Professional Documents
Culture Documents
CLINICAL REPORT
significant limitations both in intel- of GDD is estimated to be 1% to 3%, highlights a renewed emphasis on the
lectual functioning and in adaptive be- similar to that of ID. identification of “treatable” causes of
havior as expressed in conceptual, GDD/ID with the recommendation to
social and practical adaptive skills. Diagnosis consider screening for inborn errors
The disability originates before age 18 Schaefer and Bodensteiner11 wrote of metabolism in all patients with
years.”7 The prevalence of ID is esti- that a specific diagnosis is that which unknown etiology for GDD/ID.13
mated to be between 1% and 3%. “can be translated into useful clinical Nevertheless, the approach to the
Lifetime costs (direct and indirect) to information for the family, including patient remains familiar to pediatric
support individuals with ID are large, providing information about progno- primary care providers and includes
estimated to be an average of ap- sis, recurrence risks, and preferred the child’s medical history (including
proximately $1 million per person.9 modes of available therapy.” For ex- prenatal and birth histories); the
ample, agenesis of the corpus callosum family history, which includes con-
is considered a sign and not a diagnosis, struction and analysis of a pedigree of
Global Developmental Delay
whereas the autosomal-recessive Acro- 3 generations or more; the physical
Identifying the type of developmental callosal syndrome (agenesis of the and neurologic examinations empha-
delay is an important preliminary step, corpus callosum and polydactyly) is sizing the examination for minor anom-
because typing influences the path of a clinical diagnosis. Van Karnebeek alies (the “dysmorphology examination”);
investigation later undertaken. GDD is et al12 defined etiologic diagnosis as and the examination for neurologic or
defined as a significant delay in 2 or “sufficient literature evidence…to behavioral signs that might suggest
more developmental domains, including make a causal relationship of the dis- a specific recognizable syndrome or
gross or fine motor, speech/language, order with mental retardation likely, diagnosis. After the clinical genetic
cognitive, social/personal, and activi- and if it met the Schaefer-Bodensteiner evaluation, judicious use of laboratory
ties of daily living and is thought to definition.” This clinical report will use tests, imaging, and other consulta-
predict a future diagnosis of ID.10 Such this Van Karnebeek modification of the tions on the basis of best evidence are
delays require accurate documenta- Schaefer–Bodensteiner definition and, important in establishing the diagno-
tion by using norm-referenced and age- thus, includes the etiology (genetic sis and for care planning.
appropriate standardized measures mutation or genomic abnormality) as
of development administered by ex-
perienced developmental specialists.
an essential element to the definition of CHROMOSOME MICROARRAY
a diagnosis.
The term GDD is reserved for younger CMA now should be considered a first-
Recommendations are best when es-
children (ie, typically younger than 5 tier diagnostic test in all children with
tablished from considerable empirical
years), whereas the term ID is usually GDD/ID for whom the causal diagnosis
evidence on the quality, yield, and
applied to older children for whom IQ is not known. G-banded karyotyping
usefulness of the various diagnostic
testing is valid and reliable. Children historically has been the standard first-
investigations appropriate to the
with GDD are those who present with tier test for detection of genetic im-
clinical situation. The evidence for this
delays in the attainment of develop- balance in patients with GDD/ID for
clinical report is largely based on
mental milestones at the expected more than 35 years. CMA is now the
many small- or medium-size case se-
age; this implies deficits in learning standard for diagnosis of patients with
ries and on expert opinion. The report
and adaptation, which suggests that GDD/ID, as well as other conditions,
is based on a review of the literature
the delays are significant and predict such as autism spectrum disorders or
by the authors.
later ID. However, delays in development, multiple congenital anomalies.14–24
especially those that are mild, may be The G-banded karyotype allows a cyto-
transient and lack predictive reliability Highlights in This Clinical Report geneticist to visualize and analyze
for ID or other developmental disabil- Significant changes in genetic di- chromosomes for chromosomal rear-
ities. For the purposes of this report, agnosis in the last several years have rangements, including chromosomal
children with delays in a single devel- made the 2006 clinical report out- gains (duplications) and losses (dele-
opmental domain (for example, iso- of-date. First, the chromosome mi- tions). CMA performs a similar function,
lated mild speech delay) should not be croarray (CMA) is now considered a but at a much “higher resolution,” for
considered appropriate candidates for first-line clinical diagnostic test for genomic imbalances, thus increasing
the comprehensive genetic evaluation children who present with GDD/ID of the sensitivity substantially. In their
process set forth here. The prevalence unknown cause. Second, this report recent review of the CMA literature,
microdeletion, 1q21.1 microduplication, are not included currently in any whereas the yield of organic acid and
3q29 microduplication, and 12q14 micro- newborn screening blood spot pan- amino acid screening was negligible.”
