CADTH Health Technology Review

Choline Supplementation for Infants, Children, and Pregnant People

Rapid Review

What Is the Issue?

• Choline is an essential nutrient produced by humans and animals and is important during pregnancy, fetal growth, and the development of the brain and nervous system. Most people do not get enough choline from their diet.

• Fetal alcohol spectrum disorders (FASD) are a set of conditions where fetuses have been exposed to alcohol and this affects memory, learning, and development from early childhood to later life.

• Choline supplements are products used to complement choline-deficient diets. Given the role of choline in fetal development, choline supplements are a potential intervention to support pregnancy or to mitigate the developmental harms in children from prenatal exposure to alcohol if supported by evidence of their effectiveness for these purposes.

What Did We Do?

• To inform decisions about the use and timing of choline supplementation to support health outcomes in infants and children, CADTH sought to identify and summarize the literature about the effectiveness and safety of choline supplementation given to any pregnant people or given to children with either prenatal alcohol exposure or FASD. We also attempted to identify evidence-based recommendations for using choline supplementation in these populations.

• We searched key resources and conducted a focused internet search for relevant evidence published since 2014. One reviewer screened articles for inclusion based on predefined criteria, critically appraised the included studies, and narratively summarized the findings.

What Did We Find?

• We found few publications investigating this topic, and several studies had low statistical power and imprecise results. The clinical evidence was mixed depending on whether choline was given to the pregnant person or child, which interventional groups were compared, what the clinical exposures or diagnoses were in the study population, the time point and duration of choline supplementation, which outcomes were measured, and how old children were during follow-up.

• For choline supplementation in healthy pregnant people, evidence was mixed for infant and child neurocognitive and neurodevelopmental outcomes or behavioural symptoms; there were little-to-no differences in safety outcomes.

• For choline supplementation in pregnant people exposed to alcohol, evidence was mixed for infant and child neurocognitive and neurodevelopmental outcomes, body size, and brain region sizes; some minor side effects were reported overall.

• For choline supplementation in children with FASD, most evidence showed little-to-no benefits for neurocognitive and neurodevelopmental outcomes, and brain structure; limited evidence showed higher fishy body odour and some other unspecified adverse symptoms for children given choline.

• Guidelines based mostly on low-quality evidence or expert opinion recommend that all pregnant people, including those with gestational diabetes mellitus or on vegan or vegetarian diets, increase their choline intake through diet or supplements.

• We did not find clinical effectiveness evidence for choline supplementation in infants with FASD, or guidelines regarding choline supplementation in either infants or children with FASD, that met inclusion criteria for our report.

What Does it Mean?

• Health care professionals and decision-makers can use this evidence to inform decisions around applicability of choline supplementation for pregnant people, or for infants and children with FASD, in their practice.

• There may be a need to balance the knowledge that choline intake is low at the population level and important for fetal development with the identified clinical effectiveness evidence for choline supplementation, which was limited and mixed for all evaluated patient populations.

• Careful consideration of the following may also be important to inform decisions about the appropriateness of choline supplementation: the care plan and other intensive and concurrent interventions for children with FASD; stigma and challenges faced by pregnant people and children in the context of prenatal alcohol exposure; cultural dietary practices; and accessibility, cost, and availability of supplements.

Key Terminology

Gender: “Gender can refer to the individual and/or social experience of being a man, a woman, or neither. Social norms, expectations and roles related to gender vary across time, space, culture, and individuals.”¹

Nonbinary: “An umbrella term for gender identities that fall outside of the man-woman binary.”¹

Pregnant person: In this Rapid Review, this term refers to anyone who is pregnant and is inclusive of all sexes and genders. Where included study authors conducted research for a specific sex or gender group (e.g., women), or where the authors report the sex or gender of the population, they are reported in this Rapid Review as the study authors describe them.

Trans: “An umbrella term referring to people whose gender identities differ from the sex they were assigned at birth. “Trans” can mean transcending beyond, existing between, or crossing over the gender spectrum. It includes but is not limited to people who identify as transgender, transsexual, nonbinary or gender nonconforming (gender variant or genderqueer).”¹

Research Questions

1. What is the clinical effectiveness of choline supplementation during pregnancy for health outcomes in infants and children?

2. What is the clinical effectiveness of choline supplementation in infants and children with prenatal alcohol exposure or fetal alcohol spectrum disorders?

3. What are the evidence-based guidelines regarding choline supplementation for infants, children, or pregnant people?

Context and Policy Issues

What Is Choline and Choline Supplementation?

Choline is an essential nutrient that is needed for animal and plant cell membrane integrity, metabolism, and functioning of the brain and nervous system; it is specifically important for mood, memory, muscle control, cell membrane signalling, and early brain development.^2,3 During pregnancy, choline demand is higher because it plays a role in the safety of the pregnant person and in the growth and development of the fetus, the brain, and the placenta.^2,4 A lack of choline can result in adverse outcomes such as neural tube defects, cognitive deficits, and fatty liver disease in fetuses, or preeclampsia or hypertension in the pregnant person.^2,4 Studies in animals and humans have shown that lower maternal choline intake is associated with more neural tube defects in children, and that higher choline intake in pregnant people is associated with better neurocognitive function in children.⁵

Dietary choline can come from animal sources such as eggs, fish, poultry, and dairy products, and from plant sources with lower levels of choline, such as seeds, whole grains, cruciferous vegetables, beans, and nuts.^3,5 Choline is also available as a dietary supplement that can be provided alone, as a multivitamin product, or combined with B-complex vitamins; they can be in different forms, including phosphatidylcholine, citicoline-CDP—choline, choline bitartrate, choline chloride, alpha glycerophosphocholine, or lecithin.^2,4-6

Although humans can produce choline in their bodies, the amount is not high enough to meet requirements; they may need additional choline through the diet or through supplements.⁵ Certain groups may be more likely to have inadequate choline levels such as pregnant people, those with genetic variations involved in choline pathways, and infants and adults who need parenteral nutrition where food consumption bypasses the gastrointestinal tract.⁵ Canadian data show that across multiple ages, genders, pregnancy stages, and jurisdictions, choline intake from food and supplements is less than the recommended intake.^7,8

What Are FASDs?

FASD are a group of diagnoses that can lead to long-lasting disability and result from prenatal alcohol exposure (PAE); alcohol is harmful to human development and can lead to issues with memory, learning, social skills, motor skills, attention, social skills, and over 400 comorbidities.^9,10 FASD is not necessarily caused by people knowingly drinking alcohol while pregnant, something that is completely preventable or specific to a certain group of people, although it is frequently stereotyped as such.¹¹ The social determinants of health also play a large role in the incidence of FASD.¹¹ A 2017 meta-analysis showed the worldwide prevalence in children up to 16 years old was 7.7 per 1000.¹² In Canada, data on this condition is scarce; some research suggests that its prevalence is 7.9 per 1,000¹³ and other data shows that between 0.1% and 3% of children and youth have a FASD diagnosis.¹⁰ FASD may be higher in populations with limited access to care or in equity-deserving groups.¹⁴ There may also be inequities in how children with FASD access services and are supported by the health care system.¹¹ Accurate diagnosis and early and long-term support are important in helping people manage the disorder and prevent lifelong difficulties.¹⁰ Interventions for FASD include behavioural and education therapy, medication, medical specialists (e.g., speech-language pathologist, mental health professional, physical therapist), parent training, creative art therapy, and auditory training.¹⁵ The inequities in the distribution of FASD across equity-deserving groups, and the way the social determinants of health can affect its manifestation, development, and management are important considerations for appropriate patient care; however, these elements are not directly assessed within the scope of this review.

Why Is it Important to Do This Review?

Given that pregnant people have low dietary intakes of choline and that choline is important for fetal development, it is necessary to understand whether choline supplementation during pregnancy improves outcomes in infants and children and to identify guidelines around supplementation during pregnancy.

Research in animal models has suggested that choline supplementation in offspring with PAE can decrease harmful structural, behavioural, and cognitive effects, even after alcohol exposure has stopped; however, it is unclear whether choline supplementation is effective or recommended for children with PAE or FASD.^6,16-18

Therefore, the current report aims to review the evidence on choline supplementation broadly in pregnant people and, more specifically, in children with PAE or FASD who require multiple supports to determine its effects on health outcomes in children. This report also aims to summarize any recommendations on choline supplementation for pregnant people and for children with PAE or FASD.

