Fetal alcohol syndrome: maternal and neonatal characteristics

Autism Spectrum Disorder and Fetal Alcohol Spectrum Disorder: A Literature Review

Fetal alcohol spectrum disorders (FASD) are a group of conditions associated with the effects of prenatal alcohol exposure and characterized by somatic and neuropsychological alterations. On the other hand, autism spectrum disorder (ASD) is characterized by a multifaceted neurobehavioral syndrome. Since alcohol can affect every stage of brain development, some authors hypothesized that in utero alcohol exposure might be linked to an increased risk of ASD in subjects with genetic vulnerability. The present review aimed to summarize the available literature on the possible association between FASD and ASD, also focusing on the reported clinical overlaps and on the possible shared pathogenic mechanisms. Studies in this field have stressed similarities and differences between the two conditions, leading to controversial results. The available literature also highlighted that both the disorders are often misdiagnosed or underdiagnosed, stressing the need to broaden the perspective, paying specific attention to milder presentations and sub-syndromic traits.

The causal web of foetal alcohol spectrum disorders: a review and causal diagram

Foetal alcohol spectrum disorders (FASDs) are a leading cause of developmental disability. Prenatal alcohol use is the sole necessary cause of FASD, but it is not always sufficient. Multiple factors influence a child's susceptibility to FASD following prenatal alcohol exposure. Much of the FASD risk factor literature has been limited to discussions of association, rather than causation. While knowledge of predictor variables is important for identifying who is most at risk of FASD and for targeting interventions, causal knowledge is important for identifying effective mechanisms for prevention and intervention programmes. We conducted a systematic search and narrative synthesis of the evidence and used this to create a causal diagram (directed acyclic graph; DAG) to describe the causal pathways to FASD. Our results show that the aetiology of FASD is multifaceted and complex. FASD risk is determined by a range of lifestyle, sociodemographic, maternal, social, gestational, and genetic factors. The causal diagram that we present in this review provides a comprehensive summary of causal risk factors for FASD and can be used as a tool to inform data collection and statistical modelling strategies to minimise bias in future studies of FASD.

Comparison of Alcohol-Related Neurodevelopmental Disorders and Neurodevelopmental Disorders Associated with Prenatal Alcohol Exposure Diagnostic Criteria

OBJECTIVE

Recently, increased attention has been focused on the diagnosis of the most prevalent category of fetal alcohol spectrum disorders, alcohol-related neurodevelopmental disorders (ARNDs). In 2013, proposed criteria for neurodevelopmental disorders associated with prenatal alcohol exposure (ND-PAE) were included in the appendix of the latest revision of the Diagnostic and Statistical Manual of Mental Disorders. The concordance of the 2 sets of criteria is unknown. This study examines the overlap in diagnostic criteria for ND-PAE and the ARND Behavioral Checklist in children.

METHODS

Clinical charts from June 2013 to July 2016 were reviewed to identify patients with an evaluation for ARNDs and where the criteria for ND-PAE were also available.

RESULTS

The review found 86 charts with a diagnosis of ARNDs, which included the ARND Checklist and the ND-PAE criteria. We then calculated the sensitivity and specificity comparing the ND-PAE with the ARND Checklist as the comparison standard. The sensitivity was 95.0%, specificity was 75.0%, and the ND-PAE diagnosis correctly classified 89.5% of cases identified as meeting criteria for ARNDs by the checklist. The receiver operating characteristics resulted in a large shared area under the curve of 90.1%.

CONCLUSION

The 2 diagnostic constructs of ARNDs and ND-PAE seem to be very similar. Both the ARND and the ND-PAE variables are written in familiar formats and could be widely used by a variety of health care providers.

Screening for prenatal alcohol exposure and corresponding short-term neonatal outcomes

Detection of prenatal alcohol exposure (PAE) is important for early intervention and treatment. The main purpose of this study was to compare 1.) PAE rates using the biomarker, phosphatidylethanol (PEth), in umbilical cord (UC) blood vs. ethyl glucuronide (EtG) in UC tissue, the standard of care, and 2.) Pregnancy characteristics and neonatal outcomes in newborns positive vs. negative for PAE biomarkers. We examined records of neonates born over a two-year span receiving UC-PEth dried blood spots testing at the time of delivery in addition to standard of care PAE screening (n = 146). UC-PEth testing had a higher PAE detection rate (26%) vs. UC tissue EtG (0%, p < 0.01). PAE was not associated with any neonatal dysmorphic features or short-term adverse outcomes. The absence of significant clinical findings for identifying PAE in neonates reinforces alcohol biomarker necessity. We conclude that UC-PEth may be a valuable test for assessing PAE at birth and in identifying infants at risk for developing fetal alcohol spectrum disorder.

Manitoba mothers and fetal alcohol spectrum disorders study (MBMomsFASD): protocol for a population-based cohort study using linked administrative data

INTRODUCTION

Fetal alcohol spectrum disorder (FASD) is a significant public health concern. To prevent FASD, factors that place women at risk for giving birth to children with FASD must be investigated; however, there are little data in this area. This paper describes the development of the Manitoba mothers and FASD study, a retrospective cohort of mothers whose children were diagnosed with FASD, generated to investigate: (1) risk factors associated with giving birth to children with FASD; (2) maternal physical and health outcomes, as well as the usage of health and social services.

METHODS

The study population will be identified by linking children diagnosed with FASD from a provincially centralised FASD assessment clinic (from 31 March 1999 to 31 March 2012) to their birth mothers using de-identified administrative health data housed at the Manitoba Centre for Health Policy. Preliminary analysis has identified over 700 mothers, which is the largest sample size in this field to date. A comparison cohort of women with children who did not have an FASD diagnosis matched on the region of residence, date of birth of child with FASD and socioeconomic status will be generated to compare exposures and outcomes. Potential demographic, socioeconomic, family history, and physical and mental health risk factors will be investigated by linking a range of health and social databases, furthering insight into the root causes of drinking during pregnancy. The longitudinal data will allow us to document the usage patterns of healthcare and social services throughout significant periods in these women's lives to identify opportunities for prevention.

