Table Of ContentFETAL ALCOHOL SYNDROME
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FETAL ALCOHOL EFFECTS
ETAL ALCOHOL SYNDROME
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FETAL ALCOHOL EFFECTS
Ernest L. Abel
Research Institute on Alcoholism
Buffalo, New York
PLENUM PRESS • NEW YORK AND LONDON
Library of Congress Cataloging in Publication Data
Abel, Ernest L., 1943-
Fetal alcohol syndrome and fetal alcohol effects.
Includes bibliographical references and index.
I. Fetal alcohol syndrome. 2. Fetus-Effect of drugs on. I. Title. [DNLM: I. Fetal
alcohol syndrome. 2. Alcohol drinking-In pregnancy. 3. Alcoholic beverages
Adverse effects. 4. Fetus-Drug effects. WQ 211 A\39f]
RG629.F45A34 1984 618.3'68 83-26898
ISBN-l3: 978-1-4612-9662-1 e-ISBN-l3: 978-1-4613-2669-4
DOl: 10.1007/978-1-4613-2669-4
First Printing-April 1984
Second Printing-March 1987
Third Printing-May "1993
© 1984 Ernest L. Abel
Softcover reprint of the hardcover 1s t edition 1984
Plenum Press is a Division of
Plenum Publishing Corporation
233 Spring Street, New York, N.Y. 10013
All rights reserved
No part of this book may be reproduced, stored in a retrieval system, or transmitted,
in any form or by any means, electronic, mechanical, photocopying, microfilming,
recording, or otherwise, without written permission from the Publisher
Preface
I have written this book because I felt there was a need to bring together in one
place the vast amount of research that has been published in the past 10 years
concerning alcohol's effects on the conceptus. My hope is that this book will be
of value to the many clinicians, basic research scientists, social workers, and
others who are interested in this important issue.
The number of such publications continues to grow each year, and it was a
very difficult task to review even a proportion of them completely. While I have
cited many of these research studies, only those that in my very subjective
opinion warranted extended coverage were discussed. In this regard, much of my
. ask was facilitated by the many excellent reviews that have already been written.
To those whose important contributions have not been discussed or cited, I offer
my sincere apologies. Omission of these publications in most cases reflects my
own personal interests or awareness, rather than merit.
In the writing of a book such as this, there are a number of people to whom a
special thanks is owing. These are Hebe Greizerstein, Carrie Randall, Edward
Riley, and Robert Sokol, for reading various chapters of the manuscript and
suggesting improvements. Any remaining errors or biased opinions are mine, not
theirs. I also thank Carrie Randall, Robert Sokol, Phillip Spiegel, Kathy Sulik
and James West for providing photographs for the text. Diane Augustino, li
brarian of the Research Institute on Alcoholism, was, as always, of immense
help in locating research publications that might otherwise have been
unobtainable.
v
Contents
Chapter 1. Is Fetal Alcohol Syndrome a New Discovery?
The Biblical and Postbiblical Eras 2
Greece and Rome 4
The Middle Ages 9
Early Epidemiological Studies 16
Elderton-Pearson Controversy 18
Early "Animal Model" Studies 20
References 25
Chapter 2. Pharmacology of Alcohol Relating to Pregnancy and
Lactation 29
Absorption and Route of Administration 29
Distribution 31
Distribution to the Fetus 33
Distribution to the Neonate 38
Metabolism 38
Elimination 41
Toxic Blood Alcohol Levels 41
Withdrawal 42
References 42
Chapter 3. Consumption Patterns for Alcohol during Pregnancy 47
Total per capita Consumption 47
Consumption during Pregnancy 51
The "Perinatal-Protective" Mechanism 53
At-Risk Levels of Consumption 55
References 55
vii
viii Contents
Chapter 4. Acute Effects of Alcohol on the Fetus 59
References 61
Chapter 5. Adverse Consequences of Drinking during
Pregnancy 63
Spontaneous Abortion 63
Alcohol versus the Alcoholic 65
Stillbirths 67
Neonatal Mortality 70
References 70
Chapter 6. Incidence of Fetal Alcohol Syndrome and Fetal
Alcohol Effects 73
Estimated Incidence 74
References 81
Chapter 7. Intrauterine Growth Retardation 83
Clinical and Epidemiological Studies 83
Preterm Delivery 92
Hormonal Factors in Growth 94
Amino Acids, DNA, Protein 97
Protein Synthesis and Accretion 99
Trace Elements 101
Postnatal Growth Retardation 103
Summary 104
References 104
Chapter 8. Head and Facial Abnormalities 113
References 120
Chapter 9. Disorders of Bodily Organs 123
Cardiac Disorders 123
Kidney and Urogenital Tract Anomalies 123
Liver Anomalies 125
Genital Anomalies 126
Limb and Joint Anomalies and Other Skeletal
Disorders 128
Neural-Tube Defects 133
Carcinogenesis 133
References 134
Contents ix
Chapter 10. Disorders of the Central Nervous System 139
Behavioral Deficits 139
Structural and Biochemical Changes in the Brain 148
References 159
Chapter 11. Risk Factors for Fetal Alcohol Syndrome/Fetal
Alcohol Effects 165
Maternal Age 165
Nutritional Status 166
Parity 167
Length of Gestation 169
Birth Interval 169
Sex Differences 169
Marital Status 170
Paternal Factors 170
Placenta Size and Function 172
Maternal Infections and Complications of Pregnancy 172
Hormonal Imbalances and Endocrinopathy 173
Genetic Factors 173
MUltiple Drug Use 175
Poverty and Physical Stress 177
Obstetric Factors 177
Obstetric Medication 178
References 178
Chapter 12. ' 'Animal Models" for Fetal Alcohol Effects 183
Studies in Animals 184
Methodological Issues 188
References 203
Chapter 13. Mechanisms of Action 207
Alcohol-Induced Hypoxia 208
References 210
Chapter 14. Fetal Alcohol Syndrome: A Case of Prenatal Child
Abuse? 213
Fetal Alcohol Syndrome in the Canadian Courts 213
"Diminished Life" 214
Fetal Alcohol Syndrome and Negligence 216
References 217
x Contents
Chapter 15. Prevention of Fetal Alcohol Syndrome 219
The Labeling Issue 220
National Education Efforts 224
Other National Efforts 226
Public Information at the State Level 229
Evaluation of Information/Education Campaigns 235
Summary and Conclusions 238
Identification and Treatment of Alcohol-Related
Problems in Prenatal Clinics 238
References 240
Index 243
CHAPTER 1
Is Fetal Alcohol Syndrome a New
Discovery?
