The article by Elliott et al in this issue raises many questions about how best to identify children who are affected by prenatal exposure to alcohol.1 This prospective, active case-finding national surveillance study in Australia showed the very low rate (0.58 per 105 children aged <15 years per annum) of the visible subset of children diagnosed by paediatricians with fetal alcohol syndrome (FAS). The authors considered the likelihood that there had been under-reporting of the syndrome due to several factors, including difficulty in making, or lacking in skills to make, a diagnosis, lack of awareness and recognition by physicians in considering the diagnosis, lack of reporting, lack of availability of specialists in high risk and remote areas, and paediatricians not being prepared to deal with a FAS diagnosis. This is not the first time that investigators have considered the possibility that many children with fetal alcohol spectrum disorder (FASD) are missed.2

Studies in other parts of the world suggest a much higher rate and prevalence. In a high participation county from a school age population study in Washington state, the minimal prevalence of full-blown FAS was 3.1 per 1000.3 In the USA, the best estimates for the whole spectrum of affected children with FASD suggest a prevalence approaching 1%.4 In Western Canada, the rates in selected communities and regions showed …