In 2012 the British Journal of Obstetrics and Gynaecology publish five papers from the Danish Lifestyle During Pregnancy Study Group. These publications received a great deal or world wide media coverage. The emphasis of most of this coverage was in support of drinking low to moderate amounts of alcohol during pregnancy. Over a period of approximately six months I corresponded with the editor of the BJOG to have a letter of response published in the journal. Although I modified my letter as was requested it was not published. Barry Stanley

1. Letter
submitted
[
not
accepted
for
publication]
in
response
to
the
five
Danish
papers.
The
Editor,
British
Journal
of
Obstetrics
and
Gynaecology
Dear
Sir.
Re. The five papers by Kesmodel
U,
Bertrand
J,
Støvring
H,
Skarpness
B,
Denny
C,
Mortensen
E,
the
Lifestyle
During
Pregnancy
Study
Group.
BJOG
2012;
DOI:
10.1111/j.1471
-­‐-­‐
The
effect
of
alcohol
binge
drinking
in
early
pregnancy
on
general
intelligence
in
children
-­‐-­‐
The
effects
of
low
to
moderate
prenatal
alcohol
exposure
in
early
pregnancy
on
IQ
in
5-­‐year-­‐-­‐old
children.
-­‐-­‐
The effects of low to moderate alcohol consumption
and binge drinking in early pregnancy on executive
function in 5-year-old children.
- - The effects of low to moderate alcohol consumption
and binge drinking in early pregnancy on selective and
sustained attention in 5-year-old children.
-- The
effect
of
different
alcohol
drinking
patterns
in
early
to
mid
pregnancy
on
the
child’s
intelligence,
attention,
and
executive
function.
There
is
now
an
extensive
body
of
research
that
shows
the
ubiquitous
effect
of
prenatal
alcohol
on
the
developing
brain[1,2,3,5].
The
I.Q.
is
inadequate
and
misleading
as
a
tool
for
measuring
the
abilities
of
children who have been exposed to alcohol
prenatally. To exclude the disruptive effect of prenatal

2. alcohol on brain function all domains of brain function,
with subtests, need to be assessed [4,5].
The
WPPSI-­‐-­‐R
does
not
assess
all
domains
and
is
inadequate
for
totally
excluding
brain
dysfunction
in
children
exposed
to
prenatal
alcohol.
Experience
shows
that
tests
results
can
be
inconsistent
and
it
is
often
necessary
to
examine
the
domain
with
more
than
one
test.
When the test results are negative or inconclusive
in preschool years they should be repeated two to four
years later. FASD [FAS/ARND] should be excluded in all
children who have been exposed to prenatal alcohol. To
exclude the diagnosis of FASD all domains of brain
function need to be assessed [4].
Those
with
FASD
have
an
I.Q.
ranging
from
extremely
low
to
superior
[5].
Yet
even
the
intelligent,
as
measured
by
the
I.Q.,
have
chaotic
lives
;
such
is
the
variability
and
complexity
of
brain
function
following
prenatal
exposure
to
alcohol.
FASD
is
a
Complex
[Chaotic]
System
[6,
7]
that
leads
to
multiple
diagnoses
[5].
ADHD is the most common other diagnosis given to
children with FASD [5]. ADHD is often diagnosed before
FASD, sometimes years before. In such cases the
variable brain dysfunctions of FASD are missed, with
tragic consequences.
No amount of Ritalin will overcome learning disabilities.
Previously the diagnosis of ADHD has been based upon
subjective observations.
Only objective tests have been reported in the papers by
Kesmodel et.al.
In the end it is the subjective observations of the parent
and teacher that will determine how the child is seen

3. regarding attention. Whatever the method of diagnosis,
ADHD usually precludes further exploration of the
reasons for not paying attention.
For those exposed to prenatal alcohol these reasons are
not understanding what they are told, or being
instructed inappropriately for their individual
impairments. Other common causes of inattention are
sensory disabilities. Again, these need to be explored
and dealt with before diagnosing ADHD.
The test results reported by Kesmodel et.al. may be
valid in themselves for those tests on these children at
that time. However, there is no indication that they
have excluded attention problems related to
neurological impairments that have not been detected
due to insufficient testing of all brain domains and/or
the young age of the children.
When we consider the complex interaction of all of the brain’s
areas and the complex variability of alcohol on the developing
brain it is apparent that the tools presently used for assessment
need to be improved upon [6, 7, 8].
If the BRIEF [ Behavior Rating Inventory of Executive Function]
has any usefulness for PAE [ Prenatal Alcohol Exposure ] it is as a
screening tool for Executive Function and only relevant if it also
includes the teacher’s assessment.
It is my experience that those children who are less
affected by prenatal alcohol, as measured by current
tests, still have adaptive sociobehavioral sequelae
that last a life time [9]. The resulting chaos affects all
who are involved with them.
For those who have average or above average I.Q.s
expectations are too high, consequently they are seen as
selfish, willful or criminal and treated in ways that
compound their behaviour and its effects on society.

