But in a recent study , Bell found that eight brands of the vitamins contained 50 mg or less, and 17 brands had none at all. In the '70s, alcohol was seen as so harmless during pregnancy that it was often used to slow premature labor. Fetal alcohol syndrome was first identified in , said Warren, who began studying the condition four years later.
Women were given an IV drip of alcohol, keeping their blood alcohol levels for days at more than twice what would be considered legal to drive today. Most also ignored the fact that children with fetal alcohol syndrome eventually grow into adults with the disorder. Bell, a psychiatrist in a hard-scrabble neighborhood of Chicago, said the community where he works has been devastated by fetal alcohol exposure. Bell said he often sees fetal alcohol in grownups as well.
Adults with fetal alcohol may have a bad temper, poor social judgement and terrible math skills, he said. Furthermore, the warning label's impact on drinking during pregnancy has been modest. For a comprehensive review of the impact of the alcohol warning label on perception of risks including drunk driving, birth defects, and health problems; and drinking behavior in a variety of situations, see Mackinnon For example, Greenfield and Kaskutas examined exposure to the warning label among a national probability sample of adults using annual cross-sectional telephone surveys.
In a cross-sectional design, each participant is interviewed only once and a new sample is created for every year of the survey. For that study, interviews were conducted in , , , , and that included a total of approximately 8, respondents.
In , 6 months after the implementation of the label, 21 percent of respondents said they had seen the warning label during the past 12 months. By exposure to the label had reached a plateau, according to the investigators, with 51 percent of respondents reporting that they had seen the label in the past 12 months.
As part of a cross-sectional and longitudinal study of the effects of alcohol beverage warning labels, Kaskutas and colleagues conducted a phone survey of a national representative sample of pregnant women from through Exposure to the warning label fluctuated over the course of the study 7 percent saw the label in , 27 percent in both and , 58 percent in , and 42 percent in [no data was collected in ]. Exposure to signs or posters also varied over the study period from a high of 28 percent in to a low of 13 percent in , 21 percent; , 17 percent; , 17 percent.
Advertisements about drinking during pregnancy were seen by 81 percent of women during , , and , but by fewer women in and 65 percent and 58 percent, respectively. Finally, 84 percent of women had conversations about drinking during pregnancy in both and , and 87 percent in , but only 74 percent in and 58 percent in These data suggest changes, and in some cases, decreases in the proportion of women exposed to these media messages over time.
Seventy-five percent of the women reported not drinking, whereas 21 percent had one or two drinks and 4 percent admitted drinking at least three drinks on any single day during pregnancy. Several other studies have tracked the awareness of warning labels in various populations, as follows: A Detroit study using a probability sample of 1, women found that 39 percent of the women had seen a warning label in the past 12 months. Among abstainers, 18 percent had seen a warning label, compared with 52 percent of women who drank.
Seventy-seven percent of those who had seen the label recalled that it mentioned birth defects Hankin An Indiana study evaluated knowledge of the warning label among 1, 12 th grade students in the fall of i.
The study found that in the fall of , 26 percent reported having seen alcohol warning labels compared with 41 percent in the fall of In , 65 percent of respondents who reported seeing the label also reported that it mentioned birth defects, 2 2 Reports of having seen warning labels before the labels actually existed are not uncommon.
Another study tracked changes in label awareness from May through June among 7, inner-city African American women seeking prenatal care.
Over the month study period, the level of label awareness continued to increase through December , when it reached the maximum of about 80 percent Hankin et al. Using the same inner-city prenatal clinic, Hankin and colleagues examined the impact of the warning label on drinking during pregnancy. This study involved 21, pregnant African American women using the prenatal clinic between and Controlling for patient characteristics and the unemployment rate, 3 drinking began to decline 8 months after the implementation of the warning label Hankin et al.
For example, pregnant women may drink more when they have fewer resources and support. Furthermore, when unemployment is high, choices for prenatal care are limited, and more poor pregnant women may turn to the prenatal clinic where the study was conducted. Hankin and colleagues hypothesize that pregnant women may drink more when unemployment is high. They were unable to find any study that specifically examined this relationship.
However, the following studies show that alcohol consumption, binge drinking, alcohol problems, and alcohol-related diseases are related to unemployment rates: Unemployment and drinking behavior: Some data from a general population survey of alcohol use. British Journal of Addiction Economic change, alcohol consumption, and heart disease mortality in nine industrialized countries.
