The U.S. Surgeon General (2005) issued a statement that health professionals should inquire routinely about alcohol consumption by women of childbearing age, inform them of the risks of alcohol consumption during pregnancy, and advise them not to drink alcoholic beverages during pregnancy [12]. Per these guidelines, pregnant women and women who consider becoming pregnant or may become pregnant should abstain from alcohol. Because approximately half of pregnancies are unplanned and women often do not recognize pregnancy until 4-6 weeks gestation, sexually active women of childbearing age who do not consistently use effective contraception and combine the possibility of pregnancy with risky drinking are at high risk for an alcohol-exposed pregnancy. Although the specific amount of alcohol that can cause an FASD is unknown, the at-risk drinking threshold has been established as > 7 standard drinks per week or > 3 standard drinks on a day [13] or ≥ 4 standard drinks on a single occasion (i.e., binge drinking that results in a 0.08% gram or higher blood alcohol concentration) [14].

The Substance Abuse and Mental Health Services Administration recommends Screening, Brief Intervention, and Referral to Treatment (SBIRT) as part of routine health care in numerous settings, including primary care, emergency departments, trauma centers, and other community care centers [15]. The American Academy of Obstetricians and Gynecologists (ACOG) guidelines recommend screening for problematic drinking for all women seeking obstetric–gynecologic care annually and within the first trimester of pregnancy, with early intervention strategies encouraging healthy behaviors and appropriate referrals to a substance abuse professional when indicated [16, 17]. ACOG recommends the T-ACE (Tolerance, Annoyance, Cut Down, Eye-Opener) and CAGE (Cut Back, Annoyed, Guilty, Eye-Opener) screening tools [17]. The American Academy of Family Physicians recommends universal alcohol use screening for all women of childbearing age and for mothers of patients with clinical features worrisome for FASDs (facial dysmorphia, growth deficiencies, central nervous system impairment) [18, 19]. The FASD Advisory Workgroup in Canada recognizes that there is no general consensus for screening for alcohol use in women of childbearing age, and issues recommendations to improve screening and recording processes of alcohol use among women of child-bearing age [20]. The recommendations include a three-level PAE identification model: 1) practice-based approaches, such as motivational interviewing and supportive dialogue, implemented by health care providers when talking to women about alcohol use, 2) structured questionnaires, such as CAGE or T-ACE, and 3) biological tests to confirm the presence of alcohol or a drug, the level of exposure, and the presence of multiple drugs.

As part of routine adolescent care, the American Academy of Pediatrics Bright Futures [21-23] recommends a universal substance use screening, brief intervention, and referral to treatment protocol, using CRAFFT, a developmentally appropriate screening tool for alcohol and drug use [21, 22]. However, the framework for screening for parental substance use, including maternal alcohol use during pregnancy in pediatric practice is limited. The parent is not the pediatrician's patient, so there is no financial reimbursement for parental screening or a brief intervention. Furthermore, if a clinician encounters concerns for problematic substance use, referring the parent to appropriate treatment resources becomes a challenge. Even in the setting of adolescent pregnancy, where both the mother and the child are pediatric patients, there are no clear recommendations for PAE screening, prevention, and treatment with appropriate resources.

A review of the professional guidelines indicates some similarities; however, there is a lack of consistency in methods and recording results in medical records and no consensus regarding whether all pediatric patients should be screened for PAE [18, 19]. In order to identify FASDs in children and provide effective treatment, pediatric clinicians ultimately bear the responsibility for detecting PAE and, therefore, are tasked with the challenge of screening the mothers of their patients. Although primary care and obstetric clinicians have been tasked with screening and brief interventions to reduce at-risk drinking and prevent FASDs, the identification of maternal alcohol consumption is a relatively new task for pediatric clinicians. There is uncertainty about the actions that a pediatrician is expected to implement if a mother reports alcohol or drug use and about whether the pediatrician is expected to conduct a brief intervention or refer the parent for treatment if indicated. Understanding the current practices of pediatric clinicians is crucial to facing these challenges and improving identification of PAE.

