Fetal Alcohol Syndrome

Fetal alcohol syndrome is a term for the severe end of a range of birth defects that can occur when a woman drinks alcohol during pregnancy. It is one of the leading preventable causes of mental retardation and birth defects. Fetal alcohol syndrome is a lifelong condition.

The term fetal alcohol spectrum disorder (FASD) refers to not only fetal alcohol syndrome, but other types of damage caused by exposure to alcohol in utero.

Types and Terminology

Exposure to alcohol prenatally (in the womb) can cause a spectrum (wide range) of disorders. Many terms have been used to describe children who have some, but not all, of the signs of FAS. Three terms are fetal alcohol effects (FAE), alcohol-related neurodevelopmental disorder (ARND), and alcohol-related birth defects (ARBD).

The term FAE has been used to describe behavioral and cognitive (thinking) problems in children who were exposed to alcohol in the womb, but who do not have all of the typical features of FAS. In 1996, the Institute of Medicine (IOM) replaced FAE with the terms ARND and ARBD. People with ARND can have functional or mental problems linked to prenatal alcohol exposure. These include behavioral or cognitive deficits, or both. Examples are learning difficulties, poor school performance, and poor impulse control. They can have difficulties with mathematical skills, memory, attention, judgment, or a combination of these. People with ARBD can have problems with the heart, kidneys, bones, hearing, or a combination of these.

The term fetal alcohol spectrum disorders (FASDs) describes the wide range of effects that can occur in a person whose mother drank alcohol during pregnancy. These effects can include physical, mental, behavioral, learning disabilities, or a combination of these. Unlike people with FAS, those with one of the FASDs do not show the obvious physical traits of FAS, such as abnormal facial features, so they often go undiagnosed.

Signs and Symptoms

The three most important features of FAS are:

• Abnormal facial features
• Growth deficiency
• Central nervous system (brain) problems

The central nervous system or CNS (brain) problems are the most serious.

Abnormal facial features

The characteristic facial abnormalities associated with FASD include:

• Narrow eye openings (palpebral fissures)
• Thin upper lip
• Unusually smooth skin between nose and upper lip
• Underdeveloped ears
• Microcephaly (small head)
• Short, upturned nose with a flat bridge

The first three of these characteristics are needed for a diagnosis of FAS.

Growth deficiency

Children with FAS tend to be small for their age, or short compared to their peers. They may also have organ and skeletal deformities.

Central nervous system problems

Central nervous system (CNS) (brain) problems include difficulties with learning, memory, attention span, communication, vision, or hearing. These problems often lead to social and school difficulties. The learning difficulties vary; only one-fourth of FAS patients have an IQ less than 70.^[1]

Whereas the characteristics described above are all present in FAS, fetal alcohol spectrum disorder (FASD) describes one, two, or all three of these manifestations of alcohol damage to the fetus. Thus, FASD may be used to describe children who only have CNS problems. Some other CNS complications due to alcohol exposure in the womb include the following:

• Poor coordination or hyperactive behavior
• Developmental disabilities such as speech and language delays, learning disabilities, mental retardation, or low IQ
• Problems with self-care such as tying shoes or organizing one’s day
• Poor reasoning and judgment skills
• Sleep and sucking disturbances in infants

As they get older, people with FASD often have mental health problems, disrupted school experiences, trouble with the law, unemployment, inappropriate sexual behavior, or a combination of these.

Brain damage

The brain is the most sensitive organ to alcohol exposure during fetal development. If a pregnant mother drinks one alcoholic beverage a week, that is enough to cause CNS problems in the child. The hallmark feature of FASD is Microcephaly, or a small brain. Individual areas of the brain that are often damaged or shrunken include the frontal and inferior parietal and perisylvian areas, the basal ganglia, and the cerebellum, which controls body coordination. In many cases there is a striking reduction of the corpus callosum—the tract that joins the two halves of the brain together. The damage done in the womb probably continues to affect later brain growth.^[1]

Causes

FAS and the other FASDs are caused when a woman drinks alcohol during pregnancy. Alcohol is poisonous to developing fetuses, and, according to the U.S. Surgeon General,^[2] there is no known safe time to drink alcohol during pregnancy. Damage to the fetus (developing baby) can be caused even if a woman drinks before she realizes she's pregnant.

