To the Editor: O’Leary and colleagues1 rightly point to the need for better evidence on whether low to moderate maternal alcohol intake affects the fetus. Evidence to date is weak and inconsistent, largely because alcohol consumption in pregnancy is generally poorly documented,2 and few studies have recorded data on factors that could potentially modify fetal exposure. Evidence could come from large pregnancy cohort studies, usually designed to address other issues, but there are no published guidelines on how to collect information relevant to fetal alcohol exposure during gestation. There is, therefore, a great need to define a core dataset for research studies, as well as one that is sufficiently simple to use in routine pregnancy care settings.

We have identified a number of issues that need to be addressed. To stimulate discussion, the Box shows our suggested core dataset.

Maternal alcohol intake: Alcohol questionnaires have largely been designed to identify women who are heavy drinkers, misuse alcohol or are alcohol-dependent.3 Questionnaires are needed that capture information on alcohol intake across the range, from minimal to heavy drinking, as well as information on drinking patterns and alcohol intake at different periods of gestation.

Factors that may modify the relationship between maternal intake and fetal alcohol exposure: For a given maternal intake over a given period, maternal blood alcohol level and hence fetal alcohol exposure may vary according to maternal size and body composition. Other factors can affect maternal alcohol absorption and elimination, such as whether alcohol is taken with food,4 and possibly maternal genotype.5 This information is rarely reported in pregnancy studies.

Factors that may modify effects of alcohol on the fetus: There is animal evidence that maternal micronutrient supplementation may protect the fetus against some of the adverse effects of gestational alcohol exposure.6 We need to consider recording supplement use and measures of maternal nutritional intake or status. In well resourced studies, fetal genotype could also be considered.6

Researchers with expertise in the field need to reach consensus and provide guidelines on the best way to assess fetal alcohol exposure, so that pregnancy researchers and clinicians with little experience of alcohol research do not need to create their own. Better data should provide better evidence on which to base advice to women who are (or may be) pregnant. Good studies may also provide explanations for the apparently variable link between maternal alcohol consumption and adverse sequelae in the offspring.

To the Editor: I would like to put forward a consumer’s perspective in response to the recent article by O’Leary and colleagues.1

I am puzzled that they concluded that the National Health and Medical Research Council (NHMRC) guideline is in step with policies of the United Kingdom and Canada. My research of Canadian policy suggests that it is in direct contrast to current NHMRC guidelines. Health Canada states very clearly, “Whether you are trying to get pregnant or are pregnant already, stop drinking alcohol”,2 and “No amount or type of alcohol during pregnancy is considered safe”.3,4

The potential harm to the birth mother that results from an abstinence-based message was also raised by O’Leary and colleagues. Elizabeth Russell, the birth mother of two sons affected by prenatal exposure to alcohol, offers an alternative viewpoint:

Many pregnant women give up eating shellfish and processed meats and drinking coffee but still continue to consume alcohol, thinking it is safe because they have not been told otherwise. I would like to pose the following questions.

What is the potential harm of not having an abstinence message? Might this prevent women who are alcohol-dependent from seeking help to alter their drinking behaviour when pregnant because they are not aware of the risks?

Should further research to “elucidate the true association between low to moderate alcohol consumption and fetal harm” really be a priority? What are the benefits to the unborn child of trying to ascertain a safe level of consumption of a teratogen and neurotoxin that is known to disrupt fetal development, particularly the fetal brain, throughout the three trimesters of pregnancy?6

While I acknowledge the importance of scientifically sound research on the risks of prenatal exposure to alcohol, I am concerned that this argument is diverting attention and dollars away from the urgent need for diagnosis and management of fetal alcohol spectrum disorder (FASD) in Australia.

The reality is that children, adolescents and adults with FASD are seldom recognised, seldom treated effectively, and seldom connected to service dollars. Addressing this situation needs to be the priority.

In reply: Morley and colleagues and Miers raise a number of interesting discussion points. As we reported in our policy review, the Canadian, United Kingdom and Australian guidelines have similar intent but differ in emphasis.1 Health Canada’s policy position is that, although abstinence is the prudent choice, fetal risk is relative to the amount of alcohol consumed and is minimal with low levels of maternal alcohol intake. Australian policy addresses the same issues, with less emphasis on abstinence and more on avoiding intoxication and ensuring low-level alcohol consumption. Since our review was published, UK guidelines have been reframed to emphasise abstinence, but their message has not changed — they now place more weight on avoiding alcohol during pregnancy.2

We strongly agree with Morley and colleagues that screening for alcohol should be routine in all pregnant women, and that standardised items should be included in a core dataset.3 If this were implemented, Australia would be in a unique position to make a valuable contribution to alcohol and pregnancy research.

Miers comments that research into the impact of low to moderate alcohol exposure during pregnancy should not be a priority, because it may direct “attention and dollars away from the urgent need for diagnosis and management of fetal alcohol spectrum disorder”. Although we agree that specialised clinical services are important — and lacking — in Australia, it is short-sighted to suggest that there is no need for further research to establish the true risks from low to moderate alcohol consumption. Rates of alcohol consumption in Australia are high: about 80% of women report alcohol consumption in the 3 months before pregnancy, 14% report binge drinking, while 47% report that pregnancy was unplanned.4 Many fetuses may thus be exposed to alcohol before women are aware they are pregnant. Unfortunately, many women are unable to stop drinking and may expose their babies to high alcohol levels. Health professionals need to have a true estimate of risk to the fetus and know what additional factors (eg, genetics and nutrition) may alter risk, and women deserve to be well informed. The need for research is well articulated by Morley et al.

Research evidence in humans does not clearly indicate a risk to the fetus from low levels of alcohol consumption, and this has led to inconsistent policy.5,6 As we point out, the potential for harm from an abstinence message should be considered when Australian alcohol guidelines are reframed. Whatever the policy, it needs to be widely disseminated, in a “digestible” format, to health professionals and the community. Research being conducted at the Telethon Institute for Child Health Research is evaluating educational materials for health professionals about alcohol and pregnancy.