Tobacco and alcohol use among lactating women and its association with child nutrition in India: findings from National Family Health Survey 2019-2021

OBJECTIVES

Tobacco use is one of the greatest public health problems in the world. Prevalence of alcohol and tobacco use among lactating women ranged between 35.9-83.0% and 1.4-6.1%, respectively, in various parts of the world. Both alcohol and nicotine pass quickly into breast milk. The objective of this study is to estimate the prevalence of alcohol and tobacco use in lactating women and its association with having underweight, stunted, and wasted nursing children in India. The study also draws comparisons to identify the common associated socio-economic factors for alcohol and tobacco use among lactating women and having underweight, stunted, and/or wasted children.

STUDY DESIGN

A cross-sectional analytical study involving secondary data from the National Family Health Survey-5.

METHODS

A cross-sectional analytical study involving secondary data from the National Family Health Survey-5 conducted nationally in community settings in two phases during 2019-2021. Alcohol and tobacco use among lactating women was self-reported, and the nutritional status of children was assess anthropometrically during the survey and categorised into under-weight, stunted, and wasted as per standardised growth charts.

RESULTS

prevalence of tobacco use among currently lactating mothers in India was 3.24%. Prevalence of alcohol use among currently lactating mothers was 0.57%. Nursing children of mothers consuming alcohol had significantly higher odds of being wasted [OR = 1.44; (95% CI = 1.07-1.92)]. Richer wealth index {compared to poor, poorer [OR = 0.74; (95% CI = 0.59-0.91)], rich [OR = 0.64; (95% CI = 0.50-0.84)], richer [OR = 0.46; (95% CI = 0.33-0.65)], richest [OR = 0.19; (95% CI = 0.11-0.33)]}, higher education status {compared to illiterate, secondary education [OR = 0.79; (95% CI = 0.63-0.97)], higher education [OR = 0.38; (95% CI = 0.24-0.62)]}, and non-tribal ethnicity [OR = 0.40; (95% CI = 0.33-0.50)] were found to be significantly associated with lower odds of alcohol and tobacco use among lactating mothers. Age, religion, residence, and occupation were also found to be significantly associated.

CONCLUSIONS

Lactating women with lower education status or belonging to lower income groups needs to be prioritised for further qualitative assessment of alcohol and tobacco use during lactation. Our study reflects the national and state-level prevalence of alcohol and tobacco use among lactating women, which often masks the local and community-level intricacies. There is a need to further explore local and community-level factors affecting alcohol use during lactation and its association with child nutrition.

The Impact of Prenatal Alcohol Exposure on Longitudinal Growth, Nutritional Status, and Insulin-Like Growth Factor 1 in Early Childhood in Leyte, the Philippines

OBJECTIVE

To assess the impact and potential mechanistic pathways of prenatal alcohol exposure (PAE) on longitudinal growth and nutritional status in early childhood.

STUDY DESIGN

A cohort of 296 mother-infant dyads (32% with PAE vs 68% unexposed) were recruited in Leyte, the Philippines, and followed from early gestation through 24 months of age. PAE was assessed using serum phosphatidylethanol (PEth) captured twice prenatally and in cord blood and supplemented with self-reported alcohol consumption. Linear mixed models were used to examine longitudinal effects of PAE on growth from birth through 2 years including key potential mediating factors (placental histopathology, and infant serum leptin and Insulin-like Growth Factor 1 [IGF-1]).

RESULTS

After adjusting for potential confounders, we found that PAE was significantly associated with a delayed blunting of linear growth trajectories (height-for-age z-score, body length) and weight (weight-for-age z-score, body weight) that manifested between 4 and 6 months and continued through 12-24 months. PAE was also associated with a decreased rate of mid-upper-arm circumference growth from birth to 12 months, and a lower mean IGF-1 levels at birth and 6 months.

CONCLUSION

This study demonstrates a delayed impact of PAE on growth that manifested around 6 months of age, underscoring the importance of routine clinical monitoring in early childhood. Furthermore, the findings supported prior animal model findings that suggest a mechanistic role for IGF-1 in PAE-induced growth delay.

Breastfeeding and neurodevelopment in infants with prenatal alcohol exposure

BACKGROUND

Few studies have evaluated the differential benefits of breastfeeding on infant neurodevelopment at varying levels of prenatal alcohol exposure (PAE). This study examined whether the association between breastfeeding and neurodevelopment is modified by prenatal drinking pattern.

METHODS

The study included 385 infants from Ukraine born to women prospectively enrolled in a cohort study during pregnancy. Neurodevelopment was assessed at six and 12 months using the Bayley Scales of Infant Development II (BSID-II) Mental Developmental Index (MDI) and Psychomotor Developmental Index (PDI). Linear regression modeling with interaction terms and stratification by PAE group was used to determine the relationship between breastfeeding, PAE, and neurodevelopment.

RESULTS

A significant interaction between PAE and breastfeeding was observed for the MDI and PDI at six and 12 months. Infants with high PAE who were breastfed at least four months had BSID-II scores 14 or more points higher compared to those never breastfed. Counterintuitively, those with moderate PAE had poorer performance on the BSID-II at 12 months when breastfed longer.

CONCLUSION

There was a significant joint effect of PAE and breastfeeding on infant neurodevelopment at six and 12 months. Breastfeeding may provide distinct benefits to infants exposed to high levels of PAE.

