Prenatal alcohol exposure and attention, learning and intellectual ability at 14 years: a prospective longitudinal study

Systematic Review and Meta-analysis of the Relationship Between Exposure to Parental Substance Use and Attention-Deficit/Hyperactivity Disorder in Children

Attention-deficit/hyperactivity disorder (ADHD) is characterized by persistent patterns of inattention, hyperactivity, and impulsiveness. Among US children and adolescents aged 3-17 years, 9.4% have a diagnosis of ADHD. Previous research suggests possible links between parental substance use and ADHD among children. We conducted a systematic review and meta-analysis of 86 longitudinal or retrospective studies of prenatal or postnatal alcohol, tobacco, or other parental substance use and substance use disorders and childhood ADHD and its related behavioral dimensions of inattention and hyperactivity-impulsivity. Meta-analyses were grouped by drug class and pre- and postnatal periods with combined sample sizes ranging from 789 to 135,732. Prenatal exposure to alcohol or tobacco and parent substance use disorders were consistently and significantly associated with ADHD among children. Other parental drug use exposures resulted in inconsistent or non-significant findings. Prevention and treatment of parental substance use may have potential for impacts on childhood ADHD.

Low to Moderate Prenatal Alcohol Exposure and Neurodevelopmental Outcomes: A Narrative Review and Methodological Considerations

PURPOSE

Although abstinence is recommended in pregnancy, many pregnancies are exposed to alcohol. Observational studies of the effects of low to moderate prenatal alcohol exposure (PAE) and neurodevelopmental outcomes have yielded inconsistent results, with some studies finding an increased risk of adverse neurobehavioral and cognitive outcomes, and other studies finding no changes or reduced risk of the same outcomes. The purpose of this narrative review is to summarize these inconsistencies and apply a methodological framework to discuss how different parameters contribute to the findings. The authors also provide recommendations on how to advance future research in this area.

SEARCH METHODS

The PubMed, Web of Science, and Embase databases were searched, along with reference lists of selected systematic reviews and meta-analyses. Search terms used were (infant or child or children or adolescent or offspring) AND (low or light or mild or moderate or low-to-moderate) AND (drinking or alcohol or drinks) AND (pregnancy or prenatal or fetal) AND (neurodevelopment or behavioral or psychological or cognitive or developmental) NOT (mice or rat or fish or animal) NOT (meta-analysis or review). Peer-reviewed original research studies were included if they analyzed associations between an exposure defined and characterized as low/light or moderate PAE with offspring neurodevelopmental outcomes. Animal studies, studies that did not provide clear cutoff points to classify PAE categories, studies lacking an abstinence control group, and studies that did not present a multivariable-adjusted measure of association were excluded.

SEARCH RESULTS

The searches identified 2,422 papers, with 36 papers meeting eligibility criteria. These studies were carried out across nine countries and included samples ranging from approximately 500 to 40,000 participants. Cognitive, academic, socioemotional, and behavioral outcomes were assessed from infancy through age 19.

DISCUSSION AND CONCLUSION

When the findings from the selected articles were summarized by geographic region, exposure definition, or neurodevelopmental outcome, no consistent observations or patterns emerged between low to moderate PAE and offspring outcomes. Although some studies found positive (i.e., beneficial) associations between low to moderate PAE and outcomes (primarily outcomes related to cognition) and others found negative (i.e., detrimental) associations (primarily for behavioral outcomes), most findings were null (i.e., showed no effect of PAE). The heterogeneity in study results is likely due to methodological issues, including residual confounding, effect measure modification, and exposure misclassification that make synthesis of studies difficult. Alternative study designs, including longitudinal trajectory analysis, sibling design, negative controls, and instrumental variable analyses, may reduce biases and are discussed. To date, the consequences of light to moderate levels of PAE on neurodevelopment remain unresolved; studies that advance methodological rigor will be important contributions to the field.

Impact of prenatal alcohol exposure on neurodevelopmental outcomes: a systematic review

Background

Prenatal exposure to alcohol (PAE) represents a significant public health concern. Previous research linking PAE to neurodevelopmental outcomes has been mixed and often has limited focus on residual confounding or moderating factors.

Methods

A systematic review of prospective cohort studies (n = >1000) assessing the impact of PAE on neurodevelopmental outcomes was undertaken (neurophysiology, motor skills, cognition, language, academic achievement, memory, attention, executive function, affect regulation, and adaptive behaviour, social skills, or communication). Electronic searches of EMBASE, Medline, CINAHL, and Psychinfo were conducted in May 2021. A quality assessment was conducted using an adapted version of the Newcastle-Ottawa Scale (NOS).

Results

Thirty longitudinal cohort studies met the inclusion criteria. Evidence of the impact of PAE was mixed across domains. We found no evidence that PAE affects executive function, but there were impacts on motor skills, cognition, language, academic achievement, attention, affect regulation, and adaptive behaviour. The most consistent adverse effect was on affect regulation (nine out of thirteen studies, six of which found an association between heavy alcohol consumption or binge drinking during pregnancy). We found no protective factors. Few studies controlled for variables in the postnatal environment.

Discussion

This review was unable to conclude a safe level of alcohol consumption during pregnancy. Methodological improvements are needed to improve the quality and consistency in which PAE is studied. Further research into residual confounding variables is vital, including a greater focus on the postpartum environment.

Prevalence and Patterns of Prenatal Alcohol Exposure in Australian Cohort and Cross-Sectional Studies: A Systematic Review of Data Collection Approaches

This study sought to determine data collection approaches in Australian cohort studies and explore the potential impact on reported prenatal alcohol exposure (PAE) prevalence and patterns. Inclusion criteria were that studies related to a general Australian antenatal population where PAE was assessed and reported. Studies were excluded if they were not peer reviewed, examined the prevalence of PAE in pregnancies complicated by alcohol-use disorders, or were published in a language other than English. A systematic search of five electronic databases (PubMed, Embase, CINAHL, Web of Science, and Scopus) was conducted. Risk of bias was assessed using the Effective Public Health Practice Project quality assessment tool. Results were synthesised using MetaXL. Data from 16 separate birth cohorts (n = 78 articles) were included. Included cohorts were either general cohorts that included alcohol as a variable or alcohol-focused cohorts that were designed with a primary focus on PAE. PAE prevalence was estimated as 48% (95% CI: 38 to 57%). When subgroup analysis was performed, estimates of PAE prevalence when self-administered surveys and interviews were used for data collection were 53% (95% CI: 41% to 64%) and 43% (95% CI: 28% to 59%), respectively. Use of trained assessors was an influencing factor of the prevalence estimates when data were collected via interview. Alcohol-focused studies reported higher prevalence of PAE, regardless of method of survey administration. Where interviewer training is not possible, self-administered questionnaires will likely provide the most reliable PAE estimates. No funding sources are relevant to mention. Review was registered with PROSPERO (CRD42020204853).

Dose-Related Reduction in Hippocampal Neuronal Populations in Fetal Alcohol Exposed Vervet Monkeys

Fetal alcohol spectrum disorder (FASD) is a chronic debilitating condition resulting in behavioral and intellectual impairments and is considered the most prevalent form of preventable mental retardation in the industrialized world. We previously reported that 2-year-old offspring of vervet monkey (Chlorocebus sabeus) dams drinking, on average, 2.3 ± 0.49 g ethanol per Kg maternal body weight 4 days per week during the last third of pregnancy had significantly lower numbers of CA1 (−51.6%), CA2 (−51.2%) and CA3 (−42.8%) hippocampal neurons, as compared to age-matched sucrose controls. Fetal alcohol-exposed (FAE) offspring also showed significantly lower volumes for these structures at 2 years of age. In the present study, we examined these same parameters in 12 FAE offspring with a similar average but a larger range of ethanol exposures (1.01–2.98 g/Kg/day; total ethanol exposure 24–158 g/Kg). Design-based stereology was performed on cresyl violet-stained and doublecortin (DCX)-immunostained sections of the hippocampus. We report here significant neuronal deficits in the hippocampus with a significant negative correlation between daily dose and neuronal population in CA1 (r² = 0.486), CA2 (r² = 0.492), and CA3 (r² = 0.469). There were also significant correlations between DCX population in the dentate gyrus and daily dose (r² = 0.560). Both correlations were consistent with linear dose-response models. This study illustrates that neuroanatomical sequelae of fetal ethanol exposure are dose-responsive and suggests that there may be a threshold for this effect.

Periconceptual and prenatal alcohol consumption and neurodevelopment at age two and five years

OBJECTIVE

Examine the association between alcohol consumption before and during pregnancy and neurodevelopmental outcomes in the offspring at two and five years.

