Ascertainment of birth defects: the effect on completeness of adding a new source of data

Estimating the community prevalence, child traits, and maternal risk factors of fetal alcohol spectrum disorders (FASD) from a random sample of school children

OBJECTIVE

Utilize a random sample to estimate the prevalence, child traits, and maternal risk for fetal alcohol spectrum disorders (FASD) in a Southeastern United States county.

METHODS

From all first-grade students (n = 1073) a simple random sample was drawn, and 32 % (n = 231) were consented. All 231 children were examined for dysmorphology and growth, 84 were tested and rated on neurobehavior, and 72 mothers were interviewed for maternal risk.

RESULTS

Significant differences (α = .05) between the physical traits of children diagnosed with FASD and the entire sample were height, weight, head circumference, body mass index, and total dysmorphology scores, and all three cardinal features of fetal alcohol syndrome: palpebral fissure length, smooth philtrum, and narrow vermilion. Intellectual function and inhibition were not significantly different between FASD and typically-functioning children, but two executive function measures and one visual/spatial measure approached significance (α = .10). Three behavioral measures were significantly worse for the FASD group: parent-rated problems of communication, daily living, and socialization. Significant maternal risk factors reported were postpartum depression, frequency of drinking, and recovery from problem drinking. The prevalence of FASD was 71.4 per 1,000 or 7.1 %. This rate falls clearly within the prevalence range identified in eight larger samples of other communities in the Collaboration on FASD Prevalence (CoFASP) study in four regions of the United States.

CONCLUSION

Careful and detailed clinical evaluation of children from small random samples can be useful for estimating the prevalence and traits of FASD in a community.

Worldwide Prevalence of Fetal Alcohol Spectrum Disorders: A Systematic Literature Review Including Meta-Analysis

BACKGROUND

Although fetal alcohol spectrum disorders (FASD) affect communities worldwide, little is known about its prevalence. The objective of this study was to provide an overview of the global FASD prevalence.

METHODS

We performed a search in multiple electronic bibliographic databases up to August 2015, supplemented with the ascendancy and descendancy approach. Studies were considered when published in English, included human participants, and reported empirical data on prevalence or incidence estimates of FASD. Raw prevalence estimates were transformed using the Freeman-Tukey double arcsine transformation so that the data followed an approximately normal distribution. Once the pooled prevalence estimates, 95% confidence intervals and prediction intervals were calculated based on multiple meta-analyses with transformed proportions using random effects models, these estimates were transformed back to regular prevalence rates. Heterogeneity was tested using Cochran's Q and described using the I(2) statistic.

RESULTS

Among studies that estimated prevalence in general population samples, considerable differences in prevalence rates between countries were found and therefore separate meta-analyses for country were conducted. Particularly high-prevalence rates were observed in South Africa for fetal alcohol syndrome (55.42 per 1,000), for alcohol-related neurodevelopmental disorder (20.25 per 1,000), and FASD (113.22 per 1,000), For partial fetal alcohol syndrome high rates were found in Croatia (43.01 per 1,000), Italy (36.89 per 1,000), and South Africa (28.29 per 1,000). In the case of alcohol-related birth defects, a prevalence of 10.82 per 1,000 was found in Australia. However, studies into FASD exhibited substantial heterogeneity, which could only partly be explained by moderators, most notably geography and descent, in meta-regressions. In addition, the moderators were confounded, making conclusions as to each moderator's relevance tentative at best.

CONCLUSIONS

The worldwide pooled prevalence estimates are higher than assumed so far, but this was largely explained by geography and descent. Furthermore, prevalence studies varied considerably in terms of used methodology and methodological quality. The pooled estimates must therefore be interpreted with caution and for future research it is highly recommended to report methodology in a more comprehensive way. Finally, clear guidelines on assessing FASD prevalence are urgently needed, and a first step toward these guidelines is presented.

Study protocol for screening and diagnosis of fetal alcohol spectrum disorders (FASD) among young people sentenced to detention in Western Australia

INTRODUCTION

Prenatal alcohol exposure can cause lifelong disability, including physical, cognitive and behavioural deficits, known as fetal alcohol spectrum disorders (FASD). Among individuals with FASD, engagement with justice services is common. Little is known about the prevalence of FASD among young people engaged with the Australian justice system. This study aims to establish FASD prevalence among sentenced young people in detention in Western Australia (WA), and use the findings to develop a screening tool for use among young people entering detention. Translation of these results will guide the management and support of young people in detention and will have significant implications on the lives of young people with FASD and the future of Australian youth justice services.

METHODS AND ANALYSIS

Any sentenced young person in WA aged 10-17 years 11 months is eligible to participate. Young people are assessed for FASD by a multidisciplinary team. Standardised assessment tools refined for the Australian context are used, acknowledging the language and social complexities involved. Australian diagnostic guidelines for FASD will be applied. Information is obtained from young people, responsible adults, teachers and custodial officers. Individualised results and management plans for each young person are communicated to the young person and responsible adult. Prevalence of FASD will be reported and multivariate methods used to identify variables most predictive of FASD and to optimise the predictive value of screening.

ETHICS AND DISSEMINATION

Approvals have been granted by the WA Aboriginal Health Ethics Committee, University of WA Human Research Ethics Committee, Department of Corrective Services, and Department for Child Protection and Family Support. Anonymised findings will be disseminated through peer-reviewed manuscripts, presentations and the media. Extensive consultation with stakeholders (including government agencies, detention centre staff, community service providers, the young people and their families or carers) will be ongoing until findings are disseminated and translated.

Intellectual disability in Indigenous Australians: issues and challenges

OBJECTIVES

Literature on Indigenous Australians (Aboriginal and Torres Strait Islander people) and intellectual disability (ID) is summarized in order to identify current state of knowledge, gaps, and areas for further research.

METHODS

A selective review of psychiatric literature using relevant medical databases was undertaken. Key articles were identified and their findings described.

RESULTS

ID is reported to be more prevalent in Indigenous Australians. Sociocultural constructs and a lack of validated psychometric measures affect what is considered to be ID in Indigenous communities. Prenatal, perinatal, and postnatal factors impair brain development and contribute to ID in Indigenous communities. Comorbid physical and psychiatric disorders need to be assessed and managed.

CONCLUSIONS

ID is an emerging area of health concern for general and mental health professionals working with Indigenous Australians. This important area requires further research, appropriate training, and resourcing.

Prevalence of fetal alcohol syndrome in a population-based sample of children living in remote Australia: the Lililwan Project

AIM

Aboriginal leaders concerned about high rates of alcohol use in pregnancy invited researchers to determine the prevalence of fetal alcohol syndrome (FAS) and partial fetal alcohol syndrome (pFAS) in their communities.

METHODS

Population-based prevalence study using active case ascertainment in children born in 2002/2003 and living in the Fitzroy Valley, in Western Australia (April 2010-November 2011) (n = 134). Socio-demographic and antenatal data, including alcohol use in pregnancy, were collected by interview with 127/134 (95%) consenting parents/care givers. Maternal/child medical records were reviewed. Interdisciplinary assessments were conducted for 108/134 (81%) children. FAS/pFAS prevalence was determined using modified Canadian diagnostic guidelines.

RESULTS

In 127 pregnancies, alcohol was used in 55%. FAS or pFAS was diagnosed in 13/108 children, a prevalence of 120 per 1000 (95% confidence interval 70-196). Prenatal alcohol exposure was confirmed for all children with FAS/pFAS, 80% in the first trimester and 50% throughout pregnancy. Ten of 13 mothers had Alcohol Use Disorders Identification Test scores and all drank at a high-risk level. Of children with FAS/pFAS, 69% had microcephaly, 85% had weight deficiency and all had facial dysmorphology and central nervous system abnormality/impairment in three to eight domains.

