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Current Paediatrics (2001) 11, 57d63^ 2001 Harcourt Publishers Ltddoi:10.1054/cupe.2000.0143, available online at http://www.idealibrary.com on

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servMedical management of children

with Down’s syndromeE. Marder* and J. Denniss

*Consultant Paediatrician, Community Child Health, Nottingham Community Health NHS Trust, St Ann’s Health Centre,St Ann’s Well Road, Nottingham NG3 3PX, UKsChairman, Down’s Syndrome Medical Interest Group, 8 Polstead Road, Oxford, OX26TN, UK

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hDown’s syndrome, trisomy 21, is the commonestautosomal trisomy, and the commonest identifiablecause of learning disability. The natural prevalence isaround 1/600 live births. Prenatal diagnosis and termina-tion of some affected pregnancies has led to a currentincidence in the UK of around 0.9/1000 live births.1

Whilst wider availability and uptake of prenatal diagnosismay decrease this further, a projected rise in maternalage may work in the opposite direction. It is difficult topredict how these factors will interact, but it is unlikelythat incidence will reduce significantly in the nearfuture.

Most people are familiar with the physical features ofthe syndrome and are aware that learning disability isalmost inevitable. A wide range of health problems arealso recognized as being associated with Down’ssyndrome. However, many people, including healthprofessionals, have a view of the disorder that isoutdated and pessimistic. The stereotype is of a personwith severe learning difficulties, who remains totallydependent throughout a life blighted by ill health, who islikely to live in an institution, and to die in early adultlife. The positive side given is that ‘they are all good-natured, affectionate and love music’. Like allstereotypes, some of these characteristics are true ofsome people with Down’s syndrome. However, just likethe general population, there is enormous variability inappearance, personality and ability. Some enjoy verygood health. Some young adults are able to live semi-independently and to work. Some are less able, butnevertheless live fulfilling lives and make a contributionto society.

Down’s syndrome is a multi-system disorder, but theextent to which different systems are affected variesfrom person to person. In the past some treatable

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llconditions were thought to be ‘part of the syndrome’and were left untreated. Today we hope that the healthof children with Down’s syndrome will be monitored ascarefully as that of any child so that their progress is nothampered by additional secondary but preventablehandicap.

This article covers all major and some less well knownhealth problems. Inevitably it cannot be comprehensive,and less common problems are merely listed in Box 1.For further detail the reader is referred to ‘Furtherreading’ listed below.

THE PAEDIATRICIAN’S ROLE

At time of diagnosis

Usually, Down’s syndrome will be suspected at birth orin the newborn period. If the diagnosis is madeantenatally, the paediatrician may be an appropriateperson to give information to the parents in order tohelp them reach a decision about continuing thepregnancy. If the diagnosis is made at birth or later, thepaediatrician should be involved immediately in:

f Confirming the diagnosisf Giving information to the parentsf Medical assessment.

A confident diagnosis can usually be made afterexamining the baby, and although it must be confirmedby chromosomal analysis, which most laboratories areable to process in 48d72 h, in general, parents prefer tobe given the news as soon as possible, and this should notbe delayed by waiting for test results. The importance ofthe time of disclosure and the way it is handled cannot beover-stressed.2d4 This initial contact will influence theparents’ adjustment and also their subsequent workingrelationships both with the paediatrician and with other

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58 CURRENT PAEDIATRICS

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Box 2 The Down’s Syndrome Association

The Down’s Syndrome Association is a registered charityfunded mainly from voluntary donations. Services offeredinclude:f Immediate help, support and advice on all aspects

of the syndromef Specialist advisors in the following areas:d medicald speech and languaged legald welfare rightsd education

f Information leaflets and videos on a range oftopics suitable for parents, carers andprofessionals, including a medical informationseries

f Supporting research, including studentships

For further information contactDown’s Syndrome Association155 Mitcham Rd, London SW17 9PGemail:[email protected]://www.dsa-uk.com

doctors. It is essential that the paediatrician is wellinformed and able to offer up-to-date, factual informa-tion on:f The aetiology of Down’s syndromef Development of children with Down’s syndromef Immediate and future health concernsf Local resourcesf Long-term prognosis.

