Complementary and alternative therapies for Down syndrome

Psychopharmacological treatments in Down syndrome and autism spectrum disorder: State of the research and practical considerations

Individuals with Down syndrome (DS) or Autism Spectrum Disorder (ASD), and especially those with both DS and co-occurring ASD (DS + ASD) commonly display behavioral and psychiatric symptoms that can impact quality of life and places increased burden on caregivers. While the mainstay of treatment in DS and ASD is focused on educational and behavioral therapies, pharmacological treatments can be used to reduce symptom burden. There is a paucity of evidence and limited clinical trials in DS and DS + ASD. Some scientific evidence is available, primarily in open label studies and case series that can guide treatment choices. Additionally, clinical decisions are often extrapolated from evidence and experience from those with ASD, or intellectual disability in those without DS. This article reviews current research in pharmacological treatment in DS, ASD, and DS + ASD, reviews co-occurring neurodevelopmental and mental health diagnoses in individuals with DS + ASD across the lifespan, and describes practical approaches to psychopharmacological management.

Reconstructive Surgery in Children with Down Syndrome: Bioethical Implications

Down Syndrome is a genetic disorder caused by a third copy of chromosome 21. One of the main feature of the syndrome is the facial dysmorphism, characterized by broad, flat face, oblique eyelid rhymes, skin folds at the inner corner of the eyes (epicanthus), receding chin, protrusion of the tongue. These features are often social and functional obstacles, reducible with surgical interventions. The first facial plastic/cosmetic surgery approaches on Down children were performed in 1960 in Germany, Great Britain and the United States, where plastic surgeons began to reshape the Down patients physiognomy through the surgical correction of the face, tongue, eyes, nose, of the nostrils, of the neck. Recent studies have shown that in spite of the tendency to infections and early pulmonary hypertension in children with DS, surgery is not contraindicated, as previously suggested, but can be performed with very good results. This treatment has aesthetic, functional, rehabilitative, social effects, as well as favorable outcome on the familiar behavior. However different issues emerge in cases of patients presenting intellectual disability and unable to understand the consequences or the side effects related to plastic surgery. In this aspect, different Countries have enacted distinct laws directly regulating the consensuses for such intervention, with the goal to reduce the risks for the affected patients and the respect of their willing and social inclusion.

Anesthetic Management of Elderly Patients With Down Syndrome: A Case Report

In 1930, the life expectancy of patients with Down syndrome was about 10 years; today, their life expectancy is more than 60 years. With aging, there is an increased need for anesthesia and surgery. There is, however, no published information regarding the anesthetic management of older adults with Down syndrome. In this report, we described the anesthetic management of a 50-year-old woman with Down syndrome undergoing major cervical spine surgery. Components of the anesthetic that we thought would be difficult such as intravenous line placement and endotracheal intubation were accomplished without difficulty. Despite our best efforts, our patient nevertheless experienced both emergence delirium and postoperative vomiting. We advocate that physicians, advanced practice providers, and registered nurses be aware of the unique perianesthesia needs of older patients with Down syndrome.

Usage of and attitudes about green tea extract and Epigallocathechin-3-gallate (EGCG) as a therapy in individuals with Down syndrome

OBJECTIVE

Usage of and views concerning alternative therapies in the DS community are not well documented. Some positive effects of green tea extracts (GTE) containing Epigallocathechin-3-gallate (EGCG) have been reported in individuals with DS and DS mouse models, but minimal improvements or detrimental effects of pure EGCG treatment have been reported in DS mouse models. Given the uncertainty about the effectiveness of these supplements, the goal of this study was to determine the relative prevalence of and attitudes about GTE/EGCG treatments among DS caregivers.

METHODS

An anonymous survey about attitudes and usage of GTE/EGCG in individuals with DS was completed by caregivers of these individuals.

RESULTS

GTE/EGCG treatment was provided by 18% of responding caregivers who were mostly younger, highly educated, and utilized scientific sources and other parents to influence their decision to use GTE/EGCG. Individuals with DS who received GTE/EGCG were characterized as less severely disabled. Most caregivers who did not give GTE/EGCG reported concerns about potential side effects and lack of effectiveness. Few caregivers consulted with medical providers about GTE/EGCG usage.

