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Low alcohol consumption and pregnancy and childhood outcomes: time to change guidelines indicating apparently ‘safe’ levels of alcohol during pregnancy? A systematic review and meta-analyses
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  • Published on:
    Authors’ response to Dhillon and Sahu
    • Loubaba Mamluk, Senior Research Associate in Epidemiology/Knowledge Transfer University of Bristol
    • Other Contributors:
      • Luisa Zuccolo, Senior Research Fellow in Epidemiology
      • Abigail Fraser, Reader in Epidemiology

    Thank you for your ELetter. We agree with you, this is why we took issue with the misleading media coverage and made our best efforts to rectify the message where we felt it had been distorted (both in print and in radio interviews). See our rebuttal to the (London) Times for an example of this:

    "Sir
    In relation to “Light drinking does no harm in pregnancy”, The Times 12/09/2017
    We write to you to complain about the highly misleading front page coverage that your paper dedicated yesterday to our scientific study, and to rectify the wrong messages you have propagated.
    Frustratingly, in today’s paper your columnist has said: “Alcohol […] drinking in pregnancy, which many health professionals considered a crime only a month ago, now appears to be acceptable in moderation” (from “Take health advice with a big pinch of salt” The Times 13/09/2017). This continues the misinformation that yesterday’s article started. To say that “light drinking does no harm in pregnancy” is a gross misrepresentation of our findings – detailed in the scientific paper, summarised in the press release, and distilled and interpreted in plain language by one of our lead authors in conversation with your journalist.

    We went to great lengths to stress that ‘little or no evidence does not mean little or no effect’. In other words, we have little evidence that light drinking in pregnancy is harmful, but we also have little evidence that it is safe! Conversely, your bol...

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    Conflict of Interest:
    None declared.
  • Published on:
    Misinterpreting the message
    • Elissa Kaur Dhillon, Medical Doctor Royal Brompton Hospital
    • Other Contributors:
      • Ajay Sahu, Radiologist

    Dear Authors,

    Many thanks for your article regarding the safety of low alcohol consumption in pregnancy. Interestingly we heard about this article on BBC radio 4 news, while driving during rush hours, which came to us as a surprise. Having read through this comprehensive literature review, it is clear that current guidelines do not appreciate low alcohol consumption in pregnancy.

    Being doctors, it is clear to us that the risks are low, however media portrayal of this article came across that alcohol is medically acceptable in pregnancy. This argument may lead to unnecessary justification of alcohol use during pregnancy increasing vulnerability of foetus to future risk. It is eye-catching article for media and hence got a lot of attention however potentially a misleading article, which could be misinterpreted in the wrong hands, with risks not only to mothers but also to their children.

    We appreciate that although this article has looked into available literature showing little evidence for the effects of low alcohol consumption in pregnancy, and that further research in this field may come across ethical issues. However, we do feel that extrapolating this lack of evidence to make assertions such as “safety” of alcohol in pregnancy could potentially be harmful.

    Alcohol consumption in pregnancy is advised against due to the risk of foetal alcohol syndrome and other complications to the mother. Given these risks it is important to send a clear...

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    Conflict of Interest:
    None declared.
  • Published on:
    Authors’ response to Salemi and Zoorob
    • Loubaba Mamluk, Senior Research Associate in Epidemiology/Knowledge Transfer University of Bristol
    • Other Contributors:
      • Luisa Zuccolo, Senior Research Fellow
      • Abigail Fraser, Reader in Epidemiology

    We agree with Professors Salemi and Zoorob (1) that the 2016 UK guidelines’ message regarding the consumption of alcohol during pregnancy is clear: it is best to be avoided. However, this has not always been the case and previous guidelines implicitly suggested that drinking up to 4 units per week was likely to be safe. We also recognise the methodological challenges of studying long term effects of low maternal alcohol consumption in pregnancy. Like Salemi and Zoorob, we feel that the paucity of evidence is unfortunate and should be addressed. We also maintain that in light of the evidence that is available, basing guidelines on the precautionary principle is reasonable.

