Expanded Screening Fact Sheets Doctors NSRC-InT-05 I1R1

Fact Sheets
Information for DOCTORS about the

disorders included in the Expanded
Newborn Screening Panel
NEWBORN SCREENING REFERENCE CENTER Document Date: October 9, 2020 1

AMINO ACID DISORDERS
Table of Homocystinuria 3
Hypermethioninemia/Methionine Adenosine Transferase Deficiency 5
Contents Maple Syrup Urine Deficiency 7
Phenylketonuria 9
Hyperphenylalaninemia 11
6-PTPS Deficiency 13
Tyrosinemia Type I 15
Tyrosinemia Type II 17
ENDOCRINE DISORDERS
Congenital Adrenal Hyperplasia 19
Congenital Hypothyroidism 21
FATTY ACID DISORDERS
Medium Chain Acyl-CoA Dehydrogenase Deficiency (MCADD) 25
Very Long-Chain Acyl-CoA Dehydrogenase Deficiency (VLCADD) 27
Long Chain L-3 Hydroxyacyl-CoA Dehydrogenase (LCHAD) Deficiency 29
Trifunctional Protein (TFP) Deficiency 31
Carnitine Palmitoyl Transferase Deficiency Type 1 33
Carnitine Palmitoyl Transferase Deficiency Type 2 35
Carnitine Uptake Defect 37
Glutaric Aciduria Type 2 39
ORGANIC ACIDURIAS
Propionic acidemia (PA) 42
Methylmalonic academia (MMA) 44
Isovaleric acidemia (IVA) 46
3– Methylcrotnyl CoA Carboxylase Deficiency [3-MCC] 48
Beta Ketothiolase Deficiency 50
Glutaric Aciduria Type 1 52
Multiple Carboxylase Deficiency 54
THALASSEMIAS AND HEMOGLOBINOPATHIES
Hemoglobin E Disease/ Alpha Thalassemia 59
Beta Thalassemias Major 60
Hemoglobin E Disease 61
Hemoglobin C Disease 62
Hemoglobin D Disease 63
Sickle Cell Disease 64
Alpha Thalassemia Trait/ Alpha Thalassemia Minor 65
Beta Thalassemia Trait/ Beta Thalassemia Minor 66
Hemoglobin E Trait or HBFAE 67
Hemoglobin C Trait or HBFAC 68
Hemoglobin D Trait or HBFAD 69
Sickle Cell Trait or HBFAS 70
Interacting HBE Disease with B-Thalassemia 71
Interacting HBD Disease with B-Thalassemia 72
Interacting HBC Disease with B-Thalassemia 73
Interacting A-Thalassemia with Hemoglobin E 74
Interacting α-Thalassemia with β-Thalassemia 75
Other Rare Interacting Thalassemias and Hemoglobinopathies 75
UREA CYCLE DEFECTS
Argininosuccinic Aciduria 78
Citrullinemia 80
OTHERS
Biotinidase Deficiency 82
Galactosemia 84
Glucose-6-Phosphate Dehydrogenase (G6PD) Deficiency 85

HOMOCYSTINURIA (HCY)
What is HCY?
Homocysnuria (Hcy), caused by cystathionine β-synthase deficiency, is an inborn error of the transsulfaon pathway
which causes an increase in levels of homocysteine and methinonine in blood.1
Clinical Manifestaon
Paents affected with homocysnuria may present with (1) ectopia lens, which is found in 85% of paents2; (2) skeletal
abnormalies are prominent especially genu valgus, and paents are o)en described to have a “marfanoid habitus”; (3)
mental retardaon is common but not invariable and; (4) thromboembolism.2,3
Pathophysiology
Increased homocysteine levels is found to inhibit linking of collagen and elasc ssue, which predisposes zonule
generaon of the eye predisposing paents to myopia and lens dislocaon.4 Skeletal abnormalies are thought to result
from damage to fibrillin in paents with cytathionine β-synthase and due to a reducon in collagen crosslinking5 while the
mechanism that contributes to the atherogenic propensity of hyperhomocysnemia are related to endothelial dysfuncon
and injury, which leads to platelet aggregaon and thrombus formaon.6 Finally, chemical abnormalies and the
repeated thromboemolic strokes may contribute to the mental retardaon.4,6
Inheritance: autosomal recessive7
Confirmatory Tesng
Total homocysteine in plasma. Amino acids in plasma, methylmalonic acid in urine, and enzyme study in fibroblasts may
be used to confirm the diagnosis.7
Overview of Disease Management

The aim of treatment is to reduce the plasma total homocysteine through the following approaches: (1) large doses of
pyridoxine (50-100mg/day) have been effecve in reducing biochemical abnormalies in paents with cystathionine- β-
synthase deficiency where about half respond parally (2) folic acid (10mg/day) may be given along with betaine (100mg/
kg/day) that lowers homocysteine levels by remethylaon dietary modificaon by giving a low-methionine/high-cysne
diet. 2 Addional treatment may include Vitamin C (100mg/day) and hydroxocobalamin (1mg/day) starng at 5 yrs of age.
Prognosis
Early diagnosis and treatment can prevent thromboembolic events and reduce the complicaons brought about by
increased levels of homocysteine.2
Preliminary / Inial Management During Metabolic Crisis
Metabolic crises may be caused by illness, prolonged fasng or stressful situaons such as surgery and severe infecon.
The goal of treatment is to reverse the catabolic state, correct the acidosis and prevent essenal amino acid deficiency.
What To Do
If unwell and cannot tolerate oral intake:

HOMOCYSTINURIA (HCY)
• Nothing per orem

• Ensure paent’s airway is secure
• Insert IV access. Collect samples for plasma amino acids. May request for invesgaons (i.e. CBC, etc.) as needed.
• May give fluid boluses if paent requires.
• Start D12.5% 0.3NaCl at full maintenance. Assess paent clinically, if there is need to increase fluid, may do so up to
1.2 or 1.5x the maintenance.
• Start betaine, folic acid and vitamin B6.
• Monitor input and output strictly (q6 hours).
If unwell and can tolerate oral intake:

• Insert oro- or nasogatric tube and start connuous feeding with HCY formula or protein free formula at maintenance
rate
• Insert IV access. Collect samples for plasma amino acids. May request for invesgaons (i.e. CBC, etc.) as needed.
• Start D12.5% 0.3NaCl at 5-10 cc/hr
• Start betaine, folic acid and vitamin B6.
• Monitor input and output strictly (q6 hours)
*Children should not be protein restricted for longer than necessary (24-28 hours)
*Inform metabolic doctor on call for further guidance regarding on-going management
1
Schulze A, Matern D, Hoffmann GF. Chapter 2: Newborn screening in Sarafoglou K, Hoffman GF and Roth KS (eds).
Pediatric Endocrinology and Inborn Errors of Metabolism. New York:McGraw Hill, 2009 pp 17-32.
2
Chapter 22 Homocysnuria. Nyhan WL, Barshop BA and Ozand P. Atlas of Metabolic Diseases 2nd ed. Great Britain:Oxford
University Press, 2005 pp146-151.
3
Cruysburg JR, Boers GHJ, Trijbels FMJ et al. Delay in diagnosis of homocys$nuria: retrospec$ve study of consecu$ve
pa$ents. BMJ 1996;313:1037-1040.
4
Burke JP, O’Keefe M, Bowell R and Naughten ER. Ocular Complica$ons in Homocys$nuria – Early and Late Treated. Br J
Ophthalmol. 1989 June;73(6):427-431.
5
Mudd SH, Levy HL, Skovby F. Disorders of transsulfura$on. In: Scriver CR, Beaudet AL, Sly WS, Valle D, eds. The Metabolic
and Molecular Bases of Inherited Disease. 8th ed. Vol 2. New York: McGraw-Hill, 2001:2007-2056.
6
Boushey Cj, Beresford SA, Omenn GS, Motulsky AG. A Quan$ta$ve Assessment of Plasma Homocysteine as a Risk Factor
for Vascular Disease: Probable Benefits of Increasing Folic Acid Intakes. JAMA 1995;274:1049-1057.
7
Yap S. Homocys$nuria due to cystathionine β-synthase deficiency. Orphanet 2005. hOp://www.orpha.net/data/photo/
GBuk-CbS.pdf. Accessed 16 Feb 2012
8
Ueland PM. Homosysteine Species as Components of Plasma Redox Thiol Status. Clin Chem 1995;41:340-342.

METHIONINE ADENOSINE TRANSFERASE (MAT) DEFICIENCY
What is Methionine Adenosine Transferase (MAT) Deficiency?

Isolated persistent hypermethioninamia has been defined as abnormal elevaon of plasma methionine that persists
beyond infancy and is not caused by homocysnuria due to cystathionine β-synthase deficiency, tyrosinemia type I or
severe liver disease. 1 With rare excepons, this abnormality has been found to be due to inacvang mutaons in
MAT1A, the gene that encodes the catalycally acve subunit of the two isozyme forms of methinonine
adenosyltransferase.2
The great majority of paents have no clinical abnormalies except for unpleasant, sulfurous breath odor but a few
paents have shown neurologic abnormalies such as nystagmus, dysdiadochokinesis, increased tendon reflexes, mental
retardaon, dystonia and dysmetria associated with demyelinaon on MRI.3 The complete lack of MAT I/III acvity can
represent a risk for development of brain demyelinaon, but some residual acvity seems to be sufficient to maintain
clinical well-being.4
Pathophysiology
The pathogenesis of this disease is not clearly elucidated and it might result from different factors: extraordinarily high
plasma methionine levels can directly contribute to nuerological abnormalies, the lack of synthesis of S-
adenosylmethionone (AdoMet)-dependent methylated products can cause demyelinaon and hyperhomocysteinemia
might bring about an elevated risk of vascular and thromboc dieases.4
Inheritance: autosomal recessive4, 5
Confirmatory Tesng
High methinonine in plasma and urine without increased homocysteine.5 Confirmaon of the diagnosis by enzyme assay
requires liver ssue and therefore is not rounely performed.3

Treatment is generally not indicated but in paents with evidence of demyelinaon, administraon of S-
adenosylmethinonine corrects deficiency of this compound.3,5
Prognosis
Abnormal elevaons of plasma homocysteine have been reported among more severely affected MAT I/III deficient
paents and might possibly increase the long-term risk for strokes.4
Preliminary / Inial Management during Metabolic Crisis
What to Do

METHIONINE ADENOSINE TRANSFERASE (MAT) DEFICIENCY
• Insert IV access. Collect plasma amino acid sample. May request for invesgaons (i.e. CBC, liver transaminases,
blood gas, etc.) as needed.

• Insert oro- or nasogatric tube and start connuous feeding with protein free formula at maintenance rate
• Insert IV access. Collect plasma amino acid sample. May request for invesgaons (i.e. CBC, liver transaminases,
blood gas, etc.) as needed.
*Children should not be protein restricted for longer than necessary (24-48 hours)
1
Mudd SH, Chamberlin ME, Chou JY. Isolated persistent hypermethioninemia: gene$c, metabolic and clinical aspects.
As cited in Kim SZ, Santamaria E, Jeong TE et al. Methionine adenosyltransferase I/III deficiency: two Korean compound
heterozygous siblings with a novel mutaon. J Inherit Metab Dis 2002;25:661-671.
2
Kim SZ, Santamaria E, Jeong TE et al. Methionine adenosyltransferase I/III deficiency: two Korean compound hetero-
zygous siblings with a novel muta$on. J Inherit Metab Dis 2002;25:661-671.
3
Fowler B. Chapter 16: Disorders of Transsulfuraon in Sarafoglou K, Hoffman GF and Roth KS (eds). Pediatric Endocri-
nology and Inborn Errors of Metabolism. New York:McGraw Hill, 2009 pp 185-194.
4
Marns E, Marcao A, Bandeira A et al. Methionine Adenosyltransferase I/III Deficiency in Portugal: High Frequency of
a Dominantly Inherited Form in a Small Area of Douro High Lands. JIMD Reports 2011.
5
Adria G, Fowler B, Sebaso G. Chapter 21: Disorders of Sulfur Amino Acid Metabolism in Fernandes J, Saudubray JM,
van den Berghe G, Walter JH (eds). Inborn Metbaolic Disease Diagnosis and Treatment 4th ed. Germany:Springer
Medizin Verlag, 2006 pp 278-279

MAPLE SYRUP URINE DISEASE [MSUD]
What is MSUD?
Maple syrup urine disease (MSUD) is due to a defect or deficiency of the branched chain ketoacid dehydrogenase complex
in which elevated quanes of leucine, isoleucine, valine, and their corresponding oxoacids accumulate in body fluids.1
Infants with MSUD appear normal at birth.2 There are different classificaons of MSUD based on the enzyme acvity and
these include: classical, intermediate, intermiOent, thiamine response, and E-3 deficient MSUD. Classical MSUD (residual
enzyme <2%) is the most severe and common form with symptoms of poor suck, lethargy, hypo and hypertonia,
opisthotonic posturing, seizures, and coma developing 4-7 days a)er birth.3 The characterisc odor of maple syrup may be
detected as soon as neurological symptoms develop.2 Intermediate MSUD (residual enzyme 3-30%) have gradual
neurologic problems resulng in mental retardaon.3 IntermiOent form of MSUD go into metabolic crisis when there is a
stressful situaon such as an infecon or a)er surgery.2,3 Thiamine-responsive MSUD’s clinical symptomatology and
metabolic disturbance is ameliorated once pharmacologic dose of thiamine has been given.3 E-3 deficient MSUD present
with symptoms similar to those with intermediate MSUD but also have lacc acidosis.2,3
Pathophysiology
Due to a mutaon of the branched chain keto-acid dehydrogenase enzyme, the levels of leucine, valine, and isoleucine
increase in blood. The increase in leucine may cause compeve inhibion with other precursors of neurotransmiOers
causing the neurologic manifestaons.2
Inheritance: autosomal recessive2,3
Confirmatory Tesng
Diagnosis is confirmed by detecon of the highly increased branched-chain amino acids levels via quantave amino acid
analysis and/or by increased urinary excreon of α-keto and hydroxyl acids and branched chain amino acids using GC-MS
and quantave amino acid analysis.3

Long term treatment of MSUD is based on dietary restricon of branched-chain amino acids and supplementaon of
thiamine if proven beneficial; valine and isoleucine supplementaon is also recommended. 1,2,3 Frequent determinaon of
leucine levels are likewise encouraged so that proper dietary adjustments be done for effecve management of the
condion.
Prognosis
Children with the classical form of MSUD have only a sasfactory prognosis if they are diagnosed and treated early.3
The goal of treatment is to reverse the catabolic state, correct the acidosis, and prevent essenal amino acid deficiency.
What to Do
• Nothing per orem except medicaons

MAPLE SYRUP URINE DISEASE [MSUD]

• Insert IV access. Collect samples for plasma amino acids, dried blood spot (for leucine levels), blood glucose and urine
ketones. May request for invesgaons (i.e. CBC, blood gas, etc.) as needed.
• Start intralipid at 1g/kg/24 hours.
• Give valine (30-50mg/kg/day) in 6 divided doses
• Give isoleucine (20mg/kg/day) in 6 divided doses

• Insert oro- or nasogatric tube and start connuous feeding with BCAD milk formula or protein free formula at
maintenance rate
• Give valine (30-50mg/kg/day) in 6 divided doses
• Give isoleucine (20mg/kg/day) in 6 divided doses
• Insert IV access. Collect samples for plasma amino acids, dried blood spot (for leucine levels), blood glucose and urine
ketones. May request for invesgaons (i.e. CBC, blood gas, etc.) as needed.
* Children should not be protein restricted for longer than necessary (24-48 hours)
* If pa$ent does not improve with the ini$al management (within 12 hours), hemodialysis may be indicated. Monitor
pa$ent clinically, the necessity of hemodialysis will depend on pa$ent’s clinical status.
1
Nyhan WL, Barshop BA and Ozand P. Chapter 24 Maple syrup urine disease. Atlas of Metabolic Diseases 2nd ed. Great
Britain:Oxford University Press, 2005 pp 159-164.
2
Schulze A, Matern D, Hoffmann GF. Chapter 2: Newborn screening in Sarafoglou K, Hoffman GF and Roth KS (eds). Pedi-
atric Endocrinology and Inborn Errors of Metabolism. New York:McGraw Hill, 2009 pp 17-32.
3
Hoffman GF and Schulze A. Chapter 7: Organic Acidurias in Sarafoglou K, Hoffman GF and Roth KS (eds). Pediatric Endo-
crinology and Inborn Errors of Metabolism. New York:McGraw Hill, 2009 pp 93-94.

