Health problems and health checks in school-aged children with Down syndrome

Importance of TREC and KREC as molecular markers for immunological evaluation of down syndrome children

Recurrent and severe infections occurred in children with Down Syndrome (DS) due to immunological parameter defects have been reported. The aim of the study is to evaluate the importance of using T-cell receptor excision circle (TREC) and kappa-deleting recombination excision circle (KREC) as molecular markers for immunological investigation of children with DS. The study included 40 non-disjunction trisomy 21 confirmed DS children, and 25 healthy controls. Peripheral blood (PB) was analyzed for lymphocyte subpopulations by flow cytometry, serum immunoglobulin levels, and TREC and KREC copy numbers using quantitative real-time PCR. DS patients showed significantly lower absolute counts of PB T lymphocytes, T helper lymphocytes, T cytotoxic lymphocytes, B lymphocytes, and Natural killer cells, and lower serum IgA, IgG, and IgM levels compared to healthy controls. Copy number of TREC and KREC showed no significant differences between DS patients and healthy controls. There is a significant positive correlation between TREC copy number with a percentage and absolute count of helper T lymphocytes in patients. Also, the KREC copy number was significantly negatively correlated with the age of patients. These findings suggest that copy numbers of TREC and KREC could be useful as molecular markers for immunological evaluation of patients with DS.

Down Syndrome for the Otolaryngologist: A Review

Importance

There are many features of Down syndrome that prompt referral to an otolaryngologist. As the lifetime prevalence and life expectancy of individuals with Down syndrome increase, it is increasingly likely that otolaryngologists will have the opportunity to care for patients with Down syndrome.

Observations

A confluence of characteristics common to Down syndrome may be associated with issues in the head and neck, from infancy through adulthood. Hearing concerns range from narrow ear canals and cerumen impactions to eustachian tube dysfunction, middle ear effusion, cochlear malformations, and conductive, sensorineural, and/or mixed hearing loss. Immune deficiency, hypertrophy of Waldeyer ring, and hypoplastic sinuses may complicate and develop into chronic rhinosinusitis. Speech delay, obstructive sleep apnea, dysphagia, and airway anomalies are also common among this patient population. Because these concerns may necessitate otolaryngologic surgery, it is vital for otolaryngologists to familiarize themselves with anesthetic concerns, including cervical spine instability, in patients with Down syndrome. Comorbid cardiac disease, hypothyroidism, and obesity may also affect these patients and otolaryngologic care.

Conclusions and Relevance

Individuals with Down syndrome may visit otolaryngology practices at all ages. Otolaryngologists that familiarize themselves with the head and neck manifestations that are common among patients with Down syndrome and know when to order screening tests will be able to provide comprehensive care.

Clinical and epidemiological characteristics of influenza virus infection in hospitalized children with acute respiratory infections in Sri Lanka

Influenza viruses (Inf-V) are an important cause of acute respiratory infection (ARI) in children. This study was undertaken to describe the clinical and epidemiological characteristics of Inf-V infections in a sample of hospitalized children with ARI. Nasopharyngeal aspirates (NPA) from 500 children between 1 month to 5 years old with symptoms of ARI were collected at the Teaching Hospital Kegalle Sri Lanka From May 2016 to June 2018, NPAs were tested for influenza A (Inf-A) and B (Inf-B) viruses, human respiratory syncytial virus (hRSV), human parainfluenza virus (hPIV) 1–3 using an immunofluorescence assay. The Inf-V were then subtyped using a multiplex RT-PCR. Inf-V were detected in 10.75% (54/502) of the hospitalized children with ARI and in that 5.57% (28/502) were positive for Inf-A and 5.17% (26/502) were positive for Inf-B. Of the 54 Inf-V positive children, 33 were aged between 6 and 20 months. Of the 28 children infected with Inf-A, 15 had uncharacterized lower respiratory infection, 7 had bronchopneumonia and 6 had bronchiolitis. Of the 26 children infected with Inf-B, 11 had uncharacterized lower respiratory infection, 10 had bronchiolitis, and 4 had bronchopneumonia. Inf-B circulated throughout the year with a few peaks, one in June and then in August followed by November to December in 2016 and one in April 2017 and January 2018. Inf-A circulated throughout the year with a major peak in March to April 2017 and July 2018. ARI was more common in boys compared to girls. Majority of the children infected with Inf-V were diagnosed with uncharacterized lower respiratory infection and mild to moderate bronchiolitis. Inf-V infections were prevalent throughout the year in the study area of Sri Lanka with variations in the type of the circulating virus.

Management outcomes of otitis media with effusion in children with down syndrome: A systematic review

OBJECTIVE

To assesses the current state of uncertainty concerning the management options used for otitis media with effusion (OME) in children with trisomy 21.

REVIEW METHODS

A systematic review of adhering to the PRISMA statement of studies evaluating the management of OME in trisomy 21 children prior to September 2021 was conducted. Studies were identified using the following medical databases: PubMed, Google Scholar, CINAHL, Scopus and Medline. Data extraction was performed by screening of titles and abstracts based on eligibility criteria, followed by full-article analysis of selected records.

RESULTS

Twenty articles were included in this review. Studies showed conflicting outcomes regarding the different interventions used for OME in children with trisomy 21. Of those evaluating pressure equalizing tubes (PET), some studies report pronounced complication rates and recommend using a conservative approach unless complications arise and/or hearing loss is severe. In contrast, other studies reported significantly reduced complication rates and improved hearing with earlier intervention and adaptations to PETs. Hearing aids may be provided after multiple failed PETs.

CONCLUSION

Clinical equipoise still persists regarding the best method to manage children with trisomy 21 who have OME. Although PETs exhibited the lowest complication rates and highest improvement rates, further prospective trials are warranted to assess the various treatment modalities and determine which of them would provide the best outcome while reducing complications as well as the age of treatment.

