1. Newborn Screening: Ontario’s Expanded Screening Program
Prepared by: June C. Carroll, MD, CCFP, FCFP
Sydney G. Frankfort Chair in Family Medicine
Associate Professor, Department of Family Medicine
Mount Sinai Hospital, University of Toronto
Andrea L. Rideout, MS, CCGC, CGC
Project Manager / Genetic Counsellor
The Genetics Education Project
Funded by: Ontario Women’s Health Council
Version: August 2007
Slide 1: Title

2. Acknowledgments Reviewers: Members of The Genetics Education Project
Ontario Newborn Screening Program: Dr. Michael Geraghty, Mireille Cloutier MSC., Christina Honeywell MSc., Sari Zelenietz MSc.
Funded by:
Ontario Women’s Health Council as part of its funding to The Genetics Education Project
* Health care providers must use their own clinical judgment in addition to the information presented herein. The authors assume no responsibility or liability resulting from the use of information in this presentation.
Slide 2: Acknowledgements
Health care providers must use their own clinical judgment in addition to the information presented herein. The authors assume no responsibility or liability resulting from the use of information in this presentation.

3. Newborn Screening – What’s new?
Previously:
PKU, congenital hypothyroidism, hearing loss
Beginning April 2006:
Progressive expansion to 29 disorders by the end of 2008
NBS includes hearing screening but, the focus of this module will be on metabolic, endocrine and hematologic conditions
Slide 3: Newborn Screening – What’s New?
Prior to April 2006, all babies born in Ontario were screened for 3 conditions:
Phenylalanine hydroxylase deficiency (PKU)
Congenital hypothyroidism (CH)
Congenital hearing loss
Metabolic, endocrine and haematological disorders are the focus of this educational module – hearing screening will not be discussed.
Beginning in April 2006, Ontario started the gradual expansion of the newborn screening program. At this time screening for medium chain acyl-coenzyme A dehydrogenase hydroxylase deficiency (MCAD) was added to the panel.1,2
By the end of 2008 the province plans to expand the NBS panel to include 29 disorders (including cystic fibrosis), plus screening for congenital hearing loss.1,2
Tandem mass spectrometry will pick up an additional 20 disorders as variants (variants include disorders for which there is no known effective treatment and benign disorders which do not need treatment).

4. Expanded NBS – 29 conditions
20 inborn errors of metabolism
9 organic acid disorders
5 fatty acid oxidation disorders
6 amino acid disorders
3 hemoglobinopathies
Sickle cell and related disorders
2 endocrine disorders
3 other metabolic disorders
1 hearing loss
Slide 4: Expanded 29 conditions
Inborn errors of metabolism, also known as inherited metabolic diseases, comprise a large class of genetic diseases involving disorders of metabolism. The majority are due to genetic defects in genes that code for enzymes which facilitate conversion of various substances into other products. In the majority of these disorders, problems arise due to accumulation of substances which are toxic or interfere with normal function, or to the effects of reduced ability to synthesize essential compounds.
Hemoglobinopathies refer to diseases resulting from genetic alterations in the amount of, and/or structure of the alpha and/or beta chain components of hemoglobin. The clinical picture of hemoglobinopathies varies; ranging from benign (carriers) to transfusion-dependent anemia or lethal in some cases.
Endocrine disorders refer to diseases involving the production or metabolism of hormones.
Other conditions: galactosemia, biotinidase deficiency, cystic fibrosis and hearing loss. Galactosemia and biotinidase deficiency are both metabolic disorders that are not amino acid, organic acid or fatty acid disorders.
Hearing loss will not be discussed in this module.

5. Benefits of NBS Identification Early intervention
Reduced morbidity and mortality
Family planning
Slide 5: Benefits of NBS
Identification
Early intervention:
Start treatment before symptoms present
Diagnosis while newborn is in crisis – earlier, targeted treatment
Reduction in unnecessary investigations
Cost-saving
Reduced morbidity and mortality:
Prevent metabolic crisis, metal retardation, SIDS, death
Not all developmental delay/symptoms can be prevented, but with early treatment, affected children can reach their full potential
Family Planning:
Parents can be informed of diagnosis and management
Family members can be counselled about their own risk (if any) and the risk for future children
Resources and support groups for parents

6. Risks of NBS Parental anxiety (false positives)
Missed diagnosis (false negatives)
The right ‘not to know’
Unanticipated outcomes
Labelling – diagnosis of benign conditions
Slide 6: Risks of NBS
Parental anxiety:
There are concerns that parents may become anxious when they are informed of their child’s initial screen positive result. Some of these parents may have persisting concerns about their child’s health in spite of the negative confirmatory test. Other parents may express relief that the initial screening result was false.
Missed diagnosis:
False negatives. No screening test is perfect and some cases may be missed by NBS. The sensitivity and specificity of NBS for classic forms of inborn errors of metabolism are high; this may not be true for the variant or less severe forms of these conditions.
The right not to know:
Some parents would prefer not to know this information at birth and would prefer to wait until their child manifests symptoms of the disease, though with most of these conditions, the goal is to prevent and reduce symptoms before irreversible damage occurs.
Unanticipated outcomes:
Misattributed paternity: When an infant is identified with a condition on the NBS panel, sequential testing of the parents and other family members can identify previously unknown non-paternity.
The misattributed paternity rate is ~4% per a recent meta-analysis, the literature ranges from 2 to 10% depending on the study. 3
Labelling:
There is concern that particularly when children are identified as carriers of disorders through NBS (i.e. hemoglobinopathy or cystic fibrosis) that they may experience the negative consequences of “labelling”. This may include discrimination or “different” treatment by family, teachers etc.

7. Public’s attitude to NBS
Study of 200 Australian new mothers
Quinlivan 2006 J Pscyhosomatic Ob/Gyn
Supported NBS where outcomes used to prevent or reduce severity of disease (85%)
Less support if screening used for future family planning (65%)
Parental consent should be mandatory (86%)
Majority concerned re discrimination, difficulty getting insurance/employment for those with genetic condition
1/3 had similar concerns for carriers
Slide 7: Public’s attitude to NBS4
A summary of findings from the literature:
Women with more education tend to have higher knowledge scores than women with less education, regardless of counselling and informed consent process prior to their child being screened.5
Other studies found that healthcare professionals did not provide enough information.6
Women sometimes decline newborn screening due to misinformation.5
Face to face counselling resulted in better knowledge scores and understanding than telephone counselling.7
Many studies have reported that false positive screening results cause parental anxiety; but one study found that parents whose infants had lower APGAR scores were more likely to experience anxiety, suggesting that there may have been some concern about their child’s well-being before the test results were communicated.6 A more recent study found that mothers of children with false-positive results attained higher scores on the Parental Stress Index and the Parent-Child Dysfunction subscale compared with mothers of children with normal screening results. 8
A more recent study found that mothers whose children were diagnosed by NBS reported lower overall stress on the Parental Stress Index than mothers whose children were diagnosed based on clinical symptoms.8
One study of newborn screening cystic fibrosis results reported that the time from receiving NBS results to diagnostic test results can be psychologically distressing to parents, causing depressive symptoms that vary depending on their perceptions about the likelihood that their infant has CF.9
Several studies of parents with affected children diagnosed by NBS indicated that 21-67% chose to have prenatal testing for the condition in subsequent pregnancies.10,11

