1. The Newborn Screening System
Sheila Weiss, MS, LCGC

2. What is Newborn Screening?
A mandatory public health program designed “to detect, in newborns, congenital disorders leading to developmental impairments or physical disabilities”
The conditions we are looking for are RARE, so it is like finding a needle in a haystack because the goal is to screen all babies at birth, and the vast majority do not have one of the conditions we look for in NBS…so we screen a lot of babies…to find those needles, the true positive case.
Read the Definition

3. Why is it Important?
It prevents death and disability to affected infants by providing early treatment
It benefits the public through savings in health care costs and institutional care
This is a great example of what newborn screening does
Both girls are 6 years old and both have congenital Hypothyroidism
The girl on the right was identified early and received proper medical treatment
The girl on the left was not identified early and as a result has both physical and mental retardation
As you can see this illustrates the quite dramatically the effects of early diagnosis
Two 6 year old girls with congenital hypothyroidism

4. WA’s Criteria for Screening
Early identification benefits the newborn
Treatment is available
Nature of the condition justifies population-based screening
A good screening test exists
The benefits justify the costs of screening
The State Board of Health governs the conditions that are on our panel
There are lots of tests available, but before they can be included on our panel they have to meet the criteria for screening
….rather that “Risk Based” screening

5. A Complete System Includes
Universal screening - all infants
“Appropriate” follow-up response
Diagnosis of affected infants
Appropriate treatment & clinical care
Evaluation of system effectiveness

6. The Newborn Screening Process

7. NBS Sequence of Events follow-up NBS lab testing transit time
recommended window for 1st NBS specimen collection
hospital – blood collection
Birth 1
Time (days) 2 3 4 5 6 7

8. When to Screen
Washington State law requires that every newborn be tested “prior to discharge from the hospital or within five days of age”
1st screen should be taken between 18 & 48 hours of life regardless of feeding status (earlier if therapies are administered)
2nd screen strongly recommended between 7 & 14 days of age
Third screen recommended for sick and premature infants at 1 month

9. Benefits of Repeat Screens
Maximizes detection of all disorders, particularly milder forms that may benefit from treatment
May be necessary for detection of some conditions, and is critical for assessment of cystic fibrosis
Verifies hemoglobin traits, eliminating need for diagnostic lab work

10. Screening Compliance Some statistics …
>99.95% of “eligible” infants receive screening (excludes refusals & neonatal deaths)
~94% of infants receive the recommended 2nd screen
~75% of sick & premature receive the recommended 3rd screen

11. Newborn Screening in WA
~85,000 newborns are screened each year
~170,000 specimens processed
~5,500 results requiring follow-up
~2,100 false positives
In the US - > 4 million babies are screened and >6,000 True Positive Cases are identified
true positives
2011 = 188 affected infants
prevalence: 1 in 452!

12. Father of Newborn Screening
“Robert Guthrie, MD, Ph.D. was an American microbiologist, best known for developing the bacterial inhibition assay used to screen infants for phenylketonuria at birth, before the development of irreversible neurological damage.”
Wikipedia

13. Place a blood spot on a plate of agar with bacteria and a bacteria inhibitor (which suppresses the growth of the bacteria). However, phenylalanine blocks the action of the inhibitor, so when there’s bacterial growth it means that there’s phenylalanine in the blood. The phenylalanine is seen as a “ring” around the blood spot. The larger the diameter of the ring, the higher the phe level.

15. Technology that Enables Expansion
Tandem Mass Spectrometer - MS/MS

16. MS/MS Plasma Amino Acids

17. Biotinidase Screening

18. Hemoglobin Screening
FAE
AE control
FAC
AFSC control
FA normal

19. Screening Results what we would like … Normal Affected
100% specificity
100% sensitivity

20. Screening Results what we usually get … Normal Affected
Specificity vs. Sensitivity

21. Abnormal Screening Results
Response is dependent on disorder, magnitude of result, & demographics of infant (presumptive, borderline, inconclusive)

22. not all 2° markers* elevated all 2° markers* elevated.
Stratifying Results
Categorization of C3 Cutoffs
Age ≤ 6 days
Age > 6 days C3
mmol/L serum
not all 2° markers* elevated
all 2° markers* elevated
< 4.1
normal
4.1 – 4.89
borderlinea
Presumptivec
4.9 – 6.09
borderlineb
6.1 – 8.39
Presumptive c
8.4 – 11.99
borderlined
≥ 12.00
Presumptive
* normal ranges for secondary markers: C3/C2 < 0.2 and C3/C16 < 2.2

