New quality standard on fetal alcohol disorders misses the mark
Alcohol during pregnancy, the commonest cause of preventable mental impairment in Western countries, is enduringly underestimated, although not by the National Organisation for Foetal Alcohol Syndrome-UK.(1,2) The planned NICE Quality Standard on fetal alcohol disorders (FADs) should help already damaged children but is an inadequate response to the calamity.
The call for services with skills and training for early diagnosis (1) is an obvious prerequisite to assist with neurodevelopment. However, prevention must be the cornerstone considering both FAD's prevalence and the limited effectiveness of therapy, even early. Similarly, pressurising maternity services to advise women “it is safest not to drink alcohol at all while pregnant” is too little too late.(1) Since 1988 the US Code §215 required health warning statements, of regulated size, to be affixed on alcohol containers stating “GOVERNMENT WARNING: According to the Surgeon General, women should not drink alcoholic beverages during pregnancy because of the risk of birth defects”. Like most countries, the UK relies naively (at best) on voluntary labelling. France is complicit with commercial interests: the secretary of health issuing the 2006 decree (NOR: SANX0602395A) for mandatory health warnings did not rule on size, placement and covering pack material. Accordingly the warning is always the smallest information, lost on the back (Fig. 1 available on request). A robust but underappreciated study confirmed “lack of visibility and noticeability due to size, location and from marketing design elements” means that warnings were “ineffective for making participants feel concerned and influencing consumption habits.”(3) Further, requiring pregnant women alone to behave in opposition to social norms is wrong-headed:(4) alcohol control must be comprehensive, using the pillars of minimum pricing unit and restricting advertising. Otherwise marketeers of our ‘favourite poison’ have a free hand.
Concern for the vulnerable unborn child must also be comprehensive acting through empathic concern for mothers-to-be.(5) Alcohol is only one among many threats including smoking, pollution, low education, poverty, poor nutrition, inadequate housing, single motherhood and domestic violence.(6) Inattention to potentially teratogenic prescriptions such as psychotropic medications, as evidenced by the valproate scandal, also belongs on the list.(7) When so many pregnancies are unplanned (40% in the US), the public health target must be women of childbearing age. NICE cannot fix a broken system.
1 Braillon A, Dubois G. Alcohol and public health. Lancet 2005;365:1387.
2 Wise J. NICE plans new standard for fetal alcohol disorders. BMJ 2019;365:l2186.
3 Dossou G, Gallopel-Morvan K, Diouf JF. The effectiveness of current French health warnings displayed on alcohol advertisements and alcoholic beverages. Eur J Public Health 2017;27:699-704.
4 Braillon A, Bewley S. Impartial information about alcohol during pregnancy or another modern day witch hunt? BMJ 2015;351:h5680.
5 Barker M, Dombrowski SU, Colbourn T et al. Intervention strategies to improve nutrition and health behaviours before conception. Lancet 2018391:1853-1864.
6 Braillon A, Bewley S. Healthcare professionals must demand action on the social determinants of preventable low fetal growth and preterm birth. BMJ 2018;360:k399.
7 Braillon A, Bewley S. Prescribing in pregnancy shows the weaknesses in pharmacovigilance. BMJ. 2018;361:k2334.
Figure 1. Photograph. of current French alcohol warnings: On the back of the bottle, the packaging tax (black arrow in a circle on the left) measures diameter 1.0 cm and area 0.8 cm2 whilst the pictogram of a pregnant woman (with diagonal line on the right of the photograph) measures diameter 0.5 cm and area 0.2 cm2.
Competing interests: SB has worked for NICE as a Member and Chair on a variety of clinical and public health guideline development committees.