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Fetal Alcohol Syndrome and Fetal Alcohol Spectrum Disorders

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Title: Fetal Alcohol Syndrome and Fetal Alcohol Spectrum Disorders


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
Discovery of Fetal Alcohol Syndrome
  • 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)

3
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
    encompass the full range of prenatal alcohol
    elicited adverse effects
  • Fetal Alcohol Spectrum Disorders (FASD)
  • FASD is NOT a 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
Did Our Earlier Ancestors Recognize the
Consequences of Drinking in Pregnancy?
  • 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

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
19 January 1725Petition From the Royal College
of Physicians (London)To the Honorable House of
Commons
  • 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.

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
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 Fielding An enquiry into the causes of the
    late increase of robberswith 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
  • Gin, not alcohol was considered the vice
  • In William Hogarths 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
Historys 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
    eyeknows her mother drank bottled stout, and
    shouldnt 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 PregnancyFrom 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 PerspectiveThe 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 than 6 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
Surgeon Generals Advisories on Alcoholand
Pregnancy
24
1988 Bottle Label Hearings
  • By late 1980s 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
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26
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

27
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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