CONCLUSIONS

These results demonstrate a need for communication between caregivers, medical providers, and scientists about potential benefits and risks for adverse effects of GTE, EGCG, and other nutritional supplements in individuals with DS.

Transient leukemia of Down syndrome

Childhood leukemia is mostly a "developmental accident" during fetal hematopoiesis and may require multiple prenatal and postnatal "hits". The World Health Organization defines transient leukemia of Down syndrome (DS) as increased peripheral blood blasts in neonates with DS and classifies this type of leukemia as a separate entity. Although it was shown that DS predisposes children to myeloid leukemia, neither the nature of the predisposition nor the associated genetic lesions have been defined. Acute myeloid leukemia of DS is a unique disease characterized by a long pre-leukemic, myelodysplastic phase, unusual chromosomal findings and a high cure rate. In the present manuscript, we present a comprehensive review of the literature about clinical and biological findings of transient leukemia of DS (TL-DS) and link them with the genetic discoveries in the field. We address the manuscript to the pediatric generalist and especially to the next generation of pediatric hematologists.

Cognitive Functioning in Children with Down Syndrome: Current Knowledge and Future Directions

Infants and children with Down syndrome (DS) can look forward toward bright futures, as individuals with DS are living healthier, more productive lives than ever due to medical advances, opportunities for early and continued intervention, and inclusive education. Despite these advances, infants and children with DS experience challenges in specific domains of cognitive functioning relative to their typically developing (TD) peers. Over the long term, individuals with DS are also more likely to develop Alzheimer's disease relative to the general population. Understanding cognitive functioning early in life may be important in charting cognitive decline over time. This chapter synthesizes the literature on cognitive functioning in infants and children with DS specific to general intelligence or IQ, language development, recall memory, and executive functioning, with additional focus on critical issues and future directions. These research findings provide important information for understanding cognitive competencies and intervention opportunities for children with DS and also serves to provide a foundation from which to plan longitudinal studies examining stability and change in cognitive functioning over time.

The Use of Dietary Interventions in Pediatric Patients

Complementary and alternative treatment approaches are becoming more common among children with chronic conditions. The prevalence of CAM use among US adults was estimated to be around 42% in 2015 and around 44% to 50% among adults with neurologic disorders. Studies demonstrate that children with certain chronic illnesses such as asthma, cancer, genetic disorders, attention-deficit/hyperactivity disorder (ADHD), and other neurodevelopmental disorders are treated with complementary and alternative treatments at higher rates. Dietary therapies are gaining increasing popularity in the mainstream population. Although the majority of "fad" diets do not have enough supporting evidence, some dietary therapies have been utilized for decades and have numerous published studies. The objective of this review is to describe the dietary interventions used in children with the specific chronic conditions, to evaluate their efficacy based on published data and to encourage pharmacist involvement in the management and care of such patients.

Patterns of Dietary Supplement Use in Children with Down Syndrome

OBJECTIVE

To determine the frequency of dietary supplement use for children with Down syndrome, and to obtain additional descriptive data regarding the age of initial treatment, cost, perceived benefits, and disclosure of use to the pediatrician.

STUDY DESIGN

An anonymous questionnaire in English and Spanish was created for parents of children under age 18 years with Down syndrome. Surveys were completed in our clinic, or accessed on a number of Down syndrome-related websites.

RESULTS

A total of 1167 responses were completed and analyzed. Forty nine percent of responders currently/previously gave their child supplement(s). The average child received 3 supplements (ranging from 1-18). Although Nutrivene, curcumin, and green tea extract were most common, over 150 different products were reported. Supplementation began most often in infancy, generally between age 4 and 6 months. Average cost was $90.53/month. Overall, 87% of users noted improvement, mainly in speech, immunity, and attention; 17% reported side-effects, predominantly gastrointestinal disturbance. Lack of improvement and cost were the main reasons for discontinuation. Most parents learned of supplements through a parent group or friend. In almost 20%, the pediatrician was unaware of the supplement use.

CONCLUSIONS

Almost one-half of parents surveyed administer or have administered supplement(s) to their children with Down syndrome. Many of the supplements have concerning ingredient profiles and are given to children too young to articulate potential ill effects. Providers need to be aware of these products and question families about their use.

Can EGCG Alleviate Symptoms of Down Syndrome by Altering Proteolytic Activity?

