid supplementation use were age between 25 and 35 years, high level of education and recent pregnancy. Folic acid supplementation use is still not systematic before and during pregnancy, even among health professionals. There is a case for mandatory folic acid fortification for the French general population.

Society for Maternal-Fetal Medicine Consult Series #68: Sickle cell disease in pregnancy

Pregnant individuals with sickle cell disease have an increased risk of maternal and perinatal morbidity and mortality. However, prepregnancy counseling and multidisciplinary care can lead to favorable maternal and neonatal outcomes. In this consult series, we summarize what is known about sickle cell disease and provide guidance for sickle cell disease management during pregnancy. The following are Society for Maternal-Fetal Medicine recommendations.

Supplementation with (6S)-5-methyltetrahydrofolic acid appears as effective as folic acid in maintaining maternal folate status while reducing unmetabolised folic acid in maternal plasma: a randomised trial of pregnant women in Canada

Folic acid supplementation is recommended during pregnancy to support healthy fetal development; (6S)-5-methyltetrahydrofolic acid ((6S)-5-MTHF) is available in some commercial prenatal vitamins as an alternative to folic acid, but its effect on blood folate status during pregnancy is unknown. To address this, we randomised sixty pregnant individuals at 8-21 weeks' gestation to 0·6 mg/d folic acid or (6S)-5-MTHF × 16 weeks. Fasting blood specimens were collected at baseline and after 16 weeks (endline). Erythrocyte and serum folate were quantified via microbiological assay (as globally recommended) and plasma unmetabolised folic acid (UMFA) via LC-MS/MS. Differences in biochemical folate markers between groups were explored using multivariable linear/quantile regression, adjusting for baseline concentrations, dietary folate intake and gestational weeks. At endline (n 54), the mean values and standard deviations (or median, inter-quartile range) of erythrocyte folate, serum folate and plasma UMFA (nmol/l) in those supplemented with (6S)-5-MTHF v. folic acid, respectively, were 1826 (sd 471) and 1998 (sd 421); 70 (sd 13) and 78 (sd 17); 0·5 (0·4, 0·8) and 1·3 (0·9, 2·1). In regression analyses, erythrocyte and serum folate did not differ by treatment group; however, concentrations of plasma UMFA in pregnancy were 0·6 nmol/l higher (95 % CI 0·2, 1·1) in those supplementing with folic acid as compared with (6S)-5-MTHF. In conclusion, supplementation with (6S)-5-MTHF may reduce plasma UMFA by ∼50 % as compared with supplementation with folic acid, the biological relevance of which is unclear. As folate is currently available for purchase in both forms, the impact of circulating maternal UMFA on perinatal outcomes needs to be determined.

Folate - a scoping review for Nordic Nutrition Recommendations 2023

Folate is an essential micronutrient for normal development and metabolic function, and folate deficiency is associated with an increased risk of cancer, cardiovascular disease, mental dysfuntion and negative pregnancy outcomes. When estimating folate requirements, one must consider different bioavailability and functionality between synthetic folic acid and dietary folate, together with increased needs of folate in women of fertile age, pregnant and lactating women, preterm and small for gestational age weight infants and individuals who are homozygote for the 5,10-methylenetetrahydrofolate reductase (MTHFR) gene polymorphism. In order to achieve an adequate metabolic status based on the metabolic marker total homocysteine, and not merely the absence of clinical signs of folate deficiency, the recommended intake of folate differs according to age, pregnancy and lactation. According to the World Health Organization, a decision limit for folate deficiency in adults is serum folate level below 10 nmol/L, and in women of fertile age a red blood cell folate level below 906 nmol/L in order to prevent neural tube defects. Qualified systematic reviews along with identified relevant literature have been used for this scoping review prepared for the Nordic Nutrition Recommendations 2023.

Development and validation of a novel food exchange system for Chinese pregnant women

BACKGROUND

The dietary nutritional status of pregnant women is critical for maintaining the health of both mothers and infants. Food exchange systems have been employed in the nutritional guidance of patients in China, although their application in the dietary guidance of healthy pregnant women is quite limited. This study aimed to develop a novel food exchange system for Chinese pregnant women (NFES-CPW) and evaluate the relative validation of its application.

METHODS

NFES-CPW covers approximately 500 types of food from ten categories and has more elaborate food portion sizes. It established a recommendation index for guiding food selection and used energy, water content, and protein as the exchange basis to balance the supply of energy and important nutrients throughout pregnancy. Furthermore, dietitians used the NFES-CPW and traditional food exchange system to generate new recipes based on the sample recipe. There were 40 derived recipes for each of the two food exchange methods. The food consumption, energy, and key nutrients of each recipe were calculated, and the differences between the two food exchange systems were compared using the Wilcoxon rank sum test or the Chi-square test.

RESULTS

The results revealed that compared to those derived from traditional food exchange system, the NFES-CPW derived recipes had a better dietary structure, as evidenced by the intakes of whole-grain cereals, beans excluding soybeans, potatoes, fruits, fish, shrimp and shellfish, as well as eggs (P < 0.05), which were more conducive to reaching the recommended range of balanced dietary pagoda. After calculating energy and nutrients, although these two food exchange systems have similar effects on the dietary energy and macronutrient intake of pregnant women, the intake of micronutrients in NFES-CPW derived recipes was significantly higher than that from the traditional food exchange system, which was more conducive to meeting the dietary requirements of pregnant women. The outstanding improvement are primarily vitamin A, vitamin B2, folic acid, vitamin B12, vitamin C, calcium, iron, and iodine (P < 0.05). Moreover, when compared to recipes obtained from the traditional food exchange system, the error ranges of energy and most nutrients were significantly reduced after employing the NFES-CPW.

CONCLUSIONS

Therefore, NFES-CPW is an appropriate tool that adheres to Chinese dietary characteristics and can provide suitable dietary guidance to pregnant women.

Advances in Folic Acid Biosensors and Their Significance in Maternal, Perinatal, and Paediatric Preventive Medicine

Auxotrophic primates like human beings rely on exogenous dietary vitamin B9 supplementation to meet their metabolic demands. Folates play a crucial role in nucleotide synthesis and DNA methylation. Maternal folate deficiency causes several pregnancy-related complications, perinatal defects, and early childhood cognitive impairments. New evidence suggests excess FA is a potential risk factor resulting in unfavourable genomic and epigenomic alterations. Thus, it is essential to revisit the need to consistently monitor maternal folate levels during pregnancy. Yet, to date, no point-of-care folate-monitoring biosensor is commercially available. Here, we critically appraise the advances in folate biosensors to understand the translational gaps in biosensor design. Further, our review sheds light on the potential role of folate biosensors in strengthening maternal, perinatal, and child healthcare.

Periconceptional intakes of methyl donors and other micronutrients involved in one-carbon metabolism may further reduce the risk of neural tube defects in offspring: a United States population-based case-control study of women meeting the folic acid recommendations

BACKGROUND

Neural tube defects (NTDs) still occur among some women who consume 400 μg of folic acid for prevention. It has been hypothesized that intakes of methyl donors and other micronutrients involved in one-carbon metabolism may further protect against NTDs.

OBJECTIVES

To investigate whether intakes of vitamin B6, vitamin B12, choline, betaine, methionine, thiamine, riboflavin, and zinc, individually or in combination, were associated with NTD risk reduction in offspring of women meeting the folic acid recommendations.

METHODS

Data were from the National Birth Defects Prevention Study (United States population-based, case-control). We restricted deliveries between 1999 and 2011 with daily periconceptional folic acid supplementation or estimated dietary folate equivalents ≥400 μg. NTD cases were live births, stillbirths, or terminations affected by spina bifida, anencephaly, or encephalocele (n = 1227). Controls were live births without a major birth defect (n = 7095). We categorized intake of each micronutrient as higher or lower based on a combination of diet (estimated from a food frequency questionnaire) and periconceptional vitamin supplementation. We estimated NTD associations for higher compared with lower intake of each micronutrient, individually and in combination, expressed as odds ratios (ORs) and 95% confidence intervals (CIs), adjusted for age, race/ethnicity, education, and study center.

