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Maternal Vitamin B12 Status and Risk of Neural Tube Defects in a Population with High Neural Tube Defect Prevalence and No Folic Acid Fortification Anne M

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Maternal Vitamin B12 Status and Risk of Neural Tube Defects in a Population with High Neural Tube Defect Prevalence and No Folic Acid Fortification Anne M Maternal Vitamin B12 Status and Risk of Neural Tube Defects in a Population With High Neural Tube Defect Prevalence and No Folic Acid Fortification Anne M. Molloy, Peadar N. Kirke, James F. Troendle, Helen Burke, Marie Sutton, Lawrence C. Brody, John M. Scott and James L. Mills Pediatrics 2009;123;917-923 DOI: 10.1542/peds.2008-1173 The online version of this article, along with updated information and services, is located on the World Wide Web at: http://www.pediatrics.org/cgi/content/full/123/3/917 PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2009 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275. Downloaded from www.pediatrics.org. Provided by Trinity Health Sciences Centre on November 4, 2009 ARTICLE Maternal Vitamin B12 Status and Risk of Neural Tube Defects in a Population With High Neural Tube Defect Prevalence and No Folic Acid Fortification Anne M. Molloy, PhDa, Peadar N. Kirke, FFPHMIb, James F. Troendle, PhDc, Helen Burke, BSocScb, Marie Sutton, MB, MPHb, Lawrence C. Brody, PhDd, John M. Scott, ScDe, James L. Mills, MD, MSc Schools of aMedicine and eImmunology and Biochemistry and Immunology, Trinity College, Dublin, Ireland; bChild Health Epidemiology Unit, Health Research Board, Dublin, Ireland; cDivision of Epidemiology, Statistics, and Prevention Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland; dMolecular Pathogenesis Section, Genome Technology Branch, National Human Genome Research Institute, Bethesda, Maryland The authors have indicated they have no financial relationships relevant to this article to disclose. What’s Known on This Subject What This Study Adds Folic acid can prevent many, but not all, NTDs. Vitamin B12 interacts closely with folate This study confirms that low maternal vitamin B12 status is an independent risk factor for metabolism and may play a role in NTD prevention. Some studies have found low having an NTD-affected pregnancy and is the first to address the public health question vitamin B12 status in mothers of NTD-affected children. of what B12 level might be protective for women entering pregnancy. ABSTRACT OBJECTIVE. Folic acid fortification has reduced neural tube defect prevalence by 50% to 70%. It is unlikely that fortification levels will be increased to reduce neural tube defect prevalence further. Therefore, it is important to identify other modifiable risk www.pediatrics.org/cgi/doi/10.1542/ peds.2008-1173 factors. Vitamin B12 is metabolically related to folate; moreover, previous studies doi:10.1542/peds.2008-1173 have found low B12 status in mothers of children affected by neural tube defect. Our Key Words objective was to quantify the effect of low B12 status on neural tube defect risk in a vitamin B12, cobalamin, neural tube high-prevalence, unfortified population. defects, folic acid fortification, folate METHODS. We assessed pregnancy vitamin B12 status concentrations in blood samples Abbreviations taken at an average of 15 weeks’ gestation from 3 independent nested case-control NTD—neural tube defect B12—vitamin B12 groups of Irish women within population-based cohorts, at a time when vitamin AP—affected pregnancy supplementation or food fortification was rare. Group 1 blood samples were from 95 NAP—nonaffected pregnancy women during a neural tube defect–affected pregnancy and 265 control subjects. Group RCF—red cell folate 2 included blood samples from 107 women who had a previous neural tube defect birth OR—odds ratio but whose current pregnancy was not affected and 414 control subjects. Group 3 samples Accepted for publication Jul 22, 2008 Address correspondence to Anne M. Molloy, were from 76 women during an affected pregnancy and 222 control subjects. PhD, Trinity College Dublin, School of Medicine, Dublin 2, Ireland. E-mail: amolloy@ RESULTS. Mothers of children affected by neural tube defect had significantly lower B12 tcd.ie status. In all 3 groups those in the lowest B12 quartiles, compared with the highest, PEDIATRICS (ISSN Numbers: Print, 0031-4005; had between two and threefold higher adjusted odds ratios for being the mother of Online, 1098-4275). Copyright © 2009 by the Ͻ American Academy of Pediatrics a child affected by neural tube defect. Pregnancy blood B12 concentrations of 250 ng/L were associated with the highest risks. CONCLUSIONS. Deficient or inadequate maternal vitamin B12 status is associated with a significantly increased risk for Ͼ neural tube defects. We suggest that women have vitamin B12 levels of 300 ng/L (221 pmol/L) before becoming pregnant. Improving B12 status beyond this level may afford a further reduction in risk, but this is uncertain. Pediatrics 2009;123:917–923 OLIC