Alcohol and lactation: A systematic review

Maternal and paternal risk factors for fetal alcohol spectrum disorders: Alcohol and other drug use as proximal influences

OBJECTIVE

To explore and analyze the significance of proximal influences of maternal and paternal traits associated with bearing a child with a fetal alcohol spectrum disorder (FASD).

METHODS

Aggregated, maternal interview-collected data (N = 2515) concerning alcohol, tobacco, and other drug use were examined to determine risk for FASD from seven cross-sectional samples of mothers of first-grade students who were evaluated for a possible diagnosis of FASD.

RESULTS

Mothers of children with fetal alcohol syndrome (FAS) reported the highest alcohol use throughout pregnancy, proportion of binge drinking, drinks per drinking day (DDD), drinking days per week, and total drinks per week. Mothers of children with FAS also consumed significantly more alcohol than mothers of children with partial FAS (PFAS), alcohol-related neurodevelopmental disorder (ARND), or typically developing controls. Mothers of children with PFAS and ARND reported similar drinking patterns, which exposed fetuses to 3-4 times more alcohol than mothers of controls, but the PFAS group was more likely than the ARND group to abstain in latter trimesters. Fathers of all children were predominantly drinkers (70%-85%), but more fathers of children with FASD binged heavily on more days than fathers of controls. Compared to the few mothers of controls who used alcohol during pregnancy, the ARND group binge drank more (3+ DDD) throughout pregnancy and drank more DDD before pregnancy and first trimester. Regression analysis, controlling for tobacco use, indicated that mothers who reported drinking <1 DDD were significantly more likely than abstainers to bear a child with FASD (OR = 2.75) as were those reporting higher levels such as 5-5.9 DDD (OR = 32.99). Exclusive, first-trimester maternal drinking increased risk for FASD five times over that of abstinence (p < 0.001, OR = 5.05, 95% CI: 3.88-6.58), first- and second-trimester drinking by 12.4 times, and drinking all trimesters by 16 times (p < 0.001, OR = 15.69, 95% CI: 11.92-20.64). Paternal drinking during and prior to pregnancy, without adjustment, increased the likelihood of FASD significantly (OR = 1.06 and 1.11, respectively), but the significance of both relationships disappeared when maternal alcohol and tobacco use were controlled.

CONCLUSIONS

Differences in FASD risk emerged from the examination of multiple proximal variables of maternal alcohol and tobacco use, reflecting increased FASD risk at greater levels of maternal alcohol consumption.

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.

Health Education about Lifestyle-Related Risk Factors in Gynecological and Obstetric Care: A Qualitative Study of Healthcare Providers' Views in Germany

OBJECTIVE

Lifestyle-related risk factors (LRRFs) during pregnancy and lactation are associated with a range of health problems. However, previous studies have shown a large knowledge gap among pregnant women regarding the effects of LRRFs. This study aimed to investigate the role of health education about LRRFs during pregnancy and lactation in gynecological and obstetric care from healthcare providers' (HCPs) point of view.

METHODS

To explore the views of healthcare providers, a qualitative study was performed. In 2019, 22 in-depth interviews were conducted with a purposive sample of 9 gynecologists and 13 midwives. Participants came from different inpatient and outpatient care settings and from rural, urban, and socially deprived areas in southern Germany. All the interviews were tape-recorded and transcribed verbatim. A combined inductive and deductive approach was applied for data analysis.

RESULTS

Interviews with HCPs showed that they were aware of the possible impacts of LRRFs during pregnancy and lactation. They noted the importance of action, specifically among women with low socioeconomic status (SES), migrants, and women with a concerning medical history or other specific needs. However, the interviews showed that, at present, there is no standardized practice of educating patients on LRRFs in routine care. This was attributed to a lack of guidelines and time, unfavorable regulations, and undefined responsibilities. The priority of health education is lower in inpatient healthcare settings as compared to outpatient healthcare settings. HCPs apply a demand-driven healthcare approach, focusing on a woman's medical history, needs, and personal circumstances. HCPs voiced the importance of implementing pre-conception education across different healthcare settings, garnering support from other health organizations, and setting out clearly defined responsibilities among HCPs.

CONCLUSIONS

This qualitative study explored HCPs' perspectives on health education about LRRFs during pregnancy and lactation. The results from this study emphasize the need for a central strategy for health education about LRRFs during pregnancy and lactation in gynecological and obstetric care.

