Competency I :Competency I : History History

and and

Foundations in Foundations in FASFAS

@NORTHEAST REGIONAL FAS EDUCATION AND TRAINING CENTER. 2006

““Those who cannot Those who cannot learn from history are learn from history are doomed to repeat it”doomed to repeat it”

- - George George SantayanaSantayana

Alcohol is the oldest recorded and most widely used Alcohol is the oldest recorded and most widely used drug in the world.drug in the world.

Alcohol use in pregnancy has been considered a risk Alcohol use in pregnancy has been considered a risk since at least 300 B.C.since at least 300 B.C.

A wedding ritual forbade drinking of wine by the bridal couple so that a defective child would not be conceived (Ancient Carthage)

Behold, thou shall conceive and bear a

son: and now drink no wine or strong drink

Judges 13:4

Alcohol should be barred “to any man or woman who was intending to create children. Children should not be made in bodies saturated with drunkenness”. (Plato)

““Parental drinking is a cause of weak, feeble, and distempered children” (College of Physicians to the British Parliament 1726)

The Gin epidemic of 1720-1750 raised concerns that The Gin epidemic of 1720-1750 raised concerns that maternal alcohol consumption produce weak and ill-maternal alcohol consumption produce weak and ill-tempered children.tempered children.

Gin Lane - Hogarth

First scientific study on fetal effects: Sullivan in 1899 who found women who drank had a 56% increase in stillbirths and infant death 2 ½ times higher than those did not drink.

In 1942, after prohibition, a paper was published with the erroneous information that the fetus was protected in the womb.

In late 1960s, Dr. C Ulleland noted failure to thrive in infants whose mothers consumed alcohol, during pregnancy, in spite of healthy post natal environment.

Modern concept of FAS was first identified in 1968 by the French (Lemoine et al).

The term FAS was coined by Smith and Jones in the U.S. in 1973 to describe a constellation of characteristics noted in children examined by Dr. Ulleland.

In 1989, “The Broken Cord,” by Michael Dorris is published, a personal account by an adoptive father, was published.

In 2000, Linda Belle LaFever wrote a first hand account of her child with FAS and her struggle with alcoholism in “ Cheers! Here’s To The Baby”

EpidemiologyEpidemiology

Alcohol problems are increasing in adolescent girls and older women. 17.7% of women age 12-17 yrs used alcohol in the last month; 10.6% of them binged (FASD Center of Excellence,2004)

Women have a greater mortality rate and greater sensitivity to effects of alcohol than men.

Up to 80% of women with a substance abuse problem also have some form of psychiatric co-morbidity.

From 1991-1995, CDC reported a 4-fold increase in frequent(7+ drinks per week) and binge(5+ on one occasion) drinking during pregnancy.

9-12% of pregnant women in US report consuming alcohol and 3% report drinking at levels that have consistently been associated with adverse effects on the fetus CDC. 2005).

More than half of all women of childbearing age (18-44) report alcohol use; 1 in 8 report binge drinking within the last month.

Birth defects due to prenatal alcohol use can

occur in the first 3-8 weeks of pregnancy,

before most women know they are pregnant.

Animal Models and Prenatal Alcohol

Many studies cannot be done on humans

Confounding factors can rarely be controlled in human studies

Alcohol is rarely the only drug used

Many abnormalities occur at low rates

Epidemiological studies are time consuming and expensive

Animal Models – The Comparability of Effects

Growth retardationGrowth retardationFacial characteristics Facial characteristics Heart, skeletal defectsHeart, skeletal defectsMicrocephalyMicrocephalyReductions in basal Reductions in basal

ganglia and cerebellar ganglia and cerebellar volumesvolumes

Corpus callosum Corpus callosum anomaliesanomalies

Hyperactivity, attentional Hyperactivity, attentional problemsproblems

Inhibitory deficitsInhibitory deficitsImpaired learningImpaired learningPerseveration errorsPerseveration errorsFeeding difficultiesFeeding difficultiesGait anomaliesGait anomaliesHearing anomaliesHearing anomalies

Effects of Prenatal Exposure to Alcohol in Animals and

Humans

A defining feature of FAS is altered facial characteristics.A defining feature of FAS is altered facial characteristics.

These characteristics include a shortened eye openings and an altered These characteristics include a shortened eye openings and an altered upper lip.upper lip.

These features can be demonstrated across a wide range of species.These features can be demonstrated across a wide range of species.

The mouse pups above were exposed to alcohol on prenatal day 7, and The mouse pups above were exposed to alcohol on prenatal day 7, and thus a single exposure at a critical period is sufficient to produce FAS. thus a single exposure at a critical period is sufficient to produce FAS.

In one study, of 72 mouse pups tested:

• 2 did not develop brains

• 30 presented with eye and oral malformations

• Several pups were not affected

• Regular use of alcohol was not necessary to alter brain development

Animal Models of FAS

Mice are not the only animals Mice are not the only animals affected by prenatal exposure to affected by prenatal exposure to alcohol: Note the substantial alcohol: Note the substantial growth deficits observed in beagle growth deficits observed in beagle pups and chicks. Overall facial pups and chicks. Overall facial features, head circumference, and features, head circumference, and size were smaller for alcohol-size were smaller for alcohol-exposed animals.exposed animals.

