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by Norma Hayward, Brainwave Trust Kaiako

Many of us enjoy a drink of alcohol. It’s legal, relatively inexpensive and easily accessed. Lots of us will be enjoying a few glasses of something alcoholic over the coming holiday season. But what about our unborn babies? Is it safe to drink during pregnancy? What harm can alcohol do to the developing child? 

What are FAS and FASD?

It appears that the first medical investigation of alcohol consumption in pregnancy took place in 1899. It found an increased rate of still birth and infant death amongst the children of alcoholic women.1 Much research has been undertaken since then, particularly in the USA and Canada, with the research now using the latest brain scanning techniques.

FASD is Foetal Alcohol Spectrum Disorder. It is an umbrella term which describes the wide range of effects that might be present in an individual who has been exposed to alcohol prenatally. The key word here is Spectrum, meaning range. These effects are various and can be behavioural, cognitive, emotional and physical. At the most severe end of the ‘spectrum of defects’ is Foetal Alcohol Syndrome (FAS).  

According to the American Academy of Pediatrics, “prenatal exposure to alcohol can damage the developing fetus and is the leading preventable cause of birth defects and intellectual and neurodevelopmental disabilities.”2

Foetal Alcohol Syndrome was first described in 1973 when Jones and Smith identified the particular set of facial features which appeared in children whose mothers drank very heavily in pregnancy: short eyelid fissures, flat midface, thin upper lip and a flat or smooth philtrum (groove under the nose). These children also had growth deficiency and behavioural and cognitive impairments.3

So whilst an individual with FASD might not have any of the obvious facial features, they may still exhibit intellectual, behavioural or emotional problems that are common to the condition. FASD is not always evident at birth – the intellectual or behavioural deficits might only become apparent later on, perhaps when the child starts school.4

These intellectual or behavioural difficulties mentioned above are broad and imprecise terms. No two people exposed to alcohol prenatally will have exactly the same effects and issues and this can make diagnosis difficult. Children exposed to alcohol before birth may have: brain damage, memory problems, developmental delay, vision and hearing difficulties, sleep issues, speech and language defects, poor attention spans, problems with abstract thinking, low IQ, and social and behavioural problems.5

The most frequently noted co-existing disorder in the research literature is Attention Deficit Hyperactivity Disorder (ADHD).6 A 2015 Canadian meta-analysis found that children with FASD have higher rates of ADHD than unaffected children, 49–94% vs. 5%, respectively.7

How many people in New Zealand have FASD?

The exact number of adults and children with FASD in New Zealand is not known as there is no systematic approach from health and social service professionals in screening for FASD, identification or follow up.8 However, the Ministry of Health’s 2016 Action Plan seeks to address this.9

The incidence of FASD in the USA and Europe has been estimated to be 2 – 5% of all births.10 Based on international figures, it has been suggested that FASD births in New Zealand are also between 2 – 5%.11 However, as drinking during pregnancy appears to be more common and occurring at higher levels in NZ, there is some suggestion that prevalence of FASD in NZ may be higher.12 

There are approximately 61,000 live births in New Zealand every year.13 That means that approximately, between 1200 and 3000 babies could be born with foetal alcohol effects each year in New Zealand, assuming incidence rates of 2% to 5%.

At the most severe end, Foetal Alcohol Syndrome is estimated to affect between 1 and 7 per 1000 live births.14

How many NZ women drink whilst pregnant?

The per capita consumption of alcohol in New Zealand has increased 9% over the 10 years to 2008.15 Although there has been an increase in consumption by women of all ages, young women are drinking more than ever.16

The recent longitudinal study, Growing Up in New Zealand (GUiNZ) found that 71% of women reported drinking alcohol at some level before realising that they were pregnant. Once becoming aware of their pregnancy, women’s drinking followed a number of patterns including: ceasing drinking immediately; reducing drinking levels; and, for a small proportion, continued high levels of drinking during pregnancy.17 

For further information about these drinking patterns please see: http://www.health.govt.nz/system/files/documents/publications/alcohol-report-infographics-feb2015.pdf

GUiNZ also found that while 65% of women avoided alcohol at some time during their pregnancy, 52% reported avoiding alcohol throughout. This indicates that almost half of NZ women are consuming some alcohol while pregnant.18 The study also found that only 60% of pregnancies were “actively planned” meaning 40% were not. Of course, not all women with unplanned pregnancies drink. However, this is a worrying figure as many women may be exposing their unborn child to alcohol for several weeks without even realising it.

