European Journal of Clinical Nutrition (2006) 60, 1062–1066

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ORIGINAL ARTICLE
Alcohol drinking and risk of small for gestational age
birth
F Chiaffarino1, F Parazzini1,2, L Chatenoud1, E Ricci2, F Sandretti2, S Cipriani1, D Caserta3 and
L Fedele2

1
Istituto di Ricerche Farmacologiche ‘Mario Negri’, Milano, Italy; 2II Clinica Ostetrico Ginecologica, Università di Milano, Milano, Italy
and 3Dipartimento di Scienze Ginecologiche, Università La Sapienza, Rome, Italy

Objective: To assess if alcohol drinking is a risk factor for small for gestational age (SGA) birth.
Methods: Case–control study. Cases were 555 women (mean age 31 years, range 16–43) who delivered SGA babies at the
Clinica Luigi Mangiagalli and the Obstetric and Gynecology Clinic of the University of Verona. The controls were 1966 women
(mean age 31 years, range 14–43) who gave birth at term (X37 weeks of gestation) to healthy infants of normal weight at the
hospitals where cases had been identified.
Results: No increase in the risk of SGA birth was observed in women drinking one or two drinks/day in pregnancy, but three or
more per day increased the risk: odds ratios (OR) were 3.2 (1.7–6.2) for X3 drinks during the first trimester, 2.7 (1.4–5.3) during
the second and 2.9 (1.5–5.7) during the third.
Conclusions: The study shows an increased risk of SGA births in mothers who drink X3 units/day of alcohol in pregnancy.
European Journal of Clinical Nutrition (2006) 60, 1062–1066. doi:10.1038/sj.ejcn.1602419; published online 22 February 2006

Keywords: small for gestational age birth; alcohol; case–control study

Introduction during 1988–1991, light or mild alcohol consumption

Maternal alcohol abuse during pregnancy has been consis-
tently associated with reduced birth weight (IARC, 1988).
However, despite its clinical significance, the effect of
moderate alcohol drinking in pregnancy on the risk of small
for gestational age (SGA) birth is controversial (Day et al.,
1989; Shu et al., 1995; Windham et al., 1995; Passaro et al.,
1996).
In an American prospective study based on 633 women, a
marked increase in the frequency of SGA births was noted
with increased alcohol intake, rising to 27% among heavy
drinkers (daily average of more than 45 ml of absolute
alcohol) (Oulette et al., 1977). However, other studies
reported a protective effect of low–moderate alcohol con-
sumption on SGA birth risk. In a prospective investigation
based on 2714 singleton live births conducted in the USA
Correspondence: Dr F Parazzini, Istituto di Ricerche Farmacologiche ‘Mario
Negri’, Via Eritrea, 62 20157 Milano, Italy.
E-mail: parazzini@marionegri.it
Received 11 April 2005; revised 21 December 2005; accepted 11 January
2006; published online 22 February 2006
during the first month of pregnancy was associated with a
significant protective effect against SGA babies (Lundsberg
et al., 1997). Likewise, in a Canadian survey, light consumers
of alcohol had a small but significant reduction in the risk of
SGA birth relative to total abstainers (McDonald et al., 1992).
Other studies have found no effect of alcohol intake on SGA
births risk. (Sulaiman et al., 1988; Faden and Graubard,
1994). Also unclear is the potentially different role of alcohol
drinking before pregnancy or in the different trimesters.
We analyzed the association between alcohol drinking
before and during the three trimesters of pregnancy using
data from a case–control study conducted in Italy. This study
provides the opportunity to analyze the effect of alcohol
intake on the risk of SGA birth, preterm or at term, and the
potential interaction between alcohol drinking and risk
factors for SGA birth. A specific point of interest is that the
study analyzes the association between alcohol drinking and
SGA birth in a Southern European population, where
moderate alcohol drinking is more widespread than in North
American or European populations, where there may be a
lower prevalence of drinkers, but a higher frequency of heavy
drinkers.