Objectives

To support decision-makers by identifying, summarizing, and critically appraising evidence on the clinical effectiveness of or recommendations on choline supplementation in pregnant people, and in children with PAE or FASD.

Methods

Literature Search Methods

An information specialist conducted a literature search on key resources including MEDLINE, the Cochrane Database of Systematic Reviews, the International HTA Database, the websites of Canadian and major international health technology agencies, as well as a focused internet search. The search approach was customized to retrieve a limited set of results, balancing comprehensiveness with relevancy. The search strategy comprised both controlled vocabulary, such as the National Library of Medicine’s MeSH (Medical Subject Headings), and keywords. Search concepts were developed based on the elements of the research questions and selection criteria. The main search concepts were choline, pregnancy, and FASD or PAE. Additional searches were also conducted using the search concepts choline or FASD/PAE; CADTH-developed search filters were applied to limit retrieval to guidelines. Retrieval was limited to the human population. The searches were completed on January 4 and 5, 2024 and limited to English-language documents published since January 1, 2014. To capture a fuller range of literature on FASD/PAE, additional searching was also conducted in Embase and Scopus for research question 2.

Selection Criteria and Methods

One reviewer screened citations and selected studies. In the first level of screening titles and abstracts were reviewed, and then potentially relevant full-text articles were retrieved and assessed for inclusion in the second level of screening. The final set of full-text articles is based on the inclusion criteria in Table 1.

Table 1: Selection Criteria

FASD = fetal alcohol spectrum disorder; PAE = prenatal alcohol exposure.

Exclusion Criteria

Articles were excluded if they did not meet the selection criteria outlined in Table 1 or were duplicate publications.

Articles were also excluded if:

• choline supplementation was considered an exposure in an association study but clinical benefits or harms of choline supplementation were not reported

• they were broadly about supplementation but did not describe supplements or mention choline

• they measured outcomes in plasma, umbilical cords, or human milk

• the intervention was a combination of supplements where the effect of choline could not be determined.

Systematic reviews (SRs) in which all relevant studies were captured in other more recent or more comprehensive SRs were excluded. Primary studies retrieved by the search were excluded if they were captured in 1 or more included SRs. Guidelines with unclear methodology or that did not specify pregnant people, or infants and children with PAE or FASD were also excluded.

Critical Appraisal of Individual Studies

One reviewer critically appraised the included SR using A MeaSurement Tool to Assess systematic Reviews 2 (AMSTAR 2),¹⁹ randomized controlled trials (RCTs) using the Downs and Black checklist,²⁰ and guidelines using the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument.²¹ Summary scores for the included studies were not calculated; rather, the strengths and limitations of each included publication were described narratively in this report.

Equity Considerations

CADTH recognizes the need for and importance of equity considerations in health technology reviews. In this Rapid Review, PROGRESS-Plus²² was used to guide data extraction and report writing. Each included publication was checked to determine if PROGRESS-Plus²² criteria were reported by study authors to describe the participants; detailed characteristics, if available, were then extracted and reported in tables in Appendix 2. The main PROGRESS-Plus²² criteria include place of residence, race/ethnicity/culture/language, occupation, gender/sex, religion, education, socioeconomic status, and social capital. As part of report writing, we provide a discussion of these characteristics across the evidence, where available, when presenting results within the text.

We did not conduct an explicit search for information related to inequity or equity-deserving groups in relation to choline supplementation in pregnancy, or for children with PAE or FASD. We are aware that pregnant people who have consumed alcohol during pregnancy or have children with FASD experience stigma by the public, media, health care providers (e.g., clinician stereotyping), and institutions and that this can be harmful to their health; they may be worried about sharing their alcohol use history, feel uncomfortable seeking health care, experience judgment, shame, or social isolation, and this may prevent pregnant people from getting the health and social resources they need.^23-25 This Rapid Review does not include an equity analysis of these issues, which may be better suited to a dedicated review around equity considerations for choline supplementation so that these topics can be understood properly.

When reporting on sex or gender in this Rapid Review, we retained the language used by the original study authors if research was conducted specifically for women or investigators recorded participant-identified gender. In all other cases, we use the term pregnant people when referring to this population. In addition, when reporting on race or ethnicity, whenever possible, we referred to these groups based on guidance from the CADTH Style Guide at the time this Rapid Review was conducted, with an understanding that language is constantly evolving. Otherwise, we reported race and ethnicity terminology as described by the original study authors.

Summary of Evidence

Quantity of Research Available

This report includes clinical effectiveness evidence from 1 SR²⁶ and 3 RCTs^27-30 (1 RCT was based on 2 publications^28,29), and recommendations from 4 guidelines^31-34 (2 guidelines^32,33 had companion articles^35,36 describing further details on methodology or the recommendations).

Appendix 1 presents the PRISMA³⁷ flow chart of the study selection. Appendix 5 includes additional references of potential interest such as publications with evidence already in included studies, ongoing trials, a SR protocol, nonsystematic reviews, recommendations with unclear methods, and a non-English article.

Summary of Study Characteristics

Appendix 2 contains detailed characteristics of included publications.

Included Studies for Clinical Effectiveness

The SR²⁶ included 10 publications based on 7 RCTs conducted in South Africa, Ukraine, US. The 3 RCTs were conducted in South Africa and the US; 2 of the RCTs^28-30 included in this review were conducted in a population that was also included in the SR but reported results for a different sample, different outcome, or different follow-up time.²⁶

Intervention-comparisons included:

• Choline supplementation versus placebo.^26,28-30

  • Type of choline supplementation included phosphatidylcholine, choline bitartrate, or glycerophosphocholine liquid.

  • Doses of choline supplementation varied by type of supplement and population (i.e., healthy pregnant person, alcohol-exposed pregnant person, or child with FASD)

• High-dose choline chloride supplementation (930 mg/day) versus low dose (480 mg/day) choline chloride supplementation for healthy pregnant person^26,27

• Choline supplementation (750 mg/day) plus multivitamin versus multivitamin only for alcohol-exposed pregnant person²⁶ (choline type not reported).

Across all studies, populations included pregnant people in their second or third trimester who were described as healthy,²⁶ had no alcohol or tobacco use,²⁷ or were exposed to alcohol;^26,30 or children with PAE or FASD.^26,28,29 Dietary assessments for choline adequacy at baseline were not well reported across studies; average choline intake was assessed in 1 primary study within the SR²⁶ and most pregnant people included in 1 identified RCT were reported to have choline deficiency.³⁰ Pregnant people were aged 26.6 to 28.4 years old and were all described as women; sex and gender were not explicitly reported. Children were assessed from birth to 11.44 years old across studies. Two publications^27,29 reported child sex and 1 reported child gender.²⁸ For the 2 publications^28,29 of the same trial, 1 publication reported child gender²⁸ and 1 reported child sex.²⁹ The included SR²⁶ did not report the sex and gender of the included children. Articles did not report how sex and gender were defined or measured or on sex or genders outside male and female.

Two studies reported education levels of participants,^27,30 2 reported family income²⁷ or socioeconomic status,³⁰ 2 reported child race (based on 3 publications),^27-29 2 reported child ethnicity (based on 3 publications),^27-29 and 1 reported whether English was a primary language for children.²⁷ One article²⁹ indicated that race was self-identified; no other articles indicated how race or ethnicity was recorded. No other PROGRESS-Plus criteria,²² such as place of residence, occupation, religion, social capital, or disability status were reported.

Effectiveness outcomes in children included:

• neurocognitive outcomes measuring cognitive functioning, memory, attention, and reasoning, including physiological responses to tasks (e.g., saccade reaction time, brain electrical activity)

• parent-reported behaviour measuring early signs of schizophrenia (e.g., attention symptoms, withdrawn symptoms, behavioural issues)

• brain or body size or structure (e.g., weight, head circumference, brain region sizes).

Safety outcomes in children were only reported in the included SR²⁶ and not any of the included RCTs.

