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• W2017157706 abstract "Hodgetts et al. report that preconception folic acid supplementation is associated with a decreased risk of small-for-gestational-age (SGA) infants (BJOG 2014;122:478–90). Indeed, there was a 20% reduction in the risk for having an SGA infant (<10%) in women taking folic acid before conception. The risk reduction was similar for SGA <5%. The study was conducted using an observational cohort including over 100 000 pregnancies in the West Midlands, UK. Results were confirmed in a meta-analysis conducted by the authors including almost 200 000 women. The number needed to treat is estimated as 15 for SGA <10% and 24 for SGA <5%. These observations are exciting because being an SGA infant is associated with a substantial increased risk for many adverse perinatal outcomes. Hence, decreasing the risk of SGA may in turn decrease the risk for complications such as stillbirth, neonatal death, hypoxic ischaemic encephalopathy. Moreover, folic acid appears to be reasonably safe both before conception and during pregnancy. It is also inexpensive, widely available and does not cause maternal side effects. Of course it is important to exercise caution in interpreting these results. First, the study was retrospective and limited by missing data and recall bias with regard to folic acid supplementation. Second, the meta-analysis was limited by the quality of studies included as well as variation in study populations and protocols. Finally, it is not clear that a decrease in neonatal SGA associated with preconception folic acid supplementation has clinically relevant effects. SGA is not a disease but a risk factor for adverse outcomes. However, most SGA infants are constitutionally small (normal) and healthy. Folic acid may increase birthweight in otherwise normal infants but may not impact SGA infants with ‘placental insufficiency’ or other pathophysiologies associated with adverse outcomes. Nonetheless, these data should prompt further study regarding the potential benefits of micronutrients before and during pregnancy. It appears that folate influences the fetus through alterations in DNA methylation and histone modification, resulting in epigenetic programming (Barua et al. Epigenetics Chromatin 2014;7:3). Hence, folic acid supplementation has the potential to have long-term effects (favourable or otherwise) on the exposed fetus/infant. In addition to education, a considerable challenge in getting women to take folic acid before pregnancy is the large proportion of pregnancies that are unplanned. Hence, many countries have mandatory folic acid fortification of food. However, there is still justifiable concern regarding the uncertainty of downstream effects. Assessment of micronutrients in human pregnancy is notoriously difficult because of the large numbers of potential confounders. Also, it would be unethical to randomise women to receive no folic acid given what is known about neural tube defects. However, there are numerous strategies that will allow us to deal with these obstacles and learn more. We all look forward to the performance of studies assessing the long-term effects of folate supplementation. RS has no conflicts to declare." @default.
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• W2017157706 date "2015-01-20" @default.
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• W2017157706 title "Folic acid: building bigger babies" @default.
• W2017157706 doi "https://doi.org/10.1111/1471-0528.13271" @default.
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