Facts about Fetal Alcohol Spectrum Disorders (FASDs)
Alcohol is a teratogen, which is a substance that causes developmental malformations in an embryo or fetus. Alcohol passes from the maternal blood to the fetal blood.1 Because the placenta does not filter alcohol, the concentration in the fetus is nearly equal that in the pregnant woman.1
The only way to ensure prevention of the teratogenic effects of alcohol is complete avoidance during pregnancy and periods of potential conception. Alcohol can adversely affect the fetus throughout pregnancy, including the earliest phase when a woman may not realize she is pregnant. The higher the level of alcohol consumption, the greater the risk to the developing fetus.2,3
Fetal alcohol spectrum disorders (FASDs) is an umbrella term used to describe the constellation of effects seen in individuals with prenatal exposure to alcohol. Four diagnoses fall under the umbrella of FASDs, reflecting the continuum of effect from moderate to severe.4
* Alternate nomenclature includes “Alcohol Related Neurodevelopmental Disorder (ARND)” or “Neurodevelopmental Disorder-Prenatal Alcohol Exposed (ND-PAE)”
Characteristics of FASDs
Individuals with full Fetal Alcohol Syndrome (FAS) present with a unique cluster of facial anomalies, growth deficiency, and structural and/or severe functional central nervous system (CNS) impairment.5,6 The graphic below shows three children (Native American, Caucasian, and African American) with the full facial features of FAS.7
|Table: FASD Characteristics1,2,6,7|
|Abnormal facial features||Small eyes (palpebral fissure length < 2nd percentile)|
|Smooth philtrum (i.e., the vertical groove between the nose and upper lip)
(Rank 4 or 5 on the Lip-Philtrum Guide)
|Thin upper lip (Rank 4 or 5 on the Lip-Philtrum Guide)|
|Growth impairment||Head circumference ≤3rd percentile|
|Height ≤10th percentile|
|Weight ≤10th percentile|
|CNS structural and/or functional abnormalities impairment||Abnormal brain structure(s)|
|Difficulty with attention|
|Difficulty in school|
|Speech and language delays|
|Intellectual disability or low IQ|
|Poor reasoning, judgment, planning, and organizational skills|
|Poor adaptive (daily living) skills|
|Motor and sensory abnormalities|
|Sleep and sucking problems as infant|
Risk factors for FASDs
- All women are at risk, regardless of race or socioeconomic status.5
- Genetic differences make some children especially vulnerable to the damaging effects of alcohol. Twin studies have shown that non-identical twins exposed to the same level of alcohol can have different outcomes.4,8
- The goal of the Surgeon General’s Advisory, which states there is no known safe amount to drink during pregnancy, is to protect all children, including the most vulnerable.2
Key counseling messages
- When you drink alcohol, so does your baby.
- All types of alcohol can adversely affect the fetus, including beer, wine, and hard liquor.1
- There is no known safe amount of alcohol during pregnancy.
- Because the fetal brain continues to develop throughout a pregnancy, there is no safe time for a woman to drink.
- If you have been drinking during your pregnancy, you can still reduce the risk to your baby by cutting back or eliminating your alcohol consumption. It is never too late to stop.
Key counseling strategies
When counseling woman, clinicians should consider the two basic strategies for preventing FASDs: (1) avoiding alcohol during pregnancy and (2) avoiding pregnancy when drinking.
Healthcare providers should:
- Provide counseling for effective family planning
- Advise refraining from drinking alcohol during the preconception period
- Counsel women to abstain from alcohol during pregnancy
- Provide referral for treatment of alcohol use disorders if needed
Clinicians can use the TWEAK questionnaire to screen nonpregnant women for problems with alcohol use.9 In pregnant women, any amount of drinking is considered a positive result.
Tolerance: How many drinks can you hold without falling asleep or passing out? (≥=2 points)
Worried: Have friends or relatives worried about your drinking? (yes=2 points)
Eye-opener: Do you sometimes take a drink in the morning when you first get up? (yes=1 point)
Amnesia: Have friends or relatives told you about things you said or did while drinking that you could not remember? (yes=1 point)
Cut down: Do you sometimes feel the need to cut down on your drinking? (yes=1 point)
In a nonpregnant woman, an answer of ≥6 to the first question or a total score of ≥3 indicates a problem with alcohol use and a need for further assessment.
