|Year : 2008 | Volume
| Issue : 2 | Page : 134-137
Estimation and correlation of serum folic acid levels in spina bifida babies and their mothers
DK Gupta1, A Pandey1, AN Gangopadhyay1, S Prasad2, TB Singh3, HD Khanna4, VD Upadhyaya1
1 Department of Pediatric Surgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi-221 005, UP, India
2 Department of General Surgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi-221 005, UP, India
3 Department of Community Medicine, Institute of Medical Sciences, Banaras Hindu University, Varanasi-221 005, UP, India
4 Department of Biophysics, Institute of Medical Sciences, Banaras Hindu University, Varanasi-221 005, UP, India
D K Gupta
Department of Pediatric Surgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi, UP-221 005
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Spina bifida is a common neural tube defect. The relative deficiency of folic acid (FA) in mother during periconceptional period is an important factor. We measured the serum FA levels in spina bifida babies and their mothers and compared the result with the FA level in normal babies. The blood samples were collected at the time of admission to hospital. Enquiry made about the age, sex, and birth order, problem in siblings and FA supplementation and detailed examination done to access the severity of the problem. Folic acid estimation was done by enzyme-linked immunosorbent assay method. Antenatal FA supplementation was found in 40% of cases and 80% of control group. In the study group, the mean FA level in babies and mothers of FA supplemented group was 21.73 ± 5.64 ng/dl and 15.02 ± 3.02 ng/dl and in non-supplemented group were 7.41 ± 1.48 ng/dl and 4.12 ± 0.81 ng/dl, respectively. In control group mean FA level in babies and mothers of FA supplemented group were 16.88 ± 3.2 ng/dl and 14.70 ± 2.30 ng/dl and in nonsupplemented group were 14.33 ± 1.74 ng/dl and 10.75 ± 1.34 ng/dl, respectively. The serum FA levels in spina bifida babies as well as in their mothers were significantly low as compared to control group. This study suggests that the low serum FA levels in a lady at the time of pregnancy may be a causative factor in the pathogenesis of spina bifida and low levels in affected babies.
Keywords: Folic acid, neural tube defect, spina bifida
|How to cite this article:|
Gupta D K, Pandey A, Gangopadhyay A N, Prasad S, Singh T B, Khanna H D, Upadhyaya V D. Estimation and correlation of serum folic acid levels in spina bifida babies and their mothers. J Pediatr Neurosci 2008;3:134-7
|How to cite this URL:|
Gupta D K, Pandey A, Gangopadhyay A N, Prasad S, Singh T B, Khanna H D, Upadhyaya V D. Estimation and correlation of serum folic acid levels in spina bifida babies and their mothers. J Pediatr Neurosci [serial online] 2008 [cited 2020 Jun 2];3:134-7. Available from: http://www.pediatricneurosciences.com/text.asp?2008/3/2/134/43640
| Introduction|| |
Neural tube defects (NTDs) are characterized as congenital defects of the central nervous system resulting from incomplete or incorrect closure of the neural tube during early embryologic development.  NTDs are thought to be caused primarily by chromosomal abnormalities, single-gene disorders, and environmental agents. Spina bifida is a common NTD affecting 1-2/1000 live birth with geographical variation.  It is usually an isolated birth defect.
The possibility that FA was specifically linked to NTD in humans was first reported by Hibbard.  A number of observational studies reported that periconceptional use of folic acid (FA) may prevent NTDs.  Folic acid also reduces the risk of recurrent NTD-affected births among mothers at higher risk because of a previous NTD-affected birth.  It has been shown that periconceptional FA supplementation reduces the risk of NTD recurrence up to 70-85%. 
The present study was done to estimate the serum FA level in spina bifida babies and their mother to know the FA status in the postnatal period and to compare the data with the normal babies so as to find if there is any relation of the two or not.
| Materials and Methods|| |
The present study was a prospective study, approved by the hospital ethical and postgraduate committees. The study group consisted of patients with spina bifida aperta admitted in the ward for operative correction and their mothers. The control group consisted of 30 babies that did not have any congenital malformation or major illness.
Detailed history was taken with emphasis on FA intake by mother in antenatal period and birth order of the baby. The time to start the FA supplementation, its dose and duration was recorded. The baby was examined to determine the type of defect, its size, rupture or intact sac, club foot, paraparesis and paraplegia, and patulous sphincter. The ultrasonography of cranium through open fontanellels was performed in all patients and computed tomography (CT) scan was done when indicated.
