Published on September 14, 2015
1. Perspectives on FASD from Southern Ireland Prepared for Alcohol & Medications in Pregnancy Conference 9th Sept 2015. Dr Mary T O’Mahony, Specialist in Public Health Medicine, -S email@example.com
2. Public Health (Alcohol) Bill, 2015 Restrictions on cheap alcohol Warning labels & calorie details Strong new powers for Environmental Health Officers - enforcement New restrictions on advertising, marketing & sponsorship Prevention of Foetal Alcohol Spectrum Disorder
3. Irish initiatives Alcohol Harm RCPI Alcohol Advocacy Group Alcohol Health Alliance Ireland (RCPI, IHF, ICS, The Samaritans) FASD First Conference in UL June 2014: 280 Day 1; 260 Day 2 “Think Tank” Prevention of Foetal Alcohol Spectrum Disorder
4. National Geographic Feb 1992 http://www.faslink.org/national%20geographic%20-%20article%20on%20fetal%20alcohol.htm
5. Prevention of Foetal Alcohol Spectrum Disorder “When a million babies are born every year with permanent brain injury from a known and preventable cause, the response ought to be immediate, determined, sustainable and effective” International Charter on Prevention of FASD (Fetal Alcohol Spectrum Disorder) Edmonton September 23-25, 2013; Lancet March 2014.
6. Chief Medical Officer, DoH “Given the harmful drinking patterns in Ireland and the propensity to binge drink, there is substantial risk of neurobiological damage to the fetus resulting in Fetal Alcohol Spectrum Disorders (FASD). Therefore it is in the child’s best interest for a pregnant woman not to drink alcohol during pregnancy” (Alcohol Action Ireland 2013). Prevention of Foetal Alcohol Spectrum Disorder
7. Prevention of Foetal Alcohol Spectrum Disorder 2014 National Substance Misuse Strategy - extracts 6. Alcohol is associated with harms to the baby and is a factor in unplanned pregnancies. o A range of disorders known as fetal alcohol spectrum disorders (FASD) are caused by mothers drinking alcohol in pregnancy. o Alcohol is a significant factor in unplanned pregnancies. Labels on alcohol products sold in Ireland should include the number of grams of alcohol per container, along with calorific content and health warnings in relation to consuming alcohol in pregnancy. 11. Given the concerns about Fetal Alcohol Spectrum Disorder (FASD), a comprehensive awareness campaign on a national and community level is needed to increase public knowledge regarding the risks and impacts of drinking during pregnancy and to discourage the consumption of alcohol during pregnancy. Strengthen FASD surveillance in maternity hospitals through the Eurocat reporting system and promote greater awareness amongst healthcare professionals of FASD so as to improve the diagnosis and management of children born with FASD.
8. Prevention of Fetal Alcohol Spectrum Disorder Irish Guidance: 2003 HSE Little book of Women and Alcohol ALCOHOL & PREGNANCY Stopping drinking during pregnancy is the safest advice. Baby’s vital organs e.g. heart, brain & skeleton are formed between 10– 50 days after conception. Often, this is before you know you are pregnant. Cutting down or stopping alcohol while trying to become pregnant protects your baby. There are risks to your baby if you continue to drink, even in small quantities: The more you drink, the greater the amount passed on to your baby. More than 3 drinks a day increases the risk of miscarriage. More than 12 drinks a week increases the risk of premature birth. Avoid binge drinking, as sudden high levels of alcohol damage the developing brain. Children exposed to alcohol in pregnancy often show poor attention and hyperactivity, that may only become evident when they are a few years old. There is no known safe level of alcohol use in pregnancy, and stopping completely is advised. STOP! THINK TWICE! CUT IT OUT! http://www.drugsandalcohol.ie/11691/1/HSE_little_book_of_women_and_alcohol.pdf THE LITTLE BOOK OF WOMEN AND ALCOHOL
9. CONFLICTING ADVICE IS PROBLEMATIC Prevention of Foetal Alcohol Spectrum Disorder
10. Prevention of Fetal Alcohol Spectrum Disorder 2013 EU Alcohol & Pregnancy Including the HSE “Can I drink alcohol when I’m pregnant? The safest approach in pregnancy is to choose not to drink at all. It is important to be aware that when you drink alcohol, your baby also drinks. The risk of damage to your baby’s physical and mental development increases the more you drink and binge drinking is especially harmful. This risk relates to a range of conditions including Foetal Alcohol Syndrome (FAS) and Foetal Alcohol Spectrum Disorders (FASD).” http://www.drugsandalcohol.ie/20520/1/Alcohol_and_Pregnancy_Guide.pdf
