Assessment of alcohol consumption in mexican pregnant women by hair testing of ethyl glucuronide

There are no studies that have utilized both biomarkers and self-reported data to evaluate maternal alcohol use during pregnancy in Mexico. Therefore, we aimed to describe the prevalence of alcohol consumption in a cohort of 300 Mexican pregnant women. We used a validated ultra-high performance liquid chromatography-tandem mass spectrometry (UHPLC-MS/MS) method to measure hair ethyl glucuronide (EtG) in hair segments that corresponded to the first and second half of pregnancy. We compared the hair EtG values to a self-reported questionnaire on maternal drinking habits and evaluated whether the gestational alcohol use was associated with psychotropic drug use. Based on the EtG measurements, 263 women (87.7%) were alcohol-abstinent during the entire pregnancy, while 37 (12.3%) had used alcohol at least once during the pregnancy. Of these, only two women were found to have problematic alcoholic behavior during the entire pregnancy. No significant differences in sociodemographic characteristics were observed between alcohol-abstinent women and women with drinking habits. The self-reporting data and hair EtG gave heterogeneous results: although 37 women had self-reported alcohol use during pregnancy, only 54.1% of these women tested positive for hair EtG. Of the women who tested positive for hair EtG, 54.1% tested positive for psychoactive substances. In our cohort, the use of drugs of abuse was independent of gestational drinking. This study provided the first objective evidence of prenatal ethanol consumption in a cohort of Mexican pregnant women.

Predictive risk markers in alcoholism

The medical disorders of alcoholism rank among the leading public health problems worldwide and the need for predictive and prognostic risk markers for assessing alcohol use disorders (AUD) has been widely acknowledged. Early-phase detection of problem drinking and associated tissue toxicity are important prerequisites for timely initiations of appropriate treatments and improving patient's committing to the objective of reducing drinking. Recent advances in clinical chemistry have provided novel approaches for a specific detection of heavy drinking through assays of unique ethanol metabolites, phosphatidylethanol (PEth) or ethyl glucuronide (EtG). Carbohydrate-deficient transferrin (CDT) measurements can be used to indicate severe alcohol problems. Hazardous drinking frequently manifests as heavy episodic drinking or in combinations with other unfavorable lifestyle factors, such as smoking, physical inactivity, poor diet or adiposity, which aggravate the metabolic consequences of alcohol intake in a supra-additive manner. Such interactions are also reflected in multiple disease outcomes and distinct abnormalities in biomarkers of liver function, inflammation and oxidative stress. Use of predictive biomarkers either alone or as part of specifically designed biological algorithms helps to predict both hepatic and extrahepatic morbidity in individuals with such risk factors. Novel approaches for assessing progression of fibrosis, a major determinant of prognosis in AUD, have also been made available. Predictive algorithms based on the combined use of biomarkers and clinical observations may prove to have a major impact on clinical decisions to detect AUD in early pre-symptomatic stages, stratify patients according to their substantially different disease risks and predict individual responses to treatment.

Identifying Prenatal Alcohol Exposure and Children Affected by It: A Review of Biomarkers and Screening Tools

PURPOSE

Early identification of prenatal alcohol exposure (PAE) and of those in need of services resulting from this exposure is an important public health concern. This study reviewed the existing literature on potential biomarkers and screening tools of PAE and its impact.

SEARCH METHODS

Electronic databases were searched for articles published between January 1, 1996, and November 30, 2021, using the following search terms: ("fetal alcohol" or "prenatal alcohol" or "FASD" or "alcohol-related neurodevelopmental disorder" or "ARND" or "ND-PAE") and ("screening" or "identification" or "biomarker"). Duplicate articles were electronically eliminated. Titles and abstracts were reviewed for appropriateness, and selected articles were retrieved for further analysis. Additional articles were added that were referenced in the reviewed articles or identified from expert knowledge. Information about the characteristics of the sample, the biomarker or screening tool, and the predictive validity outcome data were abstracted. A narrative analysis of the studies was then performed on the data.

SEARCH RESULTS

A total of 3,813 articles were initially identified, and 1,215 were removed as duplicates. Of the remaining articles, 182 were identified as being within the scope of the review based on title and abstract inspection, and 181 articles were successfully retrieved. Of these, additional articles were removed because they were preclinical (3), were descriptive only (13), included only self-report of PAE (42), included only mean group comparison (17), were additional duplicates (2), focused on cost analysis (9), missed predictive validity data (24), or for other reasons (23). The remaining articles (n = 48) were abstracted. An additional 13 manuscripts were identified from these articles, and two more from expert knowledge. A total of 63 articles contributed to the review.

DISCUSSION AND CONCLUSIONS

Biomarkers and screening tools of PAE and its impact fall short of ideal predictive validity characteristics. Higher specificity than sensitivity was found for many of the biomarkers and screening tools used to identify PAE and its impact, suggesting that current methods continue to under-identify the full range of individuals impacted by PAE. Exceptions to this were found in recent investigations using microRNAs related to growth and vascular development, proteomic changes associated with PAE, and combinations of markers estimating levels of various cytokines. Replications of these findings are needed across other samples to confirm the limited data available. Future research on biomarkers and screening tools should attend to feasibility and scalability of implementation. This article also recommends a systematic process of evaluation to improve early identification of individuals impacted by PAE so that harm reduction and habilitative care efforts can be implemented.

