Handbook of Clinical Neurology, Vol.

162 (3rd series)

Neonatal Neurology
L.S. de Vries and H.C. Glass, Editors
https://doi.org/10.1016/B978-0-444-64029-1.00021-7
Copyright © 2019 Elsevier B.V. All rights reserved

Chapter 21

Neonatal hypotonia and neuromuscular conditions

EUGENIO MERCURI*, MARIA CARMELA PERA, AND CLAUDIA BROGNA
Department of Pediatric Neurology, Catholic University, Rome, Italy

Abstract
The differential diagnosis of neonatal hypotonia is a complex task, as in newborns hypotonia can be the
presenting sign of different underlying causes, including peripheral and central nervous system involve-
ment and genetic and metabolic diseases. This chapter describes how a combined approach, based on the
combination of clinical signs and new genetic techniques, can help not only to establish when the hypo-
tonia is related to peripheral involvement but also to achieve an accurate and early diagnosis of the specific
neuromuscular diseases with neonatal onset. The early identification of such disorders is important, as this
allows early intervention with disease-specific standards of care and, more importantly, because of the
possibility to treat some of them, such as spinal muscular atrophy, with therapeutic approaches that have
recently become available.

Generalized hypotonia is a common feature in the neona-
tal unit. Since the original description by Dubowitz
(1968) there is increasing attention on the diagnosis of
floppy infants, as this is one of the key presenting signs
in newborns with neuromuscular disorders. An accurate
differential diagnosis is, however, needed as generalized
hypotonia can also be observed in a wide range of
other conditions, including central nervous system invol-
vement and genetic and metabolic diseases (Dubowitz,
1995; Vasta et al., 2005).
While until a few years ago the main goal was to iden-
tify the clinical signs or the other investigations that
would confirm or exclude a neuromuscular disorder
(Vasta et al., 2005), recent advances in the field of
neuromuscular disorders have completely changed both
the diagnostic pathway and the level of intervention.
The advent of next generation sequencing (NGS) has
allowed simplification and identification of the specific
underlying genetic defect in most cases (Ghaoui et al.,
2015; Savarese et al., 2015, 2016; Cummings et al.,
2017). On the other hand, the development of specific
therapeutic approaches based on the genetic diagnosis
has produced a number of clinical trials that have
started to show concrete results, and treatments are
now emerging with exciting translational research work,
especially in the field of genetic therapy.
This chapter concentrates on the differential diagnosis
of neonatal hypotonia, focusing on the new approaches
for the diagnosis of neuromuscular disorders. The chap-
ter also provides a general review of the most significant
therapeutic advances for neonatal onset neuromuscular
diseases.
CLINICAL PRESENTATION
A neuromuscular disorder should be suspected when the
infant has a generalized hypotonia and additional clinical
features, such as weakness or contractures (Dubowitz,
1968; Vasta et al., 2005). There is often confusion and
a tendency to define a hypotonic infant as weak, but it
is crucial that the two aspects are examined separately,
as this is a key element in the differential diagnosis of
neonatal hypotonia.
Hypotonia means decreased muscle tone, an infant
with hypotonia “looks” floppy, as he/she does not show
the normal flexor tone observed in healthy newborns.
The appearance of a floppy infant, in the most severe
cases, is that of a “rag doll.” This is best observed

*Correspondence to: Eugenio Mercuri, M.D., Ph.D., Neuropsichiatria Infantile Policlinico Gemelli, Largo Gemelli, Rome 00168,
Italy. Tel: +39-063-015-5586, Fax: +39-063-015-4363, E-mail: eugeniomaria.mercuri@unicatt.it
436 E. MERCURI ET AL.
when the infant is held in ventral suspension. The
neurologic examination shows clear signs of hypotonia
with increased popliteal angles, scarf signs, and poor
axial tone.
A floppy infant is not always weak. One of the key
elements to detect weakness is the observation of anti-
gravity movements, as weak infants are unable or have
severe difficulties in performing antigravity movements
that are always present even in very preterm newborns.
Weak children show little or no movements, even
in response to stimulation. If the movements are not
observed when the infant is awake and calm, it is essen-
tial to make sure that they are not present at peak of activ-
ity, such as when crying or stimulated. Infants with
metabolic disorders or with neonatal encephalopathy
may not show spontaneous movements but generally
will show some abrupt movements following stimula-
tion. Observing even a few movements is a sign that there
is muscle strength and that paucity of movements is not
related to weakness.
In contrast, severely reduced or absent antigravity
movements, even after stimulation, are a sign of weak-
ness and suggest a possible neuromuscular disorder.
Some genetic syndromes, such as Prader–Willi syn-
drome, can present with severe neonatal hypotonia and
an overall appearance that is evocative of a possible
neuromuscular disorder. The predominant swallowing
difficulties and the presence of antigravity movements
in Prader–Willi syndrome, however, are of help in the
differential diagnosis.
The other key sign is the presence of contractures
that are also frequent and often involve several joints.
Neonatal contractures are often the result of reduced
motility in utero. While some contractures are obvious,
especially if there is a diffuse pattern, as observed in
severe arthrogryposis, other contractures might be more
subtle. Especially in the presence of weakness, the clin-
ical examination should include a detailed assessment
of possible contractures, especially at knee, hip, and
elbow level, where they can only be observed by
performing an assessment of each joint, looking for the
full range of extension.
A careful assessment of both weakness and contrac-
tures is important, as they are the two signs that can more
reliably identify infants with neuromuscular disorders
(Vasta et al., 2005).
In addition to contractures, other important clues
that may suggest prenatal signs of weakness are poor
fetal movements, polyhydramnios, suggesting prenatal
involvement of the swallowing muscles, and thin ribs
on the chest radiograph, suggesting poor prenatal respi-
ratory muscle movement.
Feeding abnormalities and respiratory impairment are
also frequent, but they are not specific, as they can also be
found in patients with central nervous system involve-
ment and genetic and metabolic disorders.
The family history is equally important. Establishing
a pattern of inheritance is important in the differential
diagnosis. Furthermore, there may be subclinical mani-
festations in dominant and X-linked disorders that can
help in the diagnostic process. The best example is
myotonic dystrophy, an autosomal dominant condition.
The mother, who is always affected and may be unaware
of the disease as she is only mildly clinically affected,
should be examined, looking for weakness of the
facial muscles (which may consist only of the inability
to bury the eyelashes), relaxation myotonia of the hands,
and percussion myotonia of the tongue and hands. An
ophthalmologic assessment could help to identify early
ocular involvement, such as cataracts.
It is also important to exclude myasthenia gravis in the
mother, as this may lead to transient neonatal myasthenia
due to passive transfer of antibodies across the placenta.
An accurate clinical examination will also help to
identify clinical features, such as the distribution of
weakness that may help to indicate or exclude specific
neuromuscular disorders. Overt facial weakness is char-
acteristic of myotonic dystrophy and of several congen-
ital myopathies, as well as of some forms of congenital
muscular dystrophy. In contrast, it is never observed
in spinal muscular atrophy (SMA). External ophthal-
moplegia is a feature of centronuclear myopathy and
other congenital myopathies.
The distribution of the respiratory muscle weakness is
important. Diaphragmatic weakness with paradoxical
movement of the abdominal muscles with respiration
occurs in congenital muscular dystrophy and in some
of the congenital myopathies, and in congenital myasthe-
nia. In contrast, in SMA the weakness is mainly intercos-
tal, the breathing pattern is abdominal, and the rib cage
moves paradoxically with the abdomen. More details
on clinical signs will be provided when discussing the
individual neuromuscular forms.
Investigations
The serum creatine kinase (CK) levels can help to
identify patients with muscular dystrophies. In newborns
with clinical signs of weakness and hypotonia, very
elevated levels (several 1000 units) can be a sign of
congenital myotonic dystrophy or of some form of
congenital muscular dystrophies. An accidental finding
of elevated CK levels in an asymptomatic newborn, in
contrast, is often likely to identify preclinical Duchenne’s
muscular dystrophy.
A cautionary tale is that less markedly elevated CK
levels are normal in cord blood (up to 1000 units) or in
newborns in the first days after delivery as a result of
 NEONATAL HYPOTONIA AND NEUROMUSCULAR CONDITIONS
some muscle damage during labor. The value generally
normalizes within the first 10 days of life.
The value of electromyography (EMG) in the neona-
tal period is limited, as interpretation can be difficult.