Included Guidelines

All guidelines provided broad nutrition recommendations for both diets and supplements that had specific sections on choline, among other micronutrients; there were no guidelines that only focused on choline. Three^32-36 were conducted by groups in the US (not-for profit health care professional group, government department, and academic group), and 1 from a medical professional society in Canada.³¹ Three were for pregnant people in the general population^31,33,34,36 and 1 was for pregnant people with gestational diabetes mellitus (GDM).^32,35

No guidelines were found regarding choline supplementation for children with PAE or FASD.

Summary of Critical Appraisal

Appendix 3 contains detailed about strengths and limitations of included publications.

Clinical Effectiveness Studies

Systematic Review

The SR’s²⁶ strengths included clear reporting of the research question of interest, establishing review methods and registration beforehand, performing study screening and data extraction in duplicate, and discussing bias and heterogeneity of included studies when summarizing the evidence.

A limitation of the SR²⁶ is that the search strategy may not have been comprehensive since 1 database was searched; there may have been other relevant studies in other databases or in the grey literature that could have contributed to the findings. In addition, the sources of funding for each included article were not reported; it is unclear whether there may have been any conflicts or bias in these studies. Some SR authors²⁶ also received funds from the pharmaceutical company that sponsored the review and that manufactures supplements including those for pregnant people; it is unclear whether this affected the review. The SR authors²⁶ also mentioned limitations of the included studies such as low adherence, high dropout rates, short study duration, missing data, low generalizability, and unplanned testing or analyses.

Randomized Controlled Trials

Across included RCT publications,^27-30 there were clearly reported objectives, population criteria, interventions, main outcomes, and study findings. Authors declared no conflicts of interest, or funder participant in study conduct. Participants and the research team were blinded to study assignment; all RCTs^27-30 included a placebo that was consumed in the same way as the intervention (fruit-flavoured drink). This may have reduced performance bias (e.g., where participants may be treated differently if researchers knew what treatment they received, or participants self-reported outcomes differently if they knew what study group they were in) or detection bias (e.g., outcome assessors measuring outcomes differently by knowing study assignment).

All trials were randomized to aim to make study groups comparable and attribute study findings to the effect of the intervention. One RCT²⁷ indicated groups were well matched and that participants lost to follow-up were no different from those who remained in the study. Another trial^28,29 reported that groups differed by race and had issues with missing data and loss to follow-up; authors indicated that because of a small sample size, confounding effects could not be explored.

The authors of all RCTs indicated issues with small sample sizes. One RCT²⁷ conducted a power calculation and found statistically significant results for some outcomes, the authors of the other RCTs indicated that there was not enough power to detect effects.^28-30 The generalizability of populations in each trial is also unclear since each was different from another and may be different from the general population; 1 trial²⁷ reported including highly educated white mothers who had not consumed alcohol and whose children were mostly male, another trial³⁰ reporting including pregnant people who reported drinking during pregnancy, had inadequate choline intake, and were economically disadvantaged with low education levels, and the third trial^28,29 was reported on a racially diverse group of children with FASD.

Guidelines

All guidelines^31-36 clearly outlined their scope and purpose, who the target users and intended population of the guideline were, and had a grading system for assessing the quality of evidence used to make recommendations. Two guidelines^32,33,35,36 conducted SRs, 1 conducted literature searches,³⁴ and one³¹ indicated consulting literature but did not provide details (e.g., databases searched). Three guidelines^31,32,34,35 presented each recommendation in an easily identifiable way (e.g., recommendation statements separated from explanatory text, tables within body of guideline to organize statements).

It is unclear whether any of the guidelines specifically included views and preferences of the target population; 1 guideline^33,36 mentioned seeking feedback from the public. For 3 guidelines,^31,33,34,36 the specific processes for creating recommendations (e.g., voting, consensus) were not reported. For 2 guidelines,^31,33,36 the explicit links to the evidence did not follow clearly from recommendation statements. Two guidelines^31,34 did not report supporting documents or tools to aid readers in understanding or implementing recommendations. For 3 guidelines,^31,33,34,36 it is unclear whether there were any conflicts of interest in guideline development; 1 of these guidelines³⁴ included authors who developed prenatal supplements or had pending patents on prenatal supplements.

Summary of Findings

Appendix 4 presents the main study findings.

We found clinical effectiveness evidence for choline supplementation in:

• healthy pregnant people

• pregnant people exposed to alcohol

• children with FASD.

We found guidelines for choline supplementation for:

• pregnant people

• lactating people

• pregnant people with GDM

• pregnant people consuming vegetarian or vegan diets.

Clinical Effectiveness and Safety of Choline Supplementation in Healthy Pregnant People

Choline Versus Placebo

Infants and children birthed by individuals who received choline supplementation during their healthy pregnancy showed better early results for neurocognitive outcomes and later had little-to-no differences in these outcomes compared with infants and children of those who were given placebo, specifically:

• infants showed better cerebral inhibition, a sign of fetal development, at 1 month²⁶

• infants showed little-to no differences in cerebral inhibition, global cognitive development, language, visuospatial perception, discrimination, or memory, or long-term episodic memory between groups from 3 to 12 months.²⁶

Children who were 40-months old had lower parent-reported attention issues and withdrawn symptoms on a questionnaire to detect schizophrenia, and little-to-no difference in behavioural issues on the same questionnaire.²⁶

Safety results from the included SR²⁶ had limited information:

• One trial reported little-to-no difference in adverse events between groups and no serious adverse events were reported overall

• Another trial reported 7 preterm births in the placebo group and 4 in the choline group (no statistical significance given) and little-to-no difference in infant weight, length, head circumference, perinatal complications, and general health using Apgar scores.

High-Dose Choline Versus Low-Dose Choline

Infants and children birthed by individuals who received a higher choline supplement dose during their healthy pregnancy showed mixed evidence for neurocognitive outcomes compared to infants and children of those who were given a lower dose:

• infants up to 13 months old had faster reaction times and little-to-no difference in predictive cascades²⁶

• children who were 7 years old had better attention during a signal detection task (i.e., they had better signal detection and were better at detecting difficult stimuli) and little-to-no difference in false alarms, omissions, and off-task behaviours.²⁷

One trial in the included SR²⁶ indicated that no adverse events were reported by any participants.

Clinical Effectiveness and Safety of Choline Supplementation in Pregnant People Exposed to Alcohol

Choline Versus Placebo

Infants birthed by individuals who were exposed to alcohol during pregnancy and received choline supplementation showed mixed results for neurocognitive outcomes compared to infants who were given placebo:

• infants who were 6.5 months old had little-to-no difference in learning and memory measured by eyeblink conditioning, but the choline group had higher increases in conditioned responses²⁶

• infants who were 12 months old showed better visual recognition memory as measured by FTII, a test of infant intelligence, which was based on 1 RCT from the included SR (no numerical results reported)²⁶ and little-to-no difference in FTII score measured in a smaller sample of the same trial which focused on investigating brain measurements.³⁰

Infants from birth to 12 months had higher increases in weight and head circumference,²⁶ and greater sizes in 6 out of 12 brain regions when birthed by individuals who were exposed to alcohol during pregnancy and received choline supplementation compared with infants of those who received placebo during pregnancy.³⁰

There were unclear results for safety. Dyspepsia and nausea were reported in 1 trial in the included SR;²⁶ it is unclear which study participants these data were for (e.g., pregnant person, child, intervention, or comparator group).

Choline and Multivitamin Versus Multivitamin Only

Infants birthed by individuals exposed to alcohol during pregnancy and given choline supplementation with multivitamin showed mixed results for neurocognitive outcomes compared to infants of those who were given multivitamin only:

• infants who were 4 to 11 months old had better information processing and learning based on heart rate responses to visual stimuli²⁶ and little-to-no difference in score for mental development, psychomotor development, and behaviour at 6 months²⁶

Safety outcomes were not reported for this comparison.

Clinical Effectiveness and Safety of Choline Given to Children With FASD

We found evidence for children with FASD given choline supplementation; no evidence was found for infants with FASD given choline supplementation. Overall, evidence differed depending on child age at intervention, trial duration, and which outcome was measured. Some benefits were seen when older children were given choline supplementation.

