National Drug Strategy
National Drug Strategy

Intergovernmental committee on Drugs working party on Fetal Alcohol Spectrum Disorders

Monograph

Fetal Alcohol Spectrum Disorders in Australia: An Update

June 2012

11.1 International policy

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Policies and guidelines on the use of alcohol during pregnancy have generated considerable debate in many Western countries, including Australia (Nathanson et al. 2007; O'Brien 2007; O'Leary et al. 2007; Whitehall 2007). As discussed in previous chapters, moderate and heavy prenatal alcohol exposure have been shown to increase the risk of a wide range of health and developmental effects in the fetus (Olegard et al. 1979; Abel and Sokol 1986; Jacobson et al. 1993; Sayal et al. 2007; DeRoo et al. 2008; O'Leary et al. 2009; Sayal et al. 2009; O'Leary et al. 2011). Although there is no strong evidence of increased risk to the fetus from low levels of prenatal alcohol exposure, determining whether there is a threshold effect below which there is no harm to the developing fetus is difficult and research into this continues. The lack of clarity in the published literature about the effect of prenatal exposure to low levels of alcohol has resulted in a range of opinions about whether women should be recommended to abstain from alcohol when pregnant or advised that low levels of alcohol consumption are likely to pose a low risk to the developing fetus (Payne et al. 2005; O'Leary and Bower 2011).

In 2006 a review of the policies in Australia, Canada, the UK, the USA, Ireland, New Zealand, and South Africa was conducted (Table 11.1) (O'Leary et al. 2007). Findings reflected the range of policies found within Australia, from an abstinence message to advice that the risk from low amounts of alcohol is minimal (See Table 11.2). Although abstinence from alcohol was recommended as the safest/prudent choice in all the policies from overseas countries, many of the policies advised that the risk from low amounts of alcohol is minimal. Almost every policy emphasised that the risk to the fetus was highest with heavy, frequent alcohol consumption and in particular, a binge pattern of drinking. Three policies highlighted that when women have consumed alcohol early in pregnancy, cessation or reduction of alcohol consumption will reduce the risk to the fetus (South African Department of Health 2001; Ireland Department of Health 2003; American College of Obstetricians and Gynecologists 2006).

The Royal College of Obstetricians and Gynaecologists in the UK was the only organisation included in the 2006 review to have undertaken a systematic review of the literature, which appears to be the basis for government policies in the UK. Six other organisations indicated
that their policy was based on a review (not systematic) of the literature (see Table 11.1).

The current NHMRC (2009) Guidelines now advise that for women who are pregnant or planning a pregnancy, not drinking is the safest option. The level of risk to the fetus is:


Table 11.1: Policies on alcohol and pregnancy reproduced from O’Leary et al (2007) [1]^*

SourceAbstinenceOccasional small amountsCommentsEvidence base
Canada
Health Canada – National guidelines for the childbearing yearsPrudent choiceRisk from low levels of alcohol is minimal
  • The risk is relative to the amount of alcohol consumed
  • Women who have consumed small amounts of alcohol during pregnancy should be reassured that the risk is likely to be minimal
2
Public Health Agency of CanadaSafest No safe amount
  • During pregnancy there is no safe amount, type or time to drink
2
Canadian Medical Association Prudent choice No specific advise
  • Physicians can play a leading role in educating and counselling about the dangers of alcohol
  • Pregnant women should receive high priority for alcohol and drug addiction treatment services
5
Society of Obstetricians and GynaecologistsPrudent choiceOccasional intake unlikely to cause harm
  • Excessive or persistent alcohol intake has been associated with fetal alcohol syndrome
2
United Kingdom
Royal College of Obstetricians and GynaecologistsSafest 1-2 Standard units once or twice a week
  • Binge drinking in early pregnancy may be particularly harmful
  • Alcohol offers no benefits in relation to the outcomes of pregnancy
1
UK Department of Health, National Health ServiceSafest As above
  • Heavy or frequent drinking can harm your baby; avoid getting drunk
1
Health ScotlandSafestAs above
  • Heavy drinking may seriously harm your baby’s development
1
United States
US Surgeon General (2005)AdvisedNo Safe amount
  • During pregnancy there is no safe amount, type or time to drink
  • Health professionals should take a history of oral consumption, provide information on the risks and advice abstinence
3
National Institute on Alcohol
Abuse and Alcoholism (NIAAA)
AdvisedNo safe amount
  • During pregnancy there is no safe amount, type or time to drink
  • Each pregnancy is different and alcohol may harm one baby more than another
2
US Department of Health and
Human Services, Department of
Agriculture Dietary guidelines for
Americans 2005
AdvisedNot recommended
  • NIAAA has published on its website a review of drinking moderately and pregnancy by Jacobsen and Jacobsen 7, which states ‘moderate drinking has much more impact on child development when the mother consumes several drinks in a single day than when she drinks the same quantity in doses of one to two drinks over several days’/ The review recommends using a safety factor of 10 to determine a safe drinking level. Although not stated, O’Leary et al. 1 assumed that this review influenced NIAA policy
5
American College of
Obstetricians and Gynaecologists
SafestSmall amounts
unlikely to cause
harm
  • Although small amounts of alcohol are unlikely to cause serious harm, women are best advised to refrain from alcohol entirely
  • Even when heavy drinking in early pregnancy has occurred, risk of further harm can be reduced by cessation of alcohol use
2
American Academy of PaediatricsAdvisedNo safe amount
  • Potential for harm to the fetus is much stronger with large amounts of maternal alcohol consumption
  • Maternal age, parity and health may contribute to infant outcome
2
Others
Ireland Department of Health,
Health Promotion Unit
SafestAvoid binge
drinking
  • A safe level of alcohol consumption during pregnancy has not yet been determined; cutting down or stopping protects your baby
5
New Zealand Ministry of Health
39 and Alcohol Advisory Council
of New Zealand
Safest-
  • During pregnancy there is no safe amount, type or time to drink
  • Not all women who drink during pregnancy will have a child with fetal alcohol syndrome
5
South African Department of
Health
AdvisedSafe level has not
been determined
  • Women are advised to attend antenatal clinics as early as possible
  • Damage to the baby can be limited by reducing alcohol misuse during pregnancy
  • Men should support their partners to avoid alcohol
5

^ Reproduced from O'Leary CM et al. A review of policies on alcohol use during pregnancy in Australian and other English-speaking countries, 2006. MJA 2007; 186(9): 466-471. ęCopyright 2007. The Medical Journal of Australia - reproduced with permission.
* Standard drink: UK unit = 8g,Ireland and New Zealand = 10g, South Africa = 12g, Canada = 13.5g and US = 14g.
† Key to evidence base: 1= systematic literature review, 2= literature review (not systematic review), 3= broad statement or indication that the policy is based on the evidence, but no specific references provided, 4= consensus of authors and 5=not mentioned.
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