Changes in Frequencies of Select Congenital Anomalies since the Onset of Folic Acid Fortification in a Canadian Birth Defect Registry

Kimberly A Godwin; Barbara Sibbald; Tanya Bedard; Boris Kuzeljevic; R Brian Lowry; Laura Arbour

doi:10.1007/BF03403753

. 2008 Jul 1;99(4):271–275. doi: 10.1007/BF03403753

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Changes in Frequencies of Select Congenital Anomalies since the Onset of Folic Acid Fortification in a Canadian Birth Defect Registry

Kimberly A Godwin ¹⁷, Barbara Sibbald ²⁷, Tanya Bedard ²⁷, Boris Kuzeljevic ³⁷, R Brian Lowry ²⁷, Laura Arbour ^47,^✉

PMCID: PMC6975565 PMID: 18767269

Abstract

Objectives

Fortification of grain products with folic acid has been shown to significantly reduce the occurrence of neural tube defects (NTDs) in Canada and elsewhere. However, the impact on non-NTD anomalies has not been well studied.

Methods

Using the Alberta Congenital Anomalies Surveillance System (ACASS), we examined changes in occurrence of select congenital anomalies where folic acid supplementation with multivitamins had previously been suggested to have an effect. Anomalies documented in the ACASS 1992–1996 (pre-fortification) were compared to 1999–2003 (post-fortification).

Results

A significant decrease in spina bifida (OR 0.51, 95% CI 0.36–0.73) and ostium secundum atrial septal defects (OR 0.80, 95% CI 0.69–0.93) was evident, but there was a significant increase in obstructive defects of the renal pelvis and ureter (OR 1.45, 95% CI 1.24–1.70), abdominal wall defects (OR 1.40, 95% CI 1.04–1.88) and pyloric stenosis (OR 1.49, 95% CI 1.18–1.89).

Conclusions

Consistent with other studies, a 50% reduction in spina bifida was associated with the post-fortification time period. Supporting the possibility that folic acid fortification may play a role in preventing other birth defects, a 20% reduction in atrial septal defects was also associated. The increase in abdominal wall defects, most notably gastroschisis, is likely related to pre-existing increasing trends documented in several regions around the world. The increase in pyloric stenosis and obstructive urinary tract defects was not expected and any causal relationship with folic acid fortification remains unclear. Similar studies by other birth defects surveillance systems in Canada and elsewhere are needed to confirm these trends.

Key words: Folic acid, heart septal defects, atrial, congenital abnormalities, pyloric stenosis, gastroschisis

Résumé

Objectifs

Il est prouvé que l’enrichissement en acide folique des produits céréaliers réduit la fréquence des anomalies du tube neural (ATN) au Canada et ailleurs dans le monde. Cependant, l’impact d’un apport supplémentaire en acide folique sur les autres anomalies congénitales n’a pas été suffisamment étudié.

Méthode

À l’aide du système de surveillance des anomalies congénitales de l’Alberta (ACASS), nous avons examiné les variations dans la fréquence de certaines anomalies congénitales pour lesquelles on pense qu’une supplémentation multivitaminique contenant de l’acide folique aurait un effet. Les anomalies répertoriées dans l’ACASS de 1992 à 1996 (avant l’enrichissement) ont été comparées aux données de 1999–2003 (après l’enrichissement).

Résultats

Des baisses significatives du spina bifida (RC=0,51, IC de 95 % = 0,36-0,73) et de la persistance de l’ostium secundum [variété la plus fréquente de communication interauriculaire] (RC=0,80, IC de 95 % = 0,69-0,93) ont été observées, avec par contre des augmentations significatives des malformations obstructives du bassinet du rein et de l’uretère (RC=1,45, IC de 95 % = 1,24-1,70), des malformations de la paroi abdominale (RC=1,40, IC de 95 % = 1,04-1,88) et de la sténose du pylore (RC=1,49, IC de 95 % = 1,18-1,89).

