Prevalence of fetal alcohol spectrum disorder in foster care: A scoping review

The prevalence of fetal alcohol spectrum disorder (FASD) has been reported to be disproportionately high among children in foster care compared with the general population. However, updated prevalence estimates of infants and children with FASD in foster care or the prevalence of placement of children with FASD in foster care make this unclear. This study examines two questions. Firstly, what is the prevalence of FASD among infants and children in foster care? Secondly, what is the likelihood of placement in foster care for infants and children with FASD? This review was designed using PRISMA-SCR and JBI scoping review guidelines. Three databases were searched for the period June 2012 to June 2023: PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Google Scholar for all countries. Overall prevalence estimates were calculated using a complementary log-log link model along with 95% confidence intervals. Firstly, the estimated prevalence of FASD among infants and children in foster care was 18.8%. Secondly, among children diagnosed with FASD 30.5% are placed into foster care, reflecting greatly increased risk of placement of infants and children with FASD in foster care. We conclude that routine screening for FASD is needed to improve the identification of infants and children with FASD. Increased attention is also needed on developing strategies for FASD prevention. Recognition that nearly one of every three children with FASD will enter foster care demonstrates the need for increased funding, enhanced training and greater availability of services for families and children impacted by FASD.

Neuropsychological evaluation of children and adolescents with fetal alcohol spectrum disorders in the Brazilian population

Fetal Alcohol Spectrum Disorder (FASD) is a collective name for lifelong physical and neurodevelopmental problems caused by the gestational consumption of alcohol affecting fetal development. In Brazil, the lack of awareness among healthcare professionals, and the scarcity of suitable diagnostic tools and trained clinicians, can contribute to the underestimation of FASD prevalence and severity. The present review aims to map and analyze studies conducted in Brazil on children and adolescents with FASD or a history of prenatal alcohol exposure (PAE). Additionally, it intends to report the psychometric properties of the neurodevelopmental assessment tools applied in the selected articles. Searches were carried out in the databases Scielo, LILACS, PePSIC, EMBASE, PsycINFO, Web of Science, selecting original clinical studies that have investigated the neurodevelopment of this population. From a total of 175 studies, ten articles fit the inclusion criteria in which 18 instruments were identified. The most reported deficits were related to language, general intelligence quotient (IQ), adaptive behavior, attention, and visual perception. Our results point to the need for more clinical research on FASD in Brazil, as well as for the standardization and validation of neurodevelopmental assessment tools for the accurate diagnosis of FASD in Brazil.

Altering Cell-Cell Interaction in Prenatal Alcohol Exposure Models: Insight on Cell-Adhesion Molecules During Brain Development

Alcohol exposure during pregnancy disrupts the development of the brain and produces long lasting behavioral and cognitive impairments collectively known as Fetal Alcohol Spectrum Disorders (FASDs). FASDs are characterized by alterations in learning, working memory, social behavior and executive function. A large body of literature using preclinical prenatal alcohol exposure models reports alcohol-induced changes in architecture and activity in specific brain regions affecting cognition. While multiple putative mechanisms of alcohol’s long-lasting effects on morphology and behavior have been investigated, an area that has received less attention is the effect of alcohol on cell adhesion molecules (CAMs). The embryo/fetal development represents a crucial period for Central Nervous System (CNS) development during which the cell-cell interaction plays an important role. CAMs play a critical role in neuronal migration and differentiation, synaptic organization and function which may be disrupted by alcohol. In this review, we summarize the physiological structure and role of CAMs involved in brain development, review the current literature on prenatal alcohol exposure effects on CAM function in different experimental models and pinpoint areas needed for future study to better understand how CAMs may mediate the morphological, sensory and behavioral outcomes in FASDs.

Ophthalmologic Findings in Fetal Alcohol Spectrum Disorders - A Cohort Study From Childhood to Adulthood

PURPOSE

To investigate whether ophthalmologic findings in children with fetal alcohol spectrum disorders (FASD) persist into young adulthood.

DESIGN

Prospective cohort study.

METHODS

Thirty children (13 female) adopted from eastern Europe to Sweden in the 1990s and diagnosed with FASD by a multidisciplinary team at the median age of 7.9 years were followed up by the same team 13-18 years later. Visual acuity (VA), refraction, stereoacuity, strabismus, ocular media, and fundus were investigated.