ETHICS AND DISSEMINATION

Ethical approval has been obtained by the University of Manitoba's Health Research Ethics Board and the Manitoba Health Information Privacy Committee. Dissemination of study results will include engagement of stakeholders and policymakers through presentations and reports for policymakers, in parallel with scientific papers.

A staged screening strategy for prenatal alcohol exposure and maternal risk stratification

Aims: To present an incremental process for a staged screening strategy to identify women at increased risk of having a child with fetal alcohol spectrum disorder (FASD) and to enhance the management of women using alcohol during pregnancy. We include an illustrative example of the development of a screening component using an existing data set.

Methods: We describe a seven-step protocol to screen for alcohol use during pregnancy. The screening process begins with a one-question initial screen, followed by exposure assessment, maternal risk stratification to estimate risk for FASD, and concludes with recommendations for intervention and monitoring of exposure for women drinking during pregnancy.

Conclusions: This screening process has very modest time commitments in the early stages. Time commitments increase for women drinking during pregnancy and the process focuses on the population at highest risk of having a child with FASD. The process has the benefit of risk specificity, since the process refines risk estimates for an adverse outcome specific for FASD. The process concludes with a programme to facilitate intervention and to monitor changes in prenatal alcohol exposure during pregnancy.

Prevention of FASD is an important public health priority. In addition to the ongoing study of clinical strategies to improve detection rates of alcohol exposure at all stages of pregnancy, additional research on the tools and the process used in screening efforts is urgently needed. The efforts should also include research on both the screening tools and the outcome of the screening process in routine prenatal care settings.

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.

Relationships between Head Circumference, Brain Volume and Cognition in Children with Prenatal Alcohol Exposure

Head circumference is used together with other measures as a proxy for central nervous system damage in the diagnosis of fetal alcohol spectrum disorders, yet the relationship between head circumference and brain volume has not been investigated in this population. The objective of this study is to characterize the relationship between head circumference, brain volume and cognitive performance in a large sample of children with prenatal alcohol exposure (n = 144) and healthy controls (n = 145), aged 5-19 years. All participants underwent magnetic resonance imaging to yield brain volumes and head circumference, normalized to control for age and sex. Mean head circumference, brain volume, and cognitive scores were significantly reduced in the prenatal alcohol exposure group relative to controls, albeit with considerable overlap between groups. Males with prenatal alcohol exposure had reductions in all three measures, whereas females with prenatal alcohol exposure had reduced brain volumes and cognitive scores, but no difference in head circumference relative to controls. Microcephaly (defined here as head circumference ≤ 3rd percentile) occurred more often in prenatal alcohol exposed participants than controls, but 90% of the exposed sample had head circumferences above this clinical cutoff indicating that head circumference is not a sensitive marker of prenatal alcohol exposure. Normalized head circumference and brain volume were positively correlated in both groups, and subjects with very low head circumference typically had below-average brain volumes. Conversely, over half of the subjects with very low brain volumes had normal head circumferences, which may stem from differential effects of alcohol on the skeletal and nervous systems. There were no significant correlations between head circumference and any cognitive score. These findings confirm group-level reductions in head circumference and increased rates of microcephaly in children with prenatal alcohol exposure, but raise concerns about the predictive value of this metric at an individual-subject level.

Identifying maternal risk factors associated with Fetal Alcohol Spectrum Disorders: a systematic review

To identify the demographic, psychological, and social maternal risk factors associated with the development of Fetal Alcohol Spectrum Disorders (FASD). A bibliographic search was conducted in PubMed, SciELO, Lilacs, Web of Knowledge, and PsycINFO. The Newcastle-Ottawa Quality Assessment Scale (NOS) was used to evaluate the quality of the studies with case-control design. Articles were selected based on their relevance and presentation of data related to statistical comparisons of at least one or more demographic, psychological, or social maternal risk factors for FASD. 738 references were identified, of which 15 met the criteria to be included in the present review. Mothers of FASD children tend to: be older at the time of birth of the affected child, present lower educational level, have other family relatives with alcohol abuse, have other children with FASD, present a pattern of little prenatal care and a distinguishing pattern of alcohol consumption (alcohol use before and during pregnancy, failure to reduce alcohol use during pregnancy, and frequent episodes of binge drinking). Application of the NOS scale of methodological quality indicated that 8 studies (53 %) met the criterion for selection, 4 (27 %) were suitable for the criterion for comparability and only 4 studies were suitable for the exposition criterion. Mothers of FASD children have a distinctive pattern of drinking and accumulate several social risk factors. Maternal age at birth of the child seems to accentuate the risk. There are, however, few controlled studies that are adequate according to the NOS requirements for methodological quality. Fewer are based on the verification of a theoretical model. Clinicians should be aware of the relevance of preventive assessment of FASD risk mothers.

Fetal alcohol spectrum disorders and childhood cancer: a concise review of case reports and future research considerations

We reviewed the published literature on the relationship between childhood cancer and fetal alcohol spectrum disorders (FASD). A Pub Med search identified 12 subjects with the co-occurrence of FASD and cancer. We included an additional case from the author's institution. Neuroblastomas comprised 6 of the 13 (46%) case reports, yet neuroblastomas comprise only about 10% of childhood cancers (z = 4.1; P < 0.001). Other than rhabdomyosarcoma, no other cancer was reported more than once. Few cases of childhood cancer associated with FASD were identified likely due to under ascertainment of FASD.

