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Grange DK, Hillman RE, Burton BK, Yano S, Vockley J, Fong CT, Hunt J, Mahoney JJ, Cohen-Pfeffer JL. Sapropterin dihydrochloride use in pregnant women with phenylketonuria: an interim report of the PKU MOMS sub-registry. Mol Genet Metab 2014; 112:9-16. [PMID: 24667082 DOI: 10.1016/j.ymgme.2014.02.016] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2014] [Accepted: 02/27/2014] [Indexed: 11/17/2022]
Abstract
For pregnant women with phenylketonuria (PKU), maintaining blood phenylalanine (Phe)<360μmol/L is critical due to the toxicity of elevated Phe to the fetus. Sapropterin dihydrochloride (sapropterin) lowers blood Phe in tetrahydrobiopterin (BH4) responsive patients with PKU, in conjunction with a Phe-restricted diet, but clinical evidence supporting its use during pregnancy is limited. As of June 3, 2013, the Maternal Phenylketonuria Observational Program (PKU MOMS) sub-registry contained data from 21 pregnancies - in women with PKU who were treated with sapropterin either before (N=5) or during (N=16) pregnancy. Excluding data for spontaneous abortions (N=4), the data show that the mean of median blood Phe [204.7±126.6μmol/L (n=14)] for women exposed to sapropterin during pregnancy was 23% lower, and had a 58% smaller standard deviation, compared to blood Phe [267.4±300.7μmol/L (n=3)] for women exposed to sapropterin prior to pregnancy. Women on sapropterin during pregnancy experienced fewer blood Phe values above the recommended 360μmol/L threshold. When median blood Phe concentration was <360μmol/L throughout pregnancy, 75% (12/16) of pregnancy outcomes were normal compared to 40% (2/5) when median blood Phe was >360μmol/L. Severe adverse events identified by the investigators as possibly related to sapropterin use were premature labor (N=1) and spontaneous abortion (N=1) for the women and hypophagia for the offspring [premature birth (35w4d), N=1]. One congenital malformation (cleft palate) of unknown etiology was reported as unrelated to sapropterin. Although there is limited information regarding the use of sapropterin during pregnancy, these sub-registry data show that sapropterin was generally well-tolerated and its use during pregnancy was associated with lower mean blood Phe. Because the teratogenicity of elevated maternal blood Phe is without question, sapropterin should be considered as a treatment option in pregnant women with PKU who cannot achieve recommended ranges of blood Phe with dietary therapy alone.
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Affiliation(s)
- Dorothy K Grange
- Washington University School of Medicine, One Children's Place, NWT 9th Floor, St. Louis, MO 63110, USA
| | - Richard E Hillman
- University of Missouri Health Care, One Hospital Drive, University of Missouri, Columbia, MO 65212, USA
| | - Barbara K Burton
- Ann and Robert H. Lurie Children's Hospital of Chicago, 225 E. Chicago Ave., Box #59, Chicago, IL 60611-2605, USA
| | - Shoji Yano
- Los Angeles County & University of Southern California Medical Center, 1801 Marengo Street, Rm 1G-24, Los Angeles, CA 90033, USA
| | - Jerry Vockley
- University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh, 4401 Penn Ave, Pittsburgh, PA 15224, USA; University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA 15224, USA
| | - Chin-To Fong
- University of Rochester Medical Center, Clinic of Inherited Metabolic Disease, Box 777, Genetics 601, Elmwood Avenue, Rochester, NY 14642-8315, USA
| | - Joellen Hunt
- BioMarin Pharmaceutical Inc., 105 Digital Drive, Novato, CA 94949, USA
| | - John J Mahoney
- BioMarin Pharmaceutical Inc., 105 Digital Drive, Novato, CA 94949, USA
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Olsson GM, Mårild S, Alm J, Brodin U, Rydelius PA, Marcus C. The Adolescent Adjustment Profile (AAP) in comparisons of patients with obesity, phenylketonuria or neurobehavioural disorders. Nord J Psychiatry 2008; 62:66-76. [PMID: 18389428 DOI: 10.1080/08039480801979586] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Psychosocial development in children with chronic disease is a key issue in paediatrics. This study investigated whether psychosocial adjustment could be reliably assessed with the 42-item Adolescent Adjustment Profile (AAP) instrument. The study mainly focused on adjustment-to-obesity measurement, although it compared three patient groups with chronic conditions. All phenylketonuria (PKU) patients in Sweden between ages 9 and 18 and their parents and teachers were invited to participate. Patients with neurobehavioural syndromes and obesity were age- and gender-matched with PKU patients. Healthy children constituted a reference group. Psychosocial adjustment was measured using