deletion. Some of these are also inheri- els. Although the prevalence of In a similar study from the Netherlands
ted. Consequently, among families with inherited metabolic conditions is done more recently, Engbers et al39
more than one member with disability, relatively low (0% to 5% in these reported on metabolic testing that was
it remains challenging for the medical studies), the potential for improved performed in 433 children whose GDD/
geneticist to know for which patient outcomes after diagnosis and treat- ID remained unexplained after genetic/
with GDD/ID CMA testing is not war- ment is high.41 metabolic testing, which included
ranted. In 2005, Van Karnebeek et al40 reported a standard karyotype; urine screen for
Recent efforts to evaluate reporting on a comprehensive genetic diagnostic amino acids, organic acids, mucopoly-
of CNVs among clinical laboratories evaluation of 281 consecutive patients saccharides, oligosaccharides, uric
indicate variability of interpretation referred to an academic center in the acid, sialic acid, purines, and pyrim-
because of platform variability in sen- Netherlands. All patients were sub- idines; and plasma for amino acids,
sitivity.34,35 Thus, the interpretation of jected to a protocol for evaluation and acylcarnitines, and sialotransferrins.
CMA test abnormal results and var- studies were performed for all patients Screenings were repeated, and addi-
iants of unknown significance, and the with an initially unrecognized cause of tional testing, including cerebrospinal
subsequent counseling of families mental retardation and included uri- fluid studies, was guided by clinical
should be performed in all cases by nary screen for amino acids, organic suspicion. Metabolic disorders were
a medical geneticist and certified ge- acids, oligosaccharides, acid mucopoly- identified and confirmed in 12 of these
netic counselor in collaboration with saccharides, and uric acid; plasma con- patients (2.7%), including 3 with mito-
the reference laboratory and platform centrations of total cholesterol and diene chondrial disorders; 2 with creatine
used. Test variability is resolving as sterols of 7- and 8-dehydrocholesterol to transporter disorders; 2 with short-chain
a result of international collabora- identify defects in the distal choles- acyl-coenzyme A dehydrogenase deficiency;
tions.36 With large data sets, the terol pathway; and a serum test to and 1 each with Sanfilippo IIIa, a per-
functional impact (or lack thereof) of screen for congenital disorders of oxisomal disorder; a congenital disorder
very rare CNVs is better understood. glycosylation (test names such as of glycosylation; 5-methyltetrahydrofolate
Still, there will continue to be rare or “carbohydrate-deficient transferrin”). reductase deficiency; and deficiency of the
unique CNVs for which interpretation GLUT1 glucose transporter.
In individual patients, other searches
remain ambiguous. The medical ge- Other studies have focused on the
were performed as deemed necessary
neticist is best equipped to interpret prevalence of disorders of creatine
depending on results of earlier stud-
such information to families and the synthesis and transport. Lion-François
ies. This approach identified 7 (4.6%)
medical home.