Its use is mainly limited to when there is a suspicion of
motor neuron involvement without the typical clinical
signs of SMA (see dedicated paragraph); if there is a
suggestion that the infant may have myotonic dystrophy,
then one should obtain EMGs from the mother, looking
for myotonic discharges.
Ultrasound imaging of muscle (Heckmatt and
Dubowitz, 1987; Zuberi et al., 1999), in contrast, is
increasingly used to detect signs of muscle or motor
neuron involvement and can also help to demonstrate
patterns of selective involvement.
Until recently, when clinical signs were suggestive
of neuromuscular involvement and there were no signs
suggestive of specific disorders, muscle biopsy was an
obligate choice for arriving at a diagnosis, as it provides
both structural information on possible myopathic,
dystrophic, or neurogenic changes, and also allowed
identification of specific protein defects using immunohis-
tochemistry. The exceptions were infants with suspected
congenital myotonic dystrophy or SMA, in whom the
typical clinical findings and the ease of performing
genetic tests did reliably lead to a diagnosis without the
need for muscle biopsy.
The advent of next-generation sequencing (NGS)
technologies now offers the possibility of mapping entire
genomes at affordable costs. This has increased the
possibility of achieving a genetic diagnosis, but reaching
a final diagnosis is often still difficult, as the technique
identifies many DNA variations with unpredictable
meaning. Because of this, muscle biopsy is still often
needed.
Brain imaging is generally not indicated when a
neuromuscular disorder is suspected unless there are
clinical signs that suggest a possible concomitant CNS
involvement.
It is often performed in patients with CMD and
alpha dystroglycan deficiency, as these forms are known
to often be associated with structural brain changes (see
next paragraph).
The muscular dystrophies
CONGENITAL MYOTONIC DYSTROPHY
Congenital myotonic dystrophy is the congenital form
of myotonic dystrophy type 1 (DM1) (Vanier, 1960),
a heterogeneous multisystem genetic disease caused by
expansion of a CTG trinucleotide repeat in the noncoding
region of the dystrophia myotonica gene (DMPK)
(Buxton et al., 1992). The congenital form is character-
ized by severe hypotonia and weakness at birth, often
437
with respiratory insufficiency. A recent study reports
that its incidence is 2.1/100,000 (1/47,619) live births
(Campbell et al., 2013). During the first year of life, there
is a 30% mortality for those infants ventilated for
more than 3 months (Campbell et al., 2013; Johnson
et al., 2016).
Weakness and contractures are present at birth, often
with bilateral talipes, severe facial muscle weakness, and
feeding and often respiratory difficulties.
There is often a prenatal history of polyhydramnios
and reduced fetal movements. Outside the neonatal
period, most cases with the congenital form survive
but few become independent, with most of them showing
intellectual disability.
Congenital myotonic dystrophy is one of the most
frequent causes of neonatal onset muscle disorders.
Therefore in an infant with the clinical signs consistent
with this diagnosis, signs of the disease should be inves-
tigated in the mother, who is generally affected. Facial
weakness, percussion myotonia of the tongue, and
myotonic discharge on the EMG can generally be found
in the mothers. Clinical myotonia of the hands or at eye
opening are also often present. A careful family history
often helps to support this possible diagnosis on the basis
of presenile cataract, frontal baldness, or other signs
typical of the late onset forms of DM1.
The confirmation of the diagnosis is based on
the genetic test showing an expansion of the DNA and
an increase in the number of CTG trinucleotide repeats
in the noncoding region of the dystrophia myotonica
gene (DMPK).
Performing cranial ultrasound is suggested in these
infants, as ventriculomegaly is in some cases already
diagnosed prenatally (Mutchnick et al., 2016). Progressive
enlargement of the ventricles, however, is less frequent
and only a minority will require shunt placement.
CONGENITAL MUSCULAR DYSTROPHIES
This is a heterogeneous group of neuromuscular
disorders characterized by weakness, usually from birth,
or within 6 months, and dystrophic changes on muscle
biopsy (Dubowitz, 1994; Philpot et al., 1995). Over
the years the classification of CMD has become increas-
ingly complicated due to the ever-growing numbers of
genes and proteins identified (Muntoni and Voit, 2004;
Mercuri and Longman, 2005; Godfrey et al., 2007).
Mutations in more than 20 genes have been reported
but there are still a number of forms/types with clinical
and histologic findings consistent with CMD without a
genetic diagnosis (Bonnemann et al., 2014; Sframeli
et al., 2017).
A previous nationwide population study reported that,
in Italy, the prevalence of CMD is 0.563 per 100,000
438 E. MERCURI ET AL.
(Graziano et al., 2015). CMDs due to alpha dystroglycan
glycosylation deficiency (dystroglycanopathies) were
the most common forms (40.2%) followed by laminin
a2-related CMD (24.1%) and Ullrich-CMD due to
collagen VI deficiency (20.2%). In another study per-
formed in the United Kingdom, laminin a2-related
CMD was reported as the most common CMD subtype
(37.4%), followed by dystroglycanopathies (26.5%)
and Ullrich-CMD (15.7%) (Sframeli et al., 2017). In a
recent Australian study, the most common CMD subtype
was Ullrich-CMD, followed by dystroglycanopathies
and laminin a2 deficiency (O’Grady et al., 2016).
The discrepancies of the frequencies of individual
CMD subtypes between the studies likely reflect the
mutant gene pool frequencies in these population groups,
although differences in the referral pathways between
the different studies could also have played a role. The
first classifications of CMD were mainly based on the
involvement of the CNS and on the presence or absence
of merosin, an extracellular matrix protein found to be
missing in approximately half of the cases with CMD
(Dubowitz, 1994). Subsequent classifications were
based on the genetic defect, on the assumption that each
gene was associated with a specific phenotype (Muntoni
et al., 2009). The improved understanding of the mech-
anisms underlying these forms provided new clues that
made this classification inadequate. Individual pheno-
types are often associated with mutations in different
proteins. Conversely, allelic disorders can give rise to
divergent diseases (Godfrey et al., 2007). In the last
few years, CMDs have been classified according to
combined clinical, genetic, and pathologic approaches
(Mercuri and Muntoni, 2012).
(1) Forms of CMD due to mutations in genes encoding
for structural proteins of the basal lamina or extra-
cellular matrix or receptors for extracellular matrix
proteins. This category includes mutations in the
collagen six genes, laminin a2 (merosin), integrin
a7 and the more recent variant due to integrin a9
gene deficiency. Mutations in DAG1 (dystroglycan
gene) have very recently also been described and
clearly belong to this subgroup (Hara et al., 2011).
(2) Forms secondary to genes encoding for putative
or demonstrated glycosyltransferases, which affect
the glycosylation of a-dystroglycan. These include
Fukuyama CMD, muscle–eye–brain disease (MEB)
and Walker–Warburg syndrome, MDC1C and
MDC1D, and other phenotypes associated with
mutations in one of the 15 known genes.
(3) Defects of nuclear envelope proteins (LMNA and
nesprin).
(4) Defects of proteins with, so far, unknown function
localized in the endoplasmic reticulum, which
include the form of CMD with rigid spine syn-
drome secondary to mutations in the SEPN1
CMD with mitochondrial structural abnormalities
(CMDmt).
Table 21.1 provides a complete list of the CMD types,
including protein and gene defects.
From a practical point of view, for the clinician it is
useful to separate forms with central nervous system
involvement from those in which CNS involvement is
absent or rare. We will describe the most frequent forms
of CMD, providing clinical, pathologic, and imaging
details to help their identification in the neonatal period.
As a group, the CMDs share some clinical signs.
Generalized weakness, hypotonia, and contractures
are usually present at birth. Facial weakness is frequently
present but generally is not as striking as in congenital
myotonic dystrophy. Respiratory and swallowing
involvement are also frequent at birth. Patients with
Ullrich-CMD or with SEPN1 mutations, however,
may present later in the first year of life with motor
delay. In dystroglycanopathies, the clinical signs of
CNS involvement may predominate. A few studies
have recently reported a comprehensive review of the
diagnostic aspects related to CMD (Bonnemann et al.,
2014; Kang et al., 2015; O’Grady et al., 2016).
