Prevalence of Fetal Alcohol Spectrum Disorders in 4 US Communities

A Primary Care Approach to Visual Screening in Adults with Intellectual and Developmental Disabilities

This article explores the unique challenges faced by adults with intellectual and developmental disabilities (IDDs) and proposes ways in which primary care physicians can improve ocular health in this patient population. The existing literature does not offer specific guidelines for vision screening in adults with IDDs in the primary care setting. Effectively screening for ocular issues and making timely referrals to specialists can improve ocular health. We recommend screening visual acuity at least annually, even in the absence of visual complaints in adults with IDDs to monitor for changes in visual acuity in this unique patient population that is prone to visual challenges and is vulnerable to underdiagnosis of related conditions.

Maternal, paternal, and dual-parental alcohol exposures result in both overlapping and distinct impacts on behavior in adolescent offspring

Emerging research reveals that alcohol use by fathers before conception can affect the growth and development of their offspring. Here, we used a C57BL/6J mouse model to study the effects of alcohol exposure on the behavior of the first-generation (F1) offspring, comparing the impacts of alcohol exposure by mothers, fathers, and both parents. Our goal was to determine how alcohol exposure by each parent or both parents influences the behavior of the offspring. We found that adolescent male offspring of alcohol-exposed fathers showed reduced anxiety-like behaviors as they spent more time in the center of the testing arena during the open field test. Both maternal and paternal alcohol exposure caused sex-specific increases in the nestlet shredding test while decreasing the number of buried marbles in the marble burying test. Interestingly, dual-parental alcohol exposure did not produce any significant changes in these same tests. However, during novel object recognition testing, we found that dual-parental male and female offspring exhibit an increased preference for novel objects, suggesting an increased risk preference. Finally, at sixteen weeks, male offspring of dual-exposed parents exhibited decreased voluntary physical activity on running wheels during the active phase, suggesting alterations in their circadian rhythms. Although differences in parental exposure histories between treatment groups make interpretation challenging, our findings suggest that exposure to alcohol by both parents may have unique effects on behavior and that studying both maternal and paternal alcohol use is essential for understanding the full range of factors influencing the penetrance and severity of alcohol-related phenotypes.

ASTROCYTES AND ALCOHOL THROUGHOUT THE LIFESPAN

Evidence for involvement of astrocytes in several neurodegenerative disorders and in drug addiction has been emerging over the last two decades, but only in recent years have astrocytes been investigated for their roles in alcohol use disorder (AUD). As a result, there is a need to evaluate existing preclinical literature supporting involvement of astrocytes in the effects of alcohol exposure. Here we review emerging evidence about responses of astrocytes to alcohol, and the contributions of astrocytes to the development of AUD. We review studies of single-cell RNA sequencing with a focus on alcohol and astrocyte heterogeneity, astrocyte reactivity, and the role of astrocytes in remodeling the extracellular matrix. Effects of alcohol on astrocyte-modulated synaptic transmission are also discussed emphasizing studies never reviewed before. Since astrocytes play essential roles in brain development, we review recent research on the role of astrocytes in fetal alcohol spectrum disorders (FASD) which may also shed light on fetal development of psychiatric disorders that have a high prevalence in individuals affected by FASD. Finally, this review highlights gaps in knowledge about astrocyte biology and alcohol that need further research. Particularly, the dire need to identify astrocyte subpopulations and molecules that are susceptible to alcohol exposure and may be targets for therapeutic intervention.

Thalamic Nuclear Volumes in Fetal Alcohol Spectrum Disorders: from Adolescence to Middle-Age 20 Years Later

BACKGROUND

Midline orofacial and brain structures, including the multinucleated thalamus, may be differentially sensitive to prenatal alcohol exposure and vulnerable to accelerated aging.

METHODS

Two sets of MRI data separated by 20 years are reported for controls, individuals with fetal alcohol syndrome (FAS), and nondysmorphic individuals with heavy fetal alcohol exposure (FAE). MRI1 included 179 participants with 69 reassessed at MRI2. Segmentation produced estimates of bilateral thalamic volume and 10 bilateral nuclei, which were aggregated into Anterior, Ventral, Posterior, and Medial Volumes. Differences were assessed without and with correction for intracranial volume (ICV).

RESULTS

MRI1 revealed stepwise group differences in ICV, total thalamic volume, and Anterior and Ventral regions uncorrected for ICV, where Controls>FAE>FAS. Corrected for ICV, the smaller volumes endured in the Anterior and Ventral regions, although differences between FAE and FAS groups were attenuated. Nuclei volumes were selectively smaller in the alcohol-exposed groups than controls even after controlling for ICV. Longitudinally, thalamic volumes typically declined over time maintaining the stepwise effects and with little evidence for accelerated decline in the FAE or FAS groups.

CONCLUSIONS

These novel data revealed stable deficits in thalamic nuclei of the groups with heavy fetal alcohol exposure. After 20 years, the deficits endured but without accelerated age-related decline and following the same aging pattern as controls. Despite parallel aging functions in all groups, ICV adjustment yielded volume deficits localized to the anterior and ventral thalamic nuclei, differing from patterns in the remaining thalamic nuclei and cortical brain structures.

Emotion socialization practices in non-biological parents of children with FASD

BACKGROUND

Fetal alcohol spectrum disorders (FASD) represent highly prevalent neurodevelopmental and physical differences associated with prenatal alcohol exposure. People with FASD have difficulty with emotion regulation and are often living with non-biological parents. Caregiver emotion socialization practices have been robustly associated with child emotion regulation development in other populations. Yet no research to date has examined the impact of caregiver factors such as age, relationship to child, and trauma on emotion socialization practices in children with FASD. This research is especially important in non-biological parents given complex parenting challenges they may face.

METHODS

Eighty-seven children with FASD aged 4-12 and their primary caregivers (all non-biological parents) completed interview, observation, and caregiver-report measures of emotion socialization, caregiver emotion experience, and child emotion regulation and behavior. Emotion socialization included emotion coaching (approaching and encouraging emotion) and emotion dismissing (minimizing and discouraging emotion). Correlational and path analyses were used to understand relationships among caregiver factors and study variables.

RESULTS

Correlations indicated greater emotion coaching was associated with greater emotion dismissing (p = .009). Older caregivers reported less emotion coaching (p < .001), while caregivers with greater adverse childhood experiences reported greater frequency of child disruptive behavior (p = .01).

CONCLUSION

Emotion coaching was associated was positively associated with emotion dismissing, suggesting caregivers use a combination of both. Results suggest age and childhood trauma may be important factors in caregiver emotion socialization practices, while caregiver type was less important in this sample. This emphasizes the challenges faced by non-biological parents of children with FASD.

Mutations in the bone morphogenetic protein signaling pathway sensitize zebrafish and humans to ethanol-induced jaw malformations

Fetal alcohol spectrum disorders (FASD) describe ethanol-induced developmental defects including craniofacial malformations. While ethanol-sensitive genetic mutations contribute to facial malformations, the impacted cellular mechanisms remain unknown. Signaling via bone morphogenetic protein (Bmp) is a key regulatory step of epithelial morphogenesis driving facial development, providing a possible ethanol-sensitive mechanism. We found that zebrafish carrying mutants for Bmp signaling components are ethanol-sensitive and affect anterior pharyngeal endoderm shape and gene expression, indicating that ethanol-induced malformations of the anterior pharyngeal endoderm cause facial malformations. By integrating FASD patient data, we provide the first evidence that variants of the human Bmp receptor gene BMPR1B associate with ethanol-related differences in jaw volume. Our results show that ethanol exposure disrupts proper morphogenesis of, and tissue interactions between, facial epithelia that mirror overall viscerocranial shape changes and are predictive for Bmp-ethanol associations in human jaw development. Our data provide a mechanistic paradigm linking ethanol to disrupted epithelial cell behaviors that underlie facial defects in FASD.

Choline enhances elicited imitation memory performance in preschool children with prenatal alcohol exposure: a cumulative report of 3 randomized controlled trials

BACKGROUND

Fetal alcohol spectrum disorders (FASDs) are associated with neurocognitive deficits for which there are no biological treatments. Choline supplementation may attenuate these deficits.

OBJECTIVES

This study was aimed to evaluate choline as a neurodevelopmental intervention for preschool-aged children with FASD.

METHODS

We present combined data from 104 participants with FASD (aged 2.5-5.9 y) from 3 placebo randomized controlled trials (RCTs). Participants in RCT1 and RCT2 were randomly assigned to 9 mo choline (500 mg daily) or placebo. Participants in RCT3 were randomly assigned to 9 mo choline (19 mg/kg daily) or placebo. The primary outcome measure was an elicited imitation (EI) memory task.

RESULTS

Adherence was high (78% doses received). Adverse effects were similar across groups except fishy body odor: choline group, 36%; placebo group, 8%. We observed a trend-level choline advantage; participants receiving choline performed 25% better on EI short-delay adjacent pairs (sequential memory) than those on placebo, with a steeper increase in scores between 6 and 9 mo (ŷ = -10.06; P = 0.03; 95% CI: -19.13, -0.99). No sex difference in response was seen, nor did we observe a dose-response relationship. Age-moderated response to choline between baseline and 9 mo (ŷ = 10.02; P = 0.01; 95% CI: 2.47, 17.57), with greater response in younger (≤4.2 y) than that in older (>4.2 y) participants. Overall, choline showed a beneficial effect on memory but no impact on executive functioning or intelligent quotient.

