The Maternal Drinking History Guide

Presented by Moumita Sarkar, PhDAlcohol and Substance Use Helpline

The Motherisk Program, Hospital for Sick Children

Based on a consensus report developed by the FASD Advisory Workgroup in collaboration with SOGC and PHAC

Infant born at 35 weeks of gestation with severe IUGR and APGAR score of 5

Poor tonus, poor suckling

Case #1

Case #1 cont…. Medical history does not reflect any maternal

exposure related to baby’s symptoms

Patient denies the use of alcohol and substances

Meconium test for Fatty Acid Ethyl Ester (combination of alcohol and fatty acids): 52nM/g (N=<2)

Mother is a problem drinker, unknown to the GP or gynecologist

Alcohol and Pregnancy

9-12% of women reported drinking throughout their pregnancies (Health Canada 2000)

1.4% of pregnant women reported binge drinking (CDC 2011)

Health care providers do not systematically screen all pregnant women on their consumption of alcohol 19% of women reported not being ask about their

alcohol use (Chang, 2011)

25% of pregnant women were not asked

Prenatal Alcohol Use: widespread

Problem drinking: refers to the amount of maternal drinking

associated with harm to the fetus Exceeds 3 drinks at one sitting or 7 drinks

per week (NIAAA, 2005)

Pregnant or planning: Any amount of drinking is risky for women

who are pregnant or trying to become pregnant (USDHHS, 2005)

Routine Screening Ask all women of childbearing age about

alcohol/drug use (especially pregnant women)

Advise all women planning/pregnant that no alcohol is the safest choice; women who consumed alcohol during their pregnancy to contact Motherisk

Assist all women to stop drinking through information, counselling, care and referral to appropriate programs and services

SCREEN TO PREVENT FASD

The Maternal Drinking Guide: Purpose

Determine if the mother drinks /has drank at a problem drinking level in pregnancy.

A Positive screen on TWEAK Meets the NIAAA guidelines for problem drinker

Obtain accurate maternal alcohol use report Knowledge of prenatal alcohol use is essential for

1) subsequent FASD diagnosis in the future and 2) harm reduction strategies

Benefits Validated methodology

as effective means of eliciting maternal alcohol use

Provides practitioner with options appropriate for different groups and circumstances

No training/ expertise required to screen

Integrate screening questions into standardized health questionnaires among innocuous questions related to lifestyle

When to ask?

Key times to assess alcohol use: Initial visit (to any new provider) Annual gynecological visit Preconception visit Visits for confirmation of pregnancy Mid-pregnancy (24-28 weeks) Exit visit (32-36 weeks)

Level I

Sarkar et al., CJCP 2009; 16 (1): e242-63

Level II

Sarkar et al., CJCP 2009; 16 (1): e242-63

Level III

Sarkar et al., CJCP 2009; 16 (1): e242-63

Case #1: Introduction

Explain that you will be asking a standard series of health questions that are directed to all patients in order to improve health Intro #1: “I want to ask you a series of questions

today about your lifestyle. I ask all my patients these questions because it helps me to get to know you better and provide better care.”

Level I: Practice-based When did you find out/suspect you were pregnant?

Single-question method of screening Embed at least one question to identify prenatal alcohol use among

other innocuous questions related to lifestyle

e.g. Do you take any prenatal vitamins? Do you smoke any cigarettes? If so, how many? Do you ever enjoy a drink or two? When was the last time? Do you sometimes drink beer, wine or other alcoholic beverages? In the past month or so, have you enjoyed a drink or two?

What about taking medications? Did you exercise?

