Alcohol and Pregnancy

Dr John McMenamin

GP and Primary Care Adviser

Health Promotion Agency

Take home messages (and evidence)

• Alcohol especially heavy/binge drinking causes FASD.

• Don’t drink if you are pregnant, If you're trying to

get pregnant, or there's a chance you could be pregnant.

• Pregnant women expect their GP to talk about alcohol in

pregnancy.

• Motivational talking works.

• FASD is preventable.

MOH Website 2019

How do we know this?

What does it mean for GPs?

Endorsing organisations

First report for FAS

(Ministry of Health, 2015b; Cook et al., 2015).

Previous diagnostic framework for FASD.

Old FAS criteria

Criteria for FAS Diagnosis Requires all three

of the following findings:

1. Documentation of all three facial

abnormalities (smooth philtrum, thin

vermillion border, and small palpebral

fissures)

2. Documentation of growth deficits

3. Documentation of CNS abnormality

National Center on Birth Defects and Developmental Disabilities Centers for Disease Control and Prevention Department of Health and Human Servicesin coordination with National Task Force on Fetal Alcohol Syndrome and Fetal Alcohol EffectAmerican Academy of Pediatrics American College of Obstetricians and Gynecologists July 2004

Variation in palpebral fissure length in different studies

NORMAL DISTRIBUTION OF PALPEBRAL FISSURE LENGTHS IN CANADIAN SCHOOL AGE CHILDREN Sterling K Clarren1,2, Albert E Chudley1,3,

Louis Wong2 , Janis Friesen3 , Rollin Brant2 1Canada Northwest FASD Research Network, Vancouver, Canada, 2University of British Columbia,

Vancouver, Canada, 3University of Manitoba, Winnipeg, Canada

www.fasdhub.org.au/siteassets/pdfs/figure-1-diagnostic-algorithm-for-

fasd.pdf

www.fasdhub.org.au/siteassets/pdfs/table-1-diagnostic-criteria-and-categories-for-fetal-alcohol-

spectrum-disorder.pdf

Australian diagnostic algorithm and criteria

FASDs are often characterised by communication,

behavioural and sensory issues and can exist

alongside or be mistaken for other conditions.

Issues will manifest themselves at different points

along the developmental trajectory and may not be

obvious until an important developmental

milestone is delayed or not achieved.

Ministry of Health. 2015. Taking Action on Fetal Alcohol Spectrum Disorder (FASD): A discussion document. Wellington: Ministry of Health.

FASD Diagnosis

• Multi-disciplinary assessment of a range of factors.

Key components of diagnostic assessment include

documenting the: history (presenting concerns,

obstetric, developmental, mental health,

behavioral, social; birth defects – dysmorphic

facial features, other birth defects; adverse

prenatal and post natal exposures, including

alcohol; known medical conditions – including

genetic syndromes and other disorders; and

growth.

Rationale for early diagnosis

• Associated with better long-term outcomes.

• Targeted interventions in childhood have been shown to

reduce the risk for later secondary disabilities, such as

dependent living, confinement, and addiction and mental

health concerns and help those working with a child to

better understand their learning and behavioral issues.

• Important in preventing future pregnancies by alerting

health professionals and family members that the birth

mother, the family and (potentially) other siblings are in

need of support.

O’Leary, C. (2004). Fetal alcohol syndrome: diagnosis, epidemiology, and developmental outcomes. Journal of Paediatrics and Child Health 40: 2-7

Progress on access to FASD assessments.

• The NZ FASD clinical network has joined with Australia and is

growing.

• Frontline workforce training is increasing interest in learning how to

tailor practice to best serve the needs of this vulnerable population.

• Oranga Tamariki Practice Centre (online) – FASD Informed Practice

training.

• More individual clinicians showing an interest in FASD diagnosis.

• Few health services in New Zealand are currently able to provide an

accurate FASD team assessment and diagnosis

• Strong advocacy for team diagnosis and an integrative collaborative

approach to follow-up care post-diagnosis.

• MOH working to increase diagnosis training. Working with DHBs that

have a FASD pathway to deliver diagnostic training (Hutt Valley,

Capital Coast, Tairawhiti, Taranaki, Bay of Plenty).

Multiple longitudinal studies have explored relationship between

alcohol use in pregnancy and subsequent developmental

outcomes for children.

“Findings demonstrate extensive evidence for poor global

developmental outcomes in children prenatally exposed to

alcohol, particularly with moderate to severe levels of

prenatal alcohol exposure.”

