Neurology Book


Down Syndrome

Aka: Down Syndrome, Mongolism, Trisomy 21
  1. See Also
    1. Antepartum Down Syndrome Screening
  2. Epidemiology
    1. Most common chromosomal abnormality
    2. Down Syndrome births: 10,000 per year in U.S. (1 in 691 live births)
    3. Prevalence: 10.3 per 10,000
  3. Risk Factors
    1. Advanced Maternal Age over 34
      1. Risk increases with age, but births to young mothers still account for 80% of cases
      2. Mother age 35 years old: One in 400 births have Down Syndrome
      3. Mother age 40 years old: One in 105 births have Down Syndrome
      4. Mother age 45 years old: One in 12 births have Down Syndrome
    2. Prior child with Trisomy 21 (1% recurrence risk)
    3. Carriers of a balanced translocation of Chromosome 21
  4. Pathophysiology
    1. Trisomy of Chromosome 21 (Segment 21q22, long arm)
    2. Karyotypes
      1. Trisomy of entire Chromosome with 47 Chromosomes, unfamilial (95 to 97% of cases)
      2. Unbalanced translocation (4%)
        1. Chromosome with extra or missing genetic material
      3. Genetic mosaicism (2%)
        1. At least 2 cell populations with different Genotypes in the same person
  5. Signs
    1. Head and Facies
      1. Brachycephaly (100%)
      2. Small anteroposterior cranial dimension
      3. Posterior third Fontanel
      4. Small, low set, folded ears
      5. Persistent Inner Epicanthal Folds (90%)
      6. Mongoloid, upper slanted eyes (90%)
      7. Esotropia (50%)
      8. Brushfield's Spots (Speckled, hypopigmented) of iris (50%)
      9. Short flat nose
      10. Macroglossia (75%)
      11. Small chin
      12. Arched Palate
    2. Body Habitus
      1. Broad short neck with excessive skin
      2. Protuberant Abdomen
      3. Hyperflexibility
    3. Neurologic
      1. Moderate to severe Mental Retardation
      2. Muscular hypotonicity
    4. Hands
      1. Short, broad fingers and hand
      2. Curved pinky finger (clinodactyly)
      3. Single Simian crease with loss of palmar crease
    5. Foot
      1. Absence of whorl on ball of foot
        1. Presence of whorl suggests a child without Down Syndrome
      2. Sandal gap
        1. Widened gap between first and second toes
    6. Cardiopulmonary
      1. Cardiac murmur (50%)
  6. Labs: Diagnosis
    1. Fluorescent in situ hybridization
      1. Confirms Down Syndrome
    2. Complete genetic karyotype analysis
      1. Most common: 47 Chromosomes with Trisomy 21
      2. Karyotype used to guide future pregnancy plans
  7. Associated Conditions
    1. Neurologic
      1. Developmental Delay
      2. Intellectual Disability
        1. Mild: IQ of 50 to 69
        2. Moderate: IQ 35 to 49
        3. Severe: IQ 20 to 34
      3. Seizure Disorder
      4. Autism
      5. Alzheimer's Disease clinically evident
        1. Age 30-39: 0 to 10% Prevalence
        2. Age 40-49: 10 to 25% Prevalence
        3. Age 50-59: 28 to 55% Prevalence
        4. Age 60-69: 30 to 75% Prevalence
    2. Mental Illness (30%)
      1. Major Depression (treat with SSRIs)
      2. Obsessive-Compulsive Disorder
      3. Physical abuse or sexual abuse history
      4. Conduct Disorder
      5. Self-Talk (Soliloquy) is normal (esp. when stressed)
    3. Endocrine
      1. Hypogonadism (100% in males)
      2. Congenital Hypothyroidism (10 to 40%)
      3. Hashimoto's Thyroiditis (30%)
      4. Hyperthyroidism
      5. Diabetes Mellitus (RR 4 in under age 30, RR 2 in over age 30)
    4. Musculoskeletal
      1. Atlantoaxial Instability (1-2%, although up to 14% in some studies)
        1. No routine Cervical Spine imaging indicated unless symptomatic (e.g. Cervical Myelopathy)
      2. Spinal Cord Compression (with secondary Myelopathy)
        1. May present with gait disorders, bowel or Bladder changes or muscular weakness
      3. Congenital Hip Dislocation
      4. Congenital Hip Dysplasia
      5. Patella subluxation (and other ligamentous laxity)
    5. Cardiovascular
      1. Polycythemia
      2. Mitral Valve Prolapse
      3. Pulmonary Hypertension (10%)
      4. Congenital Heart Disease (50%)
        1. Ventricular Septal Defect (most common)
        2. Endocardial Cushion Defect (most specific heart defect for Down Syndrome)
          1. AV canal defect with single chamber combining atria and ventricle
    6. Gastrointestinal
      1. Duodenal Atresia (neonates)
      2. Bowel Obstruction
      3. Celiac Sprue (Gluten Sensitive Enteropathy)
      4. Constipation
      5. Hirschsprung's Disease
        1. Presents earlier in Down's Syndrome
        2. Typically fails to pass meconium
        3. May present as Constipation, painless Abdominal Distention
    7. Otolaryngology
      1. Obstructive Sleep Apnea (>50%)
      2. Conductive and Sensorineural Hearing Loss (70%)
      3. Periodontal Disease and Gingivitis
      4. Macroglossia
