Tracking the Global Burden of Neural Tube Defects and Assessing Disparities Across World Health Organization Regions: A Scoping Literature Review

BACKGROUND AND OBJECTIVES

Neural tube defects (NTDs) are an important cause of global morbidity worldwide. Well-planned global neurosurgery and public health efforts can aid vulnerable communities, but there is a need to elucidate the global burden of NTDs and identify regions without available data to better target interventions.

METHODS

A scoping review to quantify worldwide NTD prevalence using the PubMed/Medline and birth defects surveillance registries was conducted. Data published after January 1, 1990, encompassing prevalence values of at least the 2 most prevalent NTDs-spina bifida and encephalocele-were abstracted. Average NTD prevalence rates were aggregated by World Health Organization (WHO) region and World Bank classification, and differences were determined using the analysis of variance test. Differences in availability of nationally representative data by WHO region and World Bank classification were determined using χ2 tests.

RESULTS

This review captured 140 studies from a total of 93 of 194 WHO member countries. The percentage of countries within a geographic region with available NTD prevalence data was highest in the Eastern Mediterranean (EMR) (85.7%) and lowest in Africa (AFR) (31.3%). The NTD prevalence range was 0.9-269.6 per 10 000 births. Statistically significant differences in reported NTD prevalence rates existed by WHO Region (P = .00027) and World Bank income level of study country (P = .00193). Forty countries (43%) had conducted national-level studies assessing NTD prevalence. There was a statistically significant difference in the availability of nationally representative prevalence data depending on the WHO region (P = .0081) and World Bank classification of study country (P = .0017).

CONCLUSION

There is a gap in availability of NTD prevalence data worldwide, with many WHO member states lacking national-level NTD prevalence estimates. These findings highlight the need for greater NTD surveillance efforts to identify the countries with the greatest need for targeted global intervention.

Melatonin alleviates valproic acid-induced neural tube defects by modulating Src/PI3K/ERK signaling and oxidative stress

Neural tube defects (NTDs) represent a developmental disorder of the nervous system that can lead to significant disability in children and impose substantial social burdens. Valproic acid (VPA), a widely prescribed first-line antiepileptic drug for epilepsy and various neurological conditions, has been associated with a 4-fold increase in the risk of NTDs when used during pregnancy. Consequently, urgent efforts are required to identify innovative prevention and treatment approaches for VPA-induced NTDs. Studies have demonstrated that the disruption in the delicate balance between cell proliferation and apoptosis is a crucial factor contributing to NTDs induced by VPA. Encouragingly, our current data reveal that melatonin (MT) significantly inhibits apoptosis while promoting the restoration of neuroepithelial cell proliferation impaired by VPA. Moreover, further investigations demonstrate that MT substantially reduces the incidence of neural tube malformations resulted from VPA exposure, primarily by suppressing apoptosis through the modulation of intracellular reactive oxygen species levels. In addition, the Src/PI3K/ERK signaling pathway appears to play a pivotal role in VPA-induced NTDs, with significant inhibition observed in the affected samples. Notably, MT treatment successfully reinstates Src/PI3K/ERK signaling, thereby offering a potential underlying mechanism for the protective effects of MT against VPA-induced NTDs. In summary, our current study substantiates the considerable protective potential of MT in mitigating VPA-triggered NTDs, thereby offering valuable strategies for the clinical management of VPA-related birth defects.

An evaluation of adherence to folic acid supplementation in pregnant women during early gestation for the prevention of neural tube defects

OBJECTIVE

Neural tube defects (NTD) are potentially preventable by periconceptual folic acid supplementation. Women with obesity are at higher risk of NTD, therefore, are recommended a higher dose of 5 mg folic acid to mitigate this risk. The aim of this study was to evaluate maternal practice of folic acid supplementation amongst the antenatal population in relation to maternal obesity status.

DESIGN

Prospective observational study.

SETTING

Women ≤18 weeks' gestation at their first antenatal appointment attending University Maternity Hospital Limerick (Ireland) were recruited. Maternal height and weight were measured. Obesity was defined at a threshold of ≥30·0 kg/m² and ≥27·5 kg/m² when adjusting for ethnicity. A two-part questionnaire captured maternal characteristics and assessed supplementation compliance, commencement and dosage. Fisher's exact test for independence analysed differences in variables. A P value of <0·05 was considered significant.

PARTICIPANTS

A total of 328 women participated over a duration of 6 weeks.

RESULTS

Mean gestational age was 12·4 ± 1·4 weeks and mean BMI 26·7 kg/m² ± 5·2 kg/m². 23·8 % (n 78) were classified as obese. 96·5 % (n 315) were taking folic acid and 95·7 % (n 314) supplemented daily. 30·2 % (n 99) commenced supplementation 12 weeks prior to conception. Overall, 57·9 % (n 190) of women met folic acid supplementation dose requirements. 89·1 % (n 55) of women with obesity did not. Women with obesity were less likely to meet the higher folic acid supplementation dose requirements (P =< 0·001).

