The safest choice is not to drink any alcohol if you are pregnant or are planning a pregnancy.
If a pregnant woman drinks alcohol, the alcohol also enters her babyâ€™s bloodstream. This may lead to physical, learning and behaviour problems for the baby.
It is best not to drink alcohol if you are pregnant or are planning a pregnancy because:
- There is no known safe amount of alcohol during pregnancy.
- There is no safe kind of alcohol during pregnancy.
- There is no safe time for alcohol use in pregnancy.
- The more alcohol a woman drinks, the greater the risks to her unborn baby.
If you drank alcohol before you knew you were pregnant, talk to your health care provider.
Ask for help if you want to quit drinking.
Your partner, family members, or friends can be a great source of support.
If you have trouble quitting, talk to your health care provider. There are services for pregnant women, and their families, who need help to stop drinking (see the section Learn more about where to get help).
Call ConnexOntario at 1-866-531-2600 for free, confidential information about alcohol and drug addiction services in Ontario.
The benefits of breastfeeding outweigh the risks of occasional, light alcohol consumption.
When you drink alcohol, it is transferred to your breastmilk. Alcohol in breastmilk can have effects on your baby.If you would like to decrease the amount of alcohol your baby receives:
- Drink alcohol right after breastfeeding, not before breastfeeding.
- Limit the amount you drink to one or two standard drinks per occasion. A standard drink is:
- Beer (5%) â€“ 341 mL (12 oz).
- Wine (12%) â€“ 142 mL (5 oz).
- Spirits (40%) â€“ 43 mL (1.5 oz).
- Allow enough time for the alcohol to be eliminated from your body before the next feeding. On average, it takes up to two hours for one drink to be eliminated.
Learn more about where to get help.
You can find out more about alcohol and how to quit drinking from the following resources. More suggestions can be found in the Resources and Links section
- ConnexOntario 1-866-531-2600
About Alcohol Consumption during the Perinatal Period
Alcohol consumption during the perinatal period includes occasional or moderate consumption, regular consumption, and alcohol-use disorder.
According to the Public Health Agency of Canada, approximately nine percent of women in Ontario who gave birth in 2005 reportedly consumed alcohol during pregnancy. This closely reflects the national average of 10.5 percent of Canadian women who reported alcohol consumption during pregnancy.1
However, due to stigma the numbers may, in fact, be higher, since people may be reluctant to report alcohol consumption.
Who is at Risk?
Regardless of age, education, or professional status, women who drink alcohol during pregnancy are not representative of a homogeneous group. Alcohol consumption can fall anywhere within the low- to high-risk spectrum and can have varying impacts on both the pregnant woman and fetus.2
While some women are at a higher risk for alcohol consumption during pregnancy, alcohol use is not bound specifically to certain populations.
Several studies have shown that these following risk factors have been associated with alcohol consumption by pregnant women:
- Women with higher incomes indicated more often that they had consumed alcohol during pregnancy.3
- Young women with lower incomes were most likely to have at least five drinks on the same occasion.4,5 This is known as binge drinking20 and places women and babies at greatest risk.
- Women in a higher age bracket (e.g., 35 years or older) were more likely to consume alcohol during pregnancy.3,5
- Women who previously gave birth to a child with Fetal Alcohol Spectrum Disorder (FASD) are more likely to consume alcohol during pregnancy.4,5
Potential Health Consequences
Alcohol is a teratogen that can cause birth defects.6,7
Since alcohol is not filtered by the womanâ€™s liver before reaching the placenta, alcohol travels directly across the bloodstream to the fetus.8 When alcohol is consumed during pregnancy, it can affect growth and development of the fetus and can cause adverse effects on the pregnancy and the fetus.
The effect of alcohol on the fetus is the same regardless of the type of alcoholic drink being consumed.
Women who consume alcohol are more likely to experience:
- A miscarriage.9
- A stillbirth.10,11
- A premature birth.12
The possible effects of alcohol consumption on a developing fetus can become apparent at different times in a childâ€™s life leading to various physical and developmental problems (e.g., moderate intellectual and behavioural deficits) known as Fetal Alcohol Spectrum Disorder (FASD).
Fetal Alcohol Spectrum Disorder
Fetal Alcohol Spectrum Disorder (FASD) has only recently been acknowledged in recent revisions of the Diagnostic and Statistical Manual of Mental Disorders â€“ V (DSM â€“ V) It is recognized as a neurodevelopmental disorder associated with prenatal alcohol exposure (ND â€“ PAE).
