Neonatal diagnosis of fetal alcohol syndrome: not necessarily a hopeless prognosis

Prenatal Alcohol Exposure, FASD, and Child Behavior: A Meta-analysis

CONTEXT

Fetal alcohol spectrum disorders (FASD) and prenatal alcohol exposure (PAE) are associated with behavioral difficulties, although there are no published systematic reviews that summarize and critique the literature.

OBJECTIVE

To describe the behavioral characteristics of children with PAE and/or FASD, assessed using the Achenbach System of Empirically Based Assessments (ASEBA) for school-aged children with parent, teacher, and youth (self-report) forms.

DATA SOURCES

Electronic literature databases, reference lists, hand-searches.

STUDY SELECTION

peer-reviewed observational studies.

DATA EXTRACTION

Study appraisal and data extraction were undertaken by 2 independent assessors. Meta-analyses were performed for parent-rated Internalizing, Externalizing, and Total problems scales. All other ASEBA scales were summarized qualitatively.

RESULTS

Included were 23 articles; 16 were used in meta-analyses. Pooled results showed higher Total (mean difference 12.1, 95% confidence interval [95% CI] 7.7-16.5), Internalizing (6.3, 95% CI 3.1-9.5), and Externalizing problems scores (12.5, 95% CI 7.9-17.0) in FASD than No FASD; and greater odds of scoring in the "Clinical" range in FASD. Pooled results demonstrated higher problem scores in children with PAE (P > .05). Qualitative summaries of other scales from parents, teachers, and self-report show poorer behavior ratings in children with FASD and PAE on composite Problem and Competence scores and many Syndrome subscales.

LIMITATIONS

Findings were restricted to behaviors assessed using the ASEBA. The published literature was limited, often with only 1 study reporting on a particular scale.

CONCLUSIONS

Meta-analysis reveals that FASD and PAE are associated with problematic behavior in many, but not all domains. This clearly affects families, and should be considered in clinical practice by providers.

Prevalence and epidemiologic characteristics of FASD from various research methods with an emphasis on recent in-school studies

Researching the epidemiology and estimating the prevalence of fetal alcohol syndrome (FAS) and other fetal alcohol spectrum disorders (FASD) for mainstream populations anywhere in the world has presented a challenge to researchers. Three major approaches have been used in the past: surveillance and record review systems, clinic-based studies, and active case ascertainment methods. The literature on each of these methods is reviewed citing the strengths, weaknesses, prevalence results, and other practical considerations for each method. Previous conclusions about the prevalence of FAS and total FASD in the United States (US) population are summarized. Active approaches which provide clinical outreach, recruitment, and diagnostic services in specific populations have been demonstrated to produce the highest prevalence estimates. We then describe and review studies utilizing in-school screening and diagnosis, a special type of active case ascertainment. Selected results from a number of in-school studies in South Africa, Italy, and the US are highlighted. The particular focus of the review is on the nature of the data produced from in-school methods and the specific prevalence rates of FAS and total FASD which have emanated from them. We conclude that FAS and other FASD are more prevalent in school populations, and therefore the general population, than previously estimated. We believe that the prevalence of FAS in typical, mixed-racial, and mixed-socioeconomic populations of the US is at least 2 to 7 per 1,000. Regarding all levels of FASD, we estimate that the current prevalence of FASD in populations of younger school children may be as high as 2-5% in the US and some Western European countries.

Recognition of facial features of fetal alcohol syndrome in the newborn

The diagnosis of an infant, especially a newborn, with fetal alcohol spectrum disorder is difficult due to the fact that not all of the features are apparent at that time. Many cases are also missed due to inadequate knowledge of the mother's drinking pattern and because of the examining physician's lack of experience with the disorder. While conducting a study of the use of maternal blood markers to determine alcohol use in pregnancy, we have evaluated systematically the effects of alcohol on the newborn infant. We have developed a facial scoring system consisting of six of the features commonly seen in children with fetal alcohol syndrome (FAS) and present preliminary data about its use. By using a cutoff of four or more of these six features, there is a significant correlation with the presence of these features and the mother's self-reported alcohol use. In addition, there has been no significant difference in the frequency of positive scores between newborns of Caucasian or Black ancestry. We propose that this system may be useful in the assessment of newborn infants at high risk because of alcohol exposure during pregnancy.

