abrupt end.In the 8 years since this "rediscovery" clinical, epidemiologic and animal studies have pro- vided confirmatory evidence of the serious embryo-.
SCIENTIFIC SECTION
Symposium: Alcohol and the fetus
Alcohol use during pregnancy: a challenge for the '80s
MARY JANE ASHLEY, MD
The rediscovery of the adverse effects of heavy maternal drinking on the fetus must rank among the most significant research advances of the 1970s. The term rediscovery is appropriate because historical evidence of recognition of and concern about these effects is abundant and dates back to antiquity. According to Warner and Rosett' Aristotle wrote that "foolish, drunken, and hare-brain women, [for the] most part bring forth children like unto themselves, morosos et languidos". During the gin epidemic that swept England between 1720 and 1750 many, including members of the Royal College of Physicians, noted the adverse effects on the outcome of pregnancy of heavy alcohol ingestion by the mother. At the end of the last century William Sullivan, a Liverpool physician, compared the offspring of women jailed for drunkenness with those of their relatives. Besides documenting higher rates of stillbirth and death in early childhood in the offspring of drunken women, he observed that forced abstinence during pregnancy (such as occurred with imprisonment) was associated with the birth of normal children in women whose previous drunken pregnancies had produced abnormal children. Unfortunately, most of this century has been characterized by little concern about or study of the effects of alcohol on the fetus, despite considerable interest in the effects of other drugs taken during pregnancy. Earlier evidence was forgotten, ignored or dismissed as unscientific and irrelevant. Indeed, in 1965 one eminent authority wrote: "it can now be stated categorically, after hundreds of studies covering many years, that no matter how great the amounts of alcohol taken by the mother - or by the father, for that matter - neither the germ cells nor the development of the child will be affected."2
The landmark publication in 1973 of an article by Jones and colleagues3 describing a unique constellation of abnormalities in the offspring of mothers with chronic alcoholism subsequently labelled the fetal alcohol syndrome4 brought this complacency to an abrupt end. In the 8 years since this "rediscovery" clinical, epidemiologic and animal studies have provided confirmatory evidence of the serious embryotoxic and teratogenic risks of heavy maternal alcohol consumption. In the process a range of adverse effects of alcohol on the fetus, spanning the continuum of maternal alcohol consumption from social drinking to chronic alcoholism, has been postulated. The accumulated data of the last 8 years indicate that the fetal alcohol syndrome is at the far end of the spectrum of possible effects of alcohol on the fetus. It has been found only in the offspring of mothers
From the department of preventive medicine and biostatistics, University of Toronto Reprint requests for this article to: Dr. M.J. Ashley, Department of preventive medicine and biostatistics, University of Toronto, Toronto, Ont. M5S 1A8
"Alcohol and the fetus: a hearing of the scientific evidence", a conf.erence cosponred by the Addiction Resear. Foundation Of Ontario and tthe Donwood Inestitute, was held in Torono on Apr. 18, 198. Thi issue of te: Journl prents "Alcohol and the fetus", a package of the three papers presented at the conference, and introductory remarks by Mary Jane Ashley. For a reprint of the complete package (including a reproduction in eolour of t-he :cve illustration) send requests to: Marketing servies, Addiction: Research Foundation of Ontario, 33 Russell St., Toromto, Out. MSS 251. For reprints of a specific article only, send
requests to the particular author. The cover illustration was painted by Peter Shvartsman, a native of Minsk, USSR who is now an artist and illustrato in Ottawa. The panting contrasts the craniofacial features of a healthy child with those of a child with th fel alcoho syndrome. The following features are depicted: microcephaly, short palpebral fissures, flat maxillary area, poorly developed philtrum and thin upper lip.
