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• Authors’ response to Dhillon and Sahu
  Loubaba Mamluk, Luisa Zuccolo and Abigail Fraser
  Published on: 10 November 2017
• Misinterpreting the message
  Elissa Kaur Dhillon, Ajay Sahu
  Published on: 26 October 2017
• Authors’ response to Salemi and Zoorob
  Loubaba Mamluk, Luisa Zuccolo and Abigail Fraser
  Published on: 9 October 2017
• There are plenty of problems, but paucity of evidence is not one of them
  Ulrik S Kesmodel
  Published on: 25 September 2017
• The Importance of Methodological Rigor and Communication of Information
  Jason L. Salemi, PhD, MPH, Roger J. Zoorob, MD, MPH
  Published on: 20 September 2017
• Liquor lobby cited (incorrectly) in article
  Dr Nicki Jackson, Christine Rogan
  Published on: 12 September 2017

• Published on: 10 November 2017

  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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  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 bold front page headline conveys certainty around its safety, which is irresponsible.

  Such misreporting may boost newspaper sales, but does not benefit public health. Providing a health message in plain contradiction to existing Department of Health guidelines, when this is explicitly not supported by the research supposedly being reported, is irresponsible. Today’s unborn babies won’t be buying copies of your paper anytime soon, but one day this misreporting could cost them, and the nation looking after them, very dearly."

  Yours,

  Dr Luisa Zuccolo, on behalf of the authors of “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-analysis. BMJ Open doi 10.1136/bmjopen-2016-015410”

  Despite our hard work communicating the message without ambiguity to the media and answering personally all media calls, some coverage ‘got it wrong', which was completely beyond our control. We appreciate efforts by public health and clinical colleagues like yourselves to point out which messages are misleading or plain wrong, striving for trustworthy information in this dangerous era of 'Fake news'. "

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  Conflict of Interest:
  None declared.

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• Published on: 26 October 2017

  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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  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 and coherent message to young women of conceiving age that we know about these risks and emphasise prevention is best. These types of articles need clear scrutiny and media should be more careful in spreading messages in a constructive way as their responsibility towards the welfare of our society.

  Kind Regards,

  Dr. E. Dhillon and Dr. A. Sahu

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  Conflict of Interest:
  None declared.

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• Published on: 9 October 2017

  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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  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 null.” Only later in the Discussion do they also note that “…women with an adverse pregnancy outcome may be even more likely to underreport alcohol consumption,” suggesting that alcohol consumption was ascertained retrospectively.

  Two independent reviewers read this paper and deemed it eligible for inclusion. As stated in our Methods section, we did not contact authors for further information. Having been alerted by Salemi and Zoorob to the use of birth certificates as the data source in Salihu et al., we are still unsure as to the where and when these data were ascertained. Were they abstracted from antenatal records (and hence prospectively assessed?)? Were they self-reported post-delivery (and hence retrospectively ascertained)? Do all hospitals in Missouri collect these data in the same manner? We have now contacted the authors of the original paper for clarification but have not yet had a response.

  In light of these concerns, carried out sensitivity analyses omitting the Salihu et al. study in the meta-analyses for preterm delivery and SGA. For preterm delivery, the pooled odds ratio including Salihu et al. and reported in the review was: 1.10 (95%CI: 0.95, 1.28, I2 = 59%). Excluding Salihu et al. it is 1.13 (0.92, 1.38; I2 = 41%). Respective results for SGA are: with Slaihu et al. 1.08 (95%CI: 1.02, 1.14; I2 = 0%) and 0.96 (95%CI: 0.80, 1.15, I2 = 0%) without. These changes would not affect our main findings as reported in the original review: “the two main findings are: (1) a surprisingly limited number of prospective studies specifically addressing the question of whether light maternal alcohol consumption (ie, up to 32g/week (or 4 UK units) has any causal effect (adverse or beneficial) on infant and later offspring outcomes and pregnancy outcomes, and, as a result, (2) a paucity of evidence demonstrating a clear detrimental effect, or safe limit, of light alcohol consumption on outcomes.”

  Salemi and Zoorob also question why we included specific results from Ernhart et al. (4, reference 59 in the review) in Table 2. We presented results of analyses in which Ernhart et al. used maternal self-reported alcohol consumption during pregnancy. We did not include results of analyses in which alcohol consumption prior to or just after conception was estimated from an equation developed in a separate sample. We feel that prioritising the results based on prospective maternal report, which is comparable to other studies, was a sensible decision.

