Replication of High Fetal Alcohol Spectrum Disorders Prevalence Rates, Child Characteristics, and Maternal Risk Factors in a Second Sample of Rural Communities in South Africa

Prenatal alcohol exposure and associations with physical size, dysmorphology and neurodevelopment: a systematic review and meta-analysis

BACKGROUND

Fetal alcohol spectrum disorder (FASD) is a significant public health concern, yet there is no internationally agreed set of diagnostic criteria or summary of underlying evidence to inform diagnostic decision-making. This systematic review assesses associations of prenatal alcohol exposure (PAE) and outcomes of diagnostic assessments, providing an evidence base for the improvement of FASD diagnostic criteria.

METHODS

Six databases were searched (inception-February 2023). Case-controls or cohort studies examining associations between participants with/without PAE or a FASD diagnosis and the domains of physical size, dysmorphology, functional neurodevelopment and/or brain structure/neurology were included. Excluded studies were non-empirical, sample size < 10, PAE determined via biological markers only, or no suitable comparison group. Summary data were extracted and associations between outcomes and standardised levels of PAE or FASD diagnosis determined using random-effects meta-analyses. Certainty of the evidence was assessed using GRADE.

RESULTS

Of the 306 included studies, 106 reported physical size, 43 dysmorphology, 195 functional neurodevelopment and 110 structural/neurological outcomes, with 292 different outcomes examined. There was a dose-response relationship between PAE and head circumference, as well as measures of physical size, particularly at birth. There was also an association between higher PAE levels and characteristic sentinel facial dysmorphology, as well as many of the current functional neurodevelopmental outcomes considered during diagnosis. However, data were often lacking across the full range of exposures. There was a lack of evidence from studies examining PAE to support inclusion of non-sentinel dysmorphic features, social cognition, speech-sound impairments, neurological conditions, seizures, sensory processing or structural brain abnormalities (via clinical MRI) in diagnostic criteria. GRADE ratings ranged from very low to moderate certainty of evidence.

CONCLUSIONS

This comprehensive review provides guidance on which components are most useful to consider in the diagnostic criteria for FASD. It also highlights numerous gaps in the available evidence. Future well-designed pregnancy cohort studies should specifically focus on dose-response relationships between PAE and dysmorphology, neurodevelopment and brain structure/neurological outcomes.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO: CRD42021230522.

Clinical Features of Typically Developing Children With and Without Prenatal Alcohol Exposure

OBJECTIVE

To determine if prenatal alcohol exposure (PAE) affected physical and cognitive/behavioral outcomes in apparently typically developing, first-grade children.

STUDY DESIGN

Three groups were compared: children with fetal alcohol spectrum disorders (FASD); children with PAE without FASD; and children without PAE.

RESULTS

The three groups were significantly different on most physical traits and fewer neurodevelopmental traits. Two-group comparisons of exposed and unexposed, non-FASD groups were statistically different on: height, weight, head circumference (OFC), body mass index (BMI), and palpebral fissure length (PFL). Neurobehavioral outcomes were significant in three-group, but not two-group, comparisons. Few sex differences were observed; however, sex ratios indicated fewer male offspring in first grade among women who consumed 6+ drinks per occasion during pregnancy. For weight, OFC, BMI, age, rural residence, and drinking measures, mothers of exposed children without FASD were intermediaries between, and significantly different from, the other maternal groups. Adjusted for socioeconomic covariates, multivariate analysis of covariance (MANCOVA), three-group comparisons were significantly different for cognitive/behavioral variables (p<.001); however, two-group neurobehavior comparisons for children without FASD were not significant (p>.05). Physical trait MANCOVA comparisons of the non-FASD groups were significant only for weight (p<.004) when tested univariately and through stepdown analysis. Socioeconomic-adjusted trend plots were in the expected direction for nonverbal IQ, problem behaviors, attention, height, weight, OFC, vermilion, PFL, and total dysmorphology score.

CONCLUSIONS

Even when meeting developmental norms, children with PAE exhibited trends of poorer growth and cognitive/behavioral traits than children without PAE. These findings support the notion that abstinence during pregnancy is best.

Chronic paternal alcohol exposures induce dose-dependent changes in offspring craniofacial shape and symmetry

Although dose-response analyses are a fundamental tool in developmental toxicology, few studies have examined the impacts of toxicant dose on the non-genetic paternal inheritance of offspring disease and dysgenesis. In this study, we used geometric morphometric analyses to examine the impacts of different levels of preconception paternal alcohol exposure on offspring craniofacial shape and symmetry in a mouse model. Procrustes ANOVA followed by canonical variant analysis of geometric facial relationships revealed that Low-, Medium-, and High-dose treatments each induced distinct changes in craniofacial shape and symmetry. Our analyses identified a dose threshold between 1.543 and 2.321 g/kg/day. Below this threshold, preconception paternal alcohol exposure induced changes in facial shape, including a right shift in facial features. In contrast, above this threshold, paternal exposures caused shifts in both shape and center, disrupting facial symmetry. Consistent with previous clinical studies, changes in craniofacial shape predominantly mapped to regions in the lower portion of the face, including the mandible (lower jaw) and maxilla (upper jaw). Notably, high-dose exposures also impacted the positioning of the right eye. Our studies reveal that paternal alcohol use may be an unrecognized factor contributing to the incidence and severity of alcohol-related craniofacial defects, complicating diagnostics of fetal alcohol spectrum disorders.

Maternal risk factors for fetal alcohol spectrum disorders: Distal variables

BACKGROUND

A variety of maternal risk factors for fetal alcohol spectrum disorders (FASD) have been described in the literature. Here, we conducted a multivariate analysis of a large array of potential distal influences on FASD risk.

METHODS

Interviews were conducted with 2515 mothers of first-grade students whose children were evaluated to assess risk for FASD. Topics included: physical/medical status, childbearing history, demographics, mental health, domestic violence, and trauma. Regression modeling utilized usual level of alcohol consumption by trimester and six selected distal variables (maternal head circumference, body mass index, age at pregnancy, gravidity, marital status, and formal years of education) to differentiate children with FASD from control children.

RESULTS

Despite individual variation in distal maternal risk factors among and within the mothers of children with each of the common diagnoses of FASD, patterns emerged that differentiated risk among mothers of children with FASD from mothers whose children were developing typically. Case-control comparisons indicate that mothers of children with FASD were significantly smaller physically, had higher gravidity and parity, and experienced more miscarriages and stillbirths, were less likely to be married, reported later pregnancy recognition, more depression, and lower formal educational achievement. They were also less engaged with a formal religion, were less happy, suffered more childhood trauma and interpersonal violence, were more likely to drink alone or with her partner, and drank to deal with anxiety, tension, and to be part of a group. Regression analysis showed that the predictor variables explain 57.5% of the variance in fetal alcohol syndrome (FAS) diagnoses, 30.1% of partial FAS (PFAS) diagnoses, and 46.4% of alcohol-related neurodevelopmental disorder (ARND) diagnoses in children with FASD compared to controls. While the proximal variables explained most of the diagnostic variance, six distal variables explained 16.7% (1 /6 ) of the variance in FAS diagnoses, 13.9% (1 /7 ) of PFAS, and 12.1% (1 /8 ) of ARND.

CONCLUSIONS

Differences in distal FASD risks were identified. Complex models to quantify risk for FASD hold promise for guiding prevention/intervention.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Maternal and paternal risk factors for fetal alcohol spectrum disorders: Alcohol and other drug use as proximal influences

OBJECTIVE

To explore and analyze the significance of proximal influences of maternal and paternal traits associated with bearing a child with a fetal alcohol spectrum disorder (FASD).

METHODS

Aggregated, maternal interview-collected data (N = 2515) concerning alcohol, tobacco, and other drug use were examined to determine risk for FASD from seven cross-sectional samples of mothers of first-grade students who were evaluated for a possible diagnosis of FASD.