Pregnancy-specific anxiety: which women are highest and what are the alcohol-related risks?

In a national US sample of pregnant women (n=311), we investigated the question of who becomes highly anxious about pregnancy by examining putative sociodemographic, pregnancy- and mental health-related predictors of pregnancy anxiety. We also assessed the contribution of pregnancy anxiety to the risk of significant alcohol consumption during pregnancy. English-speaking pregnant women aged 18+years were recruited online. Results indicated that sociodemographic factors (younger age, white, unmarried, lower education, lower household income, no previous children), feelings about current pregnancy (unwanted), and general anxiety (higher general and state anxiety) predicted higher pregnancy-related anxiety, whereas age, religiosity, number of weeks pregnant, unplanned pregnancy, and maternal depressive symptoms did not. Pregnancy anxiety was the single strongest predictor of alcohol drinking risk during pregnancy (p<.001, ∆R(2)=.10) a relationship that held after controlling for other significant predictors. Pregnancy anxiety also represented the strongest predictor of screening positively for drinking risk during pregnancy at the total T-ACE (an alcohol risk screener for pregnancy) level of 3+ (odds ratio 95% CI=1.61-4.14, p<.001), though not at the level of 2+ (odds ratio 95% CI=0.98-1.68, p=.07). We discuss implications for the link between maternal mental health and birth/ child outcomes.

Characteristics of children whose siblings have fetal alcohol syndrome or incomplete fetal alcohol syndrome

OBJECTIVE

To describe the clinical features of American Indian children born just before and just after a sibling with fetal alcohol syndrome or incomplete fetal alcohol syndrome.

METHODS

Two retrospective case-control studies were conducted of Northern Plains American Indian children with fetal alcohol syndrome or incomplete fetal alcohol syndrome identified from 1981 to 1993 by using International Classification of Diseases, Ninth Revision, Clinical Modification code 760.71.

RESULTS

Compared with the controls, the 39 siblings born just before children with fetal alcohol syndrome (study 1) and 30 siblings born just before children with incomplete fetal alcohol syndrome (study 2) had more facial dysmorphology (23.1% and 16.7%, respectively), growth delay (38.5% and 10.0%), and central nervous system impairment (48.7% and 33.3%). The 20 siblings born just after children with fetal alcohol syndrome (study 1) and 22 siblings born just after children with incomplete fetal alcohol syndrome (study 2) had more facial dysmorphology (20.0% and 9.1%, respectively), growth delay (45.0% and 22.7%), and central nervous system impairment (50.0% and 31.8%) than the control siblings.

CONCLUSIONS

The "before" siblings had characteristics of fetal alcohol syndrome that could have predicted that the next child was at risk for fetal alcohol syndrome. The "after" siblings had better outcomes than the previous siblings with fetal alcohol syndrome, a finding that was associated with a decrease in maternal alcohol consumption during the after-sibling pregnancy.

Effects of light ethanol consumption during pregnancy: increased frequency of minor anomalies in the newborn and altered contractility of umbilical cord artery

This study explores the effects of light maternal ethanol consumption during pregnancy on the appearance of minor malformations in neonates as well as on the contractile properties of their umbilical cord arteries (UCAs). Clinical external findings of newborns of women declaring light ethanol consumption during any period of their pregnancies [ethanol-exposed group (E group), n=79] were compared with those of nonexposed mothers [nonexposed to ethanol group (NE group), n=100]. Women who smoked or had any associated pathology were excluded. E group mothers consumed, on average, 200-250 mL ethanol/trimester (upper limit 700 mL/trimester). Sixty-six percent of the neonates in the E group presented at least one minor malformation (retromicrognathia and minor anomalies of the auricular/preauricular area were the more common), whereas only 16% of the NE group did (p=0.0000). The percentage of children exhibiting Apgar scores <7 was significantly greater in the E group (11% versus 2%, p=0.0119). UCAs from the E group developed significantly less contractile force (p<0.05) than those of the NE group when exposed to 1 microM serotonin (5-HT) or to a high K+ depolarizing solution. This difference persisted after inhibition of endothelial release of nitric oxide (NO) and prostacyclin. In conclusion, even light drinking should be considered a risk during pregnancy.

Postnatal aniracetam treatment improves prenatal ethanol induced attenuation of AMPA receptor-mediated synaptic transmission

Aniracetam is a nootropic compound and an allosteric modulator of AMPA receptors (AMPARs) which mediate synaptic mechanisms of learning and memory. Here we analyzed impairments in AMPAR-mediated synaptic transmission caused by moderate prenatal ethanol exposure and investigated the effects of postnatal aniracetam treatment on these abnormalities. Pregnant Sprague-Dawley rats were gavaged with ethanol or isocaloric sucrose throughout pregnancy, and subsequently the offspring were treated with aniracetam on postnatal days (PND) 18 to 27. Hippocampal slices prepared from these pups on PND 28 to 34 were used for the whole-cell patch-clamp recordings of AMPAR-mediated spontaneous and miniature excitatory postsynaptic currents in CA1 pyramidal cells. Our results indicate that moderate ethanol exposure during pregnancy results in impaired hippocampal AMPAR-mediated neurotransmission, and critically timed aniracetam treatment can abrogate this deficiency. These results highlight the possibility that aniracetam treatment can restore synaptic transmission and ameliorate cognitive deficits associated with the fetal alcohol syndrome.

Factors predictive of alcohol use during pregnancy in three rural states

BACKGROUND

A substance use screening instrument was used to determine factors predictive of drinking during pregnancy. Alcohol consumption during pregnancy can lead to negative birth outcomes.

