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Ronnie Falcao, LM MS, a homebirth midwife in Mountain View, CA

Long Reply to Long Piece on Fetal Alcohol Syndrome

This is very long, and the gist of it is that I don't believe anybody has produced any evidence on this list to support a recommendation against all alcohol intake by pregnant women.

My current recommendation to pregnant women regarding alcohol:

Regular use or periodic abuse of alcohol may cause serious developmental problems in the fetus. No minimum safe levels have been established. During the first four months of pregnancy, the fetus is especially vulnerable to miscarriage or birth defects, and I recommend avoiding alcohol altogether during this time. During the last five months of pregnancy, an occasional drink (a single drink no more than a couple of times per week) is probably fine. There is no evidence that this level of alcohol intake could cause any problems for your baby.

I think this recommendation states the facts reasonably and provides responsible guidelines.

With this recommendation in mind, I'll comment on the following:

Flagg [jaf56@columbia.edu] writes:

 

I am perplexed by the response to my post on alcohol use during pregnancy. My post stated that alcohol use during pregnancy is dangerous, can cause brain damage (to the child) and that pregnant women should refrain from using alcohol. Admittedly my post did have an emotional tone that stems from family experience with fetal alcohol syndrome. Since then I have been accused of spreading misinformation and had my credibility attacked by people who do not know me. I have also been told that I must site my sources including the exact passages, something that those responding to me failed to do. I do not wish to fight with those that responded to me. I have the utmost respect for them and their experience. However it is important that correct information is made available to the list. I am sending quotes from some of my sources followed by bibliographic sites in apa format. Please note that I am referring to the general use of alcohol during pregnancy. Not the use of alcohol in specific doctor or midwife recommended situations such as prodromal labor.

"Fetal alcohol syndrome is the most common preventable cause of birth defects in the United States...Fetal alcohol syndrome is the most common cause of mental retardation in the United States...Alcohol exposure during the first trimester leads to the most severe cases of fetal alcohol syndrome. Even moderate drinking can have harmful effects, ranging from fetal loss to intrauterine growth retardation...Small amounts of alcohol may cause neurologic abnormalities, even in the absence of growth retardation, dysmorphic features and congenital abnormalities. Thus it is important to counsel pregnant patients to follow the Surgeon General's warning to abstain from alcohol use during pregnancy."(Bratton, 1995)

"Complete abstinence during pregnancy is recommended, since alcohol consumption in each trimester has been associated with abnormalities, and the lowest innocuous dose of alcohol is not known...Fetal alcohol syndrome now surpasses Down syndrome and spina bifida as the leading cause of mental retardation in the United States today...All women should be warned not to drink during pregnancy."(Lewis, Woods, 1994)

"Alcohol interferes with normal pregnancy; the effects on the fetus are permanent; and even moderate use of alcohol during pregnancy may cause long-term postnatal difficulties...Since there is no known safe level of alcohol consumption in pregnancy, women who plan to become pregnant should stop consuming alcohol at least three months before they plan to conceive."(Wong, 1995)

Not only does this not offer anything other than opinion, but it also shows itself as grossly biased by making ludicrous recommendations.

 

"There is no established "safe dose" of alcohol for pregnant women...The consumption of at least one to two drinks a day was associated with a substantially increased risk of giving birth to a growth retarded baby...Since there is no known safe amount of alcohol consumption during pregnancy, the Academy recommends abstinence from alcohol for women who are pregnant or who are planning a pregnancy."(Committee on Substance Abuse, 1993)

"This study showed that moderate to heavy alcohol consumption during pregnancy, at levels well below those associated with fetal alcohol syndrome, has effects on children's psychomotor development...Interventions aimed at reducing alcohol consumption among pregnant women should not focus only on alcoholic mothers, because even lower levels of alcohol consumption can put the child at risk."(Larroque, et al., 1995)

"It is now recognized that alcohol consumed in pregnancy can damage the fetus, but the critical dose and time are still not known. Not only the regular drinkers, but also the woman who drinks infrequently with the occasional binge may put her fetus at risk at a very early stage. For this reason, women should be advised to reduce or discontinue alcohol consumption before and during pregnancy."(Bennett, Brown, 1990)

I hope this information is useful. I think you will find that it supports my statements.

Quite frankly, I worry about the formaldehyde in no-iron sheets, the pesticides and dyes in non-organic clothing, and the electromagnetic effects of irons, hair dryers and electric blankets. And is there anyone out there who wouldn't rather see pregnant women eating only organic vegetables instead of those laden with pesticides?

But until I have real facts that I can offer my clients, I'll avoid making strong recommendations about changing their lifestyle.

