The following discussion uses terms including “fetal alcohol syndrome” (FAS), “fetal alcohol effects” (FAE) (sometimes also referred to as “partial FAS with confirmed maternal alcohol exposure”), and “fetal alcohol spectrum disorder” (FASD). The content which follows will explain these conditions in detail.
The ensuing discussion also refers to moderate versus heavy and problem drinking. Although definitions of what is considered to be “moderate” vary in the scientific literature, there are government-issued guidelines around the world which establish levels of drinking considered to be “safer” or “lower-risk” for pregnant women.i Many countries’ governments recommend that pregnant women abstain from drinking alcohol beverages altogether.
BACKGROUND AND THE ISSUE
There has long been scientific evidence that certain patterns of drinking during pregnancy can be harmful to the unborn child. In particular, heavy and problem drinking patterns have been found to be harmful to the unborn child.ii There is less scientific consensus about the risks of light to moderate levels of drinking by pregnant women. While there is ongoing debate about whether there is a “safe” level of alcohol consumption during pregnancy, or during certain time frames of a woman’s pregnancy, most governments with official guidelines on the subject recommend that women abstain from alcohol during pregnancy.iii
iSee a complete table of guidelines by country at www.icap.org/policyissues/drinkingguidelines/guidelinestable/tabid/204/default.aspx.
iiInstitute of Medicine. (1996). Fetal alcohol syndrome: Diagnosis, epidemiology, prevention, and treatment. Washington, DC: The National Academy Press. Updated: April 2005, available at: www.icap.org. National Institute on Alcohol Abuse and Alcoholism (NIAAA). (1993). Eighth Special Report to the U.S. Congress on Alcohol and Health from the Secretary of Health and Human Services. Washington, DC: U.S. Government Printing Office. Plant, M. L. (1985). Women, drinking and pregnancy. London: Tavistock. Plant, M. L., Abel, E. L., & Guerri, C. (1999). Alcohol and pregnancy. In I. Macdonald (Ed.), Health issues related to alcohol consumption (pp. 182–213). 2nd ed. Oxford, UK: Blackwell Science.
iiiFaden, V. B., & Graubard, B. I. (2000). Maternal substance use during pregnancy and developmental outcome at age three. Journal of Substance Abuse, 12, 329–340. Lorente, C., Cordier, S., Goujard, J., Ayme, S., Bianchi, F., Calzolari, E., et al. (2000). Tobacco and alcohol use during pregnancy and risk of oral clefts. Occupational Exposure and Congenital Malformation Working Group. American Journal of Public Health, 90, 415–419. Lorente, C., Cordier, S., Goujard, J., Ayme, S., Bianchi, F., Calzolari, E., et al. (2000). Tobacco and alcohol use during pregnancy and risk of oral clefts. Occupational Exposure and Congenital Malformation Working Group. American Journal of Public Health, 90, 415–419. See also: International Center for Alcohol Policies, Blue Book, Module 10, Drinking and Pregnancy at http://www.icap.org/Publication/ICAPBlueBook/tabid/148/Default.aspx.
Public Health Concerns and Guidelines
There is a well-established body of research which shows that certain patterns of drinking during pregnancy can be harmful to the unborn child. These drinking patterns generally include heavy drinking.i Because this is a serious yet preventable health risk, most public health recommendations around the world encourage abstention or only light drinking at the latter stages of pregnancy. A complete table of guidelines around the world has been compiled by the International Center for Alcohol Policies at www.icap.org/policyissues/drinkingguidelines/guidelinestable/tabid/204/default.aspx.
In addition, the World Health Organization (WHO) recommends that pregnant women not drink at all.ii Similarly, the European Forum for Responsible Drinking (EFRD) counsels that, “as no threshold of safe drinking while pregnant has been established, the best advice if pregnant or planning to conceive is not to drink.”iii
Several significantly negative health consequences for children—from pre-birth to birth and even into adulthood—have been linked to maternal drinking patterns. They include fetal alcohol syndrome (FAS), fetal alcohol effects (FAE), and fetal alcohol spectrum disorder (FASD).
Infants with FAS exhibit symptoms in each of the following categories of health issues:
Pre- and post-natal growth deficiencies: Intrauterine growth retardation, including smaller than normal head circumference; small size at each term of gestation; continuing growth below the tenth percentile after birth; and failure to thrive.
Physical anomalies: A cluster of facial features, including short upturned nose, receding forehead and chin, smaller than normal eye apertures, absent groove in upper lip (philtrum), and asymmetrical ears. Other problems include cardiac, gastrointestinal, and limb and joint anomalies.
Central nervous system dysfunction: Moderate to severe learning difficulties; cognitive, hearing, and visual disabilities.