IMPACT

We found a positive effect of breastfeeding on infant neurodevelopment among infants with prenatal alcohol exposure (PAE), particularly those exposed to higher levels during gestation. This study is one of the first to evaluate whether breastfeeding mitigates harm caused by PAE. Breastfeeding may provide distinct benefits to infants with higher levels of PAE.

Vegan/vegetarian diet and human milk donation: An EMBA survey across European milk banks

The nutritional adequacy of human milk (HM) from vegan/vegetarian mothers has been a matter of debate, and a variety of recommendations regarding the eligibility of these mothers as human milk donors exists. According to the latest evidence, HM from vegans/vegetarians is similar in its composition to that from omnivores, however, some differences may be observed regarding vitamin B12 and omega-3 fatty acids concentrations. Maternal supplementation of these compounds has been proven effective in increasing their HM concentration. With this survey, we aimed to explore the practices currently in use in European human milk banks (HMBs) regarding potential donors following vegan/vegetarian diets. The online survey was distributed to European HMBs between January and July 2022. A total of 188 HMBs were contacted, and 118 replied (response rate 63%). Vegan and vegetarian mothers were recommended supplements of vitamin B12 to be accepted as donors in 27% and 26% of HMBs, respectively. Additional omega-3 fatty acid supplementation was required in 8% HMBs. In the remaining HMBs, these mothers were either systematically excluded or included regardless of supplementation. The dosage of the recommended supplements was extremely variable. Fifty-one percent of HMBs were following recommendations to guide their practice, national or local recommendations mainly. Great variability in European HMBs practices towards potential donors following vegan/vegetarian diets exists. Some of these practices can result in loss of donors and/or in potential nutritional deficiencies. Standardised evidence-based recommendations on this issue and their implementation in daily HMB practice are needed.

Academy of Breastfeeding Medicine Clinical Protocol #21: Breastfeeding in the Setting of Substance Use and Substance Use Disorder (Revised 2023)

Background: The Academy of Breastfeeding Medicine (ABM) revised the 2015 version of the substance use disorder (SUD) clinical protocol to review the evidence and provide updated literature-based recommendations related to breastfeeding in the setting of substance use and SUD treatments. Key Information: Decisions around breastfeeding are an important aspect of care during the peripartum period, and there are specific benefits and risks for substance-exposed mother-infant dyads. Recommendations: This protocol provides breastfeeding recommendations in the setting of nonprescribed opioid, stimulant, sedative-hypnotic, alcohol, nicotine, and cannabis use, and SUD treatments. Additionally, we offer guidance on the utility of toxicology testing in breastfeeding recommendations. Individual programs and institutions should establish consistent breastfeeding approaches that mitigate bias, facilitate consistency, and empower mothers with SUD. For specific breastfeeding recommendations, given the complexity of breastfeeding in mothers with SUD, individualized care plans should be created in partnership with the patient and multidisciplinary team with appropriate clinical support and follow-up. In general, breastfeeding is recommended among mothers who stop nonprescribed substance use by the time of delivery, and they should continue to receive ongoing postpartum care, such as lactation support and SUD treatment. Overall, enhancing breastfeeding education regarding substance use in pregnancy and lactation is essential to allow for patient-centered guidance.

Maternal tobacco, alcohol and caffeine consumption during the perinatal period: A prospective cohort study in Greece during the COVID-19 pandemic

INTRODUCTION

Low-level knowledge of problematic substance use during the perinatal period may lead to numerous adverse outcomes. We sought to determine maternal tobacco, alcohol and caffeine consumption during the perinatal period during the COVID-19 pandemic.

METHODS

This prospective cohort study recruited women from five Greek maternity hospitals between January and May 2020. Data were collected with a structured questionnaire initially completed by postpartum women during their hospitalization and re-administered via telephone interview in the first, third and sixth month postpartum.

RESULTS

The study sample consisted of 283 women. Smoking rates decreased during pregnancy (12.4%) compared to the pre-pregnancy period (32.9%, p<0.001) and during lactation (5.6%) compared to the antenatal period (p<0.001). The smoking rate increased again after breastfeeding cessation (16.9%) compared to the rate during lactation (p<0.001), but remained lower than the pre-pregnancy rate (p=0.008). Only 1.4% of the women reported breastfeeding cessation due to smoking, whereas those who smoked more during pregnancy were more likely to cease breastfeeding (OR=1.24; 95% CI: 1.05-1.48, p=0.012). Regarding alcohol consumption, it was significantly lower during pregnancy (5.7%), lactation (5.5%) and after breastfeeding cessation (5.2%) compared to the pre-pregnancy period (21.9%, p<0.001 for all correlations). Women who consumed alcohol during lactation were less likely to wean (OR=0.21; 95% CI: 0.05-0.83, p=0.027). Caffeine intake decreased during pregnancy compared to preconception period (p<0.001), while in lactating women it remained at low rates until the 3rd month of follow-up. Caffeine consumption at one month postpartum (β=0.09; SE=0.04, p=0.045) was positively associated with longer duration of breastfeeding.

CONCLUSIONS

Tobacco, alcohol and caffeine consumption decreased in the perinatal period compared to the preconception period. The pandemic may have contributed to the downtrend in smoking and alcohol consumption due to COVID-related restrictions and fear of potential illness. Nevertheless, smoking was associated with reduced duration of breastfeeding and breastfeeding cessation.

