Fetal Alcohol Spectrum Disorders (FASD) are the most common preventable neurodevelopmental disabilities. Despite international recognition of FASD as a major public health challenge, such as in the World Health Organization’s Global Alcohol Action Plan, this recognition has not always translated into concrete policy responses, even in high-income countries with high levels of alcohol consumption. The case of Ireland illustrates how a lack of high-level strategic recognition of FASD as a public health and social policy challenge has resulted in limited state action and a high prevalence of FASD. The paper provides an overview of FASD and presents a comparison of ten high-income countries with high alcohol consumption rates but markedly different estimates of FASD prevalence. It then provides an analysis of Ireland’s policy response to FASD, identifying its strengths, gaps, and implications for international policy learning.