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Octavius GS, Daleni VA, Sagala YDS. An insight into Indonesia's progress for newborn screening program: What is currently going on. Heliyon 2024; 10:e33479. [PMID: 39035496 PMCID: PMC11259875 DOI: 10.1016/j.heliyon.2024.e33479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 06/13/2024] [Accepted: 06/21/2024] [Indexed: 07/23/2024] Open
Abstract
Objectives In this literature review, we describe the progress of Indonesia's NBS program (which is heavily centered on CH screening), its current pilot projects, and what lies ahead for this program. Setting Since its conception began with congenital hypothyroidism (CH) screening, Indonesia has experienced plodding progress in NBS. There is a shortage of literature discussing the history, or the lack of, and journey of NBS in Indonesia. Methods We searched for literature in Pubmed and Google Scholar with keywords such as "Newborn Screening, "Neonatal Screening," "Indonesia," "Asia Pacific," "Congenital Hypothyroidism," "Congenital Adrenal Hyperplasia,""Critical Congenital Heart Disease," "Hearing Loss," and "Inborn Error of Metabolism." Results The only mandatory and regulated NBS program in Indonesia is congenital hypothyroid (CH) screening, with some pilot projects being conducted on screening for congenital adrenal hyperplasia (CAH), critical congenital heart disease (CCHD), hearing loss, and to a lesser extent, inborn error of metabolisms (IEMs). Conclusion Despite the evidence and benefits, the government does not mandate or regulate newborn diseases such as CHD, CAH, hearing loss, and IEMs. The lack of regulation exists despite multiple pilot projects and studies showing a benefit in at least trying to screen newborns for those conditions.
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Affiliation(s)
- Gilbert Sterling Octavius
- Department of Pediatrics, Universitas Pelita Harapan, Banten, Indonesia
- St. Theresia Hospital, Jambi, Indonesia
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2
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Therrell BL, Padilla CD, Borrajo GJC, Khneisser I, Schielen PCJI, Knight-Madden J, Malherbe HL, Kase M. Current Status of Newborn Bloodspot Screening Worldwide 2024: A Comprehensive Review of Recent Activities (2020-2023). Int J Neonatal Screen 2024; 10:38. [PMID: 38920845 PMCID: PMC11203842 DOI: 10.3390/ijns10020038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Revised: 03/28/2024] [Accepted: 03/28/2024] [Indexed: 06/27/2024] Open
Abstract
Newborn bloodspot screening (NBS) began in the early 1960s based on the work of Dr. Robert "Bob" Guthrie in Buffalo, NY, USA. His development of a screening test for phenylketonuria on blood absorbed onto a special filter paper and transported to a remote testing laboratory began it all. Expansion of NBS to large numbers of asymptomatic congenital conditions flourishes in many settings while it has not yet been realized in others. The need for NBS as an efficient and effective public health prevention strategy that contributes to lowered morbidity and mortality wherever it is sustained is well known in the medical field but not necessarily by political policy makers. Acknowledging the value of national NBS reports published in 2007, the authors collaborated to create a worldwide NBS update in 2015. In a continuing attempt to review the progress of NBS globally, and to move towards a more harmonized and equitable screening system, we have updated our 2015 report with information available at the beginning of 2024. Reports on sub-Saharan Africa and the Caribbean, missing in 2015, have been included. Tables popular in the previous report have been updated with an eye towards harmonized comparisons. To emphasize areas needing attention globally, we have used regional tables containing similar listings of conditions screened, numbers of screening laboratories, and time at which specimen collection is recommended. Discussions are limited to bloodspot screening.
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Affiliation(s)
- Bradford L. Therrell
- Department of Pediatrics, University of Texas Health Science Center San Antonio, San Antonio, TX 78229, USA
- National Newborn Screening and Global Resource Center, Austin, TX 78759, USA
| | - Carmencita D. Padilla
- Department of Pediatrics, College of Medicine, University of the Philippines Manila, Manila 1000, Philippines;
| | - Gustavo J. C. Borrajo
- Detección de Errores Congénitos—Fundación Bioquímica Argentina, La Plata 1908, Argentina;
| | - Issam Khneisser
- Jacques LOISELET Genetic and Genomic Medical Center, Faculty of Medicine, Saint Joseph University, Beirut 1104 2020, Lebanon;
| | - Peter C. J. I. Schielen
- Office of the International Society for Neonatal Screening, Reigerskamp 273, 3607 HP Maarssen, The Netherlands;
| | - Jennifer Knight-Madden
- Caribbean Institute for Health Research—Sickle Cell Unit, The University of the West Indies, Mona, Kingston 7, Jamaica;
| | - Helen L. Malherbe
- Centre for Human Metabolomics, North-West University, Potchefstroom 2531, South Africa;
- Rare Diseases South Africa NPC, The Station Office, Bryanston, Sandton 2021, South Africa
| | - Marika Kase
- Strategic Initiatives Reproductive Health, Revvity, PL10, 10101 Turku, Finland;
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3
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Conlon TA, Hawkes CP, Brady JJ, Loeber JG, Murphy N. International Newborn Screening Practices for the Early Detection of Congenital Adrenal Hyperplasia. Horm Res Paediatr 2023; 97:113-125. [PMID: 37231960 DOI: 10.1159/000530754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 04/11/2023] [Indexed: 05/27/2023] Open
Abstract
INTRODUCTION Newborn screening (NBS) programmes vary internationally in their approach to screening. Guidelines for congenital adrenal hyperplasia (CAH) screening recommend the use of two-tier testing and gestational age cutoffs to minimise false-positive results. The aims of this study were to describe (1) the approaches; (2) protocols used; and (3) available outcomes for CAH screening internationally. METHODS All members of the International Society for Neonatal Screening were asked to describe their CAH NBS protocols, with an emphasis on the use of second-tier testing, 17-hydroxyprogesterone (17OHP) cutoffs, and gestational age and birth weight adjustments. If available, screening outcomes were requested. RESULTS Representatives from 23 screening programmes provided data. Most (n = 14; 61%) recommend sampling at 48-72 h of life. Fourteen (61%) use single-tier testing and 9 have a two-tier testing protocol. Gestational age cutoffs are used in 10 programmes, birth weight cutoffs in 3, and a combination of both in 9. One programme does not use either method of adjusting 17OHP cutoffs. Case definition of a positive test and the response to a positive test differed between programmes. CONCLUSIONS We have demonstrated significant variation across all aspects of NBS for CAH, including timing, the use of single versus two-tier testing and cutoff interpretation. Collaboration between international screening programmes and implementation of new techniques to improve screen efficacy will facilitate ongoing expansion and quality improvement in CAH NBS.
