THE FRENCH PARADOX CHAPTER NINETEEN

Wine, Pregnancy and Fetal Alcohol Syndrome

By Wells Shoemaker, M.D.

The distinctive features of both wine and women have lured ardent feminists, zealous prohibitionists, opportunistic politicians, and somber doctors to your dinner table... without an invitation, and probably without a corkscrew.

Differences in physical size and metabolism have decreased the amounts of alcohol deemed "moderate" for women compared to men. Breast cancer and its potential relationship to alcohol, naturally, focus upon women, but nowhere is the gender emphasis so pointed as in the discussion of alcohol use during pregnancy.

It sounds simple to say that no pregnant woman needs to drink, and if there is any remote chance of harm, then "just don't drink." The question remains just how "remote" are the risks, and what are the facts a woman should consider when making her personal decision.

The American fetus became a hot issue in the 198Os. The lawyers, the preachers, the politicians, the judges, and the doctors all wanted dibs on the unborn. At the same time, alcohol became a safe and popular target for this same cast of characters. The convergence of alcohol and the fetus produced a vortex of medical, legal and political interest in a relatively rare but poignantly tragic birth defect. Fetal Alcohol Syndrome (FAS) burst into national consciousness with a whirlwind exposure through every media channel.

Michael Dorris' moving book, The Broken Cord, received tremendous media attention as did a 1992 Congressional hearing chronicling the hardship of rearing an adopted Native American child with FAS.

Two Seattle restaurant employees earned national news notoriety in 1991 when their employer fired them for refusing to serve a drink to a pregnant woman several days past her delivery due date. This episode and the subsequent repercussions highlighted both the emotional intensity and the factual ignorance of the public's awareness about FAS.

As you read further, you'll see that the occurrence of FAS has been -- and continues to be -- overexaggerated and distorted by a number of anti-alcohol groups to stir up emotional support for their crusade. FAS is a serious, rather than preventable tragedy which can be best eliminated through the use of solid facts, good science and sound public policy, distortions and demagoguery.

What Is FAS?

FAS was first described in 1968 in France and then by a group of pediatricians in Seattle in the early 1970s, although it has probably existed since ancient times. In a clinic for learning disabled children, the Seattle doctors noticed a peculiar physical similarity among several of these children. They dug into the medical histories and then discovered that each child had an alcoholic mother.

Thousands of medical articles have been published on FAS since the original description, and the syndrome now consists of a constellation of features;

-- Children with FAS are born small and never catch up;

-- Their brains are small and underdeveloped;

-- Their upper lips tend to be thin, and the philtrum (the ridges and groove that reach from the nostrils down to the upper lip) is often smooth or flattened;

-- Their noses are short and upturned, and their eyes tend to be small, widely set, downturned, and sad looking;

-- They resemble each other almost as if siblings and

-- They have a statistical increase in other physical defects, particularly congenital heart disease.

The grittiest component of FAS is mental retardation, which tends to be severe and irremediable despite the best of modern educational interventions. The pathos of the wasted life of the innocent victim has earned FAS its deserved place among modern human tragedies, right along with babies who contracted AIDS from transfusions in hospital nurseries.

There is no X ray or laboratory test that establishes the diagnosis of FAS. Any of the separate physical or developmental components of FAS can be seen in other children, but when all or most of the features are present, along with a history of maternal alcohol abuse, an observant pediatrician can make the diagnosis.

How Much Alcohol causes FAS?

FAS children are generally exposed to ponderously abusive amounts of alcohol. We're not likely to be confused by "moderation" here. Typical ingestion histories range from two or three six-packs of beer or the better part of a fifth of distilled spirits a day.

There have been no known cases of "full blown" FAS in children whose mothers consumed moderate amounts of alcohol; this is even more telling considering that patients virtually always understate their alcohol intake. There have been no cases reported in which wine was the source of ethanol.

Clearly, there may be compounding factors that stress the fetus. The typical profile of the FAS mother is a 30-plus-year old alcoholic in poor health, taking poor nutrition, smoking, living in a chaotic environment alone or in the company of a male alcoholic.

