Do you need choline supplements during pregnancy?

Most pregnant women eat less choline than recommended, but trials have not shown that a supplement makes a difference to the baby in an ordinary pregnancy. A 2025 systematic review of 4 randomized trials and 5 cohort studies found the evidence insufficient to support or refute the idea that more choline in pregnancy improves a child's development. Those four trials together enrolled 338 women. The one group where trials point to a benefit, on moderate-certainty evidence from 94 children, is narrow: children whose mothers drank heavily while pregnant.

Unsettled. The answer is open because the trials are too few and too small, and they measured different things. They ranged from 29 to 140 women, used doses from 480 to 2,000 mg a day, and mostly tested babies with experimental tasks that are not validated, so the reviewers could not pool them into one estimate.

The shortfall itself is not in doubt. Across 12 prevalence studies, 11.24 percent of pregnant women (95% CI 6.34 to 17.26) met the choline intake recommendation. According to the NIH Office of Dietary Supplements, 90 to 95 percent of pregnant women eat less choline than the adequate intake of 450 mg a day, and prenatal supplements typically contain little if any. Both figures are measured against an adequate intake, a target set without a proven requirement, so falling short of it is not the same as being deficient.

What the trials found

In ordinary pregnancies

The largest trial gave 140 pregnant women 750 mg of phosphatidylcholine a day or placebo from 18 weeks of pregnancy. At 10 and 12 months the babies did not differ in global development, language, short-term visuospatial memory or long-term episodic memory. The women in that trial were eating about 360 mg of choline a day from food.

The positive result comes from a much smaller study. In a controlled feeding trial in Ithaca, New York, 26 women entering their third trimester ate either 930 or 480 mg of choline a day. Babies of the 930 mg group had faster reaction times averaged across 4, 7, 10 and 13 months. At age 7, the 20 children followed up from the 930 mg group did better on a test of sustained attention (p = .02). The follow-up reports p values only, with no effect size, and the trial had no placebo arm because both groups ate at or above the adequate intake.

A 2022 systematic review read 10 publications from interventional studies, drawn largely from the same small set of trials, more warmly. It judged 550 mg up to 1 g a day on top of the diet in the second half of pregnancy and early after birth safe and likely to help some measures of memory, attention and visuospatial learning. It did not pool the trials, and the 2025 review of largely the same studies called the evidence insufficient.

After heavy drinking in pregnancy

In 69 heavy drinkers in Cape Town, South Africa, recruited in mid-pregnancy, 2 g of choline a day until delivery was compared with placebo. A 2025 meta-analysis of 2 trials in 94 children from alcohol-exposed pregnancies found prenatal choline likely improved memory, with a standardized mean difference of 0.61 (95% CI 0.19 to 1.02), on moderate-certainty evidence. A standardized difference is a comparison of averages across tests that use different scales, so it has no absolute number of children behind it. This is a population with a known injury, and the result does not transfer to a pregnancy without alcohol.

Neural tube defects

Across 5 case-control studies with 1,131 mothers of babies with a neural tube defect and 4,439 control mothers, low maternal choline was linked to higher odds of a defect, with an odds ratio of 1.36 (95% CI 1.11 to 1.67). Case-control studies cannot give an absolute risk, and the link is weaker where folate intake is high. No trial has tested choline to prevent these defects.

Who should be careful

Not for everyone. Very high choline intakes are associated with a fishy body odor, vomiting, heavy sweating and salivation, low blood pressure and liver toxicity, according to NIH. The upper limit is set from those effects. In the ODS table, which we read but could not quote, it is 3,500 mg a day for adults and 3,000 mg a day at 14 to 18 years, and the highest dose in the pregnancy trials was 2 g.

In the 26-woman feeding trial no adverse effects were reported at either 480 or 930 mg a day. That trial ran for about 12 weeks and was not built to detect harm. The 2022 review judged 550 mg up to 1 g a day on top of the diet safe. If you are under 19, the lower upper limit matters more than it does for adults.

What expert bodies say

The NIH Office of Dietary Supplements states that most pregnant women eat less choline than the adequate intake and that prenatal supplements carry little, and it stops short of recommending routine supplementation. The European Union refused the health claim that choline is needed for brain development in infants and young children. A refusal means the evidence did not meet the bar, and it is not a finding that choline is irrelevant. We could not obtain positions from the American College of Obstetricians and Gynecologists or the American Medical Association except through secondary pages, so they are not used here.

How we searched

What would change this answer

• A trial in ordinary pregnancy large enough to matter, with outcomes measured the same way as in other trials so the results can be pooled. Four trials in 338 women is the whole base today.
• The follow-up trial in heavy drinkers in South Africa, planned for 288 women and due to finish its main data collection in 2027, and a pilot in women who do not drink. Together they would show whether the benefit seen with alcohol exposure carries over.
• Any randomized trial of choline for preventing neural tube defects. All the evidence there is case-control.

