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Identifying the Pregnant Women Who Drink

The expectant mother you see in your practice may be a nondrinker; she may have had a little to drink recently and is worried about it; or she may be a regular or heavy drinker and not fully aware of the dangers to her baby. A few basic questions will help you identify the possible risk-drinker and provide her with the information-and the help that she needs.

Identify risk-drinkers: Exploratory questions

Information about the use of tobacco, drugs, and alcohol is usually included in the "social history" portion of a woman's intake history and physical. Questions about alcohol consumption, however, are often neglected or asked in a manner that conveys a lack of concern-which may frequently be true, since alcohol problems are not considered "medical" by many physicians. Often, aware of the stigma associated with heavy drinking, physicians are afraid to evoke anger from patients if they delve too deeply into drinking behavior.

Nonetheless, there are ways to get at the patient's drinking history that can be comfortable for both the patient and the physician. The first place to start may be by asking whether there is any family history of alcohol problems (Table 1). Beside providing useful information about alcoholism, a disease now recognized as having an important genetic component, asking about the family history indicates that drinking alcohol is an important concern and one of interest to the physician who is caring for the family.

If you do not have an opportunity to see the mother before the baby is born , you can ask about family history at the first newborn visit. If you elicit a family history of heavy alcohol consumption, you create an opportunity to explore the topic at successive newborn visits. Certainly if the mother comes to these visits with evidence of an "alcoholic fetor"-symptoms of battering or symptoms in the newborn of child abuse or neglect, you would want to explore the subject of alcohol consumption in greater detail.

After obtaining other "social history" information , we return to the alcohol history by asking the mother if she has ever had a drink of alcohol. If her answer is "No", that is all that is necessary since it is unlikely that she has an alcohol problem. If she responds "Yes", ask how old she was when she first had a drink of alcohol. In most cases, this will be sometime during the teenage years. Then ask what she preferred as a teenager-beer, wine, or liquor-and how old she was when she first got drunk. This query conveys the notion that you recognize inebriation as a common experience and that admitting that one has been drunk is "OK."

After establishing a level of comfort in the interview, move on to a few key questions:

  • How many drinks did it take to make you feel high when you were a teenager?

  • What is you current alcohol preference (beer, wine, liquor)?
  • How many cans (glasses) of beer (wine, liquor) does it take to make you feel high now?

It appears that eight or nine out of ten people will indicate that they feel high after a maximum of two drinks-two cans of beer, glasses of wine, or mixed drinks, all of which contain about the same amount of absolute alcohol. If a patient says it takes more than two drinks to make her feel high, her drinking behavior needs further exploration. Seeking evidence of alcohol tolerance seems more effective in obtaining an alcohol consumption history than merely asking a patient how much she drinks. Denial is a large component of alcohol dependence and abuse.

Some useful screening tests

Since a reliable laboratory test has not yet been developed to identify risk-drinkers, formal questionnaires have been devised to aid in identifying this group. The gold standard questionnaire has been the Michigan Alcoholism Screening Test (MAST), a 25-question instrument that is widely used in alcohol research. Recognizing that the clinician does not have the time or office staff to administer such a test, a number of simpler, briefer questionnaires have been developed recently. The efficacy of these mini questionnaires has not been widely evaluated among pregnant women, but they do appear to hold some promise.

One such test is the CAGE questionnaire (Table 2). When this test was compared with the MAST in 1,497 consecutive new registrants at a prenatal clinic, the CAGE test successfully identified five or six out of ten risk-drinkers (Bottoms, Sokol & Martier 1988). Although the CAGE misses nearly half of risk-drinkers, the test offers a very simple screening technique. It takes just 30 seconds to one minute to administer, is reasonably efficient, and fits well into many clinical settings.

To improve the sensitivity of the CAGE questionnaire , the T-ACE screening test was developed through stepwise discriminative analysis of the responses of 971 pregnant risk-drinkers and 929 pregnant women who were not at risk (Sokol, Martier & Ager, 1989). In the CAGE and T-ACE tests, three of the four questions are the same; the key difference is that the T-ACE includes a question on alcohol Tolerance (How many drinks does it take to make you feel high?).