What can alcohol do to the developing brain?

Ethanol is the active ingredient in alcoholic drinks and it can have severe effects on the brain of the developing foetus. Although heavy drinking poses the greatest risk, there is no known safe level below which no damage will occur.19  

Every drink a mother has during pregnancy is also a drink for her baby. Alcohol passes through the placenta and reaches the same levels in the foetus as in the mother, however, with an undeveloped liver, a foetus is unable to metabolise it as effectively. So the alcohol remains in the unborn baby’s system for longer, during which time it has the ability to start doing damage to the vulnerable developing brain.20

Although the teratogenic physical effects happen in early pregnancy,21 other subtler effects can continue to occur with exposure right up to delivery, as the brain continues to grow and form connections throughout the nine months of pregnancy. Therefore, the Ministry of Health advises that there is no known safe level of alcohol use at any stage of pregnancy.

The latest scanning techniques allow researchers to look at the structure and size of the brains of people prenatally exposed to alcohol. An MRI (Magnetic Resonance Imaging) study in the US found differences in the size of many regions in the brain when compared to a control group who had not been exposed to alcohol. These differences were prevalent across the full spectrum of FASD.22

Another MRI study found that those who had been affected by prenatal alcohol exposure had somewhat smaller brains, lower IQs and smaller hippocampi, which are involved in memory. The memory testing component indicated poorer performance on a range of memory tasks.23

Alcohol can reduce the size of the developing brain, disrupt its shape, and alter tissue density and symmetry. Such abnormalities have been noted in the cerebellum (motor control, language and cognition), the corpus callosum (the tract that links the two hemispheres of the brain) and the basal ganglia (associated with learning and cognition). Individuals with FASD often have deficits in learning, language ability and general executive function.24

Animal studies (in rodents and primates) also clearly indicate that even moderate pre-natal alcohol exposure can affect brain development.25 One mechanism is through lasting adverse effects on the hypothalamic-pituitary-adrenal (HPA) axis, which plays an important role in the stress response system.26

Is there a safe limit for alcohol consumption during pregnancy?

The science shows us that safest path to follow must surely be no alcohol in pregnancy or when contemplating pregnancy. Why take the risk? The risk of having an infant affected with FAS or FASD will vary according to the individual. In some cases, one or two drinks might potentially damage the baby whereas in others, heavier drinking might have no apparent effect. The problem is that we have no way of knowing our individual risk. This is why the recommendation in most developed countries is that there is no known safe amount of alcohol to drink during pregnancy.

However, damage is more likely to occur if high amounts of alcohol are consumed. The relationship between alcohol consumption and risk is one of dose response, not one where there is a threshold of consumption over which damage to the foetus occurs. Any sort of alcoholic drink can be damaging during pregnancy and the risk is proportional to the amount consumed. Frequent heavy drinking poses the highest risk. Not all children exposed to prenatal alcohol will be affected or even affected in the same way. A wide range of effects is possible. The level of harm is related to the amount, timing and frequency of alcohol consumed.27 For example, one US literature review found an adverse association between any binge drinking (more than 4 – 5 standard drinks at one time) and children’s cognitive abilities in eight studies. Moderate drinking in pregnancy was found to negatively affect child behaviour.28 

UK research found that even low exposure to alcohol during pregnancy was associated with disruption to the HPA (Hypothalamic Pituitary Adrenal axis) in 19 month-old boys, during mildly stressful situations.29 The HPA axis is the mechanism that helps the body remain stable or balanced under physiological or psychological stress.

What about drinking alcohol whilst breastfeeding?

