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Documentation of growth deficits/abnormalities Prenatal or postnatal weight fo &/or height <10% percentile
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1968: Paul Lemione first described effects of prenatal alcohol exposure. 1973: Jones, Smith, Ulleland, & StreissguthPattern of Malformation in Offspring Alcoholic Mothers. 1973: Jones & Smith coined the term FAS. Fetal Alcohol Syndrome is now recognized as the leading known cause of mental retardation in the US, surpassing spina bifida & Downs syndrome.
Adjusted for age, gender, gestational age, race, & ethnicity If pt doesnt meet criteria for <10% weight %ile they are not FAS but if they have everything else they have FASD. Growth parameters show a primordial short stature with a relative and absolute microcephaly
o Documentation of CNS or neurobehavioral disorders TEST: You never even have to ask the mom if she drank any alcohol!
No known safe amount of alcohol in pregnancy No safe type of alcohol No safe time to drink during pregnancy Alcohol damages the developing central nervous system through multiple mechanisms
Prevalence of FAS: 0.2-1.5 per 1,000 live birth o Lips gently closed FASDs estimated at 9-10 per 1,000 live births o No smile Groups with higher rates of FAS/FASDs: o Examiners eyes Frankfort Horizontal Plane Disadvantaged groups o Match to ethnic photos American Indian/Alaska Native, African Amer Important landmarks on Palpebral Fissure Children in foster care (socioeconomic) o Inner canthus Youth in juvenile justice system o Outer canthus
Palpebral fissure
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1) Universal: warning labels on alcoholic o Growth Curves: As they grow, they are below their growth beverages, public service announcements, mass curve. Difference between Males & Females media campaigns Males: Very SKINNY 2) Selective: screening women for alcohol use & Females: More likely to get OVERWEIGHT providing brief intervention 3) Indicated: alcohol treatment & measures to prevent pregnancy FAS Diagnostic Criteria: Structural Disorders
Structural Disorders Head circumference <10th percentile OFC= Occipital Frontal Circumferences Brain abnormalities observed via: imaging, (CT or MRI) seizures, impaired motor skills (expected with microcephaly)
Cute Appearing
33% abstain & 39% are low risk; The rest are HIGH RISK It is much easier to screen everyone! Screening works best if done universally! 55% will say they consumed alcohol Why Screen Pregnant Women? o 12% of women continue to drink while pregnant, despite efforts to educate on its dangers. o Alcohol use during pregnancy, even low intake levels, has been associated w/ significant negative consequences, including FASD
FAS--Differential Diagnosis
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Cardiac disorders
Williams syndrome (ELN deletion) Velocardiofacial syndrome (del 22q11) Noonan syndrome (PTPN deletion) DeLange syndrome Dubowitz syndrome Maternal PKU embryopathy Maternal Toluene embryopathy (toxin exposure)
Are Women Being Screened? o Despite potential risks & established clinical guidelines, some o Physicians are less likely to detect alcohol problems in
patients that they do not expect to have alcohol problems. individuals are not screened for problem drinking.
Alcohol dependent or abused alcohol while pregnant b4 Previous biologic child with FASD Partner/family member heavy drinker Associated depression Other drug or tobacco use Low socioeconomic status Unmarried
Why Screen?
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Alcohol use during pregnancy is one of the leading preventable causes of birth defects & childhood disabilities in the US Even low levels of alcohol during pregnancy can have negative developmental consequences. Recommended by US Preventive Services Task Force & CDC
National Institute on Alcohol Abuse & Alcoholism Quantity & Frequency Screen Standardized screening instruments No one gold standard exists Most are less accurate when used in women Laboratory evaluation: not very sensitive
What is a Drink?
o Before screening, women should be taught what constitutes a typical drink. One 12 ounce bottle of beer One 5 ounce glass of wine 1.5 ounces of distilled spirits
Brief Intervention
o In the office setting: For women with at risk or problem drinking patterns Non-pregnant woman w/ intake > low risk drinking Sexually active, non-pregnant woman NOT using effective contraception Trying to conceive or pregnant drinking at any level o Referral to Alcohol Treatment Specialist: For women with dependent drinking patterns Performing a brief intervention prior to referral has been shown to increase the patients motivation to enter counseling, even if the brief intervention fails. o agreements o Review goals or set new ones
TWEAK: Tolerance, Worried, Eye-opener, Amnesia, K(C)ut Down T-ACE : Tolerance, Annoyed, Cut down, Eye-opener CRAFFT: Car, Relax, Alone, Forget, Family+/or Friends, Trouble
Laboratory Evaluation
o None are of much clinical use Alcohol is metabolized too FAST to use blood levels Most others indicate only long-term use problems High cost less feasible for universal screening
TWEAK:
1. How many drinks does it take to feel effects of alcohol 2. Have friends/relatives worried about your drinking in the past year? 3. Ever drank first thing in the morning? 4. Ever drank but cant remember what you said or did in the AM? 5. Ever feel the need to cut down on your drinking? Tolerance Worried Eye opener Amnesia Kut down 3 or more drinks = 2 points Yes= 2 points Yes = 1 point Yes = 1 point Yes = 1 point
Yes = 1 point Yes = 1 point Yes = 1 point Yes = 1 point Yes = 1 point
Feedback
I am very concerned about how your drinking is affecting your health (sleeping, social issues, BP, headaches, elevated LFTs) I am concerned about your risk for developing liver disease There is no known safe limit for drinking during pregnancy. You may be causing harm to your baby.
Responsibility
What you do about your drinking is up to you. No one else can make you decide to change. Are you willing to work w/ me on /stopping your alcohol use?
Advice
I am worried about the level at which you are currently drinking. The current recommendations for you would be to drink less than 1 drink per day. (Explain what this is!)
I see from your drinking diary that you drank 5 beers last Saturday. It is important that we begin to identify what situations are proving to be risky for you so can you share w/ me what you were doing when you had those 5 drinks? NOT Why did you drink 5 beers last Saturday?
Self Efficacy
Can you share w/ me some ways that you think you could cope with going to that party where all of your friends will be drinking? I want you to remind yourself daily that you can drinking
Follow up
Schedule follow-up visit or phone call every 2 weeks or so during the early part of a brief intervention. Review progress, drinking diary, revise drinking