A guideline for the prevention and management of Fetal Alcohol Spectrum Disorder in South Africa

Fetal alcohol spectrum disorder resources for health professionals: a scoping review

OBJECTIVES

This scoping review aimed to identify and critically appraise resources for health professionals to identify, diagnose, refer, and support individuals with fetal alcohol spectrum disorder (FASD)-including the extent to which the resources are appropriate for use in communities with First Nations Peoples.

METHOD

Seven peer-reviewed databases (April 2022) and 14 grey literature websites (August 2022) were searched. The reference lists of all sources that underwent full-text review were handsearched, and FASD experts were consulted for additional sources. Resources were assessed using the Appraisal of Guidelines for REsearch and Evaluation II instrument and an adapted version of the National Health and Medical Research Council FORM Framework and iCAHE Guideline Quality Checklist.

RESULTS

A total of 41 resources underwent data extraction and critical appraisal, as screening and/or diagnosis guidelines were excluded because they are covered in other reviews. Most were recently published or updated (n=24), developed in the USA (n=15, 36.6%) or Australia (n=12, 29.3%) and assisted with FASD patient referral or support (n=40). Most management guidelines scored 76%-100% on overall quality assessment (n=5/9) and were recommended for use in the Australian context with modifications (n=7/9). Most of the guides (n=15/22) and factsheets (n=7/10) received a 'good' overall score. Few (n=3/41) resources were explicitly designed for or with input from First Nations Australians.

CONCLUSION

High-quality resources are available to support health professionals providing referrals and support to individuals with FASD, including language guides. Resources should be codesigned with people living with FASD to capture and integrate their knowledge and preferences.

Oxidative Effects in Early Stages of Embryo Development Due to Alcohol Consumption

Alcohol, a widely consumed drug, exerts significant toxic effects on the human organism. This review focuses on its impact during fetal development, when it leads to a spectrum of disorders collectively termed Fetal Alcohol Spectrum Disorders (FASD). Children afflicted by FASD exhibit distinct clinical manifestations, including facial dysmorphism, delayed growth, and neurological and behavioral disorders. These behavioral issues encompass diminished intellectual capacity, memory impairment, and heightened impulsiveness. While the precise mechanisms underlying alcohol-induced fetal damage remain incompletely understood, research indicates a pivotal role for reactive oxygen species (ROS) that are released during alcohol metabolism, inciting inflammation at the cerebral level. Ethanol metabolism amplifies the generation of oxidant molecules, inducing through alterations in enzymatic and non-enzymatic systems responsible for cellular homeostasis. Alcohol consumption disrupts endogenous enzyme activity and fosters lipid peroxidation in consumers, potentially affecting the developing fetus. Addressing this concern, administration of metformin during the prenatal period, corresponding to the third trimester of human pregnancy, emerges as a potential therapeutic intervention for mitigating FASD. This proposed approach holds promise for ameliorating the adverse effects of alcohol exposure on fetal development and warrants further investigation.

Actions to prevent and identify fetal alcohol spectrum disorders to be implemented in general practice: a consensus

Introduction

Fetal alcohol exposure is the most common preventable cause of non-genetic intellectual disability. Fetal Alcohol Syndrome (FAS) is characterized by intellectual disability and distinctive facial features and affects 0.1% of live births, representing approximately 800 cases per year in France. Fetal Alcohol Spectrum Disorder (FASD) are 10 times more common than FAS, with an estimated 8,000 cases per year, and are associated with behavioral and social maladjustment in both children and adults, as well as various malformations. General practitioners play a key role in preventing and identifying FASD through their involvement in pregnancy and child monitoring.

Methods

Qualitative study using the Delphi method. Items were developed from the literature and semi-structured interviews with field professionals and health institutions. A panel of multi-professional experts, mostly general practitioners, was recruited.

Results

24 initial actions were submitted to the experts. At the end of the first round, six actions reached a consensus and six were reformulated for the second round. At the end of the second round, three actions reached a consensus, for a total of 11 consensus actions. Four of these actions seem particularly relevant for rapid implementation, namely systematic proposal of pre-conceptional consultations for women planning pregnancy, systematic identification of environmental factors during child monitoring, systematic distribution of information on fetal alcohol exposure during pre-conception or early pregnancy, and the publication of a leaflet for general practitioners on the identification of children with FAS or FASD and the contact details of relevant associations.

