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Fetal Alcohol Syndrome and Fetal Alcohol Spectrum Disorders

Fetal Alcohol Syndrome and Fetal Alcohol Spectrum Disorders. Kenneth R. Warren, Ph.D. Acting Director National Institute on Alcohol Abuse and Alcoholism. May 20, 2009.

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Fetal Alcohol Syndrome and Fetal Alcohol Spectrum Disorders

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  1. Fetal Alcohol Syndrome and Fetal Alcohol Spectrum Disorders Kenneth R. Warren, Ph.D. Acting Director National Institute on Alcohol Abuse and Alcoholism May 20, 2009

  2. From the end of Prohibition in 1933 until the early 1970s, alcohol had been considered to be perfectly safe, at any dose and at anytime, in pregnancy Indeed, given this belief, alcohol even found its way into obstetric practice in 1965 for use, at very heavy doses, to prevent the onset of pre-mature label Then, in the early 1970s, a group of physicians examined several children hospitalized for failure to thrive who had a history of prenatal alcohol exposure They observed a common pattern of deficits in children, now known as Fetal Alcohol Syndrome (FAS) Discovery of Fetal Alcohol Syndrome

  3. GROWTH FACE BRAIN The Three Diagnostic Attributes of Fetal Alcohol Syndrome

  4. Fetal Alcohol Spectrum Disorders • It soon was recognized that prenatal alcohol may not always result in the full FAS. This led to the eventual introduction of a new term to encompassthe full range of prenatal alcohol elicited adverse effects: Fetal Alcohol Spectrum Disorders (FASD) • FASD isNOTa diagnostic term but an umbrella term used to describe a broad range of effects associated with alcohol use during pregnancy

  5. Within the Spectrum of FASD • Partial FAS (pFAS) – brain and facial features without growth deficits • Alcohol Related Birth Defects (ARBD) for physical effects (heart, kidney, skeletal) in the absence of other deficits • Alcohol Related Neurobehavioral Disorder (ARND) for effects on the brain that result in problems with learning, emotions and behavior, in the absence of the full syndrome • Plus a range of other adverse outcomes to which prenatal alcohol may contribute: • Spontaneous Abortions • Stillbirth • Sudden Infant Death Syndrome

  6. Prevalence of FAS and FASD • The Institute of Medicine has estimated the prevalence of FAS in the U.S. at 0.5 - 2.0 cases per 1000 births. That would translate to between 2000 – 8000 new cases per year • The prevalence of the full spectrum disorders are many fold higher, estimated in one report at 1 case per 100 • In areas with higher maternal drinking, the rates of FAS are higher – rates as high as 8/1000 found in specific locations in the U.S. • In South Africa, rates of 40 – 80 FAS cases/1000 have been repeatedly observed • FAS/D is recognized as the leading preventable birth defect in the U.S. today

  7. History - Initial Doubting • When the existence of FAS was first proposed in the 1970s many scientists and physicians questioned whether it was real • Given the common practice of drinking throughout antiquity and recent history, why had it not been seen before if it was real? • The set in motion a quest to ask what had been previously known about alcohol and pregnancy

  8. Manoah and his wife obey the admonition and have a son, Sampson, who becomes well renowned for his physical strength and wisdom However, not necessarily a warning about birth defects “Behold, thou shall conceive, and bear a son, and now drink no wine or strong drink….” ~Judges 13:7 Did Our Earlier Ancestors Recognize the Consequences of Drinking in Pregnancy?

  9. London Gin Epidemic • From 1690 to 1755 London experienced a Gin Epidemic caused by the an abundance of grain placed on the London market, the augmenting of distillation technology, and low taxes on gin • 1 in 3 shops was a ginnery • Mortality increased and alarmed the Royal College of Physicians

  10. We… do think it our Duty most humbly to represent that we have with concern observed, for some years past, the fatal effects of the frequent use of several sorts of distilled Spirituous Liquors… and too often the cause of weak, feeble, distempered children, who must be instead of an advantage and strength, a charge to their Country. 19 January 1725Petition From the Royal College of Physicians (London)To the Honorable House of Commons

  11. Impact • Despite the Petition the Gin Epidemic continued • 25 Years after the Petition, two social commentators, the artist William Hogarth and the author Henry Fielding, focused their artistic talents on the consequence of the Gin Epidemic

  12. William Hogarth: Gin Lane (1751) The etching shows much disease, decay neglect and business failure Indeed the only businesses prospering are the Pawn Shop and Coffin Maker

  13. Henry Fielding Text • Henry FieldingAn enquiry into the causes of the late increase of robbers…with some proposals for remedying this growing evil. London: A. Millar; 1751 “What must become an infant who is conceived in Gin? With the poisonous distillations of which it is nourished, both in the Womb and at the Breast” –(1751 quote of Henry Fielding) • It is the artistic works of Hogarth and Fielding that finally influenced Parliament to increase the tax on gin and limit “ginneries” in 1755

  14. William Hogarth: Beer Street (1751) • Gin, not alcohol was considered the vice • In William Hogarth’s etching Beer Street, the consumption of beer is envisioned with health and prosperity. Indeed, the only businesses suffering are the pawn shop, and the coffin maker

  15. History’s Views on Alcohol and the Fetus: Into the 19th Century • Robert MacNish of Glasgow wrote in 1827: • “The children of (confirmed drunkards) are in general neither numerous nor healthy. From the general defect of vital power in the parental system, they are apt to be puny and emaciated…” • Charles Dickens in 1836 Pickwick Papers presents the character Betsy Martin “…one child, one eye…knows her mother drank bottled stout, and shouldn’t wonder if that caused it”.

