Exposição maternal ao álcool e baixo peso ao nascer: revisão sistemática e metanálise

Pereira, Priscilla Perez da Silva; Mata, Fabiana Araújo Figueiredo Da; Figueiredo, Ana Claudia Morais Godoy; Silva, Roberta Borges; Pereira, Maurício Gomes

doi:10.1055/s-0039-1688905

Brazil

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Review Article • Rev. Bras. Ginecol. Obstet. 41 (05) • Maio 2019 • https://doi.org/10.1055/s-0039-1688905 linkcopiar

Exposição maternal ao álcool e baixo peso ao nascer: revisão sistemática e metanálise

Autoria SCIMAGO INSTITUTIONS RANKINGS

Resumo

Objetivo Investigar a associação entre a exposição maternal ao álcool e o baixo peso ao nascer.

Método A busca na literatura ocorreu em janeiro de 2017 nas seguintes bases de dados eletrônicas: Medline, Embase, LILACS, SciELO, Web of Science, Scopus, CINHAL, Proquest, e PsychInfo. A estratégia de busca utilizou os seguintes termos: alcohol drinking, binge drinking, alcohol-related disorders, alcoholism, alcohol addiction/use/ abuse/consumption, light/moderate/social/low drinking, low birthweight, case-control studies, retrospective studies, e cohort studies. Não houve restrição de idioma e ano de publicação. A busca na literatura identificou 2.383 artigos, e depois de analisados conforme os critério de elegibilidade, foram incluídos na revisão sistemática 39 estudos, e 38 estudos foram incluídos na metanálise.

Resultados A amostra foi composta por 497.023 gestantes. O consumo materno de álcool foi associado ao baixo peso ao nascer entre os estudos de coorte retrospectiva (risco relativo [RR] = 1,37; IC [intervalo de confiança] 95%: 1,10-1,77; I2 = 98,4%; p < 0,01). Os estudos de coorte prospectiva (RR = 1,11; IC95%: 0,98-1,25; I2 = 81,5%; p < 0,01) e caso-controle (razão de chances [OR, na sigla em inglês] = 1,16; IC95%: 0,68-1,97; I2 = 61,2%; p = 0,05) não apresentaram associação entre o consumo e o desfecho. Não foi identificado viés de publicação, e a metarregressão mostrou que o tamanho da amostra influenciou a heterogeneidade entre os estudos de coorte prospectiva. Na análise por subgrupo, houve diferenças entre os grupos por tamanho de amostra, por tipo de ajuste e por ano de publicação.

Conclusão Não encontramos associação entre o consumo e o baixo peso ao nascer em todas as análises por subgrupo. Além disso, encontramos alta heterogeneidade entre os estudos primários, e isto se deve possivelmente às diferenças metodológicas na condução destes estudos.

Palavras-chave:
gestante; baixo peso ao nascer; consumo de álcool; revisão sistemática; metanálise

