mary o'mahony 'the perspectives on fasd from souther ireland

Perspectives on

FASD from Southern

Ireland

Prepared for Alcohol & Medications in Pregnancy Conference 9th Sept

2015. Dr Mary T O’Mahony, Specialist in Public Health Medicine, -S

[email protected]

mailto:[email protected]

Public Health (Alcohol) Bill, 2015

Restrictions on cheap alcohol

Warning labels & calorie details

Strong new powers for Environmental

Health Officers - enforcement

New restrictions on advertising,

marketing & sponsorship

Prevention of Foetal Alcohol Spectrum Disorder

Irish initiatives

Alcohol Harm

RCPI Alcohol Advocacy Group

Alcohol Health Alliance Ireland (RCPI,

IHF, ICS, The Samaritans)

FASD

First Conference in UL June 2014:

280 Day 1; 260 Day 2

“Think Tank”


National Geographic Feb 1992

http://www.faslink.org/national%20geographic%20-%20article%20on%20fetal%20alcohol.htm


“When a million babies are born every year

with permanent brain injury from a

known and preventable cause, the

response ought to be immediate,

determined, sustainable and effective”

International Charter on Prevention of FASD (Fetal Alcohol Spectrum Disorder) Edmonton September 23-25, 2013;

Lancet March 2014.

Chief Medical Officer, DoH

“Given the harmful drinking patterns in

Ireland and the propensity to binge drink,

there is substantial risk of

neurobiological damage to the fetus

resulting in Fetal Alcohol Spectrum

Disorders (FASD). Therefore it is in the

child’s best interest for a pregnant

woman not to drink alcohol during

pregnancy” (Alcohol Action Ireland

2013). Prevention of Foetal Alcohol Spectrum Disorder


2014 National Substance

Misuse Strategy - extracts

6. Alcohol is associated with harms to the baby and is a factor in unplanned pregnancies.

o A range of disorders known as fetal alcohol spectrum disorders (FASD) are caused by mothers drinking alcohol in pregnancy.

o Alcohol is a significant factor in unplanned pregnancies.

Labels on alcohol products sold in Ireland should include the number of grams of alcohol per container, along with calorific content and health warnings in relation to consuming alcohol in pregnancy.

11. Given the concerns about Fetal Alcohol Spectrum Disorder (FASD), a comprehensive awareness campaign on a national and community level is needed to increase public knowledge regarding the risks and impacts of drinking during pregnancy and to discourage the consumption of alcohol during pregnancy.

Strengthen FASD surveillance in maternity hospitals through the Eurocat reporting system and promote greater awareness amongst healthcare professionals of FASD so as to improve the diagnosis and management of children born with FASD.

Prevention of Fetal Alcohol Spectrum Disorder

Irish Guidance: 2003 HSE Little book of Women and Alcohol

ALCOHOL & PREGNANCY

Stopping drinking during pregnancy is the safest advice.

Baby’s vital organs e.g. heart, brain & skeleton are formed between 10–50 days after conception. Often, this is before you know you are pregnant. Cutting down or stopping alcohol while trying to become pregnant protects your baby.

There are risks to your baby if you continue to drink, even in small quantities:

The more you drink, the greater the amount passed on to your baby.

More than 3 drinks a day increases the risk of miscarriage. More than 12 drinks a week increases the risk of premature birth.

Avoid binge drinking, as sudden high levels of alcohol damage the developing brain.

Children exposed to alcohol in pregnancy often show poor attention and hyperactivity, that may only become evident when they are a few years old.

There is no known safe level of alcohol use in pregnancy, and stopping completely is advised.

STOP! THINK TWICE! CUT IT OUT!

http://www.drugsandalcohol.ie/11691/1/HSE_little_book_of_women_and_alcohol.pdf

THE LITTLE BOOK OF

WOMEN AND ALCOHOL

CONFLICTING ADVICE IS

PROBLEMATIC



2013 EU Alcohol & Pregnancy

Including the HSE

“Can I drink alcohol when I’m pregnant?