Case #1: Brief questionnaires

Most effective method of screening (Stratton, 1996) Quick, practical, efficient and cost effective

Direct questioning Timeline Follow Back Tool (TLFB)

Indirect/masked screening Overcome issues of possible underreporting T-ACE, TWEAK Developed and validated for use among pregnant women TWEAK - Optimal for racially diverse groups, highly sensitive

test

TWEAKTWEAK QUESTIONS POINTS

Tolerance How many drinks does it take to make you feel the first effect (before pregnancy)? _________ (3 or more = 2 points)

Worry Have close friends worried or complained about your drinking in the past year? (yes = 2 points)

Eye-opener

Do you sometimes take a drink in the morning when you first get up? (yes = 1 point)

Amnesia Has a friend or family member ever told you about things you said or did while you were drinking that you could not remember? (yes = 1 point)

Cut down Do you sometimes feel the need to cut down on your drinking? (yes = 1 point)

Russell M. New assessment tools for risk drinking during pregnancy: T-ACE, TWEAK and Others. Alcohol Health and Research World (1994) 18 (1): 55-61

Case #1: Level III Screening (with consent)

Postpartum case (index of suspicion but deny use) If Level I and/or level II (TWEAK) screening is

not successful Level III screening (with consent)

Why is this knowledge valuable?

FASD assessment referral

Referral by a doctor required

Assessment involves physical, neurological, psychiatric, genetic examination

Confirmation of prenatal alcohol exposure required

Screening and Intervention

What can be done? Early Dx = Early Intervention

• Early diagnosis - evidence based• Stimulation in early ages - important• Parenting support materials

Introductory statement (refer to section II b): “I will begin by asking a standard series of health questions I ask all my patients in order to improve your health and the health of your child” Practice based questions (refer to section II c): General “Do you ever enjoy a drink or two?”

“Do you sometimes drink beer, wine or other alcoholic beverages?”

“Do you ever use alcohol?”

“In the past month or two have you ever enjoyed a drink or two?”

“Do you have any concerns about your drinking?”

“In a typical week, how many occasions did you usually have something to

drink?”

To assess problem drinking behaviour Apply TWEAK test (refer to section III)

Follow- up at every subsequent visit

Brief intervention Advise and Refer

Problem Drinker

If TWEAK is 2 or more

Brief intervention (harm reduction)

Advise and Refer

If response is negative (i.e. no alcohol/drugs): Educate / advise on effects of prenatal alcohol/ drug use

Follow- up at every subsequent visit

Advise

Laboratory Analysis (refer to section III c) (e.g. Hair FAEE) in relevant cases, with FULL INFORMED CONSENT

LEVEL TWO

LEVEL THREE

Not a Problem Drinker If TWEAK is less than 2 AND/ OR response is 0 times in a week or in a sitting

Advise

LEVEL ONE

Case #2 BJ has been your patient for a year. She is very private

and can be both defensive and combative by nature She has a 5 yr old child with both developmental and

behavioural issues She is now pregnant and has previously never been asked

about her alcohol use During her prenatal screening, her provider asks:

“I’m sure you know alcohol and pregnancy don’t go well together. You don’t drink, do you?” She responds: “No”

Few weeks later, her partner mentions his concern for her continued drinking

Case #2: Introduction

Explain that you will be asking a standard series of health questions that are directed to all patients in order to improve health Intro example: “I want to ask you a series of

questions today about your lifestyle. I ask all my patients these questions because it helps me to get to know you better and provide better care of your pregnancy.”

Level I: Practice-based

Begin Innocuous questions: When did you find out/suspect you were pregnant?

Single-question method of screeninge.g. Do you take any prenatal vitamins? Do you smoke any cigarettes? How is your diet? Do you ever enjoy a drink or two? When was the last time? Do you sometimes drink beer, wine or other alcoholic

beverages? In the past month or so, have you enjoyed a drink or two?

What about taking medications? Did you exercise?

Case #2 BJ has been your patient for a year. She is very private

and can be both defensive and combative by nature She has a 5 yr old child with both developmental and

behavioural issues She is now pregnant and has previously never been asked

about her alcohol use During her prenatal screening, her provider asks:

“I’m sure you know alcohol and pregnancy don’t go well together. You don’t drink, do you?” She responds: “No”

Few weeks later, her partner mentions his concern for her continued drinking

Avoid questions that suggest that you want a negative response:

Negative: You don’t drink, do you? Positive: Many women wind down the day with a glass of wine

or a few drinks on a night out…..do you sometimes enjoy a drink or two?”