subjects with “certain or probable” et al37 reported on 188 children re-
metabolic disorders among those who ferred over a period of 18 months
SCREENING FOR INBORN ERRORS completed the metabolic screening with “unexplained mild to severe
OF METABOLISM (n = 216). None of the 176 screening mental retardation, normal karyotype,
Since the 2006 AAP clinical report, sev- tests for plasma amino acids and and absence of fragile X syndrome”
eral additional reports have been pub- urine organic acids was abnormal. who were prospectively screened for
lished regarding metabolic testing for Four children (1.4%) with congenital congenital creatine deficiency syn-
a cause of ID.13,37–40 The percentage of disorders of glycosylation were iden- dromes. Children were from diverse
patients with identifiable metabolic dis- tified by serum sialotransferrins, 2 ethnic backgrounds. Children with
orders as cause of the ID ranges from children had abnormal serum choles- “polymalformative syndromes” were
1% to 5% in these reports, a range terol and 7-dehydrocholesterol concen- excluded. There were 114 boys (61%)
similar to those studies included in trations suggestive of Smith-Lemli- and 74 girls (39%) studied. Creatine
the 2006 clinical report. Likewise, these Opitz syndrome, 2 had evidence of a metabolism was evaluated by using
newer published case series varied by mitochondrial disorder, 1 had evi- creatine/creatinine and guanidinoacetate
site, age range of patients, time frame, dence of a peroxisomal disorder, and (GAA)-to-creatine ratios on a spot urine
study protocol, and results. However, 1 had abnormal cerebrospinal fluid screen. Diagnosis was further con-
they do bring renewed focus to treat- biogenic amine concentrations. These firmed by using brain proton magnetic
able metabolic disorders.13 Further- authors concluded that “screening for resonance spectroscopy and mutation
more, some of the disorders identified glycosylation defects proved useful, screening by DNA sequence analysis in
e909
FROM THE AMERICAN ACADEMY OF PEDIATRICS
far exceeds that of fragile X syndrome X-linked pedigree, genetic testing using The expected diagnostic rate remains
alone.46 Fragile X testing should be one of the panels is clinically indicated. uncertain, although many pathogenic
performed in all boys and girls with The clinical geneticist is best suited to segmental duplications are reported
GDD/ID of unknown cause. Of boys guide this genetic testing of patients (for a catalog of X-linked mutations
with GDD/ID of uncertain cause, 2% to with possible XLID. For patients with and CNVs, see http://www.ggc.org/re-
3% will have fragile X syndrome (full “syndromal” XLID (eg, Coffin-Lowry search/molecular-studies/xlid.html).
mutation of FMR1, >200 CGG repeats), syndrome), a single gene test rather Whole exome sequencing and whole-
as will 1% to 2% of girls (full muta- than a gene panel is indicated. Whereas genome sequencing are emerging
tion).48 those patients with “nonsyndromal” testing technologies for patients with
presentation might best be assessed nonspecific XLID. Recently, Tarpey et al52
GENETIC TESTING FOR by using a multigene panel compris- have reported the results of the large-
NONSPECIFIC XLID ing many of the more common non- scale systematic resequencing of the
syndromal XLID genes. The expected coding X chromosome to identify novel
Stevenson and Schwartz49 suggest 2
rate of the diagnosis may be high. genes underlying XLID. Gene coding
clinical categories for those with XLID:
Stevenson and Schwartz46 reported, sequences of 718 X-chromosome genes
syndromal and nonsyndromal. Syn-
for example, on 113 cases of non- were screened via Sanger sequenc-
dromal refers to patients in whom
specific ID testing using a 9-gene panel ing technology in probands from 208
physical or neurologic signs suggest
of whom 9 (14.2%) had pathogenic families with probable XLID. This re-
a specific diagnosis; nonsyndromal
mutations identified. de Brouwer et al51 sequencing screen contributed to the
refers to those with no signs or
reported on 600 families with multiple identification of 9 novel XLID-associated
symptoms to guide the diagnostic
boys with GDD/ID and normal karyo- genes but identified pathogenic se-
process. Using this classification has
type and FMR1 testing. Among those quence variants in only 35 of 208
practical applicability, because the
families with “an obligate female (17%) of the cohort families. This
pediatric primary care provider can
carrier” (defined by pedigree analysis figure likely underestimates the gen-
establish a specific XLID syndrome on
and linkage studies), a specific gene eral contribution of sequence var-
the basis of clinical findings. In con-
mutation was identified in 42%. In iants to XLID given the subjects were
trast, nonsyndromal conditions can
addition, in those families with more selected from a pool that had had
only be distinguished on the basis of
than 2 boys with ID and no obligate previous clinical and molecular ge-
the knowledge of their causative
female carrier or without linkage to netic screening.30
gene.50 In excess of 215 XLID con-
ditions have been recorded, and >90 the X chromosome, 17% of the ID
XLID genes have been identified.46,50 cases could be explained by X-linked BOYS WITH SUSPECTED OR KNOWN
To address male patients with GDD/ID
gene mutations. This very large study XLID
suggested that testing of individual
and X-linked inheritance, there are Table 4 lists some common XLID con-
boys for X-linked gene mutations is
molecular genetic diagnostic “panels” ditions. In cases in which the diagnosis
warranted.
