Elsevier

Drug and Alcohol Dependence

Volume 133, Issue 2, 1 December 2013, Pages 502-512
Drug and Alcohol Dependence

Maternal alcohol consumption producing fetal alcohol spectrum disorders (FASD): Quantity, frequency, and timing of drinking

https://doi.org/10.1016/j.drugalcdep.2013.07.013Get rights and content

Abstract

Background

Concise, accurate measures of maternal prenatal alcohol use are needed to better understand fetal alcohol spectrum disorders (FASD).

Methods

Measures of drinking by mothers of children with specific FASD diagnoses and mothers of randomly-selected controls are compared and also correlated with physical and cognitive/behavioral outcomes.

Results

Measures of maternal alcohol use can differentiate maternal drinking associated with FASD from that of controls and some from mothers of alcohol-exposed normals. Six variables that combine quantity and frequency concepts distinguish mothers of FASD children from normal controls. Alcohol use variables, when applied to each trimester and three months prior to pregnancy, provide insight on critical timing of exposure as well. Measures of drinking, especially bingeing, correlate significantly with increased child dysmorphology and negative cognitive/behavioral outcomes in children, especially low non-verbal IQ, poor attention, and behavioral problems. Logistic regression links (p < .001) first trimester drinking (vs. no drinking) with FASD, elevating FASD likelihood 12 times; first and second trimester drinking increases FASD outcomes 61 times; and drinking in all trimesters 65 times. Conversely, a similar regression (p = .008) indicates that drinking only in the first trimester makes the birth of a child with an FASD 5 times less likely than drinking in all trimesters.

Conclusions

There is significant variation in alcohol consumption both within and between diagnostic groupings of mothers bearing children diagnosed within the FASD continuum. Drinking measures are empirically identified and correlated with specific child outcomes. Alcohol use, especially heavy use, should be avoided throughout pregnancy.

Introduction

Evidence linking multiple maternal traits to fetal alcohol spectrum disorders (FASD) is substantial (Abel and Hannigan, 1995, May and Gossage, 2011). However, much of the evidence links only summary measures of alcohol consumption (e.g., mothers drank/did not drink or binged occasionally) to outcomes often limited to particular behavioral traits such as IQ, attention, and memory (Bailey et al., 2005, Nulman et al., 2004, Sayal et al., 2009). Also, summary drinking measures are infrequently linked to specific diagnoses within the FASD continuum, only to “FASD.” Utilizing specific diagnoses combines physical dsymorphology and cognitive/behavioral traits for a more complete outcome indicator. Overall, more empirical evidence is needed to clarify and define the quantity, frequency, and timing (QFT) of alcohol usage that produce risk for a specific diagnosis within FASD.

The search for specific measures of prenatal alcohol use levels and patterns that produce fetal alcohol syndrome (FAS) and other diagnoses within the FASD continuum has been carried out in clinic settings (Alvik et al., 2006a, Alvik et al., 2006b, Alvik et al., 2006c, Day et al., 1999), drinking surveys (Floyd et al., 1999), epidemiologic studies of various methods (Kvigne et al., 2003, May et al., 2005, May et al., 2008a, Petković and Barišić, 2010), and drawn from data in existing populations studies. Few large case control samples exist with mothers who drank heavily during pregnancy giving birth to large numbers of children with an FASD. Such samples provide an opportunity to identify specific alcohol use measures and link them with specific diagnoses in the FASD continuum (Alvik et al., 2006c, Colvin et al., 2007, Kristjanson et al., 2007, May et al., 2009).

Prenatal drinking varies among and within populations of the world (Abel, 1998). In the United States, England, and Canada, 20–32% of pregnant women drink, and in some European countries the rate may exceed 50% (Alvik et al., 2006c, Bonati and Fellin, 1991, Centers for Disease Control and Prevention, 1995, Primatesta et al., 1993, Waterson and Murray-Lyon, 1989). In South Africa (ZA), 34–51% of women report prenatal drinking (Croxford and Viljoen, 1999, May et al., 2008a).

