Elsevier

Alcohol

Volume 46, Issue 3, May 2012, Pages 269-276
Alcohol

Neonatal screening for prenatal alcohol exposure: Assessment of voluntary maternal participation in an open meconium screening program

https://doi.org/10.1016/j.alcohol.2011.09.029Get rights and content

Abstract

Meconium fatty acid ethyl esters (FAEEs) are validated biomarkers of fetal alcohol exposure. Meconium FAEE testing can potentially be used as a screen by health-care professionals to identify neonates at-risk for Fetal Alcohol Spectrum Disorder, thereby permitting diagnostic follow-up of these children and early intervention in those who develop disabilities. The purpose of this study was to assess whether women would willingly partake in a screening program of this nature. This was determined by launching a pilot screening program for prenatal alcohol exposure in a high-risk obstetric unit previously shown to have a high prevalence of FAEE-positive meconium via anonymous meconium testing. The program involved voluntary testing of meconium for FAEEs and long-term developmental follow-up of positive cases through an existing public health program. The participation rate in the screening program was significantly lower than when testing was conducted anonymously (78% vs. 95%, respectively; p < 0.05), and the positivity rate was 3% in contrast to 30% observed under anonymous conditions (p < 0.001). These low rates suggest that the majority of mothers who consumed alcohol in pregnancy refused to participate. We conclude that despite the potential benefits of such screening programs, maternal unwillingness to consent, likely due to fear, embarrassment, and guilt, may limit the effectiveness of meconium testing for population-based open screening, highlighting the need for public education and social marketing efforts for such programs to be of benefit.

Introduction

Fetal Alcohol Spectrum Disorder (FASD) is a term that describes the broad range of physical, cognitive, and behavioral disabilities that can arise due to prenatal alcohol exposure (Chudley et al., 2005; Streissguth & O'Malley, 2000). Estimated to affect 9.1/1000 live births, FASD is a leading preventable cause of mental retardation in the western world and a substantial economic burden (Sampson et al., 1997). The annual costs in Canada alone exceed $5 billion in productivity losses, medical costs, special education, social services, and externalizing behaviors (Stade et al., 2009).

Although the primary alcohol-induced damage is permanent, early diagnosis is beneficial and associated with a decreased risk of secondary disabilities such as disrupted school experience, unemployment, institutionalization, and trouble with the law; likely because it permits early intervention and specialized support (Streissguth et al., 2004). Unfortunately, recognizing FASD is extremely challenging, and diagnosis is often contingent upon establishing a history of significant in-utero alcohol exposure (Chudley et al., 2005). Since maternal reports are unreliable in supplying this information due to recall bias and common underreporting (McNamara, Orav, Wilkins-Haug, & Chang, 2005; Russell et al., 1994), objective methods and biomarkers for ascertaining prenatal alcohol exposure have been investigated.

Fatty acid ethyl esters (FAEEs) are non-oxidative metabolites of ethanol formed by the esterification of ethanol to endogenous fatty acids or fatty acyl-CoA, which deposit and accumulate in fetal meconium (Best & Laposata, 2003; Koren, Hutson, & Gareri, 2008). Numerous studies have established that elevated meconium FAEE concentration can serve as a biomarker of heavy prenatal alcohol exposure occurring in the last two trimesters of pregnancy (Bearer, Gould, Emerson, Kinnunen, & Cook, 1992; Bearer et al., 1999, 2003, 2005; Brien et al., 2006; Chan et al., 2003; Klein, Karaskov, & Korent, 1999; Littner, Cudd, O'Riordan, Cwik, & Bearer, 2008; Moore, Jones, Lewis, & Buchi, 2003). Furthermore, agreement between meconium FAEEs and various alcohol-related outcomes has been demonstrated (Brien et al., 2006; Hutson, Magri, Gareri, & Koren, 2010; Jacobson, 2006; Noland et al., 2003; Peterson et al., 2008), and this test has been used anonymously to obtain epidemiological data on prenatal alcohol exposure in select populations (Garcia-Algar et al., 2008; Gareri, Lynn, Handley, Rao, & Koren, 2008; Goh et al., 2010; Hutson et al., 2010).

