Alcohol and drugs

• Stay away from alcohol, cigarettes and drugs during pregnancy.
• These substances can seriously harm you and your baby.
• Talk to your health provider and seek help to quit.

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Drinking alcohol during pregnancy can cause a wide range of physical and mental birth defects. The term “fetal alcohol spectrum disorders” (FASDs) is used to describe the many problems associated with exposure to alcohol before birth. Each year in the United States, up to 40,000 babies are born with FASDs (1).

Although many women are aware that heavy drinking during pregnancy can cause birth defects, many do not realize that moderate or even light drinking also may harm the fetus. In fact, no level of alcohol use during pregnancy has been proven safe. Therefore, the March of Dimes recommends that pregnant women do not drink any alcohol, including beer, wine, wine coolers and liquor, throughout their pregnancy and while nursing. In addition, because women often do not know they are pregnant for a few months, women who may be pregnant or those who are attempting to become pregnant should not drink alcohol.

Recent government surveys indicate that about 1 in 12 pregnant women drink during pregnancy (2). About 1 in 30 pregnant women report binge drinking (five or more drinks on any one occasion) (2). Women who binge drink or drink heavily greatly increase the risk of alcohol-related damage to their babies.

When a pregnant woman drinks, alcohol passes through the placenta to her fetus. In the fetus’s immature body, alcohol is broken down much more slowly than in an adult's body. As a result, the alcohol level of the baby's blood can be higher and remain elevated longer than the level in the mother's blood. This sometimes causes the baby to suffer lifelong damage.

What are the hazards of drinking alcohol during pregnancy?
Drinking alcohol during pregnancy can cause FASDs, with effects that range from mild to severe. These effects include intellectual disabilities; learning, emotional and behavioral problems; and defects involving the heart, face and other organs. The most severe of these effects is fetal alcohol syndrome (FAS), a combination of physical and mental birth defects.

Drinking alcohol during pregnancy increases the risk for miscarriage and premature birth (before 37 completed weeks of pregnancy) (3, 4). Studies also suggest that drinking during pregnancy may contribute to stillbirth. A 2008 Danish study found that women who binge drink three or more times during the first 16 weeks of pregnancy had a 56 percent greater risk for stillbirth than women who did not binge drink (3). Another 2008 study found that women who had five or more drinks a week were 70 percent more likely to have a stillborn baby than non-drinking women (5).

What is fetal alcohol syndrome (FAS)?
FAS is one of the most common known causes of intellectual disabilities. It is the only cause that is entirely preventable. Studies by the Centers for Disease Control and Prevention (CDC) suggest that between 1,000 and 6,000 babies in the United States are born yearly with FAS (6).

Babies with FAS are abnormally small at birth and usually do not catch up on growth as they get older. They have characteristic facial features, including small eyes, a thin upper lip and smooth skin in place of the normal groove between the nose and upper lip. Their organs, especially the heart, may not form properly. Many babies with FAS also have a brain that is small and abnormally formed. Most have some degree of intellectual disability. Many have poor coordination, a short attention span and emotional and behavioral problems.

The effects of FAS and other FASDs last a lifetime. Even if not with intellectual disabilities, adolescents and adults with FAS and other FASDs are at risk for psychological and behavioral problems and criminal behavior (2). They often find it difficult to keep a job and live independently (2, 6).

What are other FASDs?
The CDC estimates that about three times the number of babies born with FAS are born with some, but not all, of the features of FAS (2). These FASDs are referred to as alcohol-related birth defects (ARBDs) and alcohol-related neurodevelopmental disorders (ARNDs).

• The term ARBDs describes physical birth defects that can occur in many organ systems, including the heart, liver, kidneys, eyes, ears and bones.
• The term ARNDs describes learning and behavioral problems associated with prenatal exposure to alcohol. These problems can include learning disabilities; difficulties with attention, memory and problem solving; speech and language delays; hyperactivity; psychological disorders and poor school performance.