RESULTS

Mothers of children with fetal alcohol syndrome (FAS) reported the highest alcohol use throughout pregnancy, proportion of binge drinking, drinks per drinking day (DDD), drinking days per week, and total drinks per week. Mothers of children with FAS also consumed significantly more alcohol than mothers of children with partial FAS (PFAS), alcohol-related neurodevelopmental disorder (ARND), or typically developing controls. Mothers of children with PFAS and ARND reported similar drinking patterns, which exposed fetuses to 3-4 times more alcohol than mothers of controls, but the PFAS group was more likely than the ARND group to abstain in latter trimesters. Fathers of all children were predominantly drinkers (70%-85%), but more fathers of children with FASD binged heavily on more days than fathers of controls. Compared to the few mothers of controls who used alcohol during pregnancy, the ARND group binge drank more (3+ DDD) throughout pregnancy and drank more DDD before pregnancy and first trimester. Regression analysis, controlling for tobacco use, indicated that mothers who reported drinking <1 DDD were significantly more likely than abstainers to bear a child with FASD (OR = 2.75) as were those reporting higher levels such as 5-5.9 DDD (OR = 32.99). Exclusive, first-trimester maternal drinking increased risk for FASD five times over that of abstinence (p < 0.001, OR = 5.05, 95% CI: 3.88-6.58), first- and second-trimester drinking by 12.4 times, and drinking all trimesters by 16 times (p < 0.001, OR = 15.69, 95% CI: 11.92-20.64). Paternal drinking during and prior to pregnancy, without adjustment, increased the likelihood of FASD significantly (OR = 1.06 and 1.11, respectively), but the significance of both relationships disappeared when maternal alcohol and tobacco use were controlled.

CONCLUSIONS

Differences in FASD risk emerged from the examination of multiple proximal variables of maternal alcohol and tobacco use, reflecting increased FASD risk at greater levels of maternal alcohol consumption.

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

Introduction

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

Methods

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

Results

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

Conclusion

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

A systematic review: facial, dental and orthodontic findings and orofacial diagnostics in patients with FASD

Background

The fetal alcohol spectrum disorder is a group of developmental disorders caused by maternal alcohol consumption. Patients with fetal alcohol syndrome show abnormal orofacial features. This review presents an overview over the facial, oral, dental or orthodontic findings and diagnostic tools concerning these features.

Methods

For this systematic review Cochrane, Medline and Embase databases were considered and the review was performed according to the PRISMA checklist. Two independent reviewers evaluated all studies and recorded results in a summary of findings table. Risk of bias was analyzed via Quadas-2 checklist.

Results

61 studies were eligible for inclusion. All included studies were clinical studies. Methods and results of the studies were not comparable, guidelines or methods for the detection of FASD varied across studies. Facial features most often measured or found as distinguishing parameter were: palpebral fissure length, interpupillary or innercanthal distance, philtrum, upper lip, midfacial hypoplasia or head circumference.

Conclusions

This review shows that to date a multitude of heterogeneous guidelines exists for the diagnosis of FASD. Uniform, objective diagnostic criteria and parameters for the orofacial region in FASD diagnosis are needed. A bio database with values and parameters for different ethnicities and age groups should be made available for diagnosis.

Relationship-based intervention for children who were prenatally alcohol exposed in South Africa

BACKGROUND

This early intervention study investigated the effectiveness of a relationship-based, developmental enhancement process for children who were prenatally exposed to alcohol in the South African context.

METHODS

Groups were created according to the child's level of risk for alcohol-related developmental issues based on each mother's alcohol use during pregnancy as assessed using the Alcohol Use Disorders Identification Test (AUDIT). Primary caregiver/child dyads were the focus of the intervention and child development was monitored by the Ages and Stages Questionnaire (ASQ). Eighteen caregiver/child dyads were in the heavily alcohol-exposed group, and 20 caregiver/child dyads were in the no or light alcohol-exposure group. The Home Observation Measurement of the Environment (HOME) was measured pre and post intervention.

RESULTS

The results indicated significant improvements in the home environment (p < .001) post-intervention for the entire cohort. For the total HOME score, there was a statistically significant main effect for time (pre- vs post-test), F(1, 36)= 65.205, p < .001, partial η2 = .64. with 99% confidence limits from .35 to .78. The offspring and parents from both the heavy alcohol exposure group and the no/low alcohol exposure group benefitted from the intervention over the duration of the intervention. Of the HOME domains affected, responsivity was the most improved in the households. The children's scores on the ASQ varied substantially over the months of the intervention, and the offspring of the heavy exposure group often performed significantly worse than the no/low exposure group. Nevertheless, further analysis revealed that children with the lowest performance at baseline improved their performance on most ASQ domains throughout the intervention and performed significantly better on all ASQ domains over time and at completion of the intervention.

CONCLUSIONS

This relationship-based, early intervention program for children resulted in benefits to all of the children over time.

Untargeted Metabolome Analysis of Alcohol-Exposed Pregnancies Reveals Metabolite Differences That Are Associated with Infant Birth Outcomes

Prenatal alcohol exposure can produce offspring growth deficits and is a leading cause of neurodevelopmental disability. We used untargeted metabolomics to generate mechanistic insight into how alcohol impairs fetal development. In the Western Cape Province of South Africa, 52 women between gestational weeks 5-36 (mean 18.5 ± 6.5) were recruited, and they provided a finger-prick fasting bloodspot that underwent mass spectrometry. Metabolomic data were analyzed using partial least squares-discriminant analyses (PLS-DA) to identify metabolites that correlated with alcohol exposure and infant birth outcomes. Women who consumed alcohol in the past seven days were distinguished by a metabolite profile that included reduced sphingomyelins, cholesterol, and pregnenolones, and elevated fatty acids, acyl and amino acyl carnitines, and androsterones. Using PLS-DA, 25 of the top 30 metabolites differentiating maternal groups were reduced by alcohol with medium-chain free fatty acids and oxidized sugar derivatives having the greatest influence. A separate ortho-PLS-DA analysis identified a common set of 13 metabolites that were associated with infant length, weight, and head circumference. These included monoacylglycerols, glycerol-3-phosphate, and unidentified metabolites, and most of their associations were negative, implying they represent processes having adverse consequences for fetal development.

The prevalence of fetal alcohol spectrum disorders in rural communities in South Africa: A third regional sample of child characteristics and maternal risk factors

BACKGROUND

This study is the ninth cross-sectional community study of fetal alcohol spectrum disorders (FASD) conducted by the multidisciplinary Fetal Alcohol Syndrome Epidemiology Research team in the Western Cape Province of South Africa. It is the third comprehensive study of FASD in a rural, agricultural region of South Africa.

METHODS

Population-based, active case ascertainment methods were employed among a school-based cohort to assess child physical and neurobehavioral traits, and maternal risk factor interviews were conducted to identify all children with FASD to determine its prevalence.

RESULTS

Consent was obtained for 76.7% of 1158 children attending first grade in the region's public schools. Case-control results are presented for 95 with fetal alcohol syndrome (FAS), 64 with partial fetal alcohol syndrome (PFAS), 77 with alcohol-related neurodevelopmental disorder (ARND), 2 with alcohol-related birth defects (ARBD), and 213 randomly-selected controls. Four techniques estimating FASD prevalence from in-person examinations and testing yielded a range of total FASD prevalence of 206-366 per 1000. The final weighted, estimated prevalence of FAS was 104.5 per 1000, PFAS was 77.7 per 1000, ARND was 125.2 per 1000, and total FASD prevalence was 310 per 1000 (95% CI = 283.4-336.7). Expressed as a percentage, 31% had FASD. Although the rate of total FASD remained steady over 9 years, the proportion of children within the FASD group has changed significantly: FAS trended down and ARND trended up. A detailed evaluation is presented of the specific child physical and neurobehavioral traits integral to assessing the full continuum of FASD. The diagnosis of a child with FASD was significantly associated with maternal proximal risk factors such as: co-morbid prenatal use of alcohol and tobacco (OR = 19.1); maternal drinking of two (OR = 5.9), three (OR = 5.9), four (OR = 38.3), or more alcoholic drinks per drinking day; and drinking in the first trimester (OR = 8.4), first and second trimesters (OR = 17.7), or throughout pregnancy (OR = 18.6). Distal maternal risk factors included the following: slight or small physical status (height, weight, and head circumference), lower BMI, less formal education, late recognition of pregnancy, and higher gravidity, parity, and older age during the index pregnancy.

