Drinking-While-Pregnant Debate: No Clear Answers

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There is renewed focus on the topic of drinking alcohol during pregnancy, or so it seems. Only last week, we here at the American Council addressed a new point-counterpoint discussion in BMJ entitled "Should women abstain from alcohol throughout pregnancy?"

Our position, written by Nicholas Staropoli, can be summed up with this thought: "[W]here prenatal consumption of alcohol clearly provides no benefit to the fetus, then why introduce the risk?"

Now we are learning that joining the abstinence-only approach to drinking while pregnant is the august American Academy of Pediatrics, which has endorsed that position in a report recently published in their journal Pediatrics.

Under the title "Fetal Alcohol Spectrum Disorders," written by Janet F. Williams, MD, FAAP, Vincent C. Smith, MD, MPH, FAAP for their Committee on Substance Abuse, they concluded that a large and growing body of research has led to evidence-based fetal-alcohol spectrum disorders (FASD). They recommended treatment approaches based on the following premises:

  • Alcohol-related birth defects and developmental disabilities are completely preventable when pregnant women abstain from alcohol use

  • Neurocognitive and behavioral problems resulting from prenatal alcohol exposure are lifelong

  • Early recognition, diagnosis, and therapy for any condition along the FASD continuum can result in improved outcomes

  • 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 risk; and

    ¦binge drinking poses dose-related risk to the developing fetus

The premise of the argument in favor of promoting abstinence put forward in the BMJ article -- and which forms the basis of public health guidelines advising abstinence -- is that there is no evidence for a safe threshold of consumption. While this is true, such reasoning epitomizes the precautionary principle, or "better safe than sorry" in the face of less-than-100% known risks, and in essence forbids expectant women from enjoying an occasional drink.

As the article points out, the guidances available on drinking alcohol during pregnancy are at best confusing, at worst contradictory. It is, and forever will be, impossible to examine the risk of alcohol consumption, as one would document adverse reactions in drug trials, since it can never be ethically possible to design a randomized controlled trial to test the effect of alcohol in pregnancy in a human model.

In turn, however, there is also no evidence for an unsafe threshold of consumption, and this, too, should be acknowledged.

In fact, it is practically impossible to prove that anything is "safe," since under some conditions nothing is actually always safe. Therefore, without acknowledging that little evidence exists linking low-level prenatal alcohol exposure with actual harms, such messages are likely to be met with skepticism. Threat-based messages based upon scanty evidence frame the problem of alcohol use in pregnancy in a paternalistic manner. Moreover, most (if not all) of the FASD alarmism derives from interpolation of data from binge-drinking, fetal-alcohol provoking excesses of intake.

Maintaining a clear stance in advising abstinence from alcohol during pregnancy as the safest option, in order to reduce the risk of FASD, is one approach to this issue and it can be defended.

While it may be true that complete abstinence is easier than perfect moderation, we should remember the manifold benefits of small amounts of alcohol, especially for heart health. So I'd advise that, as far as infrequent gestational tippling is concerned, let's not throw out the fetus with the bathwater.