Studies indicated that many pediatricians do not routinely screen their patients for PAE. Vagnerelli et al. [24] reported that 59% of Italian neonatologists, 78.4% of Italian pediatricians, and 60% of Spanish pediatricians endorsed always asking new mothers about ethanol consumption during pregnancy. Over 90% of all clinicians who reported PAE screening among new mothers used general questions, with less than 10% reporting use of standardized screening tools [24]. Nanson et al. [25] obtained information about screening practices among Canadian pediatricians and family and general physicians (FP/GP); pediatricians were less likely to screen mothers about their alcohol use during pregnancy than were FP/GP (58.3% vs 77.4%). An earlier survey asked a small sample of Texas practitioners what percentage of colleagues they believed screened for FAS, and the mean response was 30%; however, this study did not specifically examine the practitioners’ screening practices [26].

Other medical providers, including obstetricians and FP/GP, often routinely conduct PAE screening with pregnant and non-pregnant women of childbearing age, but utilization of standard screening tools is limited [26]. A survey of Canadian family physicians revealed that while 75% reported asking pregnant patients about alcohol use, they were unaware of current screening methods to accurately gauge alcohol use among women [27]. Another Canadian study found that 94% of family physicians, midwives, and obstetricians reported asking their pregnant patients about alcohol use; however, only 74% of family physicians, 45% of obstetricians, and 20% of midwives utilized a standard screening tool [28]. According to Tough [28], less than 50% of Canadian healthcare providers caring for women in the preconception period reported frequently discussing smoking, alcohol use, or addiction history. Arnold et al. [29] found that only 38% of medical students and residents at an U.S. university reported always screening their pregnant patients for alcohol use, suggesting that there is a need to educate practicing clinicians and trainees about the importance of PAE screening. In general, few articles reported the specific methods used to screen for PAE.

Pediatric clinicians face many barriers to accurate detection of PAE, given the social stigma, legal implications, and other factors. Women under-report alcohol consumption because of embarrassment, fear, or beliefs that small amounts of alcohol are inconsequential [30, 31]. Coles [30] noted that alcohol use is reported less frequently than other drug use in medical records. Many adopted and foster care children are at high risk of having had PAE, yet they are often no longer in the care of their biological mother. Clinicians must thus rely upon secondary reports of maternal alcohol use during pregnancy. Because many children have come into the care of other biological relatives or the foster care system, exposure information must often be obtained from medical/social service records or by hearsay. Studies have shown that information yielded in this manner is often less accurate than direct maternal self-report, contributing to the under-diagnosis of FASDs [30]. When pediatric clinicians have contact with their patients’ biological mothers, many find it difficult and feel uncomfortable asking parents about their alcohol use, and if the history is not obtained in a sensitive manner, parents may feel blamed for wrong-doing. Mothers may not reveal their alcohol use during pregnancy because of guilt or fear of legal actions that could result in losing their job, children, or relationships [31].

Clinicians may be reluctant to document PAE due to concerns with mandatory reporting of child maltreatment. ACOG states, “Seeking obstetric-gynecologic care should not expose a woman to criminal or civil penalties or the loss of custody of her children” [16, 17]. Discussing the role of obstetrician-gynecologists in substance abuse reporting and pregnancy, ACOG has expressed concerns that the threat of prosecution is an ineffective strategy in reducing the incidence of alcohol or drug abuse; it may deter women from seeking prenatal care which would be contrary to the child and maternal welfare [16].

The new Child Abuse Prevention and Treatment Act (CAPTA) [32] does not require clinicians to report maternal alcohol use or PAE to Child Protective Services (CPS). However, if a child is diagnosed with FAS/FASDs, clinicians are required to make a referral to CPS so that safe care plans and services are initiated. Additional laws regarding FASDs may differ based on the state in which the clinician practices. These new laws and procedures can improve services for children diagnosed with FASDs but could also increase challenges in obtaining accurate self-reports about alcohol use during pregnancy. When children are older at their first referral, diagnosis relies on the maternal recall of alcohol use after a period of years by a woman who may not remember well or may have some motivation, conscious or unconscious, to downplay the extent of use [30]. Pediatric clinicians should be aware of the reporting guidelines for reporting FASDs to child welfare and reporting guidelines related to maternal alcohol use within their states and include during their regular discussion of consent to evaluation/treatment and disclosure with the family. Health care professionals may be encouraged to work with state legislators to ensure that legislation support education and services to women instead of punishing pregnant women for substance use.

