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Calls to increase folic acid levels in flour ‘to prevent more birth defects’

It is estimated current proposals will help prevent around 200 neural tube defects each year – around 20% of the annual UK total.

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A hand holding a baby's feet

Proposals to fortify some flours with a vitamin which prevents babies from developing a life-threatening spinal condition do not go far enough, leading medics have warned as they said the health service could be paying out £30 million for each baby born with a neural tube defect.

Last year the Government announced that folic acid would be added to non-wholemeal wheat flour across the UK to help prevent neural tube defects.

But scientists have said that more could be done to prevent these defects – a developmental anomaly which occurs early in pregnancy.

Not getting enough folate just before, and in early pregnancy, can lead to neural tube defects and result in spinal conditions such as spina bifida or anencephaly.

Folic acid is the man-made form of folate and it is hoped that adding the vitamin to flour will mean that women who are about to become pregnant, or who are in the early stages of pregnancy, should get some level of the vitamin when they eat bread or other foods made with flour.

It has been estimated that the current proposals will help prevent around 200 neural tube defects (NTDs) each year – around 20% of the annual UK total.

But experts have said the current proposals do not go far enough.

They said that fortification at a level of 0.25mg per 100g of non-wholemeal wheat flour would mean people with coeliac or gluten intolerances could miss out on the benefits, as would those who mainly consumed carbohydrates though rice.

Sir Nicholas Wald, professor of preventive medicine, University College London, said that fortification of about 1mg of folic acid per 100g of flour and rice would mean that some 800 cases could be prevented each year – around 80% of the annual total.

He said that simply advising women to take folic acid before pregnancy “does not work”,  adding: “So the only alternative is fortification of a staple food which has been introduced in about 80 countries around the world.”

Sir Nicholas added that with “fully effective fortification” there would be no need for women to take a folic acid supplement when they were trying to, or were pregnant.

All flour and rice could be fortified unless sold with an “unfortified health alert” label, he added.

“The issue here is fully effective fortification rather than just effective fortification,” he told a Science Media Centre briefing.

“Last year, the Government made the welcome decision that there would be mandatory fortification of wheat flour, not wholemeal, in Britain.

“A higher level of fortification than the one proposed would be safe and prevent many more NTDs.”

Neena Modi, professor of neonatal medicine at Imperial College London and president-elect of the European Association of Perinatal Medicine, added: “I have personally experienced what a tragedy it is to witness the birth of a baby with a neural tube defect.

“In the UK, we have a pregnancy neural tube defect prevalence that is one of the highest in Europe.

“Now, a large number of these are terminated.

“But of course the live-born babies require surgery, and often multiple surgeries, and they invariably have substantial lifelong health care needs.

“So this is not a trivial condition. It is a serious condition. And it has major, major lifelong implications for the baby affected and for that baby’s family.

“Prevention is by far to be preferred than what is a terrible condition.”

Dame Lesley Regan, professor of obstetrics and gynaecology at Imperial College’s St Mary’s Hospital Campus and honorary consultant in gynaecology at Imperial College NHS Trust, said: “There are scientific reasons why we should be administering the correct dose to get the maximum prevention, there are medical reasons, there are ethical reasons and there are economic reasons.

“Wearing my NHS Resolution board hat, we are seeing now that children that have been damaged or who are born damaged, whether this is because of an accident that happens during the pregnancy or the labour, or because of, for example, a neural tube defect … their lawyers are basically ensuring that they will have payouts for the rest of their life, and rightly so because if I was a mother who had delivered a baby with a severe neural tube defect I would want that help and support.

“So they’re going to have complex and multiple episodes of surgery and they’re also going to need caring facilities for the rest of their lives.

“So we’re talking about, for a single baby, payouts of £30 million over a life course.

“This is just not sustainable. The NHS Resolution obstetric litigation costs – not of course, all for neural tube – but for litigation for obstetric disasters is the second most expensive item on the Chancellor’s list.”

She added: “There are now 80 countries in the world who have adopted the sensible scientifically and medically based approach and we’re lagging behind with them.

“And so all we have to do is thank the Government and the policymakers for agreeing to folic acid fortification, but let’s do it at the right dose, because it makes no sense to do something the wrong way round or half-heartedly.”

Sir Nicholas said “we are past nanny state arguments” and the issue now is what level of fortification should be set.

Concerns have previously been raised that higher levels of fortification may make a vitamin B12 deficiency worse, but he said that this was based on “flawed analysis” and the concern had now been dismissed.

The Royal College of Obstetricians and Gynaecologists (RCOG) said in a statement: “We are concerned about the proposed levels of fortification.

“As the open consultation to amend the Bread and Flour Regulations set out, modelling predicts that proposed levels of folic acid fortification will prevent around 20% of neural tube defects. We recommend that fortification of flour is set at a level sufficient to prevent about four out of five neural tube defects, namely 1mg of folic acid per 100g of flour.

“We encourage the Government to reconsider the proposed level of fortification of flour with folic acid, and SACN (the Scientific Advisory Committee on Nutrition) to review the evidence informing the Tolerable Upper Intake Level of folic acid.”

A Department of Health and Social Care spokesperson said: “We are currently analysing the responses to the consultation on amending the Bread and Flour Regulations and will provide an update in due course.

“Once published, our response will confirm the agreed level of folic acid to be added to non-wholemeal wheat flour.

“The established advice to take a folic acid supplement up to the 12th week of pregnancy, to help prevent neural tube defects, will remain in place when folic acid is added to flour.”

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