Canadian Task Force on Preventive Health Care

Structured Abstract

Please note: In 2003, the CTF updated its Grades of Recommendations to include an "I Recommendation" for situations where insufficient evidence exists to allow a recommendation to be made.  (Formerly, these situations were captured under a "C Recommendation".)  This change is not retroactive, and all "C Recommendations" made prior to 2003 have not been reevaluated in light of the new "I" recommendation grade.  For a discussion of these recommendation grades, please link to the 2003 article in the Canadian Medical Association Journal here.

Primary Prevention of Fetal Alcohol Syndrome

Prepared by David R. Offord, MD, FRCPC,  Department of Psychiatry, McMaster University, and Deborah L. Craig, MPH, Health Care Consultant, Halifax, Nova Scotia

These recommendations were finalized by the Task Force in March 1994

Up Contents

Up Objective

To make recommendations for screening and counselling pregnant Canadian women about alcohol consumption and the fetal alcohol syndrome (FAS).  This is an update of previous Canadian Task Force recommendations.
 

Up Burden of Suffering

Fetal Alcohol Syndrome (FAS) refers to a constellation of congenital and functional anomalies occurring in children born to alcohol-abusing women.  FAS is now one of the leading causes of mental retardation.  It has been estimated that 50% of FAS victims are mentally retarded and another 30% suffer borderline mental retardation.  The term "possible fetal alcohol effects" (FAE) has been introduced to indicate that alcohol is being considered as one of the possible causes of a patient's birth defects, but there are not sufficient features for a firm diagnosis of FAS or strong evidence of an alternative diagnosis.  Although the precise incidence of FAS and FAE in Canada are not known, the incidence of FAS is estimated to be between 1 and 2 per 1,000 live births in the general population.  The incidence of FAS is markedly increased in the native population and in poor, inner-city neighbourhoods, as well as rural, remote villages.

Up Options

Laboratory tests for excess drinking are not available. Screening tests are the Michigan Alcoholism Screening Test, (MAST), the CAGE test, the World Health Organization tests, the T-ACE test, the Ten Question Drinking History (TQDH) and careful history taking. No treatment options exist for FAS. Prevention strategies are case finding with education, counselling and treatment for women who are identified as being at risk.

Up Outcomes

Sensitivities and specificities for each of the tests. FAS is a constellation of birth anomalies that includes mental retardation, spontaneous abortion, and many other features. Treatment outcomes include a reduction in the number of children born with FAS and the severity of FAS. Possible fetal alcohol effects (FAE) is considered a lesser form of FAS.

Up Evidence

MEDLINE was searched for 1988 - 1993 using the MeSH terms fetal alcohol syndrome.

Recommendations were graded as:
 
 
A 
 Good evidence to support the recommendation that the condition be specifically considered in a PHE. 
B 
 Fair evidence to support the recommendation that the condition be specifically considered in a PHE. 
C 
 Poor evidence regarding inclusion or exclusion of the condition in a PHE, but recommendations may be made on other grounds. 
D 
 Fair evidence to support the recommendation that the condition be specifically excluded from consideration in a PHE. 
E 
 Good evidence to support the recommendation that the condition be specifically excluded from consideration in a PHE. 
Quality of evidence was rated according to 5 levels:
 
 
I 
 Evidence from at least 1 properly randomized controlled trial (RCT). 
II-1 
 Evidence from well-designed controlled trials without randomization. 
II-2 
 Evidence from well-designed cohort or case-control analytic studies, preferably from more than 1 centre or research group. 
II-3 
 Evidence from comparisons between times or places with or without the intervention. Dramatic results in uncontrolled experiments could also be included here. 
III 
 Opinions of respected authorities, based on clinical experience, descriptive studies or reports of expert committees. 

Up Values

The 13-member Task Force of experts in family medicine, geriatric medicine, pediatrics, psychiatry and epidemiology used an evidence-based method for evaluating the effectiveness of preventive health care interventions. Recommendations were not based on cost-effectiveness of options. Patient preferences were not discussed.

Background papers providing critical appraisal of the evidence and tentative recommendations prepared by the chapter author were pre-circulated to the members. Evidence for this topic was presented and deliberated upon in 1- to 2-day meetings, 2 to 3 times per year from January 1993 to March 1994. Consensus was reached on final recommendations.

Up Benefits, Harms, and Costs

MAST (a 25-question instrument that is time consuming to administer), CAGE, and the World Health Organization instruments have not been tested using pregnant women. A 2-question instrument ("Have you ever had a drinking problem?" and "When was your last drink?") has a sensitivity of 92% to detect alcoholism. T-ACE (a 4-question instrument) accurately identified 69% of the risk drinkers in a cohort of 971 pregnant women. The TQDH (Ten Question Drinking History) questionnaire has been shown to be reliable when used by obstetrical staff. Overall a positive result almost always identifies a problem drinker, while negative results may not be accurate.

Because no treatment exists for FAS and FAE, interventions must be targeted to reduce drinking in pregnant women. 4 cohort studies show that reduced drinking reduces the rates for FAS and FAE. One showed that of 85 pregnant women, 65% were able to reduce their alcohol consumption by 50%  after counselling.  Of the total sample, the rate of FAS was 24% and of FAE was 26%. For the women who did not reduce their drinking, 89% of infants had 1 feature of FAE compared with 40% for those who reduced their drinking. In 2 studies of supportive counselling, 67% and 76% of drinkers reduced their drinking.

Clinicians are failing to diagnose alcoholism in at least three of four alcohol-abusing patients. Reasons include bias regarding their own abuse, inadequate training for the task, poor awareness of the problem and its consequences, time restrictions, disinterest and denial.

Warning labels on alcohol products have not been evaluated for their effect on reducing drinking behaviour.

Up Recommendations

Recommendation grade [A, B, C, D, E]  and level of evidence [I, II-1, II-2, II-3, III] are indicated after each recommendation. Citations in support of individual recommendations are identified in the guideline text.

Up Validation

This report was externally peer reviewed. The Canadian Medical Association recommended that all Canadians be encouraged to reduce their alcohol consumption. They also recommended that advertising (radio, television, and print) of alcohol be restricted. A Canadian government sub-committee also recommended that the Food and Drug Act be amended to require labelling of alcohol beverage containers with warnings about consumption and pregnancy risks for FAS and FAE.

Abstinence from drinking for all pregnant women is the official policy of both Canadian and U.S. medical organizations. In addition, the U.S. Preventive Services Task Force recommended in 1989 that all persons who use alcohol, especially pregnant women, should be encouraged to limit their consumption.

Up Sponsors

The Canadian Task Force on Preventive Health Care developed this guideline with funding from Health Canada.

Up Selected References

Source Document

Other

Link to Full Text of this review

Link to Summary Table of Recommendations of this review

Link to Selected References list of this review

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