1. Approach to diagnosis of
Malformed Infant & Child
Mohammad Al-Haggar, MD.
Professor of Genetics
2. Dysmorphology vs. IEM.
• Abnormal structure ±
abnormal function
minor vs. major
dysmorphism
• Normal structure but
with abnormal
function IEMs
(enzymopathy).
Structure vs. Function
M. Al-Haggar, MD.
3. History
• Pedigree inheritance, RR.
• Parental age maternal, paternal
• Consanguinity.
• Abortion and still birth.
• Age of presentation and course.
M. Al-Haggar, MD.
4. Nomenclature
• Congenital vs Developmental / Genetic.
• Single vs multiple Major vs minor.
• Sequence vs Syndrome.
• Deformity.
• Malformation.
• Disruption.
• Dysplasia.
M. Al-Haggar, MD.
6. Diagramatic Sketch
• Malformation Production intrinsic defect
failure of embryonic proliferation and/or
differentiation Abnormal structure.
• Disruptions Production extrinsic (disruptive)
agents interferes with embryonic development of
a structure destruction or removal of structure.
• Dysplasias Production intrinsic defect abnormal
cellular organization abnormal model of structure.
• Deformation Packaging extrinsic defect
normally formed structure pushed out by mechanical
forces.
Production,Intrinsic
EXtrinsic
7. Flow Chart
• Number of malformation.
• Number of involved tissue.
• Presence of tissue damage.
• Presence of Joint and bone Involvement.
M. Al-Haggar, MD.
8. Algorithm for Malformed Infant
1. Number of Malformations1. Number of Malformations
2. No. of Involved tissues2. No. of Involved tissues
3. Primary Tissue Destruction3. Primary Tissue Destruction
May be minor or major
Single / IsolatedSingle / Isolated MultipleMultiple
OneOne ≥ Two≥ Two
YesYes NoNo
4. Primary Joint, Bone Involvement4. Primary Joint, Bone Involvement
YesYes NoNo
10. Algorithm for Malformed Infant
1. Number of Malformations1. Number of Malformations
2. No. of Involved tissues2. No. of Involved tissues
3. Primary Tissue Destruction3. Primary Tissue Destruction
May be minor or major
Single / IsolatedSingle / Isolated MultipleMultiple
OneOne
Dysplasia
≥ Two≥ Two
YesYes NoNo
4. Primary Joint, Bone Involvement4. Primary Joint, Bone Involvement
YesYes NoNo
16. Algorithm for Malformed Infant
1. Number of Malformations1. Number of Malformations
2. No. of Involved tissues2. No. of Involved tissues
3. Primary Tissue Destruction3. Primary Tissue Destruction
May be minor or major
Single / IsolatedSingle / Isolated MultipleMultiple
OneOne ≥ Two≥ Two
YesYes
Disruption Sequence
NoNo
4. Primary Joint, Bone Involvement4. Primary Joint, Bone Involvement
YesYes NoNo
M. Al-Haggar, MD.
24. Algorithm for Malformed Infant
1. Number of Malformations1. Number of Malformations
2. No. of Involved tissues2. No. of Involved tissues
3. Primary Tissue Destruction3. Primary Tissue Destruction
May be minor or major
Single / IsolatedSingle / Isolated MultipleMultiple
OneOne ≥ Two≥ Two
YesYes
Deformation Sequence
NoNo
4. Primary Joint, Bone Involvement4. Primary Joint, Bone Involvement
YesYes NoNo
M. Al-Haggar, MD.
32. Algorithm for Malformed Infant
1. Number of Malformations1. Number of Malformations
2. No. of Involved tissues2. No. of Involved tissues
3. Primary Tissue Destruction3. Primary Tissue Destruction
May be minor or major
Single / IsolatedSingle / Isolated MultipleMultiple
OneOne ≥ Two≥ Two
YesYes NoNo
4. Primary Joint, Bone Involvement4. Primary Joint, Bone Involvement
YesYes
Malformation
or MMS
NoNo
M. Al-Haggar, MD.
37. Algorithm for Malformed Infant
1. Number of Malformations1. Number of Malformations
2. No. of Involved tissues2. No. of Involved tissues
3. Primary Tissue Destruction3. Primary Tissue Destruction
May be minor or major
Single / IsolatedSingle / Isolated MultipleMultiple
OneOne
Dysplasia
≥ Two≥ Two
YesYes
Disruption Sequence
Deformation Sequence Fetal Akinesia Syndrome:-
1.Oligohydraminos Renal Agenesis (Potter).