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Affiliation(s)
- Tracey A Conlon
- Department of Paediatric Endocrinology, Children's Health Ireland at Temple Street, Dublin, Ireland
- School of Medicine, University College Dublin, Dublin, Ireland
| | - Colin P Hawkes
- INFANT Research Centre, University College Cork, Cork, Ireland
- Perelman School of Medicine, University of Pennsylvania, PA, Philadelphia, USA
- Department of Paediatrics and Child Health, University College Cork, Cork, Ireland
| | - Jennifer J Brady
- School of Medicine, University College Dublin, Dublin, Ireland
- Department of Paediatric Laboratory Medicine, Children's Health Ireland at Temple Street, Dublin, Ireland
| | - J Gerard Loeber
- Office of the International Society for Neonatal Screening, Maarssen, The Netherlands
| | - Nuala Murphy
- Department of Paediatric Endocrinology, Children's Health Ireland at Temple Street, Dublin, Ireland
- School of Medicine, University College Dublin, Dublin, Ireland
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Raveendran A, Chacko TJ, Prabhu P, Varma R, Lewis LE, Rao P, Shetty PP, Mallimoggala YSP, Hedge A, Nayak DM, Moorkoth S, Moorkoth S. Need and Viability of Newborn Screening Programme in India: Report from a Pilot Study. Int J Neonatal Screen 2022; 8:26. [PMID: 35466197 PMCID: PMC9036214 DOI: 10.3390/ijns8020026] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 03/05/2022] [Accepted: 03/10/2022] [Indexed: 02/01/2023] Open
Abstract
India, a country with the second largest population in the world, does not have a national newborn screening programme as part of its health policy. With funding support from the Grand Challenges Canada, a pilot newborn screening programme was implemented for the Udupi district of South India to study the need and viability of a national programme in India. Six disorders were selected for the study based on the availability of funding and recommendation from pediatricians in the district. Here, we report the observed incidence during the study. A cost-effectiveness analysis of implementing newborn screening in India was performed. It is evident from our analysis that the financial loss for the nation due to these preventable diseases is much higher than the overall expenditure for screening, diagnosis, and treatment. This cost-effectiveness analysis justifies the need for a national newborn screening programme in India.
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Affiliation(s)
- Arya Raveendran
- Department of Pharmaceutical Quality Assurance, Manipal College of Pharmaceutical Sciences, Manipal Academy of Higher Education, Manipal 576104, India; (A.R.); (T.J.C.); (P.P.); (R.V.)
| | - Teena Joseph Chacko
- Department of Pharmaceutical Quality Assurance, Manipal College of Pharmaceutical Sciences, Manipal Academy of Higher Education, Manipal 576104, India; (A.R.); (T.J.C.); (P.P.); (R.V.)
| | - Priya Prabhu
- Department of Pharmaceutical Quality Assurance, Manipal College of Pharmaceutical Sciences, Manipal Academy of Higher Education, Manipal 576104, India; (A.R.); (T.J.C.); (P.P.); (R.V.)
| | - Raghava Varma
- Department of Pharmaceutical Quality Assurance, Manipal College of Pharmaceutical Sciences, Manipal Academy of Higher Education, Manipal 576104, India; (A.R.); (T.J.C.); (P.P.); (R.V.)
| | - Leslie Edward Lewis
- Department of Pediatrics, Kasturba Medical College, Manipal Academy of Higher Education, Manipal 576104, India;
| | - Pragna Rao
- Department of Biochemistry, Kasturba Medical College, Manipal Academy of Higher Education, Manipal 576104, India; (P.R.); (P.P.S.); (Y.S.P.M.)
| | - Prajna P. Shetty
- Department of Biochemistry, Kasturba Medical College, Manipal Academy of Higher Education, Manipal 576104, India; (P.R.); (P.P.S.); (Y.S.P.M.)
| | - Yajna S. Phaneendra Mallimoggala
- Department of Biochemistry, Kasturba Medical College, Manipal Academy of Higher Education, Manipal 576104, India; (P.R.); (P.P.S.); (Y.S.P.M.)