CONCLUSION

Folic acid supplementation practices within this cohort were suboptimal to prevent their risk of NTD. This study showed inadequate compliance of folic acid supplementation, and inadequate dosage for women with obesity. Increased patient education and awareness are needed within the antenatal period of pregnancy to bring folic acid supplementation practices in line with best practice guidelines.

Global prevalence of congenital anencephaly: a comprehensive systematic review and meta-analysis

Background

Anencephaly is a fatal congenital anomaly characterized by the absence of brain hemispheres and cranial arch. Timely preventive measures can be taken by knowing the exact prevalence of this common neural tube defect; thus, carried out through systematic review and meta-analysis, the present study was conducted to determine the worldwide prevalence, incidence and mortality of anencephaly.

Methods

Cochran’s seven-step instructions were used as the guideline. Having determined the research question and inclusion and exclusion criteria, we studied MagIran, SID, Science Direct, WoS, Web of Science, Medline (PubMed), Scopus, and Google Scholar databases. Moreover, the search strategy in each database included using all possible keyword combinations with the help of “AND” and “OR” operators with no time limit to 2021. The I² test was used to calculate study heterogeneity, and Begg and Mazumdar rank correlation tests were employed to assess the publication bias. Data were analyzed by Comprehensive Meta-Analysis software (Version 2).

Results

In this study, the statements of Preferred Reporting Items for Systematic Reviews and Meta-Analyzes (PRISMA) were used. In the first stage, 1141 articles were found, of which 330 duplicate studies were omitted. 371 articles were deleted based on the inclusion and exclusion criteria by reviewing the title and abstract of the study. 58 articles were removed by reviewing the full text of the article because it was not relevant to the research. 360 studies with a sample size of 207,639,132 people were considered for the meta-analysis. Overall estimate of the prevalence, incidence and attenuation of anencephaly worldwide were 5.1 per ten thousand births (95% confidence interval 4.7–5.5 per ten thousand births), 8.3 per ten thousand births (95% confidence interval 5.5–9.9 per ten thousand births), 5.5 per ten thousand births (95% confidence interval 1.8–15 per ten thousand births) respectively the highest of which according to the subgroup analysis, belonged to the Australian continent with 8.6 per ten thousand births (95% confidence interval 7.7–9.5 per ten thousand births).

Conclusion

The overall prevalence of anencephaly in the world is significant, indicating the urgent need for preventive and treating measures.

Anencephaly is a fatal congenital anomaly characterized by the absence of brain hemispheres and cranial arch. Cochran’s seven-step instructions were used as the guideline. Having determined the research question and inclusion and exclusion criteria, we studied MagIran, SID, Science Direct, WoS, Web of Science, Medline (PubMed), Scopus, and Google Scholar databases. Moreover, the search strategy in each database included using all possible keyword combinations with the help of “AND” and “OR” operators with no time limit to 2021. Out of 1141 initial articles found, and after excluding repetitive ones in various databases and those irrelevant to inclusion criteria, 360 studies with a sample size of 207,639,132 people were considered for the meta-analysis. Overall estimate of the prevalence, incidence and attenuation of anencephaly worldwide were 5.1 per ten thousand births (95% confidence interval 4.7–5.5 per ten thousand births), 8.3 per ten thousand births (95% confidence interval 5.5–9.9 per ten thousand births), 5.5 per ten thousand births (95% confidence interval 1.8–15 per ten thousand births) respectively the highest of which according to the subgroup analysis, belonged to the Australian continent with 8.6 per ten thousand births (95% confidence interval 7.7–9.5 per ten thousand births). The overall prevalence of anencephaly in the world is significant, indicating the urgent need for preventive and treating measures.

Voluntary folic acid fortification levels of food staples in Ireland continue to decline: further implications for passive folic acid intakes?

BACKGROUND

Ireland previously had widespread voluntary fortification but research at Dublin City University carried out in 2014 by our research group demonstrated a major decline in the number of food staples fortified with folic acid in Irish supermarkets over the previous 10 years. The aim of the study was to repeat the audit conducted 3 years ago to compare the levels of folic acid fortification of foodstuffs over this time-frame.

METHODS

Over a period of 8-weeks between June and August 2017, the nutrition labels of all foodstuffs that might typically be fortified with micronutrients for sale in the supermarkets with the majority of market share in Ireland were examined. The amount of added folic acid detailed on the label was compared with those captured in 2014.

RESULTS

In total, 1081 products with added micronutrients were examined. In percentage terms, there has been a decline of Folic Acid (FA) fortified products within the food groups-spreads, breads, cereals, cereal snacks, milks, fruit juices, yogurts/yogurt drinks and energy drinks since 2014.

DISCUSSION

The number of food staples fortified with FA continues to decline demonstrating that voluntary fortification in Ireland is no longer an effective measure for passively augmenting the folic acid levels of consumers.

