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Tangeraas T, Ljungblad UW, Lutvica E, Kristensen E, Rowe AD, Bjørke-Monsen AL, Rootwelt-Revheim T, Sæves I, Pettersen RD. Vitamin B12 Deficiency (Un-)Detected Using Newborn Screening in Norway. Int J Neonatal Screen 2023; 9:ijns9010003. [PMID: 36648770 PMCID: PMC9844471 DOI: 10.3390/ijns9010003] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 12/26/2022] [Accepted: 01/02/2023] [Indexed: 01/06/2023] Open
Abstract
Untreated vitamin B12 (B12) deficiency may cause delayed development in infants. Several newborn screening (NBS) programs have reported an increased detection rate of B12 deficiency when second-tier dried blood spot (DBS) analyses of total homocysteine (tHcy) and methylmalonic acid (MMA) are included. This is a retrospective study of newborns reported from NBS during 2012−2021 with confirmed B12 deficiency. DBSs were retrieved from the NBS biobank for second-tier MMA and tHcy analysis. Thirty-one newborns were diagnosed with B12 deficiency out of 552970 screened. Twenty-five were ascertained from sixty-one false positive (FP) cases of methylmalonic acidemia and propionic acidemia (PA), and six infants screened positive for other NBS metabolic diseases with propionylcarnitine (C3) in the normal range. In the original DBS, 7/23 (30%) and 12/23 (52%) of B12-deficient newborns with FP methylmalonic acidemia/PA had MMA and tHcy > 99th percentile. B12 deficiency was a common differential diagnosis of screening positive for methylmalonic and PA. C3 failed to identify a subset of newborns with B12 deficiency. Second-tier MMA and tHcy analyses in the DBS showed suboptimal sensitivity for identifying infants with B12 deficiency. The shortcomings of NBS should be acknowledged when considering B12 deficiency as a primary target of NBS panels.
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Affiliation(s)
- Trine Tangeraas
- Norwegian National Unit for Newborn Screening, Division of Pediatric and Adolescent Medicine, Oslo University Hospital, 0424 Oslo, Norway
- European Reference Network for Hereditary Metabolic Disorders (MetabERN), 0424 Oslo, Norway
- Correspondence:
| | - Ulf W. Ljungblad
- Institute of Clinical Medicine, University of Oslo, Mailbox 1171 Blindern, 0318 Oslo, Norway
- Department of Pediatrics, Vestfold Hospital Trust, Mailbox 1068, 3103 Tønsberg, Norway
| | - Elma Lutvica
- Medical Faculty, University of Oslo, Mailbox 1171 Blindern, 0318 Oslo, Norway
| | - Erle Kristensen
- Department of Medical Biochemistry, Oslo University Hospital, 0424 Oslo, Norway
| | - Alex D. Rowe
- Norwegian National Unit for Newborn Screening, Division of Pediatric and Adolescent Medicine, Oslo University Hospital, 0424 Oslo, Norway
| | - Anne-Lise Bjørke-Monsen
- Department of Medical Biochemistry and Pharmacology, Haukeland University Hospital, 5021 Bergen, Norway
- Department of Clinical Science, University of Bergen, 5007 Bergen, Norway
| | - Terje Rootwelt-Revheim
- European Reference Network for Hereditary Metabolic Disorders (MetabERN), 0424 Oslo, Norway
| | - Ingjerd Sæves
- Norwegian National Unit for Newborn Screening, Division of Pediatric and Adolescent Medicine, Oslo University Hospital, 0424 Oslo, Norway
| | - Rolf D. Pettersen
- Norwegian National Unit for Newborn Screening, Division of Pediatric and Adolescent Medicine, Oslo University Hospital, 0424 Oslo, Norway
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Ljungblad UW, Lindberg M, Eklund EA, Sæves I, Sagredo C, Bjørke-Monsen AL, Tangeraas T. A Retrospective Evaluation of the Predictive Value of Newborn Screening for Vitamin B12 Deficiency in Symptomatic Infants Below 1 Year of Age. Int J Neonatal Screen 2022; 8:ijns8040066. [PMID: 36547383 PMCID: PMC9782899 DOI: 10.3390/ijns8040066] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 12/11/2022] [Accepted: 12/12/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND The sensitivity of newborn screening (NBS) in detecting infants that later develop symptomatic vitamin B12 deficiency is unknown. We evaluated the predictive value using NBS algorithms in detecting infants that later were clinically diagnosed with symptomatic B12 deficiency. Furthermore, we investigated whether being born in a hospital using nitrous oxide (N2O) as pain relief in labor may have had an impact on total homocysteine at NBS. METHODS We retrospectively retrieved NBS data and analyzed total homocysteine, methylmalonic acid and methyl citrate on stored NBS dried blood spots (DBS) of 70 infants diagnosed with symptomatic B12 deficiency and compared them to 646 matched and 434 unmatched DBS controls to evaluate the Austrian and Heidelberg B12 NBS algorithms. RESULTS The sensitivity of NBS in detecting infants later diagnosed with symptomatic B12 deficiency at median age 10.9 weeks was ≤10%. Total homocysteine was higher in DBS for the unmatched controls who were born in hospitals providing N2O compared to in hospitals not providing N2O, with median total homocysteine 4.0 µmol/L compared to 3.5 µmol/L (n = 434, 95% CI 0.04-0.87, p = 0.03). CONCLUSION NBS algorithms were unable to identify most infants diagnosed with symptomatic B12 deficiency after the neonatal period. Being born in hospitals providing N2O may impact total homocysteine at NBS.
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Affiliation(s)
- Ulf Wike Ljungblad
- Institute of Clinical Medicine, University of Oslo, P.O. Box 1171, Blindern, 0318 Oslo, Norway
- Department of Pediatrics, Vestfold Hospital Trust, P.O. Box 1068, 3103 Tønsberg, Norway
- Correspondence:
| | - Morten Lindberg
- Department of Medical Biochemistry, Vestfold Hospital Trust, P.O. Box 1068, 3103 Tønsberg, Norway
| | - Erik A. Eklund
- Department of Pediatrics, Clinical Sciences, Lund, Lund University, 221 84 Lund, Sweden
| | - Ingjerd Sæves
- Norwegian National Unit for Newborn Screening, Division of Pediatric and Adolescent Medicine, Oslo University Hospital, 0424 Oslo, Norway
| | - Carlos Sagredo
- Department of Pharmacology, Division of Laboratory Medicine, Oslo University Hospital, 0424 Oslo, Norway
| | - Anne-Lise Bjørke-Monsen
- Laboratory of Medical Biochemistry, Innlandet Hospital Trust, 2609 Lillehammer, Norway
- Laboratory of Medical Biochemistry, Førde Central Hospital, 6812 Førde, Norway
- Department of Medical Biochemistry and Pharmacology, Haukeland University Hospital, 1400 Bergen, Norway
| | - Trine Tangeraas
- Norwegian National Unit for Newborn Screening, Division of Pediatric and Adolescent Medicine, Oslo University Hospital, 0424 Oslo, Norway
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Ljungblad UW, Lindberg M, Eklund EA, Saeves I, Bjørke‐Monsen A, Tangeraas T. Nitrous oxide in labour predicted newborn screening total homocysteine and is a potential risk factor for infant vitamin B12 deficiency. Acta Paediatr 2022; 111:2315-2321. [PMID: 36029294 PMCID: PMC9825840 DOI: 10.1111/apa.16530] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 08/23/2022] [Accepted: 08/26/2022] [Indexed: 01/11/2023]
Abstract
AIM Risk factors for vitamin B12 deficiency in infants are not fully understood. The aim of the study was to assess predictors of total homocysteine and methylmalonic acid analysed in newborn screening dried blood spots. METHODS In a Norwegian case control study, we analysed total homocysteine and methylmalonic acid in newborn screening dried blood spots of 86 infants clinically diagnosed with vitamin B12 deficiency during 2012-2018. Results were compared to 252 healthy infants and 400 dried blood spot controls. Medical records were reviewed, and mothers completed questionnaires. RESULTS Both total homocysteine and methylmalonic acid were significantly higher on newborn screening dried blood spots in infants later clinically diagnosed with vitamin B12 deficiency than controls. Multiple regression analysis showed that the dose of nitrous oxide during labour was the strongest predictor for total homocysteine level in newborn screening dried blood spots for all infants, with larger effect in infants later clinically diagnosed with vitamin B12 deficiency than controls. CONCLUSION Nitrous oxide dose during labour was a predictor for total homocysteine and may impact the interpretation of total homocysteine analysis in newborn screening. Nitrous oxide is suggested as a contributing risk factor for infants prone to develop vitamin B12 deficiency.
