Research Brief: Prenatal choline supplementation improves child sustained attention: A 7-year follow-up of a randomized controlled feeding trial

We care a lot about Choline because we know how critical it is to mama and baby’s health and baby’s brain development. 

So we’re excited about a new study on choline supplementation during pregnancy. It found that higher intakes of Choline during pregnancy improve a child’s cognition.

The full study can be found here. The following brief outlines the key points and outcome of the study.

The purpose of the study

If a recommendation exists for how much Choline to take during pregnancy and breastfeeding, you might wonder, why is more research needed?

In short, because the recommendations that exist aren’t based on outcomes related to perinatal health, fetal development, or a child’s cognitive function. In fact, the adequate intake recommendation of 450mg of Choline per day for pregnant women was established in 1998 by extrapolating from evidence pertaining to the amount of Choline needed to prevent liver dysfunction in men. Not exactly a precise way to estimate the needs for a pregnant woman.

And ultimately, does it really make sense that a pregnant woman who is growing another human from scratch would need less Choline than an adult male (for which the recommended intake is 550mg?).

Perinatal researchers have been discussing optimal Choline levels for years, and this study is part of that conversation.

How it was designed

The study is a 7-year follow-up of the children born to women who participated in a randomized, double-blind, parallel-group controlled choline feeding study during their 3rd trimester of pregnancy. Here’s what that means:

  • 7-year follow-up: the administration of the study was performed 7 years ago. As part of that study, pregnant women in their third trimester were given one of two different amounts of Choline daily through food and supplementation. And then the researchers waited 7 years to observe results. The testing and evaluation of the babies who were in utero at the time of the initial study was done as part of this follow-on study, on the same children, now 7 years old
  • Randomized: the study participants selected to receive each of the two Choline doses were selected at random. This helps to remove any bias or other underlying factors that could compromise results.
  • Double-blind: both participants and study administrators are “blind” to who is getting what food/supplement. This helps to remove any bias or “placebo effect” from both researchers and participants.
  • Parallel group controlled: participants are assigned to one “arm” (in this case, Choline dose) and remain in that group for the duration of the study

The initial study

As part of the initial study, women were randomized to consume either 480mg of Choline per day (approximately the RDA or “adequate intake” in pregnancy) or 930 mg of Choline each day. They consumed this amount of Choline from the time of enrollment at the beginning of their third trimester until delivery (for approximately 12 weeks).

To achieve these total Choline intake levels each day, all women consumed the same diet, which provided 380 mg of Choline per day through food, and an additional Choline supplement of either 100mg or 550 mg of choline per day. The Choline supplement was mixed with cran-grape juice by study personnel and served in color-coded tubes so that participants and investigators remained blinded to the dose. 

It is a significant strength of the study that all of the food and choline supplements were provided by the study, and participants consumed more than 70% of the choline supplements under study personnel supervision. In fact, this study is the only maternal Choline supplementation study to ensure that Choline intake for the two treatment groups truly differed by a substantial amount.

In addition to the study diet and choline supplement, all women consumed the same additional supplements:

  • prenatal multivitamin (daily, contained no Choline)
  • 200 mg DHA (daily)
  • 250 mg potassium and 250 mg magnesium (3 times per week) 

It’s worth noting that this initial study had some compelling takeaways even before the seven-year follow up. Earlier evaluation of the babies found a correlation between higher levels of maternal Choline intake and improved processing speed in infants whose mothers took the higher 930 mg dose.

The follow-up study

Seven years later, each of the children born to the study participants were administered the Sustained Attention Task (SAT) test by one of two trained examiners blinded to group assignment as part of a two-day cognitive testing protocol. The SAT is a signal detection task designed to make demands on several aspects of cognitive control of voluntary attention.

The outcome

The findings of this study revealed that 7-year-old children born to women randomly assigned to 930mg of Choline per day during the third trimester of pregnancy performed better on a challenging sustained attention task (SAT) than children born to women assigned to 480mg of Choline per day. Children from the 930mg per day group achieved higher SAT scores.

In other words, maternal intake of the recommended amount of Choline during the third trimester resulted in poorer offspring sustained attention than was demonstrated by the offspring of mothers who consumed twice that amount, when children were assessed at age 7 years.

Why it matters

Sustained attention (and attentional control more broadly) contributes to a wide variety of higher cognitive functions, such as problem-solving and working memory and is positively associated with school performance. 

The findings from this study provide new evidence that the beneficial effects of maternal Choline supplementation during pregnancy for offspring attentional function endure into early childhood. In addition, emerging evidence from other tests administered to these children at age 7 indicates that the benefits of higher maternal choline intake during the third trimester are not limited to sustained attention, but also include improved working memory and problem-solving.

Although replication in a larger clinical trial is needed, these findings suggest that the existing Choline recommendations for pregnant women may not be sufficient for optimal child cognition, as consumption of 930mg of Choline per day produced superior child cognition relative to consumption of (approximately) the existing recommendation of 480mg (450mg RDA).

Finally, these findings amplify existing concerns around the fact that approximately 90-95% of pregnant women in North America consume Choline at levels below the existing recommendations, and that a vast majority of prenatal vitamins contain little or no Choline.

After all, it isn’t just cognition that is supported by Choline. Choline has also been shown to reduce baby’s levels of cortisol, reduce the risk of orofacial clefts, and much more.

How to Supplement Optimally

Our Choline add on provides 250 mg of Choline L(+) Bitartrate VitaCholine™ per capsule. It can be layered onto our already supportive Prenatal Multi (400mg) for added support, to our pared down Prenatal Multi Essentials (150mg) and/or Omega-3+ (100mg) to reach the RDA. It can also be added to another prenatal brand, as many other brands contain only 10% of the RDA.