Urinary tract imaging in infants with spina bifida: a selective approach to a baseline DMSA

INTRODUCTION

There is no general agreement among paediatric urologists on how infants with spina bifida (SB) should be investigated after birth. Recently the EUA/ESPU guidelines have been published recommending a baseline DMSA scan in the first year of life and a Voiding Cystourethrogram (VCUG) or Videourodynamic (VUD) between the second and third month of life.

OBJECTIVE

The aim of this study was to evaluate the outcome of renal investigations in the first year of life in infants with SB to verify if an early DMSA scan is indicated in the management of this group of patients.

METHODS

All renal imaging, Renal and Bladder Ultrasound (RBUS), VCUGs, VUDs and DMSA were reviewed by two independent assessors to evaluate outcome.

RESULTS

Seventy patients with spina bifida (40 girls) were enrolled between June 2015 and February 2020. An early VUD detected vesico-ureteral reflux (VUR) in 8/49 (16%) of patients. An early VUD also gave additional information on detrusor under or over activity, bladder trabeculation, end filling detrusor pressure (EFDP) and sphincteric incompetence. DMSA scan detected renal scarring in 4/68 (6%) patients. Three of these 4 patients had significant history of febrile UTIs while the fourth patient had grade 2 left sided VUR.

CONCLUSIONS

The initial assessment of a newborn with myelodysplasia includes a Renal and Bladder Ultrasound during birth hospitalization. This study confirms the recently published EUA/ESPU guidelines on the management of neurogenic bladder in children and adolescents, which recommend a VUD or VCUG & Cystomanometry with Electromyogram (CMG) (if VUD not available) in the first 6-12 weeks of life. A selective approach to DMSA scan only in infants with SB who either had a febrile UTI or vesico-ureteric reflux would not have missed any scarring or dysplasia and would have saved 58 unnecessary nuclear scans.

Neonatal and infant mortality associated with spina bifida: A systematic review and meta-analysis

Objectives

A systematic review was conducted in high-income country settings to analyse: (i) spina bifida neonatal and IMRs over time, and (ii) clinical and socio-demographic factors associated with mortality in the first year after birth in infants affected by spina bifida.

Data sources

PubMed, Embase, Ovid, Web of Science, CINAHL, Scopus and the Cochrane Library were searched from 1^st January, 1990 to 31^st August, 2020 to review evidence.

Study selection

Population-based studies that provided data for spina bifida infant mortality and case fatality according to clinical and socio-demographical characteristics were included. Studies were excluded if they were conducted solely in tertiary centres. Spina bifida occulta or syndromal spina bifida were excluded where possible.

Data extraction and synthesis

Independent reviewers extracted data and assessed their quality using MOOSE guideline. Pooled mortality estimates were calculated using random-effects (+/- fixed effects) models meta-analyses. Heterogeneity between studies was assessed using the Cochrane Q test and I² statistics. Meta-regression was performed to examine the impact of year of birth cohort on spina bifida infant mortality.

Results

Twenty studies met the full inclusion criteria with a total study population of over 30 million liveborn infants and approximately 12,000 spina bifida-affected infants. Significant declines in spina bifida associated infant and neonatal mortality rates (e.g. 4.76% decrease in IMR per 100, 000 live births per year) and case fatality (e.g. 2.70% decrease in infant case fatality per year) were consistently observed over time. Preterm birth (RR 4.45; 2.30–8.60) and low birthweight (RR 4.77; 2.67–8.55) are the strongest risk factors associated with increased spina bifida infant case fatality.

Significance

Significant declines in spina bifida associated infant/neonatal mortality and case fatality were consistently observed, advances in treatment and mandatory folic acid food fortification both likely play an important role. Particular attention is warranted from clinicians caring for preterm and low birthweight babies affected by spina bifida.

Octopus Watch Fosters Family Resilience by Enhancing Occupational Engagement for Children with Spina Bifida and/or Hydrocephalus: Pilot Study

BACKGROUND

Children with spina bifida and/or hydrocephalus (SB&/H) often experience difficulties with activities of daily living (ADLs) due to impaired executive functioning, increasing sedentary behaviours. The HeyJoy Octopus watch, a child-friendly icon-based smartwatch could be used as an enabler to promote purposeful ADLs (i.e., goal-orientated ADLs).

OBJECTIVE

to investigate the effectiveness of the Octopus watch in promoting purposeful ADLs for children living with SB&/H (<8 years).

METHODS

Mixed-methods engaging parents and children in four phases: (1) Administered demographic questionnaire, semi-structured interview, childhood executive functioning inventory (CHEXI) and the Canadian occupational performance measure (COPM); focus group one introducing the study, information pack using smartwatch and photovoice data collection methods. (2) Measured baseline movement for four days with smartwatch without using functions. (3) Measured activity for 16-days while using the smartwatch. (4) Re-administered assessments and conducted a second focus group based on photovoice narratives.