METHODS

The participants (n = 4,828) for the study were sampled from pregnant women attending prenatal clinics in Montana, South Dakota, and North Dakota. Clinic sites for the administration of the screening instrument were selected in each state, based on geographic and known population characteristics. Univariate and multivariate statistical procedures were used to determine factors predictive of drinking during pregnancy.

RESULTS

Women who drank tended to: be single, be between 21-25 years old, have had fewer children, have had abortions, and be unemployed. Demographic factors that were protective of drinking when pregnant were married and full-time housewife status. Other variables associated with maternal alcohol use were: past sexual abuse, current or past physical abuse, tobacco use, other drug use, lived with substance users, and had mates who were substance users. Other contributing factors for alcohol use included: feeling sad, believing that drinking any amount of alcohol while pregnant was acceptable, had been in treatment, could use treatment now, and were able to hold four or more drinks.

CONCLUSION

Because drinking rates were high and factors correlated with drinking are known, alcohol screening for this population is essential.

Prospective identification of pregnant women drinking four or more standard drinks (> or = 48 g) of alcohol per day

We aimed to identify drinking rates in a prospectively identified cohort of pregnant women, and subsequently, to identify the drinkers of 48 g or more alcohol/day among them, by using complementary methods for verifying self-reported drinking habits. A research team of social workers and health professionals at the Maipú Clinic, located in a lower middle class neighborhood of Santiago, Chile, conducted interviews of women attending a prenatal clinic between August 1995 and July 2000. Women whose interview responses met predefined criteria (identified in the text) were further evaluated by home visits. We interviewed 9,628 of 10,917 (88%) women receiving prenatal care. By initial interview, 42.6% of women reported no drinking, 57.4% some alcohol consumption, and 3.7% consuming at least one standard drink (15 mL of absolute alcohol) per day. Of the 887 women who had home visits, 101 were identified as consuming on average at least 4 drinks/day (48 g). To determine the best home visit questionnaire items for identifying those drinking at least 4 drinks per day, 48 women who openly admitted drinking this amount were compared with 786 women who were not considered drinkers after the home visit. The 48 self-reported 48 g/day drinkers were significantly more likely to get tipsy when drinking before (p = 0.01) or during (p < 0.0001) pregnancy, to have started drinking at a younger age (p = 0.007), or to exhibit signs of low self-esteem (p < 0.0001), sleep or appetite problems (p < 0.0001), bad interpersonal relationships (p < 0.0001) or having family members with fetal alcohol syndrome features (p < 0.009). In conclusion, using complementary methods of alcohol misuse ascertainment during pregnancy, we found that at least 1% of pregnant women in a Santiago, Chile, clinic population were drinking at levels that are clearly dangerous to the fetus (48 g/day or more). We identified specific interview questions that may help screen for alcohol use of 48 g/day or more in pregnant women.

Maternal age in patients with septo-optic dysplasia

AIM

To determine whether patients with septooptic dysplasia (SOD) are of normal birth weight and gestation but are born to mothers who are significantly younger than average.

METHODS

Retrospective study of 30 patients with SOD attending the Royal Hospital for Sick Children, Glasgow. Birth data for the Scottish population were used for comparison.

RESULTS

Mean birth weight was 3.42 (range 2.66-4.18) kg. One patient was born preterm while the rest were born at term. Data for the Scottish population were available from 1979 onwards and 26 patients born after this year were selected for analysis. Median maternal age in this group was 21 (range 16-41) years, significantly lower than the median maternal age for Scotland of 27.12 (range 25.8-28.6) years (95% CI 4.8-8.0 years).

CONCLUSION

Patients with SOD are of normal birth weight and gestation but are born to mothers who are significantly younger than average.

Prenatal alcohol exposure alters the size, but not the pattern, of the whisker representation in neonatal rat barrel cortex

Maternal alcohol exposure results in a variety of neurodevelopmental abnormalities that include cognitive and sensorimotor dysfunctions that often persist into adulthood. Many reports of central nervous system disturbances associated within a clinical diagnosis of fetal alcohol syndrome point toward disturbances in central information processing. In this study, we used the rat barrel field cortex as a model system to examine the effects of prenatal alcohol exposure (PAE) on the organization and size of the large whisker representation in layer IV of the posteromedial barrel subfield (PMBSF) in somatosensory cortex. Pregnant rats (Sprague-Dawley) were intragastrically gavaged daily with alcohol doses (6 gm/kg body weight) from gestational day 1 to day 20 in a chronic binge pattern which produced blood alcohol levels ranging between 260 mg/dl and 324 mg/dl. Chow-fed (CF), pair-fed (PF), and cross-foster (XF) groups served as normal, nutritionally matched, and maternal controls, respectively, for the ethanol-exposed (EtOH) treatment group. All pups were examined on gestational day 32 corresponding approximately to postnatal day 9. EtOH and control group pups were weighed, anesthetized, and perfused. Brains were removed and weighed, with and without cerebellum and olfactory bulbs, and the neocortex was removed and weighed. Cortices were then flattened, sectioned tangentially, and stained with a metabolic marker-cytochrome oxidase-to reveal the barrel field. A subset of 27 cortical barrels, associated with the representation of the large whisker pad, was selected to examine in detail. The major results were: (i) the total barrel field area comprising the PMBSF was significantly reduced in EtOH (by 17%) and XF (by 16%) pups compared with CF pups, (ii) the sizes of individual barrels within the PMBSF were also significantly reduced in EtOH (16%) and XF (18%) pups, (iii) the septal region between barrels was also significantly reduced in EtOH (18%) and XF (12%) pups, (iv) anteriorly located barrels underwent greater reduction in size relative to the posteriorly located barrels, (v) body weights were also significantly reduced in EtOH (21%) and XF (27%) pups, (vi) total brain weight [with and without (forebrain) cerebellum/olfactory bulbs] and cortical weights were also significantly reduced in EtOH (total brain weight 15%, forebrain weight 16%, cortical weight 15%) and XF (18%, 19%, 20%) pups, and in contrast (vi) neither the overall barrel field pattern nor the pattern of individual barrels in the PMBSF was altered. These findings suggest that PAE reduces body and brain weight as well as the central cortical representation of the whisker pad, while leaving the overall barrel field pattern unperturbed. While these results might appear to support a miniaturization hypothesis (smaller PMBSF, smaller brain, smaller body weight), PAE also shows regional vulnerability within the PMBSF whereby anteriorly located barrels are most affected.

