Engs, Ruth C. [Ed.], Controversies in the Addiction's Field Ernest Abel and Robert Sokol. "CHAPTER 19: Is occasional light drinking during pregnancy harmful?"

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CHAPTER 19
Is Occasional Light Drinking During Pregnancy Harmful?

Ernest L. Abel Ph.D. Robert J. Sokol, M.D.

Introduction and Background

In the last two decades more than 5,000 articles have been published on the effects of alcohol during pregnancy (Abel, 1984b; 1989). One might assume we'd now have some consensus about the dangers of occasional light drinking during pregnancy. Unfortunately, this isn't so. Our own sober (no pun intended) conclusion, based on a critical evaluation of the literature, is that there are no known clinically important risks to the fetus from an occasional drink during pregnancy (see below for our definition of "occasional" and "light"). Here are our reasons:

1. Personal Experience

About two-thirds of allAmericans drink to some extent (Malin et al., 1982). Our mothers and your mothers are probably among these 66%. One of us is a Dean of a Medical School (R.J.S.); the other is a Professor in Obstetrics and Gynecology (E.L.A.). While we are both very hairless on top and somewhat funny-looking, we are both of normal size and stature, are both slightly pudgy, do not suffer from any visible birth defects, and though you may disagree with us, (for what we are arguing), we think we are of normal intelligence.

In other words, we don't look or act as if we have suffered as a result of our mothers' having had a drink or two during their pregnancies. We have also peered carefully at the minds and bodies of our children. While it's too soon to know for sure, none of them seems to be any more funny looking than we are, none of them seems to have suffered any loss of IQ points from the occasional drinks our spouses may have taken, and our food bills reflect their overwhelming commitment to eating.

Now it's your turn reader—do you or any of your children seem to have suffered as a result of an occasional motherly drink? Do you personally know of anyone that has?

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2. Historical Evidence

When this country was on its way to nationhood, drinking was the norm. Our founding fathers and mothers drank far more than we do today. George Washington was a whiskey distiller, John Adams drank a tankard of hard cider every morning, Thomas Jefferson invented the presidential cocktail party (Rorabaugh, 1979). Historical information about drinking by women is hard to come by, but in the early 1800s there were an estimated "1OO,000 female drinkers" and many more "who consumed from one-eighth to one-quarter of the nation's spirituous liquor" (Rorabaugh, 1979). We may be mistaken (because of the adverse effects of our own in-utero alcohol exposure), but we don't believe that the people who wrote our Constitution, Declaration of Independence, our Bill of Rights end the other laws by which we live, lost any IQ points by being exposed to more alcohol in-utero than we ourselves were. (In raising this argument, we are more than aware of Dr. Johnson's precept concerning patriotism being the last refuge of the scoundrel).

3. Lies, Damn Lies, and Statistics

A) Lies. There is no practical objective way of knowing how much anyone drinks. We as researchers are therefore forced to rely on what people admit to when they are asked how many drinks they have a day, a week, a month, or something like this. But, how much is in a "drink?" We assume one drink is the same as another and each contains about 1/2 oz of alcohol. This just shows how naive we are. A bartender may use a "shot" glass but who else does? The amount of beverage actually consumed in a drink can very from one to twelve ounces (Weineret al., 1983). If you pour most of your pint into a tan glass and I just pour a finger into mine, we'll both say we've had only one drink. If you were asking questions about income you wouldn't ask "how many times do you get paid a month?", would you? You'd want to know not only how often but how much someone gets paid. This would tell you a lot provided a dollar has the same value for everyone. But suppose you had Canadians and Americans in your study. Both might say they make $250 a week, but these dollars have different values in terms of what they win buy. Or suppose you asked Israelis and Britons how much they make. If both say they make 250 "pounds", do they make the same? 'Nuff said. You get the point.

B) Damned Lies.

Simply asking someone who drinks a lot about how much he/she drinks is naive. People who drink a lot don't like to admit it. They deny. Technically speaking, they lie. Sometimes they lie a lot. Trust a used car salesman before you trust what an alcoholic tells you about his or her drinking.

Self-reports of drinking during pregnancy are always suspect. Relating the dangers of a given number of "drinks" per day to a particular risk to the fetus based on this information is sophomoric. Because of denial, actual alcohol intake is underreported by the abusive drinker—the individual most likely to be at risk for giving birth to a child with alcoholrelated birth defects (Emhardt et al., 1988; Jacobson et al., 1989; Martier et al., 1989). The risk to the fetus of what might appear to be "2 drinks a day" is undoubtedly the result of much higher intake.

