Commentary The authors of this series of articles on the effects of in utero alcohol exposure on the developing embryo/fetus make the following major points: 1. There are 3 major features of full-blown fetal alcohol syndrome (FAS): a. characteristic facial features (smooth philtrum, thin vermillion boarder, and short palpebral fissures), b. prenatal and/or postnatal growth deficiency, and c. neurologic/developmental abnormalities.

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Not infrequently, the full-blown spectrum of FAS is not present, but there are some features that suggest that the in utero alcohol exposure has affected the child. Thus, there is a spectrum of outcomes now termed the fetal alcohol spectrum disorder (FASD). The most concerning issue in FASD is the effects of in utero alcohol exposure on the developing brain of the embryo/fetus, and this exposure can occur at anytime during the pregnancy and includes heavy, continuous drinking or binge drinking. There are many variables in drug disposition related to the mother and embryo/ fetus, so it is not possible to predict the ultimate effects in a particular case. Admitted alcohol intakes provided by mothers are often not accurate, and timing of the alcohol use during the pregnancy may influence the outcome. The adverse effects on the CNS can result in significant developmental delays, learning disorders, and behavioral problems. Identification of FASD is critical to securing appropriate medical and educational services and assist in preventing secondary problems. The National Organization on Fetal Alcohol Syndrome (NOFAS) can provide health care providers with treatment centers for mothers seeking help for their alcohol addiction and local resources for children with FASD. There have been several programs with various behavioral interventions that have been shown to be of benefit to children with FASD and their families. An ethical and legal analysis of whether society can intervene and stop a pregnant woman from consuming alcohol while she is pregnant is NOT a realistic approach to preventing FASD. Rather, a public health approach to educate our citizenry about the teratogenic effects of alcohol is the most realistic approach to prevent FASD.

As a medical geneticist who is sometimes asked to offer input in the diagnosis and management of FASD, I offer my own personal experience: 1. The biologic parents rarely are the caregivers of the child when they present to me for evaluation—it is foster parents, adoptive parents, or other family members. This has cemented in my mind the pervasive and devastating effects on alcohol on family dynamics. Moreover, it is often difficult to obtain a precise alcohol drinking history during the pregnancy or information about other agents the mother may have taken during the pregnancy, as the present caregivers often do not know it. 2. The available social history and family history often suggest other confounding factors for why this child is having major learning and behavior problems: mother may have taken other drugs during the pregnancy which could affect neurologic function; the infant may have been abused and/or neglected while in the care

Curr Probl Pediatr Adolesc Health Care 2014;44:105-106 1538-5442/$ - see front matter & 2014 Mosby, Inc. All rights reserved. http://dx.doi.org/10.1016/j.cppeds.2013.12.007

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of the biologic parents; there may have been multiple foster care placements; or there is often a family history of severe mental health illness in one or both of the parents including bipolar disorder and schizophrenia. 3. Ideal care for a child with FASD who has significant learning and behavioral problems often includes a behavior modification program at home, an individual education program at school, and the use of potent psychoactive medications. Appropriate medication trialing may find a drug/drug regimen that allows for better focusing and impulse control that will lead to better learning. It is essential that the health care provider be experienced in prescribing these psychoactive medications (child psychiatrists have the most experience). If there is no documented benefit after a reasonable trial with the drug at the highest dose that is safe, then the drug should be discontinued. 4. Most can agree on two issues: A. Women who are planning a pregnancy or who might become pregnant because of unprotected sexual intercourse should not consume any alcohol. B. Mental health services for children are difficult to access in some communities. More resources for mental health services for children who have complicated neurobehavioral issues such as children with FASD are greatly needed. In summary, this excellent update on the diagnosis and management of FASD should be a valuable asset to health care providers who evaluate children with FASD.

Marvin Miller, MD Department of Medical Genetics, Dayton Children s Hospital, Dayton, OH E-mail address: [email protected] 0

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Curr Probl Pediatr Adolesc Health Care, April 2014

Commentary. Fetal alcohol exposure and complications.

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