Volume 31 Number 1 Alcoholis January 2010 The bulletin of the Medical

Council on Alcohol ISSN 1351–0541 Founded 1967

of thanks to Sir Ian Gilmore, and Professor Peter In this issue From the editor Brunt then presented the speaker with the Max 1 Editorial Glatt Memorial Medal. We were particularly honoured that Mrs Glatt, widow of Dr Max Glatt, was able to be present for this event. 2 What do we Seminar on dealing with fetal know about fetal alcohol spectrum disorder alcohol syndrome In the afternoon following the MCA’s AGM, in Scotland? the MCA Seminar was held, on fetal alcohol spectrum disorder (FASD). This was introduced and chaired by a great friend of the MCA, 3 National Alcohol Dr Dominique Florin Professor Moira Plant, who has devoted her Awareness Day professional career to the study of fetal alcohol posters MCA Annual General Meeting exposure. We heard two excellent presentations, In November, the MCA’s highly successful AGM firstly by Dr Raja Mukherjee, a psychiatrist who took place at the Royal College of . runs a specialist service in Surrey for children 4 Overview of The Max Glatt Memorial Lecture was given and families affected by FASD, and a second diagnostic issues by Professor Sir Ian Gilmore, with customary by Dr Maggie Watts, a and behavioural brilliance. The title was ‘The UK’s troubled from Ayrshire who has been working for 20 difficulties in relationship with alcohol – a challenge for years in this area. Articles based on both of these people affected policy makers’, and Professor Gilmore reviewed talks are reproduced in this issue of Alcoholis. by fetal alcohol the trends in total consumption in the UK The questions and discussions which followed spectrum disorder since the early 1900s, before comparing UK the talks were very lively, and could have gone consumption with that in Europe and the wider on for much longer. All three of the panel world. It was clear that, within Europe, both members conveyed the misery of this diagnosis,

the increase in overall consumption and our but also the need to make it, in order that the 6 Michael Frowen pattern of drinking (‘bingeing’) are matters support can be accessed, which can so improve Memorial Essay of concern. Both have led to rising pressure the experience of patients and their families. Prize 2011 on NHS resources and increased fatalities, It is timely that the topic for the Frowen Essay the latter particularly evident in the fivefold Prize for this year, advertised in this issue of increase in liver deaths over the last 30 years. Alcoholis, also concerns fetal alcohol exposure. The Medical Council Professor Gilmore put the potentially beneficial on Alcohol effects of moderate consumption – through Progress on minimum unit pricing 5 St Andrews Place reduction in ischaemic heart disease – into The MCA is aligned with all the other London, NW1 4LB context, emphasising that any benefit was age- authoritative medical voices in supporting related, and did not outweigh the risks of even the introduction of a minimum unit price Tel: 020 7487 4445 moderate consumption until mid-life. The main (MUP) for alcohol, ideally of 50 pence per unit. Fax: 020 7935 4479 drivers of the changes in UK drinking patterns The long awaited vote on MUP in Scotland were then reviewed: price, availability and took place in November and the measure was mca@medicalcouncil marketing; and the importance of tackling these removed from the bill. This is disappointing but alcol.demon.co.uk through some form of regulatory framework. not unexpected. The feeling from colleagues in www.m-c-a.org.uk Differences in governmental approaches Scotland was that, despite this result, progress within the UK were noted; the current has been made in gaining wider acceptance of coalition government approach to alcohol the importance of alcohol as a health problem. suggests that local solutions rather than central Meanwhile in Manchester, the introduction Registered Charity regulation are likely to be more in favour. of a MUP by-law of 50 pence per unit is Number 265242 Following this lecture, Dr Brian Hore gave a vote being considered. Despite the government’s

From the editor continued... in the UK may be of particular interest to our readers. In Alcohol and Alcoholism, Simon Moore writes about the resistance to this idea nationally, there seems to be some possibility of substitution of alcohol with other substances, central support for this local initiative. Most recently, the should alcohol become less accessible, for instance due to coalition government has proposed tax changes and a ban price or tax increases.1 This piece is accompanied by an on below-cost selling. The consensus among many alcohol editorial and some commentary pieces, and makes for a organisations is that these changes are much too little. The fascinating debate. In the BMJ, a group from France suggest tax increase only addresses super-strength beer, and would that a binge-drinking pattern may account for higher rates of affect less than 0.5% of total alcohol sales. Importantly, cider is ischaemic heart disease in Ireland, compared with France.2 excluded. The suggested ban on below-cost selling is likewise anticipated to have almost no effect, being equivalent to an References MUP of only 18–26 pence per unit. This would be equivalent 1 Moore SC. Substitution and complementarity in the face of to banning the sale of wine at less than £2 per bottle. alcohol-specific policy interventions. Alcohol Alcohol 2010;45:403–8. 2 Ruidavets J-B et al. Patterns of alcohol consumption and ischaemic heart disease in culturally divergent countries: the Prospective In the journals Epidemiological Study of myocardial Infarction (PRIME). BMJ Two recent articles relevant to the pattern of heavy drinking 2010;341:1146.

