epidemiology of fasd in a province of italy

EPIDEMIOLOGY OF FASD IN A PROVINCE OF ITALY
MAURO CECCANTI
Brussels 9 September 2009
BACKGROUND
HOW BIG IS THE PROBLEM?
Accurate éstimates of the prevalence and characterìstics of fetal alcohol syndrome (FAS) and fetal alcohol spectrum disorders (FASD) in a Western European population are lacking.
Prevalence of FASD in western Countries
PASSIVE ASCERTAINMENT
Clinic-­‐‑based
Record-­‐‑based
FAS 0,33 – 2,0/1000
FASD 9/1000
ACTIVE ASCERTAINMENT
Minority, low-SES*
Washington (Clarren KS 2001)
UNITED STATES TODAY
*SES: Socioeconomic-­‐‑status
S.AFRICA FAS: 46-75/1000
FAS 3.1/1000
FAS 0,6-3.0/1000
FASD 10/1000
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della Regione Lazio
EPIDEMIOLOGY OF FAS IN ITALY
Pilot project of in-­‐‑school prevalence, funded by NIH-­‐‑NIAAA and Lazio Region (2003 -­‐‑2005).
Italy is predominantly middle Socio-­‐‑Economic Status (SES) with regular, moderate drinking, practiced during meals.
First population-­‐‑based FASD epidemiology study ever in Western Europe.
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INITIAL DATA COLLECTION -­‐‑ TIER I SCREENING
Screening for height, weight, head circumference
School physicians
(≤ 10 Percentile)
Behavior and
learning
•  IPDA* (Terreni)
•  DBD** (Pelham)
Teachers
Parents
Maternal interview: risk factors
*IPDA: Questionario osservativo per l’Identificazione Precoce delle Difficoltà di Apprendimento
**DBD: Parent ⁄ Teacher Pelham Disruptive Behaviour Disorder rating scale
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DIAGNOSTIC PROCEDURES -­‐‑ TIER II
Dysmorphology examination
Dysmorphology Index (IOM criteria)
4 Dysmorphologists
2 teams Psychological assessment
• 
L a n g u a g e c o m p r e h e n s i o n (Rustioni)
•  Raven-­‐‑CPM*
•  WISC-­‐‑r**
*Raven-­‐‑Colored Progressive Matrices
**Wechsler Intelligence Scale for Children-­‐‑Revised
Psychologists
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CASE CONFERENCE FOR FINAL DIAGNOSIS
46 FASD
TIER I
M a t e r n a l Interview
H, W, OFC
Behaviour
416 SELECTED
TIER II
Dysmorphology exam
Tests
976
CONSENTS GIVEN
1988
POPULATION
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DEMOGRAPHIC AND GROWTH PARAMETERS Variable
Children
In Study (n = 976)
Children
With FAS
(n = 8)
Children
With PFAS
(n = 36)
Control
Children
(n = 116)
P
Sex
NS
Age
NS
Height (cm)
Mean (SD) 121.5 (5.5) 113.6 (3.6) 118.0 (5.0) 121.5 (4.9) < 0.001
Weight (kg)
Mean (SD) 25.1 (5.2) 18.8 (3.1) 22.2 (3.7)
BMI Percentile
Mean (SD) 60.9 (31.2) 20.6 (32.6) 51.4 (29.0) 25.1 (4.2) <0.001
65.6 (29.4) <0.001
OFC (cm)
Mean (SD) 51.9 (1.5) 49.1 (1.0) 50.6 (1.7) 52.0 (1.3) < 0.001
Dysmorphology Score***
Mean (SD)
15.8 (1.9)
11.2 (4.0)
3.6 (2.9)
<0.001
Significantly differences between groups, were also found for facial features: Palpebral fissure length, philtrum length, ptosis, epicanthal folds, anteverted nostrils, long philtrum, smooth philtrum, and narrow Centro di Riferimento Alcologico
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WISC-­‐‑R: children with FASD showed significantly lower scores on Verbal, Performance, Full scale IQ
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DEVELOPMENTAL AND BEHAVIORAL INDICATORS
Child Variables
FAS
Mean Score (SD)
(n=8)
PFAS
Mean Score (SD)
(n=36)
Controls
Mean Score (SD)
(n=116)
P
3.1 (2.0)
3.6 (2.1)
4.8 (1.7)
< 0.001
50.6 (28.7)
55.6 (22.3)
71.0 (21.2)
< 0.001
3.9 (3.7)
< 0.001
Developmental Traits
Language
comprehensiona
Non – verbal I.Q.b
Behaviorc (FASD)
a. 
b. 
c. 
