Preventing Fetal Alcohol Spectrum Disorders. Association of Reproductive Health Professionals

Transcription

1 Preventing Fetal Alcohol Spectrum Disorders Association of Reproductive Health Professionals

2 Acknowledgment This program was made possible through a cooperative agreement from The Arc, Inc.

3 Disclosure Declarations Name Lee Shulman, MD (Chair) Susie Adams, PhD, RN, PMHNP, FAANP (Planner) Susan Astley, PhD (Planner) Sarah C. M. Roberts, DrPH (Planner) Deborah Cohen, PhD (Planner) Disclosure Dr. Shulman is a speaker and/or consultant for Actavis, Teva, Merck, Bayer, Shionogi, Sequenom, Natera, Quest, Roche Labs. Dr. Adams has nothing to disclose. Dr. Astley has nothing to disclose. Dr. Roberts has nothing to disclose. Dr. Cohen has nothing to disclose.

4 Disclosure Declarations Name Disclosure Diane W. Shannon, MD (Medical Writer) Lanita L. Williams, MPH (Planner) Beth Jordan Mynett, MD (Planner) Wayne Shields (Planner) Nothing to disclose. Nothing to disclose. Nothing to disclose. Nothing to disclose.

5 Which of the following is associated with prenatal exposure to alcohol? A. Seizure disorder. B. Small head size. C. Speech delays. D. All of the above. 25% 25% 25% 25% Seizure disorder. Small head size. Speech delays. All of the above.

6 Which of the following is a true statement about the risk factors for fetal alcohol spectrum disorders (FASDs)? A. Beer consumption is not associated with FASDs. B. Children exposed to the same amount of alcohol are consistently affected to the same degree. C. Genetic differences are believed to play a role in FASDs. D. All of the above E. None of the above Beer consumption is not... Genetic differences are be... Children exposed to the... 20% 20% 20% 20% 20% All of the above None of the above

7 Regarding screening for alcohol use, which of the following is true? A. Questionnaires, such as TWEAK, should be used for both pregnant and nonpregnant women. B. In a pregnant woman, any amount of drinking is considered a positive result. C. Only woman at risk for drinking based on demographic factors should be screened. D. If brief motivational interviewing will be used, alcohol screening is not necessary. 25% 25% 25% 25% Questionnaires, such as... In a pregnant woman, an... Only woman at risk for d... If brief motivational inte...

8 Learning Objectives Understand that alcohol is a teratogen and identify the outcomes associated with prenatal alcohol exposure. Identify patients at risk for an offspring with an FASD. Integrate conversations about the risks of alcohol consumption during pregnancy into contraceptive and family planning counseling. more

9 Learning Objectives (continued) Apply appropriate patient-centered communication skills to counsel reproductive age and pregnant women on prevention strategies to reduce the risks of FASDs. Use brief motivational interviewing to assist pregnant women in choosing to avoid alcohol consumption.

10 Understanding FASDs

11 Alcohol is a Teratogen It passes across the placenta from the maternal blood to the fetal blood and causes developmental malformations. When a woman drinks alcohol, so does the fetus. The higher the level of drinking, the greater the risk to the developing fetus. CDC 2014; Astley SJ. Can J Clin Pharmacol. 2010; Astley SJ. J Popul Ther Clin Pharmacol

12 Fetal Alcohol Syndrome Astley SJ. 2004

13 Fetal Alcohol Spectrum Disorders Astley SJ. J Popul Ther Clin Pharmacol

14 FASD Characteristics Abnormal facial features Growth impairment Small head size Shorter-than-average height Low body weight CNS structural and/or functional abnormalities Abnormal brain structure(s) Seizure disorder Cognitive-behavioral effects Poor coordination Hyperactive behavior Difficulty with attention CDC more

15 FASD Characteristics (continued) Poor memory Difficulty in school Learning disabilities Speech and language delays Intellectual disability or low IQ Poor reasoning, judgment, planning and organizational skills Poor adaptive (daily living) skills Motor and sensory abnormalities Sleep and sucking problems as infant CDC

16 FASD Prevalence CDC. Morbid Mortal Weekly Rep. 2002; Sampson PD, et al. Teratology. 1997; May PA. Alcohol Res Health

17 Costs of FASDs To individuals Lifelong disabilities Mental health difficulties Other To families Care for child with lifelong disabilities To society Up to $6.5 billion annually CDC. 2014; Popova S. et al. Alcohol

18 Alcohol Abstinence During Pregnancy FASDs are completely preventable. more

19 Alcohol Abstinence During Pregnancy (continued) Like smoking and obesity, alcohol during pregnancy has adverse effects on maternal and fetal outcomes.

