The of the study can be seen in the

The title of this study is
relevant to both medical research and public health as it states important
issues such as, nutritional status during delicate life developmental periods
which are pregnancy and childhood disorder. However, the title does not relate
to the aim of the study. The conjuction ‘and’ in the title could have been
replaced with the words “in association with”. This study was published by the
American journal of epidemiology online in 2016 and considerably reliable. The abstract
summarized clearly and concisely: the study aims, objectives, design, study
setting, hypothesis, methodology and results. The PICO of the study can be seen
in the flow chart below and was outlined in the abstract as: FIGURE 1: Showing causal diagram of the
PICO for the Steenweg-de Graaff et al (2016) study.

The authors could have logically
summarised each section
of the article by using subheadings outlining what is reported in each section
of the journal. This enables readers to comprehend what is being outlined in
each section of the study. The study was designed as a prospective cohort and is
appropriate because it is high on the evidence hierarchy pyramid, different
rare exposures can be studied, interventions and time sequence of outcomes can
be measured. Nevertheless, a randomized control trial can be applied to follow
up participants to improve the theory question and provide placebo that will
reduce incidence of the disease.

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To achieve the expected outcome,
the various methodology applied were appropriate. However, interventions such
as maternal fish intake and child IQ were self- assessed. This can cause
information bias and validate the accuracy of results. The study sample size
was large and precise thereby reducing the risk of random error of estimation amongst
variables. Nevertheless, there was a slight difference in the sample size of
some subgroup, as some had significant numbers in comparison to other
subgroups. The different interventions
applied was broadly explained with detailed guidelines, recounting the
equipment’s used and procedures followed. Ethically, the study is not
questionable as ethical guidelines were followed and approved by the local
medical ethics committee. Consent and approval was obtained from adult
participants and caregivers of the participating children. Follow-up could have
been applied to explore each of the study intervention rather than focusing on
only child IQ score. The construction of a causal diagram (Fig.1) summarising various variables measured
and sample effect estimates overall is a good attempt and included the sample
exclusion, inclusions and the rationale for inclusion. However, reasons for exclusions
was not acknowledged. This questions the generalizability and homogeneity of
the sample selection because the data inputted lacked precision and was loosely
defined. For instance, the total number of eligible children who had data on IQ
scores were excluded from the flowchart but was mentioned as a criterion in the
study population. The different interventions applied was broadly explained
with descriptive guidelines, recounting details of the equipment’s and
procedures followed. Fish intake data was excluded from the flowchart.
Clinically, important cofounding variables and outcomes such as:
psychopathology in mid-pregnancy, alcohol consumption, smoking and folic acid
supplementation was reported in the paper. Considerably, the
traits of other offspring’s born to the same women in the study could be
compared to children used in the study for any similarities. Food frequency
questionnaire was used to adjust for child fatty acid status. This method has a
lot of limitations and the authors would have substituted this by using another
measure of nutritional status such as a 24-hour dietary recall which is less
prone to information bias.

 Statistical analyses is reported for each
subgroup in this paper, all analyses were carried out by using PASW statistics
software. This is particularly
important in order to answer and test the hypotheses. However, multiple
statistical testing was not performed in this paper, considering the different
subgroups categories. Nevertheless, the authors reported the use of
multivariable linear regression to test the association of overall maternal
PUFA status with child autistic traits. The linear graph/plot was not reported
in the article rather a quintile model was used to illustrate the linear
results. Most statistical analysis was adjusted for this could have been the
cause of the large increase in power for some of the outcomes. Sample size
calculations was stated to have been performed for some subgroups and not
entirely for other subgroups. Therefore, increasing the risk of accepting the
null hypothesis when it is actually false (type II error). From, Table 1 the
authors have included other types of maternal fatty acid linked with autistic
trait that was not mentioned earlier instead of focusing on just the totals of -3f
Authors adjusted for multiple covariates that might have affected the results
as the p value (0.0009), CI (-0.020, -0.009) for -3f
was significant before adjustment and after adjustment was not
significant as the P value was (0.69), CI (-0.010,0.007). Nevertheless, the
results of -6g
before and after adjustment remained significant thereby accepting the
hypothesis of the study. Additionally, from table 2 the results differ to table
1 as before and after adjustments of both -3f
the results were associated to child autistic traits.  A statistical test known as ‘Ancova’ could
have been used to adjust for baseline and analyse the covariates which could
help minimise data drenching in the result section.

the discussion, the authors acknowledged the change in -3f
results when adjusted for child autistic trait in table 1. This is because of some
study limitations such as: shortage in some study samples, selection and
information bias reported by the authors. Also, the use of biomarkers was
suggested for further research in order to confirm the study findings. In
conclusion, I think this paper is a fair attempt and can be improved in
numerous ways such as: assessing PUFA status in mid-pregnancy more than once, substituting
self-assessed data in order to minimise information bias and socioeconomic group
assessment. However, the external validity can be generalizable because the
topic seems to be applicable to other programs, population and settings rather
than the Dutch population. Nevertheless, I will be cautious when generalising
the internal validity (the results) of the study based on the study sample
selection and participants. Further research would be useful in investigating
PUFA status in pregnancy with child autistic traits.