9.3 (5.8)
Rustioni qualitative Test
Raven Coloured Progressive Matrices
Personal Behaviour Checklist (PBCL – 36)
P. May, Ceccanti M., et al. in press
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MATERNAL AND PATERNAL VARIABLES BY FASD/
COMMUNITY CHILDREN
Maternal Variable
Height (cm)*
BMI*
Gravidity*
Parity*
Paternal Legal problems (%
Yes)
Mothers of
Mothers of
Children with Community
FASD
Children
160.8 (7.1)
162.8 (6.2)
25.1 (5.0)
23.4 (3.8)
2.7 (1.7)
2.4 (1.1)
2.2 (1.3)
1.9 (0.6)
12.8
11
3.9
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COMPARISONS OF CURRENT DRINKING BY FASD/
CONTROLS
Maternal Variables
Mean drinks per current week (SD)*
Mean drinks per current drinking day (SD)*
FAS
Mean (SD)
(n=8)
PFAS
Mean (SD)
(n=36)
Controls
Mean (SD)
(n=8)
P
19.0 (25.0)
3.0 (5.3)
1.7 (2.6) <0.001
3.0 (3.4)
1.0 (0.4)
0.9 (0.5) <0.001
*Among those who reported drinking during pregnancy; includes current non-­‐‑drinkers
** T-­‐‑test significantly different (p< 0.01) from controls
P. May, Ceccanti M., et al. in press
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MATERNAL DRINKING BEFORE AND DURING PREGNANCY BY
FASD/CONTROLS
Maternal
Variables
Report drinking during pregnancy (%)
FAS
Mean (SD) (n=8)
PFAS
Mean (SD) (n=36)
50.0
Maternal Drinking Variable 54.8
Mothers of Children with FASD (n = 39) Controls
Mean (SD) (n=8)
P
40.0
NS
Mothers of Control Children p (n = 108) Total # of standard drinks per week 3 months .94 (1.65) before pregnancy, Mean (SD) .63 (.76) .007* Average # of standard drinks per week during 1.12 (3.20) pregnancy, Mean (SD) .49 (1.76) .317 Drinks consumed per drinking day during pregnancy, Mean (SD) .31 (.52) .139 .44 (.60) Binge, 3 drinks per occasion during pregnancy 135.1 (% Yes) Centro di Riferimento Alcologico
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.058 * DRINKS CONSUMED PER DRINKING DAYS PER TRIMESTER BY
FASD/CONTROLS
Mothers of Children with FASD Mothers of Control Children (n = 39) (n = 108) 1st trimester, Mean (SD) .32 (.51) .23 (.45) .553 2nd trimester, Mean (SD) .37 (.53) .22 (.44) .061 3rd trimester, Mean (SD) .36 (.54) .22 (.44) .076 Drinks consumed per drinking days 14
p Centro di Riferimento Alcologico
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R elative
R is k
In Different
P opulations
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S
ome K
nown C
o-­‐F
actors
of KNOWN CO-FACTORS OF MATERNALRISK AND FETAL DAMAGE
Maternal R is k and F etal D amage
B iologic al:
•
Nutrition, life long a nd d uring index p regnancy.
•
B ody m as s (B MI) o f the m other.
•
Alcohol m etabolis m, liver g enotype a nd liver phenotype.
S oc ioc ultural a nd D emographic : •
Maternal a ge, g ravidity, p arity, a nd b irth o rder.
•
S ocioeconomic s tatus (S E S ): including, m aternal education, income, a nd h ome e nvironment.
•
F amilial, p s ychological, a nd s piritual s tatus o f the m other.
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PREVALENCE OF FAS IN THREE POPULATIONS: SUMMARY
Population
Low
High
Avg*
Italian
4
8
?
Plains Indians
(USA)
9
10
9.5
South African
43
79
63.7
*(per 1,000)
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FASD PREVALENCE IN ITALY (‰)
Rate for Rate for Entire ETOH ETOH NOT Sample* Class**
N Confirmed
Confirmed%
%
‰
‰
FAS
8
62.5
37.5
8.2
4
PFAS
36
58.3
41.7
36.9
18.1
ARND
1
100.0
0.0
1.0
0.5
ARBD
1
100.0
0.0
1.0
0.5
-­‐‑
-­‐‑
47.1
23.1
TOTAL 46
*N=976 children screeneming no children with FASD were missed by the
consent and screening process
(May P., Ceccanti M. et al. 2013)
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BDNF
HIPPOCAMPUS
12000
*
10000
8000
6000
*
*
4000
EtOH
Vino
Saccarosio
2000
0
BDNF TOPI 30 gg
Fiore M., Ceccanti M. et al. 2008, in press
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CONCLUSIONS 1/2
FASD rates are substantially higher than previous estimates for the general populations of Western Europe or the U. S. and raise the question of whether FASD is more common in the western world than previously estimated.
Regular drinking during meals in a well-­‐‑nourished and well-­‐‑educated maternal population, as opposed to a poorly nourished, binge drinking population, however can produce a number of children with FASD Centro di Riferimento Alcologico
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CONCLUSIONS 2/2
Children with FAS or PFAS have impairment or lower scores on standard tests of intelligence, nonverbal reasoning, and language comprehension, as well as more inaventive symptoms and more behavioural problems
As children with a FASD present substantial challenges to parents, schools, and societies, there is a need to identify them early so that their development can be maximized and FASD prevention initiated for future generations. This message may well resonate for
other Western European populations.
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THANK YOU!
Mauro CECCANTI
Centro di Riferimento Alcologico della
Regione Lazio