March 3 – Birth Defects Awareness Day

With today being Birth Defects Awareness Day, I decided to reduce the price of my book about the leading preventable cause of physical and functional birth defects – our social drug of choice: alcohol.  My book is The Silent Epidemic: A Child Psychiatrist’s Journey to Death Row – Understanding, Treating and Preventing Neurodevelopmental Disorder associated with Prenatal Alcohol Exposure.  Though I had the book in my heart and mind to write for the first 20 years of my journey, I put pen to paper in December 2012 in the aftermath of the Sandy Hook tragedy in Connecticut.  The book is my hope to provide the science about how alcohol-related birth defects happen and illuminate society’s duty to the 5-10% of American children who are affected by the $220 billion dollar product of the Big Alcohol industry.

As a former pharmaceutical researcher, I know first hand what it takes to get a drug approved – from bench science through clinical trials and FDA approval.  Even life-saving cancer drugs would not be allowed to cause brain damage in children.  If a woman needs to be on a chemotherapy drug before she has children, often she’ll be given the opportunity to freeze her ovaries to avoid mutations in the eggs.  For acne medications created from Vitamin A derivatives (Retin-A, Accutane),  dermatologists will put childbearing age patients on contraceptives and conduct a pregnancy test before they give the patient their monthly prescription.  The patients also sign a waiver that they will not become pregnant.  It is very easy to prevent birth defects if a person needs a medication – contracept!

Many years ago, I was awarded a small grant from the March of Dimes to produce a preconception health information brochure for the Iroquois community.  The brochure, “Planning for the 7th Generation,” is a culturally relevant brochure for Native American men and women to become educated that birth defects happen as early as the first few weeks after conception.  Preconception health includes healthy nutrition, exercise, multivitamins, sleep, and avoiding alcohol/tobacco/other drugs of abuse as well as minimizing stress.  Even though being healthy during the few months prior to pregnancy doesn’t guarantee a healthy baby (or even that you’ll get pregnant), we can reduce exposures and improve the chances of a healthier outcome.  Preconception health is for both women and men!

Since most major organ systems, the skeletal system, and the nervous system has rapid development in the first 8 weeks after conception, physical birth defects occur very early during pregnancy – before most women know they are pregnant. In addition to physical birth defects, “neurotoxins” can cause “teratogenesis” (the origin of birth defects) of the brain and nervous system.  These chemicals are known as “neuroteratogens.”  Heavy amounts of alcohol early in pregnancy can cause physical birth defects such as cleft lip or palate, “lazy eye,” inner or outer ear defects, joint deformities, and unusual but subtle changes of the face (asymmetry, wideset small eyes, thin upper lip, small head, etc.).  As little as 4-5 drinks in one sitting as early as the 3rd week after conception can cause mild to moderate brain damage (“functional birth defects”), leading to learning disabilities, executive functioning problems, attention deficits, social communication issues, and a variety of other “neurodevelopmental” disorders.  Children can have sensory issues ranging from hypo- to hyper-sensitivities of hearing, seeing, smelling, tasting, touching, vestibular, propriocetion, or interoception. Most women don’t know they are pregnant when many of these problems are starting to happen!

The solvent ethanol dissolves the fatty insulation around neurons and kills neurons as they are migrating in the embryo to become the brain and nerve cells communicating between the body and the brain.  These changes begin to occur very early in the 2nd to 3rd week after conception.   One of the major problems affected children have is being unable to regulate their emotions and having difficulty managing their discomfort.  As babies, they are difficult to soothe, have difficulty suckling (due to nerve damage going to the facial muscles, lips, tongue, mouth, and throat), and have problems with sleep-wake cycle, developmental delays, and poor “attachment” behaviors. As toddlers and children, they are easily frustrated, overstimulated, overwhelmed, sensitive, and can have rages that are provoked by very minimal provocation. They also may have speech/language disorders, fine/gross motor or coordination problems, difficulty learning to read or do math, and other issues achieving age appropriate tasks.  Parents feel they are “walking on eggshells” to avoid the “land mines” that will set off the child’s “Hulk attacks” and may become so traumatized by the child’s “fight or flight” reactions that they develop symptoms of post traumatic stress disorder.  As their brains go through changes of adolescence, they may develop gender dysphoria, worsening mood/anxiety problems, and difficulties relating to their chronological age peers.