CONCLUSIONS

The results support choline as a neurodevelopmental intervention for improvement of memory in young children exposed to alcohol prenatally. Specifically, the use of choline bitartrate as a supplement in the range of 260-500 mg/d in children between 2.5 and 5.9 y of age is supported. Future studies are needed to further define appropriate dosage as well as optimal lengths and developmental windows for supplementation. This trial was registered at clinicaltrials.gov as NCT01149538 and NCT02735473.

Answering a Call to Action: Reducing Fetal Alcohol Spectrum Disorders Using a Healthcare Champion Model

Prenatal alcohol exposure and fetal alcohol spectrum disorders (FASDs) remain critical public health issues. Alcohol use in pregnancy is a leading preventable cause of birth defects, developmental disabilities, and learning disabilities. Alcohol screening and brief intervention (SBI) is effective at reducing excessive alcohol use. However, this clinical preventive service remains critically underutilized in primary care. In 2014, the Centers for Disease Control and Prevention called for the creation of FASD Champion programs to promote clinician education about FASDs. Six professional health organizations and groups providing reproductive and child health services set out to create FASD Champion programs. The American College of Obstetricians and Gynecologists FASDs Prevention Program was created to focus on reducing alcohol-exposed pregnancies. The American Academy of Pediatrics' Champion program maintains the goal of improving health outcomes for children with FASDs by improving pediatricians' diagnostic capacity. The American Academy of Family Physicians has prioritized training family physician champions to improve the delivery of alcohol SBI among adult patients. The University of Alaska Anchorage has partnered with the National Association of Nurse Practitioners in Women's Health, the American College of Nurse-Midwives, and the Association of Women's Health, Obstetric, and Neonatal Nurses to assure advanced practice registered nurses and midwives have the knowledge and skills to prevent alcohol-exposed pregnancies and FASDs. The American Association of Medical Assistants has prioritized expanding the knowledge and skills of medical assistants related to promoting alcohol-free pregnancies. Finally, the Champions program at the University of Texas at Austin was established to train health social workers in alcohol SBI. Through the advocacy, education, and mission of these 6 health sectors in collaboration with national organizations and educational institutions, the evidence-based approach of alcohol SBI is being disseminated throughout the United States to reduce the harmful effects of prenatal alcohol exposure.

Identifying family environment profiles in families of children with prenatal alcohol exposure

BACKGROUND

Individuals with prenatal alcohol exposure (PAE) may face unique family environments that potentially influence adaptive functioning and behavioral challenges. This study aimed to identify profiles of families of children with PAE based on family characteristics, including cohesion, conflict, and organization, and to examine the relationship between family environment profiles and child outcomes.

METHODS

Data were collected from caregivers of 283 youth (5-17 years) with histories of PAE. Caregivers completed several questionnaires, including the Child Behavior Checklist (CBCL), Vineland Adaptive Behavior Scales (VABS), and Family Environment Scale (FES). Latent profile analysis (LPA) was used to identify profiles in the family environment using three subscales from the FES (Cohesion, Conflict, and Organization). Model fit was determined by comparing 1-, 2-, 3-, 4-, and 5-profile solutions. One-way ANCOVA follow-up tests were conducted to explore differences in adaptive and behavioral functioning across family environment profiles.

RESULTS

The 4-profile solution was considered the best fit for the data. Interpretation of conditional response probabilities indicated that Profile 1 was defined by low cohesion; Profile 2 was defined by low organization; Profile 3 was defined as high cohesion and organization; and Profile 4 was defined as high conflict. After controlling for race, sex, age, and ethnicity, there were significant profile differences on the Internalizing, Externalizing, and Total Problem Behavior scales of the CBCL. There were no significant differences in adaptive functioning across profiles.

CONCLUSIONS

The results of this study highlight the importance of the family environment in understanding the strengths and challenges experienced by children with PAE. Four unique profiles of family environments emerged in families of children with PAE. The high-conflict profile was associated with increased behavioral problems in children. These findings can be used to support families of children with PAE and to identify treatment targets for interventions for children with PAE and their caregivers.

Fetal alcohol spectrum disorder and health professionals' awareness of the syndrome: A comparison of practitioners' knowledge in two french regions

BACKGROUND

Fetal alcohol spectrum disorder (FASD) is the leading cause of non-genetic intellectual disabilities. Many healthcare professionals in France have benefited from initial and continuing training programs on this public health theme. The objective of our study is to describe and compare knowledge of FASD among health professionals in two different french regions with a health prevention and information system (Indian Ocean (IO)) or without (Nouvelle-Aquitaine (NA)).

METHODS AND SETTINGS

A free and anonymous electronic survey related to perinatality, childhood and adolescence was sent by email or social networks to various health professionals in the IO and NA regions. Responses were analyzed by comparing the function and affiliation of healthcare professionals to each region.

RESULTS

We obtained 193 replies from the IO and 265 replies from NA. On the one hand, 79 % of healthcare professionals reported receiving training on FASD, and most of them were aware that there is no threshold of maternal alcohol intake without risk to the fetus. It appears that 91 % of them are aware of the cognitive-behavioral disorders associated with the diagnosis of FASD. On the other hand, barely 19 % were aware that maternal age is a risk factor, and only 39 % had knowledge of the three cardinal signs of FAS dysmorphia. Only 30 % described a neurological anomaly related to the diagnosis. Regarding alcohol-related neurodevelopmental disorders, 30 % wrongly believed that growth retardation and facial dysmorphia were necessary for diagnosis. Data analysis reveals more variability in inter-professional knowledge in the region without a platform. While there is no direct significant difference between regions regarding knowledge of the FASD, among the NA respondents, only 32 % reported that paternal alcohol consumption was a risk factor, whereas 51 % of the IO respondents were already aware of it.

CONCLUSION

This study points out the heterogeneity of healthcare professionals' knowledge of FASD within each region. It highlights the challenge of informing, training and orienting mothers and their children in an appropriate manner. The establishment of diagnostic platforms seems essential to provide early, optimised and adapted care in response to this particular public health problem.

Cross-Site Evaluation of Alcohol Screening and Brief Intervention Implementation Programs in Healthcare Systems Serving Individuals of Reproductive Age

BACKGROUND

With US Centers for Disease Control and Prevention funding, from 2018 to 2022, 4 large healthcare systems (n = 53 health centers across 7 states) serving people of reproductive age trained staff and provided implementation support for alcohol screening and brief intervention (SBI). This cross-site evaluation explores each healthcare system's implementation approach to implement SBI, reduce excessive alcohol use, and prevent prenatal alcohol exposure (PAE) and fetal alcohol spectrum disorders.

METHODS

The SBIRT (Screening, Brief Intervention, and Referral to Treatment) Program Matrix framed the multilevel strategies to implement alcohol SBI programs from 2018 to 2022. Qualitative and quantitative data sources examined outcomes, guided by one logic model, through systems-level process data and provider-level performance metrics. Data analyses utilized frequencies and means for quantitative data and themes for qualitative data according to an established framework.

RESULTS

Successful approaches within systems included using electronic health records, flexible implementation and workflow protocols, customized training and technical assistance programs, quality assurance feedback loops, and stakeholder buy-in. Centralized management structures were efficient in standardizing implementation across health centers. Decentralized management structures used tailored approaches, enhancing provider/staff SBI acceptance. Across systems, 1259 staff (eg, clinicians, medical assistants) were trained to provide alcohol SBI services and reported pre-post training increases in self-efficacy in performing brief intervention; skills in PAE counseling; and confidence in screening. Fifty-three (48 providing data) health centers implemented alcohol SBI, screening 106 826 patients over the study period with most of the 10 087 patients who screened positive for excessive alcohol use receiving a BI.

CONCLUSIONS

Maximizing the use of technology, employing flexibility in program delivery, and institutionalizing processes and protocols improved workflow, efficiency, and program reach. Ongoing partnership and stakeholder communication identify areas for ongoing improvement, engagement, and best practices for sustainability around substance use screening, which are essential with increases in substance use since the pandemic.

Centering culture in an mHealth adaptation of an alcohol-exposed pregnancy prevention program for American Indian Youth

Native WYSE CHOICES adapted an Alcohol Exposed Pregnancy (AEP) prevention curriculum for mobile health delivery for young urban American Indian and Alaska Native (AIAN) women. This qualitative study explored the relevance of culture in adapting a health intervention with a national sample of urban AIAN youth. In total, the team conducted 29 interviews across three iterative rounds. Participants expressed interest in receiving culturally informed health interventions, were open to cultural elements from other AIAN tribes, and highlighted the importance of culture in their lives. The study underscores why community voices are central in tailoring health interventions for this population.

Importance of Fetal Alcohol Spectrum Disorders Prevention and Intervention

The consumption of alcohol and other substances during pregnancy can impair prenatal development. While scientifically informed public health measures have raised awareness of the risks of harmful prenatal substance exposures, the use of alcohol and other substances during pregnancy continues to rise. The successful dissemination of consistent messaging, health care professional education and training, and universal implementation of clinical interventions may help reduce drinking in pregnancy and prevent fetal alcohol spectrum disorders (FASDs), a constellation of developmental disabilities and birth defects caused by alcohol use during pregnancy. Alcohol screening and brief intervention (alcohol SBI) is an evidence-based preventive practice that enables early identification of excessive drinking and intervention prior to serious consequences. Routine clinical implementation of alcohol SBI has been shown to effectively reduce excessive alcohol consumption among adults, including pregnant people. Many barriers prevent widespread implementation of the practice: a lack of health care professional knowledge of the prevalence and implications of prenatal alcohol exposure, stigma surrounding individuals who use substances potentially harmful to their pregnancy, resistance to public health messages encouraging alcohol avoidance during pregnancy, and discomfort and hesitancy with alcohol SBI procedures among practitioners. The Centers for Disease Control and Prevention (CDC) leads the public health effort to prevent alcohol use during pregnancy and improve identification of and care for children living with FASDs. CDC partners with health systems, health care professional associations, universities, and community-based networks to promote alcohol SBI as an effective but underused preventive health service. This special section consisting of 6 articles including this introductory commentary represents the efforts of 11 CDC projects and their partners to demonstrate the rationale for FASD prevention and intervention, engage health care disciplines to expand prevention messaging and education for providers, develop practical approaches for implementing alcohol SBI in diverse clinical settings, and prevent alcohol use in pregnancy and FASDs.