In addition, if a mother reveals alcohol misuse, a pediatrician may feel uncomfortable because of limited skills, time, or resources necessary to adequately respond to the reported problem. Many pediatric clinicians lack screening and brief intervention (SBI) skills and knowledge of community resources on alcohol misuse. Since pediatricians are already tasked with providing SBI for substance abuse in adolescent patients with high risk for pregnancy [21, 22, 23, 33], they may be well-poised to assist in providing SBI to mothers of their patients who report at-risk drinking. However, there are barriers to reimbursement for a brief intervention for a parent, a lack of skills to conduct SBI, and no formal pediatric guidelines for such services. Pediatricians need guidelines, training, and resources for improving detection of PAE in their patients and should be provided with specific instructions if they are to help prevent future PAE and FASDs.

Several studies have surveyed clinicians to inquire about their perception of barriers to eliciting a self-report of PAE. A survey of U.S. obstetricians identified several barriers, including physician bias due to own alcohol misuse, lack of training, poor awareness of the problem and its effects, denial that FAS occurs in private practice, time limitations, lack of interest, fear of offending the patient, and fear that patients will lie [34]. Another study reported that family physicians and obstetricians were 60% more likely to identify time constraints as a barrier to discussing alcohol use during pregnancy with women than were midwives, and almost half of all providers felt that existing information available for discussing PAE not in a useful form for clients [28]. An in-depth focus group of prenatal care providers in San Francisco indicated that practice setting strongly influenced providers’ screening and counseling of pregnant women about tobacco, alcohol, and illicit drug use. Providers with larger settings, like county hospitals and the Health Maintenance Organization (HMO), reported more resources, compared with private practitioners. HMO providers were also more likely to report using standardized questionnaires and toxicology screening in pregnancy. In contrast, private practices appeared to offer greater continuity of care and patient-provider relationships [35]. Clinicians have also reported the lack of training and confidence about FAS/FASDs as barriers to identification and diagnosis. In a study of Toronto family physicians, 49% reported little confidence in their ability to diagnose FAS; 81% felt their training was inadequate [27]. Italian and Spanish neonatologists and pediatricians also had low confidence in their ability to diagnose FAS and FASDs, with over 50% feeling that they needed more information regarding FAS/FASD identification in newborns and children [24].

Biological tests utilize maternal or child specimens, such as urine, blood, hair, meconium, and umbilical cord samples [36]. Biomarkers of PAE include direct ethanol metabolites/conjugation products, such as fatty acid ethyl esters (FAEEs), phosphatidylethanol (PEth), ethyl glucuronide (EtG), and ethyl sulfate (EtS), and indirect ethanol-induced protein alterations, such as gamma glutamyltranspeptidase (GGT) [37, 38•, 39-41]. Several studies indicate that biomarkers reveal higher prevalence of alcohol use during pregnancy than do maternal self-reports. A study indicated a fivefold increase in detection of PAE from a meconium FAEE test compared with traditional self-reports in a population-based sample in Canada [42]. A recent review reported PAE prevalence 4.3 times higher when testing meconium than relying on maternal self-reports [43]. These approaches are promising for detecting PAE. However, there are several drawbacks: (1) the methods are costly and may be invasive, (2) nearly two-thirds of problem drinkers do not have elevated test values, (3) scores may be elevated due to other factors, such as maternal diabetes or diet, and (4) the methods do not indicate either the amount or the time period of drinking [41]. Traditionally utilized biomarkers, such as urine and blood testing, only provide information about drinking within the last several hours. Other biomarkers, such as meconium or hair testing, provide information about PAE during the last two trimesters of pregnancy. However, these methods are expensive, detect heavier alcohol use, and may be less reliable in detecting moderate or social drinking. In addition, no currently known biomarker can detect exposure during the first trimester.

When a pediatric clinician orders biomarkers on an infant, results may reveal information about the mother, who is not their patient, which raises an ethical concern. Universal biomarker screening raises additional ethical questions. Implementing informed consent to patients about testing and providing biomarker screening only to those who consented reduces the benefits of testing, since patients who consumed alcohol are more likely to refuse testing [44]. However, testing without patient consent would violate the patient's right for autonomy. An additional consideration is that if biomarker screenings were to be routinely used, intervention resources would need to be available [36]. Identification of PAE in older children is even more challenging, as no current laboratory test can detect and quantify PAE in older children.