of X-linked genes available clinically. is not certain, molecular genetic test-
These panels examine many genes in Recently, clinical laboratories have be- ing of patients for the specific gene is
1 “test sample.” The problem for the gun offering “high-density” X-CMAs to indicated, even if the pedigree does not
clinical evaluation is in which patient assess for pathogenic CNVs (see pre- indicate other affected boys (ie, cannot
to use which test panel, because there vious discussion regarding micro- confirm X-linked inheritance).46
is no literature on head-to-head per- arrays) specifically for patients with
formance of test panels, and the test XLID. Wibley et al30 (2010) reported on
panels differ somewhat by genes in- CNVs in 251 families with evidence of FEMALE GENDER AND MECP2
cluded, test methods used, and the XLID who were investigated by array TESTING
rate of a true pathogenic genetic di- comparative genomic hybridization Rett syndrome is an X-linked condition
agnosis. Nevertheless, the imperative on a high-density oligonucleotide X- that affects girls and results from
for the diagnostic evaluation remains chromosome array platform. They MECP2 gene mutations primarily (at
the same for families and physicians, identified pathogenic CNVs in 10% of least 1 other gene has been de-
and there is a place for such testing families. The high-density arrays for termined causal in some patients with
in the clinical evaluation of children XLID are appropriate in those patients typical and atypical Rett syndrome:
with GDD/ID. For patients with an with syndromal or nonsyndromal XLID. CDKL5). Girls with mutations in the
MECP2 gene do not always present However, it is frequently not an etio- concluded that “the value for finding
clinically with classic Rett syndrome. logic or syndromic diagnosis. This abnormalities or the absence of ab-
Several large case series have exam- distinction is not always made in the normalities must be higher” than the
ined the rate of pathogenic MECP2 literature on the utility of neuro- 30% mean rate implied.
mutations in girls and boys with ID. The imaging in the evaluation of children If neuroimaging is performed in only
proportion of MECP2 mutations in with developmental delay/ID. The lack selected cases, such as children with an
these series ranged from 0% to 4.4% of a consistent use of this distinction abnormal head circumference or an
with the average of 1.5% among girls has led to confusion regarding this abnormal focal neurologic finding, the
with moderate to severe ID.53–62 MECP2 particular issue. rate of abnormalities detected is in-
mutations in boys present with severe Early studies on the use of CT in the creased further than when used on
neonatal encephalopathy and not with evaluation of children with idiopathic a screening basis in children with
GDD/ID. ID64 indicated a low diagnostic yield for a normal neurologic examination except
the nonspecific finding of “cerebral for the documentation of developmental
ADVANCES IN DIAGNOSTIC atrophy,” which did not contribute to delay. Shevell et al68 reported that
IMAGING clarifying the precise cause of the ID.65 the percentage of abnormalities were
Later studies that used MRI to detect 13.9% if neuroimaging was performed
Currently, the literature does not in-
CNS abnormalities suggested that MRI on a “screening basis” but increased to
dicate consensus on the role that
was more sensitive than CT, with an 41.2% if performed on “an indicated
neuroimaging, either by computed to-
increased diagnostic yield.10,66 The rate basis.” Griffiths et al70 highlighted that
mography (CT) or MRI, can play in the
of abnormalities actually detected on the overall risk of having a specific
evaluation of children with GDD/ID.
imaging varies widely in the literature structural abnormality found on MRI
Current recommendations range from
as a result of many factors, such as scanning was 28% if neurologic symp-
performing brain imaging on all patients
subject selection and the method of toms and signs other than develop-
with GDD/ID,63 to performing it only on
imaging used (ie, CT or MRI). Schaefer mental delay were present, but if the
those with indications on clinical ex-
and Bodensteiner,63 in their literature developmental delay was isolated, the
amination,12 to being considered as
review, found reported ranges of ab- yield was reduced to 7.5%. In a series
a second-line investigation to be un-
dertaken when features in addition to normalities from 9% to 80% of those of 109 children, Verbruggen et al71 re-
GDD are detected either on history or patients studied. Shevell et al10 re- ported an etiologic yield on MRI of 9%.
