Fetal Alcohol Spectrum Disorders

The Basics

• What are Fetal Alcohol Spectrum Disorders?

  The term fetal alcohol spectrum disorders (FASDs) describe a collection of conditions that can occur in individuals whose mothers drank alcohol during pregnancy. The manifestations can include physical problems, problems with behavior and learning, or a combination of some or all of these problems.
  
  There are several defined types of FASDs:

  • Fetal Alcohol Syndrome (FAS): FAS is the most severe end of the FASD spectrum. In the most extreme situations fetal death results from drinking alcohol during pregnancy. People with FAS might have physical symptoms such as abnormal facial features and growth problems; central nervous system problems; problems with learning, memory, attention span, communication, vision, or hearing; or any combination of these problems. People with FAS often have a hard time in academic and social settings.
  • Alcohol-Related Neurodevelopmental Disorder: Individuals with ARND might have intellectual disabilities and problems with behavior and learning; as such they might do poorly in school and have difficulties with math, memory, attention, judgment, and impulse control.
  • Alcohol-Related Birth Defects: People with alcohol-related birth defects might have various physical problems such as issues with the heart, kidneys, skeleton, or hearing. They might also have a combination of these problems.
• How common are Fetal Alcohol Spectrum Disorders?

  Data is limited on the prevalence of FASDs due to several factors, including the diverse types of FASDs and underdiagnosis or misdiagnosis. Experts estimate that the full range of FASDs in the United States might represent 2% to 5% of the population.

• Is there any safe time to drink during pregnancy?

  There is no safe time during pregnancy for a mother to drink alcohol, as it can cause developmental problems throughout pregnancy. Drinking alcohol is dangerous even before a woman knows she is pregnant. While some FASD outcomes are more likely at different times during the pregnancy, brain development in particular occurs throughout gestation, and growth and central nervous system problems can occur from drinking alcohol at any time. However, it is never too late in the pregnancy to stop drinking; the sooner a mother stops drinking during pregnancy, the less likely that symptoms will manifest or be severe.

• Is there any safe amount of alcohol to drink during pregnancy?

  No amount of alcohol is currently deemed safe for pregnant women, and for this reason there is no threshold list for alcohol consumption during pregnancy. A dose response may be considered essential in establishing teratogenicity in animals, but is uncommonly demonstrated in sufficient data among humans. A threshold dose is the dosage below which the incidence of adverse effects is not statistically greater than that of controls. With most agents, a threshold dose for teratogenic effects has not been determined; however, they are usually well below levels required to cause toxicity in adults.
  
  Since prenatal alcohol use has been proven to affect the developing fetus through a variety of mechanisms into the endocrine, nervous, circulatory, musculoskeletal, and gastrointestinal systems, it is not possible to determine the amount and timing of alcohol use that would be considered absolutely safe during a pregnancy.

• Is there any safe type of alcohol to drink during pregnancy?

  All types of alcohol are equally harmful during pregnancy, including all wines and beer. When a pregnant woman consumes alcohol of any kind, so does the developing baby.

• What is binge drinking?

  The National Institute on Alcohol Abuse and Alcoholism defines binge drinking as a pattern of drinking that brings a person’s blood alcohol concentration to 0.08 grams per cent or above. This typically happens when women drink over three drinks within a two hour period. Most people who binge drink are not alcohol dependent.

  Although many women protest that binge drinking a couple of times a year does not indicate they are an at-risk drinker, it is important for them to understand that, when they are intoxicated or recovering from drinking, they are as vulnerable to suffering from adverse consequences as habitual at-risk drinkers.

  Binge drinking is associated with many health problems, including:

  • Unintentional injuries (e.g., car crashes, falls, burns, drowning)
  • Intentional injuries (e.g., firearm injuries, sexual assault, domestic violence)
  • Alcohol poisoning
  • Sexually transmitted diseases
  • Unintended pregnancy
  • Children born with FASDs
  • High blood pressure, stroke, and other cardiovascular diseases
  • Poor control of diabetes

  Binge drinking is also associated with social and legal problems, including:

  • Poor job performance
  • Property destruction
  • Lack of appropriate parental response
  • Interpersonal relational breakdown and violence
  • Public disturbance
• What is at-risk drinking?

  The National Institute on Alcohol Abuse and Alcoholism defines at-risk alcohol use for healthy women as more than three drinks per occasion or more than seven drinks per week, and any amount of drinking for women who are pregnant or attempting to become pregnant.

• What is moderate drinking?

  The 2015 Dietary Guidelines for Americans defines moderate drinking for women as up to one drink per day or a blood alcohol level above 0.055 grams per cent. Even moderate drinking has health risks. Women who drink three to seven drinks per week are at greater risk for developing breast cancer than women who have fewer than three drinks per week.

  
  
• Why is at-risk drinking a problem for non-pregnant women?

