Patterns of growth deficiency in rats exposed in utero to undernutrition, ethanol, or the neuroteratogen methylazoxymethanol (MAM)

Comparison of the 4-Digit Code, Canadian 2015, Australian 2016 and Hoyme 2016 fetal alcohol spectrum disorder diagnostic guidelines

BACKGROUND

As clinicians strive to achieve consensus worldwide on how best to diagnose fetal alcohol spectrum disorders (FASD), the most recent FASD diagnostic systems show convergence and divergence. Applying these systems to a single clinical population illustrates the contrasts between them, but validation studies are ultimately required to identify the best system.

METHODS

The 4-Digit-Code, Hoyme 2016, Canadian 2015 and Australian 2016 FASD diagnostic systems were applied to 1,392 patient records evaluated for FASD at the University of Washington. The diagnostic criteria and tools, the prevalence and concordance of diagnostic outcomes, and validity measures were compared between the systems.

RESULTS

The proportion diagnosed with fetal alcohol syndrome (FAS) and FASD varied significantly (4-Digit-Code 2.1%, ≤79%; Hoyme 6.4%, 44%, Australian 1.8%, 29%; Canadian 1.8%, 16%). Eighty-two percent were diagnosed FASD by at least one system; only 11% by all four systems. Key factors contributing to discordance include: requiring high alcohol exposure; excluding growth deficiency; relaxing the facial criteria; requiring brain criteria that prevent diagnosis of infants/toddlers; and excluding moderate dysfunction from the spectrum. Primate research confirms moderate dysfunction (1-2 domains ≤-2 standard deviations) is the most prevalent outcome caused by PAE (FAS 5%, severe dysfunction 31%, moderate dysfunction 59%). Only the 4-Digit-Code replicated this diagnostic pattern.

CONCLUSION

The needs of individuals with FASD are best met when diagnostic systems provide accurate, validated diagnoses across the lifespan, the full spectrum of outcome, the full continuum of alcohol exposure; and utilize diagnostic nomenclature that accurately reflects the association between outcome and alcohol exposure.

The Essential Role of Growth Deficiency in the Diagnosis of Fetal Alcohol Spectrum Disorder

Background:

Laboratory studies confirm prenatal alcohol exposure (PAE) causes growth deficiency (GD). GD has traditionally been a core diagnostic feature of fetal alcohol spectrum disorders (FASD), but was removed from the Canadian and Australian FASD diagnostic guidelines in 2016. This study aimed to empirically assess the clinical role and value of GD in FASD diagnosis.

Methods:

Data from 1814 patients with FASD from the University of Washington Fetal Alcohol Syndrome Diagnostic & Prevention dataset were analyzed to answer the following questions: 1) Is there evidence of a causal association between PAE and GD in our clinical population? 2) Is GD sufficiently prevalent among individuals with PAE to warrant its inclusion as a diagnostic criterion? 3) Does GD aid the diagnostic team in identifying and/or predicting which individuals will be most impaired by their PAE?

Results:

GD significantly correlated with PAE. GD was as prevalent as the other core diagnostic features (facial and CNS abnormalities). GD occurred in all FASD diagnoses and increased in prevalence with increasing severity of diagnosis. The most prevalent form of GD was postnatal short stature. GD was as highly correlated with, and predictive of, severe brain dysfunction as the FAS facial phenotype. Individuals with GD had a two to three-fold increased risk for severe brain dysfunction. Sixty percent of patients with severe GD had severe brain dysfunction. GD accurately predicted which infants presented with severe brain dysfunction later in childhood

Conclusions:

GD is an essential diagnostic criterion for FASD and will remain in the FASD 4-Digit Code.

Safety assessment for ethanol-based topical antiseptic use by health care workers: Evaluation of developmental toxicity potential

