Presentation: Child with developmental delay or intellectual disability

A family attend the paediatric clinic concerned because their three-year-old son’s development is delayed. He sat at one year, was walking at two and a half years and, at the age of three has a few single words but is not talking in sentences. He has some dysmorphic features and was diagnosed with an atrial septal defect following the detection of a heart murmur at the newborn check.

Genomic testing should be considered if a patient presents with:

• moderate to profound intellectual disability;
• intellectual disability (of any severity) associated with:
  • behavioural problems, including autism spectrum disorder;
  • other medical problems, such as seizures;
  • congenital anomalies, such as congenital heart disease;
  • atypical growth patterns (such as growth restriction, overgrowth or asymmetric growth);
  • microcephaly or macrocephaly;
  • dysmorphic features;
  • developmental regression;
  • atypical MRI brain findings; and/or
  • a family history of learning disability (particularly if X-linked pattern) or of multiple miscarriages.

• Consult the National Genomic Test Directory. From here you can access the rare and inherited disease eligibility criteria, which provides information about individual tests and their associated eligibility criteria. You can also access a spreadsheet containing details of all available tests.
  • For those working within NHS Wales, please consult the All Wales Medical Genomics Service website for information on how to arrange testing.
• To find out which genes are included on different gene panels, see the NHS Genomic Medicine Service (GMS) Signed Off Panels Resource.
• Decide which of the panels best suits the needs of your patient or family. For developmental conditions there are a number of available panels, including:
  • R377 Intellectual disability (microarray only): This should be considered if you only want to investigate chromosomal causes, which will require a microarray;
  • R29 Intellectual disability: This should be considered if you want to investigate chromosomal and single-gene causes of developmental delay or intellectual disability (the test includes microarray and a whole genome sequencing (WGS) panel of all genes known to cause intellectual disability); and
  • R27 Paediatric disorders: This should be considered if there is developmental delay or intellectual disability in association with congenital malformation or overgrowth, and you would like to investigate chromosomal and single-gene causes (the test includes microarray and a WGS ‘super panel’ (a panel comprised of several different constituent panels forming one large panel)). Requesting R27 currently requires authorisation from clinical genetics services.
• Certain conditions, such as imprinting disorders or nucleotide repeat expansion disorders, are not reliably picked up by sequencing tests and require additional specialist tests. However, WGS pipelines are currently being optimised to more reliably detect fragile X syndrome. If you have a strong clinical suspicion of one of the following conditions, you may wish to undertake more targeted tests (also listed) before considering broader testing:
  • R47 Angelman syndrome (methylation testing and multiplex ligation-dependent probe amplification (MLPA));
  • R48 Prader-Willi syndrome (methylation testing and MLPA); and/or
  • R53 Fragile X syndrome (short tandem repeat (STR) testing).
• For tests that are undertaken using WGS, including R29 and R27, you will need to:
  • complete an NHS GMS test order form with details of the affected child (proband) and their parents, including details of the phenotype (using human phenotype ontology (HPO) terms) and the appropriate panel name(s) with associated R number (see How to complete a test order form for WGS for support in completing WGS-specific forms);
  • complete an NHS GMS record of discussion (RoD) form for each person being tested – for example, if you are undertaking trio testing of an affected child and their parents, you will need three RoD forms (see How to complete a record of discussion form for support); and
  • submit parental samples alongside the child’s sample (this is trio testing) to aid interpretation, especially for the larger WGS panels (where this is not possible, for example because the child is in care or the parents are unavailable for testing, the child may be submitted as a singleton).
• For tests that do not include WGS, including R377, R47, R48 and R53:
  • you can use your local Genomic Laboratory Hub test order and consent (RoD) forms; and
  • parental samples may be needed for interpretation of the child’s result. Parental samples can be taken alongside that of the child, and their DNA stored, or can be requested at a later date if needed.
• The majority of tests are DNA based, and an EDTA sample (purple-topped tube) is required. Exceptions include karyotype testing and DNA repair defect testing (for chromosome breakage), which require lithium heparin (green-topped tube).
• Information about patient eligibility and test indications was correct at the time of writing. When requesting a test, please refer to the National Genomic Test Directory to confirm the right test for your patient.

For clinicians

• Genomics England: NHS Genomic Medicine Service (GMS) Signed Off Panels Resource
• NHS England: National Genomic Test Directory
• StatPearls: Developmental delay

For patients

• Contact UK: Developmental delay (support for families with disabled children)
• Contact UK: Social care
• Council for Disabled Children
• Family Fund (charity that raises grants for families with disabled children)
• Gov.uk guidance: Disability Living Allowance (DLA) for children
• Gov.uk guidance: SEND code of practice: 0 to 25 years