8. Why Changes to NBS now? Reagent for PKU test unavailable
Tandem Mass Spectrometry more efficient
2 infants diagnosed post-mortem with MCAD
Ombudsman’s report 2005
Consumer lobbying
Geneticist lobbying
Political will
Slide 8: Why Changes to Newborn Screening Now?
New technology: Tandem mass spectrometry is an analytical technique that can evaluate a single sample for multiple conditions at the same time. Instead of doing one test for PKU with the Guthrie reagent and a second test for congenital hypothyroidism, both tests can be carried out concurrently on the same sample.
A recent report indicated that 5 children died in Ontario due to undiagnosed MCAD deficiency. These deaths might have been prevented by dietary modification.12

9. NBS: What’s NOT changing?
Heel prick method for sample collection
NBS: What’s changing?
New screening card
Location: Children’s Hospital of Eastern Ontario
Transportation – sample cards are sent via Canada Post courier service to Ontario NBS Program
Slide 9: NBS: What’s not changing?

10. Timing of Testing Acceptable samples Best time for sample:
between 1 day (24 hours) and 7 days after birth
Best time for sample:
between 2 days (48 hours) and 3 days (72 hours) after birth
If tested before 1 day (24 hours) of age, REPEAT the test within 5 days*
If the baby is >5 days, screening is still available
Contact Ontario NBS program for details
* Repeat sample within 5 days has been the Ontario standard of care since 2001
Slide 10: Timing of testing12
Samples should be collected between 24 hours (one day) to seven days after birth
Ideal time for sample is 24 hours (one day) to 72 hours (three days) after birth
Sample cards should be sent to the NBS laboratory when the sample is dry, about four to six hours after collection, and no later than 24 hours after collection.
Why is timing important? The levels of the various compounds in the blood spot change with the baby’s age. Analysis takes the age of the infant into consideration. Individual interpretation must be made by the lab director when an infant is tested outside of the one to seven day time frame. If infants are screened before 24 hours, the recommendation is to repeat these samples within 5 days. The goal is to conduct NBS within the first 7 days of life so that infants with these disorders can be identified and treated before serious problems such as brain damage have occurred.
If the baby is >5 days, screening is still available. Contact Ontario NBS program for details

11. Special Considerations
Prematurity or illness
If <37 weeks - collect specimen at 5-7 days old
Indicate this on NBS card
i.e. associated with false +ve congenital hypothyroidism screens
Total Parenteral Nutrition (TPN)
Certain amino acids and organic acids will be elevated
Transfusion
Disorders may be missed
Ideally complete card before transfusion
Slide 11: Special considerations12
Prematurity, total parenteral nutrition, and transfusion should be indicated on the NBS specimen collection card.
Prematurity >37 weeks gestation: collect sample between five to seven days after birth. Premature infants often have high thyroid stimulating hormone (TSH) levels and may screen positive for congenital hypothyroidism when they are not affected.
Total parenteral nutrition (hyperalimentation): certain compounds (amino and organic acids) can be elevated in these cases and need to be taken into consideration when analyzing the sample.
Transfusion: ideally a specimen card should be completed before transfusion. When completed after transfusion, the donor’s blood may normalize abnormal analyte levels (i.e. congenital hypothyroidism, biotinidase deficiency) and affected infants may be missed. Donor haemoglobin may also produce a false negative for sickle cell disease.

12. The Heel Test Slide 12: The Heel Test14 Acceptable samples: Heel prick
Dorsal hand vein
Peripheral or central line unless this line is used for hyperalimentation
Unacceptable samples:
Cord blood
Samples that have been in contact with EDTA and citrate anticoagulants – these can cause false negative results (CH, CAH, CF)
Samples that have been contaminated with water, urine, feeding formulas, antiseptic solutions, powder from gloves
Milking or squeezing puncture may cause hemolysis and an admixture of tissue fluids
How to collect a specimen:
To prevent contamination, do not touch any part of the filter paper circles before, during or after collection. Disposable gloves and powder lactose residue can contaminate the sample.
Hold the infant’s heel lower than the heart, warm with water or a towel if necessary. Heat pack not to exceed 42 degrees C.
Select puncture site. In the photograph, this is the shaded area.
Cleanse puncture site with alcohol and NOT iodine. Allow puncture site to air dry.
Puncture heel with sterile lancet, depth <2.0mm.
Wipe away first drop of blood to remove tissue fluids. Sufficient blood should collect on the heel to fill a single circle with one application.
Air-dry the blood specimens at room temperature for 2 to 4 hours in the horizontal position. Do not dry on heater or in microwave. Make sure the sample is completely dry before mailing. Mail within 24 hours of collection. If this not possible due to weekend or holiday, store in a cool room.

13. What makes a good spot? Slide 13: What makes a good spot? 15
Blood should soak all the way through the filter paper. Complete saturation is necessary for accurate testing.
Collect blood from one side of the filter paper only.
It is important NOT to superimpose or layer the blood drops on top of each other, this can cause false results.
Collect blood for each circle on the filter paper/collection card. It is better to properly collect 4 circles than inadequately fill all 5 circles.
Let each drop touch the paper 3 mm from the previous drop.
Avoid contamination
Invalid specimens
Insufficient quantity for testing:
Removing filter paper before blood has completely filled the circle or soaked through
Touching filter paper before or after specimen collection or filter paper contaminated with gloves, hand lotion, antiseptic etc.
Specimen appears scratched or abraded:
Applying blood with a capillary tube or other device
Specimen not dry before mailing:
Allow specimen to dry for 2 to 4 hours before mailing
Specimen appears supersaturated:
Applying excess blood to the filter paper, usually with a device
Applying blood to both sides of the filter paper
Specimen appears diluted, discoloured or contaminated:
Squeezing or milking the puncture site
Contamination
Blood spots exposed to direct heat
Specimen exhibits serum rings:
Puncture site was not cleaned with alcohol/antiseptic before making puncture
Improper drying
Specimen appears clotted or layered:
Touching the same circle to blood drop several times (layering)
No blood:
Failure to obtain specimen

14. Parents will ask you about NBS
NBS: What’s New?
Location
Children’s Hospital of Eastern Ontario (CHEO)
Tandem Mass Spectrometry
Allows to screen for multiple conditions concurrently
Same cost to screen for one condition as multiple
Increased sensitivity and specificity
Screening for some metabolites can give information about several diseases
Educational materials
MOH & CHEO have developed materials for the public and healthcare providers
Parents will ask you about NBS
Slide 14: What’s New?
Location: Previously newborn screening was performed at the Provincial Public Health Laboratory in Toronto. Now it has moved to Children’s Hospital of Eastern Ontario in Ottawa.
Technology: Previously individual tests were performed for each condition; i.e. the Guthrie test for PKU. Now new technology, tandem mass spectrometry (MS/MS), is available that can screen for multiple conditions at once.
What is tandem mass spectrometry? Tandem mass spectrometry is an analytical technique that measures the mass to charge ratio of ions. In NBS this technique is applied to identify the components of a blood spot and quantify the individual compounds. It is a very powerful tool and can measure multiple compounds at the same time. If a blood spot has a specific profile, for example elevated phenylalanine in the case of PKU; then the sample is considered screen positive. The family or health care professionals will be contacted for a repeat sample to confirm the diagnosis.
Education: The Ontario Ministry of Health has developed the following:
Patient brochure about NBS in multiple languages
Provider fact sheets for each condition screened
Physician guide (English and French)
In addition the website includes information such as a discussion guide for parents, interpretation of results and special considerations13

15. NBS Report Cystic fibrosis 2008 Slide 15: NBS Report
Disorders currently screened for will have a result, either positive or negative in the screening result column.
Screen negative means that the infant is not at increased risk for the disorder.
Screen positive means that the infant is at increased risk for the disorder.
Disorders marked with an asterix (*) indicate that the laboratory has not yet started screening for this disorder.

