Mecp2 Disorders
Summary
Clinical characteristics.
The spectrum of MECP2-related phenotypes in females ranges from classic Rett syndrome to variant Rett syndrome with a broader clinical phenotype (either milder or more severe than classic Rett syndrome) to mild learning disabilities; the spectrum in males ranges from severe neonatal encephalopathy to pyramidal signs, parkinsonism, and macroorchidism (PPM-X) syndrome to severe syndromic/nonsyndromic intellectual disability.
- Females: Classic Rett syndrome, a progressive neurodevelopmental disorder primarily affecting girls, is characterized by apparently normal psychomotor development during the first six to 18 months of life, followed by a short period of developmental stagnation, then rapid regression in language and motor skills, followed by long-term stability. During the phase of rapid regression, repetitive, stereotypic hand movements replace purposeful hand use. Additional findings include fits of screaming and inconsolable crying, autistic features, panic-like attacks, bruxism, episodic apnea and/or hyperpnea, gait ataxia and apraxia, tremors, seizures, and acquired microcephaly.
- Males: Severe neonatal-onset encephalopathy, the most common phenotype in affected males, is characterized by a relentless clinical course that follows a metabolic-degenerative type of pattern, abnormal tone, involuntary movements, severe seizures, and breathing abnormalities. Death often occurs before age two years.
Diagnosis/testing.
The diagnosis of a MECP2 disorder is established by molecular genetic testing in a female proband with suggestive findings and a heterozygous MECP2 pathogenic variant, and in a male proband with suggestive findings and a hemizygous MECP2 pathogenic variant.
Management.
Treatment of manifestations: Treatment is mainly symptomatic and focuses on optimizing the individual's abilities using a multidisciplinary approach that should also include psychosocial support for family members. Risperidone may help in treating agitation; melatonin can ameliorate sleep disturbances. Treatment of seizures, constipation, gastroesophageal reflux, scoliosis, prolonged QTc, and spasticity as per standard care.
Surveillance: Periodic evaluation by the multidisciplinary team; regular assessment of QTc for evidence of prolongation; regular assessment for scoliosis.
Agents/circumstances to avoid: Drugs known to prolong the QT interval.
Genetic counseling.
MECP2 disorders are inherited in an X-linked manner. More than 99% are simplex cases (i.e., a single occurrence in a family), resulting from a de novo pathogenic variant or possibly from inheritance of the pathogenic variant from a parent who has germline mosaicism. Rarely, a MECP2 variant may be inherited from a heterozygous mother in whom favorable skewing of X-chromosome inactivation results in minimal to no clinical findings. When the mother is a known heterozygote, the risk to her offspring of inheriting the MECP2 variant is 50%. When the pathogenic MECP2 variant has been identified in the family, heterozygote testing for at-risk female relatives, prenatal testing for pregnancies at increased risk, and preimplantation genetic diagnosis are possible. Because of the possibility of parental germline mosaicism, it is appropriate to offer prenatal diagnosis to couples who have had a child with a MECP2 disorder regardless of whether the MECP2 pathogenic variant has been detected in a parent.
Diagnosis
Note: Duplication of MECP2 (ranging from 0.3 to 4 Mb and larger) is associated with the allelic disorder MECP2 duplication syndrome and is not addressed in this GeneReview.
Suggestive Findings in Females
A MECP2 disorder should be suspected/considered in females with the following clinical findings suggestive of MECP2 classic Rett syndrome or variant Rett syndrome (based on clinical diagnostic criteria published by Neul et al [2010] [full text] prior to the widespread availability of molecular genetic testing), or mild learning disabilities.