Some hospitals have implemented targeted biomarker screening and may have established algorithms to determine risk for PAE (e.g., specific concerns due to lack of prenatal care, premature birth, low birth weight, or mother's intoxication at admission; personal communication with Raja Nandyal, M.D., and Vadim Ivanov, M.D., neonatologists at University of Oklahoma Children's Hospital, February 2015). However, there is no commonly accepted algorithm or procedure to record biomarker results in maternal medical charts, and transferring the information to the child's health records had been inconsistent in the U.S. and Canada [20].

Although biomarker screening could offer advantages over maternal self-reports, research is needed to further validate biomarkers and improve PAE detection [45]. Given these limitations, maternal self-report remains the most common method to assess for PAE in clinical practice.

Self-reports about alcohol consumption have been demonstrated to reliably reflect women's alcohol consumption. Babor et al. [46] indicated that, in clinical trials of research volunteers, self-report measurements are accurate. Biomarker tests and collateral informant reports do not add sufficient data to warrant their routine use. However, most published data regarding the reliability of self-reports were obtained from volunteers who provided anonymous or confidential information in research studies. A physician asking about alcohol use as part of a clinic appointment in which information is not anonymous and is likely to be included in the patient's medical record makes self-reports more likely to be affected by a social desirability bias. A recent study reported that in-depth research interviews revealed more alcohol use among pregnant women than was recorded during routine clinical care appointments with these women [47].

Several approaches to improve the accuracy of self-reports of alcohol consumption and PAE identification have been identified. Physicians can improve self-report accuracy by asking questions in a sensitive and nonjudgmental manner [33-36] and when embedding questions about alcohol use in the routine prenatal history that includes nutrition, exercise, and avoidance of environmental toxins, such as nicotine/second-hand smoke. In order to increase accurate and truthful reporting, the woman must be alcohol- and drug- free when interviewed, and the interviewer must use simple language and provide word questions clearly [48]. Asking a woman about her drinking patterns before she became pregnant is another strategy that could elicit more accurate estimates of first-trimester drinking and alcohol use later during pregnancy [49]. Robles et al. [50] found that self-reported alcohol consumption is moderately reliable over 3-month and 5-month time periods, and longer timeframes have been documented to improve sensitivity of self-reports in women of childbearing age [51]. A summary of PAE screening recommendations for pediatric practice is included in Table 1. Figure 2 provides a suggested algorithm for implementing PAE screening and appropriate action plans based upon risks identified within a pediatric practice.

A number of screening measures have been implemented for screening for at-risk drinking in different settings. Two of the instruments have been designed and validated specifically to detect the risk for alcohol use during pregnancies in women, TWEAK (Tolerance, Worried, Eye-opener, Amnesia, Kut down) and T-ACE [52-54]. These measures have been tested in diverse obstetric samples and demonstrated good performance in PAE identification [52, 55-57]. In addition, the AUDIT-C (Alcohol Use Disorders Identification Test alcohol consumption questions) has demonstrated sensitivity in identification of prenatal alcohol use among women [58]. Most women who consume alcohol during pregnancy do not meet criteria for alcohol use disorders and may not be identified with commonly used instruments, such as the standard AUDIT (Alcohol Use Disorders Identification Test) [59]. For example, the CAGE questionnaire and SMAST (Short Michigan Alcoholism Screening Test) were designed to identify hazardous and harmful drinking and alcohol dependency and were tested in specific populations (e.g., heavy-drinkers, males) [60]. These instruments do not accurately identify drinking among women [15, 16, 58]. T-ACE and TWEAK, simple screening instruments designed for identifying women who consume alcohol during pregnancy, are particularly valuable and detecting the risk for PAE.

Even brief instruments consisting of a few questions may be difficult to implement in a busy pediatric practice. Recent studies indicate that a single-question can be used for screening. The National Institute on Alcohol Abuse and Alcoholism recommended the Single “Binge” Drinking Question (SBDQ) (“How often did you have ≥ 4 drinks on one occasion?”) to screen people whose drinking puts them at risk of an alcohol use disorder [13]. Recent studies found that the SBDQ accurately identified patients with at-risk drinking in primary care [61] and also identified women whose drinking placed them at risk of PAE [62-64]. These findings support the use of SBDQ to identify prenatal alcohol use. However, the studies were conducted in research settings, and additional research is needed to evaluate the performance of the measure in pediatric care settings. It is reasonable, though, to conclude that the SBDQ and screening instruments, including T-ACE and TWEAK, are feasible and effective for PAE identification and can be recommended for implementation in pediatric care settings.