How does prenatal choline supplementation affect child attention?

Prenatal choline supplementation, particularly at higher doses, improves sustained attention in children, increasing accuracy on attention tests and reducing vigilance decline observed seven years after birth.

Which type of attention improves with prenatal choline supplementation?

Sustained attention—the capacity to maintain focus during prolonged or monotonous tasks—shows the clearest improvement; selective attention may also benefit from prenatal choline exposure.

What dose of choline was effective in the 7-year follow-up trial?

The randomized trial compared 480 mg/day (control) to 930 mg/day; children whose mothers consumed 930 mg/day demonstrated significantly better sustained attention outcomes at age seven.

When during pregnancy is choline supplementation most beneficial for attention?

Supplementation during the third trimester was associated with attention benefits in the trial, coinciding with peak fetal neuronal proliferation, synaptogenesis, and myelination.

Which foods are rich in choline for pregnant women?

Choline-rich foods include eggs (yolk), beef liver, fatty fish, soy products, lentils, and full‑fat dairy; including these can help increase dietary choline intake during pregnancy.

Can prenatal choline supplementation prevent attention disorders like ADHD?

Available evidence shows improved sustained attention but is not conclusive for preventing specific disorders such as ADHD; supplementation may reduce cognitive risk but does not replace clinical diagnosis or evaluation.

Prenatal cholinergic supplementation in children’s attentional development

In this article we cover the most important aspects of the study “Prenatal choline supplementation improves child sustained attention: a 7-year follow-up of a randomized controlled Nutrition trial”, which analyzes the impact of prenatal cholinergic supplementation on attentional development in children.

Introduction

Can a nutrient during pregnancy influence child attention years later?

Pioneering research suggests it can. The study published in The FASEB Journal by Bahnfleth et al. (2022) was the first to show that choline supplementation during the third trimester of pregnancy significantly improves sustained attention in children seven years after birth.

Based on this randomized clinical trial, this article explores the impact of prenatal cholinergic supplementation on attentional development in children, bringing together findings from both humans and animal models. We will examine the physiological role of choline in neurodevelopment, the underlying neurological mechanisms, the clinical outcomes observed in the trial, and the implications for clinical practice.

Why choline is essential for the fetal brain during pregnancy

What choline is and how it works

Choline is a water-soluble molecule traditionally included among the B-complex vitamins.

It is a precursor of:

Acetylcholine, a key neurotransmitter in attentional control.
Phosphatidylcholine and sphingomyelin, essential structural components of cell membranes and myelin.
Betaine, a methyl group donor involved in the epigenetic regulation of genes linked to neurological development.

During pregnancy, endogenous choline synthesis is insufficient to meet fetal demand, making dietary intake a critical factor for neurodevelopment.

Increased requirements during pregnancy

During the third trimester of gestation, the fetus undergoes an intense phase of neuronal proliferation and differentiation. It is also the period of active myelination and synaptogenesis. These processes depend directly on an adequate supply of choline. The recommended daily intake (RDI) established in 1998 by the Institute of Medicine is 450 mg/day for pregnant women, although new data suggest that this amount may be insufficient to optimize fetal brain development.

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Scientific evidence: effects of supplementation on child attention

Animal studies: foundations of the cholinergic model

In animal models, maternal cholinergic supplementation during gestation has shown consistent effects in improving attention and memory in the offspring.

These studies show that:

Prenatal choline deprivation impairs executive functions and spatial memory.
Supplementation increases synaptic density and cholinergic activity in the prefrontal cortex and hippocampus.
The beneficial effects persist into adulthood and are transgenerational.

First randomized controlled clinical trial in humans

The study published in The FASEB Journal (2022) represents the first long-term follow-up in humans of a randomized trial of prenatal cholinergic supplementation.

In it, 26 pregnant women were randomly assigned to two groups:

Control group: 480 mg/day of choline (equivalent to the RDI).
Experimental group: 930 mg/day of choline.

Both doses were administered during the third trimester through a controlled and supervised diet. At 7 years of age, the children participated in a battery of cognitive tests focused on sustained attention.

Study results: impact on sustained attention

Greater overall performance on attention tasks

Children in the higher supplementation group (930 mg/day) had a significantly higher score on the “Sustained Attention Task” (SAT), a computerized test designed to measure sustained attention under high-demand conditions.

Average SAT score: 0.71 (supplemented group) vs. 0.56 (control group), p = 0.02.
This result indicates greater accuracy in detecting brief visual signals and a better ability to maintain attention during 12 minutes of continuous task.

Vigilance and resistance to attentional decline

A crucial finding was the difference between groups in the so-called “vigilance decrement”, that is, the progressive decrease in performance as the task progressed:

In the 480 mg/day group, signal detection performance decreased by 16% from the start to the end of the test (p = 0.001).
In contrast, the group supplemented with 930 mg/day maintained stable performance (only a 1.5% decrement, not significant).

This difference is especially relevant in educational and clinical contexts, where sustained attention is vital for acquiring complex cognitive skills.

Sensitivity to short-duration stimuli

The effect of supplementation was more pronounced for the most difficult-to-detect stimuli (17 ms visual signals). Children in the control group showed a response efficacy 23 % lower than that of the supplemented group, while those in the supplemented group showed no loss of efficacy, suggesting better efficiency in sensory processing and selective visual attention.

