FOETAL ALCOHOL SYNDROME

Dr Fionnuala Kelly, Registrar in Psychiatry, Stewart’s Hospital, Palmerstown, outlines the clinical characteristics of this syndrome and implications for the care of children who live with the effects of prenatal alcohol exposure.

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2024

Jones and Smith first reported Foetal Alcohol Syndrome as a syndrome in 1973. It is characterised by specific growth, mental and physical birth defects associated with the mother’s high levels of alcohol use in pregnancy. Alcohol use or abuse by a pregnant woman subjects her to the same range of risk that alcohol has in the general population. However it poses unique risks to the foetus and is associated with Foetal Alcohol Syndrome (FAS). Alcohol ingested by a pregnant woman easily passes across the placental barrier to the foetus. This can cause damage throughout the pregnancy; however the earlier in the pregnancy that heavy drinking occurs, the more severe the damage.

The incidence of FAS varies from between 1 in 1,500 to 1 in 600 live births. This is related to differences in drinking practices. Increasing amounts of alcohol cause increased problems. Multiple birth defects are more common with heavy alcohol use or alcoholism.

Clinical Features

Newborns can be irritable, floppy, experience severe tremors and show other signs of alcohol withdrawal.

Children may exhibit effects from one or more of the following signs and symptoms depending on the amount and duration of foetal alcohol exposure.

  • Abnormal facial features including small head (microcephaly); small upper jaw; short upturned nose; smooth philtrum (groove in upper lip); smooth and thin upper lip, and small and unusual appearing eyes with prominent epicanthic folds.
  • Growth retardation—Babies born with FAS often have low birth weight (less than 5.5lb).
  • Central nervous system abnormalities—Exposure to large amounts of alcohol during foetal development can affect the child’s brain and spinal cord in, for example, small brain size, impaired fine motor skills and poor eye-hand coordination.
  • Developmental delay—Children with FAS often have a mild to moderate learning disability (estimated to cause 10-20% of mild learning disability (IQ 50-80)).
  • Other birth defects—Between 20 and 50% of children with FAS have eye, ear or heart anomalies.
Behavioural Changes

Children with FAS often have difficulties in their behaviour and learning. These may include:

  • problems with reasoning
  • difficulties with arithmetic
  • problems with abstract ideas and in generalising from one situation to another
  • inattentiveness and poor concentration
  • impulsivity and poor judgement
  • subtle memory difficulties.

These children may be given diagnoses of Oppositional Defiant Disorder and Conduct Disorder later in childhood.

Classification of alcohol effects in children

The American Academy of Paediatrics uses the following criteria for diagnosing alcohol-related effects in children. For a child to be diagnosed with these conditions, alcohol abuse during pregnancy must be confirmed.

  • Foetal Alcohol Syndrome (FAS). This condition may occur when a woman drinks large amounts of alcohol (4 to 5 drinks per day). It is estimated to be present in about 1 to 2 of every 1,000 babies. In the US, at least 1200 children are born with FAS every year.
  • Foetal Alcohol Effects (FAE) Children with FAE have defects in more than one, but not all, of the FAS areas. FAE is present in about 3 to 5 in every 1,000 babies.
  • Alcohol-related neurodevelopmental disorder (ARND). Children with ARND have central nervous system abnormalities and behaviour and cognitive abnormalities. They do not have the facial features and growth retardation that can be caused by foetal alcohol exposure. ARND can occur either alone or in combination with FAS or FAE.
  • Alcohol related birth defects (ARBD). Alcohol may cause one or more birth defects of the eyes, ears, heart, kidney and bones. ARBD can occur either alone or with FAS or FAE.
Tests for Foetal Alcohol Syndrome

Any low birth-weight newborn, whose mother has a history of alcohol abuse during pregnancy, needs to be evaluated for alcohol effects. The characteristic facial features may not be present, may be subtle, or may be overlooked. There are no specific tests for FAS and diagnosis may not be made until a pattern of delayed development shows up on developmental screening tests. Any baby suspected to have been affected by alcohol needs to have a thorough evaluation at about 18 months to assess language, thinking and reasoning (cognitive), and adaptive skills. Also a hearing test needs to be done if there are any concerns.

Prevention and Treatment

The effects of Foetal Alcohol Syndrome are totally preventable. Ideally, the avoidance of all alcohol in pregnancy prevents any risk of foetal alcohol-related problems. However, many women find themselves pregnant when they have been drinking socially. The UK Royal College of Obstetricians and Gynaecologists suggests a limit of one drink per day, or one-third of the conventional ‘safe’ intake for non-pregnant women (21 units per week). Evidence from a large number of studies shows that women who drink less than eight units per week do not have babies that can be shown to be different from those whose mothers abstain completely. (There are several other influences on brain development, including nutrition, smoking, illicit drugs and genetics.)