Lactational Amenorrhea: Neuroendocrine Pathways Controlling Fertility and Bone Turnover

Lactation is a physiological state of hyperprolactinemia and associated amenorrhea. Despite the fact that exact mechanisms standing behind the hypothalamus-pituitary-ovarian axis during lactation are still not clear, a general overview of events leading to amenorrhea may be suggested. Suckling remains the most important stimulus maintaining suppressive effect on ovaries after pregnancy. Breastfeeding is accompanied by high levels of prolactin, which remain higher than normal until the frequency and duration of daily suckling decreases and allows normal menstrual function resumption. Hyperprolactinemia induces the suppression of hypothalamic Kiss1 neurons that directly control the pulsatile release of GnRH. Disruption in the pulsatile manner of GnRH secretion results in a strongly decreased frequency of corresponding LH pulses. Inadequate LH secretion and lack of pre-ovulatory surge inhibit the progression of the follicular phase of a menstrual cycle and result in anovulation and amenorrhea. The main consequences of lactational amenorrhea are connected with fertility issues and increased bone turnover. Provided the fulfillment of all the established conditions of its use, the lactational amenorrhea method (LAM) efficiently protects against pregnancy. Because of its accessibility and lack of additional associated costs, LAM might be especially beneficial in low-income, developing countries, where modern contraception is hard to obtain. Breastfeeding alone is not equal to the LAM method, and therefore, it is not enough to successfully protect against conception. That is why LAM promotion should primarily focus on conditions under which its use is safe and effective. More studies on larger study groups should be conducted to determine and confirm the impact of behavioral factors, like suckling parameters, on the LAM efficacy. Lactational bone loss is a physiologic mechanism that enables providing a sufficient amount of calcium to the newborn. Despite the decline in bone mass during breastfeeding, it rebuilds after weaning and is not associated with a postmenopausal decrease in BMD and osteoporosis risk. Therefore, it should be a matter of concern only for lactating women with additional risk factors or with low BMD before pregnancy. The review summarizes the effect that breastfeeding exerts on the hypothalamus-pituitary axis as well as fertility and bone turnover aspects of lactational amenorrhea. We discuss the possibility of the use of lactation as contraception, along with this method's prevalence, efficacy, and influencing factors. We also review the literature on the topic of lactational bone loss: its mechanism, severity, and persistence throughout life.

Assessment of Ethanol Exposure from Hand Sanitizer Use and Potential for Developmental Toxicity in Nursing Infants

Ingestion of ethanol during pregnancy is known to have detrimental effects on the fetus. Although the potential developmental effects of maternal ethanol intake during lactation are less well characterized, public health guidelines recommend avoidance of alcohol or, if alcohol is consumed, to allow for 1–2 h to pass before nursing. A proposal to classify ethanol as potentially harmful to breast‐fed children warrants an investigation of the potential adverse neurodevelopmental effects of low‐dose ethanol exposure during lactation. There currently are no studies that have examined neurodevelopmental outcomes from lactational exposure to ethanol from the use of topical products that contain ethanol, such as alcohol‐based hand sanitizers (ABHS). Furthermore, the epidemiological literature of lactational ethanol exposures from maternal alcohol consumption is limited in design, provides equivocal evidence of neurological effects in infants, and is insufficient to characterize a dose–response relationship for developmental effects. Toxicological studies that observed neurodevelopmental effects in pups from ethanol via lactation did so at exceedingly high doses that also caused maternal toxicity. In this investigation, blood ethanol concentrations (BECs) of breastfeeding women following typical‐to‐intense ABHS use were computationally predicted and compared to health benchmarks to quantify the risk for developmental outcomes. Margins of 2.2 to 1000 exist between BECs associated with ABHS use compared to BECs associated with neurotoxicity adverse effect levels in the toxicology literature or oral ethanol intake per public health guidelines. Neurodevelopmental effects are not likely to occur in infants due to ABHS use by breastfeeding women, even when ABHSs are used at intense frequencies.

Adverse neurodevelopmental effects of ethanol exposure are supported by toxicological studies; ethanol as a potential “lactation hazard” needs evaluation. A lactation hazard may not be applicable for all ethanol‐containing products, such as hand sanitizers. Furthermore, internal dose assessments of hand sanitizer use are lacking. Computationally modeled blood ethanol concentrations following hand sanitizer use are lower than concentrations associated with toxicological and guideline benchmarks. Therefore, there is low potential for the use of ethanol‐containing hand sanitizers to be a lactation hazard.

Prenatal Stress Exposure and Post-traumatic Stress Disorder Associated With Risk of Postpartum Alcohol Misuse Among Women Veterans

OBJECTIVES

Maternal alcohol misuse during the postpartum period is associated with negative maternal and infant outcomes. This study examined whether greater stress exposure in the year before the baby's birth and maternal post-traumatic stress disorder (PTSD) were associated with postpartum alcohol misuse among a sample of women veterans. Maternal PTSD was also examined as a moderator of the association between stress exposure and postpartum alcohol misuse.

