The Maternal Drinking History Guide Presented by Moumita Sarkar, PhD Alcohol and Substance Use...
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Transcript of The Maternal Drinking History Guide Presented by Moumita Sarkar, PhD Alcohol and Substance Use...
The Maternal Drinking History Guide
The Maternal Drinking History Guide
Presented by Moumita Sarkar, PhDAlcohol and Substance Use Helpline
The Motherisk Program, Hospital for Sick Children
Presented by Moumita Sarkar, PhDAlcohol and Substance Use Helpline
The Motherisk Program, Hospital for Sick Children
Based on a consensus report developed by the FASD Advisory Workgroup in collaboration with SOGC and PHAC
Infant born at 35 weeks of gestation with severe IUGR and APGAR score of 5
Poor tonus, poor suckling
Infant born at 35 weeks of gestation with severe IUGR and APGAR score of 5
Poor tonus, poor suckling
Case #1Case #1
Case #1 cont….Case #1 cont…. Medical history does not reflect any maternal
exposure related to baby’s symptoms
Patient denies the use of alcohol and substances
Meconium test for Fatty Acid Ethyl Ester (combination of alcohol and fatty acids): 52nM/g (N=<2)
Mother is a problem drinker, unknown to the GP or gynecologist
Medical history does not reflect any maternal exposure related to baby’s symptoms
Patient denies the use of alcohol and substances
Meconium test for Fatty Acid Ethyl Ester (combination of alcohol and fatty acids): 52nM/g (N=<2)
Mother is a problem drinker, unknown to the GP or gynecologist
Alcohol and PregnancyAlcohol and Pregnancy
9-12% of women reported drinking throughout their pregnancies (Health Canada 2000)
1.4% of pregnant women reported binge drinking (CDC 2011)
Health care providers do not systematically screen all pregnant women on their consumption of alcohol 19% of women reported not being ask about their
alcohol use (Chang, 2011)
25% of pregnant women were not asked
9-12% of women reported drinking throughout their pregnancies (Health Canada 2000)
1.4% of pregnant women reported binge drinking (CDC 2011)
Health care providers do not systematically screen all pregnant women on their consumption of alcohol 19% of women reported not being ask about their
alcohol use (Chang, 2011)
25% of pregnant women were not asked
Prenatal Alcohol Use: widespread
Prenatal Alcohol Use: widespread
Problem drinking: refers to the amount of maternal drinking
associated with harm to the fetus Exceeds 3 drinks at one sitting or 7 drinks
per week (NIAAA, 2005)
Pregnant or planning: Any amount of drinking is risky for women
who are pregnant or trying to become pregnant (USDHHS, 2005)
Problem drinking: refers to the amount of maternal drinking
associated with harm to the fetus Exceeds 3 drinks at one sitting or 7 drinks
per week (NIAAA, 2005)
Pregnant or planning: Any amount of drinking is risky for women
who are pregnant or trying to become pregnant (USDHHS, 2005)
Routine ScreeningRoutine Screening Ask all women of childbearing age about
alcohol/drug use (especially pregnant women)
Advise all women planning/pregnant that no alcohol is the safest choice; women who consumed alcohol during their pregnancy to contact Motherisk
Assist all women to stop drinking through information, counselling, care and referral to appropriate programs and services
SCREEN TO PREVENT FASD
Ask all women of childbearing age about alcohol/drug use (especially pregnant women)
Advise all women planning/pregnant that no alcohol is the safest choice; women who consumed alcohol during their pregnancy to contact Motherisk
Assist all women to stop drinking through information, counselling, care and referral to appropriate programs and services
SCREEN TO PREVENT FASD
The Maternal Drinking Guide: Purpose
The Maternal Drinking Guide: Purpose
Determine if the mother drinks /has drank at a problem drinking level in pregnancy.
A Positive screen on TWEAK Meets the NIAAA guidelines for problem drinker
Obtain accurate maternal alcohol use report Knowledge of prenatal alcohol use is essential for
1) subsequent FASD diagnosis in the future and 2) harm reduction strategies
Determine if the mother drinks /has drank at a problem drinking level in pregnancy.
