Neugeborenenscreening 2020

The impact of a child's inborn error of metabolism: the parents' perspectives on restrictions, discrimination, family planning, and emergency management

BACKGROUND

To investigate the impact of children's inborn error of metabolism (IEMs) on the children's and their parents' lives from the parents' perspective. We focused on disease-related restrictions in various issues of daily life, experienced discrimination, parental family planning, and management of metabolic emergencies.

METHODS

We conducted a questionnaire-based survey with 108 parents of 119 children with IEM who attended a metabolic outpatient clinic. The children were categorized into 4 cohorts, based on increasing disease severity (cohort 1: IEMs with lowest severity, cohort 4: IEMs with highest severity), and compared by using Tobit regressions.

RESULTS

The severity of the child's IEM was associated with an increase in the intensity of perceived restrictions from the parents' perspective for themselves and their children in all aspects of life: in general, in contact with friends, in the pursuit of hobbies, in childcare/school/occupation, and due to emotional stress. The highest intensity of restrictions in all cohorts was found for the parents themselves in contact with friends (compared to cohort 1: cohort 2: c. 3.556, p = 0.002; cohort 3: c. 4.159, p = 0.003; cohort 4: c. 7.224, p < 0.001). Parents of 8% of children reported that their children were discriminated against because of IEM, with the highest proportion of affected children (43%) in cohort 4. Parental family planning decisions were influenced in 34% of parents, with fear of recurrence being a predominant aspect. Of the parents of children diagnosed with IEMs associated with metabolic emergencies, 68% stated that they felt well or very well prepared for the occurrence of a metabolic emergency, and 100% of parents were able to name the necessary action steps from memory. Nevertheless, 58% stated that they experienced an occurring emergency as rather or very stressful.

CONCLUSIONS

From the parents' perspective, the intensity of restrictions increased with the severity of the child's IEM. The study shows the high impact of IEM on parents of children with IEM and the daily challenges they face. These findings emphasize the importance of comprehensive support for parents of children with IEM.

Parents' Perceptions Regarding Their Children's Medications and Expert-Assessed Drug-Related Problems in Pediatric Patients with Inborn Errors of Metabolism

We aimed to explore parents' perceptions of their children's medication use for inborn errors of metabolism (IEM), including the importance of medication intake, potential complications, and concerns about adverse drug reactions (ADR). Additionally, we aimed to determine expert-assessed clinically relevant drug-related problems, particularly those attributable to IEM. We interviewed 108 parents of 119 pediatric patients with IEM using a questionnaire relating to their perceptions regarding their children's IEM medication. In affected siblings, a questionnaire was used for each child. We performed medication analyses to evaluate the patient's complete medication regimen for clinically relevant drug-related problems, including medication for conditions other than IEM. It was very important to the parents of 85% of the patients to use IEM medication exactly as prescribed. The parents of 41% of patients perceived complications in their children's use of IEM medication. The parents of 47% of patients reported fears concerning ADR because of IEM medication. Parents observed ADR in 27% of patients because of IEM medication. In 44% of patients, medication for conditions other than IEM was inadequate because of drug-related problems not associated with the IEM; a safe alternative existed in 21% of patients. In summary, almost half of the parents of patients with IEM reported complications with their child's IEM medication intake and fears of ADR. Medication analyses showed that drug-related problems occurred regardless of IEM, emphasizing the general need to prescribe and dispense adequate, child-appropriate medication to minimize clinically relevant drug-related problems in pediatric patients.

Is Our Newborn Screening Working Well? A Literature Review of Quality Requirements for Newborn Blood Spot Screening (NBS) Infrastructure and Procedures

Newborn screening using dried blood spots (NBS) is widely acknowledged as a highly successful procedure in secondary prevention. For a number of congenital disorders, severe disability or death are impressively prevented by early detection and early treatment through NBS. However, as with any other screening, NBS can also cause harm, and the principle that "the overall benefits of screening should outweigh the harms" must be considered when introducing and implementing NBS programmes. This publication compiles the results of a systematic literature research on requirements for NBS infrastructure and procedures which was conducted as part of a research project on the quality and shortcomings of the NBS pathway in Germany. The compilation contains the requirements and recommendations for realising the principle of "maximise benefits and minimise harms" in relevant NBS pathway components such as parental education and information, coverage, timeliness, laboratory quality assurance, follow-up of abnormal results, confirmatory diagnostics, documentation, and evaluation. The results reflect the complexity of NBS infrastructure, and thus, they illustrate the importance of considering and implementing NBS as a well-coordinated public health programme with continuous quality management. Special attention should be paid to the perspectives of parents and families. Some NBS issues can substantially benefit from digital instruments or international cooperation. The literature review presented here has contributed to a concept of proposals for the advancement of NBS in Germany, and despite different settings, it may as well be of interest for other countries to achieve the best possible course and outcome of NBS for each child.