The beautiful image of the baby immersed in a frosted glass of beer with the umbilical cord wrapped around and inserted in the bottle of beer was created by the award winning artist, Angela Mele.  Many of the websites, logos and books written about prenatal alcohol exposure depict a baby in a bottle of alcohol, wine or beer.  In many ways, I wanted to open the bottle and share this knowledge with alcohol consumers instead of it being a “message in a bottle.”  Angela used her creative intuition to paint a picture of a well developed infant that looks relatively normal to depict the “hidden” damage to the baby in the womb.  Only 10-15% of the children have any visible signs of the full Fetal Alcohol Syndrome, which includes the facial features, small size, and neurodevelopmental problems.  A majority have brain damage invisible to the naked eye but detectable as developmental disabilities, learning disabilities, and other deficits on neuropsychological testing.

Even though most parents of toddlers or school age children would not connect prenatal alcohol exposure with the learning, mood, motor, social skills, or attention problems their child may eventually develop, science teaches that these problems begin within the womb as early as the first few weeks after conception.  There is much to be learned from dentists who taught children to brush and floss to prevent cavities.  So too can we psychiatrists teach patients to avoid cavities in their offsprings’ brains by deciding if and when to become pregnant, contraception until ready or able to become healthy, and preconception planning to prevent birth defects.

Please share this article with anyone you know who drank during their pregnancy and has a child with neurodevelopmental problems. By improving the parenting strategies, early and accurate diagnosis, academic supports, and appropriate treatment, the child can grow into a healthy, happy individual with adequate life skills and social supports to live a fulfilled, meaningful life.

Resources:

https://www.cdc.gov/ncbddd/fasd/facts.html

http://www.lulu.com/spotlight/TheSilentEpidemic

https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/fetal-alcohol-spectrum-disorders-toolkit/Pages/default.aspx

https://store.samhsa.gov/shin/content/SMA13-4803/SMA13-4803.pdf

https://www.niaaa.nih.gov/research/major-initiatives/fetal-alcohol-spectrum-disorders

https://www.acog.org/About-ACOG/ACOG-Departments/Tobacco–Alcohol–and-Substance-Abuse/Fetal-Alcohol-Spectrum-Disorders-Prevention-Program

http://www.oregon.gov/ode/educator-resources/2016fallconference/fasd.pdf

https://www.nofas.org/

 

Global Prevalence of Prenatal Alcohol Exposure – A Call to Action

Let’s congratulate and commend Tracey W Tsang and Elizabeth J Elliott on their important publication of “High global prevalence of alcohol use during pregnancy and fetal alcohol syndrome indicates need for urgent action” in The Lancet, [http://www.thelancet.com/journals/langlo/article/PIIS2214-109X(17)30008-6/fulltext].  This publication mirrors the historical, epidemiological, and societal implications presented in my book, “The Silent Epidemic:  A Child Psychiatrist’s Journey beyond Death Row – Understanding, Treating and Preventing Neurodevelopmental Disorder associated with Prenatal Alcohol Exposure” [www.prenatalalcoholexposure.com]; as well as a an international book chapter in Fetal Alcohol Spectrum Disorders in Adults: Ethical and Legal Perspectives [https://link.springer.com/chapter/10.1007/978-3-319-20866-4_3].  The authors clearly call for global paradigm shifts in public perception of alcohol’s effects on society – through advocacy efforts, the media, the alcohol industry, advertising and public policy.
 
