In part 1, I talked about genes. Now I will share my thoughts on the other major player: environment. Most people think of environment as the family you are born into and the community and school your child belongs to. Actually, that’s all window dressing compared to the environment that you are providing in your belly! Whilst you are chomping into bacon sarnies, struggling to pull up maternity jeans that won’t stay up and mapping out where all the pregnant-lady friendly toilets are on your route to and from work (thanks Premier Inn Belsize Park!), unbeknownst to you, you are already determining your child’s future.
The bad thing about medical training is that you are all too aware of what can go wrong. Pregnancy is generally viewed as a “magical” time; the miracle of new life being generated from within your body. Paediatric cardiologists however, will start wondering whether a congenital heart malformation is present in the foetal heart beat they are hearing, an orthopaedic surgeon might worry about detecting clubbed foot in the fuzzy ultrasound scan. From the view of the child psychiatrist, forget extra digits and cleft palates, it’s all about the brain and the mind. The good thing about having medical training is that you can spot the bullsh*t that is out there in terms of pregnancy health advice. A pregnant woman is like a goldmine. While women may feel guilty about spending money on themselves, parting with money for the benefit of their unborn baby is totally justifiable and guilt-free. It’s no wonder that the health food industry piles in on this market.
In a recent study in New Zealand (Jeffries, 2012) a researcher in true Ben Goldacre style went to 21 health food shops and 21 pharmacies and asked for advice on morning sickness and what she ought to take for nutritional supplementation for early pregnancy. The recommendations were noted and any endorsed products were bought and ingredients compared with official health guidelines. Only 23.8% of pharmacies and 4.8% of health food stores made recommendations for Kate Middleton style morning sickness in line with official guidelines and 66.7% of pharmacies and 33.3% of health food stores recommended buying products, often branded to target the pregnant mother market, which were contrary to guidelines. Almost 10% of pharmacies and double this number of health food stores gave advice on nutritional supplementation with the potential for vitamin A overdose! Pharmacies were good at recommending folic acid supplementation, but fewer than 50% of health food stores got this vital message across.
If you haven’t heard of the need for folic acid supplementation (400 micrograms a day) pre-pregnancy then there is a really big problem in the dissemination of this public health message. Like the ills of smoking and the benefits of sunscreen, there is little scientific dispute about the benefits of folic acid supplementation in pregnancy in the prevention of neural tube defect. What the hell is a neural tube? Well, once the egg and sperm unite to form one cell with a complete set of DNA, it starts to reproduce by dividing into two, spawning 2 then 4, then 8, then 16 cells. Pretty soon, you have a big blob of cells called a morula (named after a blackberry as that’s what it looks like). Once you have a big enough blob, cells start to differentiate into the precursors of body organs. At around 3 weeks of pregnancy, the cells which will form the brain initially form a 2 dimensional sheet which then curls around on itself to fuse into a 3 dimensional tube: the neural tube. This tube becomes your nervous system. One end of the tube will become the brain, the remainder, your spinal cord. As everything else “brain” is formed from this initial structure, problems at this stage can’t be glossed over or compensated for.
Imagine trying to make a rocket from a flat piece of cardboard. You roll the thing up then tape it along the seam. Now, if you run out of tape, and tape just the top and bottom, you have a gaping hole in the middle. If you tape one end, you have a gap at the other. It doesn’t matter what flashy cone nose you put on the rocket, its decoration or fancy tissue paper flames, the crux of the problem is you have a gaping big hole in your rocket, and that is essentially what a neural tube defect is, a gaping hole in your brain -spinal cord system. It happens in 1 in 1000 live births in the USA (NICHD 2012), but risk is massively reduced by having enough folic acid and vitamin B12 around at the time of neural tube formation. This happens at 3 weeks, often before people even know that they are pregnant, which means that unless you have been organised enough to be taking daily folic acid before conceiving, your child’s brain formation may have been determined before you even knew you could have the most significant impact.
