The effects of alcohol in newborns

Mesquita, Maria dos Anjos

doi:10.1590/S1679-45082010RW1624

Maria dos Anjos Mesquita Corresponding author: Maria dos Anjos Mesquita – Rua Marechal Hermes da Fonseca, 185, apto 43 – Santana – CEP 02020-000 – São Paulo (SP), Brasil –E-mail: manjosmesquita@uol.com.br

MD; Neonatologist of Hospital Maternidade Cruz Azul and Hospital Maternidade Escola Vila Nova Cachoeirinha “Dr. Mário de Moraes Altenfelder Silva”, São Paulo (SP), Brazil

MD; Neonatologist of Hospital Maternidade Cruz Azul and Hospital Maternidade Escola Vila Nova Cachoeirinha “Dr. Mário de Moraes Altenfelder Silva”, São Paulo (SP), Brazil.

Corresponding author: Maria dos Anjos Mesquita – Rua Marechal Hermes da Fonseca, 185, apto 43 – Santana – CEP 02020-000 – São Paulo (SP), Brasil –E-mail: manjosmesquita@uol.com.br

Conflict of interest: none.

Study	Type
Hoyme HE, et al.(¹1. Hoyme HE, May PA, Kalberg WO, Kodituwakku P, Gossage JP, Trujillo PM, et al. A practical clinical approach to diagnosis of fetal alcohol spectrum disorders: clarification of the 1996 institute of medicine criteria. Pediatrics. 2005;115(1): 39-47.)	Cohort study
Bertrand J, et al.(²2. Bertrand J, Floyd LL, Weber MK; Fetal Alcohol Syndrome Prevention Team, Division of Birth Defects and Developmental Disabilities, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention (CDC). Guidelines for identifying and referring persons with fetal alcohol syndrome. MMWR Recomm Rep. 2005;54(RR-11):1-14.)	Recommendations
NCBDDD, et al.(³3. Fetal alcohol syndrome: guidelines for referral and diagnosis. National Center on Birth Defects and Developmental Disabilities, Centers for Control and Prevention, Department of Health and Human Services in coordination with National Task Force on Fetal Alcohol Syndrome and Fetal Alcohol Effect [Internet]. 2004 [cited 2009 Mar 9]. Available from: http://www.cdc.gov/ncbddd/fasd/documents/FAS_guidelines_accessble.pdf http://www.cdc.gov/ncbddd/fasd/documents... )	Recommendations
Riley EP, et al.(⁴4. Riley EP, Guerri C, Calhoun F, Charness ME, Foroud TM, Li TK, et al. Prenatal alcohol exposure: advancing knowledge through international collaborations. Alcohol Clin Exp Res. 2003;27(1):118-35.)	Review
Felix JA(⁵5. Felix JA. Apresentação. In: SENAD, ed. I Levantamento nacional sobre os padrões de consumo de álcool na população brasileira. Brasília: Secretaria Nacional Antidrogas; 2007. p. 5. [Internet] [citado 2008 Abr 2]. Available from: http://www.obid.senad.gov.br/portais/OBID/biblioteca/documentos/Dados_Estatisticos/população_brasileira/Padroes_consumo_alcool_populacao brasileira/327716.pdf http://www.obid.senad.gov.br/portais/OBI... )	Book chapter
WHO(⁶6. World Health Organization. Management of substance abuse. Alcohol [Internet]. 2008 [cited 2008 Mar 9]. Available from: http://www.who.int/substance_abuse/facts/alcohol/en/index.html http://www.who.int/substance_abuse/facts... )	Statement
WHO(⁷7. World Health Organization. The World Health Report 2001. Mental health: new understanding, new hope. Relatório Mundial da Saúde, 2001. Lisboa: Climepsi; 2002.)	Report
Moraes CL, et al.(⁸8. Moraes CL, Reichenheim ME. Rastreamento de uso de álcool por gestantes de serviços públicos de saúde do Rio de Janeiro. Rev Saúde Pública. 2007;41(5):695-703.)	Cross-sectional study