4. Every effort should be made at this early age to exclude FASD so
that, when necessary, appropriate and supportive measures can be
provided, especially the education of the parent, guardian or
teacher in the intricacies of FASD.
It is well known that the earlier the diagnosis, with the appropriate
environment, the less the child will experience the secondary
disabilities of alcohol and drug abuse, disrupted schooling, trouble
with the law, confinement, inappropriate sexual behaviour and
problems with employment and independent living [5].
Not with standing the caution “As alcohol is a known
teratogen, it remains the most conservative advice for
women to abstain from alcohol during pregnancy”
many women will see these publications as reasons for
continuing to consume alcohol while pregnant.
I fear the conclusions of these papers make it likely that many of
the families will not be prepared for the difficulties that lie ahead.
An additional point needs to be made. It is time that all
research into PAE took into account the epigenetic
transgenerational effect of alcohol, which includes the
effect of the father’s consumption of alcohol prior to
conception [10].
Acknowledgements – n/a
Disclosure of interests – Parent of 37 year old son diagnosed with
FASD [ARND] Contribution to authorship – nil.
Details of ethics approval and Funding – n/a
Yours truly B. Stanley
References
1 - Astley SJ, Aylward EH, Olson HC, Kerns K, Brooks A,
Coggins TE, Davies J, DornS, Gendler B, Jirikowic T,

5. Kraegel P, Maravilla K, Richards T.
Magnetic resonance imaging outcomes from a
comprehensive magnetic resonance study of children
with fetal alcohol spectrum disorders. Alcohol Clin Exp
Res. 2009 Oct;33(10):1671-89.
2 - Lebel C, Rasmussen C, Wyper K, Walker L, Andrew G,
Yager J, Beaulieu C.
Brain diffusion abnormalities in children with fetal
alcohol spectrum disorder. Alcohol Clin Exp Res. 2008
Oct;32(10):1732-40.
3 - Fagerlund A et.al. Brain metabolic alterations in
adolescents and young adults with fetal alcohol
spectrum disorders. Alcohol Clin Exp Res. 2006
Dec;30(12):2097- 104
4- Albert E. Chudley, Julianne Conry, Jocelynn L. Cook,
Christine Loock, Ted Rosales, Nicole LeBlanc. Fetal
alcohol spectrum disorder: Canadian guidelines for
diagnosis. JAMC • 1er MARS 2005; 172
5-­‐-­‐
Streissguth et.al., Fetal Alcohol and Drug Unit,
University of Washington, Seattle, U.S.A. Understanding
the Occurrence of Secondary Disabilities in Clients with
Fetal Alcohol Syndrome [FAS] and Fetal Alcohol Effects
[FAE]. Final Report, August 1996.
6- Wolf Singer. The Brain, a Complex Self-organizing
System. European Review, Vol. 17, No. 2, 321-329.
2009.
7 – Chaos theory. Wikipedia
8 - Piyadasa W. Kodituwakku. Neurocognitive Profile In
Children With Fetal Alcohol Spectrum Disorders. Dev
Disabil Res Rev. 2009 ; 15(3): 218–224
9 - Katrina Kully-Martens, Kennedy Denys, Sarah Treit,
Sukhpreet Tamana, and Carmen Rasmussen. A Review
of Social Skills Deficits in Individuals with Fetal Alcohol
Spectrum Disorders and Prenatal Alcohol Exposure:

6. Profiles, Mechanisms, and Interventions. Alcohol Clin
Exp Res. 2012 Apr;36(4):568-76.
10 - Philip Haycock. Fetal Alcohol Spectrum Disorders: The
Epigenetic Perspective The Society for the Study of Reproduction,
2009.