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Association of antenatal vitamin B complex supplementation with neonatal vitamin B12 status: evidence from a cluster randomized controlled trial



Evidence about the effect of maternal vitamin B12 supplementation on offspring’s vitamin B12 status is limited. The present interventional study sought to evaluate the association of antenatal vitamin B complex supplementation with neonatal vitamin B12 status.


In an ongoing cluster randomized controlled trial conducted in three rural counties in northwest China, pregnant women < 20 weeks of gestation were randomized to three treatment groups: blank control, iron supplements, or vitamin B complex supplements. All women were administered folic acid supplements during the periconceptional period. In a sub-study, we collected cord blood samples of 331 participants from the control or vitamin B complex groups in the Xunyi county from January 2017 to December 2017. Plasma concentrations of folate, vitamin B12, and homocysteine were measured. Linear mixed models with a random intercept for cluster were used to compare biochemical indexes between groups after controlling for covariates.


Compared with newborns whose mothers were in the control group, newborns of the vitamin B complex-supplemented women had significantly higher cord plasma vitamin B12 (P = 0.001) and lower homocysteine concentrations (P = 0.043). The association of antenatal vitamin B complex supplementation with cord blood vitamin B12 concentrations appeared to be more pronounced among newborns with high folate status than those with low folate status (Pinteraction = 0.060).


Maternal vitamin B complex supplementation during pregnancy was associated with better neonatal vitamin B12 status in rural northwest China.

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  1. 1.

    McGee M, Bainbridge S, Fontaine-Bisson B (2018) A crucial role for maternal dietary methyl donor intake in epigenetic programming and fetal growth outcomes. Nutr Rev 76:469–478

    PubMed  Google Scholar 

  2. 2.

    Stover PJ (2004) Physiology of folate and vitamin B12 in health and disease. Nutr Rev 62:S3–12

    PubMed  Google Scholar 

  3. 3.

    Gomes S, Lopes C, Pinto E (2016) Folate and folic acid in the periconceptional period: recommendations from official health organizations in thirty-six countries worldwide and WHO. Public Health Nutr 19:176–189

    PubMed  Google Scholar 

  4. 4.

    Global Progress of Industrially Milled Cereal Grain Fortification. Accessed 10 Apr 2020

  5. 5.

    Sukumar N, Rafnsson SB, Kandala NB, Bhopal R, Yajnik CS, Saravanan P (2016) Prevalence of vitamin B-12 insufficiency during pregnancy and its effect on offspring birth weight: a systematic review and meta-analysis. Am J Clin Nutr 103:1232–1251

    CAS  PubMed  Google Scholar 

  6. 6.

    Dang S, Yan H, Zeng L, Wang Q, Li Q, Xiao S, Fan X (2014) The status of vitamin B12 and folate among Chinese women: a population-based cross-sectional study in northwest China. PLoS ONE 9:e112586

    PubMed  PubMed Central  Google Scholar 

  7. 7.

    Samuel TM, Duggan C, Thomas T, Bosch R, Rajendran R, Virtanen SM, Srinivasan K, Kurpad AV (2013) Vitamin B-12 intake and status in early pregnancy among urban South Indian women. Ann Nutr Metab 62:113–122

    CAS  PubMed  PubMed Central  Google Scholar 

  8. 8.

    Chandyo RK, Ulak M, Sommerfelt H, Schneede J, Ueland PM, Strand TA (2016) Nutritional intake and status of cobalamin and folate among non-pregnant women of reproductive age in Bhaktapur. Nepal Nutrients 8:375

    Google Scholar 

  9. 9.

    Soofi S, Khan GN, Sadiq K, Ariff S, Habib A, Kureishy S, Hussain I, Umer M, Suhag Z, Rizvi A et al (2017) Prevalence and possible factors associated with anaemia, and vitamin B-12 and folate deficiencies in women of reproductive age in Pakistan: analysis of national-level secondary survey data. BMJ Open 7:e018007

    PubMed  PubMed Central  Google Scholar 

  10. 10.