  Depending on the level of drinking, the overall health of the woman, and her nutritional status, risk increases for the following medical problems:

  • Unintended pregnancy
  • Sexually transmitted diseases
  • Menstrual disorders
  • Altered fertility
  • Injuries
  • Seizures
  • Malnutrition and dietary disorders
  • Cardiomyopathies
  • Cancer of the breast, liver, rectum, mouth, throat, and esophagus.

  In addition, women who drink at risk are vulnerable to the following psychosocial problems:

  • Depression and suicide
  • Sexual assault and interpersonal violence
  • Loss of primary relationships
  • Loss of income
  • Loss of child custody
  • Driving under the influence
  • Altered judgment
• Why is at-risk drinking a problem for pregnant women?

  Even light alcohol use may affect a developing fetus throughout all stages of pregnancy. Prenatal alcohol consumption exposes the fetus FAS (See "What is FASD?").
  
  However, not all children exposed in utero to the same amount of alcohol will be similarly affected. The expression of alcohol effect on the fetus is dependent on:

  • Gestational timing
  • Genetic factors involving genes coding for alcohol metabolizing enzymes
  • Maternal age
  • Maternal nutrition and health status

  Many of the fetotoxic effects of ethanol can be attributed to the metabolite, acetaldehyde, a highly reactive substance that may bind to proteins, DNA and other cellular constituents. Ethanol metabolism also increases other metabolites with differing pharmacologic characteristics, tissue distribution, and time dependence on clearance. At present, biomarkers for embryotoxicity have not been determined.
  
  The effect of maternal alcohol consumption to the fetus often manifests itself later in the life of the child through specific deficits in learning ability and with behavioral issues resulting in legal problems. Learning difficulties include:

  • Inattentiveness and being easily distracted, which may be inconsistent from day to day
  • Overactivity or business
  • Math and visuospatial deficits
  • An uneven profile of cognitive skills
  • Difficulty completing tasks
  • Trouble with transitions
  • Poor organization and planning skills

  Youth who have been exposed to ethanol in utero have an enhanced risk of the following which can lead to issues such as:

  • Poor judgement
  • Impulsiveness
  • Poor social cognition
  • Vulnerability to being taken advantage of
  • Inability to anticipate consequences
  • An inability to alter behavior despite consequences

Intervention

• What is a brief intervention?

  Brief interventions involve a four step process of asking about alcohol use, expressing your concern and advising change, assisting in identification of changes she can make, and arranging a follow-up interaction to assess her progress. Clinical trials have demonstrated that brief interventions can promote significant, lasting reductions in drinking levels in at-risk drinkers who are not alcohol dependent.

  Ways to put this brief intervention into operation might be ... 

  • Acknowledgement that their drinking is at-risk level
  • Personalizing your concerned message on why alcohol use is a problem for reproductive health
  • Asking for feedback and assessing readiness to change
  • Having your patient set a goal for next visit and ask if she needs help in meeting her goal
  • Giving your patient some written information or a web resource
  • Setting your patient's next appointment within a short time frame
• What is motivational interviewing and how can I do this in a busy office?

  Motivational interviewing is a directive, client-centered counseling style for eliciting behavior change by helping clients explore and resolve ambivalence. Initially, it was used to motivate patients who abused alcohol to modify their drinking behaviors. The goal of motivational interviewing is to help patients identify and change behaviors that place them at risk of developing health problems or that may be preventing optimal management of a chronic condition and move through the stages of readiness for change in dealing with risky or unhealthy behavior. Recognizing the dynamics of an individual patient's readiness to change behavior is integral to this approach.

Education

• Where can I get information on alcohol education for women?

  The Patient Resources site contains patient education materials to accommodate the needs of individual patients. Another excellent free resource is the National Institute on Alcohol Abuse and Alcoholism's ReThinking Drinking.

• Where does information on contraception fit in?

  A woman who drinks alcohol at risky levels may not always follow prescribed procedures for effective contraception. To prevent these women from having an unwanted and alcohol exposed pregnancy, it is incumbent on the ob-gyn provider to review contraception use with them at every visit to ensure that they have full contraceptive coverage every time they have sexual intercourse. This might include providing secondary, back up, or emergency contraception methods. For example, along with oral contraceptives, advise her to use condoms, which have the added benefit of reducing sexually transmitted infections. Often long acting reversible contraceptives such as the IUD or implant are the best contraceptive alternatives.

Resources

• How do I determine where to refer her for treatment?

  The Substance Abuse and Mental Health Services Administration has an excellent treatment locator web site that may help to find an appropriate program within a short distance. Many outpatient centers and some inpatient centers have services that include children or child care.

• How is alcohol withdrawal managed?

  Symptoms of alcohol withdrawal usually start within a few hours of the last drink and include tremors, sweating, hypertension, tachycardia, restlessness, and nausea. Seizures may also occur. Alcohol withdrawal delirium sometimes follows. This begins one to three days after the last drink and may continue up to 10 days. The delirium consists of disorientation, altered sleep-wake cycles, and hallucinations. Withdrawal is managed with thiamine and benzodiazepines, sometimes with other drugs to address symptoms. Pregnant women and severe cases should be managed on an inpatient basis. Alcohol withdrawal is best managed in conjunction with a substance abuse treatment program.

