This is a guideline on Fetal Alcohol Spectrum Disorder from SIGN outlining the assessment and management of children who have had prenatal alcohol exposure (PAE). It was published in Jan 2019.
Prenatal alcohol exposure is important because it causes Fetal Alcohol Spectrum Disorder (FASD).
A big take home message for me is to think about prenatal alcohol exposure when seeing any child with a neurodevelopmental problem.
I'm going to outline the bits of the guideline that are of most relevance to us.
Why is this important for us as GPs?
It is thought that about 32 per 1000 children have FASD and it is very likely that it is significantly underdiagnosed. It may not be picked up for several reasons. Firstly we just don't consider it when we see a child with problems. Secondly it is thought that children who have FASD may often end up with other diagnoses instead, such as ADHD or ASD.
If it isn't picked up, children with FASD can go on to have a higher rate of mental health problems, substance misuse, crime, low educational achievement and a higher rate of premature death from violence, crime or accidents. If picked up, educational adjustments can be made and the child's outcome is much better.
What is FASD?
Fetal alcohol spectrum disorder encompasses fetal alcohol syndrome and some other related syndromes and disorders.
Fetal alcohol syndrome is characterised by the following specific diagnostic criteria:
- Evidence of prenatal alcohol exposure.
- Evidence of structural or functional CNS abnormalities (eg problems with motor skills, cognition, language, memory, attention and affect regulation among other areas).
- A specific pattern of 3 sentinel facial abnormalities (see below).
- Growth impairment (prenatally and / or postnatally).
The sentinel facial abnormalities:
- Short palpebral fissures
- Smooth philtrum.
- Thin upper lip.
The latter 2 of these can be classified using guides from Washington University.
There are quite specific criteria for all of these elements, but we don't really need to know them. We just need to spot that a child may be at risk.
What is the current advice we should be giving mothers about alcohol in pregnancy?
The Chief Medical Officer's advice regarding alcohol in pregnancy is basically don't drink at all:
- If you are pregnant or think you could become pregnant, the safest approach is not to drink alcohol at all, to keep risks to your baby to a minimum.
- Drinking in pregnancy can lead to long-term harm to the baby, with the more you drink the greater the risk.
- The risk of harm to the baby is likely to be low if you have drunk only small amounts of alcohol before you knew you were pregnant or during pregnancy.
- If you find out you are pregnant after you have drunk alcohol during early pregnancy, you should avoid further drinking. You should be aware that it is unlikely in most cases that your baby has been affected. If you are worried about alcohol use during pregnancy do talk to your doctor or midwife.
Why is the advice not to drink at all?
We used to think that surely the odd glass of wine a couple of times a week is OK for a pregnant mum.
It is true that there is little evidence of harm to the fetus from low levels of drinking in pregnancy. However, there are few relevant and good quality studies in this area, which means that it is not possible to say that low level drinking carries no risk to the fetus. We know that drinking 1 to 2 units a day can increase the risk of low birth weight, preterm birth and being small for gestational age. It was also felt that it is very difficult to study the effects of low levels of alcohol on the fetus as mothers are often not aware when they are in the early stages of pregnancy.
How should we screen women for alcohol use in pregnancy?
All women should be assessed for alcohol use prenatally and postnatally. We should consider using a validated tool (eg T-ACE, TWEAK, AUDIT-C). These can all be found on the SIGN document on FASD assessment.
If women are drinking above advised levels, then we should offer early brief interventions (eg referral or a brief structured conversation about alcohol - whatever is appropriate to her level of drinking).
How should we assess for the risk of prenatal alcohol exposure?
Studies often suggest that women either under report, or don't report their alcohol consumption in pregnancy.
If you have a child sat in front of you with neurodevelopmental problems you should consider asking a mother about her alcohol use in pregnancy. You should also consider looking at other sources of information about her alcohol use (eg clinical observation, other reliable people, other clinical records or any other evidence of drinking).
If all 3 sentinel facial features of FASD are present, then it is very specific for prenatal alcohol exposure, though there are a few other conditions that can cause them.
Who should we be referring?
We should refer children when there is:
- A probable history of prenatal alcohol exposure AND
- Significant physical, developmental or behavioural concerns.
It is very important to note that SIGN advises that any such referral be done 'sensitively'.