SMRUTHI SANATH, MD TITLE: MANAGEMENT OF Children with down syndrome

1. SMRUTHI SANATH, MDTITLE: MANAGEMENT OF Children with down syndrome • Target audience: Child Health staff physicians; all pediatric subspecialists; all courtesy faculty and referring physicians; pediatric residents, medical students and other professional staff at Children’s Hospital. • Objective: To improve the knowledge of physicians and therefore, their care for children in rural Missouri, especially those hospitalized or seen at Children’s Hospital.  To offer presentations which are clinically applicable but basic science that applies to the most contemporary treatments or illnesses.  • Speaker Disclosure: Smruthi Sanatha, MD has no relationship with any commercial firm having products related to topics discussed at this conference.  Additionally, as the chairman of this series, Dr. Thomas Loew has no conflict of interest to disclose that would lead to bias in the selection of topics and/or speakers of this series.  Actual disclosure forms are available upon request.The Office of Continuing Education, School of Medicine, University of Missouri is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.         • The Office of Continuing Education, School of Medicine, University of Missouri designates this live educational activity for a maximum of _1_ AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

2. Management of children with Down syndrome SmruthiSanath, M.D. Pediatric Resident (PGY-3) University of Missouri at Columbia

3. What will you learn from the presentation ? • What is Down syndrome? • Characteristics of DS • Medical conditions associated with DS • Updated health supervision guidelines from AAP • Recognition of co-morbidities that may be present in DS

4. Why is it called ? • Down syndrome was originally described in 1866 by John Langdon Down. • Down used the term mongoloid • It wasn't until 1959 that a French doctor, named Jerome Lejeune, discovered it was caused by the inheritance of an extra chromosome 21.

5. What causes DS?

6. Who is affected by DS? In U.S. • 1 in 691 Live births. • Odds of child with DS at age 35 are 1 in 350. • Under age 25, the odds are about 1 in 1200. • At age 40, the odds are about 1 in 100. • But 80% of births to women <35yrs. Life Expectancy increasing… • Average 58.6yrs • 25% live to >62yrs • Joyce Greenmanof London, turned 87 on March 14, 2012,

7. Who has increased risk of having a baby with DS? • Advanced maternal age • Having one child with DS previously • Carrying the genetic translocation for DS

8. Can DS be diagnosed prenatally? • First trimester • Early screening: maternal age, Nuchal fold, B-hcg, PAPP-A (sensitivity 82-87%) • Second trimester • Quadruple screen: maternal age, B-hcg, unconjugated estriol, AFP, Inhibin (sens 80%) • Integrated screen • Combination of both (sens 95%) • Diagnostic • CVS, Amniocentesis

9. New testing • Maternal T21 • 1 and 2 trimester (high risk patients) • 20 ml maternal blood sample • Extracts circulating cell-free fetal (“ccff”) DNA • Converts into a genomic DNA library • Uses massively parallel genomic sequencing • Detects T21 sensitivity 99.1%, specificity 99.9% • Also detects T18,T13

10. Counseling parents • Talking to parents in person about concerns • Social Support • Resources -CDC website (birth defects). • National center of medical home initiatives for children with special needs. • National Down syndrome Society (NDSS)

11. Prenatal visit • Prenatal test results -FISH and full karyotype. • Genetics /recurrence rates • “Range of variability”, balanced and positive outcomes • Studies/subspecialty consults • Available treatments/interventions • Options • Availability of genetic counseling.

12. Cont. If they want to continue pregnancy, • Plan for delivery/neonatal care: additional subspecialty care. • Parent- to- parent contact, local national groups. • Referral to clinical geneticist. • Refer to Maternal Fetal Medicine clinic.

13. Resources for Prenatal diagnosis • National Down syndrome society -www.ndss.org.

14. Diagnosis • Prenatal diagnosis • FISH and full karyotype. • obtain copy of the prenatal test results. • Postnatal diagnosis NEW • Share as soon as team suspects the diagnosis. • Karyotype only. • FISH • rapid (24-48 hrs) but cannot distinguish among mosaic, translocation and trisomy 21

15. NEWBORN

16. What does a child with DS look like? • Head • brachycephaly • Eyes • Inner epicanthal folds, • Brushfield spots • Upward slanting palpebral fissures • Face • Flat appearing, • low nasal bridge, • small ears • Excessive protrusion of tongue • Neck • excessive skin at the nape of the neck,short neck

17. Cont. • Fingers and Toes • single transverse palmar crease, and short fifth finger with clinodactyly. • Brachydactyly, wide spacing of 1st and 2nd toes. • CVS • VSD and endocardial cushion defects. • CNS • Absent or diminished Moro reflex, Hypotonia and joint hyperflexibility.