A baby’s brain is still very vulnerable to the effects of alcohol even after birth. The NZ Ministry of Health recommends completely avoiding alcohol whilst breastfeeding, as alcohol is passed to the baby through breast milk. If a mother does drink alcohol, it takes on average almost two hours for her body to get rid of one standard drink.30

People with FASD in the court system

People with FASD struggle with social relationships, may be aggressive, hyperactive, impulsive and make poor decisions. So is it more likely that they will end up on the wrong side of the law? Research shows that unfortunately the answer to this question is yes.  

People with FASD are more likely to end up in trouble if they do not have the appropriate support throughout life. In one study of people with FASD, 60% reported being charged, convicted or in trouble with the authorities, and 42% of adults have been incarcerated for a crime.31 People with FASD are also more likely to be victims of crime.32

Conclusion

If pregnant women do not consume alcohol there will be no cases of FASD.  FASD can be prevented but it cannot be cured. What we can do, is ensure that our families and communities understand the risks of alcohol consumption to the unborn and breastfed child. We all have a role in supporting women not to drink whilst they are pregnant or planning to be pregnant.

For accounts of some very brave NZ women telling their stories about their children with FASD visit http://www.youtube.com/watch?v=ZwrwNlaEll4

Where to go for further information, or advice

GP or midwife
Alcohol & Drug Helpline   0800 787 797
Foetal Alcohol Network NZ – www.fan.org.nz
ALAC www.alcohol.org.nz 
Ministry of Health  www.health.org.nz  or www.healthed.govt.nz 
www.kidshealth.org.nz  

Footnotes

  1. Sullivan, 1899
  2. Williams et al., 2015, p.1
  3. Jones & Smith, 1973
  4. Ministry of Health, 2010
  5. Ministry of Health, 2010
  6. Riley & McGee, 2005
  7. Kingdon et al., 2016
  8. Alcohol Healthwatch, 2010
  9. FASD Working Group, 2016
  10. Dudek et al., 2014
  11. Sellman & Connor, 2009
  12. Ho & Jacquemard, 2009
  13. Statistics New Zealand, 2015
  14. Niccols, 2007
  15. Statistics NZ, 2008, cited by Sellman & Connor, 2009
  16. Ho & Jacquemard, 2009; Law Commission, 2009
  17. SuPERU, 2015
  18. Morton et al., 2010
  19. Ministry of Health, 2010
  20. Ministry of Health, 2010
  21. Riley & McGee 2005
  22. Astley et al., 2009
  23. Dudek et al., 2014
  24. Riley & McGee, 2005
  25. Valenzuela et al., 2012
  26. Fast & Conry, 2009
  27. Ministry of Health, 2010
  28. Flak et al., 2014
  29. Oullett-Morin, 2011
  30. Ministry of Health, 2010
  31. Streissguth et al., 1996
  32. Fast & Conry, 2009

References

Alcohol Healthwatch. (2010). Towards Multidisciplinary Diagnostic Services for Fetal Alcohol Spectrum Disorder. Auckland, NZ Retrieved from http://www.ahw.org.nz/resources/Documents-other/2010/FASD%20Diagnostic%20Report%20Final%20Aug%202010.pdf.

Astley, S. J., Aylward, E. H., Olson, H. C., Kerns, K., Brooks, A., Coggins, T. E., . . . Richards, T. (2009). Magnetic Resonance Imaging Outcomes From a Comprehensive Magnetic Resonance Study of Children With Fetal Alcohol Spectrum Disorders. Alcoholism: Clinical and Experimental Research, 33(10), 1671-1689. 

Dudek, J., Skocic, J., Sheard, E., & Rovet, J. (2014). Hippocampal abnormalities in youth with alcohol-related neurodevelopmental disorder. Journal of the International Neuropsychological Society, 20(2), 181-191.

FASD Working Group. (2016). Taking Action on Fetal Alcohol Spectrum Disorder: 2016-2019: An action plan. Retrieved from Wellington, NZ: http://www.health.govt.nz/publication/taking-action-fetal-alcohol-spectrum-disorder-2016-2019-action-plan

Fast, D. K., & Conry, J. (2009). Fetal alcohol spectrum disorders and the criminal justice system. Developmental Disabilities Research Reviews, 15(3), 250-257

Flak, A. L., Su, S., Bertrand, J., Denny, C. H., Kesmodel, U. S., & Cogswell, M. E. (2014). The association of mild, moderate, and binge prenatal alcohol exposure and child neuropsychological outcomes: A meta-analysis. Alcoholism: Clinical and Experimental Research, 38(1), 214-226. 

