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Introduction   

Fetal alcohol spectrum disorders are conditions that are caused by alcohol intake during pregnancy and can have lasting effects on the child (1). There are five disorders that are included in fetal alcohol spectrum disorders, each disorder will be examined in depth in this course.  

Fetal alcohol spectrum disorders are associated with a wide variety of impairments such as restricted growth, cognitive abnormalities, craniofacial irregularities, and behavioral problems (3). These disorders are under-diagnosed or can be missed due to the mother not admitting prenatal alcohol use and can be like other diagnoses (3).  

It is important for nurses to understand the epidemiology, etiology, signs and symptoms, and strategies for treatment and prevention of this disorder.  

Epidemiology 

Formal research on prenatal alcohol exposure began around 1973 (4). In 1977, the National Institute of Alcohol Abuse and Alcoholism submitted recommendations to limit alcohol use in pregnancy (4). Prior to this research, there was a lack of understanding on the correlation between prenatal alcohol use and birth defects (4).  

The use of alcohol during pregnancy is the most common preventable cause of birth defects and cognitive impairments in the United States (4). There is limited research to provide guidance on a safe amount of alcohol in pregnancy, and abstinence from alcohol is currently the only safe way to prevent fetal alcohol spectrum disorders (5). 

The exact number of children with fetal alcohol spectrum disorders is unknown (2). It can be difficult to diagnose because there is not a blood test (1). The Centers for Disease Control and CDC studies have shown that 1 out of 1000 infants are born with FAS in certain areas. [2]. In the United States a projected 1% to 5% of first graders have a FASD based on a study by the National Institute on Alcohol Abuse and Alcoholism (15).  

Studies have shown that in 2002 the estimated lifetime cost of care for a person with fetal alcohol syndrome is $2 million (2). The United States spends on average of $4 billion annually on people with fetal alcohol syndrome (2). These numbers are staggering and can depend on the disability itself. The high cost over a lifetime can be due to the inability to work because of cognitive impairments which can affect the person’s lifestyle. 

Etiology/Causes 

Alcohol that is consumed during pregnancy passes to the fetus via the umbilical cord (1). The type of alcohol such as wine, beer, or liquor does not determine the effects on the fetus (1). Even with ongoing research, studies are still not able to determine the effects in correlation with the amount of alcohol consumed during pregnancy (1).  

Alcohol is considered teratogenic in all three trimesters, which makes alcohol consumption unsafe throughout the entirety of the pregnancy (6). The effects of alcohol cause irreversible damage to the central nervous system (6). Higher amounts of alcohol during pregnancy correlates with an increased risk of alcohol spectrum disorder and the severity of the disorder (6).  

There have been risk factors identified with an increased incidence of prenatal alcohol exposure resulting in the development of fetal alcohol spectrum disorders. Identified risk factors include mothers that metabolize alcohol slowly, mothers with poor nutrition, greater maternal age with a long-term history of alcohol use, and women that stopped using birth control to try to become pregnant (6) (7). 

Signs and Symptoms 

Prenatal alcohol exposure can affect individuals differently. Alcohol exposure in the three trimesters can produce different side effects; however, alcohol exposure anytime during the pregnancy produces risk of impairments to the fetus.  

In the first trimester, high levels of prenatal alcohol exposure can increase the incidence of facial and brain abnormalities (6). These facial features can include a smooth ridge between the nose and mouth called a philtrum, a flat widened nose, and small head circumference (1)(9). 

High levels of alcohol use in the second trimester have been associated with an elevated risk of spontaneous abortions (6).  

High levels of alcohol intake in the third trimester correlate with smaller than average height, and decreased weight (1) (6).  

Neurodevelopment is affected in all trimesters in the pregnancy and with a wide range of alcohol used (6). The neurobehavioral signs and symptoms can be speech delays, intellectual disability, hyperactive behavior, inadequate memory, and vision or hearing difficulties (1) (8) (9). Problems with the heart, kidneys, and bones have also been acknowledged (9). Infants may also have problems with sucking and sleeping (9). 