Social Science and Medicine Stressful events, stressful conditions, and alcohol problems in the United States: Journal of Studies on Alcohol Job loss and alcohol abuse: A test using data from the Epidemiologic Catchment Area Project. Journal of Health and Social Behavior However, this decline was only modest i.
Thus, by , the women's alcohol consumption rose again and by , pregnant women had become accustomed to the message. Selective prevention targets all women in their reproductive years who drink alcohol although most studies target heavy drinkers.
One randomized trial assessed the impact of a brief intervention on drinking during pregnancy in this population Chang et al. Women who score two or more points are considered risk drinkers.
The brief intervention consisted of a minute session with a physician and included the articulation of drinking goals while pregnant, identification of risk situations for drinking and alternatives to drinking, and the recommendation of abstinence during pregnancy from the Surgeon General and the Secretary of Health and Human Services. The study investigators then interviewed women once they had given birth about their alcohol consumption since the original assessment.
Women in both groups reduced their alcohol consumption during pregnancy, and no difference existed between the two groups in the decrease in average number of drinks per drinking day. Accordingly, Chang and colleagues concluded that screening alone may be related to a reduction of drinking during pregnancy.
The study also attempted to identify patient characteristics that predicted greater success of the intervention approach. For example, the brief intervention appeared most successful for women who had been drinking alcohol in the previous 6 months but who had been abstinent in the 90 days prior to their first prenatal visit.
Among current drinkers at baseline in the brief intervention group, women who articulated specific drinking goals for specific reasons were more likely to reduce alcohol consumption or abstain from alcohol during pregnancy than were women without such goals Chang et al. An ongoing randomized clinical trial is extending these selective prevention efforts by applying them to an indicated prevention program.
In this trial, recruitment focuses on a high-risk population of pregnant women who are currently drinking, drank during a previous pregnancy, or drank at least one drink daily prior to current pregnancy.
In this study, the investigators, led by Chang, are comparing the results of an assessment-only condition with an enhanced brief intervention that involves a support partner chosen by the pregnant woman. Handmaker and colleagues piloted a study to evaluate the results of motivational interviewing with 42 pregnant problem drinkers.
Women reporting any recent drinking were randomly assigned either to the experimental group that received a 1-hour motivational interview focused on weighing drinking against the risk of birth defects, or to a control group that received a letter explaining the risks of drinking during pregnancy and recommending the woman talk to her obstetrical provider about the risks.
Women in both groups had significantly reduced their alcohol intake at followup 2 months later. Women who self-reported the highest levels of blood alcohol concentrations had the greatest decrease in alcohol consumption if they were in the experimental group compared with the control group. Blood alcohol concentrations were estimated using computer projections that were based on self-reports of estimated number of drinks, alcohol content of drinks, length of drinking episodes, the woman's weight, and an average rate of alcohol metabolism for women.
Another selective prevention approach that was part of the Developing Effective Educational Resources DEER project examined the exposure and reactions to warnings about drinking during pregnancy in samples of pregnant Native Americans and African Americans living in the Northern California Bay area and Los Angeles. In this study, Kaskutas found that although the women were frequently exposed to warning messages, they were uncertain about the impact of FAS.
Specifically, only about a quarter of the women could name at least one birth defect associated with FAS and only one-fifth knew that FAS was related to alcohol consumption. Furthermore, the women did not understand the benefits of quitting drinking at any time during pregnancy, and they had the misconception that wine, beer, and wine coolers are safer to drink during pregnancy than liquor.
Finally, most of the women underestimated their drinking. Thus, when the investigator compared alcohol intake using standard drink sizes 5 5 A standard drink frequently is defined as 12 ounces of beer, 5 ounces of wine, or 1. Ongoing research is extending this methodology and testing a novel prevention program for pregnant women enrolled in a health maintenance organization Kaskutas and Graves In this randomized clinical trial, the investigators use models of alcoholic beverage containers beverage containers of various sizes, such as ounce versus ounce beer bottles or beer cans, or liquor bottles that range from milliliters, milliliters, and 1 liter or drinking vessels shot glasses, wine glasses, or drinking glasses with lines marked off with letters so women could tell the investigators how high they filled the glass and a computer program to help pregnant women understand how much they actually drink.
After the women identify the bottle or glass they typically drink from, the computer program calculates the absolute ounces of alcohol consumed. These nonconfrontational approaches of using drinking vessels and beverage containers and talking about drinking in a nonthreatening way help the women discuss their drinking habits while pregnant. Indicated prevention efforts are directed toward the population at highest risk of having children with FAS or alcohol- related effects-that is, women who have a history of drinking during pregnancy or have previously delivered a child affected by alcohol.
