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Guideline No. 405: Screening and Counselling for Alcohol Consumption During Pregnancy

      ABSTRACT

      Objective

      To establish national standards of care for screening and counselling pregnant women and women of child-bearing age about alcohol consumption and possible alcohol use disorder based on current best evidence.

      Intended Users

      Health care providers who care for pregnant women and women of child-bearing age.

      Target Population

      Pregnant women and women of child-bearing age and their families.

      Evidence

      Medline, EMBASE, and CENTRAL databases were searched for “alcohol use and pregnancy.” The results were filtered for a publication date between 2010 and September 2018. The search terms were developed using Medical Subject Headings terms and keywords, including pre-pregnancy, pregnant, breastfeeding, lactation, female, women, preconception care, prenatal care, fetal alcohol spectrum disorder, prenatal alcohol exposure, drinking behavior, alcohol abstinence, alcohol drinking, binge drinking, alcohol-related disorders, alcoholism, alcohol consumption, alcohol abuse, benzodiazepines, disulfiram, naltrexane, acamprosate, ondansetron, topiramate, cyanamide, calcium carbimide, alcohol deterrents, disease management, detoxification, Alcoholics Anonymous, alcohol counselling, harm reduction, pre-pregnancy care, prenatal care, incidence, prevalence, epidemiological monitoring, and brief intervention. Evidence was included from clinical trials, observational studies, reviews, systematic reviews and meta-analyses, guidelines, and conference consensus.

      Validation Methods

      The content and recommendations in this guideline were drafted and agreed upon by the authors. The Board of Directors of the Society of Obstetricians and Gynaecologists of Canada approved the final draft for publication. The quality of evidence was rated using the criteria described in the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology framework.

      Benefits, Harms, Costs

      Implementation of the recommendations in these guidelines using validated screening tools and brief intervention approaches may increase obstetrical care provider recognition of alcohol consumption and problematic alcohol use among women of child-bearing age and those who are pregnant. It is anticipated that health care providers will become confident and competent in managing and supporting these women so they can achieve optimal health and pregnancy outcomes.

      SUMMARY STATEMENTS (GRADE ratings in parentheses)

      • 1
        Alcohol is a known teratogen (high).
      • 2
        The current evidence cannot establish a safe threshold for alcohol consumption in pregnancy (high).
      • 3
        Abstaining from alcohol during pregnancy is the safest option (high).
      • 4
        Abstaining from alcohol while breastfeeding is the safest option (high).

      RECOMMENDATIONS (GRADE ratings in parentheses)

      • 1
        All pregnant women should be questioned about alcohol use by asking a single question (in a nonjudgmental way) to determine use. If women consume alcohol, one of the following screening tools should be used: AUDIT-C or T-ACE, or another evidence-based screening tool available in the provincial/territorial prenatal record. If women consume alcohol, pattern of use should be established to screen for binge drinking (strong, high).
      • 2
        If screening identifies an alcohol use disorder, brief intervention should be provided at the same time screening is completed (strong, high).
      • 3
        When a maternal alcohol use disorder is diagnosed, it should be documented in the infant's medical record after delivery (strong, low). Carers should be encouraged to discuss in utero alcohol exposure with their child's health care provider (strong, low).
      • 4
        Every clinical encounter is an opportunity to discuss alcohol use. All women of child-bearing age should be periodically screened for problematic alcohol use. Screening, brief intervention, and referral to treatment can be brief or in depth depending on the context. Health care providers should incorporate screening for problematic alcohol use into routine women's health screening and information sharing and include screening, brief intervention, and referral to treatment where needed (strong, high).
      • 5
        Brief interventions and, if needed, coordinated referral and follow-up should accompany screening for alcohol use. A nonjudgmental, supportive approach is important to encourage disclosure of alcohol use and accessing of services (strong, high).
      • 6
        If a woman continues to use alcohol during pregnancy, harm reduction, treatment, and social support strategies should be encouraged (strong, high).
      • 7
        Health care providers should be knowledgeable on providing brief interventions and be aware of referral pathways (strong, moderate).
      • 8
        Women need to be able to participate in brief interventions and treatment without undue risk of loss of child custody; where universal screening and brief interventions are implemented, policies must be aligned so that support and treatment can be encouraged by providers and accessed by women without fear (appropriate attention must still be given to the safety of the child) (strong, moderate).
      • 9
        Specialized, community-based interventions need to be available and accessible to women with problematic drinking and related health and social concerns (strong, moderate).

