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This study is the ninth cross‐sectional community study of fetal alcohol spectrum disorders (FASD) conducted by the multidisciplinary Fetal Alcohol Syndrome Epidemiology Research team in the Western Cape Province of South Africa. It is the third comprehensive study of FASD in a rural, agricultural region of South Africa. Population‐based, active case ascertainment methods were employed among a school‐based cohort to assess child physical and neurobehavioral traits, and maternal risk factor interviews were conducted to identify all children with FASD to determine its prevalence. Consent was obtained for 76.7% of 1158 children attending first grade in the region's public schools. Case–control results are presented for 95 with fetal alcohol syndrome (FAS), 64 with partial fetal alcohol syndrome (PFAS), 77 with alcohol‐related neurodevelopmental disorder (ARND), 2 with alcohol‐related birth defects (ARBD), and 213 randomly‐selected controls. Four techniques estimating FASD prevalence from in‐person examinations and testing yielded a range of total FASD prevalence of 206–366 per 1000. The final weighted, estimated prevalence of FAS was 104.5 per 1000, PFAS was 77.7 per 1000, ARND was 125.2 per 1000, and total FASD prevalence was 310 per 1000 (95% CI = 283.4–336.7). Expressed as a percentage, 31% had FASD. Although the rate of total FASD remained steady over 9 years, the proportion of children within the FASD group has changed significantly: FAS trended down and ARND trended up. A detailed evaluation is presented of the specific child physical and neurobehavioral traits integral to assessing the full continuum of FASD. The diagnosis of a child with FASD was significantly associated with maternal proximal risk factors such as: co‐morbid prenatal use of alcohol and tobacco (OR = 19.1); maternal drinking of two (OR = 5.9), three (OR = 5.9), four (OR = 38.3), or more alcoholic drinks per drinking day; and drinking in the first trimester (OR = 8.4), first and second trimesters (OR = 17.7), or throughout pregnancy (OR = 18.6). Distal maternal risk factors included the following: slight or small physical status (height, weight, and head circumference), lower BMI, less formal education, late recognition of pregnancy, and higher gravidity, parity, and older age during the index pregnancy. The prevalence of FASD remained a significant problem in this region, but the severity of physical traits and anomalies within the continuum of FASD is trending downwards. High community prevalence of FASD persisted over nine years, but severity of diagnosis trended downwards. Prevalence of FAS was 10.5%, and total FASD was 31%. Associated with FASD diagnoses were: co‐morbid use of alcohol and tobacco (OR = 19.1); drinking two (OR = 5.9) or four drinks per drinking day (OR = 38.2); first trimester drinking (OR = 8.4) or all trimesters (OR = 18.6). Distal maternal risks included: low formal education, slight physical status, lower BMI, late recognition of pregnancy, and higher gravidity, parity, and older age.

To investigate gestational age and growth at birth as predictors of fetal alcohol spectrum disorders (FASD). The sample analyzed here comprises 737 randomly selected children who were assessed for growth, dysmorphology, and neurobehavior at 7 years of age. Maternal interviews were conducted to ascertain prenatal alcohol exposure and other maternal risk factors. Birth data originated from clinic records and the data at 7 years of age originated from population‐based, in‐school studies. Binary linear regression assessed the relationship between preterm birth, small for gestational age (SGA), and their combination on the odds of a specific FASD diagnosis or any FASD. Among children diagnosed with FASD at 7 years of age (n = 255), a review of birth records indicated that 18.4% were born preterm, 51.4% were SGA, and 5.9% were both preterm and SGA. When compared to non‐FASD controls (n = 482), the birth percentages born preterm, SGA, and both preterm and SGA were respectively 12.0%, 27.7%, and 0.5%. Mothers of children with FASD reported more drinking during all trimesters, higher gravidity, lower educational attainment, and older age at pregnancy. After controlling for usual drinks per drinking day in the first trimester, number of trimesters of drinking, maternal education, tobacco use, and maternal age, the odds ratio of an FASD diagnosis by age 7 was significantly associated with SGA (OR = 2.16, 95% CI: 1.35 to 3.45). SGA was also significantly associated with each of the 3 most common specific diagnoses within the FASD continuum: fetal alcohol syndrome (FAS; OR = 3.1), partial FAS (OR = 2.1), and alcohol‐related neurodevelopmental disorder (OR = 2.0). SGA is a robust early indicator for FASD in this random sample of children assessed at 7 years of age. Among children diagnosed with FASD at seven years of age, 18.4% were born preterm, 51.4% were small‐for‐gestational‐age (SGA), and 5.9% were both preterm and SGA, compared to 12%, 28%, and 0.5% for non‐FASD controls. After controlling for the usual number of drinks per drinking day in 1st trimester, the number of trimesters drank, maternal education, tobacco use, and maternal age, the odds ratio of an FASD diagnosis by age seven was significantly associated with SGA (OR=2.16, 95% CI:1.35‐3.45).

Twenty years of collaborative epidemiology research in South Africa have revealed the highest reported rates of fetal alcohol spectrum disorders (FASD) in the world. The FASD research in South Africa has now expanded beyond prevalence research to maternal risk factor studies, longitudinal development studies, brain imaging studies, school intervention studies, and comprehensive prevention studies. The burden presented by the high numbers of affected individuals in South Africa is significant and a call to action is needed. This paper will outline the prevalence of FASD, review the South African governmental responses to the problem, report on the FASD research that has been completed, describe the prevention and intervention efforts that have been implemented, and outline how pediatric neuropsychologists and school psychologists can work with stakeholders to improve the lives of affected individuals and their families.

•Depending on the cutoff, PEth identified 47% - 70% as alcohol-consuming.•Self-report from participants identified 65% to 75% as alcohol-consuming.•Lower PEth cutoffs had high sensitivity and accuracy when compared to self-report.•For human research purposes, PEth >2 and >4 ng/ml are most sensitive and accurate.•For non-forensic purposes, PEth >20 ng/ml may be too strict a threshold.

•Maternal weight was inversely related with infant dysmorphology score.•The rate of change was similar among all infants regardless of maternal weight.•Maternal weight may be protective but does not eliminate adverse effects of alcohol.•Regardless of maternal weight during pregnancy, alcohol remains a teratogen.

Objectives: This is a third exploration of risk factors for the two most severe forms of fetal alcohol spectrum disorders (FASD), fetal alcohol syndrome (FAS) and Partial FAS (PFAS), in a South African community with the highest reported prevalence of FAS in the world.