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Affiliation(s)
- Ulf Wike Ljungblad
- Institute of Clinical MedicineUniversity of OsloOsloNorway,Department of PaediatricsVestfold Hospital TrustTønsbergNorway
| | - Morten Lindberg
- Department of Medical BiochemistryVestfold Hospital TrustTønsbergNorway
| | - Erik A. Eklund
- Department of Paediatrics, Clinical Sciences LundLund UniversityLundSweden
| | - Ingjerd Saeves
- Norwegian National Unit for Newborn ScreeningOslo University HospitalOsloNorway
| | - Anne‐Lise Bjørke‐Monsen
- Laboratory of Medical BiochemistryInnlandet Hospital TrustLillehammerNorway,Department of Medical Biochemistry and PharmacologyHaukeland University HospitalBergenNorway
| | - Trine Tangeraas
- Norwegian National Unit for Newborn Screening, Division of Paediatric and Adolescent MedicineOslo University HospitalOsloNorway
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Vitamin B12 (Cobalamin): Its Fate from Ingestion to Metabolism with Particular Emphasis on Diagnostic Approaches of Acquired Neonatal/Infantile Deficiency Detected by Newborn Screening. Metabolites 2022; 12:metabo12111104. [DOI: 10.3390/metabo12111104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 11/07/2022] [Accepted: 11/10/2022] [Indexed: 11/16/2022] Open
Abstract
Acquired vitamin B12 (vB12) deficiency (vB12D) of newborns is relatively frequent as compared with the incidence of inherited diseases included in newborn screening (NBS) of different countries across the globe. Infants may present signs of vB12D before 6 months of age with anemia and/or neurologic symptoms when not diagnosed in asymptomatic state. The possibility of identifying vitamin deficient mothers after their pregnancy during the breastfeeding period could be an additional benefit of the newborn screening. Vitamin supplementation is widely available and easy to administer. However, in many laboratories, vB12D is not included in the national screening program. Optimized screening requires either second-tier testing or analysis of new urine and blood samples combined with multiple clinical and laboratory follow ups. Our scope was to review the physiologic fate of vB12 and the pathobiochemical consequences of vB12D in the human body. Particular emphasis was put on the latest approaches for diagnosis and treatment of vB12D in NBS.
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Tiivoja E, Reinson K, Muru K, Rähn K, Muhu K, Mauring L, Kahre T, Pajusalu S, Õunap K. The prevalence of inherited metabolic disorders in Estonian population over 30 years: A significant increase during study period. JIMD Rep 2022; 63:604-613. [PMID: 36341167 PMCID: PMC9626666 DOI: 10.1002/jmd2.12325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 08/09/2022] [Accepted: 08/10/2022] [Indexed: 11/09/2022] Open
Abstract
Inherited metabolic disorders (IMD) are a group of hereditary diseases wherein the impairment of a biochemical pathway is intrinsic to the pathophysiology of the disease. Estonia's small population and nationwide digitalised healthcare system make it possible to perform an epidemiological study that covers the whole population. A study was performed in Tartu University Hospital, which is the only tertiary care unit in Estonia for diagnosing patients with IMD, to define the prevalence and live birth prevalence of IMDs and the effectiveness of new diagnostic methods on the diagnosis of IMD. During the retrospective study period from 1990 to 2017, 333 patients were diagnosed with IMD. Statistical analysis showed a significant increase in IMD diagnoses per year from 0.47 to 2.51 cases per 100 000 persons (p < 0.0001) during the study period. Live birth prevalence of IMD in Estonia was calculated to be 41.52 cases per 100 000 live births. The most frequently diagnosed IMD groups were disorders of amino acid metabolism, disorders of complex molecule degradation, mitochondrial disorders, and disorders of tetrapyrrole metabolism. Phenylketonuria was the most frequently diagnosed disorder of all IMD (21.6%). Our results correlated well with data from other developed countries and, along with high birth prevalence, add confidence in the effectiveness of our diagnostic yield. Implementation of new diagnostic methods during study period may largely account for the significant increase in the number of IMD diagnoses per year. We conclude that the implementation of new diagnostic methods continues to be important and contributes to better diagnosis of rare diseases.
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Affiliation(s)
- Elis Tiivoja
- Department of Clinical Genetics, Institute of Clinical MedicineUniversity of TartuTartuEstonia
- Department of Clinical Genetics, Genetic and Personalized Medicine ClinicTartu University HospitalTartuEstonia
| | - Karit Reinson
- Department of Clinical Genetics, Institute of Clinical MedicineUniversity of TartuTartuEstonia
- Department of Clinical Genetics, Genetic and Personalized Medicine ClinicTartu University HospitalTartuEstonia
| | - Kai Muru
- Department of Clinical Genetics, Institute of Clinical MedicineUniversity of TartuTartuEstonia
- Department of Clinical Genetics, Genetic and Personalized Medicine ClinicTartu University HospitalTartuEstonia
| | - Kristi Rähn
- Department of Clinical Genetics, Institute of Clinical MedicineUniversity of TartuTartuEstonia
- Department of Clinical Genetics, Genetic and Personalized Medicine ClinicTartu University HospitalTartuEstonia
| | - Kristina Muhu
- Department of Clinical Genetics, Institute of Clinical MedicineUniversity of TartuTartuEstonia
| | - Laura Mauring
- Department of Clinical Genetics, Institute of Clinical MedicineUniversity of TartuTartuEstonia
- Eye ClinicTartu University HospitalTartuEstonia
| | - Tiina Kahre
- Department of Clinical Genetics, Institute of Clinical MedicineUniversity of TartuTartuEstonia
- Department of Laboratory Genetics, Genetic and Personalized Medicine ClinicTartu University HospitalTartuEstonia
| | - Sander Pajusalu
- Department of Clinical Genetics, Institute of Clinical MedicineUniversity of TartuTartuEstonia
- Department of Laboratory Genetics, Genetic and Personalized Medicine ClinicTartu University HospitalTartuEstonia
| | - Katrin Õunap
- Department of Clinical Genetics, Institute of Clinical MedicineUniversity of TartuTartuEstonia
- Department of Clinical Genetics, Genetic and Personalized Medicine ClinicTartu University HospitalTartuEstonia
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Martín-Rivada Á, Cambra Conejero A, Martín-Hernández E, Moráis López A, Bélanger-Quintana A, Cañedo Villarroya E, Quijada-Fraile P, Bellusci M, Chumillas Calzada S, Bergua Martínez A, Stanescu S, Martínez-Pardo Casanova M, Ruíz-Sala P, Ugarte M, Pérez González B, Pedrón-Giner C. Newborn screening for propionic, methylmalonic acidemia and vitamin B12 deficiency. Analysis of 588,793 newborns. J Pediatr Endocrinol Metab 2022; 35:1223-1231. [PMID: 36112821 DOI: 10.1515/jpem-2022-0340] [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: 07/05/2022] [Accepted: 08/13/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVES We present the results of our experience in the diagnosis and follow up of the positive cases for propionic, methylmalonic acidemias and cobalamin deficiencies (PA/MMA/MMAHC) since the Expanded Newborn Screening was implemented in Madrid Region. METHODS Dried blood samples were collected 48 h after birth. Amino acids and acylcarnitines were quantitated by MS/MS. Newborns with alterations were referred to the clinical centers for follow-up. Biochemical and molecular genetic studies for confirmation of a disease were performed. RESULTS In the period 2011-2020, 588,793 children were screened, being 953 of them were referred to clinical units for abnormal result (192 for elevated C3 levels). Among them, 88 were false positive cases, 85 maternal vitamin B12 deficiencies and 19 were confirmed to suffer an IEM (8 PA, 4 MMA, 7 MMAHC). Ten out 19 cases displayed symptoms before the NBS results (6 PA, 1 MMA, 3 MMAHC). C3, C16:1OH+C17 levels and C3/C2 and C3/Met ratios were higher in newborns with PA/MMA/MMAHC. Cases diagnosed with B12 deficiency had mean B12 levels of 187.6 ± 76.9 pg/mL and their mothers 213.7 ± 95.0; 5% of the mothers were vegetarian or had poor eating while 15% were diagnosed of pernicious anemia. Newborns and their mothers received treatment with B12 with different posology, normalizing their levels and the secondary alterations disappeared. CONCLUSIONS Elevated C3 are a frequent cause for abnormal result in newborn screening with a high rate of false positive cases. Presymptomatic diagnosis of most of PA and some MMA/MMAHC is difficult. Vitamin B12 deficiency secondary to maternal deprivation is frequent with an heterogenous clinical and biochemical spectrum.