RESULTS

Median VA in right/left eye (OD/OS) was 20/32/20/32 (0.2/0.2 logMAR) in childhood and 20/22/20/20 (0.05/0.0 logMAR) in adulthood. Median (range) refraction OD/OS was +0.88/+1.25 (-8.75 to +4.75/-9.38 to +5.25) spherical equivalent diopter (D) in childhood and -0.25/-0.25 (-12 to +2.75/-13.25 to +2.63) in adulthood. Astigmatism (≥1 D) was the most common refractive error, in 13 (40%) and 14 (47%) subjects, respectively. Defective stereoacuity (>60 arc second) was noted in 20 subjects (67%) in childhood and 22 (73%) in adulthood. Heterotropia occurred in 12 subjects (40%) in childhood and 13 (43%) in adulthood. Increased tortuosity of the retinal vessels was found in 8 (27%) subjects in childhood vs 11 (37%) in adulthood. Optic nerve hypoplasia was recorded in 3 children and in 4 young adults.

CONCLUSIONS

Ophthalmologic findings such as refractive errors, strabismus, and fundus abnormalities are frequent in children with FASD and persist into early adulthood. The facial features characteristic of FAS diminish with age, making a dysmorphology evaluation in adulthood less reliable. An ophthalmologic examination is an important part of the evaluation of FASD in childhood as well as in young adulthood.

Phosphatidylethanol Levels in Postpartum Women and Their Newborns in Uruguay and Brazil

BACKGROUND

There is increasing interest in the development of newborn screening tests to identify children at risk of fetal alcohol spectrum disorder (FASD) in order to provide these children with early intervention. Phosphatidylethanol (PEth) has emerged as a potential universal newborn screening candidate.

METHODS

The aim of this report was to present the results of a study designed to compare PEth levels in 1,140 postpartum women and their newborn infants in Montevideo, Uruguay, and Sao Paulo, Brazil. Self-report alcohol use during pregnancy data was collected, along with both maternal and newborn dried blood spot samples for PEth analysis.

RESULTS

The average age and parity of the women in the sample were 26 years of age and 2.3 pregnancies. For the Uruguay sample (n = 611), 45.8% of postpartum women had PEth levels ≥ 8 ng/ml with a mean positive PEth of 43.6 ng/ml. In contrast, 86.8% of the newborns had PEth levels ≥ 8 ng/ml, with a mean positive PEth of 77.4 ng/ml. For the Brazil sample (n = 529), 33.2% of women had PEth levels ≥ 8 ng/ml with a mean positive PEth of 31 ng/ml. In contrast, 76.9% of the Brazil newborns had PEth levels ≥ 8 ng/ml and 43.9% with a mean positive PEth of 61.1 ng/ml. PEth levels were significantly higher in newborns compared with their postpartum mothers in both the Uruguay and Brazil samples. Self-reported third-trimester alcohol was 6% in the Uruguay sample and 9.1% in the Brazil sample compared with positive maternal PEth levels in 45.8% and 33.2%, respectively.

CONCLUSIONS

Clinicians may want to consider newborn PEth screening in high-risk populations where prenatal alcohol use is common. The mechanism underlying significantly higher PEth levels in newborns compared with their mothers is not known.

Fetal Alcohol Spectrum Disorders: Health Needs Assessment in Brazil

BACKGROUND

Fetal alcohol syndrome (FAS) is a disorder caused by alterations in embryo-fetal development due to prenatal alcohol exposure. It is estimated that between 0.5 and 2 per 1,000 individuals are born with FAS every year. In Brazil, there are few studies addressing the extent of the problem of FAS/fetal alcohol spectrum disorders (FASD); these studies are confined to limited geographic areas. Therefore, we decided to perform a health needs assessment for FAS/FASD in Brazil.

METHODS

To estimate the prevalence of FAS and FASD in Brazil, we used information from the literature, which estimates between 0.5 and 2/1,000 births per year for FAS and 10 to 50/1,000 for FASD.

RESULTS

We estimated that approximately 1,500 to 6,000 children are born with FAS every year. Considering the whole population, the prevalence would be 95,377 to 380,000 affected people. However, when we consider FASD as a whole, we estimate that between 1,900,000 and 9,500,000 Brazilians might suffer the more severe consequences of alcohol exposure during pregnancy and be living with FASD.