Whenever a common substance is suddenly found to be a health hazard, and
especially a possible cause of birth defects, many people begin to wonder why it
took so long for such a hazard to be discovered.
Alcohol is no exception to this general rule.
When the fetal alcohol syndrome was first brought to international attention
in 1973 by Jones and Smith,I,2 many authors, including Jones and Smith them
selves, claimed that awareness of alcohol's potential to cause birth defects was
nothing new. Jones and Smith2 cited some ancient Greek authors and a Carthagi
nian law that seemed to indicate that the dangers of drinking during pregnancy
were clearly perceived in the ancient world. Other authors subsequently noted
what they believed to be further evidence of such awareness during the course of
history.
This chapter examines the various epochs in the alleged history of the "fetal
alcohol syndrome." I use the word alleged intentionally since I believe that a
critical examination of the evidence will show that nearly all the statements
investing the ancient and medieval past with precognition of this disorder are
wrong. Most are simply repetitions of what has been written before. thus per
petuating the error. In those instances when there does seem -to be an awareness
of "fetal alcohol effects" in the ancient and medieval world, the emphasis is
almost entirely on the father. Moreover, these comments are not based on em
pirical evidence but are deductive-arising from alcohol's observable effects on
spenn production and libido. It is not until the late 19th century that a general
appreciation of the link between drinking during pregnancy and "fetal alcohol
effects" appears.
Even so, why did it take so long for the medical profession and the general
public to become aware of the potential dangers of drinking during pregnancy?
1
2 Chapter 1
The answer, is that the evidence prior to Jones and Smith was far from
convincing, and in some cases it was interpreted as showing that fetal alcohol
damage was generally a good thing for mankind as a whole!
The Biblical and Postbiblical Eras
The biblical passage that is most often cited as proof that the ancient
Hebrews were aware of alcohol's injurious effects on the fetus is Judges 13:3-4.
This is an excerpt from the saga of Samson in which an angel appears to the
hero's mother before she is pregnant and cautions:
Behold now, thou art barren, and bearest not: but
thou shalt conceive, and bear a son.
Now therefore beware, I pray thee, and drink not
wine nor strong drink, and eat not any unclean
thing.3
The reason for this injunction is not that the storyteller was aware of alco
hol's potential to produce spontaneous abortion or birth anomalies. Rather it is
because Samson is foreordained to live the austere life of a Nazirite, as stated in
the next verse (Judg. 13:5)3:
.. for the child shall be a Nazirite unto God from
the womb ...
The Nazirite vow, as described in the book of Numbers (6:2-6)3 prohibited
those who took it from all intoxicants, from cutting their hair, and from touching
dead bodies.
There is no interpretation or commentary of the passage in Judges 13:3-4 in
the Talmud or any other commentary indicating that this passage is to be consid
ered in any way other than that binding Samson as a Nazirite. The reason his
mother is enjoined from taking alcohol is that Samson was to be a Nazirite from
the moment of his conception ("from the womb"). While this passage indicates
a possible awareness that alcohol could pass from the mother's body to the
conceptus, it does not presage any awareness that such passage could be damag
ing to the conceptus.
Feldman, in his book, The Jewish Child,4 cites two Talmudic passages
(Sabbath 80b and Moed Katon 9b) that he interpreted as possibly showing that
paternal drinking could lead to hirsutism in children. The passage from the
tractate Sabbath (80b) , 5 however, states only that Rabbi Bibi had a daughter that
he treated with a depilatory. Rabbi Nachman says that he didn't have to do so to
his daughters and explains: "As for R. Bibi who drank strong liquor, his daugh-
Description:I have written this book because I felt there was a need to bring together in one place the vast amount of research that has been published in the past 10 years concerning alcohol's effects on the conceptus. My hope is that this book will be of value to the many clinicians, basic research scientists
