The Knotted Cord: An Update on Transgenerational Alcohol is a follow up to the original The Knotted Cord published in 2014. It is written as a conversation between myself in 2014 and then in 2019. The conversation is structured around the chapters of the initial book. Thus Ireland’s toxic romance with alcohol, the stigma of transgenerational alcohol and the ethical dilemma of diagnosing and managing Neurodevelopmental Disorder prenatal alcohol exposure offer the beginning thrust to the book showing what has changed in the intervening five years and what has not changed. Overall the book is a critical and academic update on the complexities of understanding transgenerational alcohol and its impacts on societies worldwide. Management has clearly been placed in a Systems of Care paradigm, which is consistent with the 2014 book. However the intervening five years have produced a new clinical instrument, the Early Childhood Service Intensity Instrument (ECSII). The clinical emphasis on mothers and children under five years of age has become the entry into decreasing the impact of transgenerational alcohol. At the moment, the teratogenic effect of alcohol on the developing fetus remains frozen in being only related to a dysmorphic face. This is far from the truth as this prenatal acquired brain injury causes a mainly hidden, non-IQ, non-Face driven Global neurodevelopmental disorder, now more correctly diagnosed as Neurodevelopmental Disorder prenatal alcohol exposure, NDPAE, DSM 5.Code 315. Lastly, the challenge of approaching transgenerational alcohol and its impacts is a challenge to traditional medical practices of child and adult care. This disconnected model of care does not fit as medical, nursing, addiction and social workers need to move out of their silos and communicate with health professionals across the age range and accept this ‘orphan’ condition.