Running head: INTEGRATIVE REVIEW 1

Integrative Review

Tara Sculthorpe

Bon Secours Memorial College of Nursing

Dr. Arlene Holowaychuck

Nursing Research

April 17, 2018

“I pledge”
INTEGRATIVE REVIEW 2

Abstract

The purpose of this integrative review is to evaluate various research studies comparing the

effects of low-to-moderate alcohol consumption during pregnancy to abstinence. Heavy drinking

negatively influences the developing fetus, yet the effects of low-to-moderate consumption

remain uncertain. Two databases, PubMed and EBSCO Discovery Services, were utilized to

search for related articles. The search yielded 576 articles at which point additional filters were

applied. Only five articles were ultimately chosen based on the established research criteria. The

results of the five articles are somewhat conflicting, yet all indicate that low consumption of

alcohol during pregnancy, except for during the first trimester, yields no increased risk to the

fetus. Light usage is defined as one to two units of alcohol per week, while moderate

consumption is one to two units of alcohol per day; one unit equals eight grams of pure alcohol.

Due to the researchers lack of experience with performing an integrative review, there are

limitations to this research. Furthermore, confounding factors differ amongst the five selected

studies, which may explain the varying results. Due to discrepancies, abstaining from alcohol

during pregnancy may continue to remain the best option for expecting mother’s, however

implications for practice can be instituted based on these research results. Alcohol should be

avoided entirely during the first trimester of pregnancy, yet in the second and third trimesters,

one to two units per week is safe. Future studies must focus on including all confounding

influences and look more closely into the effects of timing.

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Integrative Review

The purpose of this integrated review is to determine whether low-to-moderate alcohol

consumption during pregnancy is safe. While heavy usage is associated with a variety of

behavioral, developmental, and cognitive problems amongst offspring, the effects of low-to-

moderate consumption remain unclear. Recent literature suggests that light drinking is not

associated with unfavorable outcomes even though blood-alcohol concentrations in the

developing fetus reach comparable levels to maternal concentrations within roughly two hours of

consumption (Murray et al., 2016). To add to the confusion, policies vary among countries. For

instance, in the United States strict abstinence during pregnancy is recommended; however, other

English-speaking countries assert that limited amounts are unlikely to harm the developing fetus

(Nykjaer et al., 2013). Conflicting information may be confusing to expectant mothers, and

clearing up any misconceptions is important. Therefore, relevant literature pertaining to this topic

has been compiled and a related PICOT question composed, which is: Among pregnant women

with a singleton gestation resulting in a live birth, is low to moderate prenatal alcohol exposure

associated with adverse birth outcomes compared to women who did not drink alcohol during

pregnancy?

Design and Research Methods

This integrative review is based off five research articles. Two computer-based search

engines, PubMed and EBSCO Discovery Services, were utilized in the quest for articles. Key

terms used in the search included, ‘low-to-moderate’, ‘light’, ‘abstinent’, ‘alcohol’, ‘drinking’,

‘pregnancy’, ‘intake’, ‘consumption’, ‘effects’, and ‘outcomes’. PubMed yielded 96 articles and

EBSCO Discovery Services yielded 480 articles, indicating an abundance of information on the

topic. To obtain articles only published within the past five years, the search was restricted to
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those from 2013 to 2018. To further narrow down the search, filters were applied to locate peer-

reviewed qualitative and quantitative articles, which were published in English and sourced from

academic journals. Articles were selected based on the following inclusion criteria: offspring

outcomes, low-to-moderate maternal alcohol consumption, single gestation, and the presence of

an abstinence variable. Those articles not meeting these criteria were excluded from the review.

Five articles meeting all set specifications were ultimately chosen. Each of the selected five

articles detail quantitative studies directly related to the researchers PICOT question: Among

pregnant women with a singleton gestation resulting in a live birth, is low to moderate prenatal

alcohol exposure associated with adverse birth outcomes compared to women who did not drink

alcohol during pregnancy?

Findings and Results

Out of the five reviewed research studies, most suggest that light or moderate consumption

of alcohol is not associated with adverse birth outcomes as indicated by measurable results.