PHENYLKETONURIA
What is PKU?
Phenylketonuria (PKU) is a disorder of aromac amino acid metabolism in which phenylalanine cannot be converted to
tyrosine due to a deficiency or absence of the enzyme phenylalanine hydroxylase.1 Phenylalanine hydroxylase requires the
co-factor 6-pyruvoyltetrahydropterin or BH4 for acvity in the hydroxylaon to tyrosine, absence of this co-factor may
present with an increase in plasma phenylalanine similar to phenylketonuria but is considered a separate disorder.2
Paents affected with PKU appear normal at birth.2, 3 The most important and somemes the only manifestaon of PKU is
mental retardaon.2 Paents may present with constuonal, intellectual, and neurologic abnormalies and signs as well
as hypopigmentaon of the skin and hair and iris rapidly develop due to impaired metabolism of melanin.3 Seizures occur
in a fourth of paents.2
The odor of the phenylketonuric paent is that of phenylacec acid described as mousy, barny, or musty.2
Pathophysiology
PKU results from a deficiency of acvity of a liver enzyme, phenylalanine hydroxylase leading to increased concentraons
of phenylalanine in the blood and other ssues. Elevated phenylalanine interfere with myelinaon, synapc sproung,
and dendric pruning; and in addion, it compevely inhibits the uptake of neutral amino acids in the blood-brain barrier
causing reduced tyrosine and tryptophan concentraons thereby liming the producon of neurotransmiOers.3
Confirmatory Tesng
The demonstraon of decreased enzyme acvity is confirmatory.3 However, in the presence of increased phenylalanine
levels, it is important to differenate phenylketonuria from a BH4 deficiency. This is accomplished through administraon
of tetrahydrobiopterin (doses of 2mg/kg intravenously and 7.5-20mg/kd orally), which leads to a prompt decrease to
normal in the concentraon of phenylalanine. Pterin metabolites in urine are likewise useful, demonstrang a very low
biopterin and high neopterin levels.

Dietary management is key to treatment. The diet of paents has four components: (1) complete avoidance of food
containing high amounts of phenylalanine; (2) calculated intake of low protein/phenylalanine natural food; (3) sufficient
intake of fat and carbohydrates to fulfill the energy requirements of the paent and; (4) calculated intake of phenylalanine
free amino acid mixture supplemented with vitamins, minerals and trace elements as the main source of protein.3
Prognosis
When treatment is started early and performed strictly, motor and intellectual development can be expected to be near
normal.3,4

PHENYLKETONURIA
What to Do
• Insert IV access. Collect dried blood spot for phenylalanine levels. May request for invesgaons (i.e. CBC, blood gas,
etc.) as needed.

• Insert oro- or nasogatric tube and start connuous feeding with PKU milk formula or protein free formula at
maintenance rate
• Insert IV access. Collect dried blood spot for phenylalanine levels. May request for invesgaons (i.e. CBC, blood gas,
etc.) as needed.
1
Nyhan WL, Barshop BA and Ozand P. Chapter 20: Phenylketonuria. Atlas of Metabolic Diseases 2nd ed. Great Britain:
Oxford University Press, 2005 pp 127-133.
2
Nyhan WL, Barshop BA and Ozand P. Chapter 21 Hyperphenylalaninemia and defecve metabolism of
tetrahydrobiopterin. Atlas of Metabolic Diseases 2nd ed. Great Britain:Oxford University Press, 2005 pp 136-145.
3
Kaye CI and the CommiOee on Genecs. Newborn screening fact sheets. Pediatrics 2006;118:934-963.
4
5
Burgard P, Lui X, Hoffmann GF. Chapter 13: Phenylketonuria in Sarafoglou K, Hoffman GF and Roth KS (eds). Pediatric
Endocrinology and Inborn Errors of Metabolism. New York:McGraw Hill, 2009 pp 163-168.

HYPERPHENYLALANINEMIA
Hyperphenylalaninemia is a term that encompasses several disorders that result to increased phenylalanine in the body.
In majority of cases, the cause is due to a deficiency of the enzyme phenylalanine hydroxylase. Other cases can be due to
defects in the metabolism of the cofactor tetrahydrobiopterin.1 In the Philippines, all cases of defects in
tetrahydrobiopterin have been determined to be due to 6-pyruvoyl tetrahydropterin synthase {6-PTPS) deficiency.
What is mild hyperphenylalaninemia?

Mild hyperphenylalaninemia is a mild form of phenylketonuria. It is a condion o)en diagnosed only incidentally during
screening for classic phenylketonuria and the increases in phenylalanine levels are insufficiently elevated to cause
neurological damage.2
Clinical manifestaon
Children are normal at birth and are o)en asymptomac. Regular monitoring of phenylalanine levels should be done.
Pathophysiology
When the conversion of phenylalanine to tyrosine is blocked, phenylalanine that is not used for protein synthesis
accumulates in body fluids or is converted to other metabolites.1
Inheritance: autosomal recessive 1•5
Confirmatory Tesng
Regular monitoring of phenylalanine levels is recommended monthly for the first year of life then every 3 months unl 5
years of age.

Mild hyperphenylalaninemia does not require treatment. 5 But regular monitoring of levels unl 5 years of age is needed.
Should levels exceed 350, consult with a medical specialist is suggested.
Prognosis
Paents affected with mild permanent phenylalaninemia will develop normally without treatment .1

HYPERPHENYLALANINEMIA
What is Hyperphenylalaninemia?
Hyperphenylalaninemia is a general term that means that phenylalanine, an amino acid, accumulates in the blood and ssue
of the body. This can be detected through newborn screening. The cause of increase of phenylalanine may be due to either a
lack of enzyme (chemical scissors) or a lack of the co-factor (a substance needed by the body to allow the enzyme to funcon
properly).
What causes mild hyperphenylalaninemia?

Mild hyperphenylalaninemia is a mild form of phenylketonuria, a condion which causes accumulaon of the amino acid
phenylalanine in the body due to a slight decrease of the enzyme or chemical scissor known as phenylalanine hydroxylase.
This condion is inherited. The gene is contained in the genec material that we inherited from our parents. Because one part
of the genec material comes from the father and the other from the mother, the gene comes in pairs. In order to work
correctly, at least one of the pairs should be working.
Parents of children with mild hyperphenylalaninemia have one working and one non-working gene coding for mild
hyperphenylalaninemia. They do not manifest the disease but can pass them on to their children. They are known as carriers.
If the child inherits the non-working gene from both parents, he or she will have the condion. Thus, in each pregnancy, there
is a 25% chance that the child will have the disorder, 50% chance of beinga carrier and 25% chance of having two working
genes.
What are the symptoms of untreated hyperphenylalaninemia?

Children with mild hyperphenylalaninemia do not have any symptoms. While the amino acid
-phenylalanine is increased in their body, it has been determined that these increases are not harmful to the child. However,
monitoring of their blood phenylalanine levels are required.
What is the treatment of mild hyperphenylalaninemia?

There is no need to treat mild hyperphenylalaninemia and your child can have a regular diet. However, it is recommended
that periodic monitoring of blood phenylalanine levels should be done.
What should I do if my baby is sick?

Since there is no treatment needed for this condion, there are no special recommendaons to be done when your child is

6-PTPS DEFICIENCY
What is 6-PTPS Deficiency?

Phenylalanine hydroxylase requires BH4 for acvity in the hydroxylaon to tyrosine.3 A deficiency of BH4 can result in
increased phenylalnine levels in the blood. It is important to note that BH4 is also a co-factor of the enzymes tyrosine and
tryptophan hydroxylase.1
Paents are normal at birth but some may present with early hyptonia; developmental delay may be apparent by the 2nd to
3rd month presenng with seizures and leading to a progressive neurological degenerave disease.3
Pathophysiology
The lack of the cofactor causes increases of phenylalanine in the blood and other ssues. Similar to phenylketonuria, elevated
phenylalanine interfere with myelinaon, synapc sproung and dendric pruning.4
Inheritance: autosomal recessive 1•3
Confirmatory Tesng
The administraon o)etrahydrobiopterin (doses of 2mg/kg intravenously or7.5-20 mg/kg orally) leads to a prompt decrease
to normal in the concentraon of phenylalanine.1•3 Pterin metabolites in urine are likewise useful, demonstrang a very low
biopterin and high levels.

Paents with defects in pterin metabolism, especially with abnormalies of BH4 synthesis should be treated with BH4 with a
daily dose of 2-Smg/kg.3 Paents are also supplemented with levodopa {8-12 mg/kg/day) and 5-OH Tryptophan (6-9mg/kg/
day)5
Prognosis
When treatment is started early, motor and intellectual development can be normal.3
*Paents with 6-PTPS Deficiencies are not prone to metabolic crisis. Medicaons are to be maintained when they are sick.
*If there are queries about the management, contact the metaboJic doctor on call.
However, for the enzyme to funcon properly, it needs the support of a co-factor. In this case, the co-factor is known as
tetrahydrobiopterin or BH4. BH4 in turn is produced by our body through a series of metabolic processes which also makes

6-PTPS DEFICIENCY
use of enzymes. A lack of the 6-PTPS enzyme causes a decrease in the producon of BH4 which in turn affects the breakdown
of phenylalanine.
This condion is inherited. The gene is contained in the genec material that we inherited from our parents. Because one part
of the genec material comes from the father and the other from the mother, the gene comes in pairs. In order to work
correctly, at least one of the pairs should be working.
Parents of children with 6-PTPS deficiency have one working and one non-working gene coding for 6-PTPS. They do not
manifest the disease but can pass them on to their children. They are known as carriers.
If the child inherits the non-working gene from both parents, he or she will have the condion. Thus, in each pregnancy, there
is a 25% chance that the child will have the disorder, 50% chance of being a carrier and 25% chance of having two working
genes.
What are the signs and symptoms of untreated 6-PTPS deficiency?

Children are normal at birth although some may present with decreased muscle tone. At about 2-3 months of age, they may
present with seizures and developmental delay which can progress.
What is the treatment of 6-PTPS deficiency?

Dietary control is not needed. Supplementaon with BH4, levodopa and 5-0H tryptophan should be given daily in divided
doses.
What should I do when my baby is sick?

The medicaons should be connued and consult with a doctor as needed should be done.
3 Nyhan WI., Barshop BA and AI-Aqeel A. Chapter 16: Hyperphenylalaninemia and defecve metabolism of
tetrahydrobiopterin. Atlas of inherited Metabolic Diseases 3rded. Great Britain:Oxford University Press, 2012 pp123-135
4 Kaye Cl and the CommiOee on Genecs. Newborn screening fact sheets. Pediatrics 2006;118:934-963
5 Zchocke J and Hoffmann GF, Vademecum Metabolicu, 3rd ed., Germany:Milupa Metabolics, 2011

TYROSINEMIA TYPE I
What is Tyrosinemia Type I (Hepatorenal tyrosinemia)?

Tyrosinemia is also known as hepatorenal tyrosinemia, tyrosinemia type 1, tyrosinosis or hereditary tyrosinemia.1 The de-
ficient enzyme is fumarylacetoacetase.2
Tyrosine-I is usually asymptomac in newborns, but if le) untreated it affects liver, kidney, bone, and peripheral nerves.3
Two paOerns are reported: an acute or chronic form. The acute form presents with acute hepac decompensaon where
infants are noted to have jaundice, abdominal distenon, failure to thrive, ascites and hepatomegaly, renal disease is also
prominent and a “boiled cabbage” odor in urine is observed; the chronic liver disease feature is that of hepac cirrhosis.4
Pathophysiology
The deficient enzyme, fumarylacetoacetase catalyzes the last step in tyrosine degradaon.2 The increased concentraons
of tyrosine and its metabolites is postulated to inhibit many transport funcons and enzymac acvies.3
Confirmatory Tesng
Confirmaon can be done through plasma amino acid levels (increased tyrosine) and urine metabolic screening (increased
succinylacetone).2

Treatment opons for tyrosinemia include dietary therapy (restricon of phenylalanine and tyrosine), liver transplantaon
and use of the pharmacologic agent 2(2-nitro-4-trifluoro-methylbenzoyl)-1,3-cyclohexanedione or NTBC (1mg/kg).3
Prognosis
If untreated, death from liver failure may occur in the first year of life.4
What to Do
• Insert IV access. Collect samples for blood glucose, plasma amino acids, liver funcon tests, coagulaon studies and
urine succinylacetone. May request for invesgaons (i.e. CBC, blood gas, etc.) as needed.

TYROSINEMIA TYPE I
• Start nisinone (2mg/kg) per orem

• Insert oro- or nasogatric tube and start connuous feeding with TYR milk formula or protein free formula at mainte-
nance rate
• Insert IV access. Collect samples for blood glucose, plasma amino acids, liver funcon tests, coagulaon studies and
urine succinylacetone. May request for invesgaons (i.e. CBC, blood gas, etc.) as needed
• Start D12.5% 0.3NaCl at 5-10 cc/hr.
• Start nisinone (2mg/kg) per orem
1
Nyhan WL, Barshop BA and Ozand P. Chapter 26: Hepatorenal tyrosinemia. Atlas of Metabolic Diseases 2nd ed. Great
2
3
Nyhan WL, Barshop BA and Ozand P. Chapter 26: Hepatorenal tyrosinemia. Atlas of Metabolic Diseases 2nd ed. Great
4
Pass Ka and Morrissey M. Enhancing newborn screening for tyrosinemia type I. Clin Chem 2008;54(4):627-629.

TYROSINEMIA TYPE II
What is Tyrosinemia Type II?