Children with FASD between ages 2.5 and 5 years given choline supplementation for 9 months were little-to-no different for neurocognitive outcomes from children with FASD given placebo:

• little-to-no difference in global cognitive development or elicited imitation memory but those aged 2.5 to 4 years had the greatest improvement in elicited imitation delayed performance suggesting that age may moderate this effect

• little-to-no differences in brain functioning and memory measured by brain electrical activity.²⁸

Children with FASD aged 5 to 10 years given choline supplementation for 6 weeks were little-to-no different for neurocognitive outcomes from children with FASD given placebo:

• little-to-no differences in paired-associate learning, design fluency, spatial working memory, spatial working memory strategy, quotient attention-deficit/hyperactivity disorder, and fine motor speed.²⁶

Children with FASD aged 8.6 years on average who were given choline supplementation for 4 years had better intelligence scores compared to children with FASD given placebo:

• children in the supplementation group had better nonverbal IQ and working memory; there were statistically significant subscores for nonverbal visual-spatial reasoning and nonverbal working memory.²⁶

Children with FASD and an average age of 10.56 years given choline supplementation for 9 months showed mixed results for neurocognitive outcomes and brain structures compared to children with FASD and an average age of 11.44 years given placebo:

• little-to-no differences in digit span, picture span, visual scanning, number sequencing, letter sequencing, number/letter sequencing, word reading, inhibition, and inhibition/switching; the choline group showed better motor speed and colour naming²⁹

• little-to-no differences in 7 of 8 brain white matter microstructures; 1 microstructure (the splenium) was better in the choline group.²⁹

Safety results from the included SR²⁶ had limited information in the choline group:

• in 1 trial, choline was reported to be well-tolerated in children (no further details provided) and children in the choline group reported higher levels of fishy body odour (no statistical significance given) at 4 years of follow-up

• in another trial, there were little-to-no differences in adverse events; however, children in the choline group reported more adverse events in specific symptom categories (no further details provided).

Guidelines for Pregnant People

Based on limited, low-quality, or unclear evidence, the identified guidelines^31-36 made weak to fair recommendations for increased choline intake during pregnancy through diet or supplementation, given that intake is known to be lower in pregnant people and is important for maternal health and fetal development. Three guidelines^32-36 had recommendations for pregnant people who may have insufficient dietary intake (e.g., low egg consumption, vegetarian or vegan diet). Choline supplementation recommendations were 350 mg to 450 mg during the first 2 trimesters, 450 mg to 600 mg in the last trimester, and 550 mg during lactation.

Diet

• Pregnant people are encouraged to consume choline-containing foods during pregnancy and lactation stages; meeting needs through food is preferred, and they should speak with health care provider about the appropriateness of choline supplementation if they have individual concerns about not meeting recommendations.³³

• Pregnant people should be supported to understand how to meet recommendations for choline, and which foods are rich in choline as pregnancy advances.^31-33,35,36

• Daily nutritional goals for pregnant people:

  • Pregnant people aged 14 to 50 years should receive 450 mg in all trimesters, for calorie levels ranging from 1,800 to 2,400.^33,36

• Daily nutritional goals for lactating people:

  • 550 mg choline for pregnant people aged 14 to 50 years, 0 to 12 months postpartum, for calorie levels ranging from 2,200 to 2,400.^33,36

• For pregnant people with vegetarian or vegan diets:

  • Additional care is needed to ensure they have adequate amounts of nutrients in diet, and may need to consult health care providers to determine whether supplementation in necessary and if so, how much.^32,33,35,36

• For those with GDM:

  • Nutritionists should encourage pregnant people with GDM to consume a variety of foods to meet the micronutrient needs, which are the same for pregnant people without GDM (emphasis on intake of choline through diet).^32,35

  • Adequate intake is 450 mg.^32,35

Supplementation

• For all pregnant people:

  • First 2 trimesters: prenatal supplements with 350 mg of choline.³⁴

  • Third trimester: prenatal supplements with 600 mg of choline especially for pregnant people who do not consume many eggs.³⁴

• For those with GDM:

  • Where there is inadequate dietary intake or documented deficiency, nutritionists should consider recommending prenatal supplements (including for choline). Indications may include high risk for inadequate micronutrient intake, food insecurity, substance use or dependency (alcohol, tobacco), anemia, vegetarian or vegan diets, and poor eating habits.^32,35

  • Considerations for recommending prenatal supplementation include malabsorption disorder, gastrointestinal discomfort, religious diets, tolerance for supplements, increased costs.^32,35

  • Pregnant people taking over-the-counter or herbal supplements should consult a pharmacist or physician.^32,35

Limitations

Study Quality

The included SR²⁶ reported limitations of the included clinical studies such as high dropout rates, unplanned outcome measurements and statistical analyses, missing data, and low generalizability (e.g., low compliance, high drop outs). The primary clinical studies^26-30 also noted small sample sizes and missing data; the magnitude of the treatment effects reported may not be as precise as they would be if the studies had higher sample sizes. Most guidelines were based on low-quality evidence or expert opinion.

Generalizability

The clinical studies^26-30 included in the current review were conducted in South Africa, Ukraine, and the US; the generalizability of the findings to settings in Canada is unknown. For clinical studies where pregnant people were given choline supplementation, 2 RCTs^27,30 reported ages ranging from 26.6 to 28.4 years; ages were not reported in the included SR.²⁶ Therefore it is unclear whether results are applicable to younger or older pregnant people or if results apply to all ages as seen in the included guidelines where recommendations were the same for different age groups. Across evidence where children with FASD were given choline, ages ranged from 2 to 11.44 years, and trial duration lasted from 6 weeks to 4 years.^26,28,29 Since no studies were found where infants were given choline, it is unclear whether the results apply to this younger age group. The different values for age at which choline supplementation was initiated, and duration of supplementation present a challenge for interpreting when and how long supplementation is needed to realize an effect; for example, there appeared to be some or little-to-no benefits when older children were given choline.

Average choline dietary intake, type of diet, or descriptions of choline adequacy were only reported in 1 RCT in the included SR,²⁶ and 1 included RCT;³⁰ this information could have helped to contextualize the choline intake of pregnant people and children, helping to provide information to ascertain the baseline levels of choline within groups and how comparable study populations were.

Three included guidelines^31,33,34,36 were for the general population of pregnant people and 1 guideline was for pregnant people with GDM.^32,35 Two guidelines were specifically for health professionals and people from the US^33,34,36 and 1 was for health professionals in Canada;³¹ it is unclear whether these guidelines may apply to pregnant people with other comorbidities and from other countries.

Heterogeneity of Clinical Studies

There were several differences between the included primary studies which may make it difficult to interpret results as a whole. Where information was available, included primary studies^26-30 varied based on population race, education-levels, economic-levels, and whether and how much the pregnant participants consumed alcohol. When the same variable was not reported across multiple studies, it was difficult to assess whether participants were similar or different across the evidence base. The included SR²⁶ did not report on race, education-levels, economic-levels, so it is unclear whether the studies included in the SR²⁶ were similar or different to the primary studies identified for this Rapid Review.

Another limitation of the included clinical studies was the variety of ways that effectiveness was measured. The evidence included over 20 tests, scales, or measurements to assess cognition, behaviour, or neurophysiological responses in infants and children. Given the variability in measurement tools and their results, it is unclear whether included studies measure the same or similar outcomes. Clinical studies also had poor reporting of safety outcomes; in some cases, no numerical information was reported making it difficult to judge potential differences between groups.

Gaps in Equity Reporting

This Rapid Review did not include an explicit search for information related to inequity or equity-deserving groups, or a thorough investigation of the ways that stigma can affect appropriate health care for pregnant people exposed to alcohol, or infants and children with PAE or FASD, and how this relates to choline supplementation strategies for this population. A fulsome equity review and analysis would have provided a better understanding on these issues. PROGRESS-Plus²² was used to guide data extraction and report writing to identify gaps in the evidence where these criteria were not reported or were reported insufficiently. Although PROGRESS-Plus²² includes several criteria, there may be other criteria it does not include that were not extracted that may be important for this population (e.g., timeliness of FASD diagnosis based on demographics or social determinants of health).