High-resolution imaging in studies of alcohol effect on prenatal development

Fetal alcohol syndrome represents the leading known preventable cause of mental retardation. FAS is on the most severe side of fetal alcohol spectrum disorders that stem from the deleterious effects of prenatal alcohol exposure. Affecting as many as 1 to 5 out of 100 children, FASD most often results in brain abnormalities that extend to structure, function, and cerebral hemodynamics. The present review provides an analysis of high-resolution imaging techniques that are used in animals and human subjects to characterize PAE-driven changes in the developing brain. Variants of magnetic resonance imaging such as magnetic resonance microscopy, magnetic resonance spectroscopy, diffusion tensor imaging, along with positron emission tomography, single-photon emission computed tomography, and photoacoustic imaging, are modalities that are used to study the influence of PAE on brain structure and function. This review briefly describes the aforementioned imaging modalities, the main findings that were obtained using each modality, and touches upon the advantages/disadvantages of each imaging approach.

Clinical features and risk factors associated with prenatal exposure to drugs of abuse

INTRODUCTION

Early identification of neonates exposed to drugs of abuse during pregnancy allows a more precise clinical management.

OBJECTIVES

To describe the clinical characteristics and to identify risk factors associated with the early detection of neonates exposed to drugs of abuse in a Neonatal Intermediate and Intensive Care Unit.

METHODS

Prospective observational study of neonates with and without clinical suspicion of prenatal exposure to drugs of abuse. Meconium was analyzed using standard chromatographic techniques. Univariate and multivariate statistical analyzes were performed.

RESULTS

372 neonates were included. Exposure to drugs of abuse was detected in 49 (13.2%) cases: in 41 (83.7%) one drug and in 8 (16.3%) more than one. Somatometry at birth revealed: a) lower length percentile in those exposed to some drug, more than one and cannabis; b) lower weight percentile in those exposed to cannabis and of these compared to those exposed to alcohol. In neonates older than 34 pregnancy weeks (PW): a) lower length percentile in those exposed to any substance; b) lower percentile of length and weight in exposed to more than one. The most clinically relevant independent risk factors useful to detect cases of prenatal exposure to drugs of abuse were (Odds ratio (95% CI)): reason for admission other than prematurity (5.52 (2.55-1.93)), length percentile less than 33 (1.95 (1.05-3.60) and 2.14 (1.04-3.40) in older than 34 PW) and social dystocia/uncontrolled pregnancy in older than 34 PW (4.47 (1.03-19.29)).

CONCLUSIONS

There are somatometric alterations and risk factors that can help in the early detection of neonates exposed to drugs of abuse. The somatometric alterations identified can be useful to extend the differential diagnosis of these alterations and to study their causes.

Neurocognitive and behavioral profile of fetal alcohol spectrum disorder

Prenatal alcohol exposure is the leading preventable cause of cognitive deficit in developed countries and can lead to fetal alcohol spectrum disorder (FASD). This term encompasses a wide range of physical, mental, behavioral, and cognitive effects that result from damage caused by exposure to alcohol during intrauterine life. Alcohol consumption among the general population is common in Eastern European countries and especially among women at risk of social exclusion, who are the ones who lose or give up custody of their children. A high number of these children are adopted in Spain and many of them present neurocognitive and behavioral disorders, causing FASD to be a public health problem in our country. In many occasions this clinical spectrum is delayed or under-diagnosed due to the overlapping of neuropsychological symptoms caused by the abandonment. A neurocognitive and behavioral profile specific for FASD has not been defined and all the symptoms are common to other etiologies. The aim of this work is to review the neuropsychological profile in the diagnosis of FASD.

Alternative matrices in forensic toxicology: a critical review

Purpose

The use of alternative matrices in toxicological analyses has been on the rise in clinical and forensic settings. Specimens alternative to blood and urine are useful in providing additional information regarding drug exposure and analytical benefits. The goal of this paper is to present a critical review on the most recent literature regarding the application of six common alternative matrices, i.e., oral fluid, hair, sweat, meconium, breast milk and vitreous humor in forensic toxicology.

Methods

The recent literature have been searched and reviewed for the characteristics, advantages and limitations of oral fluid, hair, sweat, meconium, breast milk and vitreous humor and its applications in the analysis of traditional drugs of abuse and novel psychoactive substances (NPS).

Results

This paper outlines the properties of six biological matrices that have been used in forensic analyses, as alternatives to whole blood and urine specimens. Each of this matrix has benefits in regards to sampling, extraction, detection window, typical drug levels and other aspects. However, theses matrices have also limitations such as limited incorporation of drugs (according to physical–chemical properties), impossibility to correlate the concentrations for effects, low levels of xenobiotics and ultimately the need for more sensitive analysis. For more traditional drugs of abuse (e.g., cocaine and amphetamines), there are already data available on the detection in alternative matrices. However, data on the determination of emerging drugs such as the NPS in alternative biological matrices are more limited.

Conclusions

Alternative biological fluids are important specimens in forensic toxicology. These matrices have been increasingly reported over the years, and this dynamic will probably continue in the future, especially considering their inherent advantages and the possibility to be used when blood or urine are unavailable. However, one should be aware that these matrices have limitations and particular properties, and the findings obtained from the analysis of these specimens may vary according to the type of matrix. As a potential perspective in forensic toxicology, the topic of alternative matrices will be continuously explored, especially emphasizing NPS.