Ho, R., & Jacquemard, R. (2009). Maternal alcohol use before and during pregnancy among women in Taranaki, New Zealand. The New Zealand Medical Journal, 122(1306), 20-29.

Jones, K. L., & Smith, D. (1973). Recognition of fetal alcohol syndrome in early infancy. Lancet, 2(7836), 999-1001. 

Kingdon, D., Cardoso, C., & McGrath, J. J. (2016). Research Review: Executive function deficits in fetal alcohol spectrum disorders and attention-deficit/hyperactivity disorder – a meta-analysis. Journal of Child Psychology and Psychiatry, 52(2), 116-131.

Law Commission. (2009). Alcohol in Our Lives: An Issues Paper on the Reform of New Zealand’s Liqour Laws. Wellington, NZ Retrieved from http://www.lawcom.govt.nz/sites/default/files/publications/2009/07/Publication_154_437_Alcohol%20in%20our%20lives%20-%20Issues%20Paper%2015.pdf.

Ministry of Health. (2010). Alcohol and Pregnancy: A practical guide for health professionals.  Wellington, NZ: Ministry of Health, Retrieved from http://www.moh.govt.nz 

Morton, S. M. B., Atatoa Carr, P. E., Bandara, D. K., Grant, C. C., Ivory, V. C., Kingi, T. R., . . . Waldie, K. E. (2010). Growing Up in New Zealand: A longitudinal study of New Zealand Children and their families. Report 1: Before we are born. Auckland: Growing Up in New Zealand Retrieved from http://www.growingup.co.nz/media/12254/growing%20up%20in%20new%20zealand%20before%20we%20are%20born%20nov%202010.pdf.

Niccols, A. (2007). Fetal alcohol syndrome and the developing socio-emotional brain. Brain and Cognition, 65(1), 135 – 142. 

Oullett-Morin, D. (2011). Pre-natal alcohol exposure and cortisol activity in 19 month old toddlers:An investigation of the moderating effects of sex and testosterone. Psychopharmacology, 214, 297-365. 

Riley, E. P., & McGee, C. L. (2005). Fetal Alcohol Spectrum Disorders: An overview with emphasis on change and behaviour. Experimental Biology and Medicine, 230, 357-365. 

Sellman, D., & Connor, J. (2009). In utero brain damage from alcohol: A preventable tragedy. The New Zealand Medical Journal, 122(1306), 6-8. 

Statistics New Zealand. (2015). Births and Deaths: Year Ended December 2015. Retrieved from http://www.stats.govt.nz/browse_for_stats/population/births/BirthsAndDeaths_HOTPYeDec15.aspx 

Streissguth, A. P., Barr, H. M., Kogan, J., & Bookstein, F. L. (1996). Understanding the Occurrence of Secondary Disabilities in Clients with Fetal Alcohol Syndrome (FAS) and Fetal Alcohol Effects (FAE). Seattle: University of Washington, Fetal Alcohol & Drug Unit.

Sullivan, W. C. (1899). A note on the influence of maternal inebriety on the offspring. Journal of Mental Science, 45, 489-503.

SuPERU. (2015). Patterns and dynamics of alcohol consumption during pregnancy in a recent New Zealand cohort of expectant mothers. Wellington, NZ: Social Policy Evaluation and Research Unit. Retrieved from http://www.superu.govt.nz/publication/research-report-patterns-and-dynamics-alcohol-consumption-during-pregnancy-recent-new 

Valenzuela, C. F., Morton, R. A., Diaz, M. R., & Topper, L. (2012). Does moderate drinking harm the fetal brain? Insights from animal models. Trends in Neurosciences, 35(5), 284-292. 

Williams, J. F., & Smith, V. C. (2015). Fetal alcohol spectrum disorders. Pediatrics, 136(5), e1395-e1406.