Alcohol in pregnancy and neonatal outcome

Fetal alcohol syndrome (FAS) and other fetal alcohol effects in children are characterized by life-long compromises in growth, health, behaviour and cognitive ability. Most of the structural signs and many behavioural signs of FAS are evident at birth. This review describes the expression of fetal alcohol effects in neonates, including diagnostic criteria, alcohol withdrawal, pregnancy outcome, growth retardation, facial dysmorphology and behavioural outcomes.

Screening for fetal alcohol syndrome: is it feasible and necessary?

The potential to utilize screening strategies to improve the identification and outcome of persons with fetal alcohol syndrome (FAS) is reviewed. FAS is a condition where screening and surveillance activities would be appropriate. Development of FAS screening and surveillance programs is encouraged because the disorder is expensive. People with FAS have poor outcomes as adults with less than 10% living independently. Several useful tools and models are available. Screening would improve ascertainment and prevalence estimates. Early identification could improve access to services and long term outcome, secondary disabilities and, by extension, excess disability in affected children could be decreased. Lastly, mothers who are at the highest risk to have additional children with FAS could be identified and offered treatment. While both screening and surveillance activities are discussed, the principle focus of this article is a review of the screening process. Two screening tools and several screening methodologies for FAS are available. Since no test will be appropriate in all settings, screening tests need to be selected depending on the setting and population of interest. Screening for FAS should be conducted in a variety of settings and in populations of both high and moderate risk. The results would also provide important data to influence public policy development and resource allocation. Appropriate evaluation of the efficacy, efficiency and effectiveness of FAS screening tools and methodologies would be important before utilization in screening programs.

A review of the neurobehavioral deficits in children with fetal alcohol syndrome or prenatal exposure to alcohol

Fetal alcohol syndrome is a devastating developmental disorder caused by prenatal exposure to high amounts of alcohol. In addition to structural abnormalities and growth deficits, fetal alcohol syndrome is associated with a broad spectrum of neurobehavioral anomalies. This paper reviews the behavioral and cognitive effects of prenatal alcohol exposure. More than 20 years of research are discussed, with a focus on IQ, activity, attention, learning, memory, language, motor, and visuospatial abilities in children prenatally exposed to varying amounts of alcohol, including those with fetal alcohol syndrome.

A case definition and photographic screening tool for the facial phenotype of fetal alcohol syndrome

OBJECTIVES

The purpose of this study was to demonstrate that a quantitative, multivariate case definition of the fetal alcohol syndrome (FAS) facial phenotype could be derived from photographs of individuals with FAS and to demonstrate how this case definition and photographic approach could be used to develop efficient, accurate, and precise screening tools, diagnostic aids, and possibly surveillance tools.

STUDY DESIGN

Frontal facial photographs of 42 subjects (from birth to 27 years of age) with FAS were matched to 84 subjects without FAS. The study population was randomly divided in half. Group 1 was used to identify the facial features that best differentiated individuals with and without FAS. Group 2 was used for cross validation.

RESULTS

In group 1, stepwise discriminant analysis identified three facial features (reduced palpebral fissure length/inner canthal distance ratio, smooth philtrum, and thin upper lip) as the cluster of features that differentiated individuals with and without FAS in groups 1 and 2 with 100% accuracy. Sensitivity and specificity were unaffected by race, gender, and age.

CONCLUSIONS

The phenotypic case definition derived from photographs accurately distinguished between individuals with and without FAS, demonstrating the potential of this approach for developing screening, diagnostic, and surveillance tools. Further evaluation of the validity and generalizability of this method will be needed.