A Positive screen on TWEAK Meets the NIAAA guidelines for problem drinker
Obtain accurate maternal alcohol use report Knowledge of prenatal alcohol use is essential for
1) subsequent FASD diagnosis in the future and 2) harm reduction strategies
BenefitsBenefits Validated methodology
as effective means of eliciting maternal alcohol use
Provides practitioner with options appropriate for different groups and circumstances
No training/ expertise required to screen
Integrate screening questions into standardized health questionnaires among innocuous questions related to lifestyle
Validated methodology as effective means of eliciting maternal alcohol use
Provides practitioner with options appropriate for different groups and circumstances
No training/ expertise required to screen
Integrate screening questions into standardized health questionnaires among innocuous questions related to lifestyle
When to ask? When to ask?
Key times to assess alcohol use: Initial visit (to any new provider) Annual gynecological visit Preconception visit Visits for confirmation of pregnancy Mid-pregnancy (24-28 weeks) Exit visit (32-36 weeks)
Key times to assess alcohol use: Initial visit (to any new provider) Annual gynecological visit Preconception visit Visits for confirmation of pregnancy Mid-pregnancy (24-28 weeks) Exit visit (32-36 weeks)
Case #1: IntroductionCase #1: Introduction
Explain that you will be asking a standard series of health questions that are directed to all patients in order to improve health Intro #1: “I want to ask you a series of questions
today about your lifestyle. I ask all my patients these questions because it helps me to get to know you better and provide better care.”
Explain that you will be asking a standard series of health questions that are directed to all patients in order to improve health Intro #1: “I want to ask you a series of questions
today about your lifestyle. I ask all my patients these questions because it helps me to get to know you better and provide better care.”
Level I: Practice-basedLevel I: Practice-based When did you find out/suspect you were pregnant?
Single-question method of screening Embed at least one question to identify prenatal alcohol use among
other innocuous questions related to lifestyle
e.g. Do you take any prenatal vitamins? Do you smoke any cigarettes? If so, how many? Do you ever enjoy a drink or two? When was the last time? Do you sometimes drink beer, wine or other alcoholic beverages? In the past month or so, have you enjoyed a drink or two?
What about taking medications? Did you exercise?
When did you find out/suspect you were pregnant?
Single-question method of screening Embed at least one question to identify prenatal alcohol use among
other innocuous questions related to lifestyle
e.g. Do you take any prenatal vitamins? Do you smoke any cigarettes? If so, how many? Do you ever enjoy a drink or two? When was the last time? Do you sometimes drink beer, wine or other alcoholic beverages? In the past month or so, have you enjoyed a drink or two?
What about taking medications? Did you exercise?
Case #1: Brief questionnairesCase #1: Brief questionnaires
Most effective method of screening (Stratton, 1996) Quick, practical, efficient and cost effective
Direct questioning Timeline Follow Back Tool (TLFB)
Indirect/masked screening Overcome issues of possible underreporting T-ACE, TWEAK Developed and validated for use among pregnant women TWEAK - Optimal for racially diverse groups, highly sensitive
test
Most effective method of screening (Stratton, 1996) Quick, practical, efficient and cost effective
Direct questioning Timeline Follow Back Tool (TLFB)
Indirect/masked screening Overcome issues of possible underreporting T-ACE, TWEAK Developed and validated for use among pregnant women TWEAK - Optimal for racially diverse groups, highly sensitive
test
TWEAKTWEAKTWEAK QUESTIONS POINTS
Tolerance How many drinks does it take to make you feel the first effect (before pregnancy)? _________ (3 or more = 2 points)
Worry Have close friends worried or complained about your drinking in the past year? (yes = 2 points)
Eye-opener
Do you sometimes take a drink in the morning when you first get up? (yes = 1 point)
Amnesia Has a friend or family member ever told you about things you said or did while you were drinking that you could not remember? (yes = 1 point)
Cut down Do you sometimes feel the need to cut down on your drinking? (yes = 1 point)
Russell M. New assessment tools for risk drinking during pregnancy: T-ACE, TWEAK and Others. Alcohol Health and Research World (1994) 18 (1): 55-61
Case #1: Level III Screening (with consent)
Case #1: Level III Screening (with consent)
Postpartum case (index of suspicion but deny use) If Level I and/or level II (TWEAK) screening is
not successful Level III screening (with consent)
Why is this knowledge valuable?