Former understandings of FASD have included many sub-categories within the FASD spectrum. However, current research has eliminated the use of separate categories and acknowledges FASD as one broad spectrum characterized by moderate intellectual and behavioural deficits in addition to confirmed prenatal exposure to alcohol. Please note these are general guidelines and an accurate diagnosis requires a specialist.
Additionally, the identifiable physical characteristics typical with FASD are harder to identify after puberty. Presently, the following characteristics are commonly associated with an FASD diagnosis.13,14,15,20
1. Distinctive facial anomalies, such as:
- Microcephaly (i.e., small head).
- Short palpebral fissures (i.e., short opening between the eye lids).
- Smooth or flattened philtrum (i.e., smooth or flattened cleft between upper lip and nose).
- Thin vermillion border (i.e., thin upper lip border).
2. Central Nervous System (CNS) abnormalities, such as:
- Small cranial size at birth.
- Structural brain abnormalities.
- Neurological impairments resulting in social and behavioural challenges.
3. Social and behavioural issues include:
- Attention deficit and/or hyperactivity.
- Maladaptive behaviour.
- Difficulty with social and communication skills.
- Difficulty with abstract reasoning.
- Memory challenges.
Not all children whose mothers consumed alcohol during pregnancy will have Fetal Alcohol Spectrum Disorder. The following factors contribute to the risk that maternal alcohol consumption could be associated with harmful effects on pregnancy and the unborn child:16,17,4,2,15
- Dose-response relationship.
The more alcohol consumed throughout pregnancy, the more likely it is that there will be adverse effects on the birth outcome and the babyâ€™s health.18,7
- Patterns of alcohol use.
Consuming a large quantity of alcohol in a short time-span (five or more glasses at one sitting) or frequent consumption (more than seven glasses per week) represents the riskiest drinking habits for the fetus.2
Consuming more than one psychoactive substance (e.g., alcohol used in combination with marijuana, cocaine, opiates, or any other psychoactive substance).
- The motherâ€™s personal characteristics (e.g., state of health, nutrition, metabolic capacities).
- The individual sensitivity of the unborn child to the effects of alcohol.
- The period of alcohol consumption during pregnancy.
In the table above, the bars represent the periods during which alcohol can cause structural and functional anomalies to the fetus. The dark-blue portion of the bar represents the most-sensitive times when alcohol can cause major structural abnormalities to the child. The yellow portion of the bar represents periods where alcohol causes physiological and minor structural abnormalities.
Depending on what point alcohol is consumed during pregnancy, it can affect the development of different organs. It is strongly recommended that women not consume any alcohol while pregnant. It is important to note that alcohol affects the Central Nervous System (i.e., the brain) at all stages of fetal development.
During the â€śall-or-none periodâ€ť (i.e., two weeks before fertilization and two weeks after fertilization) the body is more or less sensitive to the effects of teratogens. Exposure to a teratogen during this period can either cause damage to all or some of the cells, which would cause the embryo to die, or it can cause damage to only a few cells, which would not threaten its survival. The embryo could then develop normally and would not present anomalies.15,19
Alcohol Consumption before a Woman Knows She is Pregnant
Some women will have consumed alcohol in early pregnancy before knowing they were pregnant. They might worry about the effects this consumption could have on their babyâ€™s health. It may be helpful for them to know that consuming alcohol during pregnancy involves possible, not absolute risks for the pregnancy and the unborn child.
Not all children exposed to alcohol in utero develop Fetal Alcohol Spectrum Disorder.39 It is critical to emphasize, though, that the only way for absolute risk to be zero is to not consume any alcohol during pregnancy.20
As indicated in Table 2 on the vulnerabilities of the fetus to teratogens, the effects vary according to when alcohol was consumed. According to the clinical practise guidelines of the Society of Obstetricians and Gynaecologists of Canada, health care providers should let women know that low-level consumption in early pregnancy does not justify terminating a pregnancy.20
Changing Alcohol Consumption: What You Need to Know
A majority of women cease or decrease their alcohol consumption when they learn they are pregnant.1,21,22,23 According to the Public Health Agency of Canada, their research shows that alcohol consumption decreases substantially within the three months prior to pregnancy, with a consumption rate of 62.4 percent before pregnancy to a consumption rate of 10.5 percent during pregnancy1.