The safest approach in pregnancy is to choose not to drink at all.

It is important to be aware that when you drink alcohol, your baby also drinks.

The risk of damage to your baby’s physical and mental development increases the more you drink and binge drinking is especially harmful. This risk relates to a range of conditions including Foetal Alcohol Syndrome (FAS) and Foetal Alcohol Spectrum Disorders (FASD).”

http://www.drugsandalcohol.ie/20520/1/Alcohol_and_Pregnancy_Guide.pdf


Contd.

What if I have been drinking alcohol before I

knew I was pregnant?

“be reassured …very little risk of harm”

“drinking heavily or ‘binge drinking’ in early

pregnancy can be harmful”

“avoid drinking alcohol until sure not preg”

Binge drinking definition

RoI: 5 units X 10g per unit

UK: 6 units X 8g per unit

(Canada: 3 units)


“ there are lies, damn lies and

statistics” Benjamin Disreali 1804-1881

The “Dr Petr Skrabanek“ of FASD”


Astley SJ replies to Oster

Evidence base appraised: Dutch studies selectively used

1 in 7 with FAS had reported prenatal exposure of 1-8

drinks per week

Children with FAS

50% development preschool normal

All severe brain dysfunction @10yrs

10% attention problem at 5 yrs

60% attention problem at 10 yrs

Only 30% IQ below normal, BUT

100% severe dysfunction in areas e.g. language,

memory, activity level


Surveillance of FAS & FASD

Fetal Alcohol Syndrome – one end of the

spectrum / may have visible signs of

abnormalities and be recognised at birth

Fetal Alcohol Spectrum Disorder – not

recognisable until preschool or school

age when difficulties manifest

Incidence/Prevalence 2009 Canada

1% of live births

2014 Alberta (2003 to 2012 data)

Incidence = 1.42% to 4.38% of live births

Prevalence = 1.17% of Alberta population

2014 Midwest USA

Prevalence = 2.4% to 4.8% of 1st graders

Australia

FAS or pFAS prevalence of 12%

Italy

FAS 0.4-1.2%; pFAS 1.8-4.6%; FASD 2.3-6.3% of children


“Children with FASD fill our Foster Care

places.

Adults with FASD fill our jails.”

25 Differential diagnoses. Many

misdiagnosed as Autism Spectrum

Disorder.

Societal impact


Economic impact – Alberta Canada

10 Strategic Plan to prevent FASD

Population 3.6m,36000 with FASD

(estimate 1%); 450 FASD babies born/a

Lifetime cost to state per child with

FASD estimated: $800K(£394K/€540K)

Prevention of 10 cases p.a. covers cost

of comprehensive services

Alberta FASD Services- Estimated to

save $20m p.a. in reduced demand for

services


Case scenario - Ireland:

evidence & anecdote

80% of nulliparous pregnant women in

the study sample drank alcohol while

pregnant

In Ireland, it’s the accepted social norm

to drink while pregnant

Ireland not alone

Australian study in 2010 (Robinson) OK to

drink

English study in 2011 (Kelly) OK to drink

US Feldman – Not OK to drink

A new 'toolkit' for health professionals was launched in the antenatal clinic in

Letterkenny General Hospital. The project, which aims to increase awareness of

the health benefits to pregnant mums and unborn children of ceasing alcohol

consumption entirely during pregnancy, Photo : L-R: Helen McFarland, ETB; Ciara Doyle, Project Lead, Hidden

Harm, HSE/Alcohol Forum; Cora McAleer, Manager, Mental Health Addiction Services; Evelyn Smith, Asst Director of Nursing/Midwifery; Christina

McEleney, Coordinator Tutor, University of Limerick Diploma in Drug and Alcohol Studies; Dr. Nandini Ravikumar, Consultant Obstetrician; Sean

Murphy, General Manager, Geraldine Hanley, CMM2 Antenatal Education Coordinator; Moira Mills, Alcohol Forum; and Mary Kelly, Health

Promotion Officer

From: Saolta-e-Newsletter-July-2015-pdf


SAOR (S&BI for subs misuse)

Tiers 1-4

18. It is essential to raise awareness of the risks of drinking during pregnancy (Recommendation 1 of Prevention Pillar; see Chapter 7) in all tier 1 and tier 2 settings, particularly in primary care, so that hazardous or harmful drinking can be identified, allowing for change. Screening for alcohol consumption should begin at the first antenatal visit for all pregnant women and be reviewed throughout the pregnancy.