This review include 57 longitudinal studies.

The Early Developmental Outcomes of Prenatal Alcohol Exposure: A Review.

Sivenesi Subramoney1, Emma Eastman1, Colleen Adnams2, Dan J. Stein2,3 and Kirsten A. Donald

Front. Neurol., 18 December 2018 | https://doi.org/10.3389/fneur.2018.01108

The relationship between alcohol consumption and risk is one of dose response, not one where there is a threshold of consumption over which damage to the developing baby occurs.

The level of harm is related to:

• the amount of alcohol consumed

• the frequency of consumption

• the timing of exposure

Committee on Substance Abuse and Committee on Children with Disabilities. Fetal alcohol syndrome and alcohol related neurodevelopmental disorders. Pediatrics 2000;106(2 part 1): 358-61

Overview of the Genetic Basis and Epigenetic Mechanisms that Contribute to FASD Pathobiology.

Liyanage VR, Curtis K, Zachariah RM, Chudley AE, Rastegar M1.

Not all babies that are exposed to alcohol during

development show FASD effects

• Ethanol is a teratogenic agent itself; but it can also alter gene expression.

• These changes may contribute to the spectrum of effects and different

phenotypes that are dependent on alcohol metabolism

• Evidence from both human patients and animal models show that genetic

factors and epigenetic mechanisms contribute to the gene expression

changes due ethanol.

• Maternal and paternal genetic factors may contribute to the sensitivity,

resistance or vulnerability of the baby to alcohol.

Dose-response relationship between alcohol consumption before and during pregnancy and the risks of low birth weight, preterm birth and small-size-for-gestational age (SGA) – A systematic review and meta-analysesJayadeep Patra,

1,2,*Rachel Bakker,

3,4Hyacinth Irving,

1Vincent W.V. Jaddoe,

3,4Shobha Malini,

5andJürgen Rehm

1,2,6,7 BJOG. 2011 Nov; 118(12): 1411–1421. Published online 2011 Jul 6. doi: 10.1111/j.1471-

0528.2011.03050.x

New Zealand and overseas (Australia, UK)

guidelines advise that there is no safe amount of

alcohol to consume for pregnant women.

• Clear evidence of the risks associated with heavy,

binge, and frequent drinking in pregnancy.

• The evidence of harm caused by low to moderate

alcohol use (less than one drink per day) is less

conclusive however, some studies have found

associations between lower amounts of alcohol and

baby’s brain development.

• As the effects of alcohol are influenced by individual

factors (such as diet, genetics, other prenatal

exposures [tobacco, marijuana], environment etc.) Due

to such mixed evidence and methodological constraints

inherent in observation studies, it is not possible to

conclude there is any ‘safe’ level of alcohol

consumption.

(National Health and Medical Research Council, 2009; May & Gossage, 2011; Eberhart &

Parnell, 2016).

Passaro, et al. (1997). Agreement between self and partner reports of paternal drinking and smoking. The ALSPAC Study Team. Avon Longitudinal Study of Pregnancy and Childhood. International Journal of Epidemiology 26(2): 315-20.

Sood, et al. (2001). Prenatal Alcohol Exposure and Childhood Behavior at Age 6 to 7 Years: I. Dose-Response Effect. Pediatrics 108(2): e34.

Jaddoe, et al. (2007). Moderate Alcohol Consumption During Pregnancy and the Risk of Low Birth Weight and Preterm Birth. The Generation R Study. Annals of Epidemiology 17(10): 834-40.

Ministry of Health. 2015. Taking Action on Fetal Alcohol Spectrum Disorder (FASD): A discussion document. Wellington: Ministry of Health.

TimingBecause the central nervous system and brain develop throughout the duration of pregnancy, there is no period of time when alcohol consumption is ‘safe’ for the unborn child.

O’Leary, C. (2004). Fetal alcohol syndrome: diagnosis, epidemiology, and developmental outcomes. Journal of Paediatrics and Child Health 40: 2-7.

• No New Zealand specific data on the incidence or

prevalence.

• MOH conservatively estimates 3-5% of the school-aged

population (1,800 to 3,000 children born with FASD each

year).

• Estimate is based on recent research from Canada and

the US and evidence of higher rates of alcohol

consumption during pregnancy in New Zealand.

• This rate is likely to be higher in some sub-populations.