Ethanol-based topical antiseptic hand rubs, commonly referred to as alcohol-based hand sanitizers (ABHS), are routinely used as the standard of care to reduce the presence of viable bacteria on the skin and are an important element of infection control procedures in the healthcare industry. There are no reported indications of safety concerns associated with the use of these products in the workplace. However, the prevalence of such alcohol-based products in healthcare facilities and safety questions raised by the U.S. FDA led us to assess the potential for developmental toxicity under relevant product-use scenarios. Estimates from a physiologically based pharmacokinetic modeling approach suggest that occupational use of alcohol-based topical antiseptics in the healthcare industry can generate low, detectable concentrations of ethanol in blood. This unintended systemic dose probably reflects contributions from both dermal absorption and inhalation of volatilized product. The resulting internal dose is low, even under hypothetical, worst case intensive use assumptions. A significant margin of exposure (MOE) exists compared to demonstrated effect levels for developmental toxicity under worst case use scenarios, and the MOE is even more significant for typical anticipated occupational use patterns. The estimated internal doses of ethanol from topical application of alcohol-based hand sanitizers are also in the range of those associated with consumption of non-alcoholic beverages (i.e., non-alcoholic beer, flavored water, and orange juice), which are considered safe for consumers. Additionally, the estimated internal doses associated with expected exposure scenarios are below or in the range of the expected internal doses associated with the current occupational exposure limit for ethanol set by the Occupational Safety and Health Administration. These results support the conclusion that there is no significant risk of developmental or reproductive toxicity from repeated occupational exposures and high frequency use of ABHSs or surgical scrubs. Overall, the data support the conclusion that alcohol-based hand sanitizer products are safe for their intended use in hand hygiene as a critical infection prevention strategy in healthcare settings.

Prenatal alcohol exposure and adolescent stress increase sensitivity to stress and gonadal hormone influences on cognition in adult female rats

Abnormal activity of stress hormone (hypothalamic-pituitary-adrenal [HPA]), and gonadal hormone (hypothalamic-pituitary-gonadal [HPG]) systems is reported following prenatal alcohol exposure (PAE). PAE increases vulnerability of brain regions involved in regulation of these systems to stressors or challenges during sensitive periods of development, such as adolescence. In addition, HPA and HPG functions are linked to higher order functions such as executive function (EF), with dysregulation of either system adversely affecting EF processes, including attention and response inhibition, that influence cognition. However, how HPA and HPG systems interact to influence cognitive performance in individuals with an FASD is not fully understood. To investigate, we used a rat model of moderate PAE. Adolescent female PAE and control offspring were exposed to 10days of chronic mild stress (CMS) and cognitive function was assessed on the radial arm maze (RAM) in adulthood. On the final test day, animals were sacrificed, with blood collected for hormone analyses, and vaginal smears taken to assess estrus stage at the time of termination. Analyses showed that adolescent CMS significantly increased levels of CORT and RAM errors during proestrus in adult PAE but not control females. Moreover, CORT levels were correlated with estradiol levels and with RAM errors, but only in PAE females, with outcome dependent on adolescent CMS condition. These results suggest that PAE increases sensitivity to the influences of stress and gonadal hormones on cognition, and thus, in turn, that HPA and HPG dysregulation may underlie some of the deficits in executive function described previously in PAE females.

Prenatal methylazoxymethanol exposure alters evoked responses in fetal rats

Although there is considerable interest in identifying methods to detect central nervous system impairment early in development, few behavioral assessment tools are available for detecting CNS deficits in the fetus. In the present study, methylazoxymethanol [MAM; Midwest Research Institute, (MRI)] was used to induce deficits in CNS development in fetal rats to assess effects on coordinated fetal behavior. Fetuses were exposed by administering MAM to pregnant rats on E17 of gestation via intraperitoneal injection and then were prepared for behavioral testing 3 days later on E20. After externalization from the uterus into a warm saline bath, fetal subjects received either an intraoral infusion of lemon extract to evoke a facial wiping response or were presented with an artificial nipple to evoke an oral grasping response. Interlimb coordination and paw-face contact during facial wiping were disrupted in MAM-exposed fetuses. Similarly, MAM exposure diminished the ability of fetuses to grasp or maintain oral contact with the artificial nipple. Although clear disruptions of movement coordination were seen in the MAM-treated subjects, there were no significant differences from saline controls in weight or anatomical measures. Together, these findings suggest that behavioral assessments of fetal motor coordination may be useful in identifying neural insult during prenatal development.