C) Statistics.

Alcohol is but one of many possible risk factors, such as social class, maternal illness, genetic susceptibility, smoking, diet, past health history, pregnancy complications, use of drugs and exposure to environmental pollutants. In epidemiology, statistical techniques are used to try to "even out" as many of these cofactors as possible. The goal is to match people as closely as possible except for their alcohol use. If you are going to do this carefully, you especially need to control for heredity. Charles Dickens made this point cogently in Pickwick Papers when he wrote about a meeting of "The Brick Lane Branch of the United Grand Junction Temperance Association." One of the new members was "Betsy Martin, widow, one child and one eye. Goes out charring and washing by day; never had more than one eye, but knows her mother drank bottled stout, and shouldn't wonder if that caused it."

ConsiderIQ scores. If you are studying the causes of subnommal IQ, isn't it reasonable to start with parental IQ? Claire Ernhardt and her coworkers (1981) did this when they examined the effects of lead in children. They found lead was associated with decreased scores on cognitive and verbal tests but when parental IQ was incorporated into the analysis, the relationship was no longer significant. No studies in fetal alcohol research have bothered to include parental IQ as a factor. In a recent study, Ann Streissguth and her coworkers (1989) used parental education as asurrogate forIQ, the assumption being the more years in school, the higher the IQ. She then matched subjects on parental school years. Black children were included in the test but race could not be considered in the regression analysis because of the "relatively small number" of black children. If these were so few, why were they included at all? This point would be totally academic except for the fact that the only 2 children with fetal alcohol syndrome in the original Seattle study were both bom to the same women who was black! (Hansonet al., 1978). Blackrace has also been found to be a major factorin susceptibility to prenatal alcohol effects (Sokol et al., 1986), and Streissguthet al. (1989) state in their conclusions that "the important covariates have been taken into account before claiming a teratogenic effect" when in fact, the covariate for race was not.

For subjects who are mentally retarded using parental school education might be reasonable. But the Streissguth et al. study dealt with trivial differences in IQ scores of 4- year-old children—less than 5 points. If you or I stay up too late at night, our I.Q.s would probably slip by more than 5 points? If you want to control for parental IQ—measure parental IQ.

What's In A Name?

Not only do we as researchers have to worry about obtaining reliable drinking histories, we need to agree on definitions or criteria for "moderate", "social", "light" and "occasional" drinking. But we still have no consensus in terminology. "Moderate" or "social" drinking in one study can include women who are "heavy" drinkers in another. Even the same research group may use these terms inconsistently. For example, Streissguth and her coworkers defined 4 drinks per day as "social" drinking in one study (Streissguth et al., 1980), 2 drinks a day as "heavy" drinking in another (Martin et al., 1977) and "nevermore than 3-4", as "social" in yet another (Landesman-Dwyer et al., 1978).

Unrealistic labels have also been used by researchers describing observations in animals. For example, Clarren and Bowden (1982) described the amount of alcohol producing a blood alcohol level of 200-300 mg% in non-human primates as "moderate." Similarly, in their study of alcohol's impact on craniofacial development in mice, Sulik et al. (1981) administered dosages of alcohol producing peak BALs of 193-215 ma% and discussed these levels in terms of "social" drinking. If these levels represent "moderate" or "social" drinking, the people drinking this much probably do most of their socializing in a stupor.

What then is an "occasional" or "social" drink? We realize any specific amount is arbitrary. We are prepared to be arbitrary. We suggest that a BAL of less than 0.04g% is compatible with "social" drinking. This is equivalent to 2 drinks (containing 1 oz. absolute alcohol) consumed over a 2 hour period for someone weighing 140 lb. (University of Michigan Alcohol Research Center). We know of no evidence to suggest that this amount consumed occasionally, e.g., once or twice a week, will cause bad things to happen to unborn babies.

