FETAL ALCOHOL SYNDROME/EFFECTS
Like a pebble hitting
the water, the impact of fetal alcohol syndrome (FAS) and fetal
alcohol effects (FAE) ripples through an entire community.
Families are affected in intensely personal
ways when a child is born with FAS/E. But schools, local health
care systems, childcare and social services, and the justice
system also feel the impact. FAS and FAE are birth defects that
result from a pregnant woman's consumption of alcohol. The alcohol
harms the developing baby, so that the infant is born with certain
characteristics. It is likely to have a low birth weight and
to grow more slowly than a normal, healthy baby. Its facial features
and ears may have an abnormal appearance, and internal organs
- most importantly, the brain - are damaged.
Beyond these primary physical effects, a child with FAS/E often
experiences secondary behavioural, mental and social effects.
These include hyperactivity, poor judgment and anti-social behaviour.
Over the years, a person with FAS/E may experience mental health
problems, disrupted schooling, involvement with crime, substance
abuse, dependent living and employment difficulties.
FAS/E is the leading cause of mental disability in Canada, yet
it is 100 per cent preventable. Studies suggest that between
one and three of every 1,000 live births in Canada are FAS, and
another eight per 1,000 are FAE. Each year, this works out to
about 350 children born with FAS and 1,000 with FAE.
To further complicate matters, FAS and FAE may be under- diagnosed.
Research indicates that most people in Canadian society who have
these conditions will never be diagnosed, but will spend a troubled
life on the margins of society. First Nations and Inuit communities
are at especially high risk for FAS/E. And on a First Nations
reserve in Manitoba, about 100 alcohol-related birth disorders
(a broad term that includes FAS/E) per 1,000 live births were
There are varying cultural values related to alcohol across First
Nations communities, and varying levels of alcohol use/abuse.
However, FAS/E is clearly of deep concern for some groups. Alcohol
abuse exists in the context of the history of colonization and
devaluation endured by First nations and Inuit, which has resulted
in a loss of culture.
In many Aboriginal communities, children born with obvious disabilities
have traditionally been accorded special status and seen as having
a gift. For many Aboriginal people working as caregivers of FAS/E
children, there has been a growing awareness that people with
FAS/E are special souls who have come to Earth to tell us what
we need to change in our communities so that all of us can live
healthy, happy lives.
How does alcohol affect the fetus?
Alcohol from beer, wine, or hard liquor easily
crosses the mother's placenta to enter the circulatory system
of the fetus. The alcohol lingers in the baby's system, since
the fetus cannot rid itself of alcohol as quickly as the mother
can. One study showed the rate of elimination of alcohol from
the fluid surrounding the fetus was twice as long as from maternal
Alcohol is a toxic agent that damages developing
cells. The more the mother drinks, the higher the risk of damage
- but harm can occur at as little as two drinks per day. Both
heavy drinking on a daily basis and occasional binge drinking
are particularly dangerous.
Alcohol is especially harmful - at any point in
the pregnancy - to the developing brain. But it also damages
cells in the developing skeleton, ears, eyes, lungs, heart, genitals
and kidneys. If the mother is stressed, malnourished, smokes
cigarettes or uses other drugs, there is an even greater likelihood
that alcohol will harm her fetus.
Note that the form of alcohol makes no difference
- the effect is the same. There is the same amount of pure alcohol
in a 12-ounce (341 ml) bottle of beer, a 5-ounce (142 ml) glass
of wine, and in 1.5 ounces (43 ml) of distilled spirits.
At birth, an alcohol-affected baby may suffer
withdrawal from alcohol and any other drugs the mother uses.
This is known as "neonatal abstinence syndrome." The
baby may also be prone to infections, fail to thrive, and have
either poor muscle tone (a "floppy" baby) or rigid
muscle tone. Infants with FAS/E may have trouble with sleeping
and with sucking and swallowing.
It is unclear if any amount of alcohol can be
safely consumed during pregnancy. Canadian and U.S. health authorities
recommend abstaining during pregnancy and also while breastfeeding,
since alcohol passes easily into breast milk.
Characteristics of infants with FAS
No two children are affected by FAS in the same way. Characteristics
of this disability may also change as a child grows (although
if the effects become less obvious, it doesn't mean the child
no longer has FAS).
A medical doctor will diagnose FAS based on whether there was
prenatal exposure to alcohol, and whether certain of the following
characteristics are present.
Growth retardation -The FAS baby grows
more slowly than a normal, healthy child. Growth delay is defined
as weight and/or length below the 10th percentile for the child's
age. These children are typically short and skinny, and grow
into short adults. Maternal smoking and poor prenatal nutrition
can also contribute to delayed growth.
Altered facial features -At least two of
these must be identified in order to make a clinical diagnosis
of FAS: shortened eye slits, epicanthal folds of the eyelids,
a short, turned-up nose, a flattened philtrum (midline ridge
between nose and lip), a thin upper lip, and other abnormalities
involving the eyes, ears and mouth (palate and teeth).
Not all clinicians agree on the frequency of facial features,
which become more difficult to diagnose as the child grows older.
Distinct features may begin to fade in adulthood.