    Specifically, Salemi and Zoorob raise concerns about the inclusion of a study by Salihu et al. (2, reference 27 in the review) in the review (3), because maternal alcohol consumption was determined retrospectively, i.e. after delivery. Our predefined eligibility criterion was explicit - we required alcohol consumption to be ascertained prior to pregnancy. Salemi and Zoorob therefore question the inclusion of Salihu et al.’s study in our review. In the Methods section, Salihu et al. state that they used “the Missouri linked cohort data files…1989 through 2005.” No further details are provided The Discussion states that “Alcohol was based on maternal recall and therefore subject to bias. Women may underreport actual alcohol consumption because of societal stigmas, biasing study results toward the nu...

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    Conflict of Interest:
    We are the authors of the paper
  • Published on:
    There are plenty of problems, but paucity of evidence is not one of them
    • Ulrik S Kesmodel, Professor of obstetrics and gynaecology Herlev University Hospital

    Dear Sir,
    In their recent paper,1 Mamluk et al describe the results of a systematic review and meta-analyses of the association between low alcohol intake in pregnancy and several adverse birth outcomes and long-term outcomes in children. The authors conclude that there is “limited evidence for a causal role of light drinking in pregnancy, compared with abstaining, on most of the outcomes examined” and that their “extensive review shows that this specific question is not being researched thoroughly enough, if at all.”

    I sympathize with the thorough work performed by the authors. Even so, a word of caution is needed with respect to the second part of their conclusion. The authors defined the intake of interest as a maximum of 32 g of alcohol per week corresponding to 4 standard UK drinks/week. While this makes sense from a British point of view, the definition of a standard drink being 8 g of alcohol, this cut-off makes little sense in most non-British countries, where a standard drink is typically defined as containing 10-12 g. Hence, a large number of non-British studies using three or four drinks as their cut-off for low intake have not been included in the present review, only because their definition did not correspond with the British.

    Several meta-analyses in recent years have used slightly more embracing definitions.2 3 These meta-analyses included far more studies, simply because a limit of 32 g fits poorly with international definitions. Using...

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    Conflict of Interest:
    None declared.
  • Published on:
    The Importance of Methodological Rigor and Communication of Information
    • Jason L. Salemi, PhD, MPH, Assistant Professor of Epidemiology Department of Family and Community Medicine, Baylor College of Medicine
    • Other Contributors:
      • Roger J. Zoorob, MD, MPH, Professor and Chair

    Dr. Mamluk and colleagues’ recent systematic review and publication in BMJ Open (1) carries with it a provocative title and over the past week its conclusions have garnered substantial attention by news organizations such as CNN (2), Newsweek (3), and the New York Post (4). Although we agree completely with the authors’ assertion that there is a significant gap in the literature concerning low levels of maternal alcohol consumption during pregnancy, we have some substantial concerns regarding misleading statements in the paper and inconsistencies between the methodology that was stated versus that which was conducted.

    First, in the introduction, the authors claim that “Internationally, clinical guidelines recommend that pregnant women should abstain from heavy or ‘binge’ drinking”. Although technically correct, it is misleading since the messaging reported in the authors’ cited reference actually shows that nearly every country advises abstaining from any alcohol consumption during pregnancy – not just heavy or binge drinking. Furthermore, the authors state that “…UK guidelines advised women to avoid drinking alcohol while trying to conceive, and in the first trimester, but at the same time indicated that consumption should be restricted to within ‘1 to 2 UK units, one or twice a week.” Their statement makes it seem as though the UK message is contradictory regarding maternal alcohol consumption during pregnancy – it is not. In the 2016 UK Chief Medical Officers’ Lo...

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    Conflict of Interest:
    None declared.
  • Published on:
    Liquor lobby cited (incorrectly) in article
    • Dr Nicki Jackson, Executive Director Alcohol Healthwatch
    • Other Contributors:
      • Christine Rogan, Health Promotion Advisor - FASD

    It is concerning to read on page 1 of the introduction that “Internationally, clinical guidelines recommend that pregnant women should abstain from heavy or ‘binge’ drinking'". The reference cites the liquor industry social aspects organisation [http://www.iard.org/] as their source, which we admit find rather unusual. What is more unfortunate is the authors then misrepresent the content found on the industry website. Rather than the guidelines recommending the avoidance of heavy drinking, all of the 54 countries’ guidelines for alcohol and pregnancy advise abstinence, and the only exception is Bulgaria which offers a low-risk level for pregnant women who do choose to consume. This appears contradictory to the statement made by the authors in their introduction.

    Conflict of Interest:
    None declared.