| | - Asha Hedge
- Department of Pediatrics, Melaka Manipal Medical College, Manipal Academy of Higher Education, Manipal 576104, India; (A.H.); (D.M.N.)
| | - Dinesh M. Nayak
- Department of Pediatrics, Melaka Manipal Medical College, Manipal Academy of Higher Education, Manipal 576104, India; (A.H.); (D.M.N.)
| | - Sudeep Moorkoth
- Chesterfield Royal Hospital NHS Trust, Calow, Chesterfield S44 5BL, UK;
| | - Sudheer Moorkoth
- Department of Pharmaceutical Quality Assurance, Manipal College of Pharmaceutical Sciences, Manipal Academy of Higher Education, Manipal 576104, India; (A.R.); (T.J.C.); (P.P.); (R.V.)
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5
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Claahsen - van der Grinten HL, Speiser PW, Ahmed SF, Arlt W, Auchus RJ, Falhammar H, Flück CE, Guasti L, Huebner A, Kortmann BBM, Krone N, Merke DP, Miller WL, Nordenström A, Reisch N, Sandberg DE, Stikkelbroeck NMML, Touraine P, Utari A, Wudy SA, White PC. Congenital Adrenal Hyperplasia-Current Insights in Pathophysiology, Diagnostics, and Management. Endocr Rev 2022; 43:91-159. [PMID: 33961029 PMCID: PMC8755999 DOI: 10.1210/endrev/bnab016] [Citation(s) in RCA: 176] [Impact Index Per Article: 88.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Indexed: 11/19/2022]
Abstract
Congenital adrenal hyperplasia (CAH) is a group of autosomal recessive disorders affecting cortisol biosynthesis. Reduced activity of an enzyme required for cortisol production leads to chronic overstimulation of the adrenal cortex and accumulation of precursors proximal to the blocked enzymatic step. The most common form of CAH is caused by steroid 21-hydroxylase deficiency due to mutations in CYP21A2. Since the last publication summarizing CAH in Endocrine Reviews in 2000, there have been numerous new developments. These include more detailed understanding of steroidogenic pathways, refinements in neonatal screening, improved diagnostic measurements utilizing chromatography and mass spectrometry coupled with steroid profiling, and improved genotyping methods. Clinical trials of alternative medications and modes of delivery have been recently completed or are under way. Genetic and cell-based treatments are being explored. A large body of data concerning long-term outcomes in patients affected by CAH, including psychosexual well-being, has been enhanced by the establishment of disease registries. This review provides the reader with current insights in CAH with special attention to these new developments.
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Affiliation(s)
| | - Phyllis W Speiser
- Cohen Children’s Medical Center of NY, Feinstein Institute, Northwell Health, Zucker School of Medicine, New Hyde Park, NY 11040, USA
| | - S Faisal Ahmed
- Developmental Endocrinology Research Group, School of Medicine Dentistry & Nursing, University of Glasgow, Glasgow, UK
| | - Wiebke Arlt
- Institute of Metabolism and Systems Research (IMSR), College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
- Department of Endocrinology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Richard J Auchus
- Division of Metabolism, Endocrinology, and Diabetes, Departments of Internal Medicine and Pharmacology, University of Michigan, Ann Arbor, MI 48109, USA
| | - Henrik Falhammar
- Department of Molecular Medicine and Surgery, Karolinska Intitutet, Stockholm, Sweden
- Department of Endocrinology, Karolinska University Hospital, Stockholm, Sweden
| | - Christa E Flück
- Pediatric Endocrinology, Diabetology and Metabolism, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
| | - Leonardo Guasti
- Centre for Endocrinology, William Harvey Research Institute, Bart’s and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Angela Huebner
- Division of Paediatric Endocrinology and Diabetology, Department of Paediatrics, Universitätsklinikum Dresden, Technische Universität Dresden, Dresden, Germany
| | - Barbara B M Kortmann
- Radboud University Medical Centre, Amalia Childrens Hospital, Department of Pediatric Urology, Nijmegen, The Netherlands
| | - Nils Krone
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
- Department of Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Deborah P Merke
- National Institutes of Health Clinical Center and the Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD 20892, USA
| | - Walter L Miller
- Department of Pediatrics, Center for Reproductive Sciences, and Institute for Human Genetics, University of California, San Francisco, CA 94143, USA
| | - Anna Nordenström
- Department of Women’s and Children’s Health, Karolinska Institutet, Stockholm, Sweden
- Pediatric Endocrinology, Karolinska University Hospital, Stockholm, Sweden
| | - Nicole Reisch
- Medizinische Klinik IV, Klinikum der Universität München, Munich, Germany
| | - David E Sandberg
- Department of Pediatrics, Susan B. Meister Child Health Evaluation and Research Center, University of Michigan, Ann Arbor, MI 48109, USA
| | | | - Philippe Touraine
- Department of Endocrinology and Reproductive Medicine, Center for Rare Endocrine Diseases of Growth and Development, Center for Rare Gynecological Diseases, Hôpital Pitié Salpêtrière, Sorbonne University Medicine, Paris, France
| | - Agustini Utari
- Division of Pediatric Endocrinology, Department of Pediatrics, Faculty of Medicine, Diponegoro University, Semarang, Indonesia
| | - Stefan A Wudy
- Steroid Research & Mass Spectrometry Unit, Laboratory of Translational Hormone Analytics, Division of Paediatric Endocrinology & Diabetology, Justus Liebig University, Giessen, Germany
| | - Perrin C White
- Division of Pediatric Endocrinology, UT Southwestern Medical Center, Dallas TX 75390, USA
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6
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Rowlands A, Deeb A, Ladjouze A, Hamza RT, Musa SA, Raza J, Jennane F, Abu-Libdeh A, Chanoine JP. Access to fludrocortisone and to hydrocortisone in children with congenital adrenal hyperplasia in the WHO Eastern Mediterranean Region: it takes a village…. BMJ Glob Health 2021; 6:bmjgh-2021-007195. [PMID: 34675026 PMCID: PMC8532553 DOI: 10.1136/bmjgh-2021-007195] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Accepted: 09/25/2021] [Indexed: 11/14/2022] Open