Several studies have assessed prevention approaches directed at this population to prevent the birth of further alcohol-affected children. Handmaker and Wilbourne  thoroughly review motivational interventions in prenatal clinics, describing additional approaches not mentioned here.
One of these approaches was the Protecting the Next Pregnancy project, which targeted women who had been identified as drinking heavily during the last pregnancy called the index pregnancy. The goal of the intervention being tested was to reduce the women's drinking during their next pregnancies Hankin and Sokol ; Hankin et al.
All women consuming at least four drinks per week i. The women's average alcohol consumption was 1. Four weeks after giving birth, the women were randomly assigned to an experimental group that received an intensive brief intervention or a control group that received standard clinical care.
The study included women, who were followed up to 5 years. The brief intervention involved a one-on-one method, which was based on a cognitive behavioral approach, and included 5 sessions beginning at 1 month after giving birth and continuing for 12 months. In those sessions, the counselor reviewed the definition of a standard drink, helped the women set the goal of abstention or reduction of alcohol use, established limits on consumption if not abstaining , and taught ways to reduce drinking.
Additional booster sessions were conducted over the 5-year followup period. The control group was simply advised that "You can have a healthier baby if you cut back or stop drinking during pregnancy. Of the participants, 96 women delivered 1 or more infants during the followup period. The investigators found that women in the experimental group drank significantly less than did women in the control group during the subsequent pregnancies. While 25 percent of the women in the control group drank at least 0.
Several characteristic craniofacial abnormalities are often visible in individuals with FAS. FAS facial features and most other visible, but non-diagnostic, deformities are believed to be caused mainly during the 10th and 20th week of gestation.
Refinements in diagnostic criteria since have yielded three distinctive and diagnostically significant facial features known to result from prenatal alcohol exposure and distinguishes FAS from other disorders with partially overlapping characteristics. The lip and philtrum are measured by a trained physician with the Lip-Philtrum Guide,  a five-point Likert Scale with representative photographs of lip and philtrum combinations ranging from normal ranked 1 to severe ranked 5.
Palpebral fissure length PFL is measured in millimeters with either calipers or a clear ruler and then compared to a PFL growth chart, also developed by the University of Washington. Ranking FAS facial features is complicated because the three separate facial features can be affected independently by prenatal alcohol. A summary of the criteria follows: Prenatal alcohol exposure, which is classified as a teratogen , can damage the brain across a continuum of gross to subtle impairments, depending on the amount, timing, and frequency of the exposure as well as genetic predispositions of the fetus and mother.
All four diagnostic systems allow for assessment of CNS damage in these areas, but criteria vary. Structural abnormalities of the brain are observable, physical damage to the brain or brain structures caused by prenatal alcohol exposure. Structural impairments may include microcephaly small head size of two or more standard deviations below the average, or other abnormalities in brain structure e.
Microcephaly is determined by comparing head circumference often called occipitofrontal circumference, or OFC to appropriate OFC growth charts. Because imaging procedures are expensive and relatively inaccessible to most people, diagnosis of FAS is not frequently made via structural impairments, except for microcephaly. Evidence of a CNS structural impairment due to prenatal alcohol exposure will result in a diagnosis of FAS, and neurological and functional impairments are highly likely.
During the first trimester of pregnancy, alcohol interferes with the migration and organization of brain cells , which can create structural deformities or deficits within the brain. As of , there were 25 reports of autopsies on infants known to have FAS.
The first was in , on an infant who died shortly after birth. Clarren described a second infant whose mother was a binge drinker. The infant died ten days after birth. The autopsy showed severe hydrocephalus , abnormal neuronal migration, and a small corpus callosum which connects the two brain hemispheres and cerebellum. When structural impairments are not observable or do not exist, neurological impairments are assessed. In the context of FASD, neurological impairments are caused by prenatal alcohol exposure which causes general neurological damage to the central nervous system CNS , the peripheral nervous system , or the autonomic nervous system.
A determination of a neurological problem must be made by a trained physician, and must not be due to a postnatal insult, such as a high fever , concussion , traumatic brain injury , etc. All four diagnostic systems show virtual agreement on their criteria for CNS damage at the neurological level, and evidence of a CNS neurological impairment due to prenatal alcohol exposure will result in a diagnosis of FAS or pFAS, and functional impairments are highly likely.
