How we tolerate risk

I’ve been thinking a lot about how we tolerate risk here in the United States, after we literally shut down a major city last week to catch one man. I am in no way saying that it wasn’t an important endeavor. I just think that many people I’ve talked to can only look at the positive outcome of catching him. They ignore the massive implications (socially, politically, economically) of what it took to do so. It’s a debate worth having, and I’m not seeing it as much as I’d like.

Ironically, at the same time, a friend pointed me to a new study in the BJOG, “Light drinking versus abstinence in pregnancy – behavioural and cognitive outcomes in 7-year-old children: a longitudinal cohort study

OBJECTIVE: To assess whether light drinking in pregnancy is linked to unfavourable developmental outcomes in children.

DESIGN: Prospective population-based cohort.


POPULATION:Ten thousand five hundred and thirty-four 7-year-olds.

METHODS:Quasi-experimental using propensity score matching (PSM) to compare children born to light (up to 2 units per week) and non-drinkers.

MAIN OUTCOME MEASURES:Behavioural difficulties rated by parents and teachers; cognitive test scores for reading, maths and spatial skills.

RESULTS:Ordinary least squares (OLS) regression and PSM analyses are presented. For behavioural difficulties, unadjusted estimates for percentage standard deviation (SD) score differences ranged from 2 to 14%. On adjustment for potential confounders, differences were attenuated, with a loss of statistical significance, except for teacher-rated boys’ difficulties. For boys, parent-rated behavioural difficulties: unadjusted, -11.5; OLS, -4.3; PSM, -6.8; teacher-rated behavioural difficulties: unadjusted, -13.9; OLS, -9.6; PSM, -10.8. For girls, parent-rated behavioural difficulties: unadjusted, -9.6; OLS, -2.9; PSM, -4.5; teacher-rated behavioural difficulties: unadjusted, -2.4; OLS, 4.9; PSM, 3.9. For cognitive test scores, unadjusted estimates for differences ranged between 12 and 21% of an SD score for reading, maths and spatial skills. After adjustment for potential confounders, estimates were reduced, but remained statistically significantly different for reading and for spatial skills in boys. For boys, reading: unadjusted, 20.9; OLS, 8.3; PSM, 7.3; maths: unadjusted, 14.7; OLS, 5.0; PSM, 6.5; spatial skills: unadjusted, 16.2; OLS, 7.6; PSM, 8.1. For girls, reading: unadjusted, 11.6; OLS, -0.3; PSM, -0.5; maths: unadjusted, 12.9; OLS, 4.3; PSM, 3.9; spatial skills: unadjusted, 16.2; OLS, 7.7; PSM, 6.4.

CONCLUSION:The findings suggest that light drinking during pregnancy is not linked to developmental problems in mid-childhood. These findings support current UK Department of Health guidelines on drinking during pregnancy.

Basically, this study looked at a cohort of more than 10,000 seven year olds to see if there was an association between light drinking in pregnancy and later developmental issues in children. They didn’t find any.

Let’s take a pause here and let me state clearly that I am not advocating that women drink during pregnancy. I’m just asking us to think about risk, and how we instinctively respond to it. OK?

When I was a resident, one of the world’s experts in fetal alcohol syndrome told me that if a fetus is exposed to a certain amount of alcohol at a certain point in development, there appears to be a significantly increased risk of developing problems. But, he explained, we don’t know for sure what that dose of alcohol is, or at what stage of development the danger zone exists. We do know some things. It’s not very late in pregnancy. We used to use alcohol in pretty hefty doses to prevent preterm labor. Not so much anymore, but its use periodically late in the third trimester did not result in increased cases of fetal alcohol syndrome.

So what do we tell women in light of this vague, but real, danger? In the United States, we tell them no alcohol in pregnancy. Ever. In any amounts. Here, from the NLM and NIH:

Pregnant women are strongly urged not to drink alcohol during pregnancy.

Drinking alcohol while you are pregnant has been shown to cause harm to a baby inside the womb and may lead to long-term medical problems in the child after birth…

Women who are pregnant or who are trying to get pregnant should avoid drinking any amount of alcohol. The only way to prevent fetal alcohol syndrome is to not drink alcohol during pregnancy.

If you did not know you were pregnant and drank alcohol, stop drinking as soon as you find out. While it is unlikely that the occasional drink you took before finding out you were pregnant will harm your baby, the sooner you stop drinking alcohol, the healthier your baby will be.

Try replacing alcoholic drinks with their nonalcoholic counterparts: for example, you might opt for a nonalcoholic pina colada instead of the real thing.

If you cannot control your drinking, avoid eating or drinking around people who are drinking alcohol.

Here is the NIAAA:

Drinking Can Hurt Your Baby

When you are pregnant, your baby grows inside you. Everything you eat and drink while you are pregnant affects your baby. If you drink alcohol, it can hurt your baby’s growth. Your baby may have physical and behavioral problems that can last for the rest of his or her life. Children born with the most serious problems caused by alcohol have fetal alcohol syndrome.

Children with fetal alcohol syndrome may:

  • Be born small.
  • Have problems eating and sleeping.
  • Have problems seeing and hearing.
  • Have trouble following directions and learning how to do simple things.
  • Have trouble paying attention and learning in school.
  • Need special teachers and schools.
  • Have trouble getting along with others and controlling their behavior.
  • Need medical care all their lives.

Here are some questions you may have about alcohol and drinking while you are pregnant.

1. Can I drink alcohol if I am pregnant?

No. Do not drink alcohol when you are pregnant. Why? Because when you drink alcohol, so does your baby. Think about it. Everything you drink, your baby also drinks.

2. Is any kind of alcohol safe to drink during pregnancy?

No. Drinking any kind of alcohol when you are pregnant can hurt your baby. Alcoholic drinks are beer, wine, wine coolers, liquor, or mixed drinks. A glass of wine, a can of beer, and a mixed drink all have about the same amount of alcohol.

Mind you, none of this is wrong. It’s abstinence at its finest. Drink no alcohol – none at all – and there is no risk of fetal alcohol syndrome. But go back to the British study I began this piece with. Look at the conclusion. They state that the idea that “light drinking is not harmful” is consistent with UK Department of Health guidelines. So I looked those up:

The UK Chief Medical Officers’ advice to women is:

‘Women who are pregnant or trying to conceive should avoid alcohol altogether.  However, if they do choose to drink, to minimise the risk to the baby, we recommend they should not drink more than 1-2 units once or twice a week and should not get drunk.’

Again, I’m not advocating that pregnant women go out and drink. There is no doubt that no alcohol is the safest way to avoid issues. But sometimes it feels like this is the way we approach risk in the US, even in health care. We think in absolutes, in terms of avoiding all harms and dismissing potential benefits instead of debating the relative contributions of both. It’s easy to dismiss alcohol as being all harms, as it’s certainly not providing any benefit to the fetus. But some studies have shown that small amounts of alcohol can be beneficial to health, and I know many, many people who would argue that it contributes positively to life in general. Moreover, this is how many issues are approached. “Never eat red meat”. “Never let kids watch TV or play video games”. “Never eat soft cheese while pregnant”. “Never fail to screen for disease”. And so on.

Is this a United States thing? Or am I just wired differently? I’m just not sure that the way we react to potential harms is the best approach. This includes, by the way, our response to terrorism.


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