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February 14, 2018

Why a new fetal alcohol disorder study in JAMA is drawing controversy

Daily Briefing

    More U.S. children than previously thought might have brain damage from prenatal drinking, according to a study published this month in JAMA.

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    Fetal alcohol spectrum disorders (FASDs) are a group of behavioral, physical, and psychological conditions that children can develop if their mothers consume alcohol during pregnancy. The disorders can cause a range of problems, including behavioral, cognitive, and physical problems that can negatively affect a child's learning and development. The most severe FASD, fetal alcohol syndrome, can result in bone and joint deformities, heart defects, and hyperactivity.

    Public health experts say it can difficult to estimate the prevalence of FASD in the United States because stigma might keep many women from sharing their prenatal alcohol consumption, and the signs and symptoms are subtle—and might apply to other conditions. According to Reuters, previous estimates suggested FASDs affected one in 100 U.S. children.  

    Study details  

    The new study focused on 6,639 first grade students in four unidentified communities in the Midwestern, Pacific Southwestern, Rocky Mountain, and Southeastern regions of the United States. The researchers between 2010 and 2016 screened the children for abnormalities tied to FASDs and interviewed many of their mothers. The study was funded by the National Institute on Alcohol Abuse and Alcoholism.

    The researchers cautioned that the study's results might not reflect the national prevalence of FASDs because it is based on four communities and includes only children who received their parents' permission to participate.


    Overall, the researchers identified 222 cases of FASDs, including 27 cases of fetal alcohol syndrome.

    The researchers estimated that FASD prevalence in the four communities ranged from a low of 3.1% in the Southeastern region to a high of 9.9% in the Rocky Mountain region.

    Based on those findings, the researchers estimated that FASDs affect 1.1% to 5% of children nationwide, which is up to five times higher than previous estimates. According to the Times, about 1.5% of U.S. children have been diagnosed with autism.

    Christina Chambers of Rady Children's Hospital San Diego and the University of California-San Diego School of Medicine, who co-led the study, said compared with autism, FASD "is an equally common, or more common, disorder and one that's completely preventable and one that we are missing." While there "is no cure for fetal alcohol spectrum disorders," Chambers said, "there are definitely intervention strategies that have been demonstrated to help," and the earlier those interventions "are initiated, the more effective they are likely to be."


    Svetlana Popova, a researcher at the Center for Addiction and Mental Health at the University of Toronto and a co-author of an editorial accompanying the study, said the study's results suggest FASDs are widespread in the United States and many U.S. women might be unaware of the risks. Popova said, "Although it has been shown that a high blood alcohol concentration is the most harmful to a developing fetus, which is achieved by drinking a large amount of alcohol over a short period of time, low amounts have also been shown to have negative consequences."

    William Fifer, a professor of medical psychiatry at Columbia University Medical Center, said, "I think this gives us a much more valid estimate of the prevalence of these disorders." Fifer added that FASD rates likely varied because it is believed that several factors—such as genetics, prenatal nutrition, and smoking—have an influence on risk of FASDs. 

    George Koob, director of the National Institute on Alcohol Abuse and Alcoholism, said, "Estimating the prevalence of FASD in the United States has been complex due to the challenges in identifying prenatally exposed children," but the "findings of this study confirm that FASD is a significant public health problem, and strategies to expand screening, diagnosis, prevention, and treatment are needed to address it."

    However, Susan Astley, director of the Fetal Alcohol Syndrome Diagnostic and Prevention Network at the University of Washington, said the study's results might not be reliable. She cited the study's limitations, including that only 60% of eligible families gave their children permission to be evaluated and more than one-third of those children's mothers did not respond to questions about whether they had consumed alcohol while pregnant. Astley said, "If we could generate accurate estimates of FASD, we'd all benefit, but the major limitations in the study design render the results, for the most part, uninterpretable." She added, "There's probably no two women on the planet who drank the same amount on the same day of pregnancy … [a]nd alcohol doesn't impact every fetus in the same way" (Rapaport, Reuters, 2/6; Belluck, New York Times, 2/6; Anderson, Argus Leader, 2/6; Norton, HealthDay/U.S. News & World Report, 2/6).

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