CONCLUSION

The results of the current study indicate that FAS and FASD are prevalent disorders in Brazil, and more policies targeting alcohol intake during pregnancy must be developed.

Prevalence of fetal alcohol spectrum disorder among special subpopulations: a systematic review and meta-analysis

AIM

To collate prevalence estimates of fetal alcohol spectrum disorder (FASD) among special subpopulations (defined by service use).

DESIGN

Systematic literature review and meta-analysis of original, quantitative studies published between 1 November 1973 and 1 December 2018. The PRISMAGATHER were adhered to. The review protocol [includes FASD prevalence in (a) general and (b) special populations] is available on PROSPERO (registration number: CRD42016033837). Prevalence estimates were collated for all included studies with country-, disorder- [FASD and fetal alcohol syndrome (FAS)] and population-specific random-effects meta-analyses conducted.

SETTING AND PARTICIPANTS

A number of service-defined subpopulations globally (see Findings).

MEASUREMENTS

The main outcome was the prevalence of FASD among special subpopulations. The critical appraisal of each study was conducted using the Joanna Briggs Institute tool.

FINDINGS

We identified 69 studies, comprising 6177 individuals diagnosed with FASD from 17 countries: Australia (n = 5), Brazil (n = 2), Canada (n = 15), Chile (n = 4), eastern Europe (Moldova, Romania and Ukraine; n = 1), Germany (n = 1), Israel (n = 1), Lithuania (n = 1), the Netherlands (n = 1), Poland (n = 1), Russia (n = 9), South Korea (n = 1), Spain (n = 1), Sweden (n = 1) and United States (n = 25). FAS and FASD prevalence rates were collated for the following five subpopulations: children in care, correctional, special education, specialized clinical and Aboriginal populations. The estimated prevalence of FASD in these special subpopulations was 10-40 times higher compared with the 7.7 per 1000 (95% confidence interval = 4.9-11.7) global FASD prevalence in the general population.

CONCLUSIONS

Global subpopulations of children in care, correctional, special education, specialized clinical and Aboriginal populations have a significantly higher prevalence of fetal alcohol spectrum disorder compared with the general population, which poses a substantial global health problem.

Clinical presentation, diagnosis, and management of fetal alcohol spectrum disorder

Although prenatal alcohol exposure causes craniofacial anomalies, growth retardation, neurological abnormalities, cognitive impairment, and birth defects, fetal alcohol spectrum disorder is underdiagnosed. Global prevalence of fetal alcohol spectrum disorder is 0·77%, with a higher prevalence of 2-5% in Europe and North America, highlighting the need for increased diagnosis and treatment. However, diagnosis remains challenging because of the poor reliability of self-reported maternal drinking histories, an absence of sensitive biomarkers, and the infrequency of diagnostic dysmorphic facial features among individuals with fetal alcohol spectrum disorder. Different diagnostic systems and disagreements over criteria have slowed progress in the diagnosis and management of the disorder. Neuroimaging shows abnormalities in brain structure, cortical development, white matter microstructure, and functional connectivity in individuals with fetal alcohol spectrum disorder. These abnormalities modify developmental trajectories and are associated with deficits in cognition, executive function, memory, vision, hearing, motor skills, behaviour, and social adaptation. Promising trials of nutritional interventions and cognitive rehabilitation therapies are underway, with the aim of treating cognitive deficits in fetal alcohol spectrum disorders.

Global Prevalence of Fetal Alcohol Spectrum Disorder Among Children and Youth: A Systematic Review and Meta-analysis

Importance

Prevalence estimates are essential to effectively prioritize, plan, and deliver health care to high-needs populations such as children and youth with fetal alcohol spectrum disorder (FASD). However, most countries do not have population-level prevalence data for FASD.

Objective

To obtain prevalence estimates of FASD among children and youth in the general population by country, by World Health Organization (WHO) region, and globally.

Data Sources

MEDLINE, MEDLINE in process, EMBASE, Education Resource Information Center, Cumulative Index to Nursing and Allied Health Literature, Web of Science, PsychINFO, and Scopus were systematically searched for studies published from November 1, 1973, through June 30, 2015, without geographic or language restrictions.