Conclusion

Conformément aux résultats d’autres études, une diminution de 50 % dans la fréquence du spina bifida était associée à la période suivant l’enrichissement en acide folique. Un tel enrichissement pourrait jouer un rôle dans la prévention d’autres anomalies congénitales, comme en témoigne la baisse de 20 % dans la fréquence de la communication interauriculaire. L’augmentation des malformations de la paroi abdominale, en particulier du laparoschisis, est probablement liée à des tendances haussières préexistantes signalées dans plusieurs régions du monde. Les augmentations de la sténose du pylore et des malformations obstructives du tractus urinaire n’étaient pas prévues, mais une relation causale entre ces anomalies et l’enrichissement en acide folique n’est pas encore établie. Il faudrait mener des études semblables à partir d’autres systèmes de surveillance des anomalies congénitales au Canada et ailleurs dans le monde pour confirmer ou infirmer ces tendances.

Mots clés: acide folique, communication interauriculaire, anomalies congénitales, sténose du pylore, laparoschisis

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[CR1] 1.Centers for Disease ControlPrevention. Trends in infant mortality attributable to birth defects–United States, 1980–1995. MMWR. 1998;47:773–78. [PubMed] [Google Scholar]

[CR2] 2.Waitzman NJ, Scheffler RM, Romano PS. The Cost of Birth Defects. Maryland: The University Press of America; 1996. pp. 1–7. [Google Scholar]

[CR3] 3.Carmona RH. The global challenges of birth defects and disabilities. Lancet. 2005;366:1142–44. doi: 10.1016/S0140-6736(05)67459-4. [DOI] [PubMed] [Google Scholar]

[CR4] 4.De Wals P, Tairou F, Van Allen MI, Uh SH, Lowry RB, Sibbald B, et al. Reduction in neural-tube defects after folic acid fortification in Canada. N Engl J Med. 2007;357(2):135–42. doi: 10.1056/NEJMoa067103. [DOI] [PubMed] [Google Scholar]

[CR5] 5.Botto L, Olney R, Erickson J. Vitamin supplements and the risk for congenital anomalies other than neural tube defects. Am J Med Genet. 2004;125C(1):12–21. doi: 10.1002/ajmg.c.30004. [DOI] [PubMed] [Google Scholar]

[CR6] 6.Goh YI, Bollano E, Einarson TR, Koren G. Prenatal multivitamin supplementation and rates of congenital anomalies: A meta-analysis. J Obstet Gynaecol Can. 2006;28(8):680–89. doi: 10.1016/S1701-2163(16)32227-7. [DOI] [PubMed] [Google Scholar]

[CR7] 7.Yazdy MM, Honein MA, Xing J. Reduction in orofacial clefts following folic acid fortification of the U.S. grain supply. Birth Defects Res A Clin Mol Teratol. 2007;79(1):16–23. doi: 10.1002/bdra.20319. [DOI] [PubMed] [Google Scholar]

[CR8] 8.MRC Vitamin Study Research Group Prevention of neural tube defects: Results of the Medical Research Council Vitamin Study. Lancet. 1991;338(8760):131–37. doi: 10.1016/0140-6736(91)90133-A. [DOI] [PubMed] [Google Scholar]

[CR9] 9.Czeizel AE, Dudas I. Prevention of the first occurrence of neural-tube defects by periconcep-tional vitamin supplementation. N Engl J Med. 1992;327(26):1832–35. doi: 10.1056/NEJM199212243272602. [DOI] [PubMed] [Google Scholar]

[CR10] 10.Public Health Agency of Canada. Folic Acid: Why All Women Who Could Become Pregnant Should Be Taking Folic Acid. Ottawa, ON: Public Health Agency of Canada; 2003. [Google Scholar]

[CR11] 11.Van Allen MI, Fraser FC, Dallaire L, Allanson J, McLeod DR, Andermann E, Friedman JM. Recommendations on the use of folic acid supplementation to prevent the recurrence of neural tube defects: Guidelines of the Clinical Teratology Committee, Canadian College of Medical Geneticists. CMAJ. 1993;149(9):1239–43. [PMC free article] [PubMed] [Google Scholar]

[CR12] 12.Public Health Agency of Canada. Evaluation of Food Fortification with Folic Acid for the Prevention of Neural Tube Defects: Executive Summary 1997–2003. Ottawa, ON: Public Health Agency of Canada; 2004. [Google Scholar]

[CR13] 13.Canada Gazette. 1998.