Postpartum case (index of suspicion but deny use) If Level I and/or level II (TWEAK) screening is
not successful Level III screening (with consent)
Why is this knowledge valuable?
FASD assessment referralFASD assessment referral
Referral by a doctor required
Assessment involves physical, neurological, psychiatric, genetic examination
Confirmation of prenatal alcohol exposure required
Referral by a doctor required
Assessment involves physical, neurological, psychiatric, genetic examination
Confirmation of prenatal alcohol exposure required
Screening and Intervention
What can be done?
Early Dx = Early Intervention• Early diagnosis - evidence based• Stimulation in early ages - important• Parenting support materials
Introductory statement (refer to section II b): “I will begin by asking a standard series of health questions I ask all my patients in order to improve your health and the health of your child” Practice based questions (refer to section II c): General “Do you ever enjoy a drink or two?”
“Do you sometimes drink beer, wine or other alcoholic beverages?”
“Do you ever use alcohol?”
“In the past month or two have you ever enjoyed a drink or two?”
“Do you have any concerns about your drinking?”
“In a typical week, how many occasions did you usually have something to
drink?”
To assess problem drinking behaviour Apply TWEAK test (refer to section III)
Follow- up at every subsequent visit
Brief intervention Advise and Refer
Problem Drinker
If TWEAK is 2 or more
Brief intervention (harm reduction)
Advise and Refer
If response is negative (i.e. no alcohol/drugs): Educate / advise on effects of prenatal alcohol/ drug use
Follow- up at every subsequent visit
Advise
Laboratory Analysis (refer to section III c) (e.g. Hair FAEE) in relevant cases, with FULL INFORMED CONSENT
LEVEL TWO
LEVEL THREE
Not a Problem Drinker If TWEAK is less than 2 AND/ OR response is 0 times in a week or in a sitting
Advise
LEVEL ONE
Case #2Case #2
BJ has been your patient for a year. She is very private and can be both defensive and combative by nature
She has a 5 yr old child with both developmental and behavioural issues
She is now pregnant and has previously never been asked about her alcohol use
During her prenatal screening, her provider asks:
“I’m sure you know alcohol and pregnancy don’t go well together. You don’t drink, do you?” She responds: “No”
Few weeks later, her partner mentions his concern for her continued drinking
BJ has been your patient for a year. She is very private and can be both defensive and combative by nature
She has a 5 yr old child with both developmental and behavioural issues
She is now pregnant and has previously never been asked about her alcohol use
During her prenatal screening, her provider asks:
“I’m sure you know alcohol and pregnancy don’t go well together. You don’t drink, do you?” She responds: “No”
Few weeks later, her partner mentions his concern for her continued drinking
Case #2: IntroductionCase #2: Introduction
Explain that you will be asking a standard series of health questions that are directed to all patients in order to improve health Intro example: “I want to ask you a series of
questions today about your lifestyle. I ask all my patients these questions because it helps me to get to know you better and provide better care of your pregnancy.”
Explain that you will be asking a standard series of health questions that are directed to all patients in order to improve health Intro example: “I want to ask you a series of
questions today about your lifestyle. I ask all my patients these questions because it helps me to get to know you better and provide better care of your pregnancy.”
Level I: Practice-basedLevel I: Practice-based
Begin Innocuous questions: When did you find out/suspect you were pregnant?
Single-question method of screeninge.g. Do you take any prenatal vitamins? Do you smoke any cigarettes? How is your diet? Do you ever enjoy a drink or two? When was the last time? Do you sometimes drink beer, wine or other alcoholic
beverages? In the past month or so, have you enjoyed a drink or two?
What about taking medications? Did you exercise?
Begin Innocuous questions: When did you find out/suspect you were pregnant?
Single-question method of screeninge.g. Do you take any prenatal vitamins? Do you smoke any cigarettes? How is your diet? Do you ever enjoy a drink or two? When was the last time? Do you sometimes drink beer, wine or other alcoholic
beverages? In the past month or so, have you enjoyed a drink or two?