      5. Tracheal stenosis
      6. Recurrent Serous Otitis Media (associated Hearing Loss)
      7. Delayed dental eruption and hypodontia
      8. Tortuous small ear canals
        1. Tympanic Membranes are often difficult to visualize
    8. Ophthalmology
      1. Cataracts (13%)
      2. Refractive Error
      3. Keratoconus (15%)
      4. Strabismus
    9. Dermatology
      1. Xerosis
    10. Hematology
      1. Polycythemia (>18%)
      2. Iron Deficiency Anemia (10%)
      3. Transient myeloproliferative disorder (10%)
      4. Leukemia (1%)
    11. Malignancy
      1. Acute Myelogenous Leukemia
      2. Acute Lymphocytic Leukemia
      3. Testicular Cancer
  8. Imaging
    1. Echocardiography
      1. Typically done following delivery as newborn, and repeated as indicated
    2. Cervical Spine XRay
      1. Not recommended for universal screening
      2. Indicated in age 3 years and older for suspicion for Atlantoaxial Instability
  9. Management: Initial Diagnosis
    1. Confirm diagnosis (see labs above)
    2. Obtain appropriate diagnostics (see approach to birth to one month below)
    3. Address consideration of Down Syndrome diagnosis with parents
      1. Unexpected Down Syndrome diagnosis will be accompanied by increased parental worry
      2. Congratulate the parents on their newborn first, then focus on the evaluation
      3. Involve consultants to help address parental questions
    4. Referrals
      1. See age specific guidelines below
      2. Early intervention program (U.S. state specific)
        1. Team of consultants (PT, OT, Speech, Vision and child psychology)
        2. Establishes medical home
        3. Investigates eligibility for services (financial, social, mental health)
        4. Creates Individual Family Services Plan (for first 3 years of life to guide care)
    5. Care Plans
      1. Individual Family Service Plan (birth to 3 years)
      2. School-focused Individualized Education Program (3 years and older)
  10. Management: Adults
    1. Disposition Options for Adult Patients
      1. Independent living with supervision
      2. Group Homes
    2. Adults assumed competent to make medical decisions
      1. Address competence early if questionable
      2. Consider guardianship
      3. Evaluate Advanced Directives
      4. Consider power of attorney for finances and health
    3. Emergency department precautions
      1. Intubation precautions
        1. Macroglossia
        2. Atlantoaxial Instability (maintain c-spine precautions)
      2. Trauma precautions
        1. Low threshold for Cervical Spine imaging
  11. Prevention: Birth to one month
    1. Findings
      1. Standard Newborn Examination
      2. Assess for oxygen desaturation in a Car Seat
      3. Respiratory: Apnea, Stridor, Wheezing
      4. Cardiovascular: Bradycardia
      5. Gastrointestinal: Constipation, Duodenal Atresia, GERD
      6. Eye: Congenital Cataracts (via red Reflex Exam)
    2. Screening and Immunizations
      1. Standard Newborn Screen for Inborn Errors of Metabolism
      2. Standard Newborn Hearing Screening
    3. Labs and Diagnostics
      1. Complete Blood Count (CBC)
      2. Complete chromosomal karyotyping
      3. Echocardiogram (50% have congenital cardiac defect)
      4. Thyroid Stimulating Hormone (TSH)
      5. Consider Swallowing study (for marked hypotonia, or feeding difficulty)
    4. Referrals
      1. Pediatric cardiology
      2. Early intervention program - see below (U.S. state specific)
      3. Consider audiology, endocrinology, pulmonology referrals
  12. Prevention: Age 1 month to 1 year
    1. Findings
      1. Neurologic: Myelopathy (spinal cord disorders), Seizure Disorder
      2. Respiratory: Sleep Apnea
      3. Eye: Congenital Cataracts (via red Reflex Exam)
    2. Screening and Immunizations
      1. Pediatric Auditory Screening at age 6 months
      2. Pediatric Eye Exam
      3. Standard Primary Series of Immunizations
    3. Labs and Diagnostics
      1. Complete Blood Count (CBC)
      2. Thyroid Stimulating Hormone (TSH) at ages 6 and 12 months
      3. Consider CRP and Serum Ferritin
    4. Referrals
      1. Ophthalmology
      2. Consider otolaryngology, pediatric sleep specialist
  13. Prevention: Age 1 to 5 years
    1. Findings
      1. HEENT: Hypodontia (or delayed Tooth Eruption), Otitis Media
      2. Neurologic: Myelopathy (spinal cord disorders), Seizure Disorder
      3. Respiratory: Sleep Apnea
    2. Screening and Immunizations
      1. Autism screening at 18 months and 24 months
        1. Consider repeating at 3 to 5 years of age if Developmental Delay interferes with screening
      2. Influenza Vaccine
      3. Vision Screening yearly
      4. Hearing screening every 6 months until 4 years of age
      5. Review care plans (every 6 months)
        1. Individual Family Service Plan (birth to 3 years)