RESULTS

NTD associations with each micronutrient were weak to modest. Greater NTD reductions were observed with concurrent higher-amount intakes of multiple micronutrients. For instance, NTD odds were ∼50% lower among participants with ≥4 micronutrients with higher-amount intakes than among participants with ≤1 micronutrient with higher-amount intake (adjusted OR: 0.53; 95% CI: 0.33, 0.86). The strongest reduction occurred with concurrent higher-amount intakes of vitamin B6, vitamin B12, choline, betaine, and methionine (adjusted OR: 0.26; 95% CI: 0.09, 0.77) compared with ≤1 micronutrient with higher-amount intake.

CONCLUSIONS

Our findings support that NTD prevention, in the context of folic acid fortification, could be augmented with intakes of methyl donors and other micronutrients involved in folate metabolism.

Initiation and duration of folic acid supplementation in preventing congenital malformations

BACKGROUND

Folic acid (FA) supplementation is associated with a lower risk of the neural tube and heart defects and is recommended for women of childbearing age. Although there are detailed recommendations, differences in the initiation time and duration of FA supplementation remain poorly studied.

METHODS

A multicentre prospective study of 17,713 women was conducted. The incidence of congenital malformations in women taking a recommended dosage (e.g. 0.4 or 0.8 mg/day) of FA was compared with that in women without supplementation. The predicted probability of malformations by the initiation time and duration of FA use was estimated to determine optimal options.

RESULTS

Periconceptional FA supplementation was associated with a lower and insignificant risk of congenital malformations (1.59% vs. 2.37%; odds ratio [OR] 0.69; 95% confidence interval [CI]: 0.44-1.08), heart defects (3.8 vs. 8.0 per 1000 infants; OR, 0.47; 0.21-1.02), and neural tube defects (7.0 vs. 11.5 per 10,000 infants; OR, 0.64; 0.08-5.15). FA use after pregnancy provided greater protection against total malformations. Statistically significant associations were found in women who initiated FA supplementation in the first month of gestation (OR, 0.55; 95% CI: 0.33-0.91) and in those who supplemented for 1 to 2 months (OR, 0.59; 95% CI: 0.36-0.98). Similar results were found for heart defects. The optimal initiation time was 1.5 (optimal range: 1.1 to 1.9) months before pregnancy and a duration of 4.0 (3.7 to 4.4) months was reasonable to achieve the lowest risk of congenital malformations. Heart defect prevention required an earlier initiation (2.2 vs. 1.1 months before pregnancy) and a longer duration (4.7 vs. 3.7 months) than the prevention of other malformations.

CONCLUSIONS

The timely initiation of FA supplementation for gestation was associated with a decreased risk of congenital malformations, which was mainly attributed to its protection against heart defects. The initiation of FA supplementation 1.5 months before conception with a duration of 4 months is the preferred option for congenital malformation prevention.

TRIAL REGISTRATION

Chictr.org.cn identifier: ChiCTR-SOC-17010976.

Monitoring medicine prescriptions before, during and after pregnancy in Italy

BACKGROUND

The use of medications during pregnancy is a common event worldwide. Monitoring medicine prescriptions in clinical practice is a necessary step in assessing the impact of therapeutic choices in pregnant women as well as the adherence to clinical guidelines. The aim of this study was to provide prevalence data on medication use before, during and after pregnancy in the Italian population.

METHODS

A retrospective prevalence study using administrative healthcare databases was conducted. A cohort of 449,012 pregnant women (15-49 years) residing in eight Italian regions (59% of national population), who delivered in 2016-2018, were enrolled. The prevalence of medication use was estimated as the proportion (%) of pregnant women with any prescription.

RESULTS

About 73.1% of enrolled women received at least one drug prescription during pregnancy, 57.1% in pre-pregnancy and 59.3% in postpartum period. The prevalence of drug prescriptions increased with maternal age, especially during the 1st trimester of pregnancy. The most prescribed medicine was folic acid (34.6%), followed by progesterone (19%), both concentrated in 1st trimester of pregnancy (29.2% and 14.8%, respectively). Eight of the top 30 most prescribed medications were antibiotics, whose prevalence was higher during 2nd trimester of pregnancy in women ≥ 40 years (21.6%). An increase in prescriptions of anti-hypertensives, antidiabetics, thyroid hormone and heparin preparations was observed during pregnancy; on the contrary, a decrease was found for chronic therapies, such as anti-epileptics or lipid-modifying agents.

CONCLUSIONS

This study represents the largest and most representative population-based study illustrating the medication prescription patterns before, during and after pregnancy in Italy. The observed prescriptive trends were comparable to those reported in other European countries. Given the limited information on medication use in Italian pregnant women, the performed analyses provide an updated overview of drug prescribing in this population, which can help to identify critical aspects in clinical practice and to improve the medical care of pregnant and childbearing women in Italy.

Folate Supplementation in Women with Pre-Existing Diabetes

Folate supplementation in the periconceptual period is the standard of care for the prevention of neural tube defects. To support dietary folate intake, some countries have introduced mandatory folic acid fortification of food products. Robust evidence supports the additional use of a low-dose folic acid supplement (0.4 mg/day) in all women from 2-3 months preconception until the end of the 12th week of gestation. For women with pre-existing diabetes, high-dose folic acid supplementation (5 mg/day) is recommended in some, but not all international guidelines. The recommendation is made based on consensus opinion and reflects the increased risk of neural tube defects in pregnant women with pre-existing diabetes. However, there is limited evidence to clarify the high-risk groups that benefit from high-dose folic acid versus those that do not. There are also some data to suggest that high-dose folic acid may be harmful to mothers and offspring, although this issue remains controversial. This narrative review explores the evidence that supports the recommendation for women with pre-existing diabetes to take high-dose folic acid in the periconceptual period. It explores the potential benefits of high-dose supplemental folate beyond the prevention of neural tube defects, and also the potential adverse impacts of high-dose folate use. These topics are considered with a specific focus on the issues that are pertinent to women with pre-existing diabetes. Based on the available evidence, a pragmatic approach to the use of folic acid supplements in women with pre-existing diabetes during the periconception period is suggested. The need for comprehensive preconception care that optimises glycaemic control and addresses other modifiable risk factors before pregnancy is emphasized.

Advances in Fetal Surgical Repair of Open Spina Bifida

Spina bifida remains a common congenital anomaly of the central nervous system despite national fortification of foods with folic acid, with a prevalence of 2-4 per 10,000 live births. Prenatal screening for the early detection of this condition provides patients with the opportunity to consider various management options during pregnancy. Prenatal repair of open spina bifida, traditionally performed by the open maternal-fetal surgical approach through hysterotomy, has been shown to improve outcomes for the child, including decreased need for cerebrospinal fluid diversion surgery and improved lower neuromotor function. However, the open maternal-fetal surgical approach is associated with relatively increased risk for the patient and the overall pregnancy, as well as future pregnancies. Recent advances in minimally invasive prenatal repair of open spina bifida through fetoscopy have shown similar benefits for the child but relatively improved outcomes for the pregnant patient and future childbearing.

