Low level alcohol consumption and the fetus
BMJ 2005; 330 doi: https://doi.org/10.1136/bmj.330.7488.375 (Published 17 February 2005) Cite this as: BMJ 2005;330:375All rapid responses
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Dear Editors - In the light of some preliminary data analysis for our
Gabonese parasitological study cohorts, we would like to follow up on your
February editorial stressing the risks of maternal alcohol consumption
during pregnancy[1]. About one third of women interviewed at delivery in
our semi-urban study area in Gabon reported alcohol consumption during
pregnancy.
In a rapid response to your editorial, Rajan already has mentioned an
“increasing alcohol consumption among women in
developing countries”. The importance of this problem is further supported
by our findings, which are all the more alarming as not only African
origin has been described as a strong risk factor for the development of
fetal alcohol syndrome (FAS)[2], but it furthermore has been speculated
that malnutrition, which is highly prevalent in developing countries,
might increase the susceptibility to teratogenic effects of prenatal
alcohol exposure[3]. However, a literature search resulted in worryingly
few relevant publications on the epidemiology of FAS/fetal alcohol
spectrum disorder and alcohol abuse in pregnant women in Africa. Even in
our studies, drinking behaviour was not further differentiated and alcohol
-related dysmorphologies were not specifically recorded, as data on this
subject was collected only incidentally as basic sociodemographic
information but not as a specific outcome variable. In addition to the
scarcity of publications on this topic in the African context, almost all
investigations available referred to South African populations. Clearly,
patterns of substance abuse may differ significantly between different
African populations, and while, e.g., the overall prevalence of alcohol
consumption during pregnancy in a South African cohort has been reported
to be comparable to our numbers, combined use of alcohol and tobacco was
quite common in that study[4], whereas it was almost negligible in ours.
Altogether, even the most basic data describing the epidemiology of FAS
and alcohol consumption in pregnant women, associated behavioural patterns
and other risk factors, are lacking for most parts of Africa, hampering
any attempts to tackle these problems effectively.
Ironically, your editorial appeared on the very same pages as the one
titled “Neglected Diseases”[5]. In our humble opinion, it becomes evident
from the above remarks, that alcohol consumption and other substance abuse
during pregnancy is exactly one of these. The attention of the scientific
community and international health authorities must be drawn to this
neglected public health problem, which endangers not only the unborn,
weakest individuals, but also especially the already deprived, yet growing
populations in the developing world.
Lutz Ph. Breitling, physician,
lutz.breitling@gmail.com
Institute for Tropical Medicine,
Department of Parasitology,
University of Tübingen, Germany
Ayola A. Adegnika, PhD student
Medical Research Unit,
Albert Schweitzer Hospital,
Lambaréné, Gabon
Reference List
1. Mukherjee RAS, Hollins S, Abou-Saleh MT, Turk J. Low level alcohol
consumption and the fetus. BMJ 2005;330:375-6.
2. Sokol RJ, Ager J, Martier S, Debanne S, Ernhart C, Kuzma J et al.
Significant determinants of susceptibility to alcohol teratogenicity. Ann
NY Acad Sci 1986;477:87-102.
3. Riley EP, Guerri C, Calhoun F, Charness ME, Foroud TM, Li TK et
al. Prenatal alcohol exposure: advancing knowledge through international
collaborations. Alcohol Clin Exp Res 2003;27:118-35.
4. May PA, Gossage JP, Brooke LE, Snell CL, Marais AS, Hendricks LS
et al. Maternal Risk Factors for Fetal Alcohol Syndrome in the Western
Cape Province of South Africa: A Population-Based Study. Am J Public
Health 2005; DOI 10.2105/AJPH.2003.037093.
5. Rawlins MD. Neglected diseases. BMJ 2005;330:376-7.
Competing interests:
None declared
Competing interests: No competing interests
Dr Wodak I am the biological mother of two children with foetal
alcohol spectrum disorder. The Australian Medical Association has issued
a request to the National Health and Medical Research Council to review
the guidelines to which you refer to an abstinence position.