physical examination. The finding of ported a similar range of finding in They noted that all of these children had
a brain abnormality or anomaly on their review. For example, in 3 studies neurologic signs or an abnormal head
neuroimaging may lead to the recogni- totaling 329 children with develop- circumference. In their practice pa-
tion of a specific cause of an individual mental delay in which CT was used in rameter, the American Academy of
child’s developmental delay/ID in the almost all patients and MRI was used Neurology and the Child Neurology
same way that a dysmorphologic ex- in but a small sample, a specific cause Society10 discussed other studies on
amination might lead to the inference of was determined in 31.4%,67 27%,68 and smaller numbers of patients who
a particular clinical diagnosis. However, 30%69 of the children. In their systematic showed similar results, which led to
like other major or minor anomalies review of the literature, van Karnebeek their recommendation that “neuro-
noted on physical examination, abnor- et al12 reported on 9 studies that used imaging is a recommended part of
malities on neuroimaging typically are MRI in children with ID. The mean rate the diagnostic evaluation,” particularly
not sufficient for determining the cause of abnormalities found was 30%, with should there be abnormal findings on
of the developmental delay/ID; the un- a range of 6.2% to 48.7%. These in- examination (ie, microcephaly, macro-
derlying precise, and presumably fre- vestigators noted that more abnor- cephaly, focal motor findings, pyramidal
quently genetic in origin, cause of the malities were found in children with signs, extrapyramidal signs) and that
brain anomaly is often left unknown. moderate to profound ID versus those MRI is preferable to CT. However, the
Thus, although a central nervous sys- with borderline to mild ID (mean yield authors of the American College of
tem (CNS) anomaly (often also called a of 30% and 21.2%, respectively). These Medical Genetics Consensus Conference
“CNS dysgenesis”) is a useful finding authors also noted that none of Report10 stated that neuroimaging by
and indeed may be considered, ac- the studies reported on the value of CT or MRI in normocephalic patients
cording to the definition of Schaefer the absence of any neurologic abnor- without focal neurologic signs should
and Bodensteiner,11 a useful “diagnosis.” mality for a diagnostic workup and not be considered a “standard of
practice” or mandatory and believed MRI alone leads to an etiologic di- a progressive or degenerative course in
that decisions regarding “cranial im- agnosis in a much lower percentage of terms of their neurologic symptom-
aging will need to follow (not precede) patients studied. They cited Kjos et al,72 atology. Bouhadiba et al73 reported
a thorough assessment of the patient who reported diagnoses in 3.9% of diagnoses in 0.9% of patients with
and the clinical presentation.” In con- patients who had no known cause for neurologic symptoms, and in 4 addi-
trast, van Karnebeek et al12 found that their ID and who did not manifest either tional studies, no etiologic or syndromic
diagnosis on the basis of neuroimaging been studied in detail. In addition, MRI treatment and prognosis. Confirm
alone was found.65,69,74,75 The authors in the young child with developmental the clinical diagnosis with the ap-
of 3 studies reported the results on delay/ID invariably requires sedation propriate genetic testing, as war-
unselected patients; Majnemer and or, in some cases, anesthesia to im- ranted by clinical circumstances.
Shevell67 reported a diagnosis by this mobilize the child to accomplish the 3. If a specific diagnosis is suspected,
typed unselected investigation in 0.2%, imaging study. This need, however, is arrange for the appropriate diag-
Stromme76 reported a diagnosis in decreasing with faster acquisition nostic studies to confirm including
1.4% of patients, and van Karnebeek times provided by more modern im- single-gene tests or chromosomal
et al40 reported a diagnosis in 2.2% of aging technology. Although the risk of microarray test.
patients. sedation or anesthesia is small, it still
4. If diagnosis is unknown and no
Although a considerable evolution has merits consideration within the de-
clinical diagnosis is strongly sus-
occurred over the past 2 decades in cision calculus for practitioners and
pected, begin the stepwise evalua-
neuroimaging techniques and modali- the child’s family.63,78,79 Thus, although
tion process:
ties, for the most part with the ex- MRI is often useful in the evaluation of
the child with developmental delay/ID, a. Chromosomal microarray should
ception of proton magnetic resonance
at present, it cannot be definitively be performed in all.