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with chronic alcoholism. Even within the exposure category of chronic heavy alcohol use, however, there is a gradation of risk and a variety of adverse outcomes. Among the offspring of women with severe chronic alcoholism possibly a third or more will have sufficient stigmata to warrant the diagnosis of fetal alcohol syndrome.5'6 In contrast, among the offspring of those who abuse alcohol less severely the risk appears to be much lower: possibly 2% to 3% will be affected.7'8 None the less, the risks of other adverse outcomes are high. Guellette and associates,9 classifying infants as abnormal if they displayed congenital anomalies, growth abnormalities or neurologic abnormalities, found 29 (71 %) of 42 infants born to heavy drinkers to be abnormal in the newborn period. Using the same classification Sokol and colleagues8 found 21 (50%) of 42 infants of alcohol abusers to be adversely affected, a risk many times greater than that for the fetal alcohol syndrome. But what of the risks associated With "social" drinking? Although there are data suggesting that consumption at an average level of one or more drinks daily may be associated with several kinds of adverse effects,'013 much more information is needed before firm statements will be possible. Given the short time since the rediscovery, the quantity and quality of the evidence that has already accumulated are quite remarkable and reflect the close cooperation of researchers from several disciplines and from a number of centres.14 Further delineation of the kinds and degrees of fetal risks associated with light to moderate alcohol ingestion by the mother and the long-term implications of these risks for the normal growth and development of the child is one important challenge for the 'SOs. The findings of the last 8 years, although incomplete, have implications for the practising health professional, the program planner and the policymaker. To provide a forum for a hearing of the accumulated scientific evidence and a discussion of its public health and clinical implications the Addiction Research Foundation of Ontario and the Donwood Institute, Toronto, cosponsored a conference for health policy and program planners in Toronto in the spring of 1980. Three articles from that conference are presented in this issue of the Journal. Sokol, in the article beginning on page 143, describes the minimum criteria for diagnosis of the fetal alcohol syndrome, the evidence that alcohol is the etiologic factor, and the importance of heavy alcohol consumption as a major risk factor in pregnancy. Issues surrounding the identification and treatment of the pregnant woman who drinks heavily are discussed by Rosett and Weiner in an article that begins on page 149. The article by Little and Streissguth beginning on page 159 summarizes evidence concerning the spectrum of effects associated with a range of maternal drinking. As well, the authors consider the population burden of the fetal alcohol syndrome and fetal alcohol effects, and suggest possible strategies for prevention programs. From the clinical perspective there are many questions still unanswered. Rosett14 has identified some of these. How should the physician advise a pregnant 142 CMA JOURNAL/JULY 15, 1981/VOL. 125
woman who has been drinking heavily? How should the physician advise a woman planning to become pregnant? What preventive strategies should be pursued in the clinical setting? Ih this symposium Rosett and Weiner address these questions and others. For epidemiologists and basic scientists there are also many questions that require fuller answers than the current data can provide. What are the interactions between alcohol and other risk variables, such as inadequate diet and the use of other drugs? Are the timing of exposure and the pattern of drinking important determinants of risk? What are the exact mechanisms by which alcohol (or its metabolite, acetaldehyde) exerts it multiple effects? What are the fetal risks associated with light and moderate maternal alcohol consumption, and how important are they to the longterm growth, development and behaviour of the child? That investigators currently working in this area differ in their interpretations of the available data is evident from the papers on "Alcohol and the fetus" in this issue. From the perspective of those involved in formulating health policy and planning programs there are other pressing issues. The existing health care system must be more effectively utilized to provide preventive and treatment services for the pregnant woman who abuses alcohol. Special services and facilities may be required. Preventive strategies and programs at the community level must be developed, implemented and evaluated. Finally, there is an obvious need in the area of professional education. The rediscovery occurred so recently that few health professionals have received formal training about the effects of alcohol during pregnancy. Among some the beliefs and attitudes of 1965, referred to earlier, still prevail. Practising health professionals must be brought up to date by professional journals and by continuing education and inservice training programs. Revision of curricula for the training of physicians, nurses, social workers, health education teachers and others is required. Canadian physicians have already been alerted to the problem15 and are asked to report suspected cases of fetal alcohol effects. The appropriate person to contact is Dr. E. Napke, Chief, product-related disease division, Rm. 41, Laboratory Centre for Disease Control, Tunney's Pasture, Ottawa, K I A 0L2. References i. WARNER RH, ROSETT HL: The effects of drinking on offspring. An historical survey of the American and British literature. J Stud Alcohol 1975; 36: 1395-1420 2. MONTAGUE A: Life Before Birth, Signet, New York, 1965: 114 3. JONES KL, SMITH DW, ULLELAND CN, STREISSOUTH AP: Pattern of malformation in offspring of chronic alcoholic mothers. Lancet 1973; .yndrome 1: 1267-1271 4. JONES KL, SMITH DW: Recognition of the fetal alcohol in early infancy. Lancet 1973; 2: 999-1001 5. JONES KL, SMITH DW, STREISSOUTH AP, MYRIANTHOPOULOs NC: Out:ome in offspring of chronic alcoholic women. Lancet 1974; 1: 1076-1078
6. SEIrENBERO J, MAJEWSKI F: Zur Haufigkeit der Alkoholembryopathie in den verschiedenen
Phasen der mutterlichen
Alkoholkrankheit.
Suchtgefahren 1978; 24: 63-75 7. WARREN KR (ed): Critical Review of the Fetal Alcohol Syndrome, National Institute on Alcohol Abuse and Alcoholism, Rockville, Md. 1977: 11 8. SoKoL RJ, MILLER SI, RLED G: Alcohol abuse during pregnancy:
an epidemiologic study. Alcoholism (NY) 1980; 4: 135-145 9. QUELLETIE EM, ROSETT HL, ROSMAN NP, WEINER L: Adverse effects on offspring of maternal alcohol abuse during pregnancy. N Engi J Med 1977; 297: 528-530 10. LITTLE RE: Moderate alcohol use during pregnancy and decreased infant birth weight. Am J Public Health 1977; 67: 1154-1156 II. KAMiNsKi N, RUMEAU-ROUQUEITE C, SCHWARZ D: Consommation d'alcool chez les femmes enceintes et issue de la grossesse. Rev Epidemiol Med Sante Publique 1976; 24: 27-40 12. HARLAP S, SHIoNo PH: Alcohol, smoking, and incidence of spon-
taneous abortions in the first and second trimester. Lancet 1980; 2: 173-176 13. KLINE J, SHROUT P, STEIN Z, SussaR M, WARBURTON D: Drinking during pregnancy and spontaneous abortions. Ibid: 176-180 14. Rosarr HL: A clinical perspective on the fetal alcohol syndrome.