      Keywords

      Abbreviations:

      FASD (Fetal alcohol spectrum disorder), MI (Motivational interviewing), SBIRT (Screening, brief intervention, and referral to treatment)
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      REFERENCES

        • Stinson FS
        • Grant BF
        • Dawson DA
        • et al.
        Comorbidity between DSM-IV alcohol and specific drug use disorders in the United States: results from the National Epidemiologic Survey on Alcohol and Related Conditions.
        Drug Alcohol Depend. 2005; 80: 105-116
        • Compton WM
        • Thomas YF
        • Stinson FS
        • Grant BF
        Prevalence, correlates, disability, and comorbidity of DSM-IV drug abuse and dependence in the United States: results from the National Epidemiologic Survey on Alcohol and Related Conditions.
        Arch Gen Psychiatry. 2007; 64: 566-576
        • Government of Canada
        Canadian Tobacco, Alcohol and Drugs Survey (CTADS): summary of results for 2017.
        2017 (Available at) (Accessed March 9, 2020)
        • Statistics Canada
        Health Fact Sheets: Heavy drinking, 2018.
        2018 (Available at) (Accessed March 9, 2020)
        • Black A
        • Guilbert E.
        The road to contraceptive consensus: new recommendations for contraceptive use in Canada.
        J Obstet Gynaecol Can. 2015; 37: 953-957
        • Oulman E
        • Kim TH
        • Yunis K
        • et al.
        Prevalence and predictors of unintended pregnancy among women: an analysis of the Canadian Maternity Experiences Survey.
        BMC Pregnancy Childbirth. 2015; 15: 260
        • Black AY
        • Guilbert E
        • Hassan F
        • et al.
        The cost of unintended pregnancies in Canada: estimating direct cost, role of imperfect adherence, and the potential impact of increased use of long-acting reversible contraceptives.
        J Obstet Gynaecol Can. 2015; 37: 1086-1097
        • Popova S
        • Lange S
        • Chudley AE
        • et al.
        World Health Organization international study on the prevalence of Fetal Alcohol Spectrum Disorder (FASD): Canadian component.
        Centre for Addiction and Mental Health. 2018; (Available at) (Accessed March 28, 2020)
        • Astley SJ
        • Bailey D
        • Talbot C
        • et al.
        Fetal alcohol syndrome (FAS) primary prevention through FAS diagnosis: II. A comprehensive profile of 80 birth mothers of children with FAS.
        Alcohol Alcohol. 2000; 35: 509-519
        • Davis EC
        • Rotheram-Borus MJ
        • Weichle TW
        • et al.
        Patterns of alcohol abuse, depression, and intimate partner violence among township mothers in South Africa over 5 years.
        AIDS Behav. 2017; 21: 174-182
        • Canadian Centre on Substance Use and Addiction
        Canada's low-risk alcohol drinking guidelines.
        2012 (Available at) (Accessed March 28, 2020)
        • Olsen J.
        Effects of moderate alcohol consumption during pregnancy on child development at 18 and 42 months.
        Alcohol Clin Exp Res. 1994; 18: 1109-1113
        • Robinson M
        • Oddy WH
        • McLean NJ
        • et al.
        Low-moderate prenatal alcohol exposure and risk to child behavioural development: a prospective cohort study.
        BJOG. 2010; 117: 1139-1150
        • Kesmodel US
        • Bertrand J
        • Stovring H
        • et al.
        The effect of different alcohol drinking patterns in early to mid pregnancy on the child's intelligence, attention, and executive function.
        BJOG. 2012; 119: 1180-1190
        • Skogerbo A
        • Kesmodel US
        • Wimberley T
        • et al.
        The effects of low to moderate alcohol consumption and binge drinking in early pregnancy on executive function in 5-year-old children.
        BJOG. 2012; 119: 1201-1210
        • Kelly YJ
        • Sacker A
        • Gray R
        • et al.
        Light drinking during pregnancy: still no increased risk for socioemotional difficulties or cognitive deficits at 5 years of age?.