Provider Concerns

• I am not ready to work with alcoholics.

  Less than 4% of the U.S. population are alcohol dependent or alcoholic to the extent of requiring medical treatment and intensive behavioral counseling. However, 25% of the population are considered to be at-risk alcohol users. The majority of those who binge drink are not alcohol dependent. Non-alcohol dependent drinkers will benefit most from brief, straightforward education and support from their primary care provider.

• I don’t think my talking about drinking is going to make a difference to the patient.

  Patients are likely to be more receptive, open, and ready to change than you expect. Most patients don’t object to being screened for alcohol use by clinicians and are open to hearing advice afterward. Primary care physicians are in an excellent position to initiate change in their patient’s drinking behavior. Clinical trials demonstrate that brief interventions can promote significant, lasting reductions in drinking levels in at-risk drinkers who are not alcohol dependent.

  Studies have shown that once advised by their physician, brief intervention and education for at-risk alcohol use is equally effective when delivered by a nurse or other mid-level professional specialist. In a report outlining patient intervention for alcohol use within five managed care organizations, 60% of those patients receiving the intervention reduced their alcohol consumption by one or more drinks per week.

  If the woman is pregnant, talking about one study indicated that stopping drinking as the result of an educational intervention during the second trimester reduced some deficits in attention disorders observed in six-year-old children of mothers who reported drinking during pregnancy. Further findings report that a partner's participation significantly enhanced the effects of brief intervention during pregnancy.

• My patients expect me to spend my time with them discussing their reason for the appointment and not their alcohol use.

  A discussion of the patient’s at risk alcohol use can be woven into your assessment of clinical issues and management options. For instance, binge drinking needs to be addressed in determining the most effective contraception method to prevent an alcohol exposed pregnancy; menstrual problems may be more intense due to alcohol use; and because at risk alcohol use is a risk factor for breast cancer, discussing drinking during a clinical breast exam is appropriate.

  Brief intervention for at-risk alcohol use is shown to be effective for individuals who are not aware that they are at-risk alcohol users, when their primary care visit is for a reason other than their alcohol use.

• I have a busy office. How can fit in screening and intervention for at risk alcohol use?

  Would you spend an extra five minutes with one or two patients a day on an intervention that is effective at decreasing:

  • Unwanted pregnancies (particularly an alcohol exposed pregnancy)?
  • Situations that increase risk of sexual assault?
  • Menstrual problems and breast cancer risk?

  If you are not able to have the conversation, could a member of your professional staff take on that responsibility?

  The AUDIT screening questionnaire can be incorporated into the general patient information and history questionnaire used for patient intake and updates. Individuals tend to respond more openly to alcohol and drug use questions when embedded into an intake form rather than within a face to face interview. Screening need only be done for first time obstetric patients and women presenting for their annual gynecologic office visit.

• How do I follow up with her on subsequent visits?

  On subsequent visits document her alcohol use and review the goals she discussed with you previously. Ask if she has been able to meet and sustain her drinking goal. If her answer is yes, reinforce and support continued adherence. Encourage her to return and re screen annually.
  
  If she is unable to keep her goal, acknowledge that change is difficult, support any positive change, and address barriers in reaching the goal. Consider renegotiating the goal and plan including considering a trial of abstinence. It may be easier for her to stop all together than to moderate her drinking. If she is unable to cut down or abstain, consider that she may have an alcohol dependence problem and discuss her getting outside assistance from a treatment specialist, a mutual help group, or an on-site social worker.

• What do I do when my efforts aren’t helping?

  Acknowledge that change is difficult, relate her drinking to problems she may be having, and consider referral to an addiction specialist or mutual help group. Try to engage a significant person in her life. Address coexisting disorders, both medical and psychiatric.

• I can smell the alcohol on her, but she denies drinking. What should I say?

  It is best to deliver your observation as a simple statement. Let the patient know that you are available to talk with her and to provide help if she wants it. Then continue with the appointment. If she is obviously inebriated, do not continue the appointment, but ask her to return when she is feeling better and able to concentrate on your guidance.

• What do I do if she refuses treatment?

  There may be a number of reasons for not accepting treatment. She may not agree with your assessment of her problem drinking. She may know the stigma associated with those undergoing treatment. Or she may greatly fear that any involvement with treatment could result in her loss of the custody of her children or her job. She may be concerned that family or neighbors will discover her alcohol problem. If you are able, explore her reasons for treatment refusal, or ask a social worker or counselor to discuss treatment with her. Remind her that whatever her choice, she remains your patient and you want to follow up with her in the near future.

• Can I get reimbursed for the screening and intervention from insurance?

  Many health plans will now pay for alcohol and substance use screening and brief intervention. These patient encounters must include both screening with a validated instrument, such as the AUDIT, and counseling by a physician or other qualified health care professional for at least 15 minutes. Visit our coding page for more information.