Alcoholism (NY) 1980; 4: 119-122
15. MoRRIsoN AB, MAYKUT MO: Potential adverse effects on maternal alcohol ingestion on the developing fetus and their sequelse in the infant and child. Can Al ed Assoc 1 1979; 120: 826-828
Alcohol and abnormal outcomes of pregnancy ROBERT I. SOKOL, MD
Heavy alcohol consumption by the mother during pregnancy has long been suspected of being a risk factor for abnormalities in the fetus or infant. Only during the last decade have these assumptions been supported by scientific studies. A clustering of fetal defects observed in some cases has been labelled the fetal alcohol syndrome. The syndrome involves prenatal and postnatal growth retardation, central nervous system involvement and craniofacial abnormalities, some of which are characteristic of the syndrome. Fetal alcohol syndrome is relatively rare, affecting from I in 300 to I in 2000 infants; approximately 450 cases have been reported since the syndrome was identified. Despite this rarity, however, heavy alcohol consumption is an important risk factor during pregnancy. A review of the current literature indicates that in animals alcohol in high doses is embryotoxic and teratogenic, that heavy drinking is not uncommon before and during pregnancy and that the fetal alcohol syndrome and other effects on the fetus associated with alcohol abuse appear with significant frequency among mothers who drink heavily. Heavy alcohol consumption is a perinatal risk factor that not only can be detected by the physician, but also can be reduced in concerned, cooperative patients. Thus, awareness of this problem gives health care personnel an opportunity to help in the prevention of abnormal outcomes of pregnancy. Une forte consommation d'alcool chez Ia mere durant Ia grossesse a longtemps. ete soupconne de presenter un risque d'anomalie pour le foetus ou le nouveau-ne. Ce n'est qu'au cours de Ia derniere decennie que cette hypothese a pu .tre confirmee par des etudes scientifiques et qu'on a pu apposer, dans quelques cas, le vocable de syndrome alcoolique foetal a un ensemble d'anomalies foetales. Ce syndrome comprend un retard de croissance prenatal et postnatal, une atteinte du systeme nerveux From the department of obstetrics and gynecology, Case Western Reserve University, and the Perinatal Clinical Research Center, Cleveland Metropolitan General Hospital, Cleveland, Ohio Reprint requests for this article to: Dr. Robert J. Sokol, Perinatal Clinical Research Center, Cleveland Metropolitan General Hospital, 3395 Scranton Rd., Cleveland, OH 44109, USA. For a copy of "Alcohol and the fetus", which contains the four papers on this topic published in this issue of the Journal, send requests to: Marketing services, Addiction Research Foundation of Ontario, 33 Russell St., Toronto, Ont. M55 2S1
central et des anomalies craniofaciales dont certains sont caracteristiques du syndrome. Le syndrome alcoolique foetal est relativement rare, sa frequence chez le nouveau-ne etant comprise entre I sur 300 et I sur 2000 enfants; environ 450 cas ont ete signales depuis que le syndrome a ete identifie. Toutefois, en depit de cette rarete, une forte consommation d'alcool constitue un important facteur de risque durant Ia grossesse. Une revue de Ia litterature actuelle revele que l'alcool a forte dose est embryotoxique et teratogene chez l'animal, qu'une forte consommation d'alcool avant et durant Ia grossesse n'est pas rare et que le syndrome alcoolique foetal et d'autres effets sur le foetus relies a l'abus de l'alcool apparaissent avec une frequence appreciable parmi les meres ayant des problemes d'alcoolisme. Une forte consommation d'alcool est un risque perinatal qui non seulement peut .tre d6tecte par le medecin, mais aussi peut .tre reduit chez les patientes Co. operatives et soucieuses de leur responsabilite. La connaissance de ce probleme offre donc aux professionnels de Ia sante Ia possibilite d'aider a prevenir certaines anomalies de Ia grossesse.
Members of the scientific community and the public are becoming increasingly aware that there is a relation between heavy drinking habits in the mother and adverse outcomes in the fetus and infant. The purpose of this paper is to provide a survey of the problem of heavy consumption of alcohol by pregnant women. I will focus on the highlights of the relevant scientific and clinical evidence, and consider the implications of this evidence for health care planning for women of childbearing age, by first reviewing the long history of the recognition of this problem and the retrospective studies in humans that indicate that there is a fetal alcohol syndrome. I will then describe the syndrome. giving an example, and present the accepted criteria for making this diagnosis. Because fetal alcohol syndrome is a relatively rare complication of pregnancy, I will attempt to answer the question as to why heavy alcohol consumption is an important risk factor during pregnancy by describing some animal studies (in which many confounding variables were controlled) indicating that alcohol may adversely affect the fetus, and I will briefly discuss the incidence of problem drinking in women. Finally, I will review some of the CMA JOURNAL/JULY 15, 1981/VOL. 125
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