Tyrosinemia Type II is also known as oculocutaneous tyrosinemia or Richner-Hanhart syndrome. The deficient enzyme is
tyrosine aminotransferase.1
The most important manifestaon are those involving the eye. which can lead to corneal scarring and permanent visual
impairment .1 Paents report lacrimaon, photophobia and eye pain.2 Cutaneous lesions are painful keratoses which occur
parcularly on peripheral pressure- bearing areas of the palms andsoles.1•2•3
Pathophysiology
Tyrosine aminotransferase normally converts tyrosine to p-hydroxyophenylpyruvicacid which is the rate-liming step in the
metabolism of tyrosine. The increased concentraon of tyrosine and its metabolites is postulated to inhibit many transport
funcon and enzymac acvies.2
Inheritance: autosomal recessive 1.2 .3
Confirmatory Tesng
Confirmaon can be done through plasma amino acid analysis and enzyme tesng 1•3

The treatment consists of the instuon of a diet low in tyrosine and phenylalanine through protein restricon and supple-
mentaon of a special milk formula.1•2•3
Prognosis
1•3
untreated
What
If unwell and cannot tolerate oral intake
Ensure paent's airway is secure
Insert IV access. Collect samples for blood glucose, plasma amino acids, liver funcon tests and coagulaon stud-
ies. May request for invesgaons (i.e., CBC, blood gas, etc) as needed
May give fluid boluses if paent requires

TYROSINEMIA TYPE II
Start D12.55 0.3NaCI at full maintenance. Assess paent clinically, if there is need to increase fluid, may
do so up to 1.2 to 1.Sxthe maintenance
If unwell and can take oral intake:

Insert oro- or asogastric tube and start connuous feeding with TYR milk formula or protein free formula at maintenance
rate

ENDOCRINE DISORDERS
CONGENITAL ADRENAL HYPERPLASIA (CAH)
What is Congenital Adrenal Hyperplasia (CAH)?

Congenital Adrenal Hyperplasia (CAH) is a group of disorders resulng from enzymac defects in the biosynthesis of
steroids. There are many enzymes involved in the synthesis of adrenal hormones but in about 90% of CAH, it is due to 21-
dydroxylase deficiency. Others are due to cholesterol desmolase 11β-hydroxylase deficiency, 17β-hydroxylase deficiency
and 3β-hydroxysteroid dehydrogenase. All forms of CAH are inherited in an autosomal recessive paOern. The Philippine
NBS data as of December 2018 reports that 1 out of 19,668 screened newborns have CAH.
Pathophysiology
21-Hydroxylase deficiency results in decreased corsol and aldosterone producon which in turn causes increased
adrenocorcotropic hormone (ACTH) secreon. High ACTH levels result in hyperplasia of the adrenal cortex. The precursor
steroids behind the block are diverted to the androgen biosynthec pathway, resulng in excess producon of androgens
that cause virilizaon in females and precocious puberty in males. The decrease in the producon of aldosterone in CAH
results in salt and water imbalance.
Clinical Features
ο Salt-wasng
ο Simple virilizing
ο Late onset
Neonates with the salt-wasng (SW) form manifest adrenal crisis in the first 2-4 weeks of life characterized as poor
feeding, voming, loose stools or diarrhea, weak cry, failure to thrive, dehydraon and lethargy. If untreated, the affected
newborn will die in a severe salt-losing crisis with hypoglycemia and hypotension. The baby who survives may have brain
damage. Affected females usually present with ambiguous genitalia.
Diagnosis
Newborn Screening for 21-hydroxylase deficiency is done by measuring the 17-OHP level on dried blood spot. Infants with
normal birth weight and a mild elevaon of 17-OHP undergo repeat dried blood spot collecon. Infants with moderate to
severe elevaon of 17-OHP and those who are low birth weight with mild elevaon are referred to a pediatric
endocrinologist for evaluaon. Plasma 17-OHP, Na, K, corsol and RBS are requested to confirm the condion. In cases of
discrepancies between the plasma 17-OHP and clinical parameters, more extensive diagnosc evaluaon is
recommended: ACTH smulaon test and/or DNA mutaon studies.
Treatment and Monitoring

The mainstay of treatment in CAH is glucocorcoid and mineralocorcoid replacement therapy which corrects the corsol
deficiency and reverses the abnormal hormonal paOerns. Paents with deficiencies of mineralocorcoids require the
appropriate replacement hormones. Glucocorcoid replacement must be increased during periods of stress. The majority
of female paents with prenatal virilizaon require surgical repair. Heterozygous carrier detecon, prenatal diagnosis, and
prenatal therapy are available for families with 21-hydroxylase deficiency and are o)en used in 11β-hydroxylase
deficiency. Regular endocrine clinic visits for monitoring of physical growth and development as well as biochemical 17-
OHP and/or corsol measurements are recommended for opmal management. Genec counseling is recommended.

ENDOCRINE DISORDERS
CONGENITAL ADRENAL HYPERPLASIA (CAH)
PROGNOSIS
Newborn screening makes early diagnosis and early treatment possible. Early treatment to prevent adrenal crisis is
lifesaving in cases of salt-wasng CAH. Early diagnosis prevents inappropriate sex assignment for affected females of the
simple virilizing (SV) form. This is very important due to the psychological and legal implicaons of wrong gender
assignment. Progressive effects of excess androgens such as short stature and psychosexual disturbance in male and
female paents are also prevented if appropriate treatment is given and monitored closely.

ENDOCRINE DISORDERS
CONGENITAL HYPOTHYROIDISM (CH)
What is Congenital Hypothyroidism (CH) ?

Congenital hypothyroidism (CH) is one of the most common preventable causes of mental retardaon in children.
According to the Philippine NBS data, (December 2018) 1 out of 2,805 screened newborns has CH. The most common
eology of CH is thyroid dysgenesis (TD): absent thyroid, ectopic or hypoplasc thyroid. In rare cases, CH results from
mutaons in the genes that control thyroid gland development including thyroid transcripon factor (TTF-2) and paired
box-8 protein (PAX-8 ). Rapid detecon by newborn screening, prompt confirmatory tesng and Levothyroxine
administraon can prevent severe mental retardaon and impaired growth due to CH.
Pathophysiology
Normal thyroid hormone levels in the body are maintained by a feedback mechanism involving the hypothalmus, pituitary
and thyroid gland. The hypothalamus senses low circulang levels of thyroid hormone (T3 and T4) and responds by
releasing thyrotropin releasing hormone (TRH). TRH smulates the anterior pituitary to produce thyroid smulang
hormone (TSH). TSH, in turn, smulates the thyroid gland to produce thyroid hormone unl levels in the blood return to
normal. Normal thyroid hormone levels exert a negave feedback to the hypothalamus and the anterior pituitary, thus
controlling the release of both TRH from hypothalamus and TSH from anterior pituitary gland. When the thyroid gland
does not produce enough T4 and T3, the pituitary gland compensates by producing high levels of TSH. This biochemical
profile of low T4 level and high TSH is a paOern consistent with Primary CH. Having the correct level of thyroid hormone in
the body is important, especially in the first two years of life, because it ensures normal growth and normal development
of the brain, bones and nervous system.
The hypothalamic-pituitary-thyroid axis (HPT axis)

ENDOCRINE DISORDERS
Clinical Features
Signs and symptoms of hypothyroidism:
• Decreased acvity
• Large anterior fontanelle
• Poor feeding
• poor weight gain
• Small stature or poor growth
• Prolonged Jaundice
• Decreased stooling or conspaon
• Hypotonia
• Hoarse cry or weak cry
• Developmental delay
Some physical signs of hypothyroidism that may or may not be present at birth:
• Coarse facial features
• Macroglossia
• Large fontanelles
• Umbilical hernia
• MoOled, cool, and dry skin
• Pallor
• Myxedema
• Goiter
Diagnosis
Newborn screening for primary CH is done by determining the thyroid smulang hormone (TSH) level on a dried blood
spot. If the TSH is significantly elevated, this signifies that the baby is at risk for CH and therefore needs confirmatory
thyroid tests. An elevated serum TSH and a low serum FT4 confirms hypothyroidism. Thyroid imaging (thyroid scan or
ultrasound) is recommended to document eology of CH.

Immediate diagnosis and treatment of congenital hypothyroidism in the neonatal period is crical to normal brain
development and physical growth. Treatment started within the first two weeks of life usually prevents
neurodevelopmental delays. Recommended treatment is the lifeme daily administraon of Levothyroxine. Only the
tablet form of Levothyroxine is currently approved for therapeuc use. The tablets should be crushed, mixed with a few
milliliters of water, and fed to the infant directly into the mouth. It is not recommended that Levothyroxine be mixed with
soy formula or with formula containing iron, as these interfere with absorpon of the medicaon. Thyroid hormone
replacement and medical monitoring are required for life.
Children with congenital hypothyroidism should be monitored clinically and biochemically. Clinical parameters should
include linear growth, weight gain, head circumference, developmental progression, and overall well-being. Serum T4 or
FT4 and TSH should be monitored at regular intervals. The following is the recommendaon of the American Academy of
Pediatrics
• at 2 and 4 weeks a)er iniaon of T4 treatment
• every 1 to 2 months during the first 6 months of life
• every 3 to 4 months between 6 months and 3 years of age
• every 6 to 12 months therea)er unl growth is completed
• a)er 4 weeks if medicaon is adjusted
• at more frequent intervals when compliance is in queson or abnormal values are obtained.

ENDOCRINE DISORDERS
However, these guidelines on biochemical parameters may be modified by the specialist depending on the clinical status
of the paent.
Such evaluaons are especially important in children whose treatment was delayed beyond 1 month of life, or in paents
whose treatment is inconsistent (non-compliance).
Prognosis
Early diagnosis and opmal treatment of congenital hypothyroidism prevents severe mental retardaon, neurologic
complicaons and physical delays. Even with early treatment, some children may demonstrate mild delays in areas such as
reading comprehension and arithmec. Although connued improvement in IQ has been documented in treated paents
through adolescence, some cognive problems may persist. These may include problems in visuospaal, language, and
fine motor funcon. Defects in memory and aOenon have been reported .

FATTY ACID OXIDATION DISORDERS [FAOD]
FAOD includes:
Medium chain acyl co-A dehydrogenase deficiency (MCAD)
Very long chain acyl Co- A dehydrogenase deficiency (VLCAD)
Long chain hydroxyacyl co-A dehydrogenase deficiency (LCHAD)
Trifunconal protein deficiency (TFI)
Carnine Palmitoyl Transferase Deficiency Type 1
Carnine Palmitoyl Transferase Deficiency Type 2
Carnine Uptake Defect
Glutaric Aciduria Type 2
What are FAOD?

FAOD are a group of autosomal recessive disorders caused by the deficiency or absence of any of the enzymes needed for
beta-oxidaon. Children born with this condion appear normal at birth but untreated paents may present with low
blood sugar which can lead to seizures, coma and death. One type of FAOD, VLCAD (or very long chain acyl-CoA
dehydrogenase deficiency) may present with cardiomyopathy and increased creane kinase (CK) levels.
Treatment of FAOD
Treatment is through the dietary restricon of fat. VLCAD paents are treated with a special milk formula containing
medium chain triglycerides.

The goal of treatment is to reverse the catabolic state and prevent hypoglycemia.
What to Do:

• Insert IV access. Monitor glucose levels. For paents with VLCAD, collect samples for serum CK. May request for
other invesgaons (i.e. CBC, Blood gas) as needed. May give fluid boluses if paent requires.
• Start D10% 0.3 NaCl at full maintenance. Assess paent clinically, if there is need to increase fluid, may do so up to 1.2
or 1.5X the maintenance.
• Monitor input and output strictly (q6 hours). Check for the color of urine.
If unwell and is able to tolerate oral intake:
• Insert oro- or nasogastric tube and start connuous feeding with a high glucose formula
• Insert IV access. Monitor glucose levels. For paents with VLCAD, collect samples for serum CK. May request for
other invesgaons (i.e. CBC, Blood gas) as needed. May give fluid boluses if paent requires.
• Start D10% 0.3 NaCl at 5-10 cc/hr.
• Monitor input and output strictly (q6 hours). Check for the color of urine.
*Pa$ents with VLCAD may have rhabdomyolysis. Monitor CK levels and hydrate adequately. If CK levels con$nually rise,
hemodialysis may be indicated.
* Inform metabolic doctor on call for further guidance regarding on-going management.
MEDIUM-CHAIN ACYL-COA DEHYDROGENASE DEFICIENCY (MCADD)
What is MCADD?
Medium chain acyl-CoA dehydrogenase (MCAD) deficiency is the most common defect of faOy acid oxidaon.1
MCAD deficiency has a very wide spectrum of clinical presentaons ranging from benign hypoglycemia to coma and
death.2 Two presentaons have been noted: (1) hypoketoc hypoglycemia or Reye syndrome which occurs within the first
two years of life and (2) the chronic disrupon of muscle funcon which include cardiomyopathy, weakness, hypotonia
and arrhythmia.2,3 In addion, MCAD deficiency has been shown to be associated with sudden infant death syndrome
(SIDS).4 A “metabolic stress” such as prolonged fasng o)en in connecon with viral infecons is usually required to
precipitate disease manifestaons but paents are completely asymptomac between episodes.2
Pathophysiology
MCAD catalyzes the inial step in the β-oxidaon of C12-C6 straight chain acyl-CoAs and MCAD deficiency results in a lack
of producon of energy from β-oxidaon of medium chain faOy acids and hepac ketogenesis and gluconeogenesis.4
Confirmatory Tesng
Urine organic acid profile will show medium chain dicarboxylic aciduria.4 Measurement of the specific MCAD enzyme
acvity in disrupted cultures skin fibroblasts, lymphocytes, or ssue biopsies from muscle can confirm the diagnosis.2
Rapid screening is available for two of the most common mutaons which account for over 93% of all MCAD mutaons
(A985G and 4 bp deleon).4

Treatment consists of avoidance of prolonged fasng by instung frequent feedings with a carbohydrate rich diet and
provision of supplementary nocturnal uncooked cornstarch.2 The use of carnine is sll under debate.2,4
Prognosis
Most authors report a mortality rate of 20-25% during the inial decompensaon. Although the majority of children
survive their inial episode, a significant amount of children who survived and perhaps children who have experienced
clinically unrecognized episodes, suffer from long term sequelae and about 40% are judged to have developmental delay.2
Long term outcome remains dependent on constant monitoring for early signs of illness and rapid medical intervenon to
prevent complicaons.3
What to Do
• Insert IV access. Monitor glucose levels. May request for invesgaons (i.e. CBC, etc.) as needed.

MEDIUM-CHAIN ACYL-COA DEHYDROGENASE DEFICIENCY (MCADD)
• Start D10% 0.3NaCl at full maintenance. Assess paent clinically, if there is need to increase fluid, may do so up to 1.2
or 1.5x the maintenance.

• Encourage regular feeding
• Start D10% 0.3NaCl at 5-10 cc/hr
1
Strauss AW, Andersen BS and BenneO MJ. Chapter 5: Mitochondrial FaOy Acid Oxidaon Defects in Sarafoglou K,
Hoffman GF and Roth KS (eds). Pediatric Endocrinology and Inborn Errors of Metabolism. New York:McGraw Hill, 2009
pp 60-62.
2
Hsu HW, Zytkovicz TH, Comeau AM et al. Spectrum of Medium chain acyl-coA dehydrogenase deficiency detected by
newborn screening. Pediatrics 2008;121:e1108-e1114.
3
Nyhan WL, Barshop BA and Ozand P. Chapter 40: Medium chain acyl-CoA dehydrogenase deficiency. Atlas of Metabol-
ic Diseases 2nd ed. Great Britain:Oxford University Press, 2005 pp 260-265.
4
Wilson CJ, Champion MP, Collins JE et al. Outcome of medium chain acyl-CoA dehydrogenase deficiency a?er diagno-
sis. Arch Dis Child 1999;80:459-462.
5
Liebig M, Schymik I, Mueller M et al. Neonatal screening for very long chain acyl-CoA dehydrogenase deficiency: enzy-
ma$c and molecular evalua$on of neonates with elevated C14:1-carni$ne levels. Pediatrics 2006;118(3):1064-1069.