What about studies that say spontaneous abortion rates are increased about twofold for women drinking 1-2 drinks per day or less during pregnancy, you say? (Harlap et al., 1980; Kline et al., 1980). We say the increased risk in these studies is almost certainly due to the heaviest drinkers who only represent a small proportion of the study population— in other words, these studies suffer from the "lies, damn lies and statistics" quandary. In the Harlap et al. (1980) study the number of "heavy" drinkers (more than 2 drinks/day) was reported as only 0.5% of the study population. This is a lot less than the national median and modal consumption for pregnant American women (Abel, 1984a). Either the people in this study am an unusual group (which raises other issues of representativeness)

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or we're dealing with an instance of the "used car salesman" syndrome— women in this study considerably underreported their alcohol consumption. A reasonable interpretation is that the risk for spontaneous abortion was present only among the 2-4% heaviest exposed pregnancies (Sokol, 1980).

Kline et al. (1980) retrospectively compared women who aborted spontaneously with a control group and concluded that as little as two drinks a week were a risk factor for spontaneous abortion. While this study controlled for smoking, use of other drugs and diet, it didn't control for social class since all women in this study were on public assistance. When Kline repeated her study with private patients the relation between drinking and spontaneous abortion was no longer there (Kolata, 1981).

Studies of abortion following alcohol exposure in nonhuman primates are very, very consistent in finding that the blood alcohol threshold level for spontaneous abortion is around 205 mug (Clarren et al., 1987; Scott and Fradkin, 1984; Altshuler and Shippenberg, 1981). In dogs, the BAL threshold is almost identical (Ellis and Pick, 1980). These studies in non-human primates and dogs are impressive in their consistency and in their support for suspicion of underreporting in human studies.

How about lowered birth weight, one of the more reliably observed effects associated with in utero alcohol exposure in humans and animals? (Abel, 1984a).

In an often cited report, Little (1977) found that consumption of 2 drinks per day produced a decrease in birth weight of 160 g. However, drinking ranged from 0 to 5 drinks a day, and 3 of the mothers in this study could have been classified as alcohol abusers. Only seven of the 801 children in the study weighed under 2500 g. Little (1977) did not indicate the birth weights of the children bom to the alcohol abusers or the drinking behavior of the mothers of the low birth weight infants. It's more than likely that the alcohol abusers accounted for most of the relationship.

In another study alleging to show significant effects of "occasional" drinking, Streissguth and her co-workers (1980) reported that eight-month-old children had significantly poorer performances on the Bayley tests after statistical adjustment for a number of confounding variables. However, infants born to women drinking more than 8 drinks per day were lumped in with those whose mothers drank 2 or more drinks perday. When Hank Rosett reanalyzed these data by specific dose and each infant was included only once, only the mental scores of the infants exposed to the higher amounts were significant—and their average score was still a normall 98! (Rosett and Weiner, 1984).

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Sutton's Law

There is good reason to believe thresholds exist for various adverse alcohol-related birth defects and it's reasonable for clinicians to recommend abstinence to patients contemplating pregnancy or already pregnant. Unfortunately, the patient who places her unborn offspring at greatest risk, i.e., the abusive drinker or alcohol-dependent woman, is the individual least willing or able to identify herself as a risk drinker or to become abstinent.

When someone asked Willie Sutton why he robbed banks, he answered, "Thatt's where the money is..." The occasional or light drinker is like the nickel in the cookie jar. The real loot, in terms of preventing alcohol-related brain damage, isn't in the cookie jar—it's in the vault, in among the risk drinkers. These are the women we must identify and help to become abstinent. Willie had the right idea? Go where the money is.

REFERENCES

Abel, E.L. (1984a). Fetal Alcohol Syndrome and Fetal Alcohol Effects. Plenum Press: New York.

Abel, E.L. (1984b). Fetal Alcohol Syndrome and Effects. Greenwood Press: Westport, Connecticut.

Abel, E.L. (1989). Alcohol-related Birth Defects. Greenwood Press:Westport, Connecticut.

Altshuler, H.L. and Shippenberg, T.S. (1981). A subhuman primate model for fetal alcohol syndrome research. Neurobehavioral Toxicology and Teratology, 3 121-126.

Clarren, S.K. and Bowden, D.M. (1982). Fetal alcohol syndrome: A new primate model for binge drinking and its relevance to human ethanol teratogenesis. Journal of Pediatrics, 101 819-824.

Clarren, S.K., Bowden, D.M., and Astley, S.J. (1987). Pregnancy outcomes after weekly oral administration of ethanol during gestation in the pig-tailed macaque (Macaca menstrina). Teratology, 35 345-354.

