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Noonan Syndrome

What Is It, Causes, Treatment and More

Author:Ali Syed, PharmD

Editors:Alyssa Haag,Stefan Stoisavljevic, MD,Kelsey LaFayette, DNP, ARNP, FNP-C

Illustrator:Jessica Reynolds, MS

Copyeditor:Stacy M. Johnson, LMSW


What is Noonan syndrome?

Noonan syndrome is a congenital genetic disorder that prevents typical development in many areas of the human body, leading to a wide range of distinctive physical features and health conditions, such as facial characteristics, short stature, heart defects, and developmental delays. Noonan syndrome is a rare disease in approximately 1 in 1000 to 1 in 2500 individuals.

Infant with large head, wide-spaced eyes, and downward slant to palpebral fissures.

What causes Noonan syndrome?

Noonan syndrome is typically caused by a genetic mutation in one of several genes involved in the Ras-MAPK pathway that regulates gene expression. Children with Noonan syndrome may inherit a copy of a defective gene from their parents or acquire it in their lifetime through spontaneous mutation in a gene.

In 50% of cases, mutations occur on the PTPN11 gene. Less commonly, the SOS1, RAF1, RIT1, and KRAS genes can be affected by mutations. Rarely mutations of the NRAS, BRAF, MEK2, RRAS, RASA2, A2ML1 and SOS2 genes can occur. Once mutated, the affected gene(s) may produce active proteins that disrupt cellular division and tissue formation.  

In most cases, Noonan syndrome is inherited in an autosomal dominant pattern, in which an individual only needs one copy of an altered gene to be affected. If one parent has Noonan syndrome, there is a 50% chance of passing the defective gene to each child. Because Noonan syndrome can present with various symptoms, the severity of the presentation may differ between the affected parent and the affected offspring.

In rare cases, individuals with Noonan syndrome may acquire the condition sporadically through spontaneous gene mutation. The parents of a child with sporadic Noonan syndrome have a minimal chance of conceiving another child with Noonan syndrome. Nonetheless, the affected individual may pass along the gene to their children, regardless of the etiology of the mutation.

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What are the signs and symptoms of Noonan syndrome?

Signs and symptoms of Noonan syndrome vary greatly among individuals depending on the gene(s) affected by the mutation and may range from mild to severe. Patients with Noonan syndrome may have specific facial features noticeable at birth, including a large head; widely spaced, downward-slanting eyes with pale blue or green irises; low-set ears that are rotated backward; and a nose that is depressed at the top with a broad base. Non-facial features of Noonan syndrome include a short neck with extra folds of skin, a sunken or bulging sternum, wide-set nipples, and short stature. Developmental delays associated with Noonan syndrome include failure to thrive, delayed walking, talking, and growth; difficulty feeding; slow weight gain; increased risk of learning disabilities; and delayed puberty. Because of its various features, Noonan syndrome might resemble other congenital disorders, like Turner syndrome.

People with Noonan syndrome may present with different complications depending on the organ system(s) affected by the disorder. Individuals with Noonan syndrome may have a visual impairment and eye conditions such as strabismus, near-sightedness, far-sightedness, or cataracts. They might also experience hearing loss due to structural abnormalities in the inner ear bones that affect their function. Heart defects, including different forms of congenital heart disease, such as pulmonary valve stenosis, characterized by the narrowing of the pulmonary valve; atrial septal defect, which is an opening in the wall that separates the left and the right atria; hypertrophic cardiomyopathy, which involves thickening of the heart muscle; and irregular heart rhythm, may also present in Noonan syndrome

Additionally, individuals with Noonan syndrome have a higher risk of complications like excessive bleeding or bruising in trauma due to low platelet counts or clotting defects; leukemia; and lymphatic complications, leading to excessive fluid collections that cause swelling of hands and feet. There may also be an increased risk of urinary tract infections due to structural abnormalities in the urinary tract and fertility concerns in males due to undescended testicles.

How is Noonan syndrome diagnosed?

Diagnosis of Noonan syndrome may occur before birth, at birth, in infancy, or even in early adulthood. Before birth, Noonan syndrome may be suspected if there is a family history of Noonan syndrome, if one or both biological parent(s) has a genetic mutation associated with Noonan syndrome, or during a routine fetal ultrasound. On ultrasound, Noonan syndrome may be suspected if findings reveal excessive amniotic fluid surrounding the fetus, build-up of fluid around other parts of the fetus, such as the lungs, or characteristic structural heart abnormalities. During pregnancy, in some cases, fetal DNA may be tested via chorionic villus sampling, where a sample of cells is removed from the placenta, or via amniocentesis, where a sample of amniotic fluid is removed for genetic testing. If the fetus is found to have genetic mutations associated with Noonan syndrome, a genetic counselor may be consulted to discuss the results and options. 

At birth or in early infancy, Noonan syndrome diagnosis typically involves identifying signs and symptoms during a physical examination. However, many signs and symptoms of Noonan syndrome are non-specific or indicative of closely related disorders (e.g., Costello syndrome or Turner syndrome); therefore, signs and symptoms alone may not be sufficient for diagnosis. Healthcare professionals may use the van der Burgt scoring system to diagnose Noonan syndrome, which calculates an individual’s score based on major and minor criteria, including facial, cardiac, height, chest wall, family history, and other features.

Noonan syndrome may also be diagnosed through genetic testing, which involves the collection of blood samples. Many individuals with Noonan syndrome have normal chromosome studies; however, in some cases, no mutations may be found, indicating that negative genetic tests do not rule out Noonan syndrome.