Mesquita MA, et al.(⁹9. Mesquita MA, Segre CAM. Frequência dos efeitos do álcool no feto e padrão de consumo de bebidas alcoólicas pelas gestantes de maternidade pública da cidade de São Paulo. Rev Bras Crescimento Desenvolv Hum. 2009;19(1):63-77.)	Cross-sectional study
May PA, et al.(¹⁰10. May PA, Gossage JP, Brooke LE, Snell CL, Marais AS, Hendricks LS, et al. Maternal risk factors for fetal alcohol syndrome in the Western cape province of South Africa: a population-based study. Am J Public Health. 2005;95(7):1190-9.)	Case control study
May PA, et al.(¹¹11. May PA, Gossage JP. Estimating the prevalence of fetal alcohol syndrome. A summary. Alcohol Res Health. 2001;25(3):159-67.)	Review
Ethen MK, et al.(¹²12. Ethen MK, Ramadhani TA, Scheuerle AE, Canfield MA, Wyszynski DF, Druschel CM, Romitti PA; National Birth Defects Prevention Study. Alcohol consumption by women before and during pregnancy. Matern Child Health J. 2009;13(2):274-85.)	Cohort study
Warren KR, et al.(¹³13. Warren KR, Calhoun FJ, May PA, Viljoen DL, Li TK, Tanaka H, et al. Fetal alcohol syndrome: an international perspective. Alcohol Clin Exp Res. 2001;25(5 Suppl ISBRA):202S-206S.)	Statement
Jones MW, et al.(¹⁴14. Jones MW, Bass WT. Fetal alcohol syndrome. Neonatal Netw. 2003;22(3):63-70.)	Review
Lemoine P, et al. (¹⁵15. Lemoine P, Harouseau H, Borteryu JT, Menuet JC. Les enfants des parents alcooliques. Anomalies observées à propos de 127 cas. Ouest Médical.1968;21:476-82.)	Cohort study
Jones KL, et al. (¹⁶16. Jones KL, Smith DW. Recognition of the fetal alcohol syndrome in early infancy. Lancet. 1973;302(7836):999-1001.)	Cohort study
Lemoine P, et al.(¹⁷17. Lemoine P, Harousseau H, Borteyru JP, Menuet JC. Children of alcoholic parents-observed anomalies: discussion of 127 cases. Ther Drug Monit. 2003;25(2):132-6.)	Cross-sectional study
Thackray H, et al.(¹⁸18. Thackray H, Tifft C. Fetal alcohol syndrome. Pediatr Rev. 2001;22(2):47-55.)	Statement
Hannigan JH, et al. (¹⁹19. Hannigan JH, Armant DR. Alcohol in pregnancy and neonatal outcome. Semin Neonatol. 2000;5(3):243-54.)	Review
Astley SJ, et al.(²⁰20. Astley SJ, Clarren SK. Diagnosing the full spectrum of fetal alcohol-exposed individuals: introducing the 4-digit diagnostic code. Alcohol Alcohol. 2000;35(4):400-10.)	Cross-sectional study
Chudley AE, et al.(²¹21. Chudley AE, Conry J, Cook JL, Loock C, Rosales T, LeBlanc N; Public Health Agency of Canada's National Advisory Committee on Fetal Alcohol Spectrum Disorder. Fetal alcohol spectrum disorder: Canadian guidelines for diagnosis. CMAJ. 2005;172(5 Suppl):S1-S21.)	Recommendations
U.S. Surgeon General Advisory(²²22. U.S. Surgeon General Advisory on Alcohol Use in Pregnancy. Urges women who are pregnant or who may become pregnant to abstain from alcohol [Internet]. Washington (DC): US Department of Health and Human Services; 2005 [cited 2009 Apr 2]. Available from: http://www.surgeongeneral.gov/pressreleases/sg02222005.html http://www.surgeongeneral.gov/pressrelea... )	Statement
Grinfeld H.(²³23. Grinfeld H. Consumo nocivo de álcool durante a gravidez. In: Andrade AG, Anthony JC, editors. Álcool e suas consequências: uma abordagem multiconceitual. São Paulo: Manole; 2009. p.179-99.)	Book chapter