Beneficial effects of folic acid on inflammatory markers in the patients with metabolic syndrome: Meta-analysis and meta-regression of data from 511 participants in 10 randomized controlled trials

Previous clinical studies on the anti-inflammatory effects of folic acid (FA) in patients with metabolic syndrome (MetS) have shown controversial results. This study aimed to synthesize the evidence on the effect of FA on inflammatory marker levels in MetS patients. We screened PubMed, Embase, Medline, and the Cochrane Library (from inception to March 2022) to identify relevant randomized controlled trials (RCTs). DerSimonian and Laird random effects were used to estimate the pooled weighted mean difference (WMD) with 95% confidence interval (CI). Funnel plot, Egger's test, and the Begg-Mazumdar correlation test was used to assess publication bias. Subgroup analysis, meta-regression and sensitivity analysis were performed to find out possible sources of between-study heterogeneity. Ten RCTs with a total of 511 participants were included. The analysis showed that FA reduced high sensitivity C-reactive protein (hs-CRP) (WMD, -0.94; 95% CI, -1.56 to -0.32; P = 0.00), interleukin-6 (IL-6) (WMD, -0.39; 95% CI, -0.51 to -0.28; P = 0.00), and tumor necrosis factor-alpha (TNF-α) (WMD, -1.28; 95% CI, -1.88 to -0.68; P = 0.00), but did not decrease the C-reactive protein (CRP) (WMD, 0.10; 95% CI, -0.13 to 0.33; P = 0.38). Sensitivity analysis, subgroup analysis, and meta-regression showed that the effect sizes remained stable. Our findings suggest that FA supplementation could reduce inflammatory markers, such as hs-CRP, IL-6, TNF-α in patients with MetS. This study is registered with PROSPERO (CRD42021223843).

Care of the Well Newborn

Care of the newborn infant is a critical skill for general pediatricians and other providers in the practice of pediatric medicine. Optimal care relies on a thorough understanding of risk factors that may be present during the pregnancy and delivery, as well as the ability to recognize and address unanticipated problems in the postnatal period. This article focuses on antenatal care of the newborn, issues that present in the immediate postdelivery period, and care of the newborn after discharge. It also includes updated information on current topics in pediatric practice, such as the importance of vaccination, parental hesitancy in accepting common medical interventions, and updated guidelines related to the coronavirus disease 2019 pandemic. At the conclusion of the article, the reader should have a general understanding of antenatal risk factors that could affect the transition from the intrauterine environment and have the knowledge to address common issues that arise in the care of newborn infants.

BMP/Smad Pathway Is Involved in Lithium Carbonate-Induced Neural-Tube Defects in Mice and Neural Stem Cells

Neural-tube defects (NTDs) are one type of the most serious birth defects. Studies have shown that inositol deficiency is closely related to the occurrence of NTDs. Bone morphogenetic protein (BMP)-mediated Smad signaling pathways have been implicated in neurogenesis and neural-tube closure. However, the role of the BMP/Smad pathway in inositol-deficiency-induced NTDs remains unclear. Inositol-deficiency models in C57 mice and mouse neural stem cells (mNSCs) were induced with Li₂CO₃ treatment or inositol withdrawal. The role of the BMP/Smad pathway in the regulation of cell proliferation and the development of NTDs was determined utilizing qRT-PCR, HE staining, Western blot, immunostaining, MTT assay, EdU staining, and flow cytometry. The intraperitoneal injection of Li₂CO₃ at Embryonic Day 7.5 induced the occurrence of NTDs. The mRNA levels of Bmp2, Bmp4, Smad1, Smad5, Smad8 and Runx2, the phosphorylation of Smad1/5/8, and the nuclear translocation of Runx2 were significantly increased in NTD embryonic brain tissues and mNSCs exposed to Li₂CO₃ or an inositol-free medium, which were suppressed by BMP receptor selective inhibitor LDN-193189. The Li₂CO₃-induced phosphorylation of Smad1/5/8 was inhibited by inositol supplementation. Cell proliferation was significantly promoted by Li₂CO₃ exposure or the absence of inositol in mNSCs, which was reversed by LDN-193189. These results suggest that the activation of the BMP/Smad signaling pathway might play an important role in the development of NTDs induced by maternal Li₂CO₃ exposure via inositol deficiency.

[Preventive activities in women. PAPPS update 2022]

In the 2022 PAPPS update we present those specific preventive activities for women's health, except those related to cancer prevention (which are included in another document) and those aspects related to differential gender morbidity, a cross-cutting aspect for all working groups. Contraception is an essential preventive activity, considering basic the right to decide both the number of children and the time to have them. We must inform about the possible contraceptive methods, guaranteeing the monitoring of their safety, efficacy and effectiveness (tables are included on changing from one method to another to preserve contraceptive protection). We must inform about emergency contraception and propose it in the event of unprotected intercourse. All this will be done through opportunistic screening without requiring screening for thrombophilia or dyslipidemia, but for arterial hypertension. Pregnancy is an important life experience and the family doctor should not remain oblivious. We must be competent both in the preconception consultation (recommending the intake of folic acid, avoiding exposure to occupational and environmental risks, screening for certain pathologies and assessing the intake of drugs not indicated during pregnancy) and in the monitoring of pregnancy. Whether or not we monitor the pregnancy, we must not disregard its control, taking advantage of this period to promote healthy lifestyles and participating in the intercurrent processes that may occur. Menopause in general and osteoporosis in particular exemplify the strategy of medicalization of vital processes that has been followed from different instances and organizations. In our update we address the prevention and treatment of symptoms secondary to estrogen deprivation. We also propose the prevention of osteoporosis, including carrying out densitometry based on the risk of fracture in the next 10 years, and therefore densitometric screening is not recommended in women under 60 years of age. In risk assessment we recommend the use of the frax tool or better, the calibration of the risk of hip fracture with prevalence data from our setting. We linked the indication for treatment with the Z-Score (bone mineral density compared with women of the same age), as it is a condition associated with aging.

Emerging Role of Nicotinamide Riboside in Health and Diseases

Among all the NAD⁺ precursors, nicotinamide riboside (NR) has gained the most attention as a potent NAD⁺-enhancement agent. This recently discovered vitamin, B3, has demonstrated excellent safety and efficacy profiles and is orally bioavailable in humans. Boosting intracellular NAD⁺ concentrations using NR has been shown to provide protective effects against a broad spectrum of pathological conditions, such as neurodegenerative diseases, diabetes, and hearing loss. In this review, an integrated overview of NR research will be presented. The role NR plays in the NAD⁺ biosynthetic pathway will be introduced, followed by a discussion on the synthesis of NR using chemical and enzymatic approaches. NR’s effects on regulating normal physiology and pathophysiology will also be presented, focusing on the studies published in the last five years.

Choline, folic acid, Vitamin D, and fetal brain development in the psychosis spectrum

Choline, folic acid, and Vitamin D are essential for fetal brain development that may be the first steps in the pathogenesis of the psychotic spectrum. Micronutrient deficiencies have been associated with changes in fetal brain development, manifest as early problems in childhood behavior, and cognition, and later as increased incidence of psychotic and autism spectrum disorders. Micronutrient supplements may not only prevent deficiency, but they may also positively affect brain development in the context of other maternal risk factors, including maternal infection, stress, inflammation, and substance abuse. Many genes associated with later psychotic illness are highly expressed in the fetal brain, where they are responsible for various neurodevelopmental mechanisms. Interaction of micronutrient vitamins with these genetically programmed mechanisms to prevent pathological brain development associated with later psychosis is under active investigation. In addition to their effects on brain development, micronutrient vitamins have effects on other aspects of gestation and fetal development, including the prevention of premature delivery and other developmental abnormalities. Supplemental micronutrient vitamins should be part of good prenatal care, as has already happened for folic acid and Vitamin D and is now advocated by the American Medical Association for choline. The benefits of these micronutrient supplements include protection of brain development and the possibility of decreased risk for future psychotic disorders in those children who are either genetically or environmentally vulnerable. The purpose of this review is to present the current evidence supporting the safety and effectiveness of micronutrients in gestation and to suggest areas for future research.