VERY LONG-CHAIN ACYL-COA DEHYDROGENASE DEFICIENCY (VLCADD)
What is VLCADD?
Very long-chain acyl-CoA dehydrogenase catalyzes the dehydrogenaon of C22-C12 straight chain faOy acids, and because
the long chain faOy acids constute a major proporon of the faOy acids, VLCAD deficiency is generally a more severe
condion than MCAD or SCAD deficiency and mulple ssues are affected.
The clinical presentaon of symptomac VLCAD deficiency is heterogenous with phenotypes of different severies., There
are three forms described: (1) severe childhood form with neonatal onset and cardiomyopathy; (2) milder childhood form
with delayed onset of symptoms o)en triggered by metabolic stress and presents as hypoketoc hypoglycemia and; (3)
adult form which presents with isolated skeletal muscle involvement with recurrent episode of muscle pain,
rhabdomyolysis and myoglobinuria.1,2
Pathophysiology
VLCAD catalyzes the dehydrogenaon of acyl CoA esters of 14-20 carbon length in the first step of mitochondrial faOy acid
oxidaon.2,3 VLCAD deficiency results in lack of producon of energy from β-oxidaon of long-chain faOy acids, because
heart and muscle ssue depend heavily on energy from long chain faOy acid oxidaon, a VLCAD deficiency severely affect
these ssues.1
Confirmatory Tesng
The enzyme defect can be detected through culture skin fibroblasts.1 The gene for VLCAD has been cloned and sequenced
successfully and play a role in diagnosis of this disorder.3

Treatment of this disorder include avoidance of fasng by frequent feeding, overnight connuous feeding, reducon of
amount of long chain fat in diet while supplying essenal faOy acids in the form of canola, walnut oil or safflower oil and
supplementaon with medium chain triglycerides.1,3
For the adult muscular form, it is advised to have a high carbohydrate intake prior to exercise to prevent lipolysis and to
restrict physical acvity to levels that are not likely to precipitate an aOack of rhabdomyolysis.1
Prognosis
Fi)y percent of paents die within 2 months of inial symptomatology.3 However, mely and correct diagnosis leads to
dramac recovery so that early detecon could prevent the onset of arrhythmias, heart failure, metabolic insufficiency and
death.

VERY LONG-CHAIN ACYL-COA DEHYDROGENASE DEFICIENCY (VLCADD)
What to Do
• Insert IV access. Monitor glucose levels. Collect samples for urine ketones and serum creane kinase (CK). May
request for invesgaons (i.e. CBC, liver transaminases, blood gas, etc.) as needed.
• Monitor input and output strictly (q6 hours). Check color of urine and may request for urinalysis to check for urine
myoglobin.

myoglobin.
1
2
Nyhan WL, Barshop BA and Ozand P. Chapter 41: Very long chain acyl-CoA dehydrogenase deficiency. Atlas of Meta-
bolic Diseases 2nd ed. Great Britain:Oxford University Press, 2005 pp 267-270.
3
Wood JC, Mager MJ, Rinaldo P et al. Diagnosis of very long chain acyl-dehydrogenase deficiency from an infant’s new-
born screening card. Pediatrics 2001l108:e19-e21.
4
Moczulski D, Majak I, Mamczur D. An overview of β-oxida$on disorders. Postepy Hig Med Dosw 2009;63:266-277.

LONG-CHAIN L-3-HYDROXY ACYL-COA DEHYDROGENASE [LCHAD] DEFICIENCY
What is LCHAD Deficiency?

Long chain L-3 hydroxyacyl-CoA dehydrogenase (LCHAD) is a component of trifunconal protein.1 Isolated LCHAD
deficiency catalyzes the third step in the faOy acid oxidaon spiral, converng long chain 3-hydroxyacyl-CoA esters into
long chain 3-keto-CoA species by using NAD as a cofactor.2
Paents exhibit moderate or severe mulorgan involvement either neonatally or during the first two years of life.3 They
may present in the first year of life with hypoketoc hypoglycemia and liver dysfuncon, Reye syndrome-like symptoms,
seizures, coma and death.2 By adolescence, ophthalmologic abnormalies including loss of visual acuity, choriorenal
atrophy, progressive renis pigmentosa and peripheral sensorimotor polyneuropathy may be observed.2,3,4 Up to 40% of
symptomac paents may have tachycardic arrhythmias, apneic episodes, cardiopulmonary arrest and unexplained
death.2
Pathophysiology
Since the enzyme LCHAD is part of the faOy acid oxidaon, a deficiency causes a problem in the energy ulizaon of the
body which causes the presentaon of signs and symptoms as listed above.1
Confirmatory Tesng
Confirmatory tesng is done through enzyme assays performed in cultured cells such as skin fibroblasts.2 The common
mutaon G1528C has been idenfied in affected individuals and may be used for confirmaon.3

Primary goal of treatment is to avoid metabolic stress brought about by infecon and long periods of fasng. Paents
should be given frequent feedings, supplementaon with medium chain triglycerides, an overnight infusion of
cornstarch.2,5 Treatment with L-carnine remains controversial.6
Prognosis
Paents with LCHAD deficiency who present symptomacally o)en die during the acute episode or suffer from sudden,
unexplained death and mortality occurs in approximately 38%.2
What to Do

LONG-CHAIN L-3-HYDROXY ACYL-COA DEHYDROGENASE LCHAD] DEFICIENCY

myoglobin.

myoglobin.
1
Nyhan WL, Barshop BA and Ozand P. Chapter 42: Long chain 3-hydroxyacyl-CoA dehydrogenase deficiency. Atlas of
Metabolic Diseases 2nd ed. Great Britain: Oxford University Press, 2005 pp 272-275.
2
newborn screening. Pediatrics 2008;121:e1108-e1114
3
Eskelin P and Tyne T. LCHAD and MTP Deficiencies – Two Disorders of Mitochondrial Fa@y Acid Beta-Oxida$on with
Unusual Features. Cur Ped Rev 2007;3:53-59.
4
Moczulski D, Majak I, Mamczur D. An overview of β-oxida$on disorders. Postepy Hig Med Dosw 2009;63:266-277.
5
Gillingham M, Van Calcar S, Ney D et al. Dietary management of long chain 3-hydroxyacyl-CoA dehydrogenase deficiency.
A Case report and survey. J Inherit Metab Dis 1999;22(2):123-131.
6
Bilic E, Deliu M, Brinar V et al. Carni$ne palmitoyltransferase type 2 deficiency – case report and review of the
literature. Nurol Croat 2013;62:57-62.

TRIFUNCTIONAL PROTEIN (TFP) DEFICIENCY
What is TFP Deficiency?

The mitochondrial trifunconal protein (TFP) is a mulenzyme complex of the β-oxidaon cycle composed of four α-
subunits harbouring long-chain enoyl-CoA hydratase and long chain L-3-hydroxyacyl-CoA dehydrogenase and four β-
subunits encoding long chain 3-ketoacyl-CoA thoilase.1 General or complete TFP deficiency is defined and occurs when
markedly decreased acvity of all three enzymac components, LCHAD, long chain 2,3 enoyl CoA drasate and LKAT exist.2
General TFP deficiency has three phenotypes: the lethal phenotype presenng with lethal cardiac failure or sudden death
due to arrhythmias, the hepac phenotype and the neuromyopathic phenotype that has later-onset, episodic, recurrent
skeletal myopathy with muscular pain and weakness o)en induced by exercise or exposure to cold and peripheral
neuropathy.2, 3
It is important to note that fetuses with complete TFP deficiency can cause maternal liver diseases of pregnancy.2
Pathophysiology
Mitochondrial faOy acid β-oxidaon is a major energy-producing pathway.4 Any defect in any enzyme may cause the
characterisc signs and symptoms which include hypoketoc hypoglycemia.2
Confirmatory Tesng
Confirmatory tesng is through the demonstraon of decreased enzyme acvity on cultured fibroblast.2 Mutaons in the
HADHA and HADHB genes may result in mitochondrial trifunconal protein deficiency5 and may play a role in confirmaon.

Treatment includes avoidance of fasng, reduced long-chain fat intake, supplementaon with medium chain triglycerides,
supplementaon with fat-soluble vitamins, and avoidance of other potenal stressors such as prolonged exercise.2
Prognosis
Paents with metabolic crises do well unless the hypoglycemia and seizures are prolonged and cause developmental delay,
older onset paents with rhabdomyolysis can reduce episodes significantly with dietary management and do well.2
What to Do

TRIFUNCTIONAL PROTEIN (TFP) DEFICIENCY

myoglobin.

myoglobin.
1
SpeikerkoeOer U, Khuchua Z, Yue Z et al. General Mitochondrial Trifunc$onal Protein (TFP) Deficiency as a results of
either α or β-subunit muta$ons exhibits imilar phenotypes because muta$on in either subunit alter TFP complex expres-
sion and subunit turnover. Ped Res 2003l55(2):1-7.
2
3
Kamijo T, Wanders RJA, Saudubray JM et al. Mitochondrial Trifunc$onal Protein Deficiency. J Clin Invest 1994;93:1740-
1747.
4
Nyhan WL, Barshop BA and Ozand P. Chapter 37: Carnine transporter deficiency. Atlas of Metabolic Diseases 2nd ed.
Great Britain:Oxford University Press, 2005 pp 246-250.
5
hOp://ghr.nlm.nih.gov/condion/mitonchondrial-funconal-protein-deficiency Accessed 30 April 2012

CARNITINE PALMITOYLTRANSFERASE TYPE 1 DEFICIENCY [CPT1]
What is CPTI Deficiency?

CPT1 is an ezyme of the outer mitochondrial membrane that converts long chain faOy acyl molecules to their
corresponding acylcarnines which are then transported across the inner mitochondrial membrane for β-oxidaon in the
mitochondrial matrix. 1 CPT1 catalyzes the rate liming step of long chain faOy acid import into the mitochondria and is
the main regulatory enzyme of the system.2
This disorder presents usually in infancy, o)en in the second six months, with acute hypoketoc hypoglycemia, metabolic
acidosis with raised transaminases, hepatomegaly, hepatosteatosis and mild to moderate hyperammonemia during an
episode of fasng brought in by an intercurrent, usually viral illness, or gastroenteris.1,3 Paents may present with a
range of cardiac arrhythmias including sudden cardiac arrest and death may occur during an acute presentaon but
surviving infants may suffer with severe developmental delay and intellectual impairment as a result of cerebral
bioenergec failure.1 Cardiac or skeletal muscle involvement is not common.4
Pathophysiology
Three different isoforms exist including the liver, muscle and brain, with only the liver-type showing deficiency in humans.3
Deficiency of CPT1 in the liver results in a failure of acylcarnine formaon and hence liOle or no entry of LCFA into
mitochondria for oxidave metabolism.1,3
Confirmatory Tesng
There is note of high plasma carnine concentraons with more than 90% in the free form.1 Organic acid analysis of the
urine is notable for the absence of dicarboxylic aciduria, hydroxycarboxylic aciduria and absence of ketones.3 The
condion is confirmed by the assay of CPT1 in fibroblasts whose acvity is reduced to 5-20%.

The major element in management is the avoidance of fasng and in the presence of intercurrent infecon or other cause
of voming or anorexia in which the oral route is excluded, the provision of intravenous glucose is essenal.3 Reducon of
intake of long chain fats appears prudent and medium chain triglycerides may be substuted.1,3
Prognosis
Survival through infancy without symptoms has been reported and between episodes of metabolic decompensaon
individuals appear developmentally and cognively normal unless there has been previous neurologic damage secondary
to a metabolic decompensaon.4

What to Do
Nothing per orem
• Insert IV access. Monitor glucose levels. May request for invesgaons (i.e. CBC, CK, liver transaminases, blood gas,
etc.) as needed.



• Insert IV access. Monitor glucose levels. May request for invesgaons (i.e. CBC, CK, liver transaminases, blood gas,
etc.) as needed.
1
Olpin SE. Pathophysiology of fa@y acid oxida$on disorders and resultant phenotypic variability. J Inherit Metab Dis
2013;36:645-658.
2
Orgel A. Carni$ne Palmitoyl transferase II: Enzyme Deficiency. hOp://www.userwebs.pomona.edu/~ejc14747/180/
student%20presentaons/Orgel%20carnine%20paper.pdf Accessed 1 August 2014
3
Chapter 39. Carni$ne palmitoyl transferase I deficiency. Nyhan WL, Barshop BA and Ozand P. Atlas of Metabolic Diseases
2nd ed. Great Britain:Oxford University Press, 2005 pp 256-259.
4
Bonnefont JP, Djouadi F, Prip-Buus C et al. Carni$ne palmitoyltransferases 1 and 2: biochemical, molecular and medical
aspects. Mol Asp Med 2004;25:495-520.
5
Bilic E, Deliu M, Brinar V et al. Carni$ne palmitoyltransferase type 2 deficiency – case report and review of the literature.
Nurol Croat 2013;62:57-62.

What is CPT2 Deficiency?

Carnine Palmitoyltransferase Type II (CPT2) is responsible for the last step of the carnine dependent transport system.1
In these disorders, long-chain acylcarnines are translocated across the inner mitochondrial membrane but are not
efficiently converted to acyl-CoAs.2
CPT2 has three phenotypes: (1) a fatal neonatal-onset form with non-ketoc hypoglycemia, liver disease, hypotonia,
cardiomyopathy and congenital abnormalies; (2) infanle form with or without cardiac disease presents with liver and
skeletal muscle involvement with episodes of decompensaon and; (3) adult form presenng with muscle pain, sffness
and myoglobinuria.1, 3 The episodes are triggered by exeronal exercise, cold, fever, infecon or prolonged fasng.3,4 CPT2
presents frequently in adults with rhabdomyolysis and myoglobinuria triggered most o)en by prolonged exercise.4
Pathophysiology
In the adult form of CPT2 deficiency, the triggering circumstances of myolysis aOacks are consistent with the fact that long
chain faOy acids are the main energy source for skeletal muscle during fasng or prolonged exercise.1,3,4 It has been
speculated that increased concentraon of long-chain acylcarnines in paent with the severe form of CPT2 deficiency
may promote cardiac arrhythmia.2 Why the two clinical presentaons of CPT2 deficiency differ both in age of onset and
ssue expression paOern remains unresolved.2,3
Confirmatory Tesng
The CPT2 acvity measured in fibroblasts or lymphocytes from CPT2-deficient paents ranges from 5-25% of control
values.2

Similar to all faOy acid oxidaon defects, long term dietary therapy is aimed at prevenng any period of fasng; restricon
of long chain fat intake along with medium chain triglyceride supplementaon is recommended and in the muscular form,
prevenve rhabdomyolysis aOacks is based on frequent meals with carbohydrate extra-intake before and during
prolonged exercise.2
Prognosis
The clinical condion of paents is normal between recurrent aOacks and the frequency of aOacks are variable ranging
from asymptomac to lethal but in all cases the symptomatology is restricted to the skeletal muscles without liver or heart
involvement.2
What to Do

myoglobin.

myoglobin.
1
Orgel A. Carni$ne Palmitoyltransferase II: Enzyme Deficiency. hOp://www.userwebs.pomona.edu/~ejc14747/180/
student%20presentaons/Orgel%20carnine%20paper.pdf Accessed 1 August 2014
2
Bonnefont JP, Djouadi F, Prip-Buus C et al. Carni$ne palmitoyltransferases 1 and 2: biochemical, molecular and medical
aspects. Mol Asp Med 2004;25:495-520.
3
2013;36:645-658.
4
Bilic E, Deliu M, Brinar V et al. Carni$ne palmitoyltransferase type 2 deficiency – case report and review of the literature.
Nurol Croat 2013;62:57-62.