FASDs are not genetic or hereditary. A women with FASD will not have a child with FASD if she avoids alcohol during her pregnancy.

Alcohol in the mother’s blood crosses the placenta freely and enters the embryo or fetus through the umbilical cord. Alcohol exposure in the first 3 months of pregnancy can cause structural defects (e.g., facial abnormalities). By contrast, growth and CNS problems can occur from drinking alcohol any time during pregnancy.

Diagnosis

FAS is diagnosed when three factors are present:

1. A characteristic pattern of facial abnormalities including a thin upper lip, smooth philtrum (the groove running vertically between the nose and lips), and small eye openings
2. Growth retardation
3. Brain damage, which often shows up as intellectual difficulties or behavioral problems

Clinicians should try to determine whether the mother has drunk alcohol during pregnancy.

Currently, FAS cannot be detected by a lab test.

Diagnoses that could be confused with FAS

A child's facial abnormalities should not be relied upon for the diagnosis of FAS, because other disorders, including Williams syndrome, DeLange syndrome, velocardiofacial syndrome, fetal hydantoin syndrome, and Dubowitz syndrome may have similar facial features. ^[1]

Some patients who were exposed to alcohol while in the womb have alcohol-related neurodevelopmental disorder (ARND), a condition related to FAS but with only the criterion of brain damage present.^[3]

Chances of Developing FAS

The reported rates of FAS vary widely. These different rates depend on the population studied and the surveillance methods used. Studies by the Centers for Disease Control and Prevention show FAS rates ranging from 0.2 to 1.5 cases per 1,000 live births in different areas of the United States. Other prenatal alcohol-related conditions, such as ARND and ARBD, may occur more often than FAS.

Risk factors for giving birth to a FAS child include: maternal age greater than 30, a history of binge drinking (five or more drinks on one occasion) and low socioeconomic status.

Treatment

FAS and the other FASDs last a lifetime, and there is no cure. Still, social services and special education can help children reach their potential, so diagnosing a child with an FASD as early as possible is critically important. The kinds of problems that often develop in children with FASDs, such as disruptive behaviors and trouble with the law, may be made less likely in a nurturing and stable environment.

See: Fetal Alcohol Spectrum Disorders Treatment

Prevention

FAS and the other FASDs can be completely prevented if a woman does not drink alcohol while pregnant.

When a pregnant woman drinks alcohol, so does her unborn baby. According to the U.S. Surgeon General,^[2] there is no known safe amount of alcohol that a pregnant woman can drink, nor any safe time during pregnancy to drink alcohol. (However, other countries have come to different conclusions; see Controversy.) Alcohol can have negative effects on a fetus in every trimester of pregnancy. Therefore, women in the U.S. are advised not to drink if they are pregnant, planning to become pregnant, or could become pregnant (that is, sexually active and not using effective birth control).

If a woman is drinking during pregnancy, it is never too late for her to stop. The sooner a woman stops drinking, the better it will be for her baby. A woman should use an effective form of birth control until her drinking is under control.

Some research into prevention of FAS has focused on antioxidants. In studies of pregnant animals given alcohol to drink, some expected abnormalities did not occur if the pregnant animals were given antioxidants, such as Vitamin E, along with the alcohol.^[4][5]

Fathers and FASDs

Alcohol's effect on male sperm has been studied in rats.^[6][7][8] There is some suggestion that human fathers' drinking alcohol may affect the fetus,^[9] but whatever the effects are, they are not FASDs. FASDs are caused specifically by the mother’s alcohol use during pregnancy.

Clinical Trials

Click here for a list of ongoing clinical trials relating to:

• FAS
• FASD

Research

• A list of research articles relating to FASD from 1973 to 2004 is available here.

• A search engine for journal articles about FAS is available from the National Organization on Fetal Alcohol Syndrome (NOFAS)

Controversy

Some women can drink heavily during pregnancy and their babies do not seem to have any problems. Others drink less and their babies show various signs of alcohol exposure.

The U.S. Surgeon General issued a warning in 1981,^[10] repeated consistently since,^[2] that women should not drink any amount of alcohol during pregnancy. This public-health advice continues to be standard in American health-care educational materials. However, other countries have come to different conclusions from the available data and have issued more permissive standards in their public-health statements.

