Foetal Alcohol Syndrome

HL Deb 18 October 2004 vol 665 cc603-19

7.52 p.m.

Lord Mitchell rose to ask Her Majesty's Government how they intend to reduce the incidence of foetal alcohol syndrome.

The noble Lord said: My Lords, binge drinking and alcohol abuse is a subject right at the heart of the Government's public health agenda. What I would like to address this evening is a little known sub-set; foetal alcohol spectrum disorder and its particular and narrower excess, the chronic foetal alcohol syndrome. I am raising this matter in your Lordships' House not only because this disorder is so tragic but also because it is totally preventable.

Foetal alcohol spectrum disorder is an umbrella term, which describes a wide disability that afflicts one in a hundred of all live births in the developed world. At its most benign, it probably encompasses attention deficit disorder in children, as well as other behavioural problems. At its most malign, it manifests itself as the full foetal alcohol syndrome.

The syndrome is estimated to affect between one and three in every 1,000 live births. FASD occurs because the foetus in the womb is unable to breakdown alcohol that has crossed from its mother's bloodstream, via the placenta, into its own bloodstream. In its early life, when the blood filtration system is underdeveloped, the foetus is totally unprotected from the alcohol circulating in its body—without a liver, alcohol remains a poison. As a poison the alcohol can cause permanent brain damage to the developing foetus.

I must declare an interest in that a dear friend of mine adopted a child who was three years old. Today she is a teenager the same age as my own twin sons. She has been diagnosed as having the full syndrome. I have been able to witness at first-hand how this one child has grown into a young person, frustrated by her own inability to be like her peers. She is increasingly angry, increasingly desperate and increasingly isolated. She will never be able to enjoy an independent life. I watch helplessly as I contrast her to my own sons and as I see her suffering and her adoptive mother suffering with her. My friend is spearheading the NO-FAS campaign in the UK.

In most cases, FASD children look pretty normal, but some do have certain facial characteristics. They may be somewhat underweight and smaller than average children, but to the untrained eye they seem much the same physically as anyone else. Typically, they continue to pass as normal, until they reach early puberty, then they tend to be abandoned by their playmates. They adopt new and younger friends, only to be dropped again when they too reach puberty. Eventually, such children become friendless. Their peers outgrow them and leave them behind. Unable to hold down even the simplest of jobs, in adulthood they become totally dependent on families and friends. They become a massive economic burden on society and many become homeless and many end up in prison. The truth is that they are permanently damaged. The irony is that it is all totally preventable.

So why is it that little is being done to address this issue? There seem to be two principal reasons. The first is that the Government are not convinced of the scale of the problem. The second is that they do not believe that they need to take any further action to alert young women to the dangers. I would like to deal with both issues.

The Department of Health collects data on foetal alcohol syndrome via the Hospital Episode Statistics. They measure finished consultant episodes and according to their numbers, in the year 2002–03 the total number of FAS FCEs was 128. Other numbers are dramatically different. FASD has been studied at great length throughout the world, but most work has taken place in the United States. Studies there have been conducted by highly respected academics and medical authorities in leading universities and hospitals. Reassuringly all the studies whether in America or elsewhere hone down to the same conclusions; that one in 100 live births results in some form of the disorder, of which between one and three in 1,000 result in the full syndrome. These figures have also been confirmed by the World Health Organisation.

Now if these figures were to be applied to the 750,000 live births each year in the United Kingdom, the results should be as follows: that 7,500 children should be born with the disorder, of which 2,000 should have the full syndrome. So if the world-wide experts say the incidence of the syndrome in the UK should be 2,000 annually, how can it be that the department says that its tally of FAS cases is barely over a hundred?

Well, I hardly feel it is because of our national temperance. Were binge drinking an Olympic sport, not only would our country win the gold medal, but they would give us the silver and bronze by way of a consolation prize. It must be the methodology of gathering data and its diagnosis.

In the UK, the syndrome is diagnosed predominantly by geneticists who look for typical facial features. But few FASD babies exhibit these features. It must also be said that awareness of FASD even among the medical profession is scant and that in consequence positive diagnosis of many cases simply does not occur, unless of course we are culturally different from the rest of the world. In some ways we are different. In our country there is a greater incidence of binge drinking, a greater incidence of unprotected sex and a greater incidence of teenage pregnancy. It simply cannot be that in the UK FASD is one-twentieth of the total that occurs elsewhere.

The second instance of the department's reluctance on this matter centres on the responsibility to alert the public to the risks taken by pregnant women who drink. Few young women are aware that alcohol, even a small amount, increases the risk that their baby will be born with some form of defect. The department recommends that a pregnant woman can drink a few units of alcohol per week during pregnancy. But how many women know this? And what constitutes a unit? To most of us a unit means a glass or two of wine. But wine glasses in pubs are getting bigger and bigger. So how large is a glass? How much liquid does it contain? How alcoholic are its contents? And what happens if the weekly quota of alcohol is consumed in one evening on a critical day in the pregnancy?