Materials and methods
We conducted a case–control study on risk factors for SGA
birth from February 1989 to October 1999. Cases were 555
women (mean age 31 years, range 16–43) who delivered SGA
babies at the Clinica Luigi Mangiagalli (the largest obstetric
hospital in Milan) and the Obstetric and Gynecology Clinic
of the University of Verona. Small for gestational age was
defined as birth weight less than the 10th percentile for the
infant’s gestational age in comparison with the birth weight
expected for the same gestational age and sex, according to
Italian standards (Parazzini et al., 1995); 143 births were
preterm SGA and 412 at term.
The controls were women who gave birth at term (X37
weeks of gestation) to healthy infants on randomly selected
days at the hospitals where cases had been identified.
The interviewers surveyed the obstetric wards on days
established at random to interview controls whose age was
comparable with cases. Cases and controls were not matched
for age, but the interviewers were instructed to select
controls comparable with cases for quinquennia of age.
A total of 1966 controls (mean age 31 years, range 14–43)
were interviewed.
Each control was interviewed within 1 month the case was
interviewed.
Overall participation rate was over 95% for cases and
controls.
Among the cases surveyed, no fetal alcohol syndrome was
observed.
Information was obtained on general socio-demographic
habits, personal characteristics and habits, gynecological and
obstetric history, smoking and alcohol consumption in
pregnancy.
Data on nausea in pregnancy were collected for each
trimester of pregnancy in terms of intensity (none, low,
moderate or serious) but only for 286 cases (51.5%) and 1232
controls (62.7%) because this information was only collected
from 1993. We defined gestational hypertension as diastolic
pressure above 90 mm Hg on at least two occasions 24 h
apart, without proteinuria. The presence of hypertension in
pregnancy was checked with clinical records.
Specific attention was paid to obtaining information from
cases and controls on alcohol consumption at conception
and during the trimesters of pregnancy. Questions on
alcohol included the number of days per week each type of
alcoholic beverage (red and white wine, beer and spirits) was
consumed before pregnancy and in each trimester, the
average number of drinks per day and the duration of the
habit in years. From these data, we estimated the total daily
average alcohol intake assuming a comparable pure alcohol
content in each type of drink (125 ml red wine ¼ 333 ml
beer ¼ 30 ml spirits ¼ B12 g pure alcohol). Wine alone ac-
counted for B90% of the alcohol consumed by women in
this population. All information, apart from birth weight
and week of gestation at birth, were obtained from personal
interview.
Alcohol drinking and risk of small for gestational age birth
F Chiaffarino et al
1063
To account simultaneously for the effects of several
potential confounding factors, we used conditional multiple
logistic regression (age as matching variable), with max-
imum likelihood fitting, to obtain odds ratios (OR) and their
corresponding 95% CI (Breslow and Day, 1980). Included in
the regression equations were terms for education, plus
terms significantly associated in this data set with the risk of
SGA birth. These factors are listed in the footnotes to tables.
Results
Table 1 shows the distribution of cases and controls
according to age, gestational week at birth and selected
factors. Smoking during the first trimester of pregnancy,
history of SGA birth and gestational hypertension increased
the risk of SGA birth. Parous women and women with
maternal body mass index (BMI) at conception between 21
and 25 kg/m2 were at lower risk.
No significant association emerged between marital status
and risk of SGA birth. Likewise, no association emerged
between coffee intake in the third trimester of pregnancy
and risk of SGA birth. In comparison with women without
nausea, the OR of SGA birth was 0.8 (95% CI 0.6–1.1) in
women with nausea in the first trimester.
Alcohol use before pregnancy and in the three trimesters
of pregnancy and risk of SGA birth are considered in Table 2.
When pregnancy was confirmed, women tended to stop
drinking, the prevalence of non-drinkers in the control
group rising from 54.6% before pregnancy to 66.0% in the
first trimester.
Small for gestational age births were more common among
women reporting three or more drinks/day during preg-
nancy: the OR was 3.2 (95% CI 1.7–6.2) for three or more
drinks/day during the first trimester, 2.7 (95% CI 1.4–5.3)
during the second and 2.9 (95% CI 1.5–5.7) during the third.
No association emerged between SGA birth risk and lower
levels of alcohol drinking.
Table 3 considers the effect of alcohol drinking on the risk
of SGA birth during the third trimester of pregnancy in strata
of selected covariates. No appreciable heterogeneity or effect
modification was found across strata of maternal age,
education, parity and gestational hypertension and smoking,
although the association was apparently stronger for smo-
kers, where the OR tended to be higher.
Discussion
Potential limitations of this study should be considered. The
choice as controls of women who delivered healthy infants
only at term may have introduced some bias. However, when
we considered only cases who delivered after 37 weeks’
gestation, no differences emerged in the OR. In fact, the OR
of SGA birth after 37 weeks’ gestation in comparison with
non-alcohol drinkers were, respectively, 0.9 (95% CI 0.6–
European Journal of Clinical Nutrition
 Alcohol drinking and risk of small for gestational age birth
F Chiaffarino et al
1064
Table 1 Distribution of 555 cases of SGA birth and 1966 controls according to selected factorsa

SGA Controls OR (95% CI)

Age (years)
o25 60 (10.8) 180 (9.2)
25–29 176 (31.7) 637 (32.4)
30–34 207 (37.3) 767 (39.0)
X35 112 (20.2) 382 (19.4)

Gestational week at birth (mean range) 37.4 (28–43) 39.6 (37–44)

Education (years)
o6 24 (4.3) 53 (2.7) 1b
7–13 415 (74.8) 1439 (73.2) 0.8 (0.4–1.4)
414 116 (20.9) 473 (24.1) 0.7 (0.4–1.4)