Specifically, four of the five research studies assert that light or moderate consumption throughout

pregnancy is safe; however, out of those four studies, one alleges that light usage is only acceptable

in the second and third trimesters. Furthermore, out of the five articles, one determined moderate

consumption to be unsafe; however, light usage was not researched in the study (Alati et al., 2013;

Kelly et al., 2013; Lundsberg, Illuzzi, Belanger, Triche, & Bracken, 2015; Murray et al., 2016;

Nykjaer et al., 2013). To clarify, light usage is considered one to two units of alcohol per week,

while moderate consumption is one to two units of alcohol per day, with one unit equaling eight

grams of pure alcohol. A summary of the research articles can be found in the Appendix. This

review is structured based on the following two categories: maternal consumption amounts and

confounding variables.
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Maternal Consumption Amounts

In each of the five research studies examined, alcohol usage by expecting mothers was

self-reported (Alati et al., 2013; Kelly et al., 2013; Lundsberg et al, 2015, Murray et al., 2016;

Nykjaer et al., 2013). Alati et al. (2013) investigated 7,062 mothers questioned about their usage

during the first three months of pregnancy and the following responses were recorded: never,

less than one drink per week, at least one drink per week, one to two drinks per day, three to nine

drinks per day, and at least 10 drinks per day. In the United Kingdom, one drink (or unit) is

equivalent to eight grams of pure alcohol, which equates to a 25-milliliter measure of liquor, a

one-third pint of beer, or an 87.5 milliliter glass of wine. Among the participants, consumption

patterns were compared to the child’s National Curriculum Key Stage 2 (KS2) exam scores,

which test in the areas of English, Mathematics, and Science. Multivariate linear regressions

were utilized in this quantitative study to estimate mean differences and ultimately, to determine

if low-to-moderate usage is related to lower testing scores at 11 years of age. Findings suggested

that consuming up to one unit of alcohol per day does not cause lower testing scores, however

drinking four units on frequent occasions is associated with reduced testing scores.

Unlike the other studies, Nykjaer et al. (2013) focused on examining the effects of low-

to-moderate amounts of alcohol in each of the three trimesters of pregnancy to determine if

timing, in addition to amount, is important. In this quantitative study, researchers utilized a

prospective cohort of 1,303 pregnant women between 18 and 45 years of age. Utilizing

questionnaires, alcohol intake was measured at four different times: pre-pregnancy and in the

first, second, and third trimesters. Consumption was categorized as follows: abstaining from

alcohol, less than or equal to two units per week, and greater than two units per week. As with

the Alati et al. (2013) study, one unit equals 10 milliliters or eight grams of pure alcohol.
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Frequency “…was converted to times per week, which was then multiplied by the units of

alcohol in each of the alcoholic beverages listed on the questionnaire to obtain weekly

consumption in units for each of the time periods” (2013, p. 2). Data regarding birth outcomes

was collected from hospital records, and results were assessed using one-way analysis of

variance (ANOVA) and multivariable logistic regressions. Negative birth outcomes were highest

for those consuming greater than two units per week in the first trimester when compared to non-

drinkers. These findings suggested that the first trimester is the most sensitive time during

pregnancy, and women should abstain entirely during that period; however, one to two units per

week in the second and third trimesters are not associated with negative effects.

Lundsberg et al. (2014) conducted a quantitative investigation in which 4,496 pregnant

women were enrolled from 56 obstetric practices and 15 clinics associated with half-a-dozen

hospitals in Connecticut and Massachusetts. Each woman participated in an interview prior to

24 weeks of pregnancy and again post-delivery in which consumption information was collected.

Drinking levels were categorized as follows: abstinent, less than one-and-a-half drinks per week,

one-and-a-half to less than three-and-a-half drinks per week, three-and-a-half to less than seven

drinks per week, seven to less than 14 drinks per week, and 14 or more drinks per week. One

standard drink contains one-and-a-half ounces or 14 grams of pure alcohol and per researchers,

roughly eight grams of pure alcohol per day is considered light drinking. Birth outcomes were

assessed via medical records. Researchers found that low-to-moderate consumption of alcohol

during pregnancy was not a causal factor for low birthweight, preterm delivery, or intrauterine

growth restriction. Furthermore, reduced birth length and head circumference as well as lower

APGAR scores were not associated with low-to-moderate consumption.