No included study described how gender or sex were defined and did not include gender identities outside of male and female. When reporting on pregnant people, the studies referred to the population as “women” or “mothers.” It is unclear whether any of the studies included trans or nonbinary pregnant people, or people with other gender identities. Two clinical trials reported on race and ethnicity; 1 trial²⁹ indicated this was self-identified and it is unclear how it was defined in the other trial.²⁷ Two trials reported education and income, and 1 trial reported English language, but not other languages spoken. No other PROGRESS-plus²² criteria were reported. Identifying these factors for each included study could have given insights into how similar or dissimilar the populations were. Because these criteria were not reported clearly or consistently across the evidence, the generalizability of the evidence is unclear, and the effect of choline supplementation in the context of potential health inequities is unknown. It is unclear whether the study populations included people from equity-deserving groups or whether these groups have access to the intervention.

Conclusions and Implications for Decision- or Policy-Making

We conducted a Rapid Review of the evidence on the clinical effectiveness of choline supplementation in pregnant people or children with PAE or FASD; we also included guidelines with recommendations for these populations. We found 5 articles^26-30 published since 2021 based on 1 SR and 3 RCTs, and 4 guidelines^31-36 published since 2016 with recommendations. Populations in the clinical evidence included healthy pregnant people, pregnant people exposed to alcohol, and children with FASD. Interventions included choline supplementation compared to placebo, choline supplementation with multivitamin compared to multivitamin only, and higher-dose choline compared to low dose choline. Guidelines were found for choline supplementation in pregnant people including those with GDM or vegan or vegetarian diets; no guidelines were found for choline supplementation in children with PAE or FASD.

Choline Supplementation Evidence

This Rapid Review found heterogenous evidence for child outcomes for studies with sample sizes ranging from 18 to 313 and with most reporting limited statistical power making findings uncertain.

More specifically, for healthy pregnant people given choline compared to those given placebo, there was favourable evidence for cerebral inhibition for 1-month old children and for parent-reported attention and withdrawn symptoms on a schizophrenia questionnaire for 40-month olds.²⁶ There were little-to-no differences between groups in cerebral inhibition, cognitive development, language, visuospatial perception, discrimination, memory, and parent-reported behavioural symptoms measured from 3 to 40 months.²⁶

For healthy pregnant people given high-dose choline compared to those given low-dose choline, there was favourable evidence for reaction times in 13-month olds²⁶ and attention during a signal detection task in 7-year-olds.²⁷ There were little-to-no differences between groups in predictive cascades in 13-month olds,²⁶ or in false alarms, omissions, and off-task behaviours in 7-year-olds.²⁷

For pregnant people exposed to alcohol and given choline compared to those given placebo, there was favourable evidence for conditioned responses in 6.5-month olds,²⁶ visual recognition memory in 12-month olds,²⁶ and weight,²⁶ head circumference,²⁶ and 6 of 12 brain regions in infants from birth to 12 months of age.²⁶ There were little-to-no differences between groups in learning and memory measured by eyeblink conditioning in 6.5-month-olds.²⁶

For pregnant people exposed to alcohol and given choline and multivitamin compared to those given multivitamin only, there was favourable evidence for information processing and learning based on heart rate responses to visual stimuli in 4 to 11-month-olds and little-to-no differences between groups in the score for mental development, psychomotor development, and behaviour at 6 months.²⁶

For children with FASD given choline compared to those given placebo, there was favourable evidence for intelligence (nonverbal IQ and working memory) in 8.6-year-olds with 4-year supplementation,²⁶ and splenium brain structure, motor speed, and colour naming for 10 to 11 year-olds given supplementation for 9 months.^28,29 There were little-to-no differences in various neurocognitive outcomes in 2.5 to 5-year-olds given supplementation for 9 months,^26,28,29 5 to 10-year-olds given supplementation for 6 weeks,²⁶ and 10 to 11 year-olds given supplementation for 9 months.^28,29

Based on limited safety information from 1 SR,²⁶ some results showed little-to-no differences in adverse events in children after choline supplementation during healthy pregnancies, and some adverse events when children with FASD were given supplementation such as fishy body odour and adverse events in specific symptom categories which were reported unclearly.

All 4 guidelines^31-36 based on limited and low-quality evidence, and with recommendations informed mostly by expert opinion, recommended that pregnant people, including those with GDM, increase their consumption of choline through diet or supplements. Recommended choline amounts ranged from 350 mg to 600 mg depending on diet versus supplement intake and on pregnancy or postpartum stage. Guidelines also brought attention to the need for health care professional support when deciding whether to supplement diet with choline, the low general intakes of choline in the population, vegetarian and vegan diets, and consideration of the total consumption of micronutrients through diet and supplements. No recommendations were found regarding choline supplementation in children with PAE or FASD.

Across the 5 included publications for effectiveness, none had participants in Canada; generalizability of the evidence as a whole to the Canadian context is unclear. Both clinical studies and guidelines were for different populations of pregnant people of different backgrounds; it may be difficult to interpret evidence and recommendations from the findings as a whole or generalize to all populations. Similarly, since there was limited information on equity-deserving groups, it is unclear what the effect of choline supplementation is in the context of potential health inequities.

Considerations for Future Research

Further clinical research may be needed in the following areas: clinical trials with larger populations and better statistical power, better investigation and reporting of safety outcomes, clear selection and reporting of clinically relevant outcomes given the variability in measures across the evidence, studies where the amounts of choline given to study populations match recommendations for the intervention groups or average intake for comparator groups, meaningful and respectful inclusion and reporting for more pregnant people including nonbinary or trans persons. The following factors may need to be considered in future guideline development: recommendations based on higher-quality evidence (if available), inclusion of the target population when making recommendations, and clearer reporting of methods with links to evidence.

Implications for Clinical Practice

Decision-makers can use clinical effectiveness and guideline evidence from this Rapid Review to inform decisions for use of choline supplementation in pregnant people and children with PAE or FASD, keeping in mind that the evidence is limited and of low quality. Evidence for most effectiveness outcomes was mixed, showing that either choline supplementation was favourable or it had little-to-no benefit; limited safety information showed some adverse events for children with FASD. However, all guidelines recommended higher choline intake through diet or supplementation for all pregnant people. In this Rapid Review, no recommendations were found for choline supplementation in children with PAE or FASD; however, given the range and intensity of interventions that children with FASD need including behaviour therapy, education therapy, medical specialists, and parent training, researchers and health care providers may need to make careful consideration of what is best for children including an appropriate balance of benefits and harms when multiple interventions are applied together. Health care providers who choose to recommend increased choline intake may wish to consider accessibility and cost concerns for pregnant people trying to obtain additional sources of choline through the diet or through supplements, the availability of choline supplements in certain regions and contexts, training on how to read and interpret nutrition information on supplement packaging, and cultural practices and needs of certain populations that affect how they incorporate choline into an existing diet. Further, given the existence of stigma around alcohol exposure during pregnancy and for children with FASD, health care providers should consider providing patient-centred care informed by the stigma and challenges faced by this population to ensure that they feel safe and have the appropriate social and health care resources they need.

References

1.The 519. The 519 Glossary of Terms. 2020; https://www.the519.org/education-training/glossary/. Accessed 2024 Feb 5.

2.Kansakar U, Trimarco V, Mone P, Varzideh F, Lombardi A, Santulli G. Choline supplements: An update. Front Endocrinol (Lausanne). 2023;14:1148166. PubMed

3.National Institutes of Health, Office of Dietary Supplements. Choline. Fact Sheet for Health Professionals 2022; https://ods.od.nih.gov/factsheets/Choline-HealthProfessional/. Accessed 2024 Jan 27.

4.Jaiswal A, Dewani D, Reddy LS, Patel A. Choline Supplementation in Pregnancy: Current Evidence and Implications. Cureus. 2023;15(11):e48538. PubMed

5.Garner CD. Nutrition in pregnancy: Dietary requirements and supplements. In: Post TW, ed. UpToDate. Waltham (MA): UpToDate; 2024: https://www.uptodate.com. Accessed 2024 Jan 2.