Central nervous system (CNS) involvement
-Damage to the CNS by alcohol exposure during pregnancy might
include such conditions as a small brain or head circumference,
brain malformations, developmental delays, intellectual impairment,
developmental disorders, learning disabilities, attention deficit/hyperactivity,
and poor judgement and reasoning.
Children with FAE have some, but not all, of the above characteristics.
They do not have a "milder" form of FAS. They may suffer
learning and behaviour problems that are just as severe as those
of a child with FAS, but their disabilities may be less obvious
due to a more normal appearance.
Brain damage is permanent for a person with FAS/E. But the more
that is learned about FAS/E, the more there is hope that affected
children can be helped. A key strategy is to lessen or prevent
the secondary disabilities linked to FAS/E. With a stable, loving
and caring environment, and with interventions such as plenty
of structure and appropriate learning techniques, FAS/E-affected
children can be helped to live productive lives.
Identifying women at risk of having an FAS/E baby
About 67 per cent of women in Canada drink alcohol, making it
the most commonly used drug by women. Women who continue to drink
heavily during pregnancy do so for several reasons - many of
which are no different for a non-pregnant woman. They include:
being around people who use alcohol and have an accepting attitude
towards its misuse; having low self-esteem; experiencing anxiety
or depression; and living in unpleasant circumstances.
The main way to identify women at risk of having an FAS/E baby
is by screening for alcohol and drug problems. Health professionals
or any other professionals who counsel women on self-care generally
do screening. Substance use screening questions should be asked
as a part of routine checkups and prenatal histories, should
be addressed to ALL women, and should allow women the opportunity
to talk freely and comfortably.
A questionnaire called T-ACE (Tolerance-Annoyance-Cut Down-Eye
Opener) has been developed to determine risk during pregnancy.
T-ACE has the following questions:
1. How much alcohol do you drink before you feel its effects?
2. Has anyone ANNOYED you by saying you should cut down on your
3. Have you ever thought you should CUT DOWN?
4. Have you ever had a drink to get going in the morning? (EYE
If a woman answers "Tolerance" with two or more drinks,
then a score of two points is given. She receives a score of
one point for each positive response to each of the other questions.
A T-ACE score of two or more indicates risky drinking behaviour.
Intervening with pregnant women who are at risk of having a baby
with FAS is a challenging task, for various reasons. One is that
pregnancy is very personal, and not obvious to an outsider until
it has progressed fairly far. Some women may not know they are
pregnant until their second or third month, or even later.
Also, not all women go to the doctor right away if they are pregnant
- particularly women who are abusing alcohol and other drugs.
Some women are very addicted to this cycle of abuse. And some
women who abuse alcohol and drugs live under difficult, often
A drinking problem is never easy to overcome. Pregnancy is an
excellent time for women with drinking problems to stop or reduce
their use of alcohol. Women need respect, understanding, caring
and support to accomplish this.
For a woman to change her drinking behaviour, she needs to understand
the dangers of alcohol abuse and choose to spend time with people
who drink responsibly, if at all. She also needs to learn how
to manage negative emotions without resorting to alcohol and
drug abuse. Finally, she needs to become aware of how her living
situation affects her use of alcohol and other drugs, and how
she can change the situation.
Health care professionals can take these approaches when counseling
pregnant women about their drinking:
Stress the positive (e.g. "If you stop drinking
now, you have a better chance of having a healthy baby.")
predict the outcome of a particular
pregnancy - every situation is unique.
Help women assess their risks.
Help women develop motivation for risk reduction.
Recommend alcohol and other drug abuse treatment when appropriate.
information on family planning and choices.
Be sensitive to the range of issues which may be related to
a woman's substance use, such as legal or custody problems, housing
instability, poor health, depression, a history of violence and
sexual abuse, sexually transmitted diseases, etc.
Be sensitive to women's fears of losing their children if they
admit to having a problem, and to their shame and denial about
having alcohol or drug problems.
Be sensitive to lack of childcare, transportation, and other
logistical barriers to accessing treatment.
Provide ongoing hope.
Addressing root causes of FAS/E
FAS/E is caused by a woman's alcohol use/abuse during pregnancy.
But to understand why that woman drinks during her pregnancy
requires a deeper analysis - one that reveals that FAS/E is a
What are reasons for alcohol abuse among Aboriginal people? Certainly,
the history of the introduction of alcohol to Aboriginal society
through colonialism needs to be recognized. It's also necessary
to address how Aboriginal society - specifically, each community
- has dealt with the influence of alcohol.
In general, certain risk factors or conditions influence a person's
environment and contribute towards a pregnant woman's consumption
low socio-economic status; poverty and stress
history of miscarriage
lack of good maternal health and nutrition
grieving and loss
lack of FAS/E knowledge in the community
chaotic living conditions and situations involving
parents who abuse alcohol/drugs
Many of these are community issues. At the same time, community
caring seems to be necessary to effectively deal with FAS/E.
Fortunately, traditional Aboriginal beliefs strongly support
the concept of "caring as a community" - especially
when it comes to children.
In Aboriginal communities of the past, it was considered the
responsibility of the prospective parents to follow the guidelines
of the elders to ensure that a child was born healthy. People
understood that children were the future, and that what happened
to them would have an impact on the next seven generations.
Today, there is hope that through education, awareness, support
and healing in women and in their communities, FAS/E can be prevented.