Nóbrega MPSS, et al(²⁴24. Nóbrega MPSS, Oliveira EM. Mulheres usuárias de álcool: análise qualitativa. Rev Saúde Pública. 2005;39(5):816-23.)	Qualitative study
Grinfeld H, et al.(²⁵25. Grinfeld H, Segre CAM, Chadi G, Goldenberg S. O alcoolismo na gravidez e os efeitos na prole. Rev Paul Pediatr. 2000;18(1):41-9.)	Review
Mattson SN, et al.(²⁶26. Mattson SN, Schoenfeld AM, Riley EP. Teratogenic effects of alcohol on brain and behavior. Alcohol Res Health. 2001;25(3):185-91.)	Review
Am. Acad. Pediatrics(²⁷27. American Academy of Pediatrics. Committee on Substance Abuse and Committee on Children With Disabilities. Fetal alcohol syndrome and alcohol-related neurodevelopmental disorders. Pediatrics. 2000;106(2 Pt 1):358-61.)	Statement
Maier SE, et al.(²⁸28. Maier SE, West JR. Drinking patterns and alcohol-related birth defects. Alcohol Res Health. 2001;25(3):168-74.)	Update
Goodlett CR, et al. (²⁹29. Goodlett CR, Horn KH. Mechanisms of alcohol-induced damage to the developing nervous system. Alcohol Res Health. 2001;25(3):175-84.)	Review
NEAD(³⁰30. Núcleo Einstein de Álcool e Drogas (NEAD). Síndrome alcoólica fetal [Internet]. 2003 [citado 2010 Fev 4]. Disponível em: http://apps.einstein.br/alcooledrogas/novosite/complicacoes_gravidez_sindrome.htm http://apps.einstein.br/alcooledrogas/no... )	Review
NOFAS(³¹31. National Organization on Fetal Alcohol Syndrome. What is fetal alcohol syndrome? [Internet]. 2003 [cited 2003 Jun 15]. Available from: http://www.nofas.org/main/what_is_FAS.htm http://www.nofas.org/main/what_is_FAS.ht... )	Update
Roebuck-Spencer TM, et al.(³²32. Roebuck-Spencer TM, Mattson SN, Marion SD, Brown WS, Riley EP. Bimanual coordination in alcohol-exposed children: role of the corpus callosum. J Int Neuropsychol Soc. 2004;10(4):536-48.)	Cohort study
Mennella JA(³³33. Mennella JA. Alcohol's effect on lactation. Alcohol Res Health. 2001;25(3):230-4.)	Review
Menella JA, et al.(³⁴34. Mennella JA, Pepino MY, Teff KL. Acute alcohol consumption disrupts the hormonal milieu of lactating women. J Clin Endocrinol Metab. 2005;90(4):1979-85.)	Cohort study
Floyd RL, et al.(³⁵35. Floyd RL, O’Connor MJ, Sokol RJ, Bertrand J, Cordero JF. Recognition and prevention of fetal alcohol syndrome. Obstet Gynecol. 2005;106(5 Pt 1):1059-64.)	Update
Peadon E, et al.(³⁶36. Peadon E, O’Leary C, Bower C, Elliott E. Impacts of alcohol use in pregnancy – the role of the GP. Aust Family Physician. 2007;36(11):935-9.)	Update
Gahagan S, et al.(³⁷37. Gahagan S, Sharpe TT, Brimacombe M, Fry-Johnson Y, Levine R, Mengel M, et al. Pediatricians’ knowledge, training, and experience in the care of children with fetal alcohol syndrome. Pediatrics. 2006;118(3):e657-68.)	Cohort study
Cook JD(³⁸38. Cook JD. Biochemical markers of alcohol use in pregnant woman. Clin Biochem. 2003;36(1):9-19.)	Review
Peadon E, et al.(³⁹39. Peadon E, Rhys-Jones B, Bower C, Elliott EJ. Systematic review of interventions for children with Fetal Alcohol Spectrum Disorders. BMC Pediatr. 2009;9:35.)	Review
Pinheiro SN, et al.(⁴⁰40. Pinheiro SN, Laprega MR, Furtado EF. Morbidade psiquiátrica e uso de álcool em gestantes usuárias do Sistema Único de Saúde. Rev Saúde Pública. 2005;39(4):593-8.)	Cross-sectional study