Relationships between Women's and Men's Modifiable Preconception Risks and Health Behaviors and Maternal and Offspring Health Outcomes: An Umbrella Review

Parental health before conception effects maternal and offspring health outcomes. Preconception care provides healthcare to prospective parents addressing modifiable preconception risks and health behaviors. This umbrella review aimed to consolidate evidence on women's and men's modifiable preconception risks or health behaviors associated with maternal and offspring health outcomes. MEDLINE, EMBASE, Maternity and Infant Care, CINAHL, and PsycINFO were searched from March 4, 2010, to March 4, 2020. Eligible studies were systematic reviews or meta-analyses of observational studies examining associations between modifiable preconception risks or health behaviors and maternal and offspring health outcomes. Screening, data extraction, and methodological quality assessment (AMSTAR 2) occurred independently by two reviewers. Degree of overlap was examined. Findings were summarized for evidence synthesis. Twenty-seven systematic reviews were included. Modifiable preconception risks and health behaviors were identified across categories: body composition (e.g., overweight, obesity), lifestyle behaviors (e.g., caffeine, smoking), nutrition (e.g., micronutrients), environmental exposures (e.g., radiation), and birth spacing (e.g., short interpregnancy intervals). Outcomes associated with exposures affected embryo (e.g., embryonic growth), maternal (e.g., gestational diabetes mellitus), fetal/neonate (e.g., preterm birth), and child (e.g., neurocognitive disorders) health. For real-world practice and policy relevance, evidence-based indicators for preconception care should include body composition, lifestyle, nutrition, environmental, and birth spacing.

Effect of folic acid supplementation on diminished ovarian reserve: study protocol of a single-centre, open-label, randomised, placebo-controlled clinical trial

INTRODUCTION

The prevalence of diminished ovarian reserve (DOR), a common gynaecological disorder, is approximately 10% across the world. Failure in early diagnosis and treatment may result in continuous decreases in ovarian function and the resultant loss in an opportunity of pregnancy, which greatly affects the happiness of the women's family and women's physical and mental health. Nevertheless, there has been no effective treatment for such a disorder until now. Folic acid, a member of the vitamin B family, is involved in one-carbon cycle and methylation regulation. It has been found that folic acid affects the whole period of pregnancy, and folic acid supplementation has shown effective to remarkably reduce the incidence of fetal neural tube defects and decrease plasma homocysteic acid levels, thereby resulting in a decline in the incidence of abortion. In addition, folic acid is reported to mediate ovarian functions. It is therefore hypothesised that folic acid may improve DOR.

METHODS AND ANALYSIS

A single-centre, open-label, randomised, placebo-controlled clinical trial is designed. We plan to recruit 140 women with DOR at ages of 30-35 years. All participants will be randomised into the folic acid group and placebo group, and each subject will be given a tablet with the same appearance daily for 6 months. The primary outcome is antral follicle count, and the secondary outcomes are ovarian reserve markers, ovarian low-dose stimulation responses and safety.

ETHICS AND DISSEMINATION

This study was approved by the Ethics Review Committee of Nanping First Hospital Affiliated to Fujian Medical University on 10 February 2021 (approval number: NPSY202002042). Written informed consent was obtained from all participants prior to randomisation, following a detailed description of the purpose of the study. The results of this clinical trial will be presented at scientific conferences and submitted to a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

Chinese Clinical Trial Registry, ChiCTR2100047410.

Dietary Supplementation Before, During and After Pregnancy: Results of the Cluster-Randomized GeliS Study

Introduction The nutritional status of women before, during, and after pregnancy plays an important role in the health of mother and child. In addition to a balanced mixed diet, the increased need for folic acid and iodine should be met and ensured with supplements. The aim of this study was to assess dietary supplementation in the context of pregnancy and to investigate the effect of targeted counselling on supplementation behavior during and after pregnancy.

Methods In the context of the “Gesund leben in der Schwangerschaft” (GeliS; “Healthy living in pregnancy”) trial, women in the intervention group (IG) received four structured lifestyle counselling sessions during pregnancy as well as postpartum, during which they were informed about appropriate dietary supplementation. The women in the control group (CG) received routine prenatal care. The intake of dietary supplements was recorded at different points using a questionnaire.

Results In total, 2099 women were included in the analysis. Prior to conception, 31.3% of the women in the IG and 31.4% of the women in the CG took folic acid supplements. Prenatally, about half of the women took folic acid (IG: 54.1%; CG: 52.0%) and iodine (IG: 50.2%; CG: 48.2%). Statistically significant differences between the groups with regard to supplementation behavior could not be observed, neither prior to inclusion in the study nor during the intervention. During pregnancy, 23.0% of all women took docosahexaenoic acid (DHA) supplements and 21.8% iron supplements. 49.4% of the women additionally took vitamin D supplements. A higher educational level (p < 0.001), advanced age (p < 0.001), primiparity (p < 0.001), and a vegetarian diet (p = 0.037) were all associated with a higher level of dietary supplementation.

Conclusion The GeliS lifestyle counselling did not significantly improve the supplementation behavior of women during and after pregnancy. Women should be informed about adequate dietary supplementation early on within the scope of gynecological prenatal care.

Serum pyridoxine, folate, cobalamin, and homocysteine levels in children presenting with vasovagal syncope

BACKGROUND

Recent studies confirm the role of B vitamins deficiency and hyperhomocysteinaemia in the development of dysautonomia that has been considered to be the main factor in vasovagal syncope development. The aim of the study was to investigate serum pyridoxine, folate, cobalamin, and homocysteine levels in children presenting with vasovagal syncope and to analyse the correlation between them and main clinical parameters of syncope.

METHODS

We studied 40 children, ages 8-17 years with a history of vasovagal syncope and 24 healthy volunteers. The serum pyridoxine, folate, cobalamin, and homocysteine levels were measured by a quantitative sandwich enzyme immunoassay technique using a commercial kit (Monobind, USA). Twenty-four-hour Holter monitoring and 24-hour ambulatory blood pressure monitoring were conducted for all participated patients.

RESULTS

Serum pyridoxine (9.42 ± 4.87, 16.11 ± 5.53 µg/L) and cobalamin (307.48 ± 95.50, 447.28 ± 108.85 ng/L) levels were reasonably low (p < 0.05) in patients with vasovagal syncope. Although there was no significant change in folate levels between syncope and healthy children (4.00 ± 1.34, 4.71 ± 1.73 µg/L; p = 0.20), we detected low folate-level association with longer duration of syncope (r = -0.42) and post syncope (r = -0.43) symptoms (p < 0.05). Finally, there was increased serum homocysteine level (13.55 ± 5.03, 7.81 ± 1.71 µmol/L; p < 0.05) in patients with vasovagal syncope. It was positively correlated with the average PQ interval (r = 0.35, p < 0.05) and average QTc interval (r = 0.49, p < 0.05).

CONCLUSIONS

The results suggested that pyridoxine, folate, cobalamin, and homocysteine may be involved in the pathogenesis of vasovagal syncope. This might provide a new approach for effective treatment of paediatric vasovagal syncope, requiring further study.

Knowledge of Neural Tube Defects and Prevention Through Folic Acid Use Among Women in Faisalabad, Punjab, Pakistan: A Cross-Sectional Survey

Objective

Neural tube defects (NTDs) are one of the most common congenital abnormalities of the central nervous system and are associated with significant mortality, morbidity, and major life-long disability. Periconceptional folic acid reduces the risk of NTDs by up to 70%; however, in Pakistan, no public information program exists concerning the risks of NTDs or promoting folic acid use. As such, the aim of this study was to assess levels of knowledge about NTDs and folic acid use among women attending the gynaecology department of DHQ Hospital, Faisalabad, Pakistan.