6.Ernst AM, Gimbel BA, de Water E, et al. Prenatal and Postnatal Choline Supplementation in Fetal Alcohol Spectrum Disorder. Nutrients. 2022;14(3):06.

7.Health Canada. Summary of Health Canada’s safety assessment of L-alpha-glycerylphosphorylcholine for use as a supplemental ingredient. 2023; https://www.canada.ca/en/health-canada/services/food-nutrition/reports-publications/summary-safety-assessment-l-alpha-glycerylphosphorylcholine-use-supplemental-ingredient.html. Accessed 2024 Jan 27.

8.Lewis ED, Subhan FB, Bell RC, et al. Estimation of choline intake from 24 h dietary intake recalls and contribution of egg and milk consumption to intake among pregnant and lactating women in Alberta. Br J Nutr. 2014;112(1):112-121. PubMed

9.U.S. Department of Health & Human Services, Centers for Disease Control and Prevention. Fetal Alcohol Spectrum Disorders: Basics about FASDs. 2023: https://www.cdc.gov/ncbddd/fasd/facts.html. Accessed 2024 Jan 27.

10.Public Health Agency of Canada. Fetal alcohol spectrum disorder: About, causes and co-occurring conditions. 2023; https://www.canada.ca/en/public-health/services/diseases/fetal-alcohol-spectrum-disorder.html. Accessed 2024 Jan 27.

11.Charlesworth J. Excluded: Increasing Understanding, Support and Inclusion for Children with FASD and Their Families. Victoria (BC): Representative for Children and Youth (British Columbia); 2021: https://rcybc.ca/reports-and-publications/excluded/. Accessed 2024 Feb 8.

12.Lange S, Probst C, Gmel G, Rehm J, Burd L, Popova S. Global Prevalence of Fetal Alcohol Spectrum Disorder Among Children and Youth: A Systematic Review and Meta-analysis. JAMA Pediatr. 2017;171(10):948-956. PubMed

13.Popova S, Lange S, Chudley AE, et al. World Health organization International study on the prevalence of fetal alcohol spectrum disorder (FASD). Canadian Component. Toronto (ON): Centre for Addiction and Mental Health, Institute for Mental Health Policy Research; 2018: https://canfasd.ca/wp-content/uploads/2018/05/2018-Popova-WHO-FASD-Prevalance-Report.pdf. Accessed 2024 Jan 27.

14.Flannigan K, Unsworth K, Harding K. FASD prevalence in special populations. Vancouver (BC): Canada FASD Research Network; 2018: https://canfasd.ca/wp-content/uploads/publications/Prevalence-2-Issue-Paper-FINAL.pdf. Accessed 2024 Feb 8.

15.Centre for Addiction and Mental Health (CAMH). Fetal Alcohol Spectrum Disorders. [2024]; https://www.camh.ca/en/health-info/mental-illness-and-addiction-index/fetal-alcohol-spectrum-disorder. Accessed 2024 Jan 27.

16.Baker JA, Breit KR, Bodnar TS, Weinberg J, Thomas JD. Choline Supplementation Modifies the Effects of Developmental Alcohol Exposure on Immune Responses in Adult Rats. Nutrients. 2022;14(14):2868. PubMed

17.Popova S, Charness ME, Burd L, et al. Fetal alcohol spectrum disorders. Nat Rev Dis Primers. 2023;9(1):11. PubMed

18.Murawski NJ, Moore EM, Thomas JD, Riley EP. Advances in Diagnosis and Treatment of Fetal Alcohol Spectrum Disorders: From Animal Models to Human Studies. Alcohol Res. 2015;37(1):97-108. PubMed

19.Shea BJ, Reeves BC, Wells G, et al. AMSTAR 2: a critical appraisal tool for systematic reviews that include randomised or non-randomised studies of healthcare interventions, or both. BMJ. 2017;358:j4008. PubMed

20.Downs SH, Black N. The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions. J Epidemiol Community Health. 1998;52(6):377-384. PubMed

21.Agree Next Steps Consortium. The AGREE II Instrument. [Hamilton (ON)]: AGREE Enterprise; 2017: https://www.agreetrust.org/wp-content/uploads/2017/12/AGREE-II-Users-Manual-and-23-item-Instrument-2009-Update-2017.pdf. Accessed 2024 Jan 22.

22.O'Neill J, Tabish H, Welch V, et al. Applying an equity lens to interventions: using PROGRESS ensures consideration of socially stratifying factors to illuminate inequities in health. J Clin Epidemiol. 2014;67(1):56-64. PubMed

23.Morrison K, Wolfson L, Harding K, Poole N. Mothers' Experiences of Stigma: Multi-Level Ideas for Action. Vancouver (BC): Canada FASD Research Network; 2020: https://canfasd.ca/wp-content/uploads/publications/Mothers-Experiences-of-Stigma-final.pdf. Accessed 2024 Feb 5.

24.Roozen S, Stutterheim SE, Bos AER, Kok G, Curfs LMG. Understanding the Social Stigma of Fetal Alcohol Spectrum Disorders: From Theory to Interventions. Foundations of Science. 2022;27(2):753-771.

25.Weber A, Miskle B, Lynch A, Arndt S, Acion L. Substance Use in Pregnancy: Identifying Stigma and Improving Care. Subst Abuse Rehabil. 2021;12:105-121. PubMed

26.Obeid R, Derbyshire E, Schon C. Association between Maternal Choline, Fetal Brain Development, and Child Neurocognition: Systematic Review and Meta-Analysis of Human Studies. Adv Nutr. 2022;13(6):2445-2457. PubMed

27.Bahnfleth CL, Strupp BJ, Caudill MA, Canfield RL. Prenatal choline supplementation improves child sustained attention: A 7-year follow-up of a randomized controlled feeding trial. FASEB J. 2022;36(1):e22054. PubMed

28.Fuglestad AJ, Miller NC, Fink BA, et al. Neurophysiological correlates of memory change in children with fetal alcohol spectrum disorders treated with choline. Front Psychol. 2022;13:936019. PubMed

29.Gimbel BA, Anthony ME, Ernst AM, et al. Long-term follow-up of a randomized controlled trial of choline for neurodevelopment in fetal alcohol spectrum disorder: corpus callosum white matter microstructure and neurocognitive outcomes. J Neurodev Disord. 2022;14(1):59. PubMed

30.Warton FL, Molteno CD, Warton CMR, et al. Maternal choline supplementation mitigates alcohol exposure effects on neonatal brain volumes. Alcohol Clin Exp Res. 2021;45(9):1762-1774. PubMed

31.Nutrition Working Group, O'Connor DL, Blake J, et al. Canadian Consensus on Female Nutrition: Adolescence, Reproduction, Menopause, and Beyond. J Obstet Gynaecol Can. 2016;38(6):508-554.e518. PubMed

32.Duarte-Gardea MO, Gonzales-Pacheco DM, Reader DM, et al. Academy of Nutrition and Dietetics Gestational Diabetes Evidence-Based Nutrition Practice Guideline. J Acad Nutr Diet. 2018;118(9):1719-1742. PubMed

33.Dietary Guidelines for Americans, 2020-2025. 9th ed. Washington (DC): U.S. Department of Agriculture and U.S. Department of Health and Human Services; 2020: https://www.dietaryguidelines.gov/sites/default/files/2021-03/Dietary_Guidelines_for_Americans-2020-2025.pdf. Accessed 2024 Jan 22.

34.Adams JB, Kirby JK, Sorensen JC, Pollard EL, Audhya T. Evidence based recommendations for an optimal prenatal supplement for women in the US: vitamins and related nutrients. Matern Health Neonatol Perinatol. 2022;8(1):4. PubMed

35.Gestational Diabetes. GDM: Full Recommendations and Supporting Evidence (2016). Evidence Analysis Library. Chicago (IL): Academy of Nutrition and Dietetics; 2017: https://www.andeal.org/vault/pq152.pdf. Accessed 2024 Jan 24.