In my mind, it’s not just to prevent a massive hole in my child’s brain; I am not very worried about a 1 in 1000 risk as this is pretty low. If my son were competing against 1000 other children for one place at that elite prep school, I wouldn’t really fancy his chances, so why worry about this level of risk? The reason I think folic acid is important is that I want to optimize brain development in my children as best I can. The majority of medical conditions are dimensional meaning that there is a continuum of damage or impairment from minor to major. Take a burn. You have a range of tissue damage from slight redness on the skin to a fourth degree burn where the burn has gone down through all layers of the skin into bone and muscle. When you have a fourth degree burn, it is without a doubt that other tissue will be damaged with lesser graded burns. What does this have to do with the neural tube? Well, the way I see it, a severe disorder like neural tube defect is your fourth degree burn. The risk of neural tube defect is low like for a fourth degree burn, but I don’t just want to prevent a fourth degree burn, I want to prevent any redness at all which in brain terms would mean any even mild problems with attention, irritability, emotional regulation, planning, memory or motor control. The risk of getting things sub-optimal at this stage of development may impact brain development even if it doesn’t result in a full-blown neural tube defect.
More recently research has headed this way. Spurred on by the well-known protective effects of folic acid on one brain development disorder, researchers (Suren 2013, Roth 2011) have conducted association studies using large cohorts (samples of over 85,000) of Norwegian mothers and babies and found associations between peri-conceptional folic acid supplementation and reduced levels of severe language delay at age 3 years and autistic spectrum disorder. Association studies can never confer causality or effect, but given that folic acid’s status in prevention of neural tube defects is pretty much established, any potential additional benefits are good extras. Thus, in my view, sod the dilemmas about private/ prep or state school, the biggest impact you can make on your child’s brain function is invest in folic acid pre-pregnancy! It doesn’t matter how much you spend on software down the line, invest in the best hardware you can from the outset: a Commodore 64 cannot keep up with the latest iPad; not just in computation, but in user-friendliness and performance across the board.
As soon as parenthood was on the agenda, I switched the contraceptive pill for the folic acid and vitamin B12 supplement, that way, the daily pill popping continued seamlessly and in the event of pregnancy I was covered. I carried on taking folic acid supplements throughout pregnancy, although the critical period is before conception and the first trimester. As soon as my pregnancy was suspected, I started popping multivitamin, iron and fish oil tablets as well. The evidence that these are required if you eat healthily throughout pregnancy is decidedly ropey as most people gain sufficient vitamins and minerals in their diet. What can I say; even I was susceptible to the powers of the nutrition supplement marketing moghuls! My one defence is that pregnancy did skew my dietary preferences towards voracious inhaling of vast quantities of Kentucky Fried Chicken, Walker’s Ready Salted and bacon butties so I probably did need the multivitamins.
Jeffries S, Healy B, Weatherall M, Beasley R, Shirtcliffe P. (2012) What risks do women face when seeking advice during pregnancy from pharmacies and natural health retailers? New Zealand Medical Journal. 125, 61-9
National Institute of Child Health and Human Development (2012). “How many people are affected by or are at risk for neural tube defects?”. Neural Tube Defects (NTD). U.S> National Institutes of Health. http://www.nichd.nih.gov/health/topics/ntds/conditioninfo/pages/risk.aspx
Suren, Roth, Bresnahan, Haugen, Hornig, Hirtz, Lie, Lipkin, Magnus, Reichborn-Kjennerud, Schjolberg, Davey Smith, Oyen, Susser &Stoltenberg. (2013). Association between maternal use of folic acid supplements and risk of autism spectrum disorders in children. Journal of the American Medical Association. 309, 570-7.
Roth, Magnus, Schjolberg, Stoltenberg, Suren, McKeague, Davey Smith, Reichborn-Kjennerud & Susser. (2011) Folic acid supplements in pregnancy and severe language delay in children. Journal of the American Medical Association. 306, 1566-73.