How much choline you need and which foods carry it is in the choline guide.

Sources

1. ev-chpg-01 · Meta-analysis or systematic review · systematic review of randomized controlled trials and observational studies · n = 4 RCTs (338 participants) and 5 observational studies (3192 participants)
   Current evidence is insufficient to support or refute the hypothesis that increasing choline intake in pregnancy improves the neurodevelopmental outcomes of the child.
   
   Who: pregnant women in randomized trials of choline supplementation and in observational studies of prenatal choline
   Effect: most neurodevelopmental outcomes null in both trials and cohorts; occasional better scores on single measures among many outcomes
   Certainty: Trials small (29 to 140 women), doses 480 to 2000 mg/d, mostly unvalidated experimental tests; no meta-analysis possible because outcomes differed.
   Nutrients, 2025 · checked 2026-10-06 · we read the abstract
2. ev-chpg-02 · Meta-analysis or systematic review · systematic review of randomized controlled trials and observational studies · n = 338
   The four trials [25,26,27,28] were conducted on 338 participants and ranged in size from 29 to 140 participants (see Table 1).
   
   Who: pregnant women in four randomized trials (three US healthy women, one South African heavy drinkers)
   Effect: maternal doses 480 to 2000 mg choline a day; given as phosphatidylcholine, choline chloride or bitartrate
   Certainty: Shows how thin the trial base is for a routine recommendation.
   Nutrients, 2025 · checked 2026-10-06 · we read the fulltext
3. ev-chpg-03 · Meta-analysis or systematic review · systematic review and meta-analysis of randomized controlled trials · n = 94
   Prenatal supplementation likely benefits memory (SMD 0.61, 95 % CI 0.19 to 1.02; Pr(SMD>0) = 96.29 %; I2 = 0 %; 2 trials; 94 participants; moderate-certainty evidence).
   
   Who: children of alcohol-exposed pregnancies in randomized trials of prenatal or postnatal choline
   Effect: memory SMD 0.61 (95% CI 0.19 to 1.02), prenatal supplementation, 2 trials, 94 children, moderate certainty
   Certainty: Narrow population with a known injury; does not transfer to ordinary pregnancy. no_pmc.
   Pediatr Neonatol, 2025 · checked 2026-10-06 · we read the abstract
4. ev-chpg-04 · Meta-analysis or systematic review · systematic review and meta-analysis · n = 10 publications with interventional designs
   Findings and critical evaluation of 10 publications with interventional designs showed that higher maternal choline intakes during the second half of pregnancy and early postnatal period (550 mg up to 1 g/d on top of the diet) or a child intake of 513 to 625 mg/d from supplements were safe and likely to demonstrate favorable effects on several domains of child neurocognition, such as memory, attention, and visuospatial learning versus the comparators.
   
   Who: mothers and children in 10 publications from interventional studies of choline
   Effect: favorable effects on memory, attention and visuospatial learning versus comparators; no safety signal at 550 mg to 1 g/d on top of diet
   Certainty: Narrative appraisal of trials, not pooled; more positive reading than the 2025 review (ev-chpg-01) of largely the same trials.
   Adv Nutr, 2022 · checked 2026-10-06 · we read the abstract
5. ev-chpg-05 · Observational data · meta-analysis of case-control studies · n = 5570
   Low maternal choline intake/circulating concentrations were associated with a higher OR for NTDs among 1131 mothers of newborns with NTDs and 4439 control mothers (pooled estimate = 1.36; 95% CI: 1.11, 1.67).
   
   Who: 1131 mothers of newborns with neural tube defects and 4439 control mothers
   Effect: pooled OR 1.36 (95% CI 1.11 to 1.67); 95% prediction interval 0.78 to 2.36
   Certainty: Case-control only; association weaker where folate intake is high (fortification era). No trial tests choline for NTD prevention.
   Adv Nutr, 2022 · checked 2026-10-06 · we read the abstract
6. ev-chpg-06 · Observational data · systematic review and meta-analysis of observational studies · n = 12 prevalence studies
   Meta-analysis of 12 prevalence studies revealed a concerning 11.24% (95% confidence interval, 6.34-17.26) prevalence of pregnant women with adequate choline intake recommendations.
   
   Who: pregnant women, international prevalence studies
   Effect: 11.24% (95% CI 6.34 to 17.26) meet the recommendation
   Certainty: Intake estimates from dietary surveys against an AI, not a requirement; no_pmc.
   Nutr Rev, 2025 · checked 2026-10-06 · we read the abstract
7. ev-chpg-07 · Randomized controlled trial(s) · randomized double-blind controlled feeding study · n = 26
   Mean reaction time averaged across the four ages was significantly faster for infants born to mothers in the 930 ( vs. 480) mg choline/d group.
   