CARNITINE UPTAKE DEFECT (CUD)
What is CUD?
Carnine uptake defect is also known as carnine transporter deficiency. It is due to an abnormality in the transporOhat
facilitates carnine’s entry into certain cells. In some instances, it is has been found that neonates who test posive for
this condion do not actually have the condion but instead reflect the decreased levels of their mothers.
Paents may present with hypoketoc hypoglycemia, modest hepatomegaly and Reye-like syndrome, progressive heart
failure and muscle weakness. Most paents present with a progressive cardiomyopathy associated with skeletal
myopathy.
Pathophysiology
Carnine is necessary for transport of long-chain faOy acids into mitochondria to enter the β-oxidaon cycle.2 Genec
defects of the carnine trasporter results in failure of ssues of the cardiac and skeletal muscle and in the renal tubules to
concentrate intracellular levels of carnine, thus reducing available cofactor for the carnine cycle.3
Confirmatory Tesng*
Confirmaon of the diagnosis can be made biochemically by monitoring the uptake of carnine by skin fibroblasts in
culture.3

Oral carnine therapy at 100mg/kg/day into four divided doses is recommended.2,3
Prognosis
Paents on long term therapy report normal skeletal muscles tone, no episodes of metabolic decompensaon, and
essenally normal intellect.3
What To Do

CARNITINE UPTAKE DEFECT (CUD)

Inform metabolic doctor on call for further guidance regarding on-going management
* If the baby’s confirmatory test is nega$ve, consider doing plasma acylcarni$ne analysis of the pa$ent’s mother to rule
out maternal CUD.
1
Chapter 37: Carnine transporter deficiency. Nyhan WL, Barshop BA and Ozand P. Atlas of Metabolic Diseases 2nd ed.
Great Britain:Oxford University Press, 2005 pp 246-250.
2
Wilcken B. Disorders of Carni$ne Cycle and Detec$on by Newborn Screening. Ann Acad Med 2008;37 (12):71-73.
3
Hsu HW, Zytkovicz TH, Comeau AM et al. Spectrum of Medium chain acyl-coA dehydrogenase deficiency detected by new-
born screening. Pediatrics 2008;121:e1108-e1114.

GLUTARIC ACIDURIA TYPE 2 [GA2]
What is GA2?
Mulple acyl-CoA dehydrogenaon deficiency (MADD) ia disorder of faOy acid, amino acid and choline oxidaon caused
by defects in any one of two flavoproteins, electron transport flavoprotein (ETF) or ETF:ubiquinone oxidoreducatase (ETF-
QO) which affect some 14 dehydrogenases.1,2
Paents may present with cyclical voming, loss of appete, progressive proximal muscle weakness parcularly affecng
neck, shoulder, hip and/or respiratory muscles but also chronic leg weakness and exercise intolerance with occasional
rhabdomyolysis.1 The clinical phenotype is heterogenous and has been classified into three groups: neonatal onset with
congenital anomalies (type 1), neonatal onset without anomalies (type 2) and mild and/or later onset (type 3).3
The infant affected with this disorder presents with life-threatening illness in the first day of life presenng with tachypnea
or dyspnea, profound metabolic acidosis and impressive hypoglycemia within a few hours of birth.2 The later on-set of
this disorder has presented with considerable variety. In adolescents and adults, muscular or cardiac symptoms or
episodic voming are usually first features suggesve for MADD.3
Pathophysiology
The metabolic defects result in impaired adenosine triphosphate (ATP) biosynthesis, excessive lipid accumulaon in
different organs and insufficient gluconeogenesis.3 The most characterisc pathological feature of MADD is increased
intracellular neutral lipid storage, especially in skeletal muscle and liver which is observed as increased intracellular lipid
droplets in both size and number.4
Confirmatory Tesng
Diagnosis is based on both the urinary organic acid profile and the acylcarnine paOern in dried blood/plasma.
Acylcarnine analysis usually revelas increased concentraons of several short-, medium- and long-chain acylcarnines.
The characterisc urinary organic acid paOern comprises elevated levels of glutaric, ethylmalonic, 3-hydroxyisovaleric, 2-
hydroxyglutaric, 5-hydroxyhexanoic, adipic, suberic, sebacic and dodecanedioic acid without relevant ketonuria especially
if combined with glycine conjugates of C4 and C5 acids.3

Therapeuc management mostly comprises a diet restricted in fat and protein and the avoidance of fasng.1 Among the
consequences of this disorder is a depleon of body stores of carnine, thus, paents may benefit from carnine
supplementaon.2 Some forms of this disorder are responsive to riboflavin (100 to 300 mg/day)2 and the clinical response
to pharmacological doses of riboflavin is usually rapid and striking.1
Prognosis
Early onset MADD is a disease with high mortality, the prognosis of late-onset MADD seems to be good; nevertheless, 5%
of paent reported in literature had died mainly during metabolic decompensaons and in some paents, death could not
be prevented despite the known diagnosis of MADD.3

What to Do
• Insert IV access. Monitor glucose levels. May request for invesgaons (i.e. CBC, blood gas, kidney funcon etc.) as
needed.

• Insert oro- or nasogatric tube and start connuous feeding with oresol at maintenance rate
• Insert IV access. Monitor glucose levels. May request for invesgaons (i.e. CBC, blood gas, kidney funcon etc.) as
needed.
1
2013;36:645-658
2
Chapter 45. Mu$ply acyl Coa dehydrogenase deficiency (MASS)/Glutaric aciduria type II/Ethylmalonic-adipic aciduria.
Nyhan WL, Barshop BA and Ozand P. Atlas of Metabolic Diseases 2nd ed. Great Britain:Oxford University Press, 2005 pp
284-291
3
Grunert S. Clinical and fene$cal heterogeneity of late-onset mul$ple acyl-coenzyme A dehydrogenase deficiency. Or-
phanet J Rare Dis 2014;9(14):1-8.
4
Liang WC and Nishino I. Riboflavin-responsive mul$ple acyl-CoA dehydrogenase deficiency: a frequent condi$on in the
southern Chinese popula$on. Neurol Clin Neurosci 2013;1:163-167.

ORGANIC ACIDURIAS
What are Organic Acidurias?

Organic acidurias are a group of autosomal recessive disorder caused by the deficiency or absence of any of the enzymes
needed for the breakdown of some proteins. They derive their names from the substance that accumulates proximal to
the block in the pathway. They are the following:
Propionic aciduria (PA) – due to a deficiency of propionyl-CoA carboxylase

Methylmalonic aciduria (MMA) – due to a deficiency of methymalonyl-CoA mutase
Isovaleric aciduria (IVA) – due to a deficiency of isovaleryl-CoA dehydrogenase
3– Methylcrotnyl CoA Carboxylase Deficiency [3-MCC]
Beta Ketothiolase Deficiency
Glutaric Aciduria Type 1
Mulple Carboxylase Deficiency
Untreated children with this condion may present with voming, irritability, drowsiness, rapid breathing and coma. Pa-
ents with propionic aciduria and isovaleric aciduria may also have hyperammonemia. As a result, untreated children
may have encephalopathy, mental retardaon or death.
Treatment of Organic Acidurias

Treatment is through the dietary restricon of protein. Children may be given a special milk formula that is protein free.
Carnine and/or glycine are also prescribed.

The goal of treatment is to reverse the catabolic state and prevent essenal amino acid deficiency.

ORGANIC ACIDURIAS
PROPIONIC ACIDEMIA
What is Propionic Acidemia (PA) ?

Propionic Acidemia (PA) is an organic acidopathy also known was propionic aciduria and ketoc hyperglycinemia.1 It is
due to the defecve acvity of propionyl CoA which is the first step in the pathway of propionate metabolism in which
propionyl CoA, the product of the metabolism of isoleucine, valine, theronine and methionine is converted to
methylmalonyl CoA acid then to succinyl CoA and oxidaon in the citric acid cycle.2
Paents usually are healthy at birth but quickly develop overwhelming disease, which may be misinterpreted as sepsis or
ventricular hemorrhage.3 Addional symptoms include voming, acidosis, dehydraon, lethargy to coma, recurrent
ketoc episodes, hypotonia, seizures and hyperammonemia.4 Some paents may have acute-onset neurological
symptoms described as metabolic strokes, arrhythmias, cardiomyopathy and an exfoliave rash.5
Paents may also present with similar dysmorphic characteriscs such as frontal bossing, widened nasal bridge, wide set
eyes, epicanthal folds, long philtrum and upward curvature of the lips.4
Pathophysiology
Due to an increase in propionic acid, abnormal ketogenesis occurs because propionic acid is an inhibitor of mitochondrial
oxidaon and succinic and alpha-ketoglutaric acid.4 Inhibion of glycine cleavage enzyme leads to hyperglycinemia adn
the inhibion of N-acetylglutamate synthase, an enzyme of the urea cycle, causes hyperammonemia.3
Confirmatory Tesng
The predominant compound found in blood and urine is 3-hydroxypropionic acid; others may include glic acid,
glyglycine, butanone and propionylglycine.5 Highly elevated levels of glycine in plasma and urine can be observed but
confirmatory tesng is through the demonstraon of low levels of enzyme on cultured fibroblasts.3,5

Long-term treatment is the lifelong dietary restricon of isoleucine, valine, threonine and methionine.5
Carnine supplementaon is also given as well as metronidazole (10 days per month at 10-20mg/kg/day) to reduce the
significant propionate producon of the bacterial intesnal flora.3
Prognosis
Despite early diagnosis and treatment, the neonatal onset form of PA is sll complicated by early death in infancy or
childhood while late onset forms reach adulthood but o)en are handicapped by severe extrapyramidal movement
disorders and mental retardaon; however, progress has been achieved in survival and prevenon of neurologic sequelae
in affected children with early diagnosis and treatment.3

ORGANIC ACIDURIAS
PROPIONIC ACIDEMIA
What to Do
• Insert IV access. Collect samples for ammonia, blood gas, electrolytes and urine ketones. May request for
invesgaons (i.e. CBC, etc.) as needed.
• Give carnine (100mg/kg/day) q6 hours.

* Monitor serum ammonia every 4 hours, if ammonia remain above 200mmol/L for three consecu$ve collec$ons, medical
treatment or hemodialysis may be indicated
1
Chapman KA and Summar ML. Propionic academia consensus conference summary. Mol Gen Metab 2011 arcle in press.
2
Nyhan WL, Barshop BA and Ozand P. Chapter 2: Propionic academia. Atlas of Metabolic Diseases 2nd ed. Great
3
Hoffman GF and Schulze A. Chapter 7: Organic Acidurias in Sarafoglou K, Hoffman GF and Roth KS (eds). Pediatric
4
5
Pena L, Franks J, Chapman KA et al. Natural history of propionic academia. Mol Gen Metab 2011: arcle
under press

ORGANIC ACIDURIAS
METHYLMALONIC ACIDEMIA
What is Methylmalonic Academia (MMA)?

Methylmalonic academia (MMA) is due to a defect in metholmalonyl CoA mutase or a defect in the enzyme’s vitamin B12
derived co-factor 5’-deoxyadenosylcobalamin.1 Among paents with a defect of methylmalonyl CoA mutase, two
subgroups exist: Mut0 paents have no enzyme acvity while Mut- paents have a spectrum of residual acvity.2
Clinical Manifestaon:
Paents present with severe metabolic crisis in the first months of life, progressive failure to thrive, feeding problems,
recurrent voming, dehydraon, hepatomegaly, lethargy, seizures and developmental delay.2 Some affected children may
also have failure of linear growth, anorexia and developmental failure.3 Paents may have metabolic decompensaons
following bouts of acute illness or minor infecons.2,3 They are prone to episodes of metabolic strokes that primarily
affect the basal ganglia.3
Neonates affected with MMA share similar physical characteriscs such as high forehead, broad nasal bridge, epicanthal
folds, long smooth philtrum and triangular mouth.3 Unique to this disorder is the development of chronic renal failure in
the second decade in 20-60% of paents.2
Pathophysiology
Methylmalonyl CoA-mutase catalyzes the conversion of methylmalonyl CoA to succinyl CoA which can enter the
tricarboxylic acid cycle. This causes the accumulaon of methylmalonate in the body which may be toxic to the brain and
the kidneys.
Screening: increase in propionylcarnine on MSMS2,3
Confirmatory Tesng
Urine metabolic screening reveal elevated methylmalonic acid, propionylglycine, 3-hydroxypropionic acid and
methylcitrate; plasma amino acids show elevated glycine, alanine and methionine.2 Definive tesng is the
demonstraon of decreased enzyme acvity through cultured fibroblasts.3

Vitamin B12 responsive MMA will benefit from the supplementaon of the cofactor.3 For paents with the absence or
decreased acvity of methylmalonyl CoA mutase are advised to limit natural protein intake and supplementaon with an
Amino Acid Mixture that is free of isoleucine, valine, methionine and threonine.2 Carnine supplementaon is considered
an adjunct to therapy.3
Intesnal bacteria can be a source of propionate and methylmalonate that is naturally produced in the gut, this can be
reduced by giving metronidazole 10 days per month at 10-20mg/kg/day, colisn or neomycin.2,3

ORGANIC ACIDURIAS
METHYLMALONIC ACIDEMIA
Prognosis
The long-term outcome of in MMA is influenced by the underlying defect.4 Mut0 paents have the worst prognosis, most
of the paents may have very early onset signs and symptoms that occur even before the results of NBS are available, and
die immediately or survive with significant neurodevelopmental disability.3 Vitamin B12 responsive methylmalonic
acidurias have a reasonable outcome.2
What to Do

1
Nyhan WL, Barshop BA and Ozand P. Chapter 3: Methylmalonic Acidemia. Atlas of Metabolic Diseases 2nd ed. Great
2
3
hOp://www.e-imd.org/rc/e-imd/htm/Arcle/2011/e-imd-20110728-195831-072/src/htm_fullText/fr/
MethylmalonicAciduria.pdf Accessed Feb 25, 2012.
4
Cheng KH, Lie MY, Kao CH et al. Newborn screening for methylmalonic aciduria by tandem mass spectrometry: 7 years’
experience from two centers in Taiwan. J Chin Med Assoc 2010;73(6)314-319.