ULLRICH-CMD
This CMD form is due to deficiency of collagen type
VI (Camacho Vanegas et al., 2001), an extracellular
matrix component. It is characterized by marked distal
laxity, contractures of the proximal joints, skin changes,
and normal intelligence (Mercuri et al., 2002; Nadeau
et al., 2009). Only patients at the severe end of the clinical
spectrum have a neonatal onset with weakness, contrac-
tures, and hypotonia, often associated with torticollis
and hip dysplasia (Nadeau et al., 2009).
In Ullrich-CMD, serum CK is often normal or only
mildly elevated (Foley et al., 2013). Muscle biopsy can
show a variable pathology ranging from myopathic
changes (always with presence of neonatal myosin
positive fibers), to clearly dystrophic patterns, with
abundant adipose tissue. A marked deficiency or absence
of collagen VI is a clear marker of Ullrich-CMD. This
can usually be detected on muscle fibers, but is best
observed in skin (Sabatelli et al., 2011).
The diagnosis needs to be confirmed by genetic anal-
ysis looking for mutations. Collagen VI is composed of
three a chains encoded by three genes: COL6A1 and
COL6A2 on chromosome 21q22 or COL6A3 on chromo-
some 2q37 (Nadeau et al., 2009; Yonekawa and Nishino,
2015). Detecting mutations in these genes will confirm
the diagnosis. Mutations in these genes, however,
Table 21.1
List of the CMD types.

Chromosome
Biochemical defect Gene location Protein Disease phenotype(s)

Extracellular matrix LAMA2 6q22–23 Laminin a2 chain of merosin Primary merosin deficiency
proteins COL6A1, 21q22.3 Collagen type VI, subunit alpha 1/2/3 Ullrich-CMD
COL6A2 2q37
COL6A3
External sarcolemmal ITGA7 12q13 Integrin a7 Integrin a7-related CMD
proteins ITGA9 3p23–21 Integrin a9 Integrin a9-related CMD
Dystroglycan and POMT1 9q34.1 Protein-1-O-mannosyl-transferase 1 Walker–Warburg syndrome, MEB, CMD with cerebellar involvement, CMD with
glycosyltransferase mental retardation and microcephaly, CMD no mental retardation
enzymes POMT2 14q24.3 Protein-O-mannosyl-transferase 2 Walker–Warburg syndrome, MEB, CMD with cerebellar involvement, CMD with
mental retardation and microcephaly
POMGnT1 1q32–34 Protein-O-linked mannose b1,2-N- Walker–Warburg syndrome, MEB, CMD with cerebellar involvement
aminyltransferase 1
FKRP 19q13.3 Fukutin-related protein Walker–Warburg syndrome, MEB, CMD with cerebellar involvement, CMD with
mental retardation and microcephaly, CMD with no mental retardation
FCMD 9q31 Fukutin Fukuyama CMD, CMD with mental retardation, CMD with no mental retardation
LARGE 22q12.3–13.1 Like-glycosyl transferase Walker–Warburg syndrome, MEB, white matter changes
DPM2/DPM3 1q12–q21 Dolichyl-phosphate CMD with mental retardation and severe epilepsy
mannosyltransferase polypeptide 2/3
ISPD 7p21.2 Isoprenoid synthase domain WWS, LGMD
GTDC2 3p22.1 O-mannose b-1,4-N- WWS
acetylglucosaminyltransferase
B3GALNT2 11q13.2 Beta-1,3-N- WWS, MEB
acetylgalactosaminyltransferase 2
GMPPB GDP-mannose pyrophosphorylase CMD with mental retardation and severe epilepsy
DAG1 3p21 Primary dystroglycanopathy, LGMD with early onset and mental retardation, normal
brain MRI
SGK196 8p11.21 Protein-O-mannose kinase MEB
— 1q42 MDC1B
Endoplasmic SEPN1 1p35–36 Selenoprotein N1 CMD with spinal rigidity (RSMD1)
reticulum protein
Nuclear envelope SYNE1 6q25 Nesprin 1 CMD with adducted thumbs
proteins LMNA 1q21.2 Lamin A Congenital laminopathy
Mitochondrial CHKB 22q13 Choline kinase Mitochondrial CMD (CMDmt)
membrane protein
440 E. MERCURI ET AL.
can also be associated with Bethlem myopathy or with an
intermediate phenotype, but these allelic forms generally
do not have a neonatal onset (Bonnemann et al., 2014).
MEROSIN-NEGATIVE CONGENITAL
MUSCULAR DYSTROPHY
Children with merosin deficiency are usually symptom-
atic at birth or in the first few weeks of life with hypotonia
and muscle weakness, weak cry, and often with contrac-
tures (Geranmayeh et al., 2010).
Muscle biopsy shows a classical dystrophic picture
and immunofluorescence techniques demonstrate the
reduction or absence of laminin a2 chain. In most cases
with neonatal onset, the protein is totally absent or only
present in traces. The diagnosis of merosin deficient
CMD should be genetically confirmed by studying the
laminin a2 chain (LAMA2) gene, mapped to chromo-
some 6q22–23 (Hillaire et al., 1994).
Diffuse white matter changes on MRI are a constant
feature in these children, affecting both hemispheres,
but sparing the internal capsule, corpus callosum, basal
ganglia, thalami, and cerebellum (Philpot et al., 1999).
These changes are not obvious on the conventional
scans performed in the first months of life and are best
visualized after 6 months (Mercuri et al., 2001).
The changes on brain MRI are thought to be the result
of an increase in water content rather than being a
sign of demyelination and are generally not associated
with clinical signs of CNS involvement, with the excep-
tion of epilepsy, observed in 10%–30% of children
(Geranmayeh et al., 2010).
Other patterns of brain lesions, such as cerebellar
hypoplasia and/or cortical dysplasia, can be observed in
a small proportion of these patients (Philpot et al., 1999).
FORMS OF CONGENITAL MUSCULAR
DYSTROPHY WITH STRUCTURAL BRAIN
CHANGES AND EYE INVOLVEMENT
The CMD forms with structural brain changes and eye
involvement fall under the group labeled as dystrogly-
canopathies, that includes a genetically heterogeneous
group of muscle disorders, with hypoglycosylated
a-dystroglycan on muscle biopsy (Godfrey et al., 2011;
Mercuri and Muntoni, 2012; Bonnemann et al., 2014).
Patients with primary or secondary dystroglycanopathies
have common features, such as predominant involvement
of the upper limbs and markedly elevated CK. Brain and
eye involvement are frequent but are not a constant
feature, as the spectrum of clinical severity ranges from
forms with severe structural muscle, eye, and brain
involvement to mild cases with late onset and no brain
or eye involvement (Clement et al., 2008; Mercuri et al.,
2009; Godfrey et al., 2011; Mercuri and Muntoni, 2012).
While the early studies following the identification of
the first genes involved mainly focused on distinct
known phenotypes, namely MEB, WW, and Fukuyama,
it has become increasingly obvious that the spectrum of
CNS involvement is much more complex (Mercuri and
Muntoni, 2012; Bonnemann et al., 2014). Brain MRI
studies have highlighted that infratentorial structures
appear to have a particular susceptibility in the majority
of the dystroglycanopathies (Clement et al., 2008;
Mercuri et al., 2009; Godfrey et al., 2011). A number
of patients have posterior fossa lesions, such as cerebellar
dysplasia or hypoplasia, that may occur in isolation, or
are variably associated with brainstem and pons abnor-
malities or with more severe and diffuse supratentorial
changes. We have proposed a simplified clinical classifi-
cation system comprising five broad phenotypic catego-
ries for the CMD forms (Godfrey et al., 2007) with
patients subdivided according to the presence/absence
and degree of structural and functional brain involvement
and motor functional abilities.
A recent study, also including newly discovered
genes, has confirmed that the spectrum of changes is
similar also in the newly identified forms (Sframeli
et al., 2017).
New Online Mendelian Inheritance in Man (OMIM)
entries have been created, subdividing the group of mus-
cular dystrophies with deficit of dystroglycan (MDDG)
into three broad phenotypic groups denoted type A, B,
and C, each including some of the seven categories
proposed by Godfrey et al. (2011).
Type A includes the phenotypes with cortical involve-
ment and the most severe phenotypes: WWS, WWS-like,
MEB, and FCMD-like.
Type B includes cases of CMD with posterior fossa
abnormalities or normal MRI, including both patients
with and without intellectual disability.
There is also a Type C including the LGMD forms,
but these will not be discussed in this chapter, as they
have onset well beyond the neonatal period.