Marital status
Married 541 (97.5) 1934 (98.4) 1b
Unmarried 14 (2.5) 32 (1.6) 1.2 (0.6–2.4)

Parity
0 404 (72.8) 1103 (56.1) 1b
1 118 (21.3) 693 (35.3) 0.4 (0.3–0.5)
X2 33 (6.0) 170 (8.7) 0.4 (0.2–0.6)

Smoking during the third trimester of pregnancy

No 414 (74.6) 1711 (87.0) 1b
Yes 141 (25.4) 255 (13.0) 2.4 (1.9–3.1)

Coffee consumption during the third trimester of pregnancy

No 226 (40.7) 750 (38.2) 1b
Yes 329 (59.3) 1216 (61.9) 0.9 (0.7–1.1)

Previous SGA birthc

No 133 (88.1) 853 (98.8) 1b
Yes 18 (11.9) 10 (1.2) 10.6 (4.6–24.1)

Maternal BMI at conception (kg/m2)

p20 255 (46.2) 776 (39.6) 1b
21–25 248 (44.9) 982 (50.1) 0.7 (0.6–0.9)
425 49 (8.9) 201 (10.3) 0.7 (0.5–1.0)

Hypertension in pregnancy
No 435 (78.4) 1863 (94.8) 1b
Yes 120 (21.6) 103 (5.2) 5.1 (3.8–6.9)

Nausea during the first trimester of pregnancy

No 126 (44.1) 441 (35.8) 1b
Yes 160 (55.9) 791 (64.2) 0.8 (0.6–1.1)

Abbreviations: BMI, body mass index (kg/m2); CI, confidence interval; OR, odds ratios adjusted in turn for education, parity and smoking during the third trimester
of pregnancy, gestational hypertension, history of SGA birth; SGA, small for gestational age.
a
In some cases, the sum does not add up to the total because of some missing values.
b
Reference category.
c
Parous women only.

1.2), 1.2 (95% CI 0.8–1.8) and 2.9 (95% CI 1.4–6.1) for
women drinking one, two, and three or more portions of
alcohol a day in the third trimester of pregnancy (data not
shown). More in general, the interest of this analysis was to
define the effect of alcohol consumption on the risk of SGA
birth in comparison with normal pregnancies, and the
inclusion in the control group of women with adverse
pregnancy outcomes (i.e. preterm birth) potentially related
to alcohol drinking might spuriously affect the potential
relation between alcohol and SGA.
Information on alcohol drinking was retrospectively
collected after delivery. The assessment of alcohol consump-
tion was based on self-reporting, so some underestimates
could have occurred. However, in Italy, alcohol consumption
is socially accepted and recommendations to avoid alcohol
in pregnancy have not received widespread attention and are
not routinely advocated by gynecologists. Good reporting of
alcohol intake at post partum interview by women deliver-
ing normal or low birth weight infant has been documented
(Delgado-Rodriguez et al., 1995).

European Journal of Clinical Nutrition

 Alcohol drinking and risk of small for gestational age birth
F Chiaffarino et al
1065
Table 2 OR of SGA birth according to alcohol drinkinga Table 3 OR of SGA birth according to alcohol drinking during the third
trimester of pregnancy and selected covariatesa
SGA Controls OR (95% CI)
No. (%) No. (%) Alcohol drinking during the third trimester of pregnancy (units/day)

1 2 X3
Alcohol drinking before conception (Units/day)
0 303 (54.6) 1132 (57.6) 1b
0.5 60 (10.8) 245 (12.5) 0.9 (0.7–1.3) Maternal age (years)
1 97 (17.5) 333 (16.9) 1.1 (0.8–1.5) p30 0.9 (0.6–1.5) 1.7 (0.9–3.0) 2.1 (0.8–5.2)
2 69 (12.4) 207 (10.5) 1.2 (0.9–1.7) X31 0.8 (0.6–1.3) 0.8 (0.4–1.3) 5.1 (1.8–14.5)
X3c 26 (4.7) 49 (2.5) 1.7 (1.0–2.9)
Education (years)
First trimester p11 0.8 (0.5–1.3) 1.5 (0.8–2.8) 3.0 (1.0–8.5)
0 366 (66.0) 1345 (68.4) 1b X12 0.9 (0.6–1.4) 0.9 (0.5–1.6) 3.0 (1.2–7.4)
0.5 63 (11.4) 187 (9.5) 1.1 (0.8–1.6)
1 65 (11.7) 281 (14.3) 0.9 (0.6–1.2) Parity
2 38 (6.9) 131 (6.7) 1.1 (0.7–1.7) 0 0.8 (0.6–1.2) 1.1 (0.7–1.9) 2.1 (0.9–5.1)
X3c 23 (4.1) 22 (1.1) 3.2 (1.7–6.2) X1 1.0 (0.6–1.6) 1.0 (0.5–1.9) 4.3 (1.5–12.1)