First author, publication year	Country	Study period	Sample size	Association measure OR/RR (95%CI) reported on the article	Type of measure	Methodological quality of the study	Comments
Retrospective cohort
1. Oster et al (2016)³⁶	Canada	2000–2009	28,286	Birthweight 1,500–2,500 g: 1.45 (1.26–1.67);≤ 1,500 g: 1.34 (1.05–1.72)	Adjusted	7	Sample composed only by native people.
2. Irner et al (2014)⁴³	Denmark	1993–1995	164	2.20 (0.76–5.42)	Crude	5	Measure generated through contingency table. Pregnant women who are using substances. Includes multiple pregnancies.
3. Silva et al (2011)⁴⁶	Brazil	2007–2008	957	4.20 (1.25–14.12)	Adjusted	8	Consumption defined by CAGE scale (positive if > 2 points)
4. Gorn et al (2007)²³	Mexico	Not reported	134	Any consumption during pregnancy: 1.90 (0.54–7.00)> 2 times/week: 0.42 (0.13–1.30)Dependence: 1.33.73 (1.1– 12.0)	Crude	5	Women who required help for problems related with alcohol consumption on treatment practices.
5. Okah et al (2005)⁵¹	USA	1990–2002	78,397	0.96 (0.58–1.58)	Adjusted	7	All infants who were born at term gestation and on their mothers over a 13-year period.
6. Bada et al (2005)²⁵	USA	1993–1995	8,637	1 d/w: 1.57 (1.12–2.22);1–3 d/m: 1.17 (0.83–1.65);< 1 d/m: 0.99 (0.79–1.24)	Crude	6	Included women that could have used cocaine, marijuana and opioids.
7. Dičkutė et al (2002)⁴⁵	Lithuania	1995–1998	151,700	10.3 (8.34–12.73)	Crude	7	National database.
8. Maruoka et al (1998)⁵²	Japan	1987–1995	23,132	0.90 (0.74–1.09)	Crude	7	Measure generated through contingency table. Consumption was assumed as more than one drink per month during pregnancy.
9. Faden et al (1997)⁴⁷	USA	1988	15,737	1.02 (1.01–1.04)	Crude	8	Measure from the systematic review by Patra et al³ (n= 10,083)
10. Windham et al (1995)²⁴	USA	1986–1987	1,201	0.1-2 d/w: 0.99 (0.58–1.7);3–5 d/w: 2.5 (1.1–6.0);≥6 d/w: 2.8 (0.77–10.4);> 3 ≥ d/w: 2.6 (1.2-5.8)	Adjusted	7	Telephone interviews on 8^th and 9^th postpartum months. Consumption on 1^st month before pregnancy and 20 first weeks of pregnancy.
11. Lazzaroni et al (1993)¹⁸	Italy	1989–1990	2,145	1–10 g/d: 0.75 (0.22–1.33); 11–20 g/d: 1.38 (0.62–3.75); > 20 g/d: 2.27 (0.86–6.02)	Adjusted	9	Low birhweight < 2,000 g.
12. Primatesta et al (1993)⁵³	Italy and UK	1986–1990	2,512	0.71 (0.50–1.00)	Crude	7	Measure generated through contingency table. In Italy, only a few selected women, mainly of lower social classes.
13. McDonald et al (1992)⁴⁸	Canada	1982–1984	40,445	0.86 (0.79–0.94)	Adjusted	9	Measure from the systematic review by Patra et al.³.
14. Virji (1991)³¹	USA	1980	5,400	1.13 (0.96–1.34);Light: 1.03 (0.84–1.26);Moderate: 1.23 (0.96–1.58);Heavy: 2.66 (1.32–5.38)	Crude	5	Measure generated through contingency table. Data related to white, married mothers giving birth to singletons.
15. Marbury et al (1983)³⁵	USA	1982	12,440	0.89 (0.76–1.04)	Crude	6	Measure from the systematic review by Patra et al.³ Article only reported the consumption measure >14 g/w: 1.1 (0.4–3.4)
Prospective cohort
16. Witt et al (2016)³⁴	USA	2001	9,350	Alcohol use before pregnancy: 1.07 (0.88–1.29);Use on the last trimester:0.88 (0.54–1.42)	Adjusted	8	Only among very low birthweight (< 1,500 g).
17. Bird et al (2016)³⁰	New Zealand	2009–2010	6,822	Alcohol use before pregnancy: < 1 d/w: 0.82 (0.56–1.19);1 d/w: 0.88 (0.49–1.51);≥2 d/w: 0.78 (0.56–1.08);Alcohol use in 1st trimester <1 d/w :0.85 (0.52–1.31); 1 d/w: 0.95 (0.40–1.92); 2 d/w: 0.70 (0.43–1.08).Alcohol use in rest of pregnancy < 1 d/w: 0.70 (0.42–1.11); 1 d/w: 1.05 (0.36–2.38); ≥2 d/w: 0.54 (0.16–1.30)	Crude	7	Interview on the last month of pregnancy.
18. Sbrana et al (2016)⁴⁹	Brazil	2010–2011	1,370	1.62 (1.03–2.54)	Adjusted	9	−
19. Lundsberg et al (2015)³³	USA	1996–2000	4,496	Alcohol use before pregnancy: (n= 4,116) < 0.10 g/d: 0.96 (0.61–1.5); 0.10–0.25 g/d: 0.57 (0.24–1.36); > 0.25 g/d: 0.52 (0.24–1.12);1^st trimester (n= 4,105): 0.78 (0.47–1.31)Use on baseline interview (n= 4,115):0.66 (0.46–0.96); 7^th month (n= 3,726): 0.67 (0.33–1.39);3^rd trimester (n= 3,672):0.56 (0.34–0.94)	Adjusted	9	Interview performed until 1^st month after birth.
20. Strutz et al (2014)⁵⁴	USA	1994–2008	3,014	0.49 (0.14–1.69)	Adjusted	8	Self-reported birth weight.
21. Miyake et al (2014)¹⁹	Japan	2007–2008	1,565	< 10 g/d: 0.98 (0.46–1.85);≥ 10 g/d: 1.31 (0.52–2.84)	Adjusted	8	−
