Reduced risks of neural tube defects and orofacial clefts with higher diet quality

Vitamin E supplementation prevents obesogenic diet-induced developmental abnormalities in SR-B1 deficient embryos

Introduction

Genetic and environmental factors influence the risk of neural tube defects (NTD), congenital malformations characterized by abnormal brain and spine formation. Mouse embryos deficient in Scavenger Receptor Class B Type 1 (SR-B1), which is involved in the bidirectional transfer of lipids between lipoproteins and cells, exhibit a high prevalence of exencephaly, preventable by maternal vitamin E supplementation. SR-B1 knock-out (KO) embryos are severely deficient in vitamin E and show elevated reactive oxygen species levels during neurulation.

Methods

We fed SR-B1 heterozygous female mice a high-fat/high-sugar (HFHS) diet and evaluated the vitamin E and oxidative status in dams and embryos from heterozygous intercrosses. We also determined the incidence of NTD.

Results and discussion

HFHS-fed SR-B1 HET females exhibited altered glucose metabolism and excess circulating lipids, along with a higher incidence of embryos with developmental delay and NTD. Vitamin E supplementation partially mitigated HFHS-induced maternal metabolic abnormalities and completely prevented embryonic malformations, likely through indirect mechanisms involving the reduction of oxidative stress and improved lipid handling by the parietal yolk sac.

An intercontinental comparison of the influence of smoking on the occurrence of nonsyndromic cleft lip and palate: a meta-analysis and systematic review

BACKGROUND

The influence of smoking on nonsyndromic clefts has been a topic of research for many years. However, few studies have investigated the effect of smoking on causing clefts in different gene pools.

METHODS

A meta-analysis was conducted of case-control studies related to smoking. Keywords such as "clefts," "cleft lip," "cleft palate," "orofacial cleft," and "smoking" were used to search the MEDLINE, Embase, and Cochrane databases.

RESULTS

In total, 51 articles were reviewed. The RevMan software was utilized for the analysis, and the Mantel-Haenszel method was employed to pool the odds ratios (ORs) and 95% confidence intervals. Although the overall OR, a measure of the association between exposure and outcome, was higher for smokers than for non-smokers, this association was significantly stronger in individuals from Asia and South America (1.73), and lowest in Europe (1.31). Among active and passive smokers in Asia, the OR was approximately 0.93, indicating an equivalent impact from both types of smoking.

CONCLUSION

This analysis indirectly suggests that restriction measures targeting both active and passive smoking are crucial in Asia.

First Trimester Use of Buprenorphine or Methadone and the Risk of Congenital Malformations

Importance

Use of buprenorphine or methadone to treat opioid use disorder is recommended in pregnancy; however, their teratogenic potential is largely unknown.

Objective

To compare the risk of congenital malformations following in utero exposure to buprenorphine vs methadone.

Design, Setting, and Participants

This population-based cohort study used health care utilization data from publicly insured Medicaid beneficiaries in the US from 2000 to 2018. A total of 13 360 pregnancies with enrollment from 90 days prior to pregnancy start through 1 month after delivery and first trimester use of buprenorphine or methadone were included and linked to infants. Data were analyzed from July to December 2022.

Exposure

A pharmacy dispensing of buprenorphine or a code for administration of methadone in the first trimester.

Main Outcomes and Measures

Primary outcomes included major malformations overall and malformations previously associated with opioids (any cardiac malformations, ventricular septal defect, secundum atrial septal defect/nonprematurity-related patent foramen ovale, neural tube defects, clubfoot, and oral clefts). Secondary outcomes included other organ system-specific malformations. Risk differences and risk ratios (RRs) were estimated comparing buprenorphine with methadone, adjusting for confounders with propensity score overlap weights.

Results

The cohort included 9514 pregnancies with first-trimester buprenorphine exposure (mean [SD] maternal age, 28.4 [4.6] years) and 3846 with methadone exposure (mean [SD] maternal age, 28.8 [4.7] years). The risk of malformations overall was 50.9 (95% CI, 46.5-55.3) per 1000 pregnancies for buprenorphine and 60.6 (95% CI, 53.0-68.1) per 1000 pregnancies for methadone. After confounding adjustment, buprenorphine was associated with a lower risk of malformations compared with methadone (RR, 0.82; 95% CI, 0.69-0.97). Risk was lower with buprenorphine for cardiac malformations (RR, 0.63; 95% CI, 0.47-0.85), including both ventricular septal defect (RR, 0.62; 95% CI, 0.39-0.98) and secundum atrial septal defect/nonprematurity-related patent foramen ovale (RR, 0.54; 95% CI, 0.30-0.97), oral clefts (RR, 0.65; 95% CI, 0.35-1.19), and clubfoot (RR, 0.55; 95% CI, 0.32-0.94). Results for neural tube defects were uncertain given low event counts. In secondary analyses, buprenorphine was associated with a decreased risk of central nervous system, urinary, and limb malformations but a greater risk of gastrointestinal malformations compared with methadone. These findings were consistent in sensitivity and bias analyses.

Conclusions and Relevance

In this cohort study, the risk of most malformations previously associated with opioid exposure was lower in buprenorphine-exposed infants compared with methadone-exposed infants, independent of measured confounders. Malformation risk is one factor that informs the individualized patient decision regarding medications for opioid use disorder in pregnancy.

Epigenetic implications in maternal diabetes and metabolic syndrome-associated risk of orofacial clefts

Orofacial clefts (OFCs) are one of the most common types of structural birth defects. The etiologies are complicated, involving with genetic, epigenetic, and environmental factors. Studies have found that maternal diabetes and metabolic syndrome are associated with a higher risk of OFCs in offspring. Metabolic syndrome is a clustering of several disease risk factors, including hyperglycemia, dyslipidemia, obesity, and hypertension. Metabolic disease during pregnancy can increase risk of adverse outcomes and significantly influence fetal development, including orofacial formation and fusion. An altered metabolic state may contribute to developmental disorders or congenital defects including OFCs, potentially through epigenetic modulations, such as histone modification, DNA methylation, and noncoding RNA expression to alter activities of critical morphogenetic signaling or related developmental genes. This review summarizes the currently available evidence and underlying mechanisms of how the maternal metabolic syndrome is associated with OFCs in mostly human and some animal studies. It may provide a better understanding of the interactions between intrauterine metabolic status and fetal orofacial development which might be applied toward prevention and treatments of OFCs.

Determinants of neural tube defects among newborns in public referral hospitals in Eastern Ethiopia

BACKGROUND

Neural tube defects (NTDs) are serious brain and spine birth defects. Although NTDs are primarily pregnancy complications, such as abortion and stillbirth, they also contribute to under-five morbidity and mortality, as well as long-term disability and psychological impact. Despite these negative outcomes, the determinants of NTDs are not widely studied in Ethiopia, particularly in the country's east. As a result, we sought to identify the risk factors for NTDs in neonates born in public referral hospitals in eastern Ethiopia.

METHODS

A facility-based unmatched case-control study was carried out at Hiwot Fana Comprehensive Specialized Hospital and Sheik Hassen Yabare Jigjiga University Referral Hospital in Eastern Ethiopia. We included 59 cases identified in the selected facilities between September 10, 2021, and February 5, 2022, and 118 control neonates, with a case-to-control ratio of 1:2. Data were gathered through the use of interviewer-administered questionnaires and medical record review. To identify determinant factors of NTDs, a multivariable logistic regression model was used, which included all predictor variables from the bivariable analysis. The results were reported using an Adjusted Odds Ratio (AOR) with a 95% confidence interval. A p-value of < 0.05 was considered statistically significant.

RESULTS

In total, 59 cases of NTDs were identified out of 2915 live birth total births registered in the two hospitals, making the incidence of NTDs 202.4/10,000 births. In the final model analysis, determinant factors such as gender of newborn [AOR = 2.97; 95%CI(1.27, 6.92)], having no history of antenatal care[AOR = 4.45;95%CI(1.30,15.20)], having a poor food consumption score (AOR = 3.38;95% CI;1.06,10.72), having history of monotonous diet consumption (AOR = 4.80; 95%CI: 1.09, 9.08; P = 0.038), and coffee consumption of three or more cups per day during pregnancy (AOR = 3.84:95% CI: 1.23, 11.97) were statistically associated with NTDs.

CONCLUSION

Modifiable and non-modifiable determinants were identified as major contributors of neural tube defect in this study. Early screening, dietary intervention counseling to increase consumption of a healthy diet, coffee consumption reduction, and pre-pregnancy supplementation programs should be developed to reduce NTDs in Ethiopia.

