Fetal Alcohol Spectrum Disorders – CDC Summary and Updates

WHAT IS IT?

The current understanding of Fetal Alcohol Spectrum Disorder (FASD) is that there is no known safe amount of alcohol during pregnancy or when trying to get pregnant. All types of alcohol are equally harmful, including all wines and beer. Professional colleges recommend screening women in pregnancy. Fetal Alcohol Syndrome (FAS) is on the most severe end of the spectrum.

Fetal Alcohol Syndrome (FAS) – Diagnostic Criteria 

Abnormal facial features (see diagram below)

  • Smooth philtrum (ridge between nose and upper lip)   
  • Thin vermillion (upper lip)  
  • Small palpebral fissures (distance between inner and outer corners of the eyes) giving the eyes a wide-spaced appearance   

Growth problems (prenatal or postnatal) 

  • Height and/or weight ≤10th percentile 

CNS 

  •  Structural  
    • Head circumference ≤10th percentile  
    • Clinically significant brain abnormalities observable through imaging 
  • Neurological deficits unrelated to a postnatal insult or fever 
  • Functional Performance below expectations  
    • Global cognitive or intellectual deficits (Low IQ or developmental delay in younger children) or  
    • Problems in at least 3 of the following areas  
      • Cognitive or developmental deficits or discrepancies | Executive functioning deficits | Motor functioning delays | Attention deficit or hyperactivity | Social skills | Other problems such as sensory / language / memory  

Maternal Alcohol Exposure

  • Helpful if maternal alcohol use can be confirmed during pregnancy
  • Confirmation of maternal alcohol use is not needed if child meets the other, above criteria

Facial Features of FAS (Credit: NIAAA)


Alcohol-Related Neurodevelopmental Disorder (ARND) 

  • CNS, cognitive and behavioral effects without growth restriction and typical facial experience  
    • Intellectual disabilities | Behavior and Learning abnormalities  
    • Difficulties with math, memory, attention, judgment and impulse control 
    • Requires confirmation of prenatal alcohol exposure

Alcohol-Related Birth Defects (ARBD) 

  • Abnormal physical findings only (see more detail below in ‘Key Points’)  
    • Heart | Kidneys | Bones | Hearing  
    • Requires confirmation of prenatal alcohol exposure

Neurobehavioral Disorder Associated with Prenatal Alcohol Exposure (ND-PAE) 

  • ND-PAE was first included as a recognized condition in the Diagnostic and Statistical Manual 5 (DSM 5) of the American Psychiatric Association (APA) in 2013 
  • Problems identified  
    • Thinking and memory, where the child may have trouble planning or may forget material he or she has already learned 
    • Behavior problems, such as severe tantrums, mood issues (for example, irritability), and difficulty shifting attention from one task to another 
    • Trouble with day-to-day living, which can include problems with bathing, dressing for the weather, and playing with other children.  
  • Diagnosis requires  
    • >13 alcoholic drinks per month (30-day period) of pregnancy or 
    • > 2 alcoholic drinks in one sitting 

KEY POINTS:

  • Structural abnormalities associated with prenatal alcohol exposure include 
    • Facial abnormalities (described above plus short nose, cleft lip/palate)  
    • Cardiac anomalies (ASD, VSD, abnormal great vessels)  
    • Auditory (Chronic serous otitis media, conductive and/or neurosensory hearing loss) 
    • Renal anomalies (Aplastic/dysplastic/hypoplastic kidneys, horseshoe kidney, hydronephrosis, ureteral duplications) 
    • Microcephaly 
    • Meningomyelocele 
    • Hydrocephalus 
    • Short or webbed neck 
    • Vertebra and rib anomalies

Screening Tool  

T-ACE & TACER-3 (same questions with different cut-offs)

