Choline Supplementation for Infants, Children, and Pregnant People
Authors: CADTH  
Published: June 2024

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.