STUDY DESIGN

Retrospective analysis of a prospective longitudinal cohort; SCOPE-BASELINE. Data on pre-conception and prenatal alcohol consumption were obtained at 15 weeks' gestation and categorised as abstinent, occasional-low (1-7units/week) and moderate-heavy (≥8units/week). Binge drinking was defined as ≥6 units/session. Outcome measures (Child Behaviour Checklist and Kaufman Brief Intelligence Test) were obtained at two and five years. Linear regression examined an alcohol consumption and Child Behaviour Checklist and Kaufman Brief Intelligence Test relationship, adjusting for several potential confounders.

RESULTS

Data on alcohol consumption was available for 1,507 women. Adjusted linear regression suggested few associations: pre-pregnancy occasional-low alcohol consumption was associated with lower log externalizing Child Behaviour Checklist scores (-0.264, 95% CI: -0.009, -0.520), while pre-pregnancy moderate-high levels of alcohol consumption was associated with lower Kaufman Brief Intelligence Test verbal standard scores (-0.034, 95% CI: -0.001, -0.068) and composite IQ scores (-0.028, 95% CI: -0.056, -0.0004) at five-years. In the first trimester, moderate-high levels of alcohol consumption was associated with lower internalizing Child Behaviour Checklist scores at two-years (-0.252, 95% CI: -0.074, -0.430). No significant associations were observed between number of binge episodes pre-pregnancy or binge drinking in the first trimester and Child Behaviour Checklist or Kaufman Brief Intelligence Test.

CONCLUSIONS

We did not find strong evidence of associations between pre-pregnancy and early pregnancy maternal alcohol consumption and adverse neurodevelopmental outcomes at age two and five years overall. Further research examining alcohol consumption (including binge drinking) beyond 15 weeks' gestation and subsequent neurodevelopmental outcomes is needed to examine the potential effect of alcohol consumption in later pregnancy.

Individual and Combined Association Between Prenatal Polysubstance Exposure and Childhood Risk of Attention-Deficit/Hyperactivity Disorder

IMPORTANCE

Polysubstance use among pregnant women has increased because of the opioid epidemic and the increasing legalization of cannabis along with persistent tobacco and alcohol consumption. Previous research on prenatal substance use and the child's risk of attention-deficit/hyperactivity disorder (ADHD) has mostly focused on single-substance exposures; simultaneous examination of multiple substance use and assessment of their synergistic health consequences is needed.

OBJECTIVES

To assess the consequences of the use of specific substances during pregnancy, investigate whether the interaction of multiple prenatal substance exposures is associated with increases in the risk of childhood ADHD, and estimate the aggregate burden of polysubstance exposure during gestation.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study analyzed data from the Boston Birth Cohort from 1998 to 2019. The sample of the present study comprised a multiethnic urban cohort of mother-child pairs who were predominantly low income. A total of 3138 children who were enrolled shortly after birth at Boston Medical Center were included and followed up from age 6 months to 21 years.

EXPOSURES

Substance use during pregnancy was identified based on self-reported tobacco smoking, alcohol consumption, and use of cannabis, cocaine, or opioids in any trimester of pregnancy. Diagnostic codes for neonatal opioid withdrawal syndrome or neonatal abstinence syndrome from the International Classification of Diseases, Ninth Revision, and the International Classification of Diseases, Tenth Revision, were also used to identify opioid exposure during gestation.

MAIN OUTCOMES AND MEASURES

ADHD diagnosis in the child's electronic medical record.

RESULTS

Among 3138 children (1583 boys [50.4%]; median age, 12 years [IQR, 9-14 years]; median follow-up, 10 years [IQR, 7-12 years]) in the final analytic sample, 486 (15.5%) had an ADHD diagnosis and 2652 (84.5%) were neurotypical. The median postnatal follow-up duration was 12 years (IQR, 9-14 years). Among mothers, 46 women (1.5%) self-identified as Asian (non-Pacific Islander), 701 (22.3%) as Hispanic, 1838 (58.6%) as non-Hispanic Black, 227 (7.2%) as non-Hispanic White, and 326 (10.4%) as other races and/or ethnicities (including American Indian or Indigenous, Cape Verdean, Pacific Islander, multiracial, other, or unknown). A total of 759 women (24.2%) reported the use of at least 1 substance during pregnancy, with tobacco being the most frequently reported (580 women [18.5%]). Cox proportional hazards models revealed that opioid exposure (60 children) had the highest adjusted hazard ratio (HR) for ADHD (2.19; 95% CI, 1.10-4.37). After including main statistical effects of all individual substances in an elastic net regression model, the HR of opioids was reduced to 1.60, and evidence of a statistical interaction between opioids and both cannabis and alcohol was found, producing 1.42 and 1.15 times higher risk of ADHD, respectively. The interaction between opioids and smoking was also associated with a higher risk of ADHD (HR, 1.17).

CONCLUSIONS AND RELEVANCE

The findings of this study suggest that it is important to consider prenatal concurrent exposure to multiple substances and their possible interactions when counseling women regarding substance use during pregnancy, the future risk of ADHD for their children, and strategies for cessation and treatment programs.

Association of adverse prenatal exposure burden with child psychopathology in the Adolescent Brain Cognitive Development (ABCD) Study

OBJECTIVE

Numerous adverse prenatal exposures have been individually associated with risk for psychiatric illness in the offspring. However, such exposures frequently co-occur, raising questions about their cumulative impact. We evaluated effects of cumulative adverse prenatal exposure burden on psychopathology risk in school-aged children.

METHODS

Using baseline surveys from the U.S.-based Adolescent Brain and Cognitive Development (ABCD) Study (7,898 non-adopted, unrelated children from 21 sites, age 9-10, and their primary caregivers), we examined 8 retrospectively-reported adverse prenatal exposures in relation to caregiver-reported total and subscale Child Behavior Checklist (CBCL) scores. We also assessed cumulative effects of these factors on CBCL total as a continuous measure, as well as on odds of clinically significant psychopathology (CBCL total ≥60), in both the initial set and a separate ABCD sample comprising an additional 696 sibling pairs. Analyses were conducted before and after adjustment for 14 demographic and environmental covariates.

RESULTS

In minimally and fully adjusted models, 6 exposures (unplanned pregnancy; maternal alcohol, marijuana, and tobacco use early in pregnancy; pregnancy complications; and birth complications) independently associated with significant but small increases in CBCL total score. Among these 6, none increased the odds of crossing the threshold for clinically significant symptoms by itself. However, odds of exceeding this threshold became significant with 2 exposures (OR = 1.86, 95% CI 1.47-2.36), and increased linearly with each level of exposure (OR = 1.39, 95% CI 1.31-1.47), up to 3.53-fold for ≥4 exposures versus none. Similar effects were observed in confirmatory analysis among siblings. Within sibling pairs, greater discordance for exposure load associated with greater CBCL total differences, suggesting that results were not confounded by unmeasured family-level effects.

CONCLUSION

Children exposed to multiple common, adverse prenatal events showed dose-dependent increases in broad, clinically significant psychopathology at age 9-10. Fully prospective studies are needed to confirm and elaborate upon this pattern.

Cognitive and Behavioural Attention in Children with Low-Moderate and Heavy Doses of Prenatal Alcohol Exposure: a Systematic Review and Meta-analysis

Attention problems are thought to be a hallmark feature of prenatal alcohol exposure (PAE). Despite decades of research however, these findings have never been pooled to assess the association between PAE and the different domains of attention functioning. This systematic review and meta-analysis aimed to examine the relationships between low-moderate, binge and heavy PAE with domains of attention functioning (encode, focus, shift, sustain and behavioural) in children. Thirteen studies compared children with PAE to abstinent controls. A significant adverse effect of any PAE on shifting attention (Cohen's d = -0.61), and a trend towards an adverse effect of heavy PAE on encoding attention (Cohen's d = -0.79) were identified. Compared to controls, there were trends showing that low-moderate PAE (odds ratio = 1.21) was associated with greater odds of behavioural attention problems. Remaining analyses were limited by insufficient studies or were non-significant. In summary, a vulnerability of higher-level attention skills to PAE was found. Urgent investigation into the effects of low to moderate PAE is needed given the prevalence of this drinking pattern, trends towards behavioural attention problems, the lack of comprehensive and high-quality research and the known impacts of attention difficulties on academic and social development in children.