Oxidative balance scores and neural crest cell-related congenital anomalies

Oxidative stress and redox imbalance adversely affect embryonic development. We developed two oxidative balance scores (OBS) that include dietary and nondietary exposures. We hypothesized that higher scores (i.e., lower oxidative stress) would be associated with lower risk of neural tube defects, orofacial clefts, conotruncal heart defects, and limb deficiencies. We used data from the National Birth Defects Prevention Study to create a dietary OBS based on intake of 13 nutrients and an overall OBS that included the 13 nutrients and eight additional nondietary factors related to oxidative balance (e.g., smoking). We used logistic regression to examine odds ratios associated with having low or high scores (i.e., <10th or >90th percentiles). Continuous models indicated reduced odds associated with high versus low scores (i.e., comparing odds at the 90th versus 10th percentile values of the distribution) on the overall OBS for cleft lip with or without cleft palate [adjusted odds ratio (aOR) 0.72, 95% confidence interval (CI) 0.63-0.82], longitudinal limb deficiency (aOR 0.73, CI 0.54-0.99), and transverse limb deficiency (aOR 0.74, CI 0.58-0.95); increased odds for anencephaly (aOR 1.40, CI 1.07-1.84); and primarily nonsignificant associations with conotruncal heart defects. Results for the dietary OBS were similar. This study provides some evidence that oxidative stress contributes to congenital anomalies related to neural crest cell development.

Early pregnancy vitamin D status and risk of select congenital anomalies in the National Birth Defects Prevention Study

INTRODUCTION

Vitamin D deficiency is associated with adverse pregnancy events. However, its role in the etiology of congenital anomalies remains unclear. We examined the association between vitamin D status, measured through prepregnancy diet, UV exposure, season of conception, and congenital anomalies.

METHODS

We used data from the National Birth Defects Prevention Study, a U.S. population-based case-control study (1997-2011). Prepregnancy dietary vitamin D was calculated from food frequency questionnaires and evaluated using tertiles, based on the distribution in controls. We used the National Oceanic and Atmospheric Administration Weather Service to assign UV indices based on location and estimated date of conception, then dichotomized UV exposure (low vs. high). Seasons of conception was categorized as fall/winter spring/summer. We used logistic regression to estimate adjusted odds ratios (aOR) and 95% confidence intervals (CI).

RESULTS

Lower prepregnancy dietary vitamin D intake (<65.21 IU/d vs. >107.55 IU/d) was associated with increased odds of anencephaly (aOR = 1.28, 95% CI 1.01, 1.63), hypospadias (aOR = 1.21, 95% CI 1.04, 1.40), septal defects (aOR = 1.16, 95% CI 1.05, 1.30), diaphragmatic hernia (aOR = 1.42, 95% CI 1.13, 1.79), and gastroschisis (aOR = 1.27, 95% CI 1.07, 1.52). Findings were consistent when we stratified by UV exposure and season of conception.

CONCLUSIONS

Our findings suggest lower dietary intake of vitamin D may be associated with increased risk of select congenital anomalies. Further investigations are warranted to evaluate the effects of other nutrients and appropriate thresholds and sources of vitamin D using serum.

New Validated Short Questionnaire for the Evaluation of the Adherence of Mediterranean Diet and Nutritional Sustainability in All Adult Population Groups

High adherence to a Mediterranean diet (MD) is favourable for its sustainability and beneficial effects on health. The available questionnaires, according to the MD dietary pattern, include the assessment of moderate alcohol consumption; but some groups, such as young adults and pre-conceptional and pregnant women, are not allowed to consume it. The aim of this study was to validate a new short questionnaire (MedQ-Sus) excluding alcohol consumption, to measure the adherence to the MD and to evaluate the nutritional adherence to a sustainable diet. The Harvard validated questionnaire was used for the validation study. A total of 316 subjects (20 to 70 YOA) completed both questionnaires. A high Spearman correlation coefficient (rho = 0.69; p < 0.01) was found between the MedQ-Sus and Harvard scores; a statistically significant positive correlation was found for all eight food groups. The MedQ-Sus had a significant discriminative capacity between adherence and non-adherence to the MD (optimal cut-off point = 9.5, sensitivity 0.86, specificity = 0.65). A very high nutritional adherence to a sustainable diet was found in the subjects for olive oil (97%), dairy food (90%), fresh vegetables (89%), fish and fish products (73), fresh fruit (56%), and cereals and cereals products (42%). A very low adherence was found for legumes (22%) and meat and meat products (9%). The results showed MedQ-Sus is a valid and quick assessment instrument for the evaluation of the adherence to the MD in all population groups, and could also be useful to evaluate the nutritional sustainability of the diet.

Maternal periconceptional nutrition matters. A scoping review of the current literature

BACKGROUND

The importance of nutrition in reproductive health is widely acknowledged with special emphasis given to periconceptional maternal diet and its implications on embryo-fetal development, pregnancy complications, and the health of the offspring.

METHODS

Following the PRISMA guidelines, we searched for literature in PubMed, CINAHL, and WoS to gather newer information on how diet composition influences the concepts from the very early stages of pregnancy and how maternal health may be affected as well. Fifty-six studies published up to June 2020 met the inclusion criteria.

RESULTS

With its proportioned and diversified macronutrient composition, the Mediterranean Diet prevents congenital anomalies, preterm birth, hypertensive disorders, and gestational diabetes. Similar dietary patterns rich in vegetables, nuts, fish, and cereals increase the likelihood of conception and have a protective action, mediated by their antioxidant properties, against orofacial clefts, congenital heart and limb defects in the progeny. Conversely, the pro-inflammatory features of western diets, rich in processed foods and low in fruit content, diminish fertility, increase miscarriage rates, and enhance the risk of neural tube defects regardless of folate supplementation.

CONCLUSIONS

It may be concluded that within the multiple dietary options, some of them are soundly associated with beneficial effects for the mother and the newborn.Implications for practiceAn appropriate counseling must be offered to the woman of fertile age to make her aware of how periconceptional nutrition may help fulfill her reproductive expectations.

Periconceptional Mediterranean diet during pregnancy on children's health

During pregnancy, rapid and subtle physiological changes are observed from conception to birth. Nutrition and other lifestyle factors before and during pregnancy have been shown in the literature to influence the health of both mother and child. A healthy and varied diet during pregnancy can provide adequate energy and nutrients for both the mother and the growing fetus. Current research focuses on the periconceptional phase, which includes the early processes of gametogenesis, embryogenesis and placentation. A variety of abnormalities and pregnancy-related problems occur during this period, including congenital defects, fetal loss, miscarriage and preterm birth. A varied and balanced diet during periconception is important to maintain fetal development and growth. To date, numerous studies have been conducted to investigate the effects of consuming different nutrients, foods or food groups during pregnancy on the health of mother and child. For example, the Mediterranean diet is considered as a balanced, nutrient-rich diet due to the low consumption of meat products and fatty foods and the high consumption of vegetables, cheese, olive oil, fish, shellfish and little meat. While many studies have been conducted in the literature to investigate the effects of a Mediterranean diet during pregnancy on fetal health, the results have been inconclusive. The aim of this article is to review the current literature on the Mediterranean diet during pregnancy.

Dietary Quality during Pregnancy and Congenital Heart Defects

Limited studies on maternal dietary quality indices and congenital heart defects (CHD) are available. This study aimed to explore the relationship between dietary quality in pregnancy and CHD among the Chinese population. A case-control study was performed in Northwest China, and 474 cases and 948 controls were included. Eligible women waiting for delivery were interviewed to recall diets and other information during pregnancy. Dietary quality was assessed by the Global Diet Quality Score (GDQS) and Mediterranean Diet Score (MDS). Logistic regression models were adopted to evaluate the associations of dietary quality scores with CHD. Pregnant women with higher scores of GDQS and MDS were at a lower risk of fetal CHD, and the adjusted ORs comparing the extreme quartiles were 0.26 (95%CI: 0.16−0.42; Ptrend < 0.001) and 0.53 (95%CI: 0.34−0.83; Ptrend = 0.007), respectively. The inverse associations of GDQS and MDS with CHD appeared to be stronger among women with lower education levels or in rural areas. Maternal GDQS and MDS had good predictive values for fetal CHD, with the areas under the receiver operating characteristic curves close to 0.8. Efforts to improve maternal dietary quality need to be strengthened to decrease the prevalence of CHD among the Chinese population.

Overview of Neural Tube Defects: Gene–Environment Interactions, Preventative Approaches and Future Perspectives

Neural tube defects (NTDs) are the second most common congenital malformations of humans, characterized by impaired development of the central nervous system. Even though the etiology of most birth defects remains undetermined, genetic and environmental risk factors in the background of NTDs have been identified and extensively reported. On top of genetic and nutritional risks which include mutations in both coding and non-coding regions and maternal folate status, respectively, recent years have seen a rise in the identification of a variety of teratogens that could be implicated in NTD development. These include polycyclic aromatic hydrocarbons, arsenic, pesticides, maternal hyperthermia and antibiotics as well as pain and seizure medication. With an increase in understanding of teratogens leading to NTD formation, preventative and treatment approaches have witnessed great advances throughout the years. While the most common preventative approach includes folic acid food fortification as well as suggested inositol supplementation, treatment and management approaches differ greatly depending on the developmental stage and the site of the lesion and include prenatal surgery, stem cell transplantation and postnatal surgery. Because NTDs still represent a large health and financial burden for the patient and society as a whole, it is crucial to investigate potential risk factors and develop novel approaches in order to fully prevent this category of disorders.

