Correspondence

Prevention of Neural-Tube Defects

N Engl J Med 1999; 341:1546November 11, 1999

Article

To the Editor:

Palomaki et al. (April 1 issue)1 reported recently that 96 women from Maine had pregnancies, with estimated or actual dates of delivery between 1991 and 1996, in which open spina bifida or anencephaly developed in the fetuses. In addition, they found no decrease in the prevalence of these preventable birth defects.

In 1991, the Medical Research Council Vitamin Study Research Group reported the results of a randomized, controlled trial that found that synthetic folic acid taken in the form of a pill prevents 72 percent of cases of spina bifida and anencephaly.2 Had an effective program of folic acid supplementation been implemented in Maine immediately after the publication of the results of the Medical Research Council vitamin study, most of the women in the study by Palomaki et al. would not have had pregnancies affected by these birth defects. Had there been an effective national program, 20,000 pregnancies in the United States between 1992 and 1999 would not have been affected — more than the number of pregnancies affected by thalidomide-induced birth defects in Europe 40 years ago.

The failure to implement effective programs for protection against folic acid–preventable birth defects is causing a continuing public health emergency. Since 1991, approximately 64 children have lost their lives because of front-seat air bags. The 20,000 pregnancies unnecessarily affected by folic acid–preventable birth defects constitute an opportunity for prevention more than 300 times as great as the opportunity to control the number of deaths among children resulting from front-seat air bags.

It is not surprising that the emergency continues. The Food and Drug Administration waited four years before requiring inadequate levels of folic acid fortification that result in the average woman's consuming only 25 percent of the amount of folic acid recommended by the Public Health Service in 1992 and the Institute of Medicine in 1998 — a deficiency tantamount to marketing polio vaccine containing only the least common of the three vaccine strains. The current administration both permitted the inadequate fortification regulation to be formulated and failed to ask Congress to appropriate a single penny for the Centers for Disease Control and Prevention (CDC) to build an effective supplementation program. Congress appropriated only about $1 million for the effort, which, to be effective, would require about $100 million a year. Since the early 1990s, Congress has made approximately $100 million a year available for a CDC-sponsored program to prevent Haemophilus influenzae meningitis. We have nearly eliminated this killer and disabler of children — what a great public health success! It is time for the President to implement a fully protective folic acid fortification program and, until that program is in place, for Congress to provide the CDC with the resources to teach women to consume vitamin supplements containing folic acid.

Godfrey P. Oakley, Jr., M.D., M.S.P.M.
Emory University, Atlanta, GA 30322

2 References

1. 1

   Palomaki GE, Williams JR, Haddow JE. Prenatal screening for open neural-tube defects in Maine. N Engl J Med 1999;340:1049-1050
   Full Text | Web of Science | Medline

2. 2

   MRC Vitamin Study Research Group. Prevention of neural tube defects: results of the Medical Research Council Vitamin Study. Lancet 1991;338:131-137
   CrossRef | Web of Science | Medline

Citing Articles (9)

Citing Articles

1. 1

   A. L. Boyles, J. L. Ballard, E. B. Gorman, D. R. McConnaughey, R. M. Cabrera, A. J. Wilcox, R. T. Lie, R. H. Finnell. (2011) Association between inhibited binding of folic acid to folate receptor   in maternal serum and folate-related birth defects in Norway. Human Reproduction 26:8, 2232-2238
   CrossRef

2. 2

   K de Meer, Y M Smulders, J R Dainty, D E C Smith, R M Kok, C D A Stehouwer, P M Finglas, C Jakobs. (2005) [6S]5-methyltetrahydrofolate or folic acid supplementation and absorption and initial elimination of folate in young and middle-aged adults. European Journal of Clinical Nutrition 59:12, 1409-1416
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3. 3

   Don C Dyke, Phyllis J Stumbo, Mary J Berg Pharm, Jennifer R Niebyl. (2002) Folic acid and prevention of birth defects. Developmental Medicine & Child Neurology 44:6, 426-429
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4. 4

   F. Garcia-Garrote. (2001) Comparative in vitro activity of the new quinolone gemifloxacin (SB-265805) with other fluoroquinolones against respiratory tract pathogens. Journal of Antimicrobial Chemotherapy 47:5, 681-684
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   Beatriz Rosón, Jordi Carratalà, Fe Tubau, Jordi Dorca, Josefina Liñares, Roman Pallares, Frederic Manresa, Francesc Gudiol. (2001) Usefulness of Betalactam Therapy for Community-Acquired Pneumonia in the Era of Drug-Resistant Streptococcus pneumoniae: A Randomized Study of Amoxicillin-Clavulanate and Ceftriaxone. Microbial Drug Resistance 7:1, 85-96
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6. 6

   (2000) Fortification of Foods with Folic Acid. New England Journal of Medicine 343:13, 970-972
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7. 7

   Ernest B. Hook. (2000) Folic acid: Abortifacient or pseudoabortifacient?. American Journal of Medical Genetics 92:5, 301-302
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8. 8

   Mills, James L., . (2000) Fortification of Foods with Folic Acid — How Much is Enough?. New England Journal of Medicine 342:19, 1442-1445
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9. 9

   (2000) Current Awareness. Prenatal Diagnosis 20:3, 267-273
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