Multi-Level Approaches to Fetal Alcohol Spectrum Disorders Prevention Education and Training for Health Professionals

BACKGROUND

Alcohol-exposed pregnancies, which can lead to fetal alcohol spectrum disorders (FASDs), is one of the most common preventable causes of lifelong intellectual and developmental disabilities in the U.S. Healthcare teams can play a critical role in preventing FASDs; however, they are currently unprepared to do so. Training can remediate this problem. This article explores the different approaches to the education and training of healthcare providers around FASD prevention used by six Centers for Disease Control (CDC)-funded programs, and how they have been adapted to (1) the specific needs of the healthcare professionals and/or the clinical setting and (2) the challenges posed by the COVID-19 pandemic.

METHODS

This article offers an in-depth description and comparison of the models utilized by the programs described, detailing the challenges of each model as well as the adaptations made. Interdisciplinary collaboration and review highlights these models and offers a variety of solutions and lessons learned that can be implemented in similar practice settings and/or educational initiatives.

RESULTS

Based on organizational structure (i.e., national organization, educational institution, and clinical settings) and program purpose, different methods were employed for FASD education. Some programs were focused on FASD prevention through staff training and alcohol screening and brief intervention/clinical intervention and others were focused on broadscale professional education and awareness. Improvements were made on an ongoing basis as challenges related to COVID-19, staff shortages, and patient and clinician discomfort were identified, resulting in modifications to content and delivery modality (e.g., online forums and use of social media).

CONCLUSION

FASD prevention education is wrought with a variety of challenges related to stigma, discomfort, and misinformation, which these programs encountered in a variety of ways.

Fetal Alcohol Spectrum Disorder and Pediatric Neurology: Are We Missing the Connection? A Scoping Review

IntroductionPediatric neurology provides care for children with complex developmental disorders with environmental, genetic, metabolic, and teratogenic etiologies. Common neurodevelopmental conditions include attention-deficit hyperactivity disorder (ADHD), and autism spectrum disorder. However, only minimal attention from pediatric neurology journals has been devoted to fetal alcohol spectrum disorder. This is surprising because fetal alcohol spectrum disorder is a common neurodevelopmental disorder with a prevalence of between 1% and 5% of school-age children.MethodsThis scoping review had 2 objectives. Objective 1 was to estimate the number of articles reporting on fetal alcohol spectrum disorder in 8 well-respected pediatric neurology journals. Objective 2 was to determine how many patients from a single pediatric neurology practice referred to a clinic for diagnosis and management of neurobehavioral disorders received a diagnosis of ADHD, autism spectrum disorder, and fetal alcohol spectrum disorder.ResultsObjective 1, a survey of 8 prominent pediatric neurology journals until January 2024, found that a title and abstract search identified 1786 articles on the three topics. Papers on autism spectrum disorder (n =1043) accounted for 58.4% of the total. Papers on ADHD (n = 685) comprised 38.4% and articles on fetal alcohol spectrum disorder (n = 58) contributed just 3.3% of the total.Objective 2, a chart review of 40 patients from a single pediatric neurology clinic who were referred for developmental assessment and management, found that 40% had prenatal alcohol exposure and 20% received a diagnosis of fetal alcohol spectrum disorder. High rates of comorbidity between fetal alcohol spectrum disorder and ADHD of 21% and of fetal alcohol spectrum disorder and autism spectrum disorder of 2.5% were found.ConclusionsBecause fetal alcohol spectrum disorder is one of the most common causes of neurodevelopmental disorders, the limited attention to fetal alcohol spectrum disorder in pediatric neurology journals is concerning. This study suggests that in addition to ADHD and autism spectrum disorder, fetal alcohol spectrum disorder may also be a common diagnosis in pediatric neurology practice. Pediatric neurology journals may need to take active steps to increase content on fetal alcohol spectrum disorder. This could include editorials, invited commentaries, or topical reviews. Early recognition and diagnosis of fetal alcohol spectrum disorder allows for the implementation of specific interventions, which can improve the quality of life for patients and families.

Assessing Prenatal Alcohol Exposure History for Pediatric Patients: Practices Among U.S. Clinicians

OBJECTIVES

The American Academy of Pediatrics recommends clinicians who treat pediatric patients screen for prenatal alcohol exposure (PAE) to facilitate the identification of children with fetal alcohol spectrum disorders and promote timely access to behavioral and cognitive interventions. We evaluated how frequently clinicians inquire about PAE in their pediatric patient interactions and the methods used to ascertain this information.

METHODS

We analyzed data from the Fall 2020 DocStyles survey, a web-based survey of primary healthcare professionals (n = 1754). Distributions for frequency of assessing PAE history for five pediatric populations and the methods used were calculated by clinician specialty (family practitioners [FP], pediatricians, and nurse practitioners/physician assistants [NP/PAs]) and overall. Chi-square and Bonferroni post-hoc tests determined whether frequency of assessing PAE history varied by specialty.

RESULTS

Among 779 clinicians serving pediatric patients, approximately 70.5%, 63.0%, and 60.7% reported often/always obtaining PAE history from parents of children with developmental/behavioral issues, adopted/foster children, and newborns, respectively. By contrast, less than half of respondents reported often/always collecting this information from parents of infants (47.6%) and new patients (38.2%). Most respondents reported collecting PAE history through interviews conducted by physicians or physician assistants (69.7%). Obtaining PAE history varied by specialty; pediatricians (71.5%) were more likely to collect PAE history for adopted/foster children when compared to FPs (57.7%, p = 0.003).

CONCLUSIONS FOR PRACTICE

PAE history is not routinely obtained for pediatric patients. These findings highlight the need for trainings and practice supports to aid clinicians in identifying and treating children at-risk of FASDs.

A method for finding epistatic effects of maternal and fetal variants

Introduction

Pregnancy involves a double genome, and genetic variants in the mother and her fetus can act together to influence risk for pregnancy complications, adverse pregnancy outcomes, and diseases in the offspring. Large search spaces have hindered the discovery of sets of single nucleotide polymorphisms (SNPs) that act epistatically.

Methods

Previously, we proposed a method for case-parent studies, called the Genetic Algorithm for Detecting Genetic Epistasis using Triads or Siblings (GADGETS), that can reveal autosomal epistatic SNP-sets in the child's genome. Here we incorporate maternal SNPs, thereby extending GADGETS to nominate SNP-sets containing offspring loci only, maternal loci only, or both. We use a permutation procedure to impose a preference for epistatic over outcome-related but non-epistatic SNP sets. Our maternal-fetal extension uses case-complement-sibling pairs together with mother-father pairs, exploiting Mendelian transmission and a mating-symmetry assumption.

Results

In simulations of 1,000 case-parents triads with 10,000 candidate SNPs, GADGETS successfully detected simulated multi-locus effects involving 3-5 SNPs but was somewhat less successful at distinguishing epistatic SNPs from sets of non-epistatic SNPs that each conferred high risk independently. Though the epistasis-mining algorithms MDR-PDT, TrioFS, and EPISFA-LD were originally designed to find epistatic offspring variants, we generalize them to include maternal SNPs and search more broadly. GADGETS outperformed those competitors and could successfully mine a much larger list of candidate SNPs. Applied to dbGaP data, GADGETS nominated several multi-SNP maternal-fetal sets as potentially-interacting risk factors for orofacial clefting.

Discussion

The extended version of GADGETS can mine for epistasis that involves maternal SNPs.

In Utero Alcohol and Unsuitable Home Environmental Exposure Combined with FMR1 Full Mutation Allele Cause Severe Fragile X Syndrome Phenotypes

We investigated the molecular and clinical profile of five boys carrying the fragile X messenger ribonucleoprotein 1 (FMR1) mutation and who suffered from the effects of prenatal alcohol exposure. Fragile X syndrome (FXS) testing was performed using PCR and Southern Blot analysis, and fragile X messenger ribonucleoprotein protein (FMRP) expression levels were measured by Western blot analysis. Clinical evaluation included cognitive functions, adaptive skills, autism phenotype, and severity of behavior measures. Fetal Alcohol Spectrum Disorder (FASD) was also assessed. Five adopted male siblings were investigated, four of which (cases 1, 2, 3, and 4) were diagnosed with FXS, FASD, and ASD, and one, the fraternal triplet (case 5), was diagnosed with FASD and ASD and no FXS. The molecular profile of case 1 and 2 showed the presence of a hypermethylated full mutation (FM) and the resulting absence of FMRP. Cases 3 and 4 (identical twins) were FM-size mosaics (for the presence of an FM and a deleted allele), resulting in 16% and 50% FMRP expression levels, respectively. FMRP expression level was normal in case 5 (fraternal twin). Severe behavioral problems were observed in all cases, including aggression, tantrum, self-harming, anxiety, and defiant behavior, due to different mutations of the FMR1 gene, in addition to biological exposure, home environmental factors, and potentially to additional background gene effects.