METHODS

Data were drawn from the Center for Maternal and Infant Outcomes Research in Translation study, a multisite prospective cohort study of pregnant and postpartum women veterans. Interviews were conducted within 12 weeks after birth. At this post-birth interview, women reported whether they experienced stressful events (e.g., loss of job, military deployment, separation/divorce) in the year before birth. PTSD diagnosis and postpartum scores on the Alcohol Use Disorders Identification Test (AUDIT-C) were derived from the Department of Veterans Affairs medical records.

RESULTS

Models testing main and interaction effects showed a statistically significant association of both PTSD (p = .02) and stress exposure (p = .04), as well as significant interaction of PTSD and stress exposure (p = .03) with AUDIT-C scores postpartum, after controlling for marital status, age, and race. Specifically, compared with women without PTSD, those with PTSD had higher overall AUDIT-C scores postpartum, regardless of stress exposure. For women without PTSD, more stress exposure before birth was associated with higher AUDIT-C scores during the postpartum phase.

CONCLUSIONS

PTSD diagnosis and life stressors before infant birth predicted maternal alcohol misuse during the postpartum period. Identifying such risk factors is an initial step in preventing alcohol misuse, with the goal of enhancing postpartum health for the birthing parent and infant.

Aberrant neurogenesis and late onset suppression of synaptic plasticity as well as sustained neuroinflammation in the hippocampal dentate gyrus after developmental exposure to ethanol in rats

Drinking alcohol during pregnancy may cause fetal alcohol spectrum disorder. The present study investigated the effects of maternal oral ethanol (EtOH) exposure (0, 10, or 12.5 % in drinking water) from gestational day 6 until day 21 post-delivery (weaning) on postnatal hippocampal neurogenesis at weaning and in adulthood on postnatal day 77 in rat offspring. At weaning, type-3 neural progenitor cells (NPCs) were decreased in the subgranular zone (SGZ), accompanied by Chrnb2 downregulation and Grin2b upregulation in the dentate gyrus (DG). These results suggested suppression of CHRNB2-mediated cholinergic signaling in γ-aminobutyric acid (GABA)ergic interneurons in the DG hilus and increased glutamatergic signaling through the NR2B subtype of N-methyl-d-aspartate (NMDA) receptors, resulting in NPC reduction. In contrast, upregulation of Chrna7 may increase CHRNA7-mediated cholinergic signaling in immature granule cells, and upregulation of Ntrk2 may cause an increase in somatostatin-immunoreactive ⁽⁺⁾ GABAergic interneurons, suggesting a compensatory response against NPC reduction. Promotion of SGZ cell proliferation increased type-2a NPCs. Moreover, an increase in calbindin-d-29 K⁺ interneurons and upregulation of Reln, Drd2, Tgfb2, Il18, and α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA)-type glutamate receptor subunit genes might participate in this compensatory response. In adulthood, reduction of FOS⁺ cells and downregulation of Fos and Arc suggested suppression of granule cell synaptic plasticity, reflecting upregulation of Tnf and downregulation of Cntf, Ntrk2, and AMPA-type glutamate receptor genes. In the DG hilus, gliosis and hyper-ramified microglia, accompanying upregulation of C3, appeared at weaning, suggesting contribution to suppressed synaptic plasticity in adulthood. M1 microglia increased throughout adulthood, suggesting sustained neuroinflammation. These results indicate that maternal EtOH exposure temporarily disrupts hippocampal neurogenesis and later suppresses synaptic plasticity. Induction of neuroinflammation might initially ameliorate neurogenesis (as evident by upregulation of Tgfb2 and Il18) but later suppress synaptic plasticity (as evident by upregulation of C3 at weaning and Tnf in adulthood).

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 and Tobacco use While Breastfeeding and Risk of Autism Spectrum Disorder or Attention Deficit/Hyperactivity Disorder

Research has linked prenatal alcohol and tobacco use with Attention Deficit Hyperactivity Disorder (ADHD), and variably with Autism Spectrum Disorder (ASD). Lactational use has been scantly considered. This study examined whether it may alter ADHD or ASD risk. Participants were 5107 infants recruited in 2004 and assessed longitudinally for the Growing Up in Australia Study. Logistic regression did not find any associations between maternal alcohol and tobacco use while breastfeeding and ADHD or ASD diagnosis at ages 6–7 or 10–11 years. Alcohol and tobacco use during lactation may not increase ADHD or ASD risk. Abstaining from alcohol and tobacco, however, may still be the safest option. Analyses were limited by lack of alcohol timing and retrospective variables that future research should address.