Today the alcohol industry is deliberately jazzing up its products. Old-fashioned bitter, for example, which has an alcoholic content of 3.8 per cent, is being rapidly replaced by fashionable, more expensive beers where the alcoholic content is close to 6 per cent. The same is true of alcopops. What does that say about the value of using the unit as a measure? It means that it is imprecise and uncertain. Anyhow, it seems to me that few young people have the vaguest knowledge of what a unit is.

On my desk, I have two cans of Guinness; one bought in New York and the other bought in London. The American can has the following warning printed on the side: Government Warning - according to the Surgeon General women should not drink alcoholic beverages during pregnancy because of the risk of birth defects". The British can is silent on the subject. Why is this?

The department says it is because the American experience shows that labelling has had virtually no impact at all on the prevalence of alcohol misuse in the United States. In which case, could somebody please tell me why we label tobacco products? Could he tell me why drugs such as Sudafed have warnings about taking them while pregnant? Furthermore, could he tell me why we are considering labelling food products to highlight salt content, as well as foods that cause obesity? I f labelling works in the case of tobacco, drugs and food, am I seriously being told that it does not work in respect of alcohol? I am informed that in France and in Poland, their Governments are now committed to introducing labelling to warn of the dangers to the unborn child.

So why not does that not happen here? Labelling, of course, is not the cure but it could be the first step the Government could take to start to inform those who are vulnerable and to demonstrate their commitment. They could also insist that warnings are posted on products associated with pregnancy, such as pregnancy test kits and baby magazines, as well as on notices in clinics and surgeries. Finally, on this subject, why do the Government not state clearly that if a woman is pregnant, or is thinking of becoming pregnant, it is best not to drink?

I am coming to the end of what I have to say, but I cannot finish without directing a few warning words to the alcohol industry itself. For its own protection, it would do well to study what has happened to the not too dissimilar tobacco industry and to draw the lessons. Tobacco today is fighting for its life under the onslaught of multiple legal cases around the world. Just like tobacco, the alcohol industry targets the young and impressionable. The marketing men, the advertising industry and the sports sponsors all conspire to make alcohol cool. I would like to see them behaving as responsible citizens, alerting their customers to the dangers, whilst balancing the fun and enjoyment that comes from sensible and informed drinking.

Having said all that, at the end of the day it is not the drinks industry that must take the lead, it is our Government. On 15 September at Prime Minister's Questions, my right honourable friend the Prime Minister, when asked a question about foetal alcohol syndrome, said: On the specific issue of foetal alcohol syndrome, we know that excessive drinking may affect the brain of a developing foetus. The evidence is absolutely clear, and I am sure that responsible women who are pregnant will take account of it".—[Official Report, Commons, 15/9/04; col. 1264.] I am delighted that the Prime Minister is so supportive, but, as we know all too well, not all women are responsible and not all women are informed.

I look forward to the rest of the debate and, in particular, to my noble friend's reply.

8.3 p.m.

Lord Chan

My Lords, I thank the noble Lord, Lord Mitchell, for securing this debate on foetal alcohol syndrome. I wholeheartedly support him in his concern for this serious and irreversible developmental abnormality in the foetus, as the result of pregnant women drinking alcohol during pregnancy. However, the damage of foetal alcohol syndrome is fully preventable, as the noble Lord, Lord Mitchell, has said if women abstain from alcohol for the nine months of pregnancy.

Foetal alcohol syndrome was identified some 30 years ago and advances have been made in diagnosis, surveillance, prevention and intervention, particularly in North America, but more work remains to be done. This timely debate reminds us that the Health Survey for England in 2002 reported that an increasing number of women were drinking in excess of the recommended maximum of 21 units of alcohol per week and that 3.6 million women, mostly 16 to 24 years of age, were drinking over 14 units per week. That figure included half a million women drinking over 35 units per week. Women in professional occupations were drinking more than women in unskilled households.