  • Tolerance: How many drinks does it take to make you feel high?  
    • Positive answer: ≥ 2 drinks  
      • One drink is the equivalent of 0.5 oz of absolute alcohol (approximately 12 oz of regular beer, 1.5 oz of liquor, or 4 oz of wine) 
    • Score: 2   
  • Annoyance:  Has anybody ever annoyed you by complaining about your drinking?  
    • Positive answer: Yes 
    • Score: 1  
  • Cut down:  Have you ever felt you ought to cut down on your drinking?  
    • Positive answer: Yes 
    • Score: 1  
  • Eye-opener:  Have you ever needed a drink first thing in the morning to get going? 
    • Positive answer: Yes  
    • Score: 1  

Note: T-ACE cut-off is 2; TACER-3 cut-off is 3, which results in fewer false positives

Learn More – Primary Sources:

CDC Fetal Alcohol Spectrum Disorders (FASD) – Basics

CDC: Fetal Alcohol Spectrum Disorders (FASD) – Training And Resources

Note: Includes guidelines and information for nurses, social workers, Family Medicine, ObGyns, Pediatricians and Medical Assistants

AAFP: Fetal Alcohol Syndrome and Fetal Alcohol Spectrum Disorders

ACOG: Fetal Alcohol Spectrum Disorders (FASD) Prevention Program 

Increased cut-point of the TACER-3 screen reduces false positives without losing sensitivity in predicting risk alcohol drinking in pregnancy 

How Prevalent is Fetal Alcohol Spectrum Disorder in the US?

BACKGROUND AND PURPOSE:

  • Fetal alcohol spectrum disorders include
    • Fetal alcohol syndrome (FAS)
    • Partial fetal alcohol syndrome
    • Alcohol-related neurodevelopmental disorder
  • Leading cause of developmental disabilities worldwide
    • Accepted US estimate: 10/1000 children affected
  • However, likely that prevalence underestimated due to ‘not diagnosed’ or ‘misdiagnosis’
  • Other countries use ‘active case ascertainment’ where “surveillance personnel are hired and trained to abstract data from all data sources. Abstractors regularly visit or have electronic access to participating institutions, such as hospitals and clinics” (CDC)
  • Philip et al. (JAMA, 2018) used active case ascertainment to estimate the overall prevalence of fetal alcohol spectrum disorder in the United States

METHODS:

  • Active case ascertainment methods using a cross-sectional design
  • Two research teams, both funded by the National Institute on Alcohol Abuse and Alcoholism
  • Children were systematically assessed in the 4 domains that contribute to the fetal alcohol spectrum disorder continuum:
    • Dysmorphic features
    • Physical growth
    • Neurobehavioral development
    • Prenatal alcohol exposure
  • The settings were 4 communities in the US
    • The Rocky Mountains
    • Midwestern US
    • Southeastern US
    • Pacific Southwestern US
  • First-grade children and their parents or guardians were enrolled
  • The primary outcome was Prevalence of fetal alcohol spectrum disorder in the 4 communities

RESULTS:

  • 6,639 children were included in the study population
    • Boys, 51.9% | Mean age, 6.7 years [SD, 0.41] | White maternal race, 79.3%
  • A total of 222 cases of fetal alcohol spectrum disorders were identified
  • The conservative prevalence estimates for fetal alcohol spectrum disorders ranged from 11.3 (95% CI, 7.8-15.8) to 50.0 (95% CI, 39.9-61.7) per 1000 children
    • Calculated as total number of children with alcohol spectrum disorder divided by number of children participating in first grade or selected randomly
  • The weighted prevalence estimates for fetal alcohol spectrum disorders ranged from 31.1 (95% CI, 16.1-54.0) to 98.5 (95% CI, 57.5-139.5) per 1000 children
    • Denominator restricted to children with sufficient information to be properly classified with the condition

CONCLUSION:

  • Using a conservative estimate, fetal alcohol spectrum disorder has a prevalence between 1.1% to 5.0% of the population with much higher prevalence using weighted approach
  • Supporting evidence “that harmful fetal alcohol exposure is common in the United States today”
  • For perspective, CDC autism spectrum disorder estimates are 14.6/1000 children (approximately 1/2 the lowest conservative estimate for fetal alcohol spectrum disorders)

Learn More – Primary Sources:

Prevalence of Fetal Alcohol Spectrum Disorders in 4 US Communities