Down syndrome (DS), also known as "trisomy 21", is a genetic disorder caused by the presence of all or part of a third copy of chromosome 21. Silencing these extra genes is beyond existing technology and seems to be impractical. A number of pharmacologic options have been proposed to change the quality of life and lifespan of individuals with DS. It was reported that treatment with epigallocatechin gallate (EGCG) improves cognitive performance in animal models and in humans, suggesting that EGCG may alleviate symptoms of DS. Traditionally, EGCG has been associated with the ability to reduce dual specificity tyrosine phosphorylation regulated kinase 1A activity, which is overexpressed in trisomy 21. Based on the data available in the literature, we propose an additional way in which EGCG might affect trisomy 21-namely by modifying the proteolytic activity of the enzymes involved. It is known that, in Down syndrome, the nerve growth factor (NGF) metabolic pathway is altered: first by downregulating tissue plasminogen activator (tPA) that activates plasminogen to plasmin, an enzyme converting proNGF to mature NGF; secondly, overexpression of metalloproteinase 9 (MMP-9) further degrades NGF, lowering the amount of mature NGF. EGCG inhibits MMP-9, thus protecting NGF. Urokinase (uPA) and tPA are activators of plasminogen, and uPA is inhibited by EGCG, but regardless of their structural similarity tPA is not inhibited. In this review, we describe mechanisms of proteolytic enzymes (MMP-9 and plasminogen activation system), their role in Down syndrome, their inhibition by EGCG, possible degradation of this polyphenol and the ability of EGCG and its degradation products to cross the blood-brain barrier. We conclude that known data accumulated so far provide promising evidence of MMP-9 inhibition by EGCG in the brain, which could slow down the abnormal degradation of NGF.

Complementary and alternative medicine treatments for children with autism spectrum disorders

There are many treatments in current use for core and associated symptoms of autism spectrum disorders (ASD). This review discusses the complementary and alternative medical (CAM) treatments commonly added to conventional interventions for children with ASD, including natural products, mind and body practices, and other biomedical treatments. The article focuses on factors associated with use of CAM, the empirical evidence for the most frequently used treatments, and how clinicians work with families who choose CAM treatments. Some treatments have been ineffective, some have unacceptable potential side effects, and others require more study in depth.

Clinical practice guidelines for management of children with Down syndrome: Part I

Working with DS patients in primary, specialty, and acute care health settings has always been a demanding task for the busy practitioner. The associated medical conditions, developmental demands, and educational demands makes it challenging for pediatric care providers to address all the specific details for each age group. The purpose of this two-part Practice Guideline is to streamline this process. Part One has summarized the care of the patient with DS until the age of 1 year. Part Two will focus on care from the child's first birthday until he or she transitions to adulthood.

Systemic oxidative stress, as measured by urinary allantoin and F(2)-isoprostanes, is not increased in Down syndrome

PURPOSE

Oxidative stress has been implicated in Down syndrome (DS) pathology. This study compares DS individuals and controls on their urinary levels of allantoin and 2,3-dinor-iPF2α-III; these biomarkers have been previously validated in a clinical model of oxidative stress.

METHODS

Urine samples were collected from 48 individuals with DS and 130 controls. Biomarkers were assayed by ultraperformance liquid chromatography-tandem mass spectrometry, normalized by urinary creatinine concentration.

RESULTS

After adjusting for age and gender, mean allantoin levels were lower among DS individuals versus controls (P = .04). The adjusted mean levels of 2,3-dinor-iPF2α-III were similar in DS individuals and controls (P = .7).

CONCLUSIONS

Our results do not support the hypothesis that DS individuals have chronic systemic oxidative stress.

Health supervision for children with Down syndrome

These guidelines are designed to assist the pediatrician in caring for the child in whom a diagnosis of Down syndrome has been confirmed by chromosome analysis. Although a pediatrician's initial contact with the child is usually during infancy, occasionally the pregnant woman who has been given a prenatal diagnosis of Down syndrome will be referred for review of the condition and the genetic counseling provided. Therefore, this report offers guidance for this situation as well.

[Vitamin A deficiency and nutritional status in patients with Down's syndrome]

INTRODUCTION

Vitamin A deficiency (VAD) is a worldwide public health problem. Epidemiological studies of VAD prevalence have been conducted in individuals with chromosome load and genetic potential compared with the general population; however, there are few studies in patients with Down's syndrome (DS). The objective of this study was to determine the prevalence of VAD and analyse nutritional status in patients with DS.