Studies of large cohorts have demonstrated that,
although the involvement of each of these genes was
originally reported in patients with a distinct phenotype
(de Bernabe et al., 2003; Brockington et al., 2005, 2010),
mutations in individual genes have subsequently been
associated with different phenotypes and, conversely,
the same phenotype has been reported in association
with many, if not all, the known genes (Godfrey et al.,
2007; Mercuri et al., 2009). This suggests that the iden-
tity of the defective gene cannot be predicted from the
clinical phenotype. Because of this, when a diagnosis
of dystroglycanopathy is suspected, either because of
the association of CMD and structural brain changes,
or because of a biopsy showing reduced glycosylation
of the alpha dystroglycan, all genes should be screened
 NEONATAL HYPOTONIA AND NEUROMUSCULAR CONDITIONS 441
(Bonnemann et al., 2014). While in the past this proved Congenital myopathies
to be a lengthy and expensive task, involving many
The congenital myopathies are a heterogeneous group of
centers, the new NGS techniques have now simplified
disorders associated with distinctive morphologic struc-
this process (O’Grady et al., 2016). We briefly report
tural abnormalities within the muscle fiber (North, 2011;
the most common phenotypes of CMD associated with
Maggi et al., 2013; North et al., 2014). They often have a
structural brain changes and ocular abnormalities.
neonatal onset. Although, as a group, congenital myop-
athies are reported to have a relatively benign, nonpro-
Walker–Warburg syndrome gressive course when compared to congenital muscular
dystrophies or other muscle disorders, this is not always
This is the most severe phenotype, with neonatal onset
the case in the neonatal onset forms.
and a combination of weakness, severe hypotonia, and
A recent study estimates a point prevalence of
signs of central nervous system involvement, such as
approximately 1:26,000, with core myopathies being
poor visual attention and decreased alertness, often
the most common histopathologic subtype and RYR1-
associated with ocular abnormalities ranging from severe
related myopathies the most prevalent genetic subtype
myopia to retinal dysgenesis, microphthalmia, or anterior
(Amburgey et al., 2011).
chamber malformations (Dobyns et al., 1989).
This group of myopathies is commonly identified on
Brain MRI shows a type II lissencephaly with
the basis of their features on muscle biopsy (North et al.,
the typical polymicrogyric cobblestone cortex, severe
2014). Classically, the most frequent forms of congenital
and diffuse white matter abnormalities, and cerebellar
myopathies that have neonatal onset are nemaline myop-
and brainstem hypoplasia or dysplasia. Progressive
athy, centronuclear myopathies, core myopathies (cen-
hydrocephalus is often present (Dobyns et al., 1989;
tral core disease and multiminicore myopathy), and
Ross, 2002).
congenital fiber type disproportion (Maggi et al., 2013).
Over the past decades, the advances in electron
Muscle–eye–brain disease microscopy, histochemistry and, more recently, molecu-
lar genetic techniques with NGS, have allowed better
In MEB, clinical signs are usually present in the neonatal
definition of the spectrum of these disorders. It has
period with hypotonia and weakness but ocular abnor-
become increasingly obvious that there is a great
malities may become evident only after the first year
heterogeneity even within specific morphologic subtypes
of life (Godfrey et al., 2007). Brain MRI shows extensive
and considerable overlap between subtypes sharing com-
abnormalities of neuronal migration, such as pachygyria
mon genetic etiologies (Sewry et al., 2008; O’Grady et al.,
and polymicrogyria and often brainstem and cerebellar
2016). As already reported for the congenital muscular
hypoplasia and periventricular white matter changes
dystrophies, the same clinical and pathologic phenotype,
(Clement et al., 2008).
e.g., nemaline myopathy, can be associated with different
genes, and an individual gene can be associated with
Fukuyama congenital muscular dystrophy multiple phenotypes (central core, nemaline, etc.)
(Table 21.2). Because of this heterogeneity and overlap,
This form was originally described in Japan (Kobayashi
the first clinical and pathologic diagnosis (nemaline, core
et al., 1998; Hayashi et al., 2001). The clinical features
myopathy, etc.) should be confirmed by genetic testing.
of the Fukuyama congenital muscular dystrophy are
We will briefly report clinical, pathologic, and genetic
mild to moderate hypotonia. Ocular abnormalities occur
findings in the most frequent forms with neonatal onset.
in approximately 70% of these children but are rarely
severe. Brain MRI shows structural changes consisting
of pachygyria and polymicrogyria and abnormal white
MYOTUBULAR (CENTRONUCLEAR) MYOPATHY
matter areas.
The centronuclear myopathies (CNMs) are characterized
by the presence of several central nuclei in skeletal
Cerebellar dysplasia/hypoplasia
muscle myofibers not associated with other structural
Following the identification of the three severe pheno- abnormalities, such as nemaline bodies (Jungbluth
types, another common phenotype has been identified et al., 2008; Romero and Bitoun, 2011) or cores. The
with neonatal onset of weakness, hypotonia and cere- disease was also called myotubular, as the muscle fibers
bellar cysts (Topaloglu et al., 2003), and/or hypoplasia with central nuclei resemble the myotubes observed
(Mercuri et al., 2003; Godfrey et al., 2006; Clement during fetal muscle development.
et al., 2008). Children with this phenotype generally also There are three clinical and genetic subtypes: (1) a
develop cognitive impairment. severe X-linked type, presenting in the neonatal period;
442 E. MERCURI ET AL.
Table 21.2 birth with severe hypotonia, weakness, including facial
List of congenital myopathy subtypes. weakness, and respiratory and feeding difficulties and
cryptorchidism.
Chromosome Inheritance Many of these infants generally die within the first
Myopathy subtype Gene location pattern days or weeks of life but there are an increasing number
of reported cases who survived, even though many
Nemaline myopathy ACTA1 1q42.1 AD, AR
were completely or partially ventilator dependent; in a
CFL2 14q13.1 AR
KBTBD13 15q22.31 AD few cases there is a “mild” phenotype with only slightly
KLHL40 3p33.1 AR delayed milestones and no need for ventilatory support
KLHL41 2q31.1 AR beyond the newborn period (Barth and Dubowitz,
NEB 2q23.3 AR 1998; Pierson et al., 2007).
RYR1 19q13.2 AR
CK is generally normal or only mildly elevated.
TNNT1 19q13.42 AR
TPM2 9p13.3 AD The diagnosis is based on muscle biopsy, showing the
TPM3 1q21.3 AD, AR typical centronuclear features, or directly on genetic
Cap disease ACTA1 1q42.1 AD testing (North, 2011). Although centronuclear myopathy
(NM variant) TPM2 9p13.3 AD has been associated with mutations in five genes, the
TPM3 1q21.3 AD
X-linked form of the disease is commonly associated
Zebra body myopathy ACTA1 1q42.1 AD
Hyaline body MYH7 14q11.2 AD with mutations in the myotubularin gene (MTM1)
myopathy (Maggi et al., 2013).
(MyosinStorage
myopathy)
Core-rod myopathy KBTBD13 15q22.31 AD NEMALINE MYOPATHY
NEB 2q23.3 AR
RYR1 19q13.2 AD, AR This congenital myopathy is of variable inheritance
TPM2 9p13.3 AD (both autosomal dominant and recessive) and severity,
Central core disease RYR1 19q13.2 AD, AR characterized by the presence of nemaline (rod) bodies
Multiminicore disease RYR1 19q13.2 AR in the muscle fibers.
SEPN1 1p36.11 AR
The classification of nemaline myopathy is based
MYH7 14q11.2 AD
Centronuclear BIN1 2q14.3 AR on age of onset and severity of motor and respiratory
myopathy CCDC78 16p13.3 AD involvement with severe congenital, intermediate con-
DNM2 19p13.2 AD genital, typical congenital, childhood-onset, and adult-
MTM1 Xq28 XL onset forms (North et al., 1997; Wallgren-Pettersson
MYF6 12q21.31 AD
and Laing, 2006; Laing and Wallgren-Pettersson, 2009).
RYR1 19q13.2 AR
TTN 2q31.2 AR The severe neonatal form presents at birth with severe
SPEG 2q35 AR hypotonia and muscle weakness and little spontaneous
Congenital fiber type ACTA1 1q42.1 AD movement. The weakness is usually most severe in
disproportion MYH7 14q11.2 AD the proximal limb muscles, in the neck flexors, and in
RYR1 19q13.2 AR
the face, which is typically elongated, with tented
SEPN1 1p36.11 AR
TPM2 9p13.3 AD upper lip and high-arched palate. Arthrogryposis may
TPM3 1q21.3 AD be present, generally associated with decreased fetal
movements and polyhydramnios.