There is also a disparity in who is more likely to discontinue drinking. Of women who live in households at or below the low-income cut-off, 92.5 percent have reported that they do not drink. Yet, 88.2 percent of women who live in a household above the low-income cut-off reported not drinking1.
It is common for women and men to consume alcohol at festive events, social occasions, or with a meal.
Many women wonder about â€śmoderateâ€ť consumption during pregnancy and wish they could have the occasional drink without causing harm to their unborn baby. They are perplexed when faced with the message recommending abstinence from alcohol. Moderate drinking is defined as no more than one alcoholic drink per occasion.39
Why listen to the message that advises abstaining from alcohol during pregnancy?
Several reasons justify abstinence from alcohol during pregnancy:
- Alcohol is a teratogen and can cause birth defects.
- There are no studies to date that show there is a safe level of alcohol consumption.18
- Knowledge is limited on how individual differences play a role in metabolizing alcohol so it is not possible to predict who is at risk and who is not.24
Consequently, the safest message that can be offered to pregnant women is to abstain from alcohol consumption during pregnancy.24
What about when alcohol is used for cooking?
Sometimes recipes (e.g., sauces, meat recipes) call for alcoholic beverages. For pregnant women, the use of alcohol for meal preparation is not a problem because alcohol evaporates when it reaches the boiling point. However, it is suggested to avoid dishes where the alcohol did not undergo a change of state (e.g., desserts that contains alcohol).
Although it would be ideal if all women abstained from consuming alcohol during pregnancy, not all women will decide or are capable of doing so. Using an approach that decreases the negative behaviour and the risk is an effective option for some women.
This approach aims to decrease high alcohol concentrations and reduce risk of adverse effects of alcohol consumption on health, when it is not possible to stop consumption completely, by employing some of the following strategies.25
- Reduce the quantity of alcohol consumed.
- Space out drinks over a time period.
- Adopt healthy behaviours that could have a positive impact on the pregnancy outcome and the babyâ€™s development, such as promoting healthy eating, participatingÂ in physical activities, regularly monitoring the pregnancy, taking folic acid and iron.2
Consequently, when a pregnant woman makes an effort to decrease her alcohol consumption, reinforcing her positive behaviour will give the fetus a chance to develop properly. It should also be recognized that women with alcohol consumption or dependency issues may have other health problems or experience difficult circumstances that require special attention. In any case, judging or stigmatizing women should be avoided and, instead, they should be encouraged to seek services that meet their needs.
Women who are dependent on alcohol must be assessed by a doctor when they stop consuming because they can experience symptoms and signs of withdrawal.26,27
Symptoms of physical withdrawal include:
Symptoms of psychological withdrawal include:
- Mood swings. A lack of pleasure.
If a pregnant woman consumes large quantities of alcohol during pregnancy, the baby can also present withdrawal symptoms at birth. In such cases, the baby should undergo a medical examination. It may also be mandatory that child protection services be consulted.Â Physical symptoms persist three to five days on average, but no longer than one week.
Psychological symptoms can, however, last for several weeks depending on the newborn’s dose and frequency of exposure to alcohol. Withdrawal symptoms in newborns include:28
- Extreme irritability or moodiness.
- Improper feeding.
Some women report feeling peer pressure to drink alcohol during pregnancy.21 People may discredit their decision to not drink alcohol or encourage them to consume during social activities and festive events. Professionals are encouraged to sensitize pregnant women to this possibility and encourage them to reflect on strategies to address these pressures.
Support provided by the partner and/or the social environment regarding alcohol cessation during pregnancy is valuable in helping the pregnant woman overcome social pressure. The womanâ€™s support network can:
- Hold social events where there is no alcohol or where it is not central to the event (e.g., meeting in a cafĂ© or at home instead of a bar).
- Ensure that non-alcoholic beverages are available and offered to everyone.
- Support the pregnant woman by reminding her that her abstinence is temporary.
- Avoid encouraging alcohol consumption and respect the choices made by the pregnant woman.
- As required, modify their own alcohol consumption to show solidarity for the pregnant woman.