A Meta-Analysis of Stressors from the Total Environment Associated with Children's General Cognitive Ability

General cognitive ability, often referred to as ‘general intelligence’, comprises a variety of correlated abilities. Childhood general cognitive ability is a well-studied area of research and can be used to predict social outcomes and perceived success. Early life stage (e.g., prenatal, postnatal, toddler) exposures to stressors (i.e., chemical and non-chemical stressors from the total (built, natural, social) environment) can impact the development of childhood cognitive ability. Building from our systematic scoping review (Ruiz et al., 2016), we conducted a meta-analysis to evaluate more than 100 stressors related to cognitive development. Our meta-analysis identified 23 stressors with a significant increase in their likelihood to influence childhood cognitive ability by 10% or more, and 80 stressors were observed to have a statistically significant effect on cognitive ability. Stressors most impactful to cognition during the prenatal period were related to maternal health and the mother’s ability to access information relevant to a healthy pregnancy (e.g., diet, lifestyle). Stressors most impactful to cognition during the early childhood period were dietary nutrients (infancy), quality of social interaction (toddler), and exposure to toxic substances (throughout early childhood). In conducting this analysis, we examined the relative impact of real-world exposures on cognitive development to attempt to understand the inter-relationships between exposures to both chemical and non-chemical stressors and early developmental life stages. Our findings suggest that the stressors observed to be the most influential to childhood cognitive ability are not permanent and can be broadly categorized as activities/behaviors which can be modified to improve childhood cognition. This meta-analysis supports the idea that there are complex relationships between a child’s total environment and early cognitive development.

Child maltreatment and attentional problems: A longitudinal birth cohort study

OBJECTIVE

To examine whether child maltreatment is associated with attentional problems in adolescence (14 years) and young adulthood (21 years), and whether outcomes depend on the type of maltreatment (sexual vs non-sexual).

METHODS

Data from a population based cohort study involving 3778 mother-child pairs were linked with data from the state child protection agency to examine associations between child abuse and neglect and attention problems, measured using the Achenbach Child Behaviour Checklist (CBCL) and the Achenbach Young Adult Self Report (YASR).

RESULTS

245 (6.5%) participants had been the subject of notification for non-sexual maltreatment (one or more of neglect, emotional or physical abuse) compared with only 54 (1.4%) who had been subject of notification for suspected sexual abuse. After adjusting for potential confounding variables including maternal, participant and sociodemographic factors, we found those exposed to non sexual maltreatment were likely to experience attentional problems at 14 years (p < .001) and 21 years of age (p = .044), compared with those participants who had not experienced non sexual maltreatment. By contrast, at age 14 years, sexual abuse was associated with attentional problems only as reported by the participant, not their carer. Results at 21 years of age for those exposed to sexual child maltreatment (p=.655) were again in contrast to the observed association between attentional problems and non sexual child maltreatment (p = .035).

CONCLUSION

In this study, non-sexual maltreatment in childhood is associated with attentional problems at both 14 years and 21 years of age. These findings highlight the need for targeted research to better understand the longer term mental health outcomes for children exposed to non-sexual maltreatment. Potential implications for mental health services include the need for broader screening at presentation and importantly, greater collaboration with schools, general practitioners and paediatricians, given the greatest impact would arguably be within these settings.

Light drinking during pregnancy: Social advantages explain positive correlates with child and early adolescent adjustment

Maternal heavy alcohol use during pregnancy is harmful to offspring's health and adjustment. However, findings from studies on lower levels of prenatal drinking are mixed; a few even predict positive cognitive and psychosocial outcomes. Given that alcohol is a neurotoxin and teratogen, scholars question developmental benefits and point to residual confounding as a potential explanation, particularly as light drinkers are positively selected with respect to health and socioeconomic status. Using prospective, intergenerational data from the nationally-representative Millennium Cohort Study (MCS) in the United Kingdom, we studied associations between mother's drinking during pregnancy and children's cognitive and psychosocial outcomes at ages 3, 5, 7, 11, and 14 years (n = 10,454). We included early life confounders (e.g., maternal education, health, smoking) and mother's cognitive ability, and assessed robustness of relationships across outcomes and alternate drinking classifications. Results of a series of multivariable regression models found no association between light drinking and cognitive and psychosocial outcomes up to and including the age of 14, after controlling for key confounders. Light drinking during pregnancy was linked to higher socioeconomic advantages (e.g., mothers' higher education, professional/managerial occupation, home ownership, cognitive scores), which together accounted for positive associations between light drinking and children's outcomes. Mother's cognitive ability was an especially important confounder.

Risk factors for alcohol use among pregnant women, ages 15-44, in the United States, 2002 to 2017

Fetal alcohol exposure can lead to severe birth and developmental defects. Determining which pregnant women are most likely to drink is essential for targeting interventions. In National Survey on Drug Use and Health data on pregnant women from 2002 to 2017 (N = 13,488), logistic regression was used to produce adjusted odds ratios (aOR) indicating characteristics associated with two past-month outcomes: any alcohol use and binge drinking. Risk factors were sociodemographic (age, race/ethnicity, marital status, education level, income) and clinical (trimester, substance use, alcohol use disorder, major depression). Where associations differed by pregnancy stage (trimester 1 vs. trimesters 2 and 3), association was evaluated by stage. Overall, higher risk for any and binge drinking was observed among those with other substance use (aORs 2.9-25.9), alcohol use disorder (aORs 4.5-7.5), depression (aORs = 1.6), and unmarried women (aORs 1.6-3.2). For any drinking, overall, higher risk was observed in adolescents (aOR = 1.5) and those with higher education (aOR = 1.4), while lower risk was observed in those with lower income (aORs = 0.7). For binge drinking, associations differed by pregnancy stage. In trimester 1, lower risk was observed in middle ages (aOR = 0.4). In trimesters 2/3, higher risk was observed in Blacks (aOR = 3.3) and those with lower income (aORs 3.5-3.9), while lower risk was observed in those with higher education (aOR = 0.3). To prevent severe prenatal harm, health care providers should focus on women at higher risk for binge drinking during pregnancy: women with tobacco or drug use, alcohol use disorder, or depression, and women who are unmarried, Black, or of lower socioeconomic status.

Role of MCP-1 and CCR2 in alcohol neurotoxicity

Alcohol abuse causes profound damage to both the developing brain and the adult brain. Prenatal exposure to alcohol results in a wide range of deficits known as fetal alcohol spectrum disorders (FASD). Alcohol abuse in adults is associated with brain shrinkage, memory and attention deficits, communication disorders and physical disabilities. Monocyte chemoattractant protein-1 (MCP-1/CCL2) is one of the key chemokines that regulate the recruitment and activation of monocytes and microglia. Both MCP-1 and its receptor C-C chemokine receptor type 2 (CCR2) expressed in the brain are involved in various neuroinflammatory disorders, such as multiple sclerosis (MS), Alzheimer's disease (AD) and Parkinson's disease (PD). However, the role of MCP-1/CCR2 in alcohol-induced brain damage is unclear. Recent evidence indicates that alcohol exposure increased the activity of MCP-1/CCR2 in both mature and developing central nervous systems (CNS). MCP-1/CCR2 signaling in the brain was involved in alcohol drinking behavior. MCP-1/CCR2 inhibition alleviated alcohol neurotoxicity by reducing microglia activation/neuroinflammation in the developing brain and spinal cord. In this review, we discussed the role of MCP-1/CCR2 signaling in alcohol-induced neuroinflammation and brain damage. We also discussed the signaling cascades that are involved in the activation of MCP-1/CCR2 in response to alcohol exposure.

Early exposure to ethanol is able to affect the memory of adult zebrafish: Possible role of adenosine

Ethanol is one of the most widely consumed drugs in the world, and the effects of ethanol during early development include morphological and cognitive problems. The regulation of adenosine levels is essential for the proper function of major neurotransmitter systems in the brain, particularly glutamate and dopamine; thus, the investigation of the relation of adenosine and memory after early ethanol exposure becomes relevant. Embryos of zebrafish were exposed to 1% ethanol during two distinct developmental stages: gastrula/segmentation or pharyngula. The evaluation of memory, morphology, and locomotor parameters was performed when fish were 3 months old. The effect of ecto-5'-nucleotidase and adenosine deaminase inhibition on the consequences of ethanol exposure with regard to memory formation was observed. Morphological evaluation showed decreases in body length and the relative telencephalic and cerebellar areas in ethanol exposed animals. The locomotor parameters evaluated were not affected by ethanol. In the inhibitory avoidance paradigm, ethanol exposure during the gastrula/segmentation and pharyngula stages decreased zebrafish memory retention. When ethanol was given in the pharyngula stage, the inhibition of ecto-5'-nucleotidase in the acquisition phase of memory tests was able to revert the effects of ethanol on the memory of adults. These findings suggest that the increased adenosine levels caused by ethanol could alter the neuromodulation of important components of memory formation, such as neurotransmitters. The adjustment of adenosine levels through ecto-5'-nucleotidase inhibition appears to be effective at restoring normal adenosine levels and the acquisition of memory in animals exposed to ethanol during the pharyngula stage.

