Prenatal alcohol exposure (PAE) is the foremost preventable cause of neurodevelopmental disabilities and congenital disorders in the United States. It is recommended that pregnant persons abstain from alcohol use during pregnancy (Centers for Disease Control & Prevention, 2005). However, rates of alcohol consumption among pregnant persons in the United States has continued to increase since 2011 (Denny et al., 2020). Recent data indicate that 13.5% of pregnant persons reported consuming alcohol in the past 30 days and 5.2% reported binge drinking (≥ 4 drinks per occasion) during 2018–2020 (Gosdin et al., 2022). Fetal alcohol spectrum disorders (FASDs) are a range of diagnoses that can occur in a person prenatally exposed to alcohol. FASDs typically manifest as adverse, lifelong cognitive, behavioral, and/or physical outcomes (Bertrand & Dang, 2012; Manning & Hoyme, 2007; Streissguth & O’Malley, 2000). Studies among selected communities indicate the prevalence of FASDs range from 2 to 7% (May et al., 2009, 2018, 2021); other studies suggest rates of FASDs are markedly higher among certain populations in comparison to the general population, such as children in adopted/foster care and children of American Indian or Alaska Native descent (Abel, 1995; Chasnoff et al., 2015; Friedrich, 2019; Lange et al., 2013).

A documented history of alcohol use during pregnancy is an important component in the identification and diagnosis of children at risk for developing FASDs or other developmental issues (Bright Futures, 2017). An early FASD diagnosis facilitates early intervention, including connecting affected children with treatments and resources that might mitigate the impact of secondary and co-occurring conditions (i.e., mental health issues, learning disabilities, etc.) and maximize developmental and life potentials (Bertrand & Dang, 2012; Williams et al., 2015). Furthermore, due to similarities between FASDS and other neurodevelopmental disorders (e.g., attention-deficit/hyperactivity disorder (ADHD), autism spectrum disorder, etc.), documented information on PAE facilitates differential diagnosis by providing information related to etiology, potentially allowing for a more accurate diagnosis (Chasnoff et al., 2015; Popova et al., 2016; Weyrauch et al., 2017). Routinely assessing PAE during pediatric visits could also create opportunities to have a conversation with birth parents regarding alcohol use during breastfeeding and subsequent pregnancies.

The American Academy of Pediatrics (AAP) recommends screening for PAE in pediatric primary care settings (Bright Futures, 2017). They note that clinicians serving pediatric patients have the unique opportunity to identify, refer for diagnostic evaluation, and coordinate care for children with FASDs and their families. Although there is no standardized method for obtaining and documenting PAE history, recommendations center on inquiring about PAE with the birth mother (or other available caregiver) at least once and re-assessing, if needed, as symptoms indicative of an FASD or other developmental issues emerge across the life course (Bright Futures, 2017).

No prior studies have examined whether PAE screening is routinely conducted during pediatric patient interactions as recommended by AAP. This analysis examines how frequently clinicians serving pediatric patients gather information about potential prenatal alcohol exposure in their practice, as well as the methods employed to obtain this history. Additionally, this analysis examines variations in this practice among specific groups of pediatric patients and across different clinician specialties.

DocStyles is a web-based panel survey that samples primary care and specialty healthcare professionals to assess their attitudes and clinical practices regarding a variety of health conditions and diseases. The DocStyles 2020 Fall survey was commissioned by Porter Novelli Public Services and sampled from SERMO, a social network consisting of more than 350,000 medical professionals, between September 14th and October 26th, 2020. Porter Novelli set sample size quotas of 1000 primary care physicians (i.e., family practitioners and internists), 250 obstetrician-gynecologists (OB/GYNs), 250 pediatricians, and 250 nurse practitioners/physician assistants (NP/PAs). The time to complete the survey ranged between 10 and 40 minutes. Participation was optional, and respondents were paid an honorarium of $54-$72 for completing the survey.

Overall, most respondents were male (57.8%), White, non-Hispanic (68.9%), worked in group outpatient practices (77.4%), saw ≥ 100 patients per week (58.0%), and practiced in suburban communities (53.9%) (Table 1). There were some differences in demographic and practice characteristics by clinician specialty. For example, NPs/PAs differed from other clinician groups as a greater proportion were 40 years old or younger, female, practiced for 10 years or less, and saw fewer than 100 patients per week.

The frequency of collecting a history of PAE varied by pediatric subpopulation (Table 2). Among all clinician specialties, the highest proportion of respondents reported often/always obtaining a PAE history for children with developmental and behavioral issues (70.5%) followed by adopted/foster children (63.0%) and newborns (60.7%). In contrast, the highest proportion of respondents reporting never/sometimes obtaining a history of PAE was observed for new patients (61.8%) and infants (52.4%). When examining the frequency of collecting a PAE history by specialty, we found statistically significant differences between specialty categories for adopted/foster children and new patients. Among adopted/foster children, a significantly lower proportion of family practitioners (57.7%) reported often/always obtaining a history of PAE than pediatricians (71.5%, p = 0.002). For new patients, a significantly greater proportion of family practitioners (40.2%) and NP/PAs (46.4%) reported obtaining a history of PAE than pediatricians (29.8%; p = 0.003 and p = 0.002, respectively). Although we observed a statistically significant difference among specialty categories for infants (p < 0.05), post-hoc tests revealed no differences between specific specialty categories at the Bonferroni adjusted significance level (p < 0.017).