The main thrust of organisations such as Alcohol Concern, the national agency on alcohol misuse, has so far been to focus on the broader mental, physical and social problems associated with excessive drinking by the habitual or binge drinker. Health impairment includes liver damage, accidents, stroke and mental illness. Birth defects are mentioned in passing without specifically naming foetal alcohol syndrome; at least, that is what I found in the Alcohol Concern leaflet on the Internet. Another document, Prevention and reduction of alcohol misuse, an evidence briefing published by the Health Development Agency in June 2002, makes a brief statement in its introduction: Alcohol is also closely linked with preventable harm associated with pregnancy (10 per cent of children of alcohol-dependent mothers suffer from foetal alcohol effects)". In North America, both in Canada and in the United States of America, foetal alcohol syndrome and related disorders have been specifically highlighted since 1996 in an important public health approach to preventing alcohol misuse in pregnant women. For example, the Ministry of Children and Family Development of the Government of British Columbia published community action guides on the prevention of foetal alcohol syndrome in 1996, which ran to about 50 pages. The US Congress in 1998 recognised the significance of a co-ordinated effort to address the concerns related to foetal alcohol syndrome. The Secretary of the US Department of Health and Human Services was directed through the Public Health Service Act, Section 399G, to establish a national task force on foetal alcohol syndrome and foetal alcohol effect. The terms of reference of the national task force were to: Foster coordination among all government agencies, academic bodies, and community groups that conduct or support FAS and FAE research, programs and surveillance; and…otherwise meet the needs of populations impacted by FAS and FAE". On 17 May 2000, in accordance with Public Law 92–463, the task force was chartered. Authority to establish the task force was delegated to the Centers for Disease Control and Prevention's National Center on Birth Defects and Developmental Disabilities. This came as, in 2002, the US Centers for Disease Control and Prevention (CDC), based in Atlanta, Georgia, identified foetal alcohol syndrome as an important and eminently preventable disorder. Guidelines for the referral and diagnosis of foetal alcohol syndrome were published in July 2004.

Foetal alcohol syndrome, as described by the noble Lord, Lord Mitchell, is a spectrum of disorders caused by prenatal exposure of the foetus to alcohol. Abnormal facial features, such as small eyes, growth deficiencies and central nervous system problems in a baby born to a mother who drank alcohol regularly during her pregnancy form the basis of diagnosis of FAS. The neurological defects in FAS include impaired memory, low intelligence, poor attention span and difficulties in communication, vision and hearing.

Alcohol-related neurodevelopmental disorder (ARND) and alcohol-related birth defects (ARBD) are terms used when the diagnostic features of foetal alcohol syndrome are present but at mild or less severe levels. Problems found include learning difficulties, poor school performance, and difficulties with mathematical skills, memory, attention and judgment. In alcohol-related birth defects, problems arise with the heart, kidneys, bones and hearing.

Foetal alcohol syndrome rates vary widely depending on the population studies. The Atlanta CDC studies show foetal alcohol syndrome rates ranging from 0.2 to 1.5 cases per 1,000 live births in different areas of the United States. If that range of rates were applied to babies in the United Kingdom, we could expect at least 700 to be affected each year. The noble Lord, Lord Mitchell, gave us other figures to compare with the paltry figure of 128 detected in our Hospital Episode Statistics.

The American CDC states that there is no known safe amount of alcohol that a woman can drink while pregnant, nor a safe time at which she can do so. Of course, a number of developmental birth defects can display diagnostic similarities to foetal alcohol syndrome. But foetal alcohol syndrome is the one abnormality that is totally preventable if pregnant women are informed that drinking alcohol in pregnancy can cause it and abstaining from alcohol can prevent it.

In view of the long-term disabilities occurring in people with foetal alcohol syndrome, should Her Majesty's Government not consider a review of this condition with a view to preventing it? There are other causes of long-term disabilities in children which require expenditure, but foetal alcohol syndrome is totally preventable.

Finally, a campaign to warn young women of the dangers of alcohol for the foetus may be the start of a community programme to reduce alcohol misuse among them. We know that the incidence of binge-drinking of alcohol has been increasing over the past 10 years or more. A campaign such as the one that we are discussing this evening may be a useful approach in stemming the tide of accepted alcohol drinking among women.

8.12 p.m.

The Earl of Listowel

My Lords, I rise briefly to speak in the gap. I take this opportunity to draw your Lordships' attention to a particular group of children who may be at special risk of this syndrome—that is children of care leavers or those who, as children, were in care.

As noble Lords may be aware, about 80 per cent of children in care are there as a result of abuse or neglect or because of family breakdown. The rate of mental disorders among those in care is four times higher than that of the general population, and for the 10 per cent of those children in residential care, the rate is seven times higher than for the general population.

The rate of teenage pregnancy in that group is two and-a-half times higher than that of the general population, and a child horn to a woman who has been in care is two-and-a-half times more likely to be in care himself during his childhood.

The point that I am trying to make is that that group might be particularly susceptible to drinking too much during pregnancy or perhaps being pregnant at too early an age. Therefore, we may first take the practical step of being very careful to ensure that they are fully informed about the dangers of drinking during pregnancy and, secondly, watching the group to discover whether there is indeed such a problem in this area. I understand that recent research has shown that unfortunately there is a worrying level of drug misuse among that group. I do not know whether any research has been carried out into alcohol use by that group.

I also believe that this is an opportunity to compliment the Government on their very responsible investment in building a capacity of foster carers in the residential care system and the schools system, but to emphasise that they are starting from a very low base and that they really must work very hard to keep that momentum going forward to prevent the kinds of outcomes that we have discussed today, such as foetal alcohol syndrome and all the other adverse outcomes that we know are associated with such poor childhood experiences.

I thank the noble Lord for bringing this very important issue to our attention, and I look forward to the Minister's response to the debate.