  Loubaba Mamluk, Luisa Zuccolo and Abigail Fraser on behalf of all co-authors

  References
  1. Salemi JL and Zoorob RJ. The importance of methodological rigor and communication of information. http://bmjopen.bmj.com/content/7/7/e015410.responses#the-importance-of-m....
  2. Salihu HM, Kornosky JL, Lynch O, Alio AP, August EM, Marty PJ. Impact of prenatal alcohol consumption on placenta-associated syndromes. Alcohol (Fayetteville, NY). 2011;45(1):73-79.
  3. Mamluk L, Edwards HB, Savović J, et al. 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. BMJ Open 2017;7:e015410. doi: 10.1136/bmjopen-2016-015410
  4. Ernhart CB, Sokol RJ, Ager JW, Morrow-Tlucak M, Martier S. Alcohol-related birth defects: assessing the risk. Annals of the New York Academy of Sciences. 1989;562:159-172.

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  Conflict of Interest:
  We are the authors of the paper

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• Published on: 25 September 2017

  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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  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 slightly higher cut-offs would have enabled the authors to include far more studies. The conclusion from all the reviews and meta-analyses remain the same, ie. little evidence of any association between low alcohol intake on a weekly basis with any adverse outcome.1 2 3 But the conclusion that the evidence is sparse does not seem correct. There is, in fact, quite a few studies if the limit for low intake is set slightly higher; and if (the majority of) studies with a higher cut-off of e.g. 36, 48 g/week or something similar generally show no association with the outcomes of interest, the conclusion should not be that there is paucity of evidence for intake up to 32 g/week. There is plenty of evidence of no association, only the evidence does not fit the British definition of 32 g but mainly with slightly higher cut-off points.

  Ulrik Schiøler Kesmodel
  Professor in obstetrics and gynaecology
  Herlev University Hospital, Copenhagen
  Institute for Clinical Medicine, University of Copenhagen

  1. Mamluk L, Edwards HB, Savović J et al. 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. BMJ Open 2017;7:e015410. doi:10.1136/bmjopen-2016-015410.
  2. Patra J, Bakker R, Irving H, et al. Dose-repsonse relationship between alcohol consumption before and during pregnancy and the risks of low birthweight, preterm birth and small for gestational age (SGA) - a systematic review and meta-analyses. BJOG 2011; 118: 1411-1421. DOI: 10.1111/j.1471-0528.2011.03050.x
  3. Flak AL, Su S, Bertrand J, Denny CH, Kesmodel US, Cogswell ME. The association between mild, moderate, and binge prenatal alcohol exposure and child

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  Conflict of Interest:
  None declared.

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• Published on: 20 September 2017

  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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  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’ Low Risk Drinking Guidelines (5) it is stated that “If you are pregnant or think you could become pregnant, the safest approach is not to drink alcohol at all, to keep risks to your baby to a minimum.” In regards to women who wish to stay below 1-2 units per day during pregnancy, they state, “Women who wish to stay below these levels need to be careful to avoid underestimating their actual consumption. The safer option is not to drink alcohol at all during pregnancy.” We feel the Chief Medical Officers’ message is quite clear.

  We are more concerned with seeming inconsistencies between the authors’ stated methodology and decisions made during the conduct of their systematic review. The methods section is well articulated and thorough and the authors [appropriately] state that eligible studies [for their review] must have had “prospective assessment of prenatal alcohol exposure (ie, before birth).” In fact, the entire case-control study design is ineligible for this reason, and the increased potential for recall bias, possibly differential based on the pregnancy outcome, that is associated with retrospective assessment of alcohol consumption. However, a single US study (6) that the authors admit accounts for >90% of participants included in the meta-analysis for SGA and preterm birth, and therefore drives the meta-analyses on these two outcomes, and is either the only or one of two studies for stillbirth, placental abruption, placenta previa, and pre-eclampsia, does not meet the authors’ own criteria. In fact, the dataset used in the study assesses maternal alcohol consumption based on what is documented on the birth certificate (6). Not only is this not prospective assessment of maternal alcohol consumption and prone to substantial bias, but birth certificates have been reported repeatedly to be one of the worst sources of such information, with extremely poor sensitivity and positive predictive value (7-10). Even the authors of that study acknowledge the 1.3% prevalence of maternal alcohol consumption during pregnancy grossly underestimates what was to be expected based on national data (10-16%). Clearly, this study fails to meet the criteria for this systematic review; regardless, the poor quality of maternal alcohol consumption data from this study would preclude its inclusion in a systematic review searching for reliable evidence to address an important public health question. Considering the overwhelming influence this study has on the meta-analysis conducted by Mamluk and colleagues, we feel this calls into question any conclusions drawn for preterm birth and SGA, and well as non-meta-analysis summaries for stillbirth, placental abruption, placenta previa, and pre-eclampsia.