CONCLUSIONS

The population prevalence of FAS/pFAS in remote Aboriginal communities of the Fitzroy Valley is the highest reported in Australia and similar to that reported in high-risk populations internationally. Results are likely to be generalisable to other age groups in the Fitzroy Valley and other remote Australian communities with high-risk alcohol use during pregnancy. Prevention of FAS/pFAS is an urgent public health challenge.

Fetal alcohol spectrum disorders: notifications to the Western Australian Register of Developmental Anomalies

AIM

There is increasing attention on fetal alcohol spectrum disorders (FASD) in Australia, but there are limited data on their birth prevalence. Our aim was to report on the birth prevalence of FASD in Western Australia.

METHODS

Data on notified cases of FASD born in Western Australia 1980-2010 were identified from the Western Australian Register of Developmental Anomalies. Tabulated denominator data were obtained from the Midwives Notification System. Prevalence rates per 1000 births were calculated by demographic variables. Prevalence ratios (PRs) and 95% confidence intervals (CIs) of Aboriginal compared with non-Aboriginal prevalence rates were calculated. PRs were also calculated to compare rates for births 2000-2010 with 1980-1989.

RESULTS

Two hundred ten cases of FASDs were identified: a birth prevalence of 0.26/1000 births (95% CI 0.23-0.30). The majority of cases reported were Aboriginal (89.5%), a rate of 4.08/1000, compared with 0.03/1000 in notified non-Aboriginal cases, giving a PR of 139 (95% CI 89-215). The prevalence of FASD in 2000-2010 was over twice that in 1980-1989 for both Aboriginal (PR 2.37; CI 1.60-3.51) and non-Aboriginal (PR 2.13; CI 0.68-6.69) children.

CONCLUSIONS

There has been a twofold increase in FASD notifications in Western Australia over the last 30 years. Population surveillance data such as these are valuable in advocating for and monitoring the effectiveness of preventive activities and diagnostic and management services.

Intellectual disability and indigenous Australians: an overview

The review summarizes important literature in the emerging field of intellectual disability (ID) in indigenous Australians. Search of various electronic databases revealed 19 papers that provide information regarding prevalence, sociodemographic factors, and issues in assessment and management. Overall, there is limited information regarding ID in indigenous Australians, which is reported to be more prevalent compared with nonindigenous Australians. Sociocultural constructs affect what is considered to be ID in indigenous communities and this may be at odds with western notions. Other difficulties include lack of validated psychometric instruments to effectively measure cognitive functioning in indigenous Australians. Prenatal, perinatal, and postnatal factors are significant factors that impair brain development and contribute to ID in indigenous communities. Comorbid physical and psychiatric disorders need to be assessed and managed. This paper provides an overview of current knowledge regarding this important area that requires further research, appropriate training, and resourcing.

Education, safe drinking practices and fetal alcohol spectrum disorder in the Kimberley region of Western Australia

AIM

There are alarming rates of fetal alcohol spectrum disorder (FASD) in the Kimberley region of Western Australia despite numerous international studies demonstrating the links between alcohol consumption during pregnancy and FASD. The aim of this research was to help determine factors that may be associated with correct knowledge about safe drinking practices during pregnancy, with these factors used to help inform future interventions.

METHOD

Ninety-nine residents (40 males, 59 females, 39% of which self-identified as Indigenous) from the Kimberley region (Broome and smaller remote communities) completed a survey examining knowledge of currently recommended safe drinking practices during pregnancy and knowledge of the outcomes for children with FASD over a period of approximately 2 months.

RESULTS

The results revealed that education level (i.e. not completing high school through to completing university) is the biggest predictor (β = 0.44, P < 0.01) of knowledge of safe drinking practices during pregnancy, and having heard of FASD (β = 0.67, P < 0.001) was the biggest predictor of knowledge of outcomes for children with FASD. Other variables such as age, sex, Indigenous status and income level were not as important.

CONCLUSIONS

These findings suggest that early education regarding the consequences of alcohol consumption for women of childbearing age should be paramount in this or similar communities. Suggestions for targeted interventions are discussed in light of these findings.

Electronic clinical laboratory reports as a source for ascertaining and confirming chromosomal anomalies reported to the New York State Congenital Malformations Registry

CONTEXT

Hospitals and physicians are required to submit case reports with confirmatory diagnosis information to the New York State Congenital Malformations Registry (CMR) on children who are born or reside in New York State and are diagnosed with major birth defects. However, the majority of the cases with chromosomal anomalies indicated in the hospital discharge files are reported to the CMR without confirmatory testing data, which are usually not available at the time of reporting.

OBJECTIVE

To link the cytogenetic test reports, submitted by cytogenetic testing laboratories via Electronic Clinical Laboratory Reporting System (ECLRS), to the CMR cases in order to obtain confirmatory diagnoses and identify unreported cases with chromosomal anomalies.

DESIGN

: Cytogenetic testing data, submitted by the New York State licensed laboratories, that are stored on the ECLRS Sybase server were retrieved and matched to the CMR cases. The laboratory testing results were used to confirm diagnoses of the CMR cases for matched reports and to ascertain new birth defects cases by auditing hospitals and physicians using unmatched reports with abnormal testing results.

RESULTS

By the end of 2010, a total of 927 reports on 747 children were submitted to the CMR by 14 cytogenetic testing laboratories via the New York State Department of Health ECLRS. Among the 747 children reported, 398 children (53%) had abnormal test results and 412 children (55%) were matched to the CMR cases. From these laboratory reports, 151 new cases with chromosomal anomalies were identified, confirmed, and were added to the CMR. The additional cases accounted for about 7.8% of all cases with chromosomal anomalies in the CMR for the reporting years 2008-2010.

CONCLUSIONS

Cytogenetic laboratory reports can serve as an important source for ascertaining and confirming chromosomal anomalies. Acquiring molecular genetics testing data directly from cytogenetic testing laboratories via ECLRS enables CMR staff to confirm diagnoses and improve the accuracy and efficiency of case reporting.

Off-label use of ondansetron in pregnancy in Western Australia

Aims. Nausea and vomiting of pregnancy is the most common medical condition in pregnancy. There is an increasing trend to prescribe ondansetron although its safety for use in pregnancy has not been established. Methods. Exposed pregnancies were all births in Western Australia, 2002–2005, where the mother was dispensed ondansetron under the Australian Pharmaceutical Benefits Scheme, compared with all other births during the same period. Outcomes investigated include maternal and child characteristics, birth defects, pregnancy, and delivery characteristics. Results. There were 96,968 births from 2002 to 2005. Ondansetron was dispensed to 251 pregnant women during this period. The women dispensed ondansetron were more likely to be privately insured (OR: 5.8; 95% CI: 4.3–7.9), to be Caucasian (3.3; 1.9–5.7), not to smoke during their pregnancy (2.9; 1.8–4.7), to have a multiple birth (2.7; 1.5–5.0), and to have used fertility treatment (1.8; 1.0–3.4). There was a small but not significantly increased risk of a major birth defect with first trimester exposure (1.2; 0.6–2.2). Conclusions. Our study did not detect any adverse outcomes from the use of ondansetron in pregnancy but could not conclude that ondansetron is safe to use in pregnancy.

Alcohol use in pregnancy: prevalence and predictors in the Longitudinal Study of Australian Children

INTRODUCTION AND AIMS

This study aimed to estimate the prevalence and describe the patterns of alcohol use during pregnancy among Australian mothers. The study also aimed to examine the characteristics associated with alcohol use in pregnancy.

DESIGN AND METHODS

Data comprised two representative samples of families (infant cohort = 5107 parents of 0- to 1-year-olds; child cohort = 4983 parents of 4- to 5-year-olds) from the 2005 Longitudinal Study of Australian Children.