For example, in Great Britain, the Royal College of Obstetricians and Gynaecologists reviewed the available evidence and concluded that there is no known harm to drinking one or two drinks once or twice a week during pregnancy.^[11]

The authors Elizabeth Armstrong and Ernest L. Abel suggest that the American concern with eliminating all alcohol consumption during pregnancy is due in part to a "moral panic."^[12]

Scope and Economic Burden

The 10th Special Report to the U.S. Congress on Alcohol and Health estimated the annual cost of FAS in 1998 to be $2.8 billion. A recent report estimates that the lifetime cost to care for one person with FAS in 2002 was $2 million. This is an average for all people with FAS. People with severe problems, such as profound mental retardation, have much higher costs.^[13]

Notable Experts

Ernest L. Abel, of the Departments of Obstetrics and Gynecology and Psychology, Wayne State University, Michigan, USA, has spent his entire career researching the effects of alcohol on the fetus and working to prevent FASDs.^[12]

See: Fetal Alcohol Spectrum Disorders: Training and Education

Related Videos

The Story of Iyal

In this podcast, a mother tells her compelling story about a family living with fetal alcohol spectrum disorders.

References

1. ↑ ^{1.0 1.1 1.2} Riley EP, McGee CL. Fetal alcohol spectrum disorders: an overview with emphasis on changes in brain and behavior. Exp Biol Med (Maywood). 2005 Jun;230(6):357-65. Abstract | Full Text
2. ↑ ^{2.0 2.1 2.2} United States Department of Health and Human Services. U.S. Surgeon General Releases Advisory on Alcohol Use in Pregnancy. February 21, 2005.
3. ↑ Wattendorf DJ, Muenke M. Fetal alcohol spectrum disorders. Am Fam Physician. 2005 Jul 15;72(2):279-82, 285. Abstract | Full Text
4. ↑ Wentzel P, Rydberg U, Eriksson UJ. Antioxidative treatment diminishes ethanol-induced congenital malformations in the rat. Alcohol Clin Exp Res. 2006 Oct;30(10):1752-60. Abstract
5. ↑ Cohen-Kerem R, Koren G. Antioxidants and fetal protection against ethanol teratogenicity. I. Review of the experimental data and implications to humans. Neurotoxicol Teratol. 2003 Jan-Feb;25(1):1-9. Abstract
6. ↑ Abel EL. Paternal and maternal alcohol consumption: effects on offspring in two strains of rats. Alcohol Clin Exp Res. 1989 Aug;13(4):533-41. Abstract
7. ↑ Leichter J. Effect of paternal alcohol ingestion on fetal growth in rats. Growth. 1986 Summer;50(2):228-33. Abstract
8. ↑ Abel EL. Duration of paternal alcohol consumption does not influence offspring growth and development. Growth Dev Aging. 1989 Winter;53(4):195-9. Abstract
9. ↑ Abel E. Paternal contribution to fetal alcohol syndrome. Addict Biol. 2004 Jun;9(2):127-33; discussion 135-6. Abstract
10. ↑ Surgeon General's Advisory on Alcohol and Pregnancy. FDA Drug Bulletin. July 1981;11(2):9-10.
11. ↑ Royal College of Obstetricians and Gynaecologists (2006) Statement No. 5: Alcohol Consumption and the Outcomes of Pregnancy Royal College of Obstetricians and Gynaecologists, London.
12. ↑ ^{12.0 12.1} Armstrong EM, Abel EL. Fetal alcohol syndrome: the origins of a moral panic. Alcohol Alcohol. 2000 May-Jun;35(3):276-82. Abstract | Full Text
13. ↑ CDC: Fetal Alcohol Spectrum Disorders

External Links

U.S. Department of Health and Human Services: Substance Abuse Treatment Facility Locator

National Task Force on Fetal Alcohol Syndrome and Fetal Alcohol Effect (2002)

Centers for Disease Control and Prevention: Guidelines for Identifying and Referring Persons with Fetal Alcohol Syndrome

National Organization on Fetal Alcohol Syndrome

Fetal Alcohol Spectrum Disorders (FASD) Center for Excellence: a federal initiative devoted to preventing and treating FASD

National Center on Birth Defects and Developmental Disabilities

Fetal Alcohol Syndrome Diagnostic and Prevention Network

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Related Accredited Articles

1. Ask the Doctor Q&A;: Risks of Alcohol During Pregnancy
2. Content from Harvard Medical School