A better future for baby: Stemming the tide of fetal alcohol syndrome

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Applied Evidence

A better future for baby: Stemming the tide of fetal alcohol syndrome

J Fam Pract. 2010 June;59(6):337-345

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References

1. Centers for Disease Control and Prevention. Fetal Alcohol Syndrome: Guidelines for Referral and Diagnosis. 2005. Available at: www.cdc.gov/ncbddd/fasd/documents/FAS_guidelines_accessible.pdf. Accessed April 10, 2010.

2. Spohr HL, Williams J, Steinhausen HC. Fetal alcohol spectrum disorders in young adulthood. J Pediatr. 2007;150:175-179.

3. Gahagan S, Sharpe TT, Brimacombe M, et al. Pediatricians’ knowledge, training, and experience in the care of children with fetal alcohol syndrome. Pediatrics. 2006;118:e657-e668.

4. Bailey BN, Delaney-Black V, Covington CY, et al. Prenatal exposure to binge drinking and cognitive and behavioral outcomes at age 7 years. Am J Obstet Gynecol. 2004;191:1037-1043.

5. CDC. Alcohol and public health/binge drinking. Quick stats. Available at: www.cdc.gov/alcohol/quickstats/binge_drinking.htm. Accessed April 21, 2010.

6. Sood B, Delaney-Black V, Covington C, et al. Prenatal alcohol exposure and childhood behavior at age 6 to 7 years: I. Doseresponse effect. Pediatrics. 2001;108:E34.-

7. Sokol RJ, Delaney-Black V, Nordstrom B. Fetal alcohol spectrum disorder. JAMA. 2003;290:2996-2999.

8. American Congress of Obstetricians and Gynecologists. ACOG Education Pamphlet AP170: Tobacco, alcohol, drugs, and pregnancy. Available at www.acog.org/publications/patient_education/bp170.cfm. Accessed May 3, 2010.

9. Committee on Substance Abuse and Committee on Children With Disabilities. Fetal alcohol syndrome and alcohol-related neurodevelopmental disorders. Pediatrics. 2000;106:358-361.

10. Jones KL, Robinson LK, Bakhireva LN, et al. Accuracy of the diagnosis of physical features of fetal alcohol syndrome by pediatricians after specialized training. Pediatrics. 2006;118:e1734-e1738.

11. University of Washington Fetal Alcohol Syndrome Diagnostic and Prevention Network. FAS facial photography and measurement instruction. Available at: www.depts.washington.edu/fasdpn/htmls/photo-face.htm. Accessed April 21,2010.

12. University of Washington Fetal Alcohol Syndrome Diagnostic and Prevention Network. Lip philtrum guides. Available at: www.depts.washington.edu/fasdpn/htmls/lip-philtrum-guides.htm. Accessed April 21, 2010.

13. Astley S. Comparison of the 4-digit diagnostic code and the Hoyme diagnostic guidelines for fetal alcohol spectrum disorder. Pediatrics. 2006;188:1532-1545.

14. Druschel CM, Fox DJ. Issues in estimating the prevalence of fetal alcohol syndrome: examination of 2 counties in New York State. Pediatrics. 2007;119:e384-e390.

15. Streissguth AP, Barr HM, Kogan J, et al. Understanding the occurrence of secondary disabilities in clients with fetal alcohol syndrome (FAS) and fetal alcohol effects (FAE). Final Report to the Centers for Disease Control and Prevention. Technical report no. 96-06. Seattle, WA: University of Washington, Fetal Alcohol and Drug Unit; 1996.

16. Streissguth AP, Bookstein FL, Barr H, et al. Risk factors for adverse life outcomes in fetal alcohol syndrome and fetal alcohol effects. J Dev Behav Pediatr. 2004;25:228-238.

17. US Preventive Services Task Force. Screening and behavioral interventions in primary care to reduce alcohol misuse: recommendation statement, April 2004. Available at: www.ahrq.gov/clinic/3rduspstf/alcohol/alcomisrs.htm. Accessed April 10, 2010.

18. Bradley KA, Boyd-Wickizer J, Powell SH, et al. Alcohol screening questionnaires in women: a critical review. JAMA. 1998;20:166-171.

19. Chan AW, Pristach EA, Welte JW, et al. Use of the TWEAK test in screening for alcoholism/heavy drinking in three populations. Alcohol Clin Exp Res. 1993;17:1188-1192.

20. Russell M, Bigler L. Screening for alcohol-related problems in an outpatient obstetric-gynecologic clinic. Am J Obstet Gynecol. 1979;134:4-12.

21. National Institute on Alcohol Abuse and Alcoholism. Helping patients who drink too much: a clinician’s guide. Updated January 2007. Available at: http://pubs.niaaa.nih.gov/publications/Practitioner/CliniciansGuide2005/clinicians_guide.htm. Accessed April 21, 2010.

22. Fleming MF, Barry KL, Manwell LB, et al. Brief physician advice for problem alcohol drinkers. JAMA. 1997;277:1039-1045.

23. Chang G, McNamara TK, Orav J, et al. Brief interventions for prenatal alcohol use: a randomized trial. Obstet Gynecol. 2005;105:991-998.