RESULTS

Alcohol use in pregnancy was reported by 37.6% of mothers of infants aged 0-1 years and 27.6% of mothers of children aged 4-5 years. The majority of women reported low level/occasional use of alcohol but, when extrapolated to population level, this equates to 131,250 children in these two age groups exposed to alcohol in utero, with over 1000 children exposed to alcohol most days and an estimated 671 infants exposed to three or more drinks per occasion. Among mothers of infants, alcohol use in pregnancy was associated with increasing maternal age, higher education, greater economic advantage and fewer physical health problems in pregnancy. Among mothers of children, maternal drinking in pregnancy was associated with increasing maternal age and smoking in pregnancy.

DISCUSSION AND CONCLUSIONS

Alcohol use during pregnancy is common with around one-third of all mothers reporting use. Most women reported only occasional use, and among those who were asked, consumed one standard drink on average per occasion. Significant numbers were exposed to three or more drinks on one occasion or to alcohol most days while in utero. National guidelines recommend abstinence as no 'safe' threshold has been determined. Public health campaigns are needed to educate pregnant women regarding national guidelines.

Counting fetal alcohol spectrum disorder in Australia: the evidence and the challenges

ISSUES

Alcohol exposure in utero is associated with a range of adverse outcomes in pregnancy and can cause long-term disability. Fetal alcohol spectrum disorder (FASD) is an umbrella term to describe a range of effects from prenatal alcohol exposure including fetal alcohol syndrome (FAS). Determining the prevalence of FASD is challenging.

APPROACH

This narrative review collates information on the prevalence of FASD in Australia and documents the various methods used for attaining estimates and the limitations of the available data.

KEY FINDINGS

Birth prevalence of FASD is most commonly measured through clinic-based studies, passive surveillance systems and active case ascertainment. Alcohol use in pregnancy and FAS in Australia is predominantly monitored through passive surveillance systems and under-ascertainment of cases is likely. State- and territory-based studies have reported birth prevalence rates of FAS of between 0.01 and 0.68 per 1000 live births. Prevalence rates of FASD have not been estimated in Australia. As reflected in the international data, Australian studies have found higher rates of FAS among some Indigenous communities. This likely reflects patterns of alcohol use and other socioeconomic risk factors.

IMPLICATIONS

Under-recognition of FASD reflects incomplete and inconsistent data collections recording alcohol use in pregnancy, lack of awareness among health professionals and a lack of diagnostic and support services.

CONCLUSION

Accurate measurement of FASD prevalence is crucial to inform policy, resource and service development in the areas of health, education, justice and community. There is a need for consensus on the collection and best use of data. [Burns L, Breen C, Bower C, O' Leary C, Elliott EJ. Counting fetal alcohol spectrum disorders in Australia: the evidence and the challenges. Drug Alcohol Rev 2013;32:461-467].

Intellectual disability: population-based estimates of the proportion attributable to maternal alcohol use disorder during pregnancy

AIM

The aim of this study was to examine the association between maternal alcohol use disorder and intellectual disability in children.

METHOD

All mothers with an International Classification of Diseases (ICD) 9 and/or 10 alcohol-related diagnosis, a proxy for alcohol use disorder, recorded on the Western Australian health, mental health, and drug and alcohol data sets were identified through the Western Australian Data Linkage Unit (n=5614 non-Aboriginal; n=2912 Aboriginal). A comparison cohort of mothers without an alcohol-related diagnosis was frequency matched on maternal age within maternal Aboriginal status and year of birth of their children. Linkage with the Western Australian Midwives Notification System (1983-2001) identified all births to these mothers (n=10 664 and 7907 respectively). Linkage to the Western Australian Intellectual Disability Database and Register of Developmental Anomalies identified cases of intellectual disability with no identified genetic origin (intellectual disability) (n=1487) and fetal alcohol syndrome (n=66). Odds ratios (ORs) and 95% confidence intervals (CIs) for intellectual disability were calculated using logistic regression incorporating generalized estimating equations and used to estimate population-attributable fractions.

RESULTS

At least 3.8% (95% CI 2.84-4.89%) of cases of intellectual disability could be avoided by preventing maternal alcohol use disorder: 1.3% (95% CI 0.81-1.86%) in non-Aboriginal and 15.6% (95% CI 10.85-20.94%) in Aboriginal children. We observed a three-fold increase in the adjusted odds of intellectual disability in children of mothers with an alcohol-related diagnosis recorded during pregnancy (non-Aboriginal OR 2.89, 95% CI 1.62-5.18; Aboriginal OR 3.12, 95% CI 2.13-4.56), with a net excess proportion of 3.7% and 5.5% respectively. One-third (32%) of children diagnosed with fetal alcohol syndrome had intellectual disability.

INTERPRETATION

Maternal alcohol use disorder is the leading known risk factor for intellectual disability with no identified genetic origin.

Alcohol-use disorders during and within one year of pregnancy: a population-based cohort study 1985-2006

OBJECTIVES

To examine alcohol-use disorders in pregnant women and the extent of under-reporting.

DESIGN

Population-based cohort study.

SETTING

Western Australia.

POPULATION

Women with a birth recorded on the Western Australian Midwives Notification System (1985-2006).

METHODS

Mothers with an International Classification of Diseases 9/10 alcohol-related diagnosis, indicating heavy alcohol consumption, recorded on population-based health datasets (non-Aboriginal n=5,839; Aboriginal n=2,583) were identified through the Western Australian data-linkage system. This 'exposed' cohort was frequency matched (on maternal age, year of birth of offspring, Aboriginal status) with comparison mothers without an alcohol-related diagnosis (non-Aboriginal n=33,979; Aboriginal n=8,005).

MAIN OUTCOME MEASURES

Trends in maternal alcohol diagnoses in relation to pregnancy for non-Aboriginal and Aboriginal women. The proportion of children diagnosed with fetal alcohol syndrome (FAS) who had a mother with an alcohol diagnosis recorded during pregnancy.

RESULTS

The proportion of Aboriginal mothers in Western Australia with an alcohol diagnosis (23.1%) is ten times greater than for non-Aboriginal mothers (2.3%). There has been a six-fold increase in the percentage of non-Aboriginal births with a maternal alcohol diagnosis recorded during pregnancy and a 100-fold increase for Aboriginal births. Around 70% of the mothers of children diagnosed with FAS did not have an alcohol diagnosis recorded during pregnancy and 18% of the mothers had no record of an alcohol diagnosis.

CONCLUSIONS

Maternal alcohol exposure during pregnancy is significantly under-ascertained. Given the severe risks to the fetus from heavy prenatal alcohol exposure, assessment and recording of alcohol use should be routinely undertaken in maternity and other health settings.

Early morbidity and mortality following in utero exposure to selective serotonin reuptake inhibitors: a population-based study in Western Australia

BACKGROUND

The early years of life have a profound effect on a child's developmental pathway. The children born to mothers suffering from depression may be at risk of increased morbidity and mortality in the first years of life.

OBJECTIVE

The objective of this study was to investigate the hospital admissions and mortality of children whose mothers were dispensed a selective serotonin reuptake inhibitor (SSRI) during their pregnancy.

METHODS

This was a population-based study of all pregnancy events in Western Australia (WA) from 2002 to 2005. The study used linkable state health administrative data from the WA Data Linkage System (WADLS) and the national Pharmaceutical Benefits Scheme (PBS), enabling birth outcomes, hospital admissions and deaths to be ascertained for the children of women dispensed an SSRI during their pregnancy.