Clinical findings of MECP2 classic Rett syndrome and variant Rett syndrome
- Most distinguishing finding: A period of regression (range: ages 1-4 years) followed by recovery or stabilization (range: ages 2-10 years; mean: age 5 years)
- Main findings
- Partial or complete loss of acquired purposeful hand skills
- Partial or complete loss of acquired spoken language or language skill (e.g., babble)
- Gait abnormalities: impaired (dyspraxic) or absence of ability
- Stereotypic hand movements including hand wringing/squeezing, clapping/tapping, mouthing, and washing/rubbing automatisms
- Supportive findings
- Breathing disturbances when awake
- Bruxism when awake
- Impaired sleep pattern
- Abnormal muscle tone
- Peripheral vasomotor disturbances
- Scoliosis/kyphosis
- Growth retardation
- Small, cold hands and feet
- Inappropriate laughing/screaming spells
- Diminished response to pain
- Intense eye communication - "eye pointing"
- Exclusionary findings
- Brain injury secondary to peri- or postnatal trauma, neurometabolic disease, or severe infection that causes neurologic problems
- Grossly abnormal psychomotor development in the first six months of life, with early milestones not being met
Clinical findings of MECP2 mild learning disability. Typically mild and non-progressive. Note: Typically, females with mild learning disability are identified through molecular genetic testing following diagnosis of a first-degree relative (e.g., a more significantly affected brother or sister).
Suggestive Findings in Males
MECP2 disorders should be considered in a male with severe neonatal encephalopathy; pyramidal signs, parkinsonism, and macroorchidism (PPM-X) syndrome; or syndromic/nonsyndromic intellectual disability.
Clinical findings of MECP2 severe neonatal encephalopathy
- Microcephaly
- Relentless clinical course that follows a metabolic-degenerative type of pattern
- Abnormal tone
- Involuntary movements
- Severe seizures
- Breathing abnormalities (including central hypoventilation or respiratory insufficiency)
Clinical findings of MECP2 severe intellectual disability (including PPM-X syndrome)
- Moderate-to-severe intellectual disability
- Resting tremor
- Slowness of movements
- Ataxia
- PPM-X syndrome: pyramidal signs, parkinsonism, and macroorchidism
- No seizures or microcephaly
- Usually normal brain MRI, EEG, EMG, and nerve conduction velocity studies
Establishing the Diagnosis
Female proband. The diagnosis of a MECP2 disorder is usually established in a female proband with suggestive findings and a heterozygous pathogenic variant in MECP2 identified by molecular genetic testing (see Table 1).
Male proband. The diagnosis of a MECP2 disorder is established in a male proband with suggestive findings and a hemizygous pathogenic variant in MECP2 identified by molecular genetic testing (see Table 1).
Molecular genetic testing approaches can include a combination of gene-targeted testing (either single-gene or multigene panel) or comprehensive genomic testing (exome sequencing, exome array, genome sequencing) depending on the phenotype.
Gene-targeted testing requires that the clinician determine which gene(s) are likely involved, whereas genomic testing does not. Because the phenotype of MECP2 disorders is broad, females with the distinctive findings described in Suggestive Findings are likely to be diagnosed using gene-targeted testing (see Option 1), whereas females and males with a phenotype indistinguishable from many other inherited disorders with intellectual disability and/or neonatal encephalopathy are more likely to be diagnosed using genomic testing (see Option 2).
Option 1
When the clinical findings suggest the diagnosis of a MECP2 disorder, molecular genetic testing approaches can include use of single-gene testing or a multigene panel:
- Single-gene testing. Sequence analysis of MECP2 detects small intragenic deletions/insertions and missense, nonsense, and splice site variants. If no pathogenic variant is found, perform gene-targeted deletion/duplication analysis to detect intragenic deletions or duplications. Note: Lack of amplification by PCR prior to sequence analysis can suggest a putative (multi)exon or whole-gene deletion on the X chromosome in affected males; confirmation requires additional testing by gene-targeted deletion/duplication analysis.
- Various multigene panels such as Rett/Angelman syndrome panels and more comprehensive childhood-onset epilepsy panels that include MECP2 and other genes of interest (see Differential Diagnosis) are most likely to identify the genetic cause of the condition at the most reasonable cost while limiting identification of variants of uncertain significance and pathogenic variants in genes that do not explain the underlying phenotype. Note: (1) The genes included in the panel and the diagnostic sensitivity of the testing used for each gene vary by laboratory and are likely to change over time. (2) Some multigene panels may include genes not associated with the condition discussed in this GeneReview. (3) In some laboratories, panel options may include a custom laboratory-designed panel and/or custom phenotype-focused exome analysis that includes genes specified by the clinician. (4) Methods used in a panel may include sequence analysis, deletion/duplication analysis, and/or other non-sequencing-based tests. For this disorder a multigene panel that also includes deletion/duplication analysis is recommended (see Table 1).For an introduction to multigene panels click here. More detailed information for clinicians ordering genetic tests can be found here.