Toxoplasma gondii Infection Among Institutionalized Children with Down syndrome in Sana'a city, Yemen: Implications of Low IgG Seroprevalence

Purpose

To assess the IgG seroprevalence of Toxoplasma gondii as an indicator of past exposure and immunity against infection among children with Down syndrome (DS) in Sana’a city, Yemen. This preliminary study is justified by the primary immunodeficiency of children with DS and the opportunistic nature of the parasite, considering the vague situation of anti-Toxoplasma IgG seroprevalence among children with DS because of neglecting its study on local and global scales.

Methods

This descriptive, facility-based, cross-sectional study was conducted among 107 children with DS hosted in six randomly selected rehabilitation centers for children with special needs in Sana’a city. Demographics of children and their mothers’ knowledge of toxoplasmosis were collected using a pre-designed, structured questionnaire. Anti-Toxoplasma IgG antibodies were measured in the sera of children using electrochemiluminescence assay.

Results

Of 107 children with DS, 3 (2.8%) were seropositive for anti-Toxoplasma IgG. Approximately two-thirds (71/106) of the mothers of children with DS were aware of toxoplasmosis. Of whom, 83.1% (59/71) were aware of its congenital complications.

Conclusion

The majority of children with DS in Sana’a city are seronegative for anti-Toxoplasma IgG, where the seropositivity rate is lower than 3.0%. Therefore, children with DS are non-immune and susceptible to the acquisition of primary infections during their life. Further analytical studies are recommended to determine whether the defective immune response of children with DS is associated with false seronegativity, to assess the role of their mothers’ knowledge in reducing their exposure to infection if they were confirmed truly seronegative and to identify the predictors of infection among them.

Interferon-Driven Immune Dysregulation in Down Syndrome: A Review of the Evidence

Down syndrome (DS) is a unique genetic disease caused by the presence of an extra copy of chromosome 21, which carries four of the six interferon receptor (IFN-R) genes on its long arm. Recent studies reporting higher levels of interferon-stimulated gene (ISG) expression in primary immune cells studied ex vivo have suggested that the additional copies of the IFN-R genes in DS result in mild interferonopathy. In this review, we analyze the potential clinical and immunological impacts of this interferonopathy in DS. We performed a literature review to explore the epidemiology and risks of celiac disease, type 1 diabetes, thyroid dysfunction, mucocutaneous manifestations, infectious diseases (including COVID-19), and Alzheimer’s disease in individuals with DS relative to the general population with or without iatrogenic exposure to interferons. We analyzed immunophenotyping data and the current experimental evidence concerning IFN-R expression, constitutive JAK-STAT activation, and ISG overexpression in DS. Despite the lack of direct evidence that implicating this mild interferonopathy directly in illnesses in individuals with DS, we highlight the challenges ahead and directions that could be taken to determine more clearly the biological impact of interferonopathy on various immune-related conditions in DS.

Meta-analysis of transcriptomic data reveals clusters of consistently deregulated gene and disease ontologies in Down syndrome

Trisomy of human chromosome 21 (HSA21) causes Down syndrome (DS). The trisomy does not simply result in the upregulation of HSA21--encoded genes but also leads to a genome-wide transcriptomic deregulation, which affect differently each tissue and cell type as a result of epigenetic mechanisms and protein-protein interactions. We performed a meta-analysis integrating the differential expression (DE) analyses of all publicly available transcriptomic datasets, both in human and mouse, comparing trisomic and euploid transcriptomes from different sources. We integrated all these data in a "DS network". We found that genome wide deregulation as a consequence of trisomy 21 is not arbitrary, but involves deregulation of specific molecular cascades in which both HSA21 genes and HSA21 interactors are more consistently deregulated compared to other genes. In fact, gene deregulation happens in "clusters", so that groups from 2 to 13 genes are found consistently deregulated. Most of these events of "co-deregulation" involve genes belonging to the same GO category, and genes associated with the same disease class. The most consistent changes are enriched in interferon related categories and neutrophil activation, reinforcing the concept that DS is an inflammatory disease. Our results also suggest that the impact of the trisomy might diverge in each tissue due to the different gene set deregulation, even though the triplicated genes are the same. Our original method to integrate transcriptomic data confirmed not only the importance of known genes, such as SOD1, but also detected new ones that could be extremely useful for generating or confirming hypotheses and supporting new putative therapeutic candidates. We created "metaDEA" an R package that uses our method to integrate every kind of transcriptomic data and therefore could be used with other complex disorders, such as cancer. We also created a user-friendly web application to query Ensembl gene IDs and retrieve all the information of their differential expression across the datasets.

Prevalence of Otological Disease in Turner Syndrome: A Systematic Review

INTRODUCTION

Girls and women with Turner syndrome (TS) present with multiple ear and hearing problems, ranging from external morphologic abnormalities to sensorineural or conductive hearing loss. The exact pathophysiology behind these otological diseases is not yet completely understood. The aim of this study is to provide a systematic review on the prevalence of otological disease in TS.

METHODS

We conducted a systematic review according to the PRISMA guidelines. A database search was performed in PubMed, Embase, Web of Science, and Cochrane library.

RESULTS

The prevalence of otological disease as external ear deformities (20-62%), recurrent otitis media (24-48%), and hearing loss (36-84%) is high in TS. The auditory phenotype in TS is complex and seems to be dynamic with CHL due to middle ear disease at young age and sensorineural hearing loss later in life.

CONCLUSION

This systematic review of the literature confirms that otological disease is definitely part of the widely variable phenotype in Turner patients. Strong evidence is lacking on the exact prevalence numbers, emphasizing the need for more prospective data gathering. Growing insights in its pathophysiology will help in the understanding and management of hearing problems in TS across lifespan.

Pulmonary hypertension in children with Down syndrome

Individuals with Down syndrome (DS) have an increased risk of developing pulmonary hypertension (PH). In this review, we explore the epidemiology and clinical characteristics of PH in the population with DS and examine genetic, molecular and clinical contributions to the condition. The presence of an additional copy of chromosome 21 (trisomy 21) increases the risk of developing PH in children with DS through many mechanisms, including increased hemodynamic stress in those with congenital heart disease, hypoxemia through impaired ventilation to perfusion matching secondary to developmental lung abnormalities, pulmonary hypoplasia from pulmonary vascular endothelial dysfunction, and an increase in pulmonary vascular resistance often related to pulmonary comorbidities. We review recent studies looking at novel biomarkers that may help diagnose, predict or monitor PH in the population with DS and examine current cardiopulmonary guidelines for monitoring children with DS. Finally, we review therapeutic interventions specific to PH in individuals with DS. Contemporary work has identified exciting mechanistic pathways including the upregulation of antiangiogenic factors and interferon activity, which may lead to additional biomarkers or therapeutic opportunities. Throughout the manuscript, we identify gaps in our knowledge of the condition as it relates to the population with DS and offer suggestions for future clinical, translational, and basic science research.