Maternal and partner prenatal alcohol use and infant cognitive development

BACKGROUND

Teratogenicity of heavy prenatal alcohol exposure is established, but uncertainty remains regarding the impact of moderate alcohol exposure on cognitive deficits in infants. Separating in utero effects from environmental confounding is a challenge for observational studies; consideration of alcohol use by partners as well as mothers may help clarify this. This study examined associations between prenatal alcohol use by both mothers and their partners and infant cognitive developmental outcomes at 12-months.

METHODS

Pregnant women (n = 1331) and their partners (n = 699) were recruited from antenatal clinics of three metropolitan public hospitals in Australia, and completed detailed interviews about alcohol consumptions throughout pregnancy. Infants were assessed with the Bayley Scales of Infant Development - Third edition (Bayley) at 12-months of age.

RESULTS

Alcohol use during pregnancy was reported by 65.7% of mothers and 84.1% of partners. Using multiple methods to adjust for confounding factors, no evidence for impaired cognitive ability associated with alcohol use by mothers or their partners was observed. Children born to women who drank low-levels of alcohol had slightly higher Bayley cognitive scores than those born to abstaining women. There was some evidence for an interaction between sociodemographic factors and prenatal alcohol exposure on infant cognitive outcomes.

CONCLUSION

This finding corroborates existing evidence to suggest there are no detrimental effects to infant cognitive development at 12-months of age following low-level prenatal alcohol exposure. Future prospective studies involving families of a broad range of backgrounds would be informative to clarify interaction between alcohol exposure and environmental factors on developmental outcomes.

Maternal alcohol consumption during pregnancy and child's cognitive performance at 6-8 years of age in rural Burkina Faso: an observational study

Background

In Burkina Faso, it is not uncommon for mothers to drink alcohol, even during pregnancy. We aimed to study the association between maternal alcohol consumption during pregnancy and the child’s cognitive performance using the Kaufman Assessment Battery for Children, 2nd edition (KABC-II) and the Children’s Category Test Level 1 (CCT-1) in rural Burkina Faso.

Methods

We conducted a follow-up study of a community cluster-randomised Exclusive breastfeeding trial, and re-enrolled the children in rural Burkina Faso. A total of 518 children (268 boys and 250 girls) aged 6–8 years were assessed using the KABC-II and the CCT-1. We examined the effect size difference using Cohen’s d and conducted a linear regression analysis to examine the association.

Results

Self-reported alcohol consumption during pregnancy was 18.5% (96/518). Children whose mothers reported alcohol consumption during pregnancy performed significantly poorly for memory and spatial abilities tests from small effect size difference for ‘Atlantis’ (0.27) and ‘Triangle’ (0.29) to moderate effect size difference for ‘Number recall’ (0.72) compared to children whose mothers did not consume alcohol during pregnancy; the exposed children scored significantly higher errors with a small effect size (0.37) at problem solving (CCT-1) test compared to unexposed children.

At unstandardized and standardized multivariable analysis, children whose mothers reported alcohol consumption during pregnancy performed significantly poorer for memory-‘Atlantis’ (p = 0.03) and ‘Number recall’ (p = 0.0001), and spatial ability tests-‘Triangle’ (p = 0.03); they scored significantly higher errors at problem solving CCT-1 test (p = 0.002); all the results were adjusted for age, sex, schooling, stunting, father’s education, mother’s employment and the promotion of exclusive breastfeeding. No statistical association was found for visual abilities-‘Conceptual Thinking’, ‘Face recognition’, ‘Story completion’, and reasoning tests-‘Rover’, ‘Block counting’, and ‘Pattern Reasoning’.

Conclusion

Maternal alcohol consumption during pregnancy is associated with poorer cognitive performance for memory, spatial ability, and problem solving tests in the offspring in rural Burkina Faso. Futures studies needs to assess in more detail the maternal alcohol consumption patterns in Burkina Faso and possible preventive strategies.

Maternal alcohol disorders and school achievement: a population cohort record linkage study in Western Australia

OBJECTIVE

Maternal alcohol use disorder is a risk factor for a range of developmental outcomes in children. This study examines school achievement in children of Indigenous and non-Indigenous mothers with an alcohol-related diagnosis.

DESIGN, SETTING AND PARTICIPANTS

This is a Western Australian population cohort study of mothers with a record of an alcohol-related diagnosis classified by the International Classification of Diseases Revisions 9/10 codes as recorded on administrative databases, and of their offspring born between 1989 and 2007 (n=18 486 exposed children), with a frequency matched comparison cohort of mothers with no record of alcohol diagnosis and their offspring (n=48 262 comparison children).

OUTCOMES

Records were linked with school achievement data for numeracy and literacy from Years 3, 5, 7 and 9 (age range: ~8-14 years) based on statewide and national testing. Mixed multivariate models with a random intercept per child were used to assess the relationship between exposure and the timing of exposure with failure to meet minimum standardised benchmarks.

RESULTS

Academic achievement was lower in all testing domains (reading, writing, spelling and numeracy) among children of mothers with an alcohol diagnosis and persisted across all year groups examined. The highest ORs at Year 9 for non-Indigenous children were in reading (adjusted OR (aOR) 1.6, 95% CI 1.4 to 1.8) and in writing for Indigenous children (aOR 2.0, 95% CI 1.8 to 2.3).

CONCLUSION

Children of mothers with alcohol use disorders are at risk of not meeting minimum educational benchmarks in numeracy and literacy, with the risk highest among Indigenous children.

From scientific article to press release to media coverage: advocating alcohol abstinence and democratising risk in a story about alcohol and pregnancy

In this article, we follow the approach taken by Riesch and Spiegalhalter in "Careless pork costs lives': Risk stories from science to press release to media' published in this journal, and offer an assessment of one example of a 'risk story'. Using content and thematic qualitative analysis, we consider how the findings of an article 'Fetal Alcohol Exposure and IQ at Age 8: Evidence from a Population-Based Birth-Cohort Study' were framed in the article itself, the associated press release, and the subsequent extensive media coverage. We contextualise this consideration of a risk story by discussing a body of work that critically engages with the development and global proliferation of efforts to advocate for alcohol abstinence to pregnant (and pre-pregnant) women. This work considers the 'democratisation' of risk, a term used to draw attention to the expansion of the definition of the problem of drinking in pregnancy to include any drinking and all women. We show here how this risk story contributed a new dimension to the democratisation of risk through claims that were made about uncertainty and certainty. A central argument we make concerns the contribution of the researchers themselves (not just lobby groups or journalists) to this outcome. We conclude that the democratisation of risk was advanced in this case not simply through journalists exaggerating and misrepresenting research findings, but that communication to the press and the initial interpretation of findings played their part. We suggest that this risk story raises concerns about the accuracy of reporting of research findings, and about the communication of unwarrantedly worrying messages to pregnant women about drinking alcohol.

Risks and guidelines for the consumption of alcohol during pregnancy

Daily average intake of alcohol during pregnancy has consistently been associated with short term adverse outcomes such as miscarriage, preterm birth and intrauterine growth restriction, a large variety of malformations, as well as long term adverse outcomes such as foetal alcohol syndrome, mental retardation and general impairment of cognitive functions including intelligence, attention, learning abilities as well as social and behavioural functions. Weekly average consumption and alcohol binge drinking (usually defined as ≥ 5 drinks on a single occasion) independently of high daily average intake has not been consistently associated with short and long term adverse outcomes. Health authorities in most countries recommend that pregnant women completely abstain from alcohol. Even so, many health professionals including doctors, midwives and nurses do not provide information to pregnant women in accordance with the official recommendations, although a large proportion of women of child bearing age and pregnant women drink alcohol, especially before recognition of pregnancy. The discrepancy between guidelines and the information practice of health personnel is likely to continue to exist because guidelines of abstinence are not clearly evidence-based and not in line with current focus on autonomy and informed choice for patients, and because guidelines do not consider the everyday clinical communication situation.