Design

A cross-sectional survey.

Setting

The gynaecology department of the District Head Quarter (DHQ) Hospital in Faisalabad, Pakistan.

Participants

Three hundred and fifty-five married women.

Primary and Secondary Outcome Measures

Primary outcome measures included knowledge of NTDs and knowledge of folic acid use.

Results

About 85.4% of participants had no knowledge of neural tube defects and 76.7% reported no knowledge about folic acid use. The majority of participants (86.2%) were unaware that folic acid protects against NTDs. Lack of knowledge of NTDs was significantly associated with education (P = 0.001), husband’s education (P = 0.002), planned pregnancy (P = 0.002), sources of antenatal care (P = 0.003), knowledge of folic acid (P = 003), knowledge that folic acid protects against NTDs (P = 0.002), and health decision-making (P = 0.003). Knowledge of folic acid use was significantly associated with age (P = 0.000), education (P = 0.004), husband’s education (P = 0.002), monthly income (P = 0.003), planned pregnancy (P = 0.003), pregnancy trimester (P < 0.001), sources of antenatal care (P < 0.001), knowledge of NTDs (P = 0.002), knowledge that folic acid protects against NTDs (P < 0.001), use of folic acid (P < 0.001), sources of vitamin information (P < 0.001), and health decision-making (P = 0.002).

Conclusion

These findings highlight extremely low levels of knowledge about NTDs and folic acid use of women in Pakistan. There is an urgent need to increase knowledge and awareness of the risks of NTDs and preventative approaches, through health education programs delivered by trusted health professionals.

Long-term health outcomes of children born to mothers with hyperemesis gravidarum: a systematic review and meta-analysis

OBJECTIVE

Hyperemesis gravidarum is characterized by severe nausea and vomiting in pregnancy, frequently resulting in severe maternal nutritional deficiency. Maternal undernutrition is associated with adverse offspring health outcomes. Whether hyperemesis gravidarum permanently affects offspring health remains unclear. This review aimed to evaluate the effects of maternal hyperemesis gravidarum on offspring health.

DATA SOURCES

MEDLINE and Embase were searched from inception to September 6, 2021.

STUDY ELIGIBILITY CRITERIA

Studies reporting on health at any age beyond the perinatal period of children born to mothers with hyperemesis gravidarum were included.

METHODS

Two reviewers independently selected studies and extracted data. The Newcastle-Ottawa Quality Assessment Scale was used to assess risk of bias. We conducted a narrative synthesis and meta-analysis where possible. In meta-analyses with high heterogeneity (I²>75%), we did not provide a pooled odds ratio.

RESULTS

Nineteen studies were included in this systematic review (n=1,814,785 offspring). Meta-analysis (n=619, 2 studies: 1 among adolescents and 1 among adults) showed that hyperemesis gravidarum was associated with anxiety disorder (odds ratio, 1.74; 95% confidence interval, 1.04-2.91; I², 0%) and sleep problems in offspring (odds ratio, 2.94; 95% confidence interval, 1.25-6.93; I², 0%). Hyperemesis gravidarum was associated with testicular cancer in male offspring aged up to 40 years on meta-analysis (5 studies, n=20,930 offspring), although heterogeneity was observed on the basis of a wide 95% prediction interval (odds ratio, 1.60; 95% confidence interval, 1.07-2.39; I², 0%; 95% prediction interval, 0.83-3.08). All 6 studies reporting on attention deficit (hyperactivity) disorder and autism spectrum disorder reported an increase among children of mothers with hyperemesis gravidarum in comparison with children of unaffected mothers. Meta-analysis showed high heterogeneity, precluding us from reporting a pooled odds ratio. Most studies reporting on cognitive and motor problems found an increase among hyperemesis gravidarum-exposed children. One study investigated brain structure and found smaller cortical volumes and areas among children from hyperemesis gravidarum-affected pregnancies than among those from unaffected pregnancies. Studies evaluating anthropometry and cardiometabolic disease risk of hyperemesis gravidarum-exposed children had inconsistent findings.

CONCLUSION

Our systematic review showed that maternal hyperemesis gravidarum is associated with small increases in adverse health outcomes among children, including neurodevelopmental disorders, mental health disorders, and possibly testicular cancer, although evidence is based on few studies of low quality.

Prenatal Folate and Choline Levels and Brain and Cognitive Development in Children: A Critical Narrative Review

Women’s nutritional status during pregnancy can have long-term effects on children’s brains and cognitive development. Folate and choline are methyl-donor nutrients and are important for closure of the neural tube during fetal development. They have also been associated with brain and cognitive development in children. Animal studies have observed that prenatal folate and choline supplementation is associated with better cognitive outcomes in offspring and that these nutrients may have interactive effects on brain development. Although some human studies have reported associations between maternal folate and choline levels and child cognitive outcomes, results are not consistent, and no human studies have investigated the potential interactive effects of folate and choline. This lack of consistency could be due to differences in the methods used to assess folate and choline levels, the gestational trimester at which they were measured, and lack of consideration of potential confounding variables. This narrative review discusses and critically reviews current research examining the associations between maternal levels of folate and choline during pregnancy and brain and cognitive development in children. Directions for future research that will increase our understanding of the effects of these nutrients on children’s neurodevelopment are discussed.

Prevalence of Congenital Heart Disease in Chinese Children With Different Birth Weights and Its Relationship to the Neonatal Birth Weight

OBJECTIVE

This study aimed to examine the prevalence and the related risk factors of congenital heart disease (CHD) in children with different birth weights in China and the relationship between the subtypes of CHD and birth weight (BW).

METHODS

This study conducted a cross-sectional survey on the data collected in the children's congenital heart disease database (CHDD) established in China. This database contained data from one Grade A, Level III Children's Public Hospital in Zhengzhou, Henan. The study included all the children and their parents in the database from 2014 to 2020 as the study subjects, and the missing data were processed by means of imputation. Diagnoses of CHD were coded using the International Classification of Diseases version 10 (ICD-10), and subtypes were classified by the codes Q20 to Q26. We reported the prevalence of CHD based on birth weight and gestational age and analyzed the related risk factors for children with CHD in different birth weight groups and factors for children of the same birth weight groups between the CHD groups and the non-CHD groups. The generalized linear model was used to assess the association between the subtypes of CHD and BW by establishing three adjusting models, and the data were stratified for further analysis by urban-rural and infant gender.

RESULTS

A total of 42,814 children were identified as having CHD among 5,071,799 live children; the overall prevalence of CHD was 8.44 per 1,000 live births during 2014-2020; and the three subtypes with the highest prevalence of CHD were atrial septal defect (ASD) (2.75‰), ventricular septal defect (VSD) (2.57‰), and patent foramen ovale (PFO) (1.12‰). The prevalence of CHD was 18.87‰ in the group with BW <1,500 g, 12.84‰ in the group with BW 1,500-2,500 g, 8.24‰ in the group with BW 2,500-4,000 g, and 4.80‰ in the group with BW ≥4,000 g. The prevalence of CHD was 16.62‰ in the small for gestational age (SGA) group, 6.99‰ in the appropriate for gestational age (AGA) group, and 6.40‰ in the larger for gestational age (LGA) group. Parental factors such as drinking, smoking, viral infections, peri-pregnancy exposure to radioactive substances, low family monthly expenditure, and low Apgar scores at 1 and 5 min were related to the increased risk of CHD in the offspring. Parental supplementation of folic acid and exercise during the peri-pregnancy period could reduce the risk of CHD in the offspring. The results of Model 3 adjusting for confounding variables showed that infants with ASD had a birth weight 461 g lower (95% CI: -1,085, -128), infants with VSD had a birth weight 426 g lower (95% CI: -932, -120), infants with tetralogy of Fallot (TOF) had a birth weight 532 g lower (95% CI: -987, -168), and without classification, infants with CHD had a birth weight 973 g lower (95% CI: -1,502, -204).

