Prenatal Alcohol Exposure. Is there a safe limit?
Drinking alcohol prior to conception and during pregnancy can have significant adverse outcomes for the fetus.
Both Fetal Alcohol Spectrum Disorder and the more severe Fetal Alcohol Syndrome are on the increase, leaving practitioners asking the question ‘is any amount of alcohol safe?’
Fetal alcohol syndrome (FAS) and fetal alcohol syndrome disorder (FASD) are known to be associated with persistent physical and neurodevelopmental abnormalities (Vaux et al. 2016). It’s a syndrome disorder that crosses all socioeconomic groups, affects all races and ethnicities and its prevention remains a significant challenge for all practitioners in the field of fertility and maternity care.
Fetal Alcohol Spectrum Disorder (FASD)
Fetal Alcohol Spectrum Disorder describes a range of effects that can occur following alcohol exposure during the nine-month prenatal period before birth. These effects may include physical, mental, behavioural and learning disabilities, and may have lifelong implications.
Diagnostic terms under the FASD umbrella include:
- Fetal Alcohol Syndrome (FAS)
- Partial Fetal Alcohol Syndrome (PFAS)
- Neurobehavioral Disorder Associated with Prenatal Alcohol Exposure (ND-PAE)
- Alcohol-Related Neurodevelopmental Disorder (ARND)
Fetal Alcohol Syndrome
It’s long been known that alcohol is a physical and behavioural teratogen. Yet FAS, although common, remains under-recognised and poorly managed.
It’s a condition that is both disabling and entirely preventable.
The suggested international prevalence rates for FASD according to Larcher and Brierley (2014) is approximately 1% of live births. In the UK alone this equates to approximately 7,000 births a year with the implication that alcohol could be responsible for up to 50% of UK disability births. Statistics for other developed countries are equally concerning.
Prenatal Alcohol Exposure
Backed up by unequivocal research, it’s now accepted that prenatal alcohol exposure causes a broad range of adverse developmental effects.
Whilst the diagnostic criteria for fetal alcohol syndrome are already specific and comprehensive, definitive criteria for diagnosing the other FASDs are still evolving.
No Amount of Alcohol is Safe
A question of concern for many practitioners is just how much alcohol, if any, is it safe to drink during pregnancy?
In a recent study published by Nykjaer (2014) it was revealed that 53% of women drank more than the upper limit of two units a week during the first trimester. Specifically, middle-class women were shown to be more likely than women from other classes to drink more than the recommended limits during their pregnancy.
It’s statistics such as these that have recently led the Royal College of Obstetricians and Gynaecologists (2018) to revise their guidance on drinking in pregnancy.
Whilst some health guidelines allow for occasional drinking after the first trimester, most countries have modified their recommendations in line with abstinence during pregnancy.
The overall message here is clear, there is no safe limit of alcohol consumption during pregnancy and women should be advised to abstain from alcohol from preconception until birth.
Variable FASD Risk Factors
One of the greatest challenges facing future research into FASD is that individual women process alcohol differently. For example, the following factors may all be important:
- The age of the mother
- The timing and regularity of alcohol consumption
- Whether the mother has eaten any food while drinking
Nurses and Midwives have an important role to play
As Mitchell et al. (2018) suggest, nurses and midwives are in an ideal position to talk to couples of reproductive age about the dangers of alcohol use in pregnancy.
Preventing alcohol-exposed pregnancies remains a challenge however and requires skilful conversations and appropriate follow up to be clinically effective.
Mamluk et al. (2017) also point out that the distinction between light drinking and abstinence is a source of considerable tension and confusion for both health professionals and pregnant women alike and this in itself may contribute to inconsistent guidance.
The fact remains that the all-important first step in reducing the incidence of FASD begins by asking about alcohol consumption and advising women about its effects during pregnancy.
Just as with other forms of lifestyle advice, however, talking alone is often not enough to bring about a behaviour change. Wherever possible pregnant women should also be given help to stop or reduce their alcohol consumption and be offered further support, referral, follow up and treatment where needed.
Specific guidance that should be offered during pregnancy:
- No amount of alcohol intake should be considered safe
- There is no safe trimester to drink alcohol
- All forms of alcohol, such as beer, wine, and liquor, pose similar risks
- Binge drinking poses dose-related risk to the developing fetus
(Williams & Smith 2015)
Implications for Practice
Williams and Smith (2015) also take this guidance further by suggesting broader prevention initiatives based on the following:
- Alcohol-related birth defects and developmental disabilities are completely preventable when pregnant women abstain from alcohol use.
- Early recognition, diagnosis, and therapy for any condition along the FASD continuum can result in improved outcomes.
However, conflicting messages about alcohol consumption persist and can lead to feelings of shame and confusion.
As Eguiagaray et al. (2016) suggest, there is currently a pressing need for greater openness with mothers to challenge the stigma of drinking alcohol during pregnancy.
Drinking in pregnancy is clearly a highly emotive issue that requires sensitive and careful management. On the one hand, delivering alcohol brief interventions at the first antenatal appointment is more likely to produce results, but it can also threaten to damage the relationship between midwife and mother.
Recognising this, Doi et al. (2015) suggest that when training midwives to screen and deliver alcohol brief interventions, special attention is needed to improve person-centred communication skills to help overcome any barriers associated with discussing alcohol use.
