AAP Statement on Prenatal Exposure to Alcohol

The Committee on Substance Abuse and the Committee on Children with Disabilities of the American Academy of Pediatrics (AAP) have issued a statement on fetal alcohol syndrome and alcohol-related neurodevelop-mental disorders. Prenatal exposure to alcohol is one of the leading preventable causes of birth defects, mental retardation and neurodevelop-mental disorders in newborns. This statement, which appears in the August 2000 issue of Pediatrics, updates a previous AAP statement and reflects the current thinking about alcohol exposure in utero and the revised nosology.

The AAP committees make the following recommendations:

• Because there is no known safe amount of alcohol consumption during pregnancy, the AAP recommends abstinence from alcohol for women who are pregnant or who are planning a pregnancy.

• Efforts should be made to develop high-quality educational programs about the dangerous consequences of alcohol in the unborn child. This information should be part of the curriculum in all elementary, junior high and high schools. It should also be included in all postsecondary and adult centers of learning.

• Physicians who provide care for women and their newborns should increase their own awareness and that of their patients about fetal alcohol syndrome (FAS), alcohol-related neurodevelopmental disorder (ARND) and alcohol-related birth defects (ARBD) and how to prevent them. When a child with problems related to maternal alcohol consumption is identified, alcohol treatment and prevention resources should be offered to the family and the affected child.

• Infants and children with a suspected diagnosis of FAS, ARND or ARBD should be evaluated by a physician who is knowledgeable and competent in the evaluation of neurodevelopmental and psychosocial problems associated with the diagnoses.

• Parents of children who are diagnosed with FAS, ARBD and ARND should receive appropriate support services for themselves and their child, including guidance for prevention of similar problems in the future.

The AAP committees also recommend physician support of state and federal legislation regarding alcohol use during pregnancy.

Use of Hypoallergenic Infant Formulas

The Committee on Nutrition of the American Academy of Pediatrics (AAP) has issued a statement on the use of hypoallergenic infant formulas. The AAP statement appears in the August 2000 issue of Pediatrics.

The AAP committee makes the following recommendations:

• Breast milk is an optimal source of nutrition for infants through the first year of life or longer. Breast-feeding infants who develop symptoms of food allergy may benefit from maternal restriction of cow's milk, eggs, fish, peanuts and tree nuts. If this is unsuccessful, a hypoallergenic formula (extensively hydrolyzed or, if allergic symptoms persist, a free amino-acid based formula) may be used as an alternative to breast-feeding. Infants with IgE-associated symptoms of allergy may benefit from a soy formula, as the initial treatment or started after six months of age after the use of a hypoallergenic formula. Benefits should be seen within two to four weeks and the formula continued until the infant is at least one year of age.

• Formula-fed infants with confirmed cow's milk allergy may benefit from the use of a hypoallergenic or soy formula as described for the breast-fed infant.

• Infants at high risk of developing allergy, identified by a strong family history of allergy, may benefit from exclusive breast-feeding or a hypoal-lergenic formula or possibly a partial hydrolysate formula. Conclusive studies are not yet available to permit definitive recommendations. However, the following recommendations seem reasonable at this time: (a) Breast-feeding mothers should continue breast-feeding for the first year of life or longer. Hypoallergenic formulas can be used to supplement breast-feeding. Mothers should eliminate peanuts and tree nuts and consider eliminating eggs, cow's milk and fish while nursing. Solid foods should not be given to high-risk infants until six months of age, with dairy products delayed until one year, eggs until two years, and peanuts, nuts and fish until three years of age. (b) No maternal dietary restrictions during pregnancy are necessary with the possible exception of excluding peanuts.

• Breast-feeding mothers on a restricted diet should consider the use of supplemental minerals (calcium) and vitamins.

FDA Approval of Single-Test for HbA_1c

The U.S. Food and Drug Administration (FDA) has approved marketing clearance for the Digital Response HbA_1c (glycosylated hemoglobin) patient monitor, a single-use quantitative test for long-term glucose monitoring in people with diabetes.

The pager-sized monitor allows physicians to measure glucose-bound hemoglobin in the office. Multiple tests can be performed simultaneously in high-volume practices. The monitor can also be used in the patient's home.

Glucose monitoring was once available only in clinical laboratories and could take up to a week to report results. The Digital Response HbA_1c monitor is designed to perform the HbA_1c test using a single drop of blood in about eight minutes. The patient's finger is pricked to gather a drop of blood with a supplied pipette, then the blood is mixed with a reagent and applied to the monitor. The HbA_1c percentage of whole blood is shown on the monitor's digital display.

According to Richard Bergenstal, M.D., director of the International Diabetes Center, the Digital Response monitor “should provide for more informed assessment of a patient's diabetes management and, ultimately, better prevention of the long-term complications of diabetes.”

NIH Statement on Antenatal Corticosteroids

Preterm delivery is a major cause of illness and death in infants. Previously, the National Institutes of Health (NIH) assessed the effectiveness of a single course of cortico-steroids in pregnant women at risk of preterm delivery, finding that it reduces the risk of death, respiratory distress syndrome and intraventricular hemorrhage in their preterm infants. Because of the recent widespread use of repeat courses of corticosteroid therapy, the NIH has recently released a consensus statement presenting research on repeat courses of antenatal corticosteroid therapy.

NIH Consensus Statement No. 112, “Antenatal Corticosteroids Revisited: Repeat Courses,” was published in August 2000. The consensus statement addressed the following three questions: Is the evidence on benefits and risks of repeat courses of antenatal corticosteroids sufficient to permit consensus recommendations? If so, what are the recommendations? If not, what additional information should be obtained?

The NIH found that data from currently available studies assessing benefits and risks are inadequate to argue for or against the use of repeat or rescue courses of antenatal corti-costeroids for fetal maturation. Therefore, the NIH makes the following recommendations:

• All pregnant women between 24 and 34 weeks of gestation who are at risk of preterm delivery within seven days should be considered candidates for antenatal treatment with a single course of corticosteroids.

• Treatment consists of two doses of 12 mg of betamethasone given intramuscularly 24 hours apart or four doses of 6 mg of dexamethasone given intramuscularly 12 hours apart, as recommended by the consensus panel in 1994. There is no proof of efficacy for any other regimen.

• Because of insufficient scientific data from randomized clinical trials regarding efficacy and safety, repeat courses of corticosteroids should not be used routinely. In general, it should be reserved for patients enrolled in randomized controlled trials. Several randomized trials are in progress.

The NIH also recommends that future research focus on well-designed randomized clinical trials that are of sufficient power to evaluate efficacy and safety. In light of possible risks, the design of clinical trials should minimize the exposure of mothers and fetuses while protecting the integrity of the research design. The statement is available on the NIH Web site athttp://www.odp.od.nih.gov/consensus/cons/112/112_statement.htm.