I would have preferred some anxiety during pregnancy to the anxiety I
experience every day now knowing that my sons have been physically harmed
by my drinking. My youngest son will be on the disability support pension
all his life because of this condition and will probably never be able to
hold down a "normal" job. If doctors had given me information when my
first son was born underweight, with failure to thrive, possibly retarded
and with suspected hearing problems, my youngest son would not be affected
and would be able to live a "normal" life.
He is currently dependent on my husband and I for almost everything
that he does - he is 20 years old - and has accessed services from the
government which have been and will continue to be a source of huge
expense.
If only I had been told during my pregnancies about this condition
and that even one drink could be harmful, my children would be safe. The
safety of the child is paramount and anxiety in the mother can be
supported by her family, friends and doctor for 9 months whereas my sons
will need support for the remainder of their lives.
I am afraid to die because of the fear of what will happen to my
youngest son without this support.
Please do not minimise the problems that drinking any amount of
alcohol during pregnancy can cause. Abstinence has to be the only option
for your pregnant patients.
Elizabeth Russell
nofasard@bigpond.com
Competing interests:
None declared
Competing interests: No competing interests
The myth that small amounts of alcohol are beneficial dies hard, and
is especially believed by those who drink regularly themselves. Relief of
anxiety by drinking alcohol or smoking tobacco may be an excuse of regular
drinkers or smokers to continue their habits, but any alcohol or smoking
is toxic to the developing fetus. As anxiety, like headaches, is more
common in women with nutritional deficiencies, and alcohol drinking causes
loss of nutrients, relief of anxiety is a poor argument for continuing to
drink during pregnancy. A mother who causes unnecessary damage to her
children can have a life time of otherwise avoidable anxiety.
Competing interests:
None declared
Competing interests: No competing interests
Dear Sir,
The claim 1 that Australia authorities have “adopted the abstinence
message” for pregnant women considering drinking alcohol is incorrect. In
fact the most recent Australian guidelines recommend 2 that “pregnant
women may consider not drinking at all; most importantly, should never
become intoxicated; if they choose to drink, over a week, should have less
than 7 standard drinks, AND, on any one day, no more than 2 standard
drinks (spread over at least two hours); [and] should note that the risk
is highest in the earlier stages of pregnancy, including the time from
conception to the first missed period”.
As a commentary accompanying this guidelines noted “The first weeks
after conception are probably the most critical in relation to alcohol,
and the woman is usually unaware of the pregnancy at this stage. The
guideline is therefore important not only for women who are pregnant, but
for those who may soon become pregnant”.
Many women experience considerable anxiety during pregnancy. Almost
all pregnant women try to do the best they can for their unborn child.
Although alcohol is the most common teratogen, is it worth risking
increasing the anxiety of pregnant women when the actual benefit of this
advice is unknown? If the prevalence of fetal alcohol syndrome is to be
reduced substantially, and if it is accepted that the first few weeks of
pregnancy are particularly important, then all pregnant women and all
women who might soon become pregnant will have to be persuaded to avoid
immoderate alcohol consumption. This is far more achievable than trying to
persuade this large population from drinking any alcohol.
Yours sincerely,
Dr. Alex Wodak,
References:
1 Mukherjee RAS, Hollins S, Abou-Saleh MT, Turk J. Low level alcohol
consumption and the fetus. BMJ 2005;330:375-376 (19 February),
doi:10.1136/bmj.330.7488.375
2 National Health and Medical Research Council. Australian Alcohol
Guidelines: Health Risks and Benefits. 2001
http://www7.health.gov.au/nhmrc/publications/pdf/ds9.pdf
Competing interests:
Member of committee which prepared: National Health and Medical Research Council. Australian Alcohol Guidelines: Health Risks and Benefits. 2001
Competing interests: No competing interests
I would like to thank Mukherjee, Hollins, Abou-Saleh and Turk (1) for
reminding us of the significance of alcohol consumption in pregnancy and
highlighting once again, the implications it can have on our clinical
practice. As an SpR in Child and Adolescent Psychiatry in South Wales I
have regular involvement in the initial assessments and follow-up of young
people suffering from attention deficit hyperactivity disorder (ADHD),
autistic spectrum disorder (ASD), and a variety of behavioural problems.
