One Drink Can Last a Lifetime
Women who consume alcohol during pregnancy put their babies at risk for a multitude of lifelong problems

By Carol Nelke Dunbar, APRN
April 11, 2005

News reports often feature stories about miracle babies who survive at incredibly low birth weights, who undergo life saving surgical procedures on their tiny organs, and who survive against incredible odds. What we don’t hear about is the number of children who are born with the defects, the disabilities, and the mental retardation that comes with alcohol consumption during pregnancy. A child born with fetal alcohol syndrome (FAS), the leading preventable birth defect in the United States, is not the kind of story that warms hearts on the evening news. But it is a story worth reporting, and there is new attention being paid to an old condition that is connected, not only to birth defects, but a lifetime of hardship.

Past – making the connection

For more than 100 years, physicians suspected there was a connection between alcohol consumption during pregnancy and newborn abnormalities. But, it wasn’t until 1973 that two Seattle pediatricians confirmed the connection, and for the first time, used the term “fetal alcohol syndrome.” In 1981, the US surgeon general issued a public health advisory recommending pregnant women limit their alcohol intake, and warnings labels on alcohol containers followed in 1989. Today, despite the warnings and advisories, surveys find a significant number of women continue to drink during pregnancy, and the numbers for binge drinking (for women, four or more drinks in a row¹) and drinking seven or more drinks per week among both pregnant and nonpregnant women of childbearing age have not declined in recent years.²

Physical effects

Alcohol is a teratogen — an agent that causes physical defects in a developing embryo. Its consumption is most damaging to the fetus during the first trimester of pregnancy, and binge drinking causes the most harm. In the first 56 days of gestation, often before the woman knows she is pregnant, the fetus’s central nervous system and heart are developed, followed quickly by the kidneys and the limbs. At the end of the first trimester, the systems are in place. When a pregnant woman drinks alcohol, she passes it quickly through the placenta to the fetus. Because the fetus cannot eliminate the alcohol as well as the mother, it is subjected to high alcohol levels for a longer time.

Pregnant women vary in their ability to break down alcohol, and the mother’s age, the time of drinking, the pattern and amount of drinking and food ingested will all affect how much alcohol is passed on to the developing baby. Researchers are also finding there may be a genetic predisposition to how people metabolize alcohol, and some groups are more susceptible to the effects than others.

Present—syndrome vs. spectrum

According to Karla Damus, RN, MSPH, PhD, professor of epidemiology at Albert Einstein College of Medicine, Bronx, NY, member of the March of Dimes national FAS Task Force and the FAS Steering Committee, and a contributor on the Centers for Disease Control and Prevention (CDC) FAS Guidelines for Referral and Diagnosis, (http://www.cdc.gov/ncbddd/fas) there are four criteria that must be met for the diagnosis of FAS (see side bar).³ However, there are also circumstances when there are apparent effects of prenatal alcohol exposure, but the child does not meet all four criteria for FAS. In an attempt to include those who do not meet the strict criteria, the terms fetal alcohol effects (FAE), alcohol-related birth defects (ARBD), and alcohol-related neurological defects (ARND), are used to describe children with a variety of problems that are thought to be related to alcohol consumption during pregnancy. In 1996, the Institutes of Medicine developed the term fetal alcohol spectrum disorder (FASD) as a way to describe the broader effects of prenatal alcohol exposure.⁴ Children with FAS are at the severe end of the spectrum.

Today, researchers and health care providers find that the effects of alcohol on the fetus can result in a wide range of structural abnormalities and behavioral, neurologic, and cognitive disabilities. In an effort to bring a more comprehensive care approach for patients and their families, the National Organization on Fetal Alcohol Syndrome, together with experts from the CDC, National Institutes of Health (NIH), Substance Abuse and Mental Health Services Administration, and Health Canada, came together last summer to sign an agreement to use the terminology FASD.

Future – speaking up

In the U.S., it is estimated that there are 0.5 to 2.0 cases of FAS in every 1,000 births, and for every child born with FAS, three more children are born who, though they don’t exhibit the classic physical characteristics, will still suffer from the neurologic and behavioral problems related to fetal alcohol exposure. Often children with FAS will have better life outcomes because their physical traits lead to quicker diagnosis and treatment.⁵ The effects of the damage live past childhood into adulthood, and Damus reports that as teens and young adults, those affected have serious behavioral problems, learning disabilities, and a high risk for suicide.

