Clinical Review


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Prevention of fetal alcohol syndrome requires routine screening of all women of reproductive age



The author reports no financial relationships relevant to this article.

Investigations of maternal alcohol consumption have consistently produced the same finding: Even a low level of alcohol—especially in the first trimester—has a harmful effect on fetal development. The American College of Obstetricians and Gynecologists (ACOG), American Academy of Pediatricians, and the US Surgeon General now support the tenet that no lower limit of alcohol consumption is safe during pregnancy.

Although a specific fetal alcohol syndrome (FAS) was not identified until 1968, the adverse effects of alcohol during pregnancy have been observed for centuries. FAS is the most severe manifestation of maternal alcohol consumption and is estimated to affect 0.2 to 1.5 of every 1,000 births. The term refers to a “constellation of physical abnormalities” and “problems of behavior and cognition in children born to mothers who drank heavily during pregnancy.”1 The syndrome is also “completely preventable.”1

The US Surgeon General recommends that health professionals:

  • routinely inquire about alcohol consumption in women of childbearing age
  • inform them of the risks of alcohol consumption during pregnancy
  • advise them not to drink during pregnancy.2

New drinking pattern emerges

Of special concern is binge drinking, initially defined as the consumption of five or more drinks during one session, even among women who do not chronically consume alcohol. Like lower levels of alcohol consumption during pregnancy, binge drinking increases the risk of developmental and growth delays in the child. The higher peak levels of alcohol associated with binge drinking appear particularly deleterious to fetal neurodevelopment. And because a woman may engage in binge drinking before she is aware that she is pregnant, the issue merits particular attention.

Hallmarks of FAS

FAS causes facial dysmorphia, including short palpebral fissures, flattened midfacies, epicanthal folds, and micrognathia. Defects of the central nervous system and cardiac, renal, and skeletal systems also can occur, along with prenatal and postnatal growth delay. In addition, developmental delay is present.

FAS can be present even if history of alcohol exposure is uncertain

In 1996, the Institute of Medicine broadened the classification of FAS to include:

  • Category 1 – FAS with a confirmed history of maternal alcohol exposure
  • Category 2 – FAS with no confirmed history of maternal alcohol exposure
  • Category 3 – partial FAS with a history of maternal alcohol exposure
  • Category 4 – alcohol-related birth defects (physical anomalies only)
  • Category 5 – alcohol-related neurodevelopmental disorders.1
The last two categories were included to describe defects or disorders that have been linked to maternal alcohol consumption in clinical or animal research but may have additional causative factors in a particular case.

Alcohol exposure linked to a spectrum of effects

In 2005, the term “fetal alcohol spectrum disorder” (FASD) entered the lexicon. FASD is not intended to be used as a clinical diagnosis but to describe a spectrum of conditions that may result from prenatal alcohol exposure.

The prevalence of FASD is uncertain, although alcohol-related neurobehavioral abnormalities that affect learning and behavior may occur in three additional children for every one child who is given a diagnosis of classic FAS.

In this Update, I highlight recent studies or publications that:

  • describe drinking patterns among women of reproductive age
  • offer screening strategies or
  • suggest a framework for counseling the patient to reduce or eliminate alcohol consumption.

Which women are most likely to drink during pregnancy?

Tsai J, Floyd RL, Green PP, Bouyle CA. Patterns and average volume of alcohol use among women of childbearing age. Matern Child Health J. 2007;11:437–445.

Tsai J, Floyd RL, Bertrand J. Tracking binge drinking among childbearing-age women. Prev Med. 2007; 44:298–302.

Caetano R, Ramisetty-Mikler S, Floyd L, McGrath C. The epidemiology of drinking among women of childbearing age. Alcohol Clin Exp Res. 2006;30:1023–1030.

Studies that led to the phenotypic description of FASD focused on women who had recognized alcohol dependency and who drank heavily. Additional research has identified another subset of women who are likely to continue alcohol consumption during pregnancy: binge drinkers. Many women who report binge drinking do not consider their alcohol consumption to be chronic or excessive.

Binge drinking is on the rise among women of childbearing age…

Binge drinking has increased steadily over the past 10 years despite public health initiatives and other programs developed to educate consumers. Tsai and colleagues used data from the Centers for Disease Control and Prevention (CDC) Behavior Risk Factor Surveillance System from 2001 to 2003 to calculate the magnitude of alcohol consumption among women of childbearing age. The rate of binge drinking increased from 10.3% to 13% between 1991 and 2003. In 2003, the highest prevalence of binge drinking was observed in the 18- to 24-year-old age group (20.5%), and among non-Hispanic white (15.5%), employed (14%), college-educated (13.3%), and unmarried women (18.7%). The highest number of binge sessions in the preceding month followed the same pattern.


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