Metabolic Diseases and Down Syndrome: How Are They Linked Together?

Down syndrome is a genetic disorder caused by the presence of a third copy of chromosome 21, associated with intellectual disabilities. Down syndrome is associated with anomalies of both the nervous and endocrine systems. Over the past decades, dramatic advances in Down syndrome research and treatment have helped to extend the life expectancy of these patients. Improved life expectancy is obviously a positive outcome, but it is accompanied with the need to address previously overlooked complications and comorbidities of Down syndrome, including obesity and diabetes, in order to improve the quality of life of Down syndrome patients. In this focused review, we describe the associations between Down syndrome and comorbidities, obesity and diabetes, and we discuss the understanding of proposed mechanisms for the association of Down syndrome with metabolic disorders. Drawing molecular mechanisms through which Type 1 diabetes and Type 2 diabetes could be linked to Down syndrome could allow identification of novel drug targets and provide therapeutic solutions to limit the development of metabolic and cognitive disorders.

Medical conditions of children and young people with Down syndrome

BACKGROUND

The life expectancy of people with Down syndrome (DS) has significantly increased in the last decades. We describe the congenital malformations and main comorbidities of a cohort of children and young people with DS and analyse their differences according to age and gender groups.

METHODS

This retrospective cross-sectional study was conducted at DS centre of Bambino Gesù Children's Hospital in Rome (Italy). The period for reviewing all electronic health records ran from July 2016 to September 2017. We collected data on clinical conditions and compared them with the general paediatric population. Moreover, we compared the main comorbidities, dental diseases and body mass index data between age groups.

RESULTS

Seven hundred sixty-three children and young people with DS included in this study were aged 7.45 ± 5.49 years. Gender distribution included 58.19% male patients. The majority of our population (71.04%) came from central regions of Italy. Respiratory diseases (19%), congenital heart defects (72.23%), malocclusions (58.62%), astigmatism (20.31%), farsightedness (16.51%), near-sightedness (12.19%) and autoimmune hypothyroidism (3.28%) were more frequent in our population compared with the typical paediatric population. Upper respiratory tract infections and underweight were significantly more frequent in the youngest children, whereas dental diseases, refractive errors, obesity and autoimmune hypothyroidism increased over age.

CONCLUSIONS

Children and young people with DS present a high prevalence of potentially treatable medical conditions making multidisciplinary teams a mandatory need for this population.

Congenital heart disease in Down syndrome – A review of temporal changes

Background

Congenital heart disease (CHD) is a well-known co-occurring condition in Down syndrome (DS). We aimed to review the literature to evaluate the current evidence to address key questions.

Methods

A series of key questions were formulated a priori to inform the search strategy and review process. These addressed the topics of prevalence, type of CHD, severity, and screening. Using the National Library of Medicine database, PubMed, detailed literature searches were performed. The quality of available evidence was then evaluated, the existing literature was summarized, and knowledge gaps were identified.

Results

Fifty-six relevant original articles were identified which addressed at least one key question. Study details, including: research design, internal validity, external validity, and relevant results are presented. The total prevalence of CHD reported in DS ranged from 20 to 57.9%. In later decades, the prevalence remained constant at 40—55%. The types and classification of CHD varied considerably between studies. Some studies indicate a trend towards a milder phenotype, but this was not consistent. Over time, some studies observed an improved prognosis for CHD in DS. Studies investigating screening for CHD by physical examination, chest X-ray, and electrocardiogram report sensitivities of 71–95%.

Conclusion

To further improve knowledge on CHD in DS, we suggest that future studies cover a wide range of nations and regions, with a longitudinal design, and account for potential confounding factors.

Use of malleoli as an indicator for flatfoot in patients with Down syndrome: development of a simple and non-invasive evaluation method through medial longitudinal arch

[Purpose] Flatfoot often presents in patients with Down syndrome, and it can be diagnosed using a simple radiograph. Consequently, due to radiograph limitations, alternative non-invasive testing must be determined. Conventionally, arch height ratio can be used for evaluation of the medial longitudinal arch, where the foot is evaluated by detecting the navicular bone on the foot surface. However, detection of the navicular tuberosity is difficult and even though the detection is relatively straightforward for patients without intellectual disability, measuring navicular bone is more difficult in patients with intellectual disability, such as those who have Down syndrome and are uncooperative with a tester. Therefore, we evaluated arch height ratio using the malleoli instead of the navicular bone to determine whether malleoli testing was appropriate for patients with Down syndrome that have an intellectual disability. [Participants and Methods] We conducted a retrospective study of 16 pairs of feet in 16 patients with Down syndrome, diagnosed with flatfoot. The height to the centre of the talo-navicular joint and that of the malleoli from the sole were measured on radiographs using weight-bearing conditions. [Results] The age range was 5.2 to 25.3 years. There was a correlation between the height of the navicular bone and that of the medial and lateral malleoli. [Conclusion] We conclude that the medial and lateral malleoli can substitute navicular bone as a landmark diagnosis test for flatfoot. Considering the close physical distance between the medial malleolus and navicular bone, and the association between the tibia and medial longitudinal arch, the medial malleolus may provide a better landmark in patients with Down syndrome with it being potentially less invasive for uncooperative patients.

