Over the last 25 years, we identified six children with a diagnosis of trisomy 18, with the majority being female and term infants, findings that are in accordance with numerous studies. (5, 6, 10–12).
In our study, neither of the children had prenatal diagnosis which makes an impossibility to reflect on what approach would have been taken in view of the clinical complexity, wishes and expectations of the parents, in the presence of prenatal diagnosis.
The great majority of anomalies found correlate with the usually described phenotype on trisomy 18 children.
All cases had a diagnosis of fetal growth restriction throughout the pregnancy, a frequent ultrasound finding documented in previous literature regarding intrauterine anomalies with fetuses with trisomy 18. (10, 13–15)
As found in other studies, in the six cases reviewed, cardiovascular and musculoskeletal anomalies occur with a high prevalence. (4–6) The high prevalence of ventricular septal defects, atrial septal defects and patent ductus arteriosus in the children in this study confirms, once again, the high prevalence of these anomalies in children with trisomy 18. (9, 10, 16)
As corroborated by several articles, the need for ventilatory support, oxygen and feeding assistance is something common throughout children with trisomy 18, and the children in our study are not exception. (10, 17, 18) These needs and medical complexity might be translated on long lengths of stay of hospital admissions. (19, 20) In addition, many studies show a relevant proportion of children discharged home and requiring specialized home care assistance. (21)
Despite the prevalence of such defects, cardiac intervention was performed in only one child (16,7%), namely a patent ductus arteriosus ligation. This proportion is reflected by other reports, in which 7-26% of the children had cardiac surgeries performed. (6, 10, 16, 22) Other studies reveal that infants may undergo major surgeries, not only cardiac surgery but others as gastrointestinal surgery and neurologic procedures. (6, 10, 21, 22)
It is needed to have into consideration that, even if corrective surgery might not be appropriate in certain cases, it is known that surgical intervention contributes to a decrease in-hospital mortality and makes it possible to achieve home care more easily. (22)
The new paradigm shift on the offer of corrective surgery for congenital anomalies has contributed, in the last decade, to increasing numbers for 1-year survival, ranging between 8% and 29% (with a Japanese multicenter study reporting as high as 43%) and 5-year survival, varying between 7,7% and 12,3%. A 9,8% 10-year survival rate was also reported recently. (3, 4, 6, 10–12, 23)
Previous studies state longer survival in children with mosaicism in comparison to the ones presenting with full trisomy, which is in accordance with our findings. Indeed, this might be a consequence of the absence of major congenital anomalies in mosaic children. (23, 24) Although our study has not shown survival beyond 3 months of life in children with full trisomy 18, some studies demonstrate that survival in these individuals can extend beyond 5 years, despite the high associated morbidity. (5, 12, 23, 25, 26)
Independently of their cytogenetic status, this is proof that the designations of “incompatible with life” or “lethal” are not adequate to characterize trisomy 18, as previously reported, and establishes the need to change this mindset emphasizing the need of improving comfort and quality of life, independently of their length, as well as end-of-life care.
Most parents will have difficulty in understanding the medical aspects, clinical characteristics and treatment needs of trisomy 18 children, resulting in a need for a trustful, honest communication between parents and physicians, validating the parent’s hopes and fears, which will, in turn, potentiate conscient, deliberate decisions regarding the children, based on a better understanding of their needs and improving their quality of life as much as possible. (26–29)
A weapon when tackling the difficult decisions that might surge may be the early implementation of specialized pediatric palliative care teams as they can assist in the prenatal and birth plans, postnatal care plan and giving new perspectives and insights to promote the most adequate treatment through an individualized advanced care plan, helping decrease futile therapy, discussing complex ethical issues and working on the child's best interest. Family expectations, beliefs and cultural background are a focal piece of advanced care plans and end-of-life care. (7, 29–31)
As the paradigm shift on management and treatment options for trisomy 18 continues, all new reports, studies and revisions of current literature contribute to the foundation of the development of future guidelines that may assist in providing personalized care to these children and their families, throughout disease progression and including bereavement support.
On account of this study being restricted to a single center in which only six cases were identified, it may be impossible to generalize these findings and conditioned statistic options. As medical records from other hospitals cannot be accessed in some cases, it was difficult to obtain further information from the hospital of the area of residence.
Due to the retrospective nature of this study, diagnoses and comorbidities may have been underdiagnosed.
In our study, neither of the children carried a trisomy 18 prenatal diagnosis, which may have resulted in a smaller number of major congenital anomalies in these children resulting in a better prognosis.