Alcohol and lactation: Developmental deficits in a mouse model

It is well documented that prenatal ethanol exposure via maternal consumption of alcohol during pregnancy alters brain and behavioral development in offspring. Thus, the Centers for Disease Control (CDC) advises against maternal alcohol consumption during pregnancy. However, little emphasis has been placed on educating new parents about alcohol consumption while breastfeeding. This is partly due to a paucity of research on lactational ethanol exposure (LEE) effects in children; although, it has been shown that infants exposed to ethanol via breast milk frequently present with reduced body mass, low verbal IQ scores, and altered sleeping patterns. As approximately 36% of breastfeeding mothers in the US consume alcohol, continued research in this area is critical. Our study employed a novel murine LEE model, where offspring were exposed to ethanol via nursing from postnatal day (P) 6 through P20, a period correlated with infancy in humans. Compared to controls, LEE mice had reduced body weights and neocortical lengths at P20 and P30. Brain weights were also reduced in both ages in males, and at P20 for females, however, female brain weights recovered to control levels by P30. We investigated neocortical features and found that frontal cortex thickness was reduced in LEE males compared to controls. Analyses of dendritic spines in the prelimbic subdivision of medial prefrontal cortex revealed a trend of reduced densities in LEE mice. Results of behavioral tests suggest that LEE mice engage in higher risk-taking behavior, show abnormal stress regulation, and exhibit increased hyperactivity. In summary, our data describe potential adverse brain and behavioral developmental outcomes due to LEE. Thus, women should be advised to refrain from consuming alcohol during breastfeeding until additional research can better guide recommendations of safe maternal practices in early infancy.

Ecological Momentary Assessment of Heavy Episodic Drinking in the Early Postpartum Period: A Feasibility Study

Background

Postpartum mothers are at heightened risk for heavy episodic drinking (HED). Research with this population is critical to developing acceptable and effective tailored interventions, but new mothers who use alcohol are often reluctant to engage in research due to stigma and fear of child removal. This study examined feasibility of recruitment and ecological momentary assessment (EMA) in early postpartum mothers with histories of HED.

Methods

Participants were recruited via Facebook and Reddit and completed 14 days of EMA surveys. Baseline characteristics, recruitment feasibility, and EMA feasibility and acceptability were examined. Participants attended focus groups to further inform quantitative data.

Results

Reddit yielded a larger proportion of eligible individuals than Facebook, and 86% of the final enroled sample was recruited via Reddit. The average compliance rate of 75% is in line with other studies of similar populations. Half the sample reported alcohol use, and 78% reported the urge to drink at least once, supporting feasibility of EMA for collecting alcohol use data. Participants reported low burden and high acceptability of the study on both quantitative and qualitative measures. Baseline low maternal self-efficacy was associated with greater EMA compliance, and first-time mothers reported lower EMA burden compared to veteran mothers. College graduates, and participants with lower drinking refusal self-efficacy and greater alcohol severity were more likely to report alcohol use on EMA.

Conclusions

Future studies should consider Reddit as a recruitment strategy. Findings generally support feasibility and acceptability of EMA to assess HED in postpartum mothers.

Women's views on moderate and low alcohol consumption: stages of the subjective transition from pregnancy to postpartum

BACKGROUND

Alcohol consumption during pregnancy and breastfeeding is associated with a risk for the child's healthy development. Nevertheless, about 16 to 25% of all women in the European region, including Switzerland, consume alcohol during pregnancy and probably even more during breastfeeding. Little is known about how women perceive this risk and how risk perception changes during the transition to motherhood. The present study aims to explore the subjective transition from the woman's perspective, focusing on perceptions of alcohol as a risk, changes in alcohol consumption in daily life and experienced support from health professionals in this period.

METHODS

The longitudinal qualitative, semi-structured interview study was jointly designed and conducted by health sociologists and midwifery researchers. Using the theoretical framework of sociocultural risk and life course transition, we interviewed 46 women from the French and German speaking part of Switzerland during pregnancy and until six months after birth.

RESULTS

In our study, we found that pregnant and breastfeeding women perceive alcohol consumption as a risk to the health of the child. Abstinence is sought especially during pregnancy, but this does not preclude occasional and low-level consumption according to some women. Alcohol consumption and risk perception change during the transition to motherhood. We identified five stages that characterise this transition in terms of alcohol consumption and risk perception. From the women's perspective, there was a lack of counselling from health professionals, and the women expressed a desire for respectful and more individualised counselling.

CONCLUSION

Many women express a need for guidance and counselling by health care professionals at some stages of the transition to motherhood. The stages identified can be used as pointers to address the subject of alcohol consumption in professional practice. The stage around conception and early pregnancy should be taken more into account, as women experience themselves as particularly vulnerable during this time. Low-threshold counselling services should be therefore offered to women before or in the stage around conception and be continued until the end of the breastfeeding period.

Use of Psychoactive Substances during the Perinatal Period: Guidelines for Interventions during the Perinatal Period from the French National College of Midwives

Based on their clinical practice and an extensive review of the literature, the authors propose a framework of procedures to be followed to provide services to all women of childbearing age who use psychoactive substances (alcohol, cannabis, cocaine, amphetamines, and opioids), especially during pregnancy or during the postpartum and breastfeeding periods, in view of their individual situations and environmental contexts.