Clinical implications of immune-mediated diseases in children with Down syndrome

Children with Down syndrome have changes in their innate and adaptive immunity, which contribute to increased rates of infections, autoimmune diseases, and haematological malignancies. While improved care for congenital heart disease has decreased mortality and morbidity, complications related to immune-mediated diseases continue to limit the life expectancy in Down syndrome. Infectious diseases are common and have a significant effect on development, behaviour and quality of life. Infection frequency and severity are influenced by various anatomical and physiological alterations in addition to immunological changes in Down syndrome. Thus, prevention of respiratory tract infections requires a multifactorial approach. This could include additional active and/or passive immunizations, prophylactic antibiotics, immunoglobulin replacement and ear, nose and throat surgical interventions. Autoimmune conditions like coeliac disease, type I diabetes mellitus and thyroid disease are classically mentioned in the context of Down syndrome. However, autoinflammatory conditions are more prevalent as well. Screening for autoimmune diseases is required and immunosuppression has to be used with caution. Future studies should address optimal screening programmes for immune-mediated diseases in individuals with Down syndrome, as well as the effect of immune modulation, to further decrease morbidity and mortality, and improve the quality of life of individuals with Down syndrome.

Prevalence of unsuspected abnormal echocardiograms in adolescents with down syndrome

The purpose of this article is to describe the prevalence of cardiac disease previously undiagnosed in healthy asymptomatic children and adolescents with Down syndrome (DS). Subjects with DS ages 10-20 years were recruited from two sites, the Children's Hospital of Philadelphia (Philadelphia, PA) and Children's National Health System (Washington, DC) for a cross-sectional study of body composition and cardiometabolic risk. Echocardiographic and clinical data were collected from patients enrolled in the parent study of cardiometabolic risk. Nine (6%) new cardiac diagnoses were identified out of 149 eligible patients. All new findings resulted in outpatient referrals to pediatric cardiology. Current guidelines recommend screening all newborns with DS for congenital heart disease. Older patients with DS may benefit from rescreening.

Genetic Syndromes Associated with Congenital Cardiac Defects and Ophthalmologic Changes - Systematization for Diagnosis in the Clinical Practice

BACKGROUND

Numerous genetic syndromes associated with heart disease and ocular manifestations have been described. However, a compilation and a summarization of these syndromes for better consultation and comparison have not been performed yet.

OBJECTIVE

The objective of this work is to systematize available evidence in the literature on different syndromes that may cause congenital heart diseases associated with ocular changes, focusing on the types of anatomical and functional changes.

METHOD

A systematic search was performed on Medline electronic databases (PubMed, Embase, Cochrane, Lilacs) of articles published until January 2016. Eligibility criteria were case reports or review articles that evaluated the association of ophthalmic and cardiac abnormalities in genetic syndrome patients younger than 18 years.

RESULTS

The most frequent genetic syndromes were: Down Syndrome, Velo-cardio-facial / DiGeorge Syndrome, Charge Syndrome and Noonan Syndrome. The most associated cardiac malformations with ocular findings were interatrial communication (77.4%), interventricular communication (51.6%), patent ductus arteriosus (35.4%), pulmonary artery stenosis (25.8%) and tetralogy of Fallot (22.5%).

CONCLUSION

Due to their clinical variability, congenital cardiac malformations may progress asymptomatically to heart defects associated with high morbidity and mortality. For this reason, the identification of extra-cardiac characteristics that may somehow contribute to the diagnosis of the disease or reveal its severity is of great relevance.

Relationship between the use of lower extremity orthoses and the developmental quotient of The Kyoto Scale of Psychological Development in children with Down syndrome

[Purpose] The Kyoto Scale of Psychological Development is an evaluation scale developed in the field of psychology. The initial aim of this study was to determine whether the quotient of the Postural-Motor area in the scale was correlated with the use of orthosis in patients with Down syndrome. The second aim was to examine a correlation among Postural-Motor, Cognitive-Adaptive, and Language-Social areas in the participants. [Participants and Methods] Patients with Down syndrome who had received a developmental examination, the Kyoto Scale of Psychological Development, were retrospectively investigated. The sample included 78 participants. Data on the participants' calendar ages ranged from 4.1 to 6.0 years, and the mean age was 4.9 at the examination. The investigated parameters were the number of participants who used an orthosis or insole and the mean developmental quotient for the Postural-Motor, Cognitive-Adaptive, and Language-Social areas. [Results] Twenty participants who completed the exam used an orthosis, and 18 of these had an insole as a first orthosis. The mean Postural-Motor quotient was significantly lower in participants who used an orthosis than in those who did not (52.3 ± 14.7). [Conclusion] The mean quotient of the Postural-Motor area was significantly lower in patients with Down syndrome who were prescribed some kind of orthosis than in those who were not. There was a significant correlation among the quotients of the three areas. The use of orthosis was expected to positively influence the Cognitive-Adaptive and Language-Social areas through the future in people with Down syndrome who have some difficulty with posture and movement.

Asthma in intellectual disability: are we managing our patients appropriately?

People with intellectual disability are a vulnerable group of people with asthma that has, to date, largely been ignored in the medical literature. Although guidelines for medication management for people with intellectual disability suggest asthma is treated as for other populations, there are special considerations that should be taken into account when managing asthma in this group. Due to their cognitive impairment as well as comorbidities, they are likely to require support with asthma self-management, including inhaler use. Their varying degrees of autonomy mean that there is often a need to provide education and information to both the person and their caregivers.

EDUCATIONAL AIMS

To understand general principles of health of people with intellectual disability and how this affects the healthcare professional's approach to asthma management.To understand how intellectual disability affects cognition, autonomy and communication, and therefore the ability of a person to self-manage asthma.To recognise ways of mitigating respiratory disease risk in people with intellectual disability.To describe ways for healthcare professionals to support people with intellectual disability and their caregivers in asthma management.

[Hospital morbidity and mortality in children with Down's syndrome: Experience in a university hospital in Chile]

INTRODUCTION

Children with Down's syndrome (DS) have a higher risk of congenital malformations and acute diseases, with increased risk of hospital admissions compared with the general population. This study describes patterns of hospital admissions for children and adolescents with DS.

PATIENTS AND METHODS

A retrospective study of hospital admissions of children with DS, younger than 15 years old, and cared for by the Paediatric Department of the Hospital Clínico Pontificia Universidad Católica de Chile, between 2008 and 2011.