Some individual children escape diagnoses within the FASD continuum in spite of substantial prenatal alcohol exposure (Abel, 1998, May et al., 2013a, Skogerbø et al., 2012, Underbjerg et al., 2012). Maternal risk to the fetus involves the interaction of biological, familial, historical, social, and psychological influences (Gomberg, 1993), and the relative importance of these co-factors to FAS or other diagnoses within the FASD continuum has been demonstrated elsewhere (Abel and Hannigan, 1995, May et al., 2011, May et al., 2013). This paper focuses on isolating particular measures of alcohol use, for alcohol use is by far the primary risk factor for the physical characteristics and behavioral deficits which define FASD (May et al., 2011, May et al., 2013b). In the study population, alcohol is virtually the sole drug used. Alcohol is the teratogen and other variables are predisposing conditions as we currently understand them (Abel and Hannigan, 1995, May and Gossage, 2011).

Recent estimates are that FAS affects 2–7 per 1000 children in the Western world (May et al., 2006, May et al., 2009, May et al., 2011, Petković and Barišić, 2010). All levels of FASD may affect 2–5% (May et al., 2009). More prevalent in ZA (May et al., 2000, May et al., 2007, Urban et al., 2008, Viljoen et al., 2005), total FASD for this study community is 13.6–20.9%, the highest ever reported (May et al., 2013a).

This paper focuses on alcohol use data reported by mothers of children with a diagnosis within the FASD continuum. Understanding alcohol use by QFT provides insight into the etiology of FASD in humans, adds to diagnostic rigor, and facilitates intervention and prevention strategies by identifying dangerous: consumption patterns, levels of use, and times for fetal exposure (Kvigne et al., 2003, May, 1995).

Section snippets

Sample

Alcohol use characteristics of mothers of children with one of three specific Institute of Medicine (IOM) FASD diagnoses are contrasted with mothers of randomly-selected, normal children (both alcohol-exposed and unexposed). These diagnoses are: FAS, partial fetal alcohol syndrome (PFAS), and alcohol-related neurodevelopmental disability (ARND; Stratton et al., 1996). All mothers and children are from the same community in ZA. A fourth study of FASD in this community, all actively consented,

Quantity and frequency of drinking before pregnancy

Maternal drinking results (Table 1) show many significant differences across groups. The number of standard drinks consumed three months before pregnancy is significantly different (F = 23.31, p < .001), with Dunnett's C post hoc analyses indicating differences between the unexposed controls (x¯=0.3, SD = 1.3) and all three other FASD diagnostic groups, FAS (x¯=11.0), PFAS (x¯=14.0), ARND (x¯=16.9), and exposed controls (x¯=8.2). More mothers of children with ARND (67.9%) reported drinking more (than

QFT measures of prenatal alcohol consumption characterize differential drinking leading to the FASD continuum

From this sample and the variables examined, a number of conclusions follow. First, several measures of QFT distinguish between drinking patterns of mothers of children with diagnoses within FASD and unexposed controls; and a few even distinguish between FAS and exposed controls and between exposed and unexposed controls. Few summary alcohol use measures have been identified before that have made these distinctions between drinking patterns that lead to the birth of children with and without an

Contributors

Philip May was the principle investigator of the NIH grant that funded this research and he, along with assistance from Julie Hasken, was the major writer and final editor of all drafts. Jason Blankenship, Barbara Tabachnick, Wendy Kalberg, and David Buckley all played major roles in data analysis and preparation of text for the methods and results sections. Anna-Susan Marais, Jan Gossage, Belinda Joubert, Marise Cloete, Ronel Barnard, Marlene De Vries, Charles Parry, and Soraya Seedat all

Role of the funding source

This project was funded by the National Institute on Alcohol Abuse, and Alcoholism (NIAAA) Grants RO1 AA09440, R01 AA11685, and RO1/UO1 AA01115134.

Conflict of interest

None of the authors have any conflicts of interest to declare.

Acknowledgements

We thank Faye Calhoun, D.P.A., Kenneth Warren, Ph.D., T.-K. Li, M.D., and Marcia Scott, Ph.D. of NIAAA who have provided intellectual guidance and support in the South African studies of FASD since 1996. Teresa Alexander and Simone Europa played a vital role in the data collection process. Our deepest thanks are extended to Mayor Herman Bailey, education officials and teachers, and many others in the study community who have hosted and assisted in the research process over the years.

Protocols

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