16. Screen Positive Results
Screen positive means:
Further testing is required to confirm the diagnosis
Does NOT mean that the infant is affected
NBS laboratory will immediately notify regional treatment centre
Regional treatment centre will notify the infant’s healthcare provider and parents and arrange confirmatory testing
If diagnosis is confirmed, regional treatment centre will provide management counselling & follow up
Report will be mailed to referring hospital and HCP, provided that correct information is completed on the screening card.
Slide 16: Screen Positive Results
What does ‘screen positive’ mean?
The infant is at increased risk for the disorder indicated on the report. Further testing is needed to confirm the diagnosis. This does not mean that the infant is affected.
The Newborn Screening Laboratory will immediately notify the regional treatment centre and will arrange with the infant’s health care provider or the infant's parent(s) for confirmatory testing.
If a diagnosis of a disorder is confirmed, the treatment centre will provide management, counselling and follow up. A report is also issued by mail to the referring hospital and health care provider, and should be filed in the baby's medical records.
Please note that in some cases, screening for one “core” disorder - those considered as having met acceptable criteria for NBS - will pick up “secondary target” or variant disorders. Secondary targets may not meet the accepted criteria; however they are often part of the differential diagnosis when evaluating an infant for one of the core disorders. For example, screening for tyrosinemia type 1 can also pick up cases of tyrosinemia type 2 and type 3. For more information about core and secondary targets of newborn screening see (16) Waston MS, Mann MY, Lloyd-Puryear MA, Rinaldo P, Howell RR. Executive summary: Newborn screening panel and system. Genet Med 2006; 8 (5, supplement): 1s-11s.
What does screen negative mean?
The infant is not at increased risk for the disorder indicated on the report. In rare cases newborn screening can miss an affected infant. If an infant exhibits signs of a specific disorder, then diagnostic testing is indicated.
Repeat sample:
The initial sample is insufficient or unacceptable, or the results are equivocal.
The provider will be contacted and asked to obtain another sample from the infant as soon as possible and repeat the submission procedure.13

17. Results of Expanded NBS by MS/MS Schulze et al. Pediatrics 2003
250,000 neonates screened for 23 IEM
106 newborns with confirmed metabolic disorder
70 required treatment
Overall prevalence of metabolic disorder = 1/2400
825 false positives (0.33% false positive rate)
Overall specificity = 99.67% (PPV = 11.3%)
Overall sensitivity = 100% for classic forms of disorders
= 92.6% for variants
61 /106 were judged to have benefited from screening and treatment
58% of true positives
1/4100 newborns
Slide 17: Results of Expanded NBS by MS/MS
MS/MS is an abbreviation of tandem mass spectrometry.
Since no Ontario specific data is currently available for the expanded NBS program, we have used published numbers for the expanded NBS program in Germany.
The sensitivity or detection rate is defined as the proportion of infants with a screen positive test result who upon diagnostic testing are confirmed to have the disorder.
The German program reported sensitivity of 100% for classic forms of the disorders. Classic forms of inborn errors of metabolism are the core conditions outlined in the American College of Medical Genetics (ACMG) recommended panel. The sensitivity for the variant forms of inborn errors of metabolism, also known as secondary targets, was 94.20%. Overall for both classic and variant forms of inborn errors of metabolism, the sensitivity was reported as 96.36%.
The specificity is defined as the proportion of infants with a screen negative result who are truly disease free; which was 99.67% in the German program.
The false positive rate is 0.33% and is defined as the percent of infants who have a screen positive result that is not confirmed with further diagnostic testing, i.e. the infant is unaffected.
The false negative rate for classic disorders was 0% and 5.80% for variants, overall rate was 3.64%. False negative rate is defined as the proportion of infants with a screen negative result who are later diagnosed with one of the conditions being screened for.17

18. Results Results will go to:
Submitting health care professional /hospital
Infant’s health care professional – if this information is completed on the screening card
Slide 18: Results
Ontario is currently testing for the same disorders using similar technology, so we would expect the sensitivity and the specificity to be similar to the results of the German program.
So using the data from the German paper, approximately 3,800 infants in Ontario will require follow up.
The disease incidence may be different, reflecting the differences between the German and the Ontario populations.

19. Expanded NBS – 29 conditions
20 inborn errors of metabolism
9 organic acid disorders
5 fatty acid oxidation disorders
6 amino acid disorders
3 hemoglobinopathies
Sickle cell and related disorders
2 endocrine disorders
3 other metabolic disorders
1 hearing loss
Slide 19: Expanded NBS 29 Conditions

20. Inborn errors of metabolism
Rare
Usually autosomal recessive inheritance
consanguinity is more common
Symptoms secondary to a problem in the metabolic pathway
Usually not significant dysmorphism
Early recognition and intervention can be lifesaving
Slide 20: Inborn Errors of Metabolism
IEM are individually rare but are collectively more common.
IEM (usually autosomal recessive inheritance) have a collective incidence ranging from 1 in 2,500 to 1 in 4,000 newborns. 18,19,20
In these cases the parents of the affected child are more likely to be related by blood.
With few exceptions, most infants with inborn errors of metabolism have normal facial appearance and no physical birth defects.
Symptoms are a result of either too much or too little of a component in a metabolic pathway.
Early diagnosis is essential to reduce morbidity (i.e. mental retardation) and mortality.

21. Frequency of Inborn Errors of Metabolism using MS/MS Tandem Mass Spectrometry
Amino Acid Disorders 1/5,100
Organic Acid Disorders 1/20,000
Fatty Acid Oxidation Defects 1/12,500
IEM combined frequency ~1/4,000
All NBS: IEM, CF, CAH, ~1/1,500
biotinidase, galactosemia
Slide 21: Frequency of Inborn Errors of Metabolism Using Tandem Mass Spectrometry
Combined inborn errors of metabolism is the frequency of metabolic diseases and total NBS is the frequency of all of the conditions screened.