Beyond the baseline: quantification of two phosphatidylethanol homologues in whole blood by LC-MS-MS and retrospective data analysis from a National Reference Laboratory

Alcohol is the most abused substance in Western society, resulting in major economic losses and negative health consequences. Therefore, there is a need for a selective and robust detection method for alcohol consumption in various clinical and forensic settings. This study aimed to validate a mass spectrometry method for quantifying phosphatidylethanol (PEth) and perform retrospective data analysis from the patient population of a national reference laboratory. Quantification of PEth in whole blood was accomplished using an LC-MS-MS assay. Isotopically labeled internal standard for the two PEth homologues was added to the whole-blood specimen, followed by protein precipitation with a mixture of acetonitrile and isopropyl alcohol. After centrifugation, an aliquot of the supernatant was buffered with ammonium acetate before LC-MS-MS analysis on an Agilent 6470 triple quadrupole mass spectrometer coupled to an Agilent 1260 Infinity II LC system. This LC-MS-MS assay was validated for clinical use in accordance with Clinical & Laboratory Standards Institute guidelines. The analytical measurement range, 10-2000 ng/mL, was linear with R2 of 0.999. The within-run and total imprecision was < 5% CV for the low (20 ng/mL), medium (200 ng/mL), and high QC (1000 ng/mL). Results from accuracy and method comparison experiments met the bias criteria of ±15%. Retrospective data analysis showed ∼27% of patients had PEth concentrations <20 ng/mL. Males and females had similar positivity rates for PEth and the positivity rate of women of reproductive age (15-44 years old) was 35% in comparison to 25% in women 45-89 years old. This study's LC-MS-MS method showed acceptable analytical performance in quantifying PEth as a sensitive and specific biomarker for evaluating alcohol consumption. Results from this study may provide an opportunity to educate women of reproductive age on drinking during pregnancy and the long-term effects of alcohol use.

Updated National and State-Specific Prevalence of Congenital Cytomegalovirus Infection, United States, 2018-2022

CONTEXT

Congenital cytomegalovirus (cCMV) infection is the most common infectious cause of birth defects and the leading non-genetic cause of sensorineural hearing loss in the United States. Prior national cCMV infection prevalence estimates were based on one multi-site screening study conducted between 2007 and 2012 and were not adjusted for sociodemographic characteristics, such as maternal race and ethnicity or age.

OBJECTIVE

This study sought to estimate national and state-specific prevalence of cCMV infection in the United States, adjusted for maternal race and ethnicity and maternal age group, by pooling estimates from published studies.

DESIGN

We searched PubMed for U.S. cCMV newborn screening studies conducted between 2003 and 2023. From included studies, we abstracted maternal race and ethnicity- and age group-stratified cCMV prevalence to estimate strata-specific pooled prevalence. We obtained strata-specific weights from live birth data.

MAIN OUTCOME MEASURE

Estimated adjusted national and state-specific prevalence estimates from 2018 to 2022.

RESULTS

Four studies (conducted 2004-2005, 2008, 2007-2012, and 2016-2021) were included for data abstraction. Overall, infants born to non-Hispanic Black (9.3 [8.2-10.5] per 1000) or non-Hispanic American Indian and Alaska Native (8.5 [2.1-33.2] per 1000) mothers had the highest cCMV prevalence. The estimated race and ethnicity-adjusted prevalence was 4.6-4.7 per 1000 live births nationally and ranged from 3.9 to 6.5 per 1000 across states from 2018 to 2022. Southern states and Alaska consistently had the highest cCMV prevalence. The estimated maternal age group-adjusted prevalence was 4.3-4.4 per 1000 live births nationally and ranged from 3.8 to 5.1 per 1000 across states from 2018 to 2022.

CONCLUSIONS

States with larger proportions of racial and ethnic minorities had higher estimated prevalence of cCMV infection compared to states with larger proportions of White persons. These estimates may be useful for informing cCMV surveillance at the jurisdiction level and developing tailored, culturally relevant education and prevention strategies for persons at higher risk.

Understanding the effects of alcohol policies on treatment admissions and birth outcomes among young pregnant people

BACKGROUND

This study examines whether state-level alcohol policy types in the United States relate to substance use disorder treatment admissions and birth outcomes among young pregnant and birthing people.

METHODS

We used data from the Treatment Episode Data Set: Admissions (TEDS-A) and Vital Statistics birth data for 1992-2019. We examined 16 state-level policies, grouped into three types: youth-specific, general population, and pregnancy-specific alcohol policies. Using Poisson and logistic regression, we assessed policy effects for those under 21 (aged 15-20) and considered whether effects differed for those just over 21 (aged 21-24).

RESULTS

Youth-specific policies were not associated with treatment admissions or preterm birth. There were statistically significant associations between family exceptions to minimum legal drinking age (MLDA) policies and low birthweight, but findings were in opposite directions across possession-focused and consumption-focused (MLDA) policies and did not differentially apply to people 15-20 versus 21-24. Most pregnancy-specific policies were not associated with treatment admissions, and none were significantly associated with birth outcomes. A few general population policies were associated with improved birth outcomes and/or increased treatment admissions. Specifically, both government spirits monopolies and prohibitions of spirits and heavy beer sales in gas stations were associated with decreased low birthweight among people 15-20 and among people 21-24. Effects of Blood Alcohol Concentration (BAC) limits varied by age, with slight reductions in adverse birth outcomes among people 15-20, as BAC limits get stronger, but slight increases for those 21-24. Although treatment admissions rates across ages were similar when BAC limits were in place, treatment admissions were greater for pregnant people 21-24 than for 15-20 when there were no BAC limits.

CONCLUSIONS

General population policies also appear effective for reducing the adverse effects of drinking during pregnancy for young people, including those under 21. Policies that target people based on age or pregnancy status appear less effective.

Investigating the Impact of Chronical Prenatal Alcohol Exposure on Fetal Vascular Development Across Pregnancy Stages Using Photoacoustic Tomography

Prenatal alcohol exposure (PAE) is a major contributor to fetal alcohol spectrum disorder (FASD), resulting in neurodevelopmental abnormalities. This study utilizes photoacoustic tomography (PAT) to investigate the effects of PAE on fetal brain vasculature in mice. PAT imaging was conducted from embryonic Day 10 (E10) to Day 20 (E20), aimed to compare two alcohol-exposed groups with a control group. Key vascular parameters, including blood vessel diameter and density, and oxygen saturation (sO2), were analyzed. Results show significant reductions in vessel size and density, as well as reduced sO2 levels, in alcohol-exposed groups, especially from E14 onward, compared to controls. These findings underscore the vulnerability of the fetal brain to alcohol exposure during early development and highlight the potential of PAT as a valuable tool for investigating FASD-related vascular changes.

Fetal alcohol spectrum disorders: where we have come from, trends, and future directions

Fetal alcohol spectrum disorder (FASD) refers to a range of conditions caused by prenatal exposure to alcohol. First described in the 1970s as fetal alcohol syndrome, continuing progress has been made in the understanding, recognition and treatment of what is now recognized to be a range of related neurodevelopmental disorders. FASD is common, especially in countries with higher levels of alcohol consumption such as those in Europe and North America, where the prevalence is estimated to be around 3%. A number of diagnostic systems are in operation in different countries, and work is ongoing to develop an internationally agreed set of diagnostic criteria. People with FASD often have other developmental, mental and somatic conditions, and there appears to be a high rate of traumatic and other adverse experiences in this population. People with FASD are at increased risk of being involved in the criminal justice system, but they may be ill-equipped to successfully navigate it and are likely to provide false confessions, leading to wrongful convictions. Some interventions and treatments have been shown to be effective in improving functioning in children and families affected by FASD, which tend to take the form of coaching, education, advocacy and support. People with FASD have many strengths, which are often overlooked in research. They have been described as skilled musicians, artists and sportspeople with wide vocabularies who are resilient, compassionate, hard-working, and kind. Increasing attention is being paid to FASD but this is not enough. More research, diagnostic capacity, recognition, understanding, infrastructure and support are needed across the world.

