Policy Statement

Pediatrics Volume 91, Number 5 May, 1993, p 1004-1006


Fetal Alcohol Syndrome and Fetal Alcohol Effects (RE9310)

AMERICAN ACADEMY OF PEDIATRICS


Committee on Substance Abuse and Committee on Children With Disabilities

        Prenatal alcohol exposure is a preventable cause of birth defects, including mental retardation and neurodevelopmental deficits. Since the initial recognition in 1968 of the multiple effects that alcohol can have on the developing fetus [1] and the subsequent delineation in 1973 of fetal alcohol syndrome (FAS), [2] it has become clear that prenatal alcohol exposure can be associated with a wide range of abnormalities. [3]
        More than 80% of children with FAS demonstrate prenatal and postnatal growth deficiency, mild to moderate mental retardation, microcephaly, infantile irritability, and characteristic facial features. Fifty percent of affected individuals also have poor coordination, hypotonia, attention deficit disorders with hyperactivity, decreased adipose tissue, and other identifiable facial features. Additionally, 20% to 50% of affected children demonstrate a variety of other birth defects, including cardiac anomalies, hemangiomas, and eye and ear anomalies ( Table). [2,4,15,16]
        Even in the absence of growth retardation or congenital abnormalities, children born to women who drank alcohol excessively during pregnancy appear to be at increased risk for attention deficit disorders with hyperactivity, fine-motor impairment, and clumsiness as well as more subtle delays in motor performance and speech disorders. [4] These findings have been referred to as fetal alcohol effects (FAE) ( Table).
        As recently described, FAS and FAE produce profound cognitive, behavioral, and psychosocial problems that persist to date of follow-up of those affected. In the most comprehensive and far-reaching study to date, Streissguth et al [5] traced the natural history into adulthood and demonstrated the profound, pervasive, and persistent nature of the biopsychosocial manifestations of these disorders. Cognitively those affected maintained subnormal intellectual functioning; demonstrated specific arithmetic deficiency; had extreme difficulty with abstractions such as time and space, cause and effect; and could not generalize from one situation to another. They also demonstrated inattention, poor concentration, memory deficit, impaired judgment, and impaired comprehensive and abstract reasoning.
        Behavioral problems such as hyperactivity and impulsivity as well as conduct problems such as lying, stealing, stubbornness, and oppositional behavior were manifest. These behavioral problems were qualitatively and quantitatively different from those found in other forms of mental retardation. [6]
        None of those in the study [5] were age appropriate in terms of socialization or communication skills. Maladaptive social function was evidenced by their failure to consider consequences for their actions, lack of response to appropriate social cues, lack of reciprocal friendships, social withdrawal, sullenness, mood lability, teasing and bullying behavior, and periods of high anxiety and excessive unhappiness.
        Fetal alcohol syndrome is one of the most common identifiable causes of mental retardation, [3] with a worldwide incidence estimated to be 1.9 per 1000 livebirths. [7] However, when children with less severe manifestations of the syndrome (FAE) are included, the estimated incidence may be as great as 1 in 300 livebirths. [8] Evidence indicates, however, that physicians may not consistently inquire about alcohol use during pregnancy [9] or recognize the full spectrum of the effects of prenatal exposure. [10]
        There is no established "safe dose" of alcohol for pregnant women. However, mothers of children with fully expressed FAS drink alcohol more and drink earlier in gestation than those with infants without fully expressed clinical features. Mothers who only drink later in gestation have an increased frequency of premature deliveries and deliveries of babies small for gestational age. [11]
        In one study, Mills et al [12] prospectively studied 31604 pregnancies in an attempt to determine how much drinking in pregnancy is safe. The consumption of at least one to two drinks a day was associated with a substantially increased risk of giving birth to a growth-retarded baby. [12]
        Alpert and Zuckerman [13] have pointed out confounding risk factors regarding alcohol use during pregnancy. Problems of historical accuracy in some studies of exposure and other possible prenatal factors create uncertainty about possible risks to the fetus, particularly when small amounts of alcohol consumption are reported. At present, the evidence for harm to the fetus is much stronger with large amounts of maternal alcohol consumption than with smaller amounts. Moreover, it appears that all infants prenatally exposed to the same amount of alcohol will not be affected to the same degree. While there is remaining controversy about the association between maternal consumption of smaller amounts of alcohol and possible damage to the fetus, current data do not support the concept that any amount of alcohol is safe for all pregnant women.
        It has recently been estimated that the economic cost associated with the growth deficiency, surgical repair of structural defects, treatment of perceptual and cognitive problems, and mental retardation associated with FAS in the United States is at least $321 million per year. [7] The mental retardation related to FAS has by itself been estimated to account for as much as 11% of the annual cost for all mentally retarded institutionalized residents in the United States and may account for up to 5% of all congenital anomalies. [7,14] Nonfiscal costs to families and affected children in terms of emotional and social impact are enormous.

