Fetal Alcohol Syndrome

Fetal alcohol syndrome (FAS) is a cluster of birth defects related to prenatal alcohol exposure. There are four diagnostic criteria for FAS: prenatal and/or postnatal growth deficiency, central nervous system abnormalities (most typically mental retardation), a set of characteristic craniofacial features, and confirmed maternal alcohol use during pregnancy. Estimates of the prevalence of FAS vary widely, in part because there is no gold standard for recognizing a child affected by FAS. In the United States, the Centers for Disease Control and Prevention estimate that FAS affects 0.2 to 1.5 births per 1,000. FAS tends to be concentrated among minority and disadvantaged populations. For example, in the United States the reported prevalence of FAS is highest among African Americans and American Indians. Reports of FAS are particularly prevalent in South Africa, in Russia, and among Native Peoples of Canada. However, numerous studies have documented both overdiagnosis and underdiagnosis of FAS in certain population groups. Moreover, FAS is subject to ascertainment bias, meaning that physicians may be more inclined to see it in some groups than in others.

Not all women who drink heavily during pregnancy have babies with FAS; the syndrome is correlated with poverty, race/ethnicity, advanced maternal age, and high number of children. Researchers have hypothesized that factors such as nutritional status, exposure to environmental toxins, smoking, and stress may exacerbate the adverse effects of alcohol. Despite widespread public belief that any alcohol exposure during pregnancy is dangerous, there is considerable uncertainty about the exact etiology of FAS. Binge drinking (the consumption of five or more drinks in a single episode) is highly correlated with FAS.

In 1973, physicians at the University of Washington discovered FAS, based on similar defects observed among eight children of alcoholic mothers. Over the past several decades the diagnosis has expanded to include categories such as “fetal alcohol effect,” “alcohol-related birth defects,” and “alcohol-related neu-rodevelopmental disorder.” There are no clear diagnostic criteria for these labels.

Governments around the world have responded in disparate ways to the policy issues raised by FAS. In the United States the surgeon general first issued a warning advising pregnant women not to drink in 1981 (updated in 2004), and congressionally mandated warning labels have appeared on all alcoholic beverages since 1989. Rates of FAS have not decreased since implementation of these measures. European countries tend to have more permissive attitudes about prenatal alcohol use, whereas drinking during pregnancy is today a highly stigmatized behavior in the United States. South Dakota and Wisconsin permit civil detention of women who drink during pregnancy; several states have brought criminal charges against women whose babies have allegedly been born with FAS or a related diagnosis. None of these prosecutions has been successful.