Prenatal Alcohol Exposure, FASD, and Child Behavior: A Meta-analysis

CONTEXT

Fetal alcohol spectrum disorders (FASD) and prenatal alcohol exposure (PAE) are associated with behavioral difficulties, although there are no published systematic reviews that summarize and critique the literature.

OBJECTIVE

To describe the behavioral characteristics of children with PAE and/or FASD, assessed using the Achenbach System of Empirically Based Assessments (ASEBA) for school-aged children with parent, teacher, and youth (self-report) forms.

DATA SOURCES

Electronic literature databases, reference lists, hand-searches.

STUDY SELECTION

peer-reviewed observational studies.

DATA EXTRACTION

Study appraisal and data extraction were undertaken by 2 independent assessors. Meta-analyses were performed for parent-rated Internalizing, Externalizing, and Total problems scales. All other ASEBA scales were summarized qualitatively.

RESULTS

Included were 23 articles; 16 were used in meta-analyses. Pooled results showed higher Total (mean difference 12.1, 95% confidence interval [95% CI] 7.7-16.5), Internalizing (6.3, 95% CI 3.1-9.5), and Externalizing problems scores (12.5, 95% CI 7.9-17.0) in FASD than No FASD; and greater odds of scoring in the "Clinical" range in FASD. Pooled results demonstrated higher problem scores in children with PAE (P > .05). Qualitative summaries of other scales from parents, teachers, and self-report show poorer behavior ratings in children with FASD and PAE on composite Problem and Competence scores and many Syndrome subscales.

LIMITATIONS

Findings were restricted to behaviors assessed using the ASEBA. The published literature was limited, often with only 1 study reporting on a particular scale.

CONCLUSIONS

Meta-analysis reveals that FASD and PAE are associated with problematic behavior in many, but not all domains. This clearly affects families, and should be considered in clinical practice by providers.

Contributions of a Child's Built, Natural, and Social Environments to Their General Cognitive Ability: A Systematic Scoping Review

The etiology of a child’s cognitive ability is complex, with research suggesting that it is not attributed to a single determinant or even a defined period of exposure. Rather, cognitive development is the product of cumulative interactions with the environment, both negative and positive, over the life course. The aim of this systematic scoping review was to collate evidence associated with children’s cognitive health, including inherent factors as well as chemical and non-chemical stressors from the built, natural, and social environments. Three databases were used to identify recent epidemiological studies (2003–2013) that examined exposure factors associated with general cognitive ability in children. Over 100 factors were evaluated from 258 eligible studies. We found that recent literature mainly assessed the hypothesized negative effects of either inherent factors or chemical exposures present in the physical environment. Prenatal growth, sleep health, lead and water pollutants showed consistent negative effects. Of the few studies that examined social stressors, results consistently showed cognitive development to be influenced by both positive and negative social interactions at home, in school or the community. Among behavioral factors related to diet and lifestyle choices of the mother, breastfeeding was the most studied, showing consistent positive associations with cognitive ability. There were mostly inconsistent results for both chemical and non-chemical stressors. The majority of studies utilized traditional exposure assessments, evaluating chemical and non-chemical stressors separately. Collective evidence from a limited number of studies revealed that cumulative exposure assessment that incorporates multiple chemical and non-chemical stressors over the life course may unravel the variability in effect on cognitive development and help explain the inconsistencies across studies. Future research examining the interactions of multiple stressors within a child’s total environment, depicting a more real-world exposure, will aid in understanding the cumulative effects associated with a child’s ability to learn.

Maternal lifestyle during pregnancy and child psychomotor development - Polish Mother and Child Cohort study

BACKGROUND

Nowadays special attention is paid to prenatal exposures to maternal lifestyle factors and their impact on a child development.

AIM

The objective of this study was to evaluate the impact of modifiable maternal lifestyle factors on child neurodevelopment based on the Polish Mother and Child Cohort study.

MATERIAL AND METHODS

The current analysis included 538 mother-child pairs. The following factors related to maternal lifestyle were considered: smoking and environmental tobacco smoke (ETS) exposure (based on the cotinine level in maternal saliva measured using LC-ESI+MS/MS method), alcohol consumption and leisure-time physical activity (LTPA) in pregnancy, pre-pregnancy BMI, and folic acid supplementations before and during pregnancy based on questionnaire data. Psychomotor development was assessed in children at the ages of one and two by the Bayley Scales of Infant and Toddler Development.

RESULTS

Significant association was observed between prenatal exposure to tobacco constituents and a decreased child motor development in assessments performed at both ages (β=-0.8, p=0.01; β=-1.4, p<0.001). Maternal pre-pregnancy underweight was associated with decreased language abilities at 12 months of age (β=-5.2, p=0.01) and cognitive and motor development at 24 months of age, for which the associations were of borderline significance (p=0.06). The recommended level of LTPA during pregnancy was beneficial for child language development at two years of age (β=4.8, p=0.02). For alcohol and folic acid consumption there were no significant associations with any of the analyzed domains of child neurodevelopment.

CONCLUSIONS

Children prenatally exposed to tobacco compounds and those of underweight mothers had a decreased psychomotor development. The recommended level of LTPA during pregnancy had positive impact on child development. These results underscore the importance of policies and public health interventions promoting healthy lifestyle among women in reproductive age and during pregnancy.

Alcohol use disorders in pregnancy

Alcohol use disorders (AUDs) are less prevalent in pregnant women than in nonpregnant women, but these disorders can create a host of clinical challenges when encountered. Unfortunately, little evidence is available to guide clinical decision making in this population. Drinking alcohol during pregnancy can have negative consequences on both fetus and mother, but it remains controversial as to the volume of alcohol consumption that correlates with these consequences. Likewise, little evidence is available to support the use of particular pharmacologic interventions for AUDs during pregnancy or to guide the management of alcohol detoxification in pregnant women. The use of benzodiazepines (the mainstay of most alcohol detoxification protocols) in pregnant women is controversial. Nevertheless, despite the lack of robust data to guide management of AUDs in pregnancy, clinicians need to make management decisions when confronted with these challenging situations. In that context, this article reviews the epidemiology of AUDs in pregnancy and the pharmacologic management of both AUDs and alcohol withdrawal in pregnant women, with the goal of informing clinicians about what is known about managing these co-occurring conditions.

Prenatal exposure to binge pattern of alcohol consumption: mental health and learning outcomes at age 11

The objective of the study is to investigate whether episodic binge pattern of alcohol consumption during pregnancy is independently associated with child mental health and academic outcomes. Using data from the prospective, population-based Avon Longitudinal Study of Parents and Children (ALSPAC), we investigated the associations between binge patterns of alcohol consumption during pregnancy (≥4 drinks per day) and child mental health [as rated by both parent (n = 4,610) and teacher (n = 4,274)] and academic outcomes [based on examination results (n = 6,939)] at age 11 years. After adjusting for prenatal and postnatal risk factors, binge pattern of alcohol consumption (≥4 drinks in a day on at least one occasion) during pregnancy was associated with higher levels of mental health problems (especially hyperactivity/inattention) in girls at age 11 years, according to parental report. After disentangling binge-pattern and daily drinking, binge-pattern drinking was independently associated with teacher-rated hyperactivity/inattention and lower academic scores in both genders. Episodic drinking involving ≥4 drinks per day during pregnancy may increase risk for child mental health problems and lower academic attainment even if daily average levels of alcohol consumption are low. Episodic binge pattern of drinking appears to be a risk factor for these outcomes, especially hyperactivity and inattention problems, in the absence of daily drinking.

Prenatal alcohol exposure and educational achievement in children aged 8-9 years

OBJECTIVE

This study examines the relationships between the dose, pattern, and timing of prenatal alcohol exposure and achievement in reading, writing, spelling, and numeracy in children aged 8 to 9 years.

METHODS

Data from a randomly selected, population-based birth cohort of infants born to non-Indigenous women in Western Australia between 1995 and 1997 (n = 4714) (Randomly Ascertained Sample of Children born in Australia's Largest State Study cohort) were linked to the Western Australian Midwives' Notification System and the Western Australian Literacy and Numeracy Assessment statewide education testing program. The records for 86% (n = 4056) of the cohort were successfully linked with education records when the children were aged 8 to 9 years. The associations between prenatal alcohol exposure and achievement of national benchmarks in school numeracy, reading, spelling, and writing tests and nonattendance for the tests was examined. Logistic regression was used to generate adjusted odds ratios (aOR) and 95% confidence intervals (CI), adjusting for potential confounding factors. The referent group included children of mothers who previously drank alcohol but who abstained during pregnancy.