Option 2
When the phenotype overlaps with many other inherited disorders characterized by intellectual disability and/or neonatal encephalopathy, comprehensive genomic testing (which does not require the clinician to determine which gene[s] are likely involved) is another option. Exome sequencing is most commonly used; genome sequencing is also possible.
If exome sequencing is not diagnostic, exome array (when clinically available) may be considered to detect (multi)exon deletions or duplications that cannot be detected by sequence analysis.
For an introduction to comprehensive genomic testing click here. More detailed information for clinicians ordering genomic testing can be found here.
Table 1.
Molecular Genetic Testing Used in MECP2 Disorders
| Gene 1 | Method | Proportion of Probands with a Pathogenic Variant 2 Detectable by Method |
|---|---|---|
| MECP2 | Sequence analysis 3, 4 | 90%-95% 5 |
| Gene-targeted deletion/duplication analysis 6 | 5%-10% 7, 8 |
- 1.
See Table A. Genes and Databases for chromosome locus and protein.
- 2.
See Molecular Genetics for information on allelic variants detected in this gene.
- 3.
Sequence analysis detects variants that are benign, likely benign, of uncertain significance, likely pathogenic, or pathogenic. Pathogenic variants may include small intragenic deletions/insertions and missense, nonsense, and splice site variants; typically, exon or whole-gene deletions/duplications are not detected. For issues to consider in interpretation of sequence analysis results, click here.
- 4.
Lack of amplification by PCR prior to sequence analysis can suggest a putative (multi)exon or whole-gene deletion on the X chromosome in affected males; confirmation requires additional testing by gene-targeted deletion/duplication analysis.
- 5.
Archer et al [2006], Philippe et al [2006]
- 6.
Gene-targeted deletion/duplication analysis detects intragenic deletions or duplications. Methods used may include quantitative PCR, long-range PCR, multiplex ligation-dependent probe amplification (MLPA), and a gene-targeted microarray designed to detect single-exon deletions or duplications. Gene-targeted deletion/duplication testing will detect deletions ranging from a single exon to the whole gene; however, breakpoints of large deletions and/or deletion of adjacent genes (e.g., those described by Hardwick et al [2007]) may not be detected by these methods.
- 7.
The sizes of many reported disease-associated deletions are at the upper limits of detection by sequence analysis and the lower limits of detection by gene-targeted deletion/duplication analysis; therefore, the proportion of pathogenic variants detected by either method depends on the methods used by a laboratory.
- 8.
Archer et al [2006], Pan et al [2006], Philippe et al [2006], Hardwick et al [2007], Zahorakova et al [2007]
Clinical Characteristics
Clinical Description
In females the spectrum of MECP2-related phenotypes ranges from classic Rett syndrome, to variant Rett syndrome (either milder or more severe than classic Rett syndrome), to mild learning disabilities. In males the spectrum ranges from severe neonatal encephalopathy, to pyramidal signs, parkinsonism, and macroorchidism (PPM-X) syndrome, to severe syndromic/nonsyndromic intellectual disability.
MECP2 Disorders in Females
Table 2.
Features of MECP2 Disorders in Females
| Phenotype | Feature | % of Persons with Feature |
|---|---|---|
| MECP2 classic Rett syndrome | Regression followed by recovery or stabilization | 99% |
| Deceleration of head growth | 80% | |
| Gait abnormalities | 99% | |
| Seizures | 60%-80% | |
| Hand stereotypies & loss of purposeful hand skills | 100% 1 | |
| Absence of speech; high-pitched crying | 99% | |
| Cold extremities | 99% | |
| Irregular breathing | 99% | |
| Variant Rett syndrome | Regression followed by recovery or stabilization | 99% |
| Gait abnormalities | 80%-99% | |
| Sleep disturbences | 80%-99% | |
| seizures | 6%-80% | |
| Hand stereotypies & loss of purposeful hand skills | 97.3% | |
| Breathing irregularities | 80%-99% | |
| Agitation | 80%-99% |
Gold et al [2018], Einspieler & Marschik [2019], Stallworth et al [2019]
- 1.