Study Selection

Original quantitative studies that reported the prevalence of FASD among children and youth in the general population, used active case ascertainment or clinic-based methods, and specified the diagnostic guideline or case definition used were included.

Data Extraction and Synthesis

Individual study characteristics and prevalence of FASD were extracted. Country-specific random-effects meta-analyses were conducted. For countries with 1 or no empirical study on the prevalence of FASD, this indicator was estimated based on the proportion of women who consumed alcohol during pregnancy per 1 case of FASD. Finally, WHO regional and global mean prevalence of FASD weighted by the number of live births in each country was estimated.

Main Outcomes and Measures

Prevalence of FASD.

Results

A total of 24 unique studies including 1416 unique children and youth diagnosed with FASD (age range, 0-16.4 years) were retained for data extraction. The global prevalence of FASD among children and youth in the general population was estimated to be 7.7 per 1000 population (95% CI, 4.9-11.7 per 1000 population). The WHO European Region had the highest prevalence (19.8 per 1000 population; 95% CI, 14.1-28.0 per 1000 population), and the WHO Eastern Mediterranean Region had the lowest (0.1 per 1000 population; 95% CI, 0.1-0.5 per 1000 population). Of 187 countries, South Africa was estimated to have the highest prevalence of FASD at 111.1 per 1000 population (95% CI, 71.1-158.4 per 1000 population), followed by Croatia at 53.3 per 1000 population (95% CI, 30.9-81.2 per 1000 population) and Ireland at 47.5 per 1000 population (95% CI, 28.0-73.6 per 1000 population).

Conclusions and Relevance

Globally, FASD is a prevalent alcohol-related developmental disability that is largely preventable. The findings highlight the need to establish a universal public health message about the potential harm of prenatal alcohol exposure and a routine screening protocol. Brief interventions should be provided, where appropriate.

Differences in neural crest sensitivity to ethanol account for the infrequency of anterior segment defects in the eye compared with craniofacial anomalies in a zebrafish model of fetal alcohol syndrome

BACKGROUND

Ethanol (ETOH) exposure during pregnancy is associated with craniofacial and neurologic abnormalities, but infrequently disrupts the anterior segment of the eye. In these studies, we used zebrafish to investigate differences in the teratogenic effect of ETOH on craniofacial, periocular, and ocular neural crest.

METHODS

Zebrafish eye and neural crest development was analyzed by means of live imaging, TUNEL (terminal deoxynucleotidyl transferase dUTP nick end labeling) assay, immunostaining, detection of reactive oxygen species, and in situ hybridization.

RESULTS

Our studies demonstrated that foxd3-positive neural crest cells in the periocular mesenchyme and developing eye were less sensitive to ETOH than sox10-positive craniofacial neural crest cells that form the pharyngeal arches and jaw. ETOH increased apoptosis in the retina, but did not affect survival of periocular and ocular neural crest cells. ETOH also did not increase reactive oxygen species within the eye. In contrast, ETOH increased ventral neural crest apoptosis and reactive oxygen species production in the facial mesenchyme. In the eye and craniofacial region, sod2 showed high levels of expression in the anterior segment and in the setting of Sod2 knockdown, low levels of ETOH decreased migration of foxd3-positive neural crest cells into the developing eye. However, ETOH had minimal effect on the periocular and ocular expression of transcription factors (pitx2 and foxc1) that regulate anterior segment development.

CONCLUSION

Neural crest cells contributing to the anterior segment of the eye exhibit increased ability to withstand ETOH-induced oxidative stress and apoptosis. These studies explain the rarity of anterior segment dysgenesis despite the frequent craniofacial abnormalities in fetal alcohol syndrome. Birth Defects Research 109:1212-1227, 2017. © 2017 Wiley Periodicals, Inc.

