Reducing fetal alcohol exposure in the United States

Reducing Prenatal Alcohol Exposure and the Incidence of FASD: Is the Past Prologue?

PURPOSE

This narrative review summarizes and synthesizes the clinical trials and randomized clinical trials that evaluated selected and targeted approaches to reducing preconception and prenatal alcohol exposure (PAE) and alcohol-exposed pregnancy (AEP) since 2011.

SEARCH METHODS

A professional hospital librarian completed the primary search using strategies specified within this review, resulting in 94 records returned in PubMed, Ovid MEDLINE, Clinical Key, the World Health Organization International Clinical Trials Registry Platform, and ClinicalTrials.gov. The author completed two supplementary literature searches.

SEARCH RESULTS

From the total of 238 records returned from the three searches, 217 records were eliminated. Elimination reasons included other medical problem (119); duplicate entry (34); no content/results (23); secondary analysis (16); focus on effects of PAE (9); treatment of childhood fetal alcohol spectrum disorders (FASD) (6); maternal risk factors (3); and other (7). The remaining 21 studies were included with four overarching themes: (1) case management efforts (n = 4); (2) preconception efforts to reduce AEP (n = 5); (3) motivational interviewing and screening, brief intervention, and referral to treatment (n = 2); and (4) use of technology to deliver the intervention (n = 10).

DISCUSSION AND CONCLUSIONS

Case management and home visits did not appear to have strong current empirical support. Study limitations included small sample sizes and no comparison groups, whereas larger efforts did not demonstrate definitive advantages to justify this intensive approach. The studies of preconception efforts, all based on the Project CHOICES approach, had similar outcomes, with the reduction in AEP risk largely due to improved contraception in women of childbearing age who were sexually active and drank alcohol but were not pregnant. It is unknown whether these women refrained from alcohol use when they became pregnant. Two studies of motivational interviewing to reduce prenatal alcohol use did not demonstrate the efficacy of the intervention. Both were small, with less than 200 pregnant women combined; moreover, the study samples had low baseline levels of alcohol use, allowing little opportunity for improvement. Finally, studies evaluating the impact of technological approaches to reducing AEP were reviewed. These exploratory investigations had small sample sizes and provided preliminary evaluations of techniques such as text messages, telephone contact, computer-based screening, and motivational interviewing. The potentially promising findings may inform future research and clinical efforts. Future directions may include research to address the limitations of the evidence to date and should reflect the complexities of FASD that include the biological and social context associated with prenatal alcohol use.

Dissemination of Prenatal Drinking Guidelines: A Preliminary Study Examining Personal Alcohol Use Among Midwives in a Southwestern US State

INTRODUCTION

The constellation of birth defects seen in fetuses exposed to alcohol in utero have been described as fetal alcohol spectrum disorders. Evidence suggests that health care providers' communication practices regarding prenatal alcohol use could have beneficial outcomes. There is a paucity of investigations, however, that have examined the health professionals' personal alcohol use and prenatal alcohol recommendations they provide.

METHODS

This study sought to examine and compare midwives' personal alcohol use and communication practices regarding prenatal alcohol consumption. Certified nurse-midwives (CNMs) and certified professional midwives (CPMs) in a southwestern US state participated. Inclusion criteria included training in prenatal care, labor, birth, and membership in a midwife professional organization. Personal drinking behaviors were assessed with Alcohol Use Disorder Identification Test-Consumption (AUDIT-C).

RESULTS

All midwives (N = 61; 100%) reported they typically screened a patient for alcohol use during an initial prenatal visit. However, 5 (8.2%) respondents opted for recommendations that advised patients to drink once in a while. Similarly, 4 (6.6%) midwives counseled no more than one drink per day. In the cohort of participants (n = 40) with AUDIT-C scores, 25 (62.5%) engaged in nonrisky drinking (AUDIT-C scores <3). Most respondents (n = 39 of 40; 97.5%) typically consumed 1 to 2 standard drinks on the day they drank. There was no statistically significant difference in mean overall AUDIT-C scores between CNMs and CPMs (P = .42). When examining midwives' (1) responses on the AUDIT-C questionnaire, (2) nonrisky or risky drinking behaviors, and 3) communication practices regarding prenatal alcohol use, Fisher's exact test showed no statistically significant differences between CNMs and CPMs.