ACID CAN prevent up to three fourths of neural tube defects (NTDs).1–3 Folic acid fortification of grain Fproducts in the United States was initially reported to reduce the incidence of NTDs by 19%,4 but this was probably an underestimate.5 Recent studies have shown reductions between 35% and 78% since mandatory fortification programs were introduced.6–10 There is debate on whether all folic acid-preventable NTDs are being prevented11–13 and whether the observed range of effectiveness can be explained by underlying ethnic differences in susceptibility10 or differences in completeness of case ascertainment.5 One argument is that insufficient folic acid has been added, and there have been calls to increase the level of fortification in the United States.11–13 Nevertheless, it is generally agreed that not all NTDs are preventable by folic acid. Therefore, to further reduce NTDs, other modifiable risk factors must be found. 14–16 Maternal obesity has been identified as 1 modifiable risk factor. Vitamin B12 (B12) status might be another, PEDIATRICS Volume 123, Number 3, March 2009 917 Downloaded from www.pediatrics.org. Provided by Trinity Health Sciences Centre on November 4, 2009 given the close metabolic association between B12 and processed in a similar manner and were stored at Ϫ folate and the importance of B12 status as a determinant 20°C before analysis. of plasma homocysteine.17,18 A link between low mater- nal serum B12 level and anencephaly was suggested as Groups 2 and 3 19 far back as 1980. Several studies found differences in Between 1986 and 1990, research blood samples were maternal B12 status (measured by serum total B12 or by collected from 56 049 women at their first antenatal visit 20–23 21,23–27 holotranscobalamin) both during and after an in the 3 major Dublin maternity hospitals. This repre- NTD-affected pregnancy (AP). Lower amniotic fluid B12 sents ϳ70% of women who delivered in these hospitals or lower B12 binding capacity was also reported in NTD- during the period. Additional details have been pub- 28–32 APs. The 2 largest positive studies, conducted during lished elsewhere.17,20,35–37 An aliquot in 1% ascorbic acid the introduction of folic acid fortification in the United for red cell folate (RCF) and a plasma sample were stored 26 22 States and postfortification in Canada, found a tri- at Ϫ20°C for each participant. pling of risk between the lowest and highest quintiles of Group 2 includes blood samples within the above 26 22 serum B12 or quartile of holotranscobalamin. biobank that were collected from women with a history In a previous study, undertaken primarily to examine of NTD-APs but who had an NAP between 1986 and the association of folate status with risk of NTD, we 1990. From the EUROCAT birth defects registry38 and found that low maternal B12 status during an AP was hospital records we ascertained that there were 303 such 20 associated with risk, independent of folate status. To women during the time period in the 3 hospitals. Of gain further insight into the role of B12 in the prevention these, 187 women had given research blood samples. of NTDs, we present results on 2 additional groups, using We excluded 65 women because they were taking vita- pregnancy blood samples from over the same years, mins, mainly as participants in the Irish Trial for the which predate the era of widespread food fortification prevention of NTD.39 A further 9 women had insufficient and when medical advice was to avoid unnecessary pro- sample for analysis. We had blood samples for 1 woman phylactic supplements during early pregnancy, including during both an AP and an NAP pregnancy. We in- 33 vitamin supplements. For comparison, we also in- cluded her AP blood in group 3 below and excluded cluded hitherto unreported risk analysis from our previ- her NAP sample. Control subjects were obtained for 20 ous study, using B12 data only from women in the each case by selecting 4 to 5 women who attended the study where we had definite information that they did antenatal clinic in the same hospital on the same day. not take vitamin supplements. Hospital charts for these women were scrutinized for vitamin supplementation and other demographic de- MATERIALS AND METHODS tails. From this, samples from 439 nonsupplemented Sample Selection women were eligible for analysis. Laboratory B12 re- sults were missing for 5 case subjects and 25 control All 3 of the studies involved a nested case-control design subjects, leaving a final data set of 107 case subjects where samples were selected from within 2 large popu- and 414 control subjects. lation-based cohorts. Groups 1 and 3 included case blood Group 3 represents a previously unpublished analysis samples taken from mothers during an NTD-AP. Group from our earlier study on maternal folate and B in 2 case blood samples were taken during pregnancy from 12 NTD-APs.20 These blood samples were also obtained mothers who previously delivered an NTD-affected in- from the 1986–1990 biobank described above.
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