2.Myopathic / Neuropathic Athrogryposis (AMC).
NoNo
4. Primary Joint, Bone Involvement4. Primary Joint, Bone Involvement
YesYes
Malformation or MMS
NoNo
46. Dysmorphology Pearls
• Pursed up lips.
• Heterochromia iridis.
• Eversion of lateral third of lower eyelid.
• Webbing of the neck.
• Absent clavicles.
• Inverted nipples.
• Broad thumbs / great toes.
• Radial ray defects.
• Thrombocytopenia absent radius syndrome.
• Mitten hands.
• Hyper extensibility of skin and joints.
M. Al-Haggar, MD.
49. Major malformation NTD;
meningomyelocele,
and occipital encephalocele
Minor malformation (Polydactyly)
Postaxial Common, isolated
malformation or part of a syndrome.
Preaxial rare, usually syndromic.
M. Al-Haggar, MD.
50. CDG Inverted nipples, Abnormal fat distribution, FTT, severe
developmental delay.
M. Al-Haggar, MD.
1. Pedigree (3-generation) to recognize pattern of inheritance e.g. AR Seckel syndrome, AD Ehlers Danlos with hyperextensibility of joints and skin, X-linked Aarskog syndrome (brachydactyly, hypertelorism, hypospadias and shawl scrotum) RR
2. Parental ages at the time of conception. Advanced maternal age numerical chromosomal anomalies e.g. trisomy 21, 13, and 18. However Turner 45, XO is not associated with advanced maternal age. Advanced paternal age new mutations in single genes e.g. in AD conditions (Achondroplasia, Marfan and Apert syndrome).
3. Consanguinity doubles risk of a malformation syndrome and increases RR of rare AR disorders. Conversely AR disorders with high gene frequency in the population, e.g. thalassemia, could occur without consanguinity.
4. Abortions, stillbirths (balanced chromosomal translocation in either parent, or an X linked dominant disorder with lethality in males e.g. Rett syndrome), Maternal illness (DM, PKU), infections (TORCH) and drugs and teratoges e.g. anticonvulsants malformations.
5. Age of onset and course of disorder: progression symptoms/signs of (developmental delay/ abnormal behavior pattern) some syndromes have very subtle features at onset BUT diagnosis will be made easy on follow up e.g. Noonan.
Malformation intrinsic no structure e.g. Cleft lip and palate, VSD, Neural tube defect.
Disruptions extrinsic (disruptive) agents destruction or removal structure. Disruptive agents can be amniotic bands (amputated limb or digit, craniofacial defect (encephalocele), congenital viral infections and tissue ischemia/ hemorrhage (caudal regression, intestinal atresia). RR is low.
Dysplasias Production Intrinsic defect abnormally abnormal cellular organization abnormal model of structure. It usually involves only one tissue type throughout the body secondary to mutations in relevant genes e.g. skeletal dysplasia and ectodermal dysplasia, osteogensis imperfecta, Lysosomal storage (MPS, ML).
Deformation (Packaging defect) normally formed structure pushed out by mechanical forces e.g. restricted fetal movements e.g. twins, oligohydramnios, uterine anomalies or fetal neurologic defects (spina bifida) club feet (Talipes), distal arhrogryposis, hip dislocation. Good prognosis with a low RR. So, Deformity is altered shape of a part (outlier i.e. outside normal range).
Extreme form of caudal regression syndrome (Lumbosacral dysgenesis).