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Confounding variables

In each of the five research studies examined, confounding variables were considered and

adjustments made (Alati et al., 2013; Kelly et al., 2013; Lundsberg et al, 2015, Murray et al.,

2016; Nykjaer et al., 2013). Kelly et al. (2013) utilized a quantitative quasi-experimental study in

which many confounding influences were taken into consideration. This study entailed four

segments and 10,534 seven-year-olds, and included home visits occurring when each of the

children were nine months, three, five, and seven years old. Confounding influences measured

include the following: “mother’s age; whether the pregnancy was planned; whether the mother

smoked during pregnancy” (2013, p. 142). Family style cofounders included: “highest parental

educational qualification; parental income; mother’s mental health; parental discipline strategies;

mother’s self-rated competence; frequency of someone reading to the child” (2013, p. 142).

Researchers made their adjustments utilizing multivariate models. Additionally, due to gender

disparities that are typical in test scores, boy and girl models were displayed separately.

In this study, information regarding alcohol usage during pregnancy, or absence of, was

self-reported. Children’s reading skills were appraised utilizing the British Ability Scale (BAS)

Word Reading assessment, Math skills were tested using an adaptive version of the National

Foundation for Educational Research (NFER) Progress in Math test, and spatial abilities were

evaluated using the BAS Pattern Construction test. Also, parents and school teachers were asked

to complete the Strengths and Difficulties Questionnaire (SDQ), which covers five areas of

social and emotional behaviors. To analyze data, researchers utilized propensity scores to match

up each mom in the ‘did not drink in pregnancy’ group with mothers in the ‘light drinking’

group. These pairings resulted in moms with identical characteristics with the only differences

being alcohol usage during pregnancy. Findings of this study indicated that light alcohol usage
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during pregnancy has no negative impact on offspring in early to mid-childhood, either

behaviorally or cognitively, and that consuming no more than one to two units per week is safe

during pregnancy. As with the Alati et al. (2013) and Nykjaer et al. (2013) studies, a unit is eight

grams of pure alcohol.

In the Murray et al. (2016) quantitative study, researchers followed children from in utero

to 13 years of age. The sample included 3,544 children with mothers who either did not drink

during pregnancy or consumed up to six units per week. Alcohol usage was self-reported.

Conduct problems were categorized as “low risk, childhood-limited, adolescence-onset or early-

onset-persistent” based on results from the Strengths and Difficulties Questionnaire (SQD) filled

out when the children were between four and 13 years of age (2016, p. 575). This is the same

questionnaire used in the Kelly et al. (2013) study. Alcohol-metabolizing genes were also

assessed. Associations between behavior problems and the amount of child risk alleles present

were examined utilizing a multinomial logistic regression. As with all the other research articles,

cofounders were considered and include: “maternal age, smoking in pregnancy, antenatal

depression, social class and education” (2016, p. 578). Social class was determined based on

occupation, and depression was assessed using the Edinburgh Postnatal Depression Scale. Final

results indicated that there is an increased risk for early-onset persistent conduct problems in

mothers who drank moderately, or up to six units per week, during pregnancy; however, authors

don’t consider the effects of light usage, meaning one to two units per week.

Potential confounders in the Alati et al. (2013) quantitative study include socio-economic

indicators, which were gathered by maternal self-reports and include: “marital status, home

ownership, an index indicating the crowding condition of the household, and ethnicity

(white/non-white)” (2013, p. 2). Like the other studies, smoking status and education level were
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accounted for. In the Lundsberg et al. (2015) study, marital status was also taken into

consideration. Furthermore, in addition to smoking and education level, confounders included

“ethnicity, parity, employment, prenatal and multivitamin use, passive smoke exposure, illicit

drug use before conception, pre-pregnancy body mass index (BMI), and exercise” (2015, p. 49).

Unlike the other studies, they also considered maternal health conditions such as hypertension,

gestational diabetes, and maternal asthma.

Lastly, in the Nykjaer et al. (2014) quantitative study, two main confounders were taken

into consideration, which were energy intake and cotinine salivary levels. The cotinine levels

were measured using the ELISA test at enrollment, and were utilized to positively identify

active, passive, and non-smokers. Energy intake considerations included “pre-pregnancy weight,

height, age, ethnicity, parity, caffeine intake and maternal education” (2014, p. 2). The latter

information was gathered utilizing a maternal self-report questionnaire.

Discussion and Implications

The five research articles selected for this integrative review thoroughly examine the

relationship between modest drinking during pregnancy and the potential negative impacts.

