Down syndrome is the most common chromosome disorder and genetic cause of mental retardation. It occurs because of the presence of an extra copy of chromosome 21. For this reason, it is also called trisomy 21.
Description
When a baby is conceived, the sperm cell from the father and the egg cell from the mother undergo a reduction of the total number of chromosomes from 46 to 23. Occasionally an error occurs in this reduction process and instead of passing on 23 chromosomes to the baby, a parent will pass on 24 chromosomes. This event is called nondisjunction and it occurs in 95% of Down syndrome cases. The baby therefore receives an extra chromosome at conception. In Down syndrome, that extra chromosome is chromosome 21. Because of this extra chromosome 21, individuals affected with Down syndrome have 47 instead of 46 chromosomes.
Genetic profile
In approximately one to two percent of Down syndrome cases, the original egg and sperm cells contain the correct number of chromosomes, 23 each. The problem occurs sometime shortly after fertilization—during the phase when cells are dividing rapidly. One cell divides abnormally, creating a line of cells with an extra copy of chromosome 21. This form of genetic disorder is called mosaicism. The individual with this type of Down syndrome has two types of cells: those with 46 chromosomes (the normal number), and those with 47 chromosomes (as occurs in Down syndrome). Individuals affected with this mosaic form of Down syndrome generally have less severe signs and symptoms of the disorder.
Another relatively rare genetic accident that causes Down syndrome is called translocation. During cell division, chromosome 21 somehow breaks. The broken off piece of this chromosome then becomes attached to another chromosome. Each cell still has 46 chromosomes, but the extra piece of chromosome 21 results in the signs and symptoms of Down syndrome. Translocations occur in about 3–4% of cases of Down syndrome.
Once a couple has had one baby with Down syndrome, they are often concerned about the likelihood of future offspring also being born with the disorder. Mothers under the age of 35 with one Down syndrome-affected child have a 1% chance that a second child will also be born with Down syndrome. In mothers 35 and older, the chance of a second child being affected with Down syndrome is approximately the same as for any woman at a similar age. However, when the baby with Down syndrome has the type that results from a translocation, it is possible that one of the two parents is a carrier of a balanced translocation. A carrier has rearranged chromosomal information and can pass it on, but he or she does not have an extra chromosome and therefore is not affected with the disorder. When one parent is a carrier of a translocation, the chance of future offspring having Down syndrome is greatly increased. The specific risk will have to be assessed by a genetic counselor.
Demographics
Down syndrome occurs in about one in every 800 live births. It affects an equal number of male and female babies. The majority of cases of Down syndrome occur due to an extra chromosome 21 within the egg cell supplied by the mother (nondisjunction). As a woman's age (maternal age) increases, the risk of having a Down syndrome baby increases significantly. By the time the woman is age 35, the risk increases to one in 400; by age
40 the risk increases to one in 110; and, by age 45, the risk becomes one in 35. There is no increased risk of either mosaicism or translocation with increased maternal age.
Down syndrome occurs with equal frequency across all ethnic groups and subpopulations.
Signs and symptoms
While Down syndrome is a chromosomal disorder, a baby is usually identified at birth through observation of a set of common physical characteristics. Not all affected babies will exhibit all of the symptoms discussed. There is a large variability in the number and severity of these characteristics from one affected individual to the next. Babies with Down syndrome tend to be overly quiet, less responsive to stimuli, and have weak, floppy muscles. A number of physical signs may also be present. These include: a flat appearing face; a small head; a flat bridge of the nose; a smaller than normal, low-set nose; small mouth, which causes the tongue to stick out and to appear overly large; upward slanting eyes; bright speckles on the iris of the eye (Brushfield spots); extra folds of skin located at the inside corner of each eye and near the nose (epicanthal folds); rounded cheeks; small, misshapen ears; small, wide hands; an unusual deep crease across the center of the palm (simian crease); an inwardly curved little finger; a wide space between the great and the second toes; unusual creases on the soles of the feet; overly flexible joints (sometimes referred to as being double-jointed); and shorter-than-normal stature.
Other types of defects often accompany Down syndrome. Approximately 30–50% of all children with Down syndrome are found to have heart defects. A number of different heart defects are common in Down syndrome. All of these result in abnormal patterns of blood flow within the heart. Abnormal blood flow within the heart often means that less oxygen is sent into circulation throughout the body, which can cause fatigue, a lack of energy, and poor muscle tone.
Malformations of the gastrointestinal tract are present in about 5–7% of children with Down syndrome. The most common malformation is a narrowed, obstructed duodenum (the part of the intestine into which the stomach empties). This disorder, called duodenal atresia, interferes with the baby's milk or formula leaving the stomach and entering the intestine for digestion. The baby often vomits forcibly after feeding, and cannot gain weight appropriately until the defect is repaired.