Parents should be given contact information for theDown’s Syndrome Association (Box 2). Some, but notall, will appreciate being put in touch with another familywith a child with Down’s syndrome. Such introductions,however, should be arranged with care. Parents shouldbe given a second opportunity to talk with the paediat-rician and ask questions within the first few days. Theyshould leave hospital knowing when they will next beseen, and who they can contact in the meantime shouldthe need arise. The primary health care team should alsobe informed of the diagnosis.

Neonatal medical assessment

It is essential that every newborn with Down’s syn-drome has a comprehensive medical assessment. Majorgastrointestinal malformations will declare themselvesclinically but evidence of cataract and congenital heartdisease must be specifically sought. The latter may not beevident on initial clinical examination and appropriateinvestigative screening and ongoing surveillance must beinitiated before discharge from hospital (see below). Indistricts where there is a neonatal auditory screening

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Box 1 Specific medical problems that occur morefrequently in people with Down’s syndrome

CardiacCongenital malformationsCor pulmonaleAcquired valvular dysfunction

OrthopaedicCervical spine instabilityHip subluxation/dislocationPatellar instabilityScoliosisMetatarsus varusPes planus

ENTConductive hearing lossSensorineural hearing lossUpper airway obstructionChronic catarrh

OphthalmicRefractive errorsBlepharitisNasolacrimal obstructionCataractsGlaucomaNystagmusSquintKeratoconus

GastrointestinalCongenital malformationsFeeding difficultiesGastro-oesophageal refluxHirschprung’s diseaseCoeliac disease

EndocrineGrowth retardationHypothyroidismHyperthyroidismDiabetes

ImmunologicalImmunodeficiencyAutoimmune diseases, e.g.arthropathy, vitiligo, alopecia

HaematologicalTransient neonatalmyeloproliferative statesLeukaemiaNeonatal polycythaemiaNeonatal thrombocytopenia

DermatologicalDry skinFolliculitisVitiligoAlopecia

NeuropsychiatricInfantile spasms and othermyoclonic epilepsiesAutismDepressive illnessDementia (adults only)

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MEDICAL MANAGEMENT OF CHILDREN WITH DOWN’S SYNDROME 59

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programme, babies with Down’s syndrome should beincluded.

Ongoing medical management

All children with Down’s syndrome should be offeredregular medical review by a paediatrician throughoutchildhood. This may be a hospital, community, or devel-opmental paediatrician depending on local service organ-ization. In some areas, services are centred in a specificDown’s syndrome clinic. Once children reach school ageit may be most appropriate for their care to becoordinated by the school doctor.

The paediatrician should review the child’s healthand development and identify medical problems bya combination of history-taking, examination and screen-ing tests, all directed at problems more likely to occurin Down’s syndrome. A number of protocols and guide-lines have been drawn up suggesting appropriate pro-grammes.5d7 The table of health checks is taken from the2nd edition of the parent-held child health record(PCHR) insert for babies born with Down’s syndrome8

(see Table 1). It is based on the medical surveillanceessentials for people with Down’s syndrome developed bythe UK Down’s Syndrome Medical Interest Group.

The paediatrician will be just one of a number of healthand non-health professionals working with the family.Others likely to be involved include:

f Primary health care teamf Other specialist doctors: cardiologist; ENT surgeon;

ophthalmologist; orthopaedic surgeon, etc.f Therapists: speech and language; physiotherapy; occu-

pational therapy.f Social workerf Education: preschool teacher/portage worker; nursery

and school staff; educational psychologist.

The paediatrician will need to refer to these otherspecialists and may also have an important role in co-ordinating the team.