18. Heart problems 40- • Structural problems with formation of the heart (40-50%) • CAVC (45%) • VSD (35%) • PDA (7%) • TOF (4%) • Other (1%) • Every newborn needs echo • Monitor symptoms of CHF (Feeding, tachypnea, poor weight gain) • Increased risk for pulmonary hypertension. • Refer to cardiologist if echo abnormal

19. Feeding problems • NEW Refer to modified barium study/MBS. • Marked hypotonia. • Slow feeding • Choking with feeds • Unexplained FTT • Recurrent pneumonia • Recurrent or persistent respiratory sx. • To begin with they have anatomical issues -Oral anomalies, tongue protrusion.

20. GROWTH ISSUES • From late infancy, children with DS show a relative increase in Mean weight-for-length and weight-for-height • BMI (weight/stature2) • Excessive weight is a problem in adulthood. • One study of individuals with Down syndrome showed • Less than 15% were within desirable with range • 20-30% were overweight, and • Almost 50% were obese

21. Breast feeding • Breast milk is ideal food for support. • Consult lactation support early. • Oromotor benefits. • Many babies get to breast milk later. Encourage pumping! • Reassure parents. Don’t give up!

22. Gastrointestinal Issues Malformations (12%) • Evaluate for duodenal atresia or anorectal atresia/stenosis by history and exam. GER- • If severe or contributing cardiorespiratory problems or FTT. Constipation- • Evaluate for restricted diet/limited fluid intake, hypotonia, hypothyroidism, GI malformations and Hirschsprung disease (1%).

23. Sensory Vision (60%) • Cataracts (5%) • May progress slowly. • Refer to ophthalmologist for evaluation and treatment. Hearing (75%) • Universal Hearing screen (brainstem auditory evoked potential or otoacoustic emission) at birth. • Follow up completed by 3 months

24. Cardiorespiratory NEW Car-seat test: For babies with hypotonia or recent cardiac surgery, evaluate in car seat prior to discharge for • Apnea • Bradycardia • O2 desaturation • Stridor • Wheezing • Noisy breathing If severe or cardiopulmonary compromise or feeding problems- refer to pulmonologist.

25. Transient myeloproliferative disease • 10% of newborns with DS show leukocytosis with presence of blast cells in PBS-Transient Leukemia. • Most children with transient leukemia go into spontaneous remission and recover by 3 months of age. Of those who recover 20% -acute megakaryocytic leukemia (AML )in 4 yrs of age. • Follow up recommended Q 3 months for PBS. • Cure rate is more than 80%. • If TMD, counsel parents re: risk of leukemia & signs • Easy bruising, petechiae, onset of lethargy and change in feeding pattern. Incidence in DS is 1 %

26. Respiratory • Increase risk for respiratory infections like RSV. • Can see OSA even in infants • Screening: • Car seat study to assess for apnea, bradycardia and oxygen desats (h/o cardiac surgery, hypotonia) • Sleep study recommended for all children by age 4 or sooner if symptomatic. • 23-valent penumococcal vaccine at >2yrs if chronic respiratory or cardiac issues.

27. thyroid • Congenital Hypothyroidism (1%) • Check TSH. Newborn screen may only include thyroxine (T4) - Many children with DS have mildly elevated TSH and normal T4. • Discuss with endocrinologist.

28. Anticipatory guidance-Newborn • Susceptibility to respiratory tract infections • Cervical spine positioning precautions (Anesthesia, surgery, radiology) • Refer for early intervention. • Family support organizations. • Individual resources for support (friends, clergy). • Recurrent risk in subsequent pregnancies • Complementary and alternative treatments (safe and dangerous)

29. 1-12 months Hearing • Review serous otitis media (50-70%) • Review prior hearing test (BAER,ABR,OAE) • If passed, re-screen at 6 months. • If failed, refer to otolaryngologist. • If tympanic membrane not visible, refer (and then follow-up every 3-6 months). • Treat middle ear dysfunction promptly

30. Vision • Refer to ophthalmologist by 6 months to evaluate for strabismus, cataracts, nystagmus • Check vision at each visit • Lacrimal duct obstruction, refer for evaluation and surgical repair if not resolved by 9-12 months.

31. Cardiac Monitor infants with heart defects (VSD or AVSD) with shunting for symptoms of CHF • Tachypnea, • feeding difficulties, • poor weight gain. Nutritional support until surgery (NEW) If large VSD without obstruction to pulmonary blood flow, repair by 4 months of age to prevent pulmonary HTN. There is risk for pulmonary HTN even without cardiac defects.

