First UK Estimates of Children Who Could Have Conditions Caused by Prenatal Drinking

Theresa Bebbington

November 30, 2018

According to new research published on 30th November in Preventive Medicine , up to 17% of children in the UK could have symptoms consistent with foetal alcohol spectrum disorder (FASD).

Although the UK has the fourth highest level of prenatal alcohol use worldwide, the prevalence on how many people may be affected by foetal alcohol spectrum disorder (FASD) in the UK is unknown. Features of FASD include facial dysmorphia, growth deficiency and neurobehavioural impairment, and it is a leading cause of developmental disability. A 2015/16 all-party parliamentary group called for a UK population-based prevalence study to guide FASD prevention efforts and policy for alcohol use in pregnancy.

A New Way to Analyse Existing Data

Researchers from the University of Bristol and Cardiff University developed novel screening algorithms to estimate the prevalence of FASD from existing data. They used data from the Avon Longitudinal Study of Parents and Children (ALSPAC), a population-based cohort study that recruited 13,495 pregnant women from the Bristol area with expected delivery dates between 1st April 1991 and 31st December 1992. The ALSPAC study included repeated measures of prenatal exposures, developmental outcomes and socio-demographic factors.

Dr Cheryl McQuire, a researcher in epidemiology and alcohol-related outcomes at the University of Bristol, led the research team. They applied different screening algorithms to the data and followed the FASD Canadian guidelines for diagnosis. The algorithm specifications corresponded to different central nervous system (CNS) and prenatal alcohol exposure (PAE) criteria. The researchers also gave participant profiles to a panel of specialists and asked them to decide if a diagnosis of FASD would be made by a clinic based on the information provided. They found:

  • 79% of children in the sample were exposed to alcohol during pregnancy

  • 17% of children screened positive for FASD

  • A positive FASD screen was more common among children of lower socioeconomic status and from unplanned pregnancies

The researchers noted that these screening prevalence estimates are not equivalent to a formal diagnosis. Dr McQuire commented in a news release: "The results are based on a screening tool, which is not the same as a formal diagnosis. Nevertheless, the high rates of prenatal alcohol use and FASD-relevant symptoms that we found in our study suggest that FASD is likely to be a significant public health concern in the UK."

Dr McQuire told Medscape News UK: "The results from our study indicate that many children are exposed to alcohol in pregnancy and are a starting point in beginning to understand the number of individuals in the UK who could have symptoms consistent with FASD."

Data on Prenatal Exposure to Alcohol

Information from the ALSPAC study was collected almost 30 years ago and guidance on drinking during pregnancy has since changed. However, Dr McQuire noted in the press release:

"Rates of prenatal alcohol exposure in the UK have remained high. Recent estimates suggest that three quarters of women drink some alcohol during pregnancy, with one third at binge levels."

The British Pregnancy Advisory Service (BPAS), in responding to the study, explained that because about half of UK pregnancies are unplanned, "many women have an episode of binge drinking before they know they are pregnant". It said, "this helps explain figures which suggest that around 75% of women in the UK report drinking some alcohol in pregnancy." The charity also reported, when most women were aware of their pregnancy, "the overwhelming majority (96%) drank low levels of just 1-2 units per week for which there is no evidence of harm".

The UK Chief Medical Officers' 2016 guidelines state: "If you are pregnant or think you could become pregnant, the safest approach is not to drink alcohol at all, to keep all risks to your baby [to] a minimum." It also notes: "The risk of harm to the baby is likely to be low if you have drunk only small amounts of alcohol before you knew you were pregnant or during pregnancy."

Controversial Results 

Although the study’s estimate of a 17% FASD screening prevalence is significantly higher than those of FASD prevalence studies of Europe and the USA of 10%, it reports that the UK’s PAE is one of the highest in the world - the PAE estimate in the USA is 15%, compare to 41% in the UK - so a relatively high FASD prevalence would be plausible.

The BPAS noted that of the 13,495 people within the cohort studied, only 223 had full data sets, and for this group the estimated prevalence was significantly lower at 7%. Clare Murphy, director of external affairs at the BPAS, said:

"We advise real caution over the interpretation and communication of these findings. This study, as the authors themselves acknowledge, does not prove any causal link between pregnancy drinking and the developmental outcomes recorded, and may cause pregnant women and parents needless anxiety."

Because many women have drunk alcohol before finding out they are pregnant, the charity is concerned that the information could "lead some women to consider ending what would otherwise be a wanted pregnancy".

Dr McQuire told Medscape News UK: "Missing data are common in these types of large cohort studies and it is correct to point out that only 223 participants had complete information on all the tests that were included in the comprehensive FASD screening measure. Compared to participants with complete data, those with some missing information experienced more adverse exposures in pregnancy and had poorer developmental outcomes relevant to FASD. Therefore, prevalence estimates based on the complete data only were likely to underestimate FASD prevalence. We used established statistical methods, known as multiple imputation, to address this issue. The 17% screening prevalence is based on this established method and is likely to provide a less biased estimate than the estimate that used complete data only."

Positive Responses

Other organisations have responded with support for the study. Dr Christopher Steer of the Royal College of Paediatrics and Child Health (RCPCH) said: "The screening methodology is well designed, ingenious, and conservative in its approach, and the large numbers of subjects in this birth cohort add considerable strength, relevance, and significance to the findings.

"This study also in my opinion underlines an urgent need for UK based active FASD surveillance studies, screening children in mid childhood at which point reliable diagnosis utilising [an] evidence based approach is entirely feasible."

Sandra Butcher, chief executive of NOFAS-UK, a charity that supports people affected by FASD, commented: "This study shines light on a staggeringly widespread and largely avoidable public health crisis. No policy maker who cares about the mental and physical health of the most vulnerable in our society should rest easy until we have in place UK-wide comprehensive action and training on FASD prevention, diagnosis, and support that extends across the individual's lifespan. Babies with FASD grow into adults with FASD and more support is needed on every level."

Preventive Medicine. Screening prevalence of fetal alcohol spectrum disorders in a region of the United Kingdom: a population-based birth-cohort study doi.org/10.1016/j.ypmed.2018.10.013 Paper .

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