Long-term treatment outcomes from the perspective of a patient with unilateral cleft lip and palate

The management of patients with orofacial cleft (OFC) often extends from diagnosis or birth well into adulthood and requires many different specialists within multidisciplinary teams (MDT). The aims of treatment are to restore form and function relating to hearing, speech, occlusion and facial aesthetics. People with OFCs that include the lip, alveolus and palate (cleft lip and palate (CLP)) require several different staged and coordinated surgical and non-surgical interventions, and the treatment pathway is associated with a heavy burden of care. Due to the extensive nature of the interaction with these patients, MDT members have opportunities to provide enhanced patient-centred care and support. This case report provides an overview of the current knowledge of the aetiology of OFC and the management of these patients. It provides a unique perspective from one of the coauthors who has a unilateral CLP (UCLP) and reports on his treatment experiences and long-term treatment outcomes. By having a better understanding of the impact of UCLP and treatment provided, MDT members can not only provide improved clinical treatment but also offer improved patient experiences for those with craniofacial anomalies, in particular, an increased awareness of the psychosocial challenges, they endure throughout their treatment pathway and beyond.

Maternal periconceptional folic acid supplementation reduced risks of non-syndromic oral clefts in offspring

Maternal periconceptional folic acid supplementation (FAS) has been documented to be associated with decreased risk of nonsyndromic oral clefts (NsOC). However, the results remain inconclusive. In this population-based case–control study of 807 singletons affected by NsOC and 8070 healthy neonates who were born between October 2010 and September 2015 in Chengdu, China, we examined the association of maternal FAS with the risk of nonsyndromic cleft lip with or without cleft palate (NsCL/P), and cleft palate (NsCP). Unconditional logistic regression analysis was used to estimate the crude and adjusted odds ratios (ORs) and 95% confidential intervals (CI). Significant associations were found between maternal periconceptional FAS and decreased risk of NsCL/P (aOR = 0.41, 95% CI 0.33–0.51). This protective effect was also detected for NsCL (aOR = 0.42, 95% CI 0.30–0.58) and NsCLP (aOR = 0.41, 95% CI 0.31–0.54). Both maternal FAS started before and after the last menstrual period (LMP) were inversely associated with NsCL/P (before LMP, aOR = 0.43, 95% CI 0.33–0.56; after LMP, aOR = 0.41, 95% CI 0.33–0.51). The association between NsCP and maternal FAS initiating before LMP was also found (aOR = 0.52, 95% CI 0.30–0.90). The findings suggest that maternal periconceptional FAS can reduce the risk of each subtype of NsCL/P in offspring, while the potential effect on NsCP needs further investigations.

The role of Vitamin B12 and genetic risk factors in the etiology of neural tube defects: A systematic review

Neural tube defects (NTDs) are birth defects that arise during embryogenesis when normal neural tube closure fails to occur. According to the World Health Organization, NTDs are detected annually in approximately 300,000 neonates worldwide. The exact etiology of NTDs remains complex and poorly understood. It is generally agreed that most NTD cases are of multifactorial origin, having a combination of multiple genes and a number of environmental risk factors. The role of folic acid, vitamin B12 deficiency, genetics and other risk factors, in the etiology of NTDs, has also been extensively studied. This knowledge synthesis brings together different types of evidence to update the role of vitamin B12 deficiency, genetics and other risk factors, in the etiology of NTDs. Following a PubMed search and screening for relevant articles, we included 40 studies in our review (30 case-control studies, 3 cross-sectional studies, 5 cohort studies, and 2 case reports). The available data showed that vitamin B12 levels were decreased in mothers and infants in NTD groups compared with control groups. Holo-transcobalamin, the active form of vitamin B12, was also found in lower levels in mothers with NTD-affected infants. Several studies reported elevated homocysteine levels in mothers and infants in NTD groups. Additionally, numerous studies reported links between genetic variants and increased NTD risk. These genes include GIF, LRP2, CUBN, TCb1R, MTHFR, and others. Several maternal factors have also been linked with significant NTD risk such as BMI, maternal diet, air pollutants, low maternal age, and many others. The majority of studies on NTDs have focused on the role of folic acid, hence there is a need for well-designed studies on the role of other risk factors like vitamin B12 deficiency in the etiology of NTDs.

Preconception Diet Quality Is Associated with Birth Weight for Gestational Age Among Women in the Hispanic Community Health Study/Study of Latinos

BACKGROUND

The nutritional status of women in the preconception period is of paramount importance due to its role in reproduction.

OBJECTIVE

Our aim was to assess overall diet quality during the preconception period and its association with infant birth weight adjusted for gestational age (GA).

DESIGN

This is an observational longitudinal cohort of Hispanic people living in the United States.

PARTICIPANTS/SETTING

Data are from the Hispanic Community Health Study/Study of Latinos baseline (2008-2011) and second clinic examinations (2014-2017). Included are the first 497 singleton live-born infants among the 2,556 women (younger than 45 years) who attended the second visit. Field sites were located in Miami, FL; Bronx, NY; Chicago, IL; and San Diego, CA, and represent individuals with heritage from Cuba, Dominican Republic, Mexico, Puerto Rico, and Central and South America.

MAIN EXPOSURE

Diet assessment included two 24-hour recalls from baseline. The 2010 Healthy Eating Index (HEI-2010) was used to measure diet quality, with higher scores indicating better quality.

STATISTICAL ANALYSES PERFORMED

Complex survey linear regression estimated the association between HEI-2010 scores (continuous variable and categorized into tertiles) and birth-weight z score and birth weight for GA percentile.

RESULTS

Mean (standard deviation) age of women was 25.8 (5.2) years and 36.4% were classified as underweight or normal weight, 30.0% were overweight, and 33.6% had obesity at baseline. Mean (standard deviation) HEI-2010 score was 56.5 (13.4), and by weight classifications was 54.4 (14.1) for underweight or normal weight and 57.7 (12.8) for overweight or obesity. Median (interquartile range) birth-weight z score was 0.5 (interquartile range [IQR], -0.2 to 1.3) overall and 0.2 (IQR, -0.5 to 1.0), 0.6 (IQR, -0.2 to 1.3), and 0.5 (IQR, -0.2 to 1.4) for the first, second, and third HEI-2010 tertile, respectively. Median birth weight for GA percentile was 68.2 (IQR, 40.2 to 89.7) overall, and 56.8 (IQR, 29.6 to 85.0), 71.5 (IQR, 42.8 to 90.0), and 70.1 (IQR, 42.9 to 91.2) by HEI-2010 tertile. In adjusted models, the highest tertile of the HEI-2010 score was associated with a higher birth-weight z score and birth weight for GA percentile, and the continuous HEI-2010 score was only associated with birth weight for GA percentile. Preconception body mass index (calculated as kg/m2) did not modify these associations.

CONCLUSIONS

Overall diet quality, as measured by the HEI-2010, in the preconception period is associated with infant birth weight adjusted for GA among US Hispanic and Latina women.

Environmental mechanisms of orofacial clefts

Orofacial clefts (OFCs) are among the most common birth defects and impart a significant burden on afflicted individuals and their families. It is increasingly understood that many nonsyndromic OFCs are a consequence of extrinsic factors, genetic susceptibilities, and interactions of the two. Therefore, understanding the environmental mechanisms of OFCs is important in the prevention of future cases. This review examines the molecular mechanisms associated with environmental factors that either protect against or increase the risk of OFCs. We focus on essential metabolic pathways, environmental signaling mechanisms, detoxification pathways, behavioral risk factors, and biological hazards that may disrupt orofacial development.

Essential trace elements in umbilical cord tissue and risk for neural tube defects

Deficient or excessive quantities of essential trace elements (ETEs)¹ in the fetal environment can compromise developmental processes. We investigated whether concentrations of zinc (Zn), manganese (Mn), selenium (Se), cobalt (Co), molybdenum (Mo), and nickel (Ni) in umbilical cord tissue are associated with risk for neural tube defects (NTDs). Umbilical cord tissues from 166 cases of NTD cases and 166 matched controls were collected and element concentrations were measured using inductively coupled plasma-mass spectrometry. Associations between ETE concentrations and the risk for NTDs were estimated using multivariate logistic regression while adjusting for potential confounders. Bayesian kernel machine regression (BKMR) was used to examine the joint effects of these ETEs. We found that median concentrations of Ni were higher but those of Mo and Co were lower in the NTD group than in the control group. Co was the only element that was associated with NTD risk after adjusting for confounders (OR 0.31, 95 % CI 0.12-0.79 for the second and OR 0.37, 95 % CI 0.15-0.91 for the top tertile relative to the lowest tertile). The association between Co and NTD risk was confirmed with the BKMR model. In addition, a joint effect of the six ETE mixture on NTD risk was observed: the risk decreased with the levels of the mixture from 25th percentile through 75th percentile. In conclusion, higher levels of Co were associated with lower risk for NTDs, and NTD risk decreased with the levels of the six ETEs as a co-exposure mixture, suggesting a protective effect.