Alcohol consumption and other maternal risk factors for fetal alcohol syndrome among three distinct samples of women before, during, and after pregnancy: the risk is relative

Data were obtained from three samples of women of childbearing age. One sample of women is from prenatal clinics serving Plains Indian women. The second sample is of women from the Plains whose children were referred to special diagnostic developmental clinics, as their children were believed to have developmental issues consistent with prenatal alcohol consumption. The third sample is of women from South Africa, each of whom has given birth to a child diagnosed with full fetal alcohol syndrome (FAS). Data across samples conform to expected trends on many variables. For example, the maternal age at time of pregnancy, a major risk factor for FAS, ranged from a mean of 23.5 years for the prenatal clinic sample, to 23.8 years for the developmental clinic sample, to 27.6 for the sample of women who have delivered children with FAS. Other variables of maternal risk for FAS expected from the extant literature, such as high gravidity and parity, binge drinking, heavy intergenerational drinking in the mother's extended family and immediate social network, and length of drinking career, were compared across the three samples with variable results. However, normative measures of drinking problems are unreliable when reported across cultures. An unexpected finding from this three-sample comparison was the differential risk found when comparing U.S. women to South African women. Women in the U.S. Plains Indian samples report a high consumption of alcohol in a binge pattern of drinking, yet there is less detectable damage to the fetus than among the South African women. Body mass index (BMI) and lifelong and current nutrition may have a substantial impact, along with the above factors, in relative risk for an FAS birth. The level of risk for producing a child with FAS is influenced by environmental and behavioral conditions that vary between populations and among individual women. Also, because many syndromes are genetically based, there is a need for full behavioral and genetic histories of the mother, family, and child being studied. Collecting extensive behavioral information as well as genetic histories will provide the requisite information for making an accurate diagnosis of FAS.

Effect of a single dose of ethanol on developing skeletal muscle of chick embryos

Fetal alcohol syndrome is a condition occurring in some children of mothers who have consumed alcohol during pregnancy. Many of these affected children show retarded physical growth in the postnatal period despite adequate nutrition. On the basis of findings from studies with animals, it has been proposed that this is due to allometric retardation of growth of skeletal muscle, although the exact reasons for this are not known. The aim of the current study was to examine the structural changes in skeletal muscle in fetal alcohol syndrome in an attempt to understand the mechanisms of growth retardation in fetal alcohol syndrome. Chick embryos were exposed to single doses of 5%, 10%, and 15% ethanol, and the effects on the general growth and development, as well as on the skeletal muscle, of these chicks were studied. There was a significant retardation in crown rump length, head circumference, and body weight in ethanol-exposed chicks when these parameters were compared with findings for appropriate control groups. This retardation was associated with significant and proportionate reductions in the weights of skeletal muscles. Microscopic examination of skeletal muscle showed areas of neutrophil infiltration and necrosis, suggestive of muscle damage, in chicks exposed to 10% and 15% ethanol. Thus, findings of the current study demonstrate the direct toxic effects of a single dose of ethanol on developing embryos in general and skeletal muscle in particular. The pathologic changes seen in skeletal muscle could account for the failure in postnatal growth in fetal alcohol syndrome.

Increased sibling mortality in children with fetal alcohol syndrome

We compared the rate of all-cause mortality in siblings of children diagnosed with fetal alcohol syndrome (FAS) with the siblings of matched controls. The siblings of children with FAS had increased mortality (11.4%) compared with matched controls (2.0%), a 530% increase in mortality. The age of death in case siblings deaths occurred later (between 1 day and 7 years) compared with the controls (1 day to 4 years) [odds ratio (OR)=2.4 (0.4-15.6)]. Siblings of children with FAS had increased risk of death due to infectious illness [OR=13.7 (1.2-361)] and sudden infant death syndrome compared with controls [OR=10.2 (1.2-75.1)]. A diagnosis of FAS is an important risk marker for mortality in the siblings of the proband even if they do not have FAS. Maternal alcoholism appears to be a useful risk marker for increased mortality risk in diagnosed cases and their siblings. This has important implications in the management of family members of children with FAS.

A comparison of the effects of parental risk markers on pre- and perinatal variables in multiple patient cohorts with fetal alcohol syndrome, autism, Tourette syndrome, and sudden infant death syndrome: an enviromic analysis

The prevalence and magnitude of effect of individual risk markers for specific developmental disorders vary widely across diagnostic category. The four study cohorts for this project were patients from four diagnostic registries in North Dakota for fetal alcohol syndrome (FAS), autism, sudden infant death syndrome (SIDS), and Tourette syndrome. These four cohorts were used to estimate prevalence and magnitude of effect of parental risk markers in patients with developmental disabilities. Cases with North Dakota birth certificates were matched with controls. Using birth certificate data, we then examined five parental risk markers for each cohort and estimated direct and indirect effects for each risk marker by cohort. The authors found two significant paternal risk markers (age in SIDS and education in FAS). Significant maternal markers were age in SIDS, education in FAS, autism, and SIDS. Marital status was a significant risk marker in FAS. Effect sizes were estimated using paired t tests, odds ratios, and population attributable risk (PAR) for both direct and indirect effects for each marker. We estimated both direct and indirect effects to allow for direct comparisons of the differential effect estimates of each of these markers. The direct effect of parental markers differs across diagnostic cohorts of patients. Use of cohorts from similar denominator populations obtained from prevalence studies is a useful methodological tool for estimating the prevalence and magnitude of effect of risk markers.