the AAP, which is a multi-informant questionnaire that contains four domains. Information concerning parents' socio-economic and civil status was requested separately. Respondents to the three questionnaires judged the PKU patients to be normal in all four domains. Patients with neurobehavioural syndromes demonstrated less competence and the most problems compared with the other three groups. According to the self-rating, the parent rating and the teacher rating questionnaires, obese patients had internalizing problems. The parent rating and the teacher rating questionnaire scored obese patients as having a lower work capacity than the reference group. Compared with the reference group, not only families with obese children but also families with children with neurobehavioural syndromes had significantly higher divorce rates. Obese patients were also investigated with the Strength and Difficulties Questionnaire (SDQ), another instrument that enables comparison between two measures of adjustment. The AAP had good psychometric properties; it was judged a useful instrument in research on adolescents with chronic diseases.
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Huijbregts SCJ, De Sonneville LMJ, Van Spronsen FJ, Berends IE, Licht R, Verkerk PH, Sergeant JA. Motor function under lower and higher controlled processing demands in early and continuously treated phenylketonuria. Neuropsychology 2003; 17:369-79. [PMID: 12959503 DOI: 10.1037/0894-4105.17.3.369] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
This study examined motor control in 61 early and continuously treated patients with phenylketonuria (PKU) and 69 control participants, aged 7 to 14 years. The pursuit task demanded concurrent planning and execution of unpredictable movements, whereas the tracking task required a highly automated circular movement that could be planned in advance. PKU patients showed significantly poorer motor control in both tasks compared with control participants. Deficits were particularly observed for younger patients (age < 11 years). Differences between control participants and PKU patients were significantly greater in the pursuit task compared with the tracking task, indicating more serious deficits when a higher level of controlled processing is required. Correlations with historical phenylalanine levels indicated a later maturation of the level of control required by the pursuit task compared with the tracking task.
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Affiliation(s)
- S C J Huijbregts
- Department of Clinical Neuropsychology, Vrije Universiteit Amsterdam, The Netherlands.
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Griffiths PV, Demellweek C, Fay N, Robinson PH, Davidson DC. Wechsler subscale IQ and subtest profile in early treated phenylketonuria. Arch Dis Child 2000; 82:209-15. [PMID: 10685922 PMCID: PMC1718264 DOI: 10.1136/adc.82.3.209] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
AIM Mildly depressed IQ is common in treated phenylketonuria. This study explored whether a particular intellectual ability profile typifies early and continuously treated phenylketonuria and whether component skills comprising the IQ relate to socioeconomic and treatment factors. METHODS IQ scores were collected retrospectively from variants of the "Wechsler intelligence scale for children" performed at age 8 on 57 children with early treated, classic phenylketonuria. The mental ability pattern underlying IQ was investigated by analysing subscale and subtest scores and dietary factors, such as historical phenylalanine blood concentrations. RESULTS The children's mean full scale IQ of 91.11 was significantly below the healthy population norm. There was a significant discrepancy between their mean verbal IQ (94.65) and mean performance IQ (89.42), suggestive of a spatial deficit, but the data did not support a biochemical or sociological explanation. Individual Wechsler subtests had no distinctive pattern. Phenylalanine control at age 2 was predictive of overall IQ. At this age, children with annual median phenylalanine < 360 micromol/litre (recommended UK upper limit) had a mean IQ 10 points higher than those above. CONCLUSIONS Early and continuous treatment of phenylketonuria does not necessarily lead to normalisation of overall IQ. Verbal intelligence in the primary school years appears to normalise if blood phenylalanine is maintained below 360 micromol/litre in infancy, but spatial intelligence may remain poor. However, the discrepancy in skill development is not the result of social status or treatment variables. Perhaps weak spatial intelligence is an ancillary effect of a protective rearing style occasioned by the dietary treatment regimen.