Ellis, F.W. and Pick, l.R. (1980). An animal model of the fetal alcohol syndrome in beagles. Alcoholism: Clinical and Experimental Research, 4 123-134.

Emhart, C.B., Landa, B., and Schnell, N.B. (1981). Subclinical levels of lead and developmental deficit—a multivoriate follow-up reassessment. Pediatrics, 67 911.

Ernhart, C.B., Morrow-Tlucak, M., Sokol, R.J., and Martier, S. (1988). Underreporting of alcohol use inpregnancy. Alcoholism: Clinical and Experimental Research, 12 506-511.

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Hanson, J.W., Streissguth, A.P., and Smith, D.W. (1978). The effects of moderate alcohol consumption during pregnancy on fetal growth and morphogenesis. Journal of Pediatrics, 92 457-46O.

Harlap, S. and Shiono, P.H. (1980). Alcohol, smoking and incidence of spontaneous abortions in the first and second trimester. Lancet, 2 173-176.

Jacobson, S.W., Sokol, R.J., Jacobson, J.L., Martier, S., Kaplan, M., Ager, J., Billings, R., and Bihun, J. (1989). How much underreporting of pregnancy drinking can be detected by one year postpartum? Alcoholism: Clinical and Experimental Research, 13 344.

Kline, J., Shrout, P., Stein, A., Susser, M., and Warburton, D. (1980). Drinking during pregnancy and spontaneous abortion. Lancet, 2 176-180.

Kolata, G.B. (1981). Fetal alcohol advisory debated. Science, 214 642-645

Landesman-Dwyer, S., Keller, S., and Streissguth, A.P. (1978). Naturalistic observation of newborns: Effects of maternal alcohol intake. Alcoholism: Clinical and Experimental Research, 2 171-177.

Little, R.E. (1977). Moderate alcohol use during pregnancy and decreased infantbirth weight. American Journal of PublicHealth, 67 1154-1156.

Malin, H., Coakley, J., Kaelber, C., Mussch, N., and Holland, W. (1982). An epidemiological perspective on alcohol use and abuse in the United States. In National Institute on Alcohol Abuse andAlcoholism. Alcohol Consumption and Related Problems. NIAAA: Rockville, MD, 99-153.

Martier, S.S., Ager, J.W., Sokol, R.J., Jacobson, J., Jacobson, S., and Bottoms, S.F. (1989). Identification of pregnancy risk-drinking: Two viruses of tolerance. Alcoholism: Clinical and Experimental Research, 13 344.

Martin J., Martin, D.C.,Lund, C.A. and Streissguth,A.P. (1977). Maternal alcohol ingestion and cigarette smoking and their effects on newborn conditioning. Alcoholism: Clinical and Experimental Research, 1 243-247.

Rosett, H.L. and Weiner, L. (1984). Alcohol and the Fetus. Oxford University Press: New York.

Rorabaugh, W.J. (1979). The Alcoholic Republic. Oxford University Press: New York.

Scott,W.J., Jr. and Fradkin, R. (1984). The effects of prenatalethanol incynomolgus monkeys Macaca fascicularis. Teratology, 29 49-56.

Sokol, R.J. (1980). Alcohol and spontaneous abortion. Lancet, 1 1079.

Sokol, R.J., Ager, J., Martier, S., Debanne, S., Ernhart, C., Kuzma, J., and Miller, S.I. (1986). Significant detemminants of susceptibility to alcohol teratogenicity. Annals of New York Academy of Sciences, 477 87-102.

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Streissguth, A.P., Barr, H.M., Martin, D.C., and Hemman, C.S. (1980). Effects of matemal alcohol, nicotine and caffeine use during plegnancy on infant mental and motordevelopment at 8 months. Alcoholism: Clinical and Experimental Research, 4 152-164.

Streissguth, A.P., Barr, H.M., Sampson, P.D., Darby, B.L., and Martin, D.C. (1989). IQ at age 4 in relation to matemal alcohol use and smoking during pregnancy. Developmental Psychology, 25 3-11.

Sulik, K.K., Johnston, M.C., and Webb, M.A. (1981). Fetal alcohol syndrome: Embryogenesis on a mouse model. Science, 214 936-938.

Weiner, L., Rosett, H.L., Edelin, K.C., Alpert, J.J., and Zuckerman, B. (1983). Alcohol consumption by pregnant women. Obstetrics and Gynecology, 61 6-12.

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