Fetal Alcohol Syndrome
September 3, 2004, KidsHealth.org

What is the leading known cause of mental and physical birth defects, surpassing both spina bifida and Down syndrome? Which drug produces more severe abnormalities in a developing fetus than heroin, cocaine, or marijuana?

The answer to both questions is the same: alcohol. Alcohol (wine, beer, or liquor) is the most common preventable cause of birth defects in the United States.

When a woman drinks alcohol during pregnancy, she risks giving birth to a child who will pay the price - in mental and physical deficiencies - for the rest of his life. Yet many pregnant women do drink alcohol, and it is estimated that one in every 750 infants is born with full-blown Fetal Alcohol Syndrome (FAS) each year in the United States. Another 50,000 children are born with Fetal Alcohol Effects (FAE) each year. Read this article to learn more about FAS and FAE, including characteristics and risk factors.

Signs and Symptoms of FAS
FAS is identified as a pattern of physical, developmental, and functional abnormalities in a child resulting from a woman's drinking alcohol during pregnancy. Characteristics of children with FAS include: [list][*]Low birth weight [*]Small head circumference [*]Failure to thrive [*]Developmental delay [*]Organ dysfunction [*]Facial abnormalities, including smaller eye openings, flattened cheekbones, and indistinct philtrum (an underdeveloped groove between the nose and the upper lip) [*]Epilepsy [*]Poor coordination/fine motor skills [*]Poor socialization skills, such as difficulty building and maintaining friendships and relating to groups [*]Lack of imagination or curiosity [*]Learning difficulties, including poor memory, inability to understand concepts such as time and money, poor language comprehension, poor problem- solving skills [*]Behavioral problems, including hyperactivity, inability to concentrate, social withdrawal, stubbornness, impulsiveness, and anxiety[/list:u]Children with FAE display the same symptoms, but to a lesser degree, and are less likely to have mental retardation.

The Hidden Handicap
It was not until 1973 that alcohol was officially recognized as a teratogen, a substance that can cause damage to a fetus. Today, FAS and FAE are still largely misunderstood by the general public.

Children with FAE are often at a disadvantage because they are frequently undiagnosed, says Georgiana Wilton, coordinator of the National Family Empowerment Network: Supporting Families Affected by FAS and FAE. This also applies to children with Alcohol-Related Neurodevelopmental Disorder (ARND), a recently recognized category of prenatal damage that refers to those children who exhibit only the behavioral and emotional problems of FAS/FAE, without any signs of developmental delay or physical growth deficiencies.

"These kids fall through the cracks and suffer for it," Wilton says. "Their behavior can look like belligerence or obstinacy, when in fact the kids are acting out of their own limited understanding of what is expected of them." Wilton explains that although children with FAE or ARND may score well on intelligence tests, their behavioral deficits often interfere with their ability to succeed. Extensive education and training of health care professionals, parents, and teachers are essential to caring for these children.

Diagnosis and Long-Term Effects
"Early diagnosis is essential," affirms Ronnie Jacobs of the Bergen County, New Jersey Council on Alcohol and Drug Abuse. "We must remember that it's not that these kids are a problem, but that they have a problem. We need to change our mindset, because the children are not going to change. FAS, FAE, and ARND are lifelong conditions. There is no cure."

Psychologist Ann Streissguth, a pioneer in the field of FAS, has conducted numerous studies mapping the long-term effects of FAS/FAE. Her research shows that the problems associated with FAS actually intensify as children move into adulthood. A majority of the adults in her studies had mental health problems, experienced trouble with the law, and were unable to live independently.

Professionals who work on a daily basis with the families of FAS/FAE victims see important changes beginning to take place. "Recent research has led to an awareness of the importance of providing early intervention to children diagnosed with FAS," says Wilton. "Development and stimulation programs begun between birth and age 5 have made enormous differences."

How Much Alcohol Is Too Much?
It is clear that abusing alcohol during pregnancy is dangerous, but what about the occasional drink? How much alcohol constitutes too much during pregnancy? No evidence exists that can determine exactly how much alcohol ingestion will produce birth defects. Individual women process alcohol differently. Other factors vary the results, too, such as the age of the mother, the timing and regularity of the alcohol ingestion, and whether the mother has eaten any food while drinking.

Many doctors believe that an occasional glass of wine during pregnancy presents no risk to the fetus. But as Linda Nicholson, a genetic counselor, points out, "We don't know how much alcohol is safe so we just say, 'Don't drink at all.'" Although full-blown FAS is the result of chronic alcohol use during pregnancy, FAE and ARND may occur with only occasional or binge drinking.

Because alcohol easily passes the placental barrier and the fetus is less equipped to eliminate alcohol than its mother, the fetus tends to receive a high concentration of alcohol, which lingers for longer periods than it would in the mother's system.

Nicholson calls it DUI, or "developing under the influence." "Mothers who drink during the first trimester of pregnancy have kids with the most severe problems, because that is when the brain is developing," she says. "The connections in the baby's brain just don't get made properly when alcohol is present. Of course, in the early months, many women don't even know they're pregnant." Nicholson suggests that women who are thinking about becoming pregnant adopt healthy behaviors before they get pregnant.

Women who abstain from alcohol in early pregnancy may feel comfortable drinking in the final months. But some of the most complex developmental stages in the brain occur in the second and third trimesters, a time when the nervous system can be greatly affected by alcohol. New information reveals that even moderate alcohol intake, and especially periodic binge drinking, can seriously damage a developing nervous system.

"Something that adds to the confusion," says Jacobs, "is that many doctors and obstetricians seem to be inordinately uncomfortable about screening women for alcohol use."

Dace Svikis, PhD, program director for The Center for Addiction and Pregnancy at Johns Hopkins Bayview Medical Center, agrees. Some doctors "present the drinking issue as a kind of double negative: 'You don't drink, do you?'" Some women feel that the only appropriate thing to say is 'no,' and that is often the end of the discussion about drinking, says Dr. Svikis. "Maybe some doctors aren't sure what to do if a woman actually says, 'Yes, I am drinking,' so they feel it's simpler just not to ask."

Prevention Is the Goal
The tragedy is that FAS is entirely preventable. The best way to prevent FAS is by not drinking. "You can't control what genes or chromosomes you give your child, but you can control what you ingest during pregnancy," Nicholson says.

Dr. Svikis emphasizes the need for treatment programs tailored specifically for women who drink. "A lot of at-risk women don't get the prenatal care they need, not because they don't want it or don't care about their babies, but because they feel this incredible stigmatization from health care providers because of their alcohol or polydrug abuse. We need to support these women, and to educate at a basic level. We also need agreement among professionals."