Three milliliters of blood was collected from all babies and their mothers in the study group as well as in the control group in the plain vials. Blood was allowed to clot and serum was separated. Folic acid estimation was done by enzyme-linked immunosorbent assay method.
All the data were entered into a MS Excel database and analyzed using SPSS 15.0 version for windows. Student's ' t '-test for independent samples was applied for continuous variables and Chi square-test and Pearson correlation coefficient were calculated wherever necessary. A two-tailed P -value of £ 0.05 was considered as significant. The values are expressed as mean ± SD.
| Results|| |
In the study group, the age of presentation varied from neonatal period to more than 1 year, but most of the patients (17 out of 30) presented in infancy. Nine out of 30 (30%) were neonates and remaining 4 out of 30 (13.3%) were toddlers. There were 13 males and 17 females, which consisted of 43.3% and 56.7%, respectively. While in the same age matched control group, there were 17 male and 13 female patients, which consisted of 56.7% and 43.3%, respectively.
Fifty percent of all cases are of first birth order, i.e. first baby is affected by the spina bifida anomaly followed by second birth order which is 10 out of 30 (33.3%) followed by third birth order which is 3 out of 30 (10%). There were two patients of fourth birth order in which their younger siblings were perfectly normal. In all the patients of higher birth order, the younger siblings were perfectly normal and none of the mother of affected child (of higher birth order) has taken FA supplementation in antenatal period. Even they have not taken supplementation in previous pregnancy.
In the study group, the mean FA level in babies and mothers of FA supplemented group was 21.73 ± 5.64 ng/dl (range: 18-24 ng/dl) and 15.02 ± 3.02 ng/dl (range: 13-18 ng/dl) and in nonsupplemented group were 7.41 ± 1.48 ng/dl (range: 5-10 ng/dl) and 4.12 ± 0.81 ng/dl (range: 3-7 ng/dl), respectively [Table 1] and [Table 2]). In control group mean FA level in babies and mothers of FA supplemented group were 16.88 ± 3.2 ng/dl (range: 13-18 ng/dl) and 14.70 ± 2.30 ng/dl (range: 11-17 ng/dl) and in non-supplemented group were 14.33 ± 1.74 ng/dl (range: 11-17 ng/dl) and 10.75 ± 1.34 ng/dl (range: 8-13 ng/dl), respectively. On calculation the correlation coefficient between the FA level in babies and mothers in different groups, it was found that in cases the FA level in babies and their mothers had good correlation as indicated by the Pearson correlation coefficient 0.937 which was statistically significant ( P value < 0.001). In case of control group, the Pearson correlation coefficient was found to be 0.822 which was also statistically significant.
| Discussion|| |
In 1980, the results of a nonrandomized trial revealed that taking multivitamins during the periconceptional period reduced the risk of having a fetus or infant with a neural-tube defect.  Since then, various observational studies have demonstrated a reduced risk among women who took multivitamin supplements containing FA , and those who had higher dietary intakes of folate ,, during early pregnancy.
In a randomized study, FA supplementation has shown the reduction in occurrence of NTDs by 100% (95% confidence interval [CI]: 0.0-0.63).  In randomized controlled trials, FA supplementation before conception and during the first trimester has been shown to reduce the recurrence of NTDs by 72% (relative risk, 0.28; 95% CI: 0.12-0.71) in women with a previous NTD-affected pregnancy.  Mills et al , in their study, however, concluded that the periconceptional use of multivitamins or folate-containing supplements by American women does not decrease the risk of having an infant with a neural-tube defect  which is in variance with the view of majority.
A woman's risk of having a fetus or infant with a neural-tube defect can be reduced by the consumption of a multivitamin containing FA during the periconceptional period - before and during the first 28 days after conception. Neural-tube formation is completed during these 28 days, before most women begin taking prenatal vitamins.  During the critical stages of organogenesis, cell growth is primarily established by cell division. Severe deficiencies of any essential nutrients may result in fetal death, and any minor deficiencies may result in malformations. FA cofactors are needed for the synthesis of nucleic acids and are essential for cell division and growth. Levels Vitamins C, B-6 and B-12 play a role in maintaining FA in its reduced form. Furthermore, FA and vitamin B-12 are involved in the remethylation of homocysteine to methionine; vitamin B-6 serves as a cofactor to the conversion of homocysteine to cystathionine, and both processes lead to reduced levels of the toxic metabolite homocysteine. Because nerve tissue is dependent on the methionine synthetase reaction, it may be affected by the absence of folate or vitamin B-12. 
