Unreliable estimation of prevalence of fetal alcohol syndrome
Authors: Simona Pichini, Francesco Paolo Busardò, Mauro Ceccanti, Luigi Tarani, Roberta Pacifici
Journal: The Lancet Global Health (2017)

Svetlana Popova and colleagues (March, 2017)1Popova S Lange S Probst C Gmel G Rehm J Estimation of national, regional, and global prevalence of alcohol use during pregnancy and fetal alcohol syndrome: a systematic review and meta-analysis.Lancet Glob Health. 2017; 5: e290-e299Summary Full Text Full Text PDF PubMed Scopus (429) Google Scholar sought to estimate the global, regional, and national prevalence of alcohol use during pregnancy and fetal alcohol syndrome (FAS). The authors reviewed international literature from 1984 for country-specific quantitative studies and for countries with one or no studies they predicted gestational alcohol use prevalence by fractional response regression modelling and prevalence of FAS by an estimated quotient for the average number of women consuming alcohol during pregnancy per one case of FAS. For estimation of FAS prevalence, Italy was reported to be among the five countries worldwide with the highest prevalence of FAS per 10 000 people. On the basis of our involvement in studies about national prevalence of gestational alcohol consumption and consequent prenatal exposure to this teratogen,2Pichini S Pellegrini M Gareri J et al.Liquid chromatography-tandem mass spectrometry for fatty acid ethyl esters in meconium: assessment of prenatal exposure to alcohol in two European cohorts.J Pharm Biomed Anal. 2008; 48: 927-933Crossref PubMed Scopus (52) Google Scholar, 3Pichini S Morini L Marchei E et al.Ethylglucuronide and ethylsulfate in meconium to assess gestational ethanol exposure: preliminary results in two Mediterranean cohorts.Can J Clin Pharmacol. 2009; 16: e370-e375PubMed Google Scholar, 4Morini L Marchei E Vagnarelli F et al.Ethyl glucuronide and ethyl sulfate in meconium and hair-potential biomarkers of intrauterine exposure to ethanol.Forensic Sci Int. 2010; 196: 74-77Summary Full Text Full Text PDF PubMed Scopus (77) Google Scholar, 5Pichini S Marchei E Vagnarelli F et al.Assessment of prenatal exposure to ethanol by meconium analysis: results of an Italian multicenter study.Alcohol Clin Exp Res. 2012; 36: 417-424Crossref PubMed Scopus (52) Google Scholar we have to disagree with the estimates reported by the authors. First, according to WHO,6WHOGlobal status report on alcohol and health.http://www.who.int/substance_abuse/publications/global_alcohol_report/en/Date: 2014Google Scholar Italy is the country with the lowest annual consumption of alcohol per capita (6·7 litres), lowest percentage of women with alcohol use disorders (0·8%) and alcohol abuse dependence (0·4%), and the highest number of female lifetime abstainers (37·5%) among all European countries with the exclusion of eastern states with a prevalent Muslim faith (eg, Azerbaijan, Kyrgyzstan, and Tajikistan). Second, only a few somewhat dated studies have investigated alcohol consumption during pregnancy in Italy,7Bonati M Fellin G Changes in smoking and drinking behaviour before and during pregnancy in Italian mothers: implications for public health intervention.Int J Epidemiol. 1991; 20: 927-932Crossref PubMed Scopus (26) Google Scholar, 8Lazzaroni F Bonassi S Magnani M et al.Moderate maternal drinking and outcome of pregnancy.Eur J Epidemiol. 1993; 9: 599-606Crossref PubMed Scopus (48) Google Scholar, 9Primatesta P Del Corno G Bonazzi MC Waters WE Alcohol and pregnancy: an international comparison.J Public Health Med. 1993; 15: 69-76Crossref PubMed Scopus (25) Google Scholar, 10Pizzi C De Stavola BL Pearce N et al.Selection bias and patterns of confounding in cohort studies: the case of the NINFEA web-based birth cohort.J Epidemiol Community Health. 