To what extent can the behavioural diagnoses occurring in children
and adolescents be attributed to the fetal alcohol spectrum disorder
described in this editorial? Hyperactivity, impulsivity, and the lack of
awareness of social cues, are all features known to be neurocognitive
effects of prenatal alcohol consumption, (2) in addition to being of
particular interest to the psychiatrist working with children of school
age.
Alcohol is one of many risk factors known to be particularly harmful
at the time of the period of rapid brain growth during fetal development
and early life, resulting in an adverse impact on cognitive development.
(3)
Indeed as described in the editorial, evidence shows overlap between
maternal alcohol consumption in pregnancy and the subsequent development
of conditions such as ADHD, and autism. (4)
Everyday we are reminded of the distress and torment that these
disorders can bring to patients and their families. The seemingly
unrelenting affliction will penetrate every area of the child’s life, from
home, through to school and the damaging of education, peer relationships
and self-esteem.
Although I believe that the developmental history is generally an area
which is covered well. I am aware that alcohol intake in pregnancy,
including the stage of gestation and quantity, is not routinely enquired
of.
Recognition of families at risk is of utmost importance, both for the
child in our care and for future children. Any ongoing alcohol use must be
acknowledged, and to what extent this is maintaining the child’s
behaviour. We should consider the effect that alcohol consumption within
the family may be having on compliance with current treatment, including
the attending of appointments, and the safe supervision of any prescribed
stimulant medication.
Until further evidence emerges, I believe widespread awareness is the
key.
(1) Mukherjee RAS, Hollins S, Abou-Saleh MT, Turk J. Low level
alcohol consumption and the fetus. BMJ 2005;330:375-6. (19 February)
(2) Jacobson JL, Jacobson SW. Effects of prenatal alcohol exposure on
child development. Alcohol Res Health 2002;26:282-6.
(3) Streissguth AP, Barr HM, Sampson PD, Bookstein FL. Prenatal
alcohol and offspring development:the first fourteen years. Drug and
Alcohol Dependence 1994;36:89-99
(4) Famy C, Streissguth AP, Unis AS. Mental illness in adults with
fetal alcohol syndrome or fetal alcohol effects. Am J Psychiatry
1998;155:552-4.
Competing interests:
None declared
Competing interests: No competing interests
Over the years in various different support groups for parents of
disabled
children and their families, I have came across mothers who had children
who
had been diagnosed with Foetal Alcohol syndrome. I have never judged
these
mothers but many of them have not had the benefit of proper genetic
counselling.
When they have had the opportunity of accessing genetic counselling
(if they
ever get access to it), the diagnosis is somewhat different to Foetal
Alcohol
Syndrome.
There are also those doctors who assume that certain syndromes such
as
DiGeorge syndrome and other similar syndromes are as a result of drinking
alcohol during pregnancy. They are not! Drinking though can exacerbate
the problems of the developing foetus.
Many of these alchoholic mothers have actually, other problems such
as
thyroid problems, bipolar disorder and manic depression which are often
left
untreated.
Whilst I agree about total abstinence during pregnancy is the best
course of
action, it is the terminology of Foetal Alcohol Syndrome which is so
judgemental and the fact that many of these children are not being
diagnosed
correctly.
Competing interests:
None declared
Competing interests: No competing interests
With increasing alcohol consumption among women in developing
countries, this report assumes significance. Young working women in India
are taking to alcohol in large numbers and hence there is a risk of them
developing complications during pregnancy. This report reiterates past
observations on the subject and should act as additional warning.
Competing interests:
None declared
Competing interests: No competing interests
Perhaps "any" consumption of alcohol is a danger to anyone of any age
or condition.