20 Risk Factors for FASDs

21 Risk Factors for FASDs Alcohol is an equal opportunity teratogen.

22 Demographic Risk Factors Ethnicity (disadvantaged groups) Lower SES status Maternal age 30 years Age at first drink <12 years Other children with FAS Unmarried status CDC

23 Other Risk Factors Amount and frequency of exposure Timing of exposure Genetics of woman Genetics of fetus Poor nutrition Unknown factors Bottom line: There is no known safe amount of alcohol during pregnancy. CDC

24 Defining Alcohol Use and Abuse

25 Definition of a Single Drink Beer 12 ounces Wine 5 ounces Spirits/hard liquor 1.5 ounces CDC. 2014; Kaskutas LE. Addiction

26 Drinking Risk Levels for Non- Pregnant Women Risk Level Drinks per day Drinks per week Low-Moderate 3 7 High >3 >7 Binge 4 drinks per occasion N/A National Institute on Alcohol Abuse and Alcoholism

27 Alcohol Consumption in the US: Adults Age 18 and Older SAMHSA

28 Drinking Intensity among Women Binge Drinkers CDC. Morb Mortal Wkly Rep. 2012; DuRant RH. Arch Pediatr Adolesc Med

29 Evidence of Risk with Low Levels of Exposure

30 Childhood Behavior Problems with Moderate Alcohol Exposure Included 12,000 children <6 drinks per week Behavioral problems (p=0.01) Flak AL, et al. Alcohol Clin Exp Res

31 Effects of prenatal alcohol exposure on neurodevelopment might start at levels <1 drink a day during the prenatal period Flak AL. Alcohol Clin Exp Res

32 Risk of FASDs with Low-Moderate Alcohol Exposure Lower birth weight Lower verbal ability in adolescence Reductions in specific brain regions in adulthood Behavioral problems in adulthood FAS Nykjaer C, et al. J Epidemiol Community Health. 2014; Flak AL, et al. Alcohol Clin Exp Res. 2014; Willford JA, et al. Alcohol Clin Exp Res. 2004; Eckstrand KL, et al. Alcohol Clin Exp Res. 2012; Day NL, et al. Alcohol Clin Exp Res. 2013; Astley S, et al. BJOG. 2012; Astley SJ. Can J Clin Pharmacol

33 Factors Affecting Reporting Recall error Feelings of guilt or shame Concern about legal repercussions

34 Contradicting Results: Danish National Birth Cohort Study Highest intake showed better outcomes Interpret results with caution Fundamental differences between women who drink and abstainers Confounding factors may be involved Niclasen J. Alcohol and Alcoholism

35 Delayed Effects of FASDs children exposed to and damaged by prenatal alcohol exposure do deceptively well in their preschool years. The full impact of their alcohol exposure will not be evident until their adolescent years.

36 Messaging about Prenatal Alcohol Use

37 Guidance Timeline Late 1960s Effects described 1988 Advisory placed on liquor containers 1981 Surgeon General: avoid alcohol in pregnancy 2005 Surgeon General: abstain if pregnant or might become pregnant Lemoine P et al. Quest Medical. 1968; Jones KL, et al. Lancet. 1973; FDA. FDA Drug Bulletin DHHS. Press release. 2005; Ulleland CN. Ann NY Acad Sci. 1972; SAMHSA. Curriculum for Addiction Professionals.

38 Other Guidance with No Alcohol During Pregnancy Message US DHHS. 2012; ACOG 2011; AAP. Pediatrics

39 No Safe Alcohol Message For Risk for specific fetus is unknown Large variation with similar exposure Consumption levels unclear Evidence of risks with low levels Nathanson V et al. BMJ. 2007; O Brien P. BMJ Against May increase under-reporting May cause anxiety in pregnant women May undermine confidence in system

40 Barriers to No Safe Level of Alcohol Message Lack of recognition of danger Social and cultural norms Reluctance of health care providers to discuss CDC

41 Effective Messaging France KE, et al. BMC Public Health *p 0.05 vs control

42 Counseling Patients

43 FASD Prevention Strategies Avoid alcohol during pregnancy Avoid pregnancy while drinking alcohol CDC. 2014; Astley 2000.

44 Setting the Stage for Counseling Dispel myths Share data Refer to guidance of advisory bodies Integrate into workflow Review risk assessment regularly Use automated alerts and audit process Maintain list of vetted referral services Screen all women of childbearing age

45 Screening Tool: TWEAK 1. Tolerance: How many drinks without falling asleep or passing out? 2. Worried: Have friends or relatives worried about your drinking? 3. Eye-opener: Do you sometimes take a drink in the morning when you first get up? Russell M, et al. Alcohol Clin Exp Res more.

