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Nottingham Down Syndrome Guidelines 1 PDF
Nottingham Down Syndrome Guidelines 1 PDF
Nottingham Down Syndrome Guidelines 1 PDF
Date of submission
Date on which guideline must be reviewed
October 2016
Explicit definition of patient group to which it applies
(e.g. inclusion and exclusion criteria, diagnosis)
Abstract
Key Words
Target audience
This guideline has been registered with the trust. However, clinical guidelines are guidelines only.
The interpretation and application of clinical guidelines will remain the responsibility of the
individual clinician. If in doubt contact a senior colleague or expert. Caution is advised when
using guidelines after the review date.
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October 2013
Pre-school Guidelines
13
14
Appendix A
15
Appendix B
16
Appendix C
17
Appendix D
18
Appendix E
Hearing Guidelines
22
Appendix F
Vision Guidelines
23
Appendix G
24
Appendix H
26
Appendix I
28
Appendix J
Physiotherapy Service
30
Appendix K
31
List of Contributors
32
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Dr Claire McCall
Clifton Cornerstone
Southchurch Drive
Clifton
Nottingham, NG11 8EW
Tel: 0115 8786334
clairemccall@nhs.net
Dr Liz Marder
Childrens Centre
City Campus
Nottingham, NG5 1PB
Tel: 0115 8831100
or via QMC switchboard
elizabeth.marder@nuh.nhs.uk
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October 2013
Down syndrome
diagnosed
antenatally
Down syndrome
diagnosed after neonatal
period or move into area
Information/counselling by
Nottingham Down
Syndrome Childrens
Service team
Pregnancy
terminated
Pregnancy
continued
Ongoing
follow-up by
hospital
specialists
continues
where
necessary
Initial Visit by
Down Syndrome Childrens Service
team ASAP usually on
NNU/postnatal ward
Follow up by local
Community paediatricians
Follow up at
Nottingham Down
syndrome
Childrens Clinic
Follow up by hospital
paediatricians
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This is usually done in the hospital but if the baby is discharged early it may be
arranged at home.
This usually takes place at home, but may need to be in the hospital.
The Community Paediatrician may be accompanied by colleagues form the Child
Development Team and/or the Health Visitor.
General discussion and provision of further information regarding Down
Syndrome and the locally available services (e.g. Childrens Centre Baby Group).
Ensure that cardiac status is checked and that all babies with significant left to
right shunt have been referred for RSV prophylaxis in season.
The specific Down Syndrome literature from the DoH Early Support materials
(Blue Box) to be given if this was not given at the first visit (Appendix K).
Offer opportunity to meet other families.
If the child is likely to have a prolonged hospital stay, refer to the Childrens
Centre Play Team.
Note: A letter to the GP and Health Visitor should be written during these
two weeks.
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The 5th and subsequent annual reviews are usually best carried out by the
local paediatrician for the childs school. This is discussed with the
parent/carer.
Children may continue to be followed up for routine reviews at the Down
Syndrome Childrens Clinic if felt more appropriate,
Referral back to the Down Syndrome clinic may be made for specific clinical
problems.
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Discussion:
Review of health to date
Requirements for ongoing care
Further education and adult placement
Preparation of medical report for GP, carers and the young person
Testicular examination discuss if self-examination is appropriate or
alternative arrangement as testicular tumours are more common in Down
Syndrome
Fertility and need for contraception
Referrals:
Transition co-ordination Social Care Team if mental health issues present
Adult Learning Disability Team, where necessary
GP for ongoing surveillance
Investigations:
Audiology
Vision
Thyroid function
Echocardiogram (A repeat is now recommended in early adult life, because of
the high incidence of mitral valve prolapse and aortic regurgitation in adults
with Down Syndrome who are asymptomatic)
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Name:
DoB:
Date:
Hospital Number:
Organised/
performed
by:
Result/Details:
Consultant:
Follow up
arranged:
Clinical findings
Cardiac examination
Age at which meconium
passed
Other major
abnormalities
Blood tests
Chromosomes
FBC
Thyroid (newborn
screen)
Referral to DS service
Telephone call
Letter
Investigations
Echocardiogram
RSV vaccine (if needed)
Cardiology follow-up (if
needed)
Hearing screening
GP and HV notified
Other referrals made
a)
b)
c)
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Down syndrome
diagnosed at birth
Referral to
cardiac
specialist for
discussion
before birth
of likely
treatment
Request Echocardiogram
mark Down sydnrome
and to be done by 4
weeks
Normal
Routine follow up
Echo ASAP
Reports to referrer
and DS clinic
Normal ECG
examination and O2
Reports to
referrer
and DS
clinic at
CDC
Minor
abnormality
PDA/PFO/VS
Urgent
echocardiogram
Significant
congenital
heart
disease.
?need for
RSV
prophylaxi
s
Cardiology
clinic Dr
Thakker by 3
months of age
CHD
Normal
Urgent
consultation
with Dr Thakker
and/or Glenfield
if clincially
indicated
Cardiology clinic Dr
Thakker within 2
weeks
Follow up depending
on nature of CHD
Routine follow
up
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Neonatal team should have arranged the following investigations and completed the
form (Appendix A). Please check they have been done!
o Echocardiogram done and reported by a Paediatric Cardiologist (follow up
arranged if necessary) OR ECG and pre- and post-ductal O2 saturations checked
with appointment for echocardiogram made for 2 weeks (Appendix C)
o Hearing screen
o Karyotype and, if parents not aware of result, when and how this will be
communicated with them
o GP and Health Visitor informed
Follow-up arrangements
o Offer to see family again in hospital if there is likely to be a prolonged
admission
o Offer a home visit, preferably with the Health Visitor in approximately 2
weeks (and if so contact the HV to arrange)
o Check if the neonatal clinic plan to follow up and if there are any planned
appointments at other clinics e.g. cardiac, ophthalmology, hip clinic
o Ask the family if they would like to meet another family of a child with DS
o Invite to DS clinic as soon as the family wish, but with a formal
appointment at 3 months of age
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Appendix E
All children will have the newborn screening and then those with known Down
Syndrome will automatically be sent an appointment for follow-up at 8 months. If
the diagnosis of Down Syndrome is not known at this point, however, this may
not happen.
