Increase in incidence of medically treated thyroid disease in children with Down Syndrome after rerelease of American Academy of Pediatrics Health Supervision guidelines

Emotional and behavioral features associated with subclinical hypothyroidism in children and adolescents with Down syndrome

Background

Subclinical hypothyroidism (SH) is particularly frequent in individuals with Down syndrome (DS). Despite the amount of evidence suggesting SH is associated with psychopathological symptoms and sleep problems in general population, poor is known about the emotional and behavioral features associated with SH in children with DS.

Objective

The first aim of the current study was to investigate differences in emotional and behavioral profiles between a group of children with DS exhibiting co-occurring SH and a group of age and BMI-matched children with DS without co-occurring SH. The second aim of the present study was to investigate differences in sleep disturbances between these groups.

Methods

We included in this retrospective study 98 participants with DS aged 3-18 years with the aim to explore differences in emotional/behavioral problems as well as in sleep difficulties between children with DS with or without co-occurring SH.

Results

Participants with co-occurring SH exhibited significantly higher scores at several scales of the Conners' Parent Rating Scales Long Version - Revised. However, they did not exhibit more sleep problems than control group.

Conclusion

These results provide specific indications for psychological and neuropsychiatric evaluation of children with DS with suspected or diagnosed SH, highlighting the importance of a multidisciplinary approach in clinical care for children and adolescents with DS.

Medicine use in people with intellectual disabilities: a Finnish nationwide register study

BACKGROUND

People with intellectual disability (ID) are a vulnerable group in our society; many of them depend on other people for assistance in their everyday lives. Compared with the general population, people with ID have poorer general health and, therefore, need more healthcare services and use more medicines. The aim of this study is to define the population of all Finnish people with ID using administrative data and to compare their medicine use and expenditure on medicines to those of the age-matched and sex-matched controls.

METHODS

People with ID and their age-matched and sex-matched controls (1:1) were extracted from nationwide healthcare and social allowance registers. Administrative register data on all prescription medicine purchases in 2019 were used to determine the prevalence of medicine use in both groups on a general level and by medicine categories. The differences in the prevalence of medicine use between the two groups were analysed using the logistic regression model. In addition, we studied the total expenditure on reimbursable medicine purchases covered by the National Health Insurance between people with ID and control group.

RESULTS

The subpopulation of people with ID consisted 37 196 individuals, of whom 82.7% purchased prescription medicines in 2019. The corresponding share of individuals purchasing prescription medicines in the control group was 70.3%. The differences in the prevalence of medicine use between the two populations were highest in the younger age groups (0-6, 7-12 and 13-17). In the study population, 28.1% (OR = 12.28; 95% CI: 11.54-13.07) of the people used antipsychotics, making it the most used medicine category in people with ID. In the control group, 3.3% of people used antipsychotics. Compared with the control group, the use of antiepileptics, drugs for constipation, mineral supplements and anxiolytics was four to seven times higher among people with ID. Furthermore, the median expenditure on medicine use among people with ID was four times higher than in the control group.

CONCLUSIONS

Compared with the control group, people with ID used more medicines, especially psychotropics, and their expenditure on medicine use was higher.

Obstructive sleep apnea in children with Down syndrome: contribution of upper airway and chemosensitivity

BACKGROUND

The high prevalence of obstructive sleep apnea syndrome (OSAS) in children with Down syndrome (DS) has been attributed to a reduced upper airway size, while the role of ventilatory control is unclear. The objectives of our case-control study were to evaluate the upper airway reduction in children with DS and moderate to severe OSAS as compared to typically developing (TD) children with similar OSAS severity and to evaluate the degree of chemical loop gain modifications including its components: controller and plant gains (CG, PG).

METHODS

Thirteen children with DS were matched for age, sex, OSAS severity and ethnicity with 26 TD children. They had undergone acoustic rhinometry and pharyngometry, chemical LG obtained during awake tidal breathing measurement and hypercapnic-hyperoxic ventilatory response testing.

RESULTS

As compared to TD, children with DS depicted reduced oropharyngeal dimensions, significantly lower CG and LG and no different PG. Their hypercapnic ventilatory response slopes were not different.