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Affiliation(s)
- Álvaro Martín-Rivada
- Sección de Gastroenterología y Nutrición, Hospital Infantil Universitario Niño Jesús, Madrid, Spain
| | - Ana Cambra Conejero
- Laboratorio de Cribado Neonatal de la Comunidad de Madrid, Servicio de Bioquímica Clínica, Hospital General Universitario GregorioMarañón, Madrid, Spain
| | - Elena Martín-Hernández
- Unidad de Enfermedades Mitocondriales-Metabólicas Hereditarias, Centro de Referencia Nacional (CSUR) y Europeo (MetabERN) en Enfermedades Metabólicas, Madrid, Spain
| | - Ana Moráis López
- Unidad de Nutrición Infantil y Enfermedades Metabólicas, Hospital Universitario La Paz, Madrid, Spain
| | - Amaya Bélanger-Quintana
- Centro de Referencia Nacional (CSUR) en Enfermedades Metabólicas, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Elvira Cañedo Villarroya
- Sección de Gastroenterología y Nutrición, Hospital Infantil Universitario Niño Jesús, Madrid, Spain
| | - Pilar Quijada-Fraile
- Unidad de Enfermedades Mitocondriales-Metabólicas Hereditarias, Centro de Referencia Nacional (CSUR) y Europeo (MetabERN) en Enfermedades Metabólicas, Madrid, Spain
| | - Marcelo Bellusci
- Unidad de Enfermedades Mitocondriales-Metabólicas Hereditarias, Centro de Referencia Nacional (CSUR) y Europeo (MetabERN) en Enfermedades Metabólicas, Madrid, Spain
| | - Silvia Chumillas Calzada
- Unidad de Enfermedades Mitocondriales-Metabólicas Hereditarias, Centro de Referencia Nacional (CSUR) y Europeo (MetabERN) en Enfermedades Metabólicas, Madrid, Spain
| | - Ana Bergua Martínez
- Unidad de Nutrición Infantil y Enfermedades Metabólicas, Hospital Universitario La Paz, Madrid, Spain
| | - Sinziana Stanescu
- Centro de Referencia Nacional (CSUR) en Enfermedades Metabólicas, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | | | - Pedro Ruíz-Sala
- Centro de Diagnóstico de Enfermedades Moleculares, Universidad Autónoma de Madrid, IdiPAZ, CIBERER, Madrid, Spain
| | - Magdalena Ugarte
- Centro de Diagnóstico de Enfermedades Moleculares, Universidad Autónoma de Madrid, IdiPAZ, CIBERER, Madrid, Spain
| | - Belén Pérez González
- Centro de Diagnóstico de Enfermedades Moleculares, Universidad Autónoma de Madrid, IdiPAZ, CIBERER, Madrid, Spain
| | - Consuelo Pedrón-Giner
- Sección de Gastroenterología y Nutrición, Hospital Infantil Universitario Niño Jesús, Madrid, Spain
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7
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Reischl-Hajiabadi AT, Garbade SF, Feyh P, Weiss KH, Mütze U, Kölker S, Hoffmann GF, Gramer G. Maternal Vitamin B 12 Deficiency Detected by Newborn Screening-Evaluation of Causes and Characteristics. Nutrients 2022; 14:3767. [PMID: 36145143 PMCID: PMC9505342 DOI: 10.3390/nu14183767] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 09/06/2022] [Accepted: 09/08/2022] [Indexed: 12/14/2022] Open
Abstract
Vitamin B12 deficiency, mostly of maternal origin in newborns, is a well-treatable condition but can cause severe neurologic sequelae in infants. Early detection of vitamin B12 deficiency allows the pre-symptomatic treatment of affected children. This evaluation assesses the characteristics of maternal vitamin B12 deficiency detected by newborn screening. In a prospective single-center study, a systematic screening strategy for vitamin B12 deficiency using a combination of two second-tier strategies was applied. In addition to confirmatory diagnostics in children, the systematic work-up of vitamin B12 status was also performed for their mothers. Maternal characteristics were assessed including ethnic origin, diet, and vitamin supplementation during pregnancy. For affected mothers, a work-up by internal medicine was recommended. In total, 121 mother-infant couples were analyzed. 66% of mothers adhered to a balanced diet including meat. The cause of maternal vitamin B12 deficiency was unknown in 56% of cases, followed by dietary causes in 32%, and organic causes in 8%. All mothers following a vegan diet and most mothers with a vegetarian diet took vitamin preparations during pregnancy, whereas only 55.8% of mothers with a balanced diet took folic acid or other vitamins. Maternal vitamin B12, folic acid, and homocysteine levels were significantly correlated with the child's folic acid levels, and with homocysteine, methylmalonic, and methylcitric acid levels in first and second NBS dried blood spots. Most children had normal blood counts and showed normocytosis. Although 36.7% of mothers showed anemia, only one presented with macrocytosis. Adherence to vitamin supplementation in pregnancy is low despite the recommendation for supplementation of folic acid. Ideally, the evaluation of mothers for vitamin B12 levels and appropriate therapy should be initiated in early pregnancy. In infants detected through newborn screening, the multidisciplinary assessment and therapy of both children and mothers should be performed.
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Affiliation(s)
- Anna T. Reischl-Hajiabadi
- Division of Neuropediatrics and Metabolic Medicine, Center for Pediatric and Adolescent Medicine, Heidelberg University Hospital, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany
| | - Sven F. Garbade
- Division of Neuropediatrics and Metabolic Medicine, Center for Pediatric and Adolescent Medicine, Heidelberg University Hospital, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany
| | - Patrik Feyh
- Division of Neuropediatrics and Metabolic Medicine, Center for Pediatric and Adolescent Medicine, Heidelberg University Hospital, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany
| | - Karl Heinz Weiss
- Department of Internal Medicine IV, Gastroenterology and Hepatology, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120 Heidelberg, Germany
| | - Ulrike Mütze
- Division of Neuropediatrics and Metabolic Medicine, Center for Pediatric and Adolescent Medicine, Heidelberg University Hospital, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany
| | - Stefan Kölker
- Division of Neuropediatrics and Metabolic Medicine, Center for Pediatric and Adolescent Medicine, Heidelberg University Hospital, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany
| | - Georg F. Hoffmann
- Division of Neuropediatrics and Metabolic Medicine, Center for Pediatric and Adolescent Medicine, Heidelberg University Hospital, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany
| | - Gwendolyn Gramer
- Division of Neuropediatrics and Metabolic Medicine, Center for Pediatric and Adolescent Medicine, Heidelberg University Hospital, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany
- University Medical Center Hamburg-Eppendorf, University Children’s Hospital, Martinistraße 52, 20246 Hamburg, Germany
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8
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Ruoppolo M, Malvagia S, Boenzi S, Carducci C, Dionisi-Vici C, Teofoli F, Burlina A, Angeloni A, Aronica T, Bordugo A, Bucci I, Camilot M, Carbone MT, Cardinali R, Carducci C, Cassanello M, Castana C, Cazzorla C, Ciatti R, Ferrari S, Frisso G, Funghini S, Furlan F, Gasperini S, Gragnaniello V, Guzzetti C, La Marca G, La Spina L, Lorè T, Meli C, Messina M, Morrone A, Nardecchia F, Ortolano R, Parenti G, Pavanello E, Pieragostino D, Pillai S, Porta F, Righetti F, Rossi C, Rovelli V, Salina A, Santoro L, Sauro P, Schiaffino MC, Simonetti S, Vincenzi M, Tarsi E, Uccheddu AP. Expanded Newborn Screening in Italy Using Tandem Mass Spectrometry: Two Years of National Experience. Int J Neonatal Screen 2022; 8:ijns8030047. [PMID: 35997437 PMCID: PMC9397032 DOI: 10.3390/ijns8030047] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 07/22/2022] [Accepted: 07/24/2022] [Indexed: 11/23/2022] Open
Abstract
Newborn screening (NBS) for inborn errors of metabolism is one of the most advanced tools for secondary prevention in medicine, as it allows early diagnosis and prompt treatment initiation. The expanded newborn screening was introduced in Italy between 2016 and 2017 (Law 167/2016; DM 13 October 2016; DPCM 12-1-2017). A total of 1,586,578 infants born in Italy were screened between January 2017 and December 2020. For this survey, we collected data from 15 Italian screening laboratories, focusing on the metabolic disorders identified by tandem mass spectrometry (MS/MS) based analysis between January 2019 and December 2020. Aminoacidemias were the most common inborn errors in Italy, and an equal percentage was observed in detecting organic acidemias and mitochondrial fatty acids beta-oxidation defects. Second-tier tests are widely used in most laboratories to reduce false positives. For example, second-tier tests for methylmalonic acid and homocysteine considerably improved the screening of CblC without increasing unnecessary recalls. Finally, the newborn screening allowed us to identify conditions that are mainly secondary to a maternal deficiency. We describe the goals reached since the introduction of the screening in Italy by exchanging knowledge and experiences among the laboratories.