I have just returned from Vilnius and Alytus, Lithuania where I gave two lectures daily for three days to large audiences of clinicians, social workers, public health professionals and policy makers (as well as the entire class of first year medical students at the Medical University of Vilnius) about this topic.  Here is a video of the talk at the Ministry of Health to a multidisciplinary group of professionals in the Center for Mental Health [https://www.youtube.com/watch?v=ZNc_RL5Z5Vo].  The introductions were given by the Director of Mental Health for the Ministry of Health who spoke about the epidemic created by alcohol abuse during the former Soviet occupation of the Baltic country.  I was moved and impressed by the city of Alytus’s efforts to end the mass institutionalization of children from alcoholic families, opting instead to offer the entire family therapeutic care with farming families where they are allowed to live in a safe, agrarian setting while learning adaptive functioning skills and vocational skills as well as parenting training.  [My trip was sponsored by a nonprofit family foundation dedicated to improving the lives of Lithuanian children.]
 
In my humble opinion, a medical journal as world renown as The Lancet taking on this issue will surely help awaken others to the devastation on developing brains caused by our western society’s social drug of choice: alcohol.  Just as the British Parliament took on the Gin epidemic in the 1750s, so too can our modern societies choose to urge doctors to encourage their patients (both male and female) to contracept if using alcohol.  After all, these problems occur as early as the 3rd week post conception – well before many know they are pregnant.  Methylation effects to sperm DNA occur up to three months prior to conception, and are transmitted through histone modifications for generations, resulting in familial anxiety, depression, addictive disorders, obesity, and a plethora of other conditions hidden within our tightly wound genome. 
There is no excuse that alcohol is allowed to cause 1 in 20 American children to be born with preventable neurodevelopmental deficits, deformities, and lifelong lost potential.  If the solvent ethanol was as important to mankind as a life-saving antitumor medication, it would not be allowed to cause 1 in 1,000 babies to be born each year with brain damage and birth defects.  We prescribe contraceptives and pregnancy testing to all patients receiving pharmaceuticals that have any potential for causing negative reproductive outcomes.  Just as condoms are promoted for HIV prevention, let’s agree that alcohol and unprotected sex don’t mix and promote contraception and preconception health for alcohol consumers. [https://www.cdc.gov/ncbddd/fasd/alcohol-use.html].   
In the spirit of prevention, identification, and treatment – Kudos to Drs. Tsang, Elliott, Horton and The Lancet.  Perhaps one day you all will be granted well-deserved knighthood!

Media Responsibility for Prevention

When I wrote my book, The Silent Epidemic: A Child Psychiatrist’s Journey beyond Death Row, I naively thought that I could stem the tide of public awareness about alcohol use during childbearing years – helping unknowing young women understand the importance of contraception if using alcohol.  Articles like this one recently in the Washington Post are a big reason people are missing the message that a lot of damage happens to babies before you find out you’re pregnant.   And alcohol doesn’t just cause Fetal Alcohol Syndrome! https://www.washingtonpost.com/opinions/five-myths-about-pregnancy/2017/05/12/7cf6e12a-3666-11e7-b373-418f6849a004_story.html?nid&utm_term=.fddddfca9788#comments

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Ilustration by Angele Mele, Coverart for The Silent Epidemic: A Child Psychiatrist’s Journey beyond Death Row.

I can’t help but wonder what responsibility the media has for creating the confusion and societal ambivalence about alcohol use during reproductive years.  Like some other drugs, alcohol is a neuroteratogen – a chemical solvent that causes birth defects of the brain and nervous system.  Yes, it’s a solvent.  Like household cleaning supplies, dry cleaning solution, gasoline, paint thinner, and rubbing alcohol.  Alcohol kills the tiny cells migrating out of the neural tube as early as the 3rd week after conception – well before most women know they are pregnant.

In my book, I indicate the role of the alcohol industry, the medical community, and the government in preventing brain damage caused by our social drug of choice in 1 in 20 American children.  The article in the Post reminds me of the media forces keeping the waters muddy about use of alcohol for women who are pregnant or planning pregnancy.  So much more can and should be done to help them as well, as women who are sexually active and using alcohol but not preventing pregnancy.