Children with ARBDs and ARNDs do not have the characteristic facial features associated with FAS (1).

In general, ARBDs are more likely to result from drinking alcohol during the first trimester, when organs are forming rapidly. Drinking at any stage of pregnancy can affect the brain, resulting in ARNDs, and can also affect growth.

An older term called fetal alcohol effects (FAEs) is sometimes used to describe alcohol-related damage that is less severe than FAS. The more specific diagnostic categories of ARBDs and ARNDs are now more frequently used.

How much alcohol is too much during pregnancy?
No level of drinking alcohol has been proven safe during pregnancy. According to the U.S. Surgeon General, the patterns of drinking that place a baby at greatest risk for FASDs are binge drinking and drinking seven or more drinks per week (7). However, FASDs can occur in babies of women who drink less.

Researchers are taking a closer look at the more subtle effects of moderate and light drinking during pregnancy.

• A 2002 study found that 14-year-old children whose mothers drank as little as one drink a week were significantly shorter and leaner and had a smaller head circumference (a possible indicator of brain size) than children of women who did not drink at all (8).
• A 2001 study found that 6- and 7-year-old children of mothers who had as little as one drink a week during pregnancy were more likely than children of non-drinkers to have behavior problems, such as aggressive and delinquent behaviors. These researchers found that children whose mothers drank any alcohol during pregnancy were more than three times as likely as unexposed children to demonstrate delinquent behaviors (9).
• A 2007 study suggested that female children of women who drank less than one drink a week were more likely to have behavioral and emotional problems at 4 and 8 years of age. The study also suggested similar effects in boys, but at higher levels of drinking (10).
• Other studies report behavioral and learning problems in children exposed to moderate drinking during pregnancy, including attention and memory problems, hyperactivity, impulsivity, poor social and communication skills, psychiatric problems (including mood disorders) and alcohol and drug use (2).

Is there a cure for FASDs?
There is no cure for FASDs. However, a 2004 study found that early diagnosis (before 6 years of age) and being raised in a stable, nurturing environment can improve the long-term outlook for individuals with FASDs (11). Children who experienced these protective factors during their school years were two to four times more likely to avoid serious behavioral problems resulting in trouble with the law or confinement in a psychiatric institution.

If a pregnant woman has one or two drinks before she realizes she is pregnant, can it harm the baby?
It is unlikely that the occasional drink a woman takes before she realizes she is pregnant will harm her baby. The baby’s brain and other organs begin developing around the third week of pregnancy, however, and are vulnerable to damage in these early weeks. Because no amount of alcohol has been proven safe during pregnancy, a woman should stop drinking immediately if she even suspects she could be pregnant, and she should not drink alcohol if she is trying to become pregnant.

Is it safe to drink alcohol while breastfeeding?
Small amounts of alcohol do get into breast milk and are passed on to the baby. One study found that breastfed babies of women who had one or more drinks a day were a little slower in acquiring motor skills (such as crawling and walking) than babies who had not been exposed to alcohol (12). Large amounts of alcohol may interfere with ejection of milk from the breast.

For these reasons, the March of Dimes recommends that women not drink alcohol while they are breastfeeding. Similarly, the American Academy of Pediatrics (AAP) recommends that breastfeeding mothers not drink alcohol (13). However, according to the AAP, an occasional alcoholic drink probably doesn’t hurt the baby, but a mother who has a drink should wait at least 2 hours before breastfeeding her baby (13).

Can heavy drinking by the father contribute to FASDs?
There is no proof that heavy drinking by the father can cause FASDs. But men can help their partner avoid alcohol by not drinking during their partner’s pregnancy.

What is the March of Dimes doing to prevent and treat FASDs?
March of Dimes-supported researchers are investigating the influence of alcohol on pregnancy.