Conclusion

Prevention and identification of FASD can be improved through short and general training supports for general practitioners. Early screening of FASD is crucial for children, and should be maintained throughout their monitoring. This study could be used for communication and dissemination of information based on the consensus obtained.

Multifaceted case management during pregnancy is associated with better child outcomes and less fetal alcohol syndrome

BACKGROUND

Pregnant women participated in multifaceted case management (MCM) to prevent Fetal Alcohol Spectrum Disorders (FASD).

METHODS

Women recruited from antenatal clinics for a longitudinal child development study were screened for alcohol use. Forty-four pregnant women were defined as high-risk drinkers on the Alcohol Use Disorder Identification Test (AUDIT) by an AUDIT score ≥8 and participated in 18 months of MCM to facilitate reduction or cessation of alcohol consumption. Forty-one women completed MCM. Fifty-five equally high-risk women who received standard antenatal care comprised the comparison/control group. Development in offspring was evaluated by a blinded interdisciplinary team of examiners through 5 years of age.

RESULTS

At five years of age, more children (34%) of MCM participating women did not meet the criteria for FASD vs. non-MCM offspring (22%). Furthermore, a statistically significant (p = .01) lower proportion of MCM offspring (24%) was diagnosed with fetal alcohol syndrome (FAS) compared to controls (49%). Children of MCM participants had significantly (p < .05) better physical outcomes: lower total dysmorphology scores, larger head circumferences, longer palpebral fissures, and higher midfacial measurements. Neurodevelopment results showed mixed outcomes. While Bayley developmental scores indicated that MCM offspring were performing significantly worse on most domains through 18 months, group scores equalized and were not significantly different on Kaufman Assessment Battery neurobehavioral measures by five years. Regression analyses indicated that offspring of women who received standard antenatal care were associated with significantly more negative outcomes than MCM offspring: a diagnosis of FAS (OR = 3.2; 95% CI: 1.093-9.081), microcephaly (OR = 5.3; 95% CI: 2.1-13.5), head circumference ≤10th centile (OR = 4.3; 95%CI: 1.8-10.4), and short palpebral fissures (OR = 2.5; 95% CI: 1.0-5.8).

CONCLUSION

At age five, proportionally fewer children of MCM participants qualified for a diagnosis of FAS, and proportionally more had physical outcomes indicating better prenatal brain development. Neurobehavioral indicators were not significantly different from controls by age five.KEY MESSAGESMultifaceted Case Management (MCM) was designed and employed for 18 months during the prenatal and immediate postpartum period to successfully meet multiple needs of women who had proven to be very high risk for birthing children with fetal alcohol spectrum disorders (FASD).Offspring of the women who participated in MCM were followed up through age five years and were found to have significantly better physical outcomes on multiple variables associated with fetal alcohol syndrome (FAS) and FASD, such as larger head circumferences and fewer minor anomalies, than those children born to equally at-risk women not receiving MCM.Fewer children of women receiving MCM were diagnosed with FASD than the offspring of equally-at-risk controls, and significantly (p = .01) fewer MCM offspring had FAS, the most severe FASD diagnosis.

Reducing the risk of prenatal alcohol exposure and FASD through social services: promising results from the FAR SEAS pilot project

Introduction

Within FAR SEAS, a multi-component evidence-based community intervention was implemented and evaluated in Mazovia (Poland), with the aim of preventing alcohol-exposed pregnancies, and therefore preventing FASD.

Methods

Multi-disciplinary professionals from different services (social, addiction, and psychology), recruited women of child-bearing age (pregnant and not pregnant) in local communities, screened them for alcohol risk, and allocated participants (n = 441) to groups for low- (70%), moderate- (23%), or high-risk (7%) of alcohol exposed pregnancy, to provide interventions tailored to their needs. The non-parametric sign test, testing differences between pairs of observations before and after intervention was used to evaluate the outcomes.

Results

Follow-up data (collected from 93% of participants) indicated positive changes in the key outcome variables: risky alcohol consumption dropped by 81%, contraception use increased by 15% and visiting a gynecologist increased by 39%; as well as in associated psychosocial risk factors (decrease in cigarette and drug use, domestic violence and depressive symptoms). No changes were noted in frequency of other service use (medical, psychological, or social). The most prominent changes were observed in the moderate-risk group.