Popova, S et al 2018. World Health Organization International Study on the Prevalence of Fetal Alcohol Spectrum Disorder. Centre for Addiction and Mental Health, Canada.

May PA, et al. 2018. Prevalence of Fetal Alcohol Spectrum Disorders in 4 US Communities. Journal of American Medical Association 3195):474–482

Popova, S., et al. 2017. ‘Estimation of national, regional, and global prevalence of alcohol use during pregnancy and fetal alcohol syndrome: a systematic review and meta-analysis’. The Lancet, 5(3): e290–e299.

See also: Rossen F et al. 2018. Alcohol consumption in New Zealand women before and during pregnancy: findings from the Growing Up in New Zealand study. The New Zealand Medical Journal 131(1479).

Prevalence

Recent Australian study estimating FASD

prevalence in youth detention centres

• Representative sample of young people in detention (n=99)

• 89% had at least one domain of severe

neurodevelopmental impairment.

• 36% were diagnosed with FASD (95% CI 27% to 46%)

Bower, C., Watkins, R. E., Mutch, R. C., Marriott, R., Freeman, J., Kippin, N. R., … Giglia, R. (2018). Fetal alcohol spectrum disorder and youth justice: a prevalence study among young people

sentenced to detention in Western Australia. BMJ Open, 8(2), e019605. https://doi.org/10.1136/bmjopen-2017-019605

Alcohol use during pregnancy

Key findings from the New Zealand Health Survey

2012/13 (Ministry of Health, 2015) (N=565)

• 19% of women who were pregnant in the last 12 months drank

alcohol during their most recent pregnancy

• Younger women (28%) and Māori women (34%) more likely to drink

• 31% stop drinking when trying and 55% when they became aware

of pregnancy

• 15% continued to drink (8.5% reduced their drinking)

Key findings from Growing Up in New Zealand 2009/10 birth cohort.

N=6822

Rossen et al. (2018) analysis

• 23% reported drinking during the first trimester, and 13% after their first trimester.

• 1% reported drinking four or more drinks a week after their first trimester.

Cheung et al. Superu (2015) analysis

• Older women (>30 years) were more likely than younger women to consume alcohol after the first

trimester.

• Low income women (<$30K) were more likely to drink heavily before becoming aware of pregnancy, but

fewer continued drinking after the first trimester (32.8% 4 or more drinks per week before awareness vs

11.1% any alcohol after first trimester), while high income women (>$150K) were more likely to drink at

low levels throughout pregnancy (14.6% before awareness vs 19.9% after first trimester).

Rossen, F., Newcombe, D., Parag, V., Underwood, L., Marsh, S., Berry, S., ... & Bullen, C. (2018). Alcohol consumption in New Zealand women before and during pregnancy: findings from

the Growing Up in New Zealand study. The New Zealand Medical Journal, 131(1479), 24-34.

Cheung, J., Timmins, J., & Wright, C. (2015). Patterns and dynamics of alcohol consumption during pregnancy in a recent New Zealand cohort of expectant mothers. Wellington: Social Policy Evaluation Research Unit.

From a post-partum survey of New Zealand women

• Unplanned pregnancies are at higher risk of exposure to alcohol because

women have not reduced their alcohol consumption in anticipation of getting

pregnant, and recognition of an unplanned pregnancy tends to happen later

than a planned pregnancy.

• Increasing frequency of alcohol consumption before pregnancy as a

predictor of drinking post-pregnancy recognition

Drug Alcohol Rev. 2013 Jul;32(4):389-97. doi: 10.1111/dar.12024. Epub 2013 Jan 11.Maternal factors associated with heavy periconceptional alcohol intake and drinking following pregnancy recognition: a post-partum survey of New Zealand women.Mallard SR1, Connor JL, Houghton LA.

Unplanned pregnancies

• Two out of five pregnancies in New Zealand are unplanned

• Women with unplanned pregnancies are more likely to drink alcohol in the

first three months of pregnancy

GUiNZ 2010

Insights from women about drinking alcohol during pregnancy A qualitative research report A qualitative research report A report commissioned by the

Health Promotion Agency November 2014

• Women want and expect health professionals to give advice.

• Health professionals are seen to have expert knowledge of health issues.

• Health professionals are well placed to support women in changing their

drinking behaviour.

• Pregnancy is a time when women are open to making changes, including

changing patterns of alcohol use.

• Most women recalled receiving advice not to drink alcohol from their midwife

and/or doctor, but few recalled this being backed up with any information.