8.15 p.m.

Baroness Neuberger

My Lords, I, too, would like to compliment the noble Lord, Lord Mitchell, on engendering this debate and drawing our attention to the issues surrounding foetal alcohol syndrome.

As we have heard from the noble Lords, Lord Mitchell and Lord Chan, a great deal is known about foetal alcohol syndrome, but I would also argue that there is still more to learn. According to the World Health Organisation, anything between 0.33 and 9.7 per thousand live births develop foetal alcohol syndrome, but many people would argue that far more children are born with foetal alcohol syndrome or that a number within that spectrum are affected by alcohol drunk by their mothers.

Dr Raja Mukherjee of St George's Medical School—I declare an interest as I used to be on the medical school's council—believes that many more babies are affected, up to one in 100, and argues that many of them have been incorrectly labelled as having behavioural problems. We know that extreme cases have abnormal facial features and often have nervous system problems. They are the obvious ones, but others may have behavioural problems as a result of alcohol in the womb, who are incorrectly diagnosed as having attention deficit hyperactivity disorders.

As both noble Lords have said, we are seeing an apparent explosion of behavioural problems and there also appears to be an explosion of drinking among young girls and women—and binge drinking at that. The question is whether the two are connected, as some definitely tend to suggest, or is there perhaps a third or indeed a fourth factor?

In April 2004, the Minister argued that: It is difficult to assess the relative impact of excessive maternal drinking and other factors such as maternal socio-economic status, maternal age at the birth and maternal nutrition during pregnancy".—[Official Report, 19/4/04; col. WA 10.] He should have added "maternal nutritional status before pregnancy".

It seems to me that other factors need to be taken into account here and that there is considerable evidence that poor diet, both during and before pregnancy, has a powerful effect on the development and health status of future children. Those, too, are matters about which something could be done. It is not only foetal alcohol syndrome that has something doable about it. Something can also be done about the nutritional status of young women. We seem to be seeing in young women, particularly before pregnancy, an odd combination of very poor diet and binge drinking at the same time.

To give just a little light relief in this very serious debate, there is a wonderful scientist, David Barker, at the Medical Research Council in Southampton—again I should declare an interest as I used to be a member of the council—who, as a result of conducting a survey of women between the ages of 18 and 35 in Southampton, which represents the rest of the UK very well, decided to pay the women of Southampton a compliment and organised a photographic exhibition of them to say "thank you". He drew lots as to who would take part in the photographic exhibition. There are some wonderful portraits of the women. There were also some portraits of the contents of their fridges. Of all the fridges that were portrayed in that random selection of women in Southampton between the ages of 18 and 35—precisely the women about whom we should he concerned in this debate—one of the most alarming revelations was that only one had any green vegetables in it, and one family, interestingly, did not have anything in the fridge except some alcohol and their pet rat.

It seems to me that we need to take some of these issues into account. If these young women are eating an appalling diet, paying great attention to keeping thin, and with a lot of binge drinking on the side, there are other factors we have to take into account. I wonder whether we should not think that there is a more complex picture here of the effects of a poor nutritional start plus heavy drinking in pregnancy. Should we not also ask whether there is a socioeconomic link? Whatever, the picture appears to be gloomy for many of our children, but does not appear to be altogether simple. Nor, of course, as both noble Lords have said, is it inevitable.

It is quite clear that better information could and should be given to women who are pregnant and women who are thinking of getting pregnant. Our standard alcohol strategy is not enough. Government advice to women who are pregnant or trying to get pregnant that they should not drink more than one to two units of alcohol a week is probably not adequate either. We and they need to know more about it. Most people do not really know what one unit consists of. Pregnant women need to know and understand the dangers that they are facing with a bit more certainty.

Clearly, there are things that could be done about that. There could be better education in ante-natal classes about alcohol, although the most vulnerable groups probably do not go to ante-natal classes. Equally, there is a question about the labelling of alcohol. We should be asking the Minister whether she will encourage the drinks industry to put warning messages on bottles and cans. There was the news today that Scottish&Newcastle are, for the first time, putting some kind of warning on bottles and cans, and that is a very good sign. The noble Lord, Lord Mitchell, has been pushing for that for some time and wants to see what is happening in the United States.

More than that, it seems to me that perhaps the Minister and some of us could be taking issue with the Portman Group, which represents the alcohol industry. One of its representatives, Jim Minton, told BBC News Online in September of this year, Women who are pregnant or planning to become pregnant should seek advice from a medical professional about recommended levels of drinking appropriate to their circumstances", That seems a bit mealy-mouthed, somewhat understated, one might say. Could not the Portman Group support precisely what Scottish & Newcastle has announced today and let us see some serious attempts by the industry to label bottles and cans so that people know that if they drink large amounts of alcohol they will almost certainly damage their unborn children and perhaps if they drink any at all that may be true too?