For the chicks, note malformations For the chicks, note malformations in the eyes and limbs.in the eyes and limbs.

Genetics May Be Involved in FAS

Identical twins are derived from a single egg, whereas fraternal twins are derived from two eggs. Thus, identical twins are more similar genetically.The child on the left is considerably more affected than his fraternal twin.Identical twins are more likely than fraternal twins to demonstrate similar FAS effects, suggesting a potential role for genetics in the expression of FAS.

The fraternal twins pictured to the left are 17 months old.

Collaborative Initiative on Fetal Alcohol Spectrum Disorders (NIAAA)

FAS is the leading preventable cause of MR and DDs FAS is the leading preventable cause of MR and DDs

U.S.: 0.5-2/ 1000 Floyd, 2006

S. Africa: 65.2-74.2/ 1000 Viljoen, 9/2005 Italy: 3.7-7.4/ 1000 May, 9/2006 Sweden: 1-5/ 1000 Sampson, 1997

Russia: Phenotypic survey- 13% strong, 45% intermediate Miller, 2006 Finland: Dysmorphology in older Autti-Ramo, 2006

children

Challenges in determining accurate prevalence:

No uniform, widely accepted diagnostic criteria (IOM, CDC, Seattle)

FAS diagnosis is based on clinical examination of features, but not all children with FAS look or act the same

Lack of knowledge and misconceptions among primary care providers.

Incidence Rates

An individual with FAS can incur a lifetime health cost of over $800,000 - $1.2 mil.

In 1998, the annual cost of FAS in the United States was estimated at $2.8 billion. In 2003, the estimated cost was $5.4 billion; direct costs were $3.9 billion and indirect costs were another $1.5 billion.

FAS and related conditions are estimated to cost between $75 million and $9.7 billion annually in the United States.

What is FAS?

Fetal Alcohol Syndrome (FAS) is a life long birth defect caused

by maternal consumption of alcohol during pregnancy.

FAS Diagnostic CriteriaGrowth RestrictionGrowth Restriction:: Babies are born Babies are born smaller than anticipated for the gestational age at smaller than anticipated for the gestational age at birth, and usually remain so throughout life.birth, and usually remain so throughout life.

Central Nervous SystemCentral Nervous System:: Any or all Any or all of the following conditions may be present- mental of the following conditions may be present- mental retardation, developmental delays, short attention retardation, developmental delays, short attention span, impulsivity, perceptual problems, hyperactivity, span, impulsivity, perceptual problems, hyperactivity, poor coordination & learning disabilities. poor coordination & learning disabilities.

Facial AnomaliesFacial Anomalies: : Babies have the Babies have the following distinctive facial features-small widely following distinctive facial features-small widely spaced eyes; a short, upturned nose; a smooth spaced eyes; a short, upturned nose; a smooth philtrum (no notch between the nose and lips); philtrum (no notch between the nose and lips); abnormally thin upper lip; & small flat cheeks. abnormally thin upper lip; & small flat cheeks.

FAS – Only the tip of the Iceberg

Fetal Alcohol Spectrum Disorders ( FASD) refers to the broad spectrum of disorders caused by prenatal exposure to alcohol including:

FAS (Fetal Alcohol Syndrome) FAE (Fetal Alcohol Effects) ARND (Alcohol Related

Neuro-developmental Disorders)

ARBD (Alcohol Related Birth Defects)

FASDFASD

Fetal Alcohol Spectrum Disorders is anFetal Alcohol Spectrum Disorders is an

umbrella term describing the range of effects that can umbrella term describing the range of effects that can occur in an individual whose mother drank during occur in an individual whose mother drank during pregnancy. These effects may include physical, mental, pregnancy. These effects may include physical, mental, behavioral, and /or learning disabilities with possible behavioral, and /or learning disabilities with possible lifelong implications. The term FASD is not intended lifelong implications. The term FASD is not intended for use as a clinical diagnosisfor use as a clinical diagnosis..

CDC July CDC July 20042004

FAS

FASD

FAEARND

ARBDPartial FAS

POLICY STATEMENTSPOLICY STATEMENTS

Since 1966, AMA and APA have recognized alcoholism Since 1966, AMA and APA have recognized alcoholism as diseaseas disease

AMA, AAP, ACOG, CDC, NIAAA, March of Dimes, AMA, AAP, ACOG, CDC, NIAAA, March of Dimes, and NOFAS all have policies regarding drinking during and NOFAS all have policies regarding drinking during pregnancypregnancy

AMA urges physicians to be alert to possible alcohol AMA urges physicians to be alert to possible alcohol related problems in women and to screen all patients for related problems in women and to screen all patients for possible alcohol abuse and dependence.possible alcohol abuse and dependence.

Be good to me...                Stay alcohol free!

                                                               A few drinks canLast forever  

No safe time. No safe amount. No safe alcohol. Period…. NIAAA/NOFAS