Identifiable drinking problem of the mother: In many cases, a drinking problem can be identified in the mother of children born with FAS symptoms. Where this cannot be established, the impairment is generally inconsistent with familial factors or environment.iv
The term FAE was originally used for conditions reflecting less significant levels of harm than FAS. More recently, researchers and public health professionals have begun to use terminology such as “partial FAS with confirmed maternal alcohol exposure” to describe such conditions.v
In addition, the term fetal alcohol spectrum disorder (FASD) has been used to describe health consequences characterized by symptoms which are less severe than those of children with FAS (for example, sleep and behavioral disorders, poor sucking reflexes, and motor dysfunction). vi
Incidences of FAS and Related Conditions
In the United States, the rates of FAS reported in different parts of the country range from 0.2 to 1.5 per 1,000 live births. The rate of disorders which fall into the FASD category is approximately three times higher—from 0.6 to 4.5 per 1,000 live births.vii
The research shows disparities in FAS and FASD incidence rates which may be attributable to variations in screening methods, assessment and diagnosis, and reporting.viii For indigenous populations within certain countries, the reported rates of FAS are significantly higher than the rates for the countries at large. These populations include Native Americans in the United States, First Nations populations in Canada, and Aboriginal communities in Australia.
The highest rates of FAS worldwide have been reported from the Western Cape Province of South Africa, where the incidence rate is 65 FAS births per every 1,000 live births.ix Research suggests that a variety of factors, including drinking patterns and access to pre-natal services, may play a role in the rates of FAS within these populations.x
Drinking Patterns and Other Influencing Factors
Certain patterns of maternal drinking have been found to be a significant factor associated with the risk of harm to a fetus. For example, heavy episodic drinking, or binge drinking, during pregnancy—especially during the early stages of pregnancy—has been linked to the severity of fetal harm in FAS cases.xi
Moreover, problem drinkers have also been found to be more likely than non-problem drinkers to experience miscarriage.xii Conversely, research has not consistently shown an increased risk of fetal harm or miscarriage in women who are light or moderate drinkers.xiii Some medical professionals even assert that “there are no known clinically important risks to the fetus from an occasional drink during pregnancy.”xiv
The effects of prenatal alcohol exposure have been found to be influenced by factors including nutrition, metabolism, genetics, and maternal age.xv For instance, the risk for fetal harm as a result of maternal drinking patterns increases for women who are older than 30 years of age.xvi In addition, nutrition during pregnancy, as well as the way ethanol is metabolized by an individual woman, plays a role in a pregnant woman’s risk for FAS for FASD.xvii Socioeconomic status—and its impact on factors such as prenatal care and nutrition—have been shown to influence the risk for FAS or FASD as well.xviii
iFlorey, C. D. (1992). EUROMAC. A European concerted action: Maternal alcohol consumption and its relation to the outcome of pregnancy and child development at 18 months: Methods. International Journal of Epidemiology, 21(Suppl.1), S38–S39. Plant, M. L., Abel, E. L., & Guerri, C. (1999). Alcohol and pregnancy. In I. Macdonald (Ed.), Health issues related to alcohol consumption (pp. 182–213). 2nd ed. Oxford, UK: Blackwell Science.
iiWorld Health Organization, Alcohol Use Disorders content accessed at http://www.who.int/substance_abuse/publications/alcohol/en/index.html.
iiiEuropean Forum for Responsible Drinking at http://www.responsibledrinking.eu/.
ivWarren, K. R., Calhoun, F. J., May, P. A., Viljoen, D. L., Li, T. K., Tanaka, H., et al. (2001). Fetal alcohol syndrome: An international perspective. Alcoholism: Clinical and Experimental Research, 25(5 Suppl. ISBRA), 202S–206S. Streissguth, A. P., & O'Malley, K. (2000). Neuropsychiatric implications and long-term consequences of fetal alcohol spectrum disorders. Seminar in Clinical Neuropsychiatry, 5, 177–190.
vInternational Center for Alcohol Policies, Blue Book, Module 10, Drinking and Pregnancy. See: http://www.icap.org/Publication/ICAPBlueBook/tabid/148/Default.aspx.
viSokol, R. J., Delaney-Black, V., & Nordstrom, B. (2003). Fetal alcohol spectrum disorder. Journal of the American Medical Association, 290, 2996–2999.
10-8 Updated: April 2005 Available at: www.icap.org.
viiCenter for Disease Control and Prevention (CDC), 2006. Information: Fetal alcohol syndrome. Washington, D.C.
viiiKyskan, C.E., & Moore, T. (2005). Global Perspectives on fetal alcohol syndrome: Assessing practices, policies, and campaigns in four English-speaking countries. Canadian Psychology/Psychologie Canadienne, 46, 153-165.
ixViljoen, D.L., Gossage, J.P., Brooke, L., Adnams, C.M., Jones, K.L., Robinson, L.K., et al. (2005) Fetal alcohol syndrome epidemiology in a South African community: A second study of a very high prevalence area. Journal of Studies on Alcohol, 66, 593-604.
xAbel, E.L., & Hannigan, J.H. (1995) Maternal risk factors in fetal alcohol syndrome: Provacative and permissive influences. Neurotoxicology and Teratology, 17, 445-462. Kyskan, C.E., & Moore, T. (2005). Global Perspectives on fetal alcohol syndrome: Assessing practices, policies, and campaigns in four English-speaking countries. Canadian Psychology/Psychologie Canadienne, 46, 153-165.