CONCLUSIONS

We concluded that the decreased CG in DS was related to decreased peripheral chemoreceptor sensitivity, and while central chemosensitivity was normal, the former explained the increased end-tidal PCO2 observed in children with DS as compared to TD. Pharyngeal dimensions are reduced in children with DS and OSAS.

IMPACT

Reduced upper airway size and nocturnal alveolar hypoventilation in children with Down syndrome (DS) have been previously reported. We confirmed that children with DS and moderate-to-severe OSA have reduced oropharyngeal size as compared to typically developing children with similar OSAS severity and demonstrated decreased peripheral chemosensitivity explaining the alveolar hypoventilation observed in children with DS. Central chemosensitivity appears to be intact in children with DS and moderate to severe OSAS Our results support growing evidence that Down syndrome is associated with autonomic nervous system dysfunction.

Sleep disturbances in individuals with down syndrome: An overview

Down Syndrome, or Trisomy 21, is one of the most common birth defects, with 6,000 babies born annually with Down Syndrome in the U.S. One of many health risk factors individuals with Down Syndrome experience is sleep issues, ranging from poor sleep quality to high prevalence of obstructive sleep apnea. This literature review aims to review these sleep challenges in this population and explore consequences and treatment options.

Prospective study of thyroid function in the first year of life in infants with Down syndrome

Current American Academy of Pediatrics (AAP) Guidelines recommend monitoring thyroid function in infants with Down syndrome (DS) at birth, 6 and 12 months, and annually thereafter. This study aimed to determine whether these guidelines are optimal for early diagnosis and treatment of (subclinical) hypothyroidism. Enrolled infants with DS less than age 7 months, born at ≥ 30 weeks gestation to monitor thyroid function test (TFT). A filter paper (FP) blood sample was analyzed for TSH and total T4 at ages 2 and 4 weeks and monthly thereafter until 12 months. Subjects with abnormal FP sample and confirmatory serum TFT for hypothyroidism promptly started treatment. Subjects with thyroid dysfunction identified had thyroid antibodies measured at diagnosis and 12 months. Descriptive statistics determined average time to diagnosis of abnormal TFT. Sixteen (30%) of 54 subjects were diagnosed with a thyroid disorder, the majority with subclinical hypothyroidism (SH) and 1 with hyperthyroidism. Diagnosis occurred in 6 (11%), 9 (17%), and 12 (22.2%) infants in the first 30, 60, and 90 days of life (DOL), respectively. Eight infants had an abnormal NBS and half were diagnosed with a thyroid disorder by DOL 8 and the remainder prior to 4 months. Among subjects with a normal NBS, four were diagnosed at a mean of 104 days and three at a mean of 101 days prior to the 6-month and 12-month routine screens, respectively.  Conclusion: Based on current AAP guidelines, thyroid disorder diagnosis would have been delayed in nearly 20% of the subjects. An additional TFT screen at 1 and 3 months can lead to earlier diagnosis and treatment. What is Known: • Current American Academy of Pediatrics (AAP) Guidelines recommend thyroid function tests (TFT) in infants with Down syndrome (DS) at birth and 6 and 12 months. • Peer- reviewed retrospective studies report an increased incidence of hypothyroidism in infants with DS undetected by the newborn screen (NBS) and prior to 6 months. What is New: • This prospective study monitored TFT in infants with DS at age 2 weeks and monthly throughout the first year of life. • The findings in this study support additional TFT screens at 1 and 3 months in infants with DS.

Guidelines for Newborn Screening of Congenital Hypothyroidism (2021 Revision)

Purpose of developing the guidelines: Newborn screening (NBS) for congenital hypothyroidism (CH) was started in 1979 in Japan, and early diagnosis and treatment improved the intelligence prognosis of CH patients. The incidence of CH was once about one in 5,000-8,000 births, but has been increased with diagnosis of subclinical CH. The disease requires continuous treatment and specialized medical facilities should conduct differential diagnosis and treatment in patients who are positive by NBS to avoid unnecessary treatment. The Guidelines for Mass Screening of Congenital Hypothyroidism (1998 version) were developed by the Mass Screening Committee of the Japanese Society for Pediatric Endocrinology in 1998. Subsequently, the guidelines were revised in 2014. Here, we have added minor revisions to the 2014 version to include the most recent findings. Target disease/conditions: Primary congenital hypothyroidism. Users of the Guidelines: Physician specialists in pediatric endocrinology, pediatric specialists, physicians referring pediatric practitioners, general physicians, laboratory technicians in charge of mass screening, and patients.