One risk of the “Five Myths” article and the book is that women will become confused by the stance that a little alcohol is okay. What is a little alcohol to one woman is a long island iced tea to another (equivalent of 6 shots). As a board certified child/adolescent and adult psychiatrist, I see patients adopted from foster care in the U.S., Eastern Europe, South/Central America, China, and Southeast Asia with a range of neurodevelopmental problems (learning, attention, memory, anxiety/arousal, mood, sensory, motor, social/communication, etc.) stemming from prenatal alcohol exposure. Psychiatrists see these patients, not obstetricians. The condition is called “Neurodevelopmental Disorder associated with Prenatal Alcohol Exposure” (ND-PAE, ICD-10 code F88).

Most people know that alcohol abuse during pregnancy can cause “The Fetal Alcohol Syndrome” (FAS). What is less known is that as little as 4-5 servings of alcohol mistimed in the late 3rd week post conception is enough to cause the full FAS. Most women don’t know they are pregnant then. Our genetics, health factors, nutrition status, and other lifestyle behaviors can protect us and our babies or make the situation worse. We also know that a man’s sperm DNA is methylated by alcohol consumed up to 3 months prior to conception (it takes 3 months for sperm to develop from the earliest stages to “fertile”). Methylation of DNA has been linked to a variety of mental health, learning, medical, and other conditions.

I am a believer in educating alcohol consumers about the risks of unintentional prenatal alcohol exposure before knowing you are pregnant and to use contraception (prevent pregnancy) if using alcohol. Preconception health is the best way to prevent ND-PAE. I believe it’s time for the alcohol industry to be held accountable that our social drug of choice (alcohol) has caused brain damage in 1 in 20 U.S. children (CDC, 2015).

For more information about Neurodevelopmental Disorder associated with Prenatal Alcohol Exposure, check out my book at www.prenatalalcoholexposure.com.

Women Physician’s Voices Count in Prenatal Alcohol Exposure Awareness

The first female physician in the United States, Dr. Elizabeth Blackwell, would turn 196 today.  In her honor, a group of physicians established February 3 as National Women Physician’s Day.  Inspired by her maverick spirit (after all, how dare a woman in the mid-19th century think she could be a doctor?!) and participation in the recent Women’s March, I envision a paradigm shift when we female doctors are going to end the ignorance surrounding prenatal alcohol exposure.

As a pioneer in medicine who graduated medical school in 1849, Dr. Blackwell may well have been at the forefront of the Temperance Movement, which occurred in the late 1800’s to early 1900’s.  At that time, medical doctors understood the devastating effects of alcohol on reproductive outcomes, low birth weight, prematurity, child/family mental health, and infant/child morbidity and mortality.  Public health statistics abounded, fueling the fire for Prohibition in 1920.  What a pity we lost all that knowledge after its repeal in 1933.

At that time in history, mostly men called the shots in society because they were the main holders of wisdom in science.  Professional papers were written, published in high brow journals, read by a handful of intellectuals and scientists, then put on shelves to collect dust.  There was no Internet for information sharing.  If one did not make it to college, medical school, or professional school (i.e., law school, doctorate programs, etc.), then most scientific advancements and knowledge about medical matters were hidden within academic institutions.

Today, only those of us motivated, bright, and resourceful can endure the rigors of 4 years of college, another 4 years of medical school, and another 3-6 years of residency in our desired field.  In many ways, our knowledge is as hidden from plain site as ever.  One of the key areas of my interest has been in raising awareness about the leading known and preventable cause of neurodevelopmental disorders, birth defects, and developmental delays – which can occur as early as the third week after conception.  Since this time frame is often before a woman may know she is pregnant, our society can and must do more to encourage sexually active alcohol consumers to contracept  to avoid unintentional exposure of their offspring.

It is my hope to help childbearing age alcohol consumers understand that they should stop using alcohol if pregnant or planning a pregnancy and to use contraception until they have stopped using alcohol.  Their partners should support them in this effort – after all, it takes sperm 3 months to develop, and alcohol methylates the sperm DNA.  These methylation effects last for several generations, passing silently through the genome into unsuspecting offspring.

Theodore Geisel, also known as Dr. Seuss, once wrote – “Unless someone like you cares a whole awful lot, nothing’s going to get better, it’s not!”  Unless we speak up about what we know about prenatal alcohol exposure happening early in pregnancy so the lay public understands, people will not hear our message.  As a change agent and spirit sister of Dr. Elizabeth Blackwell, I am determined to get this message across.