Given the uncertainty of the precise extent of the problem and the complications of disentangling one kind of developmental damage from another, should not The Government now be willing to encourage greater research in this area? Will the Minister make a commitment to greater sponsorship of research in this area? Will she look at the potential link between binge drinking among women and the exponential growth in behavioural disorders and see whether there is really a link there?

Will she also look at whether the figures that were cited by the then Health Minister, Hazel Blears, in 2002 were accurate? Those are the figures that were drawn from the Hospital Episode Statistics (HES) data, which showed that in 2000 there were 0.07 cases per thousand live births in the UK. That seems astonishingly low. It seems to me that there is something wrong with our recording as well as some of the thinking around what we should be doing about it. Perhaps then, if we could get the data right, we could look at the extent to which the link is strongest among women of lower economic status with poorer nutrition who drink heavily. It appears that they are at greater risk of foetal alcohol syndrome than middle class women drinking the same amount of alcohol at the same time.

Indeed, in a private conversation over this past weekend with the immediate past president of a faculty of public health medicine, Professor Siân Griffiths, she argued that we should be thinking far more about issues of maternal deprivation and young maternal deprivation than purely about the link between alcohol and pregnancy. It is a more complicated picture than that.

Clearly, in the United States, women are blamed for harming their foetus if they drink at all. Our guidance here does not say, "Don't drink at all". One might argue whether it should. Equally, we know that those who plan pregnancies tend to stop smoking and drinking alcohol. It is those who do not plan their pregnancies—those who are raped, or are too drunk to know what they are doing, and then get pregnant—who may be running the greatest risks.

There are women for whom the issues may he much more complicated than simply that they drink too much. I particularly want to thank the noble Earl, Lord Listowel, for raising the issue of young women—girls, really—who leave care and then get pregnant. They have a complicated set of issues to face, and clearly they are at far greater risk. Blaming them for drinking during pregnancy will not help.

To sum up, I ask the Minister to consider three things: first, whether the Government will consider labelling bottles and cans of alcoholic drink, at least giving information beyond the present alcohol reduction strategy; secondly, whether there can be a real push towards further research into both the incidence in the UK of foetal alcohol syndrome, and associated disorders, and the general link with deprivation and poor nutrition, following the evidence we already have on that; thirdly, if the Minister will encourage vastly improved health education in schools—so that long before they become pregnant, we hope, girls know the risks—and, of course, in antenatal care.

We should not succumb to the "blaming women" syndrome that has become commonplace in the United States. Here in the UK we have to think differently. We must know the incidence, and provide more information, but we also need to encourage research in those complex, linked areas of alcohol abuse, deprivation, and poor nutrition before and during pregnancy. Will the Minister comment on whether research in that area could go higher up the research council's list?

8.26 p.m.

Earl Howe

My Lords, this is one of those debates where, though the number of speakers may be few and the attendance sparse, the issue under discussion is of profound and far-reaching significance. I take my hat off to the noble Lord. Lord Mitchell, who has done so much to champion the cause about which he has spoken to us so compellingly this evening.

Like him, I shudder when I start reading what teenagers and young people do to themselves when they go out for an evening and start knocking back the drink. British teenagers are among the heaviest drinkers in Europe, and, when it comes to binge drinking, the quantities of alcohol being consumed are going up, not down. The term "lager loutette" has unfortunately entered the language. I am the first to say that there is much to be applauded in the Government's alcohol harm reduction strategy, published last March, but Ministers must know as well as anyone how big the mountain is that has to be climbed. Nobody believes that this is a problem for the Government alone to solve; it has to be a co-ordinated effort between government, industry, the voluntary sector, schools and many others. But I am sorry to say that if we look in the strategy for anything concrete about foetal alcohol syndrome, we look in vain—the strategy contains practically nothing about it.

The noble Lord, Lord Mitchell, has spoken about the incidence and prevalence of FAS and its often devastating consequences. One problem, as he rightly acknowledges, is trying to get a handle on how widespread the syndrome is. Those who exhibit physical characteristics directly symptomatic of FAS are a minority of sufferers; the majority can only be diagnosed in other ways. It is clear from reading the literature that a large number of cases are probably not being diagnosed at all. I agree entirely with what the noble Baroness has just said in that regard. This is especially probable when we bear in mind that FAS is a spectrum disorder—that is, a disorder characterised by a variety of symptoms depending on whether it is mild, moderate or severe.

The incidence of FAS recorded in the UK is considerably lower than estimates made by the WHO across a range of different countries. Obviously one has to make allowances for different levels of alcohol consumption in those countries, but it seems likely that in the UK we are not accurately recording the true incidence. That is a particular worry. Although one half of the problem is what more we ought to do to dissuade women from drinking when pregnant, the other half is what more we should do to help children who are born with the condition. If we do not sufficiently recognise the condition when it is in front of us, we are not in a position to fashion a proper policy or assess the effort required to tackle the problem. Nor can we help the women and children who need to be helped in a timely way.