Sexual dimorphism in lung transcriptomic adaptations in fetal alcohol spectrum disorders

Current fetal alcohol spectrum disorders (FASD) studies primarily focus on alcohol's actions on the fetal brain although respiratory infections are a leading cause of morbidity/mortality in newborns. The limited studies examining the pulmonary adaptations in FASD demonstrate decreased surfactant protein A and alveolar macrophage phagocytosis, impaired differentiation, and increased risk of Group B streptococcal pneumonia with no study examining sexual dimorphism in adaptations. We hypothesized that developmental alcohol exposure in pregnancy will lead to sexually dimorphic fetal lung morphological and immune adaptations. Pregnant rats were orogastrically treated once daily with alcohol (4.5 g/kg, gestational day [GD] 4 to 10, peak BAC, 216 mg/dl; 6.0 g/kg, GD 11 to 20, peak BAC, 289 mg/dl) or 50% maltose dextrin (isocalorically matched pair-fed controls) to control for calories derived from ethanol. Male and female fetal lung RNA from a total of 20 dams were assessed using the TapeStation (Agilent) and Qubit RNA broad-range assay. Samples with RNA Integrity Numbers (RINs) > 8 were prepared using the NEBNext Poly(A) mRNA Magnetic Isolation Module (NEB), xGen Broad-range RNA Library Prep (IDT), and xGen Normalase UDI Primer Plate 2 (IDT). Final libraries were checked for quality and quantity by Qubit hsDNA and LabChip. The samples were sequenced on the Illumina NovaSeq S4 Paired-end 150 bp. Fetal lung tissue were analyzed for histopathological assessments. Mean fetal weight, crown-rump length and placental efficiency of the alcohol-administered rats were significantly lower (P < 0.05) than the pair-fed control pups. Differentially expressed genes indicated a sex-linked gene regulation dichotomy with a significantly higher number of genes altered in the female fetal lungs compared to the male. Network analysis plot of downregulated genes in the females exposed to alcohol in utero showed a negative impact on T cell activation and regulation, T cell differentiation, decrease in CD8+ T cell number etc. The most altered genes were Cd8b, Ccl25, Cd3e, Cd27, Cd247, Cd3d, Ccr9, Cd2, Cd8a and were decreased by a log2fold change of > 2 (P < 0.05) in the female fetal lungs. KEGG analyses showed that male and female fetal lungs had downregulated genes associated with development and mitosis, whereas the females alone showed dysregulation of T cell genes. Comparison of gross appearance and histopathologic morphology showed that the developing lungs of both male and female fetal pups, displayed stunted differentiation, were relatively hypoplastic, and displayed a diminution of alveolar size and air spaces. Similarly, in both sexes, decreased alveolar capillarization was also evident in the alcohol-exposed fetal lungs. These data provide novel information in a growing area focused on alcohol effects on the offspring lung and its influence on appropriate fetal/neonatal immune responses and highlights the importance of examining sexual dimorphism in developmental adaptations.

Role of Drinking Attitudes and Trait Impulsivity in Prenatal Alcohol Craving and Consumption in Mothers of Reproductive Age

Recognizing the severe consequences of alcohol consumption during pregnancy, such as fetal alcohol spectrum disorders (FASDs), the present study explored the role of drinking attitudes, trait impulsivity, and decision-making toward instant gratification in alcohol craving and consumption during pregnancy among mothers of reproductive age.

Utilizing participants from Amazon Mechanical Turk (N = 141), we first categorized mothers into three groups: those who neither craved nor consumed alcohol during their last pregnancy, those who craved but did not consume, and those who craved and consumed alcohol. Using binomial logistic regression, we then examined what factors, if any, could differentiate between (a) mothers who craved alcohol during pregnancy and those who did not and (b) mothers who resisted alcohol cravings and those who yielded to them.

The findings indicated that drinking attitudes significantly predicted alcohol craving during pregnancy. However, trait impulsivity emerged as a significant predictor of alcohol consumption among those who experienced cravings.

The present study contributes to a better understanding of psychological mechanisms underlying alcohol craving and consumption during pregnancy, which in turn may contribute to the development of targeted interventions for this problem.

Medications for Alcohol Use Disorder Among Birthing People With an Alcohol-related Diagnosis

OBJECTIVES

Although safety and effectiveness of medications for alcohol use disorder (AUD) are well established for adults, literature on these medications in pregnancy is limited. Given known adverse effects of untreated AUD during pregnancy, clinicians and researchers have recently begun to call for reconsidering use of medications for AUD in pregnancy. Thus, we sought to estimate the proportion of birthing people with an alcohol-related diagnosis who received a prescription for medication related to AUD treatment.

METHODS

Data were from Meritive MarketScan, a national private insurance claims database. The study cohort included birthing people aged 25-50 who gave birth to a singleton in the United States between 2006 and 2019 and were matched with an infant. Variables included an alcohol-related diagnosis within a year of birth and receiving a prescription for a medication related to AUD treatment. We calculated proportions with alcohol-related diagnoses who received any AUD medication and each medication type.

RESULTS

Of 1,432,979 birthing person-infant dyads, 2517 (0.18%) had an alcohol-related diagnosis. Of those with an alcohol-related diagnosis, 8.70% (n = 219) received any medication. The most common was gabapentin (4.69%, n = 118), with benzodiazepines for withdrawal as the second most common (2.19%, n = 55). Approximately 2% received naltrexone (1.91%, n = 48) and/or disulfiram (1.39%, n = 35); 0.56% (n = 14) received acamprosate. No one with an alcohol-related diagnosis received phenobarbital. Almost all medications were received postpartum.

CONCLUSIONS

Very few pregnant/postpartum people with alcohol-related diagnoses are prescribed medications related to AUD treatment. Research is needed to examine whether benefits of these medications during pregnancy outweigh harms.

Maternal and paternal risk factors associated with diagnoses within the continuum of fetal alcohol spectrum disorders in the USA: Proximal and distal influences

BACKGROUND

We sought to determine risk factors for fetal alcohol spectrum disorders (FASD) in the United States.

METHOD

Mothers of first-grade children participating in the Collaboration on FASD Prevalence (CoFASP) in three regional sites were interviewed. Maternal and paternal data were reported by mothers of children with an FASD diagnosis and controls.

RESULTS

Interviews were conducted with mothers of children with an FASD (n = 114) and controls (n = 753). Fifty-seven percent of control mothers usually drank 2.7 drinks per drinking day (DDD) once per month prior to pregnancy, and 79% of mothers of children with FASD reported drinking 4.2 drinks 1-2 times per week. Mothers of children with alcohol-related neurodevelopmental disorder reported the most alcohol consumption overall: bingeing, drinking frequency, drinking in each trimester, and other drug use. Mothers of children with fetal alcohol syndrome (FAS) and partial FAS (PFAS) underreported consumption. Distal maternal risk factors were liver problems, depression, later pregnancy recognition and first prenatal visit, lower frequency of marriage, and lower spirituality. Postnatal risk indicators were low birthweight and gestational age. Regression analysis indicated that maternal reports of three DDD before pregnancy were associated with a diagnosis within the FASD continuum (p < 0.001, OR = 9.92). First-trimester exposure (p < 0.001, OR = 7.64) and all three trimesters (p < 0.001, OR = 7.77) were associated with a child's FASD diagnosis. An independent association was found between paternal DDD during pregnancy and FASD diagnoses (p = 0.002, OR = 1.08); but, once maternal drinking was a covariate, paternal influence was not significant. Stepwise models indicated that combined maternal alcohol use measures (p < 0.001, χ2 = 61.09), later pregnancy recognition (p = 0.032, χ2 = 4.58), later prenatal visits (p = 0.036, χ2 = 4.38), and depression in lifetime (p = 0.002, χ2 = 9.47) were significant FASD predictors. The final 10-step model explained 27.4% of the variance in FASD risk.

CONCLUSION

While multiple, significant maternal risk factors for FASD were identified, paternal drinking was not a statistically significant, independent risk factor.

Comparing rates of agreement between different diagnostic criteria for fetal alcohol spectrum disorder: A systematic review

Diagnostic accuracy is important in systems used to diagnose common disorders such as Fetal Alcohol Spectrum Disorder (FASD). Currently, no comprehensive study has examined rates of agreement between different diagnostic criteria for FASD. This study estimates the likelihood that a diagnosis of FASD using one set of diagnostic criteria will result in the same diagnosis when compared to different diagnostic criteria. A systematic review was conducted to identify articles reporting on the comparison of two or more diagnostic criteria for a diagnosis of FASD. Inclusion criteria required that the study present data that estimated agreement for a diagnosis of FASD or no-FASD between two or more FASD criteria using two-by-two tables or presented data that could be used to generate the tables. Meta-analyses with confidence intervals were included to demonstrate variability in the estimates. Standardized measures of agreement were assessed using the kappa statistic with 95% confidence intervals and the phi coefficient as a measure of correlation between binary outcomes. The search identified six studies reporting on eight different FASD diagnostic criteria. The studies compared agreement between 17 different pairings of the criteria. For individual children, agreement ranged from 53.7% to 91%. The agreement between the eight different diagnostic criteria ranged from 59.4% to 89.5%. The kappa statistic found that five associations had a kappa ranging from 0.6 to 0.8. This study illustrates that comparisons of multiple pairs of diagnostic criteria are likely to result in considerable variation in diagnoses of FASD for individual children and between different criteria. The lack of agreement between these commonly used systems is likely to affect clinical care and studies where diagnosis is a key variable. Large-scale multicenter research is needed to examine factors contributing to variation in diagnostic outcomes.

Adolescent Alcohol and the Spectrum of Cognitive Dysfunction in Aging

Among the many changes associated with aging, inflammation in the central nervous system (CNS) and throughout the body likely contributes to the constellation of health-related maladies associated with aging. Genetics, lifestyle factors, and environmental experiences shape the trajectory of aging-associated inflammation, including the developmental timing, frequency, and intensity of alcohol consumption. This chapter posits that neuroinflammatory processes form a critical link between alcohol exposure and the trajectory of healthy aging, at least in part through direct or indirect interactions with cholinergic circuits that are crucial to cognitive integrity. In this chapter, we begin with a discussion of how inflammation changes from early development through late aging; discuss the role of inflammation and alcohol in the emergence of mild cognitive impairment (MCI); elaborate on critical findings on the contribution of alcohol-related thiamine deficiency to the loss of cholinergic function and subsequent development of Wernicke-Korsakoff syndrome (WKS); and present emerging findings at the intersection of alcohol and Alzheimer's disease and related dementias (ADRD). In doing so, our analysis points toward inflammation-mediated compromise of basal forebrain cholinergic function as a key culprit in cognitive dysfunction associated with chronic alcohol exposure, effects that may be rescuable through either pharmacological or behavioral approaches. Furthermore, our chapter reveals an interesting dichotomy in the effects of alcohol on neuropathological markers of ADRD that depend upon both biological sex and genetic vulnerability.