ORGANIC ACIDURIAS
ISOVALERIC ACIDEMIA
What are Isovaleric Acidemia (IVA)?

Isovaleric acidemia (IVA) was the first organic acidemia to be described. It is caused by a deficiency of isovaleryl-CoA
dehydrogenase, an enzyme located proximally in the catabolic pathway of the essenal branched-chain amino acid
leucine.1
The clinical manifestaon of IVA may be acute or chronic. An acute or neonatal presentaon is characterized by non-
specific findings of voming, lethargy, poor feeding, seizures that may progress to a comatose state.2 A characterisc
odor in the urine described as “sweaty feet” or “dirty socks” has been reported among paents with IVA.1,3 It has also
been found that in bone marrow cultures, isovaleric acid is an inhibitor of granulopoiec progenitor cell proliferaon
which accounts for the pancytopenia or thrombocytopenia found in paents.1 A chronic form may present with
developmental delay or mental retardaon.1,3 Both acute or chronic paents may suffer from metabolic crisis and are
somemes misdiagnosed as suffering from diabec ketoacidosis because of the similarity in presentaon: acidosis,
hyperglycemia and ketosis.1
Pathophysiology
At present, the specific pathophysiology of IVA is unclear. It is surmised that accumulang CoA derivave sequesters CoA,
thereby disturbing the mitochondrial energy metabolism.1
Confirmatory Test
There is note of increased isovalerylcarnine and isovalerylglycine in plasma or urine. Enzymac assay on cultured
fibroblasts or mutaon analysis may also be done.1,3

Dietary management involves liming leucine intake. Detoxificaon of toxic metabolites by conjugaon with glycine
given at 150-600mg/kg/day and carnine at 50-100 mg/kg/day should also be instuted.1,3
Prognosis
In a study by Grunert et al. (2012), among paents with IVA, the mortality rate is high in associaon with early neonatal
presentaon, neurocognive outcome is beOer with early diagnosis and management and age of diagnosis but not the
number of catabolic episodes contribute to the neurocognive outcome.

ORGANIC ACIDURIAS
ISOVALERIC ACIDEMIA
What To Do
• Give glycine (150mg/kg/day) q8 hours.

• Give glycine (150mg/kg/day) q8 hours.
* Monitor serum ammonia every 4 hours, if ammonia remain above 200mmol/L for three consecu$ve collec$ons,
medical treatment or hemodialysis may be indicated
1
Endocrinology and Inborn Errors of Metabolism. New York: McGraw Hill, 2009 pp 93-94.
2
Vockley J and Ensenauer R. Isovaleric academia: new aspects of gene$c and phenotypic heterogeneity. Am J Med Genet
C Semin Med Genet 2006;142C(2):95-103.
3
Ensenauer R, Vockley J, Willard JM et al. A common muta$on is associated with a mild, poten$ally asymptoma$c
phenotype in pa$ents with isovaleric academia diagnosed by newborn screening. Am J Hum Genet 2004;75:1136-1142.
4
Gurnert SC, Wendel U, Linder M et al. Clinical and neurocogni$ve outcome in symptoma$c isovaleric academia.
Orphanet J Rar Dis 2012;7:9.

ORGANIC ACID DISORDERS
3– METHYLCROTNYL CoA CARBOXYLASE DEFICIENCY [3-MCC]
What is 3-MCC?
The deficiency of 3-methylcrotonyl CoA carboxylase (3MCC) is a disorder of leucine metabolism that was first described by
Eldjarn et al. in 1970. In most instances, it has been found that neonates who test posive for this condion in expanded
newborn screening do not actually have the condion but instead reflect the increased levels of the metabolites of their
mothers.
There is a broad spectrum of clinical presentaon ranging from no symptoms to failure to thrive, hypotonia, and
cardiomyopathy to severe metabolic decompensaon with metabolic acidosis and hypoglycemia. Some paents may
have a late presentaon (1-3 years old) with an acute episode of Reye syndrome, massive ketosis, acidosis, lethary, coma
leading to a fatal outcome.3,4
Pathophysiology
3-methycrotonyl CoA carboxylase is responsible for the carboxylaon of 3-methylcrotonyl-CoA, the fourth step in leucine
catabolism; a deficiency of which causes a disturbance in leucine catabolism.
Confirmatory Tesng*
An increase in 3-hydroxyisovaleric and 3-methylcrotonyl glycine are found in urine, confirmatory tesng is done through
the demonstraon of decreased enzyme acvity in cultured fibroblasts.3

Treatment strategies include the restricon of natural protein intake and giving of carnine supplementaon (100mg/kg).3
Prognosis
3-MCC is a common, mostly benign condion; whether treatment with a low-protein diet, carnine and glycine
supplementaon has the potenal to change the clinical course in several affected paents remains to be elucidated.5

What to Do
• Insert IV access. Monitor glucose levels. May request for invesgaons (i.e. CBC, blood gas, urine ketones) as
needed.

3– METHYLCROTNYL CoA CARBOXYLASE DEFICIENCY [3-MCC]

needed.
Children should not be protein restricted for longer than necessary (24-48 hours)
Inform metabolic doctor on call for further guidance regarding on-going management
* If the baby’s confirmatory test is nega$ve, consider doing urine organic acid analysis of the pa$ent’s mother to rule
out maternal 3-MCC deficiency.
1
Leonard JV, Seakins JWT, BartleO K et al. Inherited disorders of 3-methylcrotonyl CoA carboxyla$on. Arch Dis Child
1981;56:52-59.
2
Nyhan WL, Barshop BA and Ozand P. Chapter 9: 3-methylcrotonyl carboxylase deficiency/3-methylcrtotonyl glycinuria.
Atlas of Metabolic Diseases 2nd ed. Great Britain:Oxford University Press, 2005 pp 66-68.
3
Ficicioglu MD and Payan I. 3-Methylcrotonyl-CoA carboxylase deficiency: metabolic decompensa$on in a noncompliant
child detected through newborn screening. Pediatrics 2006;118:2555-2556.
4
Baumgartner M. 3-methylcrotonyl-CoA carboxylase deficiency. Orphanet 2005. hOp://www.orpha.net/data/patho/GB/uk-
MMC.pdf Accessed Feb. 15, 2012.
5

BETA-KETOTHIOLASE DEFICIENCY
What is Beta-Ketothiolase Deficiency?

Beta ketothiolase deficiency is a defect of mitochondrial acetoacetyl-CoA thiolase involving ketone body metabolism and
isoleucine catabolism.1
This rare disorder is characterized by normal early development followed by progressive loss of mental and motor skills, it
is clinically characterized by intermiOent ketoacidoc episodes with no clinical symptoms in between. Some paents may
present with voming, hypotonia, lethargy, coma, hypervenlaon and dehydraon. Ketoacidoc crises may occur
following a bout of infecon or mild illness.2
Pathophysiology
Mitochondrial acetoacetyl CoA thiolase is responsible for the cleavage of 2-methylacetoacetyl CoA in isoleucine
metabolism, acetoacetyl CoA formaon in ketogenesis and acetoacetyl CoA cleavage in ketolysis.2
Confirmatory Tesng
An increased excreon of 2-methyl 3-hydroxybutyric and 2-methylacetoacec acid in urine is observed but definive
diagnosis is established by demonstrang decreased enzyme acvity in cultured fibroblasts.3

Due to the heterogeneity in the severity of clinical presentaon, there should be individual treatment programs; general
guidelines for treatment include dietary isoleucine restricon and to avoid fasng.3
Prognosis
The frequency of ketoacidoc aOacks decreases with age.3 Clinical consequences can be avoided by early diagnosis and
appropriate management of ketoacidosis.2
What to Do
needed.

BETA-KETOTHIOLASE DEFICIENCY
needed.
1
Fukao T. Beta kethothiolase deficiency. Orphanet 2001 hOp://www.orpha.net/data/patho/GB/uk-T2.pdf Accessed
Feb 15, 2012.
2
Nyhan WL, Barshop BA and Ozand P. Chapter 17: Mitochondrial acetoacetyl CoA thiolase (3-oxothiolase) deficiency.
Atlas of Metabolic Diseases 2nd ed. Great Britain:Oxford University Press, 2005 pp 102-106.
3
Strauss AW, Andersen BS and BenneO MJ. Chapter 5: Mitochondrial FaOy Acid Oxidaon Defects in Sarafoglou K,
Hoffman GF and Roth KS (eds). Pediatric Endocrinology and Inborn Errors of Metabolism. New York:McGraw Hill, 2009
pp 60-62.

What is GA1?
Glutaric Acidemia 1 (GA1) was first described by Goodman and colleagues in 1975. 1 It is caused by a deficiency of glutaryl-
CoA dehydrogenase which catalyzes the oxidave decarboxylaon of glutaryl-CoA, an intermediate in the degradaon of
the amino acids lysine and tryptophan. 2 This causes an increase in glutaric, 3-hydroxyglutaric, glutaconic and
glutarylcarnine.1
Two subsets of paents are characterized based on the levels of glutaric acid excreted in the urine: the low (<100 mmol/
mmol creanine) and high excretors (>100 mmol/mmol creanine). However, the risk of developing striatal injury
resulng in neurologic dysfuncon is the same regardless of excreon status.3
Paents with GA1 may present with hypotonia with head lag, feeding difficules, irritability.1 Macrocephaly is seen in
about 75% of infants, but this is non-specific.3 If le) untreated, 90% of paents develop neurologic disease presenng as
dystonic-dyskinec posturing, athetoid movements, opisthotonus, spasc, rigidity, clenched fists, tongue thrust and
profuse sweang.1,3 The encephalopathic crises precipitated by immunizaon, infecon, surgery and fasng results in the
affectaon of the basal ganglia and exaggerates the neurologic manifestaons occur frequently unl the 4th year of life.1
Pathophysiology
It was found that 3-hydroxglutaric and glutaric acid share structural similaries with glutamate which causes excitatory cell
damage; further, the accumulaon of these metabolites modulate glutamatergic and GABAergic neurotransmission
resulng in an imbalance of excitatory and inhibitory neurotransmiOers.1
Confirmatory Test
Glutaric acid and 3-hydroxyglutaric acid is increased in urine.1 Confirmatory tesng is achieved through the demonstraon
of a decrease in enzyme acvity in skin fibroblasts.1,3

The main goal of treatment is to prevent encephalopathic crises and neurological deterioraon and this can be achieved
through dietary management.1,2 This includes lysine intake restricon, giving carnine 50-100mg/kg/day, riboflavin
100mg/day and the use of neuropharmacologic drugs to control neurologic symptoms.1,3
Prognosis
The early diagnosis and treatment intervenon in paents with GA1 prevents striatal degeneraon in 80-90% of infants.1
However, study by Beauchamp et al. (2009) showed that despite early treatment, paents with GA1 may have mild fine
motor and arculaon problems and raise the queson of prenatal damage or subtle post-natal ongoing neurotoxic
effects of glutaric and hydroxyglutaric acids or both.

What to Do
needed.
• Start IV carnine (100mg/kg/day) q6 hours.

• Insert oro- or nasogatric tube and start connuous feeding with GA1 milk formula or protein free formula at
maintenance rate
needed.
• Start IV carnine (100mg/kg/day) q6 hours.
* Co-management with a neurologist is indicated to control the dystonia
1
2
Keyser B, Muhlhause C, Dickmanns A et al. Disease-causing missense muta$ons affect enzyma$c ac$vity, stability and
oligomeriza$on of glutaryl-CoA dehydrogenase (GCDH). Hum Mol Gen 2008;17(24):3854-3863.
3
Kolker S, Christensen E and Leonard JV. Guideline for the diagnosis and management of glutaryl-CoA dehydrogenase
deficiency. J Inherit Metab Dis 2007;30:5-22
4
Beauchamp MH, Boneh A and Anderson V. Cogni$ve, behavioural and adap$ve profiles of children with glutaric aciduria
type I detected through newborn screening. J Inherit Metab Dis 2009;169:1-7. .

MULTIPLE CARBOXYLASE DEFICIENCY [MCD]
What is Mulple Carboxylase Deficiency (MCD)?

Mulple carboxylase deficiency, also known as holocarboxylase synthase leads to a failure of synthesis of all carboxylases.
Most paents present acutely in the first few hours of life.1 Paents may have dehydraon, go into deep coma leading to
death, ketosis, high anion gap metabolic acidosis, failure to thrive, alopecia and a characterisc erythematous erupon on
the skin that can be bright, red, scaly or desquamave.
Pathophysiology
Holocarboxylase synthase binds bion, an essenal cofactor in gluconeogenesis, faOy acid synthesis and the catabolism of
several amino acids.1, This in turn, leads to a failure of the synthesis of the acve holocarboxylases which is the body’s
main source of bion.1
Confirmatory Tesng
An increased methylcrotanylglycine and 3-hydroxyisovaleric acid in blood and urine with lacc acidosis can be observed
but definive tesng is done through measurement of enzyme acvity in fibroblasts.3

Treatment is through giving bion 10-20mg/day.1,3 The clinical response to treatment is dramac, ketosis and acidosis
disappear along with hyperammonemia; lethargy, hypotonia and ataxia disappear and dermatological effects of the
disorder are reversed.3
Prognosis
Prognosis is good if treatment is iniated immediately and the clinical course is followed carefully by close monitoring of
biochemical abnormalies.1
What to Do If Unwell
Nothing per orem
• Insert IV access. Collect samples for serum ammonia and blood gas. May request for invesgaons (i.e. CBC, etc.) as
needed.

MULTIPLE CARBOXYLASE DEFICIENCY [MCD]

• Start D10% 0.3NaCl at full maintenance. Assess paent clinically, if there is need to increase fluid, may do so up to
1
Hoffman GF and Schulze A. Chapter 7: Organic Acidurias in Sarafoglou K, Hoffman GF and Roth KS (eds). Pediatric En-
docrinology and Inborn Errors of Metabolism. New York:McGraw Hill, 2009 pp 93-94.
2
Nyhan WL, Barshop BA and Ozand P. Chapter 6: Mulple carboxylase deficiency/bionidase deficiency. Atlas of Meta-
bolic Diseases 2nd ed. Great Britain:Oxford University Press, 2005 pp 42-48.
3
Nyhan WL, Barshop BA and Ozand P. Chapter 5: Mulple carboxylase deficiency/holocarboxylase deficiency. Atlas of
Metabolic Diseases 2nd ed. Great Britain:Oxford University Press, 2005 pp 36-39.

What are Thalassemias and Hemoglobinopathies?