Effects of ethanol and nicotine co-administration on follicular atresia and placental histo-morphology in the first-generation mice pups during intrauterine development and lactation periods

This study is evaluating the effects of ethanol and nicotine exposure during pregnancy and lactation on placenta histology and follicular atresia in the first-generation (f1) mice pups. The experimental groups were 5 groups of NMRI pregnant mice, including: control, vehicle (received normal saline) ethanol (3 g/kg/day, 20 % v/v intraperitoneally), nicotine (1 mg/kg/day, subcutaneously), and ethanol plus nicotine which received both. Pregnant animals in each group were then divided into two groups, one group for examining the placenta that was treated for 18 days and the other group for the ovary of one-day-old (PND1) and fifty-six-day-old (PND56) female offspring who were treated for 42 days (during intrauterine development and lactation). After the autopsy procedure, histopathological and morphometrical observations were done. Data revealed that the exposed mice had a significant change in the placenta morphometry and histology as well as a marked increase in the number of ovarian TUNEL positive cells on postnatal days 1 and 56. Therefore, maternal exposure to alcohol and nicotine during developmental and lactation periods could lead to changes in the placenta properties as well as an increase in the apoptotic ovarian follicles in f1 mice pups.

Sociodemographic and lifestyle correlates of exclusive breastfeeding practices among mothers on antiretroviral therapy in the Eastern Cape, South Africa

BACKGROUND

Exclusive breastfeeding (EBF) is associated with a reduction of postnatal HIV transmission and optimal infant growth. Given that the factors influencing exclusive breastfeeding are multi-factorial and context-specific, we examined the prevalence and factors associated with exclusive breastfeeding practice in the first 6 months among mothers on antiretroviral therapy in the Eastern Cape, South Africa.

METHODS

This was a cross-sectional study conducted between January to May 2018, on 469 parturient women enlisted in the prevention of mother-to-child HIV transmission cohort study in the Eastern Cape. Mothers were asked to recall whether they breastfed their infant exclusively with breast milk from birth and if so, to state how long they did. We collected relevant sociodemographic, lifestyle, and maternal information by interview. Bivariate and multivariable logistic regression analyses were fitted to determine the sociodemographic and lifestyle factors associated with exclusive breastfeeding practice.

RESULTS

The prevalence of six-month exclusive breastfeeding, measured since birth, was 32.0%. E Exclusive breastfeeding's prevalence was significantly higher among married women (36.8%), unemployed women (36.6%), non-smokers (32.7%), and those who never drank alcohol (37.0%). Unemployed women (adjusted odds ratio [AOR] 1.66, 95% Confidence Interval [CI] 1.08-2.56) and those with grade 12 or less level of education (AOR 2.76, 95% CI 1.02-7.49) had a higher likelihood of practising EBF for 6 months since birth while mothers who consumed alcohol (AOR 0.54, 95% CI 0.34-0.85) were less likely to practice EBF for 6 months.

CONCLUSIONS

The prevalence of six-month exclusive breastfeeding in the study, although comparable with sub-Saharan Africa and worldwide prevalence, remains suboptimal. Advocacy campaigns on EBF must target alcohol cessation and the creation of a favourable workplace environment for lactating mothers.

Mendelian randomisation approaches to the study of prenatal exposures: A systematic review

BACKGROUND

Mendelian randomisation (MR) designs apply instrumental variable techniques using genetic variants to study causal effects. MR is increasingly used to evaluate the role of maternal exposures during pregnancy on offspring health.

OBJECTIVES

We review the application of MR to prenatal exposures and describe reporting of methodologic challenges in this area.

DATA SOURCES

We searched PubMed, EMBASE, Medline Ovid, Cochrane Central, Web of Science, and Google Scholar.

STUDY SELECTION AND DATA EXTRACTION

Eligible studies met the following criteria: (a) a maternal pregnancy exposure; (b) an outcome assessed in offspring of the pregnancy; and (c) a genetic variant or score proposed as an instrument or proxy for an exposure.

SYNTHESIS

We quantified the frequency of reporting of MR conditions stated, techniques used to examine assumption plausibility, and reported limitations.

RESULTS

Forty-three eligible studies were identified. When discussing challenges or limitations, the most common issues described were known potential biases in the broader MR literature, including population stratification (n = 29), weak instrument bias (n = 18), and certain types of pleiotropy (n = 30). Of 22 studies presenting point estimates for the effect of exposure, four defined their causal estimand. Twenty-four studies discussed issues unique to prenatal MR, including selection on pregnancy (n = 1) and pleiotropy via postnatal exposure (n = 10) or offspring genotype (n = 20).

CONCLUSIONS

Prenatal MR studies frequently discuss issues that affect all MR studies, but rarely discuss problems specific to the prenatal context, including selection on pregnancy and effects of postnatal exposure. Future prenatal MR studies should report and attempt to falsify their assumptions, with particular attention to issues specific to prenatal MR. Further research is needed to evaluate the impacts of biases unique to prenatal MR in practice.