Alcohol and Breastfeeding
The evidence of harm to the fetus when the pregnant woman consumes alcohol is well established. However, the effect of occasional alcohol consumption by the mother on the breastfed infant has not yet been convincingly established. Long term consequences of women with high levels of alcohol use are, as yet unknown.. The advantages of breastfeeding outweigh the risks of occasional alcohol consumption. The Nutrition for Healthy Term Infants (NHTI) recommendations for infants from birth to six months suggests advising breastfeeding mothers of newborns to limit their alcohol intake, but also states that moderate alcohol consumption is compatible with breastfeeding. Mothers who wish to reduce the amount of alcohol their babies are exposed to can choose to abstain from drinking alcohol, or breastfeed their baby before they have an occasional drink.
Effects on baby when breastmilk contains alcohol
Breastmilk will contain alcohol when a mother consumes alcohol.29 Although a baby is exposed to only a fraction of the alcohol that the mother ingests, babies eliminate alcohol slower than an adult and are more sensitive to its effects.30,31 This may impact sleep patterns, and cause decreased milk intake.35
Occasional drinking while breastfeeding has not been shown to have adversely affected breastfeeding infants. A 2014 systematic review suggests that lactating women should follow standard recommendations on alcohol consumption.33
Alcohol and breastfeeding misconceptions
According to popular belief, consuming alcohol (more specifically beer) can help breastfeeding by increasing the quantity of milk produced. However, it has been shown that alcohol negatively affects the babyâ€™s feeding.
The baby could drink up to 20 percent less milk in the three to four hours after the mother consumes alcohol.34 This decreased feeding could be attributed to decreased milk production and to the milk ejection reflex being inhibited. These consequences are the result of the effect of alcohol on the hormones involved in breastfeeding.32,35,36
Another myth suggests that a baby will sleep better when its mother has consumed a bit of alcohol. However, a babyâ€™s sleep could actually be disrupted due to the mother having consumed a moderate amount of alcohol.29,38
Among pregnant women who consume alcohol, some do have challenges with consumption cessation, alcohol dependency, or need medical supervision during withdrawal. When a woman has difficulty in ceasing alcohol consumption, has a history of alcohol-use disorder, or needs medical withdrawal management, they should seek professional assistance and referral to specialized programming.
Women can refer to the Resources and Links section for information and resources available regarding alcohol and pregnancy. Please note, the information provided here does not replace medical advice, and we strongly urge women and their support networks to speak directly with a medical provider to ensure she receives specialized care. We provide this information to ensure women are aware of the resources available and accessible to them.
Resources & Links
- National Alcohol Strategy
- Society of Obstetricians and Gynaecologists of Canada (SOGC)
- Best Start Resource Centre (BSRC)
- Canadian Centre on Substance Abuse (CCSA)
- Canada FASD Research Network
- FASD Ontario
- FASworld Canada
- Health Canada
- Public Health Agency of Canada
- Society of Obstetricians and Gynaecologists of Canada (SOGC)
- ConnexOntario | 1-866-531-2600
Prenatal Education Provider Tools
- Best Start Resource Centre (BSRC)
- Pregnancy-Related Issues in the Management of Addictions (PRIMA)
Client Resources and Handouts
- Best Start Resource Centre (BSRC)
- Saying When: How to quit drinking or cut down (2016)
- Â Omama
- Public Health Agency of Canada. (2009). What mothers say: The Canadian maternity experiences survey. Ottawa, ON: Author. Retrieved from http://www.phac-aspc.gc.ca/rhs-ssg/survey-eng.php
- Djulus, J. (2007). Consommation d’alcool. In E. Ferreira (Ed.), Grossesse et allaitement: Guide thĂ©rapeutique (1st ed.) (pp. 137-147). MontrĂ©al, QC : Ă‰ditions du CHU Sainte-Justine.