19. Pregnant women who are alcohol dependent should be prioritised for immediate access to tier 3 and tier 4 services.


TIER 1

Interventions where

main focus is not drug

treatment

TIER 2

Drug-related

Interventions

TIER 3

Specialist Drug-related

Interventions

TIER 4

Specialist Dedicated

Inpatient or Residential

Units or Wards

Family Support

Social Care

Pharmacies

Community

Based

Job

Seeking Prison

Community Education

Skills Setting

Setting Services

Primary Care

Outreach

Hospital Setting

Specialist Addiction

Services

Vocational Criminal Justice

Training & Probation

Services

General Healthcare Setting


Integrated Model of Rehabilitation Provision

PCAP – Nth America

An effective and cost efficient

intervention in the prevention of

FASD


PCAP: Parent Child

Assistance Programme

A supportive non-judgmental relationship

Support to the mother and the target child

“Wrap around service”

3 year programme, 2 visits per month

Relapse is tolerated, start again


PCAP: three objectives

Motivate the women to stop using

If can’t, help women not to get pregnant

Family planning does not mean never having another child but plan family

Effective contraception

Use mandated treatment for alcohol and drug abuse

Use women only treatment

Use service where children can stay

Provide client specific support to addiction service providers as indicated.


PCAP: Outcomes

more employed

less on welfare

months sober

% in treatment

number in education

connected to community support

services


“Safe Limiting” in Pregnancy

FASD: alcohol causal, a co-factor, correlated

No amount of RoH absolutely safe

No amount of RoH absolutely dangerous

A relative risk of harm

Multiple mechanisms direct & indirect action

Fraternal twins with lesser effect in one

Maternal nutrition

Maternal & foetal metabolism

Stop drinking – 2o prevention, selective


Alcohol use by women is increasing in all

socioeconomic groups (SEG), as is

binge drinking especially among

students and those of lower SEG

How prevalent is Prenatal Alcohol

Exposure?

Surveillance of prenatal alcohol

exposure: cord blood (EtG) on bloodspot

card / meconium (FAEE)

An increasing problem? Yes

Transgenerational aspects

ICGP Lead GP for Substance Misuse

The cycle of addiction from generation to

generation

Those with FASD at increased risk of

addiction to alcohol themselves

Prevent FASD and break the cycle

Most inspiring speaker*

Who’s the DD (designated driver) and

have the girls done their PT (pregnancy

test)?

PT ($2) dispenser in the bar restroom

Goal_mtom: “pregnant pause” - that

drinking in pregnancy will be at least as

unacceptable as drink driving


* @ First International Prevention of FASD Conference, Edmonton Sept 2013


NZ Hawkes Bay NICU

The elephant in the room –

FASD or ASD?

Need first to document prenatal alcohol

intake by pregnant women.

To document prenatal alcohol exposure

(PAE) for aetiological studies

Women and alcohol

The pregnant pause

Who are the stakeholders?

Anecdote

LIG parent group



Screening & brief intervention for alcohol

in pregnancy

Parent child assistance programmes

Many resources developed to assist

Information leaflets, posters, videos etc

on diagnosis

on strategies for care

Effective interventions in

prevention of FASD

Collect information and

evidence

Active surveillance for FAS in at risk populations Children in state care

Young offenders

Prison population

Population based within national schools – all those less than 10th / 25th centile for growth (height)

Active surveillance for prenatal alcohol exposure Antenatal screening +/- Brief intervention

Cord blood

Meconium

mary o'mahony 'the perspectives on fasd from souther ireland

Presentations & Public Speaking