The prognosis is very variable. Although some infants
will not survive after the first weeks or months due
(2) a less severe infantile type, which is probably autosomal to respiratory insufficiency, several patients, including
recessive; and (3) a mild juvenile or adult type, which some with severe floppiness and lack of spontaneous
is autosomal dominant in some cases (Jungbluth et al., respiration at birth, will survive, some of them with little
2008; Romero and Bitoun, 2011; Maggi et al., 2013). residual disability. It is of note that the prognosis or
The X-linked type is the most severe and has the the degree of respiratory muscle involvement does
earliest onset with severe hypotonia and weakness at not always reflect the severity of skeletal muscle weak-
birth, associated with persistent ventilatory failure and ness (Wallgren-Pettersson and Laing, 2006; Laing and
often with feeding difficulties. Onset is commonly Wallgren-Pettersson, 2009).
in utero with an antenatal history of polyhydramnios The serum CK levels are normal or only slightly ele-
and reduced fetal movements (Heckmatt et al., 1985; vated. As for the other congenital myopathies a diagnosis
Jungbluth et al., 2008; Romero and Bitoun, 2011; of nemaline myopathy can be suspected on the basis of
Maggi et al., 2013). Affected males usually present at the pathologic findings, but this should be genetically
 NEONATAL HYPOTONIA AND NEUROMUSCULAR CONDITIONS
confirmed. This was very challenging before the advent
of NGS, as nemaline myopathy is genetically hetero-
geneous and some of the genes involved, such as
NEB, were very large. Mutations in nine different genes
have been identified: a-tropomyosin slow (TPM3),
nebulin (NEB), skeletal muscle a-actin (ACTA1),
b-tropomyosin (TPM2), KBTBD13, CFL2, KLHL40,
KLHL41, and troponin T (TNNT1) (Maggi et al.,
2013; North et al., 2014). In the neonatal forms, de novo
dominant mutations in the ACTA1 gene account for a
significant proportion of the severe form; mutations in
NEB and TPM3 have also been frequently reported.
As the genotype–phenotype correlation is not entirely
clear, in the presence of clinical and pathologic signs
consistent with a nemaline myopathy, the whole panel
of known genes should be explored.
CORE MYOPATHIES
Core myopathies are a heterogeneous group of disorders
characterized by the presence of areas devoid of
oxidative staining, which may appear as “central cores”
or multiple smaller “minicores” (Ferreiro et al., 2002a, b;
Maggi et al., 2013; North et al., 2014).
This group of disorders usually has an onset in infancy
or childhood, with a spectrum expanding up to mild or
asymptomatic cases with adult onset, but in some cases
the onset can be neonatal with severe neonatal weakness,
arthrogryposis, and respiratory failure. In the severe
cases, independent ambulation may not be achieved
and respiratory support is often needed (Jungbluth,
2007; Klein et al., 2012; Maggi et al., 2013).
In these cases, the identification of the cores leads
to genetic investigations (North et al., 2014). Cores have
been found associated with several genes also involved
in other congenital myopathies. Mutations in RYR1
are the most frequent in this group and have often been
found in the neonatal cases (Jungbluth, 2007; Maggi
et al., 2013).
Other pathologic phenotypes, such as congenital
fiber type disproportion, can also be observed. From
the brief review of these forms, it is obvious that the
diagnostic pathway in all the cases of congenital myop-
athy is similar (North et al., 2014). While there is increas-
ing tendency to perform genetic testing as first line
investigations, at the time when the phenotype–genotype
correlation is not yet fully established, muscle biopsy still
plays an important role and should be considered.
Myasthenia Gravis
TRANSIENT NEONATAL MYASTHENIA GRAVIS
Neonatal myasthenia gravis is a transient disorder that
may occur in newborns born by myasthenic mothers.
443
It is due to the transfer of acetylcholine receptor
(ACHR) antibodies across the placenta (Djelmis et al.,
2002). Within a few days, but often within a few hours
from birth, there are feeding difficulties and often inabil-
ity to handle pharyngeal secretions, generalized weak-
ness, and poor respiratory effort. There is generally a
good response to anticholinesterases. The severity of
signs of neonatal myasthenia is not always related to
the severity or duration of maternal disease (D’Amico
et al., 2012).
CONGENITAL MYASTHENIC SYNDROMES
The term congenital myasthenic syndromes includes
a heterogeneous group of hereditary disorders affecting
the neuromuscular junction due to one or more specific
mechanisms (Souza et al., 2016; McMacken et al.,
2017, 2018; Natera-de Benito et al., 2017; Nicole
et al., 2017).
Initially, the CMSs were classified according to the
location of the mutant protein as presynaptic, synaptic,
and postsynaptic. The advent of new genetic techniques,
including whole exome sequencing, has allowed
identification of at least 30 CMS disease genes (Beeson,
2016; Souza et al., 2016; McMacken et al., 2017;
Nicole et al., 2017). The current classification takes into
account the defects in protein glycosylation where the
abnormal proteins are located.
The description of individual forms is beyond the
scope of this chapter and the diagnostic pathway leading
to the identification of specific subtypes in the neonatal
period is very challenging. Identifying this disorder is,
however, important as they are among the few neuro-
muscular disorders that can be treated.
In the neonatal period, signs of fatigable weakness
affecting especially the ocular and other cranial muscles,
a positive family history, and, in older infants, a
decremental EMG response or an abnormal single-fiber
EMG may be of help to suspect a possible genetic
diagnosis of CMS.
The genetic diagnosis of a specific CMS is facilitated
in the presence of a positive family history that, in
combination with clinical and EMG studies, can help
to target specific genes. In the other cases, new genetic
techniques, such as NGS when appropriate, should be
discussed with a specialist to help target the most appro-
priate therapeutic approaches (Beeson, 2016; Souza
et al., 2016; Nicole et al., 2017).
Spinal muscular atrophy
The term spinal muscular atrophies includes a
genetically heterogeneous group of disorders character-
ized by degeneration of alpha motor neurons in the spinal
cord with progressive muscle atrophy and weakness.
444 E. MERCURI ET AL.
Classically, the term is used for the autosomal recessive
forms of proximal symmetrical spinal muscular atrophies
due to a defect in the survival motor neuron 1 (SMN1)
gene localized to 5q11.2–q13.3 (Melki et al., 1990a, b).
In over 95% of SMA patients, the disease is caused by
homozygous absence of exons 7 or of exon 7 and 8 of
the SMN1 gene, 7 (Lefebvre et al., 1995; Wirth, 2000).
There is, however, a peculiar aspect of the genetic aspects
that has clinical relevance. The SMN locus is part of a
genomic inverted duplication region, which also con-
tains a paralog gene, SMN2. SMN2 is intact in all
SMA patients. The SMN2 copy numbers vary consider-
ably in different individuals from between 0 and 8, and
this is associated with different clinical phenotypes.
The 5q SMA includes a wide range of phenotypes of
different severity that are classified into clinical groups
on the basis of age of onset and maximum motor function
achieved. The most severe form, type 1, or Werdnig–
Hoffman disease, include infants in whom the onset is
often in the neonatal period, or within the first 6 months.
The other type have onset after the age of 6 months and
will not be discussed in this chapter.
Weakness may already be present at birth or may
develop in the first weeks of life. These infants show a
very consistent and typical phenotype characterized by
general hypotonia and a characteristic “jug-handle”
posturing of the upper limbs with internal rotation of
the shoulders and pronation of the forearms. There is
always severe axial and limb weakness but sparing of
the facial muscles. The legs are more affected than the
arms and proximal muscles more than distal, often with
very limited spontaneous activity, mainly limited to the
feet and hands. One important clinical feature is that
while the intercostal muscles are always affected, the
diaphragm is spared, with a distinctive breathing pattern.
The combination of severe hypotonia and weakness,
the posture, the sparing of the facial muscles, and the
distinctive breathing pattern are very typical of SMA 1
and the diagnosis is very straightforward to the genetic
test, looking for mutations in the SMN1 gene. Unlike
other muscle disorders, the clinical pattern in type 1 is
very evocative and there is no need to perform muscle
biopsy. The EMG may be used to confirm motor neuron
involvement, but it is often not necessary. If performed, it
will show some fibrillation potentials at rest, but often
does not show the classical changes of reinnervation
(i.e., large isolated motor units).