Neurological problems are expressed as either hard signs, or diagnosable disorders, such as epilepsy or other seizure disorders , or soft signs. Soft signs are broader, nonspecific neurological impairments, or symptoms, such as impaired fine motor skills , neurosensory hearing loss , poor gait , clumsiness , poor eye-hand coordination. Many soft signs have norm-referenced criteria , while others are determined through clinical judgment. When structural or neurological impairments are not observed, all four diagnostic systems allow CNS damage due to prenatal alcohol exposure to be assessed in terms of functional impairments.
There is no consensus on a specific pattern of functional impairments due to prenatal alcohol exposure  and only CDC guidelines label developmental delays as such,  so criteria and FASD diagnoses vary somewhat across diagnostic systems. Other conditions may commonly co-occur with FAS, stemming from prenatal alcohol exposure. However, these conditions are considered alcohol-related birth defects  and not diagnostic criteria for FAS.
Fetal alcohol syndrome usually occurs when a pregnant woman has more than four standard drinks per day. Evidence of harm from less than two drinks per day or 10 drinks per week is not clear. On the contrary, clinical and animal studies have identified a broad spectrum of pathways through which maternal alcohol can negatively affect the outcome of a pregnancy.
Clear conclusions with universal validity are difficult to draw, since different ethnic groups show considerable genetic polymorphism for the hepatic enzymes responsible for ethanol detoxification.
Genetic examinations have revealed a continuum of long-lasting molecular effects that are not only timing specific but are also dosage specific; with even moderate amounts being able to cause alterations. A human fetus appears to be at triple risk from maternal alcohol consumption: Because admission of alcohol use during pregnancy can stigmatize birth mothers, many are reluctant to admit drinking or to provide an accurate report of the quantity they drank.
This complicates diagnosis and treatment  of the syndrome. As a result, diagnosis of the severity of FASD relies on protocols of observation of the child's physiology and behavior rather than maternal self-reporting. A positive finding on all four features is required for a diagnosis of FAS. However, prenatal alcohol exposure and central nervous system damage are the critical elements of the spectrum of FASD, and a positive finding in these two features is sufficient for an FASD diagnosis that is not "full-blown FAS".
While the four diagnostic systems essentially agree on criteria for fetal alcohol syndrome FAS , there are still differences when full criteria for FAS are not met. This has resulted in differing and evolving nomenclature for other conditions across the spectrum of FASD, which may account for such a wide variety of terminology.
Most individuals with deficits resulting from prenatal alcohol exposure do not express all features of FAS and fall into other FASD conditions. However, these other FASD conditions may create disabilities similar to FAS if the key area of central nervous system damage shows clinical deficits in two or more of ten domains of brain functioning.
In these other FASD conditions, an individual may be at greater risk for adverse outcomes because brain damage is present without associated visual cues of poor growth or the "FAS face" that might ordinarily trigger an FASD evaluation. Such individuals may be misdiagnosed with primary mental health disorders such as ADHD or oppositional defiance disorder without appreciation that brain damage is the underlying cause of these disorders, which requires a different treatment paradigm than typical mental health disorders.
The following criteria must be fully met for an FAS diagnosis: To make this diagnosis or determine any FASD condition, a multi-disciplinary evaluation is necessary to assess each of the four key features for assessment. Generally, a trained physician will determine growth deficiency and FAS facial features.
These professionals work together as a team to assess and interpret data of each key feature for assessment and develop an integrative, multi-disciplinary report to diagnose FAS or other FASD conditions in an individual. People with pFAS have a confirmed history of prenatal alcohol exposure, but may lack growth deficiency or the complete facial stigmata. Central nervous system damage is present at the same level as FAS.
These individuals have the same functional disabilities but "look" less like FAS. The following criteria must be fully met for a diagnosis of Partial FAS: Fetal alcohol effects FAE is a previous term for alcohol-related neurodevelopmental disorder and alcohol-related birth defects. Alcohol-related neurodevelopmental disorder ARND was initially suggested by the Institute of Medicine to replace the term FAE and focus on central nervous system damage, rather than growth deficiency or FAS facial features.
The Canadian guidelines also use this diagnosis and the same criteria. While the "4-Digit Diagnostic Code" includes these criteria for three of its diagnostic categories, it refers to this condition as static encephalopathy. The behavioral effects of ARND are not necessarily unique to alcohol however, so use of the term must be within the context of confirmed prenatal alcohol exposure. The following criteria must be fully met for a diagnosis of ARND or static encephalopathy: Prenatal alcohol exposure is determined by interview of the biological mother or other family members knowledgeable of the mother's alcohol use during the pregnancy if available , prenatal health records if available , and review of available birth records, court records if applicable , chemical dependency treatment records if applicable , or other reliable sources.