Consumo de alcohol en mujeres embarazadas y lactantes: factores de riesgo y protección asociados

Objetivo Examinar la ocurrencia del consumo de alcohol en mujeres embarazadas o en periodo de lactancia de la provincia de Córdoba (Argentina) y los factores de riesgo/protección que explican ese consumo. Metodología Participaron 475 mujeres (202 embarazadas y 273 lactantes) entre 18-47 años que completaron una encuesta en línea, que indagó sobre su consumo de alcohol y una serie de factores de riesgo y protección para el consumo de alcohol. Resultados El 93,1% y 68,1% de las mujeres embarazadas y lactantes indicaron que no consumían alcohol en su condición. Se observó un perfil más riesgoso en mujeres lactantes. En embarazadas, solo la percepción de riesgo permitió explicar su consumo. En lactantes, la percepción de riesgo, el consumo de convivientes, la indicación de no beber en su condición por parte de familiares/amistades y la aprobación del consumo de alcohol en otras mujeres lactantes permitieron explicar su consumo. Discusión Estos resultados ponen en evidencia la necesidad de brindar información clara y precisa sobre los riesgos asociados al consumo de alcohol durante el embarazo y, especialmente, la lactancia y la necesidad de incorporar cuatro actores sociales en las campañas preventivas: los profesionales de la salud, los/las convivientes, la familia y las amistades de la mujer gestante/lactante.

Adaptive Text Messaging for Postpartum Risky Drinking: Conceptual Model and Protocol for an Ecological Momentary Assessment Study (Preprint)

Background

Risky drinking is prevalent among women of childbearing age. Although many women reduce their drinking during pregnancy, more than half return to prepregnancy levels during the early postpartum period. Risky drinking in new mothers may be associated with negative child and maternal health outcomes; however, new mothers are unlikely to seek treatment for risky drinking because of stigma and fear of child protective service involvement. SMS text messaging is a promising approach for reaching non–treatment-seeking new mothers at risk because of risky drinking. SMS text messaging interventions (TMIs) are empirically supported for alcohol use, but a tailored intervention for new mothers does not exist. This study aims to fill this gap by developing a just-in-time adaptive TMI for postpartum risky drinking.

Objective

The objectives of this paper are to present a preliminary conceptual model of postpartum risky drinking and describe the protocol for conducting an ecological momentary assessment (EMA) study with new mothers to inform the refinement of the conceptual model and development of the TMI.

Methods

This paper presents a preliminary conceptual model of postpartum risky drinking based on the motivational model of alcohol use, social cognitive theory, and temporal self-regulation theory. The model proposes three primary intervention targets: motivation, self-efficacy, and self-regulation. Theoretical and empirical literature in support of the conceptual model is described. The paper also describes procedures for a study that will collect EMA data from 30 participants recruited via social media and the perinatal Central Intake system of New Jersey. Following the baseline assessment, EMA surveys will be sent 5 times per day for 14 days. The assessment instruments and data analysis procedures are described.

Results

Recruitment is scheduled to begin in January 2022 and is anticipated to conclude in March 2022. Study results are estimated to be published in July 2022.

Conclusions

The study findings will enhance our understanding of daily and momentary fluctuations in risk and protective factors for risky drinking during the early postpartum period. The findings will be used to refine the conceptual model and inform the development of the TMI. The next steps for this work include the development of intervention components via an iterative participatory design process and testing of the resulting intervention in a pilot microrandomized trial.

International Registered Report Identifier (IRRID)

PRR1-10.2196/36849

Does breastfeeding account for the association between maternal sensitivity and infant cognitive development in a large, nationally representative cohort?

Background

Previous research has established that exposure to high maternal sensitivity is positively associated with advances in infant cognitive development. However, there are many fixed and modifiable factors that influence this association. This study investigates whether the association between maternal sensitivity and infant cognitive development in the first year of life is accounted for by other factors, such as breastfeeding, maternal depressive symptoms, maternal alcohol use, infant birth weight or demographic covariates.

Methods

Using data from the Early Childhood Longitudinal Study-Birth (ECLS-B) Cohort, a nationally representative sample of U.S. born children, multi-variable regression analyses was used to examine whether breastfeeding, maternal depressive symptoms and alcohol use were associated with maternal sensitivity, as measured by the Nursing Child Assessment Teaching Scale (NCATS), and with infant cognitive development, as measured by the Bayley Scales of Infant Development, Short Form, Research Edition, after controlling for demographic covariates (infant sex, maternal age, education, race/ethnicity, income, parity, family structure) and infant birth weight.

Results

Breastfeeding, depressive symptoms and alcohol use were not associated with maternal sensitivity scores after controlling for demographic covariates and infant birth weight. However, breastfeeding (β = .079, p < .001), depressive symptoms (β = −.035, p < .05), and maternal sensitivity (β = .175, p < .001) were each significantly associated with infant cognitive development scores, even after controlling for demographic covariates and birthweight (R² = .053, p < .001). The association between maternal sensitivity and infant cognitive development did not attenuate after adjusting for breastfeeding. Instead, both sensitivity and breastfeeding independently contributed to higher infant cognitive development scores.

Conclusion

Maternal sensitivity and breastfeeding are separate means to advancing infant cognitive development. This study is significant because it is the first to examine breastfeeding, maternal depressive symptoms and alcohol use together, upon the association between maternal sensitivity and infant cognitive development, after adjusting for demographic covariates and infant birthweight. Maternal sensitivity, a measurable quality, advances infants’ cognitive development. Moreover, sensitivity and breastfeeding had independent effects upon cognitive development after controlling for multiple fixed and modifiable covariates. Understanding factors impacting the association between sensitivity and infant cognitive development provide avenues for developing more effective parenting interventions.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12887-022-03133-4.