        J Epidemiol Community Health. 2012; 66: 41-48
        • Sood B
        • Delaney-Black V
        • Covington C
        • et al.
        Prenatal alcohol exposure and childhood behavior at age 6 to 7 years: I. dose-response effect.
        Pediatrics. 2001; 108: E34
        • Easey KE
        • Dyer ML
        • Timpson NJ
        • et al.
        Prenatal alcohol exposure and offspring mental health: a systematic review.
        Drug Alcohol Depend. 2019; 197: 344-353
        • Comasco E
        • Rangmar J
        • Eriksson UJ
        • et al.
        Neurological and neuropsychological effects of low and moderate prenatal alcohol exposure.
        Acta Physiol (Oxf). 2018; : 222
        • Kesmodel US
        • Nygaard SS
        • Mortensen EL
        • et al.
        Are low-to-moderate average alcohol consumption and isolated episodes of binge drinking in early pregnancy associated with facial features related to fetal alcohol syndrome in 5-year-old children?.
        Alcohol Clin Exp Res. 2019; 43: 1199-1212
        • Jacobson JL
        • Jacobson SW
        Prenatal alcohol exposure and neurobehavioral development: where is the threshold?.
        Alcohol Health Res World. 1994; 18: 30-36
        • Jacobson SW
        • Carter RC
        • Jacobson JL
        Commentary on Day and colleagues: the association between prenatal alcohol exposure and behavior at 22 years of age—adverse effects of risky patterns of drinking among low to moderate alcohol-using pregnant women.
        Alcohol Clin Exp Res. 2013; 37: 1069-1073
        • Eckstrand KL
        • Ding Z
        • Dodge NC
        • et al.
        Persistent dose-dependent changes in brain structure in young adults with low-to-moderate alcohol exposure in utero.
        Alcohol Clin Exp Res. 2012; 36: 1892-1902
        • Ernhart CB
        • Morrow-Tlucak M
        • Sokol RJ
        • et al.
        Underreporting of alcohol use in pregnancy.
        Alcohol Clin Exp Res. 1988; 12: 506-511
        • May PA
        • Blankenship J
        • Marais AS
        • et al.
        Maternal alcohol consumption producing fetal alcohol spectrum disorders (FASD): quantity, frequency, and timing of drinking.
        Drug Alcohol Depend. 2013; 133: 502-512
        • Feldman HS
        • Jones KL
        • Lindsay S
        • et al.
        Prenatal alcohol exposure patterns and alcohol-related birth defects and growth deficiencies: a prospective study.
        Alcohol Clin Exp Res. 2012; 36: 670-676
        • Flak AL
        • Su S
        • Bertrand J
        • et al.
        The association of mild, moderate, and binge prenatal alcohol exposure and child neuropsychological outcomes: a meta-analysis.
        Alcohol Clin Exp Res. 2014; 38: 214-226
        • Paintner A
        • Williams AD
        • Burd L
        Fetal alcohol spectrum disorders—implications for child neurology, part 1: prenatal exposure and dosimetry.
        J Child Neurol. 2012; 27: 258-263
        • Abel EL
        • Sokol RJ
        Maternal and fetal characteristics affecting alcohol's teratogenicity.
        Neurobehav Toxicol Teratol. 1986; 8: 329-334
        • May PA
        • Gossage JP.
        Maternal risk factors for fetal alcohol spectrum disorders: not as simple as it might seem.
        Alcohol Res Health. 2011; 34: 15-26
        • Chang G
        • Orav EJ
        • Jones JA
        • et al.
        Self-reported alcohol and drug use in pregnant young women: a pilot study of associated factors and identification.
        J Addict Med. 2011; 5: 221-226
        • Cook JL
        • Green CR
        • Lilley CM
        • et al.
        Fetal alcohol spectrum disorder: a guideline for diagnosis across the lifespan.
        CMAJ. 2016; 188: 191-197
      1. Public Health Agency of Canada. About fetal alcohol spectrum disorder (FASD). Available at www.canada.ca/en/public-health/services/diseases/fetal-alcohol-spectrum-disorder/about.html. Accessed March 9, 2020.