22. Organic Acid Disorders
Isovaleric acidemia (IVA)
Glutaric acidemia type 1 (GA1)
Hydrodroxymethylglutaric acidemia (HMG)
Multiple carboxylase deficiency (MCD)
Methylmalonic acidemia (MUT)
Methylmalonic acidemia (Cbl A, B)
3-methylcrotonyl glycinuria (3MCG)
Propionic acidemia (PROP)
Β-ketothiolase deficiency (BKT)
Slide 22: Organic Acid Disorders
The nine disorders listed are core disorders recommended for screening by the Ontario NBS Advisory Committee following review of several reports and NBS programs including the ACMG NBS report. Below is a list of the core organic acid disorders including the secondary organic acid disorders or variants which can be detected when screening for these core disorders:
Isovaleric acidemia (IVA)
secondary target:
2-Methylbutyryl-CoA dehydrogenase deficiency (2MBG)
Glutaric acidemia type 1 (GA1)
Hydrodroxymethylglutaric acidemia (HMG)
secondary targets:
3-Methylcrotonyl-CoA carboxylase deficiency (3MCC)
2-Methyl 3-hydroxy butyric aciduria (2M3HBA)
3-Methylglutaconic aciduria (3MGA)
Β-ketothiolase deficiency (BKT)
Multiple carboxylase deficiency (MCD)
Methylmalonic acidemia (MUT)
Methylmalonic acidemia (Cbl A, B)
Methylmalonic acidemia (Cbl C, D)
3-methylcrotonyl glycinuria (3MCG)
Propionic acidemia (PROP)

23. Organic Acid Disorders
What are organic acid disorders?
Body cannot metabolize certain amino acids and fats
Accumulation of organic acids in blood and urine
Serious potentially preventable effects on health and development, including death
Symptoms
acute encephalopathy, vomiting, metabolic acidosis, ketosis, hyperammonemia, hypoglycemia, coma
dehydration, failure to thrive, hypotonia, GDD
sepsis, death
Treatment
Low protein diet / restrict amino acids,
Supplements: carnitine, biotin, riboflavin, glycine
Avoid fasting
Slide 23: Organic Acid Disorders
For a general overview of organic acid disorders see: (21) Seashore MA. Genetest Reviews: The organic acidemias: An overview. Last updated 27 December
For a review of methylmalonic acidemia, propionic acidemia and isovaleric acidemia see: (22) Ogier de Baulny HO, Saudubray JM. Branched-chain organic acidurias. Semin Neonatol. 2002; 7:65-74.
For more information about methylmalonic acidemia see: (23) Venditti CP. Genetests Reviews: Methylmalonic Acidemia. Last updated 18 January
For more information about Β-ketothiolase deficiency, 2-Methylbutyryl-CoA dehydrogenase deficiency, 2-Methyl 3-hydroxy butyric aciduria see: (24) Korman SH. Inborn errors of isoleucine degradation: A review. Mol Genet Metab. 1006: 89:
For more information about Hydrodroxymethylglutaric acidemia see: (25) Gibson KM, Breuer J, Kiaser K, Nylan WL, McCoy EE, Ferreira P, Greene CL, Blitzer MG, Shapira E, Reverte F, Conde C, Bagnell P, Cole DEC. 3-hydroy-3-methylglutaryl-coenzyme A lyase deficiency: Report of five new patients.
For more information about multiple carboxylyase deficiency see (26) Roth KS. Holocarboxylase Deficiency. Last updated 22 September

24. Fatty Acid Oxidation Disorders
Medium-chain acyl-CoA dehydrogenase (MCAD) deficiency
Very long-chain acyl-CoA dehydrogenase deficiency (VLCAD)
Long-chain L-3-OH acyl-CoA dehydrogenase deficiency (LCHAD)
Trifunctional protein deficiency (TFP)
catalyzes 3 steps in mitochondrial beta-oxidation of fatty acids
Carnitine uptake defect (CUD)
Slide 24: Fatty Acid Oxidation Disorders
The five disorders listed are core disorders recommended for screening by the Ontario NBS Advisory Committee following review of several reports and NBS programs including the ACMG NBS report. Below is a list of core fatty acid oxidation disorders and secondary fatty acid oxidation disorders which can be detected when screening for these core disorders:
Medium-chain acyl-CoA dehydrogenase (MCAD) deficiency
secondary targets:
Glutaric acidemia type 2 (GA2)
Medium-chain ketoacyl-CoA thiolase deficiency (MCKAT)
Medium/short-chain (L-3-OH acyl) hydroxyacyl-CoA dehydrogenase deficiency (M/SCHAD)
Very long-chain acyl-CoA dehydrogenase deficiency (VLCAD)
Carnitine palmitoytransferase deficiency type 2 (CPT II)
Carnitine acylcarnitine translocase deficiency (CACAT)
Long-chain L-3-OH acyl-CoA dehydrogenase deficiency (LCHAD)
Trifunctional protein deficiency (TFP)
catalyzes 3 steps in mitochondrial beta-oxidation of fatty acids
Carnitine uptake defect (CUD)
Carnitine palmitoyltransferase deficiency type 1 (CPT I)

25. Disorders of Fatty Acid Oxidation
What are disorders of fatty acid oxidation?
Breakdown of fatty acids in mitochondria is essential part of body’s ability to produce energy
Disorder: inability to break down fatty acids
Symptoms
Decompensate with any catabolic stress
fever, fasting, intercurrent illness
Hypoketotic hypoglycemia, liver, muscle, heart disease
Lethargy, seizures, coma, sudden death (SIDS)
Treatment
Avoid fasting
Frequent feeding
IV glucose when ill to prevent hypoglycemia
Slide 25: Fatty Acid Oxidation Disorders
For a review of Fatty Acid Oxidation disorders see: (27) Angelini C, Federico A, Reichmann H, Lombes, Chinnery P, Turnbull D. Task force guidelines handbook: EFNS guidelines on diagnosis and management of fatty acid mitochondrial disorders. Eur J Neurol. 2006; 13:
(28) Saudubray JM, Martin D, deLonlay P, Touati G, Poggi-Travert F, bonnet D, Jouvet P, Boutron M, Slama A, Vianey-saban C, Bonnefont JP, Rabier, Kamoun P, Brivet M. Recognition and management of fatty acid oxidation defects: A series of 107 patients. J Inherit Metabo Dis. 1999; 22:

26. Amino Acid Disorders Phenylketonuria (PKU)
Maple syrup urine disease (MSUD)
Tyrosinemia type 1 (TYR 1)
Common in French Canadians
Homocystinuria (HCY)
Citrullinemia (CIT)
Argininosuccinic aciduria (ASA)
Slide 26: Amnio Acid Disorders
The five disorders listed are core disorders recommended for screening by the Ontario NBS Advisory Committee following review of several reports and NBS programs including the ACMG NBS report. Below is a list of core amino acid oxidation disorders and secondary or variant amino acid oxidation disorders which can be detected when screening for these core disorders:
Phenylketonuria (PKU)
secondary targets:
Defects of Biopterin cofactor biosynthesis (BIOPT (BS))
Defects of Biopterin cofactor regeneration (BIOPT (Reg))
Benign hyperphenylalaninemia (H-PHE)
Maple syrup urine disease (MSUD)
Tyrosinemia type 1 (TYR 1)
secondary targets
Tyrosinemia type 2 (TYR 2)
Tyrosinemia type 3 (TYR 3)
Homocystinuria (HCY)
Hypermetioninemia (MET)
Citrullinemia (CIT)
Citrullinemia type 2 (CIT II)
Argininosuccinic aciduria (ASA)