11. Prevention of Fetal Alcohol Spectrum Disorder Contd. What if I have been drinking alcohol before I knew I was pregnant? “be reassured …very little risk of harm” “drinking heavily or ‘binge drinking’ in early pregnancy can be harmful” “avoid drinking alcohol until sure not preg” Binge drinking definition RoI: 5 units X 10g per unit UK: 6 units X 8g per unit (Canada: 3 units)
12. Prevention of Fetal Alcohol Spectrum Disorder “ there are lies, damn lies and statistics” Benjamin Disreali 1804-1881 The “Dr Petr Skrabanek“ of FASD”
13. Prevention of Fetal Alcohol Spectrum Disorder Astley SJ replies to Oster Evidence base appraised: Dutch studies selectively used 1 in 7 with FAS had reported prenatal exposure of 1-8 drinks per week Children with FAS 50% development preschool normal All severe brain dysfunction @10yrs 10% attention problem at 5 yrs 60% attention problem at 10 yrs Only 30% IQ below normal, BUT 100% severe dysfunction in areas e.g. language, memory, activity level
14. Prevention of Fetal Alcohol Spectrum Disorder Surveillance of FAS & FASD Fetal Alcohol Syndrome – one end of the spectrum / may have visible signs of abnormalities and be recognised at birth Fetal Alcohol Spectrum Disorder – not recognisable until preschool or school age when difficulties manifest
15. Incidence/Prevalence 2009 Canada 1% of live births 2014 Alberta (2003 to 2012 data) Incidence = 1.42% to 4.38% of live births Prevalence = 1.17% of Alberta population 2014 Midwest USA Prevalence = 2.4% to 4.8% of 1st graders Australia FAS or pFAS prevalence of 12% Italy FAS 0.4-1.2%; pFAS 1.8-4.6%; FASD 2.3-6.3% of children
16. Prevention of Foetal Alcohol Spectrum Disorder “Children with FASD fill our Foster Care places. Adults with FASD fill our jails.” 25 Differential diagnoses. Many misdiagnosed as Autism Spectrum Disorder. Societal impact
17. Prevention of Foetal Alcohol Spectrum Disorder Economic impact – Alberta Canada 10 Strategic Plan to prevent FASD Population 3.6m,36000 with FASD (estimate 1%); 450 FASD babies born/a Lifetime cost to state per child with FASD estimated: $800K(£394K/€540K) Prevention of 10 cases p.a. covers cost of comprehensive services Alberta FASD Services- Estimated to save $20m p.a. in reduced demand for services
18. Prevention of Foetal Alcohol Spectrum Disorder Case scenario - Ireland: evidence & anecdote 80% of nulliparous pregnant women in the study sample drank alcohol while pregnant In Ireland, it’s the accepted social norm to drink while pregnant Ireland not alone Australian study in 2010 (Robinson) OK to drink English study in 2011 (Kelly) OK to drink US Feldman – Not OK to drink
19. A new 'toolkit' for health professionals was launched in the antenatal clinic in Letterkenny General Hospital. The project, which aims to increase awareness of the health benefits to pregnant mums and unborn children of ceasing alcohol consumption entirely during pregnancy, Photo : L-R: Helen McFarland, ETB; Ciara Doyle, Project Lead, Hidden Harm, HSE/Alcohol Forum; Cora McAleer, Manager, Mental Health Addiction Services; Evelyn Smith, Asst Director of Nursing/Midwifery; Christina McEleney, Coordinator Tutor, University of Limerick Diploma in Drug and Alcohol Studies; Dr. Nandini Ravikumar, Consultant Obstetrician; Sean Murphy, General Manager, Geraldine Hanley, CMM2 Antenatal Education Coordinator; Moira Mills, Alcohol Forum; and Mary Kelly, Health Promotion Officer From: Saolta-e-Newsletter-July-2015-pdf
20. Prevention of Foetal Alcohol Spectrum Disorder SAOR (S&BI for subs misuse) Tiers 1-4 18. It is essential to raise awareness of the risks of drinking during pregnancy (Recommendation 1 of Prevention Pillar; see Chapter 7) in all tier 1 and tier 2 settings, particularly in primary care, so that hazardous or harmful drinking can be identified, allowing for change. Screening for alcohol consumption should begin at the first antenatal visit for all pregnant women and be reviewed throughout the pregnancy. 19. Pregnant women who are alcohol dependent should be prioritised for immediate access to tier 3 and tier 4 services.