Facial anomalies

– small palpebral fissure

– palpebral ptosis

– flattened hemi-face

– anteverted nose

– smooth philtrum

– thin upper lip

Growth restriction

– low birth weight

– growth restriction despite appropriate nutrition

– low weight related to height

Changes in CNS development

– microcephaly

– structural brain abnormalities including agenesis of the corpus callosus and cerebellar hypoplasia

– other neurological signs, such as fine motor difficulties, sensorineural hearing loss, uncoordinated deambulation and impaired eye-hand coordination

Unexplained behavioral abnormalities

– impaired reading

– poor school achievement

– difficulty to control impulses

– problems with social perception

– language difficulty

– poor abstract rationale

– impaired skills

– impaired memory and judgment

Congenital defects

Including but not limited to:

– cardiac defects

– bone and limb deformities

– renal anatomical anomalies

– ophthalmologic alterations

– absence of the ear

– lip or palate cleft

Confirmed maternal alcohol exposure, at least two facial characteristics and one or more of the following structural defects

Cardiac

– atrial septal defects

– ventricular septal defects

– aberrant great vessels

– conaltruncal heart defects

Skeleton

– pectus excavatum or carinatum

– scoliosis

– radioulnar synostosis

– vertebral segmentation defects

– large joints contractions

Renal

– renal aplasia, hypoplasia and/or dysplasia

– horseshoe kidneys

– urethral duplication

Ocular

– strabismus

– palpebral ptosis

– refraction errors

– retinal vascular anomalies

– optic nerve hypoplasia

Ear

– agenesia of auditory canal

– neurosensorial hearing loss

– conductive hearing loss

– prominent ear

Minor anomalies

– nasal hypoplasia

– small fingers

– clinodactyly

– camptodactyly

– hockey-stick palmar crease

– epicanthal fold

– flat nasal bridge

– facial hypoplasia

Scale	Growth restriction	FAS facial phenotype	CNS lesion or dysfunction	Gestational alcohol exposure
1	None	Absent	Slightly probable	No risk
	Length and weight greater than or equal to 10^th percentile	None of the three characteristics	No evidence or decreased structural, neurological or functional evidence	Confirmed absence of exposure from conception to birth
2	Mild	Mild	Possible	Unknown
	Length and weight lower than 10^th percentile	Usually one of the three characteristics	Evidence of dysfunction, but less than scale 3	Not confirmed or absent exposure
3	Moderate	Moderate	Probable	Some risk
	Length and weight lower than 10^th percentile	Usually two of the three characteristics	Significant dysfunction in three or more domains	Confirmed exposure. Unknown level or exposure or lower than scale 4
4	Significant	Severe	Defined	High risk
	Length and weight lower than 3^rd percentile	All characteristics:	Structural or neurological evidence	Confirmed exposure at high levels
		– Palpebral fissure below 2 or more standard deviation
		– Thin lip: score 4 or 5
		– Smooth philtrum: score 4 or 5

Facial dysmorphism

Based on racial differences, patients present the three facial characteristics:

– smooth philtrum; (University of Washington Lip-Philtrum Guide rank 4 or 5)

– reduced red lip border; (University of Washington Lip-Philtrum Guide rank 4 or 5)

– small palpebral fissure (≤ 10^th percentile)

Growth problems

Pre- or postnatal length and/or weight ≤ 10^th percentile, adjusted for age, sex, gestational age, race or ethnicity

CNS abnormalities

Structural:

– head circumference ≤ 10^th percentile, adjusted for age and sex

– abnormalities in brain image

Neurological:

– neurological problems that are not due to postnatal insult or fever, or other mild neurological signs that are within normalcy

– Functional:

– achievement substantially below the expected for age, schooling and other circumstances, such as shown by:

– cognitive or intellectual deficit in several domains, or significant development delay in young children with achievement below 3^rd percentile (two standard deviations below the mean for standardized tests)

or

– functional deficit below 16^th percentile (one standard deviation below the mean for standardized tests) in at least three of the following domains:

– cognitive or significant discrepancy in development

– deficit in performing tasks

– delay in motor functions

– attention disorder or hyperactivity

– social skills problems

– others, such as problems related to sensory aspects, to pragmatic language or memory deficit, difficult to respond properly to family routine

[1] Corresponding author: Maria dos Anjos Mesquita – Rua Marechal Hermes da Fonseca, 185, apto 43 – Santana – CEP 02020-000 – São Paulo (SP), Brasil –E-mail: manjosmesquita@uol.com.br

Category 1	Patients in this category present the classic triad of growth restriction, characteristic facial dysmorphism and neurodevelopment abnormalities. They are defined as complete FAS.
FAS with confirmed maternal alcohol exposure
Category 2	If the triad described in category 1 is present, the diagnosis of FAS is possible, even with no confirmation of maternal alcohol exposure.
FAS with no confirmed maternal alcohol exposure
Category 3	Patients may present only some of the facial characteristics associated to growth restriction, abnormalities of neurodevelopment and/or of cognitive behavior.
Partial FAS with confirmed maternal alcohol exposure
Category 4	Patients of this category have some congenital anomalies resulting from alcohol toxicity.
FAS with confirmed maternal alcohol exposure and alcohol-related birth defects
Category 5	Patients of this category have evidence of abnormalities of CNS development and/or a complex abnormal cognitive behavior pattern, but may have no physical alteration.
FAS with confirmed maternal alcohol exposure and alcohol-related neurodevelopmental disorders

Brasil

Brasil

The effects of alcohol in newborns

ABSTRACT