There have been several attempts to subdivide type 1
patients into clinical subgroups. Dubowitz proposed a
decimal classification (Dubowitz, 1995) identifying as
(type 1.1) the infants with severe weakness and early
respiratory and bulbar difficulties at birth and an overtly
poor prognosis for survival. Type 1.5 includes the most
common presentation, infants in whom the onset of
clinical signs may be more subtle at birth but still are
showing signs in the neonatal period or soon after that,
with inability to raise the legs against gravity or maintain
the head posture in the supine or prone position, but
having, at diagnosis, no feeding and swallowing or respi-
ratory involvement. At the other end of the spectrum,
type 1.9, includes infants achieving some head control
and having a less severe respiratory involvement.
Contractures are generally not a frequent feature
of type 1 SMA but some cases of prenatal onset have
reduced fetal movements, multiple contractures, severe
respiratory involvement at birth, and short survival time
(MacLeod et al., 1999). Dubowitz (1999) suggested this
very severe form of SMA be designated SMA 0.
A revised classification, which overlaps with the
decimal one (Mercuri et al., 2012; Finkel et al., 2015),
has recently been proposed, combining onset of clinical
signs and severity: 1A, head control never achieved,
signs at birth (Finkel et al., 2015) or in the first 2 weeks
(Mercuri et al., 2012); 1B, head control never achieved,
onset after neonatal period; 1C, head control achieved,
onset after neonatal period.
The severity of the phenotype partly reflects the
SMN2 copy numbers, with infants with three copies
having lower morbidity and mortality and better function
than those having two SMN2 copies (Finkel et al., 2014).
The recent advent of clinical trials has highlighted
the need for natural history studies to capture the progres-
sion of the disease. Recent studies used functional motor
scales, such as the CHOP-INTEND (Finkel et al., 2014;
Kolb et al., 2016; De Sanctis et al., 2017), or develop-
mental assessments (De Sanctis et al., 2016) to quantify
longitudinal changes. These studies have clearly shown
that infants with type 1 never achieve developmental
milestones or improve function over time and there is
a progressive loss of function that is more rapid in infants
with type 1A and B (or 1.1 and 1.5, according to the
decimal classification).
The management of type 1 SMA has dramatically
changed over the last decade. The median age of survival
in infants with SMA 1 is reported to be around 9 months
and is even shorter in the infants with early onset and
severe phenotype. By the age of 12 and 24 months, only
15% and 8% generally survive (Finkel et al., 2014). In the
last few years, there has been increasing evidence that
infants with SMA type 1 benefit from noninvasive use
of the insufflator–exufflator machine that increase the
chance of survival during acute respiratory infections
and the overall management of these children. Recent
standards of care recommendations have recently been
published also highlighting other aspects, such as feed-
ing and nutrition (Finkel et al., 2018; Mercuri et al.,
2018). Gastrostomy is now recommended at the onset
of swallowing problems or even before their onset,
 NEONATAL HYPOTONIA AND NEUROMUSCULAR CONDITIONS
not only to prolong survival by reducing the risk of
aspiration pneumonia, but also to improve quality of
life. Other aspects include acute care, physiotherapy
and posturing, orthopedic involvement, and medications.
The most exciting results, however, come from recent
clinical trials. With a better understanding of the molec-
ular basis of SMA in the past decades, several therapeutic
approaches have been targeting the possibility of restor-
ing the full-length SMN protein that is missing in SMA
as a result of the mutation in the SMN1 gene. The use of
nusinersen, an antisense oligonucleotide (a synthetic
RNA-like molecule), has shown an increase in the pro-
duction of full-length SMN protein (Hua et al., 2011;
Porensky et al., 2012).
In type 1 infants, a large randomized double-blind
sham-controlled clinical trial (ENDEAR), in which
infants under 7 months of age with type 1 SMA received
either nusinersen or sham procedure, showed exciting
results (Finkel et al., 2017). While infants receiving the
sham procedure had no improvements on their
milestones on the Hammersmith Infant Neurological
Examination (HINE), over 50% of those treated with
nusinersen had a motor-milestone response. Further-
more, the risk of death or the use of permanent assisted
ventilation (tracheostomy or ventilatory support for
16 h per day for >21 continuous days in the absence
of an acute reversible event) was 47% lower in the
nusinersen-treated group than in the control group. Other
secondary endpoints included the CHOP-INTEND scale
and the CMAP amplitude. The second primary efficacy
end point was event-free survival, which was defined as
the time to death or the use of permanent assisted venti-
lation. Better results were observed in younger infants
and in those in whom disease duration at screening
was shorter than 13.1 weeks, suggesting that early initi-
ation of treatment may maximize its efficacy. This is
further confirmed by the dramatic improvement observed
in the preliminary results of an ongoing phase 2, open-
label, single-arm NURTURE study (NCT02386553) that
evaluates the effect of nusinersen in infants who initiate
treatment at a presymptomatic stage of SMA.
Another recently published successful approach
used, for the first time, gene therapy phase I clinical trial
to assess the safety of intravenous administration of self-
complementary adeno-associated viral vectors (scAAV)-
SMN delivering the SMN1 gene in type 1 SMA infants
(Mendell et al., 2017). As part of an open-label, dose-
escalation clinical trial, a total of 15 infants have
been enrolled in this study; the preliminary results are
extremely encouraging: all 15 patients were alive at
20 months of age and did not require permanent mechan-
ical ventilation, while as known from the natural history
studies, only 8% will survive and not require permanent
mechanical ventilation at the same age. These infants
445
also showed a rapid increase on the CHOP-INTEND
scale following gene delivery, vs no improvement, or
deterioration, reported in the historical natural history
cohort.
Both studies using antisense oligonucleotides and
gene therapy strongly indicate the need for early inter-
vention, as the response to treatment was significantly
higher/better in those treated soon after onset of clinical
signs. This highlights the need to raise more awareness
among neonatologists to promote early diagnosis and
referral for type 1 infants.
CONCLUSIONS
The main aim of this chapter is to inform the neonatolo-
gist of the wide range of neuromuscular and nonneuro-
muscular disorders that may present in the neonatal
period with hypotonia. Despite the dramatic advances
in the diagnostic procedures, especially in the genetic
field, a good clinical assessment of the baby and of the
mother remains a mandatory step, as it will establish
whether there is a neuromuscular problem, and if there
is, it can help provide a clinical diagnosis that can guide
to target the appropriate investigations in order to achieve
a diagnosis. The chapter also aimed to provide informa-
tion on the new therapeutic approaches that are becoming
available, such as those for SMA, as achieving/requiring
an early diagnosis. The advent of these therapies is
rapidly changing as well as the diagnostic perspective,
as it has become increasingly obvious that early interven-
tion produces better results in terms of improvements or
lack of deterioration. The role of the neonatologist in early
recognition and in avoiding diagnostic delays in these
cases can have a huge impact on the response to treatment.
REFERENCES
Amburgey K, McNamara N, Bennett LR et al. (2011).
Prevalence of congenital myopathies in a representative
pediatric United States population. Ann Neurol 70: 662–665.
Barth PG, Dubowitz V (1998). X-linked myotubular
myopathy—a long-term follow-up study. Eur J Paediatr
Neurol 2: 49–56.
Beeson D (2016). Congenital myasthenic syndromes: recent
advances. Curr Opin Neurol 29: 565–571.
Bonnemann CG, Wang CH, Quijano-Roy S et al. (2014).
Diagnostic approach to the congenital muscular dystro-
phies. Neuromuscul Disord 24: 289–311.
Brockington M, Torelli S, Prandini P et al. (2005).
Localization and functional analysis of the LARGE family
of glycosyltransferases: significance for muscular dystro-
phy. Hum Mol Genet 14: 657–665.
Brockington M, Torelli S, Sharp PS et al. (2010). Transgenic
overexpression of LARGE induces alpha-dystroglycan
hyperglycosylation in skeletal and cardiac muscle. PLoS
One 5: e14434.
446 E. MERCURI ET AL.
Buxton J, Shelbourne P, Davies J et al. (1992). Detection of an
unstable fragment of DNA specific to individuals with
myotonic dystrophy. Nature 355: 547–548.
Camacho Vanegas O, Bertini E, Zhang RZ et al. (2001).
Ullrich scleroatonic muscular dystrophy is caused by
recessive mutations in collagen type VI. Proc Natl Acad
Sci U S A 98: 7516–7521.