What do we know about fetal alcohol syndrome in Scotland?

Dr Maggie Watts, consultant in public health , Alisa Hospital, Ayrshire

The adverse effects of alcohol have been philtrum, thin upper lip vermilion, in terms of alcohol consumption, known for centuries, and writers have and narrowed palpebral fissures; ethnicity and demography, tend also recorded comments about alcohol and neurodevelopmental delay. This towards lower rates (0.1–0.67 in every in pregnancy, according to the social and represents fetal alcohol syndrome (FAS), 1,000), with surveillance studies using philosophical mores of the age. A specific the most easily recognisable form of fetal non-specialist medical staff giving association between alcohol and damage alcohol damage. However, ingestion of rates of 0.37–0.67 in every 1,000.3 to the fetus, producing a characteristic alcohol during pregnancy can cause a Alcohol in Scotland is ubiquitous, set of abnormalities, was first described spectrum of disorders (the fetal alcohol and the Scots people are notorious for in a medical journal by a French spectrum disorder (FASD) group of their drinking cultures. In 2009, sales paediatrician, Paul Lemoine, in 1968,1 conditions), which are characterised by of alcohol reached 50.9 million litres and subsequently in English journals growth failure and neurological deficits. of absolute alcohol – enough sold for by Jones et al in 1973.2 These articles every person over the age of 18 years to described babies and children damaged The incidence and prevalence of consume 1,227 units of pure alcohol, by alcohol in utero, such that it produced FAS varies widely around the world, an average of 23.6 units per person per a characteristic set of anomalies according to the type of study and week.4 While 21% of Scottish women encompassing growth retardation; the population examined. Those aged 16–34 report drinking no alcohol, characteristic faces with smooth in larger, more diverse populations 29% of women aged 16–34, and 24% of women aged 25–34, report drinking Table 1 Recording of FAS in data systems: Scotland, 1998–2003 more than 14 units a week, with 28% having more than six units of alcohol on Data source 1998 1999 2000 2001 2002 2003 their heaviest drinking day.5 Drinking Mortality records, 0 0 0 0 0 – behaviour during pregnancy has not Registrar General For Scotland been studied extensively in Scotland. Self- reporting in population surveys indicate SMR 1 – hospital 18 8 10 12 14 12 6 discharges prevalence of alcohol use at 25–50%. With female drinking at such levels, it is SMR 11 – neonatal 3 2 6 3 – – perhaps surprising that more attention unit dischares is not given to FASD in Scotland. Preschool child – – 3 2 – – health surveillance* Following the publication of papers by Continuous – – 0 0 3 – Jones et al in 1973 and 1974, there was Morbidity Records some interest in Scotland. In the west (GP data system)† of the country, Beattie et al produced a paper identifying 40 children with the – data unavailable; *10 of 15 health boards; † coverage 8% general population SMR = Scottish Morbidity Records features of FAS, and stated that ‘these

2 Alcoholis January 2011 findings provide clear evidence that in the west of Scotland maternal alcohol abuse during pregnancy is a significant cause of morbidity and mortality in children’.7 In the east of Scotland, Plant was carrying out a prospective cohort study designed to establish whether or not birth abnormalities were associated with self-reported drinking rates.8 Whilst Plant did not identify any cases of FAS, the study did show a level of alcohol- related birth abnormalities of 1%.

Since that time, there has been very little published on FAS or FASD in Scotland. Using the rates from surveillance,9 it is estimated that 20–36 babies are born each year in Scotland with FAS, and up to 10 times more with FASD. This would indicate 400 or more children under 16 years of age with FAS, and considerably more living with FASD.

A study undertaken in 2004 identified the occurrence of FAS as recorded in the Scottish health system (Table 1).10 Since FAS is not a condition that requires children to be hospitalised, the national recording systems for hospital discharges (Scottish Morbidity Record (SMR) 01) and for maternity units (SMR 11) show very low numbers. No children died with a diagnosis of FAS, and the preschool surveillance and GP continuous morbidity recording systems recorded very low numbers.

