Maternal risk factors for fetal alcohol spectrum disorders in a province in Italy☆
Introduction
Maternal and child risk factors that influence the severity of fetal alcohol spectrum disorders (FASD) can be grouped into factors of: (1) the host (mother's health, age, diet, body mass index (BMI), nutrition, gravidity (No. of pregnancies), and parity (No. of viable births); (2) alcohol exposure to the fetus (by quantity, frequency, and timing of dose); (3) maternal antenatal environment (socio-economic status (SES), prenatal care, social norms; May and Gossage, 2011, May et al., 2014a); and (4) for neurodevelopment, the quality of child's postnatal environment (mother's education, cognitive/behavioral stimulation, and nutrition; Gibbs and Forste, 2014, Jacobson et al., 2014, May et al., 2013c). But much of the evidence for specific maternal risk for FASD originates from studies in lower SES subpopulations, and questions remain about maternal risk in middle and upper SES populations where low fertility and better living conditions reduce the above risks (Abel and Hannigan, 1995, Abel and Sokol, 1987, May et al., 2005, May et al., 2008a, May et al., 2011b, May et al., 2013a).
In Mediterranean cultures, regular social drinking, generally with meals, is the modal pattern of alcohol consumption among females; but drinking frequency and specific levels of fetal alcohol exposure are not adequately understood. While descriptions of fetal alcohol syndrome (FAS) existed in the Italian literature (Calvani et al., 1985, Moretti and Montali, 1982, Roccella and Testa, 2003, Scianaro et al., 1978, Scotto et al., 1993), early maternal risk studies found little relationship between maternal alcohol use and adverse outcomes (De Nigris et al., 1981, Parazzini et al., 1994, Parazzini et al., 1996, Primatesta et al., 1993). Prenatal alcohol use and smoking were linked with low birth weight (Lazzaroni et al., 1993); one-third of women delivering in Italian hospitals were daily drinkers, even after recognition of pregnancy (Bonati and Fellin, 1991); and “abusive” and binge drinking were occasionally linked to spontaneous abortion and low birth weight (Cavallo et al., 1995). In Milan, 9% of women reported risky average weekly alcohol use prior to pregnancy and 29% drank daily during pregnancy (Primatesta et al., 1993). These rates are higher than those reported in the United States (Floyd et al., 1999), and comparable to those in Norway (Alvik et al., 2006b). Therefore, recognition of problem prenatal alcohol exposure started slowly in Italy.
Recent studies in Italy and Spain provide further evidence of maternal risk for FASD. In Verona, a study linked small for gestational age babies to women who reported consuming ≥3 drinks per day in each trimester (Chiaffarino et al., 2006). In Rome, antenatal clinic data indicated that 17.7% of women use alcohol during pregnancy and linked use to being unmarried, having had a previous induced abortion, and low parity (De Santis et al., 2011). In Spain, smaller head circumference at birth was associated with alcohol, illegal drug, and tobacco use, and maternal alcohol use was linked to low maternal and paternal education level, net family income, and father's alcohol use (Ortega-Garcia et al., 2012).
Biomarkers provide new ways to assess prenatal drinking. Manich et al. (2012) compared self-reported prenatal alcohol use in Barcelona, Spain, to levels of fatty acid ethyl esters (FAEE) in the meconium of their offspring, and 16% of those reporting no alcohol use were indeed exposing their fetuses to alcohol in pregnancy. In another meconium analysis of FAEE in Barcelona, gestational alcohol use was found in 45% of women (Garcia-Algar et al., 2008). A similar study in seven Italian cities concluded that 7.9% of fetuses were alcohol-exposed, the highest was in Rome (29.4%), and low maternal education and younger age were associated with maternal drinking (Pichini et al., 2012). Using meconium FAEE in three Italian sites and Barcelona, Spain, 11.9% of mothers exposed their fetuses to alcohol. Again, Rome had the highest exposure (22.6%), and those most likely to cause fetal exposure had less education and low SES (Morini et al., 2013). Especially in Rome, women reported drinking regularly before and after pregnancy, yet 65% of Roman women denied drinking during pregnancy, and “the few who admitted consumption, declared just a drink per month [or] per week” (Morini et al., 2013, p. 405). These contradictions between self reported maternal drinking and biomarker evidence led to the conclusion that “…mothers from Mediterranean countries tend to lie or underreport their toxic habits…and questionnaires often result [in] unreliable and useless [information]” (Morini et al., 2013, p. 405).
Research into the prevalence and characteristics of FASD among first grade students in the Lazio region of Italy, where Rome is located, revealed a prevalence of FAS of 4 to 12 per 1000, and FASD was estimated to be 2.3% to 6.3% (May et al., 2011a). This is higher than commonly-accepted estimates for mainstream western populations. Complete maternal interview data from the Lazio study are analyzed here to identify specific maternal characteristics that are associated with a child diagnosed with FASD. Given misrepresentation or underreporting by many women, such factors are not easily determined.
Section snippets
Institute of Medicine (IOM) diagnostic categories of FASD
The major outcome variable in this risk analysis is a child diagnosed with a FASD in the first grade. Children ages 6 and 7 are at an excellent age for accurate diagnosis of FASD, as their cognitive and behavioral development can be tested with discriminating tests and behavioral checklists. Revised diagnostic criteria for FASD of the U.S. Institute of Medicine (IOM; Stratton et al., 1996, Hoyme et al., 2005) were employed. Each child was examined for: (1) physical growth and facial and other
Results
Analysis of demographic characteristics indicated that mother's height (cm) and BMI differed significantly among the three sample groups (Mothers of Children with FASD, Mothers of Control Children, and Community Mothers). Mothers of FASD children are shorter than Control mothers and Community mothers. FASD mothers were also shown to have significantly higher BMI scores, = 25.1 than Control ( = 23.3) and Community mothers ( = 23.4). Marital status did not differ significantly among groups, as the
Discussion
The data have yielded significant maternal risk variables in both case control and multiple correlation analyses. First, case control comparisons yielded few obvious differences in the mothers’ physical characteristics (short stature and higher BMI) or childbearing history. Socially, mothers of children with FASD were more likely to be married to men with legal problems and report more drinking in the nuclear family. Drinking style also differed; mothers of children with a FASD reported more
Author disclosures
Role of funding source This research was funded in part by the National Institute on Alcohol Abuse and Alcoholism (NIAAA), as a pilot project as part of the International Consortium for the Study of FASD [(CIFASD)— AA014811 and AA014828] and also by UO1 AA11685. Italian operations were supported by a grant from the Health Department of the Lazio Regional government, Assessorato alla Sanità della Regione Lazio, and a grant by SITAC Onlus.
Contributors Philip May was the principle investigator
Acknowledgements
Faye Calhoun, Kenneth Warren, and Ting Kai Li of NIAAA and Edward Riley of SDSU facilitated the establishment of the international collaboration in many ways. In Italy many people assisted in initiating the project. Luca Deiana, Luciana Chessa, Michele Stegagno, and Agatino Battaglia, were all instrumental in facilitating the early collaboration in Rome and Lazio. Maternal interviewers were: Lucia Cupelli, Irene Di Stefano, Marcella Scamporrino, Anna Maria Galli, Federica Cereatti and Francesca
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