Fetal Alcohol Spectrum Disorder Caitlin Carew PGY3 Pediatrics

Fetal Alcohol Spectrum Disorder Caitlin Carew PGY-3 Pediatrics CHEO Telehealth Rounds March 31, 2017

What is FASD? • A diagnostic term that describes a group of effects that result from prenatal exposure to alcohol

Prevalence of FASD • 2015 Canadian Guidelines estimate that 1/100 people meet diagnostic criteria for FASD

Etiology of FASD

No Safe Threshold

Risk Factors for FASD • Child Factors • Sibling with FASD • Lived/living in foster care • Current or past involvement with child protective services

Risk Factors for FASD • Maternal Factors • Low maternal educational attainment • Higher maternal age (>30) • Poor maternal nutrition in pregnancy • Higher gravidity and parity • History of miscarriages and stillbirths

Risk Factors for FASD • Maternal Factors Continued • Substance use including tobacco • Mental health disorders • Social isolation in pregnancy • Intimate partner violence • Poverty

What is FASD?

2015 Canadian Guidelines

Sentinel Facial Features

Sentinel Facial Features

CNS Impairment • Severe impairment in 3 or more of the following domains: • motor skills • neuroanatomy/neurophysiology • cognition • language • academic achievement

CNS Impairment • memory • attention • executive function, including impulse control and hyperactivity • affect regulation • adaptive behaviour, social skills or social communication

CNS Impairment • Severe Impairment: Greater than or equal to 2 standard deviations below the mean • No neurodevelopmental deficits are pathognomonic for FASD

Associated Congenital Anomalies • Cardiac: ASD, VSD, conotruncal defects (TOF) • Skeletal: joint flexion contractures, shortened 5 th digits, scoliosis, hemivertebrae • Renal: aplastic, dysplastic, hypoplastic kidney, ureteral duplication • Ocular: strabismus, optic nerve hypoplasia • Auditory: conductive or SNHL

Management of FASD • An ounce of prevention…

Screen All Women • Abstainers • Low-risk drinkers • At-risk drinkers • Problem drinkers

T-ACE • Tolerance (2 or more drinks to feel effect) • Annoyed • Cut back • Eye opener

Management of FASD • Early diagnosis and intervention is important • Anticipatory guidance for parents

Management of FASD • Infancy: irritability, jitteriness • frequent, gentle handling • frequent eye contact and cuddling • avoid bouncing/sudden movements

Management of FASD • Young children: hyperactivity, inattention, cognitive impairment, emotional reactivity, learning disabilities, memory deficits, seizures • good structure and routine (transitions are hard) • teach acceptable interpersonal behaviour • maintain sense of self-worth

Management of FASD • Older children/adolescents: school disruption, inability to maintain employment, inappropriate sexual behaviour • keep tasks simple (poor short-term memory) • ensure safety (may not identify danger) • focus on developing life skills

Comorbidities • ADHD • Mood dysregulation and major depression • Anxiety • Substance use

Referral • Patients will benefit from a multidisciplinary approach - consider referral to developmental pediatrics (OCTC in Ottawa)

Management of FASD

Management of FASD https: //canfasd. ca/wp-content/uploads/sites/35/2016/11/I-Am-a-Caregiver-poster. pdf

Prognosis • High prevalence of adverse outcomes • Inappropriate sexual behaviour • Suspension/expulsion/school drop out • Trouble with law • Confinement (prison, psychiatric, addiction rehab) • Alcohol/drug us

Prognosis • Factors associated with improved prognosis • Diagnosis before age 6 • Access to social services and educational supports • Stable living environment • Absence of exposure to abuse

Summary • New Canadian Guidelines for diagnosis of FASD • There is no safe amount of alcohol to consume in pregnancy • Prevention is key - screen all women of childbearing age for alcohol consumption habits and counsel on reducing intake • Management should be tailored to the individual child, but in general early diagnosis and intervention is associated with better outcomes

Thank You

References Fetal alcohol spectrum disorder: Canadian guidelines for diagnosis. Chudley AE, Conry J, Cook JL, Loock C, Rosales T, Le. Blanc N; Public Health Agency of Canada's National Advisory Committee on Fetal Alcohol Spectrum Disorder. CMAJ. 2005 Mar 1; 172(5 Suppl): S 1 -S 21. Fetal alcohol spectrum disorder: a guideline for diagnosis across the lifespan. Cook JL, Green CR, Lilley CM, Anderson SM, Baldwin ME, Chudley AE, Conry JL, Le. Blanc N, Loock CA, Lutke J, Mallon BF, Mc. Farlane AA, Temple VK, Rosales T; Canada Fetal Alcohol Spectrum Disorder Research Network. CMAJ. 2016 Feb 16; 188(3): 191 -7. Fetal alcohol syndrome. First Nations and Inuit Health Committee, Canadian Pediatric Society. Paediatr Child Health. 2002 Mar; 7(3): 161 -95.