Milk's Flows: Making and Transmitting Kinship, Health, and Personhood

Milk provides a way of thinking about how the body is enacted in science, policy and popular culture. This paper follows the currents of moral and biomedical epistemologies circulating around milk, including via notions of inheritance, the practices of wet nursing, and emerging scientific knowledge about the health-related benefits of breastfeeding. By situating milk's flows historically and culturally it shows how constructions of milk production, lactation, and infant feeding have long served as a 'cultural signal' of prevailing conceptions of bodies and social identities. In so doing, it explores the simultaneous power of milk as both a source of dispositional and somatic health, and an index of customary forms of unity and division. A focus on breast milk further contributes to augmenting and expanding recent debates about the biology-society nexus in science and technology studies (STS), anthropology, and sociology. Seen within biomedicine today as a carrier of somatic signals about the environment, the article reflects on how milk is bound up in the responsibilisation of women's bodies and the internalising of potential risks to the health of their offspring. This implies an unlimited agency for women in averting health risks and in future-proofing their children to be better than well, elides the socioeconomic, and environmental forces pragmatically limiting this assumed agency, and the distinct lack of material and inter-personal support for the perinatal period in many nations.

The Term Newborn: Prenatal Substance Exposure

Care for pregnant patients with substance use disorder must be provided in a nonjudgmental manner with recognition of addiction as a chronic medical illness in order to establish a therapeutic relationship and improve outcomes. All pregnant patients should be screened for substance use during prenatal care. Screening can be accomplished through several validated screening tools. Patients who screen positive need to be evaluated and referred for treatment as appropriate. This article reviews specific adverse perinatal outcomes associated with the use of a variety of substances and provides guidance on exposure with continued breastfeeding.

Relationship between traditional maternal diet pattern and breastmilk composition of rural lactating women during the first month postpartum in Shigatse, Tibet

Maternal nutrition can influence the composition of human breastmilk by altering the components that are sensitive to maternal diet pattern. Traditional Tibetan maternal diet pattern among native rural lactating women possesses distinct characteristics due to its unique geographical environment and dietary habits. This study investigated maternal diet pattern and human breastmilk composition of Tibetan lactating women through different lactation stages during the first month postpartum in Shigatse. The results indicated that Tibetan maternal diet profile was apparently monotonous, mainly sufficient in Zanba, buttered tea, red meat, and fatty soup, yet insufficient in white meat, eggs, leafy vegetables, and fruits, leading to imperfect maternal nutritional intakes with high-level carbohydrates and deficient proteins. Distinctions of maternal diet profiles in various degrees can be discovered upon different lactation stages, which brings multiple influences to the composition of human milk. There was significantly weak-to-medium correlation of protein contents between maternal diet intakes and human milk, while other macronutrients correlated insignificantly. Micronutrient constituents in human milk, involving functional unsaturated fatty acids and free essential amino acids, were also impacted by maternal diet intakes through different lactation stages. These results show that more systematic and profound research is requisite for the clarification and development of Tibetan maternal diet to offer more enhanced and individualized nutritional recommendations for Tibetan lactating women and infants.

Role of inflammation in alcohol-related brain abnormalities: a translational study

Brain abnormalities observed in alcohol use disorder are highly heterogeneous in nature and severity, possibly because chronic alcohol consumption also affects peripheral organs leading to comorbidities that can result in exacerbated brain alterations. Despite numerous studies focussing on the effects of alcohol on the brain or liver, few studies have simultaneously examined liver function and brain damage in alcohol use disorder, and even fewer investigated the relationship between them except in hepatic encephalopathy. And yet, liver dysfunction may be a risk factor for the development of alcohol-related neuropsychological deficits and brain damage well before the development of liver cirrhosis, and potentially through inflammatory responses. The use of animal models enables a better understanding of the pathophysiological mechanisms underlying liver–brain relationships in alcohol use disorder, and more particularly of the inflammatory response at the tissue, cerebral and hepatic levels. The objective of this translational study was to investigate, both in alcohol use disorder patients and in a validated animal model of alcohol use disorder, the links between peripheral inflammation, liver damage and brain alterations. To do this, we conducted an in vivo neuroimaging examination and biological measures to evaluate brain volumes, liver fibrosis and peripheral cytokines in alcohol use disorder patients. In selectively bred Sardinian alcohol-preferring rats, we carried out ex vivo neuroimaging examination and immunohistochemistry to evaluate brain and liver inflammatory responses after chronic (50 consecutive weeks) alcohol drinking. In recently abstinent and non-cirrhotic alcohol use disorder patients, the score of liver fibrosis positively correlated with subcortical regions volumes (especially in right and left putamen) and level of circulating proinflammatory cytokines. In Sardinian alcohol-preferring rats, we found macrostructural brain damage and microstructural white matter abnormalities similar to those found in alcohol use disorder patients. In addition, in agreement with the results of peripheral inflammation observed in the patients, we revealed, in Sardinian alcohol-preferring rats, inflammatory responses in the brain and liver were caused by chronic alcohol consumption. Since the liver is the main source of cytokines in the human body, these results suggest a relationship between liver dysfunction and brain damage in alcohol use disorder patients, even in the absence of major liver disease. These findings encourage considering new therapeutic strategies aiming at treating peripheral organs to limit alcohol-related brain damage.

Guideline No. 405: Screening and Counselling for Alcohol Consumption During Pregnancy

OBJECTIVE

To establish national standards of care for screening and counselling pregnant women and women of child-bearing age about alcohol consumption and possible alcohol use disorder based on current best evidence.

INTENDED USERS

Health care providers who care for pregnant women and women of child-bearing age.

TARGET POPULATION

Pregnant women and women of child-bearing age and their families.

