METHODOLOGY CHECKLIST: CASE-CONTROL STUDIES

Allen J Wilcox, senior investigator,1 Rolv Terje Lie, professor,2 Kari Solvoll, retired,3 Jack Taylor, senior
investigator,1 D Robert McConnaughey, senior programmer,4 5 Hallvard
Vindenes, consultant plastic surgeon,6 Stein Emil Vollset, professor,2 Christian A Drevon, professor3

Folic acid supplements and risk of facial clefts: national

population based case-control study
Study identification (Include author, title, year of publication, journal title, pages)
Section 1: Internal validity
In an well conducted case control study:
1.1 The study addresses an appropriate and clearly
focused question

In this study the criterion is:

Well covered
To explore the role of folic
acid
supplements,
dietary
folates, and multivitamins in the
prevention of facial clefts.

Selection of subjects
1.2 The cases and controls are taken from comparable
populations

Well covered
Cases were drawn from a large
and well defined population,
with
virtually
complete
ascertainment,
a
high
participation rate (88%), and
clinical confirmation of all
defects.
Although
the
participation rate was lower for
controls (76%), the controls had
the advantage of being drawn
randomly from the entire
population of births.

1.3 The same exclusion criteria are used for both cases
and controls

Adequately addressed
Differential participation by
social
class
or
other
confounding
characteristics
could contribute to the observed
associations.
However,

adjustments for social factors,

alcohol, smoking, and other
potential confounding variables
had little impact on the
estimates.
1.4 What percentage of each group (cases and controls)
participated in the study?
1.5 Comparison is made between cases and controls to
establish their similarities or differences

Cases:
Controls:
Well covered
Participants 377 infants with
cleft lip with or without cleft
palate; 196 infants with cleft
palate alone; 763 controls.

1.6 Cases are clearly defined and differentiated from

controls

1.7 It is clearly established that controls are non-cases

Well covered
Case : infants with cleft lip
with or without cleft
palate and infants with cleft
palate alone
Control infants with non-cleft
birth
defects
Well covered

Assessment
1.8 Measures will have been taken to prevent knowledge Well covered
Not addressed
of primary exposure influencing case ascertainment Adequately
Not reported
addressed
Not applicable
Poorly
addressed
1.9 Exposure status is measured in a standard, valid and Well covered
reliable way
Adequately addressed
Poorly addressed
Not addressed
Not reported
Not applicable
To be consistent with previous clefts
studies, we
defined a three month exposure

window for folate

intake comprising the month before
the last menstrual
period and the first two months of
pregnancy. (Facial
structures that form the embryonic
lip fuse during the
fifth and sixth weeks of life, about
eight weeks after the
last menstrual period, whereas the
palatal shelves fuse
during weeks seven to 10.14) We
counted women as
exposed if they took folic acid for at
least one month
during this window; 81% of exposed
women took folic
acid for at least two of the three
months.
We cannot reconstruct the mothers
complete exposure
history retrospectively, but the
collection of
brands, bottles, and labels allowed us
to correct some
errors in self report.

Confounding
1.10 The main potential confounders are identified and
taken into account in the design and analysis

Well covered
Adequately addressed
Poorly addressed
Not addressed
Not reported
Not applicable
Adjustment
for
potential
confounding factors (diet and
multivitamins,
mothers
education,
mothers
employment
during
early
pregnancy, smoking, alcohol
consumption, and year of baby
s birth) slightly weakened the
association between folic acid
and cleft lip with or without
cleft palate and removed the
association entirely for cleft
palate only. Lacking any
evidence of an effect of folic
acid on cleft palate only (odds
ratio 1.07, 0.56 to 2.03), we
focused the remainder of the

analysis on cleft lip with or

without cleft palate.
Statistical analysis
1.11 Confidence intervals are provided
Section 2: Overall assessment of the study
2.1 How well was the study done to minimise the risk of +
bias or confounding?
Code ++, +, or As in all case-control studies,
recall bias is a concern. We sent
the main questionnaire to
women around three months
after delivery, much earlier than
in many previous studies.
Concerns about recall bias were
further
reduced
by
the
specificity of the findings.
In our data, the association with
folic acid was strong for cleft
lip with or without cleft palate
but absent for cleft palate only.
This is consistent with previous
positive studies, which have
found associations more often
with cleft lip with or without
cleft palate than with cleft
palate only 367. Also, recall
bias would presumably operate
among all women who took
folic acid, not only those
whotook the higher doses. The
fact that folic acid less than 400
g a day showed no association
with clefts suggests a lack of
recall bias.
Confounding Confounding is
a general threat to observational
studies, particularly when the
response
rate is higher among cases than
among controls. Differential
participation by social class or

other
confounding
characteristics could contribute
to the observed associations.
However, adjustments for social
factors, alcohol, smoking, and
other potential confounding
variables had little impact on
the estimates. This weak
evidence for confounding in the
analysis reduces the likelihood
of residual confounding by
these or other closely related
factors. We cannot rule out the
presence of
unmeasured
confounders,
although such confounders
would have to be strongly
related to cleft lip with or
without cleft palate in order to
produce the observed
results.
2.2 Taking into account clinical considerations, your
evaluation of the methodology used, and the
statistical power of the study, are you certain that the
overall effect is due to the exposure being
investigated?
2.3 Are the results of this study directly applicable to the
patient group targeted by this guideline?
Section 3: Description of the study (Note: The following information is required for
evidence tables to facilitate cross-study comparisons. Please complete all sections for which
information is available).
3.1 Do we know who the study was funded by?

[ ] Academic Institution
[ ] Healthcare Industry
[ ] Government [ ] NGO [ ]
Public funds [ ] Other
Penelitian ini dibiayai oleh
- institusi akademik, yaitu
Medical Faculty of University
of Oslo, Norway;
- Pemerintah
Intramural Research Program of

the NIH, National Institute of

Environmental Health Sciences
(NIEHS). NIH merupakan
lembaga departemen kesehatan
Amerika Serikat
-NGO (Non-Government
Organization)
the Johan Throne Holst
Foundation
for Nutrition Research
Funding: Intramural Research
Program of the NIH, National
Institute of
Environmental Health Sciences
(NIEHS), the Johan Throne
Holst Foundation
for Nutrition Research, and the
Thematic Area of Perinatal
Nutrition at the
Medical Faculty of University
of Oslo, Norway.
3.2 How many centres are patients recruited from?

3.3 What is the social setting (ie type of environment in

which they live) of patients in the study?

Pasien diambil dari 2 pusat

tempat pembedahan, ayitu di
Oslo dan Bergen.
Infants born in Norway with
orofacial clefts are treated at
government expense in one of
two surgical centres (Oslo and
Bergen). We contacted the
families of all newborn infants
born from 1996 to 2001 who
had been referred for surgical
treatment of a cleft (either
cleft lip with or without cleft
palate or cleft palate
only).
[ ] Urban [ ] Rural [ ]
Mixed

3.4 What criteria are used to decide who should cases?

3.5 What criteria are used to decide who should be
controls?
3.6 What exposure or risk factor is investigated in the
study? (Include dosage where appropriate)