- Cheng, D., Uduhiri, K., & Hurt, L. (2011). Alcohol consumption during pregnancy: Prevalence and provider assessment. Obstetrics & Gynecology, 117(2), 212-217. doi:10.1097/AOG.0b013e3182078569
- Dell, C. A., & Roberts, G. (2005). Alcohol use and pregnancy: An important Canadian Public Health and Social Issue. Ottawa, ON: Public Health Agency of Canada. Retrieved from https://www.researchgate.net/publication/235747443_Alcohol_Use_and_Pregnancy_An_Important_Canadian_Health_and_Social_Issue
- Mengel, M. B., Searight, R., & Cook, K. (2006). Preventing alcohol-exposed pregnancies: A randomized controlled trial. Journal of the American Board of Family Medicine, 19(3), 494-505. Retrieved from http://www.ajpmonline.org/
- Riley, E. P., McGee, C. L., & Sowell, E. R. (2004). Teratogenic effects of alcohol: A decade of brain imaging. American Journal of Medical Genetics, 127C, 35-41. Retrieved from http://onlinelibrary.wiley.com/journal/10.1002/%28ISSN%291552-4876
- SpĂ©zia, F. (2006). Alcohol, tobacco and cannabis: Review ofteratogenicity studies in animals. GynĂ©cologie, ObstĂ©trique & FertilitĂ©, 34, 940-944.
- Little, B. B., & VanBeveren, T. T. (1996). Placental transfer of selected substances of abuse. Seminars in Perinatology, 20(2), 147-153.
- Kesmodel, U., Wisborg, K., Olsen, S. F., Henriksen, T. B., & Secher, N. J. (2002). Moderate alcohol intake in pregnancy and the risk of spontaneous abortion. Alcohol & Alcoholism, 37(1), 87-92. http://dx.doi.org/10.1093/alcalc/37.1.87
- Aliyu, M. H., Wilson, R. E., Zoorob, R., Chakrabarty, S., Alio, R. P., Kirby, R. S., & Salihu, H. M. (2008). Alcohol consumption during pregnancy and the risk of early stillbirth among singletons. Alcohol, 42(5), 369-374. doi: 10.1016/j.alcohol.2008.04.003
- Kesmodel, U., Wisborg, K., Olsen, S. F., Henriksen, T. B., & Secher, N. J. (2002). Moderate alcohol intake during pregnancy and the risk of stillbirth and death in the first year of life. American Journal of Epidemiology, 155(4), 305-312. doi: 10.1093/aje/155.4.305
- Sokol, R. J., Janisse, J. J., Louis, J. M., Bailey, B. N., Ager, J., Jacobson, S. W., & Jacobson, J. L. (2007). Extreme prematurity: An alcohol-related birth effect. Alcoholism-Clinical and Experimental Research, 31(6), 1031-1037. DOI: 10.1111/j.1530-0277.2007.00384.x
- American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders-5. Arlington, Va: American Psychiatric Association http://www.dsm5.org
- Hoyme, H. E., May, P. A., Kalberg, W. O., Kodituwakku, P., Gossage, J. P., Trujillo, P. M., Buckley, D. G., â€¦ Robinson, L. K. (2005). A practical clinical approach to diagnosis of Fetal alcohol spectrum disorders: Clarification of the 1996 Institute of Medicine criteria. Pediatrics,115(1), 39-47. doi: 10.1542/peds.2004-0259
- Stratton, K. R., Howe, C. J., & Battaglia, F. C. (1996). Fetal alcohol syndrome: Diagnosis, epidemiology, prevention, and treatment. Washington, DC: National Academy Press.
- Abel, E. L. (1999). What really causes FAS? Teratology, 59(1), 4-6. DOI:10.1002/(SICI)1096-9926(199901)59:1
- April, N., & Bourret, A. (2004). Ă‰tat de la situation sur le syndrome d’alcoolisation foetale au QuĂ©bec. MontrĂ©al, QC: Institut national de santĂ© publique du QuĂ©bec. Retrieved from https://www.inspq.qc.ca
- Henderson, J., Gray, R., & Brocklehurst, P. (2007). Systematic review of effects of low- moderate prenatal alcohol exposure on pregnancy outcome. British Journal of Obstetrics and Gynaecology, 114, 243-252. DOI: 10.1111/j.1471-0528.2006.01163.x
- Jacobson, S. (1997). Assessing the impact of maternal drinking during and after pregnancy. Alcohol Health and Research World, 21(3), 199-203.
- The Society of Obstetricians and Gynaecologists of Canada. (2010). Alcohol use and pregnancy consensus clinical guidelines. Journal of Obstetrics and Gynaecology Canada, 32(8, S3), S1-S2.