Rates of hospitalization for urinary tract infections among medicaid-insured individuals by spina bifida status, Tennessee 2005-2013

BACKGROUND

Individuals with spina bifida are at increased risk for urinary tract infection (UTI), however there are few population-based investigations of the burden of UTI hospitalizations.

OBJECTIVE

We assessed rates and risk factors for UTI hospitalization in individuals with and without spina bifida.

METHODS

We conducted a retrospective cohort study to estimate rates of UTI hospitalization by spina bifida status. We included individuals enrolled in Tennessee Medicaid who lived in one of the Emerging Infections Program's Active Bacterial Surveillance counties between 2005 and 2013. Spina bifida was primarily defined and UTI hospitalizations were identified using International Classification of Diseases, Ninth Revision diagnoses. We also studied a subset without specific health conditions potentially associated with UTI. We used Poisson regression to calculate rate ratios (RR) of UTIs for individuals with versus without spina bifida, adjusting for race, sex and age group.

RESULTS

Over the 9-years, 1,239,362 individuals were included and 2,493 met criteria for spina bifida. Individuals with spina bifida had over a four-fold increased rate of UTI hospitalization than those without spina bifida-in the overall study population and in the subset without specific, high-risk conditions (adjusted rate ratios: 4.41, 95% confidence intervals: 3.03, 6.43) and (4.87, 95% CI: 2.99, 7.92), respectively. We detected differences in rates of UTI hospitalization by race and sex in individuals without spina bifida that were not seen among individuals with spina bifida.

CONCLUSIONS

Individuals with spina bifida had increased rates of UTI hospitalizations, and associated demographic patterns differed from those without spina bifida.

Nocturnal hypoventilation in Down syndrome children with or without sleep apnea

BACKGROUND

There is a high prevalence of obstructive sleep apnea (OSA) in children with Down syndrome (DS), sometimes associated with alveolar hypoventilation.

OBJECTIVE

To compare transcutaneous partial pressure of carbon dioxide (PtcCO₂ ) and pulse oximetry (SpO₂ ) in children with DS and in control children with OSA.

PATIENTS AND METHODS

This retrospective case-control study involved children followed in Trousseau Hospital (Paris) Sleep Center. Polysomnography (PSG) recordings and clinical files of children with DS were reviewed to identify clinical signs of OSA and comorbidities associated with DS. Controls were children who presented with OSA of ENT origin without other comorbidities (exceptions: two overweight, one obese, and three with well-controlled asthma). DS subjects and controls were matched for age and apnea hypopnea index.

RESULTS

There were 28 children in each group. Mean PtcCO₂ during sleep was significantly higher in patients with DS compared to controls (44 mm Hg vs 42 mm Hg, P = .001). Five (21%) patients with DS met the American Academy of Sleep medicine criteria for hypoventilation, compared to one (4%) in the control group. The mean PtcO₂ during sleep was significantly lower in patients with DS (77 mm Hg vs 82 mm Hg, P = .003).

CONCLUSIONS

This is the first study to compare nocturnal gas exchange in children with DS to a control group of children with similar OSA. Our data demonstrate that children with DS have increased PtcCO₂ regardless of the presence of OSA and its severity. This may be due to respiratory muscle hypotonia and/or ventilatory control alteration in patients with DS.

Disparities in Health Supervision for Children With Down Syndrome

Increasing evidence suggests children with Down syndrome do not receive recommended health care services. We retrospectively assessed adherence to the 2001 American Academy of Pediatrics health supervision guidelines for 124 children with Down syndrome. Cervical spine radiographs were completed for 94% of children, often preoperatively. Adherence to complete blood count recommendations was 55% (95% CI 44% to 66%); lower for males ( P = .01) and children with private medical insurance ( P = .04). Adherence to thyroid function recommendations was 61% (95% CI 54% to 67%); higher for children seen by a pediatrician ( P = .002) and with known thyroid disease ( P < .0001). Adherence to audiology and ophthalmology recommendations was 33% (95% CI 27% to 40%) and 43% (95% CI 37% to 50%), respectively. Adherence rates were higher for children referred to an otolaryngologist ( P = .0002) and with known eye disease ( P < .0001). Future efforts should identify barriers to care and improve adherence to recommended screening.