Stallworth et al [2019]; 44% showed different patterns including hand wringing, washing, clapping, and tapping.
MECP2 classic Rett syndrome. Most individuals with classic Rett syndrome are female; however, males meeting the clinical criteria for classic Rett syndrome who have a 47,XXY karyotype [Hoffbuhr et al 2001, Leonard et al 2001, Schwartzman et al 2001] and postzygotic MECP2 variants resulting in somatic mosaicism have been described [Clayton-Smith et al 2000, Topçu et al 2002].
Although early development is reportedly normal in children with classic Rett syndrome, parents – in retrospect – often identify subtle differences compared to unaffected sibs. Most (but not all) affected children have acquired microcephaly; stereotypic hand movements and breathing irregularities are seen in the majority.
Variant Rett syndrome. Females with variant Rett syndrome exhibit a broader spectrum of clinical features than those observed in classic Rett syndrome. At the more severe end of the spectrum, development is delayed from very early infancy; congenital hypotonia and infantile spasms are also seen. At the milder end of the spectrum, regression is less dramatic and intellectual disability is much less severe; some speech may be preserved.
Mild learning disabilities. In rare instances, females with a pathogenic MECP2 variant may only exhibit mild learning disabilities or some autistic features, presumably as a consequence of favorable skewing of X-chromosome inactivation. When there is no regression phase and no characteristic hand stereotypes, the clinical course differs from that of classic and variant Rett syndrome.
MECP2 Disorders in Males
Table 3.
Features of MECP2 Disorders in Males
| Phenotype | Feature | % of Persons with Feature | ||
|---|---|---|---|---|
| Present | Absent | Not reported | ||
| MECP2-related severe neonatal encephalopathy 1 | Normal birth parameters | 71% | 29% | |
| Head growth deceleration / microcephaly | 94% | 5.8% | ||
| Hypotonia &/or feeding difficulties in infancy | 82.4% | 17.6% | ||
| Hypertonia of extremities | 52.9% | 11.8% | 35.3% | |
| Movement disorder, e.g., myoclonus, tremors, & dystonia | 58.8% | 17.7% | 23.5% | |
| Mild cerebral atrophy | 18% | 35% | 47% | |
| Polymicrogyria | 5.9% | 23.5% | 70.6% | |
| Poor head control | 35% | 12% | 53% | |
| Seizures | 58.8% | 17.7% | 23.5% | |
| Severe development delay | 82.4% | 17.6% | ||
| Irregular breathing / sleep apnea | 47.1% | 29.4% | 23.5% | |
| Gastroesophageal reflux | 35.3% | 64.7% | ||
| EEG abnormality | 88.2% | 5.9% | 5.9% | |
| Pyramidal signs, parkinsonism, and macroorchidism (PPM-X syndrome) 2 | Psychosis | 67.6% | 10.8% | 21.6% |
| Pyramidal signs | 46% | 2.7% | 51.3% | |
| Macroorchidism | 19% | 81% | ||
| Intellectual disability | 50% | 50% | ||
| Parkinsonism | 2.7% | 97.3% | ||
| Progressive spasticity | 67.6% | 32.4% | ||
| Delayed development | 54% | 46% | ||
| Speech difficulties | 50% | 50% | ||
| Seizures | 2.7% | |||
| Bilateral juvenile cataract | 2.7% | |||
| Scoliosis or kyphosis | 10.8% | |||
| Large ears | 8.1% | |||
| Movement disorders | 32.4% | |||
| Apraxia | 2.7% | 36% | ||
| Seizures | 8.1% | 91.9% | ||
| Dysmorphic features | 5.4% | 94.6% | ||
| Syndromic/ nonsyndromic intellectual disability 3 | Severe intellectual disability | 90% | 10% | |
| Gait abnormalities | 57% | 7% | 36% | |
| Facial dysmorphism | 10% | 3% | 87% | |
| Behavioral problems | 40% | 3% | 57% | |
| Autistic-like behavior | 3% | 53% | 44% | |
| Seizures | 20% | 30% | 50% | |
| Poor/absent language skills | 47% | 17% | 36% | |
| Hypotonia | 23% | 77% | ||
| Microcephaly | 13% | 23% | 64% | |
| History of regression | 17% | 27% | 56% | |
| Spasticity | 33% | 17% | 50% | |
| Sleep disturbances | 13% | 10% | 77% | |
- 1.