Types of FASD 

As mentioned above there are currently five types of fetal alcohol spectrum disorders. Some of the disorders have had name changes throughout the years once research was conducted.  

• Fetal Alcohol Syndrome (FAS) – This diagnosis must meet certain criteria. They must have abnormal facial features, growth deficiency and neurodevelopment or behavioral problems (1) (10). For the formal diagnosis of FAS an individual must have two of the three craniofacial abnormalities: a thin upper lip, a smooth philtrum, and short palpebral fissures (8).  

This individual may have learning disabilities, problems with communication, vision, or hearing difficulties (1). This diagnosis includes physical and cognitive abnormalities (10). A proven alcohol exposure during pregnancy is not necessary to diagnose an individual with fetal alcohol syndrome (1). 

• Partial Fetal Alcohol Syndrome (pFAS) – Partial fetal alcohol syndrome is where the individual only exhibits some of the symptoms that must be met for the FAS diagnosis (10). This diagnosis is thought to not be as severe as the other types (11). Partial fetal alcohol syndrome is not as common (10). 

• Neurobehavioral Disorder Associated with Prenatal Alcohol Exposure (ND-PAE)- In 2013, this diagnosis was included in the 5th edition of the Diagnostic and Statistic Manual of the American Psychiatric Association (1). This diagnosis includes problems with memory and thinking, mental health, and activities of daily living (1) (11). These symptoms are present with or without physical deformities (10).  

These individuals may have trouble remembering information they have already learned and may experience behavioral tantrums (1). They may have problems socializing with other children and bathing or dressing themselves. The American Psychiatric Association states for an individual to be diagnosed with ND-PAE, the mother must have consumed more than 13 alcoholic beverages per month of pregnancy (1). 

• Alcohol-Related Birth Defects (ARBD)- This type of FASD affects the development of organs due to prenatal alcohol exposure (11). This can impair organ development and their function, such as the kidneys, heart, bones, and hearing or vision (10). This population does not experience cognitive delays (10).  

• Alcohol Related Neurodevelopment Disorder (ARND)- This alcohol exposure leads to intellectual disabilities, problems with behavior and difficulty learning because the exposure affected the nervous system and the brain (1) (11). They may lack impulse control and may not do well in school (1). These individuals may experience similar symptoms of ND-PAE; however, they do not exhibit any growth or facial abnormalities that individuals with ND-PAE may have (10). This diagnosis concentrates on neurodevelopment that was affected due to the prenatal alcohol exposure.  ​

Case Study

A 3-year-old with an unknown birth history is brought to their pediatrician’s office for their third year well visit. The adoptive parents voice concerns about development and behavior at home. The adoptive parent states the child has difficulty communicating their needs and does not seem to be meeting developmental goals. The child is only able to communicate a couple words. The parent states the child does not like to be around other children. The pediatrician states the child is in the 10th percentile for height and weight. The child has a thin upper lip border and a smooth philtrum. The child also did not pass their hearing screening. 

Case Study

A school nurse is caring for a 7- year-old that comes to the office frequently after having outbursts in class. The teacher states the child has a hard time with understanding instructions and paying attention. The student does not seem to remember what they recently learned. The student lacks impulse control. The child does not understand the consequences of not listening to the teacher. The nurse was informed that the child suffers from prenatal alcohol exposure. The nurse notes the child does not have any physical abnormalities.  

Treatment 

Fetal alcohol spectrum disorders do not have a cure and can affect an individual during their entire lifetime (1). Studies have shown that interventions that are implemented early can improve the quality of life for a person with prenatal alcohol exposure (1). There are a variety of treatment options for children with FASDs and the effectiveness can depend on the child.  