32. Anemia • Incidence is 3% • Hemoglobin by age 1, then annually. • Children with DS have lower dietary iron than peers. MCV is elevated. • Serum ferritin and CRP or reticulocyte count should be checked for kids with low iron intake.

33. Other concerns • Growth monitor for weight, weight/height or BMI • (NEW) Don’t use Down syndrome charts • DS charts are currently being revised. • Cervical spine instability • Signs of myelopathy, careful exam and history. Discuss maintaining neutral spine for procedures. • OSA: Discuss symptoms and refer to specialist if symptoms are present

34. Cont. • Monitor for infantile spasms (1-13%) • Check TSH at 6 months,1 year • Immunizations -Age based and Influenza vaccination for the year

35. Anticipatory guidance 1-12 months • Support groups • Assess emotional status of parents, intrafamilial relationships, educate/support siblings. • Review early intervention • Discuss recurrence and prenatal testing at least once in first year.

36. 1-5yrs of age

37. Hearing • Review risk of hearing loss (30-50% age 3-5) • Behavioral audiometry & tympanometry every 6 months until ear-specific normal hearing. • Annual hearing test • Alternatively, BAER or OAE • Refer to otolaryngology if hearing loss

38. Vision • Check at every visit. • Annual ophthalmology evaluation • 50% chance of refractive errors leading to amblyopia between age 3-5

39. Atlantoaxial instability • Incidence 1-2% • Discuss at least every 2 yrs • C-spine positioning for anesthetic, surgical, radiographic procedure. • Careful history and physical

40. Symptomatic child Symptoms parents should seek urgent medical attention • Change in gait or use of arms or hands • Change in bladder or bowel function • Neck pain, stiff neck, head tilt, torticollis, change in head position • Change in general function • Weakness Lateral x-ray in neutral only (NEW). • if abnormal – urgent referral to neurosurgery or orthopedic surgery • If normal – flexion/extension films, prompt referral

41. Asymptomatic child • X-rays do not predict risk or reassurance - Routine x-rays NOT recommended (NEW) • Participation in some sports increases risk -football, soccer, diving, gymnastics (older kids) • Special Olympics may still require films.

42. OSA • Incidence (50-75%) • Symptoms -Heavy breathing, snoring, restless sleep, uncommon sleep positions, frequent night awakening, daytime sleepiness, apneic pauses, behavior problems. • BUT poor correlation parent report with OSA. • (NEW) Sleep study for all kids with DS by age 4. • Refer to specialist. • Discuss obesity as the risk factor.

43. Celiac disease • Incidence 5% • Symptoms -Diarrhea, protracted constipation, slow growth , FTT, anemia, abdominal pain or bloating or refractory developmental or behavioral problems. • If symptoms present, check tissue transglutaminase IgA and total IgA. • If abnormal, refer to gastroenterologist. • No evidence to support screen if asymptomatic.

44. Other concerns • TSH annually • Cardiology: follow up after repair. • Neurology: monitor for seizures. • Anemia: Check hemoglobin annually. Ferritin and CRP if risk for iron deficiency.

45. Anticipatory Guidance 1-5 yrs • Early intervention (OT, PT, Speech) • Transition to preschool • Behavior or social progress. • Refer if suspicion for autism, ADHD or other psychiatric or behavioral problem. • Vaccination-PCV 23 at 2 yrs or older if chronic cardiac or pulmonary disease. • Reassure regarding delayed dental and irregular dental eruption. • Encourage and model accurate terms for genitalia and respect for body parts • Counsel re: increased risk of sexual exploitation.

46. Psychosocial concerns • Sibling adjustment, behavioral management. • Socialization, recreational skills • Child’s education program -Learning problems -IEP

47. Other considerations • Review family dietary habits and physical activity pattern. • Obesity -Snacks and Television watching. • SSI and Medicaid benefits. • Investigate trust and guardian arrangements. • ARC (Association of retarded citizens)-financial and custody arrangements.

48. 5-13y

49. 5-13 years • Review symptoms related to celiac disease. • Cervical spine: review precautions. Instruct family to call immediately if new symptoms of myelopathy. • C-spine and sports: Counsel on increased risk with some sports. • Dry skin: sign of hypothyroidism. • Discuss symptoms of OSA. Refer if signs or symptoms are present. • Discuss obesity as a risk factor

50. Anticipatory guidance 5-13yrs • Review development, appropriateness of school placement. • Discuss socialization, family status and relationships, including financial arrangements, health insurance and guardianship. • Discuss development of age appropriate social skills, self help skills and development of a sense of responsibility.