Most of the organ systems in the human fetus develop in the first two months after conception, and it is likely that most of the physical malformations occur from early exposure to episodic, very high levels of alcohol (often from binge drinking or sustained high levels with daily intoxication, the latter being the most common pattern).

Physical growth of the fetus occurs throughout pregnancy, and the small size of FAS babies likely relates to toxic effects upon cell growth throughout the nine months. Brain growth accelerates markedly in the third trimester and cessation of maternal alcohol abuse before this point can considerably reduce the neurological handicaps of FAS.

Unanswered Questions

There remain some haunting medical questions to answer about FAS:

-- A majority of heavily drinking mothers have babies with no identifiable abnormality.

-- Some alcoholic mothers have delivered twins where one has FAS and the other seems normal.

-- Some ethnic groups have a substantially higher incidence of FAS births; certain Native American groups have a 30-fold higher incidence than the general population.

It would be tremendoUsly valuable, to guide both prevention and therapy, to determine what separates the fortunate from the afflicted.

The incidence itself is still controversial. While some professionals in the field claim that 1 or 2 babies per 1,000 births suffer FAS, data collated from 50 state health departments in the United States reveals the recorded occurrences are closer to 1 in 10,000. FAS researchers hasten to point out that the latter figure may be falsely low because American medical professionals overlook or misdiagnose 90 percent of all FAS cases. The truth probably lies somewhere between the two figures.

The most carefully drawn studies suggest an intermediate figure of 1 in 3,000 births.

Experienced pediatricians traveling in Mediterranean countries have not noticed large numbers of FAS children, despite the fact that wine consumption may be tenfold higher than in the United States, and that pregnant women often continue drinking wine with their meals. National statistics do not reveal the elevated FAS occurrences that anti-alcohol activists would predict, and it's presumptuous to assert that Italian, French, Greek and Spanish doctors are less alert than American doctors.

In addition, statistics from those countries and the United States indicate that more alcohol is sold and consumed in the holidays that occur in the months of October through December. If these statistics are accurate, and if FAS is connected to alcohol consumption at any level, then we might expect to see increased incidences of FAS in births that occur from June to August. In fact, no such increase has been shown in any data.

This should offer consolation to women who have consumed alcohol at Thanksgiving, Christmas or Chanukah celebrations but who were unaware of their pregnancies.

Considerable research shows that the women who have taken FAS warnings to heart have been educated, middle-to-upper income women who were at substantially lower risk of FAS to begin with. There is no research at all which indicates that scare tactics have changed anything for women most at risk.

Fetal Alcohol "Effect"

Clearly and without controversy, abusive alcohol consumption during pregnancy is risky. Is it not plausible that some less extreme amount of consumption could cause fetal injury of a more subtle nature? It certainly seems logical that there should be some dose-effect between perfectly normal and overtly abnormal.

Fetal Alcohol Effect was coined to define a cluster of behavioral problems in alcohol-injured children who did not have the physical appearance of FAS. These include fidgetiness, short attention span, coordination problems, learning disabilities, and impaired social interactions.

None of these traits are unique to alcohol-injured children and all can be found at some time in practically any child under stress.

In addition, some studies have tried to associate moderate alcohol consumption with lower birth weights or slightly lower IQ measurements; the overall body of scientific research shows no connection at all.

For example, Dr. Keith Marton surveyed 10 major research studies which looked at moderate alcohol consumption in pregnant women and birth weight. Of the 10 studies, six found no association at all; two found that children of mothers who drank moderately during pregnancy may have weighed slightly more than abstainers; two (which studied about 500 children, compared to the previous eight studies which examined about 62,000 children) found that abstainers had slightly smaller children. Taken as a whole, these ten studies indicate that moderate consumption does not affect birth weight.

The same situation exists in studies that looked at small variations in IQ. The vast body of research shows no association between IQ variations and moderate alcohol consumption by pregnant mothers; a small number say moderate drinkers' children may have IQs as much as five points higher than abstainers, while one other investigator, who has performed several studies, asserts just the opposite. Even these latter studies show no effect below three drinks per day throughout the pregnancy -- a level that most mothers would avoid simply because the taste of alcohol is unappealing.