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Affiliation(s)
- Margherita Ruoppolo
- Department of Molecular Medicine and Medical Biotechnology, University of Naples Federico II, 80131 Naples, Italy
- CEINGE Biotecnologie Avanzate Scarl, 80131 Naples, Italy
| | - Sabrina Malvagia
- Newborn Screening, Clinical Chemistry and Pharmacology Lab, Meyer Children’s University Hospital, 50139 Florence, Italy
| | - Sara Boenzi
- Division of Metabolic Disease, Bambino Gesù Childrens Hospital IRCCS, 00165 Rome, Italy
| | - Carla Carducci
- Department of Experimental Medicine, Sapienza University of Rome, 00161 Rome, Italy
| | - Carlo Dionisi-Vici
- Division of Metabolic Disease, Bambino Gesù Childrens Hospital IRCCS, 00165 Rome, Italy
| | - Francesca Teofoli
- Department of Mother and Child, The Regional Center for Neonatal Screening, Diagnosis and Treatment of Inherited Congenital Metabolic and Endocrinological Diseases, AOUI, 37126 Verona, Italy
| | - Alberto Burlina
- Division of Inherited Metabolic Diseases, University Hospital of Padova, 35128 Padova, Italy
- Correspondence:
| | - Antonio Angeloni
- Dipartimento di Medicina Sperimentale, Sapienza University of Rome, 00161 Rome, Italy
| | | | - Andrea Bordugo
- Inherited Metabolic Disease Unit, Pediatric Department, AOUI, 37126 Verona, Italy
| | - Ines Bucci
- Center for Advanced Studies and Technology (CAST) and Department of Medicine and Aging Science, “G. d’Annunzio” University of Chieti-Pescara, 66100 Chieti, Italy
| | - Marta Camilot
- Department of Mother and Child, The Regional Center for Neonatal Screening, Diagnosis and Treatment of Inherited Congenital Metabolic and Endocrinological Diseases, AOUI, 37126 Verona, Italy
| | | | - Roberta Cardinali
- U.O.S.D. Screening Neonatale e Patologia Clinica AOU Policlinico Consorziale Ospedale Pediatrico Giovanni XXII Bari, 70121 Bari, Italy
| | - Claudia Carducci
- Dipartimento di Medicina Sperimentale, Sapienza University of Rome, 00161 Rome, Italy
| | - Michela Cassanello
- LABSIEM (Laboratory for the Study of Inborn Errors of Metabolism), Pediatric Clinic, IRCCS Istituto Giannina Gaslini, 16147 Genoa, Italy
| | | | - Chiara Cazzorla
- Division of Inherited Metabolic Diseases, University Hospital of Padova, 35128 Padova, Italy
| | - Renzo Ciatti
- Centro Screening Neonatale Regione Marche, U.O.C. Neuropsichiatria Infantile—A.O. Ospedali Riuniti Marche Nord, 61032 Fano, Italy
| | - Simona Ferrari
- UO Genetica Medica, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Giulia Frisso
- Department of Molecular Medicine and Medical Biotechnology, University of Naples Federico II, 80131 Naples, Italy
- CEINGE Biotecnologie Avanzate Scarl, 80131 Naples, Italy
| | - Silvia Funghini
- Newborn Screening, Clinical Chemistry and Pharmacology Lab, Meyer Children’s University Hospital, 50139 Florence, Italy
| | - Francesca Furlan
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Pediatria Alta Intensità di Cura, 20122 Milan, Italy
| | | | - Vincenza Gragnaniello
- Division of Inherited Metabolic Diseases, University Hospital of Padova, 35128 Padova, Italy
| | - Chiara Guzzetti
- SSD Endocrinologia Pediatrica e Centro Screening Neonatale, Ospedale Pediatrico Microcitemico “A. Cao”, 09121 Cagliari, Italy
| | - Giancarlo La Marca
- Newborn Screening, Clinical Chemistry and Pharmacology Lab, Meyer Children’s University Hospital, 50139 Florence, Italy
| | - Luisa La Spina
- Laboratorio Screening Neonatale—Clinica Pediatrica AOU Policlinico “G. Rodolico-San Marco”, 95123 Catania, Italy
| | - Tania Lorè
- U.O.S.D. Screening Neonatale e Patologia Clinica AOU Policlinico Consorziale Ospedale Pediatrico Giovanni XXII Bari, 70121 Bari, Italy
| | - Concetta Meli
- Laboratorio Screening Neonatale—Clinica Pediatrica AOU Policlinico “G. Rodolico-San Marco”, 95123 Catania, Italy
| | - MariaAnna Messina
- Laboratorio Screening Neonatale—Clinica Pediatrica AOU Policlinico “G. Rodolico-San Marco”, 95123 Catania, Italy
| | - Amelia Morrone
- Laboratory of Molecular Biology of Neurometabolic Diseases, Neuroscience Department, Meyer Children’s University Hospital, 50139 Florence, Italy
| | - Francesca Nardecchia
- Dipartimento di Neuroscienze Umane—Unità di Neuropsichiatria Infantile Università Roma Sapienza, 00161 Rome, Italy
| | - Rita Ortolano
- UO Pediatria, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Giancarlo Parenti
- Dipartimento di Scienze Mediche Traslazionali Università degli Studi di Napoli Federico II, 80131 Naples, Italy
| | - Enza Pavanello
- SS Screening Prenatale e Neonatale, SC Biochimica Clinica, AOU Città della Salute e della Scienza di Torino, 10126 Torino, Italy
| | - Damiana Pieragostino
- Center for Advanced Studies and Technology (CAST) and Department of Innovative Technologies in Medicine and Dentistry, “G. d’Annunzio” University of Chieti-Pescara, 66100 Chieti, Italy
| | - Sara Pillai
- SSD Endocrinologia Pediatrica e Centro Screening Neonatale, Ospedale Pediatrico Microcitemico “A. Cao”, 09121 Cagliari, Italy
| | - Francesco Porta
- SC Pediatria-Malattie Metaboliche, Ospedale Infantile Regina Margherita AOU Città della Salute e della Scienza di Torino, 10126 Torino, Italy
| | - Francesca Righetti
- Centro Laboratoristico Regionale di Riferimento Screening Neonatale e Malattie Endocrino-Metaboliche UO Pediatria IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Claudia Rossi
- Center for Advanced Studies and Technology (CAST) and Department of Psychological, Health and Territory Sciences, “G. d’Annunzio” University of Chieti-Pescara, 66100 Chieti, Italy
| | - Valentina Rovelli
- Clinical Department of Pediatrics, San Paolo Hospital, ASST Santi Paolo e Carlo, University of Milan, 20142 Milano, Italy
| | - Alessandro Salina
- LABSIEM (Laboratory for the Study of Inborn Errors of Metabolism), Pediatric Clinic, IRCCS Istituto Giannina Gaslini, 16147 Genoa, Italy
| | | | - Pina Sauro
- SS Screening Prenatale e Neonatale, SC Biochimica Clinica, AOU Città della Salute e della Scienza di Torino, 10126 Torino, Italy
| | | | - Simonetta Simonetti
- U.O.S.D. Screening Neonatale e Patologia Clinica AOU Policlinico Consorziale Ospedale Pediatrico Giovanni XXII Bari, 70121 Bari, Italy
| | - Monica Vincenzi
- Department of Mother and Child, The Regional Center for Neonatal Screening, Diagnosis and Treatment of Inherited Congenital Metabolic and Endocrinological Diseases, AOUI, 37126 Verona, Italy
| | - Elisabetta Tarsi
- Centro Screening Neonatale Regione Marche, U.O.C. Neuropsichiatria Infantile—A.O. Ospedali Riuniti Marche Nord, 61032 Fano, Italy
| | - Anna Paola Uccheddu
- SSD Endocrinologia Pediatrica e Centro Screening Neonatale, Ospedale Pediatrico Microcitemico “A. Cao”, 09121 Cagliari, Italy
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9
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Held PK, Singh E, Scott Schwoerer J. Screening for Methylmalonic and Propionic Acidemia: Clinical Outcomes and Follow-Up Recommendations. Int J Neonatal Screen 2022; 8:ijns8010013. [PMID: 35225935 PMCID: PMC8883915 DOI: 10.3390/ijns8010013] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 01/20/2022] [Accepted: 02/01/2022] [Indexed: 11/30/2022] Open
Abstract
Wisconsin's newborn screening program implemented second-tier testing on specimens with elevated propionylcarnitine (C3) to aid in the identification of newborns with propionic and methylmalonic acidemias. The differential diagnosis for elevated C3 also includes acquired vitamin B12 deficiency, which is currently categorized as a false positive screen. The goal of this study was to summarize screening data and evaluate their effectiveness at establishing diagnoses and categorizing false positive cases. All Wisconsin newborns born between 2013 and 2019 with a positive first-tier screen for C3 were included in this study. For each case the first- and second-tier newborn screening data and confirmatory test results were compiled. The clinical determination for each case was reviewed and categorized into groups: inborn error of metabolism, maternal B12 deficiency, infant B12 deficiency, and false positive. A review of the screening data showed a significant overlap in the concentration of biomarkers for newborns with genetic versus acquired disease. Additionally, a review of confirmatory test results showed incomplete ascertainment of maternal vitamin B12 status. The Wisconsin newborn screening program recommended a confirmatory testing algorithm to aid in the diagnosis of inborn errors of metabolism and acquired vitamin B12 deficiency.