Role of Neonatal Biomarkers of Exposure to Psychoactive Substances to Identify Maternal Socio-Demographic Determinants

Simple Summary

The rapid identification of newborns exposure to psychoactive drugs allows an appropriate clinical care. This study tried to identify maternal profiles that help to identify newborns exposed to psychoactive drugs during pregnancy. Mothers were interviewed using a questionnaire. The biomarkers of fetal exposure were measured in meconium samples. Statistical analysis was performed to identify the maternal characteristics that were most likely to be associated with drug use during pregnancy. Of a total of 372 mothers, 49 (13.2%) tested positive for psychoactive drugs use: 24 (49.0%) for cannabis, 11 (22.5%) for ethyl glucuronide, six (12.2%) for cocaine, and eight (16.3%) for more than one psychoactive substance. The maternal characteristics that most likely identify substance use during pregnancy are: maternal age < 24 years, lack of pregnancy care, single-mother families, and active tobacco smoking. The profiles of prenatal maternal exposure identified in a clinical setting can be used to request specific detection tests for identifying newborns exposed to these drugs.

Abstract

Background: The accurate assessment of fetal exposure to psychoactive substances provides the basis for appropriate clinical care of neonates. The objective of this study was to identify maternal socio-demographic profiles and risk factors for prenatal exposure to drugs of abuse by measuring biomarkers in neonatal matrices. Methods: A prospective, observational cohort study was completed. Biomarkers of fetal exposure were measured in meconium samples. The mothers were interviewed using a questionnaire. Univariate and multivariate logistic regression analyses were performed. Results: A total of 372 mothers were included, 49 (13.2%) testing positive for psychoactive substances use: 24 (49.0%) for cannabis, 11 (22.5%) for ethyl glucuronide, six (12.2%) for cocaine, and in eight (16.3%) more than one psychoactive substance. Mothers who consumed any psychoactive substance (29.7 ± 6.6 years) or cannabis (27.0 ± 5.7 years) were younger than non-users (32.8 ± 6.2 years, p < 0.05). Cocaine (50.0% vs. 96.9%, p < 0.05) and polydrug users (37.5% vs. 96.9%, p < 0.05) showed a lower levels of pregnancy care. Previous abortions were associated with the use of two or more psychoactive substances (87.5% vs. 37.8%, p < 0.05). Single-mother families (14.3% vs. 2.5%, p < 0.05) and mothers with primary level education (75.5% vs. 55.1%, p < 0.05) presented a higher consumption of psychoactive substances. Independent risk factors that are associated with prenatal exposure include: maternal age < 24 years (odds ratio: 2.56; 95% CI: 1.12–5.87), lack of pregnancy care (odds ratio: 7.27; 95%CI: 2.51–21.02), single-mother families (odds ratio: 4.98; 95%CI: 1.37–8.13), and active tobacco smoking (odds ratio: 8.13; 95%CI: 4.03–16.43). Conclusions: These results will allow us to develop several risk-based drug screening approaches to improve the early detection of exposed neonates.

[Neurocognitive and behavioral profile of fetal alcohol spectrum disorder]

Prenatal alcohol exposure is the leading preventable cause of cognitive deficit in developed countries and can lead to fetal alcohol spectrum disorder (FASD). This term encompasses a wide range of physical, mental, behavioral, and cognitive effects that result from damage caused by exposure to alcohol during intrauterine life. Alcohol consumption among the general population is common in Eastern European countries and especially among women at risk of social exclusion, who are the ones who lose or give up custody of their children. A high number of these children are adopted in Spain and many of them present neurocognitive and behavioral disorders, causing FASD to be a public health problem in our country. In many occasions this clinical spectrum is delayed or under-diagnosed due to the overlapping of neuropsychological symptoms caused by the abandonment. A neurocognitive and behavioral profile specific for FASD has not been defined and all the symptoms are common to other etiologies. The aim of this work is to review the neuropsychological profile in the diagnosis of TEAF.

[Clinical features and risk factors associated with prenatal exposure to drugs of abuse]

INTRODUCTION

Early identification of neonates exposed to drugs of abuse during pregnancy allows a more precise clinical management.

OBJECTIVES

To describe the clinical characteristics and to identify risk factors associated with the early detection of neonates exposed to drugs of abuse in a Neonatal Intermediate and Intensive Care Unit.

METHODS

Prospective observational study of neonates with and without clinical suspicion of prenatal exposure to drugs of abuse. Meconium was analyzed using standard chromatographic techniques. Univariate and multivariate statistical analyzes were performed.

RESULTS

372 neonates were included. Exposure to drugs of abuse was detected in 49 (13.2%) cases: in 41 (83.7%) one drug and in 8 (16.3%) more than one. Somatometry at birth revealed: a) lower length percentile in those exposed to some drug, more than one and cannabis; b) lower weight percentile in those exposed to cannabis and of these compared to those exposed to alcohol. In neonates older than 34 pregnancy weeks (PW): a) lower length percentile in those exposed to any substance; b) lower percentile of length and weight in exposed to more than one. The most clinically relevant independent risk factors useful to detect cases of prenatal exposure to drugs of abuse were (Odds ratio (95% CI)): reason for admission other than prematurity (5.52 (2.55-1.93)), length percentile less than 33 (1.95 (1.05-3.60) and 2.14 (1.04-3.40) in older than 34 PW) and social dystocia/uncontrolled pregnancy in older than 34 PW (4.47 (1.03-19.29)).

CONCLUSIONS

There are somatometric alterations and risk factors that can help in the early detection of neonates exposed to drugs of abuse. The somatometric alterations identified can be useful to extend the differential diagnosis of these alterations and to study their causes.