Thalassemias are characterized by a decreased producon in either theα or β globin chains. They are grouped into αand
β thalassemias.
Hemoglobinopathies, on the other hand, are structural abnormalies and are usually due to a single amino acid
substuon.
ALPHA THALASSEMIAS
Αlpha thalassemia may result from a defect in the alpha globin genes. There are 4 alpha globin genes so the defect or loss
may be from one to four of the genes. The clinical symptomatology will depend on the number of gene deleons/
mutaons. The loss of 4 genes results in hydropsfetalis which is fatal in utero. Loss of 3 genes indicates HbH disease which
may manifest later in childhood as moderately severe anemia. Iron overload, secondary to either ineffecve
erythropoiesis or transfusion therapy, becomes a majorproblem when these paents reach puberty and adulthood. Loss
of 2 genes (trait) or 1 (silent carrier) may result in mild anemia and these two are clinically insignificant.
The percentage of haemoglobin Bart’s at birth may indicate the number of alpha gene loss. If the percentage is < 10% then
the infant may have 1 or 2 gene loss. If the amount of Bart’s is >20-25% then it may indicate a more severe form of alpha
thalassemia such as HbH disease. Non-deleonalform of HbH disease such as HbH Constant Spring are clinically more
severe.
Clinical Signs of Alpha Thalassemia
Loss of 1 or 2 α genes o)en asymptomac with mild anemia at most. The smear will show microcytosis which is o)en
mistaken for iron deficiency anemia. A child who does not respond to iron therapy for his/heranemia should be worked up
for possible thalassemia. Iron supplements should be avoided therea)er. Parents of this childshould be assured that he or
she will be symptom-free but they should also be made aware that the trait may run in their family. Folic acid is
recommended for paents with alpha thalassemia with anemia.
If the Bart’s is 20-25% and the infant is either South East Asian or from the Mediterranean region then HbH should
strongly be considered and the family referred to a hematologist.
HbH disease is due to deleon of 3-alpha genes resulng in the formaon of beta tetramers (β4). Clinically this isclassified
as a form of thalassemia intermedia. A non-deleonal form of HbH disease such as HbH Constant Spring is seen when 2
alpha gene deleon such as the --SEA deleon is seen in conjuncon with anα gene mutaon such as the Constant Spring
mutaon. Paents may have a variable clinical course with some pallor and jaundice a)er febrile episodes which may
require transfusions or severe anemia requiring regular transfusions early in childhood resulng in iron overload later on
in life. This may result in growth stunng, delayed sexual maturity, and heart failure if uncorrected. These paents will
require special care.

BETA THALASSEMIAS
Beta Thalassemia mutaons may result in total absence of beta chain producon (β°) or paral reducon of the chain (β+). A
presumpve diagnosis of β thalassemia in the newborn is made if the HbF is the sole hemoglobin with absent or markedly
decreased HbA. Decreased hemoglobin producon leads to microcytosis, ineffecve erythropoiesis and skeletal changes. A
carrier state of beta thalassemia may be missed at birth because of the absence of Hgb A2 early in the neonatal period.
Clinical features may vary depending on the complete or paral absence of the beta chain. Beta thalassemia major paents
(β°β°) seem healthy a)er birth but develop symptoms within the first year of life. They are transfusion dependent as early as
the late infancy period while thalassemia intermedia (β°β+) or (β+β+) has less severe anemia and require infrequent
transfusions. Children heterozygous for a normal and a beta thalassemia gene will have very mild anemia, microcytosis, and
slight splenomegaly. Transfusion is usually not required.
There are individuals who are compound heterozygote for Hb E and β° thalassemia. HbE/β⁰ thalassemia presents in infancy
as variably severe anemia with clinical phenotype ranging from complete lack of symptoms to transfusion dependence.
Osteoporosis, iron overload, growth failure, pulmonary hypertension are commonly reported in both transfused and non-
transfused parents. Paents presenng with thalassemia intermedia phenotype during childhood o)en become transfusion
dependent as adults due to worsening anemia and fague. They may eventually develop iron overload andmay succumb to
cardiac failure later in life.
Paents with beta thalassemia major are best managed in a specialized hospital as they will need regular transfusions and
iron chelaon. Those with the minor form of the disease will not need special care. However, it is important to have their
future partner screened for the trait as their union may result in a baby with a severe case of thalassemia. Intermedia
parents may need specialized care later in childhood as iron overload may present later in life so inadvertent and prolonged
use of iron are discouraged in these paents.
HEMOGLOBIN E
Hemoglobin E (Hb E) is a variant hemoglobin with a mutaon in the β-globin gene causing substuon of glutamic acid for
lysine at posion 26 of the β globin chain. Hb E is the most common hemoglobinopathy variant in South East Asia. The βE
chain is synthesized at a reduced rateleading to an imbalance in the globin chains. Hb E disease is defined by the co-existence
of two βE alleles, resulng into homozygous state EE.
Individuals with the genotype EE are usually completely asymptomac. Hemoglobin level may be low and red cell indices are
likewise low with significant morphological abnormalies including increased numbers of target cells. Homozygous Hb E
individuals do not warrant special care.
HbE trait is defined by the heterozygous condion associang with one normal adult hemoglobin (HbA) β gene and one
variant hemoglobin E β gene. HbE trait do not exhibit clinical disease. There may be slight anemia with microcytosis. Target
cells are also seen in the smears. In most cases, children are symptom-free and will have normal growth and development.
In regions where there is a high incidence of α and β thalassemias such as the Philippines, HbE may be co-inherited with
these disorders. Interacons with various forms of α and β thalassemia produce a very wide range of clinical syndromes of
varying severity.HbE with HbH may result in moderately severe thalassemic findings similar to thalassemia intermedia.
HbE/β° on the other hand, may behave as thalassemia major and will need to be managed in a specialty center.

OTHER HEMOGLOBINOPATHIES
HEMOGLOBIN C
Hemoglobin C (Hb C) is a variant hemoglobin with a mutaon in the β globin gene causing substuon of glutamic acid for
lysine at posion 6 of the globin chain. Hb C disease is defined by the co-existence of 2 βC alleles (homozygous state CC).
Individuals with Hb C disease may have compensated hemolysis or mild to moderate anemia. They may also have
splenomegaly and increased risk of cholelithiasis due to chronic hemolysis. This disorder is most common in individuals of
African descent.
Hb C trait on the other hand is defined by the heterozygous condion associated with one normal adult hemoglobin (HbA)
gene and one variant HbC β gene. Individuals with Hb C trait are clinically asymptomac. Hemoglobin level is usually normal
but mild microcytosis is common. This hemoglobin variant may be co-inherited with alpha thalassemia and beta thalassemia
which may result in more serious clinical manifestaons.
HEMOGLOBIN D
Hemoglobin D (Hb D) is a variant hemoglobin with a mutaon in the β globin gene causing substuon of glutamine for
glutamic acid in the β globin chain. Hb D disease is defined by homozygous state DD.
Individuals with Hb D disease are usually clinically asymptomac. However, mild haemolyc anemia may develop in the first
few months of life.
Hb D trait is defined by the heterozygous condion associated with one normal adult hemoglobin and one variant HbD β
gene. Individuals with Hb D trait are clinically asymptomac. This hemoglobin variant may also be co-inherited with alpha
thalassemia and beta thalassemia which may result in more serious clinical manifestaons.
SICKLE CELL
Sickle cell disease paents have predominant HbS. This condion is most common in Africa, Middle East and the United
States. Affected infants are usually normal at birth but develop anemia later when the HbS concentraon increases and the
HbFdecreases. These paents are parcularly suscepble to encapsulated bacterial infecons such as Streptococcus
pneumonia, Hemophilus influenzae, Staphylococcus aureus, and Salmonella. Prophylacc penicillin should be started early in
infancy once diagnosis is made.
Heterozygotes (Hb AS) are usually asymptomac and are referred to as trait. In most cases of sickle cell trait, children are
symptom free and will have normal growth and development.
References:
Bachir D and F Galecteros. Hemoglobin C disease. Orphanet. November 2004. Retrieved from: hOps://www.orpha.net/data/patho/GB/uk-HbC.pdf
Bachir D and F Galecteros. Hemoglobin E disease. Orphanet. November 2004. Retrieved from: hOps://www.orpha.net/data/patho/GB/uk-HbE.pdf
Hoppe, C., Newborn Screening for Non- Sickling Hemoglobinopathy, ASH Educaon Book, 2009.
Hoyer, J. 79 Hemoglobinopathies.Annual Meeng of the American Society of Clinical Pathologists, 2011.
Welch, S. Hemoglobinopathies and Thalassemias. Clinical Lab News.Oct 2009, Vol 15.
Georgia Newborn Screening Manual for Metabolic Diseases and Hemoglobinopathies, pp 38-61.

HEMOGLOBIN H DISEASE / ALPHA THALASSEMIA
The newborn screening result may be Hb FA Barts > 25 %. Other diagnosc possibilies for this newborn screening result
include Hb H Constant Spring disease and Alpha Thalassemia Trait.
What is Hemoglobin H Disease /Alpha Thalassemia?
Hemoglobin H Disease is a red blood disorder characterized by presence of fetal hemoglobin (F) and hemoglobin A, as well as
hemoglobin Barts.
Confirmatory tesng
DNA tesng is used to confirm the diagnosis.
What should you do?
• Contact the family to inform them of the screening result. Recommend confirmatory tesng if not yet done.
• Refer paent to a Pediatric hematologist.
Clinical Consideraons
Hemoglobin Barts above 25% in the newborn indicates a possible hemoglobin H disease, a clinically significant form of alpha
thalassemia. Deleon or dysfuncon of 3 of the 4 alpha globin genes manifests as Hb H disease. This is characterized by
variable clinical course with some exhibing splenomegaly and pallor especially a)er febrile episodes and that may require
intermiOent transfusions. Absence of all four alpha globin genes results in hydropsfetalis and is usually fatal, in utero or
shortly a)er birth.
Note: For hemoglobin Bart’s <25%, parents or hematologists may opt for genotyping but this will not be covered by the
program and is at the own expense of the paents. This may be taken into account when counselling is done by the
pediatrician/hematologist.

BETA THALASSEMIA MAJOR
The newborn screening result may be Hb F only. Other diagnosc possibility for this newborn screening result include
premature infant.
What is Beta Thalassemia Major?
Beta Thalassemia Major is a red blood disorder characterized by a reducon in or lack of normal beta globin producon and
absence of Hb A (F [fetalHb] only).
Confirmatory tesng
Capillary Electrophoresis (CE), CBC and red blood cell indices (MCH, MCV) tesng for both child and parents, and DNA tesng
are used to confirm the diagnosis.
What should you do?
• Evaluate infant, assess for splenomegaly
Infants with this disorder may be normal unl the 4-6 months of life. With beta-thalassemia, severe anemia may develop in
the first few months of life. Moderate pallor may appear at this age o)en requiring regular blood transfusions. Complicaons
later in childhood may include growth retardaon, sexual immaturity, intercurrent infecons, progressive
hepatosplenomegaly, skeletal abnormalies, and severe iron overload. Comprehensive care including family educaon,
immunizaons, regular transfusions partnered with compliance to iron chelaon therapy reduces morbidity and mortality.

HEMOGLOBIN E DISEASE
The newborn screening result may be Hb FE. Other diagnosc possibility for this newborn screening result include Hemoglo-
bin E thalassemia.
What is Hemoglobin E disease?
Hemoglobin E (Hb E) is a variant hemoglobin with a mutaon in the β-globin gene causing substuon of glutamic acid for
lysine at posion 26 of the β globin chain. Hb E disease is defined by the co-existence of two βE alleles, resulng into homo-
zygous state EE.
Confirmatory tesng:
What should you do?
• Recommend CBC at 4-6 months. If with anemia, refer to a Pediatric hematologist.
The disorder is basically benign and do not require specialized treatment.

HEMOGLOBIN C DISEASE
The newborn screening result may be Hb FC. Other diagnosc possibility for this newborn screening result include Hemoglo-
bin C thalassemia.
What is Hemoglobin C disease?
Hemoglobin C(Hb C) is a variant hemoglobin with a mutaon in the β globin gene causing substuon of glutamic acid for
lysine at posion 6 of the globin chain. Hb C disease is defined by the co-existence of 2 βC alleles (homozygous state CC).
The heterozygous form is benign.
Confirmatory tesng
Capillary Electrophoresis (CE), CBC and red blood indices (MCH, MCV) tesng for both child and parents, and DNA tesngare
used to confirm the diagnosis.
What should you do?
An affected neonate is likely to appear healthy, but has a risk for mild anemia and minor complicaons. Complicaons may
include splenomegaly, jaundice and increased risk for gallstones.

HEMOGLOBIN D DISEASE
The newborn screening result may be Hb FD. Other diagnosc possibility for this newborn screening result include Hemoglo-
bin D thalassemia.
What is Hemoglobin D disease?
Hemoglobin D (Hb D) is a variant hemoglobin with a mutaon in the β globin gene causing substuon of glutamine for
glutamic acid in the β globin chain. Hb D disease is defined by homozygous state DD.
Confirmatory tesng
Capillary Electrophoresis (CE), CBC and red blood indices (MCH, MCV) tesng for both child and parents, and DNA tesng
What should you do?
• Refer paent to a pediatric hematologist.
Most individuals with Hb D disease do not have symptoms. However, some may have mild haemolyc anemia which may be
associated with a slightly enlarged spleen. Treatment is usually not necessary. Individuals with Hb D are expected to live a
normal life.

SICKLE CELL DISEASE
The newborn screening result may be Hb FS. Other diagnosc possibilies for this newborn screening result include Sickle
cell-β thalassemia and sickle cell-hereditary persistence of fetal hemoglobin.
What is Sickle Cell Disease?
Sickle cell disease paents have predominant HbS. This condion is most common in Africa, Middle East and the United
States.Affected infants are usually normal at birth but develop anemia later when the HbS concentraon increases and the
HbFdecreases. These paents are parcularly suscepble to encapsulated bacterial infecons such as Streptococcus
pneumonia, Hemophilus influenzae, Staphylococcus aureus, and Salmonella.
Confirmatory tesng
What should you do?
• Immediately refer paent to a pediatric hematologist.
• If there are no pediatric hematologists, then start oral penicillin if below 6 months.
Infants with this finding are usually normal at birth. However, severe anemia may develop in the first few months of life.
Complicaons include growth retardaon, intercurrent infecons, progressive hepatosplenomegaly, skeletal abnormalies,
and periodic episodes of pain. These episodes can occur when sickled red blood cells, which are sff and inflexible, get stuck
in small blood vessels. These episodes deprive ssues and organs of oxygen-rich blood and can lead to organ damage,
especially in the lungs, kidneys, spleen, and brain. Comprehensive care including family educaon, immunizaons, regular
blood transfusions, pain control and prompt treatment of acute illness reduces morbidity and mortality.

ALPHA THALASSEMIA TRAIT /ALPHA THALASSEMIA MINOR
The child’s newborn screening test idenfied him/her as a possible carrier of Alpha Thalassemia, also referred to as Alpha
Thalassemia Trait/Minor.
Clinical Expectaons for Carriers of Alpha Thalassemia
Being a carrier of Alpha Thalassemia will not have an adverse influence on this child’s life expectancy. The trait is basically
silent and carriers are not more likely to get sick than any other child. In most cases, children are symptom-free and will have
normal growth and development, hence do not need special medical care. Rarely, carriers can manifest with mild anemia.
Reproducve Risks
The results indicate that the child is a carrier of Alpha Thalassemia. It is important to remember that the trait may be
transmiOed by the child to his/her would-be children. Thus, it is extremely important to have his/her future partner screened
for the hemoglobin disorders as their union may result in a baby with more severe form of alpha thalassemia. Also, in a
populaon with high incidence of Hemoglobin E disease and beta thalassemia, co- inheritance with these condions may
present with more severe anemia. Family members of this child may also be at-risk for alpha thalassemia.
Important Consideraons
• Coordinaon with a pediatric hematologist is advised to evaluate iron status of the paent before giving empiric iron
supplements.
• Immunizaons are not contraindicated for this condion and may be given as recommended by the Philippine Pediatric
Society.
Note: Parents or hematologists may opt for genotyping but this will not be covered by the program and is at the own
expense of the paents. This may be taken into account when counseling is done by the pediatrician/hematologist.