24. The Project Choices Intervention Research Group. Reducing the risk of alcohol-exposed pregnancies: a study of motivational intervention in community settings. Pediatrics. 2003;111:1131-1135.

Screening should include simple quantity and frequency questions developed by the National Institute on Alcohol Abuse to clarify a patient’s current drinking patterns. The questions include the numbers of days per week of any drinking, the average number of drinks per day, and the maximum number of drinks consumed in 1 day during the past month. Determining that a woman drinks more than 7 drinks per week has a 29% sensitivity, but a 90% specificity for identifying lifetime risk of alcohol abuse or dependence.¹⁸

Other tools include TWEAK (Tolerance, Worry, Eye-opener, Amnesia, (K)Cut down), T-ACE (Tolerance, Annoyed, Cut down, Eye opener), and AUDIT (Alcohol Use Disorder Identification Test). They are detailed below and available online at Project Cork. Go to www.projectcork.org, and click on “clinical tools.”

The 5-item TWEAK tool (TABLE 2) appears to be the optimal screening questionnaire for identifying women in racially mixed populations with heavy drinking or alcohol abuse and dependence, but a score of 2 points should be the threshold for identifying female problem drinkers.^19,20 Using the lower cutoff of 2, the sensitivity of TWEAK is in the 87% to 91% range for women, with a specificity of 77% to 90%.¹⁸

The T-ACE tool is a set of 4 questions, with the question addressing tolerance weighted more heavily than the others. With a score of 2 or more, the sensitivity of T-ACE is 70% to 88%; the specificity is 79% to 85%.¹⁸

The AUDIT tool is a self-administered screen that consists of a series of 10 questions that are each scored on a scale of 0 to 4. The maximum score is 40. A score of 2 indicates some harmful use of alcohol, but a score of 8 or more has a sensitivity of 59% to 66%, with a specificity of 93% to 97% in women.¹⁸

TABLE 2
TWEAK your patients for alcohol use

Tolerance: How many drinks does it take for you to:	Score
Feel the first effects of alcohol? Fall asleep or pass out? Or, if you never pass out, what is the largest number of drinks you have on 1 occasion?	2 points for ≥3 drinks 2 points for ≥5 drinks
Worry about drinking
Have your friends or relatives worried about your drinking in the past year?	1 point for Yes
Eye-opener
Do you sometimes take a drink in the morning when you first get up?	1 point for Yes
Amnesia
Are there times when you drink and afterwards can’t remember what you said or did?	1 point for Yes
(K)Cut down
Do you sometimes feel the need to cut down on your drinking?	1 point for Yes
Scoring: ≥3 points is considered positive for alcoholism/heavy drinking. Thresholds differ for screening different populations, and a score of ≥2 points should be used as the threshold for identifying female problem drinkers.
Source: Chan AW, et al. Alcohol Clin Exp Res. 1993.¹⁹

When your patient is at risk

Brief interventions are recommended for nonpregnant and pregnant women who have exhibited a pattern of at-risk or problem drinking.²¹TABLE 3 summarizes patterns of drinking in women, from not drinking at all through various degrees of risk to alcohol dependency. Referral to an addiction specialist is recommended for women with alcohol dependence.

FAST TRACK

Brief interventions for alcohol abuse can take as little as 5 minutes

Brief interventions for alcohol abuse can be single-session encounters from 5 to 15 minutes’ duration, or multi-contact brief sessions, including possible phone follow-up contacts. Project TrEAT (Trial for Early Alcohol Treatment) provided two 15-minute sessions with the primary care physician (either a family physician or internist in community-based practice) scheduled 1 month apart, with nurse follow-up phone calls 2 weeks after each appointment.²²

TABLE 3
Drinking patterns in women

Abstainer Does not drink alcohol or has <12 drinks per year
Low-risk drinking Has ≤7 drinks per week Has ≤1 standard drink on a single occasion Abstains before driving, when pregnant, nursing, or while taking contraindicated medications Has not suffered any negative consequences from drinking.
At-risk drinking Has >7 standard drinks per week or >3 standard drinks on any 1 occasion Has any amount of alcohol when pregnant or nursing Has not experienced any negative consequences from drinking.
Problem drinking Has >7 standard drinks per week or >3 standard drinks on any 1 occasion Has any amount of alcohol when pregnant or nursing Has experienced negative medical or social consequences from drinking.* *Negative medical consequences include peptic ulcer disease, gastroesophageal reflux disease (GERD), hypertension, obesity, depression, or liver disease. Negative social consequences include receiving a summons for driving under the influence (DUI), involvement in a motor vehicle accident, relationship problems or divorce, and loss of employment.
Alcohol-dependent drinking: Maladaptive patterns of alcohol use leading to clinically significant impairment manifested by 3 or more of the following, occurring at any time during the same 12-month period: Has experienced tolerance Has experienced withdrawal Drinks greater amounts than intended Has made unsuccessful attempts to cut down or control drinking Spends significant amounts of time obtaining alcohol, drinking, and recovering from drinking Has given up important activities, or spends less time on them Continues to use alcohol despite knowledge of physical or psychological problems caused or worsened by alcohol.
Source: Training program for medical students and other health professionals on fetal alcohol syndrome. Presented by the Midwest Regional Fetal Alcohol Syndrome Training Center; March 18, 2005; St. Louis, Mo.