Chromosome 4q Deletion Syndrome is a rare chromosomal disorder in which there is deletion of a portion of the 4th chromosome. Deletions may be in the middle of the chromosome arm (“interstitial”) or at the end “terminal”) and have varying effects. There are enough common features for children with deletions anywhere along the range that it has been called a syndrome, but as with most rare genetic issues, the differences between children can be tremendous. Visually there are commonalities between kids, much as with Down Syndrome, in this case, the most distinctive visual features include short limbs, a high “frontal bossing” on the forehead, large head, wide set eyes, low set ears, thin upper lip and short, high nose. This gives children a “babyish” look for longer, which can be compounded by motor issues.
No prevalence information has been added yet.
Most 4 q deletions are “de novo”, i.e. happening randomly near the time of first cell division after conception. A small percentage of cases are inherited, and for reasons not fully understood, normally functioning parents may have severely affected children, either because they are lacking a translocated piece, or because of environmental issues during gestation or early childhood.
There are many symptoms and characteristics that affect people with Chromosome 4q Deletion Syndrome.
Low muscle tone is very common, as are gastrointestinal reflux, hearing issues, vision issues, large head, small feet, turned in pinkies, flat bridge of nose, slight epicanthic folds, low set rotated ears, “funny” feet (they bend in a strange place or have overlapping toes or are particularly flat or rocker-bottom). Short limbs compared to torso size are also not unusual, short wide hands and feet are also common.
|Abnormalities of the hands and feet||Hands and feet may be shorter and wider than normal, "tiny feet" are very common. Toes may bend at funny places (the second joint bending down for example) or overlap.|
|Growth deficiency after birth||Reflux and coordination issues may make sucking and eating difficult, and even fully nourished children may not grow very well on a normal diet. Breastfeeding children with 4q deletions is very challenging but has been done, bottlefeeding is not generally much easier.|
|Structural heart defects||Heart defects appear to be very dependent on the specific genes involved in the deletion. For example, most children with (del)4q21.1-21.3 do not have heart issues.|
|Malformations of the skull and facial region||Large head, craniostenosis, wide set eyes, small facial features, distinctive nose (wide, flat, high bridge), thin lips, small or receding chin.|
|Hypotonia and ataxia||Low muscle tone and poor muscle control due to an error in signaling between the brain and the muscle can contribute to global delays.|
Most often dysmorphic features will prompt a pediatrician or other doctor to order genetic testing. Some children are diagnosed at or near birth, others are diagnosed years later. Most children with 4qdeletion look “mostly” normal to the casual observer, the markers are a little subtle. It is not possible to determine by looking at someone whether they have 4q deletion syndrome, but visual appearance may be just different enough to prompt doctors to order tests.
Diagnosis is done with a blood test. A karyotyping test generally finds the gross chromosome deletion, other testing will explain specific breakpoints and determine whether or not the deletion was inherited or a new mutation.
We don't have any tests yet.
Most treatments are symptomatic, but it is important that all children with 4q deletion syndrome have testing done for metabolic abnormalities. Many children (even those without a frank deficiency) will benefit from use of Coenzyme Q10 (doses range from 20 mg/kg to 5 mg/kg depending on response and type of supplementation.) Other treatments that have been helpful include Carnitine (For a child with a test result showing very low carnitine) and R-Lipoic-Acid (for any child with “metabolic symptoms” such as low tone).
Multivitamin supplementation may be helpful to many.
Some children with 4q deletions show signs of reflux, treatment of that may help growth issues. CoQ10 seems to help both reflux and growth issues in some children.
Some children also show symptoms of problems with citric acid, it is suspected that this may be due to problems with the Kreb’s Cycle. Restricted citric acid diets have been helpful for some children. Some common foods which include citrates are: Most infant formulas.
The obvious (citrus foods)
Oral medications (topical ibuprofen is one alternative, tylenol suppositories are another for pain meds. Watch carefully for inhaled medications, there may be idiosyncratic reactions to epinephrine due to the citrates use to buffer it.)
Symptoms of citrate problems include severe rashes, breathing issues (following inhaled citrate).
It is inadvisable to restrict diet without evidence of a problem, but if your child is having issues with diaper rash that won’t respond to treatment, do consider citrates as a culprit. This may also explain problems post surgery, as most surgeries involve use of oral medications that contain citrates for flavor.
We don't have any treatments yet.
The best source of information on prognosis comes from rarechromo.org’s member’s pamplet section, and Dr. Strehle’s research paper (which can be found online through google or in the files section of the yahoo group). Those documents combined with personal experience and talking to other families are the background for the following:
In general, delays are endemic, in many children, most even, receptive language is better than expressive, and children may never have much functional expressive language. Early sign language and speech therapy, plus alternative communication methods may mitigate this somewhat, but oral motor skill issues combined with a fundamentally different brain process mean that language is a challenge for most children, and “lost language” even more of a problem. Some children may develop vocabulary and lose it, often learning and losing the same words over and over again.
The “official” research is pretty grim, citing a 70% mortality by age two. In our support group, we’ve seen two deaths out of approximately 80 families, both children who died were (del) 4q21.1-21.3. However, there are at least 5 other children with this deletion who are currently healthy, and the cause of deaths were not similar for both children. In any event, the death rate, though tragic, appears to be lower, not absent, but lower for our current families than the (somewhat out of date) research would indicate.
Prognosis is highly variable. We see kids who are just a little delayed, but go to a mainstream school program and learn to talk and walk just a little behind schedule. More typical seems to be to crawl sometime after the first year, walk sometime between age 2 and age 5. Some children do not sit up, crawl or walk until much older.
Most parents of older children (teens and young adults) report puberty being especially traumatic, the communications issues become very frustrating then and acting out may require some medication to control behavior according to most sources.
Autism is often diagnosed in kids with 4q deletion, there is new research indicating there may be a gene that causes autism in girls on the long arm of the fourth chromosome. Autistic symptoms may be atypical, but are very common.
We are told that most children with 4q deletions will require lifelong help and support.
All that said, they seem to be particularly charming and engaging children, all behavior issues aside, and we parents on the yahoo group have dubbed our kids the “4 q-ties” because they are so darned cute.
Love them, enjoy them. . . they are always reminding you of the real meaning of life!!
Supplements (CoQ10 and R-lipoic acid especially, but also including Omega 3 fatty acids and multivitamin) seem to have made a huge difference in my daughter’s energy level and her attempts to communicate. They are not a cure, but they sure do make a big difference.
Melatonin helps us with sleep issues, we use a very small does (250 micrograms!).
We make use of all early intervention help available.
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