Impact of Developmental Alcohol Exposure on Sleep Physiology

The present chapter summarizes the clinical and preclinical findings collected to date, showing the impact of developmental alcohol exposure on sleep physiology. Sleep is a complex physiological process that plays a pivotal role in maintaining overall health and well-being via its involvement in regulating physiological, cognitive, and emotional functions. Clinical studies consistently report a high prevalence of sleep disturbances in children and adolescents diagnosed with fetal alcohol spectrum disorders (FASDs), including short sleep duration, sleep anxiety, bedtime resistance, increased sleep fragmentation, and parasomnias. It is established that alcohol consumption during gestation impairs brain development, leading to structural and functional alterations that may affect sleep architecture. In addition, clinical investigations have found a significant correlation between sleep-wake cycle disruptions and cognitive impairments after developmental alcohol exposure, and sleep disturbances are increasingly recognized as a substantial problem among FASD patients. However, the molecular mechanisms underlying these disturbances are poorly understood. Surprisingly, few studies with animal models of FASDs have characterized the effect of developmental ethanol exposure on sleep physiology, and these have focused on high doses. This chapter provides an overview of the current knowledge, reports the sleep disturbances in FASD patients, and then summarizes the gap in understanding the molecular and physiological mechanisms.

Bone morphogenetic protein signaling pathway- Ethanol interactions disrupt palate formation independent of gata3

Fetal Alcohol Spectrum Disorders (FASD) describes a wide array of neurological defects and craniofacial malformations, associated with ethanol teratogenicity. While there is growing evidence for a genetic component to FASD, little is known of the genes underlying these ethanol-induced defects. Along with timing and dosage, genetic predispositions may help explain the variability within FASD. From a screen for gene-ethanol interactions, we found that mutants for Bmp signaling components are ethanol-sensitive leading to defects in the zebrafish palate. Loss of Bmp signaling results in reductions in gata3 expression in the maxillary domain of the neural crest in the 1st pharyngeal arch, leading to palate defects while upregulation of human GATA3 rescues these defects. Here, we show that ethanol-treated Bmp mutants exhibit misshaped and/or broken trabeculae. Surprisingly, up regulation of GATA3 does not rescue ethanol-induced palate defects and gata3 expression was not altered in ethanol-treated Bmp mutants or dorsomorphin-treated larvae. Timing of ethanol sensitivity shows that Bmp mutants are ethanol sensitive from 10 to 18 hours post-fertilization (hpf), prior to Bmp's regulation of gata3 in palate formation. This is consistent with our previous work with dorsomorphin-dependent knock down of Bmp signaling from 10 to 18 hpf disrupting endoderm formation and subsequent jaw development. Overall, this suggests that ethanol disrupts Bmp-dependent palate development independent of and earlier than the role of gata3 in palate formation by disrupting epithelial development. Ultimately, these data demonstrate that zebrafish is a useful model to identify and characterize gene-ethanol interactions and this work will directly inform our understanding of FASD.

Understanding the intersection of prenatal alcohol exposure and postnatal adversity: A systematic review from a developmental psychopathology lens

Fetal alcohol spectrum disorders (FASD) are among the most common neurodevelopmental disabilities. Individuals with FASD experience postnatal adversity (PA; i.e., child maltreatment or other potentially traumatic events) at exceedingly high rates. This adversity is connected to increased internalizing and externalizing symptomatology. The current systematic review aimed to synthesize the literature regarding the intersectionality of FASD/prenatal alcohol exposure (PAE) and postnatal adversity utilizing the developmental psychopathology (DP) framework. Adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) standards, systematic identification of studies through PsycInfo, PubMed, and Web of Science was conducted. Primary data on PAE, postnatal adversity, individual functioning (biological, cognitive, and affective), external systems, and familial and cultural contexts were extracted. Furthermore, quality assessment information was extracted for all studies. Thirty-one studies met the inclusion criteria. Overall, individuals with FASD experience a weighted mean of 4.44 adverse childhood experiences. Multifinality in developmental outcomes was evident, as FASD and postnatal exposure impact mental health, cognitive ability, and biological processes. Cultural context and familial settings contribute to risk and resilience factors. The quality assessment points to unique strengths and areas for improvement within the literature. Aligning with the DP framework, the intersection of FASD and postnatal adversity is complex and impacts various developmental processes. Systems and cultural context add to this complexity. Intervention development taking into consideration these multiple factors is necessary.

Genetic admixture predictors of fetal alcohol spectrum disorders (FASD) in a South African population

Ancestrally admixed populations are underrepresented in genetic studies of complex diseases, which are still dominated by European-descent populations. This is relevant not only from a representation standpoint but also because of admixed populations' unique features, including being enriched for rare variants, for which effect sizes are disproportionately larger than common polymorphisms. Furthermore, results from these populations may be generalizable to other populations. The South African Cape Coloured (SACC) population is genetically admixed and has one of the highest prevalences of fetal alcohol spectrum disorders (FASD) worldwide. We profiled its admixture and examined associations between ancestry profiles and FASD outcomes using two longitudinal birth cohorts (N=308 mothers, 280 children) designed to examine effects of prenatal alcohol exposure on development. Participants were genotyped via MEGAex array to capture common and rare variants. Rare variants were overrepresented in our SACC cohorts, with numerous polymorphisms being monomorphic in other reference populations (e.g., ∼30,000 and ∼ 221,000 variants in gnomAD European and Asian populations, respectively). The cohorts showed global African (51 %; Bantu and San); European (26 %; Northern/Western); South Asian (18 %); and East Asian (5 %; largely Southern regions) ancestries. The cohorts exhibited high rates of homozygosity (6 %), with regions of homozygosity harboring more deleterious variants when lying within African local-ancestry genomic segments. Both maternal and child ancestry profiles were associated with higher FASD risk, and maternal and child ancestry-by-prenatal alcohol exposure interaction effects were seen on child cognition. Our findings indicate that the SACC population may be a valuable asset to identify novel disease-associated genetic loci for FASD and other diseases.

Normative modeling of brain MRI data identifies small subcortical volumes and associations with cognitive function in youth with fetal alcohol spectrum disorder (FASD)

AIM

To quantify regional subcortical brain volume anomalies in youth with fetal alcohol spectrum disorder (FASD), assess the relative sensitivity and specificity of abnormal volumes in FASD vs. a comparison group, and examine associations with cognitive function.

METHOD

Participants: 47 children with FASD and 39 typically-developing comparison participants, ages 8-17 years, who completed physical evaluations, cognitive and behavioral testing, and an MRI brain scan. A large normative MRI dataset that controlled for sex, age, and intracranial volume was used to quantify the developmental status of 7 bilateral subcortical regional volumes. Z-scores were calculated based on volumetric differences from the normative sample. T-tests compared subcortical volumes across groups. Percentages of atypical volumes are reported as are sensitivity and specificity in discriminating groups. Lastly, Pearson correlations examined the relationships between subcortical volumes and neurocognitive performance.

RESULTS

Participants with FASD demonstrated lower mean volumes across a majority of subcortical regions relative to the comparison group with prominent group differences in the bilateral hippocampi and bilateral caudate. More individuals with FASD (89%) had one or more abnormally small volume compared to 72% of the comparison group. The bilateral hippocampi, bilateral putamen, and right pallidum were most sensitive in discriminating those with FASD from the comparison group. Exploratory analyses revealed associations between subcortical volumes and cognitive functioning that differed across groups.

CONCLUSION

In this sample, youth with FASD had a greater number of atypically small subcortical volumes than individuals without FASD. Findings suggest MRI may have utility in identifying individuals with structural brain anomalies resulting from PAE.

Caregiver approaches, resiliencies, and experiences raising individuals with fetal alcohol spectrum disorder: A study protocol paper

Fetal alcohol spectrum disorder (FASD) is a complex neurodevelopmental disability characterized by a range of brain- and body-based difficulties which, when left unsupported, can lead to experiences of significant adversity across the lifespan. Caregivers of individuals with FASD play a critical role in advocating and supporting healthy outcomes for individuals with FASD, and most caregiver research to date has been focused on stressors and challenges. Very few studies have been conducted to systematically capture the full experience of caring for someone with FASD across the lifespan, including perspectives, concerns, as well as strengths and successes of caregivers and their families. Collaborative research with individuals with living experience is essential for understanding needs and supporting healthy outcomes for individuals with FASD and their families, and caregivers are in a unique and important position to provide perspectives and share living expertise. Therefore, the current study was developed collaboratively with caregivers and researchers to capture the many aspects of caregivers' contexts, concerns, needs, and successes in raising individuals with FASD. In this study protocol paper, we describe the rationale, development, design, and anticipated impacts of this research. The goal of this paper is to share information about why and how this study is being done, and potentially guide other teams in developing similar projects to better understand caregivers' experiences, needs, and successes. Documenting and giving voice to the breadth and depth of caregiver experiences will help us to tailor services and supports, develop resources, stimulate knowledge translation based in resilience and protective factors, guide future studies, and inform evidence-based policy initiatives.