EVIDENCE

Medline, EMBASE, and CENTRAL databases were searched for "alcohol use and pregnancy." The results were filtered for a publication date between 2010 and September 2018. The search terms were developed using Medical Subject Headings terms and keywords, including pre-pregnancy, pregnant, breastfeeding, lactation, female, women, preconception care, prenatal care, fetal alcohol spectrum disorder, prenatal alcohol exposure, drinking behavior, alcohol abstinence, alcohol drinking, binge drinking, alcohol-related disorders, alcoholism, alcohol consumption, alcohol abuse, benzodiazepines, disulfiram, naltrexane, acamprosate, ondansetron, topiramate, cyanamide, calcium carbimide, alcohol deterrents, disease management, detoxification, Alcoholics Anonymous, alcohol counselling, harm reduction, pre-pregnancy care, prenatal care, incidence, prevalence, epidemiological monitoring, and brief intervention. Evidence was included from clinical trials, observational studies, reviews, systematic reviews and meta-analyses, guidelines, and conference consensus.

VALIDATION METHODS

The content and recommendations in this guideline were drafted and agreed upon by the authors. The Board of Directors of the Society of Obstetricians and Gynaecologists of Canada approved the final draft for publication. The quality of evidence was rated using the criteria described in the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology framework.

BENEFITS, HARMS, COSTS

Implementation of the recommendations in these guidelines using validated screening tools and brief intervention approaches may increase obstetrical care provider recognition of alcohol consumption and problematic alcohol use among women of child-bearing age and those who are pregnant. It is anticipated that health care providers will become confident and competent in managing and supporting these women so they can achieve optimal health and pregnancy outcomes.

SUMMARY STATEMENTS (GRADE RATINGS IN PARENTHESES)

RECOMMENDATIONS (GRADE RATINGS IN PARENTHESES).

Alcohol use in pregnancy and its impact on the mother and child

AIMS

To review the impact of prenatal alcohol exposure on the outcomes of the mother and child.

DESIGN

Narrative review.

SETTING

Review of literature.

PARTICIPANTS

Mothers and infants affected by prenatal alcohol use.

MEASUREMENTS

Outcomes of mothers and children.

FINDINGS

Prenatal alcohol exposure is one of the most important causes of preventable cognitive impairment in the world. The developing neurological system is exquisitely sensitive to harm from alcohol and there is now also substantial evidence that alcohol-related harm can extend beyond the individual person, leading to epigenetic changes and intergenerational vulnerability and disadvantage. There is no known safe level or timing of drinking for pregnant or lactating women and binge drinking (> four drinks within 2 hours for women) is the most harmful. Alcohol-exposure increases the risk of congenital problems, including Fetal Alcohol Spectrum Disorder (FASD) and its most severe form, Fetal Alcohol Syndrome (FAS).

CONCLUSION

The impact of FASD and FAS is enduring and life-long with no current treatment or cure. Emerging therapeutic options may mitigate the worst impact of alcohol exposure but significant knowledge gaps remain. This review discusses the history, epidemiology and clinical presentations of prenatal alcohol exposure, focusing on FASD and FAS, and the impact of evidence on future research, practice and policy directions.

Directive clinique no 405 : Dépistage et conseils en matière de consommation d'alcool pendant la grossesse

OBJECTIF

Établir des normes pancanadiennes fondées sur les meilleures données probantes actuelles sur le dépistage et les conseils en matière de consommation d'alcool et de troubles de consommation d'alcool chez les femmes enceintes ou en âge de procréer. PROFESSIONNELS CONCERNéS: Les fournisseurs de soins qui prodiguent des soins aux femmes enceintes et aux femmes en âge procréer.

POPULATION CIBLE

Les femmes enceintes, les femmes en âge de procréer et leurs familles. DONNéES PROBANTES: Des recherches ont été effectuées dans les bases de données Medline, Embase et CENTRAL avec le thème « alcohol use and pregnancy ». Les résultats ont été filtrés de façon à obtenir des publications parues entre 2010 et septembre 2018. Les termes de recherche ont été mis au point à partir des termes du thésaurus de référence biomédicale MeSH et de mots clés, dont les suivants : pre-pregnancy, pregnant, breastfeeding, lactation, female, women, preconception care, prenatal care, fetal alcohol spectrum disorder, prenatal alcohol exposure, drinking behavior, alcohol abstinence, alcohol drinking, binge drinking, alcohol-related disorders, alcoholism, alcohol consumption, alcohol abuse, benzodiazepines, disulfiram, naltrexane, acamprosate, ondansetron, topiramate, cyanamide, calcium carbimide, alcohol deterrents, disease management, detoxification, Alcoholics Anonymous, alcohol counselling, harm reduction, pre-pregnancy care, prenatal care, incidence, prevalence, epidemiological monitoring et brief intervention. Les données probantes retenues proviennent d'essais cliniques, d'études observationnelles, de revues de la littérature, d'analyses systématiques et méta-analyses, de lignes directrices et de conférences de consensus. MéTHODES DE VALIDATION: Les auteurs ont rédigé et accepté le contenu et les recommandations de la présente directive. Le conseil d'administration de la Société des obstétriciens et gynécologues du Canada a approuvé la version définitive aux fins de publication. La qualité des données probantes a été évaluée au moyen des critères de l'approche GRADE (Grading of Recommendations Assessment, Development, and Evaluation) (consulter les tableaux A1 et A2 de l'annexe en ligne). BéNéFICES, RISQUES, COûTS: La mise en œuvre des recommandations de la présente directive à l'aide d'outils de dépistage validés et de stratégies d'intervention brève peut améliorer la capacité des fournisseurs de soins obstétricaux à reconnaître la consommation d'alcool et la consommation problématique d'alcool chez les femmes enceintes ou en âge de procréer. Il est attendu des fournisseurs de soins de santé qu'ils deviennent confiants et compétents en matière de prise en charge et de soutien de ces femmes afin qu'elles puissent avoir la meilleure santé possible et une issue de grossesse optimale. DÉCLARATIONS SOMMAIRES (CLASSEMENT GRADE ENTRE PARENTHèSES): RECOMMANDATIONS (CLASSEMENT GRADE ENTRE PARENTHèSES).

