Friday, February 05, 2016

Drinking While Pregnant: The Experts Decide Against Nuance

Women of childbearing age should not take one sip of alcohol if they are even considering sex without any contraception. The peril of any alcohol exposure during pregnancy is so great, no amount can be considered safe, not even before women know they’re pregnant. By our modest estimates more than 3 million U.S. women are at risk for an alcohol-exposed pregnancy and millions of fetuses, at risk for Fetal Alcohol Syndrome.
 I’ve paraphrased the CDCs report released this week. The news gels quite nicely with the American Academy of Pediatrics recent “no alcohol safe” message. The medical group chronicled the dangers of mixing alcohol and pregnancy back in their October report, Fetal Alcohol Spectrum Disorders. In case you missed it.

Yes, there’s a new spectrum. FASD. Get used to it. No, the identifying traits and behaviors of FASD are not totally worked out, yet. Also, get used to reading about Pregnancy With Alcohol Exposure. Or PAE.

I know what you’re thinking.

What about the spate of studies suggesting a spot or two of wine during pregnancy was okay? Rest assured, you are not delusional. Those studies did come out. I wrote about them years ago here and on Yahoo’s Parent Dish. Emily “Expecting Better” Oster has been writing about them, a lot.

Sure, the AAP remembers them and references them, albeit briefly and often indirectly.
Although a consensus is still lacking about the effects of low levels of PAE, harmful effects are well documented related to moderate or greater PAE and to binge drinking. Fetal Alcohol Spectrum, November 2015
The CDCs know the research too. In fact, those studies are the very reason why the experts now want everyone to think no amount of alcohol is safe during pregnancy or drunken irresponsible sex. And they admit it too.

They spelled out their concerns in a Joint Call To Action on Alcohol and Pregnancy:

Studies suggesting that low to moderate drinking (defined as 1–4 or 5–8 drinks per week, respectively) causes no serious effects on intelligence, attention, and executive function4 have stirred up confusion and controversy. Some media headlines have interpreted such findings as it being safe for mothers to consume alcohol during pregnancy; however, no study has definitively concluded this. While future studies may continue to examine thresholds of drinking during pregnancy and its effects on the unborn fetus, it is critical to continue to encourage the safest choice to women, which is to completely refrain from alcohol while pregnant or trying to get pregnant. 
 In light of increased misleading media reports and misperceptions about alcohol intake during pregnancy, several health care professional organizations gathered to address the issue and develop clear and consistent messaging for their membership and target audiences. As organizations dedicated to the health of individuals, we agree that drinking any type or amount of alcohol at any time during pregnancy has the potential to cause negative health consequences for the fetus, particularly FASDs, and therefore take a pledge to continue to work together to promote the soundest and healthiest choices for women, children, and families.
 Yeah, the experts were so worried about accuracy and nuance in the media... they threw out accuracy and nuance in their own recommendations.

And the whole time they have been deeply worried about women. So worried women aren’t capable of perceiving such delicate nuance, unable to distinguish between a glass of wine and a booze bender. 

Bless their hearts, the experts simplified the message. Not just because they love accuracy and can't specify a precise line between safe and dangerous alcohol consumption and thus would hate to misspeak, but also because they recognize women (and I dearly hope men) cannot fully appreciate this important detail. It wouldn’t be right for them to make these details perfectly clear and pretend like women can understand the issue. It's simply too risky to accurately inform women of risks. It's much easier to just say no alcohol is safe even when they know this does not quite reflect what is known.

What about the media? The media that deal in "misperceptions" and "misleading" the general public? 

No surprise, the media has let the experts have at it with their reports on alcohol and pregnancy. Given them a free pass. Sure, some have decried the sexist, patronizing, tone-deaf nature of these recommendations but I’ve not seen much if any doubt or speculation over the figures and factoids. I’ve see no real questioning of the stats and studies cited in the recent CDCs report. It just came out, so fingers crossed the fact-checking and questioning will begin. It's not that I expect or suspect these studies are not okay or deeply flawed, but that they don't support such a strong recommendation. 

Then there's the AAP's "no study has definitively concluded" alcohol is safe claim. I read this statement with a heavy guffaw.* 

First off, one study, however remarkable, can't offer definitive anything. One study will never be enough to conclusively settle any matter let alone one as critical as fetal development.  Especially for scientists whose b.s. meters are always fully ON. To state no study has every proved such and such is kind of lame. 