Some research suggests that binge drinking is more dangerous than the same alcohol intake taken little and often. There is no known risk from paternal drinking. Drinking when breastfeeding does not cause any of the foetal alcohol syndromes/effects.

Unfortunately the damage caused by alcohol exposure in the foetus cannot be reversed. Foetal alcohol syndrome is not just a childhood disorder; the cognitive and behavioural effects and psychosocial problems may persist through adolescence and into adulthood. Although the facial features are not as distinctive after puberty and the growth deficiency is not as apparent as in the younger child, the central nervous system effects do persist throughout life.

Implications for care

Early intervention is important in determining the prognosis for a child with FAS/ FAE. The earlier in life that medical, clinical and educational interventions can be provided the better the outcome. Stable, structured, nurturing environments are necessary to support a child’s growth and development. Parents may feel overwhelmed by the needs of these children. Parental counselling should include discussion of the expected physical and behavioural difficulties and how to manage these. Obviously if there is any parental alcohol abuse, this should be addressed.

Children may require special educational programmes. It is important to diagnose and treat any co-existing attention deficit hyperactivity disorder (ADHD). They may need to learn ways to improve their concentration, attention and other behaviours that interfere with learning. If the child is overactive and impulsive, they may need assistance with learning appropriate social behaviour.

The teen with foetal alcohol effects may benefit from vocational training to help him or her find an appropriate job. Professional counselling may be beneficial for teens with emotional problems. Adults with foetal alcohol effects may be more at risk of psychiatric illness and early treatment should be encouraged.

Providing the best opportunities for a child diagnosed with FAS/ FAE

Providing a loving, stable home gives any child, including the child with foetal alcohol effects, the best opportunity to develop his or her full potential.

  • Babies who have been affected by alcohol exposure during foetal development tend to be very sensitive to stimulation (touch, sounds and light). They may be very irritable and colicky. Such babies can be held close in a quiet, dark room to help them sleep and crowded busy places should be avoided. They may also have trouble sucking, which affects their nutrition and weight gain. Smaller amounts of food, given more frequently, are recommended. Bottle-fed babies should be given a nipple made for a premature infant.
  • Records should be kept of the child’s developmental milestones, which may be met significantly later than by other children his or her age. The public health nurse or paediatrician can advise how to encourage the development of those skills.
  • Children with foetal alcohol effects do best in a home which has structures and routines. The rules of the family need to be clear and repeated frequently for the child.
  • The child should be enrolled in an early intervention programme as soon as possible, and his/her learning skills encouraged and improved by providing learning experiences using things he/she can touch (tactile strategies) and things he/she can do (kinaesthetic strategies). A computer or tape recorder may help the child’s memory, in addition to listening and taking handwritten notes in class.
  • Children’s independence can be encouraged; and they can be helped to learn cause and effect by role-playing situations with different reactions and outcomes.
  • As with all children with special needs, the use of praise is very important in developing self-esteem.

Irish Clinicians with a special interest in FAS:
Dr Siobhán Barry, Consultant Psychiatrist with Cluain Mhuire Services, Blackrock, Co. Dublin, and Visiting Consultant Psychiatrist at The Coombe Women’s Hospital. (Tel: 01-2833766; Email: siobhan.barry@sjog.ie)
Dr Barry’s message to the Alcohol and Family Conference in Letterkenny in October was stark, but one that is verified in the medical literature: ‘There is no safe level of alcohol consumption in pregnancy.’
Cynthia Silva, Psychologist (based inCastlebar, Co. Mayo; Tel: 087-4113885; Email: c_silva_br@yahoo.com)
Cynthia Silva is available to teach and share information on FAS—to school children, students, publicans or the media. ‘It begins with learning, admitting there is a problem, and being able to make informed decisions.’

Support Group:
Foetal Alcohol Support Ireland, for families and professionals.
Website: www.fasireland.org
Email: Michele Savage:         shellnco@hotmail.com
Jennifer Drummond:   jdrumm@gofree.indigo.ie

Websites:
In addition to the short selection below, search engines display a wide selection of informative websites on FAS, its characteristics and prevention, and the care and educational support for children with FAE/FAE.
www.fasstar.com/UK/ (This is the website of FAS-UK. It offers a wide range of information about the syndrome, with research reports, an awareness poster, and a 1992 story (with an Irish connection) by George Steinmetz in National Geographic­ (v.181:2).
www.addictionnetwork.co-uk/FAS/htm (UK)
www.fetalalcoholsyndrome.org (US)
www.fetalalcohol.com (Canadian)
www.fas-info.org.uk
www.nofas.org (US)
www.fanz.org.nz (New Zealand)

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