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Fetal Alcohol Spectrum Disorder (FASD) describes the range of abnormalities in children born to mothers who consumed alcohol (Ethyl Alcohol) during pregnancy and is a lifelong disability involving considerable personal and social costs. Fetal Alcohol Syndrome (FAS) is the most well known of the range of disease and is also the most severe. FASD is characterized by prenatal and/or postnatal growth deficiency, facial anomalies, and neurological dysfunction or mental retardation (Diagnostic Guide for FAS and Related Conditions, 9). Children with full blown FAS are the extreme end of a larger spectrum of effects that lessens in magnitude as the alcohol intake of the mother decreases (#Braun, 1996). Children whose mothers drank moderately (1 to 3 drinks per day) are prone to numerous learning disorders like slower reaction times, poor attention capabilities, and lower intelligence (#Braun, 1996). FASD has surpassed Down's syndrome and Spina Bifida as the leading cause of mental retardation in the United States and is the only one of the three that is preventable.

History


Though many attribute the beginning of scientific inquiry to the 1960s and 1970s, physicians have been aware of the negative effects of maternal consumption of alcohol on the developing fetus since ancient times. The Bible in Judges 13:7 states: "Behold thou shalt conceive and bear a son: and now drink no wine or strong drink" hinting at the problems associated alcohol and pregnancy. In Carthage, there was reported to be a prohibition against couples drinking on their wedding night to prevent producing an affected offspring. Aristotle, the founder of western thought, even proclaimed "Foolish,, drunken and harebrained women most often bring forth children like unto themselves, morose and languid" (#Streissguth at al, 1980).

From 1720-1750, the British government attempted to support the grain producing gentry by reducing control on producing and selling gin, thus resulting in an increase in its consumption. During this period, known as the "Gin Epidemic", fetal and infant death rates were much higher than previous years yet, unlike earlier periods, the social factors usually contributing to this - war, famine, poor wages among others - were not existent. This was the first time that health care providers highlighted the effects of what today is known as FASD. So pervasive and obvious was the problem, that in 1725 the College of Physicians in London warned the British House of Commons that alcohol is "too often the cause of weak and feeble, distempered children" (#Warren and Bast, 1988).

Reports of alcohol's negative effects on children continued throughout the eighteenth and nineteenth century. A study in 1899 by Dr. William Sullivan observed 600 children born from 120 alcoholic mothers and represents one of the earliest thorough descriptions of FAS (#Warren and Bast, 1988). Sullivan also noted that female drunkards in the Liverpool jail had a stillbirth and infant death rate of 56% and that the problems with the fetus increase with the mother's alcohol intake (#Martin and Blake, 1980). With the onset of prohibition in the 1920s, alcohol's negative effects on pregnancy were ignored. The research that began again in the 1940s and lasted through the 1960s often attempted to refute the idea that alcohol is detrimental to developing fetuses. This research was in part due to a backlash against the pre-Prohibition views on drinking and morality (#Warren and Bast, 1988).

The revival and beginning of modern science's interest in alcohol related effects on child development began in 1967 with the presentation of Dr. Alexandre LeMache's report to the French Academy of Medicine concerning his observations of over 1200 children born to alcoholic mothers over 37 years (#Warren and Bast, 1988). In the United States, a study published in 1970 by University of Washington scientists examined grown children of alcoholic mothers and discovered a pattern, a syndrome, in a significant number and were the first to coin the term Fetal Alcohol Syndrome (FAS) in their report published in 1973 (#Warren and Bast, 1998).

The United States set up commissions to study the effects and their adequate response. In 1981 the Surgeon General first advised that women should not drink alcohol when they were pregnant due to risks to the infant. That thinking progressed to mandating warning labels stressing the risks to mothers on alcoholic beverages in 1989 and later to the US Government explicitly stating the risks to women if they drink alcohol (#Gilbert, 2004).

Health Effects


Children whose mothers drank while pregnant are at a much greater risk to be stricken with decreased brain activity and mental retardation as they mature. Among these problems are learning disabilities, speech and language problems, hyperactivity, and attencion deficits (#Warren and Bast, 1980). These neurological difficulties intensify as the child grows. They first manifest themselves during infancy and are marked by such traits as poor sucking, disrupted sleep states, and abnormal reflexes. As the child matures the effect of alcohol on the child is witnessed through deficiencies in mental and motor skills, spoken language, and verbal recognition (#Warren and Bast, 1980).