RESULTS

There were 3764 children born to 3703 women who had been dispensed an SSRI during their pregnancy (3.8% of all pregnancies in WA, 2002-5), and 94 561 children born to 92 995 women who had not been dispensed an SSRI. Mean birth weight, length and APGAR score at 5 minutes were significantly lower in children of women dispensed an SSRI, regardless of whether the SSRI was dispensed in trimester 1, or, trimester 2 or 3 only. 0.9% of the live born children in the SSRI group had died before the age of 1 year compared with 0.5% of the non-SSRI group (odds ratio [OR] 1.8; 95% CI 1.3, 2.6). Before the age of 2 years, 42.9% of the children in the SSRI group had been admitted to hospital after their birth admission, compared with 34.1% of the non-SSRI group (OR 1.4; 95% CI 1.3, 1.6). The most common reason for admission to hospital was acute bronchiolitis (OR 1.6; 95% CI 1.3, 1.8), with an increased risk seen in children of mothers who did not smoke during their pregnancy (OR 1.7; 95% CI 1.4, 2.0).

CONCLUSIONS

The children in the SSRI group were more likely to be admitted to hospital in the first years of life, and this may reflect their prenatal exposure to SSRIs, be related to maternal depression, or SSRI use may be a proxy for an environmental exposure such as smoking, or a combination of these factors. Although the numbers of deaths in the first year of life were small, the increased risk of death in the first year of life in the SSRI group (OR 1.8; 95% CI 1.3, 2.6) is a new finding and should be investigated further.

Health professionals' perceptions about the adoption of existing guidelines for the diagnosis of fetal alcohol spectrum disorders in Australia

Background

Despite the availability of five guidelines for the diagnosis of fetal alcohol spectrum disorders (FASD), there is no national endorsement for their use in diagnosis in Australia. In this study we aimed to describe health professionals’ perceptions about the adoption of existing guidelines for the diagnosis of FASD in Australia and identify implications for the development of national guidelines.

Methods

We surveyed 130 Australian and 9 international health professionals with expertise or involvement in the screening or diagnosis of FASD. An online questionnaire was used to evaluate participants’ familiarity with and use of five existing diagnostic guidelines for FASD, and to assess their perceptions about the adoption of these guidelines in Australia.

Results

Of the 139 participants surveyed, 84 Australian and 8 international health professionals (66.2%) responded to the questions on existing diagnostic guidelines. Participants most frequently reported using the University of Washington 4-Digit Diagnostic Code (27.2%) and the Canadian guidelines (18.5%) for diagnosis. These two guidelines were also most frequently recommended for adoption in Australia: 32.5% of the 40 participants who were familiar with the University of Washington 4-Digit Diagnostic Code recommended adoption of this guideline in Australia, and 30.8% of the 26 participants who were familiar with the Canadian guidelines recommended adoption of this guideline in Australia. However, for the majority of guidelines examined, most participants were unsure whether they should be adopted in Australia. The adoption of existing guidelines in Australia was perceived to be limited by: their lack of evidence base, including the appropriateness of established reference standards for the Australian population; their complexity; the need for training and support to use the guidelines; and the lack of an interdisciplinary and interagency model to support service delivery in Australia.

Conclusions

Participants indicated some support for the adoption of the University of Washington or Canadian guidelines for FASD diagnosis; however, concerns were raised about the adoption of these diagnostic guidelines in their current form. Australian diagnostic guidelines will require evaluation to establish their validity in the Australian context, and a comprehensive implementation model is needed to facilitate improved diagnostic capacity in Australia.

The Lililwan Project: study protocol for a population-based active case ascertainment study of the prevalence of fetal alcohol spectrum disorders (FASD) in remote Australian Aboriginal communities

INTRODUCTION

Anecdotal reports suggest that high-risk drinking in pregnancy is common in some remote Australian communities. Alcohol is teratogenic and may cause a range of lifelong conditions termed 'fetal alcohol spectrum disorders' (FASD). Australia has few diagnostic services for FASD, and prevalence of these neurodevelopmental disorders remains unknown. In 2009, Aboriginal leaders in the remote Fitzroy Valley in North Western Australia identified FASD as a community priority and initiated the Lililwani Project in partnership with leading research organisations. This project will establish the prevalence of FASD and other health and developmental problems in school-aged children residing in the Fitzroy Valley, providing data to inform FASD prevention and management.

METHODS AND ANALYSIS

This is a population-based active case ascertainment study of all children born in 2002 and 2003 and residing in the Fitzroy Valley. Participants will be identified from the Fitzroy Valley Population Project and Communicare databases. Parents/carers will be interviewed using a standardised diagnostic questionnaire modified for local language and cultural requirements to determine the demographics, antenatal exposures, birth outcomes, education and psychosocial status of each child. A comprehensive interdisciplinary health and neurodevelopmental assessment will be performed using tests and operational definitions adapted for the local context. Internationally recognised diagnostic criteria will be applied to determine FASD prevalence. Relationships between pregnancy exposures and early life trauma, neurodevelopmental, health and education outcomes will be evaluated using regression analysis. Results will be reported according to STROBE guidelines for observational studies.

ETHICS AND DISSEMINATION

Ethics approval has been granted by the University of Sydney Human Research Ethics Committee, the Western Australian Aboriginal Health Information and Ethics Committee, the Western Australian Country Health Service Board Research Ethics Committee and the Kimberley Aboriginal Health Planning Forum Research Sub-committee. Results will be disseminated widely through peer-reviewed manuscripts, reports, conference presentations and the media.

Total population investigation of dental hospitalizations in indigenous children under five years in Western Australia using linked data

BACKGROUND

The aim of this study was to compare dental hospital admissions in a total state birth population of Indigenous and non-Indigenous children aged under five years in Western Australia.

METHODS

Midwives' notification data were linked to databases of deaths, admissions, birth defects and intellectual disability. Births during 1980-1995 were followed until five years of age (n = 383,665). Dental admissions were classified by ICD-9 principal diagnosis categories.

RESULTS

There were 738 dental admissions for 665 children aged up to five years of Indigenous mothers (n = 20,921). Indigenous children comprised 6.3% of all children having a dental admission in this age group; 3.2% of children with Indigenous mothers had a dental admission compared with 2.7% of non-Indigenous children. Overall, 8.7% (n = 58) of Indigenous children with a dental admission had a birth defect and 5.5% (n = 23) had an intellectual disability (compared to 8.8% and 3.2%). Indigenous children were four times more likely to be diagnosed with oral soft tissue diseases than non-Indigenous children, and less likely to be categorized as having diseases of the dental hard tissues. Indigenous children were more likely to have a longer dental admission.

CONCLUSIONS

These analyses provide important findings regarding hospital admissions for Indigenous children. Admissions for disorders of the soft tissues are more common in Indigenous children.

Paediatricians' knowledge, attitudes and practice following provision of educational resources about prevention of prenatal alcohol exposure and Fetal Alcohol Spectrum Disorder

AIM

The study aims to provide paediatricians in Western Australia (WA) with educational resources (http://www.ichr.uwa.edu.au/alcoholandpregnancy) about the prevention of prenatal alcohol exposure and fetal alcohol spectrum disorder, and assess changes in their knowledge, attitudes and practice about fetal alcohol syndrome (FAS) and alcohol consumption in pregnancy.

METHODS

Following our 2004 survey of paediatricians, we developed and distributed educational resources to 159 paediatricians in WA in 2007. Six months later, we surveyed these paediatricians and compared their responses with results from 2004 using prevalence rate ratios (PRRs) and 95% confidence intervals (CIs).

RESULTS

Of 133 eligible paediatricians, 82 (61.7%) responded: 65.9% had seen the resources, of these 66.7% had used them and 29.6% said the resources had helped them change, or influenced their intent to change, their practice. There was no change in the proportion that knew all the essential features of FAS (18.3% in 2007; 20.0% in 2004) or had diagnosed FAS (58.5% in 2007; 58.9% in 2004). An increased proportion (75.6% in 2007; 48.9% in 2004) agreed that pregnant women should completely abstain from consuming alcohol (PRR 1.55, 95% CI 1.21-1.97). Only 21.7% (no increase from 2004) routinely asked about alcohol use when taking a pregnancy history.