        • Popova S
        • Lange S
        • Shield K
        • et al.
        Comorbidity of fetal alcohol spectrum disorder: a systematic review and meta-analysis.
        Lancet. 2016; 387: 978-987
        • Burd L
        • Klug MG
        • Bueling R
        • et al.
        Mortality rates in subjects with fetal alcohol spectrum disorders and their siblings.
        Birth Defects Res A Clin Mol Teratol. 2008; 82: 217-223
        • Harding K
        • Flannigan K
        • McFarlane A
        Policy action paper: toward a standard definition of fetal alcohol spectrum disorder in Canada.
        Canada Fetal Alcohol Spectrum Disorder Research Network. 2019;
        • Pei J
        • Tremblay M
        • Poth C
        • et al.
        Best practices for serving individuals with complex needs: guide and evaluation toolkit.
        PolicyWise for children & families in collaboration with the University of Alberta. 2018;
        • Public Health Agency of Canada
        Knowledge and attitudes of health professional about fetal alcohol syndrome: results of a national survey.
        2005 (Available at) (Accessed March 9, 2020)
        • Burns E
        • Gray R
        • Smith LA
        Brief screening questionnaires to identify problem drinking during pregnancy: a systematic review.
        Addiction. 2010; 105: 601-614
        • Poole N
        • Schmidt RA
        • Bocking A
        • et al.
        The potential for fetal alcohol spectrum disorder prevention of a harmonized approach to data collection about alcohol use in pregnancy cohort studies.
        Int J Environ Res Public Health. 2019; : 16
        • Bakhireva LN
        • Gutierrez H
        • Stephens E
        • et al.
        Validity of maternal alcohol screening questionnaires vs. ethanol biomarker.
        Birth Defects Res A Clin Mol Teratol. 2013; 97: 321
        • Chiodo LM
        • Delaney-Black V
        • Sokol RJ
        • et al.
        Increased cut-point of the TACER-3 screen reduces false positives without losing sensitivity in predicting risk alcohol drinking in pregnancy.
        Alcohol Clin Exp Res. 2014; 38: 1401-1408
        • Hannigan JH
        • Chiodo LM
        • Sokol RJ
        • et al.
        A 14-year retrospective maternal report of alcohol consumption in pregnancy predicts pregnancy and teen outcomes.
        Alcohol. 2010; 44: 583-594
        • Hotham ED
        • Ali RL
        • White JM
        Analysis of qualitative data from the investigation study in pregnancy of the ASSIST Version 3.0 (the Alcohol, Smoking and Substance Involvement Screening Test).
        Midwifery. 2016; 34: 183-197
        • Knight JR
        • Shrier LA
        • Bravender TD
        • et al.
        A new brief screen for adolescent substance abuse.
        Arch Pediatr Adolesc Med. 1999; 153: 591-596
        • Johnson KE
        • Sobell MB
        • Sobell LC
        Using one question to identify women at risk for an alcohol-exposed pregnancy.
        J Am Osteopath Assoc. 2010; 110: 381-384
        • Balachova T
        • Sobell LC
        • Agrawal S
        • et al.
        Using a single binge drinking question to identify Russian women at risk for an alcohol-exposed pregnancy.
        Addict Behav. 2015; 46: 53-57
        • Shogren M
        • Harsell C
        • Heitkamp T
        Screening women for at-risk alcohol use: an introduction to screening, brief intervention, and referral to treatment (SBIRT) in women's health.
        J Midwifery Womens Health. 2017; 62: 746-754
        • Center for Substance Abuse Treatment
        TIP 51: substance abuse treatment: addressing the specific needs of women.
        SAMHSA, Rockville, MD2009
        • Poole N
        • Isaac B.
        Apprehensions: barriers to treatment for substance-using mothers.
        British Columbia Centre of Excellence for Women's Health, Vancouver, BC2001
        • Jacobs L
        • Jacobs J.
        “Bad” mothers have alcohol use disorder: moral panic or brief intervention?.
        Gender Behav. 2014; 12: 5971-5979
        • Health Canada
        Best practices: early intervention, outreach and community linkages for women with substance use problems.
        Health Canada, Ottawa2006
        • Latuskie KA
        • Andrews NCZ
        • Motz M
        • et al.
        Reasons for substance use continuation and discontinuation during pregnancy: a qualitative study.
        Women Birth. 2019; 32: e57-e64
        • Doi L
        • Jepson R
        • Cheyne H
        A realist evaluation of an antenatal programme to change drinking behaviour of pregnant women.
        Midwifery. 2015; 31: 965-972
        • Kim Y
        • Hack LM
        • Ahn ES
        • et al.
        Practical outpatient pharmacotherapy for alcohol use disorder.
        Drugs Context. 2018; 7212308
        • Angus C
        • Latimer N
        • Preston L
        • et al.
        What are the implications for policy makers? A systematic review of the cost-effectiveness of screening and brief interventions for alcohol misuse in primary care.
        Front Psychiatry. 2014; 5: 114
        • Babor TF
        • Del Boca F
        • Bray JW
        Screening, brief intervention and referral to treatment: implications of SAMHSA's SBIRT initiative for substance abuse policy and practice.
        Addiction. 2017; 112: 110-117
        • Gilinsky A
        • Swanson V
        • Power K
        Interventions delivered during antenatal care to reduce alcohol consumption during pregnancy: a systematic review.
        Addiction Res Theory. 2011; 19: 235-250
        • Osterman RL
        • Carle AC
        • Ammerman RT
        • et al.
        Single-session motivational intervention to decrease alcohol use during pregnancy.
        J Subst Abuse Treat. 2014; 47: 10-19
        • Miller W
        • Rollnick S.
        Motiviational interviewing: helping people change.
        3rd ed. Guilford Press, New York2012
        • Rubak S
        • Sandbaek A
        • Lauritzen T
        • et al.
        Motivational interviewing: a systematic review and meta-analysis.
        Br J Gen Pract. 2005; 55: 305-312
        • Marcellus L
        • MacKinnon K
        • Benoit C
        • et al.
        Reenvisioning success for programs supporting pregnant women with problematic substance use.
        Qual Health Res. 2015; 25: 500-512
        • Floyd RL
        • Sobell M
        • Velasquez MM
        • et al.
        Preventing alcohol-exposed pregnancies: a randomized controlled trial.
        Am J Prev Med. 2007; 32: 1-10
        • Ingersoll KS
        • Ceperich SD
        • Hettema JE
        • et al.
        Preconceptional motivational interviewing interventions to reduce alcohol-exposed pregnancy risk.
        J Subst Abuse Treat. 2013; 44: 407-416
      2. Centers for Disease Control and Prevention C. CHOICES as a program to prevent alcohol-exposed pregnancies. Available at www.cdc.gov/ncbddd/fasd/choices-program-prevent-alcohol-exposed-pregnancies.html. Accessed March 9, 2020.