Transition to adult care

This is often a difficult area.6 After years of regularpaediatric supervision, there is no equivalent specialistservice for adults. General practitioners are likely to bebest placed to provide the ongoing service, but may nothave the specialist knowledge. Psychiatrists with a specialinterest in learning disability are primarily concernedwith mental health and social adjustment, and maynot look at other health care needs. The paediatriciancan help the process of transition prior to dischargeby providing the general practitioner, the carers andthe young person with a comprehensive report of anymedical problems, previous health care and sugges-tions for ongoing care. Where the young person has

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specific medical problems, the paediatrician should en-sure that referral to appropriate adult specialists is made.

SPECIFIC MEDICAL PROBLEMS

Cardiovascular problems

Forty to sixty percent of babies with Down’s syndromehave congenital heart disease. Of these, around 50%have an atrio-ventricular septal defect (AVSD). Otherabnormalities include Fallot’s tetralogy and various com-binations of ventricular and atrial septal defects. It isimportant to establish the cardiac status of all babies withthe syndrome in the first few weeks of life, as irreversiblepulmonary vascular disease occurs earlier and morefrequently than in children without Down’s syndrome.Clinical examination alone is not sufficient. Some babies,even those with significant defects, will have no signs orsymptoms in the first weeks of life.11

Assessment should ideally include an echocardiogram inthe first few weeks. This should be carried out by anoperator skilled in the diagnosis of such lesions. If echo-cardiography is not available, ECG, chest X-ray and exam-ination by an experienced paediatrician at birth and againat 6 weeks should pick up nearly all significant defects.

Babies with heart defects should be referred toa paediatric cardiologist for consideration of surgery asearly as possible. In the recent past, many children withDown’s syndrome were not offered surgery. The com-plex nature of some of the abnormalities that occur inDown’s syndrome does mean that surgery may be difficultor impossible, and for some lesions operative morbidityand mortality are high. Currently, however, the operativesurvival for uncomplicated AVSD is around 90d95% inmajor centres in the UK. The decision as to whether ornot to operate should be based on the nature of the heartcondition, not the coexisting learning disability.

Children without congenital heart lesions can developheart disease at a later age. This may be secondary toupper airway obstruction (see below), or, in adolescenceor early adult life, the onset of primary valvular dysfunc-tion.12 The possibility of acquired heart disease shouldtherefore be borne in mind at medical reviews, andechocardiogram in early adult life should be considered.Parents and carers of all children with heart lesionsshould be given verbal and written information aboutinfective carditis preventative measures. In potential risksituations, if cardiac status is unknown, preventive pro-phylactic measures should be started.

Orthopaedic problems

Cervical spine instability

Laxity of the transverse ligament of C1 or dysplasias ofC1/C2 can predispose to dislocation/subluxation of the

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rvedTable 1 Down’s syndrome ! suggested schedule of health checks, taken from PCHR insert for babies with Down’s syndrome

(2nd edition).8

The following are suggested ages for health checks. Check at any other time if there are parental or other concerns

Birth to 18 months 4`4 12

6 weeks 6`10 months 12 months to 2 12 years 3`3 1

2 years years

Thyroid bloodtests

RoutineGuthrie test

Thyroid bloodtests includingantibodies

Thyroid bloodtests includingantibodies

If your area has introduced fingerprick blood tests these should be done every year.

Growthmonitoring

Length and weight should be checkedfrequently and plotted on Down’s syndromegrowth charts. (see page 9 onwards).Head circumference should be checked ateach routine medical check.

Length and weight should be checked at leastannually and plotted on Down’s syndromegrowth charts.

