Reducing Prenatal Alcohol Use: Effective Identification

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Reducing Prenatal Alcohol UseEffective
Identification

• Grace Chang, MD, MPH
• BFSS, San Francisco, CA
• 10 May 2006

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Title Slide Option 1A (with Harvard logo)
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Acknowledgements

• National Institute on Alcohol Abuse and
  Alcoholism and Office of Research on Womens
  Health
• R01 AA 9670
• R01 AA 12548
• R01 AA 14678
• K24 AA 00289

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Co-Investigators

• E. John Orav, PhD
• Susan Berman, MD
• Louise Wilkins-Haug, MD, PhD
• Research Team

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2005 Advisory on Alcohol Use in Pregnancy

• No amount of prenatal alcohol is safe
• Alcohol can damage a fetus at any stage of
  pregnancy
• Cognitive deficits and behavioral problems
  resulting from prenatal alcohol are lifelong
• Alcohol related birth defects are entirely
  preventable

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Prevalence of Prenatal Drinking

• 13 of pregnant women drink
• 40,000 babies with FASD annually
• Lifetime cost per child is 860,000
• 6 with frequent (gt 7 drinks/week) or binge (gt
  5drinks/episode) drinking
• 21 prevalence in 1988
• Healthy People Goal
• Achieving 6 prenatal drinking was the goal for
  2000
• 6 is the goal for 2010

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PRAMS Data, 2000-2001

• Pregnancy Risk Assessment Monitoring System
  identified women with the highest prevalence of
  alcohol use
• Women gt 35 years
• Non-Hispanic Women
• Women with gt high school education
• Women with higher incomes

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Pregnant Binge Drinkers

• Younger lt 30 years
• Single
• White
• Cigarette smoker
• Uses illicit drugs
• Marijuana (20), Cocaine (11), Other (9)

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Fetal Alcohol Syndrome

• With/without confirmed maternal alcohol exposure
• Characteristic pattern of facial anomalies
• Short palpebral fissures
• Abnormalities of the premaxillary zone

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Fetal Alcohol Syndrome

• Growth retardation
• Low birth weight, lack of weight gain over time,
  disproportional low weight to height
• Neurodevelopmental CNS abnormalities
• Small head size at birth
• Structural brain abnormalities with
  age-appropriate neurological hard or soft signs
  (e.g., impaired fine motor skills)

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Alcohol-Related Neurodevelopmental Disorder

• One or more neurodevelopmental effects associated
  with fetal alcohol exposure
• Alcohol-related problems
• Behavior -Memory
• Cognitive Function -Attachment
• Fine motor skills -Language
• Attention

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Alcohol-Related Birth Defects

• One or more birth defects associated with alcohol
  exposure
• Cardiac (atrial septal defect, VSD)
• Ocular (ptosis, corneal abnormalities)
• Auditory (low-set posterior rotation of the
  auricle)
• Renal (aplastic, hypoplastic, dysplastic)
• Skeletal (fusion of radius and ulna)

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Effects of One Drink

• Growing evidence that prenatal alcohol
  consumption at levels lt 1 drink/day can adversely
  affect fetal growth and development even in late
  pregnancy
• Ethanol inhibits neural cell adhesion
• Mutations in cell adhesion molecule L1 cause
  mental retardation
• Widespread apoptotic neurodegeneration
  (deletion of millions of neurons, reduced brain
  mass)

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One Drink per Week

• Adverse effects evident in children at age 6 and
  7
• Increased Aggressive and Externalizing Behavior
• Dose response relationship
• Increased Delinquent and Total Problem Behavior
• Any prenatal alcohol exposure increased the risk
  of children (3.2 times) having Delinquent
  Behavior scores in the clinically significant
  range

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Abstinence

• Recommendation to preconceptional and pregnant
  women
• American Academy of Pediatrics
• American College of Obstetricians and
  Gynecologists
• US Surgeon General
• Secretary of Health and Human Services

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Identification of Prenatal Alcohol Use

• Increased ascertainment of alcohol use among
  periconceptional and pregnant women is urgently
  needed
• Screening by obstetricians was 34 in 1987 and
  goal was 75 by 2000
• Special screening considerations

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Identification Options

• Standard Quantity and Frequency Questions
• Many will alter drinking once pregnancy is
  confirmed
• Denial and under-reporting for a multitude of
  reasons
• Concurrent versus retrospective report of
  antenatal consumption

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Current versus Retrospective Reports of Prenatal
Alcohol Use