This information, coupled with a local survey of professional staff in health,

Continuing with the theme of fetal alcohol syndrome, here we feature another two entries, from medical students, for the National Alcohol Awareness Day poster competition.

‘Mummy didn’t know’ (top) is by Matthew Baldwin, Ryan Stevens, Sam Haines and Pete Sugden.

‘Mummy I don’t want your hangover’ (bottom) is by Matt Angilley, Holly Pope, Caroline Bracchi, Sophie McGlade and Richard Gardland.

3 Alcoholis January 2011 Prevention. Trends in fetal alcohol education and social work, indicated frequency of enquiry of alcohol use, syndrome – United States, 1979–1993. an awareness of the diagnosis and a receipt of high-quality training, and MMWR 1995;44:249–51. 4 Robinson M, Catto S, Beeston C. recognition that underdiagnosis could beliefs in the benefits of early diagnosis. Monitoring and evaluating Scotland’s be a problem, but little experience in The results of these more recent studies alcohol strategy (MESAS): analysis of alcohol sales data, 2005–2009. Glasgow: either making it or working with children indicate that further research is required NHS Health Scotland; 2010. with FAS. However, professionals did into the prevention, detection, diagnosis 5 Bromley C, Given L, Ormston R (eds). The consider that alcohol in pregnancy and management of FASD in Scotland. 2009 Scottish health survey. Edinburgh: Scottish Government; 2010. could be a major issue with harmful High-quality training programmes 6 Anderson S, Bradshaw P, Cunningham- consequences for the fetus. may improve the diagnosis of FAS, Burley S et al. Growing up in Scotland: sweep 1 overview. Report. Edinburgh: but this needs to be coupled with Scottish Executive, 2007. A postal survey study in 2007 investigated improvements in case ascertainment, 7 Beattie JO, Day RE, Cockburn F, Garg RA. Alcohol and the fetus in the West of the experience, knowledge, attitudes and supported and coordinated surveillance, Scotland. BMJ 1983;287:17–19. diagnosis of FAS amongst paediatricians effective recording systems, and 8 Plant ML. Drinking in pregnancy and fetal 11 harm: results from a Scottish prospective across Scotland. This indicated that non-stigmatising approaches to study. Midwifery 1986;2(2):81–5. two-thirds of respondents had diagnosed families and affected children. 9 Centers for Disease Control and Prevention. Trends in fetal alcohol FAS, but less than a quarter reported syndrome – United States, 1979–1993. confidence in making the diagnosis. References MMWR 1995;44:249–51. Knowledge of the optimal age for 1 Lemoine P, Harousseau H, Borteyru JP, 10 Watts M. A systematic assessment of Menuet JC. Children of alcoholic parents services for children with fetal alcohol diagnosis of FAS, length of experience, – observed anomalies: discussion of syndrome in Ayrshire and Arran. and quality of training received were 127 cases. Original publication in Ouest Submission for membership of the Medical 1968; reproduced in translation in Faculty of Public Health. 2004. significantly associated with having Ther Drug Monit 2003;25:132–6. 11 Carswell, T. Diagnosis of fetal alcohol made a diagnosis of FAS in the past. 2 Jones KL, Smith DW. Recognition of the syndrome in Scotland: A survey of fetal alcohol syndrome in early infancy. paediatricians’ knowledge, beliefs and Confidence in diagnosing FAS was Lancet 1973;2:999–1001. practice. Submission for MPH significantly associated with the 3 Centers for Disease Control and Glasgow, 2007.

Overview of diagnostic issues and behavioural difficulties in people affected by fetal alcohol spectrum disorder

Dr Raja Mukherjee, Consultant Psychiatrist, National Specialist FASD Behavioural Clinic, Surrey and Borders, NHS Foundation Trust, Brackets Resource Centre