CONCLUSIONS

We recommend that asking about alcohol use during pregnancy should be emphasised in paediatric training. Unless paediatricians' capacity to ask about alcohol consumption when taking a pregnancy history and to diagnose FAS is increased, FAS will remain under-diagnosed in Australia and opportunities for management, early intervention and prevention will be overlooked.

Changes in health professionals' knowledge, attitudes and practice following provision of educational resources about prevention of prenatal alcohol exposure and fetal alcohol spectrum disorder

We provided health professionals in Western Australia (WA) with educational resources about prevention of prenatal alcohol exposure and fetal alcohol spectrum disorder and assessed changes in their knowledge, attitudes and practice concerning fetal alcohol syndrome (FAS) and alcohol consumption in pregnancy. Following our 2002 survey of health professionals in WA, we developed and distributed educational resources to 3348 health professionals in WA in 2007. Six months later we surveyed 1483 of these health professionals. Prevalence rate ratios [PRR] and 95% confidence intervals [CI] were calculated to compare 2007 results with results from the 2002 survey. Of the 1001 responding health professionals, 69.8% had seen the educational resources; of these 77.1% have used them and 48.5% said the resources had assisted them to change their practice or their intention to change their practice. Compared with 2002, there was an increase in the proportion who knew all the essential features of FAS from 11.7% to 15.8% [PRR 1.35; 95% CI 1.09, 1.67] and had diagnosed FAS, from 4.8% to 7.3% [PRR 1.52; 95% CI 1.08, 2.13]. In 2007, 98.1% of health professionals stated they would advise pregnant women to consider not drinking at all or advise them that no alcohol in pregnancy is the safest choice. Health professionals surveyed in 2007 have increased their knowledge, changed their attitudes and practice about FAS, and altered the advice they give to pregnant women about alcohol consumption since our survey in 2002. It is essential that we build on this change and continue to support health professionals' knowledge, attitudes and practice about the prevention of prenatal alcohol exposure and fetal alcohol spectrum disorder. The educational resources for health professionals may be ordered as hard copies and downloaded from the internet http://www.ichr.uwa.edu.au/alcoholandpregnancy.

RE-AIM evaluation of the Alcohol and Pregnancy Project: educational resources to inform health professionals about prenatal alcohol exposure and fetal alcohol spectrum disorder

The objective was to evaluate the Alcohol and Pregnancy Project that provided health professionals in Western Australia (WA) with educational resources to inform them about prevention of prenatal alcohol exposure and fetal alcohol spectrum disorder (FASD). The authors developed, produced, and distributed educational resources to 3,348 health professionals in WA. Six months later, they surveyed 1,483 of these health professionals. The authors used the RE-AIM framework (reach, effectiveness, adoption, implementation, and maintenance) to evaluate the project. The educational resources were effective in producing a 31% increase in the proportion of health professionals who routinely provided pregnant women with information about the consequences of drinking alcohol during pregnancy. One hundred percent of the settings adopted the project, it reached 96.3% of the target population, it was implemented as intended, and the resources were maintained (http://www.ichr.uwa.edu.au/alcoholandpregnancy). The educational resources for health professionals have potential to contribute to reducing prenatal alcohol exposure and FASD.

Dispensing patterns and pregnancy outcomes for women dispensed selective serotonin reuptake inhibitors in pregnancy

BACKGROUND

The safety of selective serotonin reuptake inhibitors (SSRIs) during pregnancy remains uncertain. The purpose of this study was to investigate dispensing patterns and pregnancy outcomes for women dispensed an SSRI in pregnancy.

METHODS

Using data linkage of population-based health datasets from Western Australia and a national pharmaceutical claims dataset, our study included 123,405 pregnancies from 2002 to 2005. There were 3764 children born to 3703 women who were dispensed an SSRI during their pregnancy.

RESULTS

A total of 42.3% of the women were dispensed an SSRI in each trimester, and 97.6% of the women used the same SSRI throughout the first trimester without switching. The women who were dispensed an SSRI were more likely to give birth prematurely (adjusted odds ratio [aOR], 1.4; 95% confidence interval [CI], 1.2-1.7), to have smoked during the pregnancy (OR, 1.9; 95% CI, 1.8-2.1), and parity>1 (OR, 1.7; 95% CI, 1.5-1.8). The singletons were found to have a lower birth weight than expected when other factors were taken into account (OR, 1.2; 95% CI, 1.1-1.3). There was an increased risk of major cardiovascular defects (OR, 1.6; 95% CI, 1.1-2.3). The children of women dispensed citalopram during the first trimester had an increased risk of vesicoureteric reflux (OR, 3.1; 95% CI, 1.3-7.6). Children born to women dispensed sertraline had a higher mean birth weight than those born to women dispensed citalopram, paroxetine, or fluoxetine. This pattern was also seen in birth length.

CONCLUSIONS

Most women were dispensed the same SSRI throughout their pregnancy. We have confirmed previous findings with an increased risk of cardiovascular defects and preterm birth. New findings requiring confirmation include an increased risk of vesicoureteric reflux with the use of citalopram.

Prenatal alcohol exposure and risk of birth defects

OBJECTIVE

The goal was to examine the associations between dose, pattern, and timing of prenatal alcohol exposure (PAE) and birth defects.

METHODS

Data from a randomly selected, population-based cohort of nonindigenous women who gave birth to a live infant in Western Australia (WA) between 1995 and 1997 (N=4714) were linked to WA Midwives Notification System and WA Birth Defects Registry data. We assessed the associations of PAE before pregnancy, in the first trimester, and in late pregnancy with any birth defect and with birth defects classified as alcohol-related birth defects (ARBDs) by the Institute of Medicine (IOM), by using logistic regression.

RESULTS

The prevalence of birth defects classified as ARBDs by the IOM was low. Compared with abstinence, heavy PAE in the first trimester was associated with increased odds of birth defects classified as ARBDs (adjusted odds ratio: 4.6 [95% confidence interval: 1.5-14.3]), with similar findings after validation through bootstrap analysis. There was no association between low or moderate PAE and birth defects.

CONCLUSIONS

A fourfold increased risk of birth defects classified as ARBDs was observed after heavy PAE in the first trimester. Many individual birth defects included in the IOM classification for ARBDs either were not present in this cohort or were not associated with PAE. Large, population-based studies are needed to strengthen the evidence base for ARBDs.

Prevalence and epidemiologic characteristics of FASD from various research methods with an emphasis on recent in-school studies

Researching the epidemiology and estimating the prevalence of fetal alcohol syndrome (FAS) and other fetal alcohol spectrum disorders (FASD) for mainstream populations anywhere in the world has presented a challenge to researchers. Three major approaches have been used in the past: surveillance and record review systems, clinic-based studies, and active case ascertainment methods. The literature on each of these methods is reviewed citing the strengths, weaknesses, prevalence results, and other practical considerations for each method. Previous conclusions about the prevalence of FAS and total FASD in the United States (US) population are summarized. Active approaches which provide clinical outreach, recruitment, and diagnostic services in specific populations have been demonstrated to produce the highest prevalence estimates. We then describe and review studies utilizing in-school screening and diagnosis, a special type of active case ascertainment. Selected results from a number of in-school studies in South Africa, Italy, and the US are highlighted. The particular focus of the review is on the nature of the data produced from in-school methods and the specific prevalence rates of FAS and total FASD which have emanated from them. We conclude that FAS and other FASD are more prevalent in school populations, and therefore the general population, than previously estimated. We believe that the prevalence of FAS in typical, mixed-racial, and mixed-socioeconomic populations of the US is at least 2 to 7 per 1,000. Regarding all levels of FASD, we estimate that the current prevalence of FASD in populations of younger school children may be as high as 2-5% in the US and some Western European countries.