   Who: women entering their third trimester, Ithaca NY, fully controlled diet
   Effect: mean reaction time across 4, 7, 10 and 13 months significantly faster in the 930 mg/d group (24 infants tested)
   Certainty: Very small; no placebo arm (both groups at or above the AI). no_fulltext: PMC6988845 gave 0 sections.
   FASEB J, 2018 · checked 2026-10-06 · we read the abstract
8. ev-chpg-08 · Randomized controlled trial(s) · 7-year follow-up of a randomized controlled feeding trial · n = 20
   Children in the 930 mg/d group showed superior performance (vs. 480 mg/d group) on the primary endpoint (SAT score, p = .02) and a superior ability to maintain correct signal detections (hits) across the 12-min session (p = .02), indicative of improved sustained attention.
   
   Who: children aged 7 of women in a third-trimester choline feeding RCT
   Effect: superior primary sustained attention score (p = .02); for the briefest signals 22.9% decline in hits vs 1.5% increase
   Certainty: Follow-up of the same 26-woman trial as ev-chpg-07; p values only, no effect size with CI.
   FASEB J, 2022 · checked 2026-10-06 · we read the abstract
9. ev-chpg-09 · Randomized controlled trial(s) · randomized double-blind placebo-controlled trial · n = 140
   Groups did not differ significantly in global development, language development, short-term visuospatial memory, or long-term episodic memory.
   
   Who: pregnant women eating about 360 mg choline a day from food, supplemented from 18 weeks gestation to 90 days postpartum
   Effect: no significant difference in global development, language, short-term visuospatial memory or long-term episodic memory at 10 and 12 months (99 infants tested)
   Certainty: Largest trial in ordinary pregnancy; null.
   Am J Clin Nutr, 2012 · checked 2026-10-06 · we read the abstract
10. ev-chpg-10 · Randomized controlled trial(s) · randomized double-blind placebo-controlled trial · n = 69
    Sixty-nine Cape Coloured (mixed ancestry) heavy drinkers in Cape Town, South Africa, recruited in mid-pregnancy, were randomly assigned to receive a daily oral dose of either 2 g of choline or placebo from time of enrollment until delivery.
    
    Who: Cape Coloured heavy drinkers in Cape Town recruited in mid-pregnancy
    Effect: 2 g choline a day vs placebo from enrollment in mid-pregnancy until delivery; infant outcomes not in the quoted text
    Certainty: Exploratory; follow-up RCT NCT04395196 (288 planned, primary completion 2027) and a non-drinking pilot NCT07699393 are recruiting.
    Alcohol Clin Exp Res, 2018 · checked 2026-10-06 · we read the abstract
11. ev-chpg-11 · Randomized controlled trial(s) · randomized double-blind controlled feeding trial (methods of 7-year follow-up) · n = 26
    No adverse effects of either choline dose were reported for the controlled feeding study.
    
    Who: healthy third-trimester pregnant women, Ithaca NY
    Effect: no adverse effects reported at 930 mg/d total choline (550 mg as choline chloride)
    Certainty: Small trial, short exposure (about 12 weeks); not powered for safety.
    FASEB J, 2022 · checked 2026-10-06 · we read the fulltext
12. ev-chpg-12 · Position of an expert body · agency fact sheet
    Approximately 90%–95% of pregnant women consume less choline than the AI [16]. Prenatal dietary supplements typically contain little if any choline [17].
    
    Who: pregnant women, US
    Effect: 90%-95% below the AI (450 mg/day in pregnancy); prenatal supplements typically contain little if any choline
    Certainty: ODS states facts on intake and does not recommend routine supplementation.
    NIH Office of Dietary Supplements, Choline Fact Sheet for Health Professionals · checked 2026-10-06 · we read the section
13. ev-chpg-13 · Position of an expert body · agency fact sheet
    High intakes of choline are associated with a fishy body odor, vomiting, excessive sweating and salivation, hypotension, and liver toxicity [1,2].
    
    Who: healthy children and adults, including pregnant women
    Effect: UL for adults 3500 mg/day and 3000 mg/day at 14-18 years (ODS Table 3, table not quoted); doses in trials (up to 2 g/d) stay below
    Certainty: ULs do not apply to people taking high doses under medical supervision.
    NIH Office of Dietary Supplements, Choline Fact Sheet for Health Professionals · checked 2026-10-06 · we read the section
14. ev-chpg-14 · Position of an expert body · entry in the EU Register on nutrition and health claims, non-authorized list
    POL-HC-8455 Choline Choline is needed for the development of brain of infants and young children from birth to three years -/- Non-authorised
    
    Who: EU food labeling
    Effect: claim POL-HC-8455, status Non-authorized
    Certainty: Refused means evidence did not meet the bar, not disproved; consistent with ev-chpg-01.
    EU Register on nutrition and health claims (European Commission) · checked 2026-10-06 · we read the dataset