 

. . . This is by no means an exhaustive list of research on this subject. I encourage anyone to read the complete articles that I have sited. They are very interesting and go into much more depth that I can do here. In addition there is a significant amount of info about FAS/FAE on the web. If others have info that contradicts these sites I would be interested in seeing it, as this is a subject that I try to keep up to date on. For me the bottom line is this, unless you know exactly what the fetus is doing at the time that you take a drink, you have no way of knowing what the effect will be. Why play Russian roulette with your baby's life?

Any clinician dispensing this kind of advice is imposing their personal belief system on their clients and should be explicit that this is what they're doing.

Here are the sources I've found for information:

"Will It Hurt the Baby?" by Richard S. Abrams, M.D. says the usual stuff and concludes with: "We now know it is best to avoid all alcohol during pregnancy, particularly during the first trimester. On the other hand if you had a few drinks before you found out you were pregnant, don't despair. There's no evidence that a few drinks on a couple of occasions early in pregnancy will prove harmful to your baby."

I just have to laugh when I read this moralistic interpretation of facts. Basically, it says that it's OK to drink lightly as long as you don't know you're pregnant. If it can say this about early pregnancy, I feel quite comfortable with a similar recommendation for late pregnancy.

And I'm always suspicious about the phrase, "We now know". It really means, "We have no new data but are now interpreting old data to mean . . ."

Varney's simply reports that chronic alcoholism can cause problems, and "alcohol must be considered teratogenic when used to excess". It adds that alcohol close to the birth can interfere with the cardiorespiratory adaptation of the newborn, which is a serious consideration regarding the use of alcohol for prodromal labor.

Anne Frye is rarely accused of letting her emotions cloud her clinical judgment, so I was eager to see what she writes in _Holistic Midwifery_ (1995):

There's a lot of technical detail about alcohol metabolism, and she makes some interesting points that women who metabolize alcohol well might be able to consume large quantities of alcohol without endangering the fetus while others might reach toxic blood levels even after moderate alcohol intake. There are implications that the latter class of woman might be the kind of person who gets drunk on small amounts of alcohol. It makes sense to me that if you're feeling drunk, there might be enough alcohol in your blood to cause problems for the baby, although I still haven't seen even a preliminary proposal for the actual mechanism by which alcohol presents a problem to the fetus. (Maybe she's talking about women with systemic candida? She doesn't say so, but it makes sense to me.)

(She uses a definition of moderate as 1 to 45 drinks/monthly. This seems like a rather broad definition and would make me reconsider my recommendation except that she later writes that alcohol use in late pregnancy is primarily associated with reduced fetal growth, rather than structural damage. I might modify the recommendation for a woman showing any signs of an abnormally small baby.)

"Women should be informed of the risks of drinking alcohol during pregnancy. Risks seem to increase with the amount a woman drinks: babies have about a 10% risk of defects if their mother drinks more than 1 ounce (30 ml.) daily or five or more drinks at once, and a 20% risk if mothers drink more than 2 ounces (50 ml.) per day. Moderate drinking seems less likely to produce visible defects, but these babies still weigh an average of 3 ounces less than those of non-drinking mothers and other symptoms such as tremors and poor neurological response are more common. Lower arousal and slower learning characteristics have also been noted in babies of moderate drinkers. Some researchers believe that "bingeing" (infrequent but heavy drinking) may have as serious an impact as sustained drinking. Babies of mothers who drink small amounts may show even more subtle effects, but studies indicate that there is no apparent difference between these babies and those of women who do not drink at all. Nevertheless it should be emphasized that there is no known minimum amount of alcohol consumption that can be declared absolutely safe for all pregnant women. If a woman drinks occasionally prior to conception she need not be concerned, but she should avoid all alcohol during the pregnancy to minimize the potential effects on the baby. Women should also be told that stopping consumption at any point during pregnancy may have beneficial results for the fetus."

By the way, Frye makes similar recommendations for caffeine, tap water, and fluoride-containing dental hygiene products.

I'm a little disappointed in Anne. She quotes real research findings, but then makes conclusions not supported by those findings. Let's look again at this line:

"Babies of mothers who drink small amounts may show even more subtle effects, but studies indicate that there is no apparent difference between these babies and those of women who do not drink at all."

Gee, if studies indicate that there is no apparent difference, why would you mention the possibility of subtle effects? I guess they're so subtle as to be undetectable.

I was interested to find a slightly different reporting of the same study in _The Well Pregnancy Book_ by Mike Samuels, M.D., and Nancy Samuels. (1986)

Here, they reveal that the study that showed an average weight of 3 ounces less for babies born to moderate drinkers defined moderate drinking as 1 ounce (roughly 2 drinks) a day or 10 drinks a week. This is a far cry from 1 drink/month, and I'm very disappointed in Anne Frye that she omitted this important distinction.