False-Positive Ethanol Level in Urine and Plasma Samples of a Resuscitated Infant

We report the case of an 11-month-old male infant with a complex congenital heart disease who was admitted in the intensive care unit following cardiorespiratory arrest at home. Toxicological urine screening reported an ethanol concentration of 0.65 g/L using an enzymatic assay, without suspicion of alcohol intake; significant ethanol concentrations were found in two plasma samples using the same enzymatic assay. Plasma and urine ethanol concentrations were then below the limit of quantification when tested using a gas chromatography method. Urine ethanol level was also below the limit of quantification when tested by enzymatic assay after an initial urine ultrafiltration. These results confirmed our suspicion of matrix interference due to elevated lactate and lactate dehydrogenase levels interfering in the enzymatic assay. This analytical interference, well-known in postmortem samples, extensively studied in vitro, has been rarely reported in vivo, especially in children. To our knowledge, this case is only the sixth one reported in an infant's plasma and the first initially discovered from urine. Indeed, as for ethanol, this last matrix has not been studied in the context of this artifact which may induce false-positive ethanol results while seeking a diagnosis in life-threatening or fatal situations that are potentially subject to forensic scrutiny. In parallel to a synthetic literature review, we propose a simple, informative decision tree, in order to help health professionals suspecting a false-positive result when performing an ethanol assay.

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).

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.

Risk Factors for Delayed Onset of Lactogenesis II Among Primiparous Mothers from a Brazilian Baby-Friendly Hospital

BACKGROUND

Low milk supply is frequently reported as a reason for exclusive breastfeeding cessation.

RESEARCH AIMS

To determine the occurrence of, and the risk factors associated with, delayed onset of lactogenesis II among primiparas seen at a Baby-Friendly Hospital in Brazil.

METHOD

We conducted a prospective longitudinal observational cohort study of 224 primiparas who had a singleton delivery. Data were first collected at the hospital. We assessed the onset of lactogenesis on day four postpartum, based on maternal reports of changes in breast fullness. Breastfeeding practices and Edinburgh Postnatal Depression Scale were evaluated on day seven postpartum. Using Poisson regression, we assessed significant factors associated with delayed onset of lactogenesis II.

RESULTS

Delayed lactogenesis II occurred in 18.8% (n = 42) of participants and was significantly associated with alcohol drinking during pregnancy (IRR = 2.710, 95% CI [1.469, 4.996]); Edinburgh Postnatal Depression Scale scores ≥ 10 (IRR = 2.092, 95% CI [1.118, 3.916]), and the age of the mother (IRR: 1.081, 95% CI [1.039, 1.125]).

CONCLUSION

Postpartum depression and alcohol ingestion during pregnancy may be associated with lactogenesis II delay, but more research is needed to elucidate the directionality of these relationships. Older mothers are at risk of delayed lactogenesis II onset. The frequency of delayed lactogenesis in this population is similar to the rates seen in previous Latin America studies and much lower than the ranges seen in North America, possibly because of the low proportion of obesity and severe gestational diabetes in this sample.

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.

Obestatin improve spatial memory impairment in a rat model of fetal alcohol spectrum disorders via inhibiting apoptosis and neuroinflammation

Clinical and experimental evidence have demonstrated that, use of alcohol during pregnancy can interrupt brain development. Alcohol-induced neurocognitive deficits in offspring's are involved with activation of oxidative-inflammatory cascade joined with extensive apoptotic neurodegeneration in different brain regions such as hippocampus. Obestatin is a newly discovered peptide with anti-inflammatory, antioxidant, activities in different animal models. In this study, we aimed to evaluate the protective effects of obestatin on alcohol-induced neuronal apoptosis and neuroinflammation in rat pups with postnatal ethanol exposure. Through intragastric intubation, ethanol (5/27 g/kg/day) was administered in male Wistar rat pups on postnatal days 2-10 (third trimester in humans). The animals received Obestatin (1 and 5 μg/kg, S.C.) on postnatal days 2-10. Thirty-six days after birth, the spatial memory test was performed using Morris water maze test, and then, antioxidant enzymes and TNF-α levels were measured by ELISA assay. The expression level of GFAP and caspase-3 proteins was determined via immunohistochemical staining after the behavioral test. Obestatin significantly improved spatial memory deficits (P < .01), and obestatin treatment could significantly increase glutathione and total superoxide dismutase activity (P < .05), reduce level of malondialdehyde (P < .05) and TNF-α in comparison with the ethanol group (P < .01). It's also reduced caspase-3 level, and decreased GFAP-positive cells in the hippocampus of ethanol-exposed rat pups (P < .01). The result of this study shows the potential involvement of oxidative-inflammatory cascade-mediated apoptotic signaling in cognitive deficits due to postnatal ethanol exposure, the results also indicated the neuroprotective effects of Obestatin on alcohol-related behavioral, biochemical and molecular deficits.

