No Amount of Alcohol Safe During Pregnancy, AAP Reiterates

Troy Brown, RN

October 19, 2015

A new clinical report on fetal alcohol spectrum disorders (FASDs) from the American Academy of Pediatrics (AAP) reiterates that no amount of alcohol consumption is safe during any trimester of pregnancy.

Prenatal alcohol exposure is the top preventable cause of birth defects and intellectual and neurodevelopmental disabilities in children, according to Janet F. Williams, MD, from the University of Texas Health Science Center at the San Antonio School of Medicine and the AAP's Committee on Substance Abuse. The report was published online October 19 in Pediatrics.

"Earlier termination of alcohol use in pregnancy is associated with fewer alcohol-related complications for the mother and her baby," the authors write. "Specifically, first trimester drinking (vs no drinking) produces 12 times the odds of giving birth to a child with FASD, first and second trimester drinking increases FASD odds 61 times, and drinking in all trimesters increases FASD odds 65 times."

Despite these risks, a recent study from the US Centers for Disease Control and Prevention found that one in 10 women drink alcohol during pregnancy.

Evolving Terminology

The new report is not the first the AAP has published on the subject of alcohol and pregnancy, but the terminology used to describe FASDs is evolving as researchers learn more about the wide range of effects that result from prenatal alcohol exposure.

"[FASD] is an overarching phrase that encompasses a range of possible diagnoses, including fetal alcohol syndrome (FAS), partial fetal alcohol syndrome, alcohol-related birth defects (ARBD), alcohol-related neurodevelopmental disorder (ARND), and neurobehavioral disorder associated with prenatal alcohol exposure (ND-PAE)," the authors explain.

"[R]esearch evidence suggests that ARBD may be declining in use while ARND/ND-PAE terminology remains incompletely defined," they add. "ND-PAE may become the accepted diagnostic term for moderate PAE findings, and 'static encephalopathy' associated with PAE is a suggested diagnostic term for severe PAE effects."

FAS is a clinical diagnosis that is made on the basis of a specific combination of prenatal and/or postnatal growth deficiency, as well as the three "cardinal facial features" (reduced palpebral fissure length, smooth philtrum, and thin upper vermillion lip border), and any of the known structural, neurologic, and/or functional central nervous system deficits.

What to Look For

Neurocognitive and behavioral deficits from PAE last a lifetime, but early recognition, diagnosis, and therapy for any of the FASDs can help.

Unfortunately, a lack of uniformly accepted diagnostic criteria for fetal alcohol-related disorders has critically limited efforts that could lessen the effect of FASDs, Dr Williams explained in an AAP news release. "Even though [FASDs] are the most commonly identifiable causes of developmental delays and intellectual disabilities, they remain significantly under-recognized."

The primary role of a pediatrician and the medical home with respect to FASD is to learn as much as possible about the disorder to be able to counsel patients on prevention, to know when and how to screen patients for FASD, and to manage and refer patients for specialized services.

"Medical home care relevant to FASD patients includes documenting a PAE and other substance exposure history and other historical details as well as physical examination findings, diagnosing FAS in patients when possible, and/or referring for comprehensive FASD assessment and diagnostic evaluation for intervention," the authors write.

Primary care providers should suspect FASD in children with "suggestive physical stigmata" and/or those who are being evaluated for poor growth, developmental delays, or behavioral issues. Children who have been adopted, especially those who come from poverty and those with child protective services involvement, may be more likely to have experienced PAE and need careful screening.

Children with any history of involvement with child protective services resulting from parental substance use, child neglect, abuse, or abandonment also have a high risk for FASD and require screening, as do children with any out-of-home or foster care placement.

The AAP offers an FASD toolkit that includes information about common diagnostic approaches, common features of children with an FASD, diagnostic tools, an algorithm for evaluation, a provider checklist, and guidelines for referral and diagnosis.

A list of frequently asked questions on FASDs for parents is also available online.

The authors have disclosed no relevant financial relationships.

Pediatrics. Published online October 19, 2015.

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