Alcohol and Pregnancy: What Have We Learned in 37 Years?

Transcription

1 Alcohol and Pregnancy: What Have We Learned in 37 Years? Kenneth Lyons Jones, M.D. Professor of Pediatrics University of California, San Diego School of Medicine La Jolla, CA

2 Generalizations About Phenotype The developing brain is structure most sensitive to prenatal effects of alcohol Most of the features are secondary to the effect of alcohol on brain development Many of the features seen in this disorder are difficult to recognize in newborns

3 Fetal Alcohol Syndrome Growth Prenatal Growth Deficiency Postnatal Growth Deficiency Microcephaly Performance Developmental Delay Fine Motor Dysfunction Face Short Palpebral Fissures Long, Smooth Philtrum Thin Vermilion Border

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5 Fetal Alcohol Syndrome Growth Prenatal Growth Deficiency Postnatal Growth Deficiency Microcephaly Performance Developmental Delay Fine Motor Dysfunction Face Short Palpebral Fissures Long, Smooth Philtrum Thin Vermilion Border

6 Fetal Alcohol Syndrome Neurobehavioral Abnormalities Problems with attention (sustained attention and shifting of attention) Executive functioning deficits e.g. Impaired planning, concept formation Reduced IQ (average in low 70s) Learning and memory deficits, including problems with habituation, spatial memory Increased reactivity and activity Perseverative (may repeat errors, have difficulty changing from doing things one way to another) Poor fine and gross motor skills Developmental delays Feeding deficits Hearing abnormalities Poor state regulation Immature social behaviors Sensory integration problems

7 Fetal Alcohol Syndrome Growth Prenatal Growth Deficiency Postnatal Growth Deficiency Microcephaly Performance Developmental Delay Fine Motor Dysfunction Face Short Palpebral Fissures Long, Smooth Philtrum Thin Vermilion Border

8 Palpebral Fissure Length (PFL) Measurement Document measurement from inner to outer canthus in millimeters Use hard, clear plastic ruler Follow curve of the face

9 Fetal Alcohol Syndrome Growth Prenatal Growth Deficiency Postnatal Growth Deficiency Microcephaly Performance Developmental Delay Fine Motor Dysfunction Face Short Palpebral Fissures Long, Smooth Philtrum Thin Vermilion Border

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11 Lip and Philtrum Assessment Ensure the patient has a neutral expression Smiling will falsely increase the score Place guide alongside face Score lip and philtrum separately 4 or 5 is considered positive

12 Fetal Alcohol Syndrome Growth Prenatal Growth Deficiency Postnatal Growth Deficiency Microcephaly Performance Developmental Delay Fine Motor Dysfunction Face Short Palpebral Fissures Long, Smooth Philtrum Thin Vermilion Border

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14 IOM works outside the Federal Government to provide unbiased, evidence-based and authoritative information and advice concerning health and science policy to policy-makers, professional leaders in every sector of society and the public at large.

15 D Phenotype Institute of Medicine with confirmed maternal alcohol exposure. A. Confirmed maternal alcohol exposure B. Characteristic facial anomalies including short palpebral fissures and abnormalities of premaxillary zone. C. Growth retardation D. CNS neuro-developmental anomalies 2. without confirmed maternal alcohol exposure. 3. Partial with confirmed maternal alcohol exposure 4. Alcohol-related birth defects (ARBD) 5. Alcohol-related neuro-developmental disorder (ARND)

16 Alcohol Related Neurodevelopmental Disorder Evidence of CNS neurodevelopmental abnormalities, as in any one of the following - decreased cranial size at birth - structural brain abnormalities (e.g. microcephaly, partial or complete agenesis of the corpus callosum, cerebellar hypoplasia) - neurological hard or soft signs, such as impaired fine motor skills, neurosensory hearing loss. Poor tandem gait, poor eye-hand coordination. and/or

17 Alcohol Related Neurodevelopmental Disorder (continued) Evidence of a complex pattern of behavior or cognitive abnormalities that are inconsistent with developmental level and cannot be explained by familial background or environment alone, such as learning difficulties ; deficits in school performance; poor impulse control; problems in social perception; deficits in higher level receptive and expressive language; poor capacity for abstraction or metacognition; specific deficits in mathematical skills; or problems in memory, attention or judgment.