RESULTS

movement data recorded for four participants, three of four showed mean activity increase (36%). N-of-1 analyses found one participant showed clear improvement (p = 0.021, r² = 0.28). Mean inhibition decreased by 16.4%, and mean change in COPM performance and satisfaction scores were 2.1 and 2.4, respectively. The photovoice narrative focus group supports findings evidenced with improved daily routines.

CONCLUSIONS

The Octopus watch is an innovative early intervention that can promote purposeful ADLs, fostering family resilience by enhancing occupational engagement. Further research is required.

Assessment of neurogenic bowel symptoms with the bowel dysfunction score in children with spina bifida: a prospective case-control study

AIM

To compare the quality of life (QoL) in children with spina bifida with a control group of their peers using a validated questionnaire, the Neurogenic Bowel Dysfunction Score (NBDS).

METHODS

The NBDS questionnaire was prospectively distributed to children attending a multi-disciplinary Spina Bifida clinic and healthy controls attending pediatric urology clinics. A score (out of 41) was assigned to each child based on their responses to the validated questionnaire. A lower score indicates better bowel function-related quality of life. SPSS software (v.25) was used for all statistical analysis.

RESULTS

There were 98 respondents to the questionnaire, 48 children with spina bifida and 50 controls. The average age of respondents was 7.88 years (3-16 years). Of those with Spina Bifida, 33 (69%) were on retrograde rectal irrigations, [19 (58%) Peristeen® system, 11 (33%) tube rectal irrigations, and 3 (9%) Willis system], 6 (12%) were on laxatives, and 9 (19%) were on no treatment. The median NBDS for Spina Bifida patients was significantly higher 13.5 (2-32) compared to the control group 2 (0-26, p < 0.001). Amongst Spina Bifida patients, there was no difference in quality of life between the modalities of bowel management (p = 0.203).

CONCLUSIONS

Despite active bowel management, children with spina bifida report a worse quality of life compared to the control group. In those with spina bifida, the lack of a difference between various bowel management strategies, including no treatment, indicates the need for a longitudinal study to evaluate the basis for this unexpected finding.

Plasma concentrations of vitamin B12 and folate and global cognitive function in an older population: cross-sectional findings from The Irish Longitudinal Study on Ageing (TILDA)

The uncertainty surrounding high intakes of folic acid and associations with cognitive decline in older adults with low vitamin B12 status has been an obstacle to mandatory folic acid fortification for many years. We estimated the prevalence of combinations of low/normal/high vitamin B12 and folate status and compared associations with global cognitive function using two approaches, of individuals in a population-based study of those aged ≥50 years in the Republic of Ireland. Cross-sectional data from 3781 men and women from Wave 1 of The Irish Longitudinal Study on Ageing were analysed. Global cognitive function was assessed by the Mini Mental State Examination (MMSE) and Montreal Cognitive Assessment (MoCA). Prevalence estimates for combinations of vitamin B12 (plasma vitamin B12 < or ≥258 pmol/l) and folate (plasma folate ≤ or >45·3 nmol/l) concentrations were generated. Negative binomial regression models were used to investigate the associations of vitamin B12 and folate status with global cognitive function. Of the participants, 1·5 % (n 51) had low vitamin B12 (<258 pmol/l) and high folate (>45·3 nmol/l) status. Global cognitive performance was not significantly reduced in these individuals when compared with those with normal status for both B-vitamins (n 2433). Those with normal vitamin B12/high folate status (7·6 %) had better cognitive performance (MMSE: incidence rate ratio (IRR) 0·82, 95 % CI 0·68, 0·99; P = 0·043, MoCA: IRR 0·89, 95 % CI 0·80, 0·99; P = 0·025). We demonstrated that high folate status was not associated with lower cognitive scores in older adults with low vitamin B12 status. These findings provide important safety information that could guide fortification policy recommendations in Europe.

Optimization of folic acid supplementation in the prevention of neural tube defects

Background

We examined the relationship between timing and duration of folic acid (FA) supplementation in achieving red blood cell (RBC) folate levels in early pregnancy which are optimal (>906 nmol/l) for the prevention of neural tube defects (NTDs).

Methods

Clinical, FA supplementation and dietary folate details were computerized at the first antenatal visit. Maternal blood samples were analysed for RBC and serum folate.

Results

Of the 502 women, 98.2% (n = 493) reported taking FA. There was a positive correlation between duration of supplementation and both RBC folate (r = 0.43, P < 0.001) and serum folate (rho = 0.29, P < 0.001). The optimal RBC folate level was achieved in 80.4% (n = 46) of women who started FA 400 μg 4-8 weeks before their LMP compared with only 53.6% (n = 153) in women who started 4-8 weeks after their LMP (P < 0.001).

Conclusions

This study provides, for the first time, information on both the timing and duration of FA that will achieve the optimum RBC folate levels associated with the prevention of NTDs. Women who are taking FA (400 μg) need to start before they conceive.