In addition, psychologists generally agree that IQ measurement is imprecise and that five points is smaller than the margin of error on such tests. Finally, numerous examinations of IQ tests have proved that they are flawed by ethnic and economic biases which means that -- regardless of drinking patterns -- children of mothers who are at highest risk (poor, Hispanic or African-American) will generally test lower on IQ tests than white, middle or upper-middle class women.

None of the FAE traits can be weighed or measured with a "hard" quantitative test, such as a blood test for diabetes or a urinalysis for a bladder infection. While experienced child psychologists can make helpful qualitative observations to guide the educational interventions for a troubled child, most behavioral tests incorporate a subjective component and considerable variation exists between different examiners.

Finally, many studies that have indicated a connection between FAS or FAE and moderate drinking have been seriously flawed in their methodology. In an article published in the September 1991 issue of the British Journal of Addiction, alcohol researcher Genevieve Knupfer showed that those studies that found a connection between moderate drinking and FAS were those which did not discriminate between moderate consumption and binging. For the purpose of these studies, a woman who drank 10 drinks at one sitting was identical to a woman who drank less than one drink per day over the course of a week.

ligh"An examination of the research literature on the results of drinking during pregnancy does not provide any evidence that drinking is harmful to the fetus," said Knupfer.

All of this means that professionals evaluating problem children face a troublesome temptation to overdiagnose FAE; if the question to them is phrased, "Is this problem consistent with FAE?", the entity is so amorphous that the answer will almost always be "Yes, possibly." Our society seems to want to fix the blame for most things and it is easier (if incorrect) to point at FAE than to try to alter structural problems in dysfunctional families -- problems whose magnitude totally overwhelms those of suspected FAE cases.

The bias to blame FAE looms larger when studies are designed to:

-- be published for "ammunition", in the anti-alcohol campaign or

-- justify continued funding from a granting agency which philosophically seeks to expand the public perception of alcohol- related injury.

Where to Draw the Line?

Fetal alcohol effect probably does exist, although once again at consumption levels any non-alcoholic person would instinctively shun. The crucial question for millions of mothers is, "What is the risk of an occasional drink? Is it true that even small consumption may damage my baby?" The answer usually comes shrink- wrapped with a legal or a political package, rather than a strictly medical one.

Reported in Time in August 1989, Dr. Robert Sokol, head of the federally-funded fetal alcohol research center at Wayne State University in Indiana, said, "Our best evidence is that we cannot detect adverse consequences to very light drinking, but that doesn't mean they don't exist."

Dr. Sokol's conservative stance is generally extrapolated by federal health and alcohol bureaus to a simple: "No drinking is safe." But is that true?

Through the 1980s all of the data for FAS and FAE had been gathered retrospectively, with an inherent bias in data collection caused by identifying affected children and -- then looking back to make connections. Since incidence claims vary widely and since much of the data is not quantitative, it seemed several years ago that the only way to determine a true dose versus incidence risk would be to do a prospective study.

There appeared to be an impasse. The proponents of the Just Say No, Zero-Tolerance doctrine had a full nelson on their critics. "We say we are right. Lives are at stake. You can't prove we are wrong, and you can't even try, so it's morally imperative that you take our view." The Zero-Tolerance attitude, however, does not serve American women well. In response to public educational efforts, the number of women in the United States drinking during pregnancy dropped from 30 percent to 20 percent between 1985 and 1988, according to a survey by the Centers for Disease Control, but 20 percent is still a large number.

The median number of drinks consumed by the drinking mothers was only four per month. Do we really have legitimate medical data to lay a lifetime guilt trip upon these women?

An answer came in the British Medical Journal in July 1991. Scottish research physicians Forrest and Florey published the first prospective study of maternal alcohol dose versus fetal outcome.

In the British health system, in contrast to our fragmented approach, all pregnant mothers in a given locale funnel through the same prenatal supervision. Families are less mobile and less likely than Americans to disappear from follow-up. This 100 percent enrollment makes the British approach a powerful epidemiological tool, eliminating the selective enrollment of individuals whose socio-economic status and other habits might bias the frequency of observed abnormalities.