23. Follow-up Responses for abnormal C3 results …
a - if first screen, wait for routine second; if second screen and previous normal, call health care provider and recommend third screen; if second screen and previous abnormal, call health care provider and recommend immediate diagnostic work-up
b - call health care provider and recommend collecting subsequent screen ASAP
c - call health care provider and recommend immediate diagnostic work-up
d - call health care provider to request second screen ASAP

24. High Urgency !! CAH Galactosemia MSUD
Diagnosis and treatment should be initiated ASAP!

25. Moderate Urgency! Congenital Hypothyroidism MCAD deficiency PKU
Treatment recommended by weeks of age

26. No Medical Urgency .. can wait over a weekend to notify
Cystic Fibrosis
Sickle Cell Disease
Treatment recommended by 2 to 4 weeks of age

27. Special Issues for adrenal (CAH) results …
low birthweight & sick babies
steroids
different forms of the disorder severe (salt-wasting) non-life threatening (simple virilizing) - other forms

28. Policy & Program Evaluation

29. WAs Newborn Screening Timeline
1967 Phenylketonuria (PKU) 1977 Congenital Hypothyroidism 1984 Congenital Adrenal Hyperplasia (CAH) 1991 Hemoglobinopathies (includes SCD) 2004 Biotinidase deficiency Galactosemia Homocystinuria Maple Syrup Urine Disease (MSUD), Medium Chain Acyl co-A Dehydrogenase (MCAD) deficiency 2006 Cystic Fibrosis Amino acid disorders (ASA, CIT, TYR-1) 4 Fatty acid disorders (CUD, LCHAD, TFP, VLCAD) 8 Organic acid isorders (HMG, BKT, GA-I, IVA, CblA-B, MUT, MCD, PROP)
Sept and Dec 2007 mtgs of the WS NBS Advisory Cmt – 17 disorders considered
3 received unanimous YES
13 received majority of YES votes (i.e ranging from 1 – 4 no’s)
1 did NOT receive a YES majority
According to the Washington State Department of Health NBS Program’s website:
In May 2008, the State Board of Health unanimously approved adding 15 new disorders to the newborn screening panel in Washington State.  We have been working hard to implement the changes as soon as possible.  On July 21, 2008 we began screening for 14 of the new conditions.  The last condition, tyrosinemia type I (TYR-I), requires a more complex testing procedure and was added September 22, 2008.  No extra blood will be needed to test for the new conditions, and there will be no fee increase, as all 15 additional conditions can be tested at the same time by instruments used currently in our laboratory.
The new conditions that have been added to the panel are:
Amino acid disorders
Argininosuccinic acidemia (ASA)
Citrullinemia (CIT)
Tyrosinemia type I (TYR-I)
 Fatty acid disorders
Carnitine uptake deficiency (CUD)
Long-chain L-3-hydroxy acyl-CoA dehydrogenase (LCHAD) deficiency
Trifunctional protein (TFP) deficiency
Very-long chain acyl-CoA dehydrogenase (VLCAD) deficiency
 Organic acid disorders
3-hydroxy-3-methylglutaric aciduria (HMG)
Beta-ketothiolase deficiency (BKT)
Glutaric acidemia type I (GA-I)
Isovaleric acidemia (IVA)
Methylmalonic acidemia CblA,B
Methylmalonic acidemia MUT
Multiple carboxylase deficiency (MCD)
Propionic acidemia (PROP)

30. # of conditions screened for by state, 2004
Go through this slides VERY QUICKLY – just mention:
In 2004:
9 or more tests: 21 states
Between 6 – 9 tests: 14
5 or fewer tests: 16

32. Major 2008 Expansion 15 Additional Disorders: 19 MS/MS disorders
3-OH 3-CH3 glutaric aciduria (HMG)
Argininosuccinic acidemia (ASA)
Beta-Ketothiolase deficiency (BKT)
Carnitine uptake defect (CUD)
Citrullinemia (CIT)
Glutaric acidemia type I (GA 1)
Isovaleric acidemia (IVA)
Long-chain L-3-OH acyl-CoA dehydrogenase deficiency (LCHADD)
Methylmalonic acidemia (Cbl A, B)
Methylmalonic acidemia - mutase deficiency (MUT)
Multiple carboxylase deficiency (MCD)
Propionic acidemia (PROP)
Trifunctional protein deficiency (TFP)
Tyrosinemia type I (TYR I)
Very long-chain acyl-CoA dehydrogenase deficiency (VLCADD)
19 MS/MS disorders
49 markers

33. What are we screening for?
9 OA
5 FAO
6 AA
3 Hb Pathies
6 Others
CORE PANEL
IVA GA I HMG MCD MMA MUT PROP BKT
3MCC
MCAD VLCAD LCHAD TFP CUD
PKU MSUD HCY CIT ASA TYR I
Hb SS Hb S/ßTh Hb S/C
CH BIOT CAH GALT HEAR CF
On seven 1/8 inch blood spots!