I suspect that, if the various barriers to diagnosis were to be magically removed and we were suddenly confronted with the true incidence of FAS, the pressure on the Government to do more than they are doing would be very great. As it is, even with the information that we have before us, the Government's response to the issue seems less than satisfactory. Among doctors who specialise in the field, there is consensus that, for a pregnant woman, no level of alcohol is safe. NOFAS—the National Organisation on Foetal Alcohol Syndrome—is right in what it has said about that. Clearly, the message that goes out should not be one that instils panic into women who may be pregnant and may have had a couple of drinks, but, in the light of recent evidence from, for example, the University of San Diego and Queen's University, Belfast, and the excellent work of Professor Raja Mukherjee at St George's Hospital Medical School, should not the warning messages be changing?

The Government's official recommendation is that mothers-to-be should limit themselves to one to two units of alcohol a week. I wonder whether the time has not come when the message should in essence be, "If you are a mother-to-be, the only sensible level of alcohol consumption, at any time during your pregnancy, is zero. But if you must drink, do not go above one to two units per week". Rephrased in that way, the advice would be better balanced. It would adopt a more precautionary stance without being alarmist.

The Government's alcohol harm reduction strategy is partly predicated on a so-called "sensible drinking message". For the population at large, that may be totally appropriate. The Government's approach has been to encourage the alcoholic drinks industry on a voluntary basis to put the sensible drinking message on bottles and cans. I have no problem with that, but should we not encourage the industry to go a little further by including a separate message for pregnant mothers? For non-pregnant women, the "sensible" recommended limit is 14 units a week, but 15 units of alcohol a week is the level at which a baby's birthweight starts to be adversely affected. Someone taking 14 or 15 units all in one go is doing herself and her baby serious harm. That point was made by the noble Lord, Lord Mitchell. I understand that the drinks industry will contribute to a fund that, among other things, will provide information to young people about alcohol misuse. We need to ask what place, if any, FAS will have in that scheme.

I hope that the Minister will agree that education and information are vital, if the incidence of FAS is to diminish—the education and information not just of women but, I suggest, of health professionals. For health professionals, the focus, as much as anything, should be on recognition and diagnosis. Dr Raja Mukherjee of St George's believes that up to one in 100 children affected by FAS are not being identified. That surely points to the need for research into bio-markers, to identify at-risk women and at-risk newborn babies.

Neurological damage caused in utero can result later in a child who is disruptive and hard to manage. The majority of FAS sufferers have behavioural problems. Research carried out at the University of Washington has found that, of a selection of school-age children diagnosed as having FAS, 60 per cent had been suspended or expelled from school or had dropped out; 60 per cent had been in contact with the police for a suspected criminal offence; and 50 per cent had been confined in some way, either in prison or in a mental hospital.

Those findings should ring alarm bells with us. FAS in a child or young person requires compassion, understanding and treatment, not punishment. Nothing can be done to cure the primary disability—the impairment of brain function. But a stable, nurturing home environment and sensitive education can do much to alleviate behavioural abnormalities. Maximising the potential of affected children is dependent on giving them encouragement and instilling a sense of achievement. It depends on teaching appropriate social behaviour and social skills. It depends on constant input from trained adults. All of that rests upon early diagnosis.

When a child reaches adolescence he or she needs to be closely supervised. If he is given too much freedom, there is a risk that he will be manipulated by others and sucked into undesirable company. The trick is to look for opportunities where the individual feels some independence, but which is none the less safe—supervised employment, sport or perhaps an artistic endeavour.

Trying to incorporate an FAS child in mainstream education can lead to that child dropping out of school; but worse, if the FAS has not been identified, the child's difficulty in complying with instructions, whether through lapses of memory or through difficulty with comprehension, can be mistaken for defiance. That is a very dangerous misdiagnosis. Parents can find themselves on the receiving end of accusations of poor parenting, or even abusive parenting, in exactly the same way that parents of children with ADHD or autism run the risk of wrongful allegations. Those conditions, too, require specialist diagnosis.

Against that background, I am extremely concerned that the provisions of the Anti-Social Behaviour Act are being implemented on the ground in a way which ignores everything that we have been discussing. It is an Act which is all about protecting the community—no more, no less. I am receiving reports from bodies such as BIBIC, the British Institute for Brain Injured Children, that indicate an attitude on the part of police officers that can only be described as oblivious. In one case, an officer was asked what he would do if confronted with a disruptive child. The reply was that if the "perpetrator" behaved anti-socially then the police would take a strong line. When asked what they would do if the child had a learning difficulty which led to challenging behaviour the reply was that the child "had to learn to behave in an accepted manner". No special help was being put in place as it was all about "protecting the public". In taking that line the officer was not being uncaring or unpleasant; he was simply doing his job in the best way he knew. But because of his lack of understanding about conditions such as autism, ADHD and FAS, it was clear that he regarded bad behaviour in children as predominantly the parents' fault.