Schüle et al [2008]
- 2.
Lindsay et al [1996], Claes et al [1997], Gendrot et al [1999], Orrico et al [2000], Klauck et al [2002], Winnepenninckx et al [2002], Moog et al [2003], Psoni et al [2010]
- 3.
Lubs et al [1999], Meloni et al [2000], Orrico et al [2000], Gomot et al [2003], Meins et al [2005], Van Esch et al [2005], Ramocki et al [2009]
Severe neonatal-onset encephalopathy is characterized by a relentless clinical course that follows a metabolic-degenerative type of pattern, abnormal tone, involuntary movements, severe seizures, and breathing abnormalities (including central hypoventilation or respiratory insufficiency) [Wan et al 1999, Villard et al 2000, Zeev et al 2002, Kankirawatana et al 2006]. Often, males with a severe neonatal encephalopathy die before age two years [Schanen et al 1998, Wan et al 1999].
The severe encephalopathy phenotype appears to be rare in females [Lugtenberg et al 2009].
X-linked ID and PPM-X syndrome. PPM-X syndrome, caused by the p.(Ala140Val) MECP2 variant in males, is characterized by moderate-to-severe intellectual disability. Most have spasticity that may be progressive; some may have extrapyramidal movements. Episodic psychosis is seen in many but not all. Most affected males also have macroorchidism. Microcephaly is variable. See also Genotype-Phenotype Correlations.
Genotype-Phenotype Correlations
Genotype-phenotype correlations are inconsistent, due in part to the pattern of X-chromosome inactivation (XCI); females who have a MECP2 pathogenic variant and favorably skewed XCI may have mild or no manifestations [Wan et al 1999, Amir et al 2000, Cheadle et al 2000, Huppke et al 2000, Weaving et al 2003, Chae et al 2004, Schanen et al 2004,Charman et al 2005].
MECP2 pathogenic variants with some residual function that are associated with milder phenotypes include the following:
- p.(Ala140Val). The phenotype is syndromic (PPM-X) intellectual disability in males and very mild cognitive impairment in females [Dotti et al 2002, Klauck et al 2002, Gomot et al 2003, Venkateswaran et al 2014, Lambert et al 2016, Sheikh et al 2016].
- p.(Arg133Cys). The phenotype is less severe than classic Rett syndrome in females; this variant can be present in affected males [Leonard et al 2003, Sheikh et al 2016].
- p.(Arg309Cys) is found in females and males with intellectual disability and some features of MECP2 disorders, but not classic or variant Rett syndrome [Campos et al 2007, Schönewolf-Greulich et al 2016].
Prevalence
The worldwide prevalence is 1:10,000-1:23,000 female births [Ellaway et al 1999, Armstrong et al 2010]. Reports of incidence are limited; available estimates range from 0.43-0.71:10,000 for females in France [Bienvenu et al 2006] to 0.586:10,000 for females in Serbia [Sarajlija et al 2015] and 1.09:10,000 for females in Australia [Laurvick et al 2006].
Differential Diagnosis
Table 4.
Disorders to Consider in the Differential Diagnosis of MECP2 Disorders
| Differential Diagnosis Disorder | Gene(s) / Genetic Mechanism | MOI | Clinical Features of Differential Diagnosis Disorder | |
|---|---|---|---|---|
| Overlapping w/MECP2 Disorders | Distinguishing from MECP2 Disorders | |||
| Angelman syndrome | Deficient expression or function of maternally inherited UBE3A allele | See footnote 1 | ID, severe speech impairment, gait ataxia &/or tremulousness of the limbs; microcephaly & seizures common; DD 1st noted at age ~6 mos | In classic Rett syndrome DD is not overtly evident in the 1st 6 mos. |
| Early infantile epileptic encephalopathy (OMIM 300672) | CDKL5 | XL | In females: early-onset severe seizures w/poor cognitive development; facial gestalt, cortical visual impairment; In males: severe-profound ID & early-onset intractable seizures 2 | Very early-onset seizures, facial dysmorphism, & cortical visual impairment are not generally seen in classic Rett syndrome. |
| Rett syndrome, congenital variant (OMIM 613454) | FOXG1 | AD | Short normal period of development before onset of regression leading to severe ID, DD, postnatal microcephaly, agenesis of the corpus callosum, seizures, dyskinesia, & hypotonia 3 | Except for microcephaly, structural abnormalities are not usually seen on brain MRI. |
AD = autosomal dominant; DD = developmental delay; ID = intellectual disability; MOI = mode of inheritance; XL = X-linked
- 1.