It has been recognized that meconium analysis for FAEEs may serve as a neonatal screening tool for the identification of alcohol-exposed newborns, which could potentially be implemented as a universal screen or targeted to high-risk populations (Goh et al., 2008). Such screening would not only provide accurate exposure history required for diagnosis, but if implemented along with a comprehensive follow-up program and interventions, could facilitate early recognition and treatment of FASD (Gifford et al., 2010; Goh et al., 2008; Hopkins et al., 2008). As an added value, it may identify and allow for intervention in problem-drinking mothers, which, in turn, may prevent future alcohol-exposed pregnancies (Koren et al., 2008). However, since informed consent from a competent patient or appointed guardian prior to treatment or testing is an ethical and legal component of medical practice (Etchells, Sharpe, Walsh, Williams, & Singer, 1996; Flagler, Baylis, & Rodgers, 1997), a screening program of this nature may require consent of the child's legal guardian (typically the parent). This could diminish the value of meconium screening in a clinical setting since embarrassment, guilt, and fears of stigma and child apprehension, may deter women who consumed alcohol from consenting to testing despite the potential value to child health.

To determine if women would willingly participate in a neonatal screening program for prenatal alcohol exposure, we offered meconium testing with subsequent follow-up, interventions, and social supports, to women from a regional Ontario population delivering in a high-risk obstetric unit previously shown to have a high prevalence of alcohol-exposed neonates as determined by anonymous meconium testing. We assessed the rates of voluntary participation and positivity for alcohol exposure in this pilot screening program, and compared these with the rates observed with anonymous testing.

Section snippets

Subject recruitment

The target population to whom screening was offered were women residing in the region of Grey-Bruce, Ontario, who were delivering at St. Joseph's Health Care (SJHC) in London, Ontario. Grey-Bruce is located in Mid Western Ontario, Canada, and occupies an area of 8586 km2, comprising of a midsized city (Owen Sound, ∼22,000 people), smaller towns, farming communities, first nation communities, and Mennonite settlements. There are ∼1200–1400 births per year in the region, but high risk or

Willingness of mothers to participate in open screening program

Sixty mothers from Grey-Bruce were identified at SJHC and offered meconium screening, of which 47 women consented, totaling a 78% consent rate (Fig. 1). The maternal and neonatal characteristics of consenting subjects are presented in Table 1. This consent rate was significantly lower than in the previous study where meconium was tested anonymously, in which 95% (54/57) of women agreed to testing (p = 0.014). Of interest, we documented one instance where a woman recalled participating in the

Discussion

To our knowledge, this is the first study to utilize biomarkers of fetal alcohol exposure in an open screening program designed to facilitate diagnosis and treatment of alcohol-affected children. The participation and positivity rates in this pilot program were significantly lower than those observed when testing was offered anonymously in the same high-risk unit, suggesting that many women who consumed alcohol in pregnancy refused to participate, not wishing to be identified by the screen. Of

Disclosure

GK was supported by a CIHR operating grant and by the Ivey Chair in Molecular Toxicology, University of Western Ontario. IZ was supported by OGS and the University of Toronto Open Fellowship. The authors are not aware of any financial or other relationship that might lead to a conflict of interest.

Acknowledgments

We would like to thank the nursing staff at St. Joseph's Health Care for their help with patient screening and sample collection.

References (41)

  • C.F. Bearer et al.

    Ethyl linoleate in meconium: a biomarker for prenatal ethanol exposure

    Alcoholism: Clinical & Experimental Research

    (1999)
  • C.A. Best et al.

    Fatty acid ethyl esters: toxic non-oxidative metabolites of ethanol and markers of ethanol intake

    Frontiers in Bioscience

    (2003)
  • J.F. Brien et al.

    Chronic prenatal ethanol exposure and increased concentration of fatty acid ethyl esters in meconium of term fetal Guinea pig

    Therapeutic Drug Monitoring

    (2006)
  • L. Burd et al.

    Biomarkers for detection of prenatal alcohol exposure: a critical review of fatty acid ethyl esters in meconium

    Birth Defects Research Part A Clinical and Molecular Teratology

    (2008)
  • D. Chan et al.

    Population baseline of meconium fatty acid ethyl esters among infants of nondrinking women in Jerusalem and Toronto

    Therapeutic Drug Monitoring

    (2003)
  • A.E. Chudley et al.

    Fetal alcohol spectrum disorder: Canadian guidelines for diagnosis

    Canadian Medical Association Journal

    (2005)
  • C. Derauf et al.

    The prevalence of methamphetamine and other drug use during pregnancy in Hawaii

    Journal of Drug Issues

    (2003)
  • E. Etchells et al.

    Bioethics for clinicians: 1. Consent

    Canadian Medical Association Journal

    (1996)
  • E. Flagler et al.

    Bioethics for clinicians: 12. Ethical dilemmas that arise in the care of pregnant women: rethinking “maternal-fetal conflicts”

    Canadian Medical Association Journal

    (1997)
  • O. Garcia-Algar et al.

    Alarming prevalence of fetal alcohol exposure in a Mediterranean city

    Therapeutic Drug Monitoring

    (2008)
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