What about taking medications? Did you exercise?
Case #2Case #2
BJ has been your patient for a year. She is very private and can be both defensive and combative by nature
She has a 5 yr old child with both developmental and behavioural issues
She is now pregnant and has previously never been asked about her alcohol use
During her prenatal screening, her provider asks:
“I’m sure you know alcohol and pregnancy don’t go well together. You don’t drink, do you?” She responds: “No”
Few weeks later, her partner mentions his concern for her continued drinking
BJ has been your patient for a year. She is very private and can be both defensive and combative by nature
She has a 5 yr old child with both developmental and behavioural issues
She is now pregnant and has previously never been asked about her alcohol use
During her prenatal screening, her provider asks:
“I’m sure you know alcohol and pregnancy don’t go well together. You don’t drink, do you?” She responds: “No”
Few weeks later, her partner mentions his concern for her continued drinking
Avoid questions that suggest that you want a negative response:
Negative: You don’t drink, do you? Positive: Many women wind down the day with a glass of wine
or a few drinks on a night out…..do you sometimes enjoy a drink or two?”
Avoid many closed or dead-ended questions: Negative: Do you drink since you found out? Yes or No How has your alcohol consumption evolved since finding out your
pregnancy?
a) I continue my usual habit b) I have cut down c) I am trying to abstain but find it difficult
Avoid questions that suggest that you want a negative response:
Negative: You don’t drink, do you? Positive: Many women wind down the day with a glass of wine
or a few drinks on a night out…..do you sometimes enjoy a drink or two?”
Avoid many closed or dead-ended questions: Negative: Do you drink since you found out? Yes or No How has your alcohol consumption evolved since finding out your
pregnancy?
a) I continue my usual habit b) I have cut down c) I am trying to abstain but find it difficult
Case #2: Motivational Interviewing TechniquesCase #2: Motivational
Interviewing Techniques
Case #2: Supportive DialogueCase #2: Supportive Dialogue
Supportive dialogue (Without any moral connotation & empathetic listening)
Can you tell me a bit about your drinking pattern before you knew you were pregnant?
Have you been able to stop or cut down since you found out?
Supportive dialogue (Without any moral connotation & empathetic listening)
Can you tell me a bit about your drinking pattern before you knew you were pregnant?
Have you been able to stop or cut down since you found out?
Case #2: Supportive DialogueCase #2: Supportive Dialogue
If alcohol problem suspected, but denied, Important to engage women to improve trust Use empathy
"it is recommended to abstain from alcohol during pregnancy, if you are having hard time stopping, or even if you drink occasionally, do not hesitate to discuss it with me"
If alcohol problem suspected, but denied, Important to engage women to improve trust Use empathy
"it is recommended to abstain from alcohol during pregnancy, if you are having hard time stopping, or even if you drink occasionally, do not hesitate to discuss it with me"
Advise/ FeedbackAdvise/ Feedback
If screen positive as problem drinker, or report continued prenatal alcohol use, begin the process by:
Here is some information that has been learned through research; I’d like to share it with you, if I may.
What is your understanding about alcohol use in pregnancy? Do you have any questions about your alcohol use?
Provide feedback that allows clients to compare their behavior to others so they know how their behavior relates to national norms
“Many women drink on a regular basis, and since half of all pregnancies are unplanned, many women are exposed to alcohol prior to pregnancy knowledge.”
Do you mind if we spend a few minutes talking about…..? Are you interested in learning more about……..?
If screen positive as problem drinker, or report continued prenatal alcohol use, begin the process by:
Here is some information that has been learned through research; I’d like to share it with you, if I may.
What is your understanding about alcohol use in pregnancy? Do you have any questions about your alcohol use?
Provide feedback that allows clients to compare their behavior to others so they know how their behavior relates to national norms
“Many women drink on a regular basis, and since half of all pregnancies are unplanned, many women are exposed to alcohol prior to pregnancy knowledge.”
Do you mind if we spend a few minutes talking about…..? Are you interested in learning more about……..?