27. Amino Acid Disorders What are Amino acid disorders?
Occur when the body cannot either metabolize or produce certain amino acids
Results in toxic accumulation of substances
Serious potentially preventable effects on health and development including death
Symptoms -example PKU
Hyperphenylalaninemia (neurotoxic)
Microcephaly, epilepsy, MR, behaviour problems
Treatment
Diet: reduce phenylalanine, low protein, supplement cofactors or essential amino acids
Avoid fasting
Slide 27: Amnio Acid Disorders
For more information about phenylketonuria see: (28)Hellekson KL; National Institutes of Health. Am Fam Physician :
(30) National Institutes of Health Consensus Development Panel. National institutes of Health consensus development conference statement: Phenylketonuria screening and management, October Pediatrics 2001; 108:
(31) Mitchell JJ, Scriver CR. Genetests Reviews: Phenylalanine hydroxylase deficiency. Last updated 19 July
For more information about maple syrup urine disease see: (32) Morton DH, Strauss KA, Robinson DL, Puffenberger EG, Kelley RI. Diagnosis and treatment of maple syrup urine disease: A study of 36 patients. Pediatrics 2002; 109:
(33) Le Roux C, Murphy E, Liblurn M. The longest surviving patient with classical maple syrup urine disease. J Inherit Metab Dis 2006; 29:
(34) Strauss KA, Puffenberger EG, Morton DH. Genetests Reviews: Maple Syrup Urine Disease. Last updated 30 January
For more information about tyrosinemias see: (35) Scott CR. The genetic tyrosinemias. Am J Med Genet Part C Semin Med Genet 2006; 142C:
(36) Russo PA, Mitchell GA, Tanguay RM. Tyrosinemia: a review. Pediatr Dev Pathol. 2001; 4:
(37) Sniderman King L, Trahms C Scott R. Genetests Reviews: Tyrosinemia Type I. Last updated 24 July
For more information about homocystinuria see: (38) Walter JH, Wraith JE, White FJ, Bridge C, Till J. Strategies for the treatment of cystathionine β-synthase deficiency: the experience of the Wilink Biochemical Genetics Unit over the past 30 years. Eur J Pediatr. 1998; 157(Suppl 2):s71-s76.
(39) De Franchis R, Sperendeo MP, Sebastio G, Andria G. The Italian Study group on Homocystinuria. Clinical aspects of the cynstathionine β-synthase deficiency: how wide is the clinical spectrum? Eur J Pediatr. 1998; 157(Suppl 2):s67-s70
(40) Picker JD. Levy HL. Genetests Reviews: Homocystinuria Caused by Cystathionine Beta-Synthase Deficiency. Last updated 29 March
Citrullinemia and argininosuccinic aciduria are both urea cycle disorders; for more information about urea acid cycle disorders see: (41) Summar M, Tuchman M. Proceeding of a consensus conference for the management of patients with urea acid cycle disorders. J Pediatr. 2001; 138(Suppl1):s6-s10.
(42) The Urea Cycle Disorders Conference Group. Consensus statement from a conference for the management of patients with urea cycle disorders. J Pediatr. 2001; 138(Suppl1):s1-s5.
(43) Summar, ML. Genetests Reviews: Urea Cycle Disorders Overview. Last updated 11 August
(44) Thoene, JG. Genetests Reviews: Citrullinemia Type I. Last updated 22 December
(45) Roth KS. Argininosuccinate Lyase Deficiency. Last Updated 7 July free registration is required. If you are already registered the direct link is:

28. Endocrine Disorders: CH
Congenital Hypothyroidism (CH)
What is CH?
inadequate thyroid hormone production
Anatomic defect in gland, IEM, iodine deficiency
Symptoms
MR, ↓ growth & bone maturation, neurologic problems: spasticity, gait abn, dysarthria, autistic behaviour
Treatment
Thyroid hormone replacement
Diagnosis made before 13 days to prevent symptoms
Slide 28: Endocrine Disorders
Congenital hypothyroidism for a review see:
(46) American Academy of Pediatrics; Rose SR; Section on Endocrinology and Committee on Genetics, American Thyroid Association; Brown RS; Public Health Committee, Lawson Wilkins Pediatric Endocrine Society; Foley T, Kaplowitz PB, Kaye CI, Sundararajan S, Varma SK. Update of newborn screening and therapy for congenital hypothyroidism. Pediatrics Jun;117:
(47) Postellon D, Bourgeois MJ, Varma S. eMedicine: Congenital Hypothyroidism. Last Updated: 23 August

29. Endocrine Disorders: CAH
Congenital Adrenal Hyperplasia (CAH)
What is CAH?
Impaired synthesis of cortisol by the adrenal cortex leads to ↑↑↑ androgen biosynthesis
Inability to maintain adequate energy & blood glucose level to meet stress of injury & illness
Symptoms
Virilization (♀ ambiguous genitalia), precocious puberty, infertility, short stature
Renal salt wasting leads to FTT, vomiting, dehydration, hypotension, hyponatremia, & hyperkalemia
Treatment
Glucocorticoid replacement therapy
Slide 29: Endocrine Disorders
Congenital Adrenal Hyperplasia for a review see:
(48) Merke DP, Bornstein SR. Congenital adrenal hyperplasia. Lancet. 2005; 365:
(49) New MI, Nimkarn S. GeneTests Reviews: Congenital Adrenal Hyperplasia, last update 7 September
Hemoglobinopathies
Sickle cell disease (Hb SS), variants include
Hemoglobin SC disease (Hb SC)
Sickle-β thalassemia (Hb S/β-thal)
Variants may have similar symptoms and treatments as classical sickle cell disease.
Other hemoglobin variants may be picked up as secondary targets (see slide 31)

30. Hemoglobinopathies Sickle cell disease (Hb SS) Hemoglobin SC disease
Sickle-β thalassemia (Hb S/β-thal)
Other hemoglobin variants may be picked up as variants
Slide 30: Hemoglobinopathies
Sickle cell disease (Hb SS), variants include
Hemoglobin SC disease (Hb SC)
Sickle-β thalassemia (Hb S/β-thal)
Variants may have similar symptoms and treatments as classical sickle cell disease.
Other hemoglobin variants may be picked up as secondary targets (see slide 31)

31. Sickle Cell Disease What is sickle cell disease? (Hb SS) Symptoms
Change in the shape of the betaglobin component of the hemoglobin molecule that interferes with hemoglobin’s ability to carry oxygen
Symptoms
Painful vaso-occlusive crises, hemolytic anemia, frequent infections, tissue ischemia, chronic organ dysfunction
Diagnosis
Quantitative hemoglobin electrophoresis
Do not rely on solubility testing methods (Sickledex etc)
Treatment
Prophylactic penicillin (84% reduction in infection)
Vaccinations (pneumococcal, influenza)
Slide 31: Sickle Cell Disease
For a review of sickle disease in primary care see:
(50) Wethers DL. Sickle cell disease in childhood: Part II. Diagnosis and treatment of major complications and recent advances in treatment. Am Fam Physician. 2000; 62:
(51) Bender MA. GeneTests Reviews: Sickle cell Disease, last update 7 March

32. Other Hemoglobinopathies
Hemoglobin C disease (Hb-CC)
‘benign’ hemoglobinopathy
mild hemolytic anemia, retinopathy & dental infarctions, gallstones, splenomegaly, joint pain
Sickle cell and C trait (carriers) (Hb AS, Hb AC)
> 50% normal hemoglobin – generally asymptomatic no clinical symptoms
Other hemoglobin variants
Autosomal recessive inheritance
Slide 32: Other Hemoglobinopathies
Hemoglobin C disease (Hb-CC):‘benign’ hemoglobinopathy. Symptoms include: mild hemolytic anemia, retinopathy, dental infarctions, gallstones, splenomegaly, joint pain. Many people with hemoglobin C disease may not even realize that they have this disease and are often picked up as part of routine hemoglobinopathy screening in prenatal care.
Hemoglobinopathy carriers: >50% normal haemoglobin plus some variant (i.e. sickle cell trait, C trait, others). Generally asymptomatic
Other hemoglobin variants Hgb E, Hgb D, beta or alpha thalassemia carriers.