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Affiliation(s)
- P V Griffiths
- Department of Psychology, University of Stirling and Royal Hospital for Sick Children, Glasgow G3 8SJ, UK.
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Dennis M, Lockyer L, Lazenby AL, Donnelly RE, Wilkinson M, Schoonheyt W. Intelligence patterns among children with high-functioning autism, phenylketonuria, and childhood head injury. J Autism Dev Disord 1999; 29:5-17. [PMID: 10097991 DOI: 10.1023/a:1025962431132] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
High-functioning children with autistic-spectrum disorder show the typical pattern of lower Comprehension relative to their own scores on Block Design. This profile is shared, almost exactly, by age- and IQ-matched children with poorer control PKU. Quite distinct profiles are shown by children with better control PKU, who show no difference between Block Design and Comprehension, and by children with head injury involving frontal lobe contusion, who show slightly better Comprehension that Block Design. The data bear on several questions: the relation between Comprehension deficits and language functions measured by Vocabulary; the limits of the advantages conveyed by higher IQ to autistic individuals; whether impaired Comprehension in autism indexes persisting symptoms and/or impairments on theory of mind tasks; the possibility that dopamine deficiency is common to autism and poorer control PKU; and the need for future research aimed at understanding the relations among neurodevelopmental disorders.
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Affiliation(s)
- M Dennis
- Department of Psychology, Hospital for Sick Children, Toronto, Canada
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Griffiths P, Campbell R, Robinson P. Executive function in treated phenylketonuria as measured by the one-back and two-back versions of the continuous performance test. J Inherit Metab Dis 1998; 21:125-35. [PMID: 9584263 DOI: 10.1023/a:1005339524847] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The executive dysfunction hypothesis in treated phenylketonuria was investigated by means of the one-back and two-back versions of the continuous performance test. Eleven non-retarded, primary school-age children with classical phenylketonuria who had been treated early and continuously were indistinguishable from healthy, matched controls on the measures and test performance was not predicted by historical or concurrent plasma phenylalanine concentrations. Mean lifetime phenylalanine concentrations for the phenylketonuric subjects were within ranges currently recommended as dietary optima in the United Kingdom. The negative neuropsychological test findings add weight to the rationale for this policy.
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Affiliation(s)
- P Griffiths
- Department of Psychology, University of Stirling, UK
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Griffiths P, Ward N, Harvie A, Cockburn F. Neuropsychological outcome of experimental manipulation of phenylalanine intake in treated phenylketonuria. J Inherit Metab Dis 1998; 21:29-38. [PMID: 9501267 DOI: 10.1023/a:1005307229813] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Blood phenylalanine concentrations were experimentally increased for 3 months by means of a phenylalanine-complemented amino acid supplement in a group of 16 children aged 10-16 years with classical phenylketonuria who had been treated early and who had remained on the restricted diet. Average concentrations achieved during challenge were between 1000 and 1300 mumol/L. Psychological outcome was measured by a neuropsychological battery consisting of tests of verbal and spatial memory, attention and fine motor coordination. A triple-blind, repeated measures, randomized, crossover design was adopted to control for practice and expectancy effects. Subjects were assessed at baseline and at the end of the first and second phenylalanine manipulation periods. Significant interactions (ANOVA) emerged as predicted for phenylalanine concentrations, but similar crossover effects were not found for any of the neuropsychological tests. The results suggested that medium-term hyperphenylalaninaemia in treated PKU is not harmful to psychological functioning in older children and adolescents who have been continuously treated up to and beyond age 10 years, though the susceptibility of executive functions needs to be further researched. The findings add some weight to the idea that by late childhood the vulnerability of the nervous system to the neurotoxic influence of phenylalanine may be much reduced.