Pattern of Thyroid Disorders in Children and Adolescents Seen at the Lagos University Teaching Hospital, Nigeria, Over a 10-year Period

Introduction:

Thyroid disorders account for a large proportion of pediatric endocrine disorders. Untreated hypothyroidism in childhood has permanent adverse effects on physical, intellectual, and neurological development. However, few studies have reported the pattern of pediatric thyroid disorders in Nigeria.

Objectives:

The objective of this study was to document the pattern of thyroid disorders in children and adolescents seen at the Lagos University Teaching Hospital (LUTH) over a 10-year period.

Participants and Methods:

This is a retrospective descriptive study involving children with thyroid disorders seen from January 1, 2006 to December 31, 2015.

Results:

Seventy-one patients with thyroid disorders (0.13%) were seen out of 52,800 new cases (incidence of 1/1000 new cases) comprising 13.4% of 546 pediatric endocrine cases with a male:female ratio of 1:1.2. Median (range) age at presentation was 1.6 (0.001–14) years. Congenital hypothyroidism (CH) constituted a major proportion of cases (46.7%), with a median (range) age at presentation of 9 (1.5–24) months. Down syndrome constituted 45% of patients with CH with associated congenital heart defects in eight (53%) patients. Acquired hypothyroidism was seen in ten patients (five goitrous and five nongoitrous). Six patients had hypothyroidism associated with multiple anterior pituitary hormone deficiency. Nine patients (all females) had hyperthyroidism with confirmed Graves' disease in 5 (55.6%), with mean age at presentation being 9.4 ± 2.09 years. Other conditions were euthyroid sick syndrome (2.8%), euthyroid goiter (1.4%), and acute thyroiditis (1.4%). Eight infants of mothers on treatment for hyperthyroidism ( first seen between the 7^th h of life to 2 months of age) had transient hypothyroidism while one 8-day-old had transient hyperthyroidism.

Conclusion:

CH was the most common disorder encountered with late age at presentation. Routine newborn screening and maintaining a high index of suspicion are advocated.

Thyroxine-Based Screening for Congenital Hypothyroidism in Neonates with Down Syndrome

OBJECTIVE

To ascertain whether thyroxine (T4)-based screening programs for congenital hypothyroidism (initial measurement of total T4 [tT4] followed by thyroid stimulating hormone [TSH] measurement in patients with tT4 <10th percentile) identifies congenital hypothyroidism in all neonates with Down syndrome.

STUDY DESIGN

Retrospective cohort study of 159 neonates with Down syndrome, born during the period 1998-2007 were included. Screening test results were compared with those of the general population. All primary care physicians of these infants were contacted and infants' thyroid status verified.

RESULTS

tT4 concentrations in children with Down syndrome were significantly lower, and TSH higher than those in the general population; tT4 concentrations did not correlate with screening TSH concentrations. Twenty children with Down syndrome were treated with L-thyroxin within the first month of life although only 10 babies had been identified by the routine screening test.

CONCLUSIONS

T4-based screening does not identify many cases of congenital hypothyroidism in neonates with Down syndrome. We recommend that neonates with Down syndrome be screened by simultaneous measurements of both tT4 and TSH.

Oxidative stress, thyroid dysfunction & Down syndrome

Down syndrome (DS) is one of the most common chromosomal disorders, occurring in one out of 700-1000 live births, and the most common cause of mental retardation. Thyroid dysfunction is the most typical endocrine abnormality in patients with DS. It is well known that thyroid dysfunction is highly prevalent in children and adults with DS and that both hypothyroidism and hyperthyroidism are more common in patients with DS than in the general population. Increasing evidence has shown that DS individuals are under unusual increased oxidative stress, which may be involved in the higher prevalence and severity of a number of pathologies associated with the syndrome, as well as the accelerated ageing observed in these individuals. The gene for Cu/Zn superoxide dismutase (SOD1) is coded on chromosome 21 and it is overexpressed (~50%) resulting in an increase of reactive oxygen species (ROS) due to overproduction of hydrogen peroxide (H₂O₂). ROS leads to oxidative damage of DNA, proteins and lipids, therefore, oxidative stress may play an important role in the pathogenesis of DS.

