Understand. Recognise. Support.

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Per SIGN 156: All three sentinel facial features must be present. These are highly specific to prenatal alcohol exposure and, when all three are present, confirmation of alcohol exposure through other means is not required.

The Three Sentinel Facial Features:

• Smooth philtrum — ranked 4 or 5 on the University of Washington Lip-Philtrum Guide
• Thin vermillion border (upper lip) — ranked 4 or 5 on the Lip-Philtrum Guide
• Short palpebral fissures — palpebral fissure length 2 or more standard deviations below the mean

Plus:

• Prenatal alcohol exposure confirmed or unknown (not when exposure is confirmed absent)
• Severe impairment in 3 or more of the 10 areas of assessment, or microcephaly in infants and young children

Note: Features such as flat midface, low nasal bridge, or short nose are associated features, not sentinel features. Only the three above are sentinel.

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This is the most common presentation. National FASD estimates fewer than 1 in 10 people with FASD have all three sentinel facial features. Facial features are absent, or fewer than three are present.

Diagnostic Criteria (both required):

• Confirmed prenatal alcohol exposure — documented evidence of alcohol use in this pregnancy is required where facial features are absent (SIGN 156)
• Pervasive brain dysfunction — severe impairment in 3 or more of the 10 SIGN 156 neurodevelopmental domains (see below)

There is no 'mild' FASD — neurodevelopmental impairment in this presentation can be equally or more severe than in the facial-features presentation.

Per SIGN 156: Severe impairment in 3 or more of these domains = pervasive brain dysfunction. Each domain must be assessed by a qualified professional using standardised tools. See the full SIGN 156 criteria for each area.

• Brain structure / Neuroanatomy / Neurophysiology
• Motor skills (fine and gross motor, coordination)
• Cognition (intellectual ability, processing)
• Language (receptive and expressive)
• Academic achievement
• Memory (overall, verbal and visual memory)
• Attention (sustained and selective attention)
• Executive function (including working memory, impulse control, hyperactivity, planning and flexibility)
• Affect regulation (diagnosed mood and anxiety disorders)
• Adaptive behaviour, social skills, and social communication

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SIGN 156 and NICE QS204 recognise a third category for children who do not yet meet full diagnostic criteria but remain at increased risk:

• Confirmed PAE with some signs of neurodevelopmental difficulty, but the assessment cannot yet meet full criteria (for example, the child is too young or the assessment is incomplete)
• All three sentinel facial features present, without yet meeting the criteria for 3 areas of assessment or microcephaly. Never used when exposure is confirmed absent
• Should receive monitoring, support, and re-assessment as the child develops

NICE QS204 states: support should not wait for a formal diagnosis — children at increased risk should receive early intervention.

• Memory difficulties (especially short-term and working memory)
• Poor cause-and-effect reasoning
• Difficulty with abstract concepts
• Impulse control challenges
• Attention and concentration difficulties
• Language delays or processing difficulties
• Inconsistent performance — 'good days and bad days'

• Difficulty understanding consequences
• Emotional dysregulation / meltdowns
• Confabulation (apparent lying — neurological, not intentional)
• Difficulty with transitions and change
• Social naivety / over-friendliness with strangers
• Sleep disturbances

• Growth restriction (height, weight, or head circumference)
• Microcephaly (OFC ≤ 3rd centile) — particularly significant in infants
• Sensory processing differences (over or under-responsive)
• Poor fine and gross motor coordination
• Feeding difficulties in infancy
• Hearing or vision problems