Fetal Alcohol Syndrome

1
Fetal Alcohol Syndrome

• Fetal alcohol syndrome is among the most commonly
  known causes of mental retardation and is a major
  public health problem. What is it, how does it
  affect people, what can we do about it? These are
  the issues that will be discussed in this
  lecture.

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Historical view of alcohol as a teratogen

• Foolish, drunken, or harebrain women most often
  bring forth children like unto themselves
  Aristotle in
  Problemata
• Behold, thou shalt conceive and bear a son And
  now, drink no wine or strong drink.
• Judges 137

Rosett, 1984
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Drug Dependence Chronic Illness(not acute
illness or a moral failing)

• Genetic heritability, personal choice, and
  environmental factors are comparably involved in
  etiology and course
• Drug dependence produces significant and
  long-term changes in organ pathophysiology
• Effective treatments (education, counseling,
  medication) are available (and often
  underutilized)
• Medication adherence and relapse risks are
  similar
• (McLellan AT, et. al. JAMA 20002841689-1695)

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Fetal Alcohol Syndrome

• Specific pattern of facial features
• Pre- and/or postnatal growth deficiency
• Evidence of central nervous system dysfunction

Photo
courtesy of Teresa Kellerman
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FAS Only the tip of the iceberg

• Fetal alcohol syndrome
• Fetal alcohol effects
• Clinical suspect but appear normal
• Normal, but never reach their potential

Adaped from Streissguth
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Incidence of FAS (rates per 1000)

• Alaska 0.2 non AI/AN
• 3 AI/AN
• Aberdeen 2.7 AI/AN
• BDMP 0.7
• Atlanta 0.1
• 0.3 full partial
• IOM 0.6-3 IOM 2 - 8.5
  AI/AN

• Seattle 2.8
• Cleveland 4.6
• Roubaix 1.3-4.8
• Seattle
• (FAS and ARND) 9.1
• South Africa (Wellington) 48

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Facies in Fetal Alcohol Syndrome
Streissguth, 1994
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Growing up with FAS
Courtesy of Ann Streissguth
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Brain damage resulting from prenatal alcohol
photo Clarren, 1986
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Change in brain size
Cerebrum
Cerebellum
Corpus Callosum
Mattson et al., 1994
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Corpus callosum abnormalities
Mattson, et al., 1994 Mattson Riley, 1995
Riley et al., 1995
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General Intellectual Performance

NC
PEA




FAS


Standard score
FSIQ
VIQ
PIQ
IQ scale
Mattson, S.N., 1997.
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Neuropsychological Performance
Mattson, et al., 1998
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Executive functioning deficits
Move only one piece at a time using one hand and
never place a big piece on top of a little piece
1
3
2
Starting position
Ending position
Mattson, et al., 1999
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Secondary Disabilities

• Individuals with FAS/FAE have a range of
  secondary
• disabilities disabilities that the individual
  is not born with, and
• which could be ameliorated with appropriate
  interventions.

Streissguth, et al., 1996
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Animal models and prenatal alcohol
Many studies simply could not be done on humans
Confounding factors can rarely be controlled in
human studies Alcohol is rarely the only drug
used Many abnormalities occur at low
rates Epidemiological studies are extremely time
consuming and expensive
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Animal models Example of the comparability of
effects

• Growth retardation
• Facial characteristics
• Heart, skeletal defects
• Microcephaly
• Reductions in basal ganglia and cerebellar
  volumes
• Callosal anomalies

• Hyperactivity, attentional problems
• Inhibitory deficits
• Impaired learning
• Perseveration errors
• Feeding difficulties
• Gait anomalies
• Hearing anomalies

Driscoll, et al., 1990 Samson, 1986
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Facial features of FAS in the mouse
Adapted from Sulik Johnston, 1982
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Alcohol and the Cerebellum
Pictures courtesy of James West
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Possible mechanisms for alcohols effects

• Impaired progression through cell cycle
• Impaired glia development - migration,
  neurotropic factor production, myelination
• Impaired cell adhesion
• Alterations in cell membranes
• Altered production of or responsiveness to factor
  that regulate growth, cell division, or cell
  survival
• Altered regulation of intracellular calcium
• Increased production of free radicals

21
Courtesy of Michael Charness from Ramanathan et
al., 1996
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Risk Factors