Abstract
Congenital adrenal hyperplasia (CAH), if untreated, carries high morbidity and mortality. A higher incidence of CAH is expected in countries where consanguinity is common, such as in the countries of the WHO Eastern Mediterranean Region (EMRO). CAH is managed through lifelong treatment with fludrocortisone and hydrocortisone. In this analysis, performed in the 22 EMRO countries and territories plus Algeria, we review which countries offer a neonatal screening programme for CAH and describe the barriers and opportunities to access oral fludrocortisone and oral and injectable hydrocortisone. Neonatal CAH screening was only available nationally in Qatar, Kuwait and partially in Lebanon and Saudi Arabia. We reviewed the national lists of essential medicines (NEMLs) and found that 13/23 (57%) countries included fludrocortisone and 18/23 (78%) included oral hydrocortisone. Fludrocortisone was not included by any of the low-income countries and oral hydrocortisone was only included by one low-income country. We then contacted paediatric endocrinologists in each country to assess perceived availability of these medicines. Overall, there was a relatively good consistency between inclusion of fludrocortisone and hydrocortisone in the NEML and their actual availability in a country. We propose several mechanisms to improve access, including prequalification by the WHO, a common registration process for groups of countries, pooled procurement, working with local pharmaceutical companies, special access status for medicines not yet registered in a country and compounding. We suggest that access to medicines requires a collaboration between health professionals, families of patients, health authorities, pharmaceutical companies and the WHO.
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Affiliation(s)
- Amanda Rowlands
- Endocrinology and Diabetes Unit, Department of Pediatrics, British Columbia Children's Hospital and University of British Columbia, Vancouver, British Columbia, Canada.,Global Pediatric Endocrinology and Diabetes, Vancouver, British Columbia, Canada
| | - Asma Deeb
- Global Pediatric Endocrinology and Diabetes, Vancouver, British Columbia, Canada.,Paediatric Endocrinology Division, Sheikh Shakhbout Medical City and Khalifa University, Abu Dhabi, UAE
| | - Asmahane Ladjouze
- Global Pediatric Endocrinology and Diabetes, Vancouver, British Columbia, Canada.,Paediatric endocrinology, Department of Paediatrics, Bab El Oued Teaching hospital, Algiers, Algeria
| | - Rasha T Hamza
- Global Pediatric Endocrinology and Diabetes, Vancouver, British Columbia, Canada.,Department of Pediatrics, Pediatric Endocrinology Unit, Faculty of Medicine, Ain Shams University Faculty of Medicine, Cairo, Egypt
| | - Salwa A Musa
- Global Pediatric Endocrinology and Diabetes, Vancouver, British Columbia, Canada.,Pediatric endocrinology, Gaafar Ibn Auf Tertiary Pediatric Hospital and University of Khartoum, Khartoum, Sudan
| | - Jamal Raza
- Executive Director, National Institute of Child Health, Karachi, Pakistan
| | - Farida Jennane
- Unité d'Endocrinologie/ Diabétologie, Faculté de Médecine de Casablanca, Hôpital Universitaire Abderrahim Harouchi Pédiatrie2 CH Ibn Rochd, Casablanca, Morocco
| | - Abdulsalam Abu-Libdeh
- Global Pediatric Endocrinology and Diabetes, Vancouver, British Columbia, Canada.,Pediatric Endocrinology Unit, Department of Pediatrics, Al-Quds Medical School Makassed Islamic Hospital, Jerusalem, Israel
| | - Jean-Pierre Chanoine
- Endocrinology and Diabetes Unit, Department of Pediatrics, British Columbia Children's Hospital and University of British Columbia, Vancouver, British Columbia, Canada .,Global Pediatric Endocrinology and Diabetes, Vancouver, British Columbia, Canada
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7
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Impact of Newborn Screening on Clinical Presentation of Congenital Adrenal Hyperplasia. ACTA ACUST UNITED AC 2021; 57:medicina57101035. [PMID: 34684072 PMCID: PMC8540623 DOI: 10.3390/medicina57101035] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 09/24/2021] [Accepted: 09/26/2021] [Indexed: 11/24/2022]
Abstract
Background and Objectives: The main reason for Newborn screening (NBS) for congenital adrenal hyperplasia (CAH) is to prevent adrenal insufficiency that can lead to life-threatening conditions. On the other hand, screening programs are not always sensitive and effective enough to detect the disease. We aimed to evaluate impact of the national NBS on the clinical presentation of patients with CAH in Lithuania. Materials and Methods: A retrospective study was performed on data of 88 patients with CAH from 1989 to 2020. Patients with confirmed CAH were divided into two groups: (1) 75 patients diagnosed before NBS: 52 cases with salt-wasting (SW), 21 with simple virilising (SV) and two with non-classical (NC) form; (2) 13 patients diagnosed with NBS: 12 cases with SW and 1 case with SV form. For the evaluation of NBS effectiveness, data of only male infants with salt-wasting CAH were analysed (n = 36, 25 unscreened and nine screened). Data on gestational age, birth weight, weight, symptoms, and laboratory tests (serum potassium and sodium levels) on the day of diagnosis, were analysed. Results: A total of 158,486 neonates were screened for CAH from 2015 to 2020 in Lithuania and CAH was confirmed in 13 patients (12 SW, one–SV form), no false negative cases were found. The sensitivity and specificity of NBS program for classical CAH forms were 100%; however, positive predictive value was only 4%. There were no significant differences between unscreened and screened male infant groups in terms of age at diagnosis, serum potassium, and serum sodium levels. Significant differences were found in weight at diagnosis between the groups (−1.67 ± 1.12 SDS versus 0.046 ± 1.01 SDS of unscreened and screened patients respectively, p = 0.001). Conclusions: The sensitivity and specificity of NBS for CAH program were 100%, but positive predictive value—only 4%. Weight loss was significantly lower and the weight SDS at diagnosis was significantly higher in the group of screened patients.
