AQUA Study Stage 1: Pregnancy to 24 months

Participants chose up to five types of alcoholic drink from a list of pictures of different drink sizes and types and nominated how often they would usually drink these. Researchers then converted the choices into a number of standard drinks consumed per week.

For example, a small 100ml glass of wine or a stubby of mid strength beer are equivalent to 1 standard drink. A glass of champagne would typically be 1.4 standard drinks.

‘Low’ level pregnancy alcohol consumption was classified as no more than 2 standard drinks per occasion or up to 7 drinks per week. ‘Moderate’ pregnancy drinking was 3-4 standard drinks per occasion, and still a maximum of 7 per week.

More than 7 drinks per week was classified as ‘high’ level pregnancy drinking and if a woman consumed 5 or more standard drinks at a time, this was considered to be a ‘binge’ episode. 

What have we found?

Of the 1,570 women who completed all this information, 41.3% did not drink alcohol at all while they were pregnant. Almost one-third drank alcohol in the first trimester only, most of whom stopped as soon as they found out that they were pregnant. A similar number of women drank alcohol at some level throughout their pregnancy, around half of whom never drank more than at low or moderate levels.

Women who drank alcohol throughout their pregnancy tended to be in their early to mid-thirties, smoke, have a higher income and were well educated.

Overall, almost one in five women (18.5%) who had binge episodes told us that this was on a special occasion.

Women who told us they had their first alcohol intoxication before they were 18 old were much more likely to drink in pregnancy and have binge episodes early in pregnancy.

What does this mean?

It is important to know about these common drinking patterns. It helps researchers, health professionals and policy makers to develop more meaningful and directed health messages on abstaining from alcohol in pregnancy. We have published our findings in a public health journal and continue to use these detailed pregnancy alcohol consumption patterns to look at any effects on the child.  

The outcome researchers are looking at in this study is facial shape. This is because the face of a child can look quite different after heavy alcohol exposure in the womb. While this doesn’t happen all the time, doctors can use the characteristics of this facial shape to help diagnose whether the child has Fetal Alcohol Syndrome or Fetal Alcohol Spectrum Disorder. In these situations, doctors look for changes in facial shape around the eyes, nose and mouth.

518 AQUA study mothers brought their child to the Royal Children’s Hospital to have a 3D photo taken around the time of their first birthday.

Our main outcome of interest in terms of facial imaging was to see whether different patterns of alcohol consumption in pregnancy are associated with the development of facial shape.

What have we found so far?

In 2017, we finished examining the images of children's faces at one-year-old and compared the facial shape of children whose mothers consumed no alcohol at all while pregnant with those whose mothers consumed some alcohol. 

We saw subtle changes to the mid-face, the nose, lips and eyes–of babies who were exposed to any amount of alcohol from the first trimester of pregnancy. The changes were only small, less than 2mm, and are not visible to the naked eye, seen only by innovative computer modelling. This is an interesting finding because children who are diagnosed with Fetal Alcohol Spectrum Disorder have larger visible changes in these same mid-face regions.

Our findings show that when analysing the detailed images in our study, any alcohol in pregnancy, even low amounts, can subtly influence how the face is formed in the womb. We have now published these findings in a scientific journal so that other researchers working in this area can benefit from this new knowledge.

What does this mean?

Our study shows that alcohol in pregnancy can subtly influence the way a baby’s face is formed in the womb. This does not mean that unborn babies have been harmed if the mother consumed some alcohol while pregnant. We don’t know if the small changes in the children’s facial shape are connected in any way to differences in their development, and we plan to look at this as the children grow. 

What will we do next?

We are now looking whether the changes we observed in facial shape are associated with child development. For this, children completed a developmental assessment with a psychologist at two years of age and outcomes from this stage of the study can be viewed below. 

482 children also had 3D photographs taken of their face and head as they turned 6-7 years of age between 2018-2019. These children also completed a developmental assessment. We are currently looking at this information and will publish our findings in the coming year. 

What else have we found when studying children’s facial shape?

While doing this research, we found that even though it is not as obvious as in older children, the faces of boys look different from the faces of girls, even at 12 months. The difference was mainly seen in the forehead and around the cheeks. It had not documented before this and we published this finding in a scientific journal in 2016.

Child development is the main study outcome of AQUA. To date, we have information on the children when they were one, two and six to seven years old.

85% of mothers in the study provided extensive information on their child’s health and development on the questionnaires sent at one and/or two years of age. 564 mothers also brought their two-year-old child to the Royal Children’s Hospital for a clinical developmental assessment, which looked at thinking, reactions, learning, recognition of sounds and words, communication and body movement. A child psychologist did these assessments.