CONCLUSION

The prevalence of FASD remained a significant problem in this region, but the severity of physical traits and anomalies within the continuum of FASD is trending downwards.

Fetal alcohol syndrome knowledge and risk behaviors among university students and community residents in Limpopo, South Africa

The Republic of South Africa has the highest documented fetal alcohol syndrome prevalence globally. In the Limpopo province, little is known about students’ or community members’ knowledge of fetal alcohol syndrome or fetal alcohol spectrum disorder rates and risk behaviors. The aim of this study was to characterize and compare knowledge about fetal alcohol syndrome and other fetal alcohol spectrum disorders and the related behaviors such as drinking among University of Venda students and local community residents in villages to inform educational efforts to prevent fetal alcohol syndrome. Participants ([Formula: see text]) were from the University of Venda and two villages, Maungani and Ha-Mangilasi, and completed an epidemiological survey about their characteristics, behaviors, and fetal alcohol spectrum disorder risks. We analyzed differences between the university students and community residents in fetal alcohol syndrome knowledge and the related risk behaviors. University students have heard of fetal alcohol syndrome (Fisher’s exact test p < .001), have seen warning labels about drinking during pregnancy (Fisher’s exact test p = .003), and were aware that a baby is born with birth defects if diagnosed with fetal alcohol syndrome (Fisher’s exact test p = .03) with more knowledge of fetal alcohol syndrome compared to community residents. Most respondents thought it was unacceptable to drink during pregnancy. Despite this, a substantial number of participants thought it was acceptable to have one drink after pregnancy recognition. There was little knowledge of best practices about alcohol consumption to prepare for pregnancy, or once recognized. We recommend an education campaign to raise awareness of fetal alcohol spectrum disorders across Limpopo, especially in smaller villages, and further research to determine demographic and experiential risk factors to aid in prevention efforts.

The Influence of Maternal Weight and Alcohol Exposure on Infant Physical Characteristics and Neurodevelopmental Outcomes

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Maternal weight was inversely related with infant dysmorphology score.

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The rate of change was similar among all infants regardless of maternal weight.

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Maternal weight may be protective but does not eliminate adverse effects of alcohol.

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Regardless of maternal weight during pregnancy, alcohol remains a teratogen.

Background

Mothers of children with fetal alcohol spectrum disorders tend to have lower weight compared to other mothers. Yet how alcohol and maternal weight may predispose infants to poorer physical growth and neurodevelopmental trajectories is relatively unexplained.

Methods

South African mothers (n = 406) were recruited prenatally and their offspring were provided standardized dysmorphology and neurodevelopment examinations at 6 weeks and 9 months of age. Maternal weight was obtained postpartum, and linear mixed modeling determined whether postpartum maternal weight and prenatal alcohol exposure significantly influenced infant growth, dysmorphology, and neurodevelopment within the first year of life.

Results

Postpartum maternal weight was positively associated with birth length, weight, and head circumference centile, but the rate of growth from birth to nine months was similar among all infants. Maternal weight was inversely associated with dysmorphology. Many infants in this population were performing within the borderline or extremely low range. Higher maternal weight was associated with significantly better cognitive and motor performance at 6 weeks; however, the rate of developmental growth was similar among all infants, regardless of postpartum maternal weight.

Conclusion

Higher postpartum maternal weight may be a protective factor but does not eliminate the adverse effects of alcohol on infant growth and dysmorphology. Regardless of maternal weight, alcohol remains a powerful teratogen and moderate to high use prenatally can result in adverse infant physical and neurocognitive development.

Characteristic physical traits of first-grade children in the United States with fetal alcohol spectrum disorders (FASD) and associated alcohol and drug exposures

We compared growth, physical features, and minor anomalies in 131 first-grade children with fetal alcohol spectrum disorders (FASD) to those of a representative comparison group of typically developing children from the same populations (n = 1212). The data were collected from three regional sites in the NIAAA-funded Collaboration on FASD Prevalence (CoFASP). Dysmorphology examinations were performed by a team of expert clinical geneticists, and FASD diagnoses were assigned according to the Revised Institute of Medicine Guidelines, which include assessments of growth, dysmorphology, neurobehavior, and maternal risk interviews. We present detailed data on 32 physical traits, minor anomalies, and a summary dysmorphology score for children within each of the four diagnostic categories in the continuum of FASD. There were few differences in the frequency of FASD diagnoses by race or Hispanic ethnicity. Children with FASD were born to mothers who reported using alcohol, tobacco (28.3%), and other drugs (14.2%) during pregnancy. Controlling for tobacco and other drug use, risk analysis indicated that women with a drinking pattern of 3 drinks per drinking day prior to pregnancy were 10 times more likely (p < 0.001, OR = 9.92, 95% CI: 4.6-21.5) to bear a child with FASD than those who reported abstinence prior to pregnancy.

Ear Abnormalities Among Children with Fetal Alcohol Spectrum Disorder: A Systematic Review and Meta-Analysis

OBJECTIVE

To systematically review and conduct meta-analysis on studies that report the type and prevalence of functional and structural ear abnormalities among children with prenatal alcohol exposure and/or fetal alcohol spectrum disorder (FASD).

STUDY DESIGN

MEDLINE, PubMed, Embase, Web of Science, PsycINFO, ERIC, CINAHL, and Maternity and Infant Care were searched from 1806 through March 2021. Reference lists of relevant articles were manually searched. Studies reporting on functional and/or structural ear abnormalities among children (<18 years) with prenatal alcohol exposure and/or FASD were eligible. Data extraction and quality assessment were performed by one reviewer and independently checked by another. A random effects meta-analysis was conducted.

RESULTS

A total of 31 studies met the inclusion criteria and 25 were included in the meta-analyses, representing a total of 843 children with prenatal alcohol exposure and 1653 children with FASD. Functional ear abnormalities with the highest pooled prevalence were chronic serous otitis media (88.5%; 95% CI, 70.4%-99.3%), abnormal auditory filtering (80.1%; 95% CI, 76.5%-84.3%), and unspecified conductive hearing loss (68.0%; 95% CI, 51.9%-82.2%). Structural ear abnormalities with the highest pooled prevalence were microtia (42.9%; 95% CI, 26.8%-59.7%), railroad track ear (16.8%; 95% CI, 8.1%-27.7%), and misplaced ear (12.3%; 95% CI, 7.6%-17.9%).

CONCLUSIONS

Our findings highlight the importance of examining the ears during assessment for FASD, and the need for public health messaging regarding the harms of prenatal alcohol exposure.

Prenatal and Postnatal Choline Supplementation in Fetal Alcohol Spectrum Disorder

Fetal alcohol spectrum disorder (FASD) is common and represents a significant public health burden, yet very few interventions have been tested in FASD. Cognitive deficits are core features of FASD, ranging from broad intellectual impairment to selective problems in attention, executive functioning, memory, visual–perceptual/motor skills, social cognition, and academics. One potential intervention for the cognitive impairments associated with FASD is the essential nutrient choline, which is known to have numerous direct effects on brain and cognition in both typical and atypical development. We provide a summary of the literature supporting the use of choline as a neurodevelopmental intervention in those affected by prenatal alcohol. We first discuss how alcohol interferes with normal brain development. We then provide a comprehensive overview of the nutrient choline and discuss its role in typical brain development and its application in the optimization of brain development following early insult. Next, we review the preclinical literature that provides evidence of choline’s potential as an intervention following alcohol exposure. Then, we review a handful of existing human studies of choline supplementation in FASD. Lastly, we conclude with a review of practical considerations in choline supplementation, including dose, formulation, and feasibility in children.