Susan D. Rich, MD, MPH, DFAPA

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Guest of Potomac-Bethesda Rotary

brian-feldman-susan-rich-bob-fuhrman-aruna-miller-091516-dsc_0635

Pictured from left to right: Senator Brian Feldman, Susan Rich, Bob Fuhrman – Rotary Pres., and Representative Aruna Miller.

It was a remarkable honor to speak last night to the prestigious group of service-oriented citizen members of the Potomac-Bethesda Rotary Club.  As a public health entrepreneur, I’m grateful to have the support of State Senator Brian Feldman and District 15 Representative Aruna Miller, who attended the Rotary club dinner presentation about my new book – The Silent Epidemic: A Child Psychiatrist’s Journey beyond Death Row.*   Sharing my journey with these remarkable legislators and the imminent Rotary scholars and community leaders was truly humbling.

My main points were to let them know much about the public health warnings and efforts leading up to Prohibition, and the reasons why our society seems deaf to the damage caused to our future generations from a chemical so ubiquitous as alcohol.  None of the Rotarians knew that as little as 4-5 standard servings of beer, wine or liquor exquisitely timed late in the 3rd week post conception can cause the Fetal Alcohol Syndrome (FAS), or that only 10-15% of children with effects of prenatal alcohol exposure have the identifiable facial characteristics.  They also didn’t know that a Long Island Iced Tea contains nearly 1.5 times the amount of alcohol (6 shots, no tea) to cause FAS.  Since 50% of U.S. pregnancies are unplanned and 13.5% of childbearing age women drink alcohol, we have an epidemic (1 in 20) of affected school-aged children in this country.

They were  dismayed that future generations could be impacted by a process known as “methylation” – the addition of “CH3-switches” placed on DNA’s histone proteins to interfere with the process of translation of the DNA/RNA into protein.  Not only is a child’s neuronal wiring affected by a mother drinking alcohol (i.e., killing the progenitor brain cells that will form important structures of the midline especially), the child’s gonads are affected (their “germ cells” – eggs and sperm) by effects of methylation.  This process affects future generations – even if the mother does not drink.  Since it takes 3 months for the process of spermatogenesis (sperm development) in the male, his use of alcohol can also potentially “methylate” his sperm DNA.   These permanent switches created by preconceptional alcohol exposure are transmitted for generations into the future. Thus, conditions such as alcoholism, chemical dependency, anxiety disorders, and neurodevelopmental disorders are carried down generation after generation – silently within the replication process of DNA.

The fact that most people don’t know that their children and grandchildren may be affected by their inebriated sperm is a problem our society should begin to face. The Better Safe Than Sorry Project, as well at the CDC and the US Surgeon General, recommend for alcohol consumers to avoid alcohol if pregnant or planning pregnancy (for males, this should be 3 months prior to conception); and to avoid pregnancy (i.e., contracept) until they are ready to abstain from alcohol.

In an effort to stem the tide of unintentional prenatal alcohol exposure (and prior to pregnancy recognition), we are hoping to work with the state legislature this fall on a state bill to require “point of purchase” messaging where alcohol is sold.  Forty-one states already have such signage, indicating that those who are pregnant or planning to be should avoid alcohol.  I would hope that we Marylanders would go one step further with an additional statement – “Alcohol consumers should avoid pregnancy (i.e., contracept), since problems can occur with exposure before knowing one is pregnant.”

Remember – alcohol and unprotected sex don’t mix!

*http://www.lulu.com/spotlight/TheSilentEpidemic; http://www.PrenatalAlcoholExposure.com.

We welcome comments from readers about this blog, as well as any others.