Eye check Visualbehaviour,check forcongenitalcataract

Visualbehaviour,check forsquint

Visualbehaviour,check forsquint

Orthopticexamination,refractionandophthalmicexamination

Visualacuity,refractionandophthalmicexamination

Hearing check Neonatalscreening, iflocally available

Fullaudiologicalreview(hearing,impedance,otoscopy)

Full audiological review(hearing, impedance, otoscopy) annually

Heart checkand otheradvice

Echocardio-gram0d6 weeks orchest X-ray &ECG at birthand 6 weeks

Dental advice

From age 5 to 19 yearsPaediatric review AnnuallyHearing 2 yearly audiological review (as above)Vision/orthoptic check 2 yearlyThyroid blood tests At age 5 years, then either 2 yearly venous surveillance or annual fingerprick.


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001atlantoaxial joint with potentially catastrophic sequelae.

Previously, this led to recommendations for X-rayscreening and selective restriction of sporting activities.It is now clear that there are no screening proceduresthat predict those at risk; in particular, cervical spineX-rays are not informative. Both the Department ofHealth and the American Academy of Pediatrics havewithdrawn previous recommendations about radio-logical screening.13,14 Although the risks may have beenoverstated, there is no doubt that a few people with


Down’s syndrome do incur acute and sometimes cata-strophic damage to the cervical spinal cord.15 Risk ofinjury from specific sporting activities seems minimal.Most dislocations occur in the course of everydayactivity, medical treatment or coincidentally whilstparticipating in sport. Neurological symptoms usuallyprecede incidents of major trauma.

Current advice, therefore, is that radiological screen-ing is not indicated and sporting activities should notbe restricted in those with no clinical signs. However,


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particular care should be taken when manipulatingthe head and neck of an unconscious child, e.g. duringanaesthesia or following a road traffic accident, andall carers and clinicians should be aware of warning signs.These include:

f Abnormal head posturef Restricted neck movementf Neck painf Altered gaitf Deteriorating manipulative skillsf Deterioration in bladder or bowel control.

Any child with such symptoms should be referred toa specialist orthopaedic or neurosurgeon for furtherinvestigation. Treatment options include decompressionby traction and spinal fusion.

Other orthopaedic problems

Hypotonia, ligamentous laxity and skeletal dysplasias maypredispose to other orthopaedic problems. Theseinclude patellar instability, scoliosis, subluxation/dislocation of the hips, pes planus and metatarsus varus.Intervention will be necessary if there is pain, limitedfunction or risk of structural damage. Surgery will some-times be necessary. Many children benefit from shoeinserts and some may need specialist footwear.

Ear, nose and throat problems

Hearing

Over 50% of children with Down’s syndrome have hear-ing loss. This is most commonly due to glue ear, buta minority have sensorineural deafness. The latter be-comes more prevalent with age. The natural history ofglue ear differs from the general population. The condi-tion often persists into adolescence and adult life. Theglue is unusually tenacious. The benefit of grommetoperations may be short-lived and frequent repeats ne-cessary. Narrow ear canals make grommet insertionmore difficult. Grommets do have their place in manage-ment, but perhaps should not be the first treatmentoption. Medical management with long-term, low doseantibiotics or orally administered decongestants are ofunproven efficacy, but may be worth trying. For manychildren, the best option will be hearing aids. These aremost likely to be accepted and useful if fitted by a special-ist paediatric service, supported by specialist teachers forhearing-impaired children.

As for all children, one of the most important factorsin managing hearing loss is the recognition that there isa problem. Unrecognized, it is a significant cause ofsecondary handicap. All people with Down’s syndromeshould have regular audiological surveillance throughoutlife. In areas where there is a neonatal screening pro-gramme, children with Down’s syndrome should be


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included. All should have audiological review between6 and 10 months of age. This will usually need to be doneby a specialist audiology service, partly because manychildren will not be developmentally ready for routinedistraction testing at 7d8 months and also because moredetailed assessment including otoscopy and impedancetesting should be done. After this, preschool childrenshould have their hearing reviewed annually and olderchildren at least biennially.