Congenital diaphragmatic hernia and maternal dietary nutrient pathways and diet quality

INTRODUCTION

We examined the association of congenital diaphragmatic hernia (CDH) with maternal dietary intake, using semi-Bayes hierarchical models and principal components analysis to consider intake of nutrients that contribute to one-carbon metabolism and oxidative stress pathways, and a diet quality index.

METHODS

We included data on 825 cases and 11,108 nonmalformed controls born from 1997-2011 whose mother participated in the National Birth Defects Prevention Study (NBDPS), a multisite, population-based case-control study. Exposure data were from maternal telephone interviews, which included a food frequency questionnaire. Adjusted odds ratios (aOR) and 95% confidence intervals (CI) were generated from logistic regression models that included nutritional factors as continuous variables and were adjusted for maternal energy intake, race-ethnicity, parity, and vitamin supplement intake.

RESULTS

In the semi-Bayes hierarchical model that included all nutrients and confounders, riboflavin was the only nutrient for which the 95% CI excluded 1.0; the aOR for a 1 SD increase was 0.83. The aORs were 0.79 (95% CI 0.69-0.91) for the one-carbon metabolism pathway score, 0.90 (95% CI 0.80-1.01) for oxidative stress, and 0.85 (95% CI 0.77-0.93) for diet quality (the aORs correspond to a 1 SD increase).

CONCLUSIONS

The findings from this study provide some support for the hypothesis that better prepregnancy nutrition is associated with reduced risk for CDH. These results provide etiologic clues but should be interpreted with caution given the novelty of the investigation.

Maternal use of folic acid and multivitamin supplements and infant risk of birth defects in Norway, 1999-2013

The association between folic acid supplementation and birth defects other than neural tube defects (NTD) remains unclear. We used a log-binomial regression model to investigate if periconceptional folic acid and/or multivitamin use was associated with birth defects in Norway with prospectively collected data from the Medical Birth Registry of Norway (MBRN) during 1999-2013. We used the European Surveillance of Congenital Anomalies (EUROCAT) classification system to define eleven organ-specific major birth defect groups (nervous system, eye, ear-face-neck, cardiovascular system, respiratory system, oral clefts, digestive system, abdominal wall, urinary system, genital organs and limb), with additional subgroups. Fetuses or infants whose mothers used folic acid and/or multivitamin supplements before and during pregnancy were classified as exposed. During the years 1999-2013, 888 294 (99·0 %) live-born infants, 6633 (0·7 %) stillborn infants and 2135 (0·2 %) fetuses from terminated pregnancies due to fetal anomalies were registered in the MBRN. Among the live- and stillborn infants of women who used vitamin supplements compared with infants of non-users, the adjusted relative risk (aRR) was 0·94 (95 % CI 0·91, 0·98) for total birth defects (n 18 382). Supplement use was associated with reduced risk of abdominal wall defects (aRR 0·58; 95 % CI 0·42, 0·80, n 377), genital organ defects (aRR 0·81; 95 % CI 0·72, 0·91, n 2299) and limb defects (aRR 0·81; 95 % CI 0·74, 0·90, n 3409). Protective associations were also suggested for NTD, respiratory system defects and digestive system defects although CI included the null value of 1. During the full study period, statistically significant associations between supplement use and defects in the eye, ear-face-neck, heart or oral clefts were not observed.

Maternal diet as a risk factor for primary congenital glaucoma and defects of the anterior segment of the eye in the National Birth Defects Prevention Study

Primary congenital glaucoma (PCG) and anterior segment defects (ASDs) are rare ocular malformations diagnosed early in life which can cause blindness. Pathogenic variants in several genes have been linked to these conditions, but little is known about nongenetic risk factors. We investigated the association between maternal nutrition and PCG and ASDs in the National Birth Defects Prevention Study, a large population-based, multicenter case-control study of major birth defects in the United States. Mothers of cases (n = 152) and control infants without a birth defect (n = 9,178) completed an interview which included a food frequency questionnaire capturing usual dietary intake in the year before pregnancy. Maternal nutrition was assessed through individual nutrient intake, calculating a Diet Quality Index for Pregnancy (DQI-P) score for each mother, and using latent class analysis to empirically derive four dietary patterns. We calculated adjusted odds ratios (aORs) and 95% confidence intervals (CI) using logistic regression. The results for individual nutrients varied, with some having an inverse or U-shaped pattern of association with increasing intake. The DQI-P was not associated with risk of PCG and ASDs (aOR 0.91; CI 0.49-1.66, highest vs. lowest quartile). The dietary pattern analysis suggested lower odds among women with a Prudent and Mexican dietary pattern (aOR 0.82, 95% CI 0.52-1.29; aOR 0.80, 95% CI 0.36-1.78, respectively) compared to those with a Western dietary pattern. We found that higher intake of some nutrients and certain dietary patterns may be inversely associated with PCG and ASDs, though caution is urged due to imprecision of estimates.

Differences in pre-pregnancy diet quality by occupation among employed women

OBJECTIVE

Maternal risk factors for pregnancy outcomes are known to vary by employment status. We evaluated whether pre-pregnancy diet quality varies by occupation in a population-based sample.

DESIGN

We analysed interview data from 7341 mothers in a national case-control study of pregnancy outcomes. Self-reported job(s) held during the 3 months before pregnancy were classified using Standard Occupational Classification (SOC) codes. Usual diet in the year before conception was assessed with a semi-quantitative FFQ and evaluated using the Diet Quality Index for Pregnancy (DQI-P). Using logistic regression, we calculated adjusted OR and 95 % CI to estimate associations between low diet quality (defined as the lowest quartile of DQI-P scores) and occupation types.

SETTING

The National Birth Defects Prevention Study: Arkansas, California, Georgia, Iowa, Massachusetts, North Carolina, New Jersey, New York, Texas, Utah.

PARTICIPANTS

Employed mothers of infants born between 1997 and 2011.

RESULTS

No occupation was strongly associated with low diet quality. Moderate but relatively imprecise associations were observed for women employed in management (OR: 1·3; 95 % CI: 1·1, 1·7); arts, design, entertainment, sports and media (OR: 1·4; 95 % CI: 0·9, 2·1); protective service (OR 1·3; 95 % CI: 0·7, 2·5) and farming, fishing, and forestry occupations (OR: 0·5; 95 % CI: 0·2, 1·1).

CONCLUSIONS

Our analyses suggest that women in certain occupations may have lower diet quality in the months before pregnancy. Further research is needed to determine whether certain occupations could benefit from interventions to improve diet quality in the workplace for women of reproductive age.

Women's Experience and Understanding of Food Cravings in Pregnancy: A Qualitative Study in Women Receiving Prenatal Care at the University of North Carolina-Chapel Hill

BACKGROUND

Although the occurrence of food cravings during pregnancy is well established, there is a paucity of qualitative data on pregnant women's perceptions of and responses to food cravings. This study sought to assess and describe pregnant women's experiences and behaviors pertaining to food cravings.

METHODS

Eight focus groups were conducted with 68 pregnant women in their second trimester from March 2015 to October 2016. Using a semistructured approach, the facilitator asked women open-ended questions regarding their experience of eating behaviors and food cravings. The content from the focus groups was analyzed using a bottom-up approach based on grounded theory and constant comparison analysis.

RESULTS

Participants described cravings as urgent, food-specific, and cognitively demanding occurrences that were differentiated from hunger. They described beliefs surrounding the physiological causes of cravings and rationales for satisfying their cravings. Strategies used to manage cravings included environmental modifications to limit proximity and availability of craved foods, cognitive and behavioral strategies like distraction, and acceptance through satisfying the craving. Participants described food cravings as a psychologically salient aspect of their pregnancy, reporting a variety of emotional precursors and reactions surrounding their cravings.

CONCLUSIONS

A better understanding of food cravings may assist with the development of interventions to improve eating behaviors and reduce eating-related distress during pregnancy. Acceptance regarding food cravings was indicated as a way to diffuse pregnancy-related stress. These findings contribute to our understanding of psychological influences on eating behaviors in pregnant women.

