# Presentation: 460721

## Reducing Prenatal Alcohol Use:Effective Identification

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

## Title Slide: Option 1A (with Harvard logo) 

- Title Slide: Option 1A (with Harvard logo)

**Notes:**
Cover: Option 1

## Acknowledgements

- National Institute on Alcohol Abuse and Alcoholism and Office of Research on Women’s Health*
- R01 AA 9670
- R01 AA 12548
- R01 AA 14678*
- K24 AA 00289

## Co-Investigators

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

## Slide 5

## Slide 6

## 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

## 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 (> 7 drinks/week) or binge (> 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

## PRAMS Data, 2000-2001

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

## Pregnant Binge Drinkers

- Younger < 30 years
- Single
- White
- Cigarette smoker
- Uses illicit drugs
- Marijuana (~20%), Cocaine (~11%), Other (~9%)

## Fetal Alcohol Syndrome

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

## Slide 12

## 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)

## 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

## 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)

## Effects of One Drink

- Growing evidence that prenatal alcohol consumption at levels < 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)

## 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

## 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

## 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

## 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

## 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

## Breathalyzer or Urinalysis

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

## 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

## 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

## 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

## 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)

## 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?

## A Positive Screen

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

## 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

## 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?

## 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

## 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

## T-ACE Positive Women

- DSM-III-R criteria for lifetime alcohol dx
- 40% + versus 14%T-ACE negative (p<.001)
- Risk drinking pre-pregnancy (>2 drinks/ day)
- 39% + versus 8% T-ACE negative  (p<.001)
- Drinking while pregnant
- 43% + versus 13% T-ACE negative (p<.001)

## 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)

## What to Do with a Positive T-ACE?

- Discussion
- Assessment
- Brief Intervention

## 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

## Slide 37

## 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.