46 Screening Tool: TWEAK 4. Amnesia: Have friends and relatives told you about things you said or did that you could not remember? 5. Cut Down: Do you sometimes feel the need to cut down on your drinking? An answer of 6 to the first question or a total score of 3 or more denotes a problem with alcohol use and a need for further assessment. Russell M, et al. Alcohol Clin Exp Res

47 Common Elements of Brief Interventions National Highway Traffic Safety Administration

48 Brief Motivational Interview One form of brief intervention Aims at increasing a patient s readiness for change May require many BMIs Clinicians should also have a list of community resources

49 BMI: Four Steps Raise the subject. Provide feedback. Assess readiness to change. Negotiate and advise. Keough VA, et al. J Obstet Gynecol Neonatal Nurs. 2009

50 One Message: Four Scenarios Preconception counseling or family planning Prenatal care for light drinkers Prenatal care for moderate-heavy drinkers Prenatal care and assessment for women with alcohol dependence or abuse

51 Preconception Counseling or Family Planning Educate about alcohol risks in pregnancy Consider contraceptive method Encourage adoption of health behaviors before pregnancy Communicate message There is no Safe Amount of Alcohol During Pregnancy

52 Prenatal Counseling for Light Drinkers Educate Communicate There is no Safe Amount of Alcohol During Pregnancy Provide perspective about past drinking Encourage health behaviors

53 Prenatal Counseling for Moderate- Heavy Drinkers Educate Communicate There is no Safe Amount of Alcohol During Pregnancy Provide perspective Emphasize importance of stopping Assess readiness Encourage health behaviors

54 Counseling for Women with Alcohol Use Disorder in Pregnancy Educate Encourage health behaviors Communicate There is no Safe Amount of Alcohol During Pregnancy Emphasize importance of stopping Assess readiness Refer for evaluation and treatment

55 Summary Prenatal exposure to alcohol can cause permanent neurologic and behavioral problems Research has not found a safe timing or level of exposure FASDs are completely preventable with abstinence from alcohol during pregnancy more

56 Summary (continued) Clinicians should communicate a single message: There is no Safe Amount of Alcohol During Pregnancy Because almost half of all pregnancies in the US are unplanned, women should also avoid alcohol when they might become pregnant It is never too late to stop drinking and reduce the risk of FASDs more

57 Summary (continued) All women of childbearing age and pregnant women should be screened Effective screening tools exist Motivational interviewing can be effective in reducing alcohol intake Women with alcohol use disorders should be referred for treatment

58 Case Presentation 1: Anne

59 Anne: FASD Risk Q: Is Anne at Risk?

60 Anne: FASD Risk A: Yes, if she drinks

61 Anne: Counseling There is no Safe Amount of Alcohol During Pregnancy

62 Anne: Health Promotion Risk is small Risk can be reduced Steps she can take

63 Case presentation 2: Carla Photo of pregnant woman more more

64 Carla: Drinking History 2-3 drinks about 4 times a week Heavier drinking about once a month 5 drinks at a wedding last week Pattern similar to drinking during past pregnancy with her son

65 Carla: Physical Exam and Tests Normal physical exam Beta HCG is positive

66 Carla: Screening for Problem Drinking TWEAK 1. Tolerance: How many drinks without falling asleep or passing out? 2. Worried: Have friends or relatives worried about your drinking? 3. Eye-opener: Do you sometimes take a drink in the morning when you first get up? 4. Amnesia: Have friends and relatives told you about things you said or did that you could not remember? 5. Cut Down: Do you sometimes feel the need to cut down on your drinking? Russell M, et al. Alcohol Clin Exp Res

67 Carla: Counseling

68 Carla: Follow up

69 Case Presentation 3: Cathy

70 Cathy: Screening for Problem Drinking TWEAK 1. Tolerance: How many drinks without falling asleep or passing out? 2. Worried: Have friends or relatives worried about your drinking? 3. Eye-opener: Do you sometimes take a drink in the morning when you first get up? 4. Amnesia: Have friends and relatives told you about things you said or did that you could not remember? 5. Cut Down: Do you sometimes feel the need to cut down on your drinking? Russell M, et al. Alcohol Clin Exp Res

71 Cathy: Counseling Educate Encourage health behaviors Communicate There is no Safe Amount of Alcohol During Pregnancy Emphasize importance of stopping Assess readiness

72 Cathy: Next Steps Advice Motivating statement Request

73 Cathy: Next Steps It s great that you feel ready to stop, but stopping can be hard on your own.

74 Cathy: Next Steps I would like you to see a specialist for evaluation and treatment to help you be successful.

75 Cathy: Next Steps Would you be willing to see someone?

76 Which of the following is associated with prenatal exposure to alcohol? A. Seizure disorder. B. Small head size. C. Speech delays. D. All of the above. 25% 25% 25% 25% Seizure disorder. Small head size. Speech delays. All of the above.

77 Which of the following is a true statement about the risk factors for fetal alcohol spectrum disorders (FASDs)? A. Beer consumption is not associated with FASDs. B. Children exposed to the same amount of alcohol are consistently affected to the same degree. C. Genetic differences are believed to play a role in FASDs. D. All of the above E. None of the above Beer consumption is not... Genetic differences are be... Children exposed to the... 20% 20% 20% 20% 20% All of the above None of the above

78 Regarding screening for alcohol use, which of the following is true? A. Questionnaires, such as TWEAK, should be used for both pregnant and nonpregnant women. B. In a pregnant woman, any amount of drinking is considered a positive result. C. Only woman at risk for drinking based on demographic factors should be screened. D. If brief motivational interviewing will be used, alcohol screening is not necessary. 25% 25% 25% 25% Questionnaires, such as... In a pregnant woman, an... Only woman at risk for d... If brief motivational inte...