Maternal Dietary Patterns during Pregnancy and Congenital Heart Defects: A Case-Control Study

Limited studies investigating the relationships between dietary patterns and congenital heart defects (CHDs) are available. This study aimed to explore the associations between dietary patterns and CHDs risk in Shaanxi, China. We conducted a hospital-based case-control study and included a total of 474 cases and 948 controls. Pregnant women waiting for delivery in the hospital were interviewed to report their diets during pregnancy using a validated food frequency questionnaire. Dietary patterns were derived using principal component factor analysis. Mixed logistic regression models were used to assess the associations between dietary patterns and CHDs. Pregnant women in the highest tertile of the prudent pattern had a lower risk of CHDs compared to those in the lowest tertile (OR = 0.65, 95%CI: 0.48–0.89). Pregnant women with high scores on the vegetarian pattern were at an increased risk of CHDs (medium vs. lowest tertile: OR = 1.50, 95%CI = 1.03–2.17; highest vs. lowest tertile: OR = 1.56, 95%CI = 1.13–2.15; p_trend = 0.015). Pregnant women with high scores on the dairy and egg pattern were at a reduced risk of CHDs (medium vs. lowest tertile: OR = 0.66, 95%CI = 0.49–0.90; highest vs. lowest tertile: OR = 0.60, 95%CI = 0.43–0.82; p_trend = 0.001). Maternal diet during pregnancy is an important target for intervention, and it may influence the likelihood of developing CHDs.

Effect of Adherence to Mediterranean Diet during Pregnancy on Children's Health: A Systematic Review

The traditional Mediterranean diet has been shown to be a healthy eating pattern that protects against the development of many diseases in adults and children. Pregnancy is a critical period of plasticity during which foetal development may be significantly influenced by different environmental factors, including maternal nutrition. In this context, several studies have examined the potential benefits of adherence to a Mediterranean diet during pregnancy on birth outcomes, considering the Mediterranean diet as a whole rather than focusing on the effect of its individual components. In this review, we systematically summarized and discussed results of studies investigating the protective role of Mediterranean diet against foetal growth, prematurity, neural tube defects and other congenital pathologies, asthma and allergy, body weight and metabolic markers. Although current data are insufficient and randomized control trials are needed, growing evidence suggests the beneficial effect of the Mediterranean diet during pregnancy on children's health. In this sense, strategies aiming to promote adherence to this dietary pattern might be of considerable importance to public health.

A case-control analysis of maternal diet and risk of neural tube defects in Bangladesh

OBJECTIVES

Mothers need a nutrient-rich diet for healthy neural tube development. Neural tube defect risk can be reduced through fortifying grain products with folic acid and taking folic acid supplements. Fortification is not required in Bangladesh. Maternal supplement use rates are low, similar to other countries. This study evaluates maternal dietary intake during pregnancy to identify possible interventions.

METHODS

A food frequency questionnaire (FFQ) assessed maternal diet. The primary aim compared dietary intake (calories, fat, carbohydrate, protein, fiber, vitamins, and minerals) between mothers of infants with myelomeningocele (cases) and mothers of controls. Secondary aims included (i) comparing foods consumed and (ii) evaluating if rice intake correlated with arsenic exposure. Paired t-tests, Wilcoxon signed rank tests, McNemar's chi-squared test, and linear regression were used.

RESULTS

This study included 110 matched mother-infant pairs (55 cases/55 controls). Mothers of cases and mothers of controls had similar caloric intake [median 2406 kcal/day vs. 2196 kcal/day (p = 0.071)]. Mothers in both groups consumed less than half the daily recommended 600 μg of folate. Diets were potentially deficient in vitamins A, D, E, potassium, sodium, and iron. Steamed rice was the primary food consumed for both groups, and this rice intake was not associated with toenail arsenic.

CONCLUSIONS

Dietary interventions should increase folate, vitamins A, D, E, potassium, sodium, and iron intake in Bangladeshi mothers. Folic acid fortification of grain products maybe the only viable strategy to achieve adequate folate intake for mothers. Given the central role of rice to the Bangladeshi diet, fortifying rice may be a viable option.

Risk factors associated with the development of double-inlet ventricle congenital heart disease

BACKGROUND

Congenital heart disease (CHD) is the most common birth defect group and a significant contributor to neonatal and infant death. CHD with single ventricle anatomy, including hypoplastic left heart syndrome (HLHS), tricuspid atresia (TA), and various double-inlet ventricle (DIV) malformations, is the most complex with the highest mortality. Prenatal risk factors associated with HLHS have been studied, but such data for DIV are lacking.

METHODS

We analyzed DIV cases and nonmalformed controls in the National Birth Defects Prevention Study, a case-control, multicenter population-based study of birth defects. Random forest analysis identified potential predictor variables for DIV, which were included in multivariable models to estimate effect magnitude and directionality.

RESULTS

Random forest analysis identified pre-pregnancy diabetes, history of maternal insulin use, maternal total lipid intake, paternal race, and intake of several foods and nutrients as potential predictors of DIV. Logistic regression confirmed pre-pregnancy diabetes, maternal insulin use, and paternal race as risk factors for having a child with DIV. Additionally, higher maternal total fat intake was associated with a reduced risk.

CONCLUSIONS

Maternal pre-pregnancy diabetes and history of insulin use were associated with an increased risk of having an infant with DIV, while maternal lipid intake had an inverse association. These novel data provide multiple metabolic pathways for investigation to identify better the developmental etiologies of DIV and suggest that public health interventions targeting diabetes prevention and management in women of childbearing age could reduce CHD risk.

Maternal Lactase Polymorphism (rs4988235) Is Associated with Neural Tube Defects in Offspring in the National Birth Defects Prevention Study

BACKGROUND

The risk of neural tube defect (NTD)-affected pregnancies is reduced with adequate folic acid intake during early pregnancy. However, NTDs have been observed among offspring of women with adequate folic acid intake. Some of these women are possibly not absorbing enough folic acid. Because lactase deficiency can lead to poor nutrient absorption, we hypothesized that lactase-deficient women will be at increased risk of having offspring with NTDs.

OBJECTIVE

We examined the association between maternal rs4988235 (a lactase deficiency genetic marker) and NTDs in offspring.

METHODS

We conducted a case-control study using data from the National Birth Defects Prevention Study, United States, 1997-2009, restricting to non-Hispanic white (NHW) and Hispanic women. Cases were women with an offspring with an NTD (n = 378 NHW, 207 Hispanic), and controls were women with an offspring without a birth defect (n = 461 NHW, 165 Hispanic). Analyses were conducted separately by race/ethnicity, using logistic regression. Women with the CC genotype were categorized as being lactase deficient. To assess potential effect modification, analyses were stratified by lactose intake, folic acid supplementation, dietary folate, and diet quality.

RESULTS

Among NHW women, the odds of being lactase deficient were greater among cases compared with controls (OR: 1.37; 95% CI: 1.02, 1.82). Among Hispanic women, the odds of being lactase deficient were significantly lower among cases compared with controls (OR: 0.50, 95% CI: 0.33, 0.77). The association differed when stratified by lactose intake in NHW women (higher odds among women who consumed ≥12 g lactose/1000 kcal) and by dietary folate in Hispanic women (opposite direction of associations). The association did not differ when stratified by folic acid supplementation or diet quality.

CONCLUSIONS

Our findings suggest that maternal lactase deficiency is associated with NTDs in offspring. However, we observed opposite directions of effect by race/ethnicity that could not be definitively explained.

Comparing Usual Dietary Intakes Among Subgroups of Mothers in the Year Before Pregnancy

OBJECTIVE

The quantity and quality of dietary intake among women of reproductive age has important public health implications for nutritional status during pregnancy. We described dietary intake during the year before pregnancy among a large, diverse group of US mothers.

METHODS

We examined data from 11 109 mothers who gave birth from 1997 through 2011 and participated in a population-based case-control study, the National Birth Defects Prevention Study, as controls (mothers who had babies without major birth defects). We examined whether subgroups of mothers at elevated risk of adverse pregnancy outcomes were more likely than their reference groups to have high dietary intake (>90th percentile of intake) or low dietary intake (<10th percentile of intake). We examined dietary intake of 22 nutritional factors, which were estimated from responses to a food frequency questionnaire.

RESULTS

Participants who were aged <20, were nulliparous, had

CONCLUSIONS

Strategies are needed to ensure optimal nutrition among all childbearing women.