DISCUSSION

Results of this study highlight the importance of advocating healthy lifestyles among health care professionals while also promoting communication practices that align with national alcohol guidelines. Future investigations that examine associations between health care professionals' personal alcohol use and type or effectiveness of services offered to patients may be beneficial.

Changes in Alcohol Intake During Pregnancy in Spain, 1980 to 2014

BACKGROUND

Even small amounts of alcohol consumed during pregnancy can have adverse effects on the embryo and the fetus. We estimated how alcohol intake among pregnant women in Spain changed between 1980 and 2014, and identified factors associated with alcohol use.

METHODS

Data came from the Spanish Collaborative Study of Congenital Malformations (ECEMC). The sample includes ECEMC's control mothers, 40,268 pregnant women from all regions of Spain. We classified alcohol consumption during pregnancy into 3 categories: no consumption; sporadic consumption of small amounts of alcohol; and regular consumption, or sporadic but in large quantities including drunkenness. Independent variables included sociodemographic factors, planned/unplanned pregnancy, maternal chronic diseases, gestational diabetes, and tobacco and illegal drug use during pregnancy. Trend analyses were performed using data from 1980 to 2014. The multinomial logistic regression models designed to identify associated factors differentiated between 2 periods: 1994 to 2004 and 2005 to 2014.

RESULTS

Prevalence of alcohol consumption declined from 29.6% (95% CI: 27.1 to 32.2) in 1980 to 5.4% (95% CI: 3.7 to 7.6) in 2014, mostly due to the reduction in regular intake. This decline was especially acute between 1980 and 1994. Sporadic and regular consumption increased among women working outside the home, born outside Spain, those whose pregnancy was unplanned, and those reporting using tobacco or other drugs. Comparing 1994 to 2004 versus 2005 to 2014, a stronger association was observed between regular alcohol consumption and tobacco consumption in the latter period (interaction p = 0.003).

CONCLUSIONS

Alcohol consumption among expectant mothers has declined substantially in the last 35 years. However, it is worth highlighting the significant and substantial associations between alcohol use and consumption of tobacco, which have become stronger in the most recent years.

Forty Years of Assessing Neurodevelopmental and Behavioral Effects of Prenatal Alcohol Exposure in Infants: What Have We Learned?

It has been known for over 4 decades that prenatal alcohol exposure (PAE) can adversely affect neurodevelopment and behavior (NDB). Yet, early detection of altered NDB due to PAE continues to present a major clinical challenge. Identification of altered NDB in the first 2 years of life, before higher-order cognitive processes develop, invites early interventions for affected children to improve long-term outcomes. Studies published in English from January of 1980 to July of 2018 were identified in PubMed/MEDLINE. The review focused on prospective birth cohort studies which used standardized NDB assessments in children up to 2 years of age, wherein PAE was the main exposure and NDB was the main outcome. NDB was categorized into the domains of neurocognitive, adaptive, and self-regulation based on the 2016 Updated Clinical Guidelines for Diagnosing fetal alcohol spectrum disorder. An initial search resulted in 1,867 articles for which we reviewed abstracts; 114 were selected for full-text review; and 3 additional abstracts were identified through review of references in eligible publications. Thirty-one publications met criteria and were included: of these, 24 reported neurocognitive outcomes, 24 reported adaptive behavior outcomes, and 12 reported outcomes in the domain of self-regulation. Although self-regulation was assessed in the fewest number of studies, 8/12 (75%) reported PAE-associated deficits. In contrast, results were mixed for the other 2 domains: 13/24 (54%) of the selected studies that included neurocognitive outcomes showed poorer performance following PAE, and 8/24 (33%) studies that assessed adaptive functioning found significant differences between PAE and comparison infants. There is considerable evidence to support the value of early-life assessments of infant NDB when PAE is known or suspected. More studies focusing on infant self-regulation, in particular, are needed to determine the utility of early evaluation of this critical developmental domain in infants with PAE.