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Affiliation(s)
- Patrice K. Held
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI 53706, USA;
- Wisconsin State Laboratory of Hygiene, University of Wisconsin School of Medicine and Public Health, Madison, WI 53706, USA
- Correspondence: ; Tel.: +1-608-265-5968
| | - Emily Singh
- Division of Genetics, Medical College of Wisconsin with Children’s Wisconsin, Milwaukee, WI 53226, USA;
| | - Jessica Scott Schwoerer
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI 53706, USA;
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10
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Ljungblad UW, Paulsen H, Mørkrid L, Pettersen RD, Hager HB, Lindberg M, Astrup H, Eklund EA, Bjørke-Monsen AL, Rootwelt T, Tangeraas T. The prevalence and clinical relevance of hyperhomocysteinemia suggesting vitamin B12 deficiency in presumed healthy infants. Eur J Paediatr Neurol 2021; 35:137-146. [PMID: 34717141 DOI: 10.1016/j.ejpn.2021.10.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 10/05/2021] [Accepted: 10/13/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Previous studies have demonstrated a high prevalence of biochemical vitamin B12 deficiency in infants in Norway. Increased total homocysteine (tHcy) is the most important marker of B12 deficiency in infants. There is a need to evaluate its clinical relevance. AIMS To investigate the prevalence of hyperhomocysteinemia (S-tHcy > 8 μmol/L) suggestive of suboptimal B12 status and the prevalence of clinically relevant hyperhomocysteinemia in presumed healthy infants in Norway. Further, to evaluate risk factors, presence of symptoms and psychomotor development in these children. METHODS In a prospective study we clinically examined 252 infants aged 3-7 months using standardized neurological and psychomotor tests prior to analyzing biochemical B12 deficiency markers in 250 infants. RESULTS Twenty-five of 250 (10%) infants had hyperhomocysteinemia combined with clinically relevant symptoms suggestive of B12 deficiency. Hyperhomocysteinemia was associated with tremor, excessive sleep, and sub-normal scores in the fine motor section of the Ages and Stages Questionnaire. One-hundred and fourteen of 250 (46%) infants had hyperhomocysteinemia. Multiple regression analysis showed months of infant formula use as the strongest negative predictor for hyperhomocysteinemia. CONCLUSION We have demonstrated associations between symptoms suggestive of infant B12 deficiency and increased levels of tHcy in presumed healthy infants The combination of hyperhomocysteinemia and associated relevant symptoms suggestive of B12 deficiency was a common finding, albeit most infants with hyperhomocysteinemia did not show symptoms.
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Affiliation(s)
- Ulf Wike Ljungblad
- Institute of Clinical Medicine, University of Oslo, Postbox 1171 Blindern, NO-0318 Oslo, Norway; Department of Pediatrics, Vestfold Hospital Trust, Postbox 1068, NO-3103, Tønsberg, Norway.
| | - Henriette Paulsen
- Department of Rehabilitation and Physiotherapy, Vestfold Hospital Trust, Postbox 1068, NO-3103, Tønsberg, Norway.
| | - Lars Mørkrid
- Institute of Clinical Medicine, University of Oslo, Postbox 1171 Blindern, NO-0318 Oslo, Norway; Department of Medical Biochemistry, Oslo, University Hospital, Norway.
| | - Rolf D Pettersen
- Norwegian National Unit for Newborn Screening, Division of Pediatric and Adolescent Medicine, Oslo University Hospital, 0424, Oslo, Norway.
| | - Helle Borgstrøm Hager
- Department of Medical Biochemistry, Vestfold Hospital Trust, Postbox 1068, NO-3103, Tønsberg, Norway.
| | - Morten Lindberg
- Department of Medical Biochemistry, Vestfold Hospital Trust, Postbox 1068, NO-3103, Tønsberg, Norway.
| | - Henriette Astrup
- Department of Pediatrics and Adolescent Medicine, Sorlandet Hospital Trust, Postbox 416, NO-4604, Kristiansand, Norway.
| | - Erik A Eklund
- Department of Pediatrics, Clinical Sciences, Lund, Lund University, 221 84, Lund, Sweden.
| | - Anne-Lise Bjørke-Monsen
- Department of Medical Biochemistry and Pharmacology, Haukeland University Hospital, Bergen, Norway; Department of Clinical Science, University of Bergen, Bergen, Norway.
| | - Terje Rootwelt
- Institute of Clinical Medicine, University of Oslo, Postbox 1171 Blindern, NO-0318 Oslo, Norway; Department of Pediatrics, Division of Pediatric and Adolescent Medicine, Oslo University Hospital, 0424, Oslo, Norway.
| | - Trine Tangeraas
- Norwegian National Unit for Newborn Screening, Division of Pediatric and Adolescent Medicine, Oslo University Hospital, 0424, Oslo, Norway; Department of Pediatrics, Division of Pediatric and Adolescent Medicine, Oslo University Hospital, 0424, Oslo, Norway.
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11
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Mütze U, Walter M, Keller M, Gramer G, Garbade SF, Gleich F, Haas D, Posset R, Grünert SC, Hennermann JB, Thimm E, Fang-Hoffmann J, Syrbe S, Okun JG, Hoffmann GF, Kölker S. Health Outcomes of Infants with Vitamin B 12 Deficiency Identified by Newborn Screening and Early Treated. J Pediatr 2021; 235:42-48. [PMID: 33581104 DOI: 10.1016/j.jpeds.2021.02.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 02/03/2021] [Accepted: 02/04/2021] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To evaluate the clinical outcomes at age 1.5 ± 0.5 years of infants with vitamin B12 deficiency identified by newborn screening (NBS). STUDY DESIGN Prospective multicenter observational study on health outcomes of 31 infants with vitamin B12 deficiency identified by NBS. Neurodevelopment was assessed by the Denver Developmental Screening Test. RESULTS In 285 862 newborns screened between 2016 and 2019, the estimated birth prevalence of vitamin B12 deficiency was 26 in 100 000 newborns, with high seasonal variations (lowest in summer: 8 in 100 000). Infants participating in the outcome study (N = 31) were supplemented with vitamin B12 for a median (range) of 5.9 (1.1-16.2) months. All achieved age-appropriate test results in Denver Developmental Screening Test at age 15 (11-23) months and did not present with symptoms characteristic for vitamin B12 deficiency. Most (81%, n = 25) mothers of affected newborns had a hitherto undiagnosed (functional) vitamin B12 deficiency, and, subsequently, received specific therapy. CONCLUSIONS Neonatal vitamin B12 deficiency can be screened by NBS, preventing the manifestation of irreversible neurologic symptoms and the recurrence of vitamin B12 deficiency in future pregnancies through adequate treatment of affected newborns and their mothers. The high frequency of mothers with migrant background having a newborn with vitamin B12 deficiency highlights the need for improved prenatal care.
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Affiliation(s)
- Ulrike Mütze
- Division of Child Neurology and Metabolic Medicine, Center for Child and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany.
| | - Magdalena Walter
- Division of Child Neurology and Metabolic Medicine, Center for Child and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Mareike Keller
- Division of Child Neurology and Metabolic Medicine, Center for Child and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Gwendolyn Gramer
- Division of Child Neurology and Metabolic Medicine, Center for Child and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Sven F Garbade
- Division of Child Neurology and Metabolic Medicine, Center for Child and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Florian Gleich
- Division of Child Neurology and Metabolic Medicine, Center for Child and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Dorothea Haas
- Division of Child Neurology and Metabolic Medicine, Center for Child and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Roland Posset
- Division of Child Neurology and Metabolic Medicine, Center for Child and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Sarah C Grünert
- Department of General Pediatrics, Adolescent Medicine and Neonatology, Medical Center, University of Freiburg, Faculty of Medicine, Freiburg, Germany
| | - Julia B Hennermann
- Villa Metabolica, Department of Pediatric and Adolescent Medicine, Mainz University Medical Center, Mainz, Germany
| | - Eva Thimm
- Department of General Pediatrics, Neonatology, and Pediatric Cardiology, University Children's Hospital, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Junmin Fang-Hoffmann
- Division of Child Neurology and Metabolic Medicine, Center for Child and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Steffen Syrbe
- Division of Pediatric Epileptology, Center for Child and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Jürgen G Okun
- Division of Child Neurology and Metabolic Medicine, Center for Child and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Georg F Hoffmann
- Division of Child Neurology and Metabolic Medicine, Center for Child and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Stefan Kölker
- Division of Child Neurology and Metabolic Medicine, Center for Child and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany
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12
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Pajares S, Arranz JA, Ormazabal A, Del Toro M, García-Cazorla Á, Navarro-Sastre A, López RM, Meavilla SM, de Los Santos MM, García-Volpe C, de Aledo-Castillo JMG, Argudo A, Marín JL, Carnicer C, Artuch R, Tort F, Gort L, Fernández R, García-Villoria J, Ribes A. Implementation of second-tier tests in newborn screening for the detection of vitamin B 12 related acquired and genetic disorders: results on 258,637 newborns. Orphanet J Rare Dis 2021; 16:195. [PMID: 33931066 PMCID: PMC8086297 DOI: 10.1186/s13023-021-01784-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 03/16/2021] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Alteration of vitamin B12 metabolism can be genetic or acquired, and can result in anemia, failure to thrive, developmental regression and even irreversible neurologic damage. Therefore, early diagnosis and intervention is critical. Most of the neonatal cases with acquired vitamin B12 deficiency have been detected by clinical symptoms and only few of them trough NBS programs. We aim to assess the usefulness of the second-tier test: methylmalonic acid (MMA), methylcitric acid (MCA) and homocysteine (Hcys) in our newborn screening program and explore the implications on the detection of cobalamin (vitamin B12) related disorders, both genetic and acquired conditions. METHODS A screening strategy using the usual primary markers followed by the analysis of MMA, MCA and Hcys as second tier-test in the first dried blood spot (DBS) was developed and evaluated. RESULTS During the period 2015-2018 a total of 258,637 newborns were screened resulting in 130 newborns with acquired vitamin B12 deficiency (incidence 1:1989), 19 with genetic disorders (incidence 1:13,613) and 13 were false positive. No false negatives were notified. Concerning the second-tier test, the percentage of cases with MMA above the cut-off levels, both for genetic and acquired conditions was very similar (58% and 60%, respectively). Interestingly, the percentage of cases with increased levels of Hcys was higher in acquired conditions than in genetic disorders (87% and 47%, respectively). In contrast, MCA was high only in 5% of the acquired conditions versus in 53% of the genetic disorders, and it was always very high in all patients with propionic acidemia. CONCLUSIONS When screening for methylmalonic acidemia and homocystinuria, differential diagnosis with acquired vitamin B12 deficiency should be done. The results of our strategy support the inclusion of this acquired condition in the NBS programs, as it is easily detectable and allows the adoption of corrective measures to avoid the consequences of its deficiency.