        • Johnson SK
        • Velasquez MM
        • von Sternberg K
        CHOICES: an empirically supported intervention for preventing alcohol-exposed pregnancy in community settings.
        Res Soc Work Pract. 2015; 25: 488-492
        • Velasquez MM
        • Ingersoll KS
        • Sobell MB
        • et al.
        A dual-focus motivational intervention to reduce the risk of alcohol-exposed pregnancy.
        Cogn Behav Pract. 2010; 17: 203-212
        • Gebara CF
        • Bhona FM
        • Ronzani TM
        • et al.
        Brief intervention and decrease of alcohol consumption among women: a systematic review.
        Subst Abuse Treat Prev Policy. 2013; 8: 31
        • Ceperich S
        • Ingersoll K.
        Motivational interviewing + feedback intervention to reduce alcohol-exposed pregnancy risk among college binge drinkers: determinants and patterns of response.
        J Behav Med. 2011; 34: 381-395
        • Ingersoll KS
        • Ceperich SD
        • Hettema JE
        • et al.
        Preconceptional motivational interviewing interventions to reduce alcohol-exposed pregnancy risk.
        J Subst Abuse Treat. 2013; 44: 407-416
        • Ondersma SJ
        • Chase SK
        • Svikis DS
        • et al.
        Computer-based brief motivational intervention for perinatal drug use.
        J Subst Abuse Treat. 2005; 28: 305-312
        • Liu W
        • Mumford EA
        • Petras H
        Maternal patterns of postpartum alcohol consumption by age: a longitudinal analysis of adult urban mothers.
        Prev Sci. 2015; 16: 353-363
        • Urban MF
        • Olivier L
        • Louw JG
        • et al.
        Changes in drinking patterns during and after pregnancy among mothers of children with fetal alcohol syndrome: a study in three districts of South Africa.
        Drug Alcohol Depend. 2016; 168: 13-21
        • McLeod D
        • Pullon S
        • Cookson T
        • et al.
        Factors influencing alcohol consumption during pregnancy and after giving birth.
        N Z Med J. 2002; 115: U29
        • Matusiewicz AK
        • Ilgen MA
        • Bohnert KM
        Changes in alcohol use following the transition to motherhood: findings from the National Epidemiologic Survey on Alcohol and Related Conditions.
        Drug Alcohol Depend. 2016; 168: 204-210
        • Wright TE
        • Terplan M
        • Ondersma SJ
        • et al.
        The role of screening, brief intervention, and referral to treatment in the perinatal period.
        Am J Obstet Gynecol. 2016; 215: 539-547
        • Frankenberger DJ
        • Clements-Nolle K
        • Yang W
        The association between adverse childhood experiences and alcohol use during pregnancy in a representative sample of adult women.
        Womens Health Issues. 2015; 25: 688-695
        • Lee King P
        • Duan L
        • Amaro H
        Clinical needs of in-treatment pregnant women with co-occurring disorders: implications for primary care.
        Matern Child Health J. 2015; 19: 180-187
        • Substance Abuse and Mental Health Services Administration
        Addressing the Needs of Women and Girls: Developing Core Competencies for Mental Health and Substance Abuse Service Professionals.
        2011 (Rockville, MD:)
        • Poole N
        • Urquhart C
        • Jasiura F
        • et al.
        Trauma informed practice guide.
        BC Provincial Mental Health and Substance Use Planning Council, Victoria, BC2013
        • SAMHSA's Trauma and Justice Strategic Initiative
        SAMHSA's Concept of Trauma and Guidance for a Trauma-Informed Approach.
        SAMHSA, Rockville, MD2014
        • Harris M
        • Fallot RD
        Using trauma theory to design service systems.
        Jossey Bass, San Francisco2001
        • Myran DT
        • Hsu AT
        • Smith G
        • et al.
        Rates of emergency department visits attributable to alcohol use in Ontario from 2003 to 2016: a retrospective population-level study.
        CMAJ. 2019; 191: E804-EE10
      3. Centers for Disease Control and Prevention. Binge drinking. Available at www.cdc.gov/alcohol/fact-sheets/binge-drinking.htm. Accessed March 9, 2020.