Among all clinician specialties, most respondents reported obtaining a history of PAE through interviews conducted by physicians or physician assistants (69.7%), and least reported using interviews by office staff (8.7%) (Table 3). About 1 in 4 respondents (26.1%) reported utilizing questions prompted by electronic health record (EHR) across clinician specialties. NP/PAs most often reported using interviews by allied health staff (e.g., medical assistants, nurses, etc.) as a method to obtain a history of PAE (44.2%) in comparison to other clinician specialties. Furthermore, pediatricians were more likely to use interviews conducted by physicians or physician assistants (79.0%).

A documented history of alcohol use during pregnancy is a valuable resource for identifying children at risk for an FASD. In this study, 30–62% of clinicians reported never or sometimes obtaining PAE history, depending on pediatric group examined. Pediatric patient subpopulations known to have high prevalence rates of FASDs (e.g. children with developmental/behavioral issues, adopted/foster children) were screened more frequently for PAE, though certain clinician specialties still showed room for improvement. However, pediatric patient groups outside of these high prevalence populations were not screened consistently, regardless of clinician specialty. These results indicate that PAE history is not routinely collected among pediatric patients, suggesting further studies are needed to understand factors that may facilitate universal PAE screening within pediatric clinical practice.

Several factors may contribute to the overall suboptimal rate of screening for PAE history and differences in PAE screening by pediatric subpopulation observed in this study. In previous studies, clinicians have reported feeling unprepared to identify, diagnose, and coordinate treatment for children with FASDs, having limited access to diagnostic resources for FASDs in their community (Gahagan et al., 2006), and experiencing time constraints due to competing medical care and screening priorities and the increased time needed for documentation (Gahagan et al., 2006; Smith et al., 2017). In addition, clinicians have also reported concerns around stigmatizing and offending families, as discussing alcohol consumption during pregnancy is a highly sensitive topic (Bright Futures, 2017; Gahagan et al., 2006; Smith et al., 2017). These concerns may create an unconscious bias, resulting in families perceived to be most at-risk for having a child with an FASD, such as foster or adoptive families, being screened more frequently than other families (Bright Futures, 2017). In this study, most clinicians reported often/always obtaining PAE history for children with developmental/behavioral issues, adopted/foster children, and newborns, but less than half reported this practice for new patients and infants. Such differential practices might reflect the sensitive nature of assessing this information and may contribute to disproportionately identifying PAE in certain populations and health disparities. Further studies examining specific factors impeding PAE screening, as well as potential facilitators, among clinicians serving pediatric patients may be necessary. Additionally, comprehensive trainings, linkages and access to resources, and reimbursement incentives for all specialties, designed to improve identifying children at risk of FASDs, might increase the proportion of clinicians who collect PAE history. Notably, the FASD Regional Education and Awareness Liaisons Champions Network provides trainings to build pediatric clinicians’ capacity for identifying children at-risk for FASD (American Academy of Pediatrics, 2021).

Our study highlights the significant role clinicians play in identifying children with FASDs and suggests creating positive patient relationships are important for collecting comprehensive and accurate family health history. The AAP recommends assessing PAE history for all children and recommends screening during any family interaction time, which may include during prenatal visits, the newborn period, adoption processes, and new patient visits (Bright Futures, 2017). In this way, questions regarding PAE are normalized to all pediatric patient populations and might decrease stigma and associated unconscious bias behaviors. A non-judgmental approach when discussing PAE can help establish a positive rapport between clinicians, patients, and their families which may help promote transparency. Furthermore, exercising cultural sensitivity is important when collecting PAE history as certain social groups may have strong beliefs regarding alcohol consumption that may impact how the caregiver responds to questions regarding PAE. The AAP has published an online toolkit and implementation guide for pediatric primary care clinicians that includes sample questions for PAE screening and prompts that clinicians may use to inquire about PAE history in a direct and compassionate manner (American Academy of Pediatrics, 2023; Bright Futures, 2017).

Few clinicians reported inquiring about PAE through questions prompted by EHR in this analysis, which might be explained by clinicians having difficulty modifying their practice’s existing EHR systems and a lack of uniformly accepted PAE documenting practices (Bright Futures, 2017). EHR systems have the potential to facilitate consistent collection and documentation of PAE history. Turchi et al., 2014; Kim et al., 2011; Spooner et al., 2007. Enhancing EHR system processes to include prompts and intake forms inquiring about PAE might facilitate clinician use of EHR systems for PAE history assessments, which could in turn promote the identification, diagnosis, and treatment of children with FASDs.

This study found that clinicians serving pediatric patients, from all specialties studied, are not routinely inquiring about instances of potential PAE in their practice interactions. The AAP recommends screening for PAE in pediatric primary care settings to facilitate identification of children with FASDs and promote timely access to behavioral and cognitive interventions. Clinicians serving pediatric patients may benefit from increased awareness of the importance of routinely screening for PAE, trainings on how to collect history of alcohol use during pregnancy, and additional practice supports to facilitate the PAE identification and documentation process. Consistent and accurate documentation of PAE history can enhance efforts to identify, diagnose, treat, and support children with FASDs and their families.