• One grantee is seeking to identify genes that may play a role in causing FAS in order to identify women who are at high risk of having an affected baby if they continue to drink. This could make it possible to provide counseling that may help prevent FAS in their offspring.
• Another is seeking to determine the mechanism by which alcohol causes birth defects. This could lead to treatments to reverse or prevent further alcohol-related damage in pregnant women who drank alcohol before they knew they were pregnant or those who do not stop drinking.

The March of Dimes also works to prevent FASDs by educating the general public, teenagers, adults of childbearing age and expectant mothers about the dangers of alcohol and other drugs to their unborn children.

Because there currently is no way to predict which babies will be damaged by alcohol, the safest course is not to drink alcohol at all during pregnancy and to avoid heavy drinking during childbearing years (because about 50 percent of pregnancies are unplanned). All women who are considering becoming pregnant should stop drinking alcohol. Heavy drinkers should avoid pregnancy until they believe they can abstain from alcohol throughout pregnancy.

Where can a woman get help to stop drinking alcohol?
Some women find it difficult to stop drinking. These organizations can help:

• National Council on Alcoholism and Drug Dependence (NCADD), (800) NCA-CALL (622-2255)
• Substance Abuse Treatment Facility Locator, (800) 622-HELP (4357)

Resources

• The Fetal Alcohol Spectrum Disorders (FASD) Center for Excellence, (866) 786-7327
• FASD Support Site
• Fetal Alcohol Spectrum Disorders, U.S. Centers for Disease Control and Prevention

References

1. Substance Abuse and Mental Health Services Administration, U.S. Department of Health and Human Services. Fetal Alcohol Spectrum Disorders. 2007.
2. Centers for Disease Control and Prevention (CDC). Fetal Alcohol Spectrum Disorders. Updated 5/2/06.
3. Strandberg-Larsen, K., et al. Binge Drinking in Pregnancy and Risk of Fetal Death. Obstetrics and Gynecology, volume 111, number 3, March 2008, pages 602-609.
4. Sokol, R.J., et al. Extreme Prematurity: An Alcohol-Related Birth Defect. Alcoholism Clinical and Experimental Research, volume 31, number 6, June 2007, pages 1031-1037.
5. Aliyu, M.H., et al. Alcohol Consumption During Pregnancy and the Risk of Early Stillbirth among Singletons. Alcohol, volume 42, August 2008, pages 369-374.
6. Bertrand, J., et al., National Task Force on FAS/FAE. Fetal Alcohol Syndrome: Guidelines for Referral and Diagnosis. Atlanta, GA: Centers for Disease Control and Prevention, July 2004.
7. Surgeon General. Surgeon General’s Advisory on Alcohol Use in Pregnancy. February 21, 2005.
8. Day, N.L., et al. Prenatal Alcohol Exposure Predicts Continued Deficits in Offspring Size at 14 Years of Age. Alcoholism Clinical and Experimental Research, volume 26, number 10, 2002, pages 1584-1591.
9. Sood, B., et al. Prenatal Alcohol Exposure and Childhood Behavior at Age 6 to 7. Pediatrics, volume 108, number 2, August 2001, page e34.
10. Sayal, K., et al. Prenatal Alcohol Exposure and Gender Differences in Childhood Mental Health Problems: A Longitudinal Population-Based Study. Pediatrics, volume 119, number 2, February 2007, pages e426-434.
11. Streissguth, A.P., et al. Risk Factors for Adverse Life Outcomes in Fetal Alcohol Syndrome and Fetal Alcohol Effects. J Dev Behav Pediatr, volume 25, number 4, August 2004, pages 228-238.
12. Little, R.E., et al. Maternal Alcohol Use During Breast-Feeding and Infant Mental and Motor Development at One Year. New England Journal of Medicine, volume 321, number 7, August 17, 1989, pages 425-430.
13. American Academy of Pediatrics (AAP). AAP Policy Statement: Breastfeeding and the Use of Human Milk. Pediatrics, volume 115, number 2, February 2005, pages 496-506. 
    

November 2008