      4. Centre for Addiction and Mental Health. Partying and getting drunk. Available at www.camh.ca/en/health-info/guides-and-publications/partying-and-getting-drunk. Accessed March 9, 2020.

        • Farrell-Carnahan L
        • Hettema J
        • Jackson J
        • et al.
        Feasibility and promise of a remote-delivered preconception motivational interviewing intervention to reduce risk for alcohol-exposed pregnancy.
        Telemed J E Health. 2013; 19: 597-604
        • Hanson JD
        • Pourier S.
        The Oglala Sioux Tribe CHOICES program: modifying an existing alcohol-exposed pregnancy intervention for use in an American Indian community.
        Int J Environ Res Public Health. 2015; 13 (ijerph13010001)
        • Wolfson L
        • Poole N
        • Ninomiya MM
        • et al.
        Collaborative action on fetal alcohol spectrum disorder prevention: principles for enacting the Truth and Reconciliation Commission Call to Action #33.
        Int J Environ Res Public Health. 2019; : 16
        • George M
        • Masotti P
        • MacLeod S
        • et al.
        Bridging the research gap: aboriginal and academic collaboration in FASD prevention. The Healthy Communities, Mothers and Children Project.
        Alaska Med. 2007; 49: 139-141
      5. Thunderbird Partnership Foundation. A cultural safety toolkit for mental health and addiction workers in-service with First Nations people: Honouring our strengths – Continuum of care. Bothwell, ON: Thunderbird Partnership Foundation; 2012. Available atthunderbirdpf.org/nnapf-document-library.