Association of maternal pre-pregnancy weight with birth defects: evidence from a case-control study in Western Australia

BACKGROUND

Maternal obesity confers increased risks of poor pregnancy outcomes. There are limited Australian data on the risk of birth defects associated with maternal pre-pregnancy obesity.

METHODS

Population-based case-control study of 418 controls, 111 cases with heart defects (and of these, 38 had conotruncal heart defects), 27 with neural tube defects, 86 cases with urinary tract defects, 48 cases with orofacial clefts, and 20 with limb reduction defects. Maternal pre-pregnancy weight and height were self-reported.

RESULTS

Women with pre-pregnancy obesity (body mass index 30+) had a twofold increased odds of having an infant with neural tube defects, conotruncal heart defects, orofacial clefts and limb reduction defects and 30-40% increase in heart defects generally and urinary tract defects. None of the estimates was statistically significant.

CONCLUSIONS

Our findings were consistent with similar, statistically significant studies in the literature. Weight reduction prior to pregnancy in obese women may be a means of primary prevention of birth defects.

Birth defects in children with autism spectrum disorders: a population-based, nested case-control study

The causes of autism spectrum disorders (ASDs) are unknown, although genetic and environmental influences have been implicated. Previous studies have suggested an association with birth defects, but most investigators have not addressed associations with specific diagnostic categories of ASD. In this study, the authors investigated the associations between birth defects and autism, Asperger syndrome, and pervasive developmental disorder not otherwise specified. Using Western Australian population-based linked data, the authors compared all children with ASD born in Western Australia during 1980-1995 (n = 465) with their siblings (n = 481) and population controls (n = 1,313) in a nested case-control study. The prevalence of birth defects was significantly higher in ASD cases than in population controls; this difference remained significant after adjustment for confounding factors. Odds ratios for birth defects were similar for autism (odds ratio (OR) = 2.0, 95% confidence interval (CI): 1.3, 3.0) and pervasive developmental disorder not otherwise specified (OR = 2.2, 95% CI: 1.1, 4.3) but not for Asperger syndrome (OR = 0.5, 95% CI: 0.1, 1.9). Birth defects in case siblings were not significantly different from those in cases and population controls. The association between birth defects and ASD may be due to underlying genetic and/or environmental factors common to both ASD and birth defects, or birth defects may predispose a child to ASD.

Need to establish a national diagnostic capacity for foetal alcohol spectrum disorders

Alcohol exposure in pregnancy can induce a broad range of physical and developmental defects in the child, collectively known as foetal alcohol spectrum disorders (FASD). In Australia, there are proven gaps in our knowledge and practice for recognising and diagnosing FASD. The challenge for the Australian health professional is agreeing on a model for diagnosing and treating FASD. The diagnostic method must be evidence based, sensitive and specific, and account for other exposures during pregnancy and early life events. Training in application of the diagnostic method needs to be readily available in metropolitan and regional Australia. The University of Washington FASD 4-digit diagnostic code fulfils all of these best practice criteria, recommending itself as the method of choice.

Risk of birth defects in Australian communities with high levels of brominated disinfection by-products

BACKGROUND

By international standards, water supplies in Perth, Western Australia, contain high trihalomethane (THM) levels, particularly the brominated forms. Geographic variability in these levels provided an opportunity to examine cross-city spatial relationships between THM exposure and rates of birth defects (BDs).

OBJECTIVES

Our goal was to examine BD rates by exposure to THMs with a highly brominated fraction in metropolitan locations in Perth, Western Australia.

METHODS

We collected water samples from 47 separate locations and analyzed them for total and individual THM concentrations (micrograms per liter), including separation into brominated forms. We classified collection areas by total THM (TTHM) concentration: low (< 60 microg/L), medium (> 60 to < 130 microg/L), and high (> or = 130 microg/L). We also obtained deidentified registry-based data on total births and BDs (2000-2004 inclusive) from post codes corresponding to water sample collection sites and used binomial logistic regression to compare the frequency of BDs aggregately and separately for the TTHM exposure groups, adjusting for maternal age and socioeconomic status.

RESULTS

Total THMs ranged from 36 to 190 microg/L. A high proportion of the THMs were brominated (on average, 92%). Women living in high-TTHM areas showed an increased risk of any BD [odds ratio (OR) = 1.22; 95% confidence interval (CI), 1.01-1.48] and for the major category of any cardiovascular BD (OR = 1.62; 95% CI, 1.04-2.51), compared with women living in low-TTHM areas.

CONCLUSIONS

Brominated forms constituted the significant fraction of THMs in all areas. Small but statistically significant increases in risks of BDs were associated with residence in areas with high THMs.

International survey of diagnostic services for children with Fetal Alcohol Spectrum Disorders

BACKGROUND

Early diagnosis and intervention for children with Fetal Alcohol Spectrum Disorder (FASD) reduces the risk of developing a range of secondary social, emotional and behavioural problems and provides an opportunity for prevention of further alcohol exposed pregnancies. The objective of this study was to describe specialist clinical service provision for the diagnosis and assessment of children exposed to alcohol in pregnancy.

METHODS

Fetal Alcohol Spectrum Disorder (FASD) diagnostic clinics were identified through literature and internet searches. Clinics were sent a questionnaire asking for information on the clinic population, clinic staff, assessment process and other services provided.

RESULTS

Questionnaires were completed for 34 clinics: 29 were in North America, 2 in Africa, 2 in Europe and 1 in South America. No clinics were identified in Asia or Australasia. There was a variety of funding sources, services offered, clinic populations, staff and methods of assessment. Thirty-three clinics had a multi-disciplinary team. In 32 clinics, at least one member of the team had specialist training in assessment of FASD. Neurobehavioural assessment was completed in 32 clinics. Eleven clinics used more than one set of diagnostic criteria or an adaptation of published criteria.

CONCLUSION

Diagnostic services are concentrated in North America. Most responding clinics are using a multidisciplinary approach with neurobehavioural assessment as recommended in published guidelines. Agreement on diagnostic criteria would enable comparison of clinical and research data, and enhance FASD research particularly for intervention trials.

Estimating the prevalence of fetal alcohol syndrome in Victoria using routinely collected administrative data

OBJECTIVE

To establish the prevalence of fetal alcohol syndrome (FAS) in Victoria through the Victorian Birth Defects Register (VBDR).

METHODS

A sample of live births from 1995-2002 was selected from the Victorian Perinatal Data Collection and VBDR based on reported microcephaly, FAS or maternal use of alcohol during pregnancy. Following ethics approval, medical records of mother and child were requested for 117 births. One hundred and nine of these were accessed and examined for factors related to FAS. Records were categorised as FAS, possible FAS, unable to categorise, or not FAS.

RESULTS

From the VBDR the prevalence was calculated at 0.006 per 1,000 live births. Four additional possible cases of FAS increased this to 0.014 per 1,000 live births. Six cases were defined as 'unable to categorise' as alcohol use was unknown but other features of FAS were evident. Including these cases, plus five where some low-level alcohol use was reported, increased the prevalence to 0.03 per 1,000 live births. Twenty-eight per cent of the audit population and 39% of the microcephalic cases had no information about maternal alcohol use recorded in the antenatal or babies' records.

CONCLUSION AND IMPLICATIONS

The audit of medical records provided additional information regarding FAS prevalence in Victoria. This prevalence ranges from 0.01 to 0.03 per 1,000 live births. To accurately assess the extent of the problem, there needs to be improved reporting of alcohol use in pregnancy and a system in place to report cases diagnosed during and beyond the perinatal period to the VBDR.

Community attitudes to the collection and use of identifiable data for health research--is it an invasion of privacy?