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8
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Conlon TA, Hawkes CP, Brady JJ, Murphy NP. The presentation of congenital adrenal hyperplasia in an unscreened population. J Pediatr Endocrinol Metab 2021; 34:1123-1129. [PMID: 34167176 DOI: 10.1515/jpem-2021-0123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 04/12/2021] [Indexed: 11/15/2022]
Abstract
BACKGROUND The aim of this study was to describe the incidence and spectrum of early clinical presentations of congenital adrenal hyperplasia (CAH) in an unscreened population. METHODS A national retrospective observational study was undertaken to identify all children diagnosed with CAH in the Republic of Ireland, between January 2005 and December 2019. Reporting clinicians completed anonymized clinical questionnaires. RESULTS There were 103 cases of CAH reported and 69 cases met the study inclusion criteria. The estimated annualized incidence of CAH in the Republic of Ireland was 1:14,754 or 0.07 cases per 1,000 live births. Forty-seven children presented clinically in the first six months of life, but only 17 of these had a confirmed diagnosis by day 10. Of these early presentations, there were 28 infants with salt-wasting, 15 females presented with virilized genitalia and four infants were detected due to a family history of CAH. Female infants presented at a median age of 0 days [IQR 0-1] and males at 14 days [IQR 9-21]. Seventy-eight percent of salt-wasting presentations occurred after day 10. Delays in clinical presentation, biochemical diagnosis and treatment initiation were identified. CONCLUSIONS The incidence of CAH is higher in Ireland than in other unscreened populations. In the absence of screening, clinicians should be aware of the possibility of CAH and appropriate investigations should be urgently requested. Life-threatening salt-wasting is the most frequent clinical presentation and many cases could be detected prior to decompensation if newborn screening were introduced.
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Affiliation(s)
- Tracey A Conlon
- Department of Paediatric Endocrinology, Children's Health Ireland at Temple Street, Dublin 1, Ireland.,School of Medicine, University College Dublin, Dublin 4, Ireland
| | - Colin P Hawkes
- Division of Endocrinology and Diabetes, The Children's Hospital of Philadelphia, Philadelphia, USA.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA.,Department of Paediatrics and Child Health, University College Cork, Cork, Ireland
| | - Jennifer J Brady
- Department of Clinical Biochemistry, Children's Health Ireland at Temple Street, Dublin 1, Ireland
| | - Nuala P Murphy
- Department of Paediatric Endocrinology, Children's Health Ireland at Temple Street, Dublin 1, Ireland.,School of Medicine, University College Dublin, Dublin 4, Ireland
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9
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Tsuji-Hosokawa A, Kashimada K. Thirty-Year Lessons from the Newborn Screening for Congenital Adrenal Hyperplasia (CAH) in Japan. Int J Neonatal Screen 2021; 7:ijns7030036. [PMID: 34209888 PMCID: PMC8293132 DOI: 10.3390/ijns7030036] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 06/24/2021] [Accepted: 06/25/2021] [Indexed: 01/02/2023] Open
Abstract
Congenital adrenal hyperplasia (CAH) is an inherited disorder caused by the absence or severely impaired activity of steroidogenic enzymes involved in cortisol biosynthesis. More than 90% of cases result from 21-hydroxylase deficiency (21OHD). To prevent life-threatening adrenal crisis and to help perform appropriate sex assignments for affected female patients, newborn screening (NBS) programs for the classical form of CAH have been introduced in numerous countries. In Japan, the NBS for CAH was introduced in 1989, following the screenings for phenylketonuria and congenital hypothyroidism. In this review, we aim to summarize the experience of the past 30 years of the NBS for CAH in Japan, composed of four parts, 1: screening system in Japan, 2: the clinical outcomes for the patients with CAH, 3: various factors that would impact the NBS system, including timeline, false positive, and LC-MS/MS, 4: Database composition and improvement of the screening program.