Maternal drinking behaviour and co-exposure from smoking during and after pregnancy in relation to the neurocognitive function of school-children in the rural Western Cape

BACKGROUND

Maternal substance use and its long-term effect on the neurocognitive functions of children is a global public health issue. Despite an increase in substance use in rural areas of low to middle-income countries, research is limited in these populations.

OBJECTIVE

We have therefore explored the effect of maternal drinking and smoking behaviors on the neurocognitive functioning of rural school children.

METHOD

A cross-sectional analysis on the determinants of current, past and gestational maternal alcohol use and gestational smoking on child neurocognitive functions was conducted on school-children (N = 482), embedded within the child health agricultural cohort (CapSA) study across seven schools in rural Western Cape, South Africa. Standardised neurocognitive assessment tools included the Cambridge Automated Neuropsychological Battery (CANTAB) and the KIDSCREEN-10 to measure health-related quality of life via a child questionnaire. Maternal smoking and drinking behaviour were captured using a parent/guardian questionnaire.

RESULTS

Of the 482 parents/guardians who completed the survey, 29 % reported current drinking 27 % reported past drinking and 10 % reported maternal gestational drinking, while 31 % reported gestational smoking. Significant associations were observed between past and current maternal drinking and child's reduced rapid visual processing accuracy in attention [β:-0.03; 95 % confidence interval (CI): -0.05;-0.004] and between maternal drinking during pregnancy and reduced child's spatial working memory (β: -0.59; CI: -1.02; -0.15). Heavy (>5 cigarettes per day) gestational smoking was associated with lowered child's learning in memory (β:-1.69; 95 % CI: -3.05; -0.33) and lower health-related quality of life (β: -3.41; CI: -6.64; -0.17). The odds of a child repeating a grade were 1.69 (CI: 2.81-1.02) for those exposed to maternal gestational smoking and 1.68 (CI: 3.31-0.85) for those exposed to maternal gestational drinking compared to those who were not exposed.

CONCLUSION

The consistent negative associations across all four maternal substance use proxies, six neurocognitive health outcomes and one health symptom is suggestive of adverse health effects, warranting longitudinal follow-up. Health policies to eliminate gestational substance use are recommended.

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

BACKGROUND

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

METHODS

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

DISCUSSION

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

SYSTEMATIC REVIEW REGISTRATION

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

Gestational age and birth growth parameters as early predictors of fetal alcohol spectrum disorders

OBJECTIVE

To investigate gestational age and growth at birth as predictors of fetal alcohol spectrum disorders (FASD).

METHODS

The sample analyzed here comprises 737 randomly selected children who were assessed for growth, dysmorphology, and neurobehavior at 7 years of age. Maternal interviews were conducted to ascertain prenatal alcohol exposure and other maternal risk factors. Birth data originated from clinic records and the data at 7 years of age originated from population-based, in-school studies. Binary linear regression assessed the relationship between preterm birth, small for gestational age (SGA), and their combination on the odds of a specific FASD diagnosis or any FASD.

RESULTS

Among children diagnosed with FASD at 7 years of age (n = 255), a review of birth records indicated that 18.4% were born preterm, 51.4% were SGA, and 5.9% were both preterm and SGA. When compared to non-FASD controls (n = 482), the birth percentages born preterm, SGA, and both preterm and SGA were respectively 12.0%, 27.7%, and 0.5%. Mothers of children with FASD reported more drinking during all trimesters, higher gravidity, lower educational attainment, and older age at pregnancy. After controlling for usual drinks per drinking day in the first trimester, number of trimesters of drinking, maternal education, tobacco use, and maternal age, the odds ratio of an FASD diagnosis by age 7 was significantly associated with SGA (OR = 2.16, 95% CI: 1.35 to 3.45). SGA was also significantly associated with each of the 3 most common specific diagnoses within the FASD continuum: fetal alcohol syndrome (FAS; OR = 3.1), partial FAS (OR = 2.1), and alcohol-related neurodevelopmental disorder (OR = 2.0).

CONCLUSION

SGA is a robust early indicator for FASD in this random sample of children assessed at 7 years of age.

Maternal Tobacco and Alcohol Use in Relation to Child Malnutrition in Gauteng, South Africa: A Retrospective Analysis

Tobacco and alcohol use among mothers is associated with numerous adverse consequences for affected offspring, including poor growth and development. This study determined the association between maternal tobacco and alcohol use, and malnutrition, among infants aged ≤ 12 months (n = 300), in selected health facilities situated in Gauteng, South Africa. Data on alcohol and tobacco use were collected using a validated questionnaire, in addition to mothers’ socio-demographic characteristics and obstetric history. Stunting (low height/length-for-age), underweight (low weight-for-age) and thinness (low body mass index-for-age) were calculated using z-scores based on the World Health Organization child growth standards. The association of tobacco and alcohol use with stunting, underweight and thinness was analysed using logistic regression analysis. The results showed a mean age of 29 years (24.0; 35.0) for mothers and 7.6 ± 3 months for infants, and over half of the mothers were unemployed (63%). Approximately 18.7% of mothers had used tobacco and 3% had used alcohol during pregnancy. The prevalence of current tobacco and alcohol use among mothers were estimated at 14.3% and 49.7%, respectively, and almost three-quarters (67.3%) of them were still breastfeeding during the study period. Stunting (55%) was the most prevalent malnutrition indicator among infants, while underweight was 41.7%, and thinness was 22%. Current tobacco use was associated with increased odds of being thin [OR = 2.40, 95% CI: 1.09–5.45), and after adjusting for confounders, current alcohol use was associated with the likelihood of being underweight [AOR = 1.96, 95% CI: 1.06–3.63] among infants. Future prospective cohort studies that examine growth patterns among infants who are exposed to maternal tobacco and alcohol use from the intrauterine life to infancy are necessary to inform, partly, the public health programmes, to reduce malnutrition among children.

The prevalence, child characteristics, and maternal risk factors for the continuum of fetal alcohol spectrum disorders: A sixth population-based study in the same South African community

BACKGROUND

Prevalence and characteristics of fetal alcohol spectrum disorders (FASD) have been described previously in this community.

METHODS

Active case ascertainment methods were employed in a new cross-sectional study with Revised Institute of Medicine criteria among first grade students (n = 735) via dysmorphology examinations and neurobehavioral assessments. Their mothers were interviewed regarding risk factors. Final diagnoses were assigned via structured case conferences.

RESULTS

Children with fetal alcohol syndrome (FAS), partial FAS (PFAS), and alcohol related-neurodevelopmental disorder (ARND) were significantly different from controls on all cardinal variables, multiple dysmorphology traits and neurobehavioral performance. Mothers of children with FASD reported significantly more drinking before and during pregnancy (mothers of children with FAS reported 7.8 (±6.1) drinks per drinking day (DDD) prior to pregnancy and 5.1 (±5.9) after pregnancy recognition). Distal risk variables for a diagnosis on the continuum of FASD were: lower maternal height, weight, and body mass index; higher gravidity; lower education and household income; and later pregnancy recognition. Alcohol and tobacco remain the only commonly used drugs. Women reporting first trimester drinking of two DDD were 13 times more likely (95 % CI:1.3-133.4) to have a child with FASD than non-drinkers; and those who reported drinking throughout pregnancy were 19.4 times more likely (95 % CI:8.2-46.0) to have a child with FASD.

