Transcript Document
The Maternal Drinking History Guide
Presented by Moumita Sarkar, PhD
Alcohol and Substance Use Helpline The Motherisk Program, Hospital for Sick Children
Based on a consensus report developed by the FASD Advisory Workgroup in collaboration with SOGC and PHAC
Case #1 Infant born at 35 weeks of gestation with severe IUGR and APGAR score of 5
Poor tonus, poor suckling
Case #1 cont….
Medical history does not reflect any maternal exposure related to baby’s symptoms Patient denies the use of alcohol and substances Meconium test for Fatty Acid Ethyl Ester (combination of alcohol and fatty acids): 52nM/g (N=<2) Mother is a problem drinker, unknown to the GP or gynecologist
Alcohol and Pregnancy
9-12% of women reported drinking throughout their pregnancies (Health Canada 2000) 1.4% of pregnant women reported binge drinking (CDC 2011) Health care providers do not systematically screen all pregnant women on their consumption of alcohol 19% of women reported not being ask about their alcohol use (Chang, 2011) 25% of pregnant women were not asked
Prenatal Alcohol Use: widespread
Problem drinking:
refers to the amount of maternal drinking associated with harm to the fetus Exceeds 3 drinks at one sitting or 7 drinks per week (NIAAA, 2005)
Pregnant or planning:
Any amount of drinking is risky for women who are pregnant or trying to become pregnant (USDHHS, 2005)
Routine Screening
Ask all women of childbearing age about alcohol/drug use (especially pregnant women) Advise all women planning/pregnant that
no
alcohol is the safest choice; women who consumed alcohol during their pregnancy to contact Motherisk Assist all women to stop drinking through information, counselling, care and referral to appropriate programs and services SCREEN TO PREVENT FASD
The Maternal Drinking Guide: Purpose
Determine if the mother drinks /has drank at a problem drinking level in pregnancy.
A Positive screen on TWEAK Meets the NIAAA guidelines for problem drinker Obtain accurate maternal alcohol use report Knowledge of prenatal alcohol use is essential for 1) subsequent FASD diagnosis in the future and 2) harm reduction strategies
Benefits
Validated methodology as effective means of eliciting maternal alcohol use Provides practitioner with options appropriate for different groups and circumstances No training/ expertise required to screen Integrate screening questions into standardized health questionnaires among innocuous questions related to lifestyle
When to ask?
Key times to assess alcohol use:
Initial visit (to any new provider)
Annual gynecological visit
Preconception visit
Visits for confirmation of pregnancy
Mid-pregnancy (24-28 weeks)
Exit visit (32-36 weeks)
Level I
Practice-based screening Single-question method Motivational Supportive dialogue
Direct questioning Time Line Follow Back Tool
Level II
Structured questionnaire Indirect/masked screening CRAFFT T-ACE TWEAK Sarkar et al., CJCP 2009; 16 (1): e242-63
Level III
Laboratory-based screening tool Liver enzymes Alcohol measures in blood/breath Hair and Meconium for FAEE Sarkar et al., CJCP 2009; 16 (1): e242-63
Case #1: Introduction
Explain that you will be asking a standard series of health questions that are directed to all patients in order to improve health Intro #1 : “I want to ask you a series of questions today about your lifestyle. I ask
all
my patients these questions because it helps me to get to know you better and provide better care.”
Level I: Practice-based
When did you find out/suspect you were pregnant?
Single-question method of screening
Embed at least one question to identify prenatal alcohol use among other innocuous questions related to lifestyle e.g. Do you take any prenatal vitamins? Do you smoke any cigarettes? If so, how many? Do you ever enjoy a drink or two? When was the last time?
Do you sometimes drink beer, wine or other alcoholic beverages?
In the past month or so, have you enjoyed a drink or two?
What about taking medications? Did you exercise?