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Affiliation(s)
- Atsumi Tsuji-Hosokawa
- Department of Systems BioMedicine, National Research Institute for Child Health and Development, Tokyo 157-8535, Japan;
- Department of Pediatrics and Developmental Biology, Tokyo Medical and Dental University (TMDU), Tokyo 113-8510, Japan
| | - Kenichi Kashimada
- Department of Pediatrics and Developmental Biology, Tokyo Medical and Dental University (TMDU), Tokyo 113-8510, Japan
- Correspondence:
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10
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Van Vliet G, Grosse SD. [Newborn screening for congenital hypothyroidism and congenital adrenal hyperplasia: Benefits and costs of a successful public health program]. Med Sci (Paris) 2021; 37:528-534. [PMID: 34003099 PMCID: PMC8387970 DOI: 10.1051/medsci/2021053] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Newborn screening is an important public health program and a triumph of preventive medicine. Economic analyses show that the benefits of newborn screening clearly outweigh the costs for certain diseases, but not necessarily for other ones. This is due to the great diversity of the natural history of the diseases detected, to the fact that each of these diseases considered individually is rare, and to differences in the effectiveness of interventions. In addition, the benefit-cost ratio of screening for a particular disorder may differ between countries, specifically between high-income and low- and middle-income countries. The burden of a disorder may also be alleviated by increased clinical awareness and effective clinical services, even in the absence of newborn screening. In this article, we focus on economic analyses of newborn screening for primary congenital hypothyroidism, which has been in place in high-income countries for roughly 40 years, and for classic congenital adrenal hyperplasia due to 21-hydroxylase deficiency. Screening for the latter is not yet universal, even in high-income countries, although the lack of universal implementation may reflect factors other than economic considerations.
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Affiliation(s)
- Guy Van Vliet
- Service d'endocrinologie et Centre de recherche, Centre hospitalier universitaire Sainte-Justine et Département de pédiatrie, Université de Montréal, 3175 Côte Sainte-Catherine, Montréal (Québec) H3T 1C5, Canada
| | - Scott D Grosse
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, 4770 Buford Highway, Atlanta, GA, 30341, États-Unis
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11
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Gau M, Konishi K, Takasawa K, Nakagawa R, Tsuji-Hosokawa A, Hashimoto A, Sutani A, Tajima T, Hasegawa T, Morio T, Kashimada K. The progression of salt-wasting and the body weight change during the first 2 weeks of life in classical 21-hydroxylase deficiency patients. Clin Endocrinol (Oxf) 2021; 94:229-236. [PMID: 33001476 DOI: 10.1111/cen.14347] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 09/17/2020] [Accepted: 09/21/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND One of the major purposes of newborn screening for 21-hydroxylase deficiency (21OHD) is preventing life-threatening adrenal crisis. However, the details of adrenal crisis in newborns are not precisely documented. AIM We aimed to clarify the clinical details of salt-wasting in newborn 21OHD patients. METHODS Based on the follow-up survey of the screening in Tokyo from 1989 to 2017, we retrospectively analysed the conditions of classical 21OHD neonates before the initiation of therapy. RESULTS One hundred classical 21OHD patients (55 male, 45 female) were analysed. The age at the first hospital visit was 0-20 days with sex difference (male: 9.0 ± 3.5 days; female: 6.2 ± 3.9 days). Thirty-seven (37.4%) patients exhibited severe salt-wasting (SSW), that is, Na < 130 mEq/L, K > 7 mEq/L or Na/K ratio < 20; except for one case, SSW developed in or after the second week of life. The serum concentrations of Na, K and Na/K were linearly correlated with age in days (R2 = .38, .25, and .34 respectively), suggesting that the risk of SSW increases linearly without a threshold. The age at which the regression lines reached Na < 130 mEq/L, K > 7 mEq/L and Na/K < 20 was approximately coincided, 11.1, 12.3 and 11.2 days, respectively. All SSW patients exhibited decreased body weight from birth in their second week of life. CONCLUSION Our data revealed that the risk of developing SSW increases during the second week of life without a threshold, and for preventing SSW, early intervention, ideally during first week of life, is desirable. An increased body weight in the second week of life indicates the absence of SSW.