Pregnancy, Fertility, Breastfeeding, and Alcohol Consumption: An Analysis of Framing and Completeness of Information Disseminated by Alcohol Industry-Funded Organizations

Objective:

Alcohol use during pregnancy can harm the developing fetus. The exact amount, pattern, and critical period of exposure necessary for harm to occur are unclear, although official guidance often emphasizes precautionary abstention. The impacts on fertility and breastfeeding are also unclear. Information on alcohol and pregnancy is disseminated by the alcohol industry–funded organizations, and there are emerging concerns about its accuracy, suggesting the need for detailed analysis.

Method:

Information on alcohol consumption in relation to fertility, pregnancy, and breastfeeding was extracted from the websites of 23 alcohol industry–funded bodies (e.g., Drinkaware [United Kingdom] and DrinkWise [Australia]), and 19 public health organizations (e.g., Health.gov and NHS Choices). Comparative qualitative and quantitative analysis of the framing and completeness of this information was undertaken.

Results:

Alcohol industry–funded organizations were statistically significantly less likely than public health websites to provide information on fetal alcohol spectrum disorder and less likely to advise that no amount of alcohol is safe during pregnancy. They were significantly more likely to emphasize uncertainties and less likely to use direct language (e.g., “don’t drink”). Some alcohol industry–funded (and no public health) websites appear to use “alternate causation” arguments, similar to those used by the tobacco industry, to argue for causes of alcohol harms in pregnancy other than alcohol.

Conclusions:

Alcohol industry–funded websites omit and misrepresent the evidence on key risks of alcohol consumption during pregnancy. This may “nudge” women toward continuing to drink during pregnancy. These findings suggest that alcohol industry–funded bodies may increase risk to pregnant women by disseminating misinformation. The public should be made widely aware of the risks of obtaining health information from alcohol industry–funded sources.

Drinking or smoking while breastfeeding and later developmental health outcomes in children

Objectives

Prenatal intake of alcohol and tobacco have been associated with negative outcomes in children. Consumption of alcohol while breastfeeding has also been associated with dose-dependent decreases in abstract reasoning ability and academic scores in children at later ages. Using longitudinal data from The Growing Up in Australia Study, the current study aimed to investigate whether intake of alcohol or tobacco while breastfeeding was related to later developmental health outcomes in children.

Results

Multivariable linear regression analyses were performed on a sample of 2008 babies who were actively breastfeeding at study entry and 4679 babies who had been breastfed at any time (actively breastfed babies combined with babies who had been previously breastfed). Only a diagnosis of Autism spectrum disorder and Attention deficit disorder were associated with lower developmental health outcomes. Neither maternal alcohol consumption nor tobacco smoking while breastfeeding were associated with developmental health outcomes at 6–7 years old or 10–11 years old for either sample group. A relationship between maternal consumption of alcohol or tobacco smoking while breastfeeding and later developmental health outcomes in children was not identified.

Drinking or Smoking While Breastfeeding and Later Academic Outcomes in Children

Alcohol consumed by breastfeeding mothers has been associated with reduced grammatical comprehension and cognition in children. This study examined whether drinking or smoking while breastfeeding was associated with reductions in Australian National Assessment Program–Literacy and Numeracy assessments. Data was sourced from The Growing Up in Australia Study. This is an ongoing longitudinal study of 5107 infants and mothers recruited in 2004 and followed over time every two years. Multivariable linear regression found that maternal alcohol consumption at study entry was associated with reductions in Grade 3 (age 7–10 years) National Assessment Program–Literacy and Numeracy writing (b = −1.56, 95% CI: −2.52; −0.60, p = 0.01), spelling (b = −2.06, 95% CI: −3.31; −0.81, p < 0.0001) and grammar and punctuation (b = −2.11, 95% CI: −3.59; −0.64, p = 0.01) scores, as well as Grade 5 (age 9–11 years) spelling scores (b = −1.58, 95% CI: −2.74; −0.43, p = 0.03) in children who had been breastfed at any time. This was not evident in babies who had never breastfed, or in the smaller group of infants who were actively breastfeeding at study entry. Smoking was not associated with any outcome variable. Drinking alcohol while breastfeeding may result in dose-dependent reductions in children’s academic abilities. While reductions are small, they may be of clinical significance if mothers drink large quantities. Further analyses are planned to assess developmental, physical and behavioural outcomes in children.

Alcohol Use During Lactation and Offspring Outcomes

News reports of decreased nonverbal reasoning in 6-year-old children exposed to alcohol in breast milk have ignited both concern about drinking during lactation and accusations of mother-shaming. Lactation consultants are often asked about the safety of drinking alcoholic beverages during lactation. Placing this study in the context of other research about alcohol use by lactating parents and the outcomes for their children can help provide evidence to support continued breastfeeding and child safety.