CONCLUSION

Seventeen years after the first study in this community, FASD prevalence remains high at 16 %-31 %. The FAS rate may have declined somewhat, but rates of PFAS and ARND seemed to plateau, at a high rate.

Fatty acid ethyl esters in meconium and substance use in adolescence

Prenatal alcohol exposure (PAE) continues to be a serious public health problem, yet no reliable clinical tools are available for assessing levels of drinking during pregnancy. Fatty acid ethyl esters (FAEEs), the nonoxidative metabolites of ethanol measured in meconium, are potential biomarkers to quantify the level of PAE. The association between the concentrations of FAEEs from meconium and adolescent substance use and related problems was examined in a prospective birth-cohort of adolescents exposed to alcohol and drugs in utero. FAEEs were quantified with gas chromatography via a flame ionization detector. Meconium was analyzed for FAEEs in 216 newborns; 183 of them (81 boys, 102 girls) were assessed at age 15 for alcohol, tobacco, and marijuana use using biologic assays and self-report. Substance use problems were assessed using the Problem Oriented Screening Instrument for Teenagers. Findings from multivariable logistic regression analyses indicated that, after controlling for other prenatal drug exposure and covariates, higher concentrations of FAEEs (ethyl myristate, ethyl palmitate, ethyl oleate, ethyl linoleate, ethyl linolenate, and ethyl arachidonate) were related to a greater likelihood of marijuana use and experiencing substance use problems, but not tobacco or alcohol use, at age 15. Elevated levels of FAEEs in meconium may be promising markers for PAE, identifying newborns at risk for early substance use and developing substance use problems.

Smoking and drinking habits of women in subsequent pregnancies after specific advice about the dangers of these exposures during pregnancy

BACKGROUND

Although women are informed about the dangers of drinking and smoking during pregnancy when they book for antenatal care, it is uncertain whether this advice is accepted, or whether attempts are made to apply it in subsequent pregnancies.

OBJECTIVES

To assess how pregnant women respond to the advice to refrain from smoking and drinking during pregnancy in subsequent pregnancies.

METHODS

Research staff were trained to obtain accurate prospective information on smoking and drinking during pregnancy in a prospective study, using well-standardised methods. Care was taken to inform participants about the dangers of smoking and drinking during pregnancy. They were also given pamphlets on these dangers in their own language and a list of telephone numbers where they could find help to quit should they need it. This information was repeated at subsequent study visits (ranging from 1 to 3, depending on the gestational age at which they enrolled). Gestational age was determined by early ultrasound. Z-scores of birthweight for gestational age were determined according to the INTERGROWTH-21st study. Pregnancy outcomes of women who enrolled twice (n=888) or three times (n=77) in the Safe Passage Study were compared with those of women in the first enrolment (n=889).

RESULTS

The proportion of drinkers did not change significantly (p=0.058) from the first to the second and third enrolments (63.8%, 59.0% and 54.6%, respectively). A similar trend was found for smokers (73.3%, 72.2% and 68.4%, respectively). Cannabis use was reported by 15.1%, 9.7% and 12.0% (p<0.005) of women, respectively, and use of methamphetamine by 10.1%, 6.6% and 12.7% (p<0.005). There was an increase in the rate of preterm births from 15.5% to 17.5% and 24.7%, respectively, but the increase was not significant. Although mean birthweight was lower in the third enrolment compared with the second, the difference was not significant. The z-score of birthweight for gestational age was significantly lower in the second enrolment compared with the first.

CONCLUSIONS

Detailed information on the adverse effects of smoking and drinking during pregnancy was not effective in the population studied. Other methods to reduce or stop these toxic exposures should therefore be investigated. A short inter-pregnancy interval, as demonstrated by three enrolments in 7.5 years, is associated with preterm labour and fetal growth restriction, and is probably indicative of the role played by confounders such as poor socioeconomic conditions and drug exposure during pregnancy.

Ocular measurements in fetal alcohol spectrum disorders

Fetal alcohol spectrum disorders (FASD) describe a range of physical, behavioral, and neurologic deficits in individuals exposed to alcohol prenatally. Reduced palpebral fissure length is one of the cardinal facial features of FASD. However, other ocular measurements have not been studied extensively in FASD. Using the Fetal Alcohol Syndrome Epidemiologic Research (FASER) database, we investigated how inner canthal distance (ICD), interpupillary distance (IPD), and outer canthal distance (OCD) centiles differed between FASD and non-FASD individuals. We compared ocular measurement centiles in children with FASD to non-FASD individuals and observed reductions in all three centiles for ICD, IPD, and OCD. However, when our non-FASD children who had various forms of growth deficiency (microcephaly, short-stature, or underweight) were compared to controls, we did not observe a similar reduction in ocular measurements. This suggests that reductions in ocular measurements are a direct effect of alcohol on ocular development independent of its effect on growth parameters, which is consistent with animal models showing a negative effect of alcohol on developing neural crest cells. Interpupillary distance centile appeared to be the most significantly reduced ocular measure we evaluated, suggesting it may be a useful measure to be considered in the diagnosis of FASD.

Fetal Alcohol Spectrum Disorders in a Southeastern County of the United States: Child Characteristics and Maternal Risk Traits

OBJECTIVE

To detail the characteristic traits of children with fetal alcohol spectrum disorders (FASDs) and maternal risk factors in a southeastern U.S. County.

METHODS

Independent samples were drawn from 2 different cohorts of first-grade students. All consented children (49.8%) were measured for height, weight, and head circumference, and those ≤ 25th centile entered the study along with a random sample drawn from all enrolled students. Study children were examined for physical growth, dysmorphology, and neurobehavior, and their mothers were interviewed.

RESULTS

Total dysmorphology scores discriminated well the physical traits of children across the FASD continuum: fetal alcohol syndrome (FAS) = 15.8, partial FAS (PFAS) = 10.8, alcohol-related neurobehavioral disorder (ARND) = 5.2, and typically developing controls = 4.4. Additionally, a neurobehavioral battery distinguished children with each FASD diagnosis from controls. Behavioral problems qualified more children for FASD diagnoses than cognitive traits. Significant proximal maternal risk variables were as follows: reports of prepregnancy drinking, drinking in any trimester, and comorbid use of other drugs in lifetime and during pregnancy, especially alcohol and marijuana (14.9% among mothers of children with FASD vs. 0.4% for controls). Distal maternal risks included reports of other health problems (e.g., depression), living unmarried with a partner during pregnancy, and a lower level of spirituality. Controlling for other drug use during pregnancy, having a child diagnosed with a FASD was 17.5 times greater for women who reported usual consumption of 3 drinks per drinking day prior to pregnancy than for nondrinking mothers (p < 0.001, 95% CI = 5.1 to 59.9). There was no significant difference in the prevalence of FASD by race, Hispanic ethnicity, or socioeconomic status. The prevalence of FASD was not lower than 17.3 per 1,000, and weighted estimated prevalence was 49.0 per 1,000 or 4.9%.

CONCLUSION

This site had the second lowest rate in the CoFASP study, yet children with FASD are prevalent.

Fetal Alcohol Spectrum Disorders in a Midwestern City: Child Characteristics, Maternal Risk Traits, and Prevalence

OBJECTIVE

To determine the characteristics of children with fetal alcohol spectrum disorders (FASD) and their mothers in a Midwestern city.

METHODS

Case-control samples were drawn from 2 separate first-grade cohorts (combined N = 4,047) in every city school using different methods. In Cohort Sample 1, all consented small children (≤25th centile on height, weight, and/or head circumference) entered the study along with a random sample from all enrolled students. Cohort Sample 2 was drawn totally at random. Child growth, dysmorphology, and neurobehavior were assessed using the Collaboration on FASD Prevalence (CoFASP) criteria, and mothers were interviewed.