Information gathered during the studies effectively supports the PICOT question, however,

conflicting results were evident. For instance, while the Kelly et al. (2013) study indicates low

alcohol usage during pregnancy is acceptable, meaning no more than one to two units per week,

the Nykjaer et al. (2013) research study supports light consumption only during the latter half of

pregnancy; the second and third trimesters. Regarding moderate usage (no greater than one unit

per day), the Alati et al. (2013) research findings indicate no adverse impact on testing scores.

The same is true for the Lundsberg et al. (2015) study, whom found no negative association with

birth outcomes and those mother’s practicing moderate consumption. Lastly, Murray et. al
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(2016) determines that moderate usage is unsafe, however no research is conducted regarding

light consumption and so those results remain unknown.

Due to these discrepancies, abstaining during pregnancy may continue to remain the best

option, however implications for practice can be instituted based on these research results. Since

three out of the five studies indicate moderate usage (one unit per day) is associated with

negative outcomes, it should be avoided throughout pregnancy. Furthermore, per Nykjaer et al.

(2014), alcohol should be avoided during the first trimester of pregnancy when the developing

fetus is most susceptible to the effects of alcohol. In the second and third trimesters, one to two

standard drinks per week is safe but expecting mothers should not exceed this amount. It must be

made very clear however what constitutes light drinking. Light drinking is no more than one to

two units of alcohol per week, which according to each of the five research studies examined

equates to eight grams of pure alcohol; a 25-milliliter measure of liquor, a one-third pint of beer,

or an 87.5 milliliter glass of wine. It’s important to note that a standard pour oftentimes equates

to two to three units of alcohol. For instance, a 175 milliliter (five-point-eight ounce) glass of

wine equals two units of alcohol, and no more than two units per week is recommended for

pregnant women in their second and third trimesters. Again, this may be confusing to expectant

mothers and therefore abstinence may be the safest suggestion. Future studies must focus on

considering all potential confounding influences and look more closely into the varying effects

of alcohol amongst the three trimesters.

Limitations and Conclusion

Several limitations should be noted regarding this integrative review. In searching for

articles, it is evident that the topic of low-to-moderate consumption remains controversial and

results are conflicting. For instance, several past studies showed associations between any
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amount of alcohol consumption during pregnancy and negative outcomes, while others found no

increased risk with light to moderate consumption. Also, while there is an abundance of articles

related to alcohol consumption during pregnancy, most of them focus on binge drinking rather

than lighter patterns of drinking. Regarding the five studies examined in this integrative review,

confounding factors vary amongst the five studies, which is a major limitation and may explain

the differences in results. Lastly, the researcher has no prior experience in conducting an

integrative review, and had some difficulty finding articles within the last five years meeting all

set specifications as many of the most recent studies are ongoing.

While the findings of this integrative review have some similarities, there are also some

obvious discrepancies. These conflicting results present a major challenge in definitively

answering the proposed PICOT question: Among pregnant women with a singleton gestation

resulting in a live birth, is low to moderate prenatal alcohol exposure associated with adverse

birth outcomes compared to women who did not drink alcohol during pregnancy? However, one

can conclude from the studies that no more than two units per week of alcohol during pregnancy

is acceptable, apart from the first trimester. Nonetheless, due to lack of uniformity amongst

confounding factors considered in each of the five studies, it may be the safest option for women

to abstain from alcohol during pregnancy.

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References

Alati, R., Davey Smith, G., Lewis, S. J., Sayal, K., Draper, E. S., Golding, J., Gray, R. (2013).

Effect of prenatal alcohol exposure on childhood academic outcomes: contrasting

maternal and paternal associations in the ALSPAC study. Plos One, 8(10), e74844.

doi:10.1371/journal.pone.0074844

Kelly, Y., Iacovou, M., Quigley, M., Gray, R., Wolke, D., Kelly, J., Sacker, A. (2013). Light

drinking versus abstinence in pregnancy - Behavioral and cognitive outcomes in 7-year-

old children: a longitudinal cohort study. BJOG: An International Journal of Obstetrics

& Gynecology, 120(11), 1340-1347. doi:10.1111/1471-0528.12246

Lundsberg, L. S., Illuzzi, J. L., Belanger, K., Triche, E. W., Bracken, M. B. (2015). Original

article: Low-to-moderate prenatal alcohol consumption and the risk of selected birth

outcomes: a prospective cohort study. Annals of Epidemiology, 25(1), 46-54.