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Affiliation(s)
- P Griffiths
- Department of Psychology, University of Stirling, UK
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Griffiths P, Tarrini M, Robinson P. Executive function and psychosocial adjustment in children with early treated phenylketonuria: correlation with historical and concurrent phenylalanine levels. JOURNAL OF INTELLECTUAL DISABILITY RESEARCH : JIDR 1997; 41 ( Pt 4):317-323. [PMID: 9297609 DOI: 10.1111/j.1365-2788.1997.tb00715.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Abstract
The issue of what level of phenylalanine (phe) constitutes a safe upper limit for the therapeutic range in dietary treatment of phenylketonuria (PKU) remains unsettled. It has been proposed that the previous guideline figure of 600 mumol l-1 may result in specific impairment of executive functions such as attention, planning and set maintenance. The executive dysfunction theory was investigated by correlation historical and concurrent phe with executive, non-executive and personality tests in a group of early and continuously treated children, aged 10-13 years, with classical PKU, whose average phe levels of 355 mumol l-1 (SD = +/-144) for the pre-school period and 480 mumol l-1 (SD +/-193) for the primary school period corresponded to the upper limits presently recommended in the UK of 360 and 480 mumol l-1 for these age ranges. No clear associations were found between historical or concurrent phe levels and any of the neuropsychological or personality measures, thereby weakening the case for the emergence of executive deficits, at least when average phe levels remain close to the upper limits now considered safe. Furthermore no significant differences were found on psychological variables where comparison with population norms was possible.
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Affiliation(s)
- P Griffiths
- Department of Psychology, University of Stirling, Scotland
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Schmidt H, Burgard P, Pietz J, Rupp A. Intelligence and professional career in young adults treated early for phenylketonuria. Eur J Pediatr 1996; 155 Suppl 1:S97-100. [PMID: 8828621 DOI: 10.1007/pl00014262] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The intellectual status and professional careers of 51 young adults with phenylketonuria whose treatment started before 3 months of age are described. Their mean IQ was 97 (SD = 16). Of the IQs, 4% were more than 2 SD below the norm. The distribution of types of schooling of the patients was comparable to that in the German population. The professional careers of nearly all the patients were according to their educational level. Within the sample the outcome was significantly correlated with phenylalanine (Phe) control, even when the patients' social background was statistically taken into account. The main influence of Phe on intelligence seems to occur during the first decade of life since IQ data remain stable even after Phe levels increased during adolescence.
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Affiliation(s)
- H Schmidt
- Universitätskinderklinik, Heidelberg, Germany
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Burgard P, Schmidt E, Rupp A, Schneider W, Bremer HJ. Intellectual development of the patients of the German Collaborative Study of children treated for phenylketonuria. Eur J Pediatr 1996; 155 Suppl 1:S33-8. [PMID: 8828606 DOI: 10.1007/pl00014245] [Citation(s) in RCA: 67] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
In a multicentric and interdisciplinary approach the German Collaborative Study of Children Treated for Phenylketonuria (PKU) investigates prospectively the effects of early started strict dietary treatment on the growth and development of 140 patients. The present paper focuses on longitudinal intelligence data from 4, 5 and 9 years of age of 89 patients in relation to the quality of dietary control in comparison to 200 healthy children tested by the same protocol. Cluster analysis of phenylalanine (Phe) levels distinguished a cluster of good dietary control with Phe levels according to the recommendation of maintaining Phe levels below 360 mumol/l, a cluster of poor dietary control with Phe levels greater than 600 mumol/l after the age of 3 years, and a cluster of intermediate control. Intelligence quotients (IQ) and Phe clusters were inversely related with non-significant differences between the clusters good and intermediate. On average, all three clusters scored significantly lower than healthy age peers. Mean IQ scores decreased for patients as well as for healthy children due to different tests used at different measurement occasions. Patients with poor dietary control showed a steeper decrease between 4 and 5 years than patients with better dietary control. Between 5 and 9 years IQ differences between patients and healthy children remained stable. Verbal IQs were higher than performance IQs for patients as well as for healthy children. It is concluded that after early and strict treatment during the pre-school years Phe levels, in the range observed, do not influence IQ development until the age of 9 years. IQ subscale pattern indicate that PKU results in a generalized reduction of IQ instead of disturbing specific abilities. It remains to be investigated whether higher Phe levels are also innocuous and/or may result in late effects.