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Affiliation(s)
- Sonia Pajares
- Sección de Errores Congénitos del Metabolismo-IBC, Servicio de Bioquímica Y Genética Molecular, Hospital Clínic de Barcelona, C/ Mejía Lequerica S/N, Edificio Helios III, 08028, Barcelona, Spain.,Center for Biomedical Research Network on Rare Diseases (CIBERER), Madrid, Spain
| | | | - Aida Ormazabal
- Center for Biomedical Research Network on Rare Diseases (CIBERER), Madrid, Spain.,Inborn Errors of Metabolism Unit, Hospital Sant Joan de Déu, Barcelona, Spain
| | - Mireia Del Toro
- Unit of Metabolic Diseases, Hospital Vall D'Hebrón, Barcelona, Spain
| | - Ángeles García-Cazorla
- Center for Biomedical Research Network on Rare Diseases (CIBERER), Madrid, Spain.,Inborn Errors of Metabolism Unit, Hospital Sant Joan de Déu, Barcelona, Spain
| | - Aleix Navarro-Sastre
- Sección de Errores Congénitos del Metabolismo-IBC, Servicio de Bioquímica Y Genética Molecular, Hospital Clínic de Barcelona, C/ Mejía Lequerica S/N, Edificio Helios III, 08028, Barcelona, Spain
| | - Rosa María López
- Sección de Errores Congénitos del Metabolismo-IBC, Servicio de Bioquímica Y Genética Molecular, Hospital Clínic de Barcelona, C/ Mejía Lequerica S/N, Edificio Helios III, 08028, Barcelona, Spain.,Biomedical Research Institute, August Pi I Sunyer (IDIBAPS), Barcelona, Spain
| | | | | | - Camila García-Volpe
- Inborn Errors of Metabolism Unit, Hospital Sant Joan de Déu, Barcelona, Spain
| | - Jose Manuel González de Aledo-Castillo
- Sección de Errores Congénitos del Metabolismo-IBC, Servicio de Bioquímica Y Genética Molecular, Hospital Clínic de Barcelona, C/ Mejía Lequerica S/N, Edificio Helios III, 08028, Barcelona, Spain
| | - Ana Argudo
- Sección de Errores Congénitos del Metabolismo-IBC, Servicio de Bioquímica Y Genética Molecular, Hospital Clínic de Barcelona, C/ Mejía Lequerica S/N, Edificio Helios III, 08028, Barcelona, Spain
| | - Jose Luís Marín
- Sección de Errores Congénitos del Metabolismo-IBC, Servicio de Bioquímica Y Genética Molecular, Hospital Clínic de Barcelona, C/ Mejía Lequerica S/N, Edificio Helios III, 08028, Barcelona, Spain
| | - Clara Carnicer
- Unit of Metabolic Diseases, Hospital Vall D'Hebrón, Barcelona, Spain
| | - Rafael Artuch
- Center for Biomedical Research Network on Rare Diseases (CIBERER), Madrid, Spain.,Inborn Errors of Metabolism Unit, Hospital Sant Joan de Déu, Barcelona, Spain
| | - Frederic Tort
- Sección de Errores Congénitos del Metabolismo-IBC, Servicio de Bioquímica Y Genética Molecular, Hospital Clínic de Barcelona, C/ Mejía Lequerica S/N, Edificio Helios III, 08028, Barcelona, Spain.,Center for Biomedical Research Network on Rare Diseases (CIBERER), Madrid, Spain.,Biomedical Research Institute, August Pi I Sunyer (IDIBAPS), Barcelona, Spain
| | - Laura Gort
- Sección de Errores Congénitos del Metabolismo-IBC, Servicio de Bioquímica Y Genética Molecular, Hospital Clínic de Barcelona, C/ Mejía Lequerica S/N, Edificio Helios III, 08028, Barcelona, Spain.,Center for Biomedical Research Network on Rare Diseases (CIBERER), Madrid, Spain.,Biomedical Research Institute, August Pi I Sunyer (IDIBAPS), Barcelona, Spain
| | - Rosa Fernández
- Maternal and Child Health Service, Public Health Agency of Catalonia, Health Department, Government of Catalonia, Barcelona, Spain
| | - Judit García-Villoria
- Sección de Errores Congénitos del Metabolismo-IBC, Servicio de Bioquímica Y Genética Molecular, Hospital Clínic de Barcelona, C/ Mejía Lequerica S/N, Edificio Helios III, 08028, Barcelona, Spain.,Center for Biomedical Research Network on Rare Diseases (CIBERER), Madrid, Spain.,Biomedical Research Institute, August Pi I Sunyer (IDIBAPS), Barcelona, Spain
| | - Antonia Ribes
- Sección de Errores Congénitos del Metabolismo-IBC, Servicio de Bioquímica Y Genética Molecular, Hospital Clínic de Barcelona, C/ Mejía Lequerica S/N, Edificio Helios III, 08028, Barcelona, Spain. .,Center for Biomedical Research Network on Rare Diseases (CIBERER), Madrid, Spain. .,Biomedical Research Institute, August Pi I Sunyer (IDIBAPS), Barcelona, Spain.
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13
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Puusepp S, Reinson K, Pajusalu S, van Kuilenburg ABP, Dobritzsch D, Roelofsen J, Stenzel W, Õunap K. Atypical presentation of Arts syndrome due to a novel hemizygous loss-of-function variant in the PRPS1 gene. Mol Genet Metab Rep 2020; 25:100677. [PMID: 33294372 PMCID: PMC7689168 DOI: 10.1016/j.ymgmr.2020.100677] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 11/06/2020] [Accepted: 11/07/2020] [Indexed: 11/30/2022] Open
Abstract
The PRPS1 gene, located on Xq22.3, encodes phosphoribosyl-pyrophosphate synthetase (PRPS), a key enzyme in de novo purine synthesis. Three clinical phenotypes are associated with loss-of-function PRPS1 variants and decreased PRPS activity: Arts syndrome (OMIM: 301835), Charcot–Marie–Tooth disease type 5 (CMTX5, OMIM: 311070), and nonsyndromic X-linked deafness (DFN2, OMIM: 304500). Hearing loss is present in all cases. CMTX5 patients also show peripheral neuropathy and optic atrophy. Arts syndrome includes developmental delay, intellectual disability, ataxia, and susceptibility to infections, in addition to the above three features. Gain-of-function PRPS1 variants result in PRPS superactivity (OMIM: 300661) with hyperuricemia and gout. We report a 6-year-old boy who presented with marked generalized muscular hypotonia, global developmental delay, lack of speech, trunk instability, exercise intolerance, hypomimic face with open mouth, oropharyngeal dysphagia, dysarthria, and frequent upper respiratory tract infections. However, his nerve conduction velocity, audiologic, and funduscopic investigations were normal. A novel hemizygous variant, c.130A > G p.(Ile44Val), was found in the PRPS1 gene by panel sequencing. PRPS activity in erythrocytes was markedly reduced, confirming the pathogenicity of the variant. Serum uric acid and urinary purine and pyrimidine metabolite levels were normal. In conclusion, we present a novel PRPS1 loss-of-function variant in a patient with some clinical features of Arts syndrome, but lacking a major attribute, hearing loss, which is congenital/early-onset in all other reported Arts syndrome patients. In addition, it is important to acknowledge that normal levels of serum and urinary purine and pyrimidine metabolites do not exclude PRPS1-related disorders. We describe a male patient with atypical presentation of Arts syndrome. Our patient harbors a novel loss-of-function variant in the PRPS1 gene. The purine and pyrimidine levels can be normal in patients with decreased PRPS activity.