• Therapy– Educational and behavioral therapies have been proven to be beneficial to children with FASDs. These therapies can range from developing social skills, helping with learning disabilities, and therapy focusing on the entire family (12). Some alternative therapies have been explored such as yoga, art therapy, relaxation, and animal therapy (12). 

• Medications– Certain medications can be used in individuals with FASDs to combat some symptoms caused by prenatal alcohol exposure. Depending on the symptom, certain medications may be more beneficial. Stimulants have been used to help ADHD in individuals with FASD (13). Antidepressants can help treat mood irregularities and sleep disruptions (12). Neuroleptics can help with behavioral problems such as aggression and anxiety (12). Choline can potentially help with cognition, such as improve memory and help with learning abilities (14). 

• Medical Care– Medical care is important for individuals with FASDs. Treatment involves follow up care and a collaborative health care team. The use of occupational therapists, physical therapists, speech language pathologists, audiologists, and ophthalmologist are just a sample of specialists that may need to be involved for optimal care (12).  

Prevention 

Fetal alcohol spectrum disorders are preventable. With this being said, the best treatment is prevention. A study that was conducted by reviewing data from 2015-2018, showed 1 in 10 (9.8%) pregnant women reported current alcohol use and 1 in 22 (4.5%) pregnant women reported binge drinking (15). For complete prevention women that might be pregnant or could become pregnant should abstain from alcohol (1). If alcohol was consumed during pregnancy, stopping alcohol consumption can help prevent further damage (1). Education can go hand in hand with prevention. Educating pregnant women or women in childbearing age on the effects of alcohol can have on their child can play a role in prevention. 

Education for Parents 

Early recognition and diagnosis of fetal alcohol spectrum disorders can help the child now and in the future. Parent education is important for the child to have the best quality of life possible. Providing education to pregnant women about the harmful effects of alcohol is crucial on the prevention side.  

Early interventions that are started between birth and 36 months can help the child develop important skills such as speaking, social interaction, and physical abilities (12). The type of treatment is based on symptoms the child is experiencing. Educating the parents on the treatments available for children with FASDs and how to receive them is important (12). 

Due to the social stigma surrounded by FASDs a formal diagnosis can be difficult for the parents to accept. However, it is beneficial for the child to educate the parents and provide resources for them. There are certain factors that can have positive effects on individuals with FASD. Studies have shown if an individual is raised in a stable household and not exposed to violence at a young age it can help prevent other conditions such as conduct disorder (12).  

A child with a fetal alcohol spectrum disorder might experience aggression or anger and they need to be taught how to manage that appropriately (12). Including this information in parent education can help prevent negative effects of these disorders in their future such as partial education and criminal behavior (12). 

Resources 

Recent research has led to an increasing number of resources available for families and for healthcare providers. This knowledge can empower healthcare providers to elevate their care for patients with FASDs and partner with families to improve the overall quality of life for these individuals.  

FASD United is a national program that has developed tools for parents and provides strategies on how to care for individuals with FASDs from infancy to adolescence (18). They also have tools for educators to implement while teaching these individuals. 

The CDC is currently working on an alcohol screening and brief intervention program for primary care. CDC found that 80% of pregnant women were asked about current alcohol use and 16% of women that reported current alcohol use were told to quit (16). Implementing these screenings and intervention protocols in primary care could help prevent prenatal alcohol exposure.  

The American College of Obstetricians has organized a FASD prevention program that can help physicians communicate with patients about prenatal alcohol exposure (17). The American Academy of Pediatrics has built a toolkit for pediatricians to increase awareness of FASDs and improve care for individuals with FASDs (17).  

Conclusion 

Fetal Alcohol Spectrum Disorders are complex conditions that require a multifaceted approach to prevent and treat. Healthcare providers must partner with families to prevent and manage individuals with prenatal alcohol exposure to improve their quality of life. Individuals with prenatal alcohol exposure may need individualized treatment plans as each person with FASDs may have a variety of symptoms. These conditions are preventable, and the goal should be prevention.  

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