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Affiliation(s)
- P Burgard
- Department of General Pediatrics, University of Heidelberg, Germany
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Cechák P, Hejcmanová L, Rupp A. Long-term follow-up of patients treated for phenylketonuria (PKU). Results from the Prague PKU Center. Eur J Pediatr 1996; 155 Suppl 1:S59-63. [PMID: 8828612 DOI: 10.1007/pl00014252] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
In order to examine the association between treatment parameters and intellectual outcome, a total of 58 adolescents with phenylketonuria (PKU) treated at the PKU center of the Department of Pediatrics at the University of Prague were tested at the age of 15 years with the Prague Child Wechsler Test. Patients were classified into three groups with different levels of dietary control that remained relatively stable over time at mean phenylalanine levels of 360, 540 and 680 mumol/l. The mean level of phenylalanine was highly correlated with IQ and school education. Patients with mean phenylalanine levels of < or = 360 mumol/l had near-normal level. Initial experience with eight cases of maternal PKU underlines the necessity for a strict treatment regimen, which must be started pre-conception in order to prevent the fetus from developmental damage.
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Affiliation(s)
- P Cechák
- Department of Pediatrics, University Hospital, Praha Královské Vinohrady, Czech Republic
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Burgard P, Rupp A, Konecki DS, Trefz FK, Schmidt H, Lichter-Konecki U. Phenylalanine hydroxylase genotypes, predicted residual enzyme activity and phenotypic parameters of diagnosis and treatment of phenylketonuria. Eur J Pediatr 1996; 155 Suppl 1:S11-5. [PMID: 8828601 DOI: 10.1007/pl00014222] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The interdependence of the predicted in vitro residual enzyme activity (PRA), as deduced from the complete genotypes of 64 hyperphenylalaninaemic patients, and parameters for diagnosis of hyperphenylalaninaemic disorders, the fluctuation of the phyenlylalanine (Phe) values during treatment, long-term dietary control during treatment, and a parameter for the outcome of therapy (IQ) was investigated by correlation analysis. A highly significant correlation was found between the PRA and diagnostic parameters, as well as the fluctuation of the Phe values during treatment. Significant correlations were also observed between the parameter describing the fluctuation of the Phe values and the IQ, as well as between the quality of dietary control and IQ. The PRA is a valuable tool for the differential diagnosis of hyperphenylalaninaemic disorders and for the prediction of one aspect of the course of the disease which is related to the intellectual outcome of therapy. The quality of dietary control was independent of the genotype, indicating that the outcome of therapy can be successfully manipulated in spite of the genetic make-up.
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Affiliation(s)
- P Burgard
- Department of General Pediatrics, University of Heidelberg, Germany
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Schmidt E, Burgard P, Rupp A. Effects of concurrent phenylalanine levels on sustained attention and calculation speed in patients treated early for phenylketonuria. Eur J Pediatr 1996; 155 Suppl 1:S82-6. [PMID: 8828617 DOI: 10.1007/pl00014258] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The effects of short-term and long-term phenylalanine (Phe) levels on sustained attention have been investigated in phenylketonuria (PKU) patients. Two studies, one cross-sectional with 103 patients aged 8.5-9.0 years, the other with 15 adult patients following an interventional design with experimentally manipulated concurrent Phe levels are reported. The effects of concurrent Phe levels separated from long-term Phe control on sustained attention and calculation speed in simple addition tasks were investigated. Children with low concurrent Phe levels performed significantly better than children with high concurrent Phe levels when long-term dietary control was good but not when long-term control was poor. Adult PKU patients with high concurrent Phe levels showed significantly longer reaction times and lower speed in calculation than a healthy control group. Deficits were partly reversible by lowering the concurrent Phe level over a period of 4-5 weeks. The results demonstrated the impact of concurrent Phe level on neuropsychological functioning in childhood as well as in adulthood.
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Affiliation(s)
- E Schmidt
- Department of Pediatrics, Ruprecht-Karls-Universität Heidelberg, Germany
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