21. Prevention of Foetal Alcohol Spectrum Disorder TIER 1 Interventions where main focus is not drug treatment TIER 2 Drug-related Interventions TIER 3 Specialist Drug-related Interventions TIER 4 Specialist Dedicated Inpatient or Residential Units or Wards Family Support Social Care Pharmacies Community Based Job Seeking Prison Community Education Skills Setting Setting Services Primary Care Outreach Hospital Setting Specialist Addiction Services Vocational Criminal Justice Training & Probation Services General Healthcare Setting
22. Prevention of Foetal Alcohol Spectrum Disorder Integrated Model of Rehabilitation Provision
23. PCAP – Nth America An effective and cost efficient intervention in the prevention of FASD
24. Prevention of Foetal Alcohol Spectrum Disorder PCAP: Parent Child Assistance Programme A supportive non-judgmental relationship Support to the mother and the target child “Wrap around service” 3 year programme, 2 visits per month Relapse is tolerated, start again
25. Prevention of Foetal Alcohol Spectrum Disorder PCAP: three objectives Motivate the women to stop using If can’t, help women not to get pregnant Family planning does not mean never having another child but plan family Effective contraception Use mandated treatment for alcohol and drug abuse Use women only treatment Use service where children can stay Provide client specific support to addiction service providers as indicated.
26. Prevention of Foetal Alcohol Spectrum Disorder PCAP: Outcomes more employed less on welfare months sober % in treatment number in education connected to community support services
27. Prevention of Foetal Alcohol Spectrum Disorder “Safe Limiting” in Pregnancy FASD: alcohol causal, a co-factor, correlated No amount of RoH absolutely safe No amount of RoH absolutely dangerous A relative risk of harm Multiple mechanisms direct & indirect action Fraternal twins with lesser effect in one Maternal nutrition Maternal & foetal metabolism Stop drinking – 2o prevention, selective
28. Prevention of Foetal Alcohol Spectrum Disorder
29. Prevention of Foetal Alcohol Spectrum Disorder Alcohol use by women is increasing in all socioeconomic groups (SEG), as is binge drinking especially among students and those of lower SEG How prevalent is Prenatal Alcohol Exposure? Surveillance of prenatal alcohol exposure: cord blood (EtG) on bloodspot card / meconium (FAEE) An increasing problem? Yes
30. Transgenerational aspects ICGP Lead GP for Substance Misuse The cycle of addiction from generation to generation Those with FASD at increased risk of addiction to alcohol themselves Prevent FASD and break the cycle
31. Most inspiring speaker* Who’s the DD (designated driver) and have the girls done their PT (pregnancy test)? PT ($2) dispenser in the bar restroom Goal_mtom: “pregnant pause” - that drinking in pregnancy will be at least as unacceptable as drink driving Prevention of Foetal Alcohol Spectrum Disorder * @ First International Prevention of FASD Conference, Edmonton Sept 2013
32. Prevention of Fetal Alcohol Spectrum Disorder NZ Hawkes Bay NICU
33. The elephant in the room – FASD or ASD? Need first to document prenatal alcohol intake by pregnant women. To document prenatal alcohol exposure (PAE) for aetiological studies Women and alcohol The pregnant pause Who are the stakeholders? Anecdote LIG parent group Prevention of Foetal Alcohol Spectrum Disorder
34. Prevention of Fetal Alcohol Spectrum Disorder Screening & brief intervention for alcohol in pregnancy Parent child assistance programmes Many resources developed to assist Information leaflets, posters, videos etc on diagnosis on strategies for care Effective interventions in prevention of FASD
35. Collect information and evidence Active surveillance for FAS in at risk populations Children in state care Young offenders Prison population Population based within national schools – all those less than 10th / 25th centile for growth (height) Active surveillance for prenatal alcohol exposure Antenatal screening +/- Brief intervention Cord blood Meconium
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