The risk to sibs of a proband depends on the genetic mechanism leading to the loss of UBE3A function: typically less than 1% risk for probands with a deletion or uniparental disomy (UPD), and as high as 50% for probands with an imprinting defect or a pathogenic variant of UBE3A.
- 2.
Elia et al [2008]
- 3.
Overlapping features and a similar facial appearance between individuals with FOXG1 pathogenic variants has led to the suggestion that these individuals should be regarded as having FOXG1 syndrome rather than a variant of Rett syndrome [Kortüm et al 2011].
Management
Evaluations Following Initial Diagnosis
To establish the extent of disease and needs in an individual diagnosed with a MECP2 disorder, the evaluations summarized in Table 5 (if not performed as part of the evaluation that led to the diagnosis) are recommended.
Table 5.
Recommended Evaluations Following Initial Diagnosis in Individuals with a MECP2 Disorder
| System/Concern | Evaluation | Comment |
|---|---|---|
| Constitutional | Measurement of height, weight, & head circumference | |
| Neurologic | Neurologic evaluation | To incl brain MRI; consider EEG / video monitoring if seizures are a concern. |
| Development | Developmental assessment |
|
| Psychiatric/ Behavioral | Neuropsychiatric evaluation | In individuals age >12 mos: screening for behavior problems incl sleep disturbances, ADHD, anxiety, &/or traits suggestive of ASD |
| Musculoskeletal | Orthopedics, physical medicine & rehabilitation, PT, OT evaluation | To incl assessment of:
|
| Gastrointestinal/ Feeding | Gastroenterology / nutrition / feeding team evaluation | To incl:
|
| Respiratory | Overnight sleep studies |
|
| Sleep disorder | Breathing monitoring using portable polygraphic screening devices | To assess occurrence of apnea & hypopnea |
| Cardiovascular | Cardiac evaluation | To assess for prolonged QTc |
| Osteopenia | Bone densitometry | To assess for osteopenia |
| Eyes | Ophthalmologic evaluation | To assess for reduced vision, abnormal ocular movement, strabismus |
| Hearing | Audiology evaluation | Assess for hearing loss |
| ENT/Mouth | ||
| Genitourinary | ||
| Integument | History & examination | Reduced perfusion of hands & feet (possible autonomic abnormalities) |
| Miscellaneous/ Other | Consultation w/clinical geneticist &/or genetic counselor | To incl genetic counseling |
| Family supports/resources | Assess:
|
ADHD = attention-deficit/hyperactivity disorder; ASD = autism spectrum disorder; GERD=gastroesophageal reflux disease; OT = occupational therapy; PT = physical therapy
Treatment of Manifestations
Treatment needs to be individualized following an assessment of the affected individual's clinical problems and needs.
Management is symptomatic and focuses on optimizing the individual's abilities using a multidisciplinary approach with input from a pediatric or adult specialist physician, dietician, occupational therapist, speech therapist, music therapist, dentist, and other medical subspecialists as needed.
Table 6.