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Affiliation(s)
- Maki Gau
- Department of Pediatrics and Developmental Biology, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Kaoru Konishi
- Newborn Screening, Tokyo Health Service Association, Tokyo, Japan
| | - Kei Takasawa
- Department of Pediatrics and Developmental Biology, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Ryuichi Nakagawa
- Department of Pediatrics and Developmental Biology, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Atsumi Tsuji-Hosokawa
- Department of Pediatrics and Developmental Biology, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Atsuko Hashimoto
- Newborn Screening, Tokyo Health Service Association, Tokyo, Japan
| | - Akito Sutani
- Department of Pediatrics and Developmental Biology, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Toshihiro Tajima
- Department of Pediatrics, Jichi Medical University, Tochigi, Japan
| | - Tomonobu Hasegawa
- Department of Pediatrics, School of Medicine, Keio University, Tokyo, Japan
| | - Tomohiro Morio
- Department of Pediatrics and Developmental Biology, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Kenichi Kashimada
- Department of Pediatrics and Developmental Biology, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
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12
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de Miranda MC, Haddad LBDP, Trindade E, Cassenote A, Hayashi GY, Damiani D, Costa FC, Madureira G, de Mendonca BB, Bachega TASS. The Cost-Effectiveness of Congenital Adrenal Hyperplasia Newborn Screening in Brazil: A Comparison Between Screened and Unscreened Cohorts. Front Pediatr 2021; 9:659492. [PMID: 34109139 PMCID: PMC8183606 DOI: 10.3389/fped.2021.659492] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 03/10/2021] [Indexed: 12/04/2022] Open
Abstract
Background: Newborn screening for congenital adrenal hyperplasia (CAH-NBS) is not yet a worldwide consensus, in part due to inconclusive evidence regarding cost-effectiveness because the analysis requires an understanding of the short- and long-term costs of care associated with delayed diagnosis. Objective: The present study aimed to conduct a cost-effectiveness analysis (CEA) to compare the costs associated with CAH-NBS and clinical diagnosis. Methods: A decision model comparing the two strategies was tested by sensitivity analysis. The cost analysis perspective was the public health system. Unscreened patients' data were extracted from medical records of Hospital das Clinicas, Saõ Paulo, and screened data were extracted from the NBS Referral Center of São Paulo. The population comprised 195 classical patients with CAH, clinically diagnosed and confirmed by hormonal/CYP21A2 analysis, and 378,790 newborns screened during 2017. Adverse outcomes related to late diagnosis were measured in both cohorts, and the incremental cost-effectiveness ratio (ICER) was calculated. We hypothesized that CAH-NBS would be cost-effective. Results: Twenty-five screened infants were confirmed with CAH (incidence: 1:15,135). The mortality rate was estimated to be 11% in unscreened infants, and no deaths were reported in the screened cohort. Comparing the unscreened and screened cohorts, mean serum sodium levels were 121.2 mEq/L (118.3-124.1) and 131.8 mEq/L (129.3-134.5), mean ages at diagnosis were 38.8 and 17 days, and hospitalization occurred in 76% and 58% of the salt-wasting patients with the in the two cohorts, respectively. The NBS incremental cost was US$ 771,185.82 per death averted, which yielded an ICER of US$ 25,535.95 per discounted life-year saved. Conclusions: CAH-NBS is important in preventing CAH mortality/morbidity, can reduce costs associated with adverse outcomes, and appears cost-effective.
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Affiliation(s)
- Mirela Costa de Miranda
- Unidade de Adrenal da Disciplina de Endocrinologia, Laboratório de Hormônios e Genética Molecular/LIM42, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Luciana Bertocco de Paiva Haddad
- Divisão de Transplantes Hepático, Departamento de Gastroenterologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Evelinda Trindade
- São Paulo State Health Technology Assessment Network, São Paulo State Department of Health, São Paulo, Brazil
| | - Alex Cassenote
- Divisão de Transplantes Hepático, Departamento de Gastroenterologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Giselle Y Hayashi
- Laboratório do Serviço de Referência em Triagem Neonatal, Instituto Jô Clemente, São Paulo, Brazil
| | - Durval Damiani
- Unidade de Endocrinologia Pediátrica Do Instituto da Criança, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Fernanda Cavalieri Costa
- Unidade de Adrenal da Disciplina de Endocrinologia, Laboratório de Hormônios e Genética Molecular/LIM42, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Guiomar Madureira
- Unidade de Adrenal da Disciplina de Endocrinologia, Laboratório de Hormônios e Genética Molecular/LIM42, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Berenice Bilharinho de Mendonca
- Unidade de Adrenal da Disciplina de Endocrinologia, Laboratório de Hormônios e Genética Molecular/LIM42, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Tania A S S Bachega
- Unidade de Adrenal da Disciplina de Endocrinologia, Laboratório de Hormônios e Genética Molecular/LIM42, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
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13
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Cacciatore P, Visser LA, Buyukkaramikli N, van der Ploeg CPB, van den Akker-van Marle ME. The Methodological Quality and Challenges in Conducting Economic Evaluations of Newborn Screening: A Scoping Review. Int J Neonatal Screen 2020; 6:ijns6040094. [PMID: 33238605 PMCID: PMC7712813 DOI: 10.3390/ijns6040094] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Revised: 11/18/2020] [Accepted: 11/19/2020] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Cost-effectiveness (CEA) and cost-utility analyses (CUA) have become popular types of economic evaluations (EE) used for evidence-based decision-making in healthcare resource allocation. Newborn screening programs (NBS) can have significant clinical benefits for society, and cost-effectiveness analysis may help to select the optimal strategy among different screening programs, including the no-screening option, on different conditions. These economic analyses of NBS, however, are hindered by several methodological challenges. This study explored the methodological quality in recent NBS economic evaluations and analyzed the main challenges and strategies adopted by researchers to deal with them. METHODS A scoping review was conducted according to PRISMA methodology to identify CEAs and CUAs of NBS. The methodological quality of the retrieved studies was assessed quantitatively using a specific guideline for the quality assessment of NBS economic evaluations, by calculating a general score for each EE. Challenges in the studies were then explored using thematic analysis as a qualitative synthesis approach. RESULTS Thirty-five studies met the inclusion criteria. The quantitative analysis showed that the methodological quality of NBS economic evaluations was heterogeneous. Lack of clear description of items related to results, discussion, and discounting were the most frequent flaws. Methodological challenges in performing EEs of neonatal screenings include the adoption of a long time horizon, the use of quality-adjusted life years as health outcome measure, and the assessment of costs beyond the screening interventions. CONCLUSIONS The results of this review can support future economic evaluation research, aiding researchers to develop a methodological guidance to perform EEs aimed at producing solid results to inform decisions for resource allocation in neonatal screening.