Modelling the impact of mandatory folic acid fortification of bread or flour in Ireland on the risk of occurrence of NTD-affected pregnancies in women of childbearing age and on risk of masking vitamin B12 deficiency in older adults

PURPOSE

The rate of neural tube defects (NTDs) in Europe has remained similar since the 1990s despite folic acid supplement recommendations (400 µg/day) for women of childbearing age. Mandatory folic acid fortification of staple foods has proved effective for reducing the prevalence of NTDs in over 80 countries. This study estimated the impact of addition of folic acid to bread or flour in the Republic of Ireland on reducing the risk of occurrence of NTD-affected pregnancies and the possible risk of masking (undiagnosed) vitamin B₁₂ deficiency in older adults.

METHODS

Analyses were based on the Irish National Adult Nutrition Survey (2008-2010). Folic acid fortification was modelled using DaDiet© software. Estimates were made of the increase in average daily folic acid intake in women (18-50 years) and the risk of exceeding the tolerable upper intake level (UL) of 1000 µg for folic acid in adults over 50 years of age.

RESULTS

The fortification scenarios examined would reduce the risk of NTD-affected pregnancies by 8-32%, corresponding to an increase of 39-152 μg in the mean daily folic acid intake of WCBA. The risk of masking anaemia associated with vitamin B₁₂ deficiency in older adults would be negligible as the probability of exceeding the UL for folic acid, even by a small amount, is very low (≤ 0.2%).

CONCLUSIONS

These levels of addition of folic acid to bread or flour would effectively reduce the risk of NTDs while allowing safe consumption of folic acid at current levels from other fortified foods and supplements.

Maternal nutrient intakes from food and drinks consumed in early pregnancy in Ireland

Background

The aim of this observational study was to measure food, macronutrient and micronutrient intakes of women presenting for antenatal care and assess compliance with current nutritional recommendations.

Methods

Women were recruited in the first trimester of pregnancy. Maternal weight and height were measured and body mass index (BMI) calculated. Body composition was measured using bioelectrical impedance analysis. Maternal energy and nutrient intakes were estimated using a validated Willett Food Frequency Questionnaire and misreporting of energy intakes (EI) determined.

Results

Plausible EIs were reported in 402 women. Mean age, weight and BMI were 30.8 years, 67.1 kg and 24.6 kg/m2 respectively. Median EIs were 2111 kcal, and median protein, carbohydrate and fat intakes were 17.3, 48.1 and 36.2 g/MJ/day, respectively. More than 90% of women exceeded the recommended daily allowance for saturated fat. Nearly all of the women (99%) did not meet estimated average requirements (EAR) for vitamin D. One in three women failed to achieve a dietary folate intake of 400 µg/day. Over one in five women failed to meet the EAR for iron, and 14% failed to achieve the EAR for calcium.

Conclusions

Our findings highlight concerning deficits in nutrient intakes among women and will help guide professional dietary advice to women attending for future obstetric care in Ireland.

Triple surveillance: a proposal for an integrated strategy to support and accelerate birth defect prevention

Preventing neural tube defects (NTDs) easily qualifies as a high-value opportunity to improve childhood survival and health: the unmet need is significant (major preventable burden), the intervention is transformative (providing sufficient folic acid), and delivery strategies (e.g., fortification) are effective in low-resource countries. Yet, NTD prevention is lagging. Can public health surveillance help fix this problem? Critics contend that surveillance is largely unnecessary, that limited resources are best spent on interventions, and that surveillance is unrealistic in developing countries. The counterargument is twofold: (1) in the absence of surveillance, interventions will provide fewer benefits and cost more and (2) effective surveillance is likely possible nearly everywhere, with appropriate strategies. As a base strategy, we propose "triple surveillance:" integrating surveillance of cause (folate insufficiency), of disease occurrence (NTD prevalence), and of health outcomes (morbidity, mortality, and disability). For better sustainability and usefulness, it is crucial to refocus and streamline surveillance activities (no recreational data collection), weave surveillance into clinical care (integrate in clinical workflow), and, later, work on including additional risk factors and pediatric outcomes (increase benefits at low marginal cost). By doing so, surveillance becomes not a roadblock but a preferential path to prevention and better care.

Historical perspective on folic acid and challenges in estimating global prevalence of neural tube defects

Neural tube defects (NTD) are major congenital malformations affecting births worldwide. NTD are associated with life-long disability, significant medical care costs, and child mortality. Their prevalence varies worldwide. We conducted a review of published literature and surveillance systems to examine challenges in estimating an overall global prevalence estimate for NTD. Our review showed that most low- and middle-income countries do not track NTD and indicate a high prevalence of these malformations where data are available. Challenges in global NTD prevalence estimation include (1) quality of surveillance methods, (2) existing risk factors (including geographic or socioeconomic factors, availability and use of folic acid, and racial-ethnic and genetic factors), and (3) limitations in education and access to care. We recommend population-based surveillance systems tracking all pregnancy outcomes and major risk factors. Countries should invest in sustainable, multisource surveillance systems, in parallel to folic acid interventions, for gaining a more accurate knowledge of global prevalence of NTD than we currently have. Such efforts will assist in both global prevention of NTD and periodic evaluation of folic acid interventions for NTD reduction. Global NTD prevalence data can drive political will and accelerate the implementation and evaluation of NTD prevention programs.

