Local psychiatrists advise those intending to get pregnant to cease social drinking
BY Ruwan Laknath JayakodyAt-risk females should be educated about the harm resulting from alcohol use during pregnancy and the associated risk of foetal alcohol syndrome, with females who intend to get pregnant also being advised to stop social drinking as alcohol can cause subtle neuro-cognitive changes in the foetus even before the pregnancy is detected, a local study recommended.The brief report in question on “Foetal alcohol syndrome: A case report from Sri Lanka” was authored by C. Suraweera (Senior Registrar in Psychiatry at the University of Colombo Psychiatry Unit at the National Hospital in Colombo) and Prof. R. Hanwella (Professor in Psychiatry at the University of Colombo Medical Faculty), and was published in the Sri Lanka Journal of Psychiatry 4 (2) in December 2013.BackgroundAlcohol is, Suraweera and Hanwella explained, a teratogen, which is an agent or factor that causes the malformation of an embryo. Foetal alcohol syndrome is, the duo further explained, the most severe form of damage due to alcohol use during pregnancy. The said syndrome, they elaborated, is associated with abnormalities in the central nervous system, facial dysmorphism (an abnormal difference in the structure of the face), and growth defects. It has been found that when there is prenatal alcohol exposure, children are born with neuro-behavioural changes which Suraweera and Hanwella mentioned are described as the foetal alcohol spectrum disorders.Alcohol, they noted, affects all stages of foetal development and the resultant neuro-cognitive consequences are lifelong. Therefore, a pregnant woman who drinks any amount of alcohol is at risk of having a child with foetal alcohol syndrome with the risk being greater, the higher the quantity that is consumed. Hence, Suraweera and Hanwella emphasised that there is no safe amount or level of alcohol use during pregnancy that has been established.Furthermore, binge drinking, it was observed, is more harmful than drinking smaller amounts of alcohol on a daily basis. Moreover, while the timing of alcohol consumption during pregnancy is important as alcohol use is most harmful during the first three months of pregnancy, W.A. Carlo maintained in “Foetal alcohol syndrome” that drinking alcohol at any time during pregnancy can be harmful.Therefore, even though foetal alcohol syndrome is rare in Sri Lanka owing to alcohol consumption among females being low, Suraweera and Hanwella presented an unusual case which described an extreme form of foetal alcohol syndrome where most of the classically described features of the syndrome were present in the baby, with a view that doctors are aware of the syndrome so that they could recognise such when cases of the syndrome are reported or presented.Case reportA 34-year-old woman had been dependent on alcohol since the age of 27. She claimed to be abstinent from alcohol since getting to know of her pregnancy in March 2012. Although it is quite certain that the foetus has been exposed to alcohol, the period of exposure cannot be determined accurately as she was unaware of her last regular menstrual period. The foetus was exposed to about five to six units of alcohol daily in the form of toddy (an alcoholic beverage made by fermenting the sap of the coconut palm).The mother had not attended antenatal care and a low-birth-weight pre-term baby was born through normal vaginal delivery. The baby failed to thrive and had frequent respiratory tract infections for which it was subsequently admitted with a lower respiratory tract infection. Although the mother denied the use of alcohol, the admitting house officer noted that she smelled of alcohol and therefore referred her to the psychiatry unit.On examination, features of foetal alcohol syndrome were present, namely, intrauterine (womb or uterus) growth retardation, the failure to thrive, decreased muscle tone, atrial septal defect (a hole in the wall/septum between the two upper chambers of the heart/atria), narrow small eyes with large epicanthal folds (a skin fold of the upper eyelid that covers the inner corner of the eye), small head, small upper jaw, smooth and thin upper lip, and absent corpus callosum (connects the left side of the brain to the right hemisphere), while poor co-ordination, developmental delay, and a smooth groove in the upper lip (per E.P. Riley, M.A. Infante and K.R. Warren’s “Foetal alcohol spectrum disorders: An overview”) were not present.The mother was motivated to stop alcohol use. The patient did not need detoxification as she did not have withdrawal symptoms. According to Suraweera and Hanwella, although it would have been best to start the patient on medication used to manage alcohol use disorder by reducing cravings and feelings of euphoria or on medication used to support the treatment of alcohol use disorder by producing an acute sensitivity to ethanol in order to maintain abstinence, they had not done so due to the need to breastfeed the baby, which was failing to thrive, and also taking into account the extremely unstable financial situation the infant and the mother were in. They had instead used cognitive behaviour therapy which focused on managing craving and the avoidance of triggers.On discharge, the care of the patient was handed over to the community mental health team of the area for follow-up and regular engagement of the patient for the maintenance of abstinence. Two months after discharge, the patient remained abstinent.Until the description of the syndrome by P. Lemoine, H. Harousseau, J.P. Borteyru, and J.C. Menuet in “Children of alcoholic parents: Abnormalities observed in 127 cases” and the term foetal alcohol syndrome being coined by K.L. Jones and D.W. Smith in “Recognition of the foetal alcohol syndrome in early infancy”, alcohol was not recognised as a teratogen. According to B.A. Bailey and R.J. Sokol’s “Pregnancy and alcohol use: Evidence and recommendations for prenatal care”, alcohol is the leading cause of birth defects and developmental disorders in the US.Foetal alcohol syndromeFoetal alcohol syndrome and the foetal alcohol spectrum disorders consist of, Suraweera and Hanwella noted, a distinct pattern of birth defects caused by in utero alcohol exposure. As explained by them, the main features of foetal alcohol syndrome include growth retardation (prenatal and postnatal), central nervous system dysfunction, and a characteristic pattern of atypical facial morphometry (the process of measuring the external shape and dimensions).Foetal alcohol spectrum disorders occur when there is heavy prenatal exposure to alcohol, but the characteristic facial morphometry of the foetal alcohol syndrome is not present as a feature. The latter commonly involves, as per S.N. Mattson and E.P. Riley’s “A review of the neuro-behavioural deficits in children with foetal alcohol syndrome or prenatal exposure to alcohol” and Mattson, Riley, L. Gramling, D.C. Delis, and K.L. Jones’s “Neuro-psychological comparison of alcohol exposed children with or without physical features of the foetal alcohol syndrome”, cognitive and psychosocial abnormalities which are consistent with foetal alcohol syndrome including slowed information processing and impaired executive control.Furthermore, H.E. Hoyme, P.A. May, W.O. Kalberg, P. Kodituwakku, P. Gossage, P.M. Trujillo, D.G. Buckley, J.H. Miller, A.S. Aragon, N. Khaole, D.L. Viljoen, K.L. Jones, and L.K. Robinson’s “A practical clinical approach to the diagnosis of foetal alcohol spectrum disorders: Clarification of the 1996 Institute of Medicine criteria” noted that persons with foetal alcohol spectrum disorders additionally exhibit greater impairment with increased task complexity, in both verbal and non verbal domains.Callosal (of, relating to, or adjoining the corpus callosum) malformation is common in foetal alcohol spectrum disorders and per “A review of the neuro-anatomical findings in children with foetal alcohol syndrome or pre-natal exposure to alcohol” by T.M. Roebuck, Mattson, and Riley, the incidence of callosal agenesis (complete absence of an organ or lack of specific cells within an organ) is reportedly 6.8% in the case of foetal alcohol syndrome, which is much higher than the incidence of the same in the general population.