  We are also a bit confused as to the authors’ decisions regarding the inclusion/exclusion of data from one of only three studies on the association between low maternal consumption of alcohol during pregnancy and FASD malformations. This 1989 study by Ernhart et al (11) assessed varying levels of maternal alcohol consumption and the “tally” of both craniofacial and total birth defects. Mamluk and colleagues report in their systematic review the results from Tables 2 and 3 from Ernhart et al., which shows no statistically significant increased ‘tally’ of birth defects for low alcohol consumers (>0.0, ≤0.1 average ounces of alcohol per day) compared to abstainers. Alcohol exposure was assessed prospectively during pregnancy and met Mamluk’s criteria. However, Ernhart and colleagues acknowledge that this method may not reflect alcohol use during the period at, or shortly after, conception (ie, before a woman knows she is pregnant). Therefore, they used an additional method – ‘estimated embryonic average ounces of alcohol per day’ – to estimate exposure during a time window that is critical for alcohol-related dysmorphology (11). This technique, too, seemed to fit Mamluk’s systematic review criteria since it was based on responses elicited prior to delivery/birth. Futhermore, Tables 6 and 7 from Ernhart et al. reveal a statistically significantly (p=0.042) increased ‘tally’ of craniofacial anomalies for low alcohol consumers (>0.0, ≤0.1 average ounces of alcohol per day) compared to abstainers, and a borderline significant results for total anomalies (p=0.06). We are curious as to why one seemingly relevant approach was included in their review, but not another.

  We appreciate the desire for Mamluk and colleagues to contribute to this very important evidence base. We also agree that in epidemiology and clinical practice, we often do a poor job of communicating absolute risk; therefore, we were pleased to read the UK Chief Medical Officers’, statement, “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” to prevent undue stress for women who drank small amounts prior to realizing they were pregnant or even during early pregnancy (5). Clearly, Mamluk’s systematic review should be a call to action for researchers to provide more reliable evidence to all stakeholders. However, in light of the clear evidence for adverse effects of higher levels of alcohol consumption, and the fact that we do not know of a safe amount of alcohol use during pregnancy, we feel hesitant to propose changes to nearly every country’s messaging in support of abstinence. We are particularly concerned by the New York Post’s title of “Light drinking during pregnancy does not harm baby: study” that covered the findings of this review.

   
  REFERENCES
  1. Mamluk L, Edwards HB, Savovic J, et al. 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. BMJ Open. 2017;7(7):e015410.
  2. Howard J. CNN: Is light drinking while pregnant OK? 2017; http://www.cnn.com/2017/09/11/health/drinking-alcohol-pregnant-study/ind.... Accessed September 12, 2017.
  3. Dovey D. Newsweek: Can You Drink While Pregnant? Even Light Drinking Can Cause Problems 2017; http://www.newsweek.com/can-you-drink-while-pregnant-even-light-drinking.... Accessed September 13, 2017.
  4. Whittfield T. New York Post: Light drinking during pregnancy does not harm baby: study. 2017; http://nypost.com/2017/09/11/light-drinking-during-pregnancy-does-not-ha.... Accessed September 12, 2017.
  5. Health UDo. UK Chief Medical Officers’ Low Risk Drinking Guidelines. . 2016; https://www.gov.uk/government/uploads/system/uploads/attachment_data/fil.... Accessed September 15, 2017.
  6. Salihu HM, Kornosky JL, Lynch O, Alio AP, August EM, Marty PJ. Impact of prenatal alcohol consumption on placenta-associated syndromes. Alcohol (Fayetteville, NY). 2011;45(1):73-79.
  7. Northam S, Knapp TR. The reliability and validity of birth certificates. J Obstet Gynecol Neonatal Nurs. 2006;35(1):3-12.
  8. Piper JM, Mitchel EF, Jr., Snowden M, Hall C, Adams M, Taylor P. Validation of 1989 Tennessee birth certificates using maternal and newborn hospital records. Am J Epidemiol. 1993;137(7):758-768.
  9. Reichman NE, Hade EM. Validation of birth certificate data. A study of women in New Jersey's HealthStart program. Ann Epidemiol. 2001;11(3):186-193.
  10. Zollinger TW, Przybylski MJ, Gamache RE. Reliability of Indiana birth certificate data compared to medical records. Ann Epidemiol. 2006;16(1):1-10.
  11. Ernhart CB, Sokol RJ, Ager JW, Morrow-Tlucak M, Martier S. Alcohol-related birth defects: assessing the risk. Annals of the New York Academy of Sciences. 1989;562:159-172.

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  Conflict of Interest:
  None declared.

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• Published on: 12 September 2017

  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.

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