In all of these studies, there has been no direct study of the serum levels of FA in mothers and their children and our study is one of the few studies where FA level is directly measured and compared. Smithells et al , directly measured the serum and red blood cell (RBC) folate level in a group of 959 pregnant women and reported significant reduced RBC folate level in six NTD affected pregnancies.  Kirke et al , collected samples from over 56,000 women at their first visit postconception. The blood samples of 81 who had NTD affected babies were analyzed and matched with 247 control subjects whose pregnancy were unaffected. Plasma folate and RBC folate were significantly lower in neural tube affected pregnancies as compared to unaffected pregnancies.  Lucock et al , measured the plasma folate, B12 and 5-methyl-tetrahydrofolate and RBC folate level in nine non-pregnant women who previously had two NTD affected pregnancies and found no difference in the levels as compared to controls.  However, they noticed that, the level of dietary folate required reaching an equivalent plasma concentration of tetrahydrofolate was significantly greater in women with NTD affected babies. Mooij et al , studied the folate levels both in the serum and RBCs along with other vitamins in women at risk for having a pregnancy complicated with a NTD but could not draw any conclusion due to the small sample size. 
In our study group, the mean FA level in the supplemented and non-supplemented subgroup of babies showed significant difference. In case of mothers of study group, the mean FA levels also showed statistically significant difference. This indicates that the supplementation taken is adequate if considered dose wise.
On comparing the cases and control, it was found that the children of supplemented subgroup of case and control group had mean FA level 21.73 ± 5.64 ng/ml and 16.88 ± 3.28 ng/ml. Although there was significant difference in the value, but that is the reflection of FA taken in the antenatal period, its doses and duration. It can be argued that the high levels of FA in the cases are against its beneficial role in preventing NTD, but it is to be noticed that the etiology of the NTD is multifactorial  and not only dependant on FA use.
The maternal serum FA level in supplemented subgroup of case and control groups were 15.02 ± 3.0 ng/ml and 14.70 ± 2.3 ng/ml, respectively. The difference was statically not significant as both groups taken FA supplementation. If concentrating on the non-supplemented subgroups of case and control group, the serum FA levels in the babies were 7.41 ± 1.48 ng/ml and 14.33 ± 1.74 ng/ml. The difference is statically highly significant and the FA level of case is at the lower limit of the normal range, while in the control group the FA level was in the mid of normal range. Most probably, it was due to the good nutrition state. The maternal serum FA level of non-supplemented subgroup of the case and control group was 4.12 ± 0.81 ng/ml and 10.75 ± 1.34 ng/ml. The difference is highly significant with P value <0.001. It was noticed that the maternal serum FA level in non-supplemented case group was below the normal level whereas in control group it is in the normal range indicating good nutrition state in the control group which seems to be preventive for spina bifida malformation.
Thus to conclude spina bifida is a very common problem in our country and in our study serum FA level was directly measured, compared, and correlated. This study shows that the FA level was low in affected children and their mothers, and its lack at the time of pregnancy can be a major causative factor in the pathogenesis of spina bifida babies. Thus, the study reinforces the results of epidemiological and interventional studies.