CONCLUSION

In very low birth weight (VLBW) and low birth weight (LBW) infants, CHDs are more prevalent than in the general live-born population. Moreover, some peri-pregnancy factors of parents are closely related to the occurrence of CHD in offspring; different types of heart defects can lead to LBW. Therefore, if the fetus is found to have a heart defect during the prenatal examination, the mother should pay more attention to maintaining weight and ensuring that the fetus is within the normal weight range, thereby increasing the postpartum survival rate, reducing complications, and promoting children's health.

Visual attention to their own paralytic limbs in children with spina bifida: Measurement of gaze direction using eye tracking

BACKGROUND

Patients with spina bifida experience sensory and motor paralysis and complications in the form of deformation and skin problems of the lower limbs. Enhancing their awareness of the paralysed lesions could be helpful for these patients to prevent secondary disorders. This study sought to investigate to what extent children with spina bifida are visually aware of their body parts and, in particular, to their paralysed lesions.

METHODS

Participants included children with spina bifida (n = 10) and typically developing control children (n = 10) between the ages of 5 and 11 years. All participants were shown still images of themselves on a monitor after which their gaze direction was measured using an eye tracker, with or without providing an instruction to direct their attention to their limbs. The gaze direction data were analyzed and compared between children with spina bifida and the control children.

RESULTS

Children with spina bifida paid visual attention to their bodies in a manner similar to that of control children. Prompts to direct their attention to their limbs were effective in both groups; however, the degree of efficacy in children with spina bifida was inferior to that in control children.

CONCLUSIONS

Promotion of visual awareness to their paralytic parts could be a reasonable and effective method for children with spina bifida to improve their understanding and recognition of their body and prevent associated skin problems.

Body knowledge in children with spina bifida

BACKGROUND

Patients with spina bifida suffer from motor paralysis and sensory disturbance, secondary deformation of the lower extremities, and development of decubitus ulcers. A deep understanding of one's body, such as identifying the names, functions, relationships, homology (e.g. upper and lower limbs) and relative position of body parts, may prevent secondary disorders. The awareness of the body and its characteristics in children with spina bifida has not been fully elucidated. This study aimed to investigate how children with spina bifida perceive their bodies, especially their paralyzed parts and related or homologous ones.

METHODS

Participants included 36 children with spina bifida and 14 control children, aged 5-11 years. They were asked to draw self-portraits, and to answer questions about the names of body parts. The number of drawn body parts in the pictures and the correct response rates to the questions were quantified and compared between children with spina bifida and control children.

RESULTS

Children with spina bifida drew fewer hands, legs, and feet than control children. In the verbal tests, children with spina bifida had a lower correct response rate than control children on questions concerning the upper limbs, hands, trunk, and feet.

CONCLUSIONS

Children with spina bifida have diminished visuospatial and lexical-semantic body knowledge of the paralyzed parts and related organs.

Excess Folic Acid Supplementation before and during Pregnancy and Lactation Alters Behaviors and Brain Gene Expression in Female Mouse Offspring

Use of folic acid (FA) during early pregnancy protects against birth defects. However, excess FA has shown gender-specific neurodevelopmental toxicity. Previously, we fed the mice with 2.5 times the recommended amount of FA one week prior to mating and during the pregnancy and lactation periods, and detected the activated expression of Fos and related genes in the brains of weaning male offspring, as well as behavioral abnormalities in the adults. Here, we studied whether female offspring were affected by the same dosage of FA. An open field test, three-chamber social approach and social novelty test, an elevated plus-maze, rotarod test and the Morris water maze task were used to evaluate their behaviors. RNA sequencing was performed to identify differentially expressed genes in the brains. Quantitative real time-PCR (qRT-PCR) and Western blots were applied to verify the changes in gene expression. We found increased anxiety and impaired exploratory behavior, motor coordination and spatial memory in FA-exposed females. The brain transcriptome revealed 36 up-regulated and 79 down-regulated genes in their brains at weaning. The increase of Tlr1; Sult1a1; Tph2; Acacb; Etnppl; Angptl4 and Apold1, as well as a decrease of Ppara mRNA were confirmed by qRT-PCR. Among these genes; the mRNA levels of Etnppl; Angptl4andApold1 were increased in the both FA-exposed female and male brains. The elevation of Sult1a1 protein was confirmed by Western blots. Our data suggest that excess FA alteres brain gene expression and behaviors in female offspring, of which certain genes show apparent gender specificity.

Folic Acid Protects Melanocytes from Oxidative Stress via Activation of Nrf2 and Inhibition of HMGB1

Vitiligo is a cutaneous depigmentation disease due to loss of epidermal melanocytes. Accumulating evidence has indicated that oxidative stress plays a vital role in vitiligo via directly destructing melanocytes and triggering inflammatory response that ultimately undermines melanocytes. Folic acid (FA), an oxidized form of folate with high bioavailability, exhibits potent antioxidant properties and shows therapeutic potential in multiple oxidative stress-related diseases. However, whether FA safeguards melanocytes from oxidative damages remains unknown. In this study, we first found that FA relieved melanocytes from H₂O₂-induced abnormal growth and apoptosis. Furthermore, FA enhanced the activity of antioxidative enzymes and remarkably reduced intracellular ROS levels in melanocytes. Subsequently, FA effectively activated nuclear factor E2-related factor 2 (Nrf2) pathway, and Nrf2 knockdown blocked the protective effects of FA on H₂O₂-treated melanocytes. Additionally, FA inhibited the production of proinflammatory HMGB1 in melanocytes under oxidative stress. Taken together, our findings support the protective effects of FA on human melanocytes against oxidative injury via the activation of Nrf2 and the inhibition of HMGB1, thus indicating FA as a potential therapeutic agent for the treatment of vitiligo.

Maternal folic acid and multivitamin supplementation: International clinical evidence with considerations for the prevention of folate-sensitive birth defects

More evidence is available for maternal intake, absorption, distribution, tissue specific concentrations, and pregnancy outcomes with folic acid (fortification/supplementation) during preconception - first trimester. This Quality Improvement prevention review used expert guidelines/opinions, systematic reviews, randomized control trials/controlled clinical trials, and observational case control/case series studies, published in English, from 1990 to August 2021. Optimization for an oral maternal folic acid supplementation is difficult because it relies on folic acid dose, type of folate supplement, bio-availability of the folate from foods, timing of supplementation initiation, maternal metabolism/genetic factors, and many other factors. There is continued use of high dose pre-food fortification 'RCT evidenced-based' folic acid supplementation for NTD recurrence pregnancy prevention. Innovation requires preconception and pregnancy use of 'carbon one nutrient' supplements (folic acid, vitamin B12, B6, choline), using the appropriate evidence, need to be considered. The consideration and adoption of directed personalized approaches for maternal complex risk could use serum folate testing for supplementation dosing choice. Routine daily folic acid dosing for low-risk women should consider a multivitamin with 0.4 mg of folic acid starting 3 months prior to conception until completion of breastfeeding. Routine folic acid dosing or preconception measurement of maternal serum folate (after 4-6 weeks of folate supplementation) could be considered for maternal complex risk group with genetic/medical/surgical co-morbidities. These new approaches for folic acid oral supplementation are required to optimize benefit (decreasing folate sensitive congenital anomalies; childhood morbidity) and minimizing potential maternal and childhood risk.

