Pre-conceptional folic acid supplementation: A possible cause for the increasing rates of ankyloglossia.

BACKGROUND: There is an increasing awareness to ankyloglossia (tongue-tie) in infants, with marked increase in its report in the medical literature. Some reports indicate increase in prevalence. Whether the increase ankyloglossia rate is a real phenomenon or merely reflects increased awareness and reports has to be determined. One explanation for the increasing ankyloglossia rates is the growing trend of breast feeding initiation, often impaired by ankyloglossia, which brings it to medical attention. We propose an alternative hypothetical explanation based on increasing utilization of periconceptional folic acid supplementation for the prevention of neural tube defects (NTDs). Inadequate folic acid supply during organogenesis impairs cell division, and the mid-line structures are at the highest risk. We postulated that higher folic acid supply during organogenesis might enhance tissue synthesis with tighter closure of mid-line structures including the lingual frenulum, resulting in ankyloglossia. METHODS: To assess this hypothesis, we undertook an observational case control study comparing folic acid utilization before pregnancy in mothers of infants with and without ankyloglossia. Infants with ankyloglossia (n = 85) were compared to a control group without ankyloglossia (n = 140). RESULTS: There was a slight, insignificant elevated frequency of reported utilization of folic acid ("any intake") among mothers of infants with ankyloglossia compared with controls (74.1% and 66.4%, respectively). This difference was slightly higher, yet insignificant when folic acid intake "in most days" was considered (65.9% and 53.6%, respectively, OR = 1.67, 95%CI = 0.93-3.05, P = 0.07). In contrast, the reported intake of pre-conceptional folic acid "on a regular basis" was significantly higher among mothers of infants with ankyloglossia compared with controls (54.1% and 25.7%, respectively, OR = 3.41, 95%CI = 1.85-6.27, p < 0.0001). INTERPRETATION: The reported association between higher frequency of regular pre-conceptional folic acid intake and ankyloglossia, supports the hypothesis for this association. More studies are required to test this hypothesis.

Folic acid supplementation for pregnant women and those planning pregnancy: 2015 update.

During the last decade critical new information has been published pertaining to folic acid supplementation in the prevention of neural tube defects (NTDs) and other folic acid-sensitive congenital malformations. These new data have important implications for women, their families, and health care professionals. We performed a review looking for the optimal dosage of folic acid that should be given to women of reproductive age who are planning or not avoiding conception to propose updated guidelines and thus help health care providers and patients. In addition to fortification of dietary staples with folic acid, women of reproductive age should supplement before conception with 0.4-1.0 mg of folic acid daily as part of their multivitamins. In the United States all enriched rice is also fortified with folic acid at 0.7 mg per pound of raw rice. However, this is not the case in many countries, and it has been estimated that only 1% of industrially milled rice is fortified with folic acid. In countries where rice is the main staple (eg, China), this does not allow effective folate fortification. Whereas the incidence of NTDs is around 1/1000 in the United States, it is 3- to 5-fold higher in Northern China and 3-fold higher in India. A recent population-based US study estimated that the reduction in NTD rates by folic acid is more modest than previously predicted. The potential of NTD prevention by folic acid is underutilized due to low adherence with folic acid supplementation, and calls for revising the policy of supplementation have been raised. We identified groups of women of reproductive age who may benefit from higher daily doses of folic acid, and this should be considered in current practice. These include women who have had previous pregnancies with NTDs, those who did not plan their pregnancy and hence did not supplement, and women with low intake or impaired adherence to daily folic acid supplementation. In addition, women with known genetic variations in the folate metabolic cycle, those exposed to medications with antifolate effects, smokers, diabetics, and the obese may benefit from higher doses of folic acid daily during the first trimester.

Anemia and iron deficiency in children: association with red meat and poultry consumption.

OBJECTIVE: The aim of this study was to study the relative contribution of dietary sources of iron in children with high prevalence of anemia and iron deficiency (ID). METHODS: A cross-sectional study in 263 healthy, 1.5- to 6-year-old children in the Jewish sector of Jerusalem, Israel. Venous blood samples and a qualitative Food Frequency Questionnaire on iron-rich foods were obtained. Anemia was defined as hemoglobin <11 g/dL for children younger than 4 years and <11.5 g/dL for children older than 4 years; ID was defined as ferritin <12 µg/L. RESULTS: Anemia was found in 11.2%, ID in 22%, and iron-deficiency anemia in 3.7%. The prevalence of anemia was higher in toddlers ages 1.5 to 3 years compared with children ages 3 to 6 years (17.7% vs 7.3%, P = 0.01). Children with extremely low red meat consumption (seldom) had 4-fold higher rates of ID than those who consumed ≥2 times per week (odds ratio 3.98; 95% confidence interval 1.21-13.03; P = 0.023), whereas poultry consumption was not associated with ID. Soy consumption was inversely associated with ferritin (marginally significant, r = -0.134, P = 0.057). CONCLUSIONS: The high prevalence of anemia and ID found in this study, mainly in children 1.5 to 3 years old, is related to low red meat consumption. The characteristically high poultry consumption in the Israeli population was not protective. The shift toward reduced red meat consumption and higher poultry consumption in developed countries may result in increasing the risk of ID.