        • Nathoo T
        • Poole N.
        Indigenous approaches to FASD prevention: community action.
        Centre of Excellence for Women's Health, Vancouver, BC2017
        • Scheim AI
        • Bauer GR
        • Shokoohi M
        Heavy episodic drinking among transgender persons: disparities and predictors.
        Drug Alcohol Depend. 2016; 167: 156-162
        • Gilbert PA
        • Pass LE
        • Keuroghlian AS
        • et al.
        Alcohol research with transgender populations: a systematic review and recommendations to strengthen future studies.
        Drug Alcohol Depend. 2018; 186: 138-146
        • Barker G
        • Ricardo C
        • Nascimento M
        Engaging men and boys in changing gender-based inequity in health: evidence from programme interventions.
        WHO, Geneva2007
        • Greene ME
        • Levack A.
        Synchronizing gender strategies: a cooperative model for improving reproductive health and transforming gender relations.
        USAID, Washington, DC2010
        • DeVido J
        • Bogunovic O
        • Weiss RD
        Alcohol use disorders in pregnancy.
        Harv Rev Psychiatry. 2015; 23: 112-121
        • Lingford-Hughes AR
        • Welch S
        • Peters L
        • et al.
        BAP updated guidelines: evidence-based guidelines for the pharmacological management of substance abuse, harmful use, addiction and comorbidity: recommendations from BAP.
        J Psychopharmacol. 2012; 26: 899-952
        • Carson G
        • Cox LV
        • Crane J
        • et al.
        No. 245-alcohol use and pregnancy consensus clinical guidelines.
        J Obstet Gynaecol Can. 2017; 39: e220-ee54
        • Burns L
        • Coleman-Cowger VH
        • Breen C
        Managing maternal substance use in the perinatal period: current concerns and treatment approaches in the United States and Australia.
        Subst Abuse. 2016; 10: 55-61
        • Ait-Daoud N
        • Bashir M.
        Women and substance abuse: health considerations and recommendations.
        CNS Spectr. 2011; 16: 37-47
        • McElhatton PR.
        The effects of benzodiazepine use during pregnancy and lactation.
        Reprod Toxicol. 1994; 8: 461-475
        • Wikner BN
        • Stiller CO
        • Bergman U
        • et al.
        Use of benzodiazepines and benzodiazepine receptor agonists during pregnancy: neonatal outcome and congenital malformations.
        Pharmacoepidemiol Drug Saf. 2007; 16: 1203-1210
        • Heberlein A
        • Leggio L
        • Stichtenoth D
        • Hillemacher T
        The treatment of alcohol and opioid dependence in pregnant women.
        Curr Opin Psychiatry. 2012; 25: 559-564
        • Rolland B
        • Paille F
        • Gillet C
        • et al.
        Pharmacotherapy for alcohol dependence: the 2015 recommendations of the French Alcohol Society, issued in partnership with the European Federation of Addiction Societies.
        CNS Neurosci Ther. 2016; 22: 25-37
        • Antonelli M
        • Ferrulli A
        • Sestito L
        • et al.
        Alcohol addiction - the safety of available approved treatment options.
        Expert Opin Drug Saf. 2018; 17: 169-177
        • Moretti ME.
        Psychotropic drugs in lactation—Motherisk update 2008.
        Can J Clin Pharmacol. 2009; 16: e49-e57
        • Becker MA
        • Mayor GF
        • Elisabeth JS
        Psychotropic medications and breastfeeding.
        Primary Psychiatry. 2009; 16: 42-51
        • Veiby G
        • Bjork M
        • Engelsen BA
        • et al.
        Epilepsy and recommendations for breastfeeding.
        Seizure. 2015; 28: 57-65
        • Anton RF.
        Naltrexone for the management of alcohol dependence.
        N Engl J Med. 2008; 359: 715-721
        • Towers CV
        • Katz E
        • Weitz B
        • et al.
        Use of naltrexone in treating opioid use disorder in pregnancy.
        Am J Obstet Gynecol. 2020; 222 (e1–e8): 83
        • Kelty E
        • Tran D
        • Lavin T
        • et al.
        Prevalence and safety of acamprosate use in pregnant alcohol-dependent women in New South Wales, Australia.
        Addiction. 2019; 114: 206-215
        • Kawata RE.
        Pregnancy outcome in topiramate treated women.
        Epilepsia. 2006; 47: 193-194
        • Hernandez-Diaz S
        • Mittendorf R
        • Smith CR
        • et al.
        Association between topiramate and zonisamide use during pregnancy and low birth weight.
        Obstet Gynecol. 2014; 123: 21-28
        • Veroniki AA
        • Cogo E
        • Rios P
        • et al.
        Comparative safety of anti-epileptic drugs during pregnancy: a systematic review and network meta-analysis of congenital malformations and prenatal outcomes.
        BMC Med. 2017; 15: 95
        • Kristensen JH
        • Ilett KF
        • Hackett LP
        • et al.
        Gabapentin and breastfeeding: a case report.
        J Hum Lact. 2006; 22: 426-428
        • Mason BJ
        • Quello S
        • Goodell V
        • et al.
        Gabapentin treatment for alcohol dependence: a randomized clinical trial.
        JAMA Intern Med. 2014; 174: 70-77
        • Smith RV
        • Havens JR
        • Walsh SL
        Gabapentin misuse, abuse and diversion: a systematic review.
        Addiction. 2016; 111: 1160-1174
        • Zahr NM
        • Kaufman KL
        • Harper CG
        Clinical and pathological features of alcohol-related brain damage.
        Nat Rev Neurol. 2011; 7: 284-294
        • Statistics Canada
        Table 13-10-0096-24 breast milk feeding initiation, by age group.
        2017 (Available at) (Accessed March 9, 2020)
      6. Statistics Canada. Table 13-10-0096-22 exclusive breastfeeding, at least 6 month, by age group. Available at www150.statcan.gc.ca/t1/tbl1/en/tv.action?pid=1310009622. Accessed March 9, 2020.