Association of maternal folate use and reduced folate carrier gene polymorphisms with the risk of congenital heart disease in offspring

Although it is generally recognized that genetic and environmental factors are associated with the risk of congenital heart disease (CHD), the mechanism remains largely uncertain. This study aimed to investigate the association of maternal folate use, the time when folate use was started, and polymorphisms of the reduced folate carrier (RFC1) gene with the risk of CHD in offspring of Chinese descent, which can help provide new insight into the etiology of folate-related birth defects. A case-control study of 683 mothers of CHD patients and 740 mothers of healthy children was performed. The present study showed that mothers who did not use folate were at a significantly increased risk of CHD (OR=2.04; 95% CI: 1.42-2.93). When compared with those who started using folate prior to conception, mothers who started using folate from the first trimester of pregnancy (OR=1.90; 95% CI: 1.43-2.54) or from the second trimester of pregnancy (OR=8.92; 95% CI: 4.20-18.97) had a significantly higher risk of CHD. Maternal RFC1 gene polymorphisms at rs2236484 (AG vs AA: OR=1.79 [95% CI: 1.33-2.39]; GG vs AA: OR=1.64 [95% CI: 1.15-2.35]) and rs2330183 (CT vs CC: OR=1.54 [95% CI: 1.14-2.09]) were also significantly associated with CHD risk. Additionally, the risk of CHD was significantly decreased among mothers who had variant genotypes but used folate when compared with those who had variant genotypes and did not use folate.Conclusion: In those of Chinese descent, maternal folate use and the time when use started are significantly associated with the risk of CHD in offspring. Furthermore, maternal folate supplementation may help to offset some of the risks of CHD in offspring due to maternal RFC1 genetic variants. What is Known: • Folate use could help prevent CHD, but the relationship between the time when folate use is started and CHD has not received sufficient attention. • Studies have assessed the associations of folate metabolism-related genes with CHD, but genes involved in cellular transportation of folate, such as the RFC1 gene, have not garnered enough attention. What is New: • In those of Chinese descents, the time when folate use is started is significantly associated with the risk of CHD in offspring. • Maternal RFC1 polymorphisms were significantly associated with the risk of CHD. • Folate supplementation may help to offset some risks of CHD due to RFC1 genetic variants.

Exposures associated with the onset of Kawasaki disease in infancy from the Japan Environment and Children's Study

Kawasaki disease (KD) is an acute systemic vasculitis that mainly affects infants and young children. The etiology of KD has been discussed for several decades; however, no reproducible risk factors have yet been proven. We used the Japan Environment and Children’s Study data to explore the association between the causal effects of exposure during the fetal and neonatal periods and KD onset. The Japan Environment and Children’s Study, a nationwide birth cohort study, has followed approximately 100,000 children since 2011. We obtained data on exposures and outcomes from the first trimester to 12 months after birth. Finally, we included 90,486 children who were followed for 12 months. Among them, 343 children developed KD. Multivariate logistic regression revealed that insufficient intake of folic acid during pregnancy (odds ratio [OR], 1.37; 95% CI 1.08–1.74), maternal thyroid disease during pregnancy (OR, 2.03; 95% CI 1.04–3.94), and presence of siblings (OR, 1.33; 95% CI 1.06–1.67) were associated with KD onset in infancy. In this study, we identified three exposures as risk factors for KD. Further well-designed studies are needed to confirm a causal relationship between these exposures and KD onset.

[Association between maternal reduced folate carrier gene polymorphisms and congenital heart disease in offspring: a case-control study]

OBJECTIVE

To study the association between maternal reduced folate carrier (RFC) gene polymorphisms and congenital heart disease (CHD) in offspring.

METHODS

A hospital-based case-control study was conducted. The mothers of 683 infants with CHD who attended the Department of Cardiothoracic Surgery, Hunan Children's Hospital, from November 2017 to March 2020 were enrolled as the case group. The mothers of 740 healthy infants without any deformity who attended the hospital during the same period of time were enrolled as the control group. A questionnaire survey was performed to collect the exposure data of subjects. Venous blood samples of 5 mL were collected from the mothers for genetic polymorphism detection. A multivariate logistic regression analysis was used to evaluate the association of RFC gene polymorphisms and their haplotypes with CHD. A generalized multifactor dimensionality reduction method was used to analyze gene-gene interactions.

RESULTS

After control for confounding factors, the multivariate logistic regression analysis showed that maternal RFC gene polymorphisms at rs2236484 (AG vs AA:OR=1.91, 95%CI:1.45-2.51; GG vs AA: OR=1.96, 95%CI:1.40-2.75) and rs2330183 (CT vs CC:OR=1.39, 95%CI:1.06-1.83) were significantly associated with the risk of CHD in offspring. The haplotypes of G-G (OR=1.21, 95%CI:1.03-1.41) and T-G (OR=1.25, 95%CI:1.07-1.46) in mothers significantly increased the risk of CHD in offspring. The interaction analysis showed significant gene-gene interactions between different SNPs of the RFC gene in CHD (P < 0.05).

CONCLUSIONS

Maternal RFC gene polymorphisms and interactions between different SNPs are significantly associated with the risk of CHD in offspring.

Magnitude and determinants of neural tube defect in Africa: a systematic review and meta-analysis

BACKGROUND

Neural tube defects (NTDs) are a group of disorders that arise from the failure of the neural tube close between 21 and 28 days after conception. About 90% of neural tube defects and 95% of death due to these defects occurs in low-income countries. Since these NTDs cause considerable morbidity and mortality, this study aimed to determine the prevalence and associated factors of NTDs in Africa.

METHODS

The protocol of this study was registered in the International Prospective Register of Systematic Reviews (PROSPERO number: CRD42020149356). All major databases such as PubMed/MEDLINE, EMBASE, CINAHL, Web of Science, African Journals Online (AJOL), and Google Scholar search engine were systematically searched. A random-effect model was used to estimate the pooled prevalence of NTDs in Africa, and Cochran's Q-statistics and I2 tests were used to assess heterogeneity between included studies. Publication bias was assessed using Begg 's tests, and the association between determinant factors and NTDs was estimated using a random-effect model.

RESULTS

Of the total 2679 articles, 37 articles fulfilled the inclusion criteria and were included in this systematic review and meta-analysis. The pooled prevalence of NTDs in Africa was 50.71 per 10,000 births (95% CI: 48.03, 53.44). Folic acid supplementation (AOR: 0.40; 95% CI: 0.19-0.85), maternal exposure to pesticide (AOR: 3.29; 95% CI: 1.04-10.39), mothers with a previous history of stillbirth (AOR: 3.35, 95% CI: 1.99-5.65) and maternal exposure to x-ray radiation (AOR 2.34; 95% CI: 1.27-4.31) were found to be determinants of NTDs.

CONCLUSIONS

The pooled prevalence of NTDs in Africa was found to be high. Maternal exposure to pesticides and x-ray radiation were significantly associated with NTDs. Folic acid supplementation before and within the first month of pregnancy was found to be a protective factor for NTDs.

Female awareness about the preconception use of folic acid supplements in childbearing age: A cross-sectional study

AIMS

Folic acid is required for the growth and development of the fetus. There is strong evidence that taking folic acid before pregnancy and during the first trimester reduces the risk of neural tube defects (NTDs). This study aimed to assess women's awareness of preconception folic acid supplementation and its importance to the mother and the fetus.

METHODS

This was a cross-sectional questionnaire study conducted in Saudi Arabia between January and April 2019. An electronic questionnaire tool was designed and distributed using Google Forms through social media (Facebook and WhatsApp) websites. Binary logistics regression was used to estimate odds ratios (ORs), with 95% confidence intervals (CIs) for predictors of poor levels of awareness about folic acid.

RESULTS

A total of 514 women participated in this study. The age range for the study participants was 18-45 years. Only 24.1% of the participants reported that they routinely took folic acid. The most commonly reported source of information about folic acid use was the doctor. The majority of the participants had poor awareness of folic acid use. Older age (30 years and above) and not taking regular folic acid supplements were important predictors of poor awareness of folic acid. Having a university degree or higher education was an important predictor of increased awareness about folic acid.