Neurobiological mechanisms: how choline modulates attention

Role of the cholinergic system in the prefrontal cortex

Sustained attention depends largely on the integrity of the basal forebrain cholinergic system, whose projections to the prefrontal cortex modulate:

Filtering of irrelevant stimuli.
Perceptual amplification of low-contrast signals.
Inhibition of distractions and cognitive perseveration.

Previous studies have shown that cholinergic activation improves performance on vigilance tasks, whereas its disruption significantly reduces it.

Structural and functional changes induced by choline

Prenatal choline modifies brain architecture by:

Increasing the number and size of cholinergic neurons in the basal forebrain.
Raising acetylcholine release in response to stimuli.
Reducing acetylcholinesterase activity, favoring longer neurotransmitter duration in the synapse.
Inducing epigenetic changes in genes related to neuronal plasticity.

These adaptations could explain the effects observed in the clinical study on child attention.

Clinical implications: an opportunity to intervene through nutrition

Review of current recommendations

The study raises a critical question: if children whose mothers consumed 480 mg/day (the currently recommended value) had worse attentional performance, shouldn’t we reconsider that threshold?

Evidence suggests that a dose of 930 mg/day is more effective to ensure optimal attention development in childhood. However, 90% of pregnant women do not even reach 450 mg daily.

Assessment in clinical practice

Health professionals, especially in gynecology, pediatrics, neurology, and nutrition, can play an active role:

Identifying diets with low choline intake (vegetarian, vegan, diets low in eggs, meats, or dairy products).
Recommending prenatal supplements that include choline, since most standard multivitamins do not contain it or do so in minimal doses.
Educating about choline-rich foods: eggs, liver, beef, soy, lentils, whole milk.

Implications for cognitive development

Sustained attention is the foundation of numerous cognitive skills:

Working memory.
Problem solving.
Inhibitory control.
Emotional regulation.

Longitudinal studies have linked child attention with academic performance in math and reading, behavioral self-regulation, and the prevention of neurodevelopmental disorders. Therefore, intervening through prenatal nutrition can have a multiplying effect on development.

Conclusions

Prenatal cholinergic supplementation —particularly during the third trimester— has a positive and lasting effect on sustained attention in childhood. The available data support a review of current choline intake recommendations during pregnancy and position this nutrient as a key preventive tool to optimize early cognitive development.

Attention is not just a brain function: it is a capacity that can be nurtured even before birth. As health professionals, recognizing the value of prenatal choline is an opportunity for early and profound impact.

References

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:e22054. https://doi.org/10.1096/fj.202101217R
Institute of Medicine. Dietary Reference Intakes for Thiamin, Riboflavin, Niacin, Vitamin B6, Folate, Vitamin B12, Pantothenic Acid, Biotin, and Choline. National Academies Press; 1998.
Meck WH, Williams CL. Metabolic imprinting of choline by its availability during gestation: implications for memory and attentional processing across the lifespan. Neurosci Biobehav Rev. 2003;27(4):385–399.
Napoli I, Blusztajn JK, Mellott TJ. Prenatal choline supplementation increases the expression of IGF2 and enhances acetylcholine release in hippocampus and frontal cortex. Brain Res. 2008;1237:124–135.
Sarter M, Givens B, Bruno JP. The cognitive neuroscience of sustained attention: where top-down meets bottom-up. Brain Res Rev. 2001;35:146–160.

Frequently asked questions about prenatal cholinergic supplementation and attention

1. What is the relationship between choline and attention in child development?

Choline is a precursor of acetylcholine, a key neurotransmitter in the control of attention. Its adequate presence during pregnancy, especially in the third trimester, promotes the formation of neural networks in the prefrontal cortex and other areas involved in sustained attention. Numerous studies have shown that higher prenatal choline intake significantly improves attentional capacity in offspring.

2. What type of attention is improved by prenatal cholinergic supplementation?

Research has shown that prenatal cholinergic supplementation specifically improves sustained attention, that is, the ability to maintain focus during prolonged periods and monotonous tasks. It may also have benefits for selective attention, by helping to filter irrelevant stimuli and thus optimizing cognitive processing.

3. What is the recommended dose of choline to improve attention during fetal development?

The currently recommended dose for pregnant women is 450 mg/day. However, recent clinical studies indicate that higher doses, such as 930 mg/day, have a more significant effect on the development of child attention. This dose has not shown side effects and could be considered as a target in clinical contexts where optimizing the cognitive development of the future newborn is desired.

4. Which choline-rich foods can be recommended to improve attention during pregnancy?

The richest choline foods are:

Eggs (especially the yolk)
Beef liver
Fatty fish
Legumes such as soy and lentils
Full-fat dairy products

Including these foods in the pregnant person’s daily diet can support the development of brain regions involved in attention.

5. Is prenatal cholinergic supplementation recommended as a strategy to prevent attention disorders?

Although data are not yet conclusive regarding specific disorders such as ADHD, the available evidence does support that prenatal cholinergic supplementation improves performance on sustained attention tasks. This suggests it could be a preventive tool with potential to reduce future cognitive risks, although it does not replace clinical evaluation or a diagnosis.

6. Can an improvement in child attention be observed with maternal dietary changes alone?

Improvement in child attention through maternal diet depends on the choline content of consumed foods. In most cases, a standard diet does not reach the levels necessary to achieve significant effects, so supplementation may be necessary. Individualized assessment is recommended and supplements should be considered if the diet is insufficient.