2012; 66: 976-981Crossref PubMed Scopus (44) Google Scholar which include a limited number of pregnant women in selected cities, and are therefore not representative of the general population. Additionally, self-reported drinking during pregnancy varied from one or more drinks per day to one per month or less in these studies. That women's self-reporting of drinking varies has been confirmed by our studies2Pichini S Pellegrini M Gareri J et al.Liquid chromatography-tandem mass spectrometry for fatty acid ethyl esters in meconium: assessment of prenatal exposure to alcohol in two European cohorts.J Pharm Biomed Anal. 2008; 48: 927-933Crossref PubMed Scopus (52) Google Scholar, 3Pichini S Morini L Marchei E et al.Ethylglucuronide and ethylsulfate in meconium to assess gestational ethanol exposure: preliminary results in two Mediterranean cohorts.Can J Clin Pharmacol. 2009; 16: e370-e375PubMed Google Scholar, 4Morini L Marchei E Vagnarelli F et al.Ethyl glucuronide and ethyl sulfate in meconium and hair-potential biomarkers of intrauterine exposure to ethanol.Forensic Sci Int. 2010; 196: 74-77Summary Full Text Full Text PDF PubMed Scopus (77) Google Scholar, 5Pichini S Marchei E Vagnarelli F et al.Assessment of prenatal exposure to ethanol by meconium analysis: results of an Italian multicenter study.Alcohol Clin Exp Res. 2012; 36: 417-424Crossref PubMed Scopus (52) Google Scholar on objective assessment of prenatal exposure to alcohol through measurement of biomarkers in neonatal meconium. The overall prevalence of newborns prenatally exposed to maternal alcohol was 7·9%, within the 20–30% of pregnant women that self-reported drinking during pregnancy. Fetal exposure varied between 0% and 10% along the Italian peninsula with an isolated maximum value of 29·4% in Rome capital. Furthermore, an observational, cross-sectional case-control study11May PA Fiorentino D Coriale G et al.Prevalence of children with severe fetal alcohol spectrum disorders in communities near Rome, Italy: new estimated rates are higher than previous estimates.Int J Environ Res Public Health. 2011; 8: 2331-2351Crossref PubMed Scopus (108) Google Scholar used by the authors of 976 children aged 6–10 years, from an area of small towns immersed in the countryside in central Italy, estimated the rate of FAS as between 4 per 1000 and 12 per 1000 people in 2011. These rates cannot in any case be representative of the Italian population, because the study refers to very few individuals belonging to a specific biased suburban, rural area of wine producers. We call on the national health community to recognise the need for a properly designed study on alcohol use during pregnancy, choosing a sample of Italian women representative of the general population with a targeted follow-up of newborns prenatally exposed by biomarker positivity to accurately calculate the prevalence of FAS cases. Any prediction based on non-reliable simulation or non-generalisable data cannot be deemed worthy of trust. We declare no competing interests. Introducing The Lancet Global Health Commission on High-Quality Health Systems in the SDG EraThe Millennium Development Goals on health have expanded access to basic health interventions to millions of people in low-income and middle-income countries (LMICs). However, access alone will not be sufficient to meet the Sustainable Development Goals (SDGs) if health systems cannot provide high quality care—ie, care that improves health outcomes and provides value to people. Emerging data show that many LMIC health systems struggle to consistently provide good quality of care.1,2 Yet change is possible. Full-Text PDF Open AccessUnreliable estimation of prevalence of fetal alcohol syndromeSvetlana Popova and colleagues (March, 2017)1 estimated that about one quarter of pregnant women in Europe drink alcohol. The authors state that this estimate is 2·6 times higher than the global prevalence and estimate that Europe has the world's highest fetal alcohol syndrome (FAS) prevalence of 37·4 per 10 000 people. If true, these numbers are alarming and require urgent action; however, we are not convinced that they are valid for contemporary Europe. Full-Text PDF Open AccessUnreliable estimation of prevalence of fetal alcohol syndrome – Authors' replyWe thank Katrine Strandberg-Larsen and colleagues from Denmark and Simona Pichini and colleagues from Italy for their comments on our paper.1 Both comments underline the immense interest in the related public health problems of alcohol use during pregnancy and fetal alcohol syndrome (FAS). Full-Text PDF Open Access