What women say about alcohol advice in pregnancy

Brief interventions in pregnancy are effective

Alcohol ABC is best model of care.

• Ask all women, particularly pregnant women about

alcohol

• Brief Advice to stop drinking and consequences of

drinking in pregnancy

• Counselling for women at increased risk

Stade, B., Bailey, C., Dzendoletas, D., Sgro, M., Dowswell, T., & Bennett, D. (2009). Psychological and/or educational interventions for reducing alcohol consumption in pregnant women and women

planning pregnancy. Cochrane Database Systematic Review 2, CD004228.

Randomised trial pending in Australasia

A practice change intervention to improve antenatal care addressing alcohol consumption by women during pregnancy: research protocol for a randomised stepped-wedge cluster trial

Melanie Kingsland,corresponding author1,2,3 Emma Doherty,1,2,3 Amy E. Anderson,2,3 Kristy Crooks,1,4 Belinda Tully,1 Danika Tremain,1,2,3 Tracey W. Tsang,5,6 John Attia,2,3 Luke

Wolfenden,1,2,3 Adrian J. Dunlop,2,3,7 Nicole Bennett,8 Mandy Hunter,8 Sarah Ward,9 Penny Reeves,2,3 Ian Symonds,10 Chris Rissel,5,11 Carol Azzopardi,8 Andrew Searles,2,3 Karen Gillham,1

Elizabeth J. Elliott,5,6 and John Wiggers1

Implement Sci. 2018; 13: 112. Published online 2018 Aug 20. doi: 10.1186/s13012-018-0806-x

Talking about alcohol in

pregnancy

• What do you know about drinking

while you are pregnant?

• Do you have any concerns yourself?

• How easy will it be not to drink?

Attitudes and Behaviour towards Alcohol Survey 2015/16 HPA

Most women already agree it’s not OK

to drink in pregnancy

Ask all women, avoid

making assumptions.

ASK

Record alcohol use.

Why shouldn’t I drink alcohol when I’m

pregnant?

• When you drink, so does your baby.

• Alcohol in the mother’s blood is carried through the

placenta to the baby.

• Alcohol can change the structure and function of a

baby’s developing organs, especially the brain.

• The child is then at risk of lifelong physical,

behavioural and learning disabilities.

• Fetal alcohol spectrum disorder (FASD) is the term

used to describe these effects.

• Drinking alcohol during pregnancy is also linked to

miscarriage, stillbirth, premature birth and reduced

birthweight.

https://www.alcohol.org.nz/sites/default/files/documents/Alcohol-and-pregnancy-

FAQs_0.pdf

Attitudes and Behaviour towards Alcohol Survey 2015/16 HPA

Facilitate enrolment with an LMC.

Brief advice

Can I drink at all?

• No.

• There is no known safe level of alcohol use during pregnancy.

• Even a small amount of alcohol at any time during pregnancy can affect your baby’s development.

• It does not matter whether it is beer, cider, wine, spirits or ready-to-drinks (RTDs)

• – they all contain alcohol.

• Research shows that harm is more likely to occur with frequent heavy drinking. However, some

studies have found associations between lower amounts of alcohol and a baby’s development.

• For women who might be pregnant, are pregnant or are planning a pregnancy, not drinking at all is

the safest option.

https://www.alcohol.org.nz/sites/default/files/documents/Alcohol-and-pregnancy-FAQs_0.pdf

Brief advice

What if I’m pregnant and have been drinking

alcohol?

• If you are pregnant and have been drinking alcohol – it

is never too late to stop.

• Stopping drinking at any time during pregnancy is best

for your baby.

https://www.alcohol.org.nz/sites/default/files/documents/Alcohol-and-pregnancy-FAQs_0.pdf

Around 70% pregnancies diagnosed in GP

NZMJ 17 October 2014, Vol 127 No 1404; ISSN 1175-8716 Page 53

http://www.nzma.org.nz/journal/subscribe © NZMA NEW ZEALAND MEDICAL JOURNAL

ORIGINAL ARTICLE Barriers to early initiation of antenatal care in a multi-ethnic sample in

South Auckland, New Zealand Sarah Corbett, Carol Chelimo, Kara Okesene-Gafa

Many opportunities

• Lab reports

• ED reports

• US scan reports

Factors influencing drinking alcohol during pregnancy

Research New Zealand | November 2014

https://www.hpa.org.nz/sites/default/files/Insights%20about%20alcohol%20and%20pregnancy.pdf