RESULTS

Children were twice as likely not to achieve the benchmark for reading after heavy prenatal alcohol exposure during the first trimester (aOR 2.26; 95% CI 1.10-4.65) and for writing when exposed to occasional binge drinking in late pregnancy (aOR 2.35; 95% CI 1.04-5.43). Low-moderate prenatal alcohol exposure was not associated with academic underachievement.

CONCLUSIONS

The type of learning problems expressed depends on the dose, pattern, and timing of prenatal alcohol exposure.

The association of mild, moderate, and binge prenatal alcohol exposure and child neuropsychological outcomes: a meta-analysis

BACKGROUND

The objective of this review is to evaluate the literature on the association between mild, moderate, and binge prenatal alcohol exposure and child neurodevelopment.

METHODS

Meta-analysis with systematic searches of MEDLINE (1970 through August 2012), EMBASE (1988 through August 2012), and PsycINFO(®) (1970 through August 2012) and examination of selected references.

RESULTS

From 1,593 articles, we identified 34 presenting data from cohort studies that met our inclusion criteria. Information on study population, outcomes, measurement instruments, timing and quantification of alcohol exposure, covariates, and results was abstracted. Outcomes included academic performance, attention, behavior, cognition, language skills, memory, and visual and motor development. The quality of each article was assessed by 2 researchers using the Newcastle-Ottawa Scale. Based on 8 studies of 10,000 children aged 6 months through 14 years, we observed a significant detrimental association between any binge prenatal alcohol exposure and child cognition (Cohen's d [a standardized mean difference score] -0.13; 95% confidence interval [CI], -0.21, -0.05). Based on 3 high-quality studies of 11,900 children aged 9 months to 5 years, we observed a statistically significant detrimental association between moderate prenatal alcohol exposure and child behavior (Cohen's d -0.15; 95% CI, -0.28, -0.03). We observed a significant, albeit small, positive association between mild-to-moderate prenatal alcohol exposure and child cognition (Cohen's d 0.04; 95% CI, 0.00, 0.08), but the association was not significant after post hoc exclusion of 1 large study that assessed mild consumption nor was it significant when including only studies that assessed moderate alcohol consumption. None of the other completed meta-analyses resulted in statistically significant associations between mild, moderate, or binge prenatal alcohol exposure and child neuropsychological outcomes.

CONCLUSIONS

Our findings support previous findings suggesting the detrimental effects of prenatal binge drinking on child cognition. Prenatal alcohol exposure at levels less than daily drinking might be detrimentally associated with child behavior. The results of this review highlight the importance of abstaining from binge drinking during pregnancy and provide evidence that there is no known safe amount of alcohol to consume while pregnant.

Alcohol use in pregnancy: prevalence and predictors in the Longitudinal Study of Australian Children

INTRODUCTION AND AIMS

This study aimed to estimate the prevalence and describe the patterns of alcohol use during pregnancy among Australian mothers. The study also aimed to examine the characteristics associated with alcohol use in pregnancy.

DESIGN AND METHODS

Data comprised two representative samples of families (infant cohort = 5107 parents of 0- to 1-year-olds; child cohort = 4983 parents of 4- to 5-year-olds) from the 2005 Longitudinal Study of Australian Children.

RESULTS

Alcohol use in pregnancy was reported by 37.6% of mothers of infants aged 0-1 years and 27.6% of mothers of children aged 4-5 years. The majority of women reported low level/occasional use of alcohol but, when extrapolated to population level, this equates to 131,250 children in these two age groups exposed to alcohol in utero, with over 1000 children exposed to alcohol most days and an estimated 671 infants exposed to three or more drinks per occasion. Among mothers of infants, alcohol use in pregnancy was associated with increasing maternal age, higher education, greater economic advantage and fewer physical health problems in pregnancy. Among mothers of children, maternal drinking in pregnancy was associated with increasing maternal age and smoking in pregnancy.

DISCUSSION AND CONCLUSIONS

Alcohol use during pregnancy is common with around one-third of all mothers reporting use. Most women reported only occasional use, and among those who were asked, consumed one standard drink on average per occasion. Significant numbers were exposed to three or more drinks on one occasion or to alcohol most days while in utero. National guidelines recommend abstinence as no 'safe' threshold has been determined. Public health campaigns are needed to educate pregnant women regarding national guidelines.

Child maltreatment and adolescent mental health problems in a large birth cohort

OBJECTIVE

To examine whether notified child maltreatment is associated with adverse psychological outcomes in adolescence, and whether differing patterns of psychological outcome are seen depending on the type of maltreatment.

METHODS

The participants were 7,223 mother and child pairs enrolled in a population-based birth cohort study in Brisbane, Australia. Exposure to suspected child maltreatment was measured by linkage with state child protection agency data. The primary outcomes were the internalizing and externalizing scales of the Youth Self Report (YSR) at approximately 14 years of age.

RESULTS

The YSR was completed by 5,172 subjects (71.6%), with increased attrition of cases of notified maltreatment. After adjustment for potential confounders, notified maltreatment was significantly associated with both internalizing behavior and externalizing behavior at 14. When evaluated as non-exclusive categories of maltreatment, physical abuse, neglect, and emotional abuse were each significantly associated with both internalizing and externalizing behavior after adjustment. When evaluated using an expanded hierarchical scheme that included combinations of multi-type maltreatment, the following groups had significantly higher internalizing behavior after adjustment: emotional abuse (with or without neglect), and multi-type maltreatment including physical (but not sexual) abuse with neglect and/or emotional abuse. The following groups were associated with externalizing behavior after adjustment: emotional abuse (with or without neglect), and multi-type maltreatment including physical abuse (with neglect and/or emotional abuse), or sexual abuse (with neglect and/or emotional abuse, and/or physical abuse).

CONCLUSION

This study suggests that child neglect and emotional abuse have serious adverse effects on adolescent mental health and warrant the attention given to other forms of child maltreatment. Additionally, it confirms that young people who are notified for more than one type of maltreatment are at particular risk of adolescent mental health problems.

Does child abuse and neglect explain the overrepresentation of Aboriginal and Torres Strait Islander young people in youth detention? Findings from a birth cohort study

OBJECTIVE

Determine whether a history of family social disadvantage and/or child abuse and neglect explain the overrepresentation of Indigenous Australian young people in youth detention.

METHODS

Maternal survey data from the Mater University Study of Pregnancy was linked with child abuse and neglect and youth justice data from the Queensland Department of Families, Youth and Community Care.

RESULTS

Indigenous Australian children were 1.81 times more likely to be notified to child protection authorities for maltreatment and 1.77 times more likely to have that maltreatment substantiated. Indigenous Australian young people were 3.07 times more likely to have a youth justice history. When adjusted for social disadvantage, the odds of the Indigenous Australian youth having had involvement with the youth justice authorities remained 2.51 times that of their non-Indigenous peers. When adjusted for substantiated maltreatment, the odds of the Indigenous Australian youth having had involvement with the youth justice authorities remained 2.83 times that of their non-Indigenous peers. When adjusted for both social disadvantage and substantiated maltreatment, the odds of the Indigenous Australian youth having had involvement with the youth justice authorities remained 2.48 times that of their non-Indigenous peers.

CONCLUSIONS

The overrepresentation of Australian Aboriginal and Torres Strait Islander young people in the youth justice system, including Youth Detention, is only partly explained by their greater social disadvantage and by their greater experience of substantiated maltreatment, either separately or combined.

Intellectual disability: population-based estimates of the proportion attributable to maternal alcohol use disorder during pregnancy

AIM

The aim of this study was to examine the association between maternal alcohol use disorder and intellectual disability in children.

METHOD

All mothers with an International Classification of Diseases (ICD) 9 and/or 10 alcohol-related diagnosis, a proxy for alcohol use disorder, recorded on the Western Australian health, mental health, and drug and alcohol data sets were identified through the Western Australian Data Linkage Unit (n=5614 non-Aboriginal; n=2912 Aboriginal). A comparison cohort of mothers without an alcohol-related diagnosis was frequency matched on maternal age within maternal Aboriginal status and year of birth of their children. Linkage with the Western Australian Midwives Notification System (1983-2001) identified all births to these mothers (n=10 664 and 7907 respectively). Linkage to the Western Australian Intellectual Disability Database and Register of Developmental Anomalies identified cases of intellectual disability with no identified genetic origin (intellectual disability) (n=1487) and fetal alcohol syndrome (n=66). Odds ratios (ORs) and 95% confidence intervals (CIs) for intellectual disability were calculated using logistic regression incorporating generalized estimating equations and used to estimate population-attributable fractions.