Caring for a Child with Congenital Adrenal Hyperplasia Diagnosed by Newborn Screening: Parental Health-Related Quality of Life, Coping Patterns, and Needs

Diagnosing a child by newborn screening with classic congenital adrenal hyperplasia due to 21-hydroxylase deficiency (CAH) causes multiple challenges for the affected parents and the whole family. We aimed to examine the health-related Quality of Life (HrQoL), coping, and needs of parents caring for a child with CAH to develop demand-responsive interventions for improving the psychosocial situation of affected families. In a retrospective cross-sectional design, we assessed HrQoL, coping patterns, and the needs of parents caring for a CAH-diagnosed child using specific questionnaires. Data of 59 families with at least one child diagnosed with CAH were analyzed. The results show that mothers and fathers in this study reached significantly higher HrQoL scores compared to reference cohorts. Decisive for the above-average parental HrQoL were effective coping behaviors and the parental needs being met. These findings verify the importance of helpful coping patterns and rapid fulfillment of parental needs for maintaining a good and stable HrQoL of parents with a child diagnosed with CAH. It is crucial to strengthen the parental HrQoL to build a reasonable basis for a healthy upbringing and improve the medical care of CAH-diagnosed children.

Second-tier strategies in newborn screening - potential and limitations

Newborn screening (NBS) is a public health measure to identify children with treatable disorders within the first days of life allowing presymptomatic treatment. It is the most successful measure of secondary medical prevention and part of public health programs in many countries worldwide. Application of second-tier strategies in NBS allows for increased specificity and consecutively a higher positive predictive value. Second-tier strategies can include analysis of specific biomarkers for a target disorder or may be based on molecular genetic analyses. Improving the quality of NBS, for example by second-tier strategies, is of utmost importance to maintain the high acceptance of NBS by families - especially as an increasing number of target disorders is being consecutively included into NBS programs.

[Interdisciplinary care path and potential IT support for people with rare diseases in Germany]

INTRODUCTION

Due to the high variability and, at the same time, rare occurrence of rare diseases, the diagnosis of these patients (approx. 4 million people in Germany) can turn into an odyssey. The large time interval between the appearance of symptoms and the final diagnosis of the rare disease leads to a delay in the appropriate treatment. The often long period of uncertainty about the cause of symptoms as well as non-specific or even wrong therapies can have negative effects on both the course of disease and the patients' quality of life. For a better understanding of the current care situation and IT landscape, the interdisciplinary care pathway for people with rare diseases will be modelled and the possible uses of IT applications identified that have the potential to improve diagnosis, treatment and therapy of rare diseases.

METHODS

In order to achieve these goals, an initial care pathway was modelled on the basis of process descriptions which are commonly used in the literature, discussed in detail, and agreed upon in a first workshop with six experts from outpatient and inpatient care as well as employees of Centers for Rare Diseases. In a second workshop, ten experts analyzed the resulting care pathway with regard to the possible use of IT applications, and the identification was agreed upon. The experts included those involved in the process, in particular physicians, patients / patient representatives, health care researchers, and experts in hospital IT, IT security, and data protection.

RESULTS

The two workshops resulted in process models including the specification of possible uses for IT applications. The most important steps in the care pathway for people with rare diseases in Germany include: neonatal screening, seeking medical advice, outpatient care by general practitioners, outpatient care by specialists, care by specialist outpatient clinic, care by clinic, care by a Center for Rare Diseases: case review and case conference and treatment and therapy. The discussion of the possible uses of IT applications resulted in a focus on registers (e. g. with regard to experts, treatment and therapy options) as well as on digital tools, such as "digital findings and findings platform" and "digital referral with referral tracking".

DISCUSSION

Our results show that the care pathway is very heterogeneous and complex. Thus, the sub-processes show different variants with many branches and repetitions. They also illustrate that the care for people with rare diseases requires a high level of interdisciplinary collaboration; diagnosis as well as treatment and therapy often take place across sectors and in cooperation between different medical health care institutions and professions. When analyzing the current IT landscape, it becomes clear that IT applications can be used at many process steps in the care for people with rare diseases and have a high potential. Therefore, they must be used to inform decisions about the adequate diagnosis and treatment as well as communication about the clinical pictures and the patient's case between practitioners and medical care sectors.

CONCLUSION

The interdisciplinary collaboration highlights the need for cooperation between the various parties involved in the process, which requires the identification and implementation of interfaces between the stakeholders and their systems. However, it is not enough to include the view of the processes; the data perspective is also required. Creating interoperability also enables the use of IT applications. The basis for this is the results obtained.