Addressing optimal folate and related B-vitamin status through the lifecycle: health impacts and challenges

The functional effects of folate within C1 metabolism involve interrelationships with vitamin B12, vitamin B6 and riboflavin, and related gene–nutrient interactions. These B vitamins have important roles throughout life, from pregnancy, through childhood, to middle and older age. Achieving optimal nutritional status for preventing folate-related disease is challenging, however, primarily as a result of the poor stability and incomplete bioavailability of folate from natural food sources when compared with the synthetic vitamin form, folic acid. Thus, in European countries, measures to prevent neural tube defects (NTD) have been largely ineffective because of the generally poor compliance of women with folic acid supplementation as recommended before and in early pregnancy. In contrast, countries worldwide with mandatory folic acid fortification policies have experienced marked reductions in NTD. Low vitamin B12 status is associated with increased risk of cognitive dysfunction, CVD and osteoporosis. Achieving optimal B12 status can be problematic for older people, however, primarily owing to food-bound B12 malabsorption which leads to sub-clinical deficiency even with high dietary B12 intakes. Optimising B-vitamin intake may be particularly important for sub-populations with impaired folate metabolism owing to genetic characteristics, most notably the 677C→T variant in the gene encoding the enzyme methylenetetrahydrofolate reductase (MTHFR). This common folate polymorphism is linked with several adverse health outcomes, including stroke, however, recent evidence has identified its novel interaction with riboflavin (the MTHFR cofactor) in relation to blood pressure and risk of developing hypertension. This review addresses why and how the optimal status of folate-related B vitamins should be achieved through the lifecycle.

Anencephaly; the maternal experience of continuing with the pregnancy. Incompatible with life but not with love

OBJECTIVE

As advances in prenatal diagnosis increasingly enable detection of life-limiting conditions, end-of-life care may start before birth. Termination of these pregnancies may have been default management, but in the Republic of Ireland, where termination is not a legal option, skilled experience in caring for mothers who continue their pregnancies has developed. This study examines the lived experience of four such mothers.

METHOD

A qualitative study was designed using interpretive phenomenological analysis, which examined the maternal experience of continuing pregnancy with a prenatal diagnosis of anencephaly. Four mothers participated in semi-structured interviews on their experience of pregnancy and delivery of a baby with anencephaly.

RESULTS

A profoundly emotional journey represented an adaptive grieving process, which culminated in rich experiences of transformative growth for all the parents. The parents' relationship with their caregivers facilitated this process and the development of a meaningful parenting relationship with their babies. This positive finding coexists alongside a parallel experience of ongoing deep sense of loss and sadness.

CONCLUSION

Perinatal palliative care for those with a prenatal lethal diagnosis is a positive life experience for some mothers. The role of relationship with healthcare professionals is vital to the process and consideration must be given to a comprehensive multi-disciplinary team approach.

Estimates of global and regional prevalence of neural tube defects for 2015: a systematic analysis

Neural tube defects (NTDs) are associated with substantial mortality, morbidity, disability, and psychological and economic costs. Many are preventable with folic acid, and access to appropriate services for those affected can improve survival and quality of life. We used a compartmental model to estimate global and regional birth prevalence of NTDs (live births, stillbirths, and elective terminations of pregnancy) and subsequent under-5 mortality. Data were identified through web-based reviews of birth defect registry databases and systematic literature reviews. Meta-analyses were undertaken where appropriate. For 2015, our model estimated 260,100 (uncertainty interval (UI): 213,800-322,000) NTD-affected birth outcomes worldwide (prevalence 18.6 (15.3-23.0)/10,000 live births). Approximately 50% of cases were elective terminations of pregnancy for fetal anomalies (UI: 59,300 (47,900-74,500)) or stillbirths (57,800 (UI: 35,000-88,600)). Of NTD-affected live births, 117,900 (∼75%) (UI: 105,500-186,600) resulted in under-5 deaths. Our systematic review showed a paucity of high-quality data in the regions of the world with the highest burden. Despite knowledge about prevention, NTDs remain highly prevalent worldwide. Lack of surveillance and incomplete ascertainment of affected pregnancies make NTDs invisible to policy makers. Improved surveillance of all adverse outcomes is needed to improve the robustness of total NTD prevalence estimation, evaluate effectiveness of prevention through folic acid fortification, and improve outcomes through care and rehabilitation.