doi:10.1016/j.annepidem.2014.10.011

Murray, J., Burgess, S., Zuccolo, L., Hickman, M., Gray, R., & Lewis, S. J. (2016). Moderate

alcohol drinking in pregnancy increases risk for children's persistent conduct problems:

causal effects in a Mendelian randomization study. Journal Of Child Psychology And

Psychiatry, And Allied Disciplines, 57(5), 575-584. doi:10.1111/jcpp.12486

Nykjaer, J., Alwan, N., Greenwood, D., Simpson, N., Hay, A., White, K. (2013). Maternal

alcohol intake prior to and during pregnancy and risk of adverse birth outcomes: evidence

from a British cohort. J. Epidemiol Community Health, 68(6), 1-8. doi:10.1136/jech-

2013-202934
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Appendix

First Author Alati, Rosa (2013) – School of Population Health, University of

(Year)/Qualifications Queensland, Queensland, Australia; Centre for Youth Substance Abuse
Research, Queensland, Australia
Background/Problem Low to moderate alcohol consumption during pregnancy and its link to
Statement childhood cognition problems remains an area of concern and debate.
Conceptual/theoretical The theoretical framework for this study is based on determining if
Framework low-to-moderate consumption during pregnancy is related to lower
testing scores at 11 years of age.

Design/ Quantitative - Researchers analyzed 7,062 of participants whose

Method/Philosophical consumption patterns were compared to the child’s National
Underpinnings Curriculum Key Stage 2 (KS2) test scores. Multivariate linear
regressions were utilized to estimate mean differences.
Sample/ Sample: 7,062 participants; Ethical Considerations: Participation was
Setting/Ethical voluntary and approval for the study was granted by the ALSPAC Law
Considerations and Ethics Committee as well as Local Research Ethics Committees.

Major Variables Variables: Mother’s consumption (units of alcohol consumed during

Studied (and their pregnancy) and KS2 test scores.
definition), if
appropriate

Measurement Self-reports of alcohol usage were used to contrast associations with

Tool/Data Collection cognitive abilities in offspring at 11-years of age. Per the UK, a unit
Method corresponds to 8 grams of alcohol. Academics were measured via a
KS2 test score with covers the areas of English, Mathematics, and
Science. Potential confounders were taken into consideration (marital
status, home ownership, smoking, education levels, etc.)

Data Analysis Information analyzed included maternal and paternal consumption with
adjustments made for confounders. Mean differences were estimated
utilizing a linear regression model. Furthermore, a multivariate linear
regression model was utilized to assess the effects of alcohol on
academics.

Findings/Discussion Findings suggest that consuming up to 1 unit of alcohol per day does
not cause lower testing scores. However, drinking 4 units (32 grams)
on frequent occasions is associated with reduced testing scores (“mean
change in offspring KS2 score was -0.68; -1.03, -0.33”).

Appraisal/Worth to Consuming no more than 1 unit of alcohol per day is acceptable during
practice pregnancy.
INTEGRATIVE REVIEW 14

First Author Kelly, Y. (2013) – Department of Epidemiology and Public Health,

(Year)/Qualifications University College London, London, UK
Background/Problem While there is a clear link between heavy drinking during pregnancy
Statement and childhood developmental delays, it remains uncertain if low levels
of alcohol are associated with the same outcomes.

Conceptual/theoretical The theoretical framework for this study is based on understanding just
Framework how alcohol usage during pregnancy effects development, with an
emphasis on determining if light consumption is acceptable.

Design/ This is a quantitative quasi-experimental study in which authors

Method/Philosophical utilized a propensity score matching (PSM) system to compare
Underpinnings offspring born to mothers who were light drinkers during pregnancy to
those who remained abstinent. The study entailed four segments -
mhome visits occurring when each of the children were 9 months, 3, 5,
and 7 years old.
Sample/ Sample: Ten thousand five hundred and thirty-four 7-year-olds born in
Setting/Ethical the United Kingdom; Setting: The children’s homes; Ethical
Considerations Considerations: Approval for the study was granted through a
pertinent Ethics Committees and all parents provided informed consent
for their child to participate.
Major Variables Variables - mothers who never drank during pregnancy but consumed
Studied (and their alcohol outside of pregnancy versus those who consumed no greater
definition), if than one to two units per week during pregnancy. Other variables -
appropriate child participants math, reading, and special skill scores, Strengths and
Difficulties Questionnaire’s (SDQ) results.
Measurement Information regarding alcohol usage during pregnancy, or absence of,
Tool/Data Collection was self-reported. Children’s reading skills were appraised utilizing the
Method British Ability Scale (BAS) Word Reading assessment, Math skills
were tested using an adaptive version of the National Foundation for
Educational Research (NFER) Progress in Math test, and spatial
abilities were evaluated using the BAS Pattern Construction test. The
Strengths and Difficulties Questionnaire (SDQ), was utilized to assess
social and emotional behaviors.
Data Analysis Researchers utilized propensity scores to match up each mom in the
‘did not drink in pregnancy’ group with mothers in the ‘light drinking’
group. These pairings resulted in moms with identical characteristics
with the only differences being alcohol usage during pregnancy.
Researchers used multivariate models to adjust for potential
confounders. Additionally, due to gender disparities that are typical in
test scores, boy and girl models were displayed separately.