June Russell
_______________
WINE/ALCOHOL HEALTHY? (and risks to the heart from smaller amounts)
THERE ARE MANY MORE REFERENCED FACTS ABOUT THE
HARM FROM SMALLER AMOUNTS OF ALCOHOL ON WWW.JRUSSELLSHEALTH.COM
I think it is important that everyone knows about the deception in
reporting alcohol as healthy. My
article below has recently been in area newspapers and on several other
websites (as well as my own). Although I have information on many health
topics on my website, I emphasize the dangers of light and moderate
alcohol use under the topic "Alcohol." This is because of the misleading
and biased reporting in the media - the public should have the right to
know of the risks and individuals cannot make responsible choices if they
do not have the correct facts.
On my website, I include information on how the studies exclude important
risk factors, change the dose, or omit the variables that skew the
outcome, and reveal the warnings from researchers that were omitted by
press releases. Oddly enough there have never been randomized, placebo
controlled, double-blind studies on the health benefits of alcohol - -
there have only been associations - not very scientific!
Resveratrol is in the news now, and although it is reported as healthy,
there are many studies (and experts) that question its health benefits. It
is a bit of a stretch to say that red wine is healthy because it contains
resveratrol - especially since the presence of alcohol negates the
advantage of the antioxidants. Alcohol is a drug - but this is one drug
that does not have a requirement to report the negative studies. You may
find the following sub-topics under "Alcohol" interesting (there are over
40): "Health Benefits Questioned," "The Effect of One Alcoholic Drink,"
and "Alcohol - Heart."
June Russell - - russells@cstone.net - - www.jrussellshealth.com
Competing interests:
None declared
Competing interests: No competing interests
Mukherjee et al make a good case for alcohol free pregnancies and for
health promotion messages to promote these [1]. However to provide a more
supportive environment it would also be desirable for the price of alcohol
to be higher. For example, raising tobacco taxes has been found to reduce
tobacco consumption by pregnant women as this population is particularly
sensitive to cigarette prices [2]. Furthermore, there are plenty of other
public health advantages of higher alcohol prices given the evidence that
these can: reduce drinking and driving and its consequences among all age
groups; lower the frequency of diseases, injuries, and deaths related to
alcohol use and abuse; and reduce alcohol-related violence and other crime
[3]. Another review also reported such benefits and noted that these
findings were “relevant for policy purposes because alcohol abuse imposes
large ‘external’ costs on others” [4]. Support for higher alcohol taxes by
the public is likely to be facilitated if governments use the revenue to
allow a reduction in income tax among low-income citizens and/or to fund
health promotion campaigns eg, for promoting alcohol-free pregnancies.
References
1) Mukherjee RAS, Hollins S, Abou-Saleh MT, Turk J. Low level alcohol
consumption and the fetus. BMJ 2005;330:375-376.
2) Ringel JS, Evans WN. Cigarette taxes and smoking during pregnancy.
Am J Public Health 2001;91:1851-6.
3) Chaloupka FJ, Grossman M, Saffer H. The effects of price on
alcohol consumption and alcohol-related problems. Alcohol Res Health
2002;26:22-34.
4) Cook PJ, Moore MJ. The economics of alcohol abuse and alcohol-
control policies. Price levels, including excise taxes, are effective at
controlling alcohol consumption. Raising excise taxes would be in the
public interest. Health Aff (Millwood) 2002;21:120-33.
http://www.niaaa.nih.gov/publications/arh26-1/22-34.htm
Competing interests:
None declared
Competing interests: No competing interests
Re: Low level alcohol consumption and the fetus
Dear Editor,
Given how unpopular the topic of maternal drinking used to be, 16 years delay does not seem surprising for this BMJ Editorial to result in published Government guidance: "Fetal alcohol spectrum disorder: health needs assessment". That guidance is multidisciplinary and draws on international knowledge. I really hope it does not take another 16 years, for guidance to result in changed practice - and improved health for a new generation!
[1] Trathen A. Guidance, DHSC 2021. Published online: https://www.gov.uk/government/publications/fetal-alcohol-spectrum-disord...
Competing interests: Member of the Alcohol Health Alliance