Fetal, infant, and child mortality in a context of alcohol use

Alcohol is an important element in the causal chain of risk for fetal, infant, and childhood mortality. Mortality risk is influenced by interactions of alcohol with other environmental and genetic factors and temporal periods of susceptibility. In this paper we discuss four time periods (preconceptual, gestational, infancy, and childhood) where alcohol use may create a context of risk. Alcohol use in one period increases the risk of alcohol use in subsequent periods. Gestational alcohol use can influence risk of mortality from abuse of mother/fetus, can cause other adverse outcomes, and can result in fetal alcohol spectrum disorders (FASDs). In infancy alcohol use can increase risk from impairment of arousal in adults who use alcohol. Infants with gestational exposure can be behaviorally difficult with sleep disturbance, irritability, and colic. This can increase the risk of harm or death, especially during periods of caretakers' alcohol use. Caretakers' alcohol use and smoking are strongly correlated. The all-cause mortality rate in people diagnosed with fetal alcohol syndrome (FAS) is over 5%. All-cause mortality in siblings of diagnosed cases of FAS is increased 530% compared to siblings of matched controls. We recommend that a context of alcohol use be considered as a marker for multifactorial risk in all fetal, infant, and child deaths. A schema to collect data on alcohol use is provided to increase awareness of alcohol use as an environmental risk marker for mortality.

Risk factors for alcohol use during pregnancy in a multistate area

A substance use screening instrument was used to select persons into two risk categories for drinking during pregnancy. About one-fourth (23.8%) of the survey participants were classified as high-risk women and the others were classified as low risk for drinking when pregnant. The participants (N=4676) for the study were sampled from four states (Montana, Minnesota, South Dakota, and North Dakota) that are a part of the Four-State Fetal Alcohol Syndrome (FAS) Consortium. Clinic sites for the administration of the prenatal screening instrument were selected in each state, based on geographic and known population characteristics. Univariate and multivariate statistical procedures were used to determine factors predictive of alcohol use. The purpose of the study was to assess risk factors for alcohol use in pregnant women. Women at high risk for alcohol use when pregnant tended to be younger, less educated, single, and unemployed. Demographic factors that were protective of drinking when pregnant were being married and full-time housewife status. Other variables associated with high-risk status for maternal alcohol use were past sexual abuse, current or past physical abuse, using tobacco, using other drugs, living with substance users, and having mates who were substance users. Other contributing factors for high-risk classification included feeling sad, believing that drinking any amount of alcohol while pregnant was acceptable, and being able to hold four or more drinks. Intervention programs that ameliorate risk factors and enhance protective attributes of high-risk pregnant women are needed.

Recognition and management of fetal alcohol syndrome

Fetal alcohol syndrome (FAS) is a common cause of developmental disability, neuropsychiatric impairment and birth defects. The disorder is identified by the presence of growth impairment, central nervous system dysfunction, and a characteristic pattern of craniofacial features. The reported prevalence of the disorder varies widely and recent estimates approach 1% of live births. Expression of these features varies by age. People with FAS have high rates of comorbid conditions: attention deficit hyperactivity disorder (40%), mental retardation (15-20%), learning disorders (25%), speech and language disorders (30%), sensory impairment (30%), cerebral palsy (4%), epilepsy (8-10%). Birth defects are common. In the United States, the annual birth cohort of persons with FAS could be as high as 39,000 cases annually. Cause-specific mortality is 6% for patients with FAS. The disorder is expensive to treat and most patients have lifelong impairment. The annual cost of care in the United States would approach US$5.0 billion. Early recognition and entry into appropriate treatment programs appear to improve outcome. Prevention efforts should involve screening for alcohol use prior to pregnancy and at the first prenatal care visit.

Fetal alcohol syndrome: neuropsychiatric phenomics

Fetal alcohol syndrome (FAS) is a common developmental disorder with impairments in multiple neuropsychiatric spheres of varying severity. Few population-derived studies of the behavioral phenotype are available. The purpose of this study was to estimate the prevalence of neuropsychiatric disorders in three groups: subjects who met criteria for FAS (n=152); subjects who met criteria for partial FAS/ARND (n=150); and referred subjects who did not meet criteria for either FAS or partial FAS/ARND (n=86). Each subject had a standardized evaluation by a medical geneticist. All subjects were from North Dakota. We found increases in the prevalence rates of neuropsychiatric disorders in subjects with FAS compared to subjects with partial FAS/ARND and the lowest rates in the group that did not meet criteria for either FAS or partial FAS/ARND. Comorbid attention deficit hyperactivity disorder occurred in 73% of cases with FAS, in 72% cases with partial FAS/ARND, and in 36% subjects who did not meet criteria for either. For other neuropsychiatric disorders, a similar distribution of comorbidity was found. This study supports the concept of a continuum of impairment resulting from prenatal alcohol exposure. The presence of complex cognitive, behavioral, and physical symptomatology in the affected subjects with prenatal alcohol exposure would seem to fit well under the diagnostic rubric of fetal alcohol spectrum disorder (FASD). Diagnosis and long-term management will require increasing access to multidisciplinary child development teams including mental health professionals who treat children and adolescents. Adults will require care primarily from teams with expertise in mental health and developmental disabilities.