Findings/Discussion The findings of this study indicate that light alcohol usage during
pregnancy has no negative impact on offspring in early to mid-
childhood, either behaviorally or cognitively.

Appraisal/Worth to Results suggest that consuming no more than one to two units per week
practice is safe during pregnancy.
INTEGRATIVE REVIEW 15

First Author Lundsberg, Lisbet (2014) – Department of Obstetrics, Gynecology and

(Year)/Qualifications Reproductive Sciences, Yale University School of Medicine, New
Haven, CT
Background/Problem Previous studies have provided inconsistent results of low to moderate
Statement alcohol consumption during pregnancy.
Conceptual/theoretical The theoretical framework for this study is based on determining if
Framework low-to-moderate alcohol consumption is associated with negative birth
outcomes - low birthweight, preterm delivery, and IUGR.

Design/ Quantitative - Pregnant women were enrolled “from 56 obstetric

Method/Philosophical practices and 15 clinics associated with six hospitals in Connecticut and
Underpinnings Massachusetts”. Each woman participated in an interview prior to 24
weeks of pregnancy and, post-delivery. Alcohol consumption
information was collected at each interview. Medical records for
mother/baby were assessed (birthweight, APGAR scores, jaundice).

Sample/ Sample: 4,496 women and singleton infants; Setting: Obstetric

Setting/Ethical practices and clinics in Connecticut and Massachusetts; Ethical
Considerations Considerations: Approval for the study was granted by the Human
Investigations Committee at Yale University. Furthermore, written
consent was received from each participant.
Major Variables Maternal alcohol exposure, birth outcomes (birthweight, preterm,
Studied (and their intrauterine growth restriction, APGAR scores, etc.)
definition), if
appropriate

Measurement Alcohol consumption - baseline and postpartum interviews were

Tool/Data Collection utilized to assess consumption patterns. Exposure during the first
Method trimester “was categorized into abstinent, drinking in month 1 only
(with no subsequent drinking in months 2 or 3), and other alcohol
exposure during months 1 to 3.”
Birth outcomes – assessed via medical records
Data Analysis Odds ratios (ORs) and 95% confidence intervals (CIs) were determined
by utilizing multivariable logistic regression, controlling for
confounding variables.
Findings/Discussion Researchers found that low-to-moderate consumption of alcohol during
pregnancy is not associated with low birthweight, preterm delivery, or
IUGR. Furthermore, reduced birth length/head circumference, and
lower APGAR scores were not associated with low-to-moderate
consumption.
Appraisal/Worth to Authors present results suggesting that low-to-moderate alcohol
practice consumption during both early and late pregnancy is safe and not
associated with negative birth outcomes.
INTEGRATIVE REVIEW 16

First Author Murray, Joseph (2016) – Department of Psychiatry, University of

(Year)/Qualifications Cambridge, Cambridge, UK
Background/Problem Heavy alcohol usage is associated with many developmental issues.
Statement This study however scrutinizes the effects of moderate drinking on
pregnancy as the effects of light to moderate consumption is unclear.

Conceptual/theoretical The theoretical framework for this study is based on understanding the
Framework potential effects of moderate drinking in pregnancy on children’s
behavior.
Design/ Quantitative - Authors utilized a prospective cohort study, which
Method/Philosophical followed children from in utero to 13 years of age. Alcohol usage was
Underpinnings self-reported. Conduct problems were assessed based on results from
the Strengths and Difficulties Questionnaire (SQD) filled out when the
children were between four and 13 years of age. Alcohol-metabolizing
genes were also assessed.
Sample/ Sample: The sample included 3,544 children with mothers who either
Setting/Ethical did not drink during pregnancy or consumed up to six units per week.
Considerations Ethical Considerations: Approval for the study was granted by the
ALSPAC Law and Ethics Committees. Written informed consent was
also acquired.

