What is the prevention and management of Fetal Alcohol Syndrome (FAS)?

Fetal Alcohol Syndrome: Prevention and Management

Primary Prevention: Complete Alcohol Abstinence During Pregnancy

The cornerstone of FAS prevention is complete abstinence from alcohol during pregnancy, as no safe threshold of alcohol consumption has been established. 1

Universal Screening and Brief Intervention

• All women of childbearing age should be universally screened for alcohol use by healthcare providers. 1
• Women drinking at risk levels (≥7 drinks per week or ≥3 drinks on multiple occasions) who are not using effective contraception require immediate brief intervention. 1
• Brief interventions using the FRAMES approach (Feedback, Responsibility, Advice, Menu of options, Empathetic style, Self-efficacy) have proven effective in reducing risk for alcohol-exposed pregnancies. 1
• Preconception counseling for at-risk women not using effective contraception represents a promising prevention method. 1

High-Risk Population Targeting

• Women who have previously given birth to a child with FAS represent the highest-risk population and should be prioritized for intervention services. 2
• Pregnant women identified as drinking should receive prompt referral for alcohol treatment programs. 3

Diagnostic Criteria for FAS

A diagnosis of FAS requires documentation of all three of the following components: 1

1. All three characteristic facial features:

   • Smooth philtrum
   • Thin vermillion border (upper lip)
   • Small palpebral fissures 1

2. Growth deficits:

   • Prenatal or postnatal deficiency in height, weight, or both 1

3. CNS abnormalities:

   • Structural (e.g., microcephaly, brain malformations)
   • Neurologic (e.g., seizures, motor problems)
   • Functional (e.g., cognitive deficits, behavioral problems) 1

The diagnosis should be classified as either confirmed prenatal alcohol exposure or unknown prenatal alcohol exposure based on available history. 1

Referral Guidelines

When Prenatal Alcohol Exposure is Known

Refer for full FAS evaluation when substantial prenatal alcohol use is confirmed (≥7 drinks per week or ≥3 drinks on multiple occasions). 1

When Prenatal Alcohol Exposure is Unknown

Refer for full FAS evaluation in any of the following circumstances: 1

• Parent or caregiver reports concern that child has or might have FAS
• All three facial features are present
• One or more facial features plus growth deficits in height, weight, or both
• One or more facial features plus one or more CNS abnormalities
• One or more facial features plus growth deficits AND one or more CNS abnormalities

Social and Family History Red Flags

Consider referral when the following risk factors are present: 1

• Premature maternal death related to alcohol use
• Living with an alcoholic parent
• Current or previous abuse or neglect
• Involvement with child protective services
• History of transient caregiving situations
• Foster or adoptive placements (including kinship care)

These social factors are particularly important because children with FAS are disproportionately likely to experience dysfunctional family situations. 1

Management and Services

Early Intervention is Critical

Early recognition and diagnosis result in better outcomes, as neurocognitive and behavioral problems from prenatal alcohol exposure are lifelong. 1, 4

Comprehensive Service Needs

The diagnostic process should be considered part of a continuum of care that facilitates appropriate services across multiple domains: 1

• Home stabilization strategies to maintain consistent caregiving environments 1
• Caregiver education to improve parent-child interaction and understanding of FAS-related challenges 1
• Advocacy for service access to ensure affected individuals receive needed support 1
• Professional education for all service providers involved with the affected person and family 1

Individualized Intervention Services

Specific interventions should target identified deficits in: 1

• Communication and social skills development
• Emotional regulation and development
• Verbal comprehension and language usage abilities
• Medication assessment when appropriate for comorbid conditions

Special Considerations for Foster/Adoptive Placements

Children in foster or adoptive care require particular attention during diagnostic and referral processes, as information about prenatal alcohol exposure may be limited or unavailable. 1

Management of Secondary Disabilities

Common mental health conditions associated with FAS include conduct disorders, oppositional defiant disorders, anxiety disorders, adjustment disorders, sleep disorders, and depression. 1

• These conditions require ongoing management throughout the lifespan 1
• Decreased adaptive skills and problems with daily living are prevalent and require habilitative therapies 1, 5
• Multidisciplinary management includes nutritional support, behavioral management, and educational accommodations 5

Critical Clinical Pitfalls

FAS is commonly missed or misdiagnosed, preventing affected children from receiving timely services. 5

• Do not wait for a definitive diagnosis before initiating early childhood intervention to prevent secondary disabilities 3
• Social stigma may prevent biological family members from seeking evaluation; approach sensitively 1
• The condition affects all socioeconomic groups, not just stereotyped populations 3
• FAS represents a leading preventable cause of intellectual and neurodevelopmental disabilities 4, 5