Exposure level is assessed as confirmed exposure , unknown exposure , and confirmed absence of exposure by the IOM, CDC and Canadian diagnostic systems. Amount, frequency, and timing of prenatal alcohol use can dramatically impact the other three key features of FASD.
While consensus exists that alcohol is a teratogen, there is no clear consensus as to what level of exposure is toxic. The IOM and Canadian guidelines explore this further, acknowledging the importance of significant alcohol exposure from regular or heavy episodic alcohol consumption in determining, but offer no standard for diagnosis.
Canadian guidelines discuss this lack of clarity and parenthetically point out that "heavy alcohol use" is defined by the National Institute on Alcohol Abuse and Alcoholism as five or more drinks per episode on five or more days during a day period. For many adopted or adults and children in foster care, records or other reliable sources may not be available for review.
Reporting alcohol use during pregnancy can also be stigmatizing to birth mothers, especially if alcohol use is ongoing. Confirmed absence of exposure would apply to planned pregnancies in which no alcohol was used or pregnancies of women who do not use alcohol or report no use during the pregnancy.
This designation is relatively rare, as most people presenting for an FASD evaluation are at least suspected to have had a prenatal alcohol exposure due to presence of other key features of FASD. The standardized approach is referred to as the Ten Brain Domains and encompasses aspects of all four diagnostic systems' recommendations for assessing CNS damage due to prenatal alcohol exposure. The framework provides clear definitions of brain dysfunction, specifies empirical data needed for accurate diagnosis, and defines intervention considerations that address the complex nature of FASD with the intention to avoid common secondary disabilities.
The proposed Ten Brain Domains include: However, the Ten Brain Domains are easily incorporated into any of the four diagnostic systems' CNS damage criteria, as the framework only proposes the domains, rather than the cut-off criteria for FASD.
The CDC reviewed nine syndromes that have overlapping features with FAS; however, none of these syndromes include all three FAS facial features, and none are the result of prenatal alcohol exposure: The only certain way to prevent FAS is to avoid drinking alcohol during pregnancy.
There is some controversy surrounding the "zero-tolerance" approach taken by many countries when it comes to alcohol consumption during pregnancy. The assertion that moderate drinking causes FAS is said to lack strong evidence and, in fact, the practice of equating a responsible level of drinking with potential harm to the fetus may have negative social, legal, and health impacts.
There is no cure for FASD, but treatment is possible. Because CNS damage, symptoms, secondary disabilities, and needs vary widely by individual, there is no one treatment type that works for everyone. Behavioral interventions are based on the learning theory , which is the basis for many parenting and professional strategies and interventions. Frequently, a person's poor academic achievement results in special education services, which also utilizes principles of learning theory , behavior modification , and outcome-based education.
Fetal Alcohol Syndrome Prevention Research Janet R. Hankin, Ph.D. Alcohol consumption during pregnancy can have numerous adverse health consequences for the developing fetus, including fetal alcohol syndrome (FAS) and alcohol-related effects, and therefore is a significant public health problem.
Feb 09, · Amanda Dreasher, a public health nurse, measures a boy's eyes in , in Emporia, Kan., at the Fetal Alcohol Syndrome Clinic. (David Doemland/AP) Fetal alcohol syndrome, which can be physically, emotionally and intellectually disabling, is quite common, and most sufferers are not being diagnosed, according to new research.
Alcohol can disrupt fetal development at any stage during a pregnancy — including at the earliest stages and before a woman knows she is pregnant. Research shows that binge drinking, which means consuming four or more drinks per occasion, and regular heavy drinking put a fetus at the greatest risk. National Organization on Fetal Alcohol Syndrome / Volunteer for CIFASD Research Prenatal alcohol exposure can harm a baby’s body or brain, and can cause challenges that can last a lifetime. However, not enough is known about Fetal Alcohol Spectrum Disorders (FASD).
Fetal Alcohol Spectrum Syndrome Research (FASDs), Prenatal Substance Exposure, and Prevention Research Fetal Alcohol Spectrum Disorders (FASDs), Prenatal Substance Exposure, and Prevention Research Preventing FAS/ARND in Russian Children (NIH, National Institute on Alcohol and Alcoholism (NIAAA) and Fogarty International Center). Fetal alcohol spectrum disorder is an umbrella phrase that includes the more well known ‘fetal alcohol syndrome,’ which can be fatal. FASD also can cause severe complications with learning ability and behavior, stunted development, and facial abnormalities.