When none of the answers to the T-ACE questions are positive, the probability that an individual is a risk-drinker is 1.5%. If the patient states that it takes more that two drinks to feel "high," this answer alone increases the probability of risk-drinking 8.5-fold, to 11.7%. If all four questions are answered positively, there is a 62.7% likelihood of risk-drinking. A score of 2 is assigned to the Tolerance question and a score of 1 to all the others. A T-ACE score of 2 or more is considered positive for risk-drinking, indicating the need to pursue the history of alcohol consumption in greater detail.

When compared with other questionnaires, including the MAST, the T-ACE appears to be superior, identifying seven out of ten risk-drinkers during pregnancy . The crucial question appears to be the one on tolerance, which resists the denial component inherent in the problem drinking.

These preliminary findings need further verification and possible adjustment to socioeconomic status and racial composition . T-ACE may be used in most clinical practices. It holds great promise for better risk identification, prevention efforts, and improved pregnancy outcomes for offspring at risk of heavy prenatal alcohol exposure.

Suggesting Interventions

Clinicians frequently wonder about their role in intervening to reduce maternal alcohol consumption. It is clear that warnings by physician's can make an impact on reducing alcohol intake in many. Counseling heavy drinkers may require more time than many busy pediatricians, obstetricians, family practice physicians, and other medical providers are able to provide, but ignoring these women may result in marked morbidity in the newborn. A team approach involving a psychiatrist, psychologist, and other psychosocial workers may improve the outcome in these cases. These health-care providers are often linked with local Alcoholic Anonymous chapters or other support groups.

The pediatrician may also be approached by women fearing that they have "damaged" their fetus by consuming alcohol early in their pregnancy. In some cases, since decreased fetal growth is a major component of FASD, serial ultrasound many be beneficial in suggesting growth abnormalities.

The majority of FASD infants are born to chronic, heavy alcohol users, a group of women who rarely seek counseling or prenatal care. A lack of prenatal care and failure to keep pediatric appointments may be red flags that suggest the need to further assessment.

Educating mothers about the dangers of alcohol consumption is an important part of prenatal and newborn care. A number of brochures and other helpful materials are available.

The value of screening efforts

Alcohol is a human teratogen capable of producing a variety of defects ranging from [spontaneous] abortion and stillbirth to birth defects that are less easily identified. Most physicians lack the formal medical training necessary to recognize the risk-drinkers in their practice. However, there are some basic screening techniques that can be used to identify risk-drinkers in the clinical setting. The results of these techniques many lead to secondary prevention efforts and improved pregnancy outcomes for the offspring at risk of FASD and alcohol-related birth defects.

TABLE 1

Preliminary questions to ask

  1. Is there a family history of alcohol problems (Indicates that drinking is an important concern to patient and physician.)

  2. Have you ever had a drink of alcohol?

    • If Yes:

    • How old were you when you had your first drink?

    • What drink did you prefer as a teenager (beer, wine, liquor)?

    • How old were you when you first got drunk?

    • How many drinks did it take to make you feel high when you were are teenager?

    • What's your current alcohol preference (beer, wine, liquor)?

    • How many cans (glasses) of been (wine, liquor) does it take to make you feel high right now?

If a patient indicates that it takes more that 2 drinks to make her feel high, this suggests her drinking behavior needs further exploration.

TABLE 2

Mini-questionnaires to use

CAGE questions

C Have you ever felt you should Cut down on your drinking?

A Have people Annoyed you by criticizing your drinking?

G Have you ever felt bad or Guilty about drinking?

E Have you ever taken a drink first thing in the morning ( Eye opener ) to steady your nerves or get rid of a hangover?

The CAGE test takes no more than 1 minute to administer and identifies about 50% to 60% of risk-drinkers.

________________________

T-ACE questions

T How many drinks does it Take to make you feel high (tolerence)?

A Have people Annoyed you by criticizing your drinking?

C Have you ever felt you ought to Cut down on your drinking?

E Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover ( Eye opener )?

Scoring: 2 points if answer to T question is "more than 2 drinks,"

1 point for answering Yes to the A, C, or E questions.

T-ACE score of 2 or more is considered positive for risk-drinking. If all 4 questions are answered in the positive, the likelihood of risk-drinking is 62.7%, if no answers are positive, the likelihood is 1.5%.2 The test identifies about 7 of 10 risk-drinkers.

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