A woman’s desire to drink alcohol is

largely determined by her

pre-pregnancy drinking behaviour

Research New Zealand | November 2014

HPA advice:

All women of childbearing age:, whether they are

pregnant or not

• should be routinely asked about alcohol use

• advised on the consequences of alcohol use during

pregnancy

• supported to stop drinking alcohol when pregnant or

planning pregnancy

ALCOHOL AND PREGNANCY – SUMMARY OF EVIDENCE

https://www.alcohol.org.nz/sites/default/files/documents/Alcohol-and-pregnancy-summary-of-

evidence.pdf

Look for opportunities to ask all patients

about alcohol including all women of

childbearing years

Routine part of

• contraception assessment

• Sexual health assessment

Clinical opportunities e.g. injuries

WHO recommendations:

The evidence supports

• encouraging changes in risky drinking (screening and

brief advice)

• greater use of contraception among women

Prevention of harm caused by alcohol exposure in pregnancy WHO http://www.euro.who.int/__data/assets/pdf_file/0005/318074/Prevention-harm-caused-

alcohol-exposure-pregnancy.pdf

Brief interventions in pregnancy are effective

• Involvement of partner improve effectiveness

• Brief interventions using any prior pregnancy as indicator

protects next pregnancy

Chang G. Screening and brief intervention in prenatal care settings. Alcohol Res Health. 2004;28(2):80–84.

Motivational Interviewing

• The client is the expert on themselves

• Role of the health professional

• Express empathy

• Develop discrepancy between current behaviour and goals/values

Roll with resistance to avoid argument, confrontation

• Encourage confidence in ability to change

https://www.fasdhub.org.au/siteassets/pdfs/module-2---brief-intervention-and-motivational-interviewing.pdf

Sample questions

• Tell me what you know about alcohol and pregnancy?

• What does this mean for you in this pregnancy?

• Tell me about your drinking before you were pregnant?

• How soon did you know you were pregnant?

• Do you have any concerns about drinking in the time before

you knew?

• How confident are you about staying alcohol free during the

pregnancy?

Offer support

Alcohol Drug Helpline Free, confidential information, help and support

0800 787 797

Alcoholdrughelp.org.nz

Free txt 8681

FASD information and supportFetal Alcohol Network NZ

Fetal Alcohol Spectrum Disorder - Care Action Network

Taking Action on Fetal Alcohol Spectrum Disorder: 2016-2019 - An action plan

Wraparound pregnancy and parenting service (PPS) for women

experiencing AOD issues.Waitematā pilot extended to Northland, Hawke’s Bay and Tairāwhiti.

https://www.alcohol.org.nz/sites/default/files/documents/Waitemata-process-evaluation.pdf

• Whanganui used an early

pregnancy assessment tool to

screen alcohol 50% pregnant

women

• EPAT being used He Korowai

Manaaki involves practices offering

added clinical visits and referral

pathways to allied services for

pregnant women.

• Northern Regional Alliance leading

development of a national

screening tool (requires approval)

Evaluation of the Early Pregnancy Assessment Approach: Final Report

file:///C:/Users/user/Downloads/FINAL%20EPAA%20EVALUATION%20REPORT%2024%2007%2015%20(2).PF

He Korowai Manaaki – A Wrap Around Approach

http://www.anzctr.org.au/AnzctrAttachments/373063practice%20PIS%20CF%20He%20Korowai%20Manaaki%20Wairoa%20AMENDMENT%20231117.pdf

Screening in early pregnancy provides opportunity for an alcohol conversation

Early pregnancy assessment approach

HPA supporting alcohol free pregnancy

https://www.alcohol.org.nz/digital-toolkit-dont-know-dont-drink

Pamphlet

New evidence summary

published this week.

Three online learning programmes

for health professionals being

designed.

• Midwifery

• General

• Healthy start workforce

Health pathways guide available at

https://www.hpa.org.nz/node/11579

www.facebook.com/dontknowdontdrink/

www.instagram.com/pretestiebestie/

Don’t know? Don’t drink social marketing campaign

Take home messages

• Alcohol especially heavy/binge drinking causes FASD

• Don’t drink if you are pregnant, If you're trying to get pregnant, or there's a

chance you could be pregnant

• Pregnant women expect their GP to talk about alcohol in pregnancy

• Talk to all women about alcohol and support those at risk

• Motivational talking works

• FASD is preventable