1 Screening Newborns for Alcohol Exposure – Clinical Implementation Sarit Shor HBSc. Division of Clinical Pharmacology and Toxicology Hospital for Sick Children, Toronto Department of Pharmacology University of Toronto Joey Gareri MSc. Irena Nulman MD. Gideon Koren MD., FRCPC

2 Fetal Alcohol Spectrum Disorder FASD FASD Physical Physical Behavioral Behavioral Cognitive disabilities Cognitive disabilities Fetal alcohol syndrome (FAS) Fetal alcohol syndrome (FAS) High rate of alcohol consumption among young reproductive women ( %) (Institute of Medicine of the National Academy of Sciences Committee for Study Fetal Alcohol Syndrome, 1996; National Centre for Health Statistics, 1990). High rate of alcohol consumption among young reproductive women ( %) (Institute of Medicine of the National Academy of Sciences Committee for Study Fetal Alcohol Syndrome, 1996; National Centre for Health Statistics, 1990).

3 Fetal Alcohol Spectrum Disorder Canadian data (Chudley et al., 2005). Canadian data (Chudley et al., 2005) % women drink ethanol at some point in pregnancy 14-25% women drink ethanol at some point in pregnancy 5-9% drink throughout the entire pregnancy 5-9% drink throughout the entire pregnancy 3% reporting binge drinking 3% reporting binge drinking The 2003 Canadian Community Health survey (Statistics Canada, 2001). The 2003 Canadian Community Health survey (Statistics Canada, 2001). 1.96% of pregnant women used ethanol once per month 1.96% of pregnant women used ethanol once per month 0.84% drank 2-3 times per month 0.84% drank 2-3 times per month 1.26% reported drinking greater than or equal to one drink per week 1.26% reported drinking greater than or equal to one drink per week

4 Incidence & Societal Impact FASD affects up to 1% of pediatric population in North America (Chavez et al., 1988; Sokol & Clarren, 1989; Sampson et al., 1994; Sampson et al., 1997; Williams et al., 1999). FASD affects up to 1% of pediatric population in North America (Chavez et al., 1988; Sokol & Clarren, 1989; Sampson et al., 1994; Sampson et al., 1997; Williams et al., 1999). Canadian annual birth rates ~335,000 Canadian annual birth rates ~335,000 These estimations indicate the scope and severity of FASD as public health concern These estimations indicate the scope and severity of FASD as public health concern The annual cost per FASD-affected individual in Canada has been estimated at $14,342 CAD The annual cost per FASD-affected individual in Canada has been estimated at $14,342 CAD

5 Secondary Disabilities A large proportion of these costs result from preventable secondary disabilities associated with FASD A large proportion of these costs result from preventable secondary disabilities associated with FASD creating a significant economic impact at the individual, familial, and societal levels (Nulman et al., 1998; Stade, 2003). creating a significant economic impact at the individual, familial, and societal levels (Nulman et al., 1998; Stade, 2003). Secondary disabilities Secondary disabilities Incarceration Incarceration Dependent living Dependent living Early death Early death Unemployment Unemployment Substance addiction Substance addiction Mental health problems Mental health problems The risk of these secondary disabilities may be decreased with early intervention in FASD affected children (Institute of Medicine of the National Academy of Sciences Committee for Study Fetal Alcohol Syndrome, 1996; Streissguth et al., 1996). The risk of these secondary disabilities may be decreased with early intervention in FASD affected children (Institute of Medicine of the National Academy of Sciences Committee for Study Fetal Alcohol Syndrome, 1996; Streissguth et al., 1996).