Avoid many closed or dead-ended questions: Negative: Do you drink since you found out? Yes or No How has your alcohol consumption evolved since finding out your

pregnancy? a) I continue my usual habit b) I have cut down c) I am trying to abstain but find it difficult

Case #2: Motivational Interviewing Techniques

Case #2: Supportive Dialogue

Supportive dialogue (Without any moral connotation & empathetic listening)

Can you tell me a bit about your drinking pattern before you knew you were pregnant?

Have you been able to stop or cut down since you found out?

Case #2: Supportive Dialogue

If alcohol problem suspected, but denied, Important to engage women to improve trust Use empathy

"it is recommended to abstain from alcohol during pregnancy, if you are having hard time stopping, or even if you drink occasionally, do not hesitate to discuss it with me"

Advise/ Feedback If screen positive as problem drinker, or report continued prenatal

alcohol use, begin the process by: Here is some information that has been learned through

research; I’d like to share it with you, if I may. What is your understanding about alcohol use in pregnancy? Do you have any questions about your alcohol use?

Provide feedback that allows clients to compare their behavior to others so they know how their behavior relates to national norms

“Many women drink on a regular basis, and since half of all pregnancies are unplanned, many women are exposed to alcohol prior to pregnancy knowledge.”

Do you mind if we spend a few minutes talking about…..? Are you interested in learning more about……..?

Introductory statement (refer to section II b): “I will begin by asking a standard series of health questions I ask all my patients in order to improve your health and the health of your child” Practice based questions (refer to section II c): Pregnant women: “Can you tell me a bit about your drinking patterns before you knew you were pregnant?”

“Do you sometimes drink beer, wine or other alcoholic beverages?”

“Do you ever use alcohol?”

“In the past month or two have you ever enjoyed a drink or two?”

“Do you have any concerns about your drinking?”

“In a typical week, how many occasions did you usually have something to

drink?”

To assess problem drinking behaviour - 3 options: In the past, how many times have you had more

than 7 drinks in a week? In the past, how many times have you had more

than 3 drinks at one sitting? OR Apply TWEAK test (refer to section III)

Follow- up at every subsequent visit Level 1 questions re alcohol (IIIb)

Brief intervention Advise and Refer

Problem Drinker

If TWEAK is 2 or more

Brief intervention (harm reduction) Advise and Refer

If response is negative (i.e. no alcohol/drugs): Educate / advise on effects of prenatal alcohol/ drug use

Follow- up at every subsequent visit Level 1 questions re alcohol/drugs

Advise

N/A

LEVEL TWO

LEVEL THREE

Not a Problem Drinker

If TWEAK is less than 2

Educate / advise on effects of prenatal alcohol/ drug use

LEVEL ONE

Recommendations: Screening During regular health exams, health care

providers should use standardized questions that should include at least Level I screening Early identification and reduction of maternal drinking No known safe limit for alcohol use in pregnancy

Level II should be adopted as standard screening process to identify alcohol use in all women of childbearing age and pregnant women

Upon screening, women need to be linked to services if required by their providers

Health care provider role in harm reduction is vital advise patients that the safest choice is not to

consume alcohol during pregnancy Adequate resources should be made available to

women requiring interventions beyond primary interaction

Recording of maternal alcohol use in newborn’s birth record and child’s health record

Early identification and subsequently early FASD Dx = intervention can occur

Take Home Message

FASD programs/resourcesBest Start (www.beststart.org)Provides online training tools for screening alcohol

Motherisk Alcohol and Substance Abuse Helpline (www.motherisk.org) National toll-free helpline 1 877 FAS-INFO providing evidence-based info and referrals on alcohol/drugs

Canadian Centre on Substance Abuse (www.ccsa.ca)

PRIMA (www.addictionpregnancy.ca)

Alberta Health Services (www.albertahealthservices.ca)

Healthy Choices in Pregnancy in BC (www.hcip-bc.org)

Acknowledgments Dr. Gideon Koren

Motherisk Alcohol and Substance Use Helpline Counselors

The National Taskforce for FASD Screening

Canadian Association for Paediatric Health Science Centre

Public Health Agency of Canada

The Maternal Drinking History Guide

Thank you for listening!

Thank You!