Prenatal alcohol exposure assessment: multiple embedded measures in a prenatal questionnaire

Alcohol exposure during pregnancy is a well-recognized public health problem. Accurate assessment of prenatal alcohol exposure is especially important to identify women in need of intervention. In this study, a 36-item prenatal questionnaire was utilized to survey a representative sample of prenatal care providers to examine prevalence rates of exposure. The questionnaire included three common screening tools for alcohol use during pregnancy and the items necessary to establish a maternal risk profile. In North Dakota, 1081 pregnant women were included in the sample. Eighty (7.4%) were Native American and 952 (88%) were White. The TWEAK screening tool was positive for 253 (23.4%) of the women. Native American women had a 71% increase in positive TWEAK screenings compared to White women. Logistic regression was used to develop a high-risk model. The data from prenatal care can also be used for maternal risk stratification. Early identification can provide opportunity for early interventions to decrease total exposure during pregnancy and to improve the outcome for the child.

Effect of prenatal exposure to ethanol on hepatic elongation factor-2 and proteome in 21 d old rats: protective effect of folic acid

In this article, we study the effects of ethanol intake during pregnancy and lactation on hepatic and pancreatic elongation factor-2 (EF-2) of 21 d old progeny. At the same time, the effect of ethanol on the level of other relevant hepatic proteins was determined using proteomic analysis. The results show that ethanol not only produces a general increase of protein oxidation, but also produces an important depletion of EF-2 and several other proteins. Among the hepatic proteins affected by ethanol, the concomitant supplementation with folic acid to alcoholic mother rats prevented EF-2, RhoGDI-1, ER-60 protease, and gelsolin depletion. This protective effect of folic acid may be related to its antioxidant properties and suggests that this vitamin may be useful in minimizing the effect of ethanol in the uterus and lactation exposure of the progeny.

Fetal alcohol syndrome: a growing concern for health care professionals

OBJECTIVE

To provide an integrated review of the literature on fetal alcohol syndrome (FAS) and fetal alcohol effects (FAE), focusing on the definition of FAS/FAE, their incidence and related problems, gestational research findings, FAS symptoms, the effects of prenatal alcohol consumption on offspring over time, and FAS/FAE preventive measures.

DATA SOURCES

Computerized searches of MEDLINE and Web sites, as well as reference lists from published articles on FAS/FAE from 1973 to present.

STUDY SELECTION

Literature was chosen from refereed journals and from current publications of the National Organization of Fetal Alcohol Syndrome.

DATA EXTRACTION

Data were extracted using keywords relevant to FAS and FAS prevention.

DATA SYNTHESIS

The consumption of alcohol during pregnancy can harm the fetus irreparably. Preventive measures can be helpful in decreasing or stopping the use of alcohol during pregnancy.

CONCLUSIONS

Alcohol is a definite teratogen. The amount of alcohol, if any, that can be safely consumed during pregnancy, the exact physiological mechanisms that make alcohol unsafe for the fetus, and the most effective prevention measures have yet to be identified. FAS/FAE is still increasing in the United States.

Biochemical markers of alcohol use in pregnant women

OBJECTIVES

To describe the serious health consequences of alcohol (ethanol) use, especially as they relate to pregnancy and the development of fetal alcohol syndrome (FAS) and fetal alcohol effects (FAE). The classic markers of alcohol exposure, including blood/breath alcohol, gamma-glutamyl transferase (gammaGT), mean corpuscular volume (MCV), hemoglobin-associated acetaldehyde (HAA) and carbohydrate deficient transferrin (CDT), are valuable and their methods of analysis are reviewed.

CONCLUSIONS

Since both FAS and FAE represent two of the leading preventable causes of mental retardation and birth defects, identification of alcohol use early in pregnancy is important to avoid adverse fetal outcomes. Unfortunately, the diagnosis of FAS and FAE is usually made after birth, when alcohol damage has become irreversible and permanent. The clinical laboratory can help prevent this damage and make a valuable contribution in assessing prenatal alcohol use. The clinical utility of blood/breath alcohol, gammaGT, MCV, HAA and CDT in alcohol use identification, especially in pregnancy, is substantial. Although none of the markers singularly has adequate sensitivity and specificity for screening, their diagnostic utility increases when measured as a panel. This is especially true in detecting alcohol use in pregnancy where the presence of several positive markers was correlated with the presence of alcohol-related fetal effects.

The epidemiology of mental retardation: challenges and opportunities in the new millennium

There are a number of problems and challenges in relating the science of epidemiology to mental retardation (MR). These relate to how MR is defined and classified and how these definitions may change over time. These as well as other differences in ascertainment sources and methods need to be considered when comparing MR prevalence over time and place. On the other hand, advances in technology also provide new and efficient methods of data collection both by data linkage and by use of web-based methods to study rare diseases. While prevalence studies have not been individually reviewed, we have examined the range of data including recent studies relating to how prevalence differs according to age, gender, social class and ethnicity. Some problems with available etiological classification systems have been identified. Recent etiological studies, most of which use different classification systems, have been reviewed and explanations have been postulated to account for differences in results. Individual risk factors for MR are considered whilst the option of considering a population as opposed to a high risk strategy to MR prevention is raised. This might well involve improving the social milieu surrounding the occurrence of individual risk factors. The impact of biotechnological advances such as antenatal and neonatal screening and assisted reproduction on MR are discussed. The issue of how inequalities in access to technology may impact on case identification and even have the potential to further widen inequalities is raised. The importance of extending the use of epidemiological tools to study the social, health and economic burden of MR is also emphasized. However, in order to apply to MR the "prevention-intervention-research" cycle, which surely underpins all epidemiology, it is vital to ensure that the methodological challenges we raise are adequately addressed.

