Diagnosing prenatal alcohol exposure and fetal alcohol syndrome in military-connected children: Insights from US military data claims, 2016-2023.

Background: Fetal alcohol spectrum disorder (FASD) is a lifelong neurodevelopmental condition resulting from prenatal alcohol exposure (PAE) during gestation. Conservative estimates of FASD prevalence in United States children are 1%-5%. Early identification could facilitate early intervention, yet fewer than 1% of children with FASD receive a diagnosis. Although heavy alcohol use has been part of military culture for decades, the epidemiology of FASD is unknown in the Military Health System (MHS), where 1.9 million children receive care.

Methods: Using an open cohort design and military claims data for 2016-2023, we calculated period prevalence, annual and cumulative incidence, and average age at first diagnosis for FASD in military children 0-18 years. FASD diagnosis was defined using available diagnostic codes representing a small subset of the broader FASD spectrum of conditions, that is, newborn affected by PAE and fetal alcohol syndrome (FAS). We conducted chi-squared tests and multivariable logistic regression to identify sociodemographic factors associated with these combined diagnoses.

Results: One thousand four hundred seventy six unique children had any diagnosis between 2016 and 2023 (PAE only: 301; FAS only: 1061; both: 114). Period prevalence was 0.42 cases per 1000 children. Cumulative incidence was 0.34 cases per 1000 children for 2017-2023 using 2016 as a 1-year washout. Average age at any diagnosis was 8.3 years. Factors associated with increased likelihood of diagnosis were male sex; being in guardianship; sponsor of senior officer rank; and sponsor affiliated with the Air Force or Other Service branch. Factors associated with decreased likelihood of diagnosis included Black or Other race; being a stepchild; sponsor of junior enlisted or junior officer rank; and sponsor in the Marine Corps.

Conclusions: Like in the US general population, FASD is underdiagnosed in the MHS. Further study of an expanded set of co-occurring conditions under the FASD umbrella may aid in refining estimates of FASD in the MHS.