36.Dietary Guidelines Advisory Committee. Scientific report of the 2020 Dietary Guidelines Advisory Committee: advisory report to the Secretary of Agriculture and the Secretary of Health and Human Services. Washington (DC): U.S. Department of Agriculture, Agricultural Research Service; 2020: https://www.dietaryguidelines.gov/sites/default/files/2020-07/ScientificReport_of_the_2020DietaryGuidelinesAdvisoryCommittee_first-print.pdf. Accessed 2024 Jan 22.

37.Liberati A, Altman DG, Tetzlaff J, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. J Clin Epidemiol. 2009;62(10):e1-e34. PubMed

Appendix 1: Selection of Included Studies

Figure 1: Selection of Included Studies

Appendix 2: Characteristics of Included Publications

Table 2: Characteristics of Included Systematic Review

FASD = fetal alcohol spectrum disorder; NR = not reported; SES = socioeconomic status.

^aSome publications reported on the same study population for different outcomes or analyses.

^bOut of the 7 included RCTs, the SR reported a average of 360mg per day dietary choline intake and a “Western diet” for 1 RCT; details for diet or choline adequacy status for other RCTs was not reported.

^cCholine type not reported.

^dSpecific measures included the Child Behaviour Checklist, Mullen Scales of Early Learning, Mac-Arthur-Bates Short form Vocabulary Checklist, Bayley Scales of Infant Development (II), Stanford–Binet Intelligence Scales, Fifth Edition (SB-5), Cambridge Neuropsychological Test Automated Battery (CANTAB), NEPSY-2 Design Fluency test, Quotient ADHD system, and Grooved Pegboard.

Note that this table has not been copy-edited.

Table 3: Characteristics of Included Randomized Controlled Trials

D-KEFS = Delis-Kaplan Executive Function System; ERP = event-related potential; FASD = fetal alcohol spectrum disorder; FTII = Fagan Test of Infant Intelligence; NIAAA = National Institute on Alcohol Abuse and Alcoholism; NIFA = National Institute of Food and Agriculture; NIH = National Institutes of Health; NODDI ODI neurite orientation dispersion and density imaging orientation dispersion index; NR = not reported; SAT = sustained attention task; SES = socioeconomic status; UNC = University of North Carolina; USDA = US Department of Agriculture; WISC-V = Wechsler Intelligence Scale for Children, Fifth Edition.

^aIntervention group vs. comparator group, respectively, unless otherwise indicated.

^bInformation about diet or choline adequacy status not reported.

^cConsumed as a fruit-flavoured powder mixed with water or in cran-grape juice.

^dThe participants in this trial are also included in the systematic review by Obeid et al. (2022) under a different publication.

^eAcross groups in the 2 articles.

Note that this table has not been copy-edited.

Table 4: Characteristics of Included Guidelines

AHRQ = Agency for Health care Research and Quality; ALT = alanine aminotransferase; AST = aspartate aminotransferase; CBC = complete blood count; DRI = Dietary Reference Intakes; ESPEN = The European Society for Clinical Nutrition and Metabolism; GDM = gestational diabetes mellitus; GGT = glutamyl transferase; GRADE = Grading of Recommendations Assessment, Development and Evaluation; HHS = US Department of Health and Human Services; MN = micronutrient; NASEM = National Academies of Sciences, Engineering, and Medicine; NESR = Nutrition Evidence Systematic Review; NHANES = National Health and Nutrition Examination Survey; NR = not reported; OHAT = Office of Health Assessment and Translation; RDA = Recommended Dietary Allowance; RDN = registered dietitian nutritionist; SIGN = Scottish Intercollegiate Guidelines Network; SOGC = Society of Obstetricians and Gynaecologists of Canada; SR = systematic review; USDA = US Department of Agriculture.

Note that this table has not been copy-edited.

Appendix 3: Critical Appraisal of Included Publications

Note that this appendix has not been copy-edited.

Table 5: Strengths and Limitations of the Systematic Review Using AMSTAR2¹⁹

AMSTAR 2 = A MeaSurement Tool to Assess systematic Reviews 2; SES = socioeconomic status.

Table 6: Strengths and Limitations of Clinical Studies Using the Downs and Black Checklist²⁰

ERP = event-related potentials (from brain responses).

Table 7: Strengths and Limitations of Guidelines Using AGREE II²¹

AGREE II = Appraisal of Guidelines for Research and Evaluation II; NA = not applicable; SOGC = Society of Obstetricians and Gynaecologists of Canada.

^aAuthors reported that there were no potential conflicts of interest.

Appendix 4: Main Study Findings

Note that this appendix has not been copy-edited.

Table 8: Summary of Findings by Outcomes in Infants and Children — Effectiveness and Safety of Choline Supplementation Versus Placebo in Healthy Pregnant People

CI = confidence interval; mg/d = milligrams per day; ms = milliseconds; NR = not reported; RCT = randomized controlled trial; SAT = sustained attention task; SD = standard deviation; SR = systematic review; vs. = versus.

^aFollow-up in months unless otherwise indicated.

^bCholine was given to pregnant person from second trimester until birth, and to infants after birth until 3 months.²⁶

^cMeasures global cognitive development and includes motor ability, language, and visual reception.²⁶

^dCognition outcomes included Short-term Visuospatial Memory Delayed Response Task to measure visuospatial memory, long-term episodic memory, The Mac-Arthur-Bates Short Form Vocabulary Checklist – level I to measure language development, and Mullen Scales of Early Learning to measure motor ability, language, and visual reception.²⁶

^eOutcomes were based on parent-reports on the Child Behaviour Checklist to detect early signs of schizophrenia, withdrawn symptoms, and attention disturbances.²⁶

^fA measure of a baby’s general condition.²⁶

Table 9: Summary of Findings by Outcomes in Infants and Children — Effectiveness and Safety of High-Dose Versus Low-Dose Choline Supplementation in Healthy Pregnant People

CI = confidence interval; mg/d = milligrams per day; ms = milliseconds; NR = not reported; RCT = randomized controlled trial; SAT = sustained attention task; SD = standard deviation; SE = standard error; SR = systematic review; vs. = versus.

^aFollow-up in months unless otherwise indicated.

^bMeasures information processing and intelligent quotient (IQ) scores.²⁶

^cBased on the child’s performance on a signal detection task that measures attentional processes.²⁶

^dMeasures sustained attention.²⁷

Table 10: Summary of Findings by Outcomes in Infants and Children — Effectiveness and Safety of Choline Supplementation Versus Placebo in Pregnant People Exposed to Alcohol

CI = confidence interval; FTII = Fagan Test of Infant Intelligence; NR = not reported; RCT = randomized controlled trial; SR = systematic review; vs. = versus.

^aFollow-up in months unless otherwise indicated.

^bTest indicates learning and memory and is sensitive to fetal alcohol syndrome.²⁶

^cA measure of information processing speed and visual recognition memory based on a child’s ability to distinguish familiar from novel pictures.²⁶

^dPAE is thought to reduce brain volumes and choline may mitigate these effects.³⁰

Table 11: Summary of Findings by Outcomes in Infants and Children — Effectiveness and Safety of Multivitamin Choline Supplementation Versus Multivitamin Only in Pregnant People Exposed to Alcohol

NA = not applicable; RCT = randomized controlled trial; SR = systematic review; vs. = versus.

^aFollow-up in months unless otherwise indicated.

^bIndicates information processing and learning.²⁶

^cA measure of mental development, psychomotor development, and behaviour including problem solving, prelinguistic development, fine and gross motor skills, orientation and engagement, emotional regulation, motor quality, and total behaviour quality.²⁶

Table 12: Summary of Findings by Outcomes in Infants and Children — Effectiveness and Safety of Choline Supplementation Versus Placebo for Children With PAE or FASD

D-KEFS = Delis-Kaplan Executive Function System; ERP = event-related potential; FASD = fetal alcohol spectrum disorder; IQ = intelligence quotient; NODDI = neurite orientation dispersion and density imaging; ODI = orientation dispersion index; PAE = prenatal alcohol exposure; SB-5 = Stanford–Binet Intelligence Scale Fifth Edition; vs. = versus; WISC-V = Wechsler Intelligence Scale for Children.

^aFollow-up age in years unless otherwise indicated.

