Most parents wish and pray for a healthy baby. We can not prevent all birth defects but we know how to prevent some. My first story is how to prevent neural tube defects (NTD). When the baby is first forming it starts as a flat sheet of cells. The brain and spine form by the nerve tissue forming a tube. If there is incomplete closure then the forming brain and/or spinal cord is left exposed to the amniotic fluid ("water" around the developing baby). This is toxic to the nerve tissue and causes the brain (fatal) not to develop or part of the spinal cord (lifetime paralysis) not to develop. See these Youtube sites for animations (1,2).
The tragedy of this birth defect is that the majority of these problems could have been prevented. In 1991 the international MRC study (3) of almost 2,000 high risk women [history of previous baby with a neural tube defect (NTD)] were randomized (Evidence Based Medicine [EBM]) to one of four groups. The four groups were folic acid (4 mg.), multivitamin (A,D,B1,B2,B6,C and nicotinamide) , both, or neither. Multivitamins without folic acid had no effect in preventing birth defects and folic acid with multivitamins had no improvement over folic acid by itself. The two folic acid groups had a 70% decrease in NTDs.
The folic acid must be started at least one month before conception to be effective. This is a problem because 50% of US pregnancies are "OOPS" (unplanned). Many planned pregnancies fail to see their OB to get started on folic acid before they get pregnant and be checked for other medical problems that can cause birth defects (diabetes and smoking are two good examples of correctable problems). Conception usually occurs 2 weeks before the famous (or infamous) "missed peroid". The neural tube should be closed by 28 days after conception. By the time you get your 1st OB appointment (6-8 weeks) it is already too late to give you any benefit from taking folic acid. All sexually active couples need to be using the "best available" contraception. This currently is Long Acting Reversible Contraception (LARC)(4). Because 50% of US pregnancies are still unplanned (unbelievable in this day and age), doctors and scientists convinced the FDA to require flour makers to add folic acid to help prevent these birth defects(5) and the pain and suffering these children and families suffer. We have added Vitamin D to milk and Iodine to salt for many years to protect the public from rickets and thyroid disease. They gave in to pressure from the conspiracy groups and cut the recommended does in half in 1998. In spite of this reduction it decreased NTD by about 1/3 in the US. In spite of 20 years of "no adverse outcomes" they have been unwilling to raise the amount to recommended levels. This is the only way to prevent NTDs in the 50% of unplanned pregnancies and the planned pregnancies that do not start folic acid at least one month before conception. We give all pregnant women "multivitamins with folic acid" on average at their first OB visit at 6-8 weeks. No study has ever shown this to be any benefit to anyone but the vitamin companies and unless started before conception will not decrease NTDs.
Since the FDA will not let us increase folic acid in the US flour supply we are only left with the option of convincing all reproductive age women to take an over the counter (OTC) folic acid pill every day in case of the "unplanned pregnancy" or use LARC. Increasing folic acid in the flour has been projected to be able to prevent at least 2/3 of NTD. Mexican Americans require larger doses. You can not get enough of natural folate from your diet (it is not absorbed as well as folic acid). Planned pregnancies should start taking folic acid at least 3-12 months prior to attempting pregnancy. Women with a previous NTD pregnancy should take at least 4-5 mg (usually requires a Rx from your doctor unless you want to take 10 OTC pills a day); unless on LARC.
Give your baby the best chance of a healthy life without birth defects. Use the best available contraception (LARC) unless you are trying to get pregnant. Take OTC folic acid (at least 400 micrograms (mcg) daily if you are a reproductive age woman or start at least 3-12 months before a planned pregnancy. See your OB doctor for a pre-conception visit before stopping contraception. They will probably start you on 1000 mcg/day (1 mg) of folic acid. They may also start you on a "prenatal vitamin" (multivitamin) even though there is little evidence of benefit. At least it does no harm. Your kidneys "pee out" the water soluble vitamins that your body does not need. Most Americans already get more vitamins from their diet (fresh fruits and vegetables are a great source) than their body needs. If you take a vitamin pill you make your kidneys work harder, it it eliminates the vitamin pill. Have your doctor test you for diabetes. One out of two adults now have diabetes and many do not know it because early stages are asymptomatic. Stay tuned for a complete blog on our current diabetes epidemic and its effect on pregnancy. Check out my introduceyourself post (
References
- Prevention of neural tube defects: results of the Medical Research Council Vitamin Study. MRC Vitamin Study Research Group. Lancet. 1991 Jul 20;338(8760):131-7.
- LARC https://en.wikipedia.org/wiki/Long-acting_reversible_contraception
- Food and Drug Administration., authors Food standards: amendment of standards of identity for enriched grain products to require addition of folic acid. Final Rule. 21 CFR Parts 136, 137, and 139. Fed. Regist. 1996;61:8781–8789.
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