        2. School-focused Individualized Education Program (3 years and older)
    3. Labs and Diagnostics
      1. Complete Blood Count (CBC) yearly
      2. Thyroid Stimulating Hormone (TSH) yearly
      3. Consider CRP and Serum Ferritin yearly
      4. Consider Cervical Spine XRay
      5. Consider Celiac Disease testing (TTG)
    4. Referrals
      1. Ophthalmology yearly
        1. Refractive Errors and Amblyopia risk in up to 50% of patients
      2. Sleep sudy by age 4 years old
      3. Consider pediatric cardiology
  14. Prevention: Age 5 to 13 years
    1. Findings
      1. Behavioral disorders (e.g. Attention Deficit Disorder)
      2. Neurologic: Myelopathy (spinal cord disorders), Seizure Disorder
      3. Xerosis
    2. Screening and Immunizations
      1. Body Mass Index (BMI)
    3. Labs and Diagnostics
      1. Complete Blood Count (CBC) yearly
      2. Thyroid Stimulating Hormone (TSH) yearly
      3. Consider CRP and Serum Ferritin yearly
    4. Referrals
      1. Audiology yearly
      2. Ophthalmology every 2 years
      3. Consider pediatric cardiology, pediatric sleep specialist
  15. Prevention: Age 13 to 21 years
    1. Findings
      1. Behavioral disorders
      2. Neurologic: Myelopathy (spinal cord disorders), Seizure Disorder
      3. Cardiovascular: Mitral and aortic valve disorders
      4. Gynecologic care
    2. Screening and Immunizations
      1. Body Mass Index (BMI)
      2. Review School-focused Individualized Education Program
      3. Review family support
    3. Labs and Diagnostics
      1. Complete Blood Count (CBC) yearly
      2. Thyroid Stimulating Hormone (TSH) yearly
      3. Consider Echocardiogram
    4. Referrals
      1. Audiology yearly
      2. Ophthalmology every 3 years
      3. Consider pediatric cardiology, pediatric sleep specialist
  16. Prevention: Adults
    1. Standard Child and Adult Immunization Schedules
    2. Routine cancer screening as general population
    3. Standard Adult Health Maintenance recommendations
      1. Encourage Healthy Diet, regular activity and Obesity Management
      2. Address Cardiovascular Risk Factors
    4. Specific Disease Screening
      1. Complete Blood Count (CBC) yearly
      2. Thyroid Stimulating Hormone (TSH) every 1 to 2 years starting at age 21 years
      3. Diabetes Mellitus Screening
        1. Hemoglobin A1C every 3 years starting at age 30 years (age 21 years if obese or other risk factors)
      4. Auditory screening every 2 years
      5. Ophthalmology exam every 2 years
      6. Dental exam every 6 months
      7. Major Depression
      8. Alzheimer's Disease (age 40 years and older)
        1. Early Detection and Screen for Dementia (NTG-EDSD)
      9. Mitral Valve Prolapse and valvular regurgitation
        1. Screening with careful auscultation sufficient
        2. SBE Prophylaxis if valve disease suspected
        3. Echocardiogram for confirmation
      10. Obstructive Sleep Apnea symptoms and signs
      11. Atlantoaxial Instability
        1. Ask family about Atlantoaxial Instability symptoms
        2. Annual Neurologic Exam of upper extremities
      12. Celiac Disease
        1. Ask about gastrointestinal symptoms, and if persistent, consider Celiac Disease screening
    5. Men's Exam
      1. Testicular exam yearly
    6. Women's Exam
      1. Consider modified Pap Smear
        1. Localize cervical os on bimanual exam
        2. Guide cytology brush into cervical os
      2. Consider pelvic Ultrasound instead of bimanual exam
      3. Consider sedation with anesthesiology support
        1. Consider combining with other procedures if sedated
        2. Sedation medications
          1. Midazolam (Versed) PO or IV
          2. Ketamine
  17. Prevention: Counseling
    1. Good dental hygiene
    2. Diet and Exercise
    3. Obesity
    4. Tobacco Cessation
    5. Alcohol use
    6. Accident prevention
    7. Contraception
    8. Functional Training
      1. Speech Therapy and Language Therapy
      2. Vocational training or job coach
    9. Support group for parent
  18. Prevention: Prenatal Screening
    1. Antepartum Down Syndrome Screening
  19. Prognosis
    1. Five-year survival: >90%
    2. Life Expectancy: Age >60 years
      1. Increased from Life Expectancy of 25 years as of 1983
      2. Early interventions and ongoing medical management have significantly improved morbidity and mortality
  20. Resources
    1. Down Syndrome Health Issues by Dr. Leshin
    2. Denison Down Syndrome Quarterly
    3. National Down Syndrome Congress
    4. National Down Syndrome Society
  21. References
    1. Cohen (1999) Down Syndrome Quarterly 4:1-15
    2. Bunt (2014) Am Fam Physician 90(12): 851-8 [PubMed]
    3. Smith (2001) Am Fam Physician 64(6):1031-40 [PubMed]
    4. Tsou (2020) JAMA 324(15):1543-56 +PMID: 33079159 [PubMed]