FASD has become the leading cause of mental retardation in developing countries. The average IQ of children with FAS - a score of 68 - is deemed mildly retarded (#Streissguth et al, 1980). One Swedish study found that 25% of all 8 and 9 year olds born to alcoholic mothers attended special schools for the mentally retarded and 35% were partially or completely mentally retarded (Warren and Bast, 1980).

Again the severity of mental deficiencies is also related to the amount of alcohol consumed by the mother during pregnancy. Although no "tipping point" for FAS can be established, mothers who drank heavily bore children that were on average, more severely mentally handicapped (#Braun, 1996).

Physical Effects


FASD Physical Defects

Craniofacial abnormalities are common in children with severe forms of FASD and are a sign of brain damage, although, there may be brain damage without the facial defects. Children with FASD normally have a lower birth weight and a smaller head circumference. Additionally, such perturbations as narrow eyes, ptosis, a thin upper lip, and a short upturned nose with underdevelopment of the groove between the base of the nose and the upper lip (#Warren and Bast, 1980). The child's chin is also more pointed and both the ears and nose seem either undeveloped or deformed. Facial abnormalities are generally most evident between 8 months and 8 years (#Koran).

Diagnostic Criteria


From a section titled The difficulty with diagnosing FAS and other disabilities associated with in utero alcohol exposure in "The Diognostic Guide for Fetal Alcohol Syndrome and Related Conditions":

For the trained clinician, dysmorphologist, or clinical geneticist there is little difficulty in making the diagnosis of FAS when the typical abnormalities in growth, face, and brain are all extreme and the alcohol exposure is conclusive and substantial. BUt ht physical, cognitive and behavioral features are not dichotomus, that is either normal or clearly abnormal. Rather, the features and the history of alcohol exposure, all range along separate continua from normal to clearly abnormal and distinctive (#Astley and Clarren, 1999).

Physicians agree on the definition of full blown FAS, but are in some discord about the diagnosis of lesser forms of FAS; or those abnormalities that are apart of the FASD spectrum but not as severe as FAS. The diagnosis of FAS and related conditions are based on a point system that determines its severity (#Astley and Clarren, 1999). The differing abnormalities of the face, brain, and growth - central characteristics of FASD - determine the specific diagnosis. Because of the diverse range of effects and combinations within the spectrum, there is no standardized clinical definition of FAS but rather guidelines for physicians to follow while diognosing.

Prevalence


While entirely accurate figures of the prevalence of FAS are unavailable, most studies have found that full blown FAS occurs in 1-3 out of 1000 births in developed countries with a worldwide average of 1.9/1000 live births which makes FAS the leading cause of mental retardation (#Warren and Bast, 1980). The rate among mothers who drank is obviously much higher. In one study conducted in Sweden, researchers found a 33% prevalence rate for the full syndrome and a 76% prevalence rate for its partail effects (#Streissguth et al., 1980). It is also important to note that the critical issue is not the exact amount of alcohol consumed during pregnancy, but rather the chronicity of her alcoholism. Other factors that increase ones susceptibility to FAS are black race, frequent beer drinking, lower maternal weight and weight gain, and low socioeconomic status (#Warren and Bast, 1980).

Prevention


FASD Pharmacology

Picture from University of Wisconsin - Eau Claire

Ethyl Alcohol is a teratogen and has been shown to disrupt growth patterns and development. No known tipping point of alcohol consumption during pregnancy that results in full or pasrtial FAS is known so the only way to reduce one's chances of harming an offspring is to abstain from alcohol use during pregnancy. No amount of alcohol, no matter how small, can be said to be safe during pregnancy. Therefore, to avoid damage one must avoid alcohol use during pregnancy.

Current Events


February 19, 2007
A growing number of health care advocates are coming to believe that even a small amount of alcohol while pregnant can have adverse effects on the fetus. See the St. Louis Post Dispatch article.

References


  • Braun, Stephen. "New Expeirments Underscore Warnings on Maternal Drinking." Science 273: 738-739 (1996).

  • Gilbert, Steven G. A Small Dose of Toxicology: The Health Effects of Common Chemicals. CRC Press (2004).

  • Koran, Dr. Gideon, Irena Nulman, Albert E. Chudley, and Christina Looke. "Practice: Fetal Alcohol Spectrum Disorder." ....more info

  • Streissguth, Ann Pytkowicz, Sharon Landesman-Dwyer, Joan C. Martin, and David W. Smith. "Teratogenic Effects of Alcohol in Humans and Laboratory Animals." Science 209: 353-361 (1980).

  • Warren, Kenneth R. and Richard J. Bast. "Alcohol Related Birth Defects: an Update." Public Health Reports 103: 638-642 (1980).
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