At the Six Month Review please refer to CHAC to check that the child is in the
system and will be sent an appointment by 8 months.
At the One Year Review it should be confirmed that the child has had a CHAC
appointment and the report is in the notes.
All children will be called for yearly follow-ups BUT if the child DNAs they may be
discharged according to protocol. The Paediatrician will be informed with a
request for further referral.
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Appendix F
At 3 and 6 Month Review ask the parents about visual behaviour, squint,
nystagmus etc. Examine for squint, nystagmus, cataracts and visual behaviour. If
there are any concerns refer for ophthalmology assessment.
Repeat above at the One Year Review. Treat and give advice as necessary e.g.
blepharitis. Nasolacrimal duct obstruction is common and may need referral.
At the Second Year Review examine and refer all children to Paediatric
Ophthalmologist unless they are already in the system. They will usually see
children with Down syndrome at the Childrens Centre.
Note: - For further information please see Vision guidelines from the DSMIG
www.dsmig.org.uk
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Appendix G
October 2013
What are the principles of the Speech and Language Therapy Service?
We provide care based on evidence, good practice guidance and professional
standards.
We work in partnership with you and your child, and other professionals to
reduce the impact of their communication difficulties on the childs well-being and
ability to participate in daily life. Working through others is the key to create
change in the childs communication skills.
We assess childrens communication skills through observations, information
gathering and assessment. We often link in with other professionals to help with
this. E.g. Early Years Teachers.
Every child can communicate. We help build on their strengths and use those to
support areas they find more difficult.
We tailor strategies to the needs of the individual child and focussing on people
they communicate with and places they go, as well as the childs own skills.
Useful resources/contacts:
These are some examples of resources available in the library at the Childrens
Centre, City Hospital.
It takes two to talk. A parents guide to helping children communicate. Ayala
Manolson.
Early Communication Skills for Children with Down Syndrome. Libby Kumin.
Books and DVDs e.g. Something Special ideal for practicing signing skills.
Other resources
Down Syndrome Educational Trust www.downsed.org
Down Syndrome online www.down-syndrome.org
Makaton. Makaton Vocabulary Project, 31 Firwood Drive, Camberley,
Surrey, GU15 3QD. www.makaton.org
To find out more, please contact us...
South Base (Nottingham City, Broxtowe,
Gedling and Rushcliffe)
Childrens Centre
City Hospital
Hucknall Rd
Nottingham
NG5 1PB
0115 831101
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Appendix H
Children with Down Syndrome are at high risk of SRBD and nocturnal
hypoxaemia, and the high incidence of congenital heart disease in these
children makes the development of pulmonary hypertension a significant risk.
SRBD may be difficult to identify on symptoms in this group.
Adenotonsillectomy may have a lower rate of success, but is still indicated.
Other interventions including CPAP are effective but may be difficult to
institute.
They recommended the following:
All children with Down Syndrome should be offered screening for SRBD,
using at least oximetry; suggested screening ages are at least once in infancy
then annually until age 3-5 years.
Children with Down Syndrome with abnormalities on screening for SRBD, or
where there is a clinical suspicion of a false negative screening test, should have
polysomnography, including oximetry, airflow, effort and CO2 measurement.
Video should be included if possible.
If significant SRBD with hypoxia is present in children with Down
Syndrome, then appropriate treatment should be offered.
Further research is needed on the benefits and risks of screening for SRBD
and Down Syndrome.
It is acknowledged in the report that there is no evidence about how long screening
should continue in these children. We have arbitrarily taken 3-5 years as including the
period of highest risk of OSA. If screening tests are negative up to this age it would
seem reasonable not to undertake further tests subsequently unless there are
suggestive symptoms.
Symptoms to consider include:
Snoring
Sleep disturbance
Mouth breathing and halitosis
Restless sleep
Chronic rhinorrhea
Subcostal and sternal recession
Odd sleep positions, such as hanging over the bed or sleeping upright with head
extended to optimise the upper airway
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Swallowing difficulties
Recurrent upper respiratory tract infections
Nausea and vomiting
Daytime sleepiness
Persistent or secondary enuresis
Nocturnal sweating
Cyanosis
Apnoea
Pulmonary hypertension
Heart failure.
All children with Down Syndrome to have overnight oximetry at 1 year of age
Specific questioning for possible symptoms at every paediatric review
Children with no suggestive symptoms and normal oximetry will have routine
follow up , with repeat oximetry at 4 years of age
Children with abnormal oximetry will be referred for further assessment by
respiratory paediatricians, including polysomnography, or to ENT surgeons if
clinical symptoms dictate
Children with significant suggestive symptoms, but normal oximetry should also
be referred for further assessment as above
Children with suggestive symptoms between or beyond the age of routine
screening should be referred for oximetry
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Appendix I
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Appendix J
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Appendix K
Dr Gillian Burton
Dr Claire McCall
Dr Pradip Thakker
Dr Liz McDermott
Dr Lucy Cliffe
Dr David Thomas
Dr Dulip Jayasinghe
Ms Claire Benton
Head of Service,
Childrens Hearing assessment Centre , NUH
Ms Gilly Flanaghan
Ms Elin Iversen
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