Major Variables Variables: Mothers engaging in no alcohol consumption in

Studied (and their pregnancy, mothers who had up to six units of alcohol per week,
definition), if children’s conduct scores, and child participant’s genotype scores
appropriate (alcohol metabolizing genes).

Measurement Maternal alcohol amounts – determined based off self-report

Tool/Data Collection questionnaires
Method Maternal reports of child conduct problems – collected at 4, 7, 8, 10,
12, and 13 years of age utilizing the Strengths and Difficulties
Questionnaire (SQD)
Genetic variants – “Single nucleotide polymorphisms were genotyped
by KBioscience using the KASPar chemistry, a competitive allele
specific PCR system using FRET quencher cassette oligos” (Murray et
al., 2016, p. 578).

Data Analysis Associations between behavior problems and the amount of child risk
alleles present were assessed utilizing a multinomial logistic regression.
The analysis was arranged based on whether the mother did or did not
drink alcohol during her pregnancy.
Findings/Discussion The main finding of this study “is that variation in children’s alcohol-
metabolizing genes predicted increased risk of early-onset-persistent
conduct problems among children whose mothers drank moderately
during pregnancy although it did not affect childhood-limited or
adolescence-onset conduct problems” (p. 580).
Appraisal/Worth to This study indicates that there is an increased risk for early-onset
practice persistent conduct problems in mothers who drank moderately during
pregnancy.
INTEGRATIVE REVIEW 17

First Author Nykjar, Camilla (2013) – Nutritional Epidemiology Group, School of

(Year)/Qualifications Food Science and Nutrition, University of Leeds, Leeds, UK
Background/Problem While alcohol is a teratogen, there is inconsistent evidence regarding
Statement low alcohol intake during pregnancy and child outcomes.
Conceptual/theoretical The theoretical framework for this study is based on understanding the
Framework association between alcohol intake during pregnancy and birth
weight/gestational age, taking into consideration timing.
Design/ Quantitative - This study utilizes a prospective cohort in Leeds, UK to
Method/Philosophical measure alcohol intake at four different times – pre-pregnancy and in
Underpinnings the 1st, 2nd, and 3rd trimesters. Intake was categorized as follows:
abstaining from alcohol, < or equal to 2 units/week, and >2 units per
week. Authors adjust for cofounders such as smoking to determine the
association between consumption and birth weight/gestational age.
Sample/ Sample: 1,303 pregnant women between 18 and 45 years of age;
Setting/Ethical Ethical Considerations: Eligible women provided consent to
Considerations participate. Approval for the study was granted by the Leeds West
Local Research Ethics Committee.
Major Variables Alcohol intake during pregnancy, birth outcomes, salivary cotinine
Studied (and their levels (to determine smoking status/adjust for cofounders)
definition), if
appropriate

Measurement Questionnaires were utilized to assess alcohol intake. Frequency “was

Tool/Data Collection converted to times per week, which was then multiplied by the units of
Method alcohol in each of the alcoholic beverages listed on the questionnaire to
obtain weekly consumption in units for each of the time periods.”

Data regarding birth outcomes was collected from hospital records.

To measure salivary cotinine levels, ELISA was utilized (active smoker

is >5 ng/mL, passive smokers is 1-5 ng/mL, and non-smokers < 1
ng/mL)

Data Analysis Analysis involved utilizing “the continuous weekly alcohol variable
divided into categories of intake based on the DH (2008) guidelines of
no more than 2 units /week with the inclusion of a non-drinking
category)”. Furthermore, “univariable analyses” was conducted
utilizing “one-way ANOVA”. Lastly, multivariable logistic regressions
were used to assess outcomes.
Findings/Discussion Negative birth outcomes were highest for those consuming >2
units/week in the 1st and 2nd trimesters when compared to non-drinkers.
Appraisal/Worth to The 1st trimester is the most sensitive time during pregnancy, and
practice women should abstain in the 1st trimester; however, 1 to 2 units per
week in the following 2nd and 3rd trimesters are not associated with
negative effects (preterm babies/low birth weight).