OBJECTIVES

To investigate community views on the statutory collection of identifiable data by the Western Australian Birth Defects Registry and the extent to which the use of such data is perceived to be an invasion of privacy, when balanced against the community benefit of three public health scenarios.

METHODS

Cross-sectional, computer-assisted telephone interviewing survey. Six hundred respondents were recruited randomly from the electronic version of the Western Australian telephone directory.

RESULTS

Interviews were conducted in August 2006 and the response rate was 78%. Most respondents indicated support for statutory notification of cases (79%) and did not consider the statutory notification of postcodes (85%) and names and addresses (65%) to be an invasion of privacy. Similarly, most (76%) did not consider the receipt of a letter requesting participation in research to be an invasion of privacy. Overall, 55% considered none of these to be an invasion of privacy and only 4% considered all to be an invasion of privacy.

CONCLUSIONS

Most Western Australians do not consider the statutory inclusion and use of identifiable data by the WA Birth Defects Registry to be an invasion of privacy, to the extent that such data are required for legitimate public health research, would be notified by the registrant's medical practitioner and would be kept confidentially and securely.

A review of policies on alcohol use during pregnancy in Australia and other English‐speaking countries, 2006

It is well accepted that heavy alcohol consumption during pregnancy is a risk factor for fetal alcohol spectrum disorder, but research findings for exposure to low to moderate alcohol levels during pregnancy are equivocal, allowing a range of interpretations. The 2001 guideline from the National Health and Medical Research Council (NHMRC) for low-risk drinking for "women who are pregnant or might soon become pregnant" recommends fewer than seven standard drinks per week, and no more than two standard drinks on any one day. This position has polarised health professional and consumer opinion in Australia. The NHMRC guidelines on alcohol are scheduled for review in 2007. We surveyed the alcohol and pregnancy policies and clinical practice guidelines of Australia and six other English-speaking countries to identify current policy. Documents were obtained through Internet searches and direct contact with the relevant organisations. The policies and guidelines varied both across and within countries, and the NHMRC guideline, while not universally supported in Australia, is in step with the policies of the United Kingdom and Canada. Research is needed to elucidate the true association between low to moderate alcohol consumption and fetal harm, the impact of different policies on rates of maternal alcohol consumption during pregnancy, and any untoward outcomes of an abstinence message, to inform and underpin future policy development in Australia.

Is cerebral palsy associated with birth defects other than cerebral defects?

The objective of the study was to identify the origin (s) of the association between cerebral palsy (CP) and birth defects in the absence of cerebral birth defects. Data from the 1980 to 1994 Western Australian birth cohorts (355 659 neonatal survivors) were linked to the Cerebral Palsy Register (941 links) and the Birth Defects Registry (17070 links). Associations between CP (congenital or acquired) and birth defects (cerebral or exclusively non-cerebral) were estimated. The origin of the association between non-cerebral defects and acquired CP was investigated with an observational study, and the origin of the association between non-cerebral defects and congenital CP was investigated with a blinded case-control study of births with non-cerebral defects with or without CP. With non-cerebral defects, the odds ratio for CP was 4.8 (95% CI 3.1-7.4) if acquired and 4.7 (3.9-5.7) if congenital. For acquired CP, the association arose primarily as a result of cardiac defects. For congenital CP, the association arose partly from ascertainment bias and partly from defects known to be associated with cerebral defects (but not identified in these data). However, a significant portion remained unexplained. The presence of non-cerebral defects should heighten clinical alertness to the possibility of CP and of cerebral birth defects.

Diagnosis of foetal alcohol syndrome and alcohol use in pregnancy: a survey of paediatricians' knowledge, attitudes and practice

AIM

To measure paediatricians' knowledge, attitudes and practices regarding foetal alcohol syndrome (FAS) and alcohol use during pregnancy.

METHODS

Postal survey of paediatricians in Western Australia in 2004. Of 179 eligible paediatricians, 132 (73.7%) responded (90 consultant paediatricians and 42 paediatric trainees).

RESULTS

Of the 132 respondents, 18.9% identified all four essential diagnostic features for FAS. Only 49.2% had previously diagnosed FAS (range 1-30 cases) but 91.7% had seen children diagnosed by others; 76.5% had suspected but not diagnosed FAS; 12.1% had been convinced of but not recorded the diagnosis; and 31.8% had referred children for diagnostic confirmation. Although 79.6% agreed early diagnosis might be advantageous, 69.6% said diagnosis might be stigmatising and 36.4% thought parents might resist referral for assessment and treatment. Although 78.2% agreed avoiding binge drinking may reduce FAS, only 43.9% believed women should abstain from using alcohol in pregnancy. Only 4.5% felt very prepared to deal with a patient with FAS: most wanted educational materials for themselves (69.7%) and child carers (71.2%). Only 23.3% routinely ask about alcohol use when taking a pregnancy history and 4.2% routinely provide information on the consequences of alcohol use. Only 11.4% had read the current Australian national health guideline regarding alcohol consumption in pregnancy and 9.1% provided advice consistent with the guideline.

CONCLUSION

Paediatricians identified the need for educational materials about FAS and alcohol use in pregnancy for themselves and their clients. Lack of knowledge about FAS diagnosis and management will limit opportunities for diagnosis, prevention and early intervention.

Primary prevention of neural tube defects with folate in Western Australia: the value of the Western Australian Birth Defects Registry

This paper reviews the role of the Western Australian Birth Defects Registry in the primary prevention of neural tube defects. The Registry provides complete and up-to-date information on all neural tube defects (NTD), including terminations of pregnancy. These data have been used to determine a baseline rate of NTD and to monitor trends in NTD over time, when health promotion of folic acid supplement use and voluntary fortification of food with folate were introduced. The register has also been used to investigate NTD in special populations (Indigenous infants in Australia) and as a sampling frame for case control studies. The data derived from these studies have been used to assist in assessing whether mandatory food fortification in Australia is indicated to prevent NTD.

A retrospective review of self-reported alcohol intake among women attending for antenatal care in Far North Queensland

BACKGROUND

Fetal alcohol syndrome and fetal alcohol spectrum disorder are known to occur among children delivered to women in Far North Queensland; to date, the problem has not been quantified or related directly to maternal alcohol consumption during pregnancy.

AIMS

To identify the characteristics of women who consume alcohol during pregnancy, in order to identify 'high-risk' women to whom educational intervention regarding fetal alcohol syndrome may be targeted.

METHODS

A retrospective descriptive study using the case notes of all women attending the antenatal booking clinic in Cairns Base Hospital over the 3-month period from April to June 2005. Obstetric and demographic information and self-reported alcohol intake before and during pregnancy were noted and self-reported alcohol intake before and during pregnancy.

RESULTS

Five hundred and forty-one women were included in this study. Of these women, 24.6% were found to consume alcohol during pregnancy and 57.7% were found to consume alcohol before pregnancy, indicating a reduction in alcohol consumed once women became aware of pregnancy. The most significant indicator for alcohol consumption during pregnancy was found to be alcohol consumption before pregnancy. Of women who consumed alcohol in pregnancy, 71.5% drank moderate amounts of alcohol before pregnancy and 28.7% drank heavily before pregnancy.

CONCLUSION

Alcohol consumption during pregnancy is common in Far North Queensland. Methods currently used during antenatal booking visits to determine alcohol consumption before and during pregnancy are unreliable. Strategies to identify women consuming alcohol before and during pregnancy and education programs are vitally important if the incidence of fetal alcohol syndrome and spectrum disorder is to be reduced.

Patterns, trends, and increasing disparities in mortality for Aboriginal and non-Aboriginal infants born in Western Australia, 1980-2001: population database study

BACKGROUND

Since there are known disparities between Aboriginal and non-Aboriginal populations in Australia, trends in infant mortality rates can be used to assess the effectiveness of programmes designed to improve the health of Aboriginal populations. We have examined mortality rates in these populations in Western Australia.