Down Syndrome (C0013080)

Definition (MSH) A chromosome disorder associated either with an extra chromosome 21 or an effective trisomy for chromosome 21. Clinical manifestations include hypotonia, short stature, brachycephaly, upslanting palpebral fissures, epicanthus, Brushfield spots on the iris, protruding tongue, small ears, short, broad hands, fifth finger clinodactyly, Simian crease, and moderate to severe INTELLECTUAL DISABILITY. Cardiac and gastrointestinal malformations, a marked increase in the incidence of LEUKEMIA, and the early onset of ALZHEIMER DISEASE are also associated with this condition. Pathologic features include the development of NEUROFIBRILLARY TANGLES in neurons and the deposition of AMYLOID BETA-PROTEIN, similar to the pathology of ALZHEIMER DISEASE. (Menkes, Textbook of Child Neurology, 5th ed, p213)
Definition (MEDLINEPLUS)

Down syndrome is a condition in which a person is born with an extra copy of chromosome 21. People with Down syndrome can have physical problems, as well as intellectual disabilities. Every person born with Down syndrome is different.

People with the syndrome may also have other health problems. They may be born with heart disease. They may have dementia. They may have hearing problems and problems with the intestines, eyes, thyroid, and skeleton.

The chance of having a baby with Down syndrome increases as a woman gets older. Down syndrome cannot be cured. Early treatment programs can help improve skills. They may include speech, physical, occupational, and/or educational therapy. With support and treatment, many people with Down syndrome live happy, productive lives.