Collapse

Key Words

• adverse pregnancy outcomes
• dietary intake
• elevated risk
• nutritional status
• preconception

Collapse

MESH Headings

• Adult
• Age Factors
• Body Mass Index
• Case-Control Studies
• Diabetes Mellitus/epidemiology
• Diet/statistics & numerical data
• Feeding Behavior
• Female
• Humans
• Hypertension/epidemiology
• Mothers/statistics & numerical data
• Nutritional Status
• Parity
• Preconception Care/statistics & numerical data
• Pregnancy
• Pregnancy, Unplanned
• Racial Groups
• Risk Factors
• Socioeconomic Factors
• United States/epidemiology
• Young Adult

Collapse

Grants

• EP-D-18-001 EPA
• P30 DK056350 NIDDK NIH HHS
• U01 DD001033 NCBDD CDC HHS
• U01 DD001226 NCBDD CDC HHS
• National Center on Birth Defects and Developmental Disabilities

Collapse

Affiliation(s)

Suzan L. Carmichael Division of Neonatology and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
Chen Ma Division of Neonatology and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
Marcia L. Feldkamp Division of Medical Genetics, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, USA
Gary M. Shaw
the National Birth Defects Prevention Study Division of Neonatology and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA

Collapse

Bariatric surgery and birth defects: A systematic literature review

BACKGROUND

Bariatric procedures are on the rise. The risk of birth defects in pregnancies following such procedures may be increased (eg, due to nutrient deficiencies) or decreased (eg, due to decreased maternal body mass index, BMI).

METHODS

We conducted a systematic literature review of the association between bariatric surgery and birth defects using Ovid MEDLINE and PubMed (1946-2017). Information was abstracted on study design, exposures, outcomes, covariates and estimates of association.

RESULTS

Fifteen studies met our inclusion criteria: 14 evaluated the outcome of any birth defect, and one evaluated neural tube defects. Estimates of association between bariatric surgery and birth defects were available for nine studies and ranged from 0.6 to 1.9 (all 95% confidence intervals included 1.0). When studies were stratified by surgery type, there was no obvious pattern of association. When stratified by the approach used to account for BMI, positive associations were observed in studies that did not account for maternal prepregnancy BMI or used women with normal BMI as the reference group (range: 1.3-1.9). Estimates from studies that either matched or adjusted for prepregnancy BMI were closer to the null (range: 1.1-1.2) and studies that compared to morbidly obese women reported protective associations (range: 0.6-0.7).

CONCLUSIONS

Studies of the association between bariatric surgery and birth defects vary with respect to the surgical procedures included, birth defects ascertainment methods and approaches used to account for maternal BMI. Consequently, it is not possible to draw a conclusion regarding the association between bariatric surgery and birth defects. Additional studies are warranted.

Women's periconceptional diet and risk of biliary atresia in offspring

INTRODUCTION

We examined the association of biliary atresia with maternal dietary intake, using National Birth Defects Prevention Study (NBDPS) data from 152 cases and 11,112 nonmalformed controls born 1997-2011.

METHODS

NBDPS is a multisite, population-based case-control study. Exposure data were from maternal telephone interviews, which included a food frequency questionnaire. Odds ratios (OR) and 95% confidence intervals (CI) were generated from logistic regression models that included nutritional factors as continuous variables and were adjusted for energy intake only or energy intake plus covariates (maternal race-ethnicity, education, age, prepregnancy body mass index, vitamin/mineral supplement intake, conception during summer). Models included a quadratic term for the nutrient if p < 0.10. ORs reflect odds of having biliary atresia for nutrient values at the 75th compared to 25th percentile values of each nutrient, based on distributions among controls.

RESULTS

ORs for which the 95% CI excluded 1.00 were energy-adjusted ORs for calcium (0.63), protein (0.65), riboflavin (0.71), and diet quality index (0.69), and fully adjusted ORs for calcium (0.68) and vitamin E (0.72). ORs that were fully adjusted for covariates tended to be closer to 1.0 than ORs adjusted only for energy intake. ORs for the other studied nutrients had 95% CIs that included 1.00.

CONCLUSIONS

NBDPS is the first study to include detailed information on maternal dietary intake and risk of biliary atresia. Our results suggest reduced risks associated with some nutrients, which may provide etiologic clues but should be interpreted with caution given the small number of cases and novelty of the investigation.

Associations between Maternal Water Consumption and Birth Defects in the National Birth Defects Prevention Study (2000-2005)

BACKGROUND

Water and water-based beverages constitute a major part of daily fluid intake for pregnant women, yet few epidemiologic studies have investigated the role of water consumption on birth outcomes.

METHODS

We used data from the National Birth Defects Prevention Study to conduct a case-control study investigating associations between maternal water consumption during pregnancy and birth defects (BD). We used interview data on water consumption during the first trimester of pregnancy in 14,454 cases (major BDs n ≥ 50) and 5,063 controls. Total water consumption was analyzed as a continuous variable and in quartiles. We evaluated the role of dietary quality and sugar sweetened beverage consumption. Logistic regression models were used to assess effects of water consumption on risk of BDs with adjustment for relevant covariates.

RESULTS

Mean daily maternal water consumption among controls was 4.4 eight-ounce glasses. We observed decreases in estimated risk associated with increases in water consumption for several BDs, including neural tube defects (spina bifida), oral clefts (cleft lip), musculoskeletal defects (gastroschisis, limb deficiencies), and congenital heart defects (hypoplastic left heart syndrome, right-sided obstructions, pulmonary valve stenosis). Our results were generally unchanged when an indicator for overall dietary quality was included; however, there was evidence of effect measure modification by heavy consumption of sugar-sweetened beverages for some defects, but not all.

CONCLUSION

These analyses suggest the importance of sufficient water consumption during early pregnancy, above and beyond it being a marker of higher diet quality. Additional analyses are warranted to understand the biological mechanism for this association. Birth Defects Research 109:193-202, 2017. © 2016 Wiley Periodicals, Inc.

Development of a Diet Quality Index Adapted for Pregnant Women

OBJECTIVE:

To develop a Diet Quality Index Adapted for Pregnant Women (IQDAG) and to evaluate its relation with the characteristics of women treated at the Brazilian Unified Health System.

METHODS:

The data on food intake come from a cross-sectional study carried out with 785 adult pregnant women in the city of Ribeirão Preto, state of São Paulo, Brazil, between 2011 and 2012. The index was based on the recommendations of the Brazilian Ministry of Health, previous national dietary indexes, and the new Dietary Guidelines for the Brazilian Population. We used the ANOVA, Kruskal-Wallis, and chi-square tests to describe the quality of the diet according to the characteristics of the mother.

RESULTS:

The IQDAG has nine components, and it is represented by three food groups (in servings/1,000 kcal), five nutrients, and a moderator component. A high proportion of pregnant women reached the maximum score for the components of legumes and vegetables. However, few women reached the maximum score for consumption of fresh fruits, fiber, omega-3, calcium, folate, iron, and ultra-processed foods. We verified a better quality of diet among older and eutrophic pregnant women who reported practicing more physical activity and taking dietary supplements. We also observed the highest index score among women with higher intake of carbohydrates, proteins, vitamins C, E, and A, and minerals calcium, folate, and iron, as well as among those with lower intake of total fats and saturated fats.

CONCLUSIONS:

This dietary index is unprecedented in incorporating the recommendation of the new Dietary Guidelines for the Brazilian Population regarding the moderation of the consumption of ultra-processed foods. It was useful in evaluating the quality of the diet of pregnant women and we verified a higher score among older and eutrophic women who reported a healthy lifestyle. Strategies are needed to promote a higher consumption of fresh fruits, foods high in fiber, omega-3, calcium, folate, iron, and minimally processed foods in pregnant women.

Nutrient intake in women before conception and risks of anophthalmia and microphthalmia in their offspring

BACKGROUND

We previously explored associations between nutrients including folate and other macro and micronutrients and risks of anophthalmia or microphthalmia in the National Birth Defects Prevention Study. In the current study, we expand those previous results with larger sample sizes and conduct analyses with an additional diet quality index using more recent data.

METHODS

The National Birth Defects Prevention Study is a population-based, multicenter case-control study of over 30 major birth defects, with estimated due dates from October 1997 to December 2011. Cases were 224 infants diagnosed with anophthalmia or microphthalmia. Controls were 11,109 live-born, nonmalformed infants randomly selected by each study center. Mothers completed a standardized, computer-assisted telephone interview between 6 weeks and 24 months after delivery. Mothers responded to a shortened food frequency questionnaire, assessing their nutrient intake for the year before pregnancy, and questions about periconceptional (2 months before to 2 months after conception) vitamin supplement use. Nutrient intake quartiles were based on the intake among controls.

RESULTS

Among vitamin supplement users, odds of anophthalmia/microphthalmia were decreased for women with intake levels in the highest quartile of folate (0.56, 95% confidence interval [CI] 0.32-0.98), magnesium (0.42, 95% CI 0.22-0.82), and vitamin E (0.50, 95% CI 0.29-0.89). Among women not reporting vitamin supplement use, the odds were significantly increased for beta-carotene (2.5, 95% CI 1.10-5.68) and decreased for retinol (0.37, 95% CI 0.19-0.73).