RESULTS

For the samples combined, 891 children received dysmorphology examinations, and 692 were case-conferenced for final diagnosis. Forty-four children met criteria for FASD. Total dysmorphology scores differentiated diagnostic groups: fetal alcohol syndrome (FAS), 16.7; partial FAS, 11.8; alcohol-related neurodevelopmental disorder (ARND), 6.1; and typically developing controls, 4.2. Neurobehavioral tests distinguished children with FASD from controls, more for behavioral problems than cognitive delay. Children with ARND demonstrated the poorest neurobehavioral indicators. An adjusted regression model of usual prepregnancy drinking indicated that maternal reports of 3 drinks per drinking day (DDD) were significantly associated with a FASD diagnosis (p = 0.020, OR = 10.1, 95% CI = 1.44 to 70.54), as were 5 or more DDD (p < 0.001, OR = 26.47, 95% CI = 4.65 to 150.62). Other significant maternal risk factors included the following: self-reported drinking in any trimester; smoking and cocaine use during pregnancy; later pregnancy recognition and later and less prenatal care; lower maternal weight, body mass index (BMI), and head circumference; and unmarried status. There was no significant difference in FASD prevalence by race, Hispanic ethnicity, or socioeconomic status at this site, where the prevalence of FASD was 14.4 to 41.2 per 1,000 (1.4 to 4.1%).

CONCLUSION

This city displayed the lowest prevalence of FASD of the 4 CoFASP sites. Nevertheless, FASD were common, and affected children demonstrated a common, recognizable, and measurable array of traits.

Four-year follow-up of a randomized controlled trial of choline for neurodevelopment in fetal alcohol spectrum disorder

BACKGROUND

Despite the high prevalence of fetal alcohol spectrum disorder (FASD), there are few interventions targeting its core neurocognitive and behavioral deficits. FASD is often conceptualized as static and permanent, but interventions that capitalize on brain plasticity and critical developmental windows are emerging. We present a long-term follow-up study evaluating the neurodevelopmental effects of choline supplementation in children with FASD 4 years after an initial efficacy trial.

METHODS

The initial study was a randomized, double-blind, placebo-controlled trial of choline vs. placebo in 2-5-year-olds with FASD. Participants include 31 children (16 placebo; 15 choline) seen 4 years after trial completion. The mean age at follow-up was 8.6 years. Diagnoses were 12.9% fetal alcohol syndrome (FAS), 41.9% partial FAS, and 45.1% alcohol-related neurodevelopmental disorder. The follow-up included measures of intelligence, memory, executive functioning, and behavior.

RESULTS

Children who received choline had higher non-verbal intelligence, higher visual-spatial skill, higher working memory ability, better verbal memory, and fewer behavioral symptoms of attention deficit hyperactivity disorder than the placebo group. No differences were seen for verbal intelligence, visual memory, or other executive functions.

CONCLUSIONS

These data support choline as a potential neurodevelopmental intervention for FASD and highlight the need for long-term follow-up to capture treatment effects on neurodevelopmental trajectories.

TRIAL REGISTRATION

ClinicalTrials.Gov #NCT01149538; Registered: June 23, 2010; first enrollment July 2, 2010.

Animal models of gene-alcohol interactions

Most birth defects arise from complex interactions between multiple genetic and environmental factors. However, our current understanding of how these interactions and their contributions affect birth defects remains incomplete. Human studies are limited in their ability to identify the fundamental causes of birth defects due to ethical and practical limitations. Animal models provide a great number of resources not available to human studies and they have been critical in advancing our understanding of birth defects and the complex interactions that underlie them. In this review, we discuss the use of animal models in the context of gene-environment interactions that underlie birth defects. We focus on alcohol which is the most common environmental factor associated with birth defects. Prenatal alcohol exposure leads to a wide range of cognitive impairments and structural deficits broadly termed fetal alcohol spectrum disorders (FASD). We discuss the broad impact of prenatal alcohol exposure on the developing embryo and elaborate on the current state of gene-alcohol interactions. Additionally, we discuss how animal models have informed our understanding of the genetics of FASD. Ultimately, these topics will provide insight into the use of animal models in understanding gene-environment interactions and their subsequent impact on birth defects.

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

Background

Fetal Alcohol Spectrum Disorder (FASD) is a public health problem globally, with South Africa having the highest recorded prevalence of all countries. Government programmes to prevent and manage FASD remain limited because of the lack of a specific policy. Herein, we developed a guideline to inform policy on the prevention and management of FASD in South Africa.

Methods

We applied a modified version of the World Health Organization’s approach to guideline development in three phases. In the first phase, we designed the initial guideline prototype. To do this, we conducted an in-depth interview with policymakers and a focus group with relevant service providers on policy requirements for FASD, a document review of policies on FASD and a scoping review of various interventions for FASD. In phase 2, we refined the initially formulated guideline prototype through a discursive approach with seven local and international experts on FASD. Phase 3 involved refining the prototype using a modified Delphi approach. Forty-three and forty-one experts participated in rounds 1 and 2 of the Delphi approach, respectively. The acceptable consensus for each included policy statement was 85%.

Results

We identified three aspects of the proposed guideline, which are the approaches and guiding principles, the prevention measures and the management measures. The guideline proposes that a FASD policy should consider lifespan needs, be culturally diverse, collaborative, evidence-based, multi-sectoral and address social determinants of health contributing to FASD. The essential components of FASD prevention policy consist of awareness and education of the dangers of drinking alcohol, access to treatment for alcohol problems and training of service providers. The management components include capacity building related to diagnosis, educating parents regarding the needs and management, appropriate referral pathways, training of teachers regarding classroom management and support for parents and individuals with FASD.

Conclusion

FASD in South Africa deserves urgent attention. Developing a specific policy to guide programmes could enhance and coordinate the efforts towards preventing and managing FASD. The guideline has the potential to assist policymakers in the development of a comprehensive and multi-sectoral policy for prevention and management of FASD, considering the consensus obtained from the experts.

Fetal Alcohol Spectrum Disorders in a Pacific Southwest City: Maternal and Child Characteristics

BACKGROUND

There are limited data on the characteristics of children with fetal alcohol spectrum disorders (FASD) and their mothers from the general population in the United States.

METHODS

During the 2012 and 2013 academic years, first-grade children in a large urban Pacific Southwest city were invited to participate in a study to estimate the prevalence of FASD. Children who screened positive on weight, height, or head circumference ≤25th centile or on parental report of developmental concerns were selected for evaluation, along with a random sample of those who screened negative. These children were examined for dysmorphology and neurobehavior and their mothers or collateral sources were interviewed. Children were classified as fetal alcohol syndrome (FAS), partial fetal alcohol syndrome (pFAS), alcohol-related neurodevelopmental disorder (ARND), or No FASD.

RESULTS

A total of 854 children were evaluated; 5 FAS, 44 pFAS, 44 ARND, and 761 No FASD. Children with FAS or pFAS were more likely to have dysmorphic features, and 32/49 (65.3%) of those met criteria for neurobehavioral impairment on cognitive measures with or without behavioral deficits. In contrast, 28/44 (63.6%) of children with ARND met criteria on behavioral measures alone. Mothers of FASD children were more likely to recognize pregnancy later, be unmarried, and report other substance use or psychiatric disorders, but did not differ on age, socioeconomic status, education, or parity. Mothers of FASD children reported more drinks/drinking day each trimester. The risk of FASD was elevated with increasing number of drinks/drinking day prior to pregnancy recognition, even at the level of 1 drink per day (adjusted odds ratio 3.802, 95% confidence interval 1.634, 8.374).

CONCLUSIONS

Data from this general population sample in a large urban region in the United States demonstrate the variability of expression of FASD and point to risk and protective factors for mothers in this setting.

"The Dop System of Alcohol Distribution is Dead, but It's Legacy Lives On…."