RESULTS

At least 3.8% (95% CI 2.84-4.89%) of cases of intellectual disability could be avoided by preventing maternal alcohol use disorder: 1.3% (95% CI 0.81-1.86%) in non-Aboriginal and 15.6% (95% CI 10.85-20.94%) in Aboriginal children. We observed a three-fold increase in the adjusted odds of intellectual disability in children of mothers with an alcohol-related diagnosis recorded during pregnancy (non-Aboriginal OR 2.89, 95% CI 1.62-5.18; Aboriginal OR 3.12, 95% CI 2.13-4.56), with a net excess proportion of 3.7% and 5.5% respectively. One-third (32%) of children diagnosed with fetal alcohol syndrome had intellectual disability.

INTERPRETATION

Maternal alcohol use disorder is the leading known risk factor for intellectual disability with no identified genetic origin.

Light drinking in pregnancy and mid-childhood mental health and learning outcomes

OBJECTIVE

To investigate whether light drinking in pregnancy is associated with adverse child mental health and academic outcomes.

DESIGN

Using data from the prospective, population-based Avon Longitudinal Study of Parents and Children (ALSPAC), we investigated the associations between light drinking in pregnancy (<1 glass per week in the first trimester) and child mental health (using both parent and teacher rated Strengths and Difficulties Questionnaires (SDQs)) and academic outcomes based on Key Stage 2 examination results at age 11 years.

PARTICIPANTS

11-year-old children from ALSPAC with parent (n=6587) and teacher (n=6393) completed SDQs and data from Key Stage 2 examination results (n=10 558).

RESULTS

39% of women had consumed <1 glass per week and 16% ≥1 glass per week of alcohol during the first trimester (45% abstaining). After adjustment, relative to abstainers, there was no effect of light drinking on teacher-rated SDQ scores or examination results. In girls, although there was a suggestion of worse outcomes (adjusted regression coefficient=0.38; 95% CI 0.01 to 0.74) on the parent-rated total SDQ score in those exposed to light drinking compared to abstainers, no dose-response relationship was evident.

CONCLUSIONS

Although the pattern of findings involving parent ratings for girls exposed to light drinking is consistent with earlier findings from this cohort, the overall lack of any adverse effects of light drinking is similar to findings from other recent cohort studies. Light drinking in pregnancy does not appear to be associated with clinically important adverse effects for mental health and academic outcomes at the age of 11 years.

Fetal alcohol exposure and IQ at age 8: evidence from a population-based birth-cohort study

Background

Observational studies have generated conflicting evidence on the effects of moderate maternal alcohol consumption during pregnancy on offspring cognition mainly reflecting problems of confounding. Among mothers who drink during pregnancy fetal alcohol exposure is influenced not only by mother’s intake but also by genetic variants carried by both the mother and the fetus. Associations between children’s cognitive function and both maternal and child genotype at these loci can shed light on the effects of maternal alcohol consumption on offspring cognitive development.

Methods

We used a large population based study of women recruited during pregnancy to determine whether genetic variants in alcohol metabolising genes in this cohort of women and their children were related to the child’s cognitive score (measured by the Weschler Intelligence Scale) at age 8.

Findings

We found that four genetic variants in alcohol metabolising genes in 4167 children were strongly related to lower IQ at age 8, as was a risk allele score based on these 4 variants. This effect was only seen amongst the offspring of mothers who were moderate drinkers (1–6 units alcohol per week during pregnancy (per allele effect estimates were −1.80 (95% CI = −2.63 to −0.97) p = 0.00002, with no effect among children whose mothers abstained during pregnancy (0.16 (95%CI = −1.05 to 1.36) p = 0.80), p-value for interaction  = 0.009). A further genetic variant associated with alcohol metabolism in mothers was associated with their child’s IQ, but again only among mothers who drank during pregnancy.

The effects of low to moderate prenatal alcohol exposure in early pregnancy on IQ in 5-year-old children

OBJECTIVE

To examine the effects of low to moderate maternal alcohol consumption during early pregnancy on children's intelligence (IQ) at age 5 years.

DESIGN

Prospective follow-up study.

SETTING

Neuropsychological testing in four Danish cities 2003-2008.

POPULATION

A cohort of 1628 women and their children sampled from the Danish National Birth Cohort.

METHODS

Participants were sampled based on maternal alcohol consumption during pregnancy. At 5 years of age, children were tested with the Wechsler Preschool and Primary Scale of Intelligence-Revised (WPPSI-R). Parental education, maternal IQ, maternal smoking in pregnancy, the child's age at testing, gender, and tester were considered core confounding factors, whereas the full model also controlled for maternal binge drinking, age, BMI, parity, home environment, postnatal smoking in the home, health status, and indicators for hearing and vision impairments.

MAIN OUTCOME MEASURES

The WPPSI-R.

RESULTS

No differences in test performance were observed between children whose mothers reported consuming between one and four or between five and eight drinks per week at some point during pregnancy, compared with children of mothers who abstained. For women who reported consuming nine or more drinks per week no differences were observed for mean differences; however, the risks of low full-scale IQ (OR 4.6; 95% CI 1.2-18.2) and low verbal IQ (OR 5.9; 95% CI 1.4-24.9) scores, but not low performance IQ score, were increased.

CONCLUSIONS

Maternal consumption of low to moderate quantities of alcohol during pregnancy was not associated with the mean IQ score of preschool children. Despite these findings, acceptable levels of alcohol use during pregnancy have not yet been established, and conservative advice for women continues to be to avoid alcohol use during pregnancy.

The effect of alcohol binge drinking in early pregnancy on general intelligence in children

OBJECTIVE

To examine the effects of binge alcohol consumption during early pregnancy, including the number of binge episodes and the timing of binge drinking, on general intelligence in 5-year-old children.

DESIGN

Follow-up study.

SETTING

Neuropsychological testing in four Danish cities 2003-2008.

POPULATION

A cohort of 1617 women and their children sampled from the Danish National Birth Cohort.

METHODS

Participants were sampled on the basis of maternal alcohol consumption during pregnancy. At 5 years of age the children were tested with six subtests from the Wechsler Preschool and Primary Scale of Intelligence - Revised (WPPSI-R). Parental education, maternal IQ, prenatal maternal smoking, the child's age at testing, the gender of the child, and tester were considered core confounding factors, whereas the full model also controlled for prenatal maternal average alcohol intake, maternal age, maternal pre-pregnancy body mass index (BMI), parity, home environment, postnatal parental smoking, health status, and indicators for hearing and vision impairment.

MAIN OUTCOME MEASURE

WPPSI-R.

RESULTS

There were no systematic or significant differences in general intelligence between children of mothers reporting binge drinking and children of mothers with no binge episodes, except that binge drinking in gestational weeks 1-2 significantly reduced the risk of low, full-scale IQ (OR 0.54; 95% CI 0.31-0.96) when adjusted for core confounding factors. The results were otherwise not statistically significantly related to the number of binge episodes (with a maximum of 12) and timing of binge drinking.

CONCLUSIONS

We found no systematic association between binge drinking during early pregnancy and child intelligence. However, binge drinking reduced the risk of low, full-scale IQ in gestational weeks 1-2. This finding may be explained by residual confounding.

The effects of low to moderate alcohol consumption and binge drinking in early pregnancy on selective and sustained attention in 5-year-old children

OBJECTIVE

The aim was to examine the effects of low to moderate maternal alcohol consumption and binge drinking in early pregnancy on children's attention at 5 years of age.

DESIGN

Prospective follow-up study.

SETTING

Neuropsychological testing in four Danish cities 2003-2008.

POPULATION

A cohort of 1628 women and their children sampled from the Danish National Birth Cohort.

METHODS

Participants were sampled based on maternal alcohol consumption during pregnancy. At 5 years of age, the children were tested with the recently developed Test of Everyday Attention for Children at Five (TEACh-5). Parental education, maternal IQ, maternal smoking in pregnancy, the child's age at testing, gender, and tester were considered core confounding factors, whereas the full model also controlled the following potential confounding factors: maternal binge drinking or low to moderate alcohol consumption, age, body mass index (BMI), parity, home environment, postnatal smoking in the home, child's health status, and indicators for hearing and vision impairments.

MAIN OUTCOME MEASURES

TEACh-5 attention scores.

RESULTS

There were no significant effects on test performance in children of mothers drinking up to 8 drinks per week compared with children of mothers who abstained, but there was a significant association between maternal consumption of 9 or more drinks per week and risk of a low overall attention score (OR 3.50, 95% CI 1.15-10.68). No consistent or significant associations were observed between binge drinking and attention test scores.

