| FETAL ALCOHOL SPECTRUM DISORDERS |
| How the Unborn Baby is Nourished Everything a woman eats, drinks, inhales, sniffs, or injects will go into her bloodstream and then will go in varying degrees to the unborn baby through the placenta. An unborn baby gets all the nutrients and oxygen it needs to develop from the mother through the placenta. How Alcohol Affects the Unborn Baby Alcohol is a teratogen. A teratogen is a substance that interferes with the normal growth and development of the unborn baby. Specifically, alcohol is called a neurobehavioral teratogen because it can cause damage to the brain and can subsequently change behavior. Range of Effects from Prenatal Alcohol Exposure Alcohol affects each pregnant woman and fetus differently. Fetal Alcohol Spectrum Disorder (FASD) is the term used to describe the range of disabilities caused by drinking alcohol during pregnancy. These lifelong disabilities can include behavioral and learning problems that can have major impacts on the individual and his or her family and will change their lives. It is important to understand that even though an individual may not meet all the criteria for a diagnosis of Fetal Alcohol Syndrome (FAS), he or she may still be living with the effects of prenatal exposure to alcohol. Fetal Alcohol Syndrome (FAS) is a combination of mental and physical disabilities present at birth. Individuals who are not diagnosed with FAS but who have Partial Fetal Alcohol Syndrome (pFAS), Alcohol-Related Neurodevelopmental Disorder (ARND), or Alcohol-Related Birth Defects (ARBD), also have special needs, which may be as severe as an individual with FAS and will require assistance throughout their lives. Characteristics of Individuals with FASD The following may be observed: Babies exposed to alcohol during pregnancy often have other health concerns. Abnormalities of the skeleton, cleft lip and palate, heart defects, and other internal organ problems are common. • Learning and memory difficulties • Language processing difficulties • Speech and language deficits • Behavioral problems • Poor comprehension of social rules and expectations • Sensory, hearing, and vision deficits • Short attention span • Impulsive behaviours • Coordination and motor skill deficits • Easily overwhelmed and over stimulated • Hyperactivity • Facial abnormalities • Growth deficiency Facts Risk Factors Involved in FASD No one can predict which infants born to mothers who drink will be affected, nor can anyone predict how severe these effects will be. There is no safe time or safe amount of alcohol to drink during pregnancy. Five factors affect how severe the damage will be to the unborn baby: 1. The time in the pregnancy at which alcohol is consumed: Damage to the fetus can occur anytime during the pregnancy. Alcohol may affect whatever growth or development is taking place at the time of the mother's consumption. The unborn baby's brain develops throughout the pregnancy and is always vulnerable to alcohol. 2. The amount of alcohol consumed during the pregnancy: There is a significant risk to damage the fetus as well as stillbirth and spontaneous abortion with "heavy" drinking. However, no one knows how much alcohol a pregnant woman can drink without hurting the baby. "Binge" drinking (five or more drinks in a drinking episode) sharply raises the amount of alcohol in the blood and greatly increases the risk to the baby. 3. Individual susceptibility to alcohol: Genetic factors determine the baby's ability to deal with the alcohol in its system and how quickly the alcohol in the baby's system can be broken down. 4. Nutrition: Alcohol affects how the placenta transfers important nutrients necessary for fetal growth. Good nutrition for the fetus is important throughout the entire pregnancy. It is important for women to eat a nutritious diet including a daily multivitamin with folic acid. 5. Additional Risks: The damage to the baby because of prenatal alcohol exposure may be compounded if the mother has poor nutritional status, smokes, is in poor health, is under increased stress, and/or uses other drugs. Prevention Fetal Alcohol Spectrum Disorder is preventable by not drinking alcohol during pregnancy. If a woman is planning a pregnancy, she should decide to stop drinking before becoming pregnant. The safest decision a woman can make is to completely avoid beer, wine, and hard liquor during her pregnancy. It is important to remember that many people need professional help in order to stop using alcohol, tobacco, and other drugs. Women who need assistance to stop drinking during pregnancy should be advised to consult with their doctors or should be directed to agencies that can assist them to stop drinking. |
| 1. The most common term and the one that has been in existence the longest to describe an individual affected by prenatal alcohol exposure is Fetal Alcohol Syndrome. Fetal Alcohol Syndrome describes an individual with the full syndrome including all of the characteristics needed to define it. The characteristics are: ~facial anomalies which include small eye openings; flat, thin upper lip; ~little or no philtrum (the groove between the nose and lip); flattened midface; ~growth retardation in at least one of the following ways: low birthweight, weight loss that is not due to poor nutrition, low weight or height ratio. ~central nervous system abnormalities in at least one of the following areas: -small head size at birth, -structural abnormalities in the brain, -poor fine motor skills, -poor hand-eye coordination, -hearing loss which is not related to injury or illness, and/or poor gait when walking. ****In addition to the evidence of these characteristics, the physician must have knowledge of alcohol consumption during pregnancy.***** 2. Fetal Alcohol Syndrome can be diagnosed without knowledge of mother's alcohol consumption during pregnancy providing all other characteristics necessary to diagnose Fetal Alcohol Syndrome are present. 