CONCLUSIONS

In this expanded analysis, we observed associations for a few nutrients, specifically forms of vitamin A. However, the heterogeneity of results by form and vitamin use necessitates further inquiry.

Low carbohydrate diets may increase risk of neural tube defects

BACKGROUND

Folic acid fortification significantly reduced the prevalence of neural tube defects (NTDs) in the United States. The popularity of "low carb" diets raises concern that women who intentionally avoid carbohydrates, thereby consuming fewer fortified foods, may not have adequate dietary intake of folic acid.

METHODS

To assess the association between carbohydrate intake and NTDs, we analyzed data from the National Birth Defects Prevention Study from 1,740 mothers of infants, stillbirths, and terminations with anencephaly or spina bifida (cases), and 9,545 mothers of live born infants without a birth defect (controls) conceived between 1998 and 2011. Carbohydrate and folic acid intake before conception were estimated from food frequency questionnaire responses. Restricted carbohydrate intake was defined as ≤5th percentile among controls. Odds ratios were estimated with logistic regression and adjusted for maternal race/ethnicity, education, alcohol use, folic acid supplement use, study center, and caloric intake.

RESULTS

Mean dietary intake of folic acid among women with restricted carbohydrate intake was less than half that of other women (p < .01), and women with restricted carbohydrate intake were slightly more likely to have an infant with an NTD (AOR = 1.30, 95% CI: 1.02, 1.67).

CONCLUSIONS

This is the first study to examine the association between carbohydrate intake and NTDs among pregnancies conceived postfortification. We found that women with restricted carbohydrate intake were 30% more likely to have an infant with anencephaly or spina bifida. However, more research is needed to understand the pathways by which restricted carbohydrate intake might increase the risk of NTDs.

Household Food Insecurity Is Not Associated with Overall Diet Quality Among Pregnant Women in NHANES 1999-2008

OBJECTIVE

Analyze the association between household food security status and diet quality during pregnancy.

METHODS

Cross-sectional analysis of pregnant women from the National Health and Nutrition Examination Survey from 1999 to 2008. Of the 1158 pregnant women with complete household food security information, we analyzed 688 women who had complete dietary information and household incomes ≤300 % of the Federal Poverty Level (FPL). Diet quality was measured by the Alternate Healthy Eating Index modified for Pregnancy (AHEI-P) from 1 to 2 24 h dietary recalls. Multivariate linear and logistic regression models were implemented to assess the association between household food security status and AHEI-P, adjusting for age, nativity, marital status, race/ethnicity, education, and household income.

RESULTS

Among women with household incomes ≤300 % of the FPL, 19 % were food insecure and 4 % were marginally food secure. The mean AHEI-P score was 41.9 (95 % CI 40.4, 43.3). Household food insecurity was not associated with overall diet quality. However, living in a food insecure household compared to a food secure household was associated with a 2.3 (1.3, 4.1) greater odds of having a calcium component score greater than the median intake of calcium scores among food secure women in the sample.

CONCLUSIONS FOR PRACTICE

In a nationally representative sample of pregnant women, 80 % lived in a fully food secure household. Improving household food security during pregnancy is a public health opportunity to improve health outcomes; however household food security status may not be associated with overall diet quality.

Using latent class cluster analysis to screen high risk clusters of birth defects between 2009 and 2013 in Northwest China

In the study, we aimed to explore the synergistic effects of multiple risk factors on birth defects, and examine temporal trend of the synergistic effects over time. Two cross-sectional surveys conducted in 2009 and 2013 were merged and then latent class cluster analysis and generalized linear Poisson model were used. A total of 9085 and 29094 young children born within the last three years and their mothers were enrolled in 2009 and 2013 respectively. Three latent maternal exposure clusters were determined: a high-risk, a moderate-risk, and a low-risk cluster (88.97%, 1.49%, 9.54% in 2009 and 82.42%, 3.39%, 14.19% in 2013). The synthetic effects of maternal exposure to multiple risk factors could increase the risk of overall birth defects and cardiovascular system malformation among live births, and this risk is significantly higher in high-risk cluster than that in low-risk cluster. After adjusting for confounding factors using a generalized linear Poisson model, in high-risk cluster the prevalence of nervous system malformation decreased by approximately 2.71%, and the proportion of cardiovascular system malformation rose by 0.92% from 2009 to 2013. The Chinese government should make great efforts to provide primary prevention for those on high-risk cluster as a priority target population.

Risk factors associated with neural tube defects in infants referred to western Iranian obstetrical centers; 2013-2014

BACKGROUND

Neural tubes defects (NTDs) are known to be the second most prevalent congenital disorder worldwide whose risk factors have not been explicitly addressed yet.

AIM

To determine the risk factors affecting NTDs among infants who referred to obstetrical centers in Kurdistan, a western province of Iran.

METHODS

This prospective case-control study was conducted in the form of prospective case-control. Sample population included all women (27,153 cases) who referred to obstetrical centers in Kurdistan for either delivery or abortion during 2013 and 2014. Inclusion criterion was the presence of a known NTD in infants, and exclusion criterion was the reluctance of patients to participate in the study. Accordingly, 46 cases participated in the study as the case group, and 138 cases (three times higher than case group) were selected to be the control group. Case and control groups were matched in terms of the number of pregnancies and place of birth. The variables investigated in the present study were as follows: age, occupation, BMI, abortion history, family relation with husband, fetus' sex, number of twins, history of previous children with NTD, receiving prenatal surveillance, consumption of folic acid and multivitamins, smoking, alcohol drinking, passive smoking, and suffering from such diseases as epilepsy and diabetes. Data were analyzed using various statistical tests, including chi-square, Fishers' exact test, multiple logistic regression analysis using SPSS version 20. In the study group, inclusion criteria included all women who had an infant with tube defects that their total number was 46 individuals. In the control group inclusion criteria included mothers with healthy infants who were similar to the study group in terms of birth place and frequency of pregnancy.

RESULTS

The results of the present study demonstrated that prenatal surveillance (p<0.002), multivitamin consumption (p<0.001), history of having a child with NTD (p<0.001), alcohol drinking (p<0.014), and passive smoking were related to NTDs (p<0.001).

CONCLUSION

Before fertilization and during pregnancy, mothers should be examined in terms of exposure to harmful agents, diet, and nutritional status in order to identify possible risk factors and find opportunities to prevent NTDs in infants.

Neurologic Decline in an Older Patient with Repaired Myelomeningocele Complicated with Lumbar Canal Stenosis

BACKGROUND

Tethered cord syndrome is a well-known complication after myelomeningocele (MMC) repair in childhood. However, late complications in adults with a repaired MMC are not well understood. In particular, the influence of a degenerative spinal deformity on a sustained tethered cord is still unclear.

CASE DESCRIPTION

A 63-year-old man with a repaired MMC exhibited a progressive gait disturbance and numbness in both lower limbs. Magnetic resonance imaging demonstrated that the tethered spinal cord was compressed by severe canal stenosis along the entire lumbar spine. After a multi-level lumbar decompression surgery, the patient recovered to baseline neurologic status.

CONCLUSION

In adults with a repaired MMC, lumbar canal stenosis should be investigated as a possible cause of late neurologic decline. Clinical manifestations may be complicated by the coexistence of both the original and subsequent neurologic disorders. Because these additional disorders result from compressive myelopathy, early surgical decompression is indicated to avoid irreversible spinal cord dysfunction.

Maternal diet quality before pregnancy and risk of childhood leukaemia

Previous studies on maternal nutrition and childhood leukaemia risk have focused on the role of specific nutrients such as folate and have not considered broader measures of diet quality, which may better capture intake of diverse nutrients known to impact fetal development. We examined the relationship between maternal diet quality before pregnancy, as summarised by a diet quality index, and risk of childhood acute lymphoblastic leukaemia (ALL) and acute myeloid leukaemia (AML) in a case-control study in California. Dietary intake in the year before pregnancy was assessed using FFQ in 681 ALL cases, 103 AML cases and 1076 matched controls. Conditional logistic regression was used to estimate OR and 95 % CI for diet quality continuous score and quartiles (Q1-Q4). Higher maternal diet quality score was associated with reduced risk of ALL (OR 0·66; 95 % CI 0·47, 0·93 for Q4 v. Q1) and possibly AML (OR 0·42; 95 % CI 0·15, 1·15 for Q4 v. Q1). No single index component appeared to account for the association. The association of maternal diet quality with risk of ALL was stronger in children diagnosed under the age of 5 years and in children of women who did not report using vitamin supplements before pregnancy. These findings suggest that the joint effects of many dietary components may be important in influencing childhood leukaemia risk.

