The Delphi method was used, a systematic and interactive prospecting method based on a panel of experts. It enables a group of experts to be questioned on a defined subject in order to reach a consensus (11). Each expert is interviewed individually and anonymously on the basis of an initial questionnaire.

The use of an expert panel should not be confused with the consultation of a group of high-ranking scientists. An expert is defined as a person with sufficient knowledge of the subject because of professional or personal involvement in the issue (11, 12).

For this study, the recruitment of experts implied knowledge in the field of FASD through their professional practice or personal involvement in this issue. The inclusion criteria for the various players who were sought to make up the expert group were:

As far as general practitioners are concerned, the inclusion of those who have or have had a practice focused on child health and/or women’s health and/or addictology was favored.

Recruitment was network-based. Experts were invited individually by email (Appendix 2), explaining the objectives of the study and the Delphi method. They were integrated into the network after having familiarized themselves with the elements and agreed to the study’s modalities.

The expert group is made up of 26 experts, including seven men and 19 women. They were mainly general practitioners (13), but also pediatricians (3), midwives (2), Localized units for school inclusion schoolteacher (1), resource center neuropsychologists (2), gynecologist (1), addictologist (1), nursery nurse (1), geneticist (1), and parent of children with fetal alcohol syndrome and association representatives (1) (Figure 1).

A request for compliance with the MR004 reference method was made to the Commission Nationale de l’Informatique et des Libertés (CNIL) prior to the study, and registered under n°2,226,567.

The data were collected anonymously via a data entry mask edited with the Google Forms® application.

Twenty-six invitations to reply to the first questionnaire were sent to the experts on July 11 2022. Experts were given 3 weeks to respond. A reminder was sent on August 1, 2022 to experts who had not responded to the initial questionnaire. A 2-week extension was granted, as several experts were on vacation during this period and did not receive their mail. Twenty-five experts were able to respond to the first questionnaire between July 11, 2022 and August 22, 2022 (Figure 2).

Among the 24 actions proposed in the first round:

Here are the eight consensus actions from the first round:

Sixteen actions did not achieve consensus in the first round. Three actions were dropped after analysis of the first questionnaire, as analysis of the comments did not reveal any new proposals. Three other actions were dropped because their objectives were close to those of the consensus actions. These were to discuss the best time to distribute an information document on fetal alcohol syndrome, and which training medium should be used to train GPs. Three actions were reformulated individually in the second questionnaire. Lastly, the comments on seven actions were analyzed by theme, leading to the proposal of three new actions to complete the second questionnaire (Table 1).

Twenty-five invitations to reply to the second questionnaire were sent to the experts on October 10, 2022. Experts were given 3 weeks to respond. Two reminders to complete the questionnaire were sent out during this period. Twenty-one experts were able to respond to the second questionnaire between October 10, 2022 and October 31, 2022. Four experts did not reply. The reasons for their non-participation have not been identified (Figure 1).

Of the six actions proposed in the second round, all six were approved by experts, including three with consensus:

The total number of actions (eight actions in the first round and three actions in the second round, i.e., 11 actions) was deemed sufficient to build consensus, enabling the Delphi Round to be closed.

Unlike the initial questionnaire analysis, comments on each action were analyzed individually (Table 2).

Various studies on the prevention or identification of FASD using a Delphi round have been carried out in Australia (13) and South Africa (14). This study is original to France. The use of a Delphi round made it possible to convene a multidisciplinary group of experts, the majority of whom were general practitioners spread across the whole of Reunion Island. The selection of experts was the subject of numerous discussions between the researchers (AP-B, SL, and MS). This search for consensus is part of an action research project on the prevention and detection of fetal alcohol spectrum disorders in general practice. Regarding the high prevalence of FASD in general population, an agreement was found to select experts in primary care first. As with any selection process, there are limits to the participation of the people involved. The strong point of this method is the possibility of commenting anonymously, thus avoiding the effect of authority or opinion leaders (15). What is furthermore, the use of email to set up this study saved time and money.

Even if several professions working with FASD were represented on the expert panel, other players could have been involved, which constitutes a recruitment bias. Several reports emphasize the importance of identifying FASD in the course of legal proceedings. In 2018, an agreement was signed between the youth legal protection agency and the Reunion resource center to train its professionals in FASD (16). The absence of patients with FASD was also noted. Including other players in the expert group could have altered the results, potentially constituting a reproducibility bias.

This research is part of an action research project. At present, four actions seem relevant for rapid implementation:

Consensus was based on two calculations: the median and the degree of convergence. After a thematic analysis, the experts’ free comments were also considered. These comments modulated the results of the calculations in the consensus decision.

The first action concerns the systematic introduction of a pre-conception consultation for women wishing to become pregnant. This non-compulsory but “strongly recommended” consultation is reimbursed at 70% (17). Its modalities have not been updated by the HAS since 2009, and were issued in response to a request from healthcare professionals following the abolition of the pre-nuptial consultation in 2007 (18). This consultation assesses medical, behavioral and social risks during pregnancy. It helps reduce the risks that can arise very early on during organogenesis, and later during embryonic and fetal development (19). A study carried out in 2015 on 392 patients suggested that only 15% had attended a pre-conception consultation, and that this constituted primiparous patients with a high socio-professional level (20).

The second action concerns the systematic identification of environmental factors during the child’s follow-up. Action levers for identifying FASD must take the environment into account. Studies of the psychosocial behavior of children with FASD have highlighted behavioral disorders that appear to be specific, resulting from an interaction between prenatal exposure to alcohol and environmental factors (21, 22). The impact of environmental factors has been demonstrated in the expression of other pathologies, notably psychiatric ones such as schizophrenia (23).

The third action proposed for implementation in the short term is the systematic distribution of an information document on the effects of fetal alcohol exposure when folic acid is prescribed pre-conceptionally or at the start of pregnancy. In 2016, in Nouvelle Aquitaine, a feasibility study was carried out on the distribution of this document by the general practitioner among women of childbearing age (24). The acceptability of the study and the information document was 100% with women, and this helped to encourage 34% of them to discuss their alcohol consumption with a healthcare professional. However, in this study, only 37% of women of childbearing age received the information leaflet. In our study, the experts suggested targeting the distribution of this type of document to women wishing to become pregnant or in early pregnancy.

Finally, the publication of an information leaflet for general practitioners on the identification of children with FASD, with contact details for associations, would also seem appropriate. The SAF France association, recognized by a number of learned societies, recommends that professionals be given the definition of FASD, as well as key figures such as incidence and patient association contacts, to help women in vulnerable situations. In 2021, a survey conducted by this association questioned 302 French general practitioners. Only 24% of them claimed to have precise knowledge of fetal alcohol spectrum disorders, and 1/3 of them said they did not systematically discuss alcohol consumption in early pregnancy (25). The publication of this brochure is a first step toward providing information and encouraging training.