Estimating Global Burden of Disease due to congenital anomaly: an analysis of European data

OBJECTIVE

To validate the estimates of Global Burden of Disease (GBD) due to congenital anomaly for Europe by comparing infant mortality data collected by EUROCAT registries with the WHO Mortality Database, and by assessing the significance of stillbirths and terminations of pregnancy for fetal anomaly (TOPFA) in the interpretation of infant mortality statistics.

DESIGN, SETTING AND OUTCOME MEASURES

EUROCAT is a network of congenital anomaly registries collecting data on live births, fetal deaths from 20 weeks' gestation and TOPFA. Data from 29 registries in 19 countries were analysed for 2005-2009, and infant mortality (deaths of live births at age <1 year) compared with the WHO Mortality Database. Eight EUROCAT countries were excluded from further analysis on the basis that this comparison showed poor ascertainment of survival status.

RESULTS

According to WHO, 17%-42% of infant mortality was attributed to congenital anomaly. In 11 EUROCAT countries, average infant mortality with congenital anomaly was 1.1 per 1000 births, with higher rates where TOPFA is illegal (Malta 3.0, Ireland 2.1). The rate of stillbirths with congenital anomaly was 0.6 per 1000. The average TOPFA prevalence was 4.6 per 1000, nearly three times more prevalent than stillbirths and infant deaths combined. TOPFA also impacted on the prevalence of postneonatal survivors with non-lethal congenital anomaly.

CONCLUSIONS

By excluding TOPFA and stillbirths from GBD years of life lost (YLL) estimates, GBD underestimates the burden of disease due to congenital anomaly, and thus declining YLL over time may obscure lack of progress in primary, secondary and tertiary prevention.

Developing a community based service model for disability: Listening to the needs of all beneficiaries and providers

PURPOSE

To inform the strategic and operational development of a community based service model at the Crann Centre, Cork, Ireland for SB children, adults, their families and providers. A needs assessment was conducted by gathering the views of multiple stakeholder perspectives within the SB community in the geographical region the Centre will serve. The intention is to create project deliverables that are responsive to the needs highlighted through this research.

METHODS

The study used a multi method design with a participatory research approach to explore the needs of SB individuals, families and providers. This involved in depth interviews, focus groups and online surveys.

RESULTS

One hundred and fifty-nine respondents contributed to this qualitative needs assessment. The research established a range of psychosocial, clinical, vocational and educational issues causing ongoing difficulties for SB individuals and families. Providers highlighted supports that would benefit the social and clinical wellbeing of persons with SB. Collectively participants in the study reported that there was an absence of coordinated, continuous and comprehensive service delivery for the SB community in the region. This was amplified by geographical location of services and access to relevant supports.

CONCLUSION

Consensus across stakeholders in this research pointed to the necessity for an innovative model of community based provision at the Crann Centre. This was described as offering a service with family at the core of an assets based model of practice. A key finding was the lack of importance placed on the social and emotional development of SB individuals. Traditionally participants described a singular focus on physical health through clinically defined treatment models. The desire for a social model of disability that informed health and wellbeing of SB individuals and families emerged as a prominent recommendation from the research.

Epidemiology of chromosomal trisomies in the East of Ireland

Background

Chromosomal trisomies are associated with advancing maternal age. In Ireland, information on the total prevalence and outcome of trisomy affected pregnancies is unavailable. This study aimed to ascertain more precise data on Trisomies 21, 18 and 13 in a large Irish region during the period 2011-2013.

Methods

Multiple information sources were used in case finding, including a regional congenital anomaly register, all maternity and paediatric hospitals in the region and the regional Department of Clinical Genetics.

Results

There were 394 trisomy cases from 80 894 total births, of which 289 were Trisomy 21, 75 were Trisomy 18 and 30 were Trisomy 13. The total prevalence rate was 48.9/10 000 births, 35.7, 9.3 and 3.7 for Trisomies 21, 18 and 13, respectively. Over 90% of Trisomies 18/13 and 47% of Trisomy 21 were diagnosed prenatally; 61% of Trisomy 21 cases and nearly 30% of Trisomies 18/13 were live births; 38% all trisomy affected pregnancies ended in a termination.

Conclusions

This study provides precise data on the total prevalence and outcome of trisomy affected pregnancies in the East of Ireland. Total prevalence rates were higher than previously reported. Prenatal diagnosis had a significant impact on outcome. These data provide a better basis for planning of services for live-born children affected by trisomy.