Childhood Leukemia and Primary Prevention

Leukemia is the most common pediatric cancer, affecting 3800 children per year in the United States. Its annual incidence has increased over the last decades, especially among Latinos. Although most children diagnosed with leukemia are now cured, many suffer long-term complications, and primary prevention efforts are urgently needed. The early onset of leukemia-usually before 5 years of age-and the presence at birth of "pre-leukemic" genetic signatures indicate that pre- and postnatal events are critical to the development of the disease. In contrast to most pediatric cancers, there is a growing body of literature-in the United States and internationally-that has implicated several environmental, infectious, and dietary risk factors in the etiology of childhood leukemia, mainly for acute lymphoblastic leukemia, the most common subtype. For example, exposures to pesticides, tobacco smoke, solvents, and traffic emissions have consistently demonstrated positive associations with the risk of developing childhood leukemia. In contrast, intake of vitamins and folate supplementation during the preconception period or pregnancy, breastfeeding, and exposure to routine childhood infections have been shown to reduce the risk of childhood leukemia. Some children may be especially vulnerable to these risk factors, as demonstrated by a disproportionate burden of childhood leukemia in the Latino population of California. The evidence supporting the associations between childhood leukemia and its risk factors-including pooled analyses from around the world and systematic reviews-is strong; however, the dissemination of this knowledge to clinicians has been limited. To protect children's health, it is prudent to initiate programs designed to alter exposure to well-established leukemia risk factors rather than to suspend judgment until no uncertainty remains. Primary prevention programs for childhood leukemia would also result in the significant co-benefits of reductions in other adverse health outcomes that are common in children, such as detriments to neurocognitive development.

Maternal active smoking and risk of oral clefts: a meta-analysis

OBJECTIVE

To assess the association between maternal active cigarette smoking and the risk of oral clefts in the offspring.

STUDY DESIGN

Oral clefts are divided into three subgroups: total clefts, cleft lip with or without cleft palate (CL ± P), and cleft palate only (CP). Data from studies on different levels of smoking were gathered to examine the dose-response effect.

RESULTS

The present meta-analysis included 29 case-control and cohort studies through Cochrane, PubMed, and Ovid Medline searches. A modest but statistically significant association was found between maternal active smoking and CL ± P (odds ratio [OR] 1.368; 95% confidence interval [CI] 1.259-1.486) as well as CP (OR 1.241; 95% CI 1.117-1.378). Half the studies showed positive dose-response effect for each subgroup (test for linear trend, P < .05).

CONCLUSIONS

There is a moderate risk for having a child with a CL ± P or CP in women who smoke during pregnancy. We could not confirm whether there was a positive dose-response effect between maternal smoking and clefts.

Pregnancy eating attributes study (PEAS): a cohort study examining behavioral and environmental influences on diet and weight change in pregnancy and postpartum

BACKGROUND

The rising prevalence of maternal overweight/obesity and excessive gestational weight gain poses a serious public health concern due to the contribution of these factors to increased risk of negative health outcomes for both mother and child. Scant intervention research has indicated moderate short-term improvement in maternal diet and gestational weight gain, with little evidence of long-term behavior change, in parallel with findings from interventions outside of pregnancy. Recent laboratory-based findings from neuroscience implicate aberrant reward processing of food at the brain level ("food reward sensitivity," the between-individual variation in the response to food stimuli) as a contributor to eating beyond energy needs. However, scant research has examined the influence of these processes on weight change in population-based settings, and the relevance of these processes to pregnancy-related weight change has not been explored. The purpose of the Pregnancy Eating Attributes Study (PEAS) is to examine the role of food reward sensitivity in maternal diet and weight change during pregnancy and postpartum. The study examines the interplay of food reward sensitivity with behavioral control, home food environment, and related aspects of eating behavior in the context of weight-related biomedical, psychosocial, genetic and behavioral factors including physical activity, stress, sleep and depression.

METHODS

Women of varying baseline weight status (n = 450) are enrolled early in pregnancy and followed, along with their infants, until 1 year postpartum. Assessments occur during each trimester of pregnancy, and postpartum at approximately 2 months, 6 months, 9 months and 12 months. Maternal food reward, self-control, home food environment, eating behaviors, dietary intake, health behaviors, and anthropometrics are assessed along with maternal and infant clinical and biological data, infant anthropometrics, and feeding practices. Primary exposures of interest include food reward sensitivity, behavioral control, and home food environment. Primary outcomes include gestational weight gain, postpartum weight retention and maternal diet quality.

DISCUSSION

With increasing evidence suggesting the relevance of food reward sensitivity for understanding eating behavior, PEAS aims to advance understanding of the determinants of eating behavior during pregnancy, informing future interventions for improving maternal diet and weight change, and leading to improved maternal and child health and weight trajectories.

TRIAL REGISTRATION

Clinicaltrials.gov, NCT02217462. Date of registration: August 13, 2014.

Environmental factors related to the occurrence of oral clefts in a Brazilian subpopulation

Background:

A cross-sectional study was conducted at the Craniofacial Rehabilitation Center in the General Hospital of the University of Cuiabá, Cuiabá city, Mato Grosso, Brazil.

Materials and Methods:

Poisson regression model was used to analyze the relationship between antenatal factors and the occurrence of oral clefts in 116 patients.

Results:

Oral clefts were more common in males (64.66%) and White race (46.02%). The mean age of the children was 21.91 months. The most common type of cleft was cleft lip and palate (CLP, 55.17%). Maternal and paternal smoking in the first trimester of pregnancy and parity were significantly associated with the occurrence of CLP. Parent's age, educational level, and occupation did not interfere in the occurrence of oral clefts. There was also no significant association between maternal illness, medication use, alcohol consumption, and maternal exposure to chemicals in the first trimester of pregnancy and the occurrence of clefts in this population.

Conclusion:

The analysis of the environmental factors present during the pregnancy of children with oral clefts revealed a significant association between parity (second onward), maternal smoking, and paternal smoking and the occurrence of CL and/or palate in this population.

Lower rate of selected congenital heart defects with better maternal diet quality: a population-based study

OBJECTIVE

To evaluate whether better diet quality in mothers is associated with lower risk for major non-syndromic congenital heart defects in their children.

DESIGN

Multicentre population-based case-control study, the National Birth Defects Prevention Study.

SETTING

Ten sites in the USA.

PARTICIPANTS

Mothers of babies with major non-syndromic congenital heart defects (n=9885) and mothers with unaffected babies (n=9468) with estimated date of delivery from 1997 to 2009.

MAIN OUTCOME MEASURES

Adjusted ORs for specific major congenital heart defects by quartiles of maternal diet quality in the year before pregnancy, assessed by the Diet Quality Index for pregnancy (DQI-P) and the Mediterranean Diet Score. Quartile 1 (Q1) reflecting the worst diet quality and Q4 the best diet quality.

RESULTS

Better diet quality was associated with reduced risk for some conotruncal and atrial septal heart defects. For DQI-P, estimated risks reductions (Q4 vs Q1) for conotruncal defects were 37% for tetralogy of Fallot (OR 0.63, 95% CI 0.49 to 0.80) and 24% overall (OR 0.76, 95% CI 0.64 to 0.91); and for septal defects, 23% for atrial septal defects (OR 0.77, 95% CI 0.63 to 0.94) and 14% overall (OR 0.86, 95% CI 0.75 to 1.00). Risk reductions were weaker or minimal for most other major congenital heart defects.

CONCLUSIONS

Better diet quality is associated with a reduced occurrence of some conotruncal and septal heart defects. This finding suggests that a reduction in certain cardiac malformations may be an additional benefit of improved maternal diet quality, reinforcing current preconception care recommendations.

Elevated body mass index and decreased diet quality among women and risk of birth defects in their offspring

BACKGROUND

We examined whether risks of 32 birth defects were higher than expected in the presence of overweight or obese body mass index (BMI) and low diet quality, based on estimating individual and joint effects of these factors and calculating relative excess risk due to interaction.

METHODS

Analyses included mothers of 20,250 cases with birth defects and 8617 population-based controls without birth defects born from 1997 to 2009 and interviewed for the National Birth Defects Prevention Study. We used logistic regression to generate adjusted odds ratios (AORs) reflecting the combined effects of BMI and diet quality. We focused analyses on 16 birth defects (n = 11,868 cases, 8617 controls) for which initial results suggested an association with BMI or diet quality.

RESULTS

Relative to the reference group (normal weight women with not low diet quality, i.e., >lowest quartile), AORs for low diet quality among normal weight women tended to be >1, and AORs for overweight and obese women tended to be stronger among women who had low diet quality than not low diet quality. For 9/16 birth defects, AORs for obese women who had low diet quality-the group we hypothesized to have highest risk-were higher than other stratum-specific AORs. Most relative excess risk due to interactions were positive but small (<0.5), with confidence intervals that included zero.

CONCLUSION

These findings provide evidence for the hypothesis of highest birth defect risks among offspring to women who are obese and have low diet quality but insufficient evidence for an interaction of these factors in their contribution to risk.