    Lindstrom E, Hossain MB, Lonnerdal B, Raqib R, EI Arifeen S, Ekstrom EC (2011) Prevalence of anemia and micronutrient deficiencies in early pregnancy in rural Bangladesh, the MINIMat trial. Acta Obstet Gynecol Scand 90:47–56

    PubMed  Google Scholar 

  11. 11.

    Liu D, Cheng Y, Dang S, Wang D, Zhao Y, Li C, Li S, Lei F, Qu P, Mi B et al (2019) Maternal adherence to micronutrient supplementation before and during pregnancy in Northwest China: a large-scale population-based cross-sectional survey. BMJ Open 9:e028843

    PubMed  PubMed Central  Google Scholar 

  12. 12.

    Molloy AM, Kirke PN, Troendle JF, Burke H, Sutton M, Brody LC, Scott JM, Mills JL (2009) Maternal vitamin B12 status and risk of neural tube defects in a population with high neural tube defect prevalence and no folic acid fortification. Pediatrics 123:917–923

    PubMed  PubMed Central  Google Scholar 

  13. 13.

    Lai JS, Mohamad Ayob MN, Cai S, Quah PL, Gluckman PD, Shek LP, Yap F, Tan KH, Chong YS, Godfrey KM et al (2019) Maternal plasma vitamin B12 concentrations during pregnancy and infant cognitive outcomes at 2 years of age. Br J Nutr 121:1303–1312

    CAS  PubMed  PubMed Central  Google Scholar 

  14. 14.

    Yajnik CS, Deshpande SS, Jackson AA, Refsum H, Rao S, Fisher DJ, Bhat DS, Naik SS, Coyaji KJ, Joglekar CV et al (2008) Vitamin B12 and folate concentrations during pregnancy and insulin resistance in the offspring: the Pune Maternal Nutrition Study. Diabetologia 51:29–38

    CAS  PubMed  Google Scholar 

  15. 15.

    Eneroth H, El Arifeen S, Persson LA, Lonnerdal B, Hossain MB, Stephensen CB, Ekström EC (2010) Maternal multiple micronutrient supplementation has limited impact on micronutrient status of Bangladeshi infants compared with standard iron and folic acid supplementation. J Nutr 140:618–624

    CAS  PubMed  Google Scholar 

  16. 16.

    Duggan C, Srinivasan K, Thomas T, Samuel T, Rajendran R, Muthayya S, Finkelstein JL, Lukose A, Fawzi W, Allen LH et al (2014) Vitamin B-12 supplementation during pregnancy and early lactation increases maternal, breast milk, and infant measures of vitamin B-12 status. J Nutr 144:758–764

    CAS  PubMed  PubMed Central  Google Scholar 

  17. 17.

    Siddiqua TJ, Ahmad SM, Ahsan KB, Rashid M, Roy A, Rahman SM, Shahab-Ferdows S, Hampel D, Ahmed T, Allen LH et al (2016) Vitamin B12 supplementation during pregnancy and postpartum improves B12 status of both mothers and infants but vaccine response in mothers only: a randomized clinical trial in Bangladesh. Eur J Nutr 55:281–293

    CAS  PubMed  Google Scholar 

  18. 18.

    Van Spall HG, Toren A, Kiss A, Fowler RA (2007) Eligibility criteria of randomized controlled trials published in high-impact general medical journals: a systematic sampling review. JAMA 297:1233–1240

    PubMed  Google Scholar 

  19. 19.

    Rutterford C, Copas A, Eldridge S (2015) Methods for sample size determination in cluster randomized trials. Int J Epidemiol 44:1051–1067

    PubMed  PubMed Central  Google Scholar 

  20. 20.

    Project management plan on folic acid supplementation prevented neural tube defects. Accessed 24 Jun 2009

  21. 21.

    Devalia V, Hamilton MS, Molloy AM (2014) Guidelines for the diagnosis and treatment of cobalamin and folate disorders. Br J Haematol 166:496–513

    CAS  PubMed  Google Scholar 

  22. 22.