RESULTS

There were 222 admissions of 161 patients with DS during the study period, of which 110 were girls. The median age was 8 months, and the median hospital stay was 6 days. Just over half (56.7%) of the hospital stays were in the Paediatric Critic Care Unit. Heart surgery was performed on 59.4%, and the principal congenital heart defect attended was atrioventricular canal. The principal diagnosis, other than heart surgery, was lower respiratory tract infection. In this series, 3 children died.

CONCLUSIONS

Children with DS are a relevant group for inpatient care, because their high incidence in Chile, their respiratory and cardiovascular risk, prolonged hospitalizations, high frequency of critical care days and mortality risk. This group has special and complex needs during their hospitalizations and it is necessary to create a multidisciplinary team with competences to take care the particular characteristics of this vulnerable group.

Assessment of the feasibility and clinical value of further research to evaluate the management options for children with Down syndrome and otitis media with effusion: a feasibility study

BACKGROUND

There is clinical uncertainty of the benefits and costs of different treatment options for children with Down syndrome who have glue ear. This study was designed to assess the extent of this lack of knowledge and determine if pursuing further information would be practical, beneficial and cost-effective.

OBJECTIVES

To assess the level and practical effect of current uncertainty around treatment options for children with Down syndrome and glue ear. To assess the feasibility of studying the options for management of glue ear in children with Down syndrome via a randomised controlled trial (RCT) or multicentre prospective cohort study by evaluating the willingness of (1) parents to agree to randomisation for their children and (2) clinicians to recruit participants to a definitive study. To undertake value of information analyses to demonstrate the potential economic benefit from undertaking further research.

DESIGN

A feasibility study exploring the views of parents of children with Down syndrome and professionals who have responsibility for the health and education of children with Down syndrome, on the participation in, and value of, future research into interventions for glue ear. Data were collected from parents via self-completed questionnaires, face-to-face interviews and focus groups and from professionals via online questionnaires and a Delphi review exercise. Development of economic models to represent clinical pathways of care and a RCT informed a value of information (VOI) analysis.

SETTING

UK (professionals); East Midlands region of the UK (parents).

PARTICIPANTS

Parents of children aged 1-11 years with Down syndrome (n = 156). Professionals including audiologists, ear, nose and throat surgeons, audiological physicians, speech and language therapists, and teachers of the deaf (n = 128).

MAIN OUTCOME MEASURES

Quantitative and qualitative data on parental views and experiences of glue ear and its effects; interventions and treatment received; taking part in research and factors that would encourage or discourage participation; and the importance of various outcome domains to them and for their children. For professionals: information on caseloads; approaches to clinical management; opinions on frequency and significance of the consequences of glue ear for this population; importance of different outcome measures; opinions of interventions and their role in future research; views on health research; facilitators and barriers to recruitment, and participation in research involving RCTs.

RESULTS

The complexity of the experience and individual characteristics of children with Down syndrome poses challenges for the design of any future research but these challenges were not considered by professionals to raise sufficient barriers to prevent it being undertaken. Parents were generally supportive of the need for, and value of, research but identified practical and emotional issues that would need addressing. Glue ear was considered to impact more on speech, language and communication than on hearing. Outcome measures for future research would need to evaluate these elements but measures should be designed specifically for the population. Parents and professionals identified randomisation as a significant barrier to participation. The VOI analyses identified lack of data as problematic but concluded that a future trial involving surgical intervention would be feasible at costs of < £650,000.

CONCLUSIONS

Future research into the benefits of interventions for glue ear in children with Down syndrome would be feasible and could be cost-effective but should be carefully designed to facilitate and maximise participation from parents and professionals responsible for recruitment.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Respiratory medication use in an Australian developmental disability clinic population: messages for health care professionals

Australian data suggest up to 15% of people with intellectual disability (ID) have asthma. The inhaled route of administration is optimal for the management of obstructive airways diseases; however, correct inhaler use requires dexterity and particular breathing patterns and potentially represents a problem in this population due to physical and cognitive deficits. Understanding the nature and extent of inhaler use in persons with ID is important, as correct inhaler technique is imperative for optimal clinical outcomes; however, currently no evidence base exists to inform health professionals. This study describes respiratory medication use, reported prevalence of asthma, and asthma management practices undertaken in a clinic sample of Australian adults with ID. Results showed a prevalence of retrospectively reported asthma of 6%, with 86% of asthma patients prescribed inhaled medication. A review of patient records also indicated omission of some recommended asthma management strategies.

Epidemiology of respiratory symptoms in children with Down syndrome: a nationwide prospective web-based parent-reported study

Background

Children with Down syndrome suffer from recurrent respiratory tract and ear-nose-throat complaints that influence daily life. Little is known about the frequency of these complaints, as well as their relation to co-morbidity and ageing.

Methods/design

A prospective web-based parent-reported observational study was designed for parents having a child with Down syndrome (age 0 to 18 years). Upon registration, parents receive an email containing a link to a weekly questionnaire regarding respiratory symptoms during two consecutive years. Additionally, at the beginning, after one year and at the end of the study they receive an extended questionnaire concerning baseline data, daily activities and medical history. The data will be compared to the ongoing “child-is-ill” study, which collects weekly data in an identical fashion in children that are considered to be “normal as to being ill” by their parents.

Discussion

This study will provide important data on the epidemiology of respiratory symptoms in children with Down syndrome, which will be useful for further studies on treatment options. Also, this study will gain insight in healthcare usage and work absence due to the child’s illnesses.

Hospitalization of children with down syndrome

Introduction: Children with Down syndrome present with multiple medical problems in a higher prevalence compared with the general population, which may lead to hospitalizations.

Methods: Analysis of 560 hospitalizations of 162 children aged 0–16 years with Down syndrome at Hadassah Medical Center during the years 1988–2007 compared with data on children in the general population, hospitalized at the same period. Data was collected from patient files and statistical data from the Ministry of Health.