Thyroid function in Down syndrome

Down syndrome is the most commonly encountered human chromosomal disorder. Down syndrome is associated with thyroid dysfunction including: hypothyroidism, both congenital and acquired, and hyperthyroidism. A genetic predisposition and a propensity to acquire autoimmune disorders seem to be possible factors, though their causal relation remains unclear. The aim of the review is to describe what is currently known about the association between Down syndrome and thyroid dysfunction.

Guidelines for Mass Screening of Congenital Hypothyroidism (2014 revision)

Purpose of developing the guidelines: Mass screening for congenital hypothyroidism started in 1979 in Japan, and the prognosis for intelligence has been improved by early diagnosis and treatment. The incidence was about 1/4000 of the birth population, but it has increased due to diagnosis of subclinical congenital hypothyroidism. The disease requires continuous treatment, and specialized medical facilities should make a differential diagnosis and treat subjects who are positive in mass screening to avoid unnecessary treatment. The Guidelines for Mass Screening of Congenital Hypothyroidism (1998 version) were developed by the Mass Screening Committee of the Japanese Society for Pediatric Endocrinology in 1998. Subsequently, new findings on prognosis and problems in the adult phase have emerged. Based on these new findings, the 1998 guidelines were revised in the current document (hereinafter referred to as the Guidelines). Target disease/conditions: Primary congenital hypothyroidism. Users of the Guidelines: Physician specialists in pediatric endocrinology, pediatric specialists, physicians referring patients to pediatric practitioners, general physicians, laboratory technicians in charge of mass screening, and patients.

Down syndrome, insulin-dependent diabetes mellitus and hyperthyroidism: a rare association

The association between Down syndrome (DS) and autoimmune endocrinopathies is well established. These disorders become increasingly frequent as children grow older and the onset of one often predisposes to the development of others. However, there are few cases in the literature reporting the simultaneous onset of type 1 diabetes mellitus and hyperthyroidism in children with DS. We describe a case of an 8-year-old girl with DS who presented at the emergency department with hyperglycaemia and ketosis as a primary manifestation of type 1 diabetes mellitus. During the initial investigation, hyperthyroidism was detected, with thyroid-stimulating hormone<0.01 µUI/mL, positive antithyroid antibodies and an increase in thyroid gland on ultrasound. The authors present this case to underline the usefulness of monitoring thyroid function at the diagnosis of diabetes, even without apparent clinical manifestations, and to alert for the possibility of autoimmune endocrine dysfunction in children with DS.

Stem and progenitor cell dysfunction in human trisomies

Trisomy 21, the commonest constitutional aneuploidy in humans, causes profound perturbation of stem and progenitor cell growth, which is both cell context dependent and developmental stage specific and mediated by complex genetic mechanisms beyond increased Hsa21 gene dosage. While proliferation of fetal hematopoietic and testicular stem/progenitors is increased and may underlie increased susceptibility to childhood leukemia and testicular cancer, fetal stem/progenitor proliferation in other tissues is markedly impaired leading to the characteristic craniofacial, neurocognitive and cardiac features in individuals with Down syndrome. After birth, trisomy 21-mediated premature aging of stem/progenitor cells may contribute to the progressive multi-system deterioration, including development of Alzheimer's disease.

Revisiting early hypothyroidism screening in infants with Down syndrome

OBJECTIVE

To identify if the incidence of hypothyroidism in infants with Down syndrome is higher than previous childhood estimates (15%) when examined prior to the standard retesting at 6 months of age.

STUDY DESIGN

A retrospective observational cohort study of 122 children with Down syndrome admitted to a university-based birthing hospital between May 2000 and March 2012. Demographic data (for example, date of birth, gender, gestational age, inborn) and diagnostic data (Down syndrome, congenital heart disease and gastrointestinal disease) were cross-linked with thyroid hormone laboratory tests (total thyroxine, free thyroxine and thyroid stimulating hormone) to determine incidence of identified hypothyroidism and thyroid testing prior to 4 months of age (n=80).

RESULT

In all, 32.5% were found to have any hypothyroidism. Of these, 14 were primary hypothyroidism (17.5%) needing supplemental T4 therapy, 12 were compensated hypothyroidism (15%) and euthyroid was identified in 54 infants (67.5%).