According to U.S. Surgeon General Richard Carmona’s Advisory on Alcohol Use in Pregnancy, published in February of this year, the amount of alcohol a pregnant woman drinks directly increases the risk of her baby being born with any of the fetal alcohol spectrum disorders. So how much alcohol is safe? According to the advisory, no level of alcohol consumption during pregnancy has been determined to be safe.⁵ This is the first update since the 1981 surgeon general’s advisory that suggested that pregnant women limit the amount of alcohol they ingest.

Unfortunately not everyone follows the latest advice, and Damus reports that up to one half of the obstetric physicians in the U.S. still say that a pregnant patient can have one drink per day. A survey of obstetricians, pediatricians, and family medicine physicians, published as late as 1998, found that 41% of the physicians surveyed placed the threshold for FAS at one to three drinks per day, while 38% placed the threshold at one or fewer drinks per day.⁷

In her talking points on the surgeon general’s advisory, Damus makes the follow­ing recommendations —

1. Develop diagnostic criteria that will enable clinicians to identify children along the full spectrum of FASD.
2. Disseminate evidence-based approaches to FASD prevention in multiple venues in community-based settings.
3. Improve access to information and treatment resources for childbearing-age women at risk for an alcohol-exposed pregnancy.
4. Develop standards of care for children diagnosed with disorders on the fetal alcohol spectrum.
5. Continue research to identify the underlying mechanisms of fetal alcohol-induced injury, concurrent risk factors, and effective ways of treating alcohol abuse and dependency in pregnant and nonpregnant, childbearing-aged women.

Spread the word

Nurses in all settings can play an instrumental role in getting the message out to women who are pregnant or are planning to become pregnant. They should never assume that a patient knows the risks, and never assume that some clients are not at risk. Screening should take place for all pregnant women of all ages, all socioeconomic classes, and all cultural groups. Nurses can take the lead in educating women through a nonjudgmental, culturally connected approach. While research­ers are discovering more about the effects of alcohol during pregnancy, there is little debate about today’s information. So says the Surgeon General: During pregnancy, there is no safe time to drink nor is there a safe amount of alcohol to drink.

Diagnostic criteria for fetal alcohol syndrome

1. Facial dysmorphia – based on racial norms, individuals exhibit all three characteristic facial features: smooth philtrum, thin vermilion, and small palpebral fissures
2. Growth problems – confirmed prenatal or postnatal height or weight, or both, at or below the 10th percentile.
3. Central Nervous System (CNS) Abnormalities
   • Structural – head circumference at or below 10th percentile and clinically significant brain abnormalities observable through imaging.
   • Neurological problems
   • Functional – performance substantially below that expected
   evidenced by global cognitive or intellectual deficits or functional deficits below the 16th percentile in at least three domains: cognitive or developmental, executive functioning, motor functioning, problems with attention or hyperactivity, social skills, or other sensory, language or memory deficits.
4. Maternal Alcohol Exposure
   • confirmed prenatal alcohol exposure
   • unconfirmed prenatal alcohol exposure³

In the United States and Canada, out of 10,000 births

• 3 will have Muscular Dystrophy
• 4 will be infected with HIV
• 4 will have Cystic Fibrosis
• 8 will be born with Spina Bifida
• 10 will be diagnosed with Down’s syndrome
• 20 will have Fetal Alcohol Syndrome
• 100 will have Fetal Alcohol Effects (which will likely never be diagnosed)⁶

Carol Nelke Dunbar, APRN, is a contributing writer for Nursing Spectrum.

References

1. Binge Drinking in Adolescents and College Students. U.S. Department of HHS and SAMHSA’s National Clearinghouse for Alcoholg & Drug Information. Available at http://www.health.org/govpubs/rpo995/. Accessed 04/4/2005.

2. CDC: Alcohol consumption among women who are pregnant or who might become pregnant, US 2002, MMWR: 2004 53(50): 1178-81.

3. Gerbeding JL, Cordero J, Floyd RL, FAS: Guidelines for Referral and Diagnosis, July 2004. Available at http://www.cdc.gov/ncbddd/fas. Accessed 02/24/2005.

4. Agreement on terminology for FASD, News-Medical in Medical Condition News, August 17, 2004. Available at http://www.news-medical.net. Accessed 02/22/2005.

5. US Surgeon General releases advisory on alcohol use in pregnancy, US Department of HHS, news release. 02/21/2005. Available at www.hhs.gov/surgeongeneral. Accessed 02/24/2005.

6. Key facts on FASD. FAS Facts, available at http://www.fasworld.com/facts.ihtml. Accessed 02/22/2005.

7. Abel EL, Kruger M. What do physicians know and say about FAS? Alcohol Clin Exp Res. 1998, 22(9):1951-1954.