spectroscopy, this has not been applied
or reported in the clinical situation of recommended as a mandatory study, b. Specific metabolic testing should
developmental delay/ID in childhood. and it certainly has higher diagnostic be considered and should in-
yields when concurrent neurologic clude serum total homocysteine,
Proton resonance spectroscopy provides
indications exist derived from a care- acyl-carnitine profile, amino acids;
a noninvasive mechanism of measuring
ful physical examination of the child and urine organic acids, glycos-
brain metabolites, such as lactate, using
(ie, microcephaly, microcephaly, seizures, aminoglycans, oligosaccharides,
technical modifications to MRI. Martin
or focal motor findings). purines, pyrimidines, GAA/creatine
et al77 did not detect any differences
in brain metabolite concentrations metabolites.
among stratifications of GDD/ID into RECOMMENDED APPROACH c. Fragile X genetic testing should
mild, moderate, and severe levels. The following is the recommended be performed in all.
Furthermore, they did not detect any medical genetic diagnostic evaluation 5. If no diagnosis is established:
significant differences in brain me- flow process for a new patient with a. Male gender and family history
tabolite concentration between chil- GDD/ID. All patients with ID, irre- suggestive X-linkage, complete
dren with GDD/ID and age-matched spective of degree of disability, merit XLID panel that contains genes
typically developing control children. a comprehensive medical evaluation causal of nonsyndromic XLID and
Thus, these authors concluded that coordinated by the medical home in complete high-density X-CMA. Con-
proton resonance spectroscopy “has conjunction with the medical genetics sider X-inactivation skewing in the
little information concerning cause of specialist. What follows is the clinical
mother of the proband.
unexplained DD.” Similarly, the studies genetics evaluation (Fig 1):
b. Female gender: complete MECP2
by Martin et al77 and Verbruggen 1. Complete medical history; 3-generation
deletion, duplication, and sequenc-
et al71 did not reveal that proton mag- family history; and physical, dys-
ing study.
netic resonance spectroscopy was morphologic, and neurologic exami-
particularly useful in the determina- nations. 6. If microcephaly, macrocephaly, or
tion of an underlying etiologic diag- abnormal findings on neurologic
2. If the specific diagnosis is certain,
nosis in children with unexplained examination (focal motor findings,
inform the family and the medical
developmental delay/ID. pyramidal signs, extrapyramidal
home, providing informational re-
signs, intractable epilepsy, or focal
All of these findings suggest that ab- sources for both; set in place an
seizures), perform brain MRI.
normal findings on MRI are seen in explicit shared health care plan80
∼30% of children with developmental with the medical home and family, 7. If brain MRI findings are negative
delay/ID. However, only in a fraction of including role definitions; provide or normal, review status of diag-
these children does MRI lead to an sources of information and sup- nostic evaluation with family and
etiologic or syndromic diagnosis. The port to the family; provide genetic medical home.
precise value of a negative MRI result counseling services by a certified 8. Consider referrals to other specialists,
in leading to a diagnosis has not yet genetic counselor; and discuss signs of inborn errors of metabolism
a. If no or uncertain, obtain micro- medical geneticist can then agree on clinical report to guide the process.
array, perform fragile X testing, the frequency and timing of diagnos- The manner in which the elements of
and consider the metabolic test- tic reevaluation while providing the this clinical protocol are applied is
ing listed previously. Confirm family and child services needed. subject to local circumstances, as well
that newborn screening was as the decision-making by the involved
completed and reported nega- EMERGING TECHNOLOGIES pediatric primary care provider and
tive. Refer to medical genetics family. The goals and the process of the
Several research reports have cited
while testing is pending. diagnostic evaluation are unchanged:
whole-exome sequencing and whole-
b. If yes, send case summary and to improve the health and well-being of
genome sequencing in patients with
clinical photo to medical genetics those with GDD/ID. It is important to
known clinical syndromes for whom the
center for review for syndrome emphasize the new role of the genomic
causative gene was unknown. These re-
identification. If diagnosis is sus- microarray as a first-line test, as well
search reports identified the causative
pected, arrange for expedited as the renewal of efforts to identify the
genes in patients with rare syndromes
child with an inborn error of metab-
medical genetics referral and (eg, Miller syndrome,86 Charcot-Marie-
olism. The future use of whole-genome
hold all testing listed above. Med- Tooth disease,87 and a child with se-
sequencing offers promise and chal-
ical geneticist to arrange visit vere inflammatory bowel disease88).