RECOMMENDATIONS


1. Since there is no known safe amount of alcohol consumption during pregnancy, the Academy recommends abstinence from alcohol for women who are pregnant or who are planning a pregnancy.
2. Special efforts should be directed toward educating women, prior to and during the childbearing years, regarding the harmful effects of alcohol on the developing fetus.
3. Major efforts at all levels of society should be made to develop quality educational programs regarding the deleterious consequences of alcohol on the unborn child. These programs should be integrated into mandatory curriculum for all elementary, junior high, and high school students. They should be a part of the educational curriculum in all postsecondary and adult centers of learning.
4. Pediatricians and other health professionals caring for women and their newborns should increase their own awareness and that of their patients about FAS and FAE and their prevention.
5. Pediatricians should increase their awareness of maternal alcohol exposures during pregnancy to help identify the possible cause of birth defects and to help identify other adverse fetal outcomes in future pregnancies.
6. Those infants and children who are thought to have FAS or FAE should be evaluated by a pediatrician who is knowledgeable, skilled, and competent in the evaluation of neurodevelopmental and psychosocial problems. Otherwise, the necessity for a skilled evaluation requires early referral to a specialist in this area. If such problems are identified or if the child is considered to be at risk for the later identification of developmental problems, referral should be made for early educational services available under the provisions of the Education for All Handicapped Children Act (PL 94-142 and PL 99-457).
7. The Academy supports federal legislation that would require the inclusion of health-and-safety messages in all print and broadcast alcohol advertisements, based on the US Surgeon General's warning: "Drinking during pregnancy may cause mental retardation and other birth defects. Avoid alcohol during pregnancy."
8. The Academy supports the development of state legislation that makes information about FAS and FAE available at marriage-licensing bureaus and other appropriate public places, including points of alcohol sale.

COMMITTEE ON SUBSTANCE ABUSE, 1992 TO 1993
Manuel Schydlower MD, Chair
Paul G. Fuller, Jr, MD
Richard B. Heyman, MD
Edward A. Jacobs, MD
Albert W. Pruitt, MD
Jonathan M. Sutton, MD
Milton Tenenbein, MD

LIAISON REPRESENTATIVES
George W. Bailey, MD, American Academy of Child & Adolescent Psychiatry
Gayle M. Boyd, PhD, National Institute of Alcohol Abuse and Alcoholism
Dorynne Czechowicz, MD, National Institute on Drug Abuse

SECTION LIAISON
J. Ward Stackpole, MD, Section on School Health

CONSULTANTS
Lucy S. Crain, MD, University of California, San Francisco
Kenneth Lyons Jones, MD, University of California, San Diego
Margretta R. Seashore, MD, Yale School of Medicine

COMMITTEE ON CHILDREN WITH DISABILITIES, 1992 TO 1993
James Perrin, MD, Chair
Gerald Erenberg, MD
Ruth K. Kaminer, MD
Robert La Camera, MD
John A. Nackashi, MD
John R. Poncher, MD
Virginia Randall, MD
Renee C. Wachtel, MD
Philip R. Ziring, MD

LIAISON REPRESENTATIVES
Connie Garner, RN, MSN, EdD, US Dept of Education Programs
Ross Hays, MD, American Academy of Physical Medicine and Rehabilitation
Joseph G. Hollowell, MD, Centers for Disease Control, Center for Environmental Health and Injury Control

SECTION LIAISON
Harry Gewanter, MD, Section on Rheumatology

REFERENCES

1. Lemoine P, Harrousseau H, Borteyro JP, et al. Les enfants de parents alcoholiques. Ouest Med. 1968;21:476-492
2. Jones KL, Smith DW, Ulleland CW, et al. Pattern of malformation in offspring of chronic alcoholic mothers. Lancet. 1973;1:1267-1271
3. Gorlin RJ, Cohen MM, Levin LS. Teratogenic agents. In: Syndromes of the Head and Neck. 3rd ed. New York, NY: Oxford University Press Inc;1990:16-19
4. Streissguth AP. The behavioral teratology of alcohol: performance, behavioral, and intellectual deficits in prenatally exposed children. In: West JR, ed. Alcohol and Brain Development. New York, NY: Oxford University Press Inc; 1986:3-44
5. Streissguth AP, Aase JM, Clarren SK, et al. Fetal alcohol syndrome in adolescents and adults. JAMA. 1991;265:1961-1967
6. Harris JC. Psychological adaptation and psychiatric disorders in adolescents and young adults with Down syndrome. In: Pueschel SM, ed. The Young Person With Down Syndrome: Transition From Adolescence to Adulthood. Baltimore, MD: PH Brookes; 1988:35-51
7. Abel EL, Sokol RJ. Incidence of fetal alcohol syndrome and economic impact of FAS-related anomalies. Drug Alcohol Depend. 1987;19:51-70
8. Olegard R, Sabel KG, Aronsson M, et al. Effects on the child of alcohol abuse during pregnancy. Acta Paediatr Scand Suppl. 1979; (No. 275):112-121
9. Donovan CL. Factors predisposing, enabling, and reinforcing routine screening of patients for preventing fetal alcohol syndrome: a survey of New Jersey physicians. J Drug Educ. 1991;21:35-42
10. Little BB, Snell LM, Rosenfeld CR, et al. Failure to recognize fetal alcohol syndrome in newborn infants. AJDC. 1990;144:1142-1146
11. Jones KL, Smith DW, Streissguth AP, Myrianthopoulos NC. Outcome in offspring of chronic alcoholic women. Lancet. 1974;1:1076-1078
12. Mills JL, Graubard BI, Harley EE, Rhoads GG, Berends HW. Maternal alcohol consumption and birth weight: how much drinking in pregnancy is safe? JAMA. 1984;252:1875-1879
13. Alpert JJ, Zuckerman B. Alcohol use during pregnancy: what is the risk? Pediatr Rev. 1991;12:375-379
14. Charness ME, Simon RP, Greenberg DA. Ethanol and the nervous system. N Engl J Med. 1989;321:442-454
15. Clarren SK, Smith DW. The fetal alcohol syndrome. N Engl J Med. 1978;298:1063-1067
16. Jones KL. Fetal alcohol syndrome. Pediatr Rev. 1986;8:122-126
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This statement has been approved by the Council on Child and Adolescent Health.
The recommendations in this statement do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.
PEDIATRICS (ISSN 0031 4005). Copyright (c) 1993 by the American Academy of Pediatrics.
No part of this statement may be reproduced in any form or by any means without prior written permission from the American Academy of Pediatrics except for one copy for personal use.

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