Forrest and Florey obtained alcohol consumption histories from 846 consecutive women and repeatedly verified the information through the series of prenatal visits. They subsequently studied 592 of the children up to 18 months age.

Forrest and Florey found no increase in alcohol injury indicators on motor or mental development until consumption reached twelve drinks per week, correlating with a 1988 retrospective study published in the British Medical Journal that proposed ten drinks a week as a threshold level.

Bordering upon the heretical, the investigators found that children of light drinkers actually fared better than the children of abstainers in all categories of the Scottish tests.

Forrest and Florey concluded, "Pregnant women probably need not abstain from alcohol altogether as no detectable adverse relation was found between the child's mental and physical development and the mother's weekly consumption at levels in excess of 100 grams absolute alcohol. However, to allow for a margin of safety and taking into account the findings of an earlier phase of this study on the immediate effects on the newborn, it is recommended that pregnant women should drink no more than eight units of alcohol a week, the equivalent of about one drink a day.

What does a responsible society do with this information? One conclusion is abundantly clear: There is no legitimate reason to frighten, rebuke or abort the mothers who consume lightly.

A second conclusion is that society -- or government -- really shouldn't be acting on this information. Counseling and decisions about personal health practices ought to belong in the confidence of a physician's office, not the billboard.

Regrettably, since all too many American mothers can't afford personalized medical care, the government is going to play a role. Indeed, it does.

Preventable by Decree?

The warning labels on your wine bottles and restaurant walls are successes for the anti-alcohol forces, but they probably have not prevented one single FAS birth.

Wayne State University professor Dr. Ernest Abel, M.D., in his 1990 text, Fetal Alcohol Syndrome, states, "Prevention of FAS should be a simple matter involving public education. Advising women that drinking during pregnancy can be harmful to the developing fetus would seem a straightforward and simple matter...However, despite national, state, and local public education campaigns, there is no indication that these efforts have reduced FAS."

The mothers at risk for FAS aren't paying attention, which comes as no surprise to physicians experienced with the behavior of alcoholism.

Well-intentioned activists, as well as a few opportunists, harp upon FAS as the third leading birth defect and the only preventable one, e.g. simply by abstinence. That's a smug and frustrating attitude when it floats down to a real-life doctor dealing with real people in the real world.

The only way FAS is going to become truly preventable is to provide alcoholic mothers access to prenatal care, a scandalous impossibility for many in the United States. FAS will continue as long as alcoholic women are isolated, impoverished, under-nourished and deprived of access to the health care system. We need to offer psychological support and supervised therapy for the disease of alcoholism. And subsequently, we must refrain from abandoning this recovering mother after her politically-appealing fetus becomes another welfare neonate. Alcohol abuse and FAS will continue until we, as a society, are willing to spend real resources on behalf of human beings with the disease of alcoholism, not just decals and innuendo.

Meanwhile, anti-alcohol activists use FAS to scare the people who consume moderately and condemn the people who make alcoholic beverages.

Exaggerating and distorting the risks of alcohol as a matter of public policy hinders the preventive potential of public health. It also insults the intelligence of women who wish to draw their own conclusions, based on all the facts, rather than accept a politically and governmentally controlled position on the effects of alcohol consumption. Transforming the issue of light consumption during pregnancy from a health issue into a moral or legal one -- to the point of using the inflammatory term "child abuse" -- will drive away the small but desperate minority who truly need help.

This Pediatrician's Recommendations

-- Ideally, mothers should not drink during pregnancy.

-- Mothers who do choose to drink should take no more than one drink a day, gradually, concurrent with a meal. Wine or beer would be preferable to distilled spirits.

-- Exposure to any reputed fetal toxin carries the highest risk in the first trimester of pregnancy. Most women with morning sickness aren't enticed by a glass of wine, anyway.

-- If a mother has difficulty limiting herself to a drink a day, or if there are occasional days when she drinks three or more, both she and her fetus have a problem that needs professional help.