Results: Respiratory infections were the leading cause for hospitalization of children with Down syndrome. The number of hospitalizations of children with Down syndrome compared to the number of all children, who were hospitalized was surprisingly similar to their proportion in the general population. Eleven children died during their hospitalization (five heart failure, three sepsis, one respiratory tract infection, and one due to complication after surgery). Nine of the 11 had a congenital heart anomaly.

Conclusion: Children with Down syndrome can present with complex medical issues and we support the concept of a multidisciplinary team that has experience and knowledge to serve as a “one stop shop” for these individuals and their families, with timely visits in which a comprehensive evaluation is performed, problems attended to and prevention plans applied. In this way, we may prevent morbidity, hospitalizations, and mortality.

How I treat ALL in Down's syndrome: pathobiology and management

Children with Down syndrome are at high risk for developing B-cell precursor acute lymphoblastic leukemia (DS-ALL) associated with poor outcome due to both a high relapse rate and increased treatment-related mortality (TRM) from infections. Biologically, these heterogeneous leukemias are characterized by under-representation of the common cytogenetic subgroups of childhood ALL and overrepresentation of CRLF2-IL7R-JAK-STAT activating genetic aberrations. Although relapse is the major determinant of poor outcomes in this population, de-escalation of chemotherapy intensity might be feasible in the 10% to 15% DS-ALL patients with ETV6-RUNX1 or high hyperdipoidy in whom TRM is the major limiting event. As infection-associated TRM occurs during all treatment phases, including the maintenance period, increased surveillance and supportive care is required throughout therapy. Improvement in outcome will require better understanding of the causes of treatment failure and TRM, incorporation of new therapies targeting the unique biological properties of DS-ALL, and enhanced supportive care measures to reduce the risk of infection-related TRM. To facilitate these goals, an international collaboration plans to establish a prospective DS-ALL registry and develop specific supportive care recommendations for this at-risk population.

Respiratory problems in children with Down syndrome

Down syndrome is associated with a significant health burden, which is particularly apparent in young children who will frequently present with cardiac and respiratory problems. Respiratory presentations include problems related to structural abnormalities of the airways and lungs, glue ears, recurrent lower respiratory tract infections and obstructive sleep apnoea. These conditions are readily identifiable and able to be treated. An awareness of the breadth of respiratory problems and a plan to monitor patients with Down syndrome for their development has the potential to improve outcomes.

National profile of children with Down syndrome: disease burden, access to care, and family impact

OBJECTIVE

To measure the co-morbidities associated with Down syndrome compared with those in other children with special health care needs (CSHCN). Additionally, to examine reported access to care, family impact, and unmet needs for children with Down syndrome compared with other CSHCN.

STUDY DESIGN

An analysis was conducted on the nationally representative 2005 to 2006 National Survey of Children with Special Health Care Needs. Bivariate analyses compared children with Down syndrome with all other CSHCN. Multivariate analyses examined the role of demographic, socioeconomic, and medical factors on measures of care receipt and family impact.

RESULTS

An estimated 98,000 CSHCN have Down syndrome nationally. Compared with other CSHCN, children with Down syndrome had a greater number of co-morbid conditions, were more likely to have unmet needs, faced greater family impacts, and were less likely to have access to a medical home. These differences become more pronounced for children without insurance and from low socioeconomic status families.

CONCLUSIONS

Children with Down syndrome disproportionately face greater disease burden, more negatively pronounced family impacts, and greater unmet needs than other CSHCN. Promoting medical homes at the practice level and use of those services by children with Down syndrome and other CSHCN may help mitigate these family impacts.

Infections and immunodeficiency in Down syndrome

Down syndrome (DS) is the most common genetic disease and presents with cognitive impairment, cardiac and gastrointestinal abnormalities, in addition to other miscellaneous clinical conditions. DS individuals may have a high frequency of infections, usually of the upper respiratory tract, characterized by increased severity and prolonged course of disease, which are partially attributed to defects of the immune system. The abnormalities of the immune system associated with DS include: mild to moderate T and B cell lymphopenia, with marked decrease of naive lymphocytes, impaired mitogen-induced T cell proliferation, reduced specific antibody responses to immunizations and defects of neutrophil chemotaxis. Limited evidence of genetic abnormalities secondary to trisomy of chromosome 21 and affecting the immune system is available, such as the potential consequences of gene over-expression, most significantly SOD1 and RCAN1. Secondary immunodeficiency due to metabolic or nutritional factors in DS, particularly zinc deficiency, has been postulated. Non-immunological factors, including abnormal anatomical structures (e.g. small ear canal, tracheomalacia) and gastro-oesophageal reflux, may play a role in the increased frequency of respiratory tract infections. The molecular mechanisms leading to the immune defects observed in DS individuals and the contribution of these immunological abnormalities to the increased risk of infections require further investigation. Addressing immunological and non-immunological factors involved in the pathogenesis of infectious diseases may reduce the susceptibility to infections in DS subjects.

A population-based assessment of the health, functional status, and consequent family impact among children with Down syndrome

BACKGROUND

Many health conditions have been described in children with Down syndrome (DS). However, there are little comparative population-based data available.

OBJECTIVE/HYPOTHESES

We sought to examine the health impacts associated with DS and other disabling conditions in U.S. children included in the 2005-2006 National Survey of Children with Special Health Care Needs.

METHODS

We assessed numerous health and functional outcomes in children with DS and without DS but with (1) mental retardation/developmental delay(1) and another developmental disability associated with a high functional impact; (2) mental retardation/developmental delay but no co-occurring high-impact disability; (3) other special health care needs; and (4) no special health care needs (referent).

RESULTS

Children with DS and in all 3 special health care needs comparison groups had substantially more health and functional difficulties than did the referent sample. Overall, children with DS were fairly comparable to children in the other mental retardation/developmental delay groups on health indicators; however, young children with DS were more likely than young children in both "other mental retardation" groups to have difficulties with breathing/respiration and swallowing/digestion/metabolism. Children with both DS and mental retardation associated with another high-impact disability had the highest levels of functional difficulties, unmet health needs, and family financial impacts. Nearly 60% of families in both groups provided home health care; in over 40%, a family member stopped working because of the child's condition; and about 40% reported the child's condition caused financial problems.

