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Recent reports have described a marked increase in binge (heavy episodic) drinking among young people in the UK. These reports have outlined the potential impact of binge-drinking behaviour from a health, economic and social perspective.1–3 However, no mention has been made in any of these publications of the effects alcohol can have on the developing fetus; this despite the fact that 27% of women in the 16- to 24-year-old age group in the UK report binge drinking at least once a week.3 Although most women in this age group are not currently pregnant, it is important to note that the majority of pregnancies are unplanned.4 Therefore, women often continue their usual pattern of alcohol consumption into the early weeks of an unplanned pregnancy, a period during which the fetus is particularly vulnerable to alcohol exposure.

Prenatal alcohol exposure, especially a binge pattern of drinking, is associated with a spectrum of characteristic abnormalities known as fetal alcohol spectrum disorders (FASD). Features of FASD include growth deficiency, structural defects and problems with intellectual performance and behaviour. The primary effect of alcohol on the fetus is on the developing brain. Thus, the most common and serious consequences are cognitive deficits and behavioural problems, including mental illness and other secondary disabilities. Although early referral to specialists for assessment and diagnosis of affected children may improve prognosis, the multitude of problems associated with FASD are lifelong. A number of maternal characteristics such as older maternal age, low socio-economic status, nonwhite race/ethnicity, and poor nutritional status have been suggested as risk factors for having an affected child. However, irrespective of any of these factors, FASD can and does occur in children born to any woman who drinks during pregnancy.5

Given the concern regarding the consequences of alcohol use in pregnancy, physicians caring for women in their childbearing years are responsible for assessing patterns of alcohol consumption in their patients. Although biomarkers of alcohol abuse are available, they are insufficiently sensitive or specific for identifying all women who are at risk. Thus, physicians must make consistent and careful efforts to elicit this information from their patients, while providing advice regarding the risks of exposure in the event of pregnancy.

In this regard, official recommendations in the UK for alcohol consumption among pregnant women are pertinent. The published Alcohol Harm Reduction Strategy for England prepared by the Prime Minister’s Strategy Unit recommends that women should be careful about alcohol consumption during pregnancy and limit their intake to no more than one unit (8 g) of alcohol per day.6 Similarly, the statement on ‘Alcohol consumption and the outcomes of pregnancy’ published by the Royal College of Obstetricians and Gynaecologists (RCOG), although revised to advise reduced maximum levels of alcohol consumption, continues to suggest that there is no evidence of risk for pregnant women who consume low levels of alcohol, i.e. up to four units per week throughout pregnancy.7

Although, as the revised RCOG statement indicates, there is no extensive evidence that a level of alcohol consumption at or below four units a week is likely to result in fetal harm, it is also true that there is no established threshold dose or upper limit of alcohol consumption in pregnancy that is known to be safe. Furthermore, given the fact that the primary effect of alcohol is on brain development, alcohol consumption during all trimesters of pregnancy is of potential concern. The RCOG is to be commended for calling for long-term prospective studies to further address the question of a level of alcohol that is safe to drink. However, in the meantime, lack of evidence does not equal evidence of safety.

The RCOG statement generates confusion for clinicians and the public by stating that the consumption of alcohol offers no benefits to the outcomes of pregnancy, that the safest approach may be to avoid any alcohol in pregnancy, and that there is a need for more research, while still concluding that alcohol consumption up to four units a week is harmless. Further confusion is generated by use of the unit system for defining alcohol quantity. Although the statement includes a conversion table for typical drink sizes and brands, the large variation in drink sizes and alcohol content could easily lead to underestimation by a pregnant woman of the number of units of alcohol actually being consumed on a given occasion.

The US Surgeon General has reiterated his recommendations regarding alcohol consumption while pregnant, stating that the safest course is abstinence throughout pregnancy,8 a conclusion that has been reached by seven of nine countries that have a stated policy about alcohol exposure during pregnancy. Only the UK, Australia, and New Zealand recommend otherwise.9

Based on studies indicating that a broad range of maternal alcohol consumption can be associated with adverse pregnancy outcomes, that a woman’s usual pattern of alcohol consumption may continue into the early weeks of an unplanned pregnancy, that a binge pattern of drinking is of particular concern to the developing fetus, and that the effects on fetal brain development span all trimesters of pregnancy, we strongly suggest that the UK’s RCOG statement for alcohol consumption during pregnancy be re-evaluated to recommend abstinence. We also recommend that alcohol-exposed pregnancies be considered a major focus of England’s Alcohol Harm Reduction Strategy.

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