Campbell C, Levin S, Siu VM et al. (2013). Congenital
myotonic dystrophy: Canadian population-based surveil-
lance study. J Pediatr 163: 120–125 e121-123.
Clement E, Mercuri E, Godfrey C et al. (2008). Brain involve-
ment in muscular dystrophies with defective dystroglycan
glycosylation. Ann Neurol 64: 573–582.
Cummings BB, Marshall JL, Tukiainen T et al. (2017).
Improving genetic diagnosis in Mendelian disease with
transcriptome sequencing. Sci Transl Med 9.
D’Amico A, Bertini E, Bianco F et al. (2012). Fetal acetylcho-
line receptor inactivation syndrome and maternal myasthe-
nia gravis: a case report. Neuromuscul Disord 22: 546–548.
de Bernabe DB, van Bokhoven H, van Beusekom E et al.
(2003). A homozygous nonsense mutation in the fukutin
gene causes a Walker–Warburg syndrome phenotype.
J Med Genet 40: 845–848.
De Sanctis R, Coratti G, Pasternak A et al. (2016).
Developmental milestones in type I spinal muscular
atrophy. Neuromuscul Disord 26: 754–759.
De Sanctis R, Pane M, Coratti G et al. (2017). Clinical
phenotypes and trajectories of disease progression in type 1
spinal muscular atrophy. Neuromuscul Disord 28 (1): 24–28.
Djelmis J, Sostarko M, Mayer D et al. (2002). Myasthenia
gravis in pregnancy: report on 69 cases. Eur J Obstet
Gynecol Reprod Biol 104: 21–25.
Dobyns WB, Pagon RA, Armstrong D et al. (1989). Diagnostic
criteria for Walker–Warburg syndrome. Am J Med Genet
32: 195–210.
Dubowitz V (1968). The floppy infant—a practical approach
to classification. Dev Med Child Neurol 10: 706–710.
Dubowitz V (1994). 22nd ENMC sponsored workshop
on congenital muscular dystrophy held in Baarn, The
Netherlands, 14–16 may 1993. Neuromuscul Disord 4:
75–81.
Dubowitz V (1995). Chaos in the classification of SMA:
a possible resolution. Neuromuscul Disord 5: 3–5.
Dubowitz V (1999). Very severe spinal muscular atrophy
(SMA type 0): an expanding clinical phenotype. Eur
J Paediatr Neurol 3: 49–51.
Ferreiro A, Monnier N, Romero NB et al. (2002a). A recessive
form of central core disease, transiently presenting as
multi-minicore disease, is associated with a homozygous
mutation in the ryanodine receptor type 1 gene. Ann
Neurol 51: 750–759.
Ferreiro A, Quijano-Roy S, Pichereau C et al. (2002b).
Mutations of the selenoprotein N gene, which is implicated
in rigid spine muscular dystrophy, cause the classical phe-
notype of multiminicore disease: reassessing the nosology
of early-onset myopathies. Am J Hum Genet 71: 739–749.
Finkel RS, McDermott MP, Kaufmann P et al. (2014).
Observational study of spinal muscular atrophy type I
and implications for clinical trials. Neurology 83: 810–817.
Finkel R, Bertini E, Muntoni F et al. (2015). 209th ENMC
international workshop: outcome measures and clinical
trial readiness in spinal muscular atrophy 7–9 november
2014, Heemskerk, The Netherlands. Neuromuscul Disord
25: 593–602.
Finkel RS, Mercuri E, Darras BT et al. (2017). Nusinersen ver-
sus sham control in infantile-onset spinal muscular atrophy.
N Engl J Med 377: 1723–1732.
Finkel RS, Mercuri E, Meyer OH et al. (2018). Diagnosis and
management of spinal muscular atrophy: part 2: pulmonary
and acute care; medications, supplements and immuni-
zations; other organ systems; and ethics. Neuromuscul
Disord 28 (3): 197–207.
Foley AR, Quijano-Roy S, Collins J et al. (2013). Natural
history of pulmonary function in collagen VI-related
myopathies. Brain 136: 3625–3633.
Geranmayeh F, Clement E, Feng LH et al. (2010).
Genotype–phenotype correlation in a large population
of muscular dystrophy patients with LAMA2 mutations.
Neuromuscul Disord 20: 241–250.
Ghaoui R, Cooper ST, Lek M et al. (2015). Use of
whole-exome sequencing for diagnosis of limb-girdle
muscular dystrophy: outcomes and lessons learned. JAMA
Neurol 72: 1424–1432.
Godfrey C, Escolar D, Brockington M et al. (2006). Fukutin
gene mutations in steroid-responsive limb girdle muscular
dystrophy. Ann Neurol 60: 603–610.
Godfrey C, Clement E, Mein R et al. (2007). Refining
genotype phenotype correlations in muscular dystrophies
with defective glycosylation of dystroglycan. Brain 130:
2725–2735.
Godfrey C, Foley AR, Clement E et al. (2011).
Dystroglycanopathies: coming into focus. Curr Opin Genet
Dev 21: 278–285.
Graziano A, Bianco F, D’Amico A et al. (2015). Prevalence
of congenital muscular dystrophy in Italy: a population
study. Neurology 84: 904–911.
Hara Y, Balci-Hayta B, Yoshida-Moriguchi T et al. (2011).
A dystroglycan mutation associated with limb-girdle
muscular dystrophy. N Engl J Med 364: 939–946.
Hayashi YK, Ogawa M, Tagawa K et al. (2001).
Selective deficiency of alpha-dystroglycan in Fukuyama-
type congenital muscular dystrophy. Neurology 57:
115–121.
Heckmatt JZ, Dubowitz V (1987). Ultrasound imaging and
directed needle biopsy in the diagnosis of selective involve-
ment in muscle disease. J Child Neurol 2: 205–213.
Heckmatt JZ, Sewry CA, Hodes D et al. (1985). Congenital
centronuclear (myotubular) myopathy. A clinical, patho-
logical and genetic study in eight children. Brain 108:
941–964. Pt 4.
Hillaire D, Leclerc A, Faure S et al. (1994). Localization
of merosin-negative congenital muscular dystrophy to
chromosome 6q2 by homozygosity mapping. Hum Mol
Genet 3: 1657–1661.
Hua Y, Sahashi K, Rigo F et al. (2011). Peripheral SMN
restoration is essential for long-term rescue of a severe
spinal muscular atrophy mouse model. Nature 478:
123–126.
 NEONATAL HYPOTONIA AND NEUROMUSCULAR CONDITIONS
Johnson NE, Butterfield R, Berggren K et al. (2016).
Disease burden and functional outcomes in congenital
myotonic dystrophy: a cross-sectional study. Neurology
87: 160–167.
Jungbluth H (2007). Central core disease. Orphanet J Rare
Dis 2: 25.
Jungbluth H, Wallgren-Pettersson C, Laporte J (2008).
Centronuclear (myotubular) myopathy. Orphanet J Rare
Dis 3: 26.
Kang PB, Morrison L, Iannaccone ST et al. (2015). Evidence-
based guideline summary: evaluation, diagnosis, and
management of congenital muscular dystrophy: report of
the guideline development subcommittee of the
American Academy of Neurology and the Practice Issues
Review Panel of the American Association of
Neuromuscular & Electrodiagnostic Medicine. Neurology
84: 1369–1378.
Klein A, Lillis S, Munteanu I et al. (2012). Clinical and genetic
findings in a large cohort of patients with ryanodine
receptor 1 gene-associated myopathies. Hum Mutat 33:
981–988.
Kobayashi K, Nakahori Y, Miyake M et al. (1998). An ancient
retrotransposal insertion causes Fukuyama-type congenital
muscular dystrophy. Nature 394: 388–392.
Kolb SJ, Coffey CS, Yankey JW et al. (2016). Baseline
results of the NeuroNEXT spinal muscular atrophy infant
biomarker study. Ann Clin Transl Neurol 3: 132–145.
Laing NG, Wallgren-Pettersson C (2009). 161st ENMC
International Workshop on nemaline myopathy and related
disorders, Newcastle upon Tyne, 2008. Neuromuscul
Disord 19: 300–305.
Lefebvre S, Burglen L, Reboullet S et al. (1995). Identification
and characterization of a spinal muscular atrophy-
determining gene. Cell 80: 155–165.