CONCLUSIONS

Children with DS can have substantial health and functional difficulties, with numerous financial impacts on their families.

Distinct abnormalities in the innate immune system of children with Down syndrome

OBJECTIVE

To analyze the frequency and phenotype of cells of the innate immune system in the peripheral blood of children with Down syndrome (DS).

STUDY DESIGN

Flow cytometric analysis of expression of cell surface markers was performed in children with DS (n = 41) and healthy age-matched controls (n = 41).

RESULTS

Compared with controls, children with DS had significantly lower absolute total leukocyte counts, lymphocytes, monocytes, and granulocytes, but 1.5-times higher absolute numbers of CD14(dim)CD16(+) monocytes (147 x 10(6)/L vs 93 x 10(6)/L; P = .02). This difference is fully explained by a higher percentage of CD14(dim)CD16(+) monocytes within the monocyte compartment (28.7% vs 13.4%; P <.001). The absolute numbers of myeloid dendritic cells were lower in DS (13.8 x 10(6)/L vs 22.7 x 10(6)/L; P <.001). The numbers of plasmacytoid dendritic cells and natural killer cells were normal. Absolute numbers of invariant natural killer T cells were very low overall, but significantly lower in children with DS than in controls (1.2 x 10(6)/L vs 3.7 x 10(6)/L; P = .01).

CONCLUSIONS

Children with DS exhibited distinct abnormalities in cells of the innate immune system. Most strikingly, they had a high number of proinflammatory CD14(dim)CD16(+) monocytes. This elevated level of CD14(dim)CD16(+) monocytes may play an important role in the onset and maintenance of chronic inflammatory disease in DS.

High incidence of recurrent wheeze in children with down syndrome with and without previous respiratory syncytial virus lower respiratory tract infection

BACKGROUND

Respiratory syncytial virus (RSV)-induced lower respiratory tract infection (LRTI) is associated with the subsequent development of recurrent wheeze. In a recent study, we found a high incidence (9.9%) of hospitalization for RSV-induced LRTI among children with Down syndrome (DS), indicating DS as a new risk factor for RSV-induced LRTI. In the current study we aimed to investigate the development of long-term airway morbidity in children with DS after hospitalization for RSV-induced LRTI.

METHODS

A combined retrospective cohort and prospective birth cohort of children with DS with a history of hospitalization for RSV-induced LRTI was studied (n = 53). Three control populations were included: children with DS without hospitalization for RSV-induced LRTI (n = 110), children without DS but with hospitalization for RSV-induced LRTI (n = 48), and healthy siblings of the previous 3 groups mentioned (n = 49). The primary outcome was physician-diagnosed wheeze up to 2 years of age.

RESULTS

The incidence of physician-diagnosed recurrent wheeze in children with DS with a history of hospitalization for RSV-induced LRTI was 36%. Unexpectedly, up to 30% of children with DS without a history of RSV-induced LRTI had physician-diagnosed recurrent wheeze (no significant difference). In children without DS physician-diagnosed wheeze was found more frequently in children hospitalized for RSV-induced LRTI than healthy controls (31% vs. 8%, P = 0.004).

CONCLUSIONS

In this combined retrospective/prospective cohort study RSV-induced LRTI did not significantly contribute to the risk of recurrent wheeze in children with DS. An unexpected finding was that recurrent wheeze was very common among children with DS.

Health of children 3 to 17 years of age with Down syndrome in the 1997-2005 national health interview survey

OBJECTIVE

This study provides population-based estimates of recent medical conditions, concurrent developmental disorders, and health impact and utilization indicators for US children with and without Down syndrome.

METHODS

The sample included children 3 to 17 years of age in the 1997-2005 National Health Interview Survey Child Sample Core and specifically included 146 children with Down syndrome, 604 children with mental retardation but without Down syndrome, and 95 454 children without either condition reported. Developmental and medical conditions, health status, and service use were reported by parents or other knowledgeable caregivers.

RESULTS

After adjustment for demographic factors, children with Down syndrome had higher odds, compared with children without mental retardation, of recent food/digestive allergy, frequent diarrhea/colitis, > or =3 ear infections in the previous year, very recent head/chest cold, and developmental disabilities other than mental retardation. They had increased odds that approached significance for recent seizures, very recent stomach/intestinal illness, and asthma. They had substantially higher rates (threefold or higher, compared with children without mental retardation) for nearly all health impact and health and special education service use measures. Of note, >25% of children with Down syndrome needed help with personal care, regularly took prescription medications, had recently seen a medical specialist, and received physical therapy or related therapy. The comparison group with mental retardation without Down syndrome represented many children with multiple serious disabilities who also had high rates of medical conditions and high levels of health impact and service use.

CONCLUSION

These findings provide empirical, population-based data to inform guidelines for frequent monitoring and support for children with Down syndrome.

Treatment-related death in childhood acute lymphoblastic leukaemia in the Nordic countries: 1992-2001

Despite continuously more successful treatment of childhood acute lymphoblastic leukaemia (ALL), 2-5% of children still die of other causes than relapse. The Nordic Society of Paediatric Haematology and Oncology-ALL92 protocol included 1652 patients < or =15 years of age with precursor B- and T-cell ALL diagnosed between 1992 and 2001. Induction deaths and deaths in first complete remission (CR1) were included in the study. A total of 56 deaths (3%) were identified: 19 died during induction (1%) and 37 in CR1 (2%). Infection was the major cause of death in 38 cases. Five patients died of early death before initiation of cytotoxic therapy. Five patients died because of toxicity of inner organs and one of accidental procedure failures. Seven patients died of complications following allogenic haematopoietic stem cell transplantation (HSCT) in CR1. Girls were at higher risk of treatment-related death (TRD) [relative risk (RR) = 2.2; 95% confidence interval (CI(95%)): 1.2-4.0, P < 0.01], mostly because of infections. Risk of TRD was also higher in children with Down syndrome (RR = 4.5; CI(95%): 2.0-10.2, P < 0.00). In conclusion, 3% of children with ALL died of TRD, with bacterial infections as the most common cause of death. Girls and Down syndrome patients had a higher risk of TRD. Infections still remain a major challenge in childhood ALL.

