FETAL ALCOHOL SPECTRUM DISORDERS
Alcohol can cause irreversible damage to a child’s developing brain and nervous system - a known neurotoxin or teratogen. Mothers who drink alcoholic beverages at any point during pregnancy risk exposing their unborn children to alcohol. When alcohol enters the fetal blood circulation, it could cause detrimental effects on physical or neurodevelopmental growth, or even at the same time, leading to a related set of medical conditions known as Fetal Alcohol Spectrum Disorders (FASDs).
In this case, the type or amount of alcohol doesn’t determine how severe the effects may be, and neither does the stage of pregnancy during exposure. This includes the first few weeks of pregnancy when most mothers are unaware that they are pregnant.
Alcohol easily crosses from the mother’s blood to the child’s circulation, through the umbilical cord. Because babies still have relatively underdeveloped organs, alcohol stays in the body for much longer than usual before it is metabolized to unharmful substances and removed from the body. Alcohol disrupts the normal development of the brain, and in some cases, can even cause miscarriage.
For reference, an alcoholic drink is defined as any drink with 14 grams (or 0.6 fluid ounces) of pure alcohol. Rough estimates include 4 ounces of wine, 12 ounces of beer, and 1 ounce of hard liquor.
FASD can be traced back to maternal intake of alcohol. Unfortunately, research shows that 1 out of 10 pregnant women drink alcohol, and as much as 1 out of 33 pregnant women drink a large amount of alcohol (binge drinking). The Centers for Disease Control and Prevention (CDC) reports that approximately 800 to 8,000 newborns are eventually diagnosed with FASDs yearly.
While prenatal exposure to alcohol is one of the most common causes of congenital defects, and behavioral and neurodevelopmental issues in children in developed countries such as the United States, it is easily preventable.
The most important risk factor for FASDs is alcohol exposure. The possibility of developing FASDs may be higher for moms who drink a large amount of alcohol or drink more frequently, as in binge drinking. This is roughly four alcoholic drinks in the span of 2 hours, or a blood alcohol concentration of at least 0.08 grams of alcohol per deciliter.
Other risk factors include smoking, a family history of high alcoholic beverage intake, women with malnutrition, women at least 30 years old with a history of frequent alcohol intake, women living in a stressful environment or community, and women who have previously given birth to a child with fetal alcohol syndrome (FAS). There is still some uncertainty on whether there is an increased risk for FASD in babies whose mothers have been diagnosed with FASD.
Effects of alcohol
FASDs can affect both organ function and various areas of growth and development in babies, often permanently. This starts the moment alcohol comes into contact with the baby’s blood circulation. Too much exposure can even cause miscarriages, especially in the second trimester of pregnancy. However, there is no consensus as to how much alcohol can lead to this.
The most commonly affected is the central nervous system, which includes the brain and nerves. Exposure, specifically during the third trimester of pregnancy, can lead to decreased weight and height in babies. Other examples include the heart, kidneys, bones, muscles, and joints. Primary senses and functions, such as vision, hearing, speech, movement, balance, memory, concentration, and learning may be impaired. Behavioral issues, such as basic social skills, and emotional control, may be present. Common problems include hyperactivity and impulsivity.
Signs and symptoms
Symptoms of FASD may differ in severity for each child. There is still ongoing research to determine which factors lead to more severe symptoms.
Common signs and symptoms at birth include low body weight or height, decreased head size, and abnormal facial features, including a thin upper lip and less prominent (or absent) philtrum. As they grow up, learning or intellectual disabilities and behavioral issues may become prominent.
Newborns may present with non-specific symptoms, such as irritability, and difficulty falling asleep or forming attachments with mothers and other caregivers. Toddlers and pre-school kids may have difficulty holding in impulses or aggression, maintaining attention, and socializing with other children. School-aged children may be challenged to keep up with their peers as they can struggle with math, memory, hearing and visual-spatial skills, language, comprehension, and other executive functioning skills. Teenagers with FASD may find it difficult to further develop abstract reasoning, emotional development, social skills, and other life skills, such as budgeting and time management.
FASD spectrum and criteria
Experts have created a subset of conditions to determine the specific type of FASD a child may have:
Fetal alcohol syndrome (FAS) typically has a combination of physical and developmental issues. The brain and nervous system are affected, as well as physical growth, learning, and behavior. Characteristic facial features are present. Often, no further laboratory tests are needed to confirm the diagnosis. A diagnosis of partial fetal alcohol syndrome (pFAS) is given to children who may have incomplete FAS criteria.
