Intergovernmental committee on Drugs working party on Fetal Alcohol Spectrum Disorders
Fetal Alcohol Spectrum Disorders in Australia: An Update
Despite more than 40 years of research into this area, there remains confusion about the relationship between alcohol and fetal harm. Debate continues around whether this relationship is linear or whether there is a threshold effect below which there is no harm to the developing child. The lack of clarity in the published literature and the lack of consensus about whether there is a safe level of alcohol consumption has been reflected in the policies and guidelines across Australia and other English speaking countries (O'Leary et al. 2007).
There is sufficient evidence to show that chronic heavy alcohol use or frequent intermittent heavy alcohol use during pregnancy increases the risk of FASD (Jacobson et al. 1993; Mattson and Riley 1998; Jacobson and Jacobson 1999; DeRoo et al. 2008). The most recent research suggests that there is no strong evidence to implicate low levels of prenatal alcohol exposure with fetal harm. However, as recent studies have shown increased risk of neurodevelopmental problems (Sayal et al. 2009; O'Leary et al. 2010) and preterm birth (O’Leary et al. 2009) following exposure of as little as 30-40g per occasion and 70g per week, there is at most only a small margin before there is increased risk (O'Leary and Bower 2011). The conservative approach is therefore to recommend that women abstain from alcohol during pregnancy. This abstinence message should be presented in a balanced and rational format.
With the high rate of drinking and binge drinking among young Australian women of child bearing age including during pregnancy and the high rate of unplanned pregnancies in Australia, we need to ensure that we have a sound evidence base (Koren 1996; Australian National Council on Drugs 2003; O'Callaghan et al. 2003; White and Hayman 2004; Colvin et al. 2007; Todorow et al. 2010). This will enable policy makers and health professionals to provide consistent and accurate advice without generating unnecessary fear or guilt, which may lead a woman to seek a termination of pregnancy when the absolute risk to the fetus is likely to be been small.
Rosett and Weiner (1982) clearly pointed out more than two decades ago that there were many unanswered questions about dose and timing of fetal alcohol exposure, most of which remain unanswered today. They argued that the most conservative policy is to recommend abstinence (Rosett and Weiner 1982). They also state, however, that it is important not to exaggerate the danger from light drinking, which they defined as less than two standard drinks per day, since ‘exaggeration will decrease credibility concerning the established adverse effects of heavy drinking’.
- Fetal exposure to alcohol during pregnancy increases the risk of a range of poor outcomes, which are classified under the umbrella term ‘Fetal Alcohol Spectrum Disorders’ (FASD). FASD comprises a number of diagnostic categories including Fetal Alcohol Syndrome (FAS), partial FAS (pFAS), Fetal Alcohol Effects (FAE), Alcohol Related Birth Defects (ARBD), and Alcohol Related Neurodevelopmental Disorders (ARND).
- A number of diagnostic approaches have been used to classify FASD. A uniform diagnostic capacity, agreed and applicable across Australia, would assist in identifying opportunities for intervention, prevention and treatment for FASD.
- Secondary outcomes such as behavioural and mental health problems, alcohol and drug problems, disrupted school education and trouble with the law are among the long-term sequelae for adults with FASD. These secondary disabilities may be ameliorated by protective factors including early diagnosis and treatment.
- The effect from low levels of prenatal alcohol exposure is unclear and controversy remains. Further research and new techniques are required.
- The lack of evidence regarding a safe level of alcohol use leads many policies to recommend abstinence or that avoiding alcohol is the safest choice. Messages about low level drinking need to be credible and well disseminated if they are to be effective and should not exaggerate the risk from low levels of alcohol use lest women seek a termination when the risk is small.