34. 3-Methylcrotonyl-CoA carboxylase deficiency (3MCC)
Without treatment many people have no clinical symptoms.
Treatment prevents and corrects all problems in symptomatic patients.
Screening test is very good at detecting affected infants, but not totally specific. Also detects asymptomatic mothers.
Not evident at birth – a sudden metabolic crisis can bring on severe illness (but in a very small percentage of patients).

35. Amino Acid Disorders
PKU: severe, permanent ID
MSUD: ID, hallucinations, ataxia
HCY: connective tissue damage (joints, heart), ID, psychiatric disturbances
CIT: risk of hyperammonemia  ID, coma, death
ASA: brittle hair, liver disease ID
TYR I: acute or chronic liver disease, liver cancer, neurologic pain crises
Amino acids not used to make proteins are recycled by their specific metabolic pathways.
Enzymatic deficiencies in these pathways lead to various clinical phenotypes.
Diagnosed by plasma amino acids, urine amino acids, and/or urine organic acids

36. Other: 1 ASA, 1 CIT, 1 HCY, 1 TYR

37. Organic Acid Disorders
Organic acids are breakdown products of protein and fatty acid metabolism. Defects in their breakdown lead to (generally):
Vomiting, metabolic acidosis, elevated ammonia in crises
ID, motor delay, ataxia, cardiac/renal/pancreatic problems
Diagnosed by urine organic acids and/or plasma acylcarnitines
IVA: Isovaleric acidemia
GA I: Glutaric acidemia type I
HMG: 3-OH 3-CH3 glutaric aciduria
MCD: Multiple carboxylase deficiency
MUT: Methylmalonic acidemia (mutase deficiency)
3MCC: 3-Methylcrotonyl-CoA carboxylase deficiency
Cbl A,B: Methylmalonic acidemia
PROP: Propionic acidemia
BKT: Beta-ketothiolase deficiency

39. Fatty Acid Disorders
Fatty acid disorders lead to impaired energy production
Hypoglycemia, cardiomyopathy, muscle weakness can be seen
Diagnosed by plasma acylcarnitines, and urine organic acids can be helpful
MCAD: Medium-chain acyl-CoA dehydrogenase deficiency
VLCAD: Very long-chain acyl-CoA dehydrogenase deficiency
LCHAD: Long-chain L-3-OH acyl-CoA dehydrogenase deficiency
TFP: Trifunctional protein deficiency
CUD: Carnitine uptake defect

42. Objective for an Affected Child
PROMPT DIAGNOSIS & TREATMENT to prevent death and disability by:
modifying their feedings
supplementing carnitine
administering hormone replacement
other therapies

43. The results produced by the mass spectrometer display the data as vertical lines distributed across a horizontal axis (called a mass spectrum). Where the vertical line occurs in the spectrum identifies a compound’s mass (weight), while the height of the line represents how much of the compound there is.
Advantages: phenylalanine levels are more precise, it indicates the tyrosine level. Also, it produces a result in less about 2 hours.

44. Clinical Management: PKU
Correct substrate imbalance
Restrict phenylalanine intake to normalize plasma concentration
Supply product
Supplement tyrosine to maintain normal plasma tyrosine levels
Phenylalanine //  Tyrosine
(substrate) phenylalanine hydroxylase (product)

45. Stabilizing Phe Levels
Equilibrium achieved by
14 days of age
Blood levels every 2 days
because of rapid growth

46. Management Tools Specialized formula provides
80-90% energy intake
85-90% protein intake
tyrosine supplements
no phenylalanine
Phenylalanine to meet requirement from infant formula or foods

47. Effective Phe Level Management
Blood levels once per month, or more frequently if needed for good management

48. Goals of PKU Management
Normal growth rate
Normal physical development
Normal cognitive development
Normal nutritional status

49. Maternal PKU Concerns/Outcomes
Women with PKU are at high risk for delivering a damaged infant
Placenta concentrates phe 2-4x
Microcephaly
Cardiac problems
Infant IQ directly related to maternal blood phe level
Outcome improved with maternal blood phe <2 mg/dl prior to conception and during pregnancy

50. Maternal PKU Syndrome
… and moderate to severe intellectual disability

51. Other Program Services
Provide metabolic treatment products
Subsidize low-protein foods for low-income families
Contract consultant & clinical services
Evaluate long-term outcomes

52. On the Horizon Current National Recommendations
Severe combined immunodeficiency (SCID)
(Congenital Heart Defects)
Potential Additions to National List
Lysosomal storage disorders
Fragile X
Spinal Muscular Atrophy
Muscular dystrophy

53. Washington State Newborn Screening
(206) or
Come visit our lab!