Another malformation of the gastrointestinal tract seen in patients with Down syndrome is an abnormal connection between the windpipe (trachea) and the digestive tube of the throat (esophagus) called a tracheoesophageal fistula (T-E fistula). This connection interferes with eating and/or breathing because it allows air to enter the digestive system and/or food to enter the airway.
Other medical conditions occurring in patients with Down syndrome include an increased chance of developing infections, especially ear infections and pneumonia; certain kidney disorders; thyroid disease (especially low or hypothyroid); hearing loss; vision impairment requiring glasses (corrective lenses); and a 20 times greater chance than the population as a whole of developing leukemia.
Development in a baby and child affected with Down syndrome occurs at a much slower than normal
rate. Because of weak, floppy muscles (hypotonia), babies learn to sit up, crawl, and walk much later than their unaffected peers. Talking is also quite delayed. The level of mental retardation is considered to be mild-to-moderate in Down syndrome. The degree of mental retardation varies a great deal from one child to the next. While it is impossible to predict the severity of Down syndrome at birth, with proper education, children who have Down syndrome are capable of learning. Most children affected with Down syndrome can read and write and are placed in special education classes in school. The majority of individuals with Down syndrome become semi-independent adults, meaning that they can take care of their own needs with some assistance.
As people with Down syndrome age, they face an increased chance of developing the brain disease called Alzheimer's (sometimes referred to as dementia or senility). Most people have a 12% chance of developing Alzheimer disease, but almost all people with Down syndrome will have either Alzheimer disease or a similar type of dementia by the age of 50. Alzheimer disease causes the brain to shrink and to break down. The number of brain cells decreases, and abnormal deposits and structural arrangements occur. This process results in a loss of brain functioning. People with Alzheimer's have strikingly faulty memories. Over time, people with Alzheimer disease will lapse into an increasingly unresponsive state.
As people with Down syndrome age, they also have an increased chance of developing a number of other illnesses, including cataracts, thyroid problems, diabetes, and seizure disorders.
Diagnosis
Diagnosis is usually suspected at birth, when the characteristic physical signs of Down syndrome are noted. Once this suspicion has been raised,genetic testing (chromosome analysis) can be undertaken in order to verify the presence of the disorder. This testing is usually done on a blood sample, although chromosome analysis can also be done on other types of tissue, including the skin. The cells to be studied are prepared in a laboratory. Chemical stain is added to make the characteristics of the cells and the chromosomes stand out. Chemicals are added to prompt the cells to go through normal development, up to the point where the chromosomes are most visible, prior to cell division. At this point, they are examined under a microscope and photographed. The photograph is used to sort the different sizes and shapes of
chromosomes into pairs. In most cases of Down syndrome, one extra chromosome 21 will be revealed. The final result of such testing, with the photographed chromosomes paired and organized by shape and size, is called the individual's karyotype. An individual with Down syndrome will have a 47 XX+21 karyotype if they are female and a 47 XY+21 karyotype if they are male.
Women who become pregnant after the age of 35 are offered prenatal tests to determine whether or not their developing baby is affected with Down syndrome. A genetic counselor meets with these families to inform them of the risks and to discuss the types of tests available to make a diagnosis prior to delivery. Because there is a slight risk of miscarriage following some prenatal tests, all testing is optional, and couples need to decide whether or not they desire to take this risk in order to learn the status of their unborn baby.
Screening tests are used to estimate the chance that an individual woman will have a baby with Down syndrome. A test called the maternal serum alpha-fetoprotein test (MSAFP) is offered to all pregnant women under the age of 35. If the mother decides to have this test, it is performed between 15 and 22 weeks of pregnancy. The MSAFP screen measures a protein and two hormones that are normally found in maternal blood during pregnancy. A specific pattern of these hormones and protein can indicate an increased risk for having a baby born with Down syndrome. However, this is only a risk and MSAFP cannot diagnose Down syndrome directly. Women found to have an increased risk of their babies being affected with Down syndrome are offered amniocentesis. The MSAFP test can detect up to 60% of all babies who will be born with Down syndrome.
Ultrasound screening for Down syndrome is also available. This is generally performed in the midtrimester of pregnancy. Abnormal growth patterns characteristic of Down syndrome such as growth retardation, heart defects, duodenal atresia, T-E fistula, shorter than normal long-bone lengths, and extra folds of skin along the back of the neck of the developing fetus may all be observed via ultrasonic imaging.