^bMeasures global cognitive development and includes motor ability, language, and visual reception.²⁶

^cA measure of hippocampus-dependent sequential memory.²⁶

^dA measure of brain functioning and memory using brain electrical activity.²⁸

^eOutcomes were measured using the Cambridge Neuropsychological Test Automated Battery (CANTAB), NEPSY-2 Design Fluency test, Quotient ADHD system and grooved pegboard.²⁶

^fOutcomes measure executive function performance.²⁹

^gMRI (MRI) data were used to measure brain white matter microstructure which can indicate cognitive functioning.²⁹

^hMore coherent fibres and less fanning or bending.

Table 13: Summary of Recommendations in Included Guidelines – For Pregnant People

AI = adequate intake; DRI = Dietary Reference Intake; GDM = gestational diabetes mellitus; mg = milligram; NR = not reported; OTC = over the counter; RDN = registered dietitian nutritionist; SOGC = Society of Obstetricians and Gynaecologists of Canada

^aExpert opinion supports the recommendation even though controlled trials were lacking or the evidence was inconsistent.

^bBroadly applies to the target population.

^cBased on opinions of authorities, clinical experience, descriptive studies, or expert committee reports.

^dBased on well-design cohort or case-control studies.

Appendix 5: References of Potential Interest

Additional Publications With Findings also Reported in an Included Study

Curioni CC, Mocellin MC, Tavares MDS, et al. Effectiveness of nutritional interventions to prevent nonprogressive congenital and perinatal brain injuries: a systematic review and meta-analysis of randomized trials. Nutr Rev. 2022;80(11):2136-2153. PubMed

Freedman R, Hunter SK, Law AJ, Clark AM, Roberts A, Hoffman MC. Choline, folic acid, Vitamin D, and fetal brain development in the psychosis spectrum. Schizophr Res. 2022;247:16-25. PubMed

Ordenewitz LK, Weinmann T, Schluter JA, et al. Evidence-based interventions for children and adolescents with fetal alcohol spectrum disorders - A systematic review. Eur J Paediatr Neurol. 2021;33:50-60. PubMed

Derbyshire E, Obeid R. Choline, Neurological Development and Brain Function: A Systematic Review Focusing on the First 1000 Days. Nutrients. 2020;12(6):10. PubMed

Wozniak JR, Fink BA, Fuglestad AJ, et al. Four-year follow-up of a randomized controlled trial of choline for neurodevelopment in fetal alcohol spectrum disorder. J Neurodev Disord. 2020;12(1):9. PubMed

Sarkar DK, Gangisetty O, Wozniak JR, et al. Persistent Changes in Stress-Regulatory Genes in Pregnant Women or Children Exposed Prenatally to Alcohol. Alcohol Clin Exp Res. 2019;43(9):1887-1897. PubMed

Akison LK, Kuo J, Reid N, Boyd RN, Moritz KM. Effect of Choline Supplementation on Neurological, Cognitive, and Behavioral Outcomes in Offspring Arising from Alcohol Exposure During Development: A Quantitative Systematic Review of Clinical and Preclinical Studies. Alcohol Clin Exp Res. 2018;42(9):1591-1611. PubMed

Caudill MA, Strupp BJ, Muscalu L, Nevins JEH, Canfield RL. Maternal choline supplementation during the third trimester of pregnancy improves infant information processing speed: a randomized, double-blind, controlled feeding study. FASEB J. 2018;32(4):2172-2180. PubMed

Jacobson SW, Carter RC, Molteno CD, et al. Feasibility and Acceptability of Maternal Choline Supplementation in Heavy Drinking Pregnant Women: A Randomized, Double-Blind, Placebo-Controlled Clinical Trial. Alcohol Clin Exp Res. 2018;42(7):1315-1326. PubMed

Nguyen TT, Risbud RD, Mattson SN, Chambers CD, Thomas JD. Randomized, double-blind, placebo-controlled clinical trial of choline supplementation in school-aged children with fetal alcohol spectrum disorders. Am J Clin Nutr. 2016;104(6):1683-1692. PubMed

Ross RG, Hunter SK, Hoffman MC, et al. Perinatal Phosphatidylcholine Supplementation and Early Childhood Behavior Problems: Evidence for CHRNA7 Moderation. Am J Psychiatry. 2016;173(5):509-516. PubMed

Coles CD, Kable JA, Keen CL, et al. Dose and Timing of Prenatal Alcohol Exposure and Maternal Nutritional Supplements: Developmental Effects on 6-Month-Old Infants. Matern Child Health J. 2015;19(12):2605-2614. PubMed

Freedman R, Ross RG. Prenatal choline and the development of schizophrenia. Shanghai Arch Psychiatry. 2015;27(2):90-102. PubMed

Kable JA, Coles CD, Keen CL, et al. The impact of micronutrient supplementation in alcohol-exposed pregnancies on information processing skills in Ukrainian infants. Alcohol. 2015;49(7):647-656. PubMed

Leermakers ET, Moreira EM, Kiefte-de Jong JC, et al. Effects of choline on health across the life course: a systematic review. Nutr Rev. 2015;73(8):500-522. PubMed

Wozniak JR, Fuglestad AJ, Eckerle JK, et al. Choline supplementation in children with fetal alcohol spectrum disorders: a randomized, double-blind, placebo-controlled trial. Am J Clin Nutr. 2015;102(5):1113-1125. PubMed

Ongoing Trials

NCT05108974: Choline Supplementation as a Neurodevelopmental Intervention in Fetal Alcohol Spectrum Disorders Study (CHOLINE4). ClinicalTrials.gov. Bethesda (MD): U.S. National Library of Medicine; https://clinicaltrials.gov/study/NCT05108974. Accessed 2024 Jan 26.

NCT04395196: RCT of Prenatal Choline Supplementation During Pregnancy to Mitigate Adverse Effects of Prenatal Alcohol Exposure. ClinicalTrials.gov. Bethesda (MD): U.S. National Library of Medicine; https://clinicaltrials.gov/study/NCT04395196. Accessed 2024 Jan 26.

Systematic Review Protocol

Saha S, Saha S. The effects of prenatal dietary supplements on blood glucose and lipid metabolism in gestational diabetes mellitus patients: A systematic review and network meta-analysis protocol of randomized controlled trials. PLoS One. 2022;17(5):e0267854. PubMed

Nonsystematic Reviews

Jaiswal A, Dewani D, Reddy LS, Patel A. Choline Supplementation in Pregnancy: Current Evidence and Implications. Cureus. 2023;15(11):e48538. PubMed

Ernst AM, Gimbel BA, de Water E, et al. Prenatal and Postnatal Choline Supplementation in Fetal Alcohol Spectrum Disorder. Nutrients. 2022;14(3):06.

Recommendations or Position Papers with Unclear Methods

Health Canada. Reference values for Folate, Vitamin B12, Pantothenic acid, Biotin, and Choline. 2023: https://www.canada.ca/en/health-canada/services/food-nutrition/healthy-eating/dietary-reference-intakes/tables/reference-values-vitamins.html. Accessed 2024 Jan 26.

Marshall NE, Abrams B, Barbour LA, et al. The importance of nutrition in pregnancy and lactation: lifelong consequences. Am J Obstet Gynecol. 2022;226(5):607-632. PubMed

EFSA Panel on Dietetic Products, Nutrition and Allergies (NDA). Dietary Reference Values for choline. EFSA Journal. 2016;14(8):e04484.

Hanson MA, Bardsley A, De-Regil LM, et al. The International Federation of Gynecology and Obstetrics (FIGO) recommendations on adolescent, preconception, and maternal nutrition: “Think Nutrition First”. Int J Gynaecol Obstet. 2015;131 Suppl 4:S213-253. PubMed

Procter SB, Campbell CG. Position of the Academy of Nutrition and Dietetics: Nutrition and Lifestyle for a Healthy Pregnancy Outcome. J Acad Nutr Diet. 2014;114(7):1099-1103. PubMed

Not in English

Heras-Sola J, Gallo-Vallejo JL. Importance of choline during pregnancy and lactation: A systematic review. Semergen. 2024 Jan-Feb;50(1):102089. PubMed