The convergence of mTOR signaling and ethanol teratogenesis

Ethanol is one of the most common teratogens and causes of human developmental disabilities. Fetal alcohol spectrum disorders (FASD), which describes the wide range of deficits due to prenatal ethanol exposure, are estimated to affect between 1.1 % and 5.0 % of births in the United States. Ethanol dysregulates numerous cellular mechanisms such as programmed cell death (apoptosis), protein synthesis, autophagy, and various aspects of cell signaling, all of which contribute to FASD. The mechanistic target of rapamycin (mTOR) regulates these cellular mechanisms via sensing of nutrients like amino acids and glucose, DNA damage, and growth factor signaling. Despite an extensive literature on ethanol teratogenesis and mTOR signaling, there has been less attention paid to their interaction. Here, we discuss the impact of ethanol teratogenesis on mTORC1's ability to coordinate growth factor and amino acid sensing with protein synthesis, autophagy, and apoptosis. Notably, the effect of ethanol exposure on mTOR signaling depends on the timing and dose of ethanol as well as the system studied. Overall, the overlap between the functions of mTORC1 and the phenotypes observed in FASD suggest a mechanistic interaction. However, more work is required to fully understand the impact of ethanol teratogenesis on mTOR signaling.

Prenatal Alcohol Exposure Disrupts Performance in a Differential Reinforcement of Low Rates Task Specifically in Adolescent Male Rats

Prenatal alcohol exposure (PAE) can lead to a wide range of adverse effects in humans, including impaired self-control and increased impulsive behavior. Deficits in self-control can interfere with academic performance and have lasting impacts. In the present study, a rodent model of PAE was used to assess impulsivity through operant conditioning. Pregnant rats were assigned to one of three groups: ad-lib control (CON), pair-fed (PF), and alcohol-exposed (ALC). ALC rats were given a liquid diet containing 6% alcohol, PF rats were yoked to an ALC rat and given a CON liquid diet, and CON rats received ad libitum food. Operant conditioning was used to evaluate extinction in adolescents (Experiment 1) and differential reinforcement of low rates (DRL) in adolescents and adults (Experiment 2). PAE resulted in an increase in responses and resets during DRL testing, indicative of impaired self-control, an effect that was only observed in adolescent males. Females, regardless of age, did not show increased impulsivity following PAE. This indicates that children with PAE may exhibit attentional deficits similar to those with attention deficit hyperactivity disorder, with males at a higher risk.

Investigation of Uncovering Molecular Mechanisms of Alcohol-Induced Female Infertility-A Rational Approach

This study aimed to investigate the molecular mechanisms by which chronic alcohol consumption impacts female infertility, highlighting significant societal implications. By conducting a comprehensive literature review, we examined existing evidence on the association between long-term alcohol use and female reproductive health. Relevant studies were identified through systematic searches of electronic databases and key journals. We synthesized information on the molecular pathways affected by alcohol consumption, with particular emphasis on oxidative stress, inflammation, and hormonal disruptions. Additionally, we reviewed efforts to address alcohol-related health issues, including public health interventions, regulatory measures, and educational initiatives. Our study found strong evidence linking chronic alcohol consumption to increased mortality rates and a range of preventable diseases globally. Alcohol's effects extend beyond physiological consequences to psychological, social, and economic burdens. Chronic alcohol consumption disrupts hormonal balance and reproductive function, contributing to female infertility. Future research should focus on quantifying mortality risks associated with alcohol consumption, understanding gender-specific patterns in alcohol-related health outcomes, and elucidating the molecular mechanisms underlying female infertility. Addressing these gaps will inform strategies to mitigate the burden of alcohol-induced health issues and promote overall well-being. Collaborative efforts among diverse stakeholders are essential for advancing research agendas and translating findings into effective interventions.

Differential effects of prenatal alcohol exposure on brain growth reveals early upregulation of cell cycle and apoptosis and delayed downregulation of metabolism in affected offspring

Fetal Alcohol Spectrum Disorder (FASD) encompasses the deleterious consequences of Prenatal Alcohol Exposure (PAE), including developmental delay, microcephaly, dysmorphologies, and cognitive and behavioral issues. The dose and timing of alcohol exposure, maternal and environmental factors, and genetics all impact FASD outcomes, but differential susceptibility and resiliency to PAE remains poorly understood. In this study, we examined the differential effects of PAE during early mouse development on brain growth and gene expression. Brains were weighed and collected either 24 hours or five days after treatment. We then performed transcriptomics to determine whether offspring differentially affected by PAE, by brain weight, also differ in gene expression, despite having the same genetic background, alcohol exposure, and maternal factors. We found within litter variation in brain weights after PAE, and classified offspring as having normal, middle, and low-weight brains relative to saline-treated controls. The normal-weight brains showed no significant differences in gene expression, suggesting these offspring were both phenotypically and transcriptionally unaffected by PAE. While both middle- and low-weight brains showed changes in gene expression, the middle-weight brains showed the most robust transcriptome differences. Twenty-four hours after PAE, we saw an upregulation of cell cycle and apoptosis in affected offspring, whereas at roughly a week later, we saw a downregulation of metabolic processes. Overall, these findings highlight variability in response to PAE and demonstrate the molecular processes involved in offspring phenotypically affected by alcohol.

The Prevalence and Changes in Alcohol Consumption across Three Trimesters of Pregnancy Assessed by Ethyl Glucuronide Concentration in Maternal Hair and Self-Reports: A Cross-Sectional Study

INTRODUCTION

The teratogenic effect of alcohol is well known, but its prevalence is usually underestimated. This study presents the findings of a cross-sectional study conducted in Poland, which aimed to assess the prevalence and changes in alcohol consumption during pregnancy. The study utilized ethyl glucuronide (EtG) concentration in maternal hair and self-reports as measures to evaluate alcohol intake across the three trimesters of pregnancy.

METHODS

The study involved postpartum women (n = 150) and their babies. Hair samples from 135 participants allowed segmental analysis (separately for the three trimesters), and hair from 15 were analysed for the entire 9 months by gas chromatography tandem mass spectrometry. Survey data included self-reports of health-related behaviours and socio-demographic characteristics; medical records - information on the course of a pregnancy and newborn's health.

RESULTS

Standard medical interview revealed no cases of alcohol use during pregnancy. The analysis of EtG indicated 50.3% of women had been drinking alcohol at any time during pregnancy, including 10% with excessive alcohol consumption. Most participants maintained the same level of alcohol consumption throughout the pregnancy, but 8.7% of women decreased and 20.7% increased the amount of alcohol consumed between the 1st and 2nd or 2nd and 3rd trimesters. Gestational consumption of alcohol was not related to socio-demographic characteristics, course of pregnancy, and self-reported health behaviours, but babies of women who drank alcohol during pregnancy were more often small for gestation age than babies of abstainers (odds ratio [OR] = 6.008), with the highest risk observed in case of increased alcohol consumption (OR = 12.348).

CONCLUSIONS

Maternal hair analysis is useful in detecting pregnancy alcohol use and allows retrospective analysis over a longer period than other biological samples, providing a more comprehensive pattern of use throughout pregnancy. However, there is a need to improve routine methods of interviewing patients about alcohol use and to implement effective preventive strategies regarding alcohol consumption during pregnancy in Poland.

Bone Morphogenetic Protein signaling pathway - ethanol interactions disrupt palate formation independent of gata3

Fetal Alcohol Spectrum Disorders (FASD) describes a wide array of neurological defects and craniofacial malformations, associated with ethanol teratogenicity. While there is growing evidence for a genetic component to FASD, little is known of the genes underlying these ethanol-induced defects. Along with timing and dosage, genetic predispositions may help explain the variability within FASD. From a screen for gene-ethanol interactions, we found that mutants for Bmp signaling components are ethanol-sensitive leading to defects in the zebrafish palate. Loss of Bmp signaling results in reductions in gata3 expression in the maxillary domain of the neural crest in the 1st pharyngeal arch, leading to palate defects while upregulation of human GATA3 rescues these defects. Here, we show that ethanol-treated Bmp mutants exhibit misshaped and/or broken trabeculae. Surprisingly, up regulation of GATA3 does not rescue ethanol-induced palate defects and gata3 expression was not altered in ethanol-treated Bmp mutants or dorsomorphin-treated larvae. Timing of ethanol sensitivity shows that Bmp mutants are ethanol sensitive from 10-18 hours post-fertilization (hpf), prior to Bmp's regulation of gata3 in palate formation. This is consistent with our previous work with dorsomorphin-dependent knock down of Bmp signaling from 10-18 hpf disrupting endoderm formation and subsequent jaw development. Overall, this suggests that ethanol disrupts Bmp-dependent palate development independent of and earlier than the role of gata3 in palate formation by disrupting epithelial development. Ultimately, these data demonstrate that zebrafish is a useful model to identify and characterize gene-ethanol interactions and this work will directly inform our understanding of FASD.

Highlights

Bmp pathway mutants are ethanol sensitive resulting in palate defects. Ethanol disrupts Bmp-dependent palate development independent of gata3 . Timing of ethanol sensitivity suggests ethanol disrupts Bmp-dependent epithelial morphogenesis.

Reduction of APOE accounts for neurobehavioral deficits in fetal alcohol spectrum disorders

A hallmark of fetal alcohol spectrum disorders (FASD) is neurobehavioral deficits that still do not have effective treatment. Here, we present that reduction of Apolipoprotein E (APOE) is critically involved in neurobehavioral deficits in FASD. We show that prenatal alcohol exposure (PAE) changes chromatin accessibility of Apoe locus, and causes reduction of APOE levels in both the brain and peripheral blood in postnatal mice. Of note, postnatal administration of an APOE receptor agonist (APOE-RA) mitigates motor learning deficits and anxiety in those mice. Several molecular and electrophysiological properties essential for learning, which are altered by PAE, are restored by APOE-RA. Our human genome-wide association study further reveals that the interaction of PAE and a single nucleotide polymorphism in the APOE enhancer which chromatin is closed by PAE in mice is associated with lower scores in the delayed matching-to-sample task in children. APOE in the plasma is also reduced in PAE children, and the reduced level is associated with their lower cognitive performance. These findings suggest that controlling the APOE level can serve as an effective treatment for neurobehavioral deficits in FASD.