[CR14] 14.Mills JL, Signore C. Neural tube defect rates before and after food fortification with folic acid. Birth Defects Res A Clin Mol Teratol. 2004;70(11):844–45. doi: 10.1002/bdra.20075. [DOI] [PubMed] [Google Scholar]

[CR15] 15.De Wals P, Rusen ID, Lee NS, Morin P, Niyonsenga T. Trend in prevalence of neural tube defects in Quebec. Birth Defects Res A Clin Mol Teratol. 2003;67(11):919–23. doi: 10.1002/bdra.10124. [DOI] [PubMed] [Google Scholar]

[CR16] 16.Ray JG, Meier C, Vermeulen MJ, Boss S, Wyatt PR, Cole DEC. Association of neural tube defects and folic acid fortification in Canada. Lancet. 2002;360(9350):2047–48. doi: 10.1016/S0140-6736(02)11994-5. [DOI] [PubMed] [Google Scholar]

[CR17] 17.Persad VL, Van den Hof MC, Dube JM, Zimmer P. Incidence of open neural tube defects in Nova Scotia after folic acid fortification. CMAJ. 2002;167(3):241–45. [PMC free article] [PubMed] [Google Scholar]

[CR18] 18.Shaw GM, Lammer EJ, Wasserman CR, O’Mally CD, Tolarova MM. Risks of orofacial clefts in children born to women using multivitamins containing folic acid periconceptionally. Lancet. 1995;346(8972):393–96. doi: 10.1016/S0140-6736(95)92778-6. [DOI] [PubMed] [Google Scholar]

[CR19] 19.Tolorova M, Harris J. Reduced recurrence of orofacial clefts after periconceptional supplementation with high-dose folic acid and multivitamins. Teratology. 1995;51(2):71–78. doi: 10.1002/tera.1420510205. [DOI] [PubMed] [Google Scholar]

[CR20] 20.Werler MM, Hayes C, Louik C, Shapiro S, Mitchell AA. Multivitamin supplementation and risk of birth defects. Am J Epidemiol. 1999;150(7):675–82. doi: 10.1093/oxfordjournals.aje.a010070. [DOI] [PubMed] [Google Scholar]

[CR21] 21.Czeizel AE, Timar L, Sarkozi A. Dose-dependent effect of folic acid on the prevention of orofacial clefts. Pediatrics. 1999;104(6):e66. doi: 10.1542/peds.104.6.e66. [DOI] [PubMed] [Google Scholar]

[CR22] 22.Itikala PR, Watkins ML, Mulinare J, Moore CA, Liu Y. Maternal multivitamin use and orofacial clefts in offspring. Teratology. 2001;63(2):79–86. doi: 10.1002/1096-9926(200102)63:2<79::AID-TERA1013>3.0.CO;2-3. [DOI] [PubMed] [Google Scholar]

[CR23] 23.van Rooij I, Ocke M, Straatman H, Zielhuis G, Merkus H, Steegers-Theunissen R. Periconceptional folate intake by supplement and food reduces the risk of nonsyndromic cleft lip with or without cleft palate. Prev Med. 2004;39(4):689–94. doi: 10.1016/j.ypmed.2004.02.036. [DOI] [PubMed] [Google Scholar]

[CR24] 24.Shaw GM, O’Mally CD, Wasserman CR, Tolarova MM, Lammer EJ. Maternal pericon-ceptional use of multivitamins and reduced risk for contruncal heart defects and limb deficiencies among offspring. Am J Med Genet. 1995;59(4):536–45. doi: 10.1002/ajmg.1320590428. [DOI] [PubMed] [Google Scholar]

[CR25] 25.Yang Q, Khoury MJ, Olney RS, Mulinare J. Does periconceptional multivitamin use reduce the risk for limb deficiency in offspring. Epidemiology. 1997;8(2):157–61. doi: 10.1097/00001648-199703000-00006. [DOI] [PubMed] [Google Scholar]