That is a sentiment which we hear rather often from the Home Office at the moment. I must therefore ask the Minister what guidance, if any, has been issued to police forces and other bodies on the implementation of the Anti-Social Behaviour Act; and whether such guidance takes account of genetic and non-genetic mental conditions in children, which may point to a therapeutic rather than a punitive solution to disruptive behaviour. It would be completely wrong for the law to be enforced in a way which rode roughshod over such children.

All that points once again to the need for greater public awareness of FAS and for early identification of sufferers. The cost of looking after such children is, in many cases, very substantial; but the earlier the diagnosis, the more the cost can be kept down. I hope that the Minister will be able to hold out the prospect of further government engagement on the issue when the public health White Paper is published later this year. For all the reasons referred to tonight, there really is a great deal of ground to be made up.

8.39 p.m.

Baroness Andrews

My Lords, like all noble Lords who have spoken in this excellent and—as usual—expert debate, I am grateful to my noble friend Lord Mitchell for the opportunity to follow up the remarks he made some time ago in a more thoughtful and considered way than we were able to then. I am particularly pleased to welcome the noble Baroness, Lady Neuberger, to the Front Bench and appreciated what she said about the context in which we are considering the relationship between alcohol and pregnant women.

I thank all noble Lords, including the most opportunistic of all, the noble Earl, Lord Listowel, who brought to our attention some very vulnerable young people and made some important points; and the noble Lord, Lord Chan, for the international dimension by which he measured what we are doing in the UK. I thank particularly my noble friend Lord Mitchell, who, as the noble Earl said, has taken this very much as a personal and professional campaign and has been a powerful advocate and champion of people with foetal alcohol syndrome and their children.

I have a lot to say and I will have to go rather fast. We have a duty to be clear in what we are saying to pregnant women about the risks of drinking. No drinking is totally risk-free. Drinking during pregnancy can put the developing foetus at risk in many different ways, including miscarriage. In the interim analysis for the alcohol harm reduction strategy, which devoted some pages to FAS, we considered a range of issues connected with FAS.

Although there is relatively small risk, there is clearly the potential that some heavy drinkers will develop FAS, with all the personal consequences that we have heard so graphically described tonight on the basis of evidence from all around the world.

I would like to pay tribute in that context to the work of the National Organisation for Foetal Alcohol Syndrome. I have looked at its website and read its reviews. There is no doubt that it provides essential support and information to such families. I know that colleagues at the Department of Health are always prepared to meet its representatives to discuss their concerns.

I want to start with what we can agree on because there are issues on which we can agree; notably that FAS is preventable and that the evidence suggests that it is caused by excessive alcohol consumption. The problem is that the definition of "excessive" seems to differ for individual women. The noble Lord, Lord Chan, said that more should be done. The noble Baroness, Lady Neuberger, said that we need to learn more. Indeed we do. We know quite a lot, but it seems that this is a relatively recent syndrome about which a great deal more research could be carried out. There seem to be no hard-and-fast rules about why some women are more vulnerable than others.

Evidence suggests that most women who drink heavily—more than 35 units per week—will not go on to have a baby with FAS. On the other hand, as the noble Baroness, Lady Neuberger, said powerfully, there is a range of other factors that also affect maternal and child health; particularly, I agree, about pre-maternal nutritional syndromes. We know a great deal more than we used to about fish oils, for example, and fruit and vegetables. We need to take that and socio-economic conditions into account when we are looking for explanations of vulnerability.

In this country there is uncertainty about the scale. Reputable medical expertise has concluded over the past 10 years that FAS is difficult to diagnose, especially as the child develops; and it is difficult to establish the scale of the problem, particularly if nothing is known about the mother's drinking habits. We can also agree that it is difficult to make a robust or agreed estimate of the prevalence of FAS. Noble Lords have quoted different figures, including the WHO figures, which show a wide spectrum. It is true that our figures for FAS in the UK may be on the cautious side, but we have deliberately chosen the Hospital Episode Statistics because they are the most certain. Having said that, rather than debate the statistics, perhaps I may say that not only do I believe that statistics are influenced by different methodologies and definitions but under the circumstances I am happy to offer my noble friend Lord Mitchell the opportunity to put his figures and evidence to the Department of Health, which will be glad to look at them. I notice that he quoted from more recent French figures. That offer goes to all noble Lords who have spoken.

However, I disagree with my noble friend in that we certainly think that we need to take further action. We are not complacent. Our responsibility in government is to reduce the known risks; that means improving the information and support available to all pregnant women, particularly those at greatest risk. Again, I pick up the point of the noble Earl, Lord Listowel. Some of the most vulnerable young women may be binge drinkers; others may be older women who are chronic drinkers. The message needs to be different in each case.