"To date, studies have not shown any statistical differences between babies whose mothers drank under 1 ounce a day and babies whose mothers did not drink at all. But studies in this area are not yet definitive."

This book goes on to describe the high risks of spontaneous abortion from drinking even a single drink, or at least that's the way the study is presented. This is the Kline study, and the claim is that "the odds of spontaneous abortion went up 3 percent with each additional day that alcohol was consumed, beginning with as little as one drink. The odds of spontaneous abortion for a woman who drinks every day are 2.53 times greater than the odds are for a woman who neither drinks nor smokes."

I find the mathematics here a little questionable. 3 percent every day over the course of a 280-day pregnancy is 840% or 8 times greater, even without compounding. Is this statistic really just for the first trimester, an important fact that was omitted in the reporting?

The way this is presented, alcohol becomes the perfect recommendation for pregnant women at 38 weeks; it will help keep their babies from getting "too big", and it will prevent postdates.

Although _Holistic Midwifery_ was published in 1995, the only references she cites are a study from 1980, and the Samuels book, published in 1986. I read and reported on the Frye and Samuels books in reverse chronological order. It's interesting that although Anne Frye doesn't cite any more recent studies, she attempts to present a stronger argument against very moderate alcohol consumption by omitting some of the facts. Political correctness at work?

If there were more recent, compelling research, I would think Frye would mention it, as she has such a strong recommendation against all alcohol use in pregnancy.

Why do I get the feeling that the whole truth isn't being reported in these books?

_Guide to Effective Care in Pregnancy_ provides its usual level of unbiased reporting of current research:

"The damaging effects of excessive alcohol consumption in pregnancy are well know. They include fetal growth retardation; mental retardation and a dysmorphic syndrome with variable features (at high levels of consumption), and altered neonatal behaviour. Developmental abnormalities are associated only with regular consumption of at least 28.5 ml alcohol (two standard drinks) per day, although one case has been reported following a single massive exposure to alcohol in the early weeks of pregnancy."

"Campaigns to increase public awareness of the dangers of alcohol during pregnancy run the risk of arousing anxiety in some women already pregnant, partly because of the uncertainty about the safe lower limit for alcohol intake and also because of the possibility that the most dangerous time for dysmorphic effects may be the first trimester, sometimes even before women know that they may be pregnant. The very first weeks of pregnancy are often reported to be a period of high anxiety and depression that may increase drinking to relieve tension."

I'm having a little trouble understanding the relevance of this last remark. Is this meant to "excuse" drinking in early pregnancy? And I think it's right to arouse anxiety about something that we have facts about, e.g. that more than two drinks a day is probably not good for the baby, and perhaps she might want to consider alternatives, such as a warm bath, massage, meditation.

They do make a good point that it's stupid to increase anxiety levels (which is said to be harmful to the fetus) by dispensing inaccurate information about something which probably doesn't cause fetal harm.

"Policy development on alcohol and pregnancy requires, first of all, clarification as to the degree of risk around conception for low levels of regular alcohol consumption (fewer than two standard drinks a day) and for regular but infrequent "binge" drinking. No formal trials of interventions to reduce high levels of consumption in pregnancy have been reported, and it may be that better detection of heavy drinkers should be the priority."

In the Conclusions section: "With the implied promise that it will help her have a perfect birth, a perfect baby, and become a perfect mother, a pregnant woman is exhorted to lead a selfless healthy life, uncontaminated by sex, cigarettes, alcohol, employment, or anxiety. The evidence for most of these exhortations is slight. Where the evidence is stronger, the flaw has been in the way that research and prescription fail to take into account the real lives and responsibilities of women."

Now this makes sense to me. Yes, if I were growing a baby in a test tube, I probably would make a point of not adding alcohol to the environment, just as I would try to eliminate all other known toxins.

But the baby isn't growing in a test tube. The baby is being grown inside and by a real woman who has real emotions about her pregnancy and all the changes she's making in her life around the pregnancy. There may be women who rejoice in their avoidance of alcohol, caffeine, tap water, non-organic vegetables and laundry detergents because this is their way of celebrating their pregnancy. That's great for them.

But what about the woman who's had a life-long ritual of going out Friday night with the gang for pizza and beer. Is it right to tell her that she shouldn't enjoy the very real pleasure of a single beer because we have no proof positive that it's safe for her baby? Truth is, we have no proof positive that the pizza is safe for her baby. Tomatoes are a member of the deadly nightshade family, mushrooms are renowned for their toxicity and as a fungus might support the growth of systemic yeast with its alcohol byproduct, and pepperoni contains things too horrible to mention.

