Paeds · genetics-dysmorphology-and-metabolism
Noonan syndrome and RASopathies
Also known as Noonan syndrome · RASopathies · RAS/MAPK pathway syndromes · NSML (LEOPARD syndrome) · Costello syndrome · Cardio-facio-cutaneous syndrome · Male Turner syndrome
A fellowship approach to Noonan syndrome and the RASopathies: recognise the shared facio-cardio-cutaneous phenotype produced by gain-of-function germline variants in the RAS/MAPK pathway, distinguish Noonan syndrome from Noonan syndrome with multiple lentigines, Costello syndrome, cardio-facio-cutaneous syndrome, and neurofibromatosis type 1 by gene and cardiac profile, and apply a genotype-aware surveillance schedule anchored by an early echocardiogram.
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Target exams
Red flags
- A newborn with a Turner-like phenotype but a normal karyotype and hypertrophic cardiomyopathy or pulmonary valve stenosis has a RASopathy until genetic testing excludes one
- An infant with Noonan syndrome and a heart murmur or cardiomegaly needs an echocardiogram urgently because hypertrophic cardiomyopathy may be asymptomatic yet carry a risk of sudden death
- A neonate with Costello syndrome and refractory hypoglycaemia, cardiac arrhythmia, or hypertrophic cardiomyopathy is at high risk for early mortality
- New onset of easy bruising, hepatosplenomegaly, or monocytosis in a child with a RASopathy raises juvenile myelomonocytic leukaemia and warrants urgent haematology assessment
- A bleeding diathesis in a child with Noonan syndrome is not always a simple factor XI deficiency — evaluate before any surgical or dental procedure
- Developmental regression or loss of motor skills in a child with a RASopathy is not expected and mandates investigation for a complication such as cardiac decompensation, intracranial bleed, or metabolic disturbance
Life stages
Care settings
Clinical exam formats
Board mappings
- General and Community Paediatrics
- Growth and Development
- Genetics
- General Paediatrics - recognise, investigate and manage single-gene syndromes including Noonan syndrome and the RASopathies
- Cardiology - recognise and manage congenital and hypertrophic cardiomyopathy
- Child Development and Behaviour - assess and support developmental differences
- Genetics 13-15
- Clinical Applications
- Long Cases
- Short Cases
- 1. Neonates and infants with congenital abnormalities
- 2. Genetics: single-gene and multi-system disorders
- 4. Professional skills and knowledge: Patient management
- Foundation of Practice (FOP)
- Theory and Science (TAS)
- Applied Knowledge in Practice (AKP)
- Clinical
- Development
- Communication
- History
- General Pediatrics Content Outline - D19 Genetics (6%)
- General Pediatrics Content Outline - D13 Cardiology (6%)
- Patient Care 4: Clinical Reasoning
- Patient Care 5: Patient Management
- Medical Knowledge 1: Congenital and Genetic Disorders
- Systems-Based Practice 1: Patient Safety
- Medical Expert
- Pediatrics: Genetics and Metabolism
- Pediatrics: Cardiology
A newborn is noted to have a Turner-like phenotype — webbed neck, low posterior hairline, widely spaced nipples — but the karyotype is 46,XX or 46,XY. The same infant may have a heart murmur that points to pulmonary valve stenosis rather than coarctation, or no murmur at all yet a thickened ventricular wall on ultrasound. The fellowship task is not merely to name the syndrome — the facies and the cardiac lesion begin to do that — but to place it within the RASopathy family, to confirm the gene, and to construct a surveillance plan that prevents the two preventable harms: undiagnosed cardiomyopathy and missed malignancy. [1] [7]
The RASopathies share a single signal transduction cascade, and the high-yield syndromes sit on R.A.S.O.P.A.T.H.Y. — Roberts and Romano wrote the Noonan guidelines (the anchoring references), Autosomal dominant inheritance (fifty per cent recurrence), Short stature with growth hormone response, Overlapping facies (triangular face, hypertelorism, low-set ears), Pulmonary valve stenosis and Ptosis (the classic cardiac and ocular signs), Aechocardiogram by six weeks (the non-negotiable), Tumour predisposition (especially Costello and NF1), Hypertrophic cardiomyopathy (the life-threatening complication), and You should test a multigene panel (because one gene cannot be predicted from the face alone). [1] [3]
Overview & Definition
Noonan syndrome is the prototypical member of the RASopathies — a family of developmental disorders caused by germline gain-of-function variants in the RAS/MAPK mitogen-activated protein kinase signal transduction pathway. It is one of the most common syndromic causes of congenital heart disease encountered in general paediatric practice, with an estimated incidence of one in one thousand to one in two thousand five hundred live births. The face, the short stature, and the cardiac lesion make the diagnosis suspected at the bedside, but the confirmation is molecular and the gene matters — the gene predicts the cardiac profile, the tumour risk, and the genetic counselling. [1] [3]
The RASopathies share a unifying pathophysiology: upregulated RAS/MAPK signalling during embryonic development disrupts the carefully choreographed processes of cell proliferation, differentiation, migration, and survival. Because the pathway is active in nearly every tissue during development, the phenotype is multisystem, and because different genes operate at different levels of the same cascade, the syndromes overlap but retain discriminating features. Noonan syndrome itself is caused most often by variants in PTPN11 — encoding the SHP-2 phosphatase — but a substantial minority carry variants in SOS1, RAF1, KRAS, BRAF, NRAS, LZTR1, or other pathway genes. [2] [4]
The lifespan trajectory is shaped less by intellectual disability — which is usually mild or absent — and more by the cardiovascular and haematological risks that run through childhood and into adult life. Structured surveillance has improved outcomes, and the clinical task has shifted from making the diagnosis in the newborn to sustaining a surveillance net across the lifespan. A fellowship answer that lists features without linking them to the RAS/MAPK pathway reads as a catalogue; the pathway link is the teaching that holds the topic together. [1] [7]
References9ShowHide
- [1]Roberts AE, Allanson JE, Tartaglia M, Gelb BD. Noonan syndrome. Lancet, 2013.PMID 23312968
- [2]Tartaglia M, Mehler EL, Goldberg R, et al. Mutations in PTPN11, encoding the protein tyrosine phosphatase SHP-2, cause Noonan syndrome. Nat Genet, 2001.PMID 11704759
- [3]Romano AA, Allanson JE, Dahlgren J, et al. Noonan syndrome: clinical features, diagnosis, and management guidelines. Pediatrics, 2010.PMID 20876176
- [4]Sarkozy A, Carta C, Moretti S, et al. Germline BRAF mutations in Noonan, LEOPARD, and cardiofaciocutaneous syndromes: molecular diversity and associated phenotypic spectrum. Hum Mutat, 2009.PMID 19206169
- [5]Gelb BD, Cavé H, Dillon MW, et al. ClinGen's RASopathy Expert Panel consensus methods for variant interpretation. Genet Med, 2018.PMID 29493581
- [6]Romano AA. Growth and growth hormone treatment in Noonan syndrome. Pediatr Endocrinol Rev, 2019.PMID 31115197
- [7]Zenker M, Wolf CM Cardiovascular aspects of Noonan syndrome and related disorders. Med Genet, 2025.PMID 40207038
- [8]Ichikawa Y, Kuroda H, Ikegawa T, et al. Cardiac features of Noonan syndrome in Japanese patients. Cardiol Young, 2023.PMID 35475426
- [9]Niihori T, Aoki Y, Okamoto N, et al. HRAS mutants identified in Costello syndrome patients can induce cellular senescence: possible implications for the pathogenesis of benign tumours. J Hum Genet, 2011.PMID 21850009