Fetal alcohol spectrum disorder (FASD) and the criminal justice system: A guide for legal professionals

Fetal Alcohol Spectrum Disorder (FASD) is a lifelong disorder caused by prenatal alcohol exposure (PAE) and is one of the most common causes of brain damage and developmental disability. FASD has been characterized by an array of symptoms that negatively affects cognitive, social, and adaptive functioning. Individuals living with FASD, relative to the general population, are more likely to become entangled in the legal system due to challenges associated with the disorder. Moreover, symptomology of FASD often contributes to these individuals struggling in successfully navigating various stages of the legal system, including arrest, interrogation, working with their defense counsel, and courtroom appearances. The difficulties faced by defendants living with FASD are exacerbated by systemic failure from legal professionals in recognizing and accommodating for the extent and complexities of this disorder. Consequently, defendants living with FASD often do not receive effective due process of law in comparison to their neurotypical peers. Moreover, attempts at punishment and deterrence through probation and jail terms are often ineffective for individuals living with FASD because of the effects of their disorder. This article is intended to provide valuable information and best practices for professionals in the legal system, particularly judges, prosecutors, defense attorneys, social workers/mitigation specialists, and psychologists, who are likely to encounter individuals living with FASD or suspected FASD early in the judicial process.

Ethanol-activated microglial exosomes induce MCP1 signaling mediated death of stress-regulatory proopiomelanocortin neurons in the developing hypothalamus

BACKGROUND

Microglia, a type of resident immune cells within the central nervous system, have been implicated in ethanol-activated neuronal death of the stress regulatory proopiomelanocortin (POMC) neuron-producing β-endorphin peptides in the hypothalamus in a postnatal rat model of fetal alcohol spectrum disorders. We determined if microglial extracellular vesicles (exosomes) are involved in the ethanol-induced neuronal death of the β-endorphin neuron via secreting elevated levels of the chemokine monocyte chemoattractant protein 1 (MCP1), a key regulator of neuroinflammation.

METHODS

We employed an in vitro model, consisting of primary culture of hypothalamic microglia prepared from postnatal day 2 (PND2) rat hypothalami and treated with or without 50 mM ethanol for 24 h, and an in vivo animal model in which microglia were obtained from hypothalami of PND6 rats fed daily with 2.5 mg/kg ethanol or control milk formula for five days prior to use. Exosomes were extracted and characterized with nanosight tracking analysis (NTA), transmission electron microscopy and western blot. Chemokine multiplex immunoassay and ELISA were used for quantitative estimation of MCP1 level. Neurotoxic ability of exosome was tested using primary cultures of β-endorphin neurons and employing nucleosome assay and immunocytochemistry. Elevated plus maze, open field and restraint tests were used to assess anxiety-related behaviors.

RESULTS

Ethanol elevated MCP1 levels in microglial exosomes both in vitro and in vivo models. Ethanol-activated microglial exosomes when introduced into primary cultures of β-endorphin neurons, increased cellular levels of MCP1 and the chemokine receptor CCR2 related signaling molecules including inflammatory cytokines and apoptotic genes as well as apoptotic death of β-endorphin neurons. These effects of microglial exosomes on β-endorphin neurons were suppressed by a CCR2 antagonist RS504393. Furthermore, RS504393 when injected in postnatal rats prior to feeding with ethanol it reduced alcohol-induced β-endorphin neuronal death in the hypothalamus. RS504393 also suppressed corticosterone response to stress and anxiety-like behaviors in postnatally alcohol-fed rats during adult period.

CONCLUSION

These data suggest that alcohol exposures during the developmental period elevates MCP1 levels in microglial exosomes that promote MCP1/CCR2 signaling to increase the apoptosis of β-endorphin neurons and resulting in hormonal and behavioral stress responses.

Sleep Characteristics Among Children with a Parental History of Alcohol Use Disorder

Purpose of Review

The purpose of the review was to examine findings on sleep characteristics among children with a parental history of alcohol use disorder (CPHAUDs) in different age groups. We identified unanswered questions and discussed directions for future research. We also discussed the implications of these current findings on alcohol prevention and intervention programs.

Recent Findings

Parental ratings and youth report of sleep difficulties have been longitudinally associated with the emergence of alcohol use and alcohol-related problems among both CPHAUDsand non-CPHAUDs. There were inconsistent findings comparing sleep characteristics in these two groups. Studies that used self-report and parental ratings reported no or minimal differences while studies that used actigraphy and polysomnography found significant, albeit moderate but meaningful differences.

Summary

Current research shows that CPHAUDs and non-CPHAUDs are similar on most objective and subjective sleep measures. There are a few significant differences between the two groups that may have implications for the development of behavioral problems, substance use and other risk behaviors.

Late-term moderate prenatal alcohol exposure impairs tactile, but not spatial, discrimination in a T-maze continuous performance task in juvenile rats

Existing maze apparatuses used in rodents often exclusively assess spatial discriminability as a means to evaluate learning impairments. Spatial learning in such paradigms is reportedly spared by moderate prenatal alcohol exposure in rats, suggesting that spatial reinforcement alone is insufficient to delineate executive dysfunction, which consistently manifests in humans prenatally-exposed to alcohol. To address this, we designed a single-session continuous performance task in the T-maze apparatus that requires rats to discriminate within and between simultaneously-presented spatial (left or right) and tactile (sandpaper or smooth) stimuli for food reinforcement across four sequential discrimination stages: simple discrimination, intradimensional reversal 1, extradimensional shift, and intradimensional reversal 2. This design incorporates elements of working memory, attention, and goal-seeking behavior which collectively contribute to the executive function construct. Here, we found that rats prenatally-exposed to alcohol performed worse in both the tactile intradimensional reversal and extradimensional shift; alternatively, rats prenatally-exposed to alcohol acquired the extradimensional shift faster when shifting from the tactile to spatial dimension. In line with previous work, moderate prenatal alcohol exposure spared specifically spatial discrimination in this paradigm. However, when tactile stimuli were mapped into the spatial dimension, rats prenatally-exposed to alcohol required more trials to discriminate between the dimensions. We demonstrate that tactile stimuli can be operantly employed in a continuous performance T-maze task to detect discriminatory learning impairments in rats exposed to moderate prenatal alcohol. The current paradigm may be useful for assessing features of executive dysfunction in rodent models of fetal alcohol spectrum disorders.

Administratively reported fetal alcohol spectrum disorders in commercially- and Medicaid-insured samples of children in the United States, 2015 - 2021

BACKGROUND

Fetal alcohol spectrum disorders (FASDs) are lifelong conditions that can occur in a person with prenatal alcohol exposure. Although studies using intensive, in-person assessments of children in selected communities have found higher estimates of children with FASDs than studies of healthcare claims data, claims-based studies provide more current information about individuals with recognized FASDs from diverse populations. We estimated the proportion of children with administratively reported FASDs in two large healthcare claims databases.

METHODS

We analyzed Merative™ MarketScan® commercial and Medicaid claims databases, that include nationwide data from employer-sponsored health plans and from Medicaid programs in 8-10 states, respectively. For each database, we estimated the proportion of children aged 0-17 years with administratively reported FASDs, identified by one inpatient or two outpatient codes for prenatal alcohol exposure or fetal alcohol syndrome during the entire seven-year period from 2015 to 2021 and during each year.

RESULTS

During 2015-2021, 1.2 per 10,000 commercially-insured and 6.1 per 10,000 Medicaid-insured children had an administratively reported FASD; estimates varied by sex, geography, and other available demographics. Among commercially-insured children, 0.5 per 10,000 in 2015 and 0.6 per 10,000 children in 2021 had an administratively reported FASD; among Medicaid-insured, 1.2 per 10,000 in 2015 and 2.1 per 10,000 children in 2021 had an administratively reported FASD.

CONCLUSIONS

Although an underestimate of the true population of children with FASDs, patterns in administratively reported FASDs by demographics were consistent with previous studies. Healthcare claims studies can provide timely, ongoing information about children with recognized FASDs to complement in-persons studies.

An introduction to the HEALthy Brain and Child Development Study (HBCD) study

The fundamental organization of the human brain is established before birth, with rapid growth continuing over the first postnatal years. Children exposed before or after birth to various biological (e.g., substance exposure) or psychosocial hazards (e.g., maltreatment) are at elevated likelihood of deviating from a typical developmental trajectory, which in turn can be associated with psychological, behavioral, and physical health sequelae. In the HEALthy Brain and Child Development (HBCD) Study, a multi-site prospective longitudinal cohort study, brain, physical, biological, cognitive, behavioral, social, and emotional development is being examined starting in pregnancy and planned through age 10 (data are sampled at varying degrees of granularity depending on age, with more dense sampling earlier in life). HBCD aims to determine the short- and long-term impacts of a variety of both harmful and protective factors, including prenatal substance use, on developmental trajectories through early childhood. Organized as a nationwide consortium across 27 sites, the HBCD Study will collect multimodal data that will be made publicly available on a yearly basis, through a data use application and approval process. Here we provide an overview of the HBCD Study design, sampling, protocol development, and data management. Data collected through HBCD will be fundamental to informing future prenatal and early childhood interventions and policies to promote wellbeing and resilience in all children.