CONCLUSION

Despite normal newborn screens, the incidence of any hypothyroidism (early compensated hypothyroidism and primary hypothyroidism) was higher than previously reported.

Slipped capital femoral epiphysis and hypothyroidism in a patient with Down syndrome

Early screening is key for patients, such as those with Down syndrome, at high risk for associated diseases. Slipped capital femoral epiphysis and hypothyroidism require a high level of suspicion, screening, and early referral to avoid long-term complications.

Down syndrome and thyroid function

Thyroid dysfunction in children with Down syndrome (DS) can occur as early as birth. As children with DS age, their risk for thyroid autoimmunity manifested as autoimmune hypothyroidism or Graves disease increases. The optimal timing and method for thyroid screening in children with DS remains controversial. The American Academy of Pediatrics recommends annual screening in this population. Consensus is needed to establish working definitions of euthyroidism and mild hypothyroidism in all infants, but especially in those with DS.

TSH neurosecretory dysfunction (TSH-nd) in Down syndrome (DS): low risk of progression to Hashimoto's thyroiditis

INTRODUCTION

Patients with Down syndrome (DS) often have elevated TSH (hypothalamic origin), which is called TSH neurosecretory dysfunction (TSH-nd). In these cases, there is slight elevation in TSH (5-15 µUI/mL), with normal free T4 and negative thyroid antibodies (AB).

OBJECTIVE

To recognize the risk of progression to Hashimoto's thyroiditis (HT).

SUBJECTS AND METHODS

We retrospectively analyzed 40 DS patients (mean age = 4.5 years), followed up for 6.8 years.

RESULTS

HT was diagnosed in 9/40 patients, three early in monitoring, and six during evolution. In 31/40 patients, TSH-nd diagnosis remained unchanged over the years, with maximum TSH values ranging from 5 to 15 µUI/mL. In this group, free T4 also remained normal and AB were negative. There was a significant TSH reduction (p = 0.017), and normal TSH concentrations (< 5.0 µUI/mL) were observed in 29/31 patients, in at least one moment. No patient had TSH > 15 µUI/mL.

CONCLUSION

DS patients with TSH-nd present low risk of progression to HT (10% for females and 6% for males).

Identification of novel candidate maternal serum protein markers for Down syndrome by integrated proteomic and bioinformatic analysis

OBJECTIVE

This study aimed to identify candidate protein biomarkers from maternal serum for Down syndrome (DS) by integrated proteomic and bioinformatics analysis.

METHODS

A pregnancy DS group of 18 women and a control group with the same number were prepared, and the maternal serum proteins were analyzed by isobaric tags for relative and absolute quantitation and mass spectrometry, to identify DS differentially expressed maternal serum proteins (DS-DEMSPs). Comprehensive bioinformatics analysis was then employed to analyze DS-DEMSPs both in this paper and seven related publications.

RESULTS

Down syndrome differentially expressed maternal serum proteins from different studies are significantly enriched with common Gene Ontology functions, Kyoto Encyclopedia of Genes and Genomes (KEGG) pathways, transcription factor binding sites, and Pfam protein domains, However, the DS-DEMSPs are less functionally related to known DS-related genes. These evidences suggest that common molecular mechanisms induced by secondary effects may be present upon DS carrying. A simple scoring scheme revealed Alpha-2-macroglobulin, Apolipoprotein A1, Apolipoprotein E, Complement C1s subcomponent, Complement component 5, Complement component 8, alpha polypeptide, Complement component 8, beta polypeptide and Fibronectin as potential DS biomarkers.

CONCLUSION

The integration of proteomics and bioinformatics studies provides a novel approach to develop new prenatal screening methods for noninvasive yet accurate diagnosis of DS.

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.