Risk factors for alcohol use among pregnant women, ages 15-44, in the United States, 2002 to 2017

Fetal alcohol exposure can lead to severe birth and developmental defects. Determining which pregnant women are most likely to drink is essential for targeting interventions. In National Survey on Drug Use and Health data on pregnant women from 2002 to 2017 (N = 13,488), logistic regression was used to produce adjusted odds ratios (aOR) indicating characteristics associated with two past-month outcomes: any alcohol use and binge drinking. Risk factors were sociodemographic (age, race/ethnicity, marital status, education level, income) and clinical (trimester, substance use, alcohol use disorder, major depression). Where associations differed by pregnancy stage (trimester 1 vs. trimesters 2 and 3), association was evaluated by stage. Overall, higher risk for any and binge drinking was observed among those with other substance use (aORs 2.9-25.9), alcohol use disorder (aORs 4.5-7.5), depression (aORs = 1.6), and unmarried women (aORs 1.6-3.2). For any drinking, overall, higher risk was observed in adolescents (aOR = 1.5) and those with higher education (aOR = 1.4), while lower risk was observed in those with lower income (aORs = 0.7). For binge drinking, associations differed by pregnancy stage. In trimester 1, lower risk was observed in middle ages (aOR = 0.4). In trimesters 2/3, higher risk was observed in Blacks (aOR = 3.3) and those with lower income (aORs 3.5-3.9), while lower risk was observed in those with higher education (aOR = 0.3). To prevent severe prenatal harm, health care providers should focus on women at higher risk for binge drinking during pregnancy: women with tobacco or drug use, alcohol use disorder, or depression, and women who are unmarried, Black, or of lower socioeconomic status.

Characteristics of Low-income Racial/Ethnic Minority Pregnant Women Screening Positive for Alcohol Risk

The current study examined the prevalence and characteristics associated with alcohol risk among low-income, predominantly racial/ethnic minority pregnant women in an urban area. We surveyed 225 pregnant women receiving nutritional care. Twenty-six percent screened positive for alcohol risk. Current smoking status (AOR 2.9, p = 0.018, 95 % CI [1.2, 7.0]) and a history of marijuana use (AOR 3.1, p = 0.001, 95 % CI [1.6, 6.2]) were the strongest predictors of alcohol risk status. This study underscores the need for screening for alcohol risk, smoking, and illicit drug use among low-income, racial/ethnic minority pregnant women and highlights the usefulness of the TWEAK in identifying alcohol risk in WIC settings.

Substance use during pregnancy

Prenatal substance use is a critical public health concern that is linked with several harmful maternal and fetal consequences. The most frequently used substance in pregnancy is tobacco, followed by alcohol, cannabis and other illicit substances. Unfortunately, polysubstance use in pregnancy is common, as well as psychiatric comorbidity, environmental stressors, and limited and disrupted parental care, all of which can compound deleterious maternal and fetal outcomes. There are few existing treatments for prenatal substance use and these mainly comprise behavioral and psychosocial interventions. Contingency management has been shown to be the most efficacious of these. The purpose of this review is to examine the recent literature on the prenatal use of tobacco, alcohol, cannabis, stimulants, and opioids, including the effects of these on maternal and fetal health and the current therapeutic options.