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.

Determinants of breastfeeding initiation among mothers in Sydney, Australia: findings from a birth cohort study

Background

Breastfeeding has short-term and long-term benefits for both the infant and the mother. The objective of this study was to identify the incidence of breastfeeding initiation among women in South Western Sydney, and the factors associated with the initiation of breastfeeding.

Methods

Child and Family Health Nurses recruited mother-infant dyads (n = 1035) to the Healthy Smiles Healthy Kids birth study in South Western Sydney, an ethnically and socio-economically diverse area, at the first post-natal home visit. A sample of 935 women completed a structured, interviewer-administered questionnaire at 8 weeks. Multivariate logistic regression analysis was used to identify those factors independently associated with the initiation of breastfeeding.

Results

In total, 92% of women (n = 860) commenced breastfeeding in hospital. Women who completed a university degree were more likely to initiate breastfeeding compared to those who did not complete high school (AOR = 7.16, 95% CI 2.73, 18.79). Vietnamese women had lower odds of breastfeeding initiation compared to Australian born women (AOR = 0.34. 95% CI 0.13, 0.87). Women who had more than one child were less likely to breastfeed than those who had one child (AOR = 0.38, 95% CI 0.19, 0.79). Women who gave birth via a caesarean section were less likely to breastfeed their baby compared to those who had a vaginal delivery (AOR = 0.27, 95% CI 0.14, 0.52). Women who drank alcohol during pregnancy had 72% lower odds to breastfeed compared to those who did not drink alcohol during pregnancy (AOR = 0.28, 95% CI 0.11, 0.71). Women who reported that their partner preferred breastfeeding were more likely to initiate breastfeeding (AOR = 11.77, 95% CI 5.73, 24.15) and women who had chosen to breastfeed before pregnancy had more than 2.5 times the odds of breastfeeding their baby compared to those women who made their decision either during pregnancy or after labour (AOR = 2.80, 95% CI 1.31, 5.97).

Conclusions

Women with lower levels of education, who consume alcohol during pregnancy, have more than one child, and make infant feeding decision after becoming pregnant, and those born in Vietnam should be targeted when implementing breastfeeding promotion programs. Further, women who deliver by caesarean section require additional breastfeeding support post-delivery and it is important to include fathers in breastfeeding related decisions and encourage them to participate in antenatal programs.

Perinatal maternal alcohol consumption and methylation of the dopamine receptor DRD4 in the offspring: the Triple B study

Maternal alcohol use during the perinatal period is a major public health issue, the higher ends of which are associated with foetal alcohol spectrum disorder and a range of adverse health outcomes in the progeny. The underlying molecular mechanisms remain largely unknown but may include the epigenetic disruption of gene activity during development. Alcohol directly activates the neurotransmitter dopamine, which plays an essential role in neurodevelopment. To investigate whether antenatal and early postnatal alcohol consumption were associated with differential dopamine receptor DRD4 promoter methylation in infants (n = 844). Data were drawn from the large population based Triple B pregnancy cohort study, with detailed information on maternal alcohol consumption in each trimester of pregnancy and early postpartum. DNA was extracted from infant buccal swabs collected at 8-weeks. DRD4 promoter DNA methylation was analysed by Sequenom MassARRAY. No strong evidence was found for an association between alcohol consumption during pregnancy and infant DRD4 methylation at 8-weeks postpartum. However, maternal alcohol consumption assessed contemporaneously at 8-weeks postpartum was associated with increased methylation at 13 of 19 CpG units examined (largest Δ + 3.20%, 95%Confidence Interval:1.66,4.75%, P = 0.0001 at CpG.6). This association was strongest in women who breastfeed, suggesting the possibility of a direct effect of alcohol exposure via breast milk. The findings of this study could influence public health guidelines around alcohol consumption for breastfeeding mothers; however, further research is required to confirm these novel findings.

Breastfeeding and maternal alcohol use: Prevalence and effects on child outcomes and fetal alcohol spectrum disorders

OBJECTIVE

Determine any effects that maternal alcohol consumption during the breastfeeding period has on child outcomes.

METHODS

Population-based samples of children with fetal alcohol spectrum disorders (FASD), normally-developing children, and their mothers were analyzed for differences in child outcomes.