[CR26] 26.Li DK, Daling JR, Mueller BA, Hickok DE, Fantel AG, Weiss NS. Periconceptional multivitamin use in relation to the risk of congenital urinary tract anomalies. Epidemiology. 1995;6(3):212–18. doi: 10.1097/00001648-199505000-00004. [DOI] [PubMed] [Google Scholar]

[CR27] 27.Czeizel AE. Reduction of urinary tract and cardiovascular defects by periconceptional vitamin supplementation. Am J Med Genet. 1996;62(2):179–83. doi: 10.1002/(SICI)1096-8628(19960315)62:2<179::AID-AJMG12>3.0.CO;2-L. [DOI] [PubMed] [Google Scholar]

[CR28] 28.Botto L, Mulinare J, Erickson J. Occurrence of omphalocele in relation to maternal multivitamin use: A population-based study. Pediatrics. 2002;109(5):904–8. doi: 10.1542/peds.109.5.904. [DOI] [PubMed] [Google Scholar]

[CR29] 29.Botto LD, Khoury MJ, Mulinare J, Erickson JD. Periconceptional multivitamin use and the occurrence of conotruncal heart defects: Results from a population-based, case-control study. Pediatrics. 1996;98(5):911–17. [PubMed] [Google Scholar]

[CR30] 30.Botto LD, Mulinare J, Erickson J. Occurrence of congenital heart defects in relation to maternal multivitamin use. Am J Epidemiol. 2000;151(9):878–84. doi: 10.1093/oxfordjournals.aje.a010291. [DOI] [PubMed] [Google Scholar]

[CR31] 31.Canfield M, Collins J, Botto L, Williams L, Mai C, Kirby R, et al. Changes in the birth prevalence of selected birth defects after grain fortification with folic acid in the United States: Findings from a multi-state population-based study. Birth Defects Res A Clin Mol Teratol. 2005;73(10):679–89. doi: 10.1002/bdra.20210. [DOI] [PubMed] [Google Scholar]

[CR32] 32.Botto LD, Loffredo C, Scanlon KS, Ferencz C, Khoury MJ, Wilson D, Correra A. Vitamin A and cardiac outflow tract defects. Epidemiology. 2001;12(5):491–96. doi: 10.1097/00001648-200109000-00005. [DOI] [PubMed] [Google Scholar]

[CR33] 33.Sinning AR. Role of Vitamin A in the formation of congenital heart defects. Anat Rec (New Anat) 1998;253(5):147–53. doi: 10.1002/(SICI)1097-0185(199810)253:5<147::AID-AR8>3.0.CO;2-0. [DOI] [PubMed] [Google Scholar]

[CR34] 34.Simmons C, Mosley B, Fulton-Bond C, Hobbs C. Birth defects in Arkansas: Is folic acid fortification making a difference. Birth Defects Res A Clin Mol Teratol. 2004;70(9):559–64. doi: 10.1002/bdra.20063. [DOI] [PubMed] [Google Scholar]

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Changes in Frequencies of Select Congenital Anomalies since the Onset of Folic Acid Fortification in a Canadian Birth Defect Registry

Kimberly A Godwin, MSc

Barbara Sibbald, MSc

Tanya Bedard, BSc

Boris Kuzeljevic, MA

R Brian Lowry, MD, DSc

Laura Arbour, MD

Abstract

Objectives

Methods

Results

Conclusions

Résumé

Objectifs

Méthode

Résultats

Conclusion

References

ACTIONS

PERMALINK

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PERMALINK

Changes in Frequencies of Select Congenital Anomalies since the Onset of Folic Acid Fortification in a Canadian Birth Defect Registry

Kimberly A Godwin, MSc

Barbara Sibbald, MSc

Tanya Bedard, BSc

Boris Kuzeljevic, MA

R Brian Lowry, MD, DSc

Laura Arbour, MD

Abstract

Objectives

Methods

Results

Conclusions

Résumé

Objectifs

Méthode

Résultats

Conclusion

References

ACTIONS

PERMALINK

RESOURCES

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