Objective: Determine the prevalence of Dop, a system of labor payment via alcoholic beverages, in a South African province, and its influence on maternal drinking and fetal alcohol spectrum disorders (FASD). Methods: Data from studies of FASD epidemiology were analyzed. Results: Forty-two percent to 67% of mothers reported drinking. In 1999, 5% of women reported Dop allocations in their lifetime: 14% of mothers of FASD children and 1% of controls. In 2010, 1.1% of mothers reported lifetime Dop: 1.6% of FASD mothers and 0.7% of controls. Commercial alcohol sales have replaced the Dop system. Total FASD rates remained high in rural areas in 2010 and rose in urban settings. Urban rates of total FASD surpassed rural area rates in 2010. Correlation analysis did not reveal a strong or significant, direct relationship between Dop experience and heavy drinking (r = 0.123, p < 0.001, r² = 0.015), or the diagnosis of FASD in children (OR = 0.003, p = 0.183). Conclusion: Dop, as a systematic practice, is dead and does not have a direct influence on alcohol availability, heavy maternal drinking, or the probability of an FASD diagnosis. Nevertheless, today’s problematic drinking patterns were heavily influenced (shaped) by Dop and have negatively impacted the prevalence and severity of FASD.

To what extent is Fetal Alcohol Spectrum Disorder considered in policy-related documents in South Africa? A document review

BACKGROUND

South Africa is considered to have the highest prevalence of fetal alcohol spectrum disorder (FASD) globally. Nevertheless, the extent to which the South African government has responded to the high FASD prevalence at the policy level is unclear. Herein, we aimed to identify targeted and generic clauses that could be attributed to the prevention and management of FASD in relevant South African policy documents.

METHODS

We conducted a search of two search engines (PubMed and Google) and the websites of South African national and provincial departments from January to April 2018. A total of 33 policy documents were included in this review. Using content analysis, we sought documents that mention the terms 'fetal alcohol syndrome' and 'fetal alcohol spectrum disorder'. The Framework method was also used to thematically identify specific and generic clauses attributed to the prevention and management of FASD in South Africa.

RESULTS

The content analysis indicated that 12 policy documents contained the searched terms. Findings from the thematic analysis showed that targeted and generic clauses for FASD exist in various policy documents. Some of the generic clauses focused on the regulation of liquor outlets, enforcement of liquor laws, and the general management of persons with mental and educational challenges. Specific clauses focused on creating platforms to improve the awareness, screening, identification and support for individuals with FASD.

CONCLUSIONS

There is a noticeable increase in the number of policy documents that considered elements of FASD enacted in the last decade. Although this study revealed the existence of targeted and generic clauses that could be attributed to the prevention and management of FASD, the sustained high prevalence of FASD in South Africa, as reported in the literature, calls for more holistic and comprehensive approaches to tackle the FASD problem in South Africa.

Policymakers' Perspectives Towards Developing a Guideline to Inform Policy on Fetal Alcohol Spectrum Disorder: A Qualitative Study

Fetal alcohol spectrum disorder (FASD) has a high prevalence in South Africa, especially among the poor socioeconomic communities. However, there is no specific policy to address FASD. Using a qualitative study design, we explored the perspectives of policymakers on guidelines/policies for FASD, current practices and interventions, and what practices and interventions could be included in a policy for FASD. The data analysis was done using the Framework Method. Applying a working analytical framework to the data, we found that there is no specific policy for FASD in South Africa, however, clauses of FASD policy exist in other policy documents. Preventive services for women and screening, identification, assessment, and support for children are some of the current practices. Nevertheless, a multi-sectoral collaboration and streamlined program for the prevention and management of FASD are aspects that should be included in the policy. While there are generic clauses in existing relevant policy documents, which could be attributed to the prevention and management of FASD, these clauses have not been effective in preventing and managing the disorder. Therefore, a specific policy to foster a holistic and coordinated approach to prevent and manage FASD needs to be developed.

Screening prevalence of fetal alcohol spectrum disorders in a region of the United Kingdom: A population-based birth-cohort study

Fetal alcohol spectrum disorders (FASDs) are lifelong disabilities caused by prenatal alcohol exposure. Prenatal alcohol use is common in the UK, but FASD prevalence was unknown. Prevalence estimates are essential for informing FASD prevention, identification and support. We applied novel screening algorithms to existing data to estimate the screening prevalence of FASD. Data were from a population-based cohort study (ALSPAC), which recruited pregnant women with expected delivery dates between 1991 and 1992 from the Bristol area of the UK. We evaluated different missing data strategies by comparing results from complete case, single imputation (which assumed that missing data indicated no exposure and no impairment), and multiple imputation methods. 6.0% of children screened positive for FASD in the analysis that used the single imputation method (total N = 13,495), 7.2% in complete case analysis (total N = 223) and 17.0% in the analysis with multiply imputed data (total N = 13,495). A positive FASD screen was more common among children of lower socioeconomic status and children from unplanned pregnancies. Our analyses showed that the complete case and single imputation methods that are commonly used in FASD prevalence studies are likely to underestimate FASD prevalence. Although not equivalent to a formal diagnosis, these screening prevalence estimates suggest that FASD is likely to be a significant public health concern in the UK. Given current patterns of alcohol consumption and recent changes in prenatal guidance, active case ascertainment studies are urgently needed to further clarify the current epidemiology of FASD in the general population of the UK.

Systematic literature review on which maternal alcohol behaviours are related to fetal alcohol spectrum disorders (FASD)

OBJECTIVES

Fetal alcohol spectrum disorders (FASD) is a worldwide problem. Maternal alcohol consumption is an important risk factor for FASD. It remains unknown which alcohol consumption patterns most strongly predict FASD. The objective of this study was to identify these.

DESIGN

Systematic literature review.

METHODS

We searched in PubMed, PsychINFO, PsycARTICLES, ERIC, CINAHL, Embase and MEDLINE up to August 2018. The query consisted of keywords and their synonyms related to FASD, pregnancy and behaviour. Studies were excluded when not published in English, were reviews or involved non-human subjects. Substantial heterogeneity precluded aggregation or meta-analysis of the data. Instead, data were qualitatively inspected.

RESULTS

In total, 21 studies were eligible for further data analysis. All studies that measured both maternal alcohol drinking behaviours and FASD reported retrospective data on maternal drinking patterns, employing both continuous and categorical measures and exhibiting substantial heterogeneity in measures of alcohol consumption (eg, timing of exposure, quantification of alcohol measure and definition of a standard drink). Study quality improved over time and appeared higher for studies based on active case ascertainment, especially when conducted in schools and when behaviour was assessed through interviews.

CONCLUSIONS

We aimed to identify specific maternal drinking behaviour(s) related to FASD. The state of the literature precludes such conclusions. Evidence-based preventive measures necessitate identifying which prenatal alcohol drinking behaviour(s) are most in need of intervention. Therefore, we formulate three recommendations for future research. First, future studies can optimise the value of the collected dataset through specifying measurements and reporting of maternal drinking behaviours and avoiding categorised measures (nominal or ordinal) whenever possible. Second, samples should not be selected based on FASD status, but instead, FASD status as well as maternal alcohol consumption should both be measured in a general population sample. Finally, we provide 10 reporting guidelines for FASD research.

Heavy drinking and contextual risk factors among adults in South Africa: findings from the International Alcohol Control study

Background

There is limited information about the potential individual-level and contextual drivers of heavy drinking in South Africa. This study aimed to identify risk factors for heavy drinking in Tshwane, South Africa.

Methods

A household survey using a multi-stage stratified cluster random sampling design. Complete consumption and income data were available on 713 adults. Heavy drinking was defined as consuming ≥120 ml (96 g) of absolute alcohol (AA) for men and ≥ 90 ml (72 g) AA for women at any location at least monthly.

