Unlike early reports of children with DiGeorge syndrome, many of whom died in early infancy prior to the availability of sophisticated cardiac surgeries and antibiotics to fight infections, the mortality rate in children with the 22q11.2 deletion is very low (~ 4%). Those children who do succumb to problems associated with the deletion often pass away at a very young age (~ 4 months). However, many children and adults have numerous medical problems during their lifetimes that require specialized care. These include:
- Cardiac defects: 75% of children have some type of heart defect, many of whom require surgery to correct the problem, often in the newborn period.
- Developmental delays: Most children (>95%) have motor milestone delays (like walking), delays in emergence of language and specific learning differences requiring special help in school; and a subset of children have autism or autistic-like features and/or behavioral differences like ADHD, OCD, anxiety, perseverations, and psychosis.
- Palatal differences: 75% of children have differences in their palate allowing milk to come through their nose in infancy (known as nasal regurgitation) and later causing them to have hypernasal speech which makes it difficult for the child to be understood. Here too, many children benefit from surgical interventions, usually performed by a Plastic Surgeon or an ENT as part of a Cleft Palate Team.
- Endocrine imbalances: Approximately 50% of children have low calcium levels which usually resolve in infancy, but some children require calcium supplements for a longer period of time or during times of illness or stress such as at puberty or post operatively; in addition, some children have trouble with their thyroid (under active or over active) and some have growth hormone deficiency –all of which respond to treatment.
- Hearing loss: Ear infections are common (often due to the high incidence of palatal problems), as is the presence of hearing loss (both conductive and sensorineural), and problems with the child’s airway due to structural differences such as a vascular ring or laryngeal web or associated with reflux. Occasionally a child will have a connection between the windpipe and feeding pipe (tracheoesophageal fistula) or an abnormal feeding pipe (esophageal atresia). Many children benefit from ear tube placement; some need hearing aides; whereas others require more complex care from an Otolaryngologist.
- Gastrointestinal and feeding difficulties: Around 35% of children have significant feeding and swallowing problems such as gastroesophageal reflux (GERD) and dysmotility leading to reflux and constipation; less common problems include umbilical hernia, intestinal malrotation, an absent anal opening, Hirshsprung’s disease (where the child has severe constipation/blockage of the bowel), a diaphragmatic hernia where loops of bowel can be in the chest. Most common feeding problems exist in the newborn period and often resolve with medical assistance by school age.
- Blood disorders: Rarely, a child has had problems with bleeding due to the deletion of a gene that codes for clotting on the chromosome with the deletion and a non-working gene on the other chromosome 22 called Bernard-Soullier syndrome and occasionally children have had problems with their blood counts due to an autoimmune problem such Idiopathic Thrombocytopenia and Autoimmune Neutropenia; some children have rarely had a tumor, most notably in the liver (hepatoblastoma) and sometimes elsewhere such as the kidney (Wilm’s tumor, Renal Cell carcinoma) or thyroid; as well as an occasional individual with Leukemia or Lymphoma. With the exception of Bernard-Soullier syndrome, these problems are likely related to the individuals’ “pokey” immune system as well as other genes on other chromosomes that may predispose them to having these problems.
- Immunological and rheumatological issues: 77% of children have immunodeficiency regardless of whether or not they appear to have recurrent infections including things like recurrent infections, not mounting a normal response to vaccines, and not being able to receive live viral vaccines. Most problems resolve in infancy but some older children and adults have chronic infections. In addition, children and adults are more prone to autoimmune diseases such as Juvenile Rheumatoid arthritis, Idiopathic Thrombocytopenia, Autoimmune Neutropenia, Grave’s disease, and Vitiligo.
- Neurological findings: Rarely, children have seizures unrelated to their low calcium levels and/or structural brain differences/a small head. An occasional child will have spina bifida.
- Eye differences: Some children have eye problems such as droopy eyelids (known as ptosis); differences in the whites of their eyes (scleracornea); differences in the colored parts of their eyes (coloboma); and differences with their eye muscles. Some of these problems need surgical treatment or other interventions such as patching of the eyes and others do not.
- Bone troubles: Approximately half of children have differences in the way the vertebrae of the spine are formed at the neck causing decreased room surrounding the spinal cord at the neck in a very small subset of children which often benefit from surgical correction; differences in the bones of the spine in other areas such as the chest (butterfly vertebrae); curvature of the spine (scoliosis); extra ribs, extra fingers and toes; differences in “wing bones (scapula); and occasionally premature fusion of the bones of the skull (craniosynostosis) all of which are able to be helped surgically if needed. Many children also have unexplained leg pain.
- Genito-urinary issues: Around 35% of children have differences in the way their kidneys are formed or how they work such as a single or malformed kidney and/or kidney reflux, as well as, problems with infections, potty training, and differences in the way the genito-urinary system may be formed (hypospadias in boys where the opening of the penis is not at the tip and undescended testes and occasionally an absent uterus in girls); and hernias in the groin.
Ideally, children with the 22q11.2 deletion should receive coordinated care from centers that offer multidisciplinary teams of clinicians, often drawn from more than 20 specialties. Centers address each child’s individual health problems, as well as issues such as speech or learning delays, in order to help these children and their families lead the best life possible.
See our bibliography of medical and professional articles on the 22q11.2 deletion syndrome.
Upon initial diagnosis, the standard assessment and work-up for all ages generally includes:
- Speech/Language/Developmental Assessments
- A Renal Ultrasound (to check the kidneys)
- X-rays of the neck (in children old enough to cooperate and where the bones are well ossified – so ~ 3 to 4 years of age)·
- Deletion studies in both parents when available
Thereafter, the work-up is individualized, depending on the symptoms, but may include any or all of the following:
- Plastic Surgery/ENT/Audiology
- Gastroenterology/Feeding Team
- General Surgery
Cynthia B. Solot and Team (2019)
Speech-language pathologists (SLPs) may work with children with 22q at different stages of their lives. It is important for SLPs to become familiar with the many speech-language disorders in these patients, as early diagnosis and management will lead to the best possible outcome.
This document first provides an overview of the aspects of 22q that may affect speech and language development. The authors then go into details of the possible features in the categories of language, speech sound disorders, and velopharyngeal dysfunction (VPD), before discussing surgeries for VPD. The five appendices provide best practices for individuals with 22q through their different stages stages of life. The authors recommend that SLP apply management strategies based on each patient’s unique health and personal situation.
Note: Knowledge in speech-language disorders will be helpful in the understanding of the materials described in this document.