The only way to definitively establish (with about 99% accuracy) the presence or absence of Down syndrome in a developing baby is to test tissue during the pregnancy itself. This is usually done either by amniocentesis, or chorionic villus sampling (CVS). All women under the age of 35 who show a high risk for having a baby affected with Down syndrome via an MSAFP screen and all mothers over the age of 35 are offered either CVS or amniocentesis. In CVS, a tiny tube is inserted into the opening of the uterus to retrieve a small sample of the placenta (the organ that attaches the growing baby to the mother via the umbilical cord, and provides oxygen and nutrition). In amniocentesis, a small
amount of the fluid in which the baby is floating is withdrawn with a long, thin needle. CVS may be performed as early as 10 to 12 weeks into a pregnancy. Amniocentesis is generally not performed until at least the fifteenth week. Both CVS and amniocentesis carry small risks of miscarriage. Approximately 1% of women miscarry after undergoing CVS testing, while approximately one-half of one percent miscarry after undergoing amniocentesis. Both amniocentesis and CVS allow the baby's own karyotype to be determined.
Approximately 75% of all babies diagnosed prenatally as affected with Down syndrome do not survive to term and spontaneously miscarry. In addition, these prenatal tests can only diagnose Down syndrome, not the severity of the symptoms that the unborn child will experience. For this reason, a couple might use this information to begin to prepare for the arrival of a baby with Down syndrome, to terminate the pregnancy, or in the case of miscarriage or termination, decide whether to consider adoption as an alternative.
Treatment and management
No treatment is available to cure Down syndrome. Treatment is directed at addressing the individual concerns of a particular patient. For example, heart defects may require surgical repair, as will duodenal atresia and T-E fistula. Many Down syndrome patients will need to wear glasses to correct vision. Patients with hearing impairment benefit from hearing aids.
While some decades ago all children with Down syndrome were quickly placed into institutions for lifelong care, research shows very clearly that the best out-look for children with Down syndrome is a normal family life in their own home. This requires careful support and education of the parents and the siblings. It is a life-changing event to learn that a new baby has a permanent condition that will affect essentially all aspects of his or her development. Some community groups help families deal with the emotional effects of raising a child with Down syndrome. Schools are required to provide services to children with Down syndrome, sometimes in separate special education classrooms, and sometimes in regular classrooms (this is called mainstreaming or inclusion).
As of May 2000, the genetic sequence for chromosome 21 was fully determined, which opens the door to new approaches to the treatment of Down syndrome through the development of gene-specific therapies.
Prognosis
The prognosis for an individual with Down syndrome is quite variable, depending on the types of complications (heart defects, susceptibility to infections, development of leukemia, etc.). The severity of the retardation can also vary significantly. Without the presence of heart defects, about 90% of children with Down syndrome live into their teens. People with Down syndrome appear to go through the normal physical changes of aging more rapidly, however. The average age of death for an individual with Down syndrome is about 50 to 55 years.
Still, the prognosis for a baby born with Down syndrome is better than ever before. Because of modern medical treatments, including antibiotics to treat infections, and surgery to treat heart defects and duodenal atresia, life expectancy has greatly increased. Community and family support allows people with Down syndrome to have rich, meaningful relationships. Because of educational programs, some people with Down syndrome are able to hold jobs.
As of early 2001, there has only been one report of a male affected with Down syndrome becoming a father. Approximately 60% of women with Down syndrome are fully capable of having children. The risk of a woman with trisomy 21 having a child affected with Down syndrome is 50%.
BOOKS
Pueschel, Siegfried M. A Parent's Guide to Down Syndrome: Toward a Brighter Future. Revised ed. New York: Paul H. Brookes Publishing Co., 2000.
Selikowitz, Mark. Down Syndrome: The Facts. 2nd ed. London: Oxford University Press, 1997.
Stray-Gunderson, K. Babies with Down Syndrome: A New Parents' Guide. Kensington: Woodbine House, 1986.
PERIODICALS
Carlson, Tucker, and Jason Cowley. "When a Life is Worth Living: Down's Syndrome Children." The Times (29 November 1996): 18+.
Cohen, William, ed. "Health Care Guidelines for Individuals with Down Syndrome: 1999 Revision." Down Syndrome Quarterly (September 1999).
Hattori, M., A. Fujiyama, D. Taylor, H. Watanabe, et al. "The DNA sequence of human chromosome 21." Nature (18 May 2000): 311–19.
ORGANIZATIONS
National Down Syndrome Congress. 7000 Peachtree-Dunwoody Rd., Bldg 5, Suite 100, Atlanta, GA 30328-1662. (770) 604-9500 or (800) 232-6372. Fax: (770) 604-9898. ndsccenter@aol.com. <http://www.ndsccenter.org>.
National Down Syndrome Society. 666 Broadway, New York, NY 10012-2317. (212) 460-9330 or (800) 221-4602. Fax: (212) 979-2873. <http://www.ndss.orginfo@ndss.org>.
WEBSITES
Down Syndrome Health Issues. <http://www.ds-health.com/>. (15 February 2001).