Treatment of Manifestations in Individuals with a MECP2 Disorder
| Manifestation/ Concern | Treatment | Considerations/Other |
|---|---|---|
| DD/ID | See Developmental Delay / Intellectual Disability Management Issues. | |
| Epilepsy | Standardized treatment w/AEDs by an experienced neurologist |
|
| Psychiatric/ Behavioral | Risperidone (low dose) or selective serotonin uptake inhibitors have been somewhat successful in treating agitation. | |
| Musculoskeletal | Scoliosis | As per guidelines 2 |
| Poor weight gain / failure to thrive | Feeding therapy; gastrostomy tube placement may be required for persistent feeding issues | Low threshold for clinical feeding evaluation &/or radiographic swallowing study when showing clinical signs or symptoms of dysphagia; nutritional guidelines are available. 3 |
| Spasticity | Orthopedics / physical medicine & rehabilitation / PT / OT incl stretching to help avoid contractures & falls | Consider need for positioning & mobility devices, disability parking placard. |
| Sleep disorder | Melatonin can ameliorate sleep disturbances. | Chloral hydrate, hydroxyzine, or diphenhydramine may be used w/melatonin. |
| Abnormal vision &/or strabismus | Standard treatment(s) as recommended by ophthalmologist | Community vision services through early intervention or school district |
| Central visual impairment | No specific treatment; early intervention to help stimulate visual development | |
| Hearing | Hearing aids may be helpful as per otolaryngologist | Community hearing services through early intervention or school district |
| Gastrointestinal |
| |
| Cardiovascular | Treatment for prolonged QTc | Under care of pediatric cardiologist |
| Osteopenia | Baseline densitometry; optimization of physical activity & calcium & vitamin D levels | Guidelines for management of bone health are available. 4 |
| Family/ Community |
|
|
AED = antiepileptic drug; DD = developmental delay; GERD = gastroesophageal reflux disease; ID = intellectual disability
- 1.
Education of parents/caregivers regarding common seizure presentations is appropriate. For information on non-medical interventions and coping strategies for children diagnosed with epilepsy, see Epilepsy & My Child Toolkit.
- 2.
Downs et al [2009]
- 3.
Leonard et al [2013]
- 4.
Jefferson et al [2016]
Developmental Disability / Intellectual Disability Management Issues
The following information represents typical management recommendations for individuals with developmental delay / intellectual disability in the United States; standard recommendations may vary from country to country.
Ages 0-3 years. Referral to an early intervention program is recommended for access to occupational, physical, speech, and feeding therapy as well as infant mental health services, special educators, and sensory impairment specialists. In the US, early intervention is a federally funded program available in all states that provides in-home services to target individual therapy needs.
Ages 3-5 years. In the US, developmental preschool through the local public school district is recommended. Before placement, an evaluation is made to determine needed services and therapies and an individualized education plan (IEP) is developed for those who qualify based on established motor, language, social, or cognitive delay. The early intervention program typically assists with this transition. Developmental preschool is center based; for children too medically unstable to attend, home-based services are provided.
All ages. Consultation with a developmental pediatrician is recommended to ensure the involvement of appropriate community, state, and educational agencies and to support parents in maximizing quality of life. Some issues to consider:
- Individualized education plan (IEP) services:
- An IEP provides specially designed instruction and related services to children who qualify.
- IEP services will be reviewed annually to determine if any changes are needed.
- As required by special education law, children should be in the least restrictive environment feasible at school and included in general education as much as possible and when appropriate.
- Vision and hearing consultants should be a part of the child's IEP team to support access to academic material.
- PT, OT, and speech services will be provided in the IEP to the extent that the need affects the child's access to academic material. Beyond that, private supportive therapies based on the affected individual's needs may be considered. Specific recommendations regarding type of therapy can be made by a developmental pediatrician.
- As a child enters teen years, a transition plan should be discussed and incorporated in the IEP. For those receiving IEP services, the public school district is required to provide services until age 21.
- A 504 plan (Section 504: a US federal statute that prohibits discrimination based on disability) can be considered for those who require accommodations or modifications such as front-of-class seating, assistive technology devices, classroom scribes, extra time between classes, modified assignments, and enlarged text.
- Developmental Disabilities Administration (DDA) enrollment is recommended. DDA is a public agency that provides services and support to qualified individuals. Eligibility differs by state but is typically determined by diagnosis and/or associated cognitive/adaptive disabilities.
- Families with limited income and resources may also qualify for supplemental security income (SSI) for their child with a disability.
Motor Dysfunction
Gross motor dysfunction
- Physical therapy is recommended to maximize mobility and to reduce the risk for later-onset orthopedic complications (e.g., contractures, scoliosis, hip dislocation).
- Consider use of durable medical equipment and positioning devices as needed (e.g., wheelchairs, walkers, bath chairs, orthotics, adaptive strollers).
- For muscle tone abnormalities including hypertonia or dystonia, consider involving appropriate specialists to aid in management of baclofen, tizanidine, Botox®, anti-parkinsonian medications, or orthopedic procedures.