  16. Pre 20th Century Understanding of Alcohol and Pregnancy In these early writings and artwork, it is difficult to state whether deficits in children were being ascribed to: • alcohol consumption in pregnancy • male and/or female alcohol use at the time of conception or before conception • damage to genetic factors (germ cells) • toxic damage to the fetus from alcohol-exposure in the womb • alcohol exposure post pregnancy through breast milk • direct feeding of alcohol, in place of breast milk, to the infant • or even alcoholic persons just being “an inferior stock”

  17. Sullivan (1899) • First true epidemiological study • Liverpool Jail • 600 children of 120 alcoholic women • 28 non-drinking relative controls • Infant mortality 2-1/2 times higher • Healthy children with forced abstinence in prison • this is the first evidence that it was alcohol exposure during pregnancy rather than pre-pregnancy effect on germ cells that caused fetal damage – • But with Prohibition in America (1918-1933) anti-alcohol literature was dismissed and forgotten

  18. Post- Prohibition Mid- 20th Century Views on Alcohol and Pregnancy Risk • Post-Prohibition literature rejected all pre-prohibition writings and beliefs, perhaps because of their moralistic tone. • “...the idea of germ poisoning by alcohol in humans may be safely dismissed..., Jellinek, E.M., and Jolliffe, N.Journal of Studies on Alcohol. Vol. 1, Number 1, pg 110-181 (1940) • …mental deficiencies due to “poor stock” of alcoholic families. Alcohol Explored, Haggard and Jellinek, 1942 • Mark Keller (1955) “the old notions about children of drunken parents being born defective can be cast aside…”* * Popular Pamplet #3, Rutgers Centers for the Study of Alcohol

  19. Alcohol and Pregnancy:From Obscurity to Health Advisories Given this history, the clinical findings by the team of U.S. physicians in 1973, and the discovery of other recent findings from France, set in motion a process of careful animal and human epidemiological research, supported by NIAAA, to confirm the adverse effects of prenatal alcohol and the existence of FAS

  20. Changing Perspective:The Onset of U.S. Government Advisories • With its support of alcohol and pregnancy outcome research between 1973 – 1977, NIAAA held the first international research conference on FAS in 1977 • Attendees were so impressed with the findings to date that they collectively recommended that NIAAA issue first government health advisory on FAS

  21. 1977 FAS Advisory • Issued on June 1, 1977, the Advisory was written from a “conservative perspective” • From perspective “safe until proven dangerous” rather than opposite • Stated that more than6 drinks a day was established as a risk • Recommended a “2-Drink Limit” per day

  22. Effect of the 1977 Advisory • Though written and published in newsletters for physicians, the Advisory caught the attention of news media and the Congress • The Senate held hearings in 1977-1978 on whether the risks warranted Warning Labels on Alcohol Beverages • The final recommendation was to request a joint study to be undertaken by Treasury and DHHS • The Study Report issued in November 1980 entitled “Health Hazards Associated with Alcohol and Methods to Inform the General Public of These Hazards” did not recommend a warning label at that time. Rather, it recommended the issuance of an updated advisory, this time from the Surgeon General

  23. New perspective:  Rather than “safe” until proven dangerous , advise caution until proven “safe” In February 2005,  the Surgeon General’s Advisory was re-issued at the request of the National Task Force on Fetal Alcohol Syndrome and Fetal Alcohol Effects, an Advisory Body established by statute and active 2000-2007 Surgeon General’s Advisories on Alcoholand Pregnancy

  24. 1988 Bottle Label Hearings • By late 1980’s the issue of Bottle Labeling arose • Senate Committee on Commerce, Science and Transportation, Subcommittee on the Consumer, hearing on Alcohol Warning Labels: S. 2047, 100th Cong., 2d sess., August 10, 1988 • This led rather rapidly to passage of the Omnibus Drug Act of 1988, (P. L. 100-690) which was signed into law on November 18, 1988 • Became Effective November 1989 • Treasury was given authority to develop regulations on size, placement and appearance of the label

  25. The Problem Remains • Despite a bottle warning label, and Surgeon General Advisories, the issue of FAS and FASD remains a significant problem of public health • Research on FAS/D is critical to advance our understanding of these disorders and to address the problem

  26. Thank you! Kenneth R. Warren, Ph.D. Acting Director National Institute on Alcohol Abuse and Alcoholism http://www.niaaa.nih.gov

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