Determination of ethyl glucuronide in human hair samples: Decontamination vs extraction

Decontamination of samples prior to analysis is common practice and recommended for ethyl glucuronide (EtG) hair testing. The aim of this study was to evaluate the applied decontamination procedure during routine hair EtG analysis by monitoring the ethyl glucuronide concentrations in the washing solutions from a representative cohort of individual hair samples. Hair samples from 150 individuals were tested for hair EtG by a validated routine procedure (liquid chromatography/tandem mass spectrometry). A four-step decontamination procedure (ethanol, water, acetone, dichloromethane) was applied to all samples prior to analysis. Hair samples from 20 individuals were analyzed along with the complete set of individual washing solutions. Hair samples from an additional 130 individuals were analyzed along with the corresponding aqueous wash fraction only. No EtG was detected in the washing solutions from hair samples that tested negative for EtG (n = 42). Hair samples positive for ethyl glucuronide (n = 108) were found to liberate different amounts of EtG during decontamination: whereas no, or low portions of, EtG (< 10% of extracted hair EtG) were found in the corresponding washing solutions of the majority (n = 91) of individual samples, there was a minority of samples (n = 6) with more than half of the extracted hair EtG present in the decontamination solvent. No correlation of the decontaminated amount of EtG and the extracted hair EtG was observed. Further experimental studies are necessary to investigate if the observed easily removable fraction of EtG is associated with external contamination and if analysis of wash solutions could be helpful for identifying external contamination in hair testing for ethyl glucuronide.

Improvement of hair testing for Ethylglucuronide by supported liquid extraction and ultra-high performance liquid chromatography tandem mass spectrometry

To improve the reproducibility, suitability and speed of hair testing for Ethylglucuronide (EtG), an ultra-high performance liquid chromatography coupled to tandem mass spectrometry (UHPLC-MS/MS) method was developed and validated together with a supported liquid extraction (SLE) EtG from the keratin matrix. EtG was analyzed using reversed phase chromatography with gradient elution and detection with tandem mass spectrometry operated in multiple reaction monitoring (MRM) mode via negative electrospray ionization (ESI). The method showed good linearity from limit of quantification (LOQ) to 100 pg/mg hair (r² 0.996 ± 0.004). Recovery of the analyte was always higher than 80%, whereas intra- and inter-assay precision were always better than 15%. The developed method was applied to the analysis of more than 200 samples with medico-legal and epidemiological purposes ranging from non-detection of the analyte to 88.1 pg/mg and its robustness was proved by reanalysis of six different proficiency testing samples from the Society of hair testing obtaining a Z-score always less than 2.

Ethyl glucuronide hair testing: A review

Ethyl glucuronide (EtG) is a minor, non-oxidative ethanol metabolite that can be detected in several matrices (e.g. blood, urine, hair, meconium) for variable periods of time. Quantification of EtG in hair (hEtG) has established itself, over recent years, as one of the most reliable biomarkers of long-term alcohol consumption habits, with the Society of Hair Testing (SoHT) offering cut-off values for assessment of both abstinence and heavy drinking (>60 g/day). Despite its high diagnostic performance, however, issues concerning inter- and intra-laboratory variability as well as data interpretation are still being investigated and represent the ultimate barrier to widespread acceptance of hEtG in the forensic context. The aim of this review is to summarize currently available analytical methods of hEtG testing, provide a framework to understand current hEtG cut-offs and their possible upcoming changes (in particular, a lower abstinence cut-off has been proposed for the 2019 revision of the SoHT consensus), and offer a schematic but exhaustive overview of the pitfalls in result reproducibility and interpretation that may limit applications of hEtG testing in the forensic context. Ultimately, the purpose of the authors is not to undermine the reliability of hEtG as an alcohol use marker, but rather to enhance it by promoting familiarization with all aspects related to it, from ethanol pharmacokinetics and EtG incorporation into hair, to sample preparation and analytical methods, to specific cases warranting close attention and additional tests for correct interpretation of hEtG results.

Serum concentrations of IGF-I/IGF-II as biomarkers of alcohol damage during foetal development and diagnostic markers of Foetal Alcohol Syndrome

Foetal Alcohol Syndrome (FAS) is the most deleterious health effect derived from alcohol consumption during pregnancy and is placed at the end of the Foetal Alcohol Spectrum Disorders (FASD). Few studies have proposed potential molecular biomarkers of physical and neurological damage associated with prenatal alcohol exposure. We prospectively recruited 55 children from 8 to 12 years old, with a prenatal assessment for ethanol exposure using meconium analysis of fatty acid ethyl esters (FAEE). The control group was established for FAEE < 2 nmol/g (n = 31) and a Prenatal Ethanol Exposure (PEE) group for FAEEs > 2 nmol/g (n = 33). Moreover, 98 children adopted from Eastern European Countries (EEC) were also recruited to evaluate FASD diagnosis comprising 31 cases with complete FAS, 42 with partial FAS, 6 with ARBD and 5 with ARND. Serum values of IGF-I and IGF-II for all children recruited were determined by immunoassay. Anthropometric and neurocognitive evaluation showed severe impairments in FAS children, moderate effects in PEE and no harmful effects in the control group with no prenatal exposure to alcohol. Analysis of IGF-I and IGF-II serum concentrations revealed that FASD from EEC as well as PEE children showed significantly lower concentrations of both IGF-I and IFG-II than the control group and reference values. Moreover, Spearman correlations showed a significant effect of IGF-I on anthropometric measurements in girls, whereas IGF-II affected the neuropsychological variables in both genders. These findings validate the use of growth factors IGF-I and IGF-II as surrogate biomarkers of damage induced by prenatal exposure to ethanol and could be used in the diagnosis of foetal alcohol spectrum disorders.