Brief motivational interviewing
A brief motivational interview (BMI) is a form of intervention. The goal of BMI is not to persuade a patient to change behavior; rather it is to enhance her motivation through supportive listening. Patients may require many BMIs to be ready to make a change.
This is a sample 4-step brief motivational interview process for addressing alcohol use during pregnancy10:
- Raise the subject. Ask, “are you willing to spend a few minutes discussing your alcohol use?”
- Provide feedback. Review the results of the screening test and help the patient see the connection between alcohol use and her pregnancy. Show recommended guidelines for responsible alcohol use and review the consequences of prenatal alcohol exposure.
- Assess readiness to change. Ask,”on a scale of 1 to 10, how motivated are you to change your drinking behavior?” If she is ready, move to step 4. If she is not ready, inquire about why and what factors might make her more ready.
- Negotiate and advise. For patients who indicate readiness to consider changing behavior ask, “what would you like to do next?” Consider a written agreement outlining new behaviors (a commitment to herself). Provide written materials on ways to decrease intake and offer referrals for self-help groups such as Alcoholics Anonymous or private counselors.
One message: four scenarios
The single message for FASDs prevention is “no amount of alcohol is safe during pregnancy.” With this one message, there are at least four clinical scenarios in which women require counseling about alcohol in pregnancy. The table below details the counseling approach for each.
|Preconception counseling or family planning||
|Prenatal care for light drinkers who were unaware of the need to avoid alcohol||
|Prenatal care for moderate to heavy drinkers who desire to continue drinking||
|Prenatal care and assessment for women with alcohol use disorder||
- Centers for Disease Control and Prevention. Facts about FASDs. Available at: http://www.cdc.gov/ncbddd/fasd/facts.html. Accessed May 19, 2014.
- Astley SJ. Validation of the fetal alcohol spectrum disorder (FASD) 4-Digit Diagnostic Code. J Popul Ther Clin Pharmacol. 2013;20(3):e416-467.
- Astley SJ. Profile of the first 1,400 patients receiving diagnostic evaluations for fetal alcohol spectrum disorder at the Washington State Fetal Alcohol Syndrome Diagnostic & Prevention Network. Can J Clin Pharmacol. 2010;17(1):e132-64.
- Astley SJ. Diagnosing Fetal Alcohol Spectrum Disorders (FASD). In: Adubato SA and Cohen DE (eds.) Prenatal Alcohol Use and Fetal Alcohol Spectrum Disorders: Diagnosis, Assessment and New Directions in Research and Multimodal Treatment. Oak Park, IL: Bentham Science Publishers Ltd. 2011:3-29.
- Astley SJ, Bailey D, Talbot C, Clarren SK. Fetal alcohol syndrome (FAS) primary prevention through FAS diagnosis: II. A comprehensive profile of 80 birth mothers of children with FAS. Alcohol Alcohol. 2000;35(5):509-19.
- Centers for Disease Control and Prevention. The FASD Competency-Based Curriculum Development Guide for Medical and Allied Health Education and Practice. No date. Available at: http://www.cdc.gov/ncbddd/fasd/curriculum. Accessed April 9, 2014.
- Astley SJ. Diagnostic Guide for Fetal Alcohol Spectrum Disorders: The 4-Digit Diagnostic Code, 3rd ed. Seattle WA: University of Washington Publication Services. 2004.
- Streissguth AP, Dehaene P. Fetal alcohol syndrome in twins of alcoholic mothers: concordance of diagnosis and IQ. Am J Med Genet. 1993;47(6):857-61.
- Russell M, Martier SS, Sokol RJ, et al. Screening for pregnancy risk drinking. Alcohol Clin Exp Res. 1994; 18:1156¢®¡×C1161.
- Keough VA, Jennrich JA. Including a screening and brief alcohol intervention program in the care of the obstetric patient. J Obstet Gynecol Neonatal Nurs. 2009;38(6):715-22.