18 Looking at the broader spectrum of and ARND Population-based study in Seattle, WA measured rate of at 3.1 per 1,000 but full spectrum of D was measured to be 9.1 per 1,000 or 3-9 x greater than rates of alone. The combined rate of and ARND was thus almost one in every 100 livebirths. Sampson et al Teratology; 56: (1997)

19 Questions to be Answered Regarding the Prenatal Effects of Alcohol as of May 2013 Spectrum of defects (D) Neurobehavioral phenotype Successful prevention strategy Successful intervention strategy Genetic Susceptibility Nutritional factors Prevalence in various populations throughout the world Incidence in offspring of women who drink various amounts of alcohol

20 Feature N (%) p-value* Railroad Track Ears No Ptosis No Heart Murmur No 29 (11.8) 12 (4.9) 6 (1.8) 30 (12.2) 11 (4.5) 4 (1.2) 25 (10.2) 5 (2.0) 5 (1.5) Fetal Alcohol Spectrum Disorders: Establishing the Broad Range of Structural Defects Kenneth Lyons Jones, H. Eugene Hoyme, Luther K. Robinson, Miguel del Campo, Melanie A. Manning, Lela M. Prewitt, Christina D. Chambers. Decreased elbow pronation/supination No 36 (14.7) 13 (5.3) 4 (1.2) Incomplete extension of digits No 90 (36.7) 43 (17.6) 21 (6.1) Other joint contractures No 6 (2.4) 2 (0.8) 1 (0.3) Hockey Stick crease No 53 (21.6) 28 (11.5) 18 (5.3) Other palmar crease abnormalities No 38 (15.5) 20 (8.2) 13 (3.8)

21 Feature N (%) p-value* Railroad Track Ears No Ptosis No Heart Murmur No 29 (11.8) 12 (4.9) 6 (1.8) 30 (12.2) 11 (4.5) 4 (1.2) 25 (10.2) 5 (2.0) 5 (1.5) Fetal Alcohol Spectrum Disorders: Establishing the Broad Range of Structural Defects Kenneth Lyons Jones, H. Eugene Hoyme, Luther K. Robinson, Miguel del Campo, Melanie A. Manning, Lela M. Prewitt, Christina D. Chambers. Decreased elbow pronation/supination No 36 (14.7) 13 (5.3) 4 (1.2) Incomplete extension of digits No 90 (36.7) 43 (17.6) 21 (6.1) Other joint contractures No 6 (2.4) 2 (0.8) 1 (0.3) Hockey Stick crease No 53 (21.6) 28 (11.5) 18 (5.3) Other palmar crease abnormalities No 38 (15.5) 20 (8.2) 13 (3.8)

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23 Feature N (%) p-value* Railroad Track Ears No Ptosis No Heart Murmur No 29 (11.8) 12 (4.9) 6 (1.8) 30 (12.2) 11 (4.5) 4 (1.2) 25 (10.2) 5 (2.0) 5 (1.5) Fetal Alcohol Spectrum Disorders: Establishing the Broad Range of Structural Defects Kenneth Lyons Jones, H. Eugene Hoyme, Luther K. Robinson, Miguel del Campo, Melanie A. Manning, Lela M. Prewitt, Christina D. Chambers. Decreased elbow pronation/supination No 36 (14.7) 13 (5.3) 4 (1.2) Incomplete extension of digits No 90 (36.7) 43 (17.6) 21 (6.1) Other joint contractures No 6 (2.4) 2 (0.8) 1 (0.3) Hockey Stick crease No 53 (21.6) 28 (11.5) 18 (5.3) Other palmar crease abnormalities No 38 (15.5) 20 (8.2) 13 (3.8)

24 Feature N (%) p-value* Railroad Track Ears No Ptosis No Heart Murmur No 29 (11.8) 12 (4.9) 6 (1.8) 30 (12.2) 11 (4.5) 4 (1.2) 25 (10.2) 5 (2.0) 5 (1.5) Fetal Alcohol Spectrum Disorders: Establishing the Broad Range of Structural Defects Kenneth Lyons Jones, H. Eugene Hoyme, Luther K. Robinson, Miguel del Campo, Melanie A. Manning, Lela M. Prewitt, Christina D. Chambers. Decreased elbow pronation/supination No 36 (14.7) 13 (5.3) 4 (1.2) Incomplete extension of digits No 90 (36.7) 43 (17.6) 21 (6.1) Other joint contractures No 6 (2.4) 2 (0.8) 1 (0.3) Hockey Stick crease No 53 (21.6) 28 (11.5) 18 (5.3) Other palmar crease abnormalities No 38 (15.5) 20 (8.2) 13 (3.8)