CONCLUSION

Our study found that the awareness of the Saudi women was poor in identifying the generic name of folic acid, recognising the sources of folic acid, the correct dose of folic acid, and the side effects of high doses of folic acid and that there was good knowledge about the importance of folic acid, the consequences of folic acid deficiency, and the belief that even non-pregnant women and girls of childbearing age should take folic acid.

Folic acid supplementation during pregnancy and associations with offspring size at birth and adiposity: a cohort study

Objective

Previously we observed that maternal multiple micronutrient supplementation in pregnancy was associated with increased offspring size at birth and adiposity, as well as with maternal gestational diabetes risk, in the Cambridge Baby Growth Study. In this study we therefore investigated whether folic acid supplementation specifically is associated with similar changes, to test the hypothesis that folic acid supplementation mediates such changes.

Results

The majority of mothers who reported supplementing with folic acid in pregnancy (n = 776 in total, 526 of which took multiple micronutrient preparations) did so either from pre- (n = 139) or post-conception (n = 637) largely for all or just the first half of pregnancy. A minority of mothers (n = 198) reported not supplementing with folic acid. Folic acid supplementation in pregnancy was not associated with birth weight [β’ = − 0.003, p = 0.9], height [β’ = − 0.013, p = 0.6], head circumference [β’ = 0.003, p = 0.09] or adiposity (ponderal index [β’ = 0.020, p = 0.5], skinfolds thicknesses [β’ = − 0.029 to + 0.008, p = 0.4–0.9]). Neither was it associated with the development of maternal gestational diabetes (risk ratio 1.2 [0.6‒2.2], p = 0.6). These results suggest that folic acid supplementation in pregnancy did not mediate the previously observed increases in offspring size at birth and adiposity, or the raised gestational diabetes risk, in response to supplementation with multiple micronutrients.

Type 1 Diabetes: Management in Women From Preconception to Postpartum

CONTEXT

This review presents an up-to-date summary on management of type 1 diabetes mellitus (T1DM) among women of reproductive age and covers the following time periods: preconception, gestation, and postpartum.

EVIDENCE ACQUISITION

A systematic search and review of the literature for randomized controlled trials and other studies evaluating management of T1DM before pregnancy, during pregnancy, and postpartum was performed.

EVIDENCE SYNTHESIS

Preconception planning should begin early in the reproductive years for young women with T1DM. Preconception and during pregnancy, it is recommended to have near-normal glucose values to prevent adverse maternal and neonatal outcomes, including fetal demise, congenital anomaly, pre-eclampsia, macrosomia, neonatal respiratory distress, neonatal hyperbilirubinemia, and neonatal hypoglycemia.

CONCLUSION

Women with T1DM can have healthy, safe pregnancies with preconception planning, optimal glycemic control, and multidisciplinary care.

Maternal serum zinc concentration and neural tube defects in offspring: a meta-analysis

OBJECTIVE

This study was to assess the relationship between maternal serum zinc concentration and NTDs in offspring by conducting a meta-analysis.

METHODS

We searched Pubmed, Medline and Web of Science for all English studies about the relationship between maternal serum zinc level and NTDs in offspring (published between 1 January 1975 and 1 January 2020). Pooled effect sizes with corresponding 95% CIs were calculated using a random-effect model by Revman 5.3 and Stata 15.1 software.

RESULTS

Eight articles met our selection criteria and a total of 187 cases and 894 controls were included in this meta-analysis. Our results showed that mothers with NTDs infants had lower serum zinc concentration than those with healthy infants (SMD= -0.77, 95%CI [-1.16, -0.37], p = .0001, I ² = 73%).

CONCLUSIONS

Compared with mothers with healthy infants, mothers with NTDs infants have lower serum zinc levels, suggesting that low maternal serum zinc level during pregnancy is probably associated with the risk of NTDs in offspring. But the mechanism of the association remains to be ascertained by large-scale cohort studies.

Folate fortification and supplementation in prevention of folate-sensitive neural tube defects: a systematic review of policy

OBJECTIVE

Neural tube defects (NTDs) are common congenital neurological defects, resulting in mortality, morbidity, and impaired quality of life for patients and caregivers. While public health interventions that increase folate consumption among women who are or plan to become pregnant are shown to reduce folate-sensitive NTDs, public health policy reflecting the scientific evidence lags behind. The authors aimed to identify the types of policies applied, associated outcomes, and impact of folate fortification and supplementation on NTDs worldwide. By identifying effective legislation, the authors aim to focus advocacy efforts to more broadly effect change, reducing the burden of NTDs in neurosurgery.

METHODS

A systematic review was conducted exploring folate fortification and supplementation policies using the PubMed and Scopus databases. Titles and abstracts from articles identified were read and selected for full-text review. Studies meeting inclusion criteria were reviewed in full and analyzed for study design, aim, population, interventions, and outcomes.

RESULTS

Of 1637 resultant articles, 54 were included. Mandatory folate fortification was effective at reducing folate-sensitive NTDs. Mandatory fortification also decreased hospitalization rates and deaths after discharge and increased 1st-year survival for infants with NTDs. Recommended folate supplementation also resulted in decreased NTDs; however, issues with compliance and adherence were a concern and impacted effectiveness. Folate fortification and/or supplementation resulted in decreased NTD prevalence, although more change was attributed to fortification. Dual policies may hold the most promise. Furthermore, reductions in NTDs were associated with significant cost savings over time.

CONCLUSIONS

Both mandatory folate fortification and recommended supplementation policies were found to effectively decrease folate-sensitive NTD rates when applied. A comprehensive approach incorporating mandatory folate fortification, appropriate folate supplementation, and improved infrastructure and access to prenatal care may lead to decreased NTDs worldwide. This approach should be context-specific, emphasize education, and account for regional access to healthcare and social determinants of health. With wide implications for NTDs, associated health outcomes, quality of life of patients and caregivers, and economic impacts, policy changes can drastically improve global NTD outcomes. As caretakers of children with NTDs, the authors as neurosurgeons advocate for a comprehensive policy, the engagement of stakeholders, and a broader global impact.

Interventions to Increase Multivitamin Use Among Women in the Interconception Period: An IMPLICIT Network Study

INTRODUCTION

Each year, 3% of infants in the Unites States (US) are born with congenital anomalies, including 3000 with neural tube defects. Multivitamins (MVIs) including folic acid reduce the incidence of these birth defects. Most women do not take recommended levels of folic acid prior to conception or during the interconception period.

METHODS

The Interventions to Minimize Preterm and Low Birth Weight Infants through Continuous Improvement Techniques (IMPLICIT) ICC model was implemented to screen mothers who attend well child visits (WCVs) for their children aged 0-24 months. Mothers were queried for maternal behavioral risks known to affect pregnancy including multivitamin use and use of family planning methods to enhance birth spacing. When appropriate, interventions targeted at those at risk behaviors are offered. A mixed effects logistic regression model was used to calculate the odds ratio (OR) of behavior change in MVI use among mothers who reported not using MVIs.

RESULTS

37.7% of mothers reported not using MVIs at WCVs. 64.0% of mothers received an intervention to improve MVI use in this model. Mothers who received an intervention were more likely to report taking an MVI at the subsequent WCV if they received advice to take MVIs (OR 1.64) or directly received MVI samples (OR 3.09).

CONCLUSIONS

Dedicated maternal counseling during pediatric WCVs is an opportunity to influence behavioral change in women at risk of becoming pregnant. Direct provision of MVIs increases the odds that women will report taking them at a higher rate than provider advice or no counseling at all.