Protective effect of folic acid against oxidative stress produced in 21-day postpartum rats by maternal-ethanol chronic consumption during pregnancy and lactation period

In this paper we show the protective effect of folic acid on oxidative stress in offspring caused by chronic maternal ethanol consumption during pregnancy and the lactation period. Glutathione reductase (GR) specific activity was assayed in liver and pancreas of offspring and mothers. In the offspring, these tissues were also assayed for markers of oxidative damage to lipids and proteins. The results show that ethanol exposure during pregnancy and lactation increased the specific activity of GR in tissues of the mothers (32-34% increase) as well as in the liver of their progeny (24%). Thiobarbituric acid reactive substances (TBARS) were also increased in the liver and pancreas of 21-day-old rats (37- and 54%, respectively). Alcohol also increased the amount of carbonyl groups in proteins in both tissues. These measures of ethanol-mediated oxidative stress were mitigated when pregnant rats were treated with folic acid concomitantly to ethanol administration. The antioxidant capacity of folic acid seems to be involved in its protective effect. The results obtained in the present work suggest that folic acid may be useful in the prevention of damage and promotion of health of the progeny of ethanol-treated rats.

Alcohol in pregnancy and neonatal outcome

Fetal alcohol syndrome (FAS) and other fetal alcohol effects in children are characterized by life-long compromises in growth, health, behaviour and cognitive ability. Most of the structural signs and many behavioural signs of FAS are evident at birth. This review describes the expression of fetal alcohol effects in neonates, including diagnostic criteria, alcohol withdrawal, pregnancy outcome, growth retardation, facial dysmorphology and behavioural outcomes.

Prenatal and perinatal risk factors for autism

AIM

To identify pre- and perinatal risk factors for autism.

METHOD

Case control study. We matched names of patients from North Dakota who met DSM criteria for autism, a pervasive developmental disorder, and autistic disorder with their birth certificates. Five matched controls were selected for each case.

RESULTS

Univariate analysis of the 78 cases and 390 controls identified seven risk factors. Logistic modeling to control for confounding produced a five variable model. The model parameters were chi 2 = 36.6 and p < 0.001. The five variables in the model were decreased birth weight, low maternal education, later start of prenatal care, and having a previous termination of pregnancy. Increasing father's age was associated with increased risk of autism.

CONCLUSION

This methodology may provide an inexpensive method for clinics and public health providers to identify risk factors and to identify maternal characteristics of patients with mental illness and developmental disorders.

Screening for fetal alcohol syndrome: is it feasible and necessary?

The potential to utilize screening strategies to improve the identification and outcome of persons with fetal alcohol syndrome (FAS) is reviewed. FAS is a condition where screening and surveillance activities would be appropriate. Development of FAS screening and surveillance programs is encouraged because the disorder is expensive. People with FAS have poor outcomes as adults with less than 10% living independently. Several useful tools and models are available. Screening would improve ascertainment and prevalence estimates. Early identification could improve access to services and long term outcome, secondary disabilities and, by extension, excess disability in affected children could be decreased. Lastly, mothers who are at the highest risk to have additional children with FAS could be identified and offered treatment. While both screening and surveillance activities are discussed, the principle focus of this article is a review of the screening process. Two screening tools and several screening methodologies for FAS are available. Since no test will be appropriate in all settings, screening tests need to be selected depending on the setting and population of interest. Screening for FAS should be conducted in a variety of settings and in populations of both high and moderate risk. The results would also provide important data to influence public policy development and resource allocation. Appropriate evaluation of the efficacy, efficiency and effectiveness of FAS screening tools and methodologies would be important before utilization in screening programs.

Fetal alcohol exposure alters serotonin transporter sites in rat brain

This study examined the effects of fetal alcohol exposure (FAE) on serotonin transporter (5-HTT) binding sites in the brains of developing male and female rat offspring using the technique of quantitative autoradiography. Time-pregnant dams were fed liquid ethanol diet, isocaloric diet without ethanol or normal rat chow. Male and female offspring were sacrificed at 21, 40 and 60 days of age, brains removed and sectioned for analysis of 5-HTT sites. FAE led to distinct effects on 5-HTT sites depending on the age and gender of the offspring. FAE increased 5-HTT binding sites in cortical layers 5, 6, hippocampal layers CA(2,3), lateral nucleus of the amygdala and in the dorsal raphe nucleus. FAE decreased 5-HTT binding sites in the medial nucleus of amygdala, dorsomedial and ventromedial nuclei of the hypothalamus. FAE decreased 5-HTT binding sites temporarily in the ventromedial nucleus of the hypothalamus in the 21-day-old female; this effect was found to disappear by day 40. In contrast, FAE increased 5-HTT sites in the lateral nucleus of the amygdala in the adult animal, suggesting that ethanol exposure in utero may alter serotonin neurotransmission in discrete brain regions permanently.

Prenatal and perinatal risk factors for Tourette disorder

AIMS

To identify pre- and perinatal risk factors for Tourette disorder.

METHODS

Case control study. We matched names of patients who met DSM criteria for Tourette disorder with their birth certificates. For each case five controls were selected. The controls were matched by sex, year and month of birth.

RESULTS

Univariate analysis of the 92 cases and the 460 matched controls identified 4 risk factors; one categorical variable--trimester prenatal care begun and 3 continuous variables--apgar score at 5 minutes, month prenatal began and number of prenatal visits. Logistic modeling to control for confounding produced a three variable model (apgar score at 5 minutes (OR = 1.31), number of prenatal visits (OR = .904) and fathers age (OR = .909). The model parameters were: chi 2 = 19.76; df = 3; p < .001.

CONCLUSIONS

This is an inexpensive methodology to identify potential risk factors of patients with Tourette disorder and other mental illness.