33. Other Disorders: Biotinidase deficiency
What is biotinidase deficiency?
Biotinidase is responsible for recycling biotin – a cofactor for 4 dependant carboxylases
Symptoms
Metabolic ketoacidosis, organic aciduria, mild hyperammonemia
Seizures, hypotonia, ataxia, developmental delay, vision problems, hearing loss, cutaneous abnormalities
Treatment
5-10mg of oral biotin per day, long term treatment prevents all symptoms
Slide 33: Other Disorders: Biotinidase Deficiency
For more information about biotinidase deficiency see: (52)Moslinger D, Stockler-ipsiroglu S, Scheibenreiter S, Tiefenthaler M, Muhl A, Seidl R, Strobl W, Plecko B, Suormala T, Baumgartner ER. Clinical and neuropsychological outcome in 33 patients with biotinidase deficiency ascertained by nationwide newborn screening and family studies in Austria. Eur J Pediatr. 2001;160:
(53) Wolf B. Worldwide survey of neonatal screening for biotinidase deficiency. J Inherit Metab Dis. 1991; 14:
(54) Wolf B. GeneTests Reviews: Biotinidase Deficiency, last update 2 March

34. Other Disorders: Galactosemia
What is galactosemia?
Lactose is main sugar in breast milk & infant formulas
Metabolized into glucose and galactose in the intestine
Unable to break down galactose
Symptoms
Feeding problems, FTT, bleeding, infection, liver failure, cataracts, MR
Treatment
Lactose-galactose-restricted diet
must be started in first 10 days of life to prevent symptoms
Even with treatment - ↑ developmental delay, speech problems, abn motor function, premature ovarian failure
Slide 34: Other Disorders: Galactosemia
Classical galactosemia (transferase deficient galactosemia) (GALT)
Variants:
Galactokinase deficiency (GALK)
Galactose epimerase deficiency (GALE)
For a review of galatosemia see: (55) Bosch AM. Classical galatosemia revisited. J Inherit. Metab. Dis. 2006; 29:
(56) Schweitzer-Krantz S. Early diagnosis of inherited metabolic disorders improving outcome: the controversial issue of galactosemia. Eur J Pediatr. 2003; 162:s50-s503.
(57) Elsas LJ. GeneTests Reviews: Galactosemia, last update 2 May

35. Other Disorders: Cystic fibrosis
What is cystic fibrosis?
Due to mutations in the CFTR gene which is responsible for chloride regulation and other transport pathways.
Symptoms
Chronic sinopulmonary disease
Gastrointestinal/nutritional abnormalities
Azoospermia (males)
Salt loss syndrome
Shortened life span – but improving with treatment
Treatment
Pulmonary: oral, inhaled, or IV antibiotics, bronchodilators, anti-inflammatory agents, mucolytic agents, chest physiotherapy
Gastrointestinal: Nutritional therapy special formulas for weight gain via improved intestinal absorption, and additional fat-soluble vitamins & zinc to prevent deficiencies

36. Cases

37. Case 1 Carmen and George bring Amy into your office for 1 week visit
Healthy 1 week old
Parents worried re risk of SIDS
First daughter died of SIDS 5 years earlier
Carmen’s cousin died of SIDS at 18 months

38. Case 1: Amy – 5 days old
You receive a call that Amy has screened positive for MCAD deficiency
Medium chain acyl-CoA dehydrogenase deficiency
You ask Carmen and George to bring her in that day
Healthy 5 day old
Parents worried about risk of SIDS
First daughter died of SIDS 5 years earlier
Carmen’s cousin died of SIDS at 13 months

39. Case 1 SIDS 8 months Legend Prostate cancer SIDS British / French
Irish / German P C S 79
Prost Ca Dx 74 72
A&W 49
Accident 65
A&W
MI – died 69 25
A&W 39
A&W 37
Schizophrenic 35
George
A&W 32
Carmen
A&W 29
A&W
SIDS
13 months
1 wk
Amy
A& W
A&W A&W
SIDS
8 months

40. Case 1 Amy’s expanded newborn screening report is the following:
Screen positive for medium chain acyl-CoA deficiency

41. MCAD (medium chain acyl-CoA deficiency)
Incidence
1 in 4,900 – 1 in 17,000
most prevalent in North Europeans
Inheritance
Autosomal recessive (Gene: ACADM)
Enzyme
Medium-chain acyl-coenzyme A dehydrogenase
Function
Mitochrondrial fatty acid β-oxidation
Energy source once hepatic glycogen stores become depleted
Important during prolonged fasting

42. MCAD: Symptoms Usually presents at 3 to 24 months
Triggered by fever, illness, or fasting
Symptoms:
Hypoglycemia, vomiting
Lethargy → coma → death
Encephalopathy, respiratory arrest, hepatomegaly, seizures
Long term outcomes: developmental & behavioural disabilities, chronic muscle weakness, seizures, cerebral palsy, ADD

43. MCAD: a preventable cause of SIDS
Sudden death is the first symptom in 25% of MCAD cases
Early diagnosis and treatment of MCAD can prevent sudden death
MCAD responsible for ~1% of SIDS cases, all FAO disorders ~4%
Opdal et al. Pediatrics 2004;114:
Reference: Opdal SH The sudden infant death syndrome gene: does it exist? Pediatrics 2004; 114:

44. MCAD: Management Infants require frequent feedings
Formulas containing medium chain triglycerides as the primary source of fat should be avoided
Toddlers: 2g/kg of uncooked cornstarch at bedtime to ensure sufficient glucose overnight
High carbohydrate, low fat diet
Carnitine supplementation
Avoid fasting, hypoglycemia

45. Case 2 How would you proceed?
Peter and Tina come to your office for a routine newborn visit
Kechia is a healthy 1 week old newborn
Her NBS results show that she is a carrier of hemoglobin S - sickle cell trait
How would you proceed?