6 Intervention & Treatment Intervention and treatment Intervention and treatment adapting FASD-affected individuals to their environment by addressing their neurodevelopmental issues. adapting FASD-affected individuals to their environment by addressing their neurodevelopmental issues. Animal studies (Hannigan et al.,1993; Christie et al., 1999; Rema & Ebner, 1999). Animal studies (Hannigan et al.,1993; Christie et al., 1999; Rema & Ebner, 1999). attenuation of prenatal ethanol-related neurodevelopmental effects in rats that experience enriched/stimulating post-natal environments attenuation of prenatal ethanol-related neurodevelopmental effects in rats that experience enriched/stimulating post-natal environments early intervention and treatment in the first years of life could improve neurological performance, potentially reducing deficits in cortical function, learning, and memory processing early intervention and treatment in the first years of life could improve neurological performance, potentially reducing deficits in cortical function, learning, and memory processing

7 Diagnosis Intervention requires diagnosis Intervention requires diagnosis The optimal time period for diagnosis and intervention is prior to 6 years of age The optimal time period for diagnosis and intervention is prior to 6 years of age only 11% of alcohol-affected individuals are diagnosed by this time (Streissguth et al., 1996). only 11% of alcohol-affected individuals are diagnosed by this time (Streissguth et al., 1996). Diagnosis of FASD can be challenging as several other medical disorders can exhibit similar features. Diagnosis of FASD can be challenging as several other medical disorders can exhibit similar features.

8 Diagnosis Canadian guidelines (2005) (Chudley et al., 2005). Canadian guidelines (2005) (Chudley et al., 2005). providing recommendations to Canadian physicians for screening and referral practices providing recommendations to Canadian physicians for screening and referral practices in the absence of craniofacial features (present in only 10% of alcohol-affected individuals), evidence of maternal prenatal ethanol use is required for a diagnosis. in the absence of craniofacial features (present in only 10% of alcohol-affected individuals), evidence of maternal prenatal ethanol use is required for a diagnosis. Accurate ethanol exposure history is paramount to mounting an effective strategy to address the impact of FASD in the general population. Accurate ethanol exposure history is paramount to mounting an effective strategy to address the impact of FASD in the general population.

9 Obtaining Exposure History Maternal self-reporting of prenatal alcohol consumption Maternal self-reporting of prenatal alcohol consumption subjective and often unreliable due to guilt and fear of reprisal (Russell et al., 1996; Neumann & Spies, 2003). subjective and often unreliable due to guilt and fear of reprisal (Russell et al., 1996; Neumann & Spies, 2003). Maternal blood markers Maternal blood markers ineffective at identifying alcohol use in pregnancy (Stoler et al., 1998; Bearer, 2001; Cook, 2003). ineffective at identifying alcohol use in pregnancy (Stoler et al., 1998; Bearer, 2001; Cook, 2003). Maternal or neonatal blood and urine for ethanol Maternal or neonatal blood and urine for ethanol limited usefulness due to rapid elimination (Kalant & Khanna, 1998). limited usefulness due to rapid elimination (Kalant & Khanna, 1998).

10 Meconium Analysis Meconium Meconium Comprises the first few bowel movements of the neonate Comprises the first few bowel movements of the neonate Formation begins around 12 weeks of pregnancy (Miller & Holzen, 1974; Kwong & Ryan, 1997) Formation begins around 12 weeks of pregnancy (Miller & Holzen, 1974; Kwong & Ryan, 1997) Provide a record of prenatal alcohol exposure Provide a record of prenatal alcohol exposure Fatty acid ethyl esters (FAEEs) Fatty acid ethyl esters (FAEEs) Formed as a result of enzyme-mediated esterification of ethanol and free fatty acids Formed as a result of enzyme-mediated esterification of ethanol and free fatty acids OO OO ║║ ║║ R – C – OH + CH3CH2OH  R – C – O – CH2CH3 + H 2 O R – C – OH + CH3CH2OH  R – C – O – CH2CH3 + H 2 O Fatty AcidEthanol FAEE Water Fatty AcidEthanol FAEE Water (Best and Laposata, 2003)