Technically it's not possible to prove a negative in science - here, that no differences exist between children exposed to small amounts versus no alcohol. A lack of harm or "safety" if you prefer, can't be proven per se.  Safety can only be established through a body of solid studies that don't show adverse outcomes for some alcohol level of exposure. In geek speak, these studies fail to reject the null hypothesis. There are more than a few already. So it's not like there is no evidence. The tricky part, the essential task then, is testing enough outcomes (e.g., cognitive, emotional, social, physical, etc.) in a variety of studies to rule out potential effects of alcohol. 

In terms of causal evidence of alcohol harm, I assume there are no randomly controlled trials nor will there ever be any. Not with humans. Experiments generally aren't performed on pregnant women. 

I don't love the idea of pregnant women drinking.  Alcohol never passed my lips during any of my three pregnancies, mainly because I was nauseous or suffering from heartburn most of the time. I had no desire to drink a glass of wine. Because I'd gotten pregnant on purpose, I'd stopped drinking before I got with child.  The thought of women who might be pregnant getting wasted does not sit well with me. Still, this latest set of recommendations don't reflect current evidence. Adults deserve accurate and nuanced information.  

Now I have homework for you. Forget the experts and think about reality. Your life, your friends, the people you know. 

Question 1: How many women do you suspect or know had a drop of liquor while pregnant?  

Question 2: Do you know anyone diagnosed or affected by Fetal Alcohol Syndrome? 

FASDs are pervasive according to these reports here and yet I don’t know a single man, woman or fetus impacted by the more serious version that the experts have identified mostly on the basis of facial features, growth retardation and a behavioral and cognitive component. Look at the photos. 

*Note: Some of you might remember the lesson about science's problem with "proving" negatives (or safety/no danger) from the autism-vaccine controversy. In that case, the public health establishment repeatedly reminded the general public that science could never prove vaccines or any other treatment or toxins were safe (i.e. not dangerous) in the same way it could establish harm. Even though science can't deliver this conclusive or definitive "proof" it is by now well established that vaccines do not cause autism based on a large number of studies that have failed to find a link. The experts conclude vaccines are safe not because studies have definitively "proved" it but because they've failed (in a good way) to find harm after many attempts. In the case of vaccine safety versus alcohol safety, there is one considerable difference. The former only dealt with one adverse effect (autism), the latter, numerous ones both known and unknown. 

Friday, January 29, 2016

Parenting This Week: Schizophrenia and Postpartum Depression

Two promising developments this week...schizophrenia research goes CSI and postpartum depression screening gets a thumbs up. 

First, a new study finds a gene that might play a role in schizophrenia. 

After perusing the genomes of more than 60,000 people, researchers discovered those with schizophrenia were more likely to show a variation in a gene linked to the pruning of synaptic connections in the brain, the pre-frontal lobe to be precise. Much of this neural housecleaning occurs from adolescence through early adulthood, the same period when schizophrenia tends to emerge. 

The media and the experts hail this as a landmark study. But I didn't need them to tell me. I already knew it because Benedict Carey at the New York Times covered it and did so with nuance. Even more than his usual. Then there was this other clue:

Photo credit: Kayana Szymczak for The New York Time
The lead researchers stepped out of their lab coats for this totally glam photo. To my knowledge, they have not yet signed off to star in a new CSI spin-off or their own reality show.

Am I being dramatic? If so I'm right in step with the media.

The Washington Post headline declared "Scientist Open The 'Black Box' of Schizophrenia with Way Dramatic Genetic Discovery. Just to clarify, there is no flight data recorder involved, just postmortem brain tissue that admittedly does lend a certain CSI flavor. The lead researcher first used the term "black box." But still. Way to pump up the drama, WashPo.

Science Daily, no stranger to pumping up the drama by confusing correlation and correlation, reported the study represented "the first time that the origin of this devastating psychiatric disease has been causally linked to specific gene variants and a biological process."  Hold your horses, SciDay. This is not causal evidence. Not yet anyhow. It could be that schizophrenia causes this pruning or that another factor cause both. It's too early for such strong language. 


I could go on and on with the dramatic claims and reports but you get the point. 

Second, experts recommend screening women for postpartum depression. Finally. 

The U.S. Preventive Services Task Force concluded all adults should be screened for depression, including postpartum and pregnant women. You can find their recommendations in a paper published in JAMA. Or you can save yourself some time and tears by checking out coverage at NPR, CNN, New York Times or another content distributor. It's anyone's guess as to when women will routinely be screened. 

Congratulations. You've survived another week in the Parenting Media.