        • Haastrup MB
        • Pottegard A
        • Damkier P
        Alcohol and breastfeeding.
        Basic Clin Pharmacol Toxicol. 2014; 114: 168-173
        • Wilson J
        • Tay RY
        • McCormack C
        • et al.
        Alcohol consumption by breastfeeding mothers: frequency, correlates and infant outcomes.
        Drug Alcohol Rev. 2017; 36: 667-676
        • Tearne E
        • Cox K
        • Giglia R
        Patterns of alcohol intake of pregnant and lactating women in rural Western Australia.
        Matern Child Health J. 2017; 21: 2068-2077
        • Koren G
        Drinking alcohol while breastfeeding. Will it harm my baby?.
        Can Fam Physician. 2002; 48: 39-41
      7. Committee opinion no. 633: alcohol abuse and other substance use disorders: ethical issues in obstetric and gynecologic practice.
        Obstet Gynecol. 2015; 125: 1529-1537
        • Giglia R
        • Binns C.
        Alcohol and lactation: a systematic review.
        Nutr Diet. 2006; 63: 103-116
        • Horst PG
        • Madjunkov M
        • Chaudry S
        Alcohol: a pharmaceutical and pharmacological point of view during lactation.
        J Popul Ther Clin Pharmacol. 2016; 23: e145-e150
        • May PA
        • Hasken JM
        • Blankenship J
        • et al.
        Breastfeeding and maternal alcohol use: prevalence and effects on child outcomes and fetal alcohol spectrum disorders.
        Reprod Toxicol. 2016; 63: 13-21