Individuals diagnosed with Noonan syndrome typically require further testing to assess for any additional abnormalities or complications. In cases where heart defects are suspected, a cardiologist may be consulted to diagnose the condition, using an electrocardiogram (EKG), which measures the electrical activity of the heart, or an echocardiogram, an ultrasound of the heart. Educational assessments, blood tests, eye exams, and hearing tests may also be conducted to assess signs, symptoms, and complications associated with Noonan syndrome. Other tests may include magnetic resonance imaging (MRI), or computed tomography (CT) scans to visualize organ systems that may be affected by Noonan syndrome. Educational assessments, blood tests, eye exams, and hearing tests may also be conducted to assess signs, symptoms, and complications associated with Noonan syndrome.

How is Noonan syndrome treated?

There is currently no cure for Noonan syndrome; therefore, treatment is generally focused on managing any signs, symptoms, and complications associated with Noonan syndrome.

Visual impairment associated with Noonan syndrome may be managed with close monitoring of eye health, prescription glasses, or surgery in certain circumstances, such as if the individual develops cataracts. Hearing impairment may be monitored closely with auditory exams and hearing aids depending on the degree of hearing loss

Short stature may be managed by monitoring growth rates closely until adulthood, ensuring adequate nutrition, and measuring growth hormone levels. In individuals with insufficient growth hormone levels, treatment with growth hormone therapies, such as somatropin, may be an option that starts around four or five years of age and continues until the child stops growing. 

Genital problems, such as undescended testicles, may be managed with a surgical procedure called an orchidopexy, in which the undescended testicle is surgically moved into the scrotum, typically before two years of age, to avoid future fertility issues.

Heart defects may involve various treatments, including medications or surgery, depending on the nature and severity of the heart defect. In many mild cases, treatment involves close monitoring of heart function, such as through routine ECGs and echocardiograms.  Irregular heart rate may be managed using medications such as beta-blockers (e.g., metoprolol), while surgery may be required to repair heart valves

Treatment of bleeding and clotting disorders may be managed by avoiding blood thinners, such as aspirin, or with blood transfusions, depending on the degree of blood loss.

Finally, learning disabilities may be managed using simulation programs, physical and speech therapies, and special education using individualized teaching strategies.

The life expectancy of individuals with Noonan syndrome is typically similar to that of any other individual. However, the presence and severity of symptoms and complications, especially heart conditions, alongside their diagnosis and treatment, may impact life expectancy.

What are the most important facts to know about Noonan syndrome?

Noonan syndrome is a congenital genetic disorder that prevents typical development, leading to a wide range of distinctive physical features and health conditions. A genetic mutation in several genes typically causes Noonan syndrome. Children with Noonan syndrome may inherit a copy of a defective gene from their parents or acquire it in their lifetime through spontaneous gene mutation. Signs and symptoms of Noonan syndrome vary greatly among individuals depending on the gene(s) affected by the mutation and may range from mild to severe. Diagnosis of Noonan syndrome may occur before birth, at birth, in infancy, or even in early adulthood. Treatment for Noonan syndrome is generally focused on managing any symptoms and complications associated with Noonan syndrome.

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Related links

Miscellaneous genetic disorders: Pathology review
Inheritance patterns
Hypertrophic cardiomyopathy

Resources for research and reference

Allanson JE, Roberts AE. Noonan syndrome. Cassidy and Allanson's Management of Genetic Syndromes. 2021:651-669. 

Gripp, K (2022). Noonan Syndrome. In Nemours KidsHealth. Retrieved July 26th 2022, from: https://kidshealth.org/en/parents/noonan-syndrome.html

Moawad, H (2021). An Overview of Noonan Syndrome. In Very Well Health. Retrieved August 2nd, 2022 from: https://www.verywellhealth.com/noonan-syndrome-overview-4160006

Mayo Clinic Staff (n.d.) Noonan Syndrome. In Mayo Clinic. Retrieved July 25th 2022, from: https://www.mayoclinic.org/diseases-conditions/noonan-syndrome/symptoms-causes/syc-20354422

National Health Service (n.d.). Noonan syndrome. Retrieved August 1st, 2022 from:https://www.nhs.uk/conditions/noonan-syndrome/

National Human Genome Research Institute (n.d.). About Noonan syndrome. Retrieved August 1st, 2022 from: https://www.genome.gov/Genetic-Disorders/Noonan-Syndrome

National Library of Medicine (n.d). Noonan Syndrome. In MedlinePlus. Retrieved July 26th, 2022, from: https://medlineplus.gov/genetics/condition/noonan-syndrome/

National Organization for Rare Disorders (n.d.). Noonan Syndrome. In Rare Disease Database. Retrieved July 25th, 2022 from: https://rarediseases.org/rare-diseases/noonan-syndrome/

Noonan Syndrome Awareness Association (n.d.) Noonan syndrome. Retrieved August 1st, 2022 from: https://noonansyndrome.com.au/wp-content/uploads/2019/01/Van-Der-Burgt-Criteria.png

van der Burgt, Ineke. “Noonan Syndrome.” Orphanet Journal of Rare Diseases, vol. 2, Jan. 2007, p. 4. PubMed Central, https://doi.org/10.1186/1750-1172-2-4.

Thatcher, Jack D. “The Ras-MAPK Signal Transduction Pathway.” Science Signaling, vol. 3, no. 119, Apr. 2010. DOI.org (Crossref), https://doi.org/10.1126/scisignal.3119tr1