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Affiliation(s)
- Pasquale Cacciatore
- Sezione di Igiene, Istituto di Sanità Pubblica, Università Cattolica del Sacro Cuore, 00168 Rome, Italy;
| | - Laurenske A. Visser
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, 3062 PA Rotterdam, The Netherlands; (L.A.V.); (N.B.)
| | - Nasuh Buyukkaramikli
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, 3062 PA Rotterdam, The Netherlands; (L.A.V.); (N.B.)
| | | | - M. Elske van den Akker-van Marle
- Unit Medical Decision Making, Department of Biomedical Datasciences, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
- Correspondence:
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14
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Grosse SD, Van Vliet G. Challenges in Assessing the Cost-Effectiveness of Newborn Screening: The Example of Congenital Adrenal Hyperplasia. Int J Neonatal Screen 2020; 6:E82. [PMID: 33239603 PMCID: PMC7712219 DOI: 10.3390/ijns6040082] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 10/16/2020] [Accepted: 10/21/2020] [Indexed: 12/27/2022] Open
Abstract
Generalizing about the cost-effectiveness of newborn screening (NBS) is difficult due to the heterogeneity of disorders included in NBS panels, along with data limitations. Furthermore, it is unclear to what extent evidence about cost-effectiveness should influence decisions to screen for specific disorders. Screening newborns for congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency can serve as a useful test case, since there is no global consensus on whether CAH should be part of NBS panels. Published and unpublished cost-effectiveness analyses of CAH screening have yielded mixed findings, largely due to differences in methods and data sources for estimating health outcomes and associated costs of early versus late diagnosis as well as between-country differences. Understanding these methodological challenges can help inform future analyses and could also help interested policymakers interpret the results of economic evaluations.
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Affiliation(s)
- Scott D. Grosse
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA 30341, USA
| | - Guy Van Vliet
- Endocrinology Service and Research Center of the Sainte-Justine Hospital and Department of Pediatrics, University of Montreal, Montreal, QC H3T 1C5, Canada;
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15
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Held PK, Bird IM, Heather NL. Newborn Screening for Congenital Adrenal Hyperplasia: Review of Factors Affecting Screening Accuracy. Int J Neonatal Screen 2020; 6:67. [PMID: 33117906 PMCID: PMC7569755 DOI: 10.3390/ijns6030067] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 08/17/2020] [Indexed: 12/28/2022] Open
Abstract
Newborn screening for 21-hydroxylase deficiency (21OHD), the most common form of congenital adrenal hyperplasia, has been performed routinely in the United States and other countries for over 20 years. Screening provides the opportunity for early detection and treatment of patients with 21OHD, preventing salt-wasting crisis during the first weeks of life. However, current first-tier screening methodologies lack specificity, leading to a large number of false positive cases, and adequate sensitivity to detect all cases of classic 21OHD that would benefit from treatment. This review summarizes the pathology of 21OHD and also the key stages of fetal hypothalamic-pituitary-adrenal axis development and adrenal steroidogenesis that contribute to limitations in screening accuracy. Factors leading to both false positive and false negative results are highlighted, along with specimen collection best practices used by laboratories in the United States and worldwide. This comprehensive review provides context and insight into the limitations of newborn screening for 21OHD for laboratorians, primary care physicians, and endocrinologists.
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Affiliation(s)
- Patrice K. Held
- Wisconsin State Laboratory of Hygiene, University of Wisconsin School of Medicine and Public Health, Madison, WI 53706, USA
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI 53706, USA
| | - Ian M. Bird
- Department of Obstetrics and Gynecology, University of Wisconsin School of Medicine and Public Health, Madison, WI 53715, USA;
| | - Natasha L. Heather
- Newborn Screening, LabPlus, Auckland City Hospital, Auckland 1023, New Zealand;
- Liggins Institute, University of Auckland, Auckland 1010, New Zealand
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16
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Dabas A, Bothra M, Kapoor S. CAH Newborn Screening in India: Challenges and Opportunities. Int J Neonatal Screen 2020; 6:E70. [PMID: 33239596 PMCID: PMC7570061 DOI: 10.3390/ijns6030070] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 08/22/2020] [Accepted: 08/25/2020] [Indexed: 01/16/2023] Open
Abstract
Congenital adrenal hyperplasia (CAH) is a common treatable disorder which is associated with life-threatening adrenal crisis, sexual ambiguity, and/or abnormal growth if undiagnosed. Newborn screening is a cost-effective tool to detect affected babies early after birth to optimize their treatment and follow-up. Newborn screening however is in its nascent stage in India where it is not yet introduced universally for all babies. The following review briefly highlights the challenges (e.g., lack of universal screening, healthcare resources) and opportunities (e.g., reduction in morbidity and early correct gender assignment in females) associated with newborn screening for CAH in a large Indian birth cohort.
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Affiliation(s)
| | | | - Seema Kapoor
- Department of Pediatrics, Maulana Azad Medical College and Lok Nayak Hospital, New Delhi 110002, India; (A.D.); (M.B.)
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