Case #1: Brief questionnaires
Most effective method of screening (Stratton, 1996) Quick, practical, efficient and cost effective Direct questioning Timeline Follow Back Tool (TLFB) Indirect/masked screening Overcome issues of possible underreporting T-ACE, TWEAK Developed and validated for use among pregnant women TWEAK - Optimal for racially diverse groups, highly sensitive test
TWEAK Tolerance Worry Eye opener Amnesia Cut down
TWEAK
QUESTIONS
How many drinks does it take to make you feel the first effect (before pregnancy)? _________ (3 or more = 2 points) Have close friends worried or complained about your drinking in the past year? (yes = 2 points) Do you sometimes take a drink in the morning when you first get up?
(yes = 1 point) Has a friend or family member ever told you about things you said or did while you were drinking that you could not remember?
(yes = 1 point) Do you sometimes feel the need to cut down on your drinking?
(yes = 1 point)
POINTS
Russell M. New assessment tools for risk drinking during pregnancy: T-ACE, TWEAK and Others. Alcohol Health and Research World (1994) 18 (1): 55-61
Case #1: Level III Screening ( with consent )
Postpartum case (
index of suspicion but deny use)
If Level I and/or level II (TWEAK) screening is not successful Level III screening (with consent) Why is this knowledge valuable?
FASD assessment referral
Referral by a doctor required Assessment involves physical, neurological, psychiatric, genetic examination
Confirmation of prenatal alcohol exposure required
Screening and Intervention
What can be done?
Early Dx = Early Intervention
• Early diagnosis - evidence based • Stimulation in early ages - important • Parenting support materials
LEVEL ONE I nt roducto ry s tate m ent ( ref er to s ectio n II b):
“I will begin by asking a standard series of health questions I ask all my patients in order to improve your health and the health of your child”
Practice based questions (refer to section II c)
: General “Do you ever enjoy a drink or two?” “Do you sometimes drink beer, wine or other alcoholic beverages?”
LEVEL TWO
“Do you ever use alcohol?” “In the past month or two have you ever enjoyed a drink or two?”
(i.e. no alcohol/drugs):
Educa te / advise on eff ects of drink?”
Problem Drinker
If TWEAK is 2 or more Brief intervention (harm reduc tion) Advise and Refer
Not a Problem Drinker
If TWEAK is less than 2 AND/ OR response is 0 tim es in a week or in a sitting Advise Foll ow- up at every subsequent visit Brief intervention Advise and Refer
LEVEL THREE
Foll ow- up at every subsequent visit Advise
Labo ratory Ana lysis (refer to section III c)
(e.g. Hair FAEE) in relevant cases, with F ULL INFORMED CONSENT
Case #2
BJ has been your patient for a year. She is very private and can be both defensive and combative by nature She has a 5 yr old child with both developmental and behavioural issues She is now pregnant and has previously never been asked about her alcohol use During her prenatal screening, her provider asks: “I’m sure you know alcohol and pregnancy don’t go well together. You don’t drink, do you?” She responds: “No” Few weeks later, her partner mentions his concern for her continued drinking
Case #2: Introduction
Explain that you will be asking a standard series of health questions that are directed to all patients in order to improve health
Intro example:
“I want to ask you a series of questions today about your lifestyle. I ask all my patients these questions because it helps me to get to know you better and provide better care of your pregnancy.”
Level I: Practice-based
Begin Innocuous questions: When did you find out/suspect you were pregnant?
Single-question method of screening e.g. Do you take any prenatal vitamins? Do you smoke any cigarettes? How is your diet?
Do you ever enjoy a drink or two? When was the last time?
Do you sometimes drink beer, wine or other alcoholic beverages?
In the past month or so, have you enjoyed a drink or two?
What about taking medications? Did you exercise?
Case #2
BJ has been your patient for a year. She is very private and can be both defensive and combative by nature She has a 5 yr old child with both developmental and behavioural issues She is now pregnant and has previously never been asked about her alcohol use During her prenatal screening, her provider asks: “I’m sure you know alcohol and pregnancy don’t go well together. You don’t drink, do you?” She responds: “No” Few weeks later, her partner mentions his concern for her continued drinking
Case #2: Motivational Interviewing Techniques
Avoid questions that suggest that you want a negative response:
Negative:
You don’t drink, do you?
