DOWN SYNDROME

Down syndrome is a combination of physical abnormalities and mental retardation characterized by a genetic defect in chromosome pair 21.

Human cells normally contain 23 pairs of chromosomes. One chromosome in each pair comes from your father, the other from your mother. Down syndrome is caused by three types of abnormal cell division involving the 21st chromosome. All three abnormalities result in extra genetic material from chromosome 21, which is responsible for the characteristic features and developmental problems of Down syndrome. The three genetic variations that can cause Down syndrome include:

Trisomy 21. More than 90 percent of cases of Down syndrome are caused by trisomy 21. A child with trisomy 21 has three copies of chromosome 21 instead of the usual two copies in all of his or her cells. This form of Down syndrome is caused by abnormal cell division during the development of the sperm cell or the egg cell. Mosaic Down syndrome. In this rare form of Down syndrome, children have some cells with an extra copy of chromosome 21, but not all. This mosaic of normal and abnormal cells is caused by abnormal cell division after fertilization. Translocation Down syndrome. Down syndrome can also occur when part of chromosome 21 becomes attached (translocated) onto another chromosome, before or at conception. Children with translocation Down syndrome have the usual two copies of chromosome 21, but they also have additional material from chromosome 21 stuck to the translocated chromosome. This form of Down syndrome is uncommon.

There are no known behavioral or environmental factors that cause Down syndrome. Is it inherited? Most cases of Down syndrome aren't inherited. They're caused by a mistake in cell division during the development of the egg, sperm or embryo. Translocation Down syndrome is the only form of the disorder that can be passed from parent to child. However, only about 4 percent of children with Down syndrome have translocation. And only about half of these cases are inherited from one of the parents. In these cases, the mother or father is a balanced carrier of the translocation, which means he or she has some rearranged genetic material, but no extra

genetic material. A balanced carrier has no signs or symptoms of Down syndrome, but he or she can pass the translocation on to children. The chance of passing on the translocation depends on the sex of the parent who carries the rearranged chromosome 21:

If the father is the carrier, the risk if about 3 percent. If the mother is the carrier, the risk is about 12 percent.

Some parents have a greater risk of having a baby with Down syndrome. These include:

Advancing maternal age. As a woman's eggs age, there's a greater inclination for chromosomes to divide improperly. So a woman's chances of giving birth to a child with Down syndrome increase with age. Arbitrarily, age 35 is usually considered the threshold of concern. However, most children with Down syndrome are actually born to women under age 35 because this younger group of women has far more babies. Mothers who already have one child with Down syndrome. Typically, a woman who has one child with Down syndrome has about a 1 percent chance of having another child with Down syndrome.

DIAGNOSTIC TEST Screening tests during pregnancy Various screening tests can help identify whether your baby has an increased possibility of Down syndrome. Traditionally, screening blood tests such as the quad screen or the maternal serum alpha-fetoprotein (MSAFP) test were offered around the 16th week of pregnancy. Although these tests are still available, a new study supports the use of other screening methods from the 11th to 14th week of pregnancy. First-trimester screening for Down syndrome is done in two parts:

Ultrasound. The doctor uses ultrasound to measure a specific region on the back of a baby's neck. This is known as a nuchal translucency screening test. Babies with certain abnormalities tend to accumulate more fluid in this tissue than otherwise expected. Blood tests. Results of the ultrasound are paired with blood tests that measure levels of pregnancy-associated plasma protein A (PAPP-A) and a hormone known as human chorionic gonadotropin (HCG).

When this two-step screening is done during the 11th week of pregnancy, researchers say it can identify 87 percent of babies with Down syndrome. By 13 weeks, accuracy of this two-step approach drops to 82 percent about the same as traditional second-trimester blood tests. Although the statistics are high, keep in mind that screening tests of any type aren't fool-proof. They simply give you a better idea of your baby's likelihood of having Down syndrome. It's also important to remember that all of these tests have a 5 percent falsepositive rate. That means that about one in 20 women will have a false-positive result with any of these screening tests far more than those who have a baby with a chromosomal abnormality. Diagnostic tests during pregnancy If your screening tests are positive or worrisome or you're at high risk of having a baby with Down syndrome, you might consider further testing to confirm the diagnosis. Diagnostic tests that can identify Down syndrome include:

Amniocentesis. A sample of the amniotic fluid surrounding the fetus is withdrawn through a needle inserted into the mother's uterus. This sample is then used to analyze the chromosomes of the fetus. Doctors usually perform this test after 15 weeks of gestation. The test carries a risk of miscarriage of one in 200. Chorionic villus sampling (CVS). Cells taken from the mother's placenta can be used to analyze the fetal chromosomes. Typically performed between the ninth and 14th week of pregnancy, this test carries a risk of miscarriage of one in 100. Percutaneous umbilical blood sampling (PUBS). Blood is taken from a vein in the umbilical cord and examined for chromosomal defects. Doctors generally perform this test after 18 weeks of gestation. This test carries a greater risk of miscarriage than does amniocentesis or chorionic villus sampling. Generally, this test is only done when speed of diagnosis is essential.

Each of these three tests is 98 percent to 99 percent accurate in diagnosing Down syndrome before birth. Diagnostic tests for newborns After birth, the initial diagnosis of Down syndrome is often based on the baby's appearance. If your child displays some or all of the characteristics of Down syndrome, your doctor will probably order a test called a chromosomal karyotype. This test is an analysis of your child's chromosomes. If there's an extra chromosome 21 present in all or some of the cells, the diagnosis is Down syndrome.

Children with Down syndrome can have a range of complications. These include:

Heart defects. Approximately 50 percent of children with Down syndrome are born with some type of heart defect. These heart problems can be life-threatening and may require surgery in early infancy. Leukemia. Young children with Down syndrome are more likely to develop leukemia than are children who don't have Down syndrome. Infectious diseases. Because of abnormalities in their immune systems, kids with Down syndrome are much more susceptible to infectious diseases. For example, their risk of contracting pneumonia is much higher than that of children without this disorder. Dementia. Later in life, people with Down syndrome have a greatly increased risk of dementia. Signs and symptoms of dementia often appear before age 40 in people with Down syndrome. Other problems. Down syndrome may also be associated with a variety of other health conditions, including gastrointestinal blockage, thyroid problems, hearing loss or poor vision.

Life spans have increased dramatically for people with Down syndrome. In 1929, a baby born with Down syndrome often didn't live to age 10. Today, someone with Down syndrome can expect to live to 50 and beyond, depending on the severity of his or her health problems. This age continues to rise because of early interventions and better care.

Treatment
There's no medical cure for Down syndrome. But children with Down syndrome do benefit from medical help and early interventions, starting in infancy. If your child has Down syndrome, you'll likely become acquainted with a team of doctors that may include a pediatric cardiologist, a gastroenterologist, a developmental pediatrician and other specialists. These doctors can detect and treat complications of Down syndrome, such as heart defects, gastrointestinal problems and hearing problems. Your child's care team may also include a physical therapist, speech pathologist, occupational therapist and others. These specialists can help your child develop skills as fully as possible. For example, babies with Down syndrome don't have good muscle tone, so a physical therapist can help your baby learn to roll over, sit up and walk. Meanwhile, a speech pathologist or occupational therapist may help with feeding, hand coordination and language skills. Ask your doctor about early intervention programs in your area. These specialized programs in which children with Down syndrome are stimulated at an early age with appropriate sensory, motor and cognitive activities are

available in most states. Programs vary from location to location, but they usually involve therapists and special educators whose goal is to help your baby develop motor skills, language, social skills and self-help skills. In general, children with Down syndrome usually meet developmental milestones, but it usually takes them a little longer than it does for children without Down syndrome. For example, children with Down syndrome may take twice as long to sit, crawl, walk or say a first word. However, early intervention programs, started as soon as possible, seem to give kids with Down syndrome the best chance of success.

Prevention
There's no way to prevent Down syndrome. However, if you are at high risk of having a child with Down syndrome or you already have one child with Down syndrome, you may wish to consult a genetic counselor before becoming pregnant. A genetic counselor can help you understand your chances of having a child with Down syndrome. He or she can also explain the prenatal tests you will be offered and help you figure out the pros and cons of testing for your particular situation.