Discussion

Changing risky behaviors (alcohol consumption and sex without contraception) to prevent alcohol exposed pregnancies is feasible at the local level, even without engagement of medical professionals. Key challenges, related to engaging professionals and local authorities, must be addressed; and procedures should be adapted to local contexts and needs.

Knowledge, attitudes, practices, and beliefs regarding prenatal alcohol consumption among women in Leyte, the Philippines

Objectives

Fetal alcohol spectrum disorder (FASD) captures the broad range of emotional, cognitive, behavioral, and congenital abnormalities associated with maternal alcohol consumption, and women living in resource-limited settings may be higher risk. This study aims to examine knowledge, attitudes, practices, and beliefs (KAPB) of women in Leyte, The Philippines regarding prenatal alcohol consumption.

Methods

One hundred postpartum women were recruited from a birth cohort in Leyte. A prenatal alcohol use KAPB survey was constructed in Waray, the local language. The survey was administered in June-September 2019. Descriptive statistics, chi-squared test, and Fisher's exact test were used to analyze responses.

Results

Seventy-five percent of subjects reported drinking tuba, a local palm wine, during pregnancy. Most participants (75%) did not believe tuba contained alcohol. Women who believed tuba contains no alcohol were more likely to drink tuba during pregnancy (81.3%) than women who believed tuba contains alcohol (56.0%), X2(1, N = 100) = 6.41, p = .011. Women who drank tuba during pregnancy were more likely to believe tuba has health benefits (60%) than women who did not drink tuba during pregnancy (12%), Fisher's exact p < .05, citing increased red blood cell count and unproven antiparasitic qualities. Fifteen percent of subjects reported having fed their babies tuba. Nearly all (98%) were willing to attenuate tuba/alcohol consumption if told that this practice negatively impacts pregnancies.

Conclusion

Misinformation about tuba appears widespread in Leyte. Educating women of reproductive age in Leyte regarding prenatal tuba use may lead to a reduction in tuba use.

Community-based counselling programme for pregnant women with alcohol problems in Cape Town, South Africa: a qualitative study of the views of pregnant women and healthcare professionals

Introduction

South Africa lacks services to detect and address alcohol use during pregnancy, particularly outside of health-care facilities. This study aimed to explore pregnant women and healthcare providers' perceptions of the acceptability, feasibility and appeal of a community-based counselling programme for pregnant women with alcohol problems.

Methods

Twenty-eight in-depth interviews with pregnant women who drink, Community Health Workers (CHWs) and antenatal service providers were conducted. Transcribed interviews were analyzed thematically using a combined deductive and inductive approach.

Results

Women reported feeling uncomfortable seeking help for their alcohol use at antenatal clinics, limiting usefulness of current support services. All stakeholders perceived a community-based intervention to be acceptable and feasible as it could be integrated with other CHW-delivered services. Participants thought an intervention should facilitate early linkage to antenatal services and should include partners or family members. The feasibility of an intervention may depend on the relationship between CHWs and clinic-based antenatal staff, and their relationships with pregnant women. Clinic and community challenges to implementation were raised. Clinic-level challenges included shortage of space, staff capacity, high number of pregnant women, long waiting times, financial burden of having to travel to a clinic, lack of comfort and privacy and staff attitudes. Community-level challenges included crime, lack of privacy, lack of attention given competing interests in the home, fear due to abuse, and stigma and discrimination from other community members. Suggestions for overcoming these challenges were provided.

Conclusion

Findings provide essential information to facilitate the adaptation of a community-based alcohol counselling programme for greater acceptability, feasibility and cultural appropriateness for the South African context. Intensive training, supervision and support is required to ensure the programme is delivered as planned.

Reported health, social support, stress and associations with choline intake in pregnant women in central South Africa: the NuEMI study 2018-2019

BACKGROUND

The health and well-being of pregnant women can influence pregnancy outcomes and are closely associated with social support and experiences of stress. Poor nutrition predisposes to poor health with choline intake affecting pregnancy outcome. This study determined reported health, social support, and stress and how these factors are associated with choline intake in pregnancy.