Vitamin D deficiency in children in Jerusalem: the need for updating the recommendation for supplementation.

BACKGROUND: Hypovitaminosis D is common worldwide, even in sunny regions. OBJECTIVES: To assess the prevalence and determinants of vitamin D deficiency in toddlers. METHODS: A cross-sectional prospective study was conducted in healthy Jewish children aged 1.5-6 years at five primary care pediatric clinics in the Jerusalem area during the period October 2009 to November 2010. Parents were interviewed regarding personal and demographic data and sun exposure. Blood samples were obtained for serum 25-hydroxyvitamin D [25-OHD] level. Vitamin D deficiency and insufficiency were defined as 25-OHD < 20 ng/ml and < 30 ng/ml, respectively. RESULTS: Of 247 children studied, 188 (76%) were ultra-Orthodox and 59 (24%) were Orthodox, traditional or secular. Mean (+/- SD) 25-OHD level was 25.7 +/- 10 ng/ml. Only 73 children (29.6%) had sufficient 25-OHD levels, 104 (42.1%) had insufficiency, and 70 (28.3%) had 25-OHD deficiency. The difference between ultra-Orthodox and others was insignificant (25 +/- 10 vs. 27.8 +/- 10.5 ng/ml respectively, P = 0.062). Children aged 1.5-3 years had higher 25-OHD levels than those aged 3-6 years (28.6 +/- 10.7 and 24 +/- 9.2 ng/ml respectively, P < 0.001). Vitamin D deficiency was more common in winter (53%) and autumn (360%) than in summer (19%) and spring (16%). Toddlers attending long-day kindergartens had higher 25-OHD level than those staying at home or at short-day kindergartens (28.8 +/- 11.5 and 24.7 +/- 9.6 ng/ml respectively, P < 0.05). CONCLUSIONS: A high prevalence of vitamin D deficiency was found in toddlers in our study, mainly in older children and in the winter and autumn. We recommend routine supplementation of vitamin D for children beyond the age of one year.

Preconceptional folic acid utilization in Israel: five years after the guidelines.

OBJECTIVE: In Israel, a national survey was conducted in order to assess the efficacy of the ongoing national folic acid (FA) campaign launched in 2000. The Ministry of Health had issued official guidelines in August 2000 recommending daily FA supplementation for all childbearing age women. METHODS: In 2005, structured interviews of pregnant and postpartum women were conducted by the nursing staff of the Maternal Child Health Clinics administered by the Public Health Service. The results of the 2005 survey are compared with similar surveys done in 2002 and 2000 (baseline). RESULTS: In the 2005 survey (n=1860), FA awareness, knowledge, timing knowledge and preconceptional utilization were 90.3%, 80.8%, 74.6% and 34.0%, respectively. Education was significantly associated with compliance: only 13.6% of women with <12 years of education utilized FA preconceptionally versus 48.1% of women with >or=16 years. In the 2002 survey (n=1661), FA awareness, knowledge, and preconceptional utilization were 85%, 77.7% and 30.5%, respectively. In the 2000 survey (n=1719), FA awareness was 54.6%, knowledge was 17.6% and preconceptional utilization was 5.2%. CONCLUSIONS: The national preconceptional FA campaign in Israel has resulted in significant increases in awareness, knowledge and preconceptional utilization.

Surveillance of neural tube defects in Israel: the effect of the recommendation for periconceptional folic acid.

BACKGROUND: Open neural tube defects are among the most common severely disabling birth defects. Secondary prevention by early diagnosis during pregnancy and abortion of affected fetuses lead to a marked reduction of NTD incidence at birth. For primary prevention of these defects, in August 2000 the Israel Ministry of Health issued guidelines recommending a daily 0.4 mg folic acid supplement for all women in their childbearing years with special emphasis on the 3 months preceding conception and the first trimester of pregnancy. OBJECTIVES: To compare the epidemiologic characteristics of NTD in Israel before and after the guidelines for folic acid supplementation. METHODS: A national registry of NTD was begun in 1999. Since the Ministry of Health published the recommendation for folic acid supplementation in mid-2000, the years 1999-2000 represent the status prior to the recommendation and the years 2002-2004 the status after. RESULTS: A marked decline in the rate of spina bifida was observed in the last 3 years (from 4.9 to 2.7 per 10,000 live births among Jews and 9.5 to 6.2 among Arabs and Druze). There was no apparent reduction for anencephaly. CONCLUSIONS: Following the Ministry of Health guidelines on folic acid supplementation for women in the reproductive age, a marked reduction in the rates of NTD was observed. In light of this apparent success, continuous efforts should be made to increase the percentage of women taking the supplementation and, especially, to introduce folic acid fortification.

