Title: Fetal Alcohol Syndrome and Fetal Alcohol Spectrum Disorders
1Fetal Alcohol Syndrome and Fetal Alcohol Spectrum
Disorders
- Kenneth R. Warren, Ph.D.
- Acting Director
- National Institute on Alcohol Abuse and Alcoholism
May 20, 2009
2Discovery 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)
3The Three Diagnostic Attributes of Fetal Alcohol
Syndrome
4Fetal 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
5Within 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
6Prevalence 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
7History - 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
8Did 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
9London 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
1019 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.
11Impact
- 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
12The etching shows much disease, decay neglect and
business failure
Indeed the only businesses prospering are the
Pawn Shop and Coffin Maker
13Henry 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
15Historys 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.
16Pre 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
17Sullivan (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
18Post- 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
19Alcohol 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
20Changing 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
22Effect 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
23Surgeon Generals Advisories on Alcoholand
Pregnancy
241988 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
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26The 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
27Thank you!
Kenneth R. Warren, Ph.D. Acting Director National
Institute on Alcohol Abuse and Alcoholism
http//www.niaaa.nih.gov