Upper airway obstruction

People with Down’s syndrome are particularly prone topartial upper airway obstruction and obstructive sleepapnoea.16 Narrow airways and tongue hypotonia arecommon contributory factors. The condition may lead togrowth retardation, poor developmental progress, tired-ness and lethargy. Significant hypoxia and cor pulmonalecan result. Sleep disturbance, snoring, drooling and swal-lowing difficulties may be diagnostic pointers. Symptomsare likely to worsen around age 2 or 3 as lymphoid tissuebecomes relatively large in a restricted pharyngeal space.Some children require adenotonsillectomy. Thepaediatrician should consider the possibility of upperairway obstruction in all children with Down’s syndrome,and ask specific questions in history-taking.

Catarrh

Many children with Down’s syndrome have persistentmucopurulent nasal discharge. In addition to predisposingto glue ear, this may make the child feel constantly belowpar. It reduces social acceptability and may interfere withsleeping and eating. For children who are unable toeffectively blow their noses, mechanical decongestersmay help. Oral and nasal decongestants can be useful.Some children benefit from low dose, long-term anti-biotics. Some improve markedly on a milk-free diet.

Ophthalmological problems

Ophthalmological problems, including congenitalcataracts, nystagmus, squint, glaucoma, keratoconus,blepharitis and blocked nasolacrimal ducts, are over-represented in Down’s syndrome.17 Refractive errors,including hypermetropia, occur in approximately 70%,and if uncorrected, constitute a significant cause ofsecondary handicap. The possibility of ophthalmic prob-lems should be considered at every review, starting withthe routine neonatal examination where a check shouldbe made for congenital cataracts. After this, the paediat-rician should monitor visual behaviour by observationand parental history. If any abnormality is suspected, thechild should be referred to an ophthalmologist. Evenwhere there are no concerns, referral for full ophthalmicassessment, including refraction, fundoscopy and


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orthoptic testing, should be made in the second year oflife. Vision should continue to be checked at least every2 years throughout life. This can be done by a schoolnurse or high street optician once the child is develop-mentally ready to cooperate with standard vision testing.More serious ophthalmic problems such as glaucoma orkeratoconus will be picked up either because the childhas pain, red eye or because of changing vision.

Growth

Short stature is a characteristic feature of Down’s syn-drome. Mean adult height is 145 cm (4@8@@) for femalesand 157 cm (4@11@@) for males. New centile charts forChildren with Down’s syndrome based on data from theUK and Republic of Ireland are now available.18 Childrenwith Down’s syndrome do not generally suffer fromclassical growth hormone deficiency, and the cause of thegrowth retardation is not known. However, poorgrowth may be an indicator of congenital heart disease,upper airway obstruction, coeliac disease, hypothyro-idism, and other conditions that are more commonin the syndrome. Children with Down’s syndromeshould therefore be weighed and measured regularly,and measurements plotted on Down’s specific charts.Any significant deviation from these centiles should leadto detailed assessment. The Down’s syndrome specificcharts, suggest that in older children with Down’s syn-drome, obesity is the norm. However, obesity is not aninevitable consequence of the syndrome. Weight forheight should be plotted on BMI charts (included on UKDown’s Growth Charts). Excessive weight gain shouldbe thoroughly assessed and advice on exercise andnutrition offered where appropriate.

Sexual development

Parents often ask questions about sexual development.By and large this proceeds as in the general population,and most adolescents cope well with the demands ofpuberty. There are, however, small variations. Someboys have small genitalia. Subfertility occurs in both sexesbut more so amongst men. There are many reports ofwomen with Down’s syndrome having children. There isa 50:50 risk of Down’s syndrome in a pregnancy whereone parent has the syndrome.