METHODS

We used the most comprehensive and valid total population data available for an Australian state to determine all-cause and cause-specific mortality for Aboriginal and non-Aboriginal infants born in Western Australia from 1980 to 2001.

FINDINGS

Overall, infant mortality rates fell in both populations, but less so in Aboriginal (from 25.0 in 1980-84 to 16.1 in 1998-2001) than in non-Aboriginal infants (from 8.4 in 1980-84 to 3.7 in 1998-2001) such that disparities between the two groups increased for all major causes of infant death. The relative risk for Aboriginal compared with non-Aboriginal infants rose from 3.0 (95% CI 2.5-3.6) to 4.4 (3.5-5.5), and there were significantly more potentially preventable deaths, such as those caused by infections (5.9 per 1000 livebirths vs 0.7 per 1000 livebirths, RR 8.5, 95% CI 7.1-10.2). Additionally, for Aboriginal infants, postneonatal mortality rates were higher than neonatal mortality rates (11.2 per 1000 livebirths vs 9.7 per 1000 livebirths), trend analyses showed that previous reductions in deaths due to preterm birth (4.3 per 1000 livebirths--1.4 per 1000 livebirths from 1980-97) were not sustained in the most recent years studied (3.5 per 1000 livebirths), and rates of sudden infant death syndrome did not fall significantly (4.9 per 1000 livebirths vs 4.7 per 1000 livebirths).

INTERPRETATION

These increasing disparities between Aboriginal and non-Aboriginal infants, especially in remote areas, demand immediate action in partnership with Aboriginal communities, focusing on both access to primary health care and better living conditions. Implementation and assessment of policies to reduce the continuing social and economic disadvantage faced by Aboriginal families are vital.

First-trimester combined screening for Down syndrome and other fetal anomalies

OBJECTIVE

This study assessed fetal outcomes for pregnancies identified at increased risk for Down syndrome by first-trimester combined ultrasound examination and maternal serum biochemistry screening.

METHODS

First-trimester combined screening data were obtained from ultrasound clinics across Western Australia between August 2001 and October 2003. Prenatal screening data were linked with pregnancy outcome information held in state health database registers using probabilistic record-linkage techniques.

RESULTS

In 50 of the 60 pregnancies affected by Down syndrome, the adjusted risk was greater than 1 in 300, providing a detection rate of 83% (95% confidence interval [CI] 74-93%). Among all women screened (n = 22,280), 827 had increased risk results but did not have a Down syndrome pregnancy, representing a false-positive rate of 3.7% (95% CI 3.5-3.9%). Ten cases of Down syndrome were detected among women considered not at increased risk, consistent with a false-negative rate of 1 in 2,227. First-trimester combined screening reduced the number of Down syndrome births by 50 in 22,280 (2.24 cases per 1,000 births), which represents the detection of one case of fetal Down syndrome for every 446 women screened. Furthermore, 25% of pregnancies with other birth defects occurred among those identified at increased risk of Down syndrome, and 1 in 8 pregnancies at increased risk were found to have a significant chromosomal or structural defect.

CONCLUSION

First-trimester combined screening in Western Australia detected 83% (95% CI 74-93%) of Down syndrome pregnancies at a 3.7% (95% CI 3.5-3.9%) false-positive rate.

LEVEL OF EVIDENCE

II-2.

Health professionals' knowledge, practice and opinions about fetal alcohol syndrome and alcohol consumption in pregnancy

OBJECTIVE

To measure the knowledge, attitudes and practices of health professionals regarding fetal alcohol syndrome (FAS) and alcohol use during pregnancy.

METHOD

A postal survey of a representative random sample of health professionals was conducted in Western Australia (WA) in 2002/03. 1,143 (79%) of 1,443 eligible health professionals completed the survey (87 Aboriginal Health Workers, 286 allied health professionals, 537 community nurses, 170 general practitioners and 63 obstetricians).

RESULTS

Of 1,143 health professionals, 12% identified all four essential diagnostic features of FAS. Most (95%) had never diagnosed FAS. Although 82% believed that making a diagnosis of FAS might improve treatment plans and 85% agreed FAS was preventable, 53% said the diagnosis might be stigmatising. Only 2% felt very prepared to deal with FAS and most wanted information for themselves and their clients. Of the 659 health professionals caring for pregnant women, only 45% routinely ask about alcohol use in pregnancy, only 25% routinely provide information on the consequences of alcohol use in pregnancy and only 13% provide advice consistent with NHMRC guidelines on alcohol consumption in pregnancy.

CONCLUSION

Health professionals have identified the need for educational materials for themselves and their clients.

IMPLICATIONS

FAS is likely to be under-ascertained in Australia due to a lack of knowledge of FAS by health professionals. Until this lack of knowledge is addressed, opportunities for diagnosis and prevention of FAS will be limited.

An assessment of intellectual disability among Aboriginal Australians

BACKGROUND

The health and well-being of Indigenous people is a significant global problem, and Aboriginal Australians suffer from a considerably higher burden of disease and lower life expectancy than the non-Indigenous population. Intellectual disability (ID) can further compromise health, but there is little information that documents the prevalence of ID among indigenous populations. This study provides information on ID among the Aboriginal population of Western Australia.

METHODS

The Disability Services Commission (DSC) of Western Australia has maintained a statewide database of people with ID since 1953. Data on people of Aboriginal descent were extracted from the DSC database and linked to two other state-based databases, the Hospital Morbidity Data System and the Deaths Registry, with additional linkage to the National Death Index. The linked data were used to assess the prevalence, survival patterns and causes of death in Aboriginal people with ID.

RESULTS

Although comprising 3.5% of the population, Aboriginal Australians represented 7.4% of all people registered for ID services. The level of ID was assessed as borderline or mild in 40.7% of cases, moderate in 19.9%, severe or profound in 12.1%, but had not been specified in 27.2% cases. Median survival was 55.1 years for men and 64.0 years for women, with a mean age at death (n = 102) of 19.6 years. The leading causes of death were respiratory diseases, diseases of the circulatory system, and accidents.

CONCLUSIONS

The study presents unique population summary data for ID in the Aboriginal community of Western Australia. To provide appropriate prevention and intervention strategies, there is an urgent need for more detailed information on the prevalence and patterns of ID.

The effect of terminations of pregnancy for fetal abnormalities on trends in mortality to one year of age in Western Australia

Summary highlighted the contribution of birth defects. Over this time there has also been an increasing number of terminations of pregnancy for fetal abnormality. However, the effect of these terminations on mortality rates in Australia has not yet been estimated. The Western Australian Birth Defects Registry (BDR) records all birth defects that are diagnosed in stillbirths, livebirths and in pregnancies terminated because of a fetal abnormality. All cases on the BDR over the period 1980-98 were categorised into one of eight main birth defect groups and analysed in four time periods to show trends. Linkage provided information on deaths to one year of age, defined as perinatal plus postneonatal deaths. The proportion of terminations for fetal abnormality that would have resulted in a death before one year of age was estimated in two ways. The first method used the proportion of births with a birth defect in each diagnostic category that resulted in a death. The second method involved determination of likelihood of survival to one year of all terminations for fetal abnormality through independent review by two experts. Whilst mortality to one year of age for all birth defects has declined from 4.36/1000 births in 1980-84 to 2.75/1000 births in 1995-98, terminations of pregnancies for fetal abnormalities increased from 1.19/1000 births to 4.70/1000 births. After including the estimated mortality associated with terminations for fetal abnormality, the decline in mortality to one year of age associated with birth defects from 1980 to 1998 changed from a 37% reduction to a 15% reduction based on observed mortality 1980-84, and an 11% increase in mortality based on individual case review, highlighting the importance of considering terminations in mortality analyses.