11 Meconium Analysis Use of meconium FAEE has been extensively validated through cohort and population-based studies (Bearer et al., 1992; Bearer et al., 1999; Klein et al., 1999; Yamashita et al., 1997; Bearer et al., 2003; Chan et al., 2003; Chan et al., 2004; Brien et al., 2006). Use of meconium FAEE has been extensively validated through cohort and population-based studies (Bearer et al., 1992; Bearer et al., 1999; Klein et al., 1999; Yamashita et al., 1997; Bearer et al., 2003; Chan et al., 2003; Chan et al., 2004; Brien et al., 2006). Studies also have shown an association between meconium FAEE concentrations and some FASD-related outcome measures (Derauf et al., 2003; Noland et al., 2003; Peterson et al., 2005 ; Brien et al., 2006; Jacobson et al., 2006). Studies also have shown an association between meconium FAEE concentrations and some FASD-related outcome measures (Derauf et al., 2003; Noland et al., 2003; Peterson et al., 2005 ; Brien et al., 2006; Jacobson et al., 2006). Lower birth weight Lower birth weight Smaller head circumference Smaller head circumference Elevated ethyl oleate correlated with FAS or pFAS diagnosis at 5 years of age Elevated ethyl oleate correlated with FAS or pFAS diagnosis at 5 years of age Demonstrated high specificity and sensitivity in identifying prenatal exposures Demonstrated high specificity and sensitivity in identifying prenatal exposures 5-fold increase in prenatal alcohol exposure detection over standard clinical practice (Gareri et al., 2006). 5-fold increase in prenatal alcohol exposure detection over standard clinical practice (Gareri et al., 2006).

12 Neonatal Screening Meconium analysis of FAEE appears to be a valuable tool in obtaining the prenatal exposure history required by the Canadian Guidelines for FASD diagnosis in the absence of craniofacial features Meconium analysis of FAEE appears to be a valuable tool in obtaining the prenatal exposure history required by the Canadian Guidelines for FASD diagnosis in the absence of craniofacial features In clinical practice, participation in screening with informed consent may be limited due to stigmatization of prenatal drinking In clinical practice, participation in screening with informed consent may be limited due to stigmatization of prenatal drinking This may pose a limitation to the usefulness of meconium FAEE screening. This may pose a limitation to the usefulness of meconium FAEE screening.

13 Pilot Study - Objectives Primary Objective: (Part 1) To assess the level of voluntary participation in prenatal alcohol exposure screening with informed consent. To assess the level of voluntary participation in prenatal alcohol exposure screening with informed consent. Secondary Objective: (Part 2) To determine if the presence of FAEEs in meconium correlates with standard childhood developmental milestones and Bayley’s test for neurodevelopmental screening. To determine if the presence of FAEEs in meconium correlates with standard childhood developmental milestones and Bayley’s test for neurodevelopmental screening.

14 Hypotheses The rate of voluntary participation in meconium screening for prenatal alcohol exposure with written informed consent will be significantly lower compared to the rate of voluntary participation in previous anonymous testing regimens as established by Gareri et al. (2006) in the same region (Grey Bruce, Ontario). The rate of voluntary participation in meconium screening for prenatal alcohol exposure with written informed consent will be significantly lower compared to the rate of voluntary participation in previous anonymous testing regimens as established by Gareri et al. (2006) in the same region (Grey Bruce, Ontario). Children with FAEE positive meconium will exhibit clinically significant differences in developmental milestones in comparison to children with negative FAEE results. Children with FAEE positive meconium will exhibit clinically significant differences in developmental milestones in comparison to children with negative FAEE results.

15 Method Study Design Prospective cohort study Prospective cohort studySubjects: Inclusion Criteria: Inclusion Criteria: All neonates born to women living in the region of Grey Bruce between October 2007 and September 2008 and whose mothers provided written informed consent. All neonates born to women living in the region of Grey Bruce between October 2007 and September 2008 and whose mothers provided written informed consent. Exclusion Criteria: Exclusion Criteria: All neonates born to women living outside the region of Grey Bruce and all neonates whose mothers refused to provide informed consent. All neonates born to women living outside the region of Grey Bruce and all neonates whose mothers refused to provide informed consent. Feasibility (N = ~ ) Based on the public health data provided by the Grey Bruce Health Unit, it is estimated that infants will be delivered per year in all the birth units in the region. Based on the public health data provided by the Grey Bruce Health Unit, it is estimated that infants will be delivered per year in all the birth units in the region.