Epidemiology of Pediatric Traumatic and Acquired Nontraumatic Spinal Cord Injury in Ireland

Objective: To examine the epidemiology of pediatric traumatic (TSCI) and acquired nontraumatic spinal cord injury (NTSCI) in Ireland. There are few studies reporting pediatric TSCI incidence and fewer of pediatric NTSCI incidence, although there are several case reports. As there is a single specialist rehabilitation facility for these children, complete population-level data can be obtained. Method: Retrospective review of prospectively gathered data in the Patient Administration System of the National Rehabilitation Hospital of patients age 15 years or younger at the time of SCI onset. Information was retrieved on gender, age, etiology, level of injury/AIS. Population denominator was census results from 1996, 2002, 2006, and 2011, rolled forward. Results: Since 2000, 22 children have sustained TSCI and 26 have sustained NTSCI. Median (IQR) age at TSCI onset was 6.3 (4.4) years, and at NTSCI onset it was 7.3 (8.1) years. Most common TSCI etiology was transportation (n = 10; 45.5%), followed by surgical complications (n = 8; 36.4%); most common injury type was complete paraplegia (n = 12; 54.5%) followed by incomplete paraplegia (n = 5; 22.7%). Most common NTSCI etiology was transverse myelitis (n = 11; 42.3%) followed by vascular (n = 5; 20%); most common injury type was incomplete paraplegia (n = 17; 65.4%) followed by incomplete tetraplegia (n = 6; 24%). Incidence of TSCI ranged from 0 to 3.1 per million per year; incidence of NTSCI ranged from 0 to 6.5 per million per year. Conclusion: Incidence of SCI in Ireland seems similar to or slightly lower than other developed countries. Injury patterns are also similar, considering variations in reporting methods.

Synthetic folic acid intakes and status in children living in Ireland exposed to voluntary fortification

BACKGROUND

In the context of mandatory and voluntary folic acid fortification, the exposure of children to folic acid has been a focus of concern, particularly regarding the possibility of whether any potentially adverse effects will emerge in the future.

OBJECTIVE

We explored concentrations of fasting unmetabolized folic acid (UFA) in the circulation of children living in Ireland who were exposed to the voluntary folic acid-fortification regimen in place in Ireland.

DESIGN

Healthy children who were attending Our Lady's Children's Hospital, Crumlin, for routine minor surgery were recruited to provide a fasting 3-mL blood sample that was taken while a general anesthetic was administered. The samples were analyzed for plasma folate, red blood cell folate, and UFA concentrations. A short dietary questionnaire that captured recent and habitual intakes of folic acid, both as supplements and as fortified foods, was completed face to face with parents.

RESULTS

We collected fasting samples (n = 68) and completed questionnaires that captured recent and habitual daily folic acid intakes of children grouped as follows: 0-5 y of age: 6 girls and 21 boys (27 children total); 6-10 y of age: 10 girls and 10 boys (20 children total); and 11-16 y of age: 10 girls and 11 boys (21 children total). UFA was detected in 10.3% of the samples tested (range: 0.5-1.3 nmol/L). Mean plasma folate and red blood cell folate concentrations were 35.1 nmol/L (range: 21-47 nmol/L) and 956 nmol/L (range: 305-2319 nmol/L), respectively. Mean daily intake of folic acid from fortified foods and supplements was 109 μg (range: 0-767 μg).

CONCLUSIONS

We showed that there was UFA in the plasma of just >10% of the children sampled after an overnight fast. These findings should be considered by policy makers who are responsible for folic acid fortification. This trial was registered at www.isrctn.com as ISRCTN90038765.

Maternal folic acid supplementation trends 2009-2013

OBJECTIVE

We analyzed trends in folic acid supplementation among women booking for antenatal care between 2009 and 2013.

DESIGN

Prospective observational study.

SETTING

Large university teaching hospital.

POPULATION

We included all women who delivered an infant ≥500 g from 1 January 2009 to 31 December 2013.

METHODS

Body mass index was calculated using early pregnancy weight and height measured at first antenatal visits. Sociodemographic and clinical data were gathered prospectively. Multivariate logistic regression analyses were applied to determine the correlates of periconceptional folic acid supplementation.

MAIN OUTCOME MEASURES

Rates and correlates of folic acid supplementation.

RESULTS

Of 42 362 women, 99.2% (n = 42 042) were suitable for analysis. The mean age was 30.7 years and mean body mass index was 25.6 kg/m(2) , 40.7% (n = 17 054) were primigravidas and 70.6% (n = 29 741) were Irish-born. Overall, 43.9% (n = 18 473) took periconceptional (preconceptional and postconceptional) folic acid, 49.4% (n = 20 782) took postconceptional folic acid only, and 6.6% (n = 2787) took no folic acid. The women most likely to take folic acid were those who planned their pregnancy and were >30 years old, non-obese, Irish-born and employed professionally. The periconceptional folic acid rate decreased from 45.1% in 2009 to 43.1% in 2013 (p = 0.01). Over five years, periconceptional folic acid supplementation decreased among women who were multiparous (43.8-41.6%, p = 0.02), aged 30-39 years (58.9-55.0%, p < 0.001), Irish-born (50.1-47.1%, p < 0.001) and obese (38.6-36.9%, p = 0.02).

CONCLUSION

Overall, the rate of periconceptional folic acid supplementation decreased in the five years 2009-2013, particularly among women who were multiparous, aged 30-39 years, Irish-born and obese.