Results

53% of the sample were heavy drinkers. Bivariate analyses revealed that heavy drinking differed by marital status, primary drinking location, and container size. Using simple logistic regression, only cider consumption was found to lower the odds of heavy drinking. Persons who primarily drank in someone else’s home, nightclubs, and sports clubs had increased odds of heavy drinking. Using multiple logistic regression and adjusting for marital status and primary container size, single persons were found to have substantially higher odds of heavy drinking. Persons who drank their primary beverage from above average-sized containers at their primary location had 7.9 times the odds of heavy drinking as compared to persons who drank from average-sized containers. Some significant associations between heavy drinking and age, race, and income were found for certain beverages.

Conclusion

Rates of heavy drinking were higher than expected giving impetus to various alcohol policy reforms under consideration in South Africa. Better labeling of the alcohol content of different containers is needed together with limiting production, marketing and serving of alcohol in large containers.

Exploring service providers' perspectives on the prevention and management of fetal alcohol spectrum disorders in South Africa: a qualitative study

Background

Fetal alcohol spectrum disorder (FASD) is among the leading causes of developmental and intellectual disabilities in individuals. Although efforts are being made toward the prevention and management of FASD in South Africa, the prevalence remains high. The sustained high prevalence could be attributed to several factors, including the lack of policy for a coordinated effort to prevent, diagnose and manage FASD nationally. In this study, our aim was to explore the perspectives of service providers (health and allied professionals, teachers, social workers) on the prevention and management of FASD towards developing a guideline to inform policy.

Method

Guided by the exploratory qualitative research design, we purposively sampled relevant service providers in the field of FASD prevention and management for focus group discussions. Nine of these discussions were conducted with to eight participants per discussion session. The discussants were asked various questions on the current and required interventions and practices for the prevention and management of FASD. Following the Framework Method, data were transcribed verbatim and analysed using the thematic content analysis approach.

Results

Our findings show that aspects of the prevention and management of alcohol-related conditions are present in various policies. However, there is no clear focus on coordinated, multi-sectoral efforts for a more comprehensive approach to the prevention and management of FASD. The participants recognized the need for specific requirements on broad-based preventive awareness programs, training and support for parents and caregivers, inclusive education in mainstream schools and training of relevant professionals.

Conclusion

Comprehensive and coordinated prevention and management programs guided by a specific policy could improve the prevention and management of FASD. Policy formulation demonstrates commitment from the government, highlights the importance of the condition, and elaborates on context-specific prevention and management protocols.

Electronic supplementary material

The online version of this article (10.1186/s12889-018-6126-x) contains supplementary material, which is available to authorized users.

Diving into the world of alcohol teratogenesis: a review of zebrafish models of fetal alcohol spectrum disorder

The term fetal alcohol spectrum disorder (FASD) refers to the entire suite of deleterious outcomes resulting from embryonic exposure to alcohol. Along with other reviews in this special issue, we provide insight into how animal models, specifically the zebrafish, have informed our understanding of FASD. We first provide a brief introduction to FASD. We discuss the zebrafish as a model organism and its strengths for alcohol research. We detail how zebrafish has been used to model some of the major defects present in FASD. These include behavioral defects, such as social behavior as well as learning and memory, and structural defects, disrupting organs such as the brain, sensory organs, heart, and craniofacial skeleton. We provide insights into how zebrafish research has aided in our understanding of the mechanisms of ethanol teratogenesis. We end by providing some relatively recent advances that zebrafish has provided in characterizing gene-ethanol interactions that may underlie FASD.

A utilitarian comparison of two alcohol use biomarkers with self-reported drinking history collected in antenatal clinics

BACKGROUND

Alcohol use is reported accurately among pregnant women in some populations.

METHODS

Self-reported alcohol use via the AUDIT and 90-day recall for 193 women from antenatal clinics was compared to biomarker results: phosphatidylethanol (PEth) from bloodspots and ethyl glucuronide (EtG) in fingernails.

RESULTS

AUDIT was positive for 67.9% of respondents, and 65.3% directly reported drinking. Individual biomarkers detected less drinking (PEth = 57.0%, EtG = 38.9%) than self-report. But 64.8% had drinking-positive values (>8 ng) on one or both biomarkers, which was not significantly different from self-report. Biomarkers indicated that 3.1% -6.8% of drinkers denied drinking. Combined biomarker sensitivity was 95% -80% and specificity 49% -76% for drinking in the previous 7-90 days. Combined biomarker results have their best yield (89.6%) and accuracy (78.8%) when measuring 90 day drinking.

CONCLUSIONS

Women reported their alcohol use accurately, and the combined use of PEth and EtG is supported.

Thyroid Function in Pregnant Women With Moderate to Severe Alcohol Consumption Is Related to Infant Developmental Outcomes

INTRODUCTION

Fetal alcohol spectrum disorders (FASD) have an estimated global prevalence of 2-5% of births, but prevalence is reported to be as high as 15.5% for FASD in certain high-risk communities in South Africa. Preclinical studies demonstrate that alcohol consumption during pregnancy interferes with thyroid hormone availability and function and negatively impacts exposed offspring. Very little is currently reported on this phenomenon in humans.

METHODS

This pilot study was embedded in the Drakenstein Child Health Study, a multi-disciplinary longitudinal birth cohort study investigating the early biological and psychosocial determinants of child health in South Africa. Twenty one mothers and their children with moderate-severe prenatal alcohol exposure (PAE) and 19 mothers and their children with no alcohol exposure were investigated. Maternal exposure history and blood samples were collected in mid-pregnancy and analyzed for serum-free thyroxin (FT4), free triiodothyronine (FT3), and thyroid stimulating hormone (TSH). Children were assessed with formally measured growth parameters and development was evaluated using the Bayley III Scales of Infant and Toddler Development (BSID III) at 6 and 24 months of age.

RESULTS

While there were no significant differences in serum TSH and FT4 between groups, FT3 levels were significantly higher in mothers with moderate-severe prenatal alcohol use. In abstinent pregnant women, levels of FT4 were significantly correlated with infants' scores on cognitive measures at 6 and 24 months of age and with levels of gross motor skills at 24 months. However, in mothers with alcohol use, FT4 levels were not correlated with any cognitive or motor skills, but FT3 levels were significantly associated with scores on children's social-emotional development at 24 months of age.

DISCUSSION

Thyroid function in PAE is sufficiently disrupted to lead to alterations in serum FT3 levels. The contrast in findings between PAE and abstinent dyads in their association of maternal thyroid function and infant development further suggests that such disruption is present and may contribute to adverse neurodevelopment. Further work is needed to determine the relationship between peripheral thyroid indices during pregnancy and neurodevelopmental outcomes in the context of PAE.

The Prevalence of Fetal Alcohol Syndrome and Its Impact on a Child's Classroom Performance: A Case Study of a Rural South African School

Alcohol consumption is high among farm labourers in the Western and Northern Cape of South Africa. Excessive alcohol consumption during pregnancy is common, resulting in a high prevalence of Fetal Alcohol Syndrome (FAS) among children. FAS causes intellectual and behavioural problems, which create considerable obstacles to a child’s education. The aim of this study is to provide a prevalence estimate of FAS in a rural school and to examine the effects of FAS on learners’ educational outcomes. The study was conducted at a farm school near Clanwilliam in the Western Cape of South Africa. The sample comprises 166 learners from Grades 1 to 4. Educational outcomes include class scores (Afrikaans home language and mathematics), reading ability, and classroom behaviour. A physician diagnosed FAS using a three-stage process. We find FAS prevalence of 127 per 1000 (12.7%). Children with FAS score significantly lower (at the 10% level) for home language and behaviour than children who do not have FAS. Large-scale interventions in rural areas of the Western and Northern Cape that specifically target females of child-bearing age, as well as children with FAS, are necessary.