Health advice on alcohol consumption in pregnant women in Seville (Spain)

OBJECTIVE

To analyse to what extent pregnant women remembered having received health advice regarding alcohol consumption during pregnancy, what the message they perceived was and whether there is social inequality in this regard.

METHOD

A cross-sectional descriptive study was performed with a sample of 426 pregnant women (in their 20th week of pregnancy) receiving care in the outpatient clinics of a university hospital in a southern Spanish city (Seville). The data were collected through face-to-face structured interviews carried out by trained health professionals.

RESULTS

43% of the interviewed women stated that they had not received any health advice in this regard. Only 43.5% of the sample remembered having received the correct message (not to consume any alcohol at all during pregnancy) from their midwife, 25% from their obstetrician and 20.3% from their general practitioner. The women with a low educational level were those who least declared having received health advice on the issue.

CONCLUSION

The recommended health advice to avoid alcohol consumption during pregnancy does not effectively reach a large proportion of pregnant women. Developing institutional programmes which help healthcare professionals to carry out effective preventive activities of foetal alcohol spectrum disorder is needed.

Dermatoglyphics in children prenatally exposed to alcohol: Fluctuating asymmetry (FA) as a biomarker of alcohol exposure

BACKGROUND

Dermatoglyphics alterations have been demonstrated to be an effective complement in the diagnosis of developmental disorders and a marker of prenatal stress. Several genetic and environmental factors can modify their morphology. Once defined, dermatoglyphics remain constant throughout life, being considered fossilized markers of the intrauterine development. Variations in bilateral morphological traits within an individual reflect developmental disturbances and can be measured by fluctuating asymmetry. The aim of this study was to evaluate if dermatoglyphic variations can be used as a surrogate marker prenatal alcohol exposure (PAE) during foetal development. Dermatoglyphics from 58 individuals who were either exposed or non-exposed to alcohol during pregnancy (according to the levels of Fatty Acid Ethyl Ethers (FAEE) found in meconium at birth) were analyzed.

METHODS

Total a-b ridge count (TABRC) and levels of fluctuating asymmetry from the a-b ridge count (FA_ABRC) were obtained.

RESULTS

A significant correlation between FA and FAEE levels was found in prenatally alcohol exposed individuals (r = 0.64, p = 0.0032). Remarkably, samples with highest values of FAEEs showed greater FA_ABRC (6.33 ± 4.18) levels than the values of non-exposed to alcohol (2.87 ± 1.74) as well as the exposed at low concentrations (2.6 ± 1.43) (U = 61, p = 0.05 and U = 14.5, p = 0.05, respectively).

CONCLUSION

Heavy prenatal ethanol exposure (demonstrated by high levels of FAEEs) alters the neuroectoderm developmental program during pregnancy: PAE correlates with FA_ABRC, which behaves as a dermatoglyphic variable sensitive to FASD and deserves to be studied as a surrogate marker of neurodevelopmental damage during foetal development.

The Effects of Alcohol and Drugs of Abuse on Maternal Nutritional Profile during Pregnancy

The consumption of alcohol and drugs of abuse among pregnant women has experienced a significant increase in the last decades. Suitable maternal nutritional status is crucial to maintain the optimal environment for fetal development but if consumption of alcohol or drugs of abuse disrupt the intake of nutrients, the potential teratogenic effects of these substances increase. Despite evidence of the importance of nutrition in addicted pregnant women, there is a lack of information on the effects of alcohol and drugs of abuse on maternal nutritional status; so, the focus of this review was to provide an overview on the nutritional status of addicted mothers and fetuses. Alcohol and drugs consumption can interfere with the absorption of nutrients, impairing the quality and quantity of proper nutrient and energy intake, resulting in malnutrition especially of micronutrients (vitamins, omega⁻3, folic acid, zinc, choline, iron, copper, selenium). When maternal nutritional status is compromised by alcohol and drugs of abuse the supply of essential nutrients are not available for the fetus; this can result in fetal abnormalities like Intrauterine Growth Restriction (IUGR) or Fetal Alcohol Spectrum Disorder (FASD). It is critical to find a strategy to reduce fetal physical and neurological impairment as a result of prenatal alcohol and drugs of abuse exposure combined with poor maternal nutrition. Prenatal nutrition interventions and target therapy are required that may reverse the development of such abnormalities.

Postnatal nutritional treatment of neurocognitive deficits in fetal alcohol spectrum disorder

Ethanol is the most important teratogen agent in humans. Prenatal alcohol exposure can lead to a wide range of adverse effects, which are broadly termed as fetal alcohol spectrum disorder (FASD). The most severe consequence of maternal alcohol abuse is the development of fetal alcohol syndrome, defined by growth retardation, facial malformations, and central nervous system impairment expressed as microcephaly and neurodevelopment abnormalities. These alterations generate a broad range of cognitive abnormalities such as learning disabilities and hyperactivity and behavioural problems. Socioeconomic status, ethnicity, differences in genetic susceptibility related to ethanol metabolism, alcohol consumption patterns, obstetric problems, and environmental influences like maternal nutrition, stress, and other co-administered drugs are all factors that may influence FASD manifestations. Recently, much attention has been paid to the role of nutrition as a protective factor against alcohol teratogenicity. There are a great number of papers related to nutritional treatment of nutritional deficits due to several factors associated with maternal consumption of alcohol and with eating and social disorders in FASD children. Although research showed the clinical benefits of nutritional interventions, most of work was in animal models, in a preclinical phase, or in the prenatal period. However, a minimum number of studies refer to postnatal nutrition treatment of neurodevelopmental deficits. Nutritional supplementation in children with FASD has a dual objective: to overcome nutritional deficiencies and to reverse or improve the cognitive deleterious effects of prenatal alcohol exposure. Further research is necessary to confirm positive results, to determine optimal amounts of nutrients needed in supplementation, and to investigate the collective effects of simultaneous multiple-nutrient supplementation.