Alcohol-related neurodevelopmental disorder (ARND) is diagnosed in children with prenatal alcohol exposure and behavioral or learning problems. Children diagnosed with ARND do not have abnormal facial features (or may only be minimal). Alcohol-related birth defect (ARBD) focuses on physical defects that affected specific organs, such as the heart, bones, ears, or kidneys. In this subcategory, there are no diagnosed neurobehavioral problems. The last category termed neurobehavioral disorder associated with prenatal alcohol exposure (ND-PAE), comprises of behavioral and developmental problems, with specific documented levels of alcohol intake during pregnancy.
There is no specific laboratory exam or imaging that can diagnose FASDs or any of its subcategories. Healthcare providers will assess the patient’s birth and maternal history, as well as a physical examination, to rule out other medical conditions with similar signs and symptoms. These include some genetic syndromes, such as Williams syndrome and Noonan syndrome.
Management and Therapy
While most consequences of FASDs are permanent, early diagnosis and management produce better outcomes. Children may have different presentations of FASD; as such, treatment is tailored specifically per patient, on a case-to-case basis. This may include a combination of the following:
- multi-specialty referral and coordination
- behavioral modification
- developmental assessment and services
- school-based interventions (special education if required)
- parent or caregiver training
- pharmacological therapy (psychotropic medications if required)
- introduction to family and community support
Novel therapies are being researched and reviewed, including choline supplementation and maternal nutritional supplementation.
Children who are diagnosed before 6 years old, provided a warm and caring environment or community, or provided special education when required are most likely to respond well to overall clinical management.
A significant number of women accidentally expose their unborn babies to alcohol during the first trimester, when they are unaware of the pregnancy. The best way to prevent FASDs is to avoid alcohol intake if there is a possibility of pregnancy. Some women may also choose abstinence or effective birth control methods as an adjunct to prevention.
FASDs may develop in children who were exposed to maternal alcohol intake before birth. This can lead to unusual facial features, low weight and height, abnormal organ development, and cognitive or behavioral deficits. Ultimately, FASDs can be prevented through avoiding alcohol.
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- Smith, V.C. & Turchi, R. (2018). Fetal Alcohol Spectrum Disorders: FAQs of Parents & Families. Fetal Alcohol Spectrum Disorders Program. Healthychildren.org. Taken from: https://www.healthychildren.org/English/health-issues/conditions/chronic/Pages/Fetal-Alcohol-Spectrum-Disorders-FAQs-of-Parents-and-Families.aspx
- Centers for Disease Control and Prevention (2022). Basics about FASDs. National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention. Taken from: https://www.cdc.gov/ncbddd/fasd/facts.html
- National Health Service (2020). Foetal alcohol spectrum disorder. NHS. Taken from: https://www.nhs.uk/conditions/foetal-alcohol-spectrum-disorder/
- Ministry of Health – Manatu Hauora (2022). Fetal alcohol spectrum disorder (FASD). Manatu Hauora Ministry of Health, New Zealand Government. Taken from: https://www.health.govt.nz/your-health/conditions-and-treatments/disabilities/fetal-alcohol-spectrum-disorder-fasd
- Vorgias D, Bernstein B. Fetal Alcohol Syndrome. [Updated 2021 Nov 15]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK448178/
- Weeks, O.; Bossé, G.D.; Oderberg, I.M.; Akle, S.; Houvras,Y.; Wrighton, P.; LaBella, K.; Iversen, I.; Tavakoli, S.; Adatto, I.; Schwartz, A.; Kloosterman, D.; Tsomides, A; Charness, M.E.; Peterson, R.T.; Steinhauser, M.L.; Fazeli, P.K.; and Goessling, W. Fetal alcohol spectrum disorder predisposes to metabolic abnormalities in adulthood. J Clin Invest. 2020 Mar 23. pii: 132139. doi: 10.1172/JCI132139. Taken from: https://www.niaaa.nih.gov/news-events/research-update/fetal-alcohol-spectrum-disorders-may-increase-risk-type-2-diabetes-and-other-metabolic-issues
- National Institute on Alcohol Abuse and Alcoholism (n.d.) Fetal Alcohol Exposure. NIAAA. Taken from: https://www.niaaa.nih.gov/publications/brochures-and-fact-sheets/fetal-alcohol-exposure
- Janet F. Williams, Vincent C. Smith, the COMMITTEE ON SUBSTANCE ABUSE, Sharon Levy, Seth D. Ammerman, Pamela K. Gonzalez, Sheryl A. Ryan, Lorena M. Siqueira, Vincent C. Smith; Fetal Alcohol Spectrum Disorders. Pediatrics November 2015; 136 (5): e1395–e1406. 10.1542/peds.2015-3113
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