The Newborn Screening System Sheila Weiss, MS, LCGC sheila.weiss@doh.wa.gov

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

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

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

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

The Newborn Screening Process http://www.cdc.gov/ncbddd/jaundice/families http://www2.aap.org http://www.europaediatrics2008.org

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

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

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

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

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 170 - 200 true positives 2011 = 188 affected infants prevalence: 1 in 452!

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

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.

Technology that Enables Expansion Tandem Mass Spectrometer - MS/MS

MS/MS Plasma Amino Acids

Biotinidase Screening

Hemoglobin Screening FAE AE control FAC AFSC control FA normal

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

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

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

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

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

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

Moderate Urgency! Congenital Hypothyroidism MCAD deficiency PKU Treatment recommended by 1 - 3 weeks of age

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

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

Policy & Program Evaluation

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 2008 3 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)

# 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

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

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!

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).

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

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

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

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

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

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.

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)

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

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

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

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

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

Maternal PKU Syndrome … and moderate to severe intellectual disability

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

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

Washington State Newborn Screening www.doh.wa.gov/nbs (206) 418-5410 or 1-866-660-9050 Come visit our lab!