    Huijgen HJ, Frans PW, Tegelaers FPW, Schoenmakers CHH, Pronk-Admiraal CJ, Ekema S (2004) Multicenter analytical evaluation of an enzymatic method for the measurement of plasma homocysteine and comparison with HPLC and immunochemistry. Clin Chem 50:937–941

    CAS  PubMed  Google Scholar 

  23. 23.

    Filmer D, Pritchett LH (2001) Estimating wealth effects without expenditure data–or tears: an application to educational enrollments in states of India. Demography 38:115–132

    CAS  PubMed  Google Scholar 

  24. 24.

    Villar J, Cheikh Ismail L, Victora CG, Ohuma EO, Bertino E, Altman DG, Lambert A, Papageorghiou AT, Carvalho M, Jaffer YA et al (2014) International standards for newborn weight, length, and head circumference by gestational age and sex: the Newborn Cross-Sectional Study of the INTERGROWTH-21st Project. Lancet 384:857–868

    PubMed  Google Scholar 

  25. 25.

    Hedeker D, Gibbons RD, Flay BR (1994) Random-effects regression models for clustered data with an example from smoking prevention research. J Consult Clin Psychol 62:757–765

    CAS  PubMed  Google Scholar 

  26. 26.

    Leyrat C, Morgan KE, Leurent B, Kahan BC (2018) Cluster randomized trials with a small number of clusters: which analyses should be used? Int J Epidemiol 47:321–331

    PubMed  Google Scholar 

  27. 27.

    Li P, Redden DT (2015) Comparing denominator degrees of freedom approximations for the generalized linear mixed model in analyzing binary outcome in small sample cluster-randomized trials. BMC Med Res Methodol 15:38

    PubMed  PubMed Central  Google Scholar 

  28. 28.

    Hay G, Clausen T, Whitelaw A, Trygg K, Johnston C, Henriksen T, Refsum H (2010) Maternal folate and cobalamin status predicts vitamin status in newborns and 6-month-old infants. J Nutr 140:557–564

    CAS  PubMed  Google Scholar 

  29. 29.

    Mickey RM, Greenland S (1989) The impact of confounder selection criteria on effect estimation. Am J Epidemiol 129:125–137

    CAS  PubMed  Google Scholar 

  30. 30.

    Sedgwick P (2015) Randomized controlled trials: understanding effect sizes. BMJ 350:h1690

    Google Scholar 

  31. 31.

    Dijkman B, Kooistra B, Bhandari M, Evidence-Based Surgery Working Group (2009) How to work with a subgroup analysis. Can J Surg 52:515–522

    PubMed  PubMed Central  Google Scholar 

  32. 32.

    Rogne T, Tielemans MJ, Chong MF-F, Yajnik CS, Krishnaveni GV, Poston L, Jaddoe VWV, Steegers EA, Joshi S, Chong YS et al (2017) Associations of maternal vitamin b12 concentration in pregnancy with the risks of preterm birth and low birth weight: a systematic review and meta-analysis of individual participant data. Am J Epidemiol 185:212–223

    PubMed  PubMed Central  Google Scholar 

  33. 33.

    Bjorke Monsen AL, Ueland PM (2003) Homocysteine and methylmalonic acid in diagnosis and risk assessment from infancy to adolescence. Am J Clin Nutr 78:7–21

    PubMed  Google Scholar 

  34. 34.

    Shane B (2008) Folate and vitamin B12 metabolism: overview and interaction with riboflavin, vitamin B6, and polymorphisms. Food Nutr Bull 29(2 Suppl):S5–S19

    PubMed  Google Scholar 

  35. 35.

    Frery N, Huel G, Leroy M, Moreau T, Savard R, Blot P, Lellouch J (1992) Vitamin B12 among parturients and their newborns and its relationship with birthweight. Eur J Obstet Gynecol Reprod Biol 45:155–163

    CAS  PubMed  Google Scholar 

  36. 36.