Maternal hair testing to disclose self-misreporting in drinking and smoking behavior during pregnancy

This study aimed to objectively verify smoking and drinking behavior during pregnancy and to disclose self-misreporting through maternal hair analysis. A total of 153 women attending a university hospital in Barcelona (Spain) were selected and interviewed after delivery, on their smoking and drinking habits during pregnancy. A 9-cm hair strand was collected and analyzed by liquid chromatography tandem mass spectrometry for the presence of nicotine (NIC) and ethyl glucuronide (EtG) as biomarkers of tobacco and alcohol consumption, respectively. Concentrations of EtG <7 pg/mg hair and ≥30 pg/mg hair in the 0-3-cm hair segment have been used to assess, respectively, total abstinence and chronic excessive consumption in the previous 3 months, with repetitive moderate drinking lying in the interval 7-30 pg EtG per mg hair. Hair NIC less than 1 ng/mg hair indicates non-exposure to tobacco smoke while hair NIC indicates daily active smoking. In the interview, 28.1% of women declared to have smoked occasionally during gestation, while only 2.6% stated to have consumed alcohol on more than one occasion during pregnancy. Hair testing of smoking biomarkers disclosed that 7.2% of women remained active smokers during the whole pregnancy (hair NIC: 3.21-56.98 ng/mg hair), 16.3% were passive non-smokers or occasional smokers (hair NIC: 1.04-2.99 ng/mg hair), while 76.5% were not exposed to any cigarette smoke (hair NIC < limit of quantification - 0.91 ng/mg hair). Conversely, alcohol hair biomarkers showed that only 35.3% of women were totally abstinent during gestation (hair EtG: 3.89-6.73 pg/mg hair), while 62.7% drank a non-negligible amount of alcohol during pregnancy (hair EtG: 7.06-26.57 pg/mg hair), and 2% were chronic excessive drinkers (hair EtG: 35.33-47.52 pg/mg hair). Maternal hair analysis has shown to be significantly more sensitive than interviews in revealing an alarming misreported prevalence of alcohol use during pregnancy. These findings stress the need to use objective measures to assess alcohol exposure and to consider the inclusion of targeted actions to reduce alcohol consumption in maternal-child health policies.

Promises and pitfalls in the development of biomarkers that can promote early intervention in children at risk

The cost to individuals and to society of psychopathology that emerges in childhood is substantial. Children whose problems are undiagnosed or inadequately treated struggle in school, experience rejection by peers, and become a source of stress for caregivers and teachers. As adults, their mental health problems tend to recur and their cognitive difficulties persist. Clinicians hold a well-founded belief that early identification of children who are at risk for psychopathology is the key to prevention.

Assessment of tobacco, alcohol and cannabinoid metabolites in 645 meconium samples of newborns compared to maternal self-reports

Prenatal psychoactive substance exposure has significant impact on neonatal health and child development and the development of reliable biomarkers is critical. Meconium presents several advantages for detecting prenatal exposure to psychoactive substances, as it is easy to collect and provides a broad time frame of exposure (third trimester). The aim of our study was to compare the prevalence of alcohol, tobacco and/or cannabis use during the third trimester of pregnancy (using maternal self-reports) with the results of meconium testing of their metabolites in newborns (cotinine, ethyl-glucuronide (EtG) and cannabinoid metabolites). Among all deliveries (993) that occurred in all maternities in Rouen (Normandy) during a defined time period (5 consecutive weeks in August, 2010 and August, 2011), 724 mothers were included and 645 meconium samples were collected. Maternal self-reports, using the Addiction Severity Index (5th edition), and meconium samples were collected within 72 h of delivery. Cotinine detection appears highly correlated to maternal self-reports (Kappa value: 0.79; [95%CI: 0.73-0.85]). Moreover, detection in meconium seems more accurate in the prediction of neonatal consequences of prenatal tobacco exposure as compared to maternal self-reports. In contrast, we have found a lower concordance between maternal self-reports and meconium testing for EtG and cannabinoid metabolites (Kappa value: 0.13; [95%CI: 0.04-0.22] and: 0.30; [95%CI: -0.03-0.63], respectively); however the total number of EtG- and cannabinoid-positive meconium samples was small. Interestingly, meconium samples with the highest levels of EtG mainly corresponded to negative maternal self-reports. Fetal exposure to alcohol, tobacco or cannabis may also considerably differ as displayed in our pairs of dizygotic twins. Finally, a polyconsumption of these psychoactive substances was not frequently observed according to meconium testing. In conclusion, cotinine detection appears as a valuable meconium biomarker. EtG measurement in meconium samples seems interesting if there is any risk of high fetal exposure, whereas assessment of prenatal cannabis exposure, using meconium testing, needs to be improved.