• Dose of alcohol
• Pattern of exposure - binge vs chronic
• Developmental timing of exposure
• Genetic variation
• Maternal characteristics
• Synergistic reactions with other drugs
• Interaction with nutritional variables

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Drinking Prevalence in Pregnancy

• 12.8 of women continue to drink in pregnancy
  (2.7 binge and 3.3 heavy) based upon a 1999
  survey
• Increased since 1991, (1 binge and heavy
  combined)
• 45 reported consuming alcohol during the 3
  months before they found out they were pregnant
• 60 of those didnt find out they were pregnant
  until after their 4th week of gestation
• (MMWR 200251C13273-6/Floyd, et. al. AJPM
  199917101-7)

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Knowledge Deficits

• Surveys document knowledge, attitude, and belief
  deficits in many populations, for example, among
  African-American women in St. Louis
• 12 think there is a safe level of alcohol
  consumption
• 36 think it is OK to drink at certain times
  during pregnancy
• 31 feel the effects of alcohol are treatable
• 54.9 feel sure they know when they are pregnant
• 12.3 feel that sexually active women who are at
  risk for pregnancy can drink
• (RDD Survey of African American Women in St.
  Louis)

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Physician Deficits

• Physician deficits contribute
• Women rely on their physician for advice
• In a survey of obstetricians
• 50 believed there was a safe level
• 90 asked, but many barriers to follow-up
• Only 50 educated all patients about alcohol
• Only ¼ of OB text books state that there is no
  safe level for EtOH consumption during pregnancy
• (Dickman et. al. Am J OB GYN 200095756-763)

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Prevention

• Knowledge improves outcomes in intervention
  studies
• In a brief intervention study of chronic drinkers
  of pregnant women, those who knew about the
  relationship between alcohol use and FAS and gave
  that as a reason for not drinking, reduced their
  alcohol consumption more than those women who did
  not.
• (Chang et. al. JSAT 200018365-9)

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Dose Response I

• Aggression Delinquency

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Dose Response II

• Regression for Aggression Delinquency

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Screening for Alcohol Use Among Pregnant Women-
Physician Barriers

• Physician communication skills
• Physician lack of knowledge and skill regarding
  evaluation and treatment
• Physicians feeling alcohol use in their
  populations is not prevalent
• Patients not willing to disclose alcohol use

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Screening Among Pregnant Women

• Traditional tools insensitive
• Laboratory tests not reliable
• Three questions
• Have you ever drank alcohol?
• How much alcohol did you drink in the month
  before pregnancy?
• How many cigarettes did you smoke in the month
  before pregnancy?

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Screening Among Pregnant Women

• Three risk groups
• Low risk (lt2 / no alcohol use reported)
• Average risk (6 / used alcohol in past, not
  smoked gt 3 cigarettes or drank in the month
  before)
• High risk (30 / used alcohol in past and smoked
  gt 3 cigarettes or drank in the month before)

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Treatment Intervention

• Brief intervention in the primary care setting
• Standard Alcoholism Treatment for the Mom
• AA
• Counseling (outpatient or inpatient)
• Aggressive inpatient treatment
• Medication
• Intensive case-management for the children
• Animal and human data indicates that early
  intervention in children with FAS on
  environmental variables might have a beneficial
  effect

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Prevention

• Very little research done on prevention
• Warning labels may not be reaching the women most
  likely to have a child with FAS
• On-going research
• Clinical interventions
• Community-based interventions

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Remediation of prenatal alcohol effects
Number of slips
Klintsova AY., 1998
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Case Management The Birth to 3 Program

• Parent-child assistance program
• Intensive home visitation model for the highest
  risk mothers
• Paraprofessional Advocates
• Paired with client for 3 years following the
  birth of the target Baby
• Link clients with community services
• Extensively trained and closely supervised
• Maximum caseload of 15
• Outcomes
• Fewer alcohol/drug affected children
• Reduced foster care placement
• Reduced dependence on welfare

Grant, T.M., 1999 Ernst, C. C., et al. 1999
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Summary

• Fetal Alcohol Syndrome is a devastating
  developmental disorder that affects children born
  to women who abuse alcohol during pregnancy.
• Although FAS is entirely preventable, and in
  spite of our increasing knowledge about the
  effects of prenatal alcohol exposure, children
  continue to be born exposed to high amounts of
  alcohol.
• Its consequences affect the individual, the
  family, and society.
• Its costs are tremendous, both personally and
  financially.
• Effective treatment and prevention strategies
  must be developed and made available.