| References|| |
|1.||Bol KA, Collins JS, Kirby RS; National Birth Defects Prevention Network . Survival of infants with neural tube defects in the presence of folic acid fortification. Pediatrics 2006;117:803-13. |
|2.||Smith JL. Management of neural tube defects, hydrocephalus, refractory epilepsy, and central nervous system infections. In: Grosfeld JL, O'Neill JA Jr, Fonkalsrud EW, Coran AG, editors. Pediatric surgery, 6 th ed. Mosby; Elsevier; 2006. p. 1987-2017. |
|3.||Hibbard BM. The role of folic acid in pregnancy-with particular reference to anaemia, abruption and abortion. J Obstet Gynaecol Br Common 1964;71:529-42. |
|4.||Green NS. Folic acid supplementation and prevention of birth defects. J Nutr 2002;132:2356S-60S. [PUBMED] [FULLTEXT]|
|5.||Smithells RW, Sheppard S, Schorah CJ, Seller MJ, Nevin NC, Harris R, et al . Possible prevention of neural-tube defects by periconceptional vitamin supplementation. Lancet 1980;1:339-40. [PUBMED] [FULLTEXT]|
|6.||Mulinare J, Cordero JF, Erickson JD, Berry RJ. Periconceptional use of multivitamins and the occurrence of neural tube defects. JAMA 1988;260:3141-5. [PUBMED] |
|7.||Milunsky A, Jick H, Jick SS, Bruell CL, MacLaughlin DS, Rothman KJ, et al . Multivitamin/folic acid supplementation in early pregnancy reduces the prevalence of neural tube defects. JAMA 1989;262:2847-52. [PUBMED] |
|8.||Bower C, Stanley FJ. Dietary folate as a risk factor for neural-tube defects: Evidence from a case-control study in Western Australia. Med J Aust 1989;150:613-9. [PUBMED] |
|9.||Werler MM, Shapiro S, Mitchell AA. Periconceptional folic acid exposure and risk of occurrent neural tube defects. JAMA 1993;269:1257-61. [PUBMED] |
|10.||Shaw GM, Schaffer D, Velie EM, Morland K, Harris JA. Periconceptional vitamin use, dietary folate, and the occurrence of neural tube defects in California. Epidemiology 1995;6:219-26. [PUBMED] |
|11.||Czeizel AE, Dudas I. Prevention of the first occurrence of neural tube defects by periconceptional vitamin supplementation. N Engl J Med 1992;327:1832-5. |
|12.||MRC Vitamin Study Research Group. Prevention of neural tube defects. Lancet 1991;338:131-7. [PUBMED] |
|13.||Mills JL, Rhoads GG, Simpson JL, Cunningham GC, Conley MR, Lassman MR, et al . The absence of a relation between the periconceptional use of vitamins and neural-tube defects. N Engl J Med 1989;321:430-5. [PUBMED] |
|14.||Berry RJ, Li Z, Erickson JD, Li S, Moore CA, Wang H, et al . Prevention of neural-tube defects with folic acid in China: China-US collaborative project for neural tube defect prevention. N Engl J Med 1999;341:1485-90. [PUBMED] [FULLTEXT]|
|15.||Mooij PN, Steegers-Theunissen RP, Thomas CM, Doesburg WH, Eskes TK. Periconceptional vitamin profiles are not suitable for identifying women at risk for neural tube defects. J Nutr 1993;123:197-203. [PUBMED] [FULLTEXT]|
|16.||Smithells RW, Sheppard S, Schorah CJ. Vitamin deficiencies and neural tube defects. Arch Dis Child 1976;51:994-50. |
|17.||Kirke PN, Molloy AM, Daly LE, Burke H, Weir DG, Scott JM. Maternal plasma folate and vitamin B12 are independent risk factors for neural tube defects. Q J Med 1993;86:703-8. [PUBMED] [FULLTEXT]|
|18.||Lucock MD, Wild J, Schorah GI, Levene MI, Hartley R. The methylfolate axis in neural tube defects: In vitro characterization and clinical investigation. Rimhem Med Metab Eiol 1994;52:101-4 |
[Table 1], [Table 2]
|This article has been cited by|
||Clinical spectrum of neural tube defects with special reference to karyotyping study
| ||Kumar, V. and Singh, A. and Sharma, S.P. and Srivastava, A. and Saxena, A. and Gangopadhyay, A.N. |
| ||Journal of Pediatric Neurosciences. 2012; 7(2): 82-84 |
||Development of a highly sensitive and selective hyphenated technique (molecularly imprinted micro-solid phase extraction fiber-molecularly imprinted polymer fiber sensor) for ultratrace analysis of folic acid
| ||Prasad, B.B., Tiwari, M.P., Madhuri, R., Sharma, P.S. |
| ||Analytica Chimica Acta. 2010; 662(1): 14-22 |
||Development of a highly sensitive and selective hyphenated technique (molecularly imprinted micro-solid phase extraction fiber–molecularly imprinted polymer fiber sensor) for ultratrace analysis of folic acid
| ||Bhim Bali Prasad,Mahavir Prasad Tiwari,Rashmi Madhuri,Piyush Sindhu Sharma |
| ||Analytica Chimica Acta. 2010; 662(1): 14 |
|[Pubmed] | [DOI]|
||Imprinted polymer-carbon consolidated composite fiber sensor for substrate-selective electrochemical sensing of folic acid
| ||Prasad, B.B., Madhuri, R., Tiwari, M.P., Sharma, P.S. |
| ||Biosensors and Bioelectronics. 2010; 25(9): 2140-2148 |