Prevalence of externalizing disorders and Autism Spectrum Disorders among children with Fetal Alcohol Spectrum Disorder: systematic review and meta-analysis

Owing to their central nervous system impairments, children with Fetal Alcohol Spectrum Disorder (FASD) commonly exhibit externalizing behaviours such as hyperactivity, impulsivity, and (or) delinquency. The purpose of this study was to estimate the prevalence of neurodevelopmental disorders with prominent externalizing behaviours, namely Attention-Deficit Hyperactivity Disorder (ADHD), Conduct Disorder (CD), Oppositional Defiant Disorder (ODD), as well as Autism Spectrum Disorders (ASD) among children with FASD. A comprehensive systematic literature search was performed, followed by disorder-specific random-effects meta-analyses. Of the disorders investigated, ADHD was found to be the most common co-morbid disorder among children with FASD (52.9%), followed by ODD (12.9%), CD (7.0%), and ASD (2.6%). When compared with the general population of the USA, these rates are notably higher: 15 times higher for ADHD, 2 times higher for ASD, 3 times higher for CD, and 5 times higher for ODD. The results call attention to the need for identifying a distinct neurodevelopmental profile to aid in the accurate identification of children with FASD and the discrimination of FASD from certain idiopathic neurodevelopmental disorders.

Comorbid Mental Disorders in Fetal Alcohol Spectrum Disorders: A Systematic Review

OBJECTIVE

A systematic review of published literature to estimate prevalence of comorbid mental disorders in fetal alcohol spectrum disorders (FASDs) and compare with general population prevalence estimates.

METHODS

A PubMed search was used to locate articles reporting on FASD and mental disorders published through June 2015. Next, lists of published studies from all issues of the National Organisation for Foetal Alcohol Syndrome-UK publication Fetal Alcohol Forum-were searched. Weighted average prevalence was estimated for the comorbid mental disorders with sufficient data for analysis. We then compared prevalence of mental disorders in the FASD population with rates in the mental health literature.

RESULTS

We identified 26 articles reporting 5984 cases of FASD. Of the 15 comorbid mental disorders, 11 had sufficient data for inclusion in the analysis. Attention-deficit/hyperactivity disorder occurred in 50% of persons with FASD (10 times the expected rate). Intellectual disability occurred at 23 times the expected rate. In 5 of the 12 disorders, rates in the FASD population significantly exceeded expected rates by 10% to 45%.

CONCLUSION

Increased rates of mental disorders in people with FASD are commonly reported. Mental health providers should routinely consider FASD in the diagnosis and management of mental illness and developmental disorders. The quality of the research and precision of comorbidity estimates would be improved by additional studies including people with FASD and non-FASD comparison subjects. Until these studies are available, this review provides the best available estimates of comorbid mental disorders in people with FASD.

What can be done to lessen morbidity associated with fetal alcohol spectrum disorders?

Fetal alcohol syndrome and its wider spectrum of presentation fetal alcohol spectrum disorders represent a range of disorders that are sometimes difficult to recognise as they may present in a way that overlaps with other conditions. This makes identification and recognition challenging, which increases the burden associated with the disorder. When considering the reduction in morbidity, both prevention of exposure to alcohol by the fetus and early identification of cases are required. This selective review seeks to highlight some of the complexities involved as well as highlighting the challenges. By considering populations particularly at risk to exploring the reality of alcohol risk it will seek to offer some solutions to begin the process of change.

Teratogens: a public health issue - a Brazilian overview

Congenital anomalies are already the second cause of infant mortality in Brazil, as in many other middle-income countries in Latin America. Birth defects are a result of both genetic and environmental factors, but a multifactorial etiology has been more frequently observed. Here, we address the environmental causes of birth defects - or teratogens - as a public health issue and present their mechanisms of action, categories and their respective maternal-fetal deleterious effects. We also present a survey from 2008 to 2013 of Brazilian cases involving congenital anomalies (annual average of 20,205), fetal deaths (annual average of 1,530), infant hospitalizations (annual average of 82,452), number of deaths of hospitalized infants (annual average of 2,175), and the average cost of hospitalizations (annual cost of $7,758). Moreover, we report on Brazilian cases of teratogenesis due to the recent Zika virus infection, and to the use of misoprostol, thalidomide, alcohol and illicit drugs. Special attention has been given to the Zika virus infection, now proven to be responsible for the microcephaly outbreak in Brazil, with 8,039 cases under investigation (from October 2015 to June 2016). From those cases, 1,616 were confirmed and 324 deaths occurred due to microcephaly complications or alterations on the central nervous system. Congenital anomalies impact life quality and raise costs in specialized care, justifying the classification of teratogens as a public health issue.