Positive:
or a few drinks on a night out…..do you sometimes enjoy a drink or two?” Many women wind down the day with a glass of wine Avoid many closed or dead-ended questions:
Negative:
Do you drink since you found out? Yes or No How has your alcohol consumption evolved since finding out your pregnancy? a) I continue my usual habit b) I have cut down c) I am trying to abstain but find it difficult
Case #2: Supportive Dialogue
Supportive dialogue (Without any moral connotation & empathetic listening) Can you tell me a bit about your drinking pattern before you knew you were pregnant?
Have you been able to stop or cut down since you found out?
Case #2: Supportive Dialogue
If alcohol problem suspected, but denied ,
Important to engage women to improve trust Use empathy "it is recommended to abstain from alcohol during pregnancy, if you are having hard time stopping, or even if you drink occasionally, do not hesitate to discuss it with me"
Advise/ Feedback
If screen positive as problem drinker, or report continued prenatal alcohol use, begin the process by: Here is some information that has been learned through research; I’d like to share it with you, if I may. What is your understanding about alcohol use in pregnancy?
Do you have any questions about your alcohol use?
Provide feedback that allows clients to compare their behavior to others so they know how their behavior relates to national norms “Many women drink on a regular basis, and since half of all pregnancies are unplanned, many women are exposed to alcohol prior to pregnancy knowledge.” Do you mind if we spend a few minutes talking about…..?
Are you interested in learning more about……..?
LEVEL ONE I nt roducto ry s tate m ent ( ref er to s ectio n II b):
“I will begin by asking a standard series of health questions I ask all my patients in order to improve your health and the health of your child”
Practice based questions (refer to section II c)
you were pregnant?” : Pregnant women: “Can you tell me a bit about your drinking patterns before you knew
LEVEL TWO
“Do you sometimes drink beer, wine or other alcoholic beverages?” “Do you ever use alcohol?”
To assess problem drinking behaviou r - 3 options:
than 7 drinks in a week? “Do you have any concerns about your drinking?” than 3 drinks at one sitting? drink?”
If response is negative (i.e. no alcohol/drugs):
Educa te / advise on eff ects of prenatal alcohol/ drug use “In a typical week, how many occasions did you usually have something to Apply TWEAK test
(refer to section III) Problem Drinker Not a Problem Drinker
If TWEAK is 2 or more If TWEAK is less than 2 Brief intervention (harm reduc tion) Advise and Refer Educa te / advise on eff ects of prenatal alcohol/ drug use Foll ow- up at every subsequent visit Level 1 questions re alcohol
(IIIb)
Brief intervention Advise and Refer Foll ow- up at every subsequent visit Level 1 questions re alcohol/drugs Advise
N/A LEVEL THREE
Recommendations: Screening
During regular health exams, health care providers should use standardized questions that should include at least Level I screening Early identification and reduction of maternal drinking No known safe limit for alcohol use in pregnancy Level II should be adopted as standard screening process to identify alcohol use in all women of childbearing age and pregnant women Upon screening, women need to be linked to services if required by their providers
Take Home Message
Health care provider role in harm reduction is vital advise patients that the safest choice is not to consume alcohol during pregnancy Adequate resources should be made available to women requiring interventions beyond primary interaction Recording of maternal alcohol use in newborn’s birth record and child’s health record Early identification and subsequently early FASD Dx = intervention can occur
FASD programs/resources
Best Start ( www.beststart.org
) Provides online training tools for screening alcohol Motherisk Alcohol and Substance Abuse Helpline ( www.motherisk.org
) National toll-free helpline 1 877 FAS-INFO providing evidence-based info and referrals on alcohol/drugs Canadian Centre on Substance Abuse ( www.ccsa.ca
) PRIMA ( www.addictionpregnancy.ca
) Alberta Health Services ( www.albertahealthservices.ca
) Healthy Choices in Pregnancy in BC ( www.hcip-bc.org
)
Acknowledgments
Dr. Gideon Koren Motherisk Alcohol and Substance Use Helpline Counselors The National Taskforce for FASD Screening Canadian Association for Paediatric Health Science Centre Public Health Agency of Canada
The Maternal Drinking History Guide
Thank You!