RESULTS

Ninety percent (90%) of mothers breastfed for an average of 19.9 months. Of mothers who drank postpartum and breastfed (MDPB), 47% breastfed for 12 months or more. In case control analyses, children of MDPB were significantly lighter, had lower verbal IQ scores, and more anomalies in comparisons controlling for prenatal alcohol exposure and final FASD diagnosis. Utilizing a stepwise logistic regression model adjusting for nine confounders of prenatal drinking and other maternal risks, MDPB were 6.4 times more likely to have a child with FASD than breastfeeding mothers who abstained from alcohol while breastfeeding.

CONCLUSIONS

Alcohol use during the period of breastfeeding was found to significantly compromise a child's development.

Feed Safe: a multidisciplinary partnership approach results in a successful mobile application for breastfeeding mothers

Issue addressed: Mobile applications are increasingly being used in health promotion initiatives. Although there is evidence that developing these mobile health applications in multidisciplinary teams is good practice, there is a gap in the literature with respect to evaluation of the process of this partnership model and how best to disseminate the application into the community. The aim of this paper is twofold, to describe the partnership model in which the Feed Safe application was developed and to investigate what worked in terms of dissemination.Methods: The process of working in partnership was measured using the VicHealth partnership analysis tool for health promotion. The dissemination strategy and reach of the application was measured using both automated analytics data and estimates of community-initiated promotion.Results: The combined average score from the partnership analysis tool was 138 out of a possible 175. A multipronged dissemination strategy led to good uptake of the application among Australian women.Conclusions: Multidisciplinary partnership models are important in the development of health promotion mobile applications. Recognising and utilising the skills of each partner organisation can help expand the reach of mobile health applications into the Australian population and aid in good uptake of health promotion resources.So what?: Developing mobile applications in multidisciplinary partnerships is good practice and can lead to wide community uptake of the health promotion resource.

Alcohol use and self-perceived mental health status among pregnant and breastfeeding women in Canada: a secondary data analysis

OBJECTIVE

To estimate the prevalence of alcohol consumption during pregnancy and while breastfeeding in Canada from 2003 to 2010, and to test the relation between self-perceived mental health status and alcohol consumption during pregnancy and while breastfeeding.

DESIGN

Secondary analysis of four cycles of the Canadian Community Health Survey, a population-based cross-sectional survey.

SETTING

Canada.

SAMPLE

A total of 18 612 pregnant and 15 836 breastfeeding women.

METHODS

The prevalence of alcohol consumption during pregnancy and while breastfeeding and 95% confidence intervals (CI) were calculated by province and territory, and cycle. The relation between self-perceived mental health status and alcohol consumption during pregnancy and while breastfeeding was explored using quasi-Poisson regression models.

MAIN OUTCOME MEASURES

Alcohol consumption during pregnancy and while breastfeeding, and self-perceived mental health status.

RESULTS

In Canada, between 2003 and 2010, approximately one in every ten pregnant women (9.9%; 95%CI 9.2-10.5%) and two in every ten breastfeeding women (20.3%; 95%CI 19.4-21.2%) women consumed alcohol. Women with a lower self-perceived mental health status (i.e. 'good') were 1.40 (95%CI 1.18-1.67, P < 0.001) times more likely to have consumed alcohol during pregnancy, compared with women with an 'excellent' self-perceived mental health. There were no notable differences between the categories of mental health status in regard to alcohol consumption while breastfeeding.

CONCLUSION

Despite public health efforts in Canada, a significant proportion of pregnant and breastfeeding women consume alcohol. It is imperative that a standard screening protocol be initiated among pregnant and breastfeeding women, especially in high-risk populations (e.g. women utilising substance abuse treatment programs).

TWEETABLE ABSTRACT

In Canada in 2003-2010, approximately 10% of pregnant and 20% of breastfeeding women consumed alcohol.

Postpartum substance use and depressive symptoms: a review

National survey data suggest that new mothers have high prevalences of alcohol and illicit drug use. Depression correlates with substance use, and new mothers with postpartum depression may be at high risk for substance use. Understanding postpartum substance use and its relationship to postpartum depression can inform future research and intervention. A literature search was conducted resulting in 12 studies published from 1999-2012 examining postpartum alcohol use, drug use, or combined postpartum depression and substance use. Postpartum alcohol (prevalence range 30.1%-49%) and drug use (4.5%-8.5%) were lower than use among not pregnant, not postpartum women (41.5%-57.5%, 7.6%-10.6%, respectively) but higher than use among pregnant women (5.4%-11.6%, 3.7%-4.3%, respectively). Correlates of postpartum problem drinking were being unemployed, unmarried, and a cigarette smoker. Prevalence of drug use was highest among white new mothers, followed by blacks and Hispanics, but black new mothers appeared at greater risk of drug use. No identified studies examined correlates of postpartum drug use beyond race/ethnicity. Postpartum depressive symptoms were prevalent among postpartum substance users and those with a substance use history (19.7%-46%). The postpartum period is a critical time. Prevalent substance use and the scarcity of studies warrant research to identify means to reduce maternal substance use.