Is Breast Best? Examining the effects of alcohol and cannabis use during lactation

Maternal drug use during lactation may have adverse effects on the health of their children. Two common drugs used during this period are alcohol and cannabis. A literature search was conducted using PubMed, CINAHL, Nursing and Allied Health, and Google Scholar with the following search terms: marijuana, cannabis, THC, alcohol, ethanol, breastfeeding, lactation, and breastmilk. The search strategy was restricted to papers since the year 2000, and limited to English language journals. Reference lists were also used to capture any articles that were missed from the database searches. In total, 19 articles were found related to alcohol and breastfeeding (n = 17 original research papers; n = 2 systematic reviews), and 4 articles were specific to cannabis (n = 2 original papers; n = 2 systematic reviews). The most common outcomes associated with alcohol consumption and breastfeeding included changes in sleep patterns, reduced milk production and flow, lower milk intake, and impaired immune function. Maternal outcomes related to cannabis consumption included panic attacks, delayed response time, increased heart rate, reduced short-term memory, dizziness, and impaired motor performance; infant outcomes associated with maternal cannabis use and breastfeeding were reduced muscular tonus, poor sucking, and growth delay and restriction. Mothers should be advised to refrain from substance use during the lactation period for the health and safety of their children.

Parental drinking in Australia: Does the age of children in the home matter?

INTRODUCTION AND AIMS

Parental role modelling of alcohol use is known to influence alcohol consumption in adolescence and in later life. This study aimed to assess relationships between parental status, child age and alcohol consumption, which have not been well documented.

DESIGN AND METHODS

Data were sourced from the 2013 Australian National Drug Strategy Household Survey. Analyses were conducted for 25-55 year olds (n = 11 591) by parental status, gender and age of youngest child in the household, controlling for socio-demographic factors.

RESULTS

Parents were less likely than non-parents to exceed the alcohol guideline for increased lifetime risk (18.2% vs. 24.2%) and short-term risk: at least weekly (14.2% vs. 21.2%); and at least monthly (27.5% vs. 35.9%). Fathers were just as likely to exceed the guidelines for lifetime risk as other men, but those with children aged 0-2, were less likely to exceed the guideline for short-term risk. Women were least likely to exceed the guideline for lifetime risk if they had children aged 0-2, 6-11 or 15 years and over, or the guideline for short-term risk, if they had children aged 0-2, or 15 years and over in the household. Parents were more likely to report drinking in the home.

DISCUSSION AND CONCLUSIONS

Parents were less likely to exceed alcohol guidelines than non-parents, especially mothers whose youngest child was an infant or in high school or older. Consistent with population rates in men, fathers were more likely to exceed alcohol guidelines than mothers, and this excess consumption warrants public health attention.

Maternal Behavioral Health: Fertile Ground for Behavior Analysis

The World Health Organization has identified four behavioral health priorities as risk factors for noncommunicable diseases in maternal populations: tobacco use, harmful alcohol use, poor nutrition, and lack of physical activity. These risk factors also significantly affect pregnant and immediately postpartum mothers, doubling the health risk and economic burden by adversely affecting maternal and birth or infant outcomes. Psychosocial and behavioral interventions are ideal for pregnant and immediately postpartum women as opposed to pharmacotherapy. Among other behavioral interventions, the use of incentives based on the principles of reinforcement has been a successful yet controversial way to change health behaviors. Implementing an incentive-based intervention in maternal health often brings up social validity concerns. The existing guideline on how to develop and conduct research in incentive-based interventions for maternal health lacks enough information on the specific variables to control for to maintain the intervention's effectiveness. This article outlines some of the critical variables in implementing an effective behavior-analytic intervention and addressing social validity concerns to change maternal behaviors in a sustainable manner, along with specific research topics needed in the field to prevent adverse maternal, birth, and infant outcomes.

Drinking or Smoking While Breastfeeding and Later Cognition in Children

BACKGROUND AND OBJECTIVES

Although prenatal alcohol and nicotine exposure are associated with reduced cognition in children, associations between consumption of alcohol during lactation and cognition have not been examined. We aimed to examine whether drinking or smoking while breastfeeding lowers children's cognitive scores. We hypothesized that increased drinking or smoking would be associated with dose-dependent cognitive reductions.

METHODS

Data were sourced from Growing Up in Australia: The Longitudinal Study of Australian Children. Participants were 5107 Australian infants recruited in 2004 and assessed every 2 years. Multivariable linear regression analyses assessed relationships between drinking and smoking habits of breastfeeding mothers and children's Matrix Reasoning, Peabody Picture Vocabulary Test-Third Edition and Who Am I? scores at later waves.

RESULTS

Increased or riskier wave 1 maternal alcohol consumption was associated with reductions in Matrix Reasoning scores at age 6 to 7 years in children who had been breastfed (B = -0.11; SE = 0.03; 95% confidence interval: -0.18 to -0.04; P = .01). This relationship was not evident in infants who had never breastfed (B = -0.02; SE = 0.10; 95% confidence interval = -0.20 to 0.17; P = .87). Smoking during lactation was not associated with any outcome variable.

CONCLUSIONS

Exposing infants to alcohol through breastmilk may cause dose-dependent reductions in their cognitive abilities. This reduction was observed at age 6 to 7 years but was not sustained at age 10 to 11 years. Although the relationship is small, it may be clinically significant when mothers consume alcohol regularly or binge drink. Further analyses will assess relationships between alcohol consumption or tobacco smoking during lactation and academic, developmental, physical, and behavioral outcomes in children.