METHODS

A prospective and cross-sectional study was performed, with 50 karyotypically normal (KN) individuals (10.4+/-3.7 years old) and 38 randomly selected patients with DS (8.2+/-4.1 years old). Serum retinol was determined by HPLC using the Bieri method, with an international reference standard to define VAD (serum retinol <20 microg/dL). The data were analysed using the SAS/STAT statistical program.

RESULTS

The prevalence of VAD was 18.4% in individuals with DS and 4% in KN individuals (OR: 5.42; 95% CI=0.93-40.64; p=0.02). Children with DS between two and six years old shown a significativily lower serum retinol (p=<0.05).The patients with DS also showed a significant decrease in height and weight compared to KN (p=<0.001).

CONCLUSIONS

The prevalence of VAD detected in patients with DS could be considered a public health problem. Also, the chromosome 21 trisomy represent a risk factor associated with VAD.

Molecular genetic analysis of Down syndrome

Down syndrome (DS) is caused by trisomy of all or part of human chromosome 21 (HSA21) and is the most common genetic cause of significant intellectual disability. In addition to intellectual disability, many other health problems, such as congenital heart disease, Alzheimer's disease, leukemia, hypotonia, motor disorders, and various physical anomalies occur at an elevated frequency in people with DS. On the other hand, people with DS seem to be at a decreased risk of certain cancers and perhaps of atherosclerosis. There is wide variability in the phenotypes associated with DS. Although ultimately the phenotypes of DS must be due to trisomy of HSA21, the genetic mechanisms by which the phenotypes arise are not understood. The recent recognition that there are many genetically active elements that do not encode proteins makes the situation more complex. Additional complexity may exist due to possible epigenetic changes that may act differently in DS. Numerous mouse models with features reminiscent of those seen in individuals with DS have been produced and studied in some depth, and these have added considerable insight into possible genetic mechanisms behind some of the phenotypes. These mouse models allow experimental approaches, including attempts at therapy, that are not possible in humans. Progress in understanding the genetic mechanisms by which trisomy of HSA21 leads to DS is the subject of this review.

Coenzyme Q10 (ubiquinol-10) supplementation improves oxidative imbalance in children with trisomy 21

Endogenous coenzyme Q10 is an essential cofactor in the mitochondrial respiratory chain, a potent antioxidant, and a potential biomarker for systemic oxidative status. Evidence of oxidative stress was reported in individuals with trisomy 21. In this study, 14 children with trisomy 21 had significantly increased (P < 0.0001) plasma ubiquinone-10 (the oxidized component of coenzyme Q10) compared with 12 age- and sex-matched healthy children (historical controls). Also, the mean ratio of ubiquinol-10 (the biochemically reduced component):total coenzyme Q10 was significantly decreased (P < 0.0001). After 3 months of ubiquinol-10 supplementation (10 mg/kg/day) to 10 patients with trisomy 21, the mean ubiquinol-10:total coenzyme Q10 ratio increased significantly (P < 0.0001) above baseline values, and 80% of individual ratios were within normal range. No significant or unexpected adverse effects were reported by participants. To our knowledge, this is the first study to indicate that the pro-oxidant state in plasma of children with trisomy 21, as assessed by ubiquinol-10:total coenzyme Q10 ratio, may be normalized with ubiquinol-10 supplementation. Further studies are needed to determine whether correction of this oxidant imbalance improves clinical outcomes of children with trisomy 21.

Complementary and alternative medicine in developmental disabilities

Developmental disabilities (DD) are defined as a diverse group of severe chronic conditions due to mental and/or physical impairments. Individuals with developmental disabilities have difficulty with major life activities including language, mobility, and learning. Developmental disabilities can begin anytime during development--from prenatal up to 22 years of age, and the disability usually lasts throughout a person's lifetime. Autism spectrum disorders, cerebral palsy, mental retardation, and attention deficit hyperactivity disorder are common conditions falling within the definition of developmental disabilities. Complementary and alternative medicine (CAM) is becoming increasingly utilized in the general population for treatment of everything from the common cold to complex and chronic medical conditions. This article reviews the prevalence of different types of CAM used for various developmental disabilities.