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Up to 10 times more children have disabilities related to fetal alcohol exposure — drinking during pregnancy — than previously believed, finds a new study. As many as one in 10 children in some U.S. communities may have some type of disability due to maternal drinking during pregnancy, the research suggests.

Not only does this finding reveal substantial numbers of children with potentially unrecognized disabilities who need help, but it also drives home how widespread disabilities are from drinking during pregnancy—even if it’s not heavy or binge drinking.

When most people think about drinking during pregnancy, they often think about heavy or binge drinking, which can cause fetal alcohol syndrome (FAS). FAS is a physical and developmental disability that affects growth, facial features and cognitive development and behavior. The CDC estimates that 1 in 1,000 children has FAS, though some estimates range up to 9 in 1,000.

But FAS is part of the larger, broader category of fetal alcohol spectrum disorders (FASD). FASD includes all disabilities and conditions resulting from any alcohol exposure in the womb, even if the drinking was not heavy enough and the disabilities are not severe enough for an FAS diagnosis. Until recently, low-end estimates of FASD were 1% of children, ranging up to 5%.

But the new research in JAMA suggests that 3.1% to 9.9% of children throughout the U.S. have a fetal alcohol spectrum disorder. This study looked at four regions of the U.S., but since alcohol use patterns differ across geographical areas, the prevalence of FASD will vary geographically as well.

Regardless, the overall underreporting of FASD, combined with the lack of public awareness about the spectrum of disorders, has undoubtedly fueled the misconception that very small amounts of alcohol are “safe” to drink during pregnancy.

The study, led by Phillip A. May, PhD, from the University of North Carolina at Chapel Hill, at two points in time: November 2010 and July 2016.

The researchers assessed 6,639 first graders for four contributions to FASD: 1) known prenatal exposure to alcohol, 2) difficulties in neurological or behavioral development, 3) stunted or atypical physical growth and 4) the facial features that indicate prenatal alcohol exposure. These characteristic facial features include small eye width, a smoothed area between the nose and upper lip and a thin upper lip.

The children came from one of four communities across the U.S.: a Midwest community of 172,000 people, a Rocky Mountains community of 60,000 people, a Southeast community of 206,000 people and a Pacific Northwest city of 1.4 million.

Overall, 222 children had FASD, including 27 with FAS, 104 with partial FAS and 91 with a neurodevelopmental disorder resulting from prenatal alcohol exposure. Yet only 2 of these children had previously been diagnosed with FASD. The other 220, despite having symptoms, had been missed.

The researchers made several calculations to extrapolate a range of estimates for FASD more broadly. The lowest prevalence was 3.1% in the Rocky Mountain location, and the highest was 9.9% in the Southeast location. Even the most conservative calculations suggested prevalence ranging from 1.1% to 5%. The most severe disorder, FAS, made up less than one fifth (20%) of all the FASD cases — which means the most common cases are far from the most severe.

These findings are not that different from recent global estimates that found FASD is more common than previously believed across the world. It’s still difficult to get reliable estimates, however, of differences across the world in study methods, definitions of FASD and alcohol use and norms in different countries.

But one thing is evident: many more children are affected by drinking during pregnancy than researchers previously realized.

“These prevalence estimates are consistent with mounting evidence that harmful fetal alcohol exposure is common in the United States today and highlight the public health burden due to fetal alcohol spectrum disorders,” the authors wrote. That public health burden includes at least $4 billion a year only for those with FAS—excluding the much larger population of people with FASD.

Even though the findings cannot be generalized to all communities in the U.S., and there is potential for some over-diagnosis, these results are probably more accurate than past U.S. estimates, the authors wrote. They also note that data have shown an increase in women’s alcohol use from 2001 until 2013.

According to a JAMA commentary on the study, the methods used in this study are the most reliable for estimating FASD prevalence.

“The high prevalence of fetal alcohol spectrum disorders in the United States suggests better education of girls and women of childbearing age about the detrimental consequences of alcohol use during pregnancy on the fetus is needed,” wrote the editorial authors. “As suggested by the American Academy of Pediatrics, the message about alcohol use during pregnancy to the public should be clear and consistent: there is no safe amount, time, or type of alcohol to drink during pregnancy or when trying to get pregnant.”

Evidence shows that drinking any amount of alcohol during pregnancy carries risks—despite a strong national narrative of denial that just a few drinks here and there carries insignificant risk. Epidemiological studies suggesting no effects have substantial limitations and flaws, including an inability to detect the effects with the tools and methods used and assessing children before more evident issues appear. Many problems caused by alcohol exposure in the womb don’t show up until children are in the mid or late teens.

Ideally, this study is a wake-up call in recognizing how common disabilities are from drinking during pregnancy—and that the only way to eliminate these risks completely is to eliminate alcohol completely during pregnancy and while attempting to conceive.

What is FASD? Check Out Our FASD Resource Directory Drinking & Pregnancy

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