[Hormonal influence on hearing]

BACKGROUND

Hearing loss leads to impairments in communication, social interactions, and cognitive functions. This renders early treatment particularly important. A causal therapy is not yet available. Human and animal studies have shown that certain hormones can have a positive effect on hearing.

OBJECTIVE

This review provides an overview of the effects of various hormones on hearing and describes the potential benefit for future therapeutic approaches.

MATERIALS AND METHODS

A systematic literature review of reviews dealing with the effects of various hormones on hearing in humans and animals published in PubMed between 2015 and 2020 was conducted.

RESULTS

Hormones may mediate antiapoptotic effects on structure-relevant cells of the cochlea and auditory pathway, and may influence hair cell functionality or the electrolyte balance of the endo- and perilymph. Current research focuses on glucocorticoids; the mineral corticoid aldosterone; the sex hormones estrogen, progesterone, and testosterone; the growth hormones GH (growth hormone) and IGF‑1 (insulin-like growth factor 1); thyroid hormones; and insulin. Study results are still inconsistent at this time, but various hormones appear to represent a possible future treatment option for acute hearing loss. Long-term hormone treatment, which would be necessary particularly in the case of age-related hearing loss, does not currently represent a sensible course of action due to the side effect profile of the systemic treatment/lack of practicable topical application options.

CONCLUSION

The mode of action of hormones is complex. Whether they can be used in the future for individualized treatment of patients with acute hearing impairment requires further investigation.

Neonatal Screening for Congenital Metabolic and Endocrine Disorders–Results From Germany for the Years 2006–2018

BACKGROUND

The purpose of neonatal screening is the early detection of congenital metabolic and endocrine disorders that, if untreated, could lead to fatal crises or other long-term adverse sequelae. In Germany, neonatal screening is legally regulated. Quality-assurance reports ("DGNS reports") are created and published annually by the German Society for Neonatal Screening (Deutsche Gesellschaft für Neugeborenen-Screening). Data from the DGNS reports for the years 2006-2018 serve as the basis of the present publication.

METHODS

For the years 2006-2018, prevalences were calculated and data on process quality were evaluated.

RESULTS

Among 9 218 538 births, 6917 neonates were identified who had one of the target diseases. The overall prevalence was 75 per 100 000 neonates; the disorders most commonly found were congenital hypothyroidism (30 per 100 000) followed by phenylketonuria (PKU) and medium-chain acyl-CoA dehydrogenase deficiency (MCAD) (10 per 100 000 each). Of the 272 205 follow-up screenings requested, 80% were received. The rate of positive screening findings (recall rate) declined over the observation period, from 0.90% in 2006 to 0.37% in 2018. For every five positive screening findings, one case of a target disorder was confirmed. 79% of the children for whom treatment was indicated began to receive treatment within two weeks.

CONCLUSION

The low recall rate and the early initiation of treatment in 79% of the affected children indicate that neonatal screening for metabolic and endocrine disorders in Germany is effective. The incorporation of tracking structures and the introduction of a registry could further improve the quality of the program.

High incidence of maternal vitamin B12 deficiency detected by newborn screening: first results from a study for the evaluation of 26 additional target disorders for the German newborn screening panel

BACKGROUND

Newborn screening (NBS) in Germany currently includes 15 target disorders. Recent diagnostic improvements suggest an extension of the screening panel.

METHODS

Since August 2016, a prospective study evaluating 26 additional target disorders (25 metabolic disorders and vitamin B₁₂-deficiency) in addition to the German screening panel is performed at the Newborn Screening Center Heidelberg. First-tier results from tandem-MS screening are complemented by second-tier strategies for 15 of the additional target disorders. NBS results of seven patients diagnosed symptomatically with one of the additional target disorders by selective screening since August 2016 are retrospectively evaluated.

RESULTS

Over a 13-month period, 68,418 children participated in the study. Second-tier analyses were performed in 5.4% of samples. Only 59 (0.1%) of study participants had abnormal screening results for one of the additional target disorders. Target disorders from the study panel were confirmed in 12 children: 1 3-hydroxy-3-methylglutaryl coenzyme A (CoA)-lyase deficiency, 1 citrullinemia type I, 1 multiple acyl-CoA dehydrogenase-deficiency, 1 methylenetetrahydrofolate reductase-deficiency, and 8 children with maternal vitamin B₁₂-deficiency. In addition, six of seven patients diagnosed symptomatically outside the study with one of the target disorders would have been identified by the study strategy in their NBS sample.

CONCLUSIONS

Within 13 months, the study "Newborn Screening 2020" identified additional 12 children with treatable conditions while only marginally increasing the recall rate by 0.1%. Maternal vitamin B₁₂-deficiency was the most frequent finding. Even more children could benefit from screening for the additional target disorders by extending the NBS panel for Germany and/or other countries.