3. Partial Fetal Alcohol Syndrome (pFAS) is a term used to describe individuals who do not have all of the characteristics necessary to receive a diagnosis of FAS. To be described as having Partial Fetal Alcohol Syndrome, the following criteria are necessary: ~~knowledge that there was alcohol consumption during pregnancy ~~some of the facial anomalies which are characteristic of Fetal Alcohol Syndrome One of the following three characteristics: ~~growth retardation in at least one of the following ways: -low birthweight, -weight loss that is not due to poor nutrition, -low weight to height ratio Central nervous system abnormalities in at least one of the following areas: -small head size at birth, -structural abnormalities in the brain, -poor fine motor skills, -poor hand-eye coordination, -hearing loss which is not related to injury or illness, and/or poor gait when walking. A pattern of behaviour or cognitive abnormalities that are not age-appropriate and cannot be explained by heredity or environment alone. These abnormalities include: -poor school performance, -deficits in language (both expression and comprehension) and specific mathematical skills, -poor abstract thinking ability, -poor impulse control, -inability to interpret and respond to social situations, problems with memory, attention, and judgment . 4. Alcohol-Related Birth Defects (ARBD) is a term used to describe congenital abnormalities related to: -the heart -the skeleton -the kidneys -the eyes -the ears To relate these abnormalities to alcohol, there must be knowledge alcohol consumption during pregnancy. 5. Alcohol-Related Neurodevelopmental Disorder (ARND) is a term used to describe the presence of one or both of the following: ~Central nervous system abnormalities in at least one of the following areas: -small head size at birth, -structural abnormalities in the brain, -poor fine motor skills, -poor hand-eye coordination, -hearing loss which is not related to injury or illness, -poor gait when walking. ~a pattern of behaviour or cognitive abnormalities that are not age-appropriate and cannot be explained by heredity or environment alone. These abnormalities include: -poor school performance, -deficits in language, both expression and comprehension, -specific mathematical skills, -poor abstract thinking ability, -poor impulse control, -inability to interpret and respond to social situations, -problems with memory, attention, and judgment. To relate these abnormalities to alcohol, there must be knowledge of alcohol consumption during pregnancy. 6. Fetal Alcohol Effects (FAE) is another term that has been used commonly to describe a condition which does not meet all of the criteria needed to diagnose FAS. The Institute on Medicine in the United States has recommended that the term Partial FAS be used since the term FAE causes confusion among professionals and the public. The use of the word "partial" does not imply that the condition is less severe than FAS. |
| Fetal alcohol spectrum disorder –New diagnostic initiatives Rachel Greenbaum MA, Gideon Koren MD Of all forms of substance abuse, alcohol abuse is the most serious in pregnancy, whether judged by its frequency or capacity to harm the fetus. Prenatal alcohol exposure is the most prevalent, single cause of intellectual impairment in children in the western world. Although alcohol’s role in human teratogenicity was not systematically studied until the 1970s, adverse effects of alcohol consumption during pregnancy have been noted throughout history, dating back to the Bible and Greek history. The first scientific study of children of alcoholic mothers was conducted by a British physician, Dr. William Sullivan, in 1899. However, until the past few decades, little attention was paid to the plausibility of alcohol being a teratogen. In 1968, an article in France by Lemoine and Lemoine provided the first description in the medical literature of the effects of alcohol on the fetus. Jones and Smith coined the term ‘fetal alcohol syndrome’ (FAS) in 1973, after recognizing a distinct dysmorphic syndrome associated with gestational alcoholism. The criteria for the diagnosis of FAS is based on the presence of the following: • evidence of excessive maternal drinking during pregnancy; • characteristic facial dysmorphology (ie, microcephaly, poorly developed philtrum, thin upper lip and flattened maxillary area); • pre- and/or postnatal growth retardation (weight, length and/or height below the 10th percentile); and • central nervous system (CNS) damage (signs of neurological abnormality, developmental delay, intellectual impairment or neurobehavioural anomalies). However, very few alcohol-exposed children present with the full- blown syndrome, especially with all the facial features listed for FAS. Moreover, of the dysmorphic characteristics listed, most are not ‘disfiguring’, and in fact, many lead to appealing or attractive- looking faces. Further, these facial features often tend to fade with age and may become undetectable in adolescence, whereas the associated CNS damage is life-long and debilitating. Full-blown FAS encompasses a relatively small proportion of children prenatally affected by alcohol. It is estimated that only 10% to 40% of the offspring of alcohol-abusing women meet the criteria necessary for a diagnosis of FAS. As a consequence, the term ‘alcohol-related neurodevelopmental disorder’ (ARND) is used to describe the large number of children affected by prenatal alcohol exposure who do not fit all of the criteria for a diagnosis of full-blown FAS. The combined incidence of fetal alcohol-related abnormalities has been estimated to be about 0.91% in the general population and up to 10% to 20% of the population in some Native communities in which drinking in pregnancy is a common lifestyle activity. A slightly more conservative estimate of one to three children in a general obstetric population