Biomarkers for the Detection of Prenatal Alcohol Exposure: A Review

Alcohol exposure during pregnancy can cause adverse effects to the fetus, because it interferes with fetal development, leading to later physical and mental impairment. The most common clinical tool to determine fetal alcohol exposure is maternal self-reporting. However, a more objective and useful method is based on the use of biomarkers in biological specimens alone or in combination with maternal self-reporting. This review reports on clinically relevant biomarkers for detection of prenatal alcohol exposure (PAE). A systematic search was performed to ensure a proper overview in existing literature. Studies were selected to give an overview on clinically relevant neonatal and maternal biomarkers. The direct biomarkers fatty acid ethyl esters (FAEEs), ethyl glucuronide (EtG), ethyl sulfate, and phosphatidylethanol (PEth) were found to be the most appropriate biomarkers in relation to detection of PAE. To review each biomarker in a clinical context, we have compared the advantages and disadvantages of each biomarker, in relation to its window of detectability, ease of collection, and the ease and cost of analysis of each biomarker. The biomarkers PEth, FAEEs, and EtG were found to be applicable for detection of even low levels of alcohol exposure. Meconium is an accessible matrix for determination of FAEEs and EtG, and blood an accessible matrix for determination of PEth.

Assays of Gamma-Glutamyl Transferase and Carbohydrate-Deficient Transferrin Combination from Maternal Serum Improve the Detection of Prenatal Alcohol Exposure

BACKGROUND

Alcohol use during pregnancy leads to detrimental effects on fetal development. As self-reports by mothers are known to be unreliable for assessing prenatal alcohol exposure, there is a need for sensitive and specific biomarkers for identifying those at risk for alcohol-affected offspring.

METHODS

We measured serum gamma-glutamyl transferase (GGT), carbohydrate-deficient transferrin (CDT), a mathematically formulated combination of GGT and CDT (GGT-CDT), and ethylglucuronide (EtG) concentrations from 1,936 mothers with a positive (n = 480) or negative (n = 1,456) history of alcohol use at the time of pregnancy. The material included 385 alcohol-abusing mothers who subsequently gave birth to children with fetal alcohol syndrome (FAS) and 1,551 mothers without FAS children including 95 women who reported a median of 1.0 standard drinks of alcohol per day during pregnancy and 1,456 nondrinking controls. Among those without FAS outcome, there were 405 mothers with gestational diabetes mellitus (GDM) and 745 mothers representing lifelong abstainers.

RESULTS

Mothers of FAS children had higher mean GGT, CDT, GGT-CDT, and EtG levels than abstainers (p < 0.001 for all comparisons) or mothers reporting some alcohol consumption but whose children were not diagnosed with FAS (p < 0.001 for all comparisons). In receiver operating characteristic analyses using cutoffs based on abstainers, the area under the curves (AUCs) for GGT-CDT (0.873) were higher than those of GGT (0.824), CDT (0.776), or EtG (0.584) for differentiating the mothers of FAS children and abstainers. Unlike CDT, this combination marker also differed significantly between drinking mothers without FAS outcome and abstainers (AUC = 0.730, p < 0.001). In comparisons adjusted for GDM and body mass index, the group of mothers who had reported a median of 1.0 standard drinks of alcohol per day during pregnancy also differed from the group reporting no current alcohol intake in GGT (p < 0.02) and GGT-CDT (p < 0.01) levels.

CONCLUSIONS

Combination of GGT and CDT improves the identification of prenatal alcohol exposure and associated high-risk pregnancies. A more systematic use of biomarkers may help intervention efforts to prevent alcohol-induced adverse effects on fetal development.

Objective Measures of Prenatal Alcohol Exposure: A Systematic Review

CONTEXT

Objective measurement of prenatal alcohol exposure (PAE) is essential for identifying children at risk for adverse outcomes, including fetal alcohol spectrum disorders. Biomarkers have been advocated for use in universal screening programs, but their validity has not been comprehensively evaluated.

OBJECTIVE

To systematically review the validity of objective measures of PAE.

DATA SOURCES

Thirteen electronic databases and supplementary sources were searched for studies published between January 1990 and October 2015.

STUDY SELECTION

Eligible studies were those that evaluated the diagnostic accuracy of objective measures of PAE.

DATA EXTRACTION

Three reviewers independently verified study inclusion, quality assessments, and extracted data.

RESULTS

Twelve studies met inclusion criteria. Test performance varied widely across studies of maternal blood (4 studies; sensitivity 0%-100%, specificity 79%-100%), maternal hair (2 studies; sensitivity 19%-87%, specificity 56%-86%) maternal urine (2 studies; sensitivity 5%-15%, specificity 97%-100%), and biomarker test batteries (3 studies; sensitivity 22%-50%, specificity 56%-97%). Tests of the total concentration of 4 fatty acid ethyl esters (in meconium: 2 studies; in placenta: 1 study) demonstrated high sensitivity (82%-100%); however, specificity was variable (13%-98%).

LIMITATIONS

Risk of bias was high due to self-report reference standards and selective outcome reporting.

CONCLUSIONS

Current evidence is insufficient to support the use of objective measures of prenatal alcohol exposure in practice. Biomarkers in meconium and placenta tissue may be the most promising candidates for further large-scale population-based research.