lenges needing to be addressed before
with genetic counselor for testing Applying similar whole-genome se-
regular implementation in the clinic.
for suspected condition. quencing of a family of 4 with 1 affected
2. Does the child have microcephaly, individual, Roach et al86 identified the
LEAD AUTHORS
macrocephaly, or abnormal neuro- genes for Miller syndrome and primary John B. Moeschler, MD, MS, FAAP, FACMG
logic examination (listed above)? If ciliary dyskinesia. The ability to do Michael Shevell, MDCM, FRCP
“yes,” measure parental head cir- whole-genome sequencing and inter-
cumferences and review the family pretation at an acceptable price is on AMERICAN ACADEMY OF PEDIATRICS
the horizon.87,89 The use of exome or COMMITTEE ON GENETICS, 2013–
history for affected and unaffected 2014
members. If normal head circum- whole-genome sequencing challenges
Robert A. Saul, MD, FAAP, Chairperson
ferences in both parents and neg- the field of medical genetics in ways Emily Chen, MD, PhD, FAAP
ative family history, obtain brain not yet fully understood. When a child Debra L. Freedenberg, MD, FAAP
presents with ID and whole-genome se- Rizwan Hamid, MD, FAAP
MRI and refer to medical genetics. Marilyn C. Jones, MD, FAAP
quencing is applied, one will identify
3. Does child also have features of au- Joan M. Stoler, MD, FAAP
mutations that are unrelated to the Beth Anne Tarini, MD, MS, FAAP
tism, cerebral palsy, epilepsy, or
question being addressed, in this case
sensory disorders (deafness, blind-
“What is the cause of the child’s in- PAST COMMITTEE MEMBERS
ness)? This protocol does not ad- Stephen R. Braddock, MD
tellectual disability?” One assumes that
dress these patients; manage and this will include mutations that families John B. Moeschler, MD, MS, FAAP, FACMG
refer as per local circumstances. do not want to have (eg, adult-onset
CONTRIBUTOR
4. As above are arranged and completed disorders for which no treatment now Michael Shevell, MDCM, FRCP
and negative, refer to medical ge- exists). This is a sea change for the field
netics and hold on additional diag- of medical genetics, and the implications LIAISONS
nostic testing until consultation of this new technology have not been Katrina M. Dipple, MD, PhD – American College
completed. Continue with current fully explored. In addition, ethical issues of Medical Genetics
Melissa A. Parisi, MD, PhD – Eunice Kennedy
medical home family support ser- regarding validity of new tests, un- Shriver National Institute of Child Health and
vices and health care. certainty, and use of resources will need Human Development
5. Should a diagnosis be established, to be addressed as these technologies Nancy Rose, MD – American College of Obste-
become available for clinical use.90,91 tricians and Gynecologists
the medical home, medical geneti-
Joan A. Scott, MS, CGC – Health Resources and
cist, and family might then agree to Services Administration, Maternal and Child
a care plan with explicit roles and CONCLUSIONS Health Bureau
responsibilities of all. Stuart K. Shapira, MD, PhD – Centers for Disease
The medical genetic diagnostic evalu- Control and Prevention
6. Should a diagnosis not be estab- ation of the child with GDD/ID is best
lished by medical genetics consulta- accomplished in collaboration with the STAFF
tion, the medical home, family, and medical home and family by using this Paul Spire
35. Tucker T, Montpetit A, Chai D, et al. Com- 48. Hersh JH, Saul RA; Committee on Genetics. explained mental retardation. Clin Genet.
parison of genome-wide array genomic Health supervision for children with fragile X 2006;70(2):140–144
hybridization platforms for the detection of syndrome. Pediatrics. 2011;127(5):994–1006 62. Campos M, Jr, Abdalla CB, Santos-Rebouças
copy number variants in idiopathic mental 49. Stevenson RE, Schwartz CE. Clinical and mo- CB, et al. Low significance of MECP2 muta-
retardation. BMC Med Genomics. 2011;4:25 lecular contributions to the understanding of tions as a cause of mental retardation in
36. Kaminsky EB, Kaul V, Paschall J, et al. An X-linked mental retardation. Cytogenet Ge- Brazilian males. Brain Dev. 2007;29(5):293–297
evidence-based approach to establish the nome Res. 2002;99(1–4):265–275 63. Schaefer GB, Bodensteiner JB. Radiological
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