    Obeid R, Munz W, Jager M, Schmidt W, Herrmann W (2005) Biochemical indexes of the B vitamins in cord serum are predicted by maternal B vitamin status. Am J Clin Nutr 82:133–139

    CAS  PubMed  Google Scholar 

  37. 37.

    List of 832 poverty-stricken counties in China. Accessed 23 Dec 2014

  38. 38.

    Variant: rs1801133.;r=1:11795821-11796821;v=rs1801133;vdb=variation;vf=502019084. Accessed 10 Apr 2020

  39. 39.

    Yang B, Fan S, Zhi X, Xia R, Wang Y, Zheng Q, Sun G (2017) Geographical and ethnic distribution of MTHFR gene polymorphisms and their associations with diseases among Chinese population. Clin Genet 92:243–258

    CAS  PubMed  Google Scholar 

  40. 40.

    Zinck JW, de Groh M, MacFarlane AJ (2015) Genetic modifiers of folate, vitamin B-12, and homocysteine status in a cross-sectional study of the Canadian population. Am J Clin Nutr 101:1295–1304

    CAS  PubMed  Google Scholar 

  41. 41.

    Horan MK, McGowan CA, Gibney ER, Donnelly JM, McAuliffe FM (2015) The association between maternal dietary micronutrient intake and neonatal anthropometry—secondary analysis from the ROLO study. Nutr J 14:105

    PubMed  PubMed Central  Google Scholar 

  42. 42.

    Bhate V, Deshpande S, Bhat D, Joshi N, Ladkat R, Watve S, Fall C, de Jager CA, Refsum H, Yajnik C (2008) Vitamin B12 status of pregnant Indian women and cognitive function in their 9-year-old children. Food Nutr Bull 29:249–254

    PubMed  PubMed Central  Google Scholar 

  43. 43.

    Hrobjartsson A, Emanuelsson F, Skou Thomsen AS, Hilden J, Brorson S (2014) Bias due to lack of patient blinding in clinical trials. A systematic review of trials randomizing patients to blind and nonblind sub-studies. Int J Epidemiol 43:1272–1283

    PubMed  PubMed Central  Google Scholar 

  44. 44.

    Farrell C-JL, Kirsch SH, Herrmann M (2013) Red cell or serum folate: what to do in clinical practice? Clin Chem Lab Med 51:555–569

    CAS  PubMed  Google Scholar 

  45. 45.

    Nexo E, Hoffmann-Lücke E (2011) Holotranscobalamin, a marker of vitamin B-12 status: analytical aspects and clinical utility. Am J Clin Nutr 94:359S–365S

    CAS  PubMed  PubMed Central  Google Scholar 

  46. 46.

    Bjørke Monsen AL, Ueland PM (2003) Homocysteine and methylmalonic acid in diagnosis and risk assessment from infancy to adolescence. Am J Clin Nutr 78:7–21

    PubMed  Google Scholar 

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The authors thank all participants and researchers who participated in this study. The authors are also grateful to the Xunyi County Hospital and the Xunyi County Maternal and Child Health Hospital for their collaboration during the implementation of this trial.


This study was sponsored by the National Key Research and Development Program of China (grant number 2017YFC0907200, grant number 2017YFC0907201), the National Natural Science Foundation of China (grant number 81230016), the Project of birth defect control and prevention in Shaanxi (grant number Sxwsjswzfcght2016-013), the China Postdoctoral Science Foundation (grant number 2015M582678) and Xi’an Jiaotong University (xjj2018146). The funders had no role in the design of the study; in the collection, analyses, and interpretation of the data; in the writing of the manuscript, and in the decision to submit the manuscript for publication.

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Correspondence to Xin Liu or Shaonong Dang.

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Li, S., Mi, B., Qu, P. et al. Association of antenatal vitamin B complex supplementation with neonatal vitamin B12 status: evidence from a cluster randomized controlled trial. Eur J Nutr 60, 1031–1039 (2021).

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  • Antenatal vitamin B complex supplementation
  • Newborns
  • Vitamin B12 status
  • Cluster randomized controlled trial
  • Rural northwest china