Thyroid dysfunction

Thyroid dysfunction, commonly hypothyroidism, is moreprevalent in people with Down’s syndrome at all ages.19

The prevalence increases with age. Uncompensatedhypothyroidism is found in around 10% of the school agepopulation. Signs and symptoms may not be obvious andif present may be dismissed as being part of the


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syndrome. Diagnosis on clinical grounds is therefore notreliable and biochemical screening is essential. In the UK,all babies are screened for hypothyroidism. For childrenwith Down’s syndrome each district should have a policyfor thyroid screening thereafter. This should includeeither estimation of T4, TSH, and thyroid autoantibodiesin venous blood at least every 2 years or annual driedblood spot TSH measurement (Guthrie) usingfingerprick blood.20 Transient changes in TFTs may oc-cur. Mildly raised TSH or the presence of autoantibodieswith normal T4 and no clinical evidence of hypothyroidismdoes not usually warrant treatment. However, thesechildren have a high risk of developing clinical disease andmore frequent testing is essential. Though less common,hyperthyroidism is also more frequently seen in Down’ssyndrome. The paediatrician should always bear in mindthe frequency of thyroid dysfunction and have a lowthreshold of suspicion at all times.

Gastrointestinal problems

Ten percent of children with Down’s syndrome havecongenital malformations, including atresia of thejejunum, duodenum, oesophagus and anus, annular pan-creas, and exomphalos. These may be picked up onantenatal scan, or present in the neonatal period. Thereare less severe forms, e.g. anal or duodenal stenosis,where symptoms are milder and may go unrecognizedfor some time. Children with Down’s syndrome shouldnot be denied treatment for surgically correctable condi-tions on the grounds that they have Down’s syndrome.

Also more common in Down’s syndrome are coeliacdisease (around 4%) and Hirschprung’s disease (around2%). It is important to consider these in the differentialdiagnosis of constipation, diarrhoea and poor growth.Many infants with Down’s syndrome will have feedingdifficulties.21 This is often due to oral motor dysfunction,but gastro-oesophageal reflux is also common and canplay a part. Appropriate management of these in infancymay prevent eating problems later on.

CONCLUSION

Anyone undertaking a medical literature search onDown’s syndrome will find that much current researchfocuses on prenatal diagnosis with the aim of terminatingall affected pregnancies. Also, over the years, there havebeen numerous fashions involving unconventionaltreatments. Thus the main focus seems to be on what wecannot yet (or may not want to) do and on treatments ofunproven efficacy. However, a great deal is known abouta wide range of treatable medical problems that occurmore frequently in people with Down’s syndrome. Atpresent, the most significant benefit that medicine has tooffer children with Down’s syndrome is to offer quality


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screening and assessment specific to their needs, and thesame opportunities for medical treatment as the rest ofthe population.

ACKNOWLEDGEMENTS

We acknowledge with gratitude the contribution ofmember of the UK Down’s Syndrome Medical InterestGroup-DSMIG UK whose ideas and advice haveinfluenced the contents of this article.

REFERENCES

1. Alberman E, Mutton D, Ide R, Nicholson A, Bobrow M. Down’ssyndrome births and pregnancy terminations in 1989 to 1993:preliminary findings. Br J Obstet Gynaecol 1995; 102: 445d447.

2. Newton R W, Newton J A. Management of Down’s syndrome. In:David T J, ed. Recent advances in paediatrics 10. Edinburgh:Churchill Livingstone, 1992: 21d35.

3. Lingam S, Newton R. Right from the start. Paediatric practiceguidelines. London: British Paediatric Association, 1996.

4. Cunningham C C, Morgan P A, McGucken R B. Down’s syndrome:is dissatisfaction with diagnosis inevitable? Dev Med Child Neurol1984; 26: 33d39.

5. American Academy of Pediatrics Committee on Genetics. HealthSupervision for Children with Down Syndrome. Pediatrics 1994;93: 855d859.

6. Pueschel S M, Anneren G, Durlach R, Flores J, Sustrova M, VermaI C. Guidelines for optimal medical care of persons with Downsyndrome. Acta Paediatr 1995; 84: 823d827.