Fine motor dysfunction. Occupational therapy is recommended for difficulty with fine motor skills that affect adaptive function such as feeding, grooming, dressing, and writing.
Oral motor dysfunction should be assessed at each visit and clinical feeding evaluations and/or radiographic swallowing studies should be obtained for choking/gagging during feeds, poor weight gain, frequent respiratory illnesses, or feeding refusal that is not otherwise explained. Assuming that the child is safe to eat by mouth, feeding therapy (typically by an occupational or speech therapist) is recommended to improve coordination or sensory-related feeding issues. Feeds can be thickened or chilled for safety. When feeding dysfunction is severe, an NG-tube or G-tube may be necessary.
Communication issues. Consider evaluation for alternative means of communication (e.g., Augmentative and Alternative Communication [AAC]) for individuals who have expressive language difficulties. An AAC evaluation can be completed by a speech-language pathologist who has expertise in the area. The evaluation will consider cognitive abilities and sensory impairments to determine the most appropriate form of communication. AAC devices can range from low-tech, such as picture exchange communication, to high-tech, such as voice-generating devices. Contrary to popular belief, AAC devices do not hinder verbal development of speech and in many cases can improve it.
Social/Behavioral Concerns
Children may qualify for and benefit from interventions used in treatment of autism spectrum disorder, including applied behavior analysis (ABA). ABA therapy is targeted to the individual child's behavioral, social, and adaptive strengths and weaknesses and typically performed one on one with a board-certified behavior analyst.
Consultation with a developmental pediatrician may be helpful in guiding parents through appropriate behavior management strategies or providing prescription medications, such as medication used to treat attention-deficit/hyperactivity disorder (ADHD), when necessary.
Concerns about serious aggressive or destructive behavior can be addressed by a pediatric psychiatrist.
Surveillance
Many of the clinical features in females with atypical Rett syndrome (Table 2) evolve with age and hence should be reassessed every six to 12 months.
Table 7.
Recommended Surveillance for Individuals with a MECP2 Disorder
| System/Concern | Evaluation | Frequency |
|---|---|---|
| Feeding | Measurement of growth parameters | At each multidisciplinary clinic visit; minimum annually |
| Evaluation of nutritional status & safety of oral intake | ||
| Gastrointestinal | Monitor for constipation. | |
| Respiratory | Monitor for evidence of aspiration, respiratory insufficiency. | |
| Neurologic | Monitor those w/seizures as clinically indicated. | |
| Assess for new manifestations, e.g., seizures, changes in tone, movement disorders. | ||
| Development | Monitor developmental progress & educational needs. | |
| Speech & language | Monitor communication skills. | |
| Psychiatric/ Behavioral | Behavioral assessment for anxiety, attention, & aggressive or self-injurious behavior | |
| Musculoskeletal | Physical medicine, OT/PT assessment of mobility, self-help skills | |
| Monitor scoliosis. | ||
| Cardiovascular | Monitor for prolonged QTc. | |
| Respiratory | Apnea/hyperventilation | |
| Miscellaneous/ Other | Assess family need for social work support (e.g., palliative/respite care, home nursing; other local resources) & care coordination. |
Agents/Circumstances to Avoid
Because individuals with MECP2 disorders are at increased risk for life-threatening arrhythmias associated with a prolonged QT interval, avoidance of drugs known to prolong the QT interval, including the following, is recommended:
- Prokinetic agents (e.g., cisapride)
- Antipsychotics (e.g., thioridazine), tricyclic antidepressants (e.g., imipramine)
- Antiarrhythmics (e.g., quinidine, sotolol, amiodarone)
- Anesthetic agents (e.g., thiopental, succinylcholine)
- Antibiotics (e.g., erythromycin, ketoconazole)
Click here (pdf) for a more extensive list of drugs to avoid.
Evaluation of Relatives at Risk
See Genetic Counseling for issues related to testing of at-risk relatives for genetic counseling purposes.
Therapies Under Investigation
A number of clinical trials are currently under way, including observational studies, studies focused on improvement of language and communication skills, and drug trials.
For details see www.rettsyndrome.org.
Search ClinicalTrials.gov in the US and EU Clinical Trials Register in Europe for access to information on clinical studies for a wide range of diseases and conditions.