Introduction 1967.2 He reported, with his midwifery manifestation of this syndrome, full fetal Fetal alcohol spectrum disorder (FASD) colleague, 127 cases of affected alcohol syndrome (FAS), represents less is an umbrella term that denotes the individuals. Unfortunately, as this was than 10% of those affected. The majority range of outcomes seen in people not in an English language journal, it did of exposed individuals sustain damage exposed to alcohol whilst in the not come to recognition until later on. to the brain, without facial features womb. This can vary greatly in terms of presentation and severity. While Diagnosis Box 1 Facial features and much of the early work was conducted For almost 40 years now, there has been diagnostic criteria defined by IOM in people who were most clearly a great deal of work on the condition. In affected, there has been an increasing 1996, the Institute of Medicine (IOM) recognition of people exposed to alcohol, in America – broadly equivalent to our Core facial features but who do not show obvious initial medical royal colleges – came together 1 Short palpebral fissures characteristics. Those without clear to define a set of criteria by which 2 Flattened elongated philtrum neurological deficits or facial features the condition should be diagnosed. 3 Thinner upper lip vermillion can still have significant behavioural, Despite this, there remain confusion Diagnostic labels functional and emotional conditions and disagreement over how to diagnose 1 Fetal alcohol syndrome alcohol that require lifelong input and support. FASD, especially in the absence of facial known 2 Fetal alcohol syndrome alcohol The term fetal alcohol syndrome was features. Box 1 highlights the core unknown first coined by Smith and Jones in 1973; facial features and the wider diagnostic 3 Partial fetal alcohol syndrome they presented a case report of eight criteria set out by the IOM in 1996. 4 Alcohol-related birth defect children in The Lancet.1 Despite this, 5 Alcohol-related neurodevelopmental disorder the first actual reports in the scientific What has become increasingly clear, and (ARND) literature of alcohol consumption has also led to the most controversy, affecting children, was by Lemoine in is the fact that the most recognisable

4 Alcoholis January 2011 necessarily being affected. The face is disagreement about making an ARND including a high-risk alcohol group) affected in a window of opportunity, at diagnosis, and what should constitute for full FAS. This was further shown to around weeks 6–8 of gestation. It also this, has perpetuated the problem. These represent only 10% of the whole group requires heavy alcohol exposure to cause discrepancies continue to affect the in these respective studies. While the significant issues. The literature would ability of families to get appropriate help. figure in the UK remains unknown, suggest that only around 40% of women the international rates quoted by the who drink heavily during pregnancy will Epidemiology Centre for Disease Control (CDC) have children with recognisable facial The rates of FASD in the community suggest that 1–2% of the US population features. This period of vulnerability vary by the population studied. Early may be affected by alcohol, and high- is in contrast to that which affects the experiences suggested that the condition risk populations exponentially so. brain, which begins to develop from was one confined to the Native around day 18 in gestation, and develops American population. This was later Behavioural difficulties throughout pregnancy. In animal found not to be the case. FASD cases Behavioural conditions in people with models, different timing of alcohol have been found in all populations FASD are complicated, as they do not exposure has been shown to cause and all socioeconomic backgrounds. always present in consistent ways. different types of damage to the fetus. With increasing understanding, the That is to say, standard diagnostic These relate specifically to apoptotic rates of FASD have also been revised. profiles using the criteria of the damage, influencing gene expression, cell Recent studies in different parts of Diagnostic and Statistical Manual of signalling, cell adhesion and scaffolding, the world have found differing levels. Mental Disorders or the International all of which are damaged by smaller Two broad methods have been used to Classification of Diseases are not amounts of alcohol than those required derive estimates of prevalence, namely always neatly met. The underlying to cause the facial effects. The brain is passive and active surveillance models. behavioural profile has, however, thus vulnerable throughout pregnancy. The passive surveillance models offered been reasonably well defined. It is some insights, but have been shown understanding the relationship between Because of the uncertainty in making to underreport considerably the rates the phenomenological diagnostic the wider diagnosis, attempts to better of FASD. Active surveillance research criteria and the underlying function, classify the full range of conditions has increasingly been conducted in that can help to guide both areas for have been developed. These include several countries. Whilst some issues assessment and later management. tools such as the four-digit assessment exist about the design, they remain tool. The differences and similarities the best epidemiological studies Children and adults with FASD between the diagnostic systems are in the field conducted to date. classically have a very mixed profile shown in Table 1. What is interesting of cognitive functioning, with deficits is that there are many similarities, Rates reported vary between 3 per in areas such as working memory, but also differences. These relate to 1,000 (population study in Lazio, executive function, and processing the desire to maximise sensitivity and Italy) and 85 per 1,000 (population speed. This has been shown in numerous specificity of diagnosis. The ongoing study in Cape Town, South Africa, studies of neurocognitive functioning in people with FASD. Importantly, the profiles have been shown not to Table 1 Different diagnostic classification systems currently in be consistent with expected patterns use today: similarities and differences compared to their IQ, or by their FASD Centre for Institute of Canadian Four-digit diagnosis. Damage has been shown in Disease Control Medicine the myelination of white matter of the