Remember those discussions we had recently about how first-trimester nausea might be a protection for the woman against foods that might be toxic to the fetus in its most vulnerable stage? The book under discussion was _Protecting Your Baby To Be_ by Marjie Profet, and the contention is that most vegetables contain toxins that cause the nausea. One of the examples given was that if a ewe eats skunk cabbage on the 21st day of gestation her lamb will have only one eye and that in the center of its forehead. Cruciferous vegetables are particular no-nos.

Somehow, we're just not seeing the same amount of zeal applied to the anti-cruciferous-vegetable movement as to the anti-alcohol movement. My suspicion is that most women don't have an abusive relationship with cruciferous vegetables, so it's not a big problem.

Yes, it's possible to abuse alcohol, and that can have devastating effects on the fetus. But abuse is not the same as very occasional use.

I'm still waiting for a citation for a study that claims to have real evidence that a single glass of wine on no more than two separate occasions a week during the last five months of pregnancy can cause any problems whatsoever for the fetus. If someone has such a study, please cite the study (give information that makes it possible to track it down, such as title, author, publication, date of publication) and quote the specific finding so I'll know it's worth going to the med. library for.

And I'm looking for scientific data here, such as "Women drinking even just a single glass of wine on two separate occasions per week in the last half of pregnancy were shown to have a greater incidence of X." Ideally, there would be some implication of causality rather than mere association. For example, above could probably be stated for smoking, but I do not believe that drinking causes smoking.

For those who really believe that any alcohol exposure whatsoever is harmful to a pregnant woman at any stage of her pregnancy, what do you think of the following:

Recommendation that pregnant women avoid skin contact with rubbing alcohol.

Recommendation that pregnant women avoid air-borne exposure to alcohol molecules, as happens in social situations where others are drinking or in restaurants where alcohol is used in cooking. (Do you suggest denying entrance to pregnant women or banning use of alcohol in public places?)

Recommendation that pregnant women follow a strict anti-yeast diet, as candida albicans in the digestive tract is implicated in the internal production of alcohol. (Anti-yeast diet avoids yeast foods (breads, cheese), wheat/gluten, fruit, any high-sugar or high-carbohydrate food, milk products).

After all, even though there is no proof that rubbing alcohol, wine in the air, or eating cheese will cause fetal damage, we don't want women playing Russian Roulette with their babies, do we?

Researchers have determined that even SMALL amounts of alcohol can be detrimental to child development.

Do they cite studies for this?  I've done quite a bit of searching for real studies, and even the "experts" who are strongly opposed to all alcohol consumption don't have anything conclusive about moderate drinking, and certainly not about light drinking, even a daily glass of wine throughout pregnancy.  Anne Frye is usually pretty good about citing research, and she had nothing to contribute to my search.

I practice evidence-based midwifery, so I won't lie to my clients about imaginary risks.  Here's an off-the-cuff list of things that I consider more harmful to the baby than a daily glass of wine:

Any ultrasound exposure, including a Doppler

Sitting daily in front of a computer - this isn't going to be a popular pronouncement with this crowd, obviously, but I challenge anyone out there to produce any research showing that it is safer to sit in front of a computer for an hour every day than it is to drink a glass of wine daily.

Frequent driving and consequent exposure to air pollution

Airplane travel

Travel to high-altitudes

Use of noxious chemicals in the house, including household bleach and mainstream cleaning solutions.

Paints, wallpapers and new carpets installed in anticipation of baby's arrival

Regular drinking of tap water

Pumping your own gas

Non-organic produce

So, if you're going to criticize a pregnant woman for occasionally enjoying a glass of wine, I don't dare think what you'd say to the average woman who probably does at least half of the "high risk" activities listed.

Oh, by the way, did you all know that most herbal tinctures are mostly brandy?

Pregnancy is hard enough without   having other people impose moral standards based on   imaginary risks

P.S.  Yes, Fetal Alcohol Syndrome is a serious problem, but spreading misinformation about it isn't going to help anyone.  The pregnant women who are getting drunk aren't doing so because they're ignorant about the risks - they're doing so because they're alcoholics.  If you're seriously concerned about Fetal Alcohol Syndrome, become an activist and make sure that your community has adequate social services to provide help for pregnant alcoholics who want help.  Last I heard, rehab centers for pregnant alcoholics were routinely having to turn people away for lack of resources.

P.P.S.  The Big Clue I got that light to moderate alcohol consumption during pregnancy is a moral rather than a medical issue was reading, "We now know it is best to avoid all alcohol during pregnancy, particularly during the first trimester.  On the other hand, if you had a few drinks before you found out you were pregnant, don't despair.  There's no evidence that a few drinks on a couple of occasions early in pregnancy will prove harmful to your baby." [from "Will It Hurt the Baby" by Richard S. Abrams, M.D.]