Relevance of the developmental toxicity of ethanol in the occupational setting: a review

Numerous studies have been conducted investigating the reproductive toxicology of ethanol, the overwhelming majority concerning the adverse effects of consuming alcohol in beverages during pregnancy. Because many of the in vivo studies were designed to model alcoholism, they used comparatively high doses and assessed relatively few endpoints. Outcomes may have been affected by disturbances of metabolism at such high exposures, giving rise to secondary effects on development. The available data on ethanol from "conventional" developmental toxicity study test methods of the type used for regulatory hazard assessment of chemicals are limited. It is in this context, however, i.e. the use of ethanol as an industrial chemical rather than as a component of beverages, that this review is based. Using the usual criteria applied for the purpose of hazard assessment of industrial chemicals, it is concluded that there is no evidence that industrial exposure to ethanol is a developmental toxicity hazard. Developmental toxicity may result from drinking alcoholic beverages, the threshold level for all aspects of which has yet to be de fi ned. This is not, however, considered relevant to the low blood alcohol concentrations resulting from any conceivable inhalation or dermal exposure in the workplace or through the directed use of any consumer product containing ethanol.

Sexually dimorphic effects of maternal alcohol intake and adrenalectomy on left ventricular hypertrophy in rat offspring

In humans, low birth weight and increased placental weight can be associated with cardiovascular disease in adulthood. Low birth weight and increased placental size are known to occur after fetal alcohol exposure or prenatal glucocorticoid administration. Thus the effects of removing the alcohol-induced increase in maternal corticosterone by maternal adrenalectomy on predictors of cardiovascular disease in adulthood were examined in rats. Alcohol exposure of dams during the last 2 wk of gestation resulted in significantly decreased fetal weight and increased placental weight on gestational day 21. Adult female, but not male, offspring of alcohol-consuming mothers exhibited left ventricular hypertrophy. Placental 11beta-hydroxysteroid dehydrogenase-2 (11beta-HSD-2) mRNA levels, measured by Northern blot, were decreased in females but not males. Adrenalectomy of alcohol-consuming dams reversed the increase in placental weight and the decrease in female placental 11beta-HSD-2 expression and eliminated the left ventricular hypertrophy of adult female offspring. These data suggest that alcohol-induced changes in placental 11beta-HSD-2 mRNA levels and left ventricular weight are coupled in female offspring only and depend on maternal adrenal status.

Infantile handling eliminates reversal learning deficit in rats prenatally exposed to alcohol

Prenatal exposure to ethanol results in learning deficits and alters physiological response to stress. Neonatal handling and stimulation. on the other hand, produce long-lasting physiological and behavioral changes in response to stress. To determine whether early handling, consisting of daily separation and tactile stimulation for the first 3 weeks, can modify fetal alcohol effects on learning ability of young adult rats, offspring of rats chronically exposed to ethanol throughout pregnancy and control animals were trained in a T-maze to learn a position response and then to reverse the learned response. The nonhandled, ethanol-treated rats were deficient on reversal, but the ethanol-treated rats that were handled during the first 3 weeks of postnatal development showed no deficit in learning to reverse their previously learned responses. Postnatal handling had no effect on acquisition in alcohol-treated rats. Neither reversal nor acquisition was affected by infantile handling in pair-fed or normal control animals. Early handling may have eliminated the reversal deficit in the ethanol-treated offspring by altering their physiological and behavioral reactivity to stress.

Nutrition and fetal growth

Essential factors for normal fetal growth include the correct utilization by the fetus of a suitable supply of energy and plastic nutrients, together with the adequate genic expression of the factors promoting tissue growth and an optimal hormonal framework. The nutritional state and welfare of the mother, the endocrine changes experienced and the uteroplacental function have all been related to the health of the fetus and the newborn infant, premature births, fetal nutritional disorders, certain diseases and even death.

Prenatal ethanol exposure in rats: long-lasting effects on learning

Pregnant Sprague-Dawley rats were fed a liquid diet containing either 0% (group C), 18% (group L), or 36% (group H) ethanol-derived calories (EDC) from gestational day 1 to 20. Male offspring were assessed under a conditioned taste aversion paradigm (PND 35-45), in a complex maze (PND 68-80), and for operant behavior (temporal response differentiation and motivation to work for food, PND 140-198). Although conditioned taste aversion was fully acquired by all groups, retention of the conditioned taste aversion response was impaired in group H animals. Importantly, deficits in the acquisition of timing behavior were found in group H (group L not tested), confirming that this operant task is quite sensitive in detecting prenatal drug effects and demonstrating that neurological effects of prenatal ethanol exposure persist into late adulthood.