Increased awareness, knowledge and utilization of preconceptional folic acid in Israel following a national campaign.

BACKGROUND: To decrease the risk of neural tube defects (NTDs), the Israeli Ministry of Health (MOH) issued guidelines in August 2000 recommending daily folic acid (FA) supplementation for women in their childbearing age, and concurrently launched a national FA campaign. Campaign effects were assessed by comparing the results of a survey done in 2002 with a baseline survey done in June 2000. METHODS: Both surveys were done within the network of the Public Health Services' Mother and Child Health Clinics (MCHC). Nursing staff conducted structured interviews of pregnant women and mothers of newborn infants. RESULTS: In the 2002 survey (n = 1661), awareness was 85%, correct knowledge was 77.7% and 30.5% utilized FA preconceptionally. Ratios of awareness, knowledge and utilization were highest among women with post-university education (93%, 84%, 46%), and awareness and utilization were significantly higher in the 25-29 year age bracket (90%, 35%). In the baseline 2000 survey (n = 1719), FA awareness had been 54.6%, knowledge of the benefits of FA was 17.6% and preconceptional utilization was reported by a mere 5.2%. CONCLUSIONS: A national periconceptional FA campaign in Israel resulted in significant increases in awareness and correct knowledge, and a sixfold increase in its intake.

Towards an integrated adolescent health policy in Israel.

The principle health issues of Israeli adolescents are largely related to health risk behaviors, and are therefore preventable. Deciding which public health interventions are of highest priority ought to be determined according to the relative importance of these issues among Israeli youth. Violence in the schools and dieting to lose weight are highly prevalent in this population, with unintentional accidents, smoking and other substance abuse, and reproductive health being other important issues. Special health planning considerations that take into account Israel's unique population mix are necessary. Israel does not yet have a comprehensive, integrated health policy for youth. Nevertheless, legislation has been enacted that provides universal national health insurance, as well as preventive school health services to all school children from the 1st to 9th grade under the Ministry of Health's responsibility, setting the foundations for such a comprehensive youth health policy. In addition, policy makers and health care providers have recently recognized the need for a pro-active approach regarding health service development for adolescents. In this article, we give an overview of current Israeli health policies that impact upon the adolescent population, and propose seven priority areas that should be addressed in order to advance the health of youth in this country.

Surveillance of neural tube defects in Israel.

BACKGROUND: Open neural tube defects are among the most common malformations of the fetus. Secondary prevention by early diagnosis during pregnancy and abortion of affected fetuses result in a marked reduction of NTD incidence at birth. The dramatic effect of folic acid for primary prevention of these defects led to recommendations for folic acid supplementation in women of reproductive age. OBJECTIVE: To describe the epidemiologic features of NTD in Israel in 1999-2000. METHODS: A national registry of NTD was begun in 1999. During the years 1999-2000, a non-syndromic NTD was diagnosed in at least 394 pregnancies (166 anencephaly, 166 spina bifida, 43 encephalocele, and 19 with other types of NTD). The religious-ethnic affiliation was known in 392 cases (209 Jews and 183 non-Jews). RESULTS: Despite a marked decline in the rate of NTD at birth in the last few decades, the total rates during pregnancy did not change significantly, demonstrating that the changes were secondary to termination of affected pregnancies. At birth, NTD were almost four times more frequent among non-Jews (3.6 per 10,000 live births for anencephaly and 5.9 for spina bifida) than among Jews (anencephaly 1/10,000 live births, spina bifida 1.4/10,000 live births). The complete data of the registry showed an approximately twofold difference in the overall rates during pregnancy between Jews (anencephaly 5.3, spina bifida 4.6, total 11/10,000 live births) and non-Jews (anencephaly 8.8, spina bifida 10.3, total 22.3/10,000 live births). The registry demonstrated that the significant differences in NTD incidence observed at birth between Jews and non-Jews are secondary to a combined effect of a higher frequency of the malformations among non-Jews and a lower proportion of termination of affected pregnancies among non-Jews. CONCLUSIONS: The data presented here will serve as a basis for evaluating the impact of the Ministry of Health recommendations for folic acid supplementation on the incidence of NTD.