16 Ethical Considerations Available Information Pamphlets will be given to each mother that will provide Pamphlets will be given to each mother that will provide Information on FASD and the importance of early detection Information on FASD and the importance of early detection Contact information for the Motherisk program. Contact information for the Motherisk program. Informed Consent: Will be administered by a trained research personnel Will be administered by a trained research personnel Information requested will include Information requested will include TWEAK questionnaire TWEAK questionnaire Antenatal 1 & 2 Forms Antenatal 1 & 2 Forms Delivery information Delivery information Permission to call for follow up for developmental milestones & neurodevelopmental testing Permission to call for follow up for developmental milestones & neurodevelopmental testing There will be complete understanding that positive test results will not be reported to Children’s Aid Society (CAS) There will be complete understanding that positive test results will not be reported to Children’s Aid Society (CAS)Sample One meconium sample will be collected for each live birth One meconium sample will be collected for each live birth Shipped to the Hospital for Sick Children for analysis Shipped to the Hospital for Sick Children for analysis

17 Part 2 Milestones & Neurodevelopment Subjects: Infants who were tested positive for meconium FAEEs will be matched to infants who tested negative for presence of meconium FAEEs and whose mothers were tested negative on the TWEAK questionnaire. Infants who were tested positive for meconium FAEEs will be matched to infants who tested negative for presence of meconium FAEEs and whose mothers were tested negative on the TWEAK questionnaire.Methods: Follow up via phone interviews for developmental milestones Follow up via phone interviews for developmental milestones smile, lift head, sit, crawl, stand, speak, walk smile, lift head, sit, crawl, stand, speak, walk Trained psychometrist will administer Bayley’s developmental screening test. Trained psychometrist will administer Bayley’s developmental screening test.

18 MOTHERS – Engagement & Assessment Engagement Engagement Outreach worker Outreach worker Will provide general information to mothers of infants whose meconium tested positive for FAEE Will provide general information to mothers of infants whose meconium tested positive for FAEE Will identify families at risk (and provide referrals) Will identify families at risk (and provide referrals) Multidisciplinary program Multidisciplinary program Mediated by the Public Health Unit Mediated by the Public Health Unit

19 MOTHERS - Prevention by Intervention Biological mothers of children with FAS exhibit a 77% risk of having subsequent FAS-affected offspring (Huebert & Raftis, 1996; Riley & McGee, 2005) Biological mothers of children with FAS exhibit a 77% risk of having subsequent FAS-affected offspring (Huebert & Raftis, 1996; Riley & McGee, 2005) Substance-addicted women have an 85% incidence of multiple pregnancies (~4 pregnancies each) (Pepler et al., 2002). Substance-addicted women have an 85% incidence of multiple pregnancies (~4 pregnancies each) (Pepler et al., 2002). Detection of a first-born child with prenatal ethanol exposure can thus prevent future alcohol-exposed pregnancies by engaging mothers in substance abuse treatment. Detection of a first-born child with prenatal ethanol exposure can thus prevent future alcohol-exposed pregnancies by engaging mothers in substance abuse treatment. screening has the potential to facilitate FASD prevention as well as intervention for both the mother and alcohol-affected child. screening has the potential to facilitate FASD prevention as well as intervention for both the mother and alcohol-affected child.

20 Long Term Goals & Future Studies Successful completion of this study will assess the level of voluntary participation in prenatal alcohol exposure screening with written informed consent in clinical settings. Successful completion of this study will assess the level of voluntary participation in prenatal alcohol exposure screening with written informed consent in clinical settings. Recommendations will be made regarding the utility of this test for screening for prenatal ethanol exposure in pregnancy in clinical practice. Recommendations will be made regarding the utility of this test for screening for prenatal ethanol exposure in pregnancy in clinical practice. In addition, children who exhibit developmental delays will be enrolled in early intervention programs and will be followed to observe their progress. In addition, children who exhibit developmental delays will be enrolled in early intervention programs and will be followed to observe their progress. Women enrolled in support services may be followed to observe for changes in quality of life. Women enrolled in support services may be followed to observe for changes in quality of life. A cost-effectiveness evaluation will be conducted on this program. A cost-effectiveness evaluation will be conducted on this program.