What have we found?

Many aspects of the mother’s pregnancy, the child’s early health and their family environment influence a child’s learning and behaviour, especially in the early years. We looked at all these factors carefully and found that the development of the two-year-old AQUA children was the same whether they were exposed to alcohol before birth. There were some differences in one aspect of toddler behaviour. Mothers of children exposed to binge drinking early in pregnancy were more likely to report that their child used disruptive behaviours, such as temper tantrums, when trying to cope with stressful situations.

What does this mean?

We think that follow up to two years may not be long enough to detect any differences in child development, as they may not be apparent until the children start school and have to develop more complex social, academic and physical abilities, like fitting in with their peers and classroom routine, physical education, or literacy and numeracy skills. 

Between June 2018 and April 2021, we collected detailed information about the children as they turned 6-8 years old. Analysis for the information collected during this time is underway and findings will soon be published. 

• AQUA Stage 2: Early school age (AQUA 6)

95% of women in the study gave us a sample of their cheek cells to study genes associated with how alcohol is metabolised. When the women in AQUA filled in their first questionnaire, we also asked if they generally felt the effects of alcohol slowly, normally or quickly. We are interested to see if this information could be related to alcohol metabolism. It may be that in mothers who metabolise alcohol quickly, the baby is exposed to lower levels or for a shorter period of time.

Many AQUA participants also gave us permission to collect samples from their placenta, umbilical cord, or their baby’s cheek cells. Our study midwives attended as many births as possible and mothers also sent us cheek swabs from their baby where we missed the birth. We have over 200 placenta and cord blood samples and around 730 cheek swabs from babies in the AQUA study. In the cheek swabs of babies, we have been studying a process called DNA methylation. DNA methylation regulates whether or not particular genes are being used. This is important in growth and development as not all the thousands of genes we have are always active in every cell of our body all of the time.

What have we found?

In mothers so far, we looked at 59 DNA coding changes in and around genes that are involved in metabolising alcohol and are in the process of analysing whether any of them might have influenced the drinking patterns of pregnant women. For example, we found one genetic marker more likely to be present in women who feel the effects of alcohol slowly than in women who feel the effects quickly. We are planning further study to understand what this means.

In the placenta of babies, we have studied the overall methylation across the genome to see if levels might be changed by alcohol consumption. We found that in boys, overall methylation levels were different when alcohol had been consumed, but in girls there was no difference. This means that alcohol exposure changes the activity of some genes in the placenta for boys. We now need to look at these findings more in-depth, because changes in gene activity can influence later health and development. 

What will we do next?

We have a lot of work left to do in our study of genes and DNA methylation in mothers and babies. We aim to include quick or slow metabolism of alcohol when we look at alcohol effects on the child, but we have not finalised which genes might be important.

427 children provided a cheek swab as part of the AQUA at 6. We now plan to study the same genes we looked at in mothers, because the baby also helps to clear alcohol from their body, especially later in pregnancy when their organs are quite developed. 

Good nutrition during pregnancy is important for the development of a healthy baby. The need for certain nutrients, such as iron, iodine and folate is increased at this time, and many women take extra vitamin supplements.

We asked all participants about their diet with a Food Frequency Questionnaire and also if they were taking any vitamin supplements, such as folate, and when they started taking these. We will take this information into account when we look at any possible effects of drinking alcohol on the baby’s development.

What have we found?

Over half of women were taking supplements before pregnancy and almost all women took some when they were pregnant (91%). Mostly these were multivitamins, but many women also took Vitamin D and/or iron later in pregnancy. Women who planned their pregnancy were more likely to take pregnancy-specific multivitamins or folate preparations in the 3 months before they became pregnant. We also took into account any vitamins and minerals from the women’s diet as well as any supplements taken. Here, we found that even though many women increased their iron intake over the course of their pregnancy, 70% of pregnant women did not reach the recommended dietary intake for this nutrient by the third trimester.

What will we do next?

We have published these findings in a public health nutrition journal because it is important for midwives and doctors to know whether pregnant women consume enough micronutrients for their health and wellbeing, as well as that of their baby. We also looked further into the diet of pregnant women and compared this to the Australian Dietary Guidelines recommendations to better understand what women in Australia eat. This has given us important information to take into account when looking at possible effects of pregnancy alcohol consumption on the child (as some nutrients and diet types may lessen any harm). It will also help target healthy-eating programs to positively change food choices.