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Affiliation(s)
- Sanna Puusepp
- Department of Clinical Genetics, United Laboratories, Tartu University Hospital, Tartu, Estonia.,Department of Clinical Genetics, Institute of Clinical Medicine, Faculty of Medicine, University of Tartu, Tartu, Estonia
| | - Karit Reinson
- Department of Clinical Genetics, United Laboratories, Tartu University Hospital, Tartu, Estonia.,Department of Clinical Genetics, Institute of Clinical Medicine, Faculty of Medicine, University of Tartu, Tartu, Estonia
| | - Sander Pajusalu
- Department of Clinical Genetics, United Laboratories, Tartu University Hospital, Tartu, Estonia.,Department of Clinical Genetics, Institute of Clinical Medicine, Faculty of Medicine, University of Tartu, Tartu, Estonia.,Department of Genetics, Yale University School of Medicine, New Haven, CT, USA
| | - André B P van Kuilenburg
- Department of Clinical Chemistry, Cancer Center Amsterdam, Amsterdam Gastroenterology & Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | | | - Jeroen Roelofsen
- Department of Clinical Chemistry, Cancer Center Amsterdam, Amsterdam Gastroenterology & Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Werner Stenzel
- Department of Neuropathology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Leibniz Science Campus Chronic Inflammation, Berlin, Germany
| | - Katrin Õunap
- Department of Clinical Genetics, United Laboratories, Tartu University Hospital, Tartu, Estonia.,Department of Clinical Genetics, Institute of Clinical Medicine, Faculty of Medicine, University of Tartu, Tartu, Estonia
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14
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Vitamin B 12 Deficiency in Newborns and their Mothers-Novel Approaches to Early Detection, Treatment and Prevention of a Global Health Issue. Curr Med Sci 2020; 40:801-809. [PMID: 33123894 DOI: 10.1007/s11596-020-2260-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Accepted: 09/01/2020] [Indexed: 02/06/2023]
Abstract
Vitamin B12 deficiency, mostly of maternal origin in newborns, is a well treatable condition but can cause severe neurologic sequelae. In women of childbearing age and pregnant women worldwide vitamin B12 deficiency has been reported with frequencies of 10%-50%. Children with vitamin B12 deficiency are asymptomatic at birth but may develop severe multisystemic symptoms, including irreversible developmental impairment in the second half-year of life. Early detection of vitamin B12 deficiency allows for presymptomatic treatment. This article provides an overview over the function of vitamin B12 and discusses causes and frequency of vitamin B12 deficiency in newborns, infants, and women of childbearing age. It describes novel successful approaches to newborn screening (NBS) for vitamin B12 deficiency and results of a pilot study which performed systematic NBS for vitamin B12 deficiency using so-called second-tier strategies by measuring homocysteine and methylmalonic acid in dried blood spots. Recommendations for diagnostics in mothers of children with vitamin B12 deficiency are described as well as results of systematic work-up in mothers and treatment and follow-up of children with vitamin B12 deficiency detected by NBS. Treatment options of vitamin B12 deficiency are presented including a newly developed standardized supplementation scheme with exclusively oral vitamin B12 supplementation. Recommendations for preventive approaches to vitamin B12 deficiency for children and mothers are stated. Many children worldwide could benefit from systematic inclusion of vitamin B12 deficiency into NBS panels. In addition, preventive approaches to maternal vitamin B12 deficiency should be implemented systematically during maternal care.
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15
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Rozmarič T, Mitulović G, Konstantopoulou V, Goeschl B, Huemer M, Plecko B, Spenger J, Wortmann SB, Scholl-Bürgi S, Karall D, Greber-Platzer S, Zeyda M. Elevated Homocysteine after Elevated Propionylcarnitine or Low Methionine in Newborn Screening Is Highly Predictive for Low Vitamin B12 and Holo-Transcobalamin Levels in Newborns. Diagnostics (Basel) 2020; 10:diagnostics10090626. [PMID: 32846920 PMCID: PMC7555675 DOI: 10.3390/diagnostics10090626] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 08/18/2020] [Accepted: 08/20/2020] [Indexed: 12/21/2022] Open
Abstract
Early diagnostics and treatment of vitamin B12 deficiency (B12D) in infants, mainly maternally conditioned, is crucial in preventing possible developmental delay and neurological deficits. Currently, B12D is rarely listed in regular newborn screening panels and mostly regarded as an incidental finding. The aim of this study was to evaluate a targeted newborn screening strategy for detection of suspected B12D. A decision strategy based on the primary parameters propionylcarnitine and methionine for selection of samples to be analyzed for total homocysteine by mass spectrometry was established. Therefore, 93,116 newborns were initially screened. Concentrations of vitamin B12 and holotranscobalamin in serum were obtained from clinical follow-up analyses of recalled newborns. Moreover, an extremely sensitive mass spectrometric method to quantify methylmalonic acid from the dried blood spots was developed. Overall, 0.15% of newborns were screened positive for suspected B12D, of which 64% had vitamin B12 concentrations below 148 pM. We also determined a cutoff value for methylmalonic acid in dried blood spots indicative for B12D in infants. Overall, we calculated a prevalence of 92/100,000 for suspected B12D in the Austrian newborns. In conclusion, we present a screening algorithm including second-tier measurement of total homocysteine that allows detection of low B12 serum concentrations with a high detection rate and low false-positive rate.
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Affiliation(s)
- Tomaž Rozmarič
- Austrian Newborn Screening, Division of Pediatric Pulmonology, Allergology and Endocrinology, Department of Pediatrics and Adolescent Medicine, Comprehensive Center for Pediatrics, Medical University of Vienna, 1090 Vienna, Austria; (T.R.); (V.K.); (B.G.); (S.G.-P.)
| | - Goran Mitulović
- Clinical Department of Laboratory Medicine, Medical University of Vienna, 1090 Vienna, Austria;
| | - Vassiliki Konstantopoulou
- Austrian Newborn Screening, Division of Pediatric Pulmonology, Allergology and Endocrinology, Department of Pediatrics and Adolescent Medicine, Comprehensive Center for Pediatrics, Medical University of Vienna, 1090 Vienna, Austria; (T.R.); (V.K.); (B.G.); (S.G.-P.)
| | - Bernadette Goeschl
- Austrian Newborn Screening, Division of Pediatric Pulmonology, Allergology and Endocrinology, Department of Pediatrics and Adolescent Medicine, Comprehensive Center for Pediatrics, Medical University of Vienna, 1090 Vienna, Austria; (T.R.); (V.K.); (B.G.); (S.G.-P.)
| | - Martina Huemer
- Department of Paediatrics, Landeskrankenhaus Bregenz, 6900 Bregenz, Austria;
- Division of Metabolism and Children’s Research Center, University Children’s Hospital, 8032 Zürich, Switzerland
| | - Barbara Plecko
- Department of Pediatrics and Adolescent Medicine, Division of General Pediatrics, University Childrens’ Hospital Graz, Medical University Graz, 8036 Graz, Austria;
| | - Johannes Spenger
- University Children’s Hospital, Paracelsus Medical University, 5020 Salzburg, Austria; (J.S.); (S.B.W.)
| | - Saskia B. Wortmann
- University Children’s Hospital, Paracelsus Medical University, 5020 Salzburg, Austria; (J.S.); (S.B.W.)
| | - Sabine Scholl-Bürgi
- Department of Pediatrics I (Inherited Metabolic Disorders), Medical University of Innsbruck, 6020 Innsbruck, Austria; (S.S.-B.); (D.K.)
| | - Daniela Karall
- Department of Pediatrics I (Inherited Metabolic Disorders), Medical University of Innsbruck, 6020 Innsbruck, Austria; (S.S.-B.); (D.K.)
| | - Susanne Greber-Platzer
- Austrian Newborn Screening, Division of Pediatric Pulmonology, Allergology and Endocrinology, Department of Pediatrics and Adolescent Medicine, Comprehensive Center for Pediatrics, Medical University of Vienna, 1090 Vienna, Austria; (T.R.); (V.K.); (B.G.); (S.G.-P.)
| | - Maximilian Zeyda
- Austrian Newborn Screening, Division of Pediatric Pulmonology, Allergology and Endocrinology, Department of Pediatrics and Adolescent Medicine, Comprehensive Center for Pediatrics, Medical University of Vienna, 1090 Vienna, Austria; (T.R.); (V.K.); (B.G.); (S.G.-P.)
