(MUSIC PLAYING)
Dr. Wargowski: Hello. This is first in a
series of podcasts related to the Curriculum
Development Guide for FASD training from the
Centers
for Disease Control and Prevention. My name
is David
Wargowski. I'm a physician in the Division
of Medical
Genetics in the Department of Pediatrics at
the
University of Wisconsin School of Medicine
and Public
Health. I've been working for several years
on
clinical aspects of fetal alcohol spectrum
disorders,
evaluating individuals suspected of having
these
conditions, and trying to learn more about
the
spectrum and how to train other individuals,
professionals, in various fields to identify
and
intervene in the care of individuals with
these
disorders.
The first podcast is regarding the first
competency which is foundations of fetal alcohol
syndrome, basically, an overview of some of
the
basic concepts related to fetal alcohol spectrum
disorders. We have to begin by talking about
alcohol and pregnancy in general. What we
can say
in a general statement is that drinking alcohol
during pregnancy can cause a range of birth
defects
and developmental disabilities, and the umbrella
term that we use for all of those is fetal
alcohol
spectrum disorders or FASDs. That is not a
diagnosis, but more of a conceptual term.
Fetal
alcohol syndrome is a specific diagnosis that
falls
within the FASD spectrum. One of the questions
that comes up frequently is how common are
these
disorders? The best information that we have
suggests that fetal alcohol syndrome, itself,
as a
prevalence of roughly 0.2 to 1.5 cases in
every
1,000 live births. FAS, however, is sort of
a tip
of the iceberg phenomenon and the best evidence
we
have suggests that the full range of FASDs
occur
in about 9 to 10 per 1,000 live births. This,
of
course, puts it at about a 1% level and brings
it
to the level of other issues that are regarded
as
public health concerns. Looking at statistical
information, we can begin by looking at drinking
behavior in general. National data suggests
that
just over half of nonpregnant women of child
bearing age, that is between the ages of 18
and 44,
report alcohol use at some level. Just over
10% of
nonpregnant women in that age group report
frequent
or binge drinking or other types of risky
drinking
behavior. Binge drinking, according to these
criteria defined for women, is four drinks
or more
on an occasion. Regarding drinking during
pregnancy, the national data suggests that
roughly
10% of women, of child bearing age who are
pregnant, report alcohol use during their
pregnancy. 2 to 4% of pregnant women, report
frequent or binge drinking during pregnancy.
One
of the steps that's necessary to address FASDs
is, of course, prevention. And prevention
relies
on delivering up-to-date and accurate information,
but it starts with the basics. And so informing
women of child bearing age that many women
who
drink during those years become pregnant
unintentionally. Secondly, that alcohol is
a
teratogen, which in its simplest way, is defined
as
a substance that has the capacity to cause
birth
defects, and therefore, can harm the embryo
or
fetus during its development during the pregnancy.
Third, effects of alcohol exposure can vary
widely
from person to person or even from pregnancy
to
pregnancy in the same mother, and can include
physical problems, learning difficulties,
and
behavioral problems as well as growth impairment,
and all of these can range from mild to severe.
In
fact, to establish a diagnosis of fetal alcohol
syndrome, we look at these three criteria,
the
growth impairment, a specific set of facial
characteristics, and central nervous system
impairments, and these can either be structural
as
might be seen an on an MRI scan or functional
problems which are more common and more problematic
for most individuals and families. Whenever
possible, we generally try to correct for
the
background of the individual, whether that's
family
background or racial background, and there
is some
controversy about this in the genetics community,
but generally we try to account for background
whenever possible. In regard to growth, data
suggests that for each ounce of alcohol consumed
per day, birth weight is reduced by roughly
160
grams. Generally weight gain remains impaired
throughout childhood but it may improve. Often,
it
increases more dramatically during adolescents
and
adulthood, particularly for women, in whom
obesity
is quite common. Linear growth impairment
is
reflected in short stature, typically at birth,
and
this also usually persist, although, again,
there
have been demonstrations of individuals who
have
regained linear growth rates and attained
normal
stature later in childhood. Similarly,
microcephaly is typically present at birth
and we
would expect this to persist or even worsen
over
time, but there have been reports of individuals
whose cranial growth improves and normalizes
over
time. This is important because microcephaly
is
both a growth phenomenon and also a central
nervous
system effect of alcohol exposure. And if
microcephaly is identified at any point in
time in
a child's growth this is an important part
of the
diagnostic evaluation. But it also suggests
that
even if a child's head size is normal at a
point in
time, it doesn't necessarily follow that their
head
size was always normal if they've had a significant
exposure. At some point, we had to make a
decision, a collective decision, about how
to
characterize growth retardation. The 10th
percentile for height and or weight was chosen
somewhat arbitrarily but consensus as the
cut off
level for identifying growth retardation.
It's
important also to note that the consensus
is that
this can be noted at any time throughout the
child's life. In regard to the facial features,
the typical nearly consistent features in
children
with fetal alcohol syndrome include short
palpebral
fissures. Palpebral fissure is the horizontal
measurement of the opening the eye lids. The
second is a hypoplastic philtrum which is
the
groove between the nose and the mouth and
hypoplastic means that this groove is smooth,
and a
thin upper lip. This picture shows a cartoon
depiction of those facial characteristics
and a few
others. It also shows that the cranium is
small
compared to the face and shows the smooth
elongated
philtrum and small eye openings as well as
the thin
upper lip. Regarding the central nervous system
problems, common problems among individuals
with
fetal alcohol spectrum disorders include
developmental delay, hyperactivity, learning
disabilities and behavior problems, again,
these
can range widely from mild to severe, and
can have
different levels of impact on different affected
individuals. As a general rule, however, behavior
problems are among the most demanding on
individuals and families. Returning to prevention,
the core message that we try to deliver
consistently is that there is no safe kind,
known
safe amount, or safe time to drink alcohol
during
pregnancy. Again, effects of alcohol exposure
during pregnancy vary widely. We estimate,
based
on gathering data from numerous sources, that
between 30% and 40% of individuals who have
significant prenatal alcohol exposure will
have
some effects of fetal alcohol spectrum disorders.
That means that there is a significant proportion
of individuals who have no demonstrable effects
of
such exposures. The specific manifestations
of the
exposure vary in part because of differences
in
timing of the exposure, amount of alcohol
consumed,
and other fetal and maternal factors which
are not
nearly as well understood. Again, some catch
up in
fetal growth and development is possible if
drinking stops at any time during the pregnancy.
The other message that is important at the
outset
is that there are interventions that have
been
shown to be effective for people with fetal
alcohol
spectrum disorders. Individuals can benefit
from
an array of services, including early intervention,
nurturing and structured home environments
and
school environments, education and information
for
parents and care providers, and involvement
of
caregivers in planning services and delivery.
Additional information about FASD is available
through the Great Lakes FASD Regional Training
Center with contact information as presented
on
this slide. Or if you're outside the great
lakes
region, other regional training centers are
located
at various sites around the nation and can
be
accessed at this website. (music playing)