of 1000 was reported by Korkman et al for European communities. The incidence of FAS appears to vary both within and between countries, and was reported to be more than 20 times higher in the United States than in other countries. Diagnosing ARND In 1996, the National Institute of Medicine, Washington, District of Columbia, formally established the diagnostic criteria for ARND. These criteria include a history of prenatal alcohol exposure in conjunction with the following. • There is evidence of CNS neurodevelopmental abnormalities, including any of the following: – decreased cranial size at birth; – structural brain abnormalities (ie, microcephaly, partial or complete agenesis of the corpus callosum, cerebellar hypoplasia); and – neurological hard or soft signs such as impaired fine motor skills, neurosensory hearing loss, poor tandem gait and poor eye-hand coordination. • There is evidence of a complex pattern of behaviour or of cognitive abnormalities that are inconsistent with the child’ s developmental level, and they cannot be explained by familial background or by the environment alone. These factors include the following: – learning difficulties and deficits in school performance; – poor impulse control; – problems in social perception; – deficits in higher level receptive and expressive language; – poor capacity for abstraction or metacognition; – specific deficits in mathematical skills; and – problems in memory |
| Static Encephalopathy, as defined by Easter Seals: "Permanent or unchanging brain damage. The effects on development depend on the part of the brain involved and on the severity of the damage. Developmental problems may include any of a range of disabilities such as cerebral palsy, learning disabilities, mental retardation, autism, PDD, speech delays, attention deficits, hearing & vision impairments, oral motor problems, etc." The leading cause of developmental disabilities characterized by Static Encephalopathy is consumption of alcohol during pregnancy. Static Encephalopathy is present in persons diagnosed with Fetal Alcohol Syndrome (FAS) and Fetal Alcohol Effects (FAE). FAS and FAE are terms used to describe disabilities suffered by persons who were prenatally exposed to alcohol. Tens of thousands of children are born each year with FAS or FAE. According to the World Health Organization (WHO), FAS affects approximately one in every 500 children born in Australia, Europe and North America, regions for which data are available. Each day, ten babies in the U.S. alone are born with severe enough disabilities to warrant a diagnosis of FAS in infancy, necessitating specialized care and direct supervision throughout their entire lifetime. As many as one hundred babies are born each day in the U.S. alone who, because of prenatal exposure to alcohol, sustain a considerable amount of damage to interfere with their ability to succeed in life, causing difficulties with school, behavior, social interactions, and eventually employment and independence. When a developing baby is exposed to alcohol in the womb, any and all areas of the developing brain are at risk of sustaining damage. Static Encephalopathy may involve the frontal lobe, which affects judgment and impulse control, and the corpus callosum, the membrane between the left brain and right brain which affects the ability to process information. Some of the neurological characteristics of Static Encephalopathy in persons who were prenatally exposed to alcohol include: ~Easily distracted and disorganized ~Poor judgment ~Difficulty with abstract math and money management ~Difficulty remembering things (short term memory) ~Difficulty retrieving information from memory ~Emotional immaturity ~Inability to control impulses Static Encephalopathy is not always apparent and can be misdiagnosed or go entirely unrecognized by parents, teachers, and medical professionals. Persons with alcohol induced Static Encephalopathy are often not identified and may not receive intervention and needed support services. Without identification and intervention, these persons are at high risk of secondary disabilities such as: ~mental illness ~suspension or expulsion from school ~trouble with law enforcement ~victimization or perpetration of sexual abuse ~abuse of alcohol or other drugs ~difficulty achieving independent living ~difficulty maintaining employment ~early or unwanted pregnancy or paternity The primary factors in preventing the secondary disabilities associated with alcohol-induced Static Encephalopathy are: Early identification Early intervention and support services Stable home environment |
| The pictures below are from the American Academy of Family Physicians website, http://www.aafp.org, News and Publications. Characteristic facial features in a child with fetal alcohol spectrum disorders. Findings may include a smooth philtrum, thin upper lip, upturned nose, flat nasal bridge and midface, epicanthal folds, small palpebral fissures, and small head circumference. |
| Lip-Philtrum Guide. (A) The smoothness of the philtrum and the thinness of the upper lip are assessed individually on a scale of 1 to 5 (1 = unaffected, 5 = most severe). The patient must have a relaxed facial expression, because a smile can alter lip thinness and philtrum smoothness. Scores of 4 and 5, in addition to short palpebral fissures, correspond to fetal alcohol syndrome. (B) Guide for white patients. (C) Guide for black patients. |
| Characteristic features of an ear of a child with fetal alcohol spectrum disorders. Note the underdeveloped upper part of the ear parallel to the ear crease below ("railroad track" appearance). Characteristic features of a hand of a child with fetal alcohol spectrum disorders. Note the curved fifth finger (clinodactyly) and the upper palmar crease that widens and ends between the second and third fingers ("hockey stick" crease). |
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