Second trimester Smoking during 3rd trimester

0 371 (66.9) 1353 (68.8) b
1 No 0.8 (0.6–1.2) 1.0 (0.7–1.7) 2.0 (0.9–4.8)
0.5 61 (11.0) 190 (9.7) 1.1 (0.8–1.5) Yes 1.1 (0.6–2.0) 1.2 (0.5–2.6) 7.6 (1.8–32.2)
1 66 (11.9) 273 (13.9) 0.9 (0.7–1.2)
2 38 (6.9) 127 (6.5) 1.1 (0.7–1.7) Gestational hypertension
X3d 19 (3.4) 23 (1.2) 2.7 (1.4–5.3) No 0.9 (0.6–1.2) 1.1 (0.7–1.7) 3.2 (1.6–6.2)
Yes 0.9 (0.4–2.1) 0.8 (0.2–3.3) 1.2 (0.1–23.9)
Third trimester
0 372 (67.0) 1319 (67.1) 1b Reference category: no alcohol drinking.
a
0.5 58 (10.5) 204 (10.4) 0.9 (0.7–1.3) Adjusted in turn for age, education, parity, smoking during the third trimester
1 68 (12.3) 292 (14.9) 0.8 (0.6–1.2) of pregnancy and gestational hypertension.Abbreviation: OR, odds ratio.
2 38 (6.9) 129 (6.6) 1.1 (0.7–1.6)
X3d 19 (3.4) 22 (1.1) 2.9 (1.5–5.7)

Abbreviations: CI, confidence interval; OR, odds ratios adjusted in turn for
education, parity and smoking during the third trimester of pregnancy,
gestational hypertension, history of SGA birth; SGA, small for gestational age.
a
In some cases, the sum does not add up to the total because of some missing
values.
b
Reference category.
c
Women drinking 10 Units/day or more: two cases of SGA and four controls.
d
Women drinking 10 Units/day or more: one case of SGA and two controls.
Other sources of bias, including selection or confounding
factors, are unlikely to have produced marked effects,
especially considering that cases and controls were inter-
viewed in the same institution and that participation was
practically complete. Further, the findings were largely
consistent when the analysis was run separately for cases
and controls collected in the two hospitals or by different
interviewers or when the models included terms for center
and interviewers (data not shown). Finally, the questionnaire
was satisfactorily reproducible (D’Avanzo et al., 1997).
We did not analyze information on nutritional status, but
inclusion of BMI in the model did not change the estimated
OR (data not shown).
Our study suggests that there is no risk of SGA birth when
one or two drinks a day are taken, and that there is, at most,
an effect at higher levels. These findings are in general
agreement with other studies, but some differences in the
study design and in the definitions of alcohol consumption
make the results difficult to compare.
In a British cohort study, infant born to women who
reported three or more drinks daily had an adjusted mean
birth weight approximately 150 g less than those whose
mothers abstained during pregnancy. No effect was seen in
infants born to women who drank weekly in early preg-
nancy, less than weekly or not at all (Passaro et al., 1996).
Shu et al. (1995) found that alcohol consumption in the
first trimester (average four drinks per week) was associated
with a 155 g reduction in fetal weight, even after adjustment
for number of cigarettes smoked. In a recent US survey of
women who delivered a live infant (Whitehead and
Lipscomb, 2003), SGA births were more common among
moderate (4–13 drinks/week) and heavy (14 or more drinks/
week) drinkers during the last 3 months than non-drinkers.
Smoking and drinking three or more drinks/day during the
third trimester have a marked effect on SGA birth. Some
other studies showed an association between alcohol intake
and smoking, and the effect of smoking on birth weight was
independent of but additive with the effect of alcohol. In a
Californian study on 1233 women, moderate drinkers (X3
drinks/week) who also smoked more than half a pack/day
had a greater weight decrement than was expected on the
basis of additivity of effects (Windham et al., 1995). In a
population-based case–control study in New York on 701
cases of SGA birth, smoking increased the risk of SGA birth,
which was even greater for heavy alcohol consumption
(Yang et al., 2001).
The biological mechanism through which alcohol drink-
ing affects fetal growth is not completely understood.
Alcohol or its metabolites may affect fetal development by
causing hypoxia, impairing cell proliferation or affecting

European Journal of Clinical Nutrition

 Alcohol drinking and risk of small for gestational age birth
F Chiaffarino et al
1066
placental development (Abel, 1982). The effects of moderate
maternal alcohol consumption may be multifactorial, and
the combined effects with other environmental and genetic
factors may increase the risk for SGA birth. Smoking may be
one of these factors.
In conclusion, the study shows an increased risk of SGA
births only in mothers who drink three units/day or more of
alcohol in pregnancy.
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