MacLeod MJ, Taylor JE, Lunt PW et al. (1999). Prenatal onset
spinal muscular atrophy. Eur J Paediatr Neurol 3: 65–72.
Maggi L, Scoto M, Cirak S et al. (2013). Congenital
myopathies—clinical features and frequency of individual
subtypes diagnosed over a 5-year period in the United
Kingdom. Neuromuscul Disord 23: 195–205.
McMacken G, Abicht A, Evangelista T et al. (2017). The
increasing genetic and phenotypical diversity of congenital
myasthenic syndromes. Neuropediatrics 48: 294–308.
McMacken G, Whittaker RG, Evangelista T et al. (2018).
Congenital myasthenic syndrome with episodic apnoea:
clinical, neurophysiological and genetic features in the long-
term follow-up of 19 patients. J Neurol 265 (1): 194–203.
Melki J, Abdelhak S, Sheth P et al. (1990a). Gene for chronic
proximal spinal muscular atrophies maps to chromosome
5q. Nature 344: 767–768.
Melki J, Sheth P, Abdelhak S et al. (1990b). Mapping of acute
(type I) spinal muscular atrophy to chromosome 5q12–q14.
The French Spinal Muscular Atrophy Investigators. Lancet
336: 271–273.
Mendell JR, Al-Zaidy S, Shell R et al. (2017). Single-dose
gene-replacement therapy for spinal muscular atrophy.
N Engl J Med 377: 1713–1722.
Mercuri E, Longman C (2005). Congenital muscular dystro-
phy. Pediatr Ann 34: 560–562. 564–568.
447
Mercuri E, Muntoni F (2012). The ever-expanding spectrum of
congenital muscular dystrophies. Ann Neurol 72: 9–17.
Mercuri E, Rutherford M, De Vile C et al. (2001). Early white
matter changes on brain magnetic resonance imaging in a
newborn affected by merosin-deficient congenital muscu-
lar dystrophy. Neuromuscul Disord 11: 297–299.
Mercuri E, Yuva Y, Brown SC et al. (2002). Collagen VI
involvement in Ullrich syndrome: a clinical, genetic, and
immunohistochemical study. Neurology 58: 1354–1359.
Mercuri E, Brockington M, Straub V et al. (2003). Phenotypic
spectrum associated with mutations in the fukutin-related
protein gene. Ann Neurol 53: 537–542.
Mercuri E, Messina S, Bruno C et al. (2009). Congenital mus-
cular dystrophies with defective glycosylation of dystro-
glycan: a population study. Neurology 72: 1802–1809.
Mercuri E, Bertini E, Iannaccone ST (2012). Childhood spinal
muscular atrophy: controversies and challenges. Lancet
Neurol 11: 443–452.
Mercuri E, Finkel RS, Muntoni F et al. (2018). Diagnosis and
management of spinal muscular atrophy: part 1: recom-
mendations for diagnosis, rehabilitation, orthopedic and
nutritional care. Neuromuscul Disord 28 (2): 103–115.
Muntoni F, Voit T (2004). The congenital muscular
dystrophies in 2004: a century of exciting progress.
Neuromuscul Disord 14: 635–649.
Muntoni F, Guicheney P, Voit T (2009). 158th ENMC
international workshop on congenital muscular dystrophy
(Xth international CMD workshop) 8th–10th February
2008 Naarden, The Netherlands. Neuromuscul Disord
19: 229–234.
Mutchnick IS, Thatikunta MA, Gump WC et al. (2016).
Congenital myotonic dystrophy: ventriculomegaly and
shunt considerations for the pediatric neurosurgeon.
Childs Nerv Syst 32: 609–616.
Nadeau A, Kinali M, Main M et al. (2009). Natural history of
Ullrich congenital muscular dystrophy. Neurology 73: 25–31.
Natera-de Benito D, Topf A, Vilchez JJ et al. (2017).
Molecular characterization of congenital myasthenic syn-
dromes in Spain. Neuromuscul Disord 27: 1087–1098.
Nicole S, Azuma Y, Bauche S et al. (2017). Congenital myas-
thenic syndromes or inherited disorders of neuromuscular
transmission: recent discoveries and open questions.
J Neuromuscul Dis 4: 269–284.
North KN (2011). Clinical approach to the diagnosis of con-
genital myopathies. Semin Pediatr Neurol 18: 216–220.
North KN, Laing NG, Wallgren-Pettersson C (1997).
Nemaline myopathy: current concepts. The ENMC interna-
tional consortium and nemaline myopathy. J Med Genet
34: 705–713.
North KN, Wang CH, Clarke N et al. (2014). Approach to the
diagnosis of congenital myopathies. Neuromuscul Disord
24: 97–116.
O’Grady GL, Lek M, Lamande SR et al. (2016). Diagnosis and
etiology of congenital muscular dystrophy: we are halfway
there. Ann Neurol 80: 101–111.
Philpot J, Sewry C, Pennock J et al. (1995). Clinical phenotype
in congenital muscular dystrophy: correlation with expres-
sion of merosin in skeletal muscle. Neuromuscul Disord 5:
301–305.
448 E. MERCURI ET AL.
Philpot J, Cowan F, Pennock J et al. (1999). Merosin-deficient-
congenital muscular dystrophy: the spectrum of brain
involvement on magnetic resonance imaging.
Neuromuscul Disord 9: 81–85.
Pierson CR, Agrawal PB, Blasko J et al. (2007). Myofiber size
correlates with MTM1 mutation type and outcome in
X-linked myotubular myopathy. Neuromuscul Disord 17:
562–568.
Porensky PN, Mitrpant C, McGovern VL et al. (2012).
A single administration of morpholino antisense oligomer
rescues spinal muscular atrophy in mouse. Hum Mol Genet
21: 1625–1638.
Romero NB, Bitoun M (2011). Centronuclear myopathies.
Semin Pediatr Neurol 18: 250–256.
Ross ME (2002). Full circle to cobble brain. Nature 25 (6896):
376–377. 418.
Sabatelli P, Gara SK, Grumati P et al. (2011). Expression of the
collagen VI alpha5 and alpha6 chains in normal human skin
and in skin of patients with collagen VI-related myopathies.
J Invest Dermatol 131: 99–107.
Savarese M, Di Fruscio G, Tasca G et al. (2015). Next gener-
ation sequencing on patients with LGMD and nonspecific
myopathies: findings associated with ANO5 mutations.
Neuromuscul Disord 25: 533–541.
Savarese M, Di Fruscio G, Torella A et al. (2016).
The genetic basis of undiagnosed muscular dystrophies
and myopathies: results from 504 patients. Neurology 87:
71–76.
Sewry CA, Jimenez-Mallebrera C, Muntoni F (2008).
Congenital myopathies. Curr Opin Neurol 21: 569–575.
Sframeli M, Sarkozy A, Bertoli M et al. (2017). Congenital
muscular dystrophies in the UK population: clinical and
molecular spectrum of a large cohort diagnosed over a
12-year period. Neuromuscul Disord 27: 793–803.
Souza PV, Batistella GN, Lino VC et al. (2016). Clinical and
genetic basis of congenital myasthenic syndromes. Arq
Neuropsiquiatr 74: 750–760.
Topaloglu H, Brockington M, Yuva Y et al. (2003). FKRP
gene mutations cause congenital muscular dystrophy,
mental retardation, and cerebellar cysts. Neurology 60:
988–992.
Vanier TM (1960). Dystrophia myotonica in childhood.
Br Med J 2: 1284–1288.
Vasta I, Kinali M, Messina S et al. (2005). Can clinical signs
identify newborns with neuromuscular disorders? J Pediatr
146: 73–79.
Wallgren-Pettersson C, Laing NG (2006). 138th ENMC
Workshop: nemaline myopathy, 20–22 May 2005,
Naarden, The Netherlands. Neuromuscul Disord 16:
54–60.
Wirth B (2000). An update of the mutation spectrum of the sur-
vival motor neuron gene (SMN1) in autosomal recessive
spinal muscular atrophy (SMA). Hum Mutat 15: 228–237.
Yonekawa T, Nishino I (2015). Ullrich congenital muscular
dystrophy: clinicopathological features, natural history
and pathomechanism(s). J Neurol Neurosurg Psychiatry
86: 280–287.
Zuberi SM, Matta N, Nawaz S et al. (1999). Muscle ultrasound
in the assessment of suspected neuromuscular disease in
childhood. Neuromuscul Disord 9: 203–207.