Childhood and maternal infections and risk of acute leukaemia in children with Down syndrome: a report from the Children's Oncology Group

Children with Down syndrome (DS) are highly susceptible to acute leukaemia. Given the potential role of infections in the aetiology of leukaemia in children without DS, we investigated whether there was an association between early-life infections and acute leukaemia in children with DS. Maternal infections during pregnancy were also examined. We enrolled 158 incident cases of acute leukaemia in children with DS (97 acute lymphoblastic leukaemia (ALL) and 61 acute myeloid leukaemia (AML)) diagnosed at Children's Oncology Group institutions between 1997 and 2002. DS controls (N=173) were selected from the cases' primary care clinics and frequency matched on age at leukaemia diagnosis. Data were collected on demographics, child's medical history, mother's medical history, and other factors by maternal interview. Analyses were conducted using unconditional logistic regression adjusted for potential confounders. A significant negative association was observed between acute leukaemia and any infection in the first 2 years of life (adjusted odds ratio (OR)=0.55, 95% confidence interval (CI) (0.33–0.92); OR=0.53, 95% CI (0.29–0.97); and OR=0.59, 95% CI (0.28–1.25) for acute leukaemia combined, ALL, and AML respectively). The association between acute leukaemia and maternal infections during pregnancy was in the same direction but not significant. This study offers support for the hypothesis that early-life infections may play a protective role in the aetiology of acute leukaemia in children with DS.

Functional status of school-aged children with Down syndrome

OBJECTIVE

To field test, in questionnaire format, the Functional Independence Measure for Children (WeeFIM, a schedule usually administered by interview) on parents of a cohort of school-aged children with Down syndrome.

METHODS

The parents of 211 Western Australian children with Down syndrome participated in the present study, representing 79.9% of all children with Down syndrome in the State. Subjects were identified using two sources: (i) the Birth Defects Registry; and (ii) the Disability Services Commission.

RESULTS

The total WeeFIM score was 106.2 +/- 17.0 (mean +/- SD) out of a possible 126. Girls scored higher than boys (108.6 vs 103.6; P = 0.05). Scores increased across all age groups (P < 0.0001), even relative to normative data. Performance was strongest in the transfer and locomotion domains and weakest in social cognition.

CONCLUSION

We found that severe functional limitations are rare in school-aged children with Down syndrome. Some support and supervision are required for complex self-care, communication and social skill tasks. This study demonstrates the feasibility of using the WeeFIM for collecting population survey data in children with developmental disability. This may be useful for the longitudinal tracking of such populations, as well as the monitoring of response to interventions.

Ear and hearing in relation to genotype and growth in Turner syndrome

Hearing loss, auricular anomalies and middle ear infections are common findings in many genetic disorders, but the mechanisms have remained unknown. We studied ear and hearing problems in Turner's syndrome (TS) in relation to the degree of X chromosome loss (i.e. degree of mosaicism) and growth. One hundred and nineteen girls and women with TS were studied regarding audiometry, fluorescent in situ hybridisation, serum concentration of insulin-like growth factor-1 (IGF-1) and body height. It was found that sensorineural hearing loss and occurrence of auricular anomalies were significantly increased the greater the proportion of 45,X cells in a particular individual (P<0.05 and P<0.001, respectively). Middle ear infections and sensorineural hearing loss were negatively correlated with IGF-1 (P<0.05 and P<0.001, respectively). Hearing correlated positively with height (P<0.01) and IGF-1 independently of age (P<0.05). Height correlated positively with IGF-1 (P<0.001). Auricular malformations, middle ear infections and hearing impairment in TS were interpreted as due to growth disturbances during development. A new hypothesis on the pathophysiology of external, middle and inner ear disorders due to a delayed cell cycle caused by chromosomal aberrations per se and not only to the specific X chromosome deletion is presented.

Respiratory morbidity of hospitalized children with Trisomy 21

OBJECTIVE

To review the respiratory morbidity in children with Trisomy 21 admitted to a teaching hospital.

METHODOLOGY

A retrospective chart review of 232 admissions to John Hunter Children's Hospital during a 6.5-year period (1991-98). The primary outcome measures included: (i) primary reason for admission, (ii) concomitant respiratory pathology, (iii) admission to the Intensive Care Unit (ICU), (iv) length of stay and (v) costs of admission.

RESULTS

Fifty-four per cent of admissions were primarily for respiratory tract pathology, dominated by pneumonia, bronchiolitis and croup. Admission to the ICU was required for 10% of admissions, most commonly for pneumonia (10/23). Congenital heart disease (CHD) was present in 33% of patients. The median length of stay and cost of admission for a child with Trisomy 21 (without CHD) with common respiratory conditions such as bronchiolitis, asthma or pneumonia was two to three times greater than in patients without Trisomy 21.

CONCLUSION

Lower respiratory pathology is most common cause for acute hospital admission in children with Trisomy 21. The presence of CHD did not influence admission rates to hospital. However, patients with CHD had longer lengths of stay, appeared to have more severe illness, were more likely to require admission to an ICU and were more likely to require ventilatory support.

Orthopedic conditions of the cervical spine and shoulder

Orthopedic conditions of the cervical spine and shoulder can range from benign to life threatening. A careful history and examination are crucial to evaluate these children, and additional investigations may be necessary. The signs and symptoms in these conditions and the indications for referral are discussed.

Short-term efficacy of tympanostomy tubes for secretory otitis media in children with Down syndrome

Twenty-four children with Down syndrome, aged six to 14 years, were tested with audiometry six to nine weeks after insertion of tympanostomy tubes for bilateral secretory otitis media (SOM). There was no improvement in hearing in 40 per cent of ears, compared with only 9 per cent of ears in 21 age-matched controls with bilateral SOM. Tympanostomy tubes for SOM in children with Down syndrome have a high short-term failure rate, which should be explained to the parents before insertion, and the children should have audiometry tests shortly after the operation. Persistent hearing-loss may require the fitting of hearing aids. Management should involve ensuring that the children are in a situation in which they can hear as well as possible, and making allowances for the hearing impairment.