Substance Use in the Perinatal Period

Perinatal substance use remains a major public health problem and is associated with a number of deleterious maternal and fetal effects. Polysubstance use in pregnancy is common and can potentiate adverse maternal and fetal outcomes. Tobacco is the most commonly used substance in pregnancy, followed by alcohol and illicit substances. The treatments for perinatal substance use are limited and consist mostly of behavioral and psychosocial interventions. Of these, contingency management has shown the most efficacy. More recently, novel interventions such as progesterone for postpartum cocaine use have shown promise. The purpose of this review is to examine the recent literature on the use of tobacco, alcohol, cannabis, stimulants, and opioids in the perinatal period, their effects on maternal and fetal health, and current treatments.

High postnatal susceptibility of hippocampal cytoskeleton in response to ethanol exposure during pregnancy and lactation

Ethanol exposure to offspring during pregnancy and lactation leads to developmental disorders, including central nervous system dysfunction. In the present work, we have studied the effect of chronic ethanol exposure during pregnancy and lactation on the phosphorylating system associated with the astrocytic and neuronal intermediate filament (IF) proteins: glial fibrillary acidic protein (GFAP), and neurofilament (NF) subunits of low, medium, and high molecular weight (NFL, NFM, and NFH, respectively) in 9- and 21-day-old pups. Female rats were fed with 20% ethanol in their drinking water during pregnancy and lactation. The homeostasis of the IF phosphorylation was not altered in the cerebral cortex, cerebellum, or hippocampus of 9-day-old pups. However, GFAP, NFL, and NFM were hyperphosphorylated in the hippocampus of 21-day-old pups. PKA had been activated in the hippocampus, and Ser55 in the N-terminal region of NFL was hyperphosphorylated. In addition, JNK/MAPK was activated and KSP repeats in the C-terminal region of NFM were hyperphosphorylated in the hippocampus of 21-day-old pups. Decreased NFH immunocontent but an unaltered total NFH/phosphoNFH ratio suggested altered stoichiometry of NFs in the hippocampus of ethanol-exposed 21-day-old pups. In contrast to the high susceptibility of hippocampal cytoskeleton in developing rats, the homeostasis of the cytoskeleton of ethanol-fed adult females was not altered. Disruption of the cytoskeletal homeostasis in neural cells supports the view that regions of the brain are differentially vulnerable to alcohol insult during pregnancy and lactation, suggesting that modulation of JNK/MAPK and PKA signaling cascades target the hippocampal cytoskeleton in a window of vulnerability in 21-day-old pups. Our findings are relevant, since disruption of the cytoskeleton in immature hippocampus could contribute to later hippocampal damage associated with ethanol toxicity.

Prenatal ethanol exposure disrupts intraneocortical circuitry, cortical gene expression, and behavior in a mouse model of FASD

In utero ethanol exposure from a mother's consumption of alcoholic beverages impacts brain and cognitive development, creating a range of deficits in the child (Levitt, 1998; Lebel et al., 2012). Children diagnosed with fetal alcohol spectrum disorders (FASD) are often born with facial dysmorphology and may exhibit cognitive, behavioral, and motor deficits from ethanol-related neurobiological damage in early development. Prenatal ethanol exposure (PrEE) is the number one cause of preventable mental and intellectual dysfunction globally, therefore the neurobiological underpinnings warrant systematic research. We document novel anatomical and gene expression abnormalities in the neocortex of newborn mice exposed to ethanol in utero. This is the first study to demonstrate large-scale changes in intraneocortical connections and disruption of normal patterns of neocortical gene expression in any prenatal ethanol exposure animal model. Neuroanatomical defects and abnormal neocortical RZRβ, Id2, and Cadherin8 expression patterns are observed in PrEE newborns, and abnormal behavior is present in 20-d-old PrEE mice. The vast network of neocortical connections is responsible for high-level sensory and motor processing as well as complex cognitive thought and behavior in humans. Disruptions to this network from PrEE-related changes in gene expression may underlie some of the cognitive-behavioral phenotypes observed in children with FASD.