Huma Zia (Doctor of physical therapy)
Folic acid intake may reduce the risk of spina bifida or not in periconceptional women
Abstract :
spina bifida is a neurological disorder which affects the neural tube in fetal life tuft of hair is present with depression at the site of the neurological defect and in severe condition the neural tissues containing meninges comes out of the babies body so folic acid is useful in forming genetic materials its intake in the periconceptional mother for six months reduces the risk of neurological disorder spina bifida.
Key words :spina bifida ,folic acid ,neurological disorders,neural defects.
Introduction:
Definition:
Spina bifida is the neurological developmental disorder and it has a defect in the neural tube in which posterior part of the vertebrae doesn’t cease it is a genetic problem (Mitchell et al.,2004). The neural tube is closed during 2nd and 6th week of the embryological stage while the brain develops from the cranial part of the neural tube so when this neural tube is not developed within the fetal life this condition is called spina bifida(Ozaras,2015).
Causes: There are some causes of spina bifida such as:
· Chromosome abnormalities
· Single gene disorders
· Teratogenic exposure
· Environmental factors
· Nutritional deficiencies (Swark,1996).
Stages of spina bifida:
It has three stages :
· spina bifida occulta
· spina bifida myelomeningocele
· Spina bifida meningocele (Northrup et al.,2000).
The initial and mild stage is occulta in which tuft of hair and depression is present at the effected side and the most severe form of the spina bifida is myelomeningocele in which a fluid-filled sac containing meninges and neural tissues come out of the baby’s body (Boone et al.,1985).
The spina bifida can be diagnosed in fetal life by three-dimensional ultrasound (Ozaras,2015). Fetal surgical repair of myelomeningocele occurs when the baby born (Copp et al.,2015).
At the initial stage of spina bifida there is no such severe sign and symptoms but with time if it is not treated then it will cause paralysis of lower limb and urine incontinency and severe complications (Bowmen et al.,2004).
Fig 1. spina bifida neurological disorder (Stanfordchildren ,n.d)
Risk factors: following are some risk factors of spina bifida:
· Obesity (Watkins et al.,1996)
· Diabetes (Soler et al.,1976)
· Family history with neural tube defects (Holmbeck et al.,1997)
· Folate deficiency (Czeizel et al.,2013)
Folic acid :
Birth defects are the most of the serious cause of infant death and the relationship of folic acid and a life-threatening birth defect is common and the Intake of folic acid vitamin supplements and food enriched with folic acid for 6th months in non-pregnant women helps to reduce NTD (Boweretal.,2005). The food fortification with folic acid like many cereal products are useful to increase folic acid level (Dewals et al.,1998). Promotion of folate for NTD occurs in the early stages of fetal life so prevention is very important in the early phases of pregnancy (Shaw et al.,1998). Spina bifida risk is high in women who are not taking folic acid during pregnancy (Shaw et al.,2002).
A huge number of women facing the deficiency of folic acid which is the major cause of NTD and hence as far as back in 1970 until mid 1980 and early 1990 studies showed that NTD major cause is a folic acid deficiency , in 1990 different trials shown that periconceptional folic acid vitamin supplements help to reduce the risk of NTD. British medical research council the study concluded in which women had a previous history of NTD pregnancy was treated by giving high doses of folic acid, In a 1999 study, the CDC reported its results of a randomized control trial of folic acid in China in two different regional populations Women took 400 g of folic acid daily from the time of their premarital examination until the end of their first trimester of pregnancy. Among the fetuses or infants (at least 20 weeks gestational age) of women who did not take any folic acid, the rates of NTDs were 4.8 per 1000 pregnancies in the the northern region and 1.0 per 1000 in the southern region.Among the fetuses or infants of the women with periconceptional use of folic acid, the rates were 1.0 per 1000 in the northern region and 0.6 per 1000 in the southern region.Regional differences in NTD rates, both with and without folic acid treatment, are likely attributable to dietary and genetic differences. The authors note: “The greatest reduction in risk occurred among the fetuses or infants of a subgroup of women in the northern region with periconceptional use who took folic acid pills 80% of the time”( Green, 2002).
Results: Folic acid intake 400g for 6 months reduce the risk of spina bifida in periconceptional women and food fortification also increase the folic acid level which reduces the risk of spina bifida.
Fig 2: Maternal use of folic acid supplements(Research gate ,n.d).
Discussion:
Folic acid (in the diet and/or in a supplement)with a multivitamin has been proven to decrease or minimize specific birth defects including neural tube defects, congenital heart disease, urinary tract anomalies, oral-facial clefts with or without cleft the palate, limb defects, and hydrocephalus, as well as some pediatric cancers. The public health flour fortification initiative has been very beneficial with respect to primary prevention of birth defects. The recent comprehensive Canadian analysis of neural tube reduction after folic acid flour fortification has reported a 46% reduction the observed reduction was greater for spina bifida (53%)than for anencephaly (38%) and encephalocele (31%). Further reductions in the incidence of congenital anomalies sensitive to folic acid and multivitamins should be possible with the participation of key stakeholders (Wilson et al.,2007).
Folic acid use began more than 3 months before pregnancy for 6.6% of women, and 1–3 months before pregnancy for 8.2%. In all, 14.8% (95% CI 14.2–15.4) of women started folic acid supplementation before pregnancy. Another 11.7% of women started folic acid use during the first month of pregnancy (Tort et al.,2013).
Daily use of folic acid supplements in the periconceptional period were reported by mothers of 8% of cases and mothers of 13% of controls; the crude and multivariate RR estimates (and 95% confidence intervals [CIs]) were 0.5 (0.3 to 0.7) and 0.6 (0.4 to 0.8), For less than daily use in the periconceptional period, the crude and multivariate estimates were both 0.9 (95% CI, 0.6 to 1.3). Less than 2% of case mothers and control mothers used multivitamin supplements with an unknown folie acid content or without folie acid and RRs were not estimated. For the first use of folic acid supplements in the second lunar month, crude and multivariate estimates were 0.7 (95% CI, 0.6 to 0.9) and 0.8 (95% CI, 0.6 to 1.0), respectively. No mothers of cases and seven mothers of controls had unknown starting or stopping dates The results from this study support and extend previous findings that use of folic acid supplements before and during early pregnancy reduce the risk of NTDs (Werler et al.,1993).
Conclusion :
Folic acid has important role in preventing spina bifida because it has a major role in forming genetic material DNA and hence deficiency of the folic acid cause major NTD the supplements of vitamin folic acid on daily basis for six months in periconceptional women reduce the risk of spina bifida and food fortification of folic also increase the folic acid level.
Recommendations:
The majority of evidence the base guideline recommends 5mg or 4mg dose of folic acid to reduce risk of NTD but they didn’t mention this dose to prescribing it to another high-risk group like epilepsy and obese patients so there should be a standardized dose evidence-based guideline for high-risk pregnancy of NTD in epilepsy and obesity patients.
References:
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