Eguiagaray et al. (2016) go further by suggesting that guidelines for media reporting should also be revised to discourage stigmatising mothers and that media articles should also consider the role that government, non-government organisations and the alcohol industry itself could play in improving FASD shame.
In some contrast to these views, Mamluk et al. (2017) propose that there is actually limited evidence supporting light drinking in pregnancy, compared with abstaining completely.
Their research highlights the distinction between light drinking and abstinence as the point of most tension and confusion between health professionals and pregnant women and suggests that further research is needed in this area. They also raise the controversial suggestion that there might be possible benefits of light alcohol consumption versus complete absence.
Whilst doubt remains as to whether infrequent, low levels of alcohol consumption during pregnancy can cause long-term harm, most practitioners now agree that recommending no alcohol consumption during pregnancy is the safest way forward.
Alongside this are calls for more education and counselling to raise awareness of conditions such as FAS and FASD. Larcher and Brierley (2014) recommend that this could also helpfully be part of a wider public health and social policy initiative on reducing alcohol consumption.
As Tsang and Elliott (2017) conclude, the high global prevalence of alcohol use during pregnancy and the consequent high incidence of fetal alcohol syndrome indicates a need for urgent action.
Alongside this is the need for new evidence-based initiatives to prevent FAS, together with further education and awareness-raising training for fertility nurses and midwives.
- Doi, L, Jepson, R & Cheyne, H 2015, ‘A realist evaluation of an antenatal programme to change drinking behaviour of pregnant women’, Midwifery, vol. 31, no. 10, pp. 965-72, viewed 3 April 2018, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4596150/
- Eguiagaray, I, Scholz, B & Giorgi, C 2016, ‘Sympathy, shame, and few solutions: News media portrayals of fetal alcohol spectrum disorders’, Midwifery, vol. 40, pp. 49-54, viewed 4 April 2018, https://www.ncbi.nlm.nih.gov/pubmed/27428098
- Larcher,V, Brierley, J 2014, ‘Fetal alcohol syndrome (FAS) and fetal alcohol spectrum disorder (FASD)—diagnosis and moral policing; an ethical dilemma for paediatricians’, BMJ, vol. 99, no. 11, viewed 4 April 2018, http://adc.bmj.com/content/99/11/969
- Mamluk, L, Edwards, HB, Savovic, J, Leach, V, Jones, T, Moore, THM, Ijaz, S, Lewis, SJ, Donovan, JL, Lawlor, D, Smith, GD, Fraser, A & Zuccolo, L 2017, ‘Low alcohol consumption and pregnancy and childhood outcomes: time to change guidelines indicating apparently ‘safe’ levels of alcohol during pregnancy? A systematic review and meta-analyses’, BMJ, vol. 7, no. 7, viewed 3 April 2018, http://bmjopen.bmj.com/content/7/7/e015410
- Mitchell, A, King, DK, Kameg, B, Hagle, H, Lindsay, D, Hanson, BL, Kane, I, Puskar, K, Albrecht, S, Shaputnic, C, Porter, BR, Edwards, AE & Knapp, E 2018, ‘An Environmental Scan of the Role of Nurses in Preventing Fetal Alcohol Spectrum Disorders’, Issues in Mental Health Nursing, vol. 39, no. 2, pp. 151-8, viewed 3 April 2018, https://www.ncbi.nlm.nih.gov/pubmed/29370546
NOFAS. 2018. National Organization on Fetal Alcohol Syndrome. [Online]. [4 March 2018]. Available from: https://www.nofas.org/about-fasd/
- Nykjaer, C, Alwan, NA, Greenwood, DC, Simpson, NAB, Hay, AWM, White, KLM & Cade, JE 2014, ‘Maternal alcohol intake prior to and during pregnancy and risk of adverse birth outcomes: evidence from a British cohort’, BMJ, viewed 3 April 2018, http://jech.bmj.com/content/early/2014/02/11/jech-2013-202934.short?g=w_jech_ahead_tab
- Royal College of Obstetricians & Gynaecologists 2018, Alcohol and pregnancy, Royal College of Obstetricians and Gynaecologists, London, viewed 3 April 2018, https://www.rcog.org.uk/en/patients/patient-leaflets/alcohol-and-pregnancy/
- Singh, S, Laufer, BI & Kapalanga, J 2014, ‘Fetal alcohol and the right to be born healthy…’, Frontiers in Genetics, viewed 3 April 2018, https://www.frontiersin.org/articles/10.3389/fgene.2014.00356/full
- Tsang, T & Elliott, E 2017, ‘High global prevalence of alcohol use during pregnancy and fetal alcohol syndrome indicates need for urgent action’, The Lancet Global Health, vol. 5, no. 3, viewed 3 April 2018, http://www.thelancet.com/pdfs/journals/langlo/PIIS2214-109X(17)30008-6.pdf
- Vaux, KK, Chambers, C, Windle, ML, Pramanik, AK, Rosenkrantz, T & Itani, O 2016, Fetal Alcohol Syndrome, Medscape, viewed 3 April 2018, https://emedicine.medscape.com/article/974016-overview
- Williams, J, Smith, V & The Committee on Substance Abuse 2015, Fetal Alcohol Spectrum Disorders, Pediatrics, vol. 106, no. 2, p. 358, viewed 3 April 2018, http://pediatrics.aappublications.org/content/136/5/e1395