NIH: National Institute of Child Health and Human Development

Definition (NCI) A chromosomal dysgenesis syndrome resulting from a triplication or translocation of chromosome 21. Down syndrome occurs in approximately 1:700 live births. Abnormalities are variable from individual to individual and may include mental retardation, retarded growth, flat hypoplastic face with short nose, prominent epicanthic skin folds, small low-set ears with prominent antihelix, fissured and thickened tongue, laxness of joint ligaments, pelvic dysplasia, broad hands and feet, stubby fingers, transverse palmar crease, lenticular opacities and heart disease. Patients with Down syndrome have an estimated 10 to 30-fold increased risk for leukemia; most have symptoms of Alzheimer's disease by age 40. Also known as trisomy 21 syndrome.
Definition (NCI) A syndrome characterized by the presence of three complete copies of genetic material for chromosome 21, instead of the normal two. It leads to a variety of abnormalities that include mental retardation, macroglossia, microgenia, epicanthic eyelids, and a single transverse palmar crease.
Definition (NCI_NCI-GLOSS) A disorder caused by the presence of an extra chromosome 21 and characterized by mental retardation and distinguishing physical features.
Definition (CSP) chromosome disorder associated either with an extra chromosome 21 or an effective trisomy for chromosome 21; clinical manifestations include hypotonia, short stature, brachycephaly, upslanting palpebral fissures, epicanthus, brushfield spots on the iris, protruding tongue, small ears, short, broad hands, fifth finger clinodactyly, simian crease, and moderate to severe mental retardation.
Concepts Disease or Syndrome (T047) , Congenital Abnormality (T019)
MSH D004314
ICD9 758.0
ICD10 Q90, Q90.9
SnomedCT 41040004, 254263008, 205618003, 205614001, 157019002
LNC LP70386-5, LP19800-9, MTHU010201, MTHU020584, LA20088-3
English Down Syndrome, Down's Syndrome, Mongolism, Trisomy 21, Syndrome, Down's, Syndrome, Down, DOWN'S SYNDROME, Down's syndrome, MONGOLISM, Down's syndrome NOS, Down's syndrome, unspecified, trisomy 21 syndrome, DOWN SYNDROME, TRISOMY 21, mongolism, Trisomy 21 Syndrome, trisomy 21 Down syndrome (diagnosis), trisomy 21 Down syndrome, Syndrome Down's, Trisomy 21 NOS, Down Syndrome [Disease/Finding], down s syndrome, morbus down, 21 trisomies, 21 trisomy, mongoloidism, downing syndrome, trisomy 21, Down syndrome, unspecified, Downs syndrome, Trisomy 21 (Down Syndrome), Complete Trisomy 21 Syndrome, 47,XX,+21, Trisomy G, 47,XY,+21, Down's syndrome NOS (disorder), Down's syndrome (disorder), Down's syndrome - trisomy 21, Chromosome 21 trisomy, Complete trisomy 21 syndrome, Down syndrome, T21 - Trisomy 21, Complete trisomy 21 syndrome (disorder), Down, Langdon Down, chromosome; 21, trisomy, syndrome; trisomy, 21, trisomy; 21, trisomy; syndrome, 21, Downs Syndrome, G Trisomy, Mongol
French MONGOLISME, SYNDROME DE DOWN, Mongolisme, Trisomie 21, Syndrome de Down
Portuguese SINDROME DE DOWN, MONGOLISMO, Trissomia do Cromossomo 21, Trissomia 21, Mongolismo, Síndrome de Down, Trissomia do 21
Spanish SINDROME DE DOWN, MONGOLISMO, mongolismo, síndrome de Down, SAI, síndrome de Down, SAI (trastorno), Down's syndrome NOS, trisomía del par 21, Trisomía del Cromosoma 21, síndrome de Down, síndrome de trisomía 21 completa (trastorno), síndrome de trisomía 21 completa, Mongolismo, Síndrome de Down, Trisomía 21
Dutch mongolisme, syndroom van Down, chromosoom; 21, trisomie, syndroom; trisomie, 21, trisomie; 21, trisomie; syndroom, 21, Syndroom van Down, niet gespecificeerd, trisomie 21, Syndroom van Down, Down-syndroom, Mongolisme, Syndroom, Down-, Trisomie 21
German Down Syndrom, DOWN SYNDROM, Down-Syndrom, nicht naeher bezeichnet, MONGOLISMUS, Down-Syndrom, Mongolismus, Trisomie 21
Japanese 21トリソミー, モウコショウ, ダウンショウコウグン, 21トリソミー, Down症候群, Down症, ダウン症候群, トリソミー21, モンゴリスム, 蒙古症, モンゴリスムス
Swedish Downs syndrom
Czech Downův syndrom, mongolismus, Trizomie 21, Mongolismus, trizomie 21
Finnish Downin oireyhtymä
Italian Mongolismo, Trisomia 21, Sindrome di Down, Sindrome Down
Korean 다운 증후군, 상세불명의 다운 증후군
Polish Mongolizm, Zespół Downa
Hungarian ((down-kór)), Down-syndroma, Syndroma Down, Trisomia 21
Norwegian Downs syndrom, Trisomi 21-syndrom, Trisomi 21
Derived from the NIH UMLS (Unified Medical Language System)

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