46. Hemoglobin S Carriers Carriers of sickle cell trait (HbAS) Benefits
no clinical symptoms
should they be notified?
Benefits
Sequential testing and identification of carriers/ affected in family
Reproductive counselling/prenatal diagnosis
Risks
Exposure of non-paternity
Fear of chronic illness
Fear of sickle cell disease in future pregnancies
Stigmatization
Diminished self esteem
Potential discrimination
Misdiagnosis

47. Case 2 – sequential testing of family members
HbAS- Sickle
cell trait
HbSS – Sickle
cell disease
Legend
Barbados
Jamaica
Hb - AA 24
Hb - AS 22
Hb - AS
Hb - AA
Hb - AS
Hb - AS
Hb - AS
Hb - AA
Hb - AA
Hb - AS P
1 week
Hb - AS
3months
Hb - SS
Hb - AA
Hb - AA
Hb - AA
Hb - AA

48. Prevalence : Hemoglobinopathies
Ethnicity
Hb S trait
Hb C trait
β thal trait
α thal trait
Mediterranean
1/30 -50
Rare
1/20 – 30
1/30-50
African American
1/12
1/50
1/75
1/30
Non-Hispanic Caribbean
1/50 -75
West African
1/6
1/20-30
Hispanic Caribbean
Variable
Mexican, Central American
1/30-200
Asian
1/20 *
Southeast Asian
>1/20*
Asian subcontinent
1/50–100
Middle Eastern
1/50-100
variable
*In cis – 2 α thal deletions on same chromosome
Source: March of Dimes

49. NBS – Bottom Line Offer newborn screening Discuss the benefits
Discuss how testing is done
Discuss timing
Repeat sample sometimes required
Discuss difference between screening and diagnostic test
Discuss possible results
Answer questions/brochure

50. MOH Educational Materials
MOHLTC INFOline at / TTY:
Contact the Ontario Newborn Screening Program at:
Department of Genetics
Children’s Hospital of Eastern Ontario
Room 3127, 401 Smyth Road
Ottawa, ON K1H 8L1
(613)
Educational materials are available free-of-charge and can be ordered through or by calling

51. Education: http://www.health.gov.on.ca

52. Disorder Fact Sheets
/newbornscreening

53. Resources CHEO’s Newborn Screening Website: March of Dimes:
March of Dimes:
Genetests:
National Newborn Screening & Genetics Resource Center:
genes-r-us.uthscsa.edu
Pediatrix – US private lab offering NBS

54. The Genetics Education Project Committee
June Carroll MD CCFP
Judith Allanson MD FRCP FRCP(C) FCCMG FABMG
Sean Blaine MD CCFP
Mary Jane Esplen PhD RN
Sandra Farrell MD FRCPC FCCMG
Judy Fiddes
Gail Graham MD FRCPC FCCMG
Jennifer MacKenzie MD FRCPC FAAP FCCMG
Wendy Meschino MD FRCPC FCCMG
Fiona Miller PhD
Ms. Joanne Miyazaki
Andrea Rideout MS CGC CCGC
Linda Spooner RN BScN
Cheryl Shuman MS CGC
Anne Summers MD FCCMG FRCPC
Sherry Taylor PhD FCCMG
Brenda Wilson BSc MB ChB MSc MRCP(UK) FFPH
Slide 28:
The Genetics Education Project Committee
Committee Members

55. References Quinlivan 2006 J Pscyhosomatic Ob/Gyn
Ontario Ministry of Health and Long Term Care, News release November 2, 2005: Ontario becomes national leader in newborn screening, New state-of-the-art testing program means that children will have a better start on life
Ontario Ministry of Health and Long Term Care, News release November 23, 2006: McGuinty government expands newborn screening, Screening for cystic fibrosis brings total number of tests to 28.
Bellis MA, Hughes K, Hughes S, Aston JR. Measuring parent discrepancy and its public health consequences. J Epidemiol Community Health 2005; 59:
Quinlivan 2006 J Pscyhosomatic Ob/Gyn
Holtzman NA, Faden R, Chwalow AJ, Horn SD. Effect of informed parental consent on mothers' knowledge of newborn screening. Pediatrics. 1983; 72:

56. References
Tymstra T. False positive results in screening tests: experiences of parents of children screened for congenital hypothyroidism. Fam Pract. 1986; 3:92-96.
Tluczek A, Mischler EH, Bowers B, Peterson NM, Morris ME, Farrell PM, Bruns WT, Colby H, McCarthy C, Fost N, et al. Psychological impact of false-positive results when screening for cystic fibrosis. Pediatr Pulmonol Suppl. 1991;7:29-37.
Waisbren SE, Albers S, Amato S, Ampola M, Brewster TG, Demmer L, Eaton RB, Greenstein R, Korson M, Larson C, Marsden D, Msall M, Naylor EW, Pueschel S, Seashore M, Shih VE, Levy HL. Effect of expanded newborn screening for biochemical genetic disorders on child outcomes and parental stress. JAMA. 2003;290:
Tluczek A, Koscik RL, Farrell PM, Rock MJ. Psychosocial risk associated with newborn screening for cystic fibrosis: parents' experience while awaiting the sweat-test appointment. Pediatrics. 2005;115:

57. References
Mischler EH, Wilfond BS, Fost N, Laxova A, Reiser C, Sauer CM, Makholm LM, Shen G, Feenan L, McCarthy C, Farrell PM. Cystic fibrosis newborn screening: impact on reproductive behavior and implications for genetic counseling. Pediatrics. 1998; 102:44-52.
Dudding T, Wilcken B, Burgess B, Hambly J, Turner G. Reproductive decisions after neonatal screening identifies cystic fibrosis. Arch Dis Child Fetal Neonatal Ed. 2000; 82:F
Martin, A. Ontario Ombudsman Report: The Right to be impatient. September 2005.
Ontario Ministry of Health and Long Term Care, Newborn Screening website:
NCCLS (National Committee for Clinical Laboratory Standards now known as CLSI – Clinical Laboratory Standards Institute) LAR-A3 “Blood collection on filter paper for neonatal screening programs: approved standard, third edition.”

58. References
“Simple Spot Check” 04/03/02 Lit. #718 produced by Schleicher & Schuell BioScience Inc. 10 Optical Ave, Keene NH USA. Scheicher & Schuell BioScience GmbH P.O. Box 1160, D Dassel, Germany.
Waston MS, Mann MY, Lloyd-Puryear MA, Rinaldo P, Howell RR. Executive summary: Newborn screening panel and system. Genet Med 2006; 8 (5, supplement): 1s-11s.
Schulze A, Lindner M, Kohlmuller D, Olgemoller K, Mayatepek E, Hoffmann GF. Expanded newborn screening for inborn errors of metabolism by electrospray ionization-tandem mass spectrometry: Results, outcome and implications. Pediatrics 2003; 111:
Applegarth Da, Toone JR, Lowry RB. Incvidence of inborn errors of metabolism in British Columbia, 1969 – Pediatrics 2000: 105:e10-e16.
Frazier DM, Millington DS, McCandless SE, Keoberl DD, Weavil Sd, Chaing SH, Muenzer J. The tandem mass spectrometry newborn screening experience in North Carolina: J Inhert Metab Dis 2006; 29:76-85.
Marsden D, Larson C, Levy Hl. Newborn screening for metabolic disorders. J Pediatr 2006; 148:

59. References
Seashore MA. Genetest Reviews: The organic acidemias: An overview. Last updated 27 december
Ogier de Baulny HO, Saudubray JM. Branched-chain organic acidurias. Semin Neonatol. 2002; 7:65-74.
Venditti CP. Genetests Reviews: Methylmalonic Acidemia. Last updated 18 January
Korman SH. Inborn errors of isoleucine degradation: A review. Mol Genet Metab. 1006: 89:
Gibson KM, Breuer J, Kiaser K, Nylan WL, McCoy EE, Ferreira P, Greene CL, Blitzer MG, Shapira E, Reverte F, Conde C, Bagnell P, Cole DEC. 3-hydroy-3-methylglutaryl-coenzyme A lyase deficiency: Report of five new patients. J Inhert Metab Dis 1988; 11:76-87.
Roth KS. Holocarboxylase Deficiency. Last updated 22 September

60. References
Angelini C, Federico A, Reichmann H, Lombes, Chinnery P, Turnbull D. Task force guidelines handbook: EFNS guidelines on diagnosis and management of fatty acid mitochondrial disorders. Eur J Neurol. 2006; 13:
Saudubray JM, Martin D, deLonlay P, Touati G, Poggi-Travert F, bonnet D, Jouvet P, Boutron M, Slama A, Vianey-saban C, Bonnefont JP, Rabier, Kamoun P, Brivet M. Recognition and management of fatty acid oxidation defects: A series of 107 patients. J Inherit Metabo Dis. 1999; 22:
Hellekson KL; National Institutes of Health. Am Fam Physician :
National Institutes of Health Consensus Development Panel. National institutes of Health consensus development conference statement: Phenylketonuria screening and management, October Pediatrics 2001; 108:
Mitchell JJ, Scriver CR. Genetests Reviews: Phenylalanine hydroxylase deficiency. Last updated 19 July
Morton DH, Strauss KA, Robinson DL, Puffenberger EG, Kelley RI. Diagnosis and treatment of maple syrup urine disease: A study of 36 patients. Pediatrics 2002; 109:

61. References
Le Roux C, Murphy E, Liblurn M. The longest surviving patient with classical maple syrup urine disease. J Inherit Metab Dis 2006; 29:
Strauss KA, Puffenberger EG, Morton DH. Genetests Reviews: Maple Syrup Urine Disease. Last updated 30 January
Scott CR. The genetic tyrosinemias. Am J Med Genet Part C Semin Med Genet 2006; 142C:
Russo PA, Mitchell GA, Tanguay RM. Tyrosinemia: a review. Pediatr Dev Pathol. 2001; 4:
Sniderman King L, Trahms C Scott R. Genetests Reviews: Tyrosinemia Type I. Last updated 24 July
Walter JH, Wraith JE, White FJ, Bridge C, Till J. Strategies for the treatment of cystathionine β-synthase deficiency: the experience of the Wilink Biochemical Genetics Unit over the past 30 years. Eur J Pediatr. 1998; 157(Suppl 2):s71-s76.

62. References
De Franchis R, Sperendeo MP, Sebastio G, Andria G. The Italian Study group on Homocystinuria. Clinical aspects of the cynstathionine β-synthase deficiency: how wide is the clinical spectrum? Eur J Pediatr. 1998; 157(Suppl 2):s67-s70.
Picker JD. Levy HL. Genetests Reviews: Homocystinuria Caused by Cystathionine Beta-Synthase Deficiency. Last updated 29 March
Summar M, Tuchman M. Proceeding of a consensus conference for the management of patients with urea acid cycle disorders. J Pediatr. 2001; 138(Suppl1):s6-s10.
The Urea Cycle Disorders Conference Group. Consensus statement from a conference for the management of patients with urea cycle disorders. J Pediatr. 2001; 138(Suppl1):s1-s5.
Summar, ML. Genetests Reviews: Urea Cycle Disorders Overview. Last updated 11 August
Thoene, JG. Genetests Reviews: Citrullinemia Type I. Last updated 22 December

63. References
Roth KS. Argininosuccinate Lyase Deficiency. Last Updated 7 July free registration is required. If you are already registered the direct link is:
American Academy of Pediatrics; Rose SR; Section on Endocrinology and Committee on Genetics, American Thyroid Association; Brown RS; Public Health Committee, Lawson Wilkins Pediatric Endocrine Society; Foley T, Kaplowitz PB, Kaye CI, Sundararajan S, Varma SK. Update of newborn screening and therapy for congenital hypothyroidism. Pediatrics Jun;117:
Postellon D, Bourgeois MJ, Varma S. eMedicine: Congenital Hypothyroidism. Last Updated: 23 August
Merke DP, Bornstein SR. Congenital adrenal hyperplasia. Lancet. 2005; 365:

64. References
New MI, Nimkarn S. GeneTests Reviews: Congenital Adrenal Hyperplasia, last update 7 September
Wethers DL. Sickle cell disease in childhood: Part II. Diagnosis and treatment of major complications and recent advances in treatment. Am Fam Physician. 2000; 62:
Bender MA. GeneTests Reviews: Sickle cell Disease, last update 7 March
Wolf B. Worldwide survey of neonatal screening for biotinidase deficiency. J Inherit Metab Dis. 1991; 14:
Wolf B. GeneTests Reviews: Biotinidase Deficiency, last update 2 March
Bosch AM. Classical galatosemia revisited. J Inherit. Metab. Dis. 2006; 29:

65. References
Schweitzer-Krantz S. Early diagnosis of inherited metabolic disorders improving outcome: the controversial issue of galactosemia. Eur J Pediatr. 2003; 162:s50-s503.
Elsas LJ. GeneTests Reviews: Galactosemia, last update 2 May
Moskowitz SM, Gibson RL, Sternen DL, Cutting GR. Genetests Reviews: CFTR-Related Disorders. Last updated 24 August
Yankaskas JR, Marshall BC, Sufian B, Simon RH, Rodman D. Cystic fibrosis adult care: Consensus conference report. Chest 2004;125:s1-s39.
Saiman L, Siegel J. Infection control recommendations for patients with cystic fibrosis: Microbiology, important pathogens and infection control to prevent patient to patient transmission, Cystic fibrosis consensus conference on infection control participants. Am J Infection Control 2003; 31:s1-s62.

66. References
Cystic Fibrosis Trust Clinical Standards and Accreditation Group. Standards of care for children and adults with cystic fibrosis in the UK. May 2001.
Matern D, Rinaldo P. GeneTests Reviews: Medium-Chain Acyl-Coenzyme A Dehydrogenase Deficiency. Last update 3 February
Opdal SH, Rognum TO. The sudden infant death gene: does it exist? Pediatrics 2004; 114:
American Academy of Pediatrics, Newborn Screening Fact Sheets Kaye CL and the Committee on Genetics. Newborn screening fact sheets. Pediatrics 2006; 118:e934-e963.
Pass K A, Lane PA, Fernhoff PM, Hinton CF, Panny SR, parks JS, Pelias MZ, Rhead WJ, Ross SI, Wethers DL, Elsas LJ for CORN. US newborn screening system guidelines II: Follow-up of children, diagnosis, management and evaluation. Statement of the councilof regional networks for genetic services (CORN). Pediatrics 2000; 137(4):s1-s46.

67. Slide 60:
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