- Audet, C., April, N., Guyon, L., & De Koninck, M. (2006). ReprĂ©sentations de la consommation d’alcool pendant la grossesse et perceptions des messages de prĂ©vention chez des femmes enceintes. MontrĂ©al, QC: Institut national de santĂ© publique du QuĂ©bec. Retrieved from http://www.inspq.qc.ca/pdf/publications/547-ConsommationAlcool_Grossesse.pdf
- Hayes, M. J., Brown, E., Hofmaster, P. A., Davare, A. A., Parker, K. G., & Raczek, J. A. (2002). Prenatal alcohol intake in a rural, Caucasian clinic. FamilyMedicine-KansasCity, 34(2), 120-125.
- Ockene, J. K., Ma, Y., Zapka, J., Pbert, L., Valentine Goins, K., & Stoddard, A. (2002). Spontaneous cessation of smoking and alcohol use among low-income pregnant women. American Journal of Preventive Medicine, 23(3), 150-159. http://dx.doi.org/10.1016/S0749-3797(02)00492-0
- Mukherjee, R. A., Hollins, S., Abou-Saleh, M. T., & Turk, J. (2005). Low level alcohol consumption and the fetus. BMJ, 330, 375-376. Retrieved from http://www.bmj.com/thebmj
- Peterson, R., & LafreniĂ¨re, R. (2002). Toxicomanies et pĂ©rinatalitĂ©: Document de rĂ©fĂ©rence pour les intervenants. Saint-Charles-BorromĂ©e, QC: Direction de santĂ© publique.
- CAMH. (2012). Do you knowâ€¦ Alcohol. Retrieved from http://store.camh.net/product.php?productcode=P251
- MinistĂ¨re de la SantĂ© et des Services Sociaux. (2009). Unis dans l’action: Programme de formation en dĂ©pendances pour les centres de santĂ© et de service sociaux (CSSS). QuĂ©bec: Author.
- Canadian Paediatric Society. (2012). Fetal alcohol spectrum disorder. Retrieved from http://pubs.niaaa.nih.gov/publications/arh341/toc34_1.htm
- Mennella, J. (2001). Alcohol’s effect on lactation. Alcohol Research and Health, 25(3),230-234. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/11810962
- Abel, E. L. (1984). Pharmacology of alcohol relating to pregnancy and lactation.In E. L. Abel (Ed.), Fetal alcohol syndrome and fetal alcohol effects (pp. 29-45). New York, NY: Plenum Press.
- DorĂ©, N., & Le HĂ©naff, D. (2010). Mieux vivre avec notre enfant de la grossesse Ă deux ans: Guide pratique pour les mĂ¨res et les pĂ¨res. QuĂ©bec: Institut national de santĂ© publique du QuĂ©bec.
- Mennella, J., Pepino, Y., & Teff, K. (2005). Acute alcohol consumption disrupts the hormonal milieu of lactating women. The Journal of Clinical Endocrinology & Metabolism,90(4), 1979-1985. http://dx.doi.org/10.1210/jc.2004-1593
- Haastrup, Maija Bruun; PottegĂĄrd, Anton; Damkier, Per (2014). Alcohol and Breastfeeding. Basic & Clinical Pharmacology & Toxicology. Vol. 114 Issue 2, p168-173. 6p. DOI: 10.1111/bcpt.12149.
- Mennella, J. A. (2001). Regulation of milk intake after exposure to alcohol in mothers’ milk. Alcoholism: Clinical and Experimental Research, 25(4), 590-593.
- Giglia, R., & Binns, C. (2006). Alcohol and lactation: A systematic review. Nutrition & Dietetics, 63(2), 103-116.
- Giglia, R. C. (2010). Alcohol and lactation: An updated systematic review. Nutrition & Dietetics, 67(4), 237-243. DOI: 10.1111/j.1747-0080.2010.01469.x
- Cobo, E. (1973). Effect of different doses of ethanol on the milk-ejecting reflex in lactating women. American Journal of Obstetrics and Gynecology, 115(6), 817-821.
- Mennella, J. and Gerrish, C. J. (1998). Effects of exposure to alcohol in mother’s milk on infant sleep. Pediatrics, 101(5), 21-25.
- Patra, Y., Bakkar, R., Irving, H., Jaddoe, V. W. V., Malini, S., Rehm, J. (2011). Dose-response relationship between alcohol consumption before and during pregnancy and the risks of low birth weight, preterm birth and small-size-for-gestational age (SGA) â€“ A systematic review and meta-analyses. BJOG 118(12): 1411-1421.