Did you drink alcohol during pregnancy? Inaccuracy and discontinuity of women's self-reports: On the way to establish meconium ethyl glucuronide (EtG) as a biomarker for alcohol consumption during pregnancy

Consuming alcohol during pregnancy is one of the most verified prenatal risk factors for impaired child development. Information about the amount of alcohol consumed prenatally is needed to anticipate negative effects and to offer timely support. Women's self-reports are not reliable, often influenced by social stigmas and retrospective recall bias, causing biomarkers of intrauterine ethanol exposure to become more and more relevant. The present study compares both women's gestational and retrospective self-reports of prenatal alcohol consumption with levels of ethyl glucuronide (EtG) in meconium. Women (n = 180) gave self-reports of prenatal alcohol consumption both during their 3rd trimester (gestational self-report) and when their children were 6-8 years old (retrospective self-report). Child meconium was collected after birth and analyzed for EtG. No individual feedback of children's EtG level was given to the women. All analyses were run separately for two cut-offs: 10 ng/g (limit of detection) and 120 ng/g (established by Goecke et al., 2014). Mothers of children with EtG values above 10 ng/g (n = 42) tended to report prenatal alcohol consumption more frequently. There was no trend or significance for the EtG cut-off of 120 ng/g (n = 26) or for retrospective self-report. When focusing on women who retrospectively reported alcohol consumption during pregnancy, a claim to five or more consumed glasses per month made an EtG over the 10 ng/g and the 120 ng/g cut-off more probable. Women whose children were over the 10 ng/g EtG cut-off were the most inconsistent in their self-report behavior, whereas the consistency in the above 120 ng/g EtG group was higher than in any other group. The next step to establish EtG as a biomarker for intrauterine alcohol exposure is to correlate EtG values in meconium with child developmental impairments.

Fetal alcohol-spectrum disorders: identifying at-risk mothers

Fetal alcohol-spectrum disorders (FASDs) are a collection of physical and neurobehavioral disabilities caused by prenatal exposure to alcohol. To prevent or mitigate the costly effects of FASD, we must identify mothers at risk for having a child with FASD, so that we may reach them with interventions. Identifying mothers at risk is beneficial at all time points, whether prior to pregnancy, during pregnancy, or following the birth of the child. In this review, three approaches to identifying mothers at risk are explored: using characteristics of the mother and her pregnancy, using laboratory biomarkers, and using self-report assessment of alcohol-consumption risk. At present, all approaches have serious limitations. Research is needed to improve the sensitivity and specificity of biomarkers and screening instruments, and to link them to outcomes as opposed to exposure. Universal self-report screening of all women of childbearing potential should ideally be incorporated into routine obstetric and gynecologic care, followed by brief interventions, including education and personalized feedback for all who consume alcohol, and referral to treatment as indicated. Effective biomarkers or combinations of biomarkers may be used during pregnancy and at birth to determine maternal and fetal alcohol exposure. The combination of self-report and biomarker screening may help identify a greater proportion of women at risk for having a child with FASD, allowing them to access information and treatment, and empowering them to make decisions that benefit their children.

Biomarker-Based Approaches for Assessing Alcohol Use Disorders

Although alcohol use disorders rank among the leading public health problems worldwide, hazardous drinking practices and associated morbidity continue to remain underdiagnosed. It is postulated here that a more systematic use of biomarkers improves the detection of the specific role of alcohol abuse behind poor health. Interventions should be initiated by obtaining information on the actual amounts of recent alcohol consumption through questionnaires and measurements of ethanol and its specific metabolites, such as ethyl glucuronide. Carbohydrate-deficient transferrin is a valuable tool for assessing chronic heavy drinking. Activities of common liver enzymes can be used for screening ethanol-induced liver dysfunction and to provide information on the risk of co-morbidities including insulin resistance, metabolic syndrome and vascular diseases. Conventional biomarkers supplemented with indices of immune activation and fibrogenesis can help to assess the severity and prognosis of ethanol-induced tissue damage. Many ethanol-sensitive biomarkers respond to the status of oxidative stress, and their levels are modulated by factors of life style, including weight gain, physical exercise or coffee consumption in an age- and gender-dependent manner. Therefore, further attention should be paid to defining safe limits of ethanol intake in various demographic categories and establishing common reference intervals for biomarkers of alcohol use disorders.

Segmental hair analysis to assess effectiveness of single-session motivational intervention to stop ethanol use during pregnancy

BACKGROUND

This study aimed to test the effectiveness of single-session motivational intervention to stop ethanol use during pregnancy using segmental hair analysis of ethyl glucuronide to objectively verify drinking behavior before and after intervention.

METHODS

168 pregnant women attending Hospital del Mar (Barcelona, Spain) for antenatal visit were included in the study and randomly assigned to one of two conditions: single-session motivational intervention (MI; N=83) or single-session educational control condition (ECC; N=85). Ethyl glucuronide was measured in maternal hair divided into three segments of 3 cm each corresponding to the three different gestation trimesters by a validated liquid chromatography tandem mass spectrometry method. Concentrations of EtG<7 pg/mg, between 7 and 30 pg/mg and ≥30 pg/mg in each segment were used to assess total abstinence, repetitive moderate drinking and chronic excessive consumption in the previous three months.

RESULTS

About a third of pregnant women self-reporting no ethanol consumption during gestation showed hair EtG values corresponding to ethanol drinking. Single-session MI helped in decreasing alcohol consumption during pregnancy as assessed by lower hair EtG concentrations in 2nd and 3rd trimesters. However, it did not significantly increase complete abstinence in pregnant women who previously showed hair EtG compatible with ethanol consumption.

CONCLUSIONS

Pregnant women did not correctly self reported ethanol consumption during gestation, while hair EtG was essential to correctly identify drinking patterns. Single-session MI was not enough to stop ethanol use during pregnancy. Interventions at any visit during pregnancy are strongly recommended.