Face 10th percentile 10th percentile 3rd percentile 3rd percentile brain, the connections between brain PFL and rank 4/5 PFL and rank 4/5 PFL and rank 4/5 PFL and rank 4/5 regions, and the volumetric size of on lip philtrum on lip philtrum on lip philtrum on lip philtrum brain regions compared with normal Growth Pre- / post-natal Pre- / post-natal Pre- / post-natal Pre- / post-natal controls. These have been shown on growth below growth below growth below growth below function and volumetric MRI scans. 10th percentile 10th percentile 10th percentile 10th percentile

Neurological 1 out of several 1 out of l brain 3+ soft hard 1 out of several These deficits are further affected by brain perameters perameters neurological brain perameters including OFC including OFC signs including OFC time pressure and the need for accuracy. <10%, CNS deficits <10%, CNS <10%, CNS deficits The implication is that you will see deficits or an individual who will act and not abnormal structure necessarily think of the consequences Alcohol Cofirmed or Confirmed to be Confirmed or Confirmed or of their behaviours where rapid unknown excessive or unknown unknown unknown processing and linking of information is required. High-pressure situations make this worse. This description is OFC = orbitofrontal circumfrence; PFL = palpebral fissure length; CNS = central nervous system consistent with the common complaints made by carers about individuals

5 Alcoholis January 2011 Table 2 Secondary disabilities not to say they cannot learn, only that it affected, only by first assessing in found in a cohort of over 300 can take longer, and that other methods detail both the phenotype and the individuals in a 21-year cohort using multi-source approaches may be measurable endophenotype, can a plan with FASD (Streissguth)3 required. Often, the fact that information of management be formulated. This can be presented from the distant past assessment will include careful picking Disability % (long-term memory) confuses the out of the effects of early environmental Psychiatric problem 90 picture. The impression, then, is of experiences, as well as understanding deliberate non-compliance, especially their relationships to inherent biological Disrupted school to those unfamiliar with the condition. vulnerability. Often, simply by replacing experience 60 or supporting the areas of deficit and Trouble with the law 60 Probably the single area of greatest providing consistency, the individual difficulty lies in executive functioning. will improve. The earlier an individual Confinement 50 Deficits and damage to frontal lobe accepts their diagnosis, the more likely a Inappropriate sexual functioning, through its connections to good outcome is. For those who do not behaviour 50 other areas, cause the most problems get support, or who fail to accept their Alcohol/drug problems 30 faced by this group. This often presents diagnosis, the outcomes have been shown as a struggle with inhibitory control to be poor. Over 90% will have secondary with FASD. Namely, that they cannot and social understanding. At its worst mental health problems, and many stop themselves from acting and that this leads to the individual meeting struggle with wide areas of function. they fail to learn from consequence. diagnostic criteria for attention deficit hyperactivity disorder (ADHD) References The latter part is also affected by deficits or autism, but to lesser degrees of 1 Jones KL, Smith DW. Recognition of the in working memory. Animal literature difficulty, simply lead to problems fetal alcohol syndrome in early infancy. Lancet 1973;2:999–1001. has shown damage to the neural in their daily lives and potential 2 Lemoine P, Harousseau H, Borteyru JP, pathways that consolidate memory. over-expectation by society. Menuet JC. Children of alcoholic parents CA1 and CA3 fibres have been shown – observed anomalies: discussion of 127 to be damaged, leading to problems in cases. Ouest Medical 1968. Management approaches 3 Streissguth AP, O’Malley K. working memory and the consolidation The management of this group begins Neuropsychiatric implications and pathways. The behavioural presentation with prevention, but the public health long-term consequences of fetal is of someone who cannot remember strategies employed will only ever have alcohol spectrum disorders. Semin Clin what has just been told to them. This is a limited effect. For those individuals Neuropsychiatry 2000;5:177–90.

Michael Frowen Memorial Essay Prize 2011

Awarded for a paper not exceeding 3,000 words (excluding references and title)

Is drinking during pregnancy a form of child abuse?’

First prize £500 • Second prize £300 • Third prize £200

All winners will be invited to attend the 2011 AGM and CPD-approved seminar, and will be awarded with a signed certificate. In addition, the 1st-placed essay will be published in the MCA Annual Report.

To apply send your essay to: Entrants must be current medical students in The Medical Council on Alcohol the 5 St Andrews Place London, NW1 4LB or email to [email protected] Closing date: 31 March 2011

Alcoholis, the quarterly bulletin for medical and The Medical Council on Alcohol is a allied professions is published by the Medical Council small national charity committed to on Alcohol, in association with the Royal College of Physicians. Views expressed by contributors are improving the medical understanding not necessarily those of the MCA who, nevertheless, welcome comments from other parties and will of alcohol-related problems. pubish selected signed correspondence.

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