- Correspondence: ; Tel.: +43-1-40400-32050
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16
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Weiss KJ, Röschinger W, Blessing H, Lotz-Havla AS, Schiergens KA, Maier EM. Diagnostic Challenges Using a 2-Tier Strategy for Methylmalonic Acidurias: Data from 1.2 Million Dried Blood Spots. ANNALS OF NUTRITION AND METABOLISM 2020; 76:268-276. [PMID: 32683363 DOI: 10.1159/000508838] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 05/19/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND The detection of methylmalonic acid (MMA) by second-tier analysis has been shown to reduce the number of false positives in newborn screening (NBS) for genetically determined methylmalonic acidurias (MMAuria). In addition to genetic conditions, MMA is an indicator of vitamin B12 status, thus applicable to detect maternal vitamin B12 deficiency in the newborns screened. METHODS Biochemical and clinical follow-up data of a 7.5-year pilot study with 1.2 million newborns screened were reviewed. RESULTS Among 1,195,850 NBS samples, 3,595 (0.3%) fulfilled criteria for second-tier analysis of MMA. In 37 (0.003%; 1/32,000) samples, elevated concentrations of MMA were detected, resulting in diagnostic workup at a metabolic center in 21 newborns. In 6 infants (1/199,000), genetic conditions were established, 1 infant with cobalamin C deficiency (CblC) showed only a moderate elevation of MMA. The remaining 15 newborns (1/79,000) displayed significantly lower concentrations of MMA and were evaluated for maternal vitamin B12 deficiency. In 9 mothers, vitamin B12 deficiency was verified, and 6 showed no indication for vitamin B12 deficiency. Treatment with vitamin B12 normalized biochemical parameters in all 15 infants. CONCLUSIONS Applying a 2-tier strategy measuring MMA in NBS identified genetic conditions of MMAuria. It was possible to separate severe, early-onset phenotypes from maternal vitamin B12 deficiency. However, the detection of CblC deficiency with mildly elevated MMA interferes with impaired vitamin B12 status of unknown relevance and thus burdens possibly healthy newborns. Regarding maternal vitamin B12 deficiency, testing and supplementing mothers-to-be is preferable. This might decrease straining follow-up of newborns and improve quality and overall perception of NBS.
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Affiliation(s)
- Katharina J Weiss
- Department of Inborn Errors of Metabolism, Dr. von Hauner Children's Hospital, Ludwig Maximilian University, Munich, Germany
| | - Wulf Röschinger
- Newborn Screening Unit, Becker and Colleagues Laboratory, Munich, Germany
| | - Holger Blessing
- Department of Inborn Errors of Metabolism, Children's and Adolescents' Hospital, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Amelie S Lotz-Havla
- Department of Inborn Errors of Metabolism, Dr. von Hauner Children's Hospital, Ludwig Maximilian University, Munich, Germany
| | - Katharina A Schiergens
- Department of Inborn Errors of Metabolism, Dr. von Hauner Children's Hospital, Ludwig Maximilian University, Munich, Germany
| | - Esther M Maier
- Department of Inborn Errors of Metabolism, Dr. von Hauner Children's Hospital, Ludwig Maximilian University, Munich, Germany,
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17
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Gramer G, Fang-Hoffmann J, Feyh P, Klinke G, Monostori P, Mütze U, Posset R, Weiss KH, Hoffmann GF, Okun JG. Newborn Screening for Vitamin B 12 Deficiency in Germany-Strategies, Results, and Public Health Implications. J Pediatr 2020; 216:165-172.e4. [PMID: 31604629 DOI: 10.1016/j.jpeds.2019.07.052] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Revised: 07/14/2019] [Accepted: 07/23/2019] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To evaluate a systematic newborn screening (NBS) strategy for vitamin B12 deficiency. STUDY DESIGN In a prospective single-center NBS study, a systematic screening strategy for vitamin B12 deficiency was developed and evaluated. Tandem-mass spectrometry screening was complemented by 2 second-tier strategies, measuring methylmalonic/3-OH-propionic/methylcitric acid, and homocysteine from dried blood spots. RESULTS In a cohort of 176 702 children screened over 27 months, 33 children were detected by NBS in whom (maternal) vitamin B12 deficiency was confirmed. Homocysteine was the most sensitive marker for vitamin B12 deficiency, but only combination with a second-tier strategy evaluating methylmalonic acid allowed for detection of all 33 children. Mothers were of various ethnic origins, and 89% adhered to a balanced diet. Treatment in children was performed predominantly by oral vitamin B12 supplementation (84%), and all children remained without clinical symptoms at short-term follow-up. CONCLUSIONS Vitamin B12 deficiency is a treatable condition but can cause severe neurologic sequelae in infants if untreated. The proposed screening strategy is feasible and effective to identify moderate and severe cases of vitamin B12 deficiency. With an incidence of 1:5355 newborns, vitamin B12 deficiency is more frequent than inborn errors of metabolism included in NBS panels. Treatment of vitamin B12 deficiency is easy, and additional benefits can be achieved for previously undiagnosed affected mothers. This supports inclusion of vitamin B12 deficiency into NBS but also stresses the need for increased awareness of vitamin B12 deficiency in caregivers of pregnant women.
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Affiliation(s)
- Gwendolyn Gramer
- Division of Neuropaediatrics and Metabolic Medicine, Centre for Paediatric and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany.
| | - Junmin Fang-Hoffmann
- Division of Neuropaediatrics and Metabolic Medicine, Centre for Paediatric and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Patrik Feyh
- Division of Neuropaediatrics and Metabolic Medicine, Centre for Paediatric and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Glynis Klinke
- Division of Neuropaediatrics and Metabolic Medicine, Centre for Paediatric and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Peter Monostori
- Division of Neuropaediatrics and Metabolic Medicine, Centre for Paediatric and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Ulrike Mütze
- Division of Neuropaediatrics and Metabolic Medicine, Centre for Paediatric and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Roland Posset
- Division of Neuropaediatrics and Metabolic Medicine, Centre for Paediatric and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Karl Heinz Weiss
- Department of Internal Medicine IV, Gastroenterology and Hepatology, University Hospital Heidelberg, Heidelberg, Germany
| | - Georg F Hoffmann
- Division of Neuropaediatrics and Metabolic Medicine, Centre for Paediatric and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Jürgen G Okun
- Division of Neuropaediatrics and Metabolic Medicine, Centre for Paediatric and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany
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18
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Muru K, Reinson K, Künnapas K, Lilleväli H, Nochi Z, Mosegaard S, Pajusalu S, Olsen RKJ, Õunap K. FLAD1-associated multiple acyl-CoA dehydrogenase deficiency identified by newborn screening. Mol Genet Genomic Med 2019; 7:e915. [PMID: 31392824 PMCID: PMC6732309 DOI: 10.1002/mgg3.915] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Revised: 07/18/2019] [Accepted: 07/22/2019] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND Multiple acyl-CoA dehydrogenase deficiency (MADD), also known as glutaric aciduria type II, is a mitochondrial fatty acid oxidation disorder caused by variants in ETFA, ETFB, and ETFDH. Recently, riboflavin transporter genes and the mitochondrial FAD transporter gene have also been associated with MADD-like phenotype. METHODS We present a case of MADD identified by newborn biochemical screening in a full-term infant suggestive of both medium-chain acyl-CoA dehydrogenase deficiency and MADD. Urine organic acid GC/MS analysis was also concerning for both disorders. However, panel sequencing of ETFA, ETFB, ETFDH, and ACADM was unrevealing. Ultimately, a variant in the FAD synthase gene, FLAD1 was found explaining the clinical presentation. RESULTS Exome sequencing identified compound heterozygous variants in FLAD1: NM_025207.4: c.[442C>T];[1588C>T], p.[Arg148*];[Arg530Cys]. The protein damaging effects were confirmed by Western blot. The patient remained asymptomatic and there was no clinical decompensation during the first year of life. Plasma acylcarnitine and urinary organic acid analyses normalized without any treatment. Riboflavin supplementation was started at 15 months. CONCLUSION Newborn screening, designed to screen for specific treatable congenital metabolic diseases, may also lead to the diagnosis of additional, very rare metabolic disorders such as FLAD1 deficiency. The case further illustrates that even milder forms of FLAD1 deficiency are detectable in the asymptomatic state by newborn screening.
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Affiliation(s)
- Kai Muru
- Department of Clinical Genetics, United Laboratories, Tartu University Hospital, Tartu, Estonia.,Department of Clinical Genetics, Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
| | - Karit Reinson
- Department of Clinical Genetics, United Laboratories, Tartu University Hospital, Tartu, Estonia.,Department of Clinical Genetics, Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
| | - Kadi Künnapas
- Department of Clinical Genetics, United Laboratories, Tartu University Hospital, Tartu, Estonia
| | - Hardo Lilleväli
- Department of Clinical Genetics, United Laboratories, Tartu University Hospital, Tartu, Estonia.,Institute of Biomedicine and Translational Medicine, University of Tartu, Tartu, Estonia
| | - Zahra Nochi
- Research Unit for Molecular Medicine, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Signe Mosegaard
- Research Unit for Molecular Medicine, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Sander Pajusalu
- Department of Clinical Genetics, United Laboratories, Tartu University Hospital, Tartu, Estonia.,Department of Clinical Genetics, Institute of Clinical Medicine, University of Tartu, Tartu, Estonia.,Department of Genetics, Yale University School of Medicine, New Haven, CT, USA
| | - Rikke K J Olsen
- Research Unit for Molecular Medicine, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Katrin Õunap
- Department of Clinical Genetics, United Laboratories, Tartu University Hospital, Tartu, Estonia.,Department of Clinical Genetics, Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
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