CONCLUSIONS

The findings suggest an effect of maternal consumption of 9 or more drinks per week on attention functions in children, but the study detected no effects of lower levels of maternal consumption and no consistent effects of maternal binge drinking.

Substance exposure in utero and developmental consequences in adolescence: a systematic review

BACKGROUND

The impacts of maternal substance use have been observed in both research and clinical experience. Several studies have shown that preschool children are at heightened risk of developing various cognitive, behavioral, and socioemotional difficulties. Most knowledge has been generated concerning alcohol consumption during pregnancy and the postnatal effects thereof. Less is known about substance use other than alcohol (for instance, opiates, marijuana, and cocaine) during pregnancy and the long-term developmental consequences.

OBJECTIVE

The aims of this review are to identify relevant published data on adolescents who have been exposed in utero to alcohol and/or other substances and to examine developmental consequences across functions and mental health at this point in life.

METHODS

PubMed, Embase, and PsychInfo were searched for publications during the period of 1980-2011 and titles and abstracts selected according to prespecified broad criteria.

RESULTS

Twenty-five studies fulfilled all of the specific requirements and were included in this review. Most research covered prenatal alcohol exposure. Other substances, however, included cocaine, marijuana, opiates, and poly-substances. Results showed that prenatal exposure to alcohol has long-term cognitive, behavioral, social, and emotional developmental consequences depending on amount and timing of exposure in utero. Less evidence exists for long-term consequences of exposure in utero to other substances than alcohol. However, recent brain-imaging studies have provided important evidence of serious effects of other substance exposure on the developing brain and recent follow-up studies have found an association with deficits in language, attention, areas of cognitive performance and delinquent behavior in adolescence.

Executive function and memory in children with Fetal Alcohol Spectrum Disorder

A complex relation exists between memory and executive functioning (EF), particularly when learning and recalling multifaceted or extensive information ( Moscovitch & Winocur, 2002 ). A common instrument for evaluating this relationship is the Rey-Osterrieth Complex Figure (ROCF; Rey, 1941 ; Osterrieth, 1944 ). The ROCF has proved particularly useful in pediatric research; however, little research has been conducted among children with Fetal Alcohol Spectrum Disorders (FASD). Seventy children (35 FASD, 35 control), aged 6 to 12 years, were tested using the ROCF. All participants with FASD had received a diagnosis according to the Canadian guidelines for FASD ( Chudley et al., 2005 ) using the 4-digit diagnostic code ( Astley, 2004 ). Significant group differences were revealed with children with FASD demonstrating substantial difficulties in organization, accuracy, and memory. Among children with FASD, a distinctive profile emerged, lending support to the argument that children with FASD experience deficits in EF and memory throughout their development. Information from the present study will not only help to improve understanding of functioning in this population but also provide insight into how to deal with EF and memory deficits in terms of testing, treatment, and intervention.

Cognitive and behavioral effects of prenatal alcohol exposure

Children exposed to substantial amounts of alcohol prenatally are known to display a range of physical and cognitive anomalies, referred to as fetal alcohol spectrum disorders (FASDs). Animal models and neuroimaging studies of FASDs have consistently demonstrated that specific regions of the brain (e.g., midline structures) are more vulnerable to the teratogenic effects of alcohol than other regions. The main aim of this article is to assess whether findings from cognitive–behavioral studies of FASDs yield a profile that maps onto the pattern of damage revealed by neuroanatomical investigations. To achieve this aim, the findings from studies that have investigated elementary functions (e.g., associative learning), general functions (e.g., intellectual abilities), specific functions (e.g., language and memory) and behavior in children and adults with FASDs are examined. The cognitive–behavioral profile emerging from the data is defined as a generalized deficit in processing and integrating complex information. It is proposed that slow processing of information mainly contributes to this deficit. The clinical implications of the above characterization of the cognitive–behavioral profile in FASDs are discussed.

Prevalence and predictors of alcohol use in pregnancy and breastfeeding among Australian women

BACKGROUND

Previous research suggests that alcohol use during pregnancy and breastfeeding has a negative impact on birth and neonatal outcomes. No threshold for this effect has been determined. The aim of this study is to determine the prevalence and correlates of alcohol use in pregnancy and lactation in a large representative sample of Australian women.

METHOD

Data were used from a large representative sample of Australian women drawn from the 2007 National Drug Strategy Household Survey. A complex sampling framework was used to elicit prevalence estimates for alcohol use during pregnancy and lactation. A logistic regression analysis was used to determine the psychosocial characteristics associated with alcohol use during the perinatal period.

RESULTS

Alcohol use was reported by 29 percent of women who were pregnant in the past 12 months. In addition, 43 percent of women who were breastfeeding in the past 12 months reported alcohol use, whereas 36 percent of women who were both pregnant and breastfeeding in the past 12 months reported alcohol use. Most women (95%) reported a reduction in the quantity of their alcohol use while pregnant or breastfeeding. Older age was significantly associated with alcohol use in pregnancy, and also with alcohol use while breastfeeding (after controlling for other psychosocial characteristics). Higher educational attainment, and breastfeeding for more weeks in the past 12 months were significantly associated with alcohol use while breastfeeding, after controlling for confounding psychosocial factors.

CONCLUSIONS

More research is needed to ease uncertainty about "safe" levels of alcohol use during pregnancy and while breastfeeding. A high proportion of the sample reported alcohol use during pregnancy or lactation, despite uniform international government guidelines recommending that no alcohol should be consumed during the prenatal and postnatal periods. These results indicate that public health education campaigns about the risks of alcohol during these periods are needed.

The limbic-hypothalamic-pituitary-adrenal axis and the development of alcohol use disorders in youth

OBJECTIVE

As the initiation and acceleration of alcohol use commonly occurs during adolescence, the etiological basis for this phenomenon is of critical importance. Using the diathesis-stress model as a framework, this review will evaluate the emerging evidence implicating the limbic-hypothalamic-pituitary-adrenal (LHPA) axis in the development of alcohol use disorder (AUD).

METHOD

Searches were conducted of the PubMed/Medline, PsycInfo, PsycBooks, Cochrane and ISI Web of Science databases, using a specified set of search terms.

RESULTS

Genetic liabilities, antenatal stress/anxiety or exposure to addictive substances, exposure to maltreatment or other traumatic events in childhood and psychiatric illness in childhood/adolescence can all increase the risk, or diathesis, for AUD. Greater LHPA dysfunction may serve as a marker for higher diathesis levels in youth. When exposed to stressors in adolescence, high-risk youth (or those with greater LHPA dysfunction) may use alcohol and/or other substances to cope with stressors and, in turn, become more vulnerable to AUD.

CONCLUSION

Evidence suggests that LHPA dysfunction and stress play an important role in the development of AUD. Genetic liabilities, antenatal insults, maltreatment, and psychiatric illness appear to increase LHPA dysfunction, raising risk for AUD. Further research is needed to clarify the complex interplay among adverse developmental experiences, LHPA dysfunction, and the development of AUD in adolescents.

Acetaldehyde-Mediated Neurotoxicity: Relevance to Fetal Alcohol Spectrum Disorders

Ethanol-induced neuro-developmental abnormalities are associated with impaired insulin and IGF signaling, and increased oxidative stress in CNS neurons. We examined the roles of ethanol and its principal toxic metabolite, acetaldehyde, as mediators of impaired insulin/IGF signaling and oxidative injury in immature cerebellar neurons. Cultures were exposed to 3.5 mM acetaldehyde or 50 mM ethanol ± 4-methylpyrazole (4-MP), an inhibitor of ethanol metabolism, and viability, mitochondrial function, oxidative stress, DNA damage, and insulin responsiveness were measured 48 hours later. Acetaldehyde or ethanol increased neuronal death and levels of 8-OHdG and 4-HNE, and reduced mitochondrial function. Ethanol inhibited insulin responsiveness, whereas acetaldehyde did not. 4-MP abated ethanol-induced oxidative stress and mitochondrial dysfunction, but failed to restore insulin responsiveness. Furthermore, alcohol and aldehyde metabolizing enzyme genes were inhibited by prenatal ethanol exposure; this effect was mediated by acetaldehyde and not ethanol + 4MP. These findings suggest that brain insulin resistance in prenatal alcohol exposure is caused by direct effects of ethanol, whereas oxidative stress induced neuronal injury is likely mediated by ethanol and its toxic metabolites. Moreover, the adverse effects of prenatal ethanol exposure on brain development may be exacerbated by down-regulation of genes needed for metabolism and detoxification of alcohol in the brain.