Early onset of primary hypogonadism revealed by serum anti-Müllerian hormone determination during infancy and childhood in trisomy 21

Male patients with an extra sex chromosome or autosome are expected to present primary hypogonadism at puberty owing to meiotic germ-cell failure. Scarce information is available on trisomy 21, a frequent autosomal aneuploidy. Our objective was to assess whether trisomy 21 presents with pubertal-onset, germ-cell specific, primary hypogonadism in males, or whether the hypogonadism is established earlier and affects other testicular cell populations. We assessed the functional status of the pituitary-testicular axis, especially Sertoli cell function, in 117 boys with trisomy 21 (ages: 2months-20year). To compare with an adequate control population, we established reference levels for serum anti-Müllerian hormone (AMH) in 421 normal males, from birth to adulthood, using a recently developed ultrasensitive assay. In trisomy 21, AMH was lower than normal, indicating Sertoli cell dysfunction, from early infancy, independently of the existence of cryptorchidism. The overall prevalence rate of AMH below the 3rd percentile was 64.3% in infants with trisomy 21. Follicle-stimulating hormone was elevated in patients <6months and after pubertal onset. Testosterone was within the normal range, but luteinizing hormone was elevated in most patients <6months and after pubertal onset, indicating a mild Leydig cell dysfunction. We conclude that in trisomy 21, primary hypogonadism involves a combined dysfunction of Sertoli and Leydig cells, which can be observed independently of cryptorchidism soon after birth, thus prompting the search for new hypotheses to explain the pathophysiology of gonadal dysfunction in autosomal trisomy.

Healthcare and guidelines: a population-based survey of recorded medical problems and health surveillance for people with Down syndrome

BACKGROUND

Medical problems are described in a population of persons with Down syndrome. Health surveillance is compared to the recommendations of national guidelines.

METHOD

Case records from the specialised and primary healthcare and disability services were analysed.

RESULTS

A wide spectrum of age-specific medical and surgical problems was described. Congenital heart defects and middle ear infections were mostly experienced by younger people, while thyroid disease, epilepsy, and Alzheimer's disease were frequent among older people. Psychiatric disorders and behavioural problems were frequent in all age groups.

CONCLUSIONS

Health surveillance remained insufficient, despite the guidelines available. A joint effort by healthcare and disability service providers is required to ensure that the medical needs of people with Down syndrome are adequately met across their entire lifespan. An active provision of healthcare and monitoring for this vulnerable group is needed.

Variation over time in medical conditions and health service utilization of children with Down syndrome

OBJECTIVES

To compare the prevalence of parent reported medical conditions and rates of health service utilization in school-aged children with Down syndrome in Western Australia in 1997 and 2004.

STUDY DESIGN

We compared two cross-sectional surveys completed by parents of children with Down syndrome identified from population-based sources in 1997 (n = 210) and 2004 (n = 208). Surveys collected information on family demographics, medical conditions, health issues, and service utilization. The analysis described medical conditions in 2004 and compared frequencies in both years. Regression analyses compared medical conditions and health utilisation in the two cohorts.

RESULTS

In 2004, children with Down syndrome had greater odds of having a bowel condition (OR, 1.69; 95%, 1.16 to 2.45; P = .01), were less likely to have a current problem due to their cardiac condition (OR, 0.32; 95% CI, 0.15 to 0.68, P = .003), and demonstrated an overall reduction in episodic illnesses and infections. The use of GP services (incidence rate ratio [IRR] = 0.91; 95% CI, 0.83 to 1.00, P = .05) and combined medical specialist visits (IRR = 0.92; 95% CI, 0.84 to 1.01; P = .09) were reduced in 2004, as were overnight hospital admissions (IRR = 0.60; 95% CI, 0.37 to 0.96; P = .03) and length of stay (IRR = 0.33; 95% CI, 0.24 to 0.44; P < .001).

CONCLUSIONS

The health status of children with Down syndrome has varied over time with reductions in current cardiac problems, episodic illnesses, and health service use. Research is now needed to investigate the impact of these changes on the overall health and quality of life of children and families living with Down syndrome.

Severe hypothyroidism presenting as obstructive sleep apnea

A 5-year-old child with Down syndrome (DS) diagnosed with mild to moderate obstructive sleep apnea (OSA) and subsequently found to have severe hypothyroidism is presented. Following 3 months of treatment with levothyroxine, she had full resolution of her OSA. This case underscores the importance of routine thyroid function screening in children with DS and demonstrates that OSA in children with DS can be caused by other underlying medical issues that themselves require therapy, such as the hypothyroidism in this child. Although empiric testing of thyroid function is not recommended as part of the routine workup of patients with OSA, when caring for children at higher risk for thyroid dysfunction, such as those with DS, it is important to establish whether or not it is present, as treating it may bring about partial or full resolution of the OSA, as was shown to occur in this patient.