22. Nykjaer et al (2014)²⁹	UK	2003–2006	1,303	Before pregnancy≤ 2 d/w: 0.4 (0.1–2.7);> 2 d/w: 1.1 (0.2–6.1);1^st trimester≤ 2 d/w: 4.6 (1.4–14.7);> 2 d/w:: 3.5 (1.1–11.2) 2^nd trimester≤ 2 d/w: 0.8 (0.3–1.8);> 2 d/w: 0.9 (0.43–2.1);3^rd trimester≤ 2 d/w: 1.0 (0.3–3.2);> 2 d/w:1.0 (0.3–2.9)	Adjusted	9	Consumption was evaluated between 4 weeks before pregnancy until the 12th week of gestation; between weeks 13th to 28th; and between the 29th to 40th weeks of gestation.
23. Jaddoe et al (2007)²⁰	Netherlands	2002–2006	7,141	< 1 d/w: 1.31 (0.87–2.44); 1- 6 d/w: 1.38 (0.66–2.90);> 1 d/d: 4.81 (1.10–21.08)	Adjusted	9	Information about maternal alcohol consumption was obtained by postal questionnaires in early, middle, and late pregnancy.
24. Li et al (2005)⁵⁵	Taiwan	1998–1999	1,128	1.16 (0.39–3.42)	Adjusted	8	−
25. Ruijter et al (1999)⁴²	USA	1996–1997	225	5.15 (1.07–24.80)	Adjusted	5	Only African-Americans
26. Lundsberg et al (1997)²¹	USA	1988–1991	2,714	1^st month≤ 0.10 g/d: 0.79 (0.48–1.28);0.10–0.25 g/d: 0.88 (0.48–1.59);0.25–1.00 g/d: 1.24 (0.66–2.33);≥ 1.00 g/d: 0.93 (0.23–3.72); 7^th month≤ 0.10 g/d: 3.20 (1.87–5.46); 0.10–0.25 g/d: 1.36 (0.48–3.88)	Adjusted	7	−
27. Passaro et al (1996)⁴¹	UK	1991–1992	10,539	0.74 (0.64–0.85)	Crude	6	Measure from the systematic review by Patra et al.³. Limiting analysis to exclude users of marijuana, crack, and cocaine, and excluding women with a history of alcoholism.
28. Olsen et al (1991)²⁶	Denmark	1984–1987	11,698	1 g/w: 1.0 (0.7–1.3); 30 g/w: 1.0 (0.7–1.5); 60 g/w: 0.9 (0.5–1.5); 90 g/w: 0.9 (0.5–2.5); >120 g/w: 2.7 (1.5–4.8)	Adjusted	9	Information collected on 36^th gestational week.
29. Day et al (1989)⁴⁰	USA	Not reported	650	1.46	Crude	5	Did not report 95%CI
30. Brooke et al (1989)²⁸	UK	Not reported	1,513	1–19 g/w: 1.037 (1.02–.05); 20–49 g/w: 1.032 (1.02–1. 05);50–99 g/w: 1.02 (0.99 to 1.05);> 100 g/w: 1.00 (0.96–1.04)	Crude	7	Only White women. Interviews performed on the 28^th and 36^th gestational weeks.
31. Little et al (1986)³⁹	UK	1979–1980	144	8.70 (2.18–34.72)	Crude	5	Measure of systematic review by Patra et al.³ Sample of white women, aged 19–35 years, athletes, low middle class, non-smoker, non-alcoholic, good health and with the first prenatal visit until the 16th gestational week.
32. Lumley et al (1985)⁵⁰	Australia	1981–1982	10,319	1.04 (0.88–1.23)	Crude	7	Measure from the systematic review by Patra et al.³ All Tasmanian births.
33. Mills et al (1984)³⁷	USA	1974–1977	31,503	1.20 (1.09–1.32)	Crude	6
34. Grisso et al (1984)³⁸	UK	1972–1973	1,256	0.95 (0.56–1.63)	Crude	5	Measure from the systematic review by Patra et al.³ Survey mailed to participants. Group from a previous randomized trial regarding smoking.
35. Sokol et al (1980)¹⁷	USA	Not reported	12,127	1.89 (1.47–2.43)	Crude	5	Only white women, including Latin American.
Case-control
36. Márquez et al (2011)⁴⁴	Cuba	2007–2008	84	20.76 (1.08–400.49)	Crude	3
37. Jackson et al (2007)³²	South Africa	2002–2003	400	Some use during pregnancy:1.38 (0.37–5.13);current drinking: 2.15 (1.37–3.39);CAGE score > 2: 1.28 (0.59–2.79)	Adjusted	7
38. Mariscal et al (2006)²²	Spain	1998–2002	2,003	Alcohol consumption1–5.9 g/d: 0.64 (0.46–0.88);6–11.9 g/d: 0.92 (0.52–1.62);> 12 g/d: 1.56 (0.91–2.69);Type of beverage:Beer only: 0.59 (0.35–1.00);Wine only: 0.88 (0.64–1.22);Spirits only: 0.89 (0.34–2.35);Other patterns: 0.84 (0.46–1.53);On weekdays during pregnancy:1–11.9 g/d: 0.96 (0.44–2.06)> 12 g/d: 2.67 (1.39–5.12)	Adjusted	7
39. Borges et al (1993)²⁷	Mexico	1988	1,372	Alcohol during pregnancy: 1.32 (0.85–2.06)Alcohol frequency last year: > once a month 1.17 (0.79–1.72); once a month 0.66 (0.32–1.37); 2–3 t/m: 0.79 (0.33–1.94); 1–2 t/w: 1.72 (0.81–3.67); ≥ 3 to 4 t/w: (0.17–3.34)Grams of alcohol0.01–1,800 g/y: 1.04 (0.73–1.50);1,800.01–3,600 g/y: 0.61 (0.18–2.08);≥ 3600.01 g/y: 1.28 (0.61–2.65)Drunkenness frequency last year: Never: 0.90 (0.63–1.31);1 to 7 t/y: 1 0.97 (1.09–3.56);once a month and more often: 2.45 (0.46–12.88);Alcohol drinking pattern: Infrequent: 1.17 (0.77–1.77); Less frequent, low maximum: 0.55 (0.27–1.14); Less frequent, high maximum: 1.30 (0.68–2.49); Frequent, low maximum: 1.13 (0.42–3.03); Frequent, high maximum: 1.20 (0.40–3.65); Frequent, heavy drinker: 4.21 (0.90–19.74); Alcohol dependency: 16.29 (1.65–160.9)	Adjusted	5	Household survey. Self-reports of alcohol consumption in the last 12 months.