METHODS

A cross sectional study was performed. Pregnant women in their second and third trimesters attending a high-risk antenatal clinic at a regional hospital in Bloemfontein, South Africa, were included. Trained fieldworkers obtained information during structured interviews using standardised questionnaires. Logistic regression with backward selection (p < 0.05) was used to select significant independent factors associated with choline intake. Variables with a p-value < 0.15 in bivariate analysis were considered for inclusion in the model.

RESULTS

Median age and gestation in the sample (N = 682) were 31.8 years and 32.0 weeks, respectively. Most participants (84.7%) consumed less than the adequate intake (AI) of 450 mg of choline per day. Most participants (69.0%) were either overweight or obese. One in eight participants (12.6%) reported not having anyone that could help them in times of need, more than one third (36.0%) reported having unpayable debt and one in twelve (8.4%) reported experiencing physical abuse by their partners. Normotensive participants and those using anti-retroviral therapy (ART) (thus HIV-infected), were more likely to consume choline in amounts below the AI (p = 0.042 and p = 0.011, respectively). Logistic regression analysis showed that the odds of consuming choline in amounts below the AI were lower for participants that were not using ART versus those using ART, with an odds ratio of 0.53.

CONCLUSION

HIV-infected participants were more likely to consume choline in levels below the AI. This vulnerable group should be the focus of targeted efforts to improve choline intake.

A pooled prevalence of fetal alcohol spectrum disorders in South Africa: a systematic review and meta-analysis protocol

BACKGROUND

Fetal Alcohol Spectrum Disorder (FASD) remains a global public health problem. South Africa is estimated to have the highest recorded prevalence of FASD. However, no study has systematically evaluated the available prevalence studies to provide estimates that may facilitate effective planning and delivery of prevention and management services. Therefore, we propose to conduct a systematic review and meta-analysis to report a pooled estimate of the FASD prevalence among children, youth and adults in South Africa.

METHODS

We will include quantitative (cohort and cross-sectional) studies that reported on the prevalence of FASD in South Africa. We will search databases such as Academic Search Complete, Education Resource Information Center (ERIC), SocINDEX, Health Source: Nursing/Academic Edition, Cumulative Index of Nursing and Allied Health and PsycARTICLES), Scopus, Science Direct, Springer Link, JSTOR, SAGE journals, PubMed, Web of Science and Sabinet. The references of included studies will be searched for additional studies on the prevalence of FASD. The search will be from inception to October 2021. Screening of (titles, abstracts and full text of the potentially relevant articles) will be done by two independent authors using software. All disagreements will be resolved by discussion. A standardised data extraction form will be designed for the extraction. Two authors will independently extract the data from the selected articles and all disagreements will be resolved by discussion. We will use a tool developed by Munn and colleagues to critically appraise all the included studies. The primary outcome will be the proportion of individuals with FASD in South Africa. We will use the Freeman-Tukey double arcsine transformation to transform the raw prevalence estimates so that the data can follow an approximately normal distribution. We will use random-effects models to calculate 95% confidence intervals and prediction intervals based on multiple meta-analyses with transformed proportions. We will test heterogeneity using Cochran's Q and describe using the I2 statistic.

DISCUSSION

The pooled prevalence estimate will assist the government and other stakeholders (such as non-profit organisations and researchers) to plan and prioritise prevention and management interventions.

SYSTEMATIC REVIEW REGISTRATION

The protocol has been registered with PROSPERO (registration number: CRD42020197979 ).

Policy Requirements for the Prevention and Management of Fetal Alcohol Spectrum Disorder in South Africa: A Policy Brief

This policy brief is aimed to guide policymakers in developing a comprehensive and multi-sectoral policy for the prevention and management of fetal alcohol spectrum disorder (FASD). FASD is a leading source of non-genetic developmental and intellectual disability globally and is usually associated with primary and secondary disabilities. South Africa has been identified to have the highest reported prevalence of FASD in the world. Nevertheless, evidence shows that there is no specific policy for FASD, albeit there are clauses that could be attributed to its prevention and management in other existing policies. In this brief, we present a guideline to inform programmes and interventions to tackle the FASD problem in South Africa and other relevant contexts through developing a policy.