7. Cohen W I. Health care guidelines for individuals with Downsyndrome. Down Syndrome Quarterly 1996; 2: 1d10.

8. Down’s Syndrome Medical Interest Group (2000) Insert for Per-sonal Child Health Record for babies born with Down’s syndrome(2nd edition). DSMIG, UK (available from Harlow Printing, NE334PU, UK)

9. Down’s Syndrome Medical Interest Group (2000) Basic medicalsurveillance essentials for people with Down’s syndrome. DSMIG,UK (available from DSMIS, Children’s Centre, City Hospital,Nottingham NG5 1PB, UK, www.dsmig.org.uk).

10. Howells G. Situations vacant: doctors required to provide carefor people with learning disability. Br J Gen Pract 1996; 60d61.

11. Tubman T R J, Shields M D, Craig B G, Mullholland H C, Nevin N C.Congenital heart disease in Down’s syndrome: two year prospec-tive early screening study. BMJ 1991; 302: 1425d1427.

12. Geggel R L, O’Brien J E, Feingold M. Development of valvedysfunction in adolescents and young adults with Down syndromeand no known congenital heart disease. J Pediatr 1993; 122:821d823.


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13. American Academy of Pediatrics, Committee on Sports Medicineand Fitness. Atlantoaxial instability in Down syndrome: subjectreview. Pediatrics 1995; 96: 151d153.

14. Department of Health. Cervical spine instability in people withDown syndrome. CMOs Update 1995; 7: 4.

15. Davidson R G. Atlantoaxial instability in individuals with Downsyndrome: a fresh look at the evidence. Pediatrics 1988; 81:857d865.

16. Stebbens V A, Dennis J, Samuels M P, Croft C B, Southall D P. Sleeprelated upper airway obstruction in a cohort with Down’s syn-drome. Arch Dis Child 1991; 66: 1333d1338.

17. Roizen N J, Mets M B, Blondis T A. Ophthalmic disorders inchildren with Down syndrome. Dev Med Child Neurol 1994; 36:594-600.

18. Down’s Syndrome Medical Interest Group (2000) Downssyndrome growth charts. DSMIG UK (available from HarlowPrinting, NE33 4PU, UK).

19. Stewart B. The prevalence of unrecognised thyroid dysfunction inschool age children with Down’s syndrome in Oxfordshire.In: Medical Issues in Down’s syndrome. Proceedings of a medicalconference. London: Down’s Syndrome Association, 1994:43d50.

20. Noble S E, Leyland K, Findlay C A, Clark C E, Redfern J, MackenzieU M, GuK rdwood RWA. Donaldson MC School based screening forhypothyroidism in Down’s syndrome by dried blood spot TSHmeasurement. Arch. Dis. Child. 2000; 82: 27d31.

21. Spender Q, Stein A, Dennis J, Reilly S, Percy E, Cave D. Anexploration of feeding difficulties in children with Down syndrome.Dev Med Child Neurol 1996; 38: 681d694.

FURTHER READING

Newton R. Down’s syndrome: the practical handbook for parents andcarers. Vermillion, 1997.

Rogers P T, Coleman M. Medical care in Down syndrome: a preventa-tive medicine approach. New York: Marcel Dekker, 1992.

Selikowitz M. ‘Down Syndrome: The Facts’ Oxford University Press.1997.

Van Dyke D C, Mattheis P, Schoon Eberly S, Williams J. Medical andsurgical care for children with Down syndrome: A guide forparents. Bethesda: Woodbine House, 1995.

Additional resources:

Down’s Syndrome Medical Interest Group (DSMIG(UK)) andDown’s Syndrome Medical Information Services (DSMIS)Children’s Centre, City Hospital Campus, Nottingham NG5 1PBTel 0115 9627658 ext 45667. Fax 0115 9627915.email: [email protected]://www.dsmig.org.uk


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