Variable	Groups	Number of studies/participants	RR (95%)	I² (%)	Number of studies/participants	RR (95%)	I² (%)	Number of studies/participants	OR (95%)	I² (%)
		Retrospective cohort n= 15			Prospective cohort n= 19			Case-control n= 4
Sample size	< 1,000	3 /1,255	2.46 (1.28–4.74)	<1	2 /369	6.92 (2.45–19.55)	<1	2 /484	3.82 (0.29–50.01)	68.8
	≥ 1,000	12 / 370,032	1.31 (1.04–1.63)	98.7	17 / 120,858	1.08 (0.97–1.21)	81.0	2 / 3,375	1.01 (0.64–1.58)	62.8
Type of measure	Crude	9/ 219,856	1.45 (1.08–1.96)	99.0	8/ 33,780	1.13 (0.95–1.35)	91,1	1/ 84	20.75 (1.08–400.49)	−
Type of measure	Adjusted	6/ 151,437	1.24 (0.88–1.72)	90.1	11 / 84,447	1.08 (0.91–1.29)	44.2	3/ 3,775	1.02 (0.70–1.47)	43.6
Methodologic quality	High	10/ 330,793	1.36 (0.96–1.92)	98.4	13/ 62,433	1.08 (0.95–1.21)	61.5	2/ 2,403	0.84 (0.66–1.08)	<1
	Average	5/ 26,775	1.26 (0.90–1.77)	93.1	6/ 55,794	1.38 (0.93–2.03)	92.1	1/ 1,372	1.32 (0.85–2.05)	−
	Low	−	−	−	−	−	−	1/ 84	20.75 (1.08–400.49)	−
Year of publication	2010–2016	3 / 29,407	1.80 (1.05–3.10)	42.8	7 / 27,920	0.89 (0.65–1.21)	52.6	1 / 84	20.75 (1.08–400.49)	−
	2000–2009	4 / 238,868	2,38 (0,62–8,17)	99.0	2 / 8,269	1.32 (1.00–1.74)	<1	2 / 2,403	0.84 (0.66–1.08)	<1
	1990–1999	7/ 90,572	0.97 (0.87–1.09)	74.9	4/ 27,176	1.00 (0.75–1.33)	84.5	1/ 1,372	1.32 (0.85–2.05)	−
	1980–1989	1 / 12,440	0.89 (0.76–1.04)	−	6 / 56,862	1.32 (1.08–1.60)	90.7	−	−	−
Region	America	10 / 191,643	1.17 (0.97–1.43)	97.8	8 / 64,799	1.17 (0.92–1.48)	78.2	2 / 1,456	3.49 (0.26–46.13)	69.3
Region	Europa	4 / 156,521	2.11 (0.38–11.65)	98.3	7 / 33,594	1.05 (0.86–1.28	82.2	1 / 2,003	0.83 (0.65–1.06)	−
	Asia	1 / 23,132	0.90 (0.74–1.09)	−	2 / 2,693	1.11 (0.68–1.80)	89.6	−	−	−
	Oceania	−	−	−	2/ 17,141	1.03 (0.54–1.97)	<1	−	−	−
	Africa	−	−	−	−	−	−	1 / 400	1.38 (0.37–5.13)	−

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