The Department of Health advises women who are pregnant or who are trying to get pregnant to drink no more than one to two units of alcohol a week. Again, that evidence is based on the soundest, most consistent and most independent medical and scientific judgment available. Based on a major review of research studies, it has been standard since 1995 and has not been challenged by the medical establishment. In the absence of any more compelling evidence or any pressure or desire from the medical profession to change this, it remains our current advice. The whole history of the way we make public health policy in this country is that we base it on evidence. If that evidence should change, we would change our working practice.

We try to make sure that this advice reaches pregnant women in ways and places we know it can reach them: face to face in the surgery; with the health visitor; in the home; directly through leaflets called Drinking for Two which are aimed at pregnant women; through women's magazines; through health publications targeted at women and, increasingly, through health websites.

This seems to be getting through to women. The infant feeding survey, which monitors women during pregnancy, was last carried out in 2000. We will do another one next year, so we will look at it again. The survey found that nearly 30 per cent of women gave up drinking entirely during pregnancy and only 1 per cent drank more than 14 units per week—about one and a half bottles of wine. So of the 600,000 live births each year, about 6,000 women fall into that category. That seems to indicate that women are increasingly aware of the risks.

For those women who are already addicted and have serious problems, a range of specialised help is available. They can get help from surgeries, referrals, helplines and specialised treatment services. We are auditing these specialised treatment services to establish how many we have and how many we need.

I should like to focus specifically on what else we intend to do. We are intent on doing more. I have been asked tonight why we do not tell pregnant women not to drink, full stop. Why do we not make the message clearer? Why not target pregnant women? Why not remove the confusion caused by measurements in units?

On the first point, for the message on alcohol and pregnancy to be effective in the face of the weight of the evidence—we know this from all the work we have done on drugs—it must be credible. If we say, "Do not drink", while our scientific evidence says that it is safe to drink one to two units, we would not be believed. We know that once you lose the trust of people whose behaviour you are trying to influence and change, they are likely to dispute the evidence which is sound.

Secondly, why not simply ensure that all alcohol containers carry warnings? The alcohol strategy says quite clearly that we will, completely overhaul the way we present the messages". The DoH is co-ordinating and conducting the review of sensible drinking messages. By next year, we will have a new platform. It is a significant step change in our communications; it covers all government departments, the drinks industry and the voluntary sector. It will look at testing which messages and which media work. It will involve the public in developing these messages, as we have done in other areas. It will consider the different genders and look at how we can target different types of drinkers. We are also looking at better targeting. While we cannot anticipate the outcome, there may well be specific messages targeted on pregnant women and on binge drinkers.

These changes also mean that we will look at how we can spread the message by way of universal and compulsory labelling. We must put this in the European context because we are looking, with Europe, at a whole range of compulsory labelling improvements which may well include alcohol and go beyond what we can say at present. We are looking at how it is possible to move to compulsory messages, and we will take advantage of our EU presidency next year.

In the mean time, we are working with the drinks industry on developing a voluntary labelling scheme. I am delighted that Scottish&Newcastle has come forward voluntarily with a responsible drinking message.

We hope that we can develop the range of messages. We certainly could look at a suite of messages composed for different people, including a message on drinking in pregnancy. I would say to my noble friend Lord Mitchell that we have made it clear in the alcohol strategy that, if the range of industry action we envisage does not have the impact we wish to see, we will assess the need for additional steps.

We are well aware that measuring alcohol in terms of units is not satisfactory. The NAS documents the problem. It is difficult to find an alternative which is scientifically valid and which is also simple; but that is the challenge that the alcohol strategy has set and, yes, if we do decide to stick with units, we will look at how that can be presented in a better way.

As to the question posed by the noble Earl about training and support, it is because it is difficult to diagnose that we are now looking at improving training for doctors. We are looking at a new range of training modules, which will include alcohol and FAS. Crucially, we need to make sure that doctors establish the history of drinking during pregnancy. The Chief Nursing Officer and the Deputy Chief Medical Officer are working as training champions.

We are improving our commissioning framework and the Department of Health is co-ordinating the research strategy. We do need to raise our game. We need to plot, and to fill, the gaps in our knowledge.

In response to the specific question the noble Earl asked, I am sorry that I am not able to go into any detail about what we are doing for these particular children. I would simply say that it is in the context of everything we are doing in schools in terms of emotional literacy, to raise the support and expertise that we put into our schools in relation to children with behavioural difficulties. However, the guidance on the anti-social behaviour orders does say that if an individual has a disability, a practitioner with specialist knowledge should be involved in the assessment process to help establish whether that behaviour is a result of disability and how it should be addressed. It should also look at undiagnosed problems. I would be very happy to write to the noble Earl in that regard.

I am afraid that I now have to finish this rather speedy review, but I feel sure that the public health White Paper will, on the basis of the consultations, put a major emphasis on alcohol, because those problems have been brought to the attention of the Government so forcefully, not least in this debate. I hope that I have given the noble Lord, Lord Mitchell, some room for comfort and some hope that we are indeed taking this very seriously.