Genetics Service

It's B's third birthday today and we're back in hospital meeting the clinical geneticist from the south west Thames regional genetics service.. He has been referred by the Paediatric neurologist. They want to consider if there could be an underlying genetic diagnosis for B's problems. There is no significant family history of note. We go over B's birth history and my pregnancy and she makes notes about this. I have to go over the last 3 years again explaining that we had concerns about his development in the first couple of months particularly when we noticed that he was not reaching and did not roll. His is unsteady on his feet and falls over frequently. He has difficulty climbing stairs and getting on and off seats. He has been delayed on all important milestones. His fine motor skills are more age appropriate although delayed. He can pull up a zip and use a knife and fork. His understanding is inconsistent and he doesn't always respond to his name.. Sometimes he follows simple tasks. We're using Makaton but he does not have a good understanding of this.

He vocalises but has no words. He's currently getting one-to-one support at pre-school. He is quite chesty and often has a cough or cold. Cystic Fibrosis has previously been excluded. He has no heart or kidney problems. His urine smells quite a bit and can be quite dark yellow and it's not affected by what he eats or drinks. He has puffy feet which turn bright red sometimes. But it doesn't cause him any discomfort.

B looks like his brother and sister with no unusual features. He had some molluscum on his head. He has normal hands, normal skin pigmentation and normal heart sounds. He had a chesty upper airways but a clear chest. He was hypo-tonic (poor muscle tone). On standing his feet became puffy and developed a striking red colouration which sometimes rises to his ankles. There was no pitting or indenting when pressure was applied.

B had already had a special genetit test called an array which looks in close details at his chromosomes and is normal. In view of his absent speech she wanted to exclude one diagnosis and organised this on the stored DNA. She explained that when considering genetic conditions they look for specific clues in how children look or behave. With B there are clues which suggested a particular diagnosis which can make it difficult when trying to reach a diagnosis. Genetic testing is improving all the time and this might help make a diagnosis for B. I'm told that B can join a large study called DDD (Deciphering Developmental Disorders) in a few months time. They are going to use the very latest technology and are looking specifically at causes of developmental delay in children like B. No more appointments but they will let me know the outcome of the additional test that's requested and with regards to the DDD study.

Letter from the health clinic

Just after B's first birthday I get a letter following up the appointment at the health clinic. They list the "problems" as concerns regarding motor delay, faltering growth and puffy feet.

The specialist registrar reports that B is hungry and ratty but settles after a breastfeed. He seemed active in the clinic but he's not that active at home. She says he appeared pale but his conjectiva were pink. He had a small anterior fontanelle but was well perfused centrally. She noted B had purple swollen feet that were cold to touch. I told her they are always like this and it doesn't matter how many pairs of socks that you put on him, he continues to have cold puffy feet. He has some excema on his feet and I told her that he has previously been treated for a fungal infection of his feet. His peripheral pulses were normal and his femorals were of good character and volume.

His heart sounds were normal and chest was clear. His abdomen was soft and non tender with no organomegly. His neurological system as grossly intact with normal power tone and reflexes. There is no evidence of wasting. His buttock muscles looked normal and there seem to be normal hip creases. Still pointing out his weight growth and without having anything to compare it too (I didn't have him weighed at all since birth) she can't assess whether or not this is genetically where he is meant to be. She has no explanation for his cold purple puffy feet at present.

She mentions again that she is confused regarding his cold puffy feet and has included autoimmune profile in the blood works. She is referring B to the Physiotherapists so they can see  him regarding his gross motor delay. I  don't want to see a dietician and she agrees that this is acceptable given his dietary history appears appropriate for his age. I promise to use follow on milk instead of cow's milk from now on at home.