Alcohol Embryopathy

Letter to the Washington Post Editor submitted 1/25/16 by Susan D. Rich, MD, MPH, DFAPA:

An article on January 18, 2016 in the Washington Post’s Health and Science section, “This mother drank while pregnant. Here’s what her daughter’s like at 43,” features a courageous mother, Kathy Mitchell, and her daughter Karli who should be applauded for their tireless efforts to raise awareness about this prevalent and preventable condition.  Over the past 22-25+ years, Kathy and Karli have done great work to raise awareness about FAS. Kathy is the renown spokesperson for and Vice President of the National Organization on Fetal Alcohol Syndrome.  Karli has worked diligently as a volunteer in the office, stuffing envelopes, creating artwork for their logos, and providing an optimistic outlook with her beautiful smile that lights up a room. She won the Presidential Points of Light Award for her volunteerism. Their story is depicted in my 2001 Documentary: Dispelling Myths about Alcohol-related Birth Defects:  http://www.susanrich.info/psychoffice/patient_myths.html.  

Unfortunately, the article perpetuates the myth that intellectual disability and other neurodevelopmental problems only occur in heavy drinkers and that effects of prenatal alcohol exposure are relatively uncommon.  Alcohol can cause a range of neurodevelopmental disorders – actually nearly every neurodevelopmental disorder of childhood can be caused by alcohol.  Here’s a chapter I co-authored in an International book on autism: http://www.intechopen.com/…/clinical-implications-of-a-link….  We’ve known since 1981 about an important “missing link” about prenatal alcohol exposure (from a seminal paper published by Dr. Kathleen K. Sulik at the University of North Carolina)  that neurodevelopmental disorders (brain damage) associated with prenatal alcohol exposure (ND-PAE) can happen with as little as 4-5 servings of alcohol in one “binge” episode as early as the 3rd week post conception.  This is actually the period of embryonic development, not fetal development.  So, the real term for babies with the facial features and severe deficits associated with prenatal alcohol exposure is “alcohol embryopathy.”

With 13.5% of childbearing age women binge drinking and 50% of pregnancies unplanned, inadvertent prenatal alcohol exposure before a woman knows she is pregnant means that not only alcoholic women are having babies with FAS.  In truth, not all affected children have the tell-tell signs of characteristic facial features, severe intellectual disability and growth deficiency like Karli.  As a child/adolescent and adult psychiatrist, I see first-hand the mood dysregulation, sensory and motor disorders, ADHD and executive functioning problems, and social communication delays caused by prenatal alcohol exposure. According to the Centers for Disease Control and Prevention, we have an epidemic of 1 in 20 school age American children with preventable brain damage caused by prenatal alcohol exposure.  Neurodevelopmental Disorder associated with Prenatal Alcohol Exposure (ND-PAE), the topic of my upcoming book – “The Silent Epidemic: A Child Psychiatrist’s Journey beyond Death Row,” may be among the most significant public health crises since polio.

For 23 years, I have asked this simple question:  Why has the alcohol industry not been held accountable for a failure to warn about this prevalent and preventable condition?  A small label on their products indicating risk for birth defects in pregnant women is too little too late in my opinion – since much damage has already occurred before a woman knows she is pregnant.  Pharmaceutical manufacturers, the tobacco industry, and other corporate megaliths have been called out for harm caused by their products.  Attorney Laura Riley and I recently addressed this question in a chapter in an international book on Legal/Ethical issues in FASD http://www.springer.com/us/book/9783319208657   Neurodevelopmental Disorder Associated with Prenatal Alcohol Exposure: Consumer Protection and the Industry’s Duty to Warn [Rich, Susan D. ​ and Riley, Laura J​.  Pages 39-47​;  ​Fetal Alcohol Spectrum Disorders in Adults: Ethical and Legal Perspectives. An overview on FASD for professionals. Editors: Nelson, Monty, Trussler, Marguerite (Eds.)].  My blog attempts to address the missing link by recommending that alcohol users prevent pregnancy not just stopping drinking after pregnancy recognition.  See http://www.bettersafethansorryproject.com.

 

Remember – if you drink alcohol and are of childbearing potential, avoid pregnancy (i.e., contracept or avoid sex). If you are pregnant or planning pregnancy, avoid alcohol.  The Centers for Disease Control and Prevention are now promoting our message – It’s better to be safe than sorry – alcohol and unprotected sex don’t mix!!! http://www.cdc.gov/media/releases/2016/p0202-alcohol-exposed-pregnancy.html.