Alcohol use patterns among postpartum women

While much attention has been paid to women's drinking during pregnancy, few studies address a woman's drinking once she has given birth, which presents potential dangers to herself and her child. This time of transition can be extremely stressful, potentially leading to problem drinking. On the other hand, this new role and change in lifestyle may be protective against alcohol use and abuse. We used the California Women's Health Survey (CWHS), a randomized sample of adult women in California, to compare new mothers' drinking behaviors to other women. In order to obtain a large enough sample to observe trends in subpopulations, we combined CWHS data from years 1997-2008 (n = 28,537 women aged 18-48). We used logistic regression to determine the individual-level characteristics that best predicted the outcomes postpartum and to compare new mothers (those with a child in the household <1 year and pregnant in the last 5 years) to other women for any alcohol use, heavy episodic drinking and number of days of alcohol use. New mothers were significantly less likely to engage in all behavior outcomes after adjustment for race/ethnicity, income, employment, education, age, and marital status, though new mothers who are not married and those in higher income brackets were identified as groups at higher risk of drinking. Although new motherhood could prove to be a risk factor for some women, we found that being a new mother is protective against all measures of drinking.

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.

Patterns of alcohol intake of pregnant and lactating women in Perth, Australia

INTRODUCTION AND AIMS

Australian alcohol consumption data for women during the period of pregnancy and lactation is limited. The purpose of this paper is to provide current alcohol consumption data for pregnant and lactating women in Perth, Western Australia (WA). Data were collected from 587 women between mid-September 2002 and mid-July 2003.

DESIGN AND METHODS

Women from two public hospitals with maternity wards in the Perth metropolitan area completed a self-administered baseline questionnaire while in hospital or shortly after discharge. All women, regardless of their chosen infant feeding method, were followed-up by telephone interview at 4, 10, 16, 22, 32, 40 and 52 weeks postpartum. Data were analysed to determine alcohol use patterns of the women during the period of pregnancy and lactation and results were compared to national guidelines for alcohol consumption.

RESULTS

Approximately 32% of women stopped drinking alcohol during pregnancy. A remaining 35% of pregnant women consumed alcohol during pregnancy, with 82.2% of these women consuming up to two standard drinks per week. At 4, 6 and 12 months postpartum, 46.7%, 47.4% and 42.3% of breastfeeding women were consuming alcohol, respectively.

DISCUSSION AND CONCLUSIONS

The majority of breastfeeding women consumed up to two standard drinks per week, which is within levels recommended by national authorities. There is, however, a small proportion of women consuming alcohol at levels above national recommendations for pregnancy and lactation. The development of 'safe' alcohol intake practices, within national recommendations, during the postnatal period would remove any potential health risks to the infant from alcohol exposure at this vulnerable growth stage.

The effect of alcohol intake on breastfeeding duration in Australian women

AIM

This study investigated the relationships between alcohol consumption and breastfeeding initiation and duration.

METHODS

DESIGN AND SETTING

A 12-month longitudinal study was conducted in two public hospitals in Perth, Australia between September 2002 and July 2003.

INTERVENTION

Participating mothers completed a self-administered baseline questionnaire. Follow-up telephone interviews were conducted at 4, 10, 16, 22, 32, 40 and 52 weeks.

MAIN OUTCOME MEASURES

Association of the relationships between alcohol consumption and breastfeeding initiation and duration.

RESULTS

After 6 months of follow-up, women who consumed alcohol at levels of more than two standard drinks per day were almost twice as likely to discontinue breastfeeding than women who drank below these levels (HR 1.9, 95% CI 1.1, 3.0).

CONCLUSION

Consuming alcohol in excess of two standard drinks per day during lactation was found to be independently associated with shorter breastfeeding duration, even after consideration of previously identified predictors of breastfeeding duration. Guidelines that provide direction on safe alcohol consumption for lactating mothers may help support extended breastfeeding duration.

The International society for developmental psychobiology 39th annual meeting symposium: Alcohol and development: beyond fetal alcohol syndrome

As has been repeatedly demonstrated, alcohol can exert deleterious morphological and physiological effects during early stages in development. The present review examines nonteratological links existing between alcohol and ontogeny. Human and animal studies are taken into consideration for the analysis of fetal, neonatal, infantile, adolescent, and adult responsiveness to the drug. Sensitivity to alcohol's chemosensory and postabsorptive properties, as well as learning and memory processes mediated by such properties, are examined from this developmental perspective. The studies under discussion indicate that, within each stage in development, we can trace alcohol-related experiences capable of determining or modulating alcohol seeking and intake patterns.