AAP Recs on FASD Focus on Integrated Treatment

Troy Brown, RN

September 10, 2018

An updated clinical report from the American Academy of Pediatrics (AAP) provides guidance for pediatricians on managing children with fetal alcohol spectrum disorder (FASD) within the medical home after diagnosis and includes advice for transitioning older children to adult-oriented systems.

"The goal and scope of this clinical report is to support pediatric providers in managing patients after a diagnosis of an FASD. It emphasizes the lifelong effects of having an FASD and suggests strategies to support families who are interacting with early intervention services, the educational system, the behavioral and/or mental health system, other community resources, and the transition to adult-oriented heath care systems when appropriate," the authors explain.

Renee M. Turchi, MD, MPH, from St. Christopher's Hospital for Children and Drexel Dornsife School of Public Health, Philadelphia, Pennsylvania, and Vincent C. Smith, MD, MPH, from Beth Israel Deaconess Medical Center and Harvard Medical School, Harvard University, Boston, Massachusetts, published the report online today in Pediatrics, along with the Committee on Substance Use and Prevention and the Council on Children with Disabilities.

Pediatricians should know the epidemiology of FASDs, the authors say. Its prevalence is close to, if not higher than, that of more commonly known conditions, including autism spectrum disorder. Recent data show that rates of FASD are much higher than previously estimated, yet Turchi says FASD is underreported and underappreciated.

In addition, Turchi notes that although alcohol is legal, it is often more teratogenic to the developing brain than cocaine and some of the other substances of abuse.

The AAP has published several guidelines on FASD, most recently in July 2016, as terminology and diagnostic criteria have evolved. However, many pediatricians still feel ill-equipped to care for these children long-term. The clinical report aims to help clinicians understand the different classifications and diagnostic criteria for these disorders and what they mean for screening, care, and management.

FASD is an umbrella term with varying severities that fall along a spectrum. "Just like with autism, [in which] you see kids who are just socially quirky to kids who are nonverbal, FASD is very similar," Turchi told Medscape Medical News.

Universal Screening for Prenatal Alcohol Exposure Is Critical

Having a standardized approach to universal screening for prenatal alcohol exposure is key, Turchi said. Clinicians should screen all pediatric patients, "regardless of socioeconomic status, regardless of race, regardless of whether they're adopted," Turchi explained.

"You can screen at prenatal visits, you can screen at the newborn visit. Sometimes you might have to screen more than once. Even if you are seeing a new patient in your office and they're 6 years of age — let's say they've moved — you should still screen," she added.

Clinicians should monitor children with prenatal alcohol exposure for physical, developmental, behavioral, and cognitive issues, including attention-deficit/hyperactivity disorder and depression, using "evidence-based screening tools, medication management, and behavioral interventions, often in collaboration with neurobehavioral professionals," the authors write.

Likewise, pediatricians should screen for FASD in children already diagnosed with attention-deficit/hyperactivity disorder, oppositional defiant disorder, and those with other cognitive and behavioral concerns, referring when necessary.

It is also important for pediatricians to be aware of reporting laws and mandates in their practicing states and/or territories with respect to exposures and child outcomes, the AAP says. "Under the federal Child Abuse Prevention and Treatment Act (CAPTA), health care providers are mandated reporters. CAPTA does not require clinicians to report to child protective services if a child has been exposed prenatally to alcohol (ie, for a positive [prenatal alcohol exposure] screening result)," the authors write. "Referral to child protective services is required if the child has been diagnosed with an FASD in the period between birth and 3 years. The intent of this referral is to develop safe care and possible treatment plans for the infant and caregiver if needed, not to initiate punitive actions."

Diagnosis Is Only the Beginning

For most families, a diagnosis of FASD is only the beginning. After a child is diagnosed, they and their family "need help with school, they need help with specialists, they need help with therapy, and so the role of that medical home, the primary care office where you're coordinating care and you're doing things in that space between the medical visits, has become so integral," Turchi explained.

She said the clinical report highlights the role of resources and of supporting families and helping them set goals for the child. Engaging families, "hearing from them and having them be partners in care," is very important, she said.

Engaging youth and linking them with other youth can also be an important source of support for young people with FASD. Adults with FASD may have more difficulty navigating their daily lives and are more likely to have legal problems, including incarceration, when compared with typically developing individuals.

"Family-centered care in a patient-centered medical home model may greatly improve transition experiences for a youth with an FASD. Youth with special health care needs obtaining care within a medical home are more likely to receive transition services than those who do not receive care through a medical home," the authors write.

Finally, clinicians who care for children and women of childbearing age should emphasize that no amount of alcohol consumption during pregnancy is acceptable.

The authors have disclosed no relevant financial relationships.

Pediatrics. Published online September 10, 2018. Abstract

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