• Jacobson et al. (91) found that 53 of the women
  who reported drinking more than 1.3 drinks/week
  while pregnant, recalled drinking more when
  interviewed after delivery
• 42.1 drank more than 1.0 ounce of alcohol per
  day while pregnant

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Breathalyzer or Urinalysis

• Limited usefulness in the prenatal setting
• Rapid metabolism of alcohol
• Pattern of drinking by most pregnant women
• Legal versus clinical procedure

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Methods of Identification

• Maternal Blood Markers
• Combinations of MCV, GGT, CDT, WBAA (Whole Blood
  Acetaldehyde) for physically affected infants
  (Stoler et al., 98)
• Neurobehavioral dysfunction (most frequent
  outcome) not recognized in the newborn period
• Unlikely to be applicable to a substantial
  proportion of pregnant women
• Harmful, but lesser amounts of consumption

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Traditional Screening Instruments

• Frequently developed among male drinkers
• Limited utility in the prenatal setting
• Brief questionnaires are most effective
• Avoid triggering denial
• Alcohol intake before pregnancy most important
  clinical predictor of subsequent use

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Screening Instruments

• Traditional screening instruments normed on male
  alcoholics (CAGE, SMAST)
• Do not detect low but risky levels of drinking
• Limitations among women and minorities
• AUDIT
• 10 items
• Infrequently used
• No established cut points for pregnant women

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Other Options

• AUDIT-C
• Not well studied in prenatal populations
• T-WEAK
• Level of at-risk drinking detected is double the
  currently accepted level of a drink per day,
  (Sokol et al., 2003)
• Low sensitivity as an alcohol screener among
  female veterans (Bust et al., 2003)

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Sensitivity and Specificity A Balance

• Sensitivity
• The probability that a person who should test
  positive, does so
• Specificity
• The probability that a person who should test
  negative, does so
• More false positives versus more false negatives?

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A Positive Screen

• Not synonymous with an alcoholism diagnosis
• Not an indictment
• A signal for discussion
• Appropriate balance between sensitivity and
  specificity

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The T-ACE

• Developed by Dr. R. J. Sokol
• 4-item questionnaire based on the CAGE
• Reflects a pattern of use
• Validated in diverse patient samples
• Detroit, MI and Boston, MA
• Self-administered format in Boston

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T-ACE Questions

• T How many drinks does it take to make
• you feel high (effects)?
• A Have people ever annoyed you by criticizing
  your drinking?
• C Have you ever felt you ought to cut down on
  your drinking?
• E Have you ever had a drink first thing in the
  morning to steady your nerves or get rid of a
  hang-over?

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Scoring the T-ACE

• T is given two points if the woman reports more
  than 2 drinks
• A, C, E get one point each for each yes reply
• T-ACE is positive with a score of 2 or more

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Measures of Merit for the T-ACE

• Superior to the AUDIT, MAST, Medical Record
• Current Drinking
• Risk Drinking
• DSM-III-R Lifetime Alcohol Diagnoses
• PAST drinking is most predictive of pregnancy
  drinking

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T-ACE Positive Women

• DSM-III-R criteria for lifetime alcohol dx
• 40 versus 14T-ACE negative (plt.001)
• Risk drinking pre-pregnancy (gt2 drinks/ day)
• 39 versus 8 T-ACE negative (plt.001)
• Drinking while pregnant
• 43 versus 13 T-ACE negative (plt.001)

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T-ACE versus Medical Record

• 278 pregnant women, all T-ACE positive
• Electronic and paper obstetric records reviewed
• 10.8 identified as potential drinkers
• 82.2 of those who physicians did not consider to
  be at risk for alcohol use, drank
• White women less likely to be identified by their
  doctors, even controlling for income, education,
  pre-pregnancy consumption (p.026)

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What to Do with a Positive T-ACE?

• Discussion
• Assessment
• Brief Intervention

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Recommendations

• All pregnant women should be screened
• Risk of prenatal alcohol use is not limited to
  the uneducated or impoverished
• Use of a screening instrument will increase
  efficiency
• Discussion, Assessment, or Brief Intervention
• Highly therapeutic and effective in reducing
  drinking

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References

• Chang G, Wilkins-Haug L, Berman S, et al.
  Alcohol use and pregnancy improving
  identification. Obstet Gynecol. 1998 91
  892-8.
• Chang G. Screening and brief intervention in
  prenatal care settings. Alcohol Research and
  Health. 2004/2005 28 80-84.