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26 Questions to be Answered Regarding the Prenatal Effects of Alcohol as of May 2013 Spectrum of defects (D) Neurobehavioral phenotype Successful prevention strategy Successful intervention strategy Genetic Susceptibility Nutritional factors Prevalence in various populations throughout the world Incidence in offspring of women who drink various amounts of alcohol

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28 Russia/Ukraine CID Clinical Project Prospective cohort study involving 300 moderate to heavily exposed pregnant women recruited from Ladies Consultation Prenatal Care Centers and 300 low/unexposed comparison women

29 Specific Aim 1 Measure incidence and spectrum of alcohol-related birth outcomes in relation to specific dose and timing of alcohol: Standardized repeated in-person maternal interviews; supplemented by biomarkers of exposure Standardized physical examinations by specially trained neonatologists/geneticists Neurobehavioral testing at 6 m and 12 m with BSID II; infant stimulus response testing at 6 m

30 Specific Aim 2 Assess contribution of nutritional status and effect of nutritional intervention trial initiated in mid-pregnancy Blood samples taken at enrollment and third trimester - evaluated for vitamin and mineral status Multivitamin/mineral supplement provided for 50% of sample upon enrollment Additional choline supplement provided to 25% of sample upon enrollment

31 Specific Aim 2: Results Specific maternal micronutrient levels in pregnancy vary by maternal dose of alcohol. Specific maternal micronutrient levels in pregnancy are significantly correlated with cardinal facial features and growth in alcohol exposed/affected children. A MVM intervention initiated mid-gestation appears in preliminary analysis to have a protective effect on some alcohol-associated neurocognitive performance measures and growth in infants in the first year of life.

32 Questions to be Answered Regarding the Prenatal Effects of Alcohol as of May 2013 Spectrum of defects (D) Neurobehavioral phenotype Successful prevention strategy Successful intervention strategy Genetic Susceptibility Nutritional factors Prevalence in various populations throughout the world Incidence in offspring of women who drink various amounts of alcohol

33 Prevalence of Fetal Alcohol Syndrome Western Cape Province, South Africa - Wave 3 Category Number of Children Total in 1st grade 1,013 Screened for growth (Tier 1) 818 Dysmorphology exam (Tier 2) Preliminary diagnosis Final diagnosis D Rate /1,000 May PA et al Drug and Alcohol Dependence 88: (2007)

34 Prevalence of Fetal Alcohol Syndrome Lazio Province, Italy Category Number of Children Total N in 1st grade 1,086 Total evaluated (Tier 1) 543 Total dysmorphology exam (Tier 2) Final diagnosis Rates D + 1 ARND per 1, per 1,000 D May PA Alcoholism Clin Exp Res 30: (2006)

35 Fetal Alcohol Syndrome in Boarding Schools and Orphanages in Moscow Facility Total Number Children Children Examined Preliminary Diagnosis Confirmed Diagnosis Boarding Schools for Children Mental Deficiency N = 5 Orphanages for Children with Mental Deficiency N = (76%) (6.1%) (87%) (12.3%) Orphanages for Normal or Mildly Delayed Children N = (76%) (8.9%) Marintcheva G et al Soc Clin Psychiatry 3:17-22 (2003)

36 Questions to be Answered Regarding the Prenatal Effects of Alcohol as of May 2013 Spectrum of defects (D) Neurobehavioral phenotype Successful prevention strategy Successful intervention strategy Genetic Susceptibility Nutritional factors Prevalence in various populations throughout the world Incidence in offspring of women who drink various amounts of alcohol

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38 Moderate Alcohol Consumption Alcohol Evidence of Prenatal Effect Consumed Alcohol Normal 2 or more ounces of absolute alcohol (n=16) 3/16 (19%) 13/16 (81%) 1-2 ounces absolute alcohol (n=54) Less than 1 ounce absolute alcohol (n=93) 6/54 (11%) 48/54 (89%) 2/93 (2%) 91/93 (98%)

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40 Conclusion and where from here? We can improve ability of clinicians to make a diagnosis We can move diagnosis to an earlier age Risk factors for /D may vary by population and subgroup but heavy episodic drinking is the primary factor Prevention of prenatal alcohol exposure among risky drinkers should be the goal