Introductory statement (refer to section II b): “I will begin by asking a standard series of health questions I ask all my patients in order to improve your health and the health of your child” Practice based questions (refer to section II c): Pregnant women: “Can you tell me a bit about your drinking patterns before you knew you were pregnant?”
“Do you sometimes drink beer, wine or other alcoholic beverages?”
“Do you ever use alcohol?”
“In the past month or two have you ever enjoyed a drink or two?”
“Do you have any concerns about your drinking?”
“In a typical week, how many occasions did you usually have something to
drink?”
To assess problem drinking behaviour - 3 options: In the past, how many times have you had more
than 7 drinks in a week? In the past, how many times have you had more
than 3 drinks at one sitting? OR Apply TWEAK test (refer to section III)
Follow- up at every subsequent visit Level 1 questions re alcohol (IIIb)
Brief intervention Advise and Refer
Problem Drinker
If TWEAK is 2 or more
Brief intervention (harm reduction) Advise and Refer
If response is negative (i.e. no alcohol/drugs): Educate / advise on effects of prenatal alcohol/ drug use
Follow- up at every subsequent visit Level 1 questions re alcohol/drugs
Advise
N/A
LEVEL TWO
LEVEL THREE
Not a Problem Drinker
If TWEAK is less than 2
Educate / advise on effects of prenatal alcohol/ drug use
LEVEL ONE
Recommendations: ScreeningRecommendations: Screening During regular health exams, health care
providers should use standardized questions that should include at least Level I screening Early identification and reduction of maternal drinking No known safe limit for alcohol use in pregnancy
Level II should be adopted as standard screening process to identify alcohol use in all women of childbearing age and pregnant women
Upon screening, women need to be linked to services if required by their providers
During regular health exams, health care providers should use standardized questions that should include at least Level I screening Early identification and reduction of maternal drinking No known safe limit for alcohol use in pregnancy
Level II should be adopted as standard screening process to identify alcohol use in all women of childbearing age and pregnant women
Upon screening, women need to be linked to services if required by their providers
Health care provider role in harm reduction is vital advise patients that the safest choice is not to
consume alcohol during pregnancy Adequate resources should be made available to
women requiring interventions beyond primary interaction
Recording of maternal alcohol use in newborn’s birth record and child’s health record
Early identification and subsequently early FASD Dx = intervention can occur
Health care provider role in harm reduction is vital advise patients that the safest choice is not to
consume alcohol during pregnancy Adequate resources should be made available to
women requiring interventions beyond primary interaction
Recording of maternal alcohol use in newborn’s birth record and child’s health record
Early identification and subsequently early FASD Dx = intervention can occur
Take Home MessageTake Home Message
FASD programs/resourcesFASD programs/resourcesBest Start (www.beststart.org)Provides online training tools for screening alcohol
Motherisk Alcohol and Substance Abuse Helpline (www.motherisk.org) National toll-free helpline 1 877 FAS-INFO providing evidence-based info and referrals on alcohol/drugs
Canadian Centre on Substance Abuse (www.ccsa.ca)
PRIMA (www.addictionpregnancy.ca)
Alberta Health Services (www.albertahealthservices.ca)
Healthy Choices in Pregnancy in BC (www.hcip-bc.org)
Best Start (www.beststart.org)Provides online training tools for screening alcohol
Motherisk Alcohol and Substance Abuse Helpline (www.motherisk.org) National toll-free helpline 1 877 FAS-INFO providing evidence-based info and referrals on alcohol/drugs
Canadian Centre on Substance Abuse (www.ccsa.ca)
PRIMA (www.addictionpregnancy.ca)
Alberta Health Services (www.albertahealthservices.ca)
Healthy Choices in Pregnancy in BC (www.hcip-bc.org)
AcknowledgmentsAcknowledgments Dr. Gideon Koren
Motherisk Alcohol and Substance Use Helpline Counselors
The National Taskforce for FASD Screening
Canadian Association for Paediatric Health Science Centre
Public Health Agency of Canada
Dr. Gideon Koren
Motherisk Alcohol and Substance Use Helpline Counselors
The National Taskforce for FASD Screening
Canadian Association for Paediatric Health Science Centre
Public Health Agency of Canada