xiColes, C.D., Russell, C.L., & Schuetze, P. (1997). Maternal substance use: epidemiology, treatment outcome, and developmental effects: an annotated bibliography, 1995. Substance Use and Misuse, 32, 149-168. Abel, E.L., & Hannigan, J.H. (1995) Maternal risk factors in fetal alcohol syndrome: Provocative and permissive influences. Neurotoxicology and Teratology, 17, 445-462.
xiiHenriksen, T. B., Hjollund, N. H., Jensen, T. K., Bonde, J. P., Andersson, A. M., Kolstad, H., et al. (2004). Alcohol consumption at the time of conception and spontaneous abortion. American Journal of Epidemiology, 160, 661–667.
xiiiCavallo, F., Russo, R., Zotti, C., Camerlengo, A., & Ruggenini, A. M. (1995). Moderate alcohol consumption and spontaneous abortion. Alcohol and Alcoholism, 30, 195–201.
xivAbel, E.L., PhD. And Sokol, R.J., M.D. Is Occasional Light Drinking During Pregnancy Harmful? Alcohol Problems and Solutions. See: http://www2.potsdam.edu/hansondj/HealthIssues/1043239516.html.
xvFetal Alcohol Exposure, International Center for Alcohol Policies, 2007. See: http://www.icap.org/PolicyIssues/ICAPHealthBriefings/tabid/275/Default.aspx.
xviJacobson, S. W., Jacobson, J. L., Sokol, R. J., Martier, S. S., Ager, J. W., & Kaplan, M. G. (1991). Maternal recall of alcohol, cocaine, and marijuana use during pregnancy. Neurotoxicology and Teratology, 13, 535–540.
xviiShankar, K., Ronis, M.J., & Badger, T.M. (2007). Effects of pregnancy and nutritional status on alcohol metabolism. Alcohol Research and Health, 30, 55-59. Shankar, K., Hidestrand, M., Liu, X., Xiao, R., Skinner, C.M., Simmen, F.A., et al. (2006) Physiologic and genomic analyses of nutrition-ethanol interactions during gestation: Implications for fetal ethanol toxicity. Experimental Biology and Medicine (Maywood, N.J.), 231, 1379-1397.
xviiiCaan, W. (2007). Remember the links in the causal chain of fetal alcohol effects. Lancet, 369(9575), 1789.
Education and Information
FAS, FASD, and FAS-related problems are preventable. One first logical step in reducing the potential for this kind of harm is providing clear, understandable, and consistent health information to women who are pregnant or may become pregnant. Although guidelines for drinking and pregnancy have been established by governments in most countries, this information is not always communicated accurately or effectively. Such information can and should be shared by health care providers, but also by other professionals such as social workers—in particular, in instances where health care access may not be accessible or affordable. Educators and family members also play a potentially significant role in sharing information about the risks of harm associated with certain patterns of drinking and pregnancy.i
Variations in Guidelines and “Standard Drinks”
There is strong general consensus that women should either abstain from—or only drink low amounts of—alcohol during pregnancy. Beyond this important point of consensus, opinions and recommendations vary. The countries that recommend abstinence for pregnant women include the United States, Sweden, and Canada. The countries that recommend occasionally drinking only low to moderate amounts of beverage alcohol during pregnancy include Australia and Denmark.ii
In addition, the meaning of various recommendations is affected by what is considered to be a “standard drink” in any given country. For instance, a single standard drink for a pregnant woman in the United Kingdom would be defined as 8 grams of ethanol, but for a pregnant woman in Australia a standard drink would be 14 grams, nearly twice that amount.iii
Screening, Intervention, and Counseling
Rates of Fetal Alcohol Syndrome (FAS) are particularly high in certain groups and communities, which increases the likelihood for positive results with targeted prevention, screening, and intervention efforts. Such efforts provide resources—both written and verbal—for providing accurate information about the relationship between pregnancy, drinking patterns, and outcomes. In addition, pregnant women can be advised and supported in changing their drinking patterns through interventions and counseling.
For example, in Canada, a new framework for brief interventions in conjunction with prenatal medical visits has been established by the public health ministry. The program is based on research which shows that limited intervention can help reduce drinking by pregnant women by 40 percent. The study identified 92 women who were given information about pregnancy and drinking, with results ranging from abstention to women setting goals for--and employing new behavior patterns directed toward--reducing their alcohol intake.iv
iiInternational Center for Alcohol Policies, Blue Book, Module 10, Drinking and Pregnancy. See: http://www.icap.org/Publication/ICAPBlueBook/tabid/148/Default.aspx.
iiiInternational Center for Alcohol Policies, Blue Book, Module 20, Standard Drinks. See: http://www.icap.org/Publication/ICAPBlueBook/tabid/148/Default.aspx.
ivSee: http://www.articlearchives.com/medicine-health/diseases-disorders-developmental/115400-1.html and http://www.phac-aspc.gc.ca/publicat/fasd-ru-ectaf-pr-06/7_3-eng.php