Estimation of national, regional, and global prevalence of alcohol use during pregnancy and fetal alcohol syndrome: a systematic review and meta-analysis

BACKGROUND

Alcohol use during pregnancy is the direct cause of fetal alcohol syndrome (FAS). We aimed to estimate the prevalence of alcohol use during pregnancy and FAS in the general population and, by linking these two indicators, estimate the number of pregnant women that consumed alcohol during pregnancy per one case of FAS.

METHODS

We began by doing two independent comprehensive systematic literature searches using multiple electronic databases for original quantitative studies that reported the prevalence in the general population of the respective country of alcohol use during pregnancy published from Jan 1, 1984, to June 30, 2014, or the prevalence of FAS published from Nov 1, 1973, to June 30, 2015, in a peer-reviewed journal or scholarly report. Each study on the prevalence of alcohol use during pregnancy was critically appraised using a checklist for observational studies, and each study on the prevalence of FAS was critically appraised by use of a method specifically designed for systematic reviews addressing questions of prevalence. Studies on the prevalence of alcohol use during pregnancy and/or FAS were omitted if they used a sample population not generalisable to the general population of the respective country, reported a pooled estimate by combining several studies, or were published in iteration. Studies that excluded abstainers were also omitted for the prevalence of alcohol use during pregnancy. We then did country-specific random-effects meta-analyses to estimate the pooled prevalence of these indicators. For countries with one or no empirical studies, we predicted prevalence of alcohol use during pregnancy using fractional response regression modelling and prevalence of FAS using a quotient of the average number of women who consumed alcohol during pregnancy per one case of FAS. We used Monte Carlo simulations to derive confidence intervals for the country-specific point estimates of the prevalence of FAS. We estimated WHO regional and global averages of the prevalence of alcohol use during pregnancy and FAS, weighted by the number of livebirths per country. The review protocols for the prevalence of alcohol use during pregnancy (CRD42016033835) and FAS (CRD42016033837) are available on PROSPERO.

FINDINGS

Of 23 470 studies identified for the prevalence of alcohol use, 328 studies were retained for systematic review and meta-analysis; the search strategy for the prevalence of FAS yielded 11 110 studies, of which 62 were used in our analysis. The global prevalence of alcohol use during pregnancy was estimated to be 9·8% (95% CI 8·9-11·1) and the estimated prevalence of FAS in the general population was 14·6 per 10 000 people (95% CI 9·4-23·3). We also estimated that one in every 67 women who consumed alcohol during pregnancy would deliver a child with FAS, which translates to about 119 000 children born with FAS in the world every year.

INTERPRETATION

Alcohol use during pregnancy is common in many countries and as such, FAS is a relatively prevalent alcohol-related birth defect. More effective prevention strategies targeting alcohol use during pregnancy and surveillance of FAS are urgently needed.

FUNDING

Centre for Addiction and Mental Health (no external funding was sought).

Fetal alcohol spectrum disorders: Clinical phenotype among a high-risk group of children and adolescents in Korea

Little is known about the prevalence and phenotype of fetal alcohol syndrome (FAS) or spectrum disorders (FASD) in Korea. This study was performed to describe the distribution of alcohol-related physical features in a genetically homogeneous sample of children and adolescents in institutional settings in Korea. Children and adolescents receiving services in one of seven institutions in Seoul, Korea were screened for growth deficiency. Those who screened positive were assessed using a structured protocol for the key cardinal features of FAS, and for 11 additional alcohol-related dysmorphologic features. Based on these findings, children and adolescents were categorized as FAS, Deferred (some characteristic features of FAS), and No FAS. Groups were compared on the prevalence of specific additional features and number of additional features, stratified by gender and age. Of 307 children and adolescents screened, 87 received the dysmorphology evaluation. Thirteen were classified as FAS, 44 Deferred, and 30 No FAS. The frequency of 10 of the 11 additional alcohol-related features did not differ significantly by FAS category. Palmar crease abnormalities were more common in FAS (53.8%) than in the Deferred category (25.0%) or the No FAS category (6.7%) (P = 0.003). A high prevalence across all groups was found for midfacial hypoplasia and epicanthal folds, whereas only one child exhibited ptosis. This study suggests that an FASD phenotype variant related to ethnic differences in the range of defects specific to prenatal alcohol exposure may be present in the Korean population.