BETA THALASSEMIA TRAIT /BETA THALASSEMIA MINOR
The child’s newborn screening test idenfied him/her as a possible carrier of Beta Thalassemia, also referred to as Beta
Thalassemia Trait/Minor.
Clinical Expectaons for Carriers of Beta Thalassemia
Being a carrier of Beta Thalassemia will not have an adverse influence on this child’s life expectancy. The trait is basically
silent and carriers are not more likely to get sick than any other child. In most cases, children are symptom-free and will have
Reproducve Risks
The results indicate that the child is a carrier of Beta Thalassemia. It is important to remember that the trait may be
for the hemoglobin disorders as their union may result in a baby with severe form of beta thalassemia. Also, in a populaon
with high incidence of Hemoglobin E disease and alpha thalassemia, co- inheritance with these condions may present with
more severe anemia. Family members of this child may also be at-risk for beta thalassemia.
• Coordinaon with a pediatric hematologist is advised to evaluate iron status of the paent before giving empiric iron
supplements.
Society.

HEMOGLOBIN E TRAIT OR HBFAE
The baby’s newborn screening test idenfied him/her as a possible carrier of Hemoglobin E, also referred to as Hemoglobin
E Trait or HbFAE.
Clinical Expectaons for Carriers of Hemoglobin E
Being a carrier of Hemoglobin E will not have an adverse influence on this child’s life expectancy. The trait is basically silent
and carriers are not more likely to get sick than any other child. In most cases, children are symptom-free and will have
Reproducve Risks
The results indicate that the child is a carrier of the Hemoglobin E. It is important to remember that the trait may be
for the hemoglobin disorders as their union may result in a baby with a hemoglobin E disease which, at most, may present
with mild anemia. More importantly, in a populaon with high incidence of alpha or beta thalassemia, co- inheritance with
these condions may present with moderate to severe anemia. Family members of this child may also be at-risk for
hemoglobin E disease.
• Treatment is typically not needed.

• Immunizaons are not contraindicated for this condion, and may be given as recommended by the Philippine Pediatric
Society.
expense of the family. This may be taken into account when counseling is done by the pediatrician/hematologist.

HEMOGLOBIN C TRAIT OR HBFAC
The child’s newborn screening test idenfied him/her as a possible carrier of Hemoglobin C, also referred to as Hemoglobin C
Trait or HbFAC.
Clinical Expectaons for Carriers of Hemoglobin C
Being a carrier of Hemoglobin C will not have an adverse influence on this child’s life expectancy. The trait is basically silent
Reproducve Risks
The results indicate that the child is a carrier of the Hemoglobin C. It is important to remember that the trait may be
for the hemoglobin disorders as their union may result in a baby with a hemoglobin C disease which, at most, may present
these condions may present with moderate to severe anemia Family members of this child may also be at-risk for
hemoglobin C disease.

Society.

HEMOGLOBIN D TRAIT OR HBFAD
The child’s newborn screening test idenfied him/her as a possible carrier of Hemoglobin D, also referred to as Hemoglobin
D Trait or HbFAD.
Clinical Expectaons for Carriers of Hemoglobin D
Being a carrier of Hemoglobin D will not have an adverse influence on this child’s life expectancy. The trait is basically silent
Reproducve Risks
The results indicate that the child is a carrier of the Hemoglobin D. It is important to remember that the trait may be
for the hemoglobin disorders as their union may result in a baby with a hemoglobin D disease which, at most, may present
these condions may present with moderate to severe anemia. Family members of this child may also be at-risk for
hemoglobin D disease.

Society.

SICKLE CELL TRAIT OR HBFAS
child’s newborn screening test idenfied him/her as a possible carrier of Sickle Cell Disease (SCD), also referred to as Sickle
Cell Trait or HbFAS.
Clinical Expectaons for Carriers of Sickle Cell Disease
Being a carrier of Hemoglobin S will not have an adverse influence on this child’s life expectancy. The trait is basically silent
Reproducve Risks
The results indicate that the child is a carrier of the Hemoglobin S (Sickle cell Hemoglobin). It is important to remember that
the trait may be transmiOed by the child to his/her would-be children. Thus, it is extremely important to have his/her future
partner screened for carrier state as their union may result in a baby with Sickle cell disease which will present with severe
clinical manifestaons. Also, in a populaon with high incidence of alpha or beta thalassemia, co- inheritance with these
condions may present with moderate to severe anemia. Family members of this child may also be carriers for sickle cell
disease.

Society. It is parcularly recommended that they be given Pneumococcal, Influenza and Haemophilusinfluenzae Type B
(HiB) vaccines.

INTERACTING HBE DISEASE WITH Β-THALASSEMIA
The newborn screening result may be Hb FEA or Hb FE. HbE/β-thalassemia results from co-inheritance of a β-thalassemia
allele from one parent and the structural variant Hemoglobin E from the other.
Confirmatory tesng
What should you do?

• Evaluate infant and assess for splenomegaly
Infants with this result are usually normal at birth. Clinical severity is influenced by the instability of the HbE and the degree
and severity of the β thalassemia mutaon. Hence,HbE/β⁰ will correspond to the clinical picture of thalassemia majorand will
require life-long transfusion.While HbE/β+ will be similar to the presentaon of thalassemia intermedia.
References:
American College of Medical Genecs. Newborn Screening ACT Sheet. Retrieved from: hOps://www.acmg.net/PDFLibrary/
Hemoglobin-E-ACT-Sheet.pdf. Accessed 8 April 2020.
Fucharoen S and DJ Weatherall. The Hemoglobin E Thalassemias. Cold Spring HarbPerspect Med. 2012; 2:a011734.
Kohne, E., Compendium of Hemoglobinopathies, pp 49-53

INTERACTING HBD DISEASE WITH Β-THALASSEMIA
The newborn screening result may be Hb FDA or Hb FD.HbD/β-thalassemia results from co-inheritance of a β-thalassemia
allele from one parent and the structural variant Hemoglobin D from the other.
Confirmatory tesng
Capillary Electrophoresis (CE), CBC and red blood cell indices (MCH, MCV) tesng for both child and parents, and DNA
tesng.
What should you do?

Infants with this result are usually normal at birth. Clinical severity is variable and depends on the specific β-thalassemia
mutaon. The factor reliably responsible for the phenotype is the imbalance in the globin chain synthesis.If HbD/β+, a clinical
presentaon of thalassemia intermedia is observed. Clinical manifestaons may range from microcyc, hypochromic anemia
to hemolyc anemia and splenomegaly.
References
de Souza Torres L, Okumura JV, da Silva DGH and CR Bonini-Domingos. Hemoglobin D-Punjab: origin, distribu'on and
laboratory diagnosis. Brazilian Journal of Hematology and Hemotherapy. 2015; 37(2): 120-126.
Shekhda KM, Leuva AC, Mannari JG et al. Co-Inheritance of Hemoglobin D Punjab and Beta Thalassemia – A Rare Variant.
Journal of Clinical and Diagnosc Research.2017; 11(6): OD21-OD22.

INTERACTING HBC DISEASE WITH Β-THALASSEMIA
The newborn screening result may be Hb FCA or Hb FC. Hb C/β-thalassemia results from co-inheritance of a β-thalassemia
allele from one parent and the structural variant Hemoglobin C from the other.
Confirmatory tesng
Capillary Electrophoresis (CE), CBC and red blood cell indices (MCH, MCV) tes'ng for both child and parents, and DNA tes'ng
What should you do?

• Refer pa'ent to a pediatric hematologist.
Infants are usually normal at birth.The combina'on of HbC/β-thalassemia on whether there is complete or par'al produc'on
of Beta chain.If HbC/β+, the clinical presenta'on will correspond to thalassemia intermedia.The clinical manifesta'ons may
range from mild to moderate hemoly'c anemia, splenomegaly and bone changes. Serious hemoly'c anemia may be observed
in the complete absence of Beta chain (β⁰).
References:
American College of Medical Genecs. Newborn Screening ACT Sheet. Retrieved from: hOps://www.acmg.net/PDFLibrary/
Hemoglobin-C-ACT-Sheet.pdf . Accessed 8 April 2020.

INTERACTING Α-THALASSEMIA WITH HEMOGLOBIN E
Hemoglobin (Hb)E is the most common abnormal hemoglobin in Southeast Asia countries. Alpha thalassemia is also
prevalent in the region. Thus, the coinheritance of Hb E with α-thalassemia is frequently observed.
Confirmatory tesng
What should you do?

The clinical manifestaon ofHb E/α-thalassemia will depend on the number of deleons in the α gene. Hb E/ -α/αα (1
deleon), Hb E/ -α/-α (2 deleons) or Hb E/ --/αα(2 deleons) will give rise to a mild type of hypochromic anemia with mild
splenomegaly. Hb E/ --/-α (3 deleons) may give to severe form of HbH disease requiring blood transfusions.
References:
Fucharoen S and P Winichagoon. Hemoglobinopathies in Southeast Asia. Indian J Med Res. 2011; 134(4): 498 – 506.

INTERACTING Α-THALASSEMIA WITH Β-THALASSEMIA
Co-inheritance the two types of thalassemiasis relavely common in Southeast Asia. In a study on a Chinese populaon, one
in every six β-thalassemia carriers co-inherits α-thalassemia.
Confirmatory tesng
What should you do?

The clinical manifestaon ofα-/β-thalassemia interacon shows considerable clinical heterogeneity. The clinical
improvement depends on the severity of the β-thalassemia alleles and the number of funconal α-globin genes. Co-
inheritance of two α-globin gene deleons or a non-deleonal α2-globin gene mutaon in β0-thalassemia homozygotes is
more likelyto produce a thalassemia intermedia phenotype. On the other hand, co-inheritance of a single α-globin gene
deleon in the same group of paents is usually associated with athalassemia major phenotype. The SEA deleon (--/αα)
improves the clinical presentaon of β0/β+ but not necessarily of β0/β0-thalassemia. Co-inheritance of a single α-globin
gene deleon in homozygous or compound heterozygous β+-thalassemia produces an improved phenotype. On the other
hand, co-inheritance of Hb H disease with β0/β+-thalassemia present as β thalassemia minor.
Just as presence of α-thalassemia can improve the clinical severity of βthalassemia major, the co-inheritance of β
thalassemia can improve presentaon of non-deleonal Hb H disease.
References:
Li J, Xie XM, Liao C, Li DZ. Co-inheritance of α-thlassaemia and β-thlassaemia in a prenatal screening populaon in mainland
China. J Med Screen 2014. Vol 21(4)167-171
Kohne, E. Compendium of Hemoglobinopathies 2014. SEBIA Educaonal Library

OTHER RARE INTERACTING THALASSEMIAS AND HEMOGLOBINOPATHIES
Other rare interacng thalassemias and hemoglobinopathies may be detected via the newborn screening. This will warrant
confirmatory tesng
Confirmatory tesng
What should you do?

The clinical manifestaons of the interacng thalassemias and hemoglobinopathies may vary depending on the combinaon.
This may vary from mild to severe presentaon.

UREA CYCLE DEFECTS
UREA CYCLE DEFECTS: Citrullinemia AND Argininosuccinic Aciduria
What are UCDs?

The urea cycle is the main pathway of the body to dispose of excess nitrogen. It allows for the conversion of ammonia
into urea that can be excreted into the urine. Citrullinemia and Argininosuccinic Aciduria are inherited in an autosomal
recessive manner. Citrullinemia occurs as a result of argininosuccinic synthase deficiency while argininosuccinic aciduria is
due to a deficiency of argininosuccinic lyase. Both condions may manifest with tachypnea, lethargy, voming, irritability,
seizures, coma and ulmately death if le) untreated. The increased levels of ammonia may cause brain damage.
Due to blocks in the urea cycle owing to the enzyme deficiency, paents with UCD have low levels of arginine. This makes
arginine an essenal amino acid among paents with UCD.
Treatment of UCDs
Treatment is through the dietary restricon of protein and the supplementaon of a protein free formula. Sodium
benzoate, an ammonia scavenger, is given as well as arginine supplementaon.
Preliminary / Inial Management During Metabolic Crises

Metabolic crises may be caused by an excess intake of protein, illness, prolonged fasng or stressful situaons such as
surgery and severe infecon. The goal of treatment is to reverse the catabolic state and prevent essenal amino acid
deficiency.

UREA CYCLE DEFECT
ARGININOSUCCINIC ACIDURIA (ASA)
What is ASA?
Arigininosuccinic aciduria is an inborn error of metabolism resulng from the deficiency of the enzyme argininosuccinic
lyase.1
The classic presentaon of argininosuccinic aciduria is an overwhelming illness in the newborn period presenng with
voming, lethargy progressing rapidly to deep coma, apnea, seizures
athophysiology
Argininosuccinate lyase is an enzyme that converts argininosuccinic acid to arginine, the absence of which causes an increase
in argininosuccinic acid, citrulline and ammonia.2
Inheritance: autosomal recessive.
Confirmatory Tesng
Confirmatory tesng may be done through plasma amino acid analysis (increased argininosuccinic acid, increased citrulline
and decreased arginine), increased oroc acid and
fibroblasts.

Long-term management, as with other urea cycle disorders, consists of a low protein diet supplemented with special milk
formula, provision of arginine and sodium benzoate or
Prognosis
Prognosis for intellectual development probably depends on the nature of the inial hyperammoniemia, especially in
duraon or the nature of recurrent episodes.2
Preliminary/ Inial Management during Metabolic Crisis

1
Zchocke J and Hoffmann GF, Vademecum Metabolicu, 3rd ed., Germany:Milupa Metabolics, 2011
2
Nyhan WL, Barshop BA and AI-Aqeel A. Chapter 27: Argininosuccinic aciduria. Atlas of Inherited Metabolic
Diseases 3rd ed. Great Britain:Oxford University Press, 2012 pp216-222

UREA CYCLE DEFECT
ARGININOSUCCINIC ACIDURIA (ASA)
What to do
If Unwell and cannot tolerate oral intake
If Unwell and can tolerate oral intake

UREA CYCLE DEFECT
CITRULLINEMIA
What is Citrullinemia?
Citrullinemia is an inborn error of metabolism resulng from the deficiency of arginosuccinate synthetase, an enzyme pre-
sent in all ssues but the level of which is highest in the liver where it funcons in the urea cycle.
Following a brief hiatus in which the newborn appears normal, anorexia, voming and therapy develop followed rapidly
by progression to deep coma. The symptoms mimic that of sepsis and affected newborns present with severe lethargy,
poor feeding to respiratory distress, jiOeriness and seizures.
A late onset form may occur as late as 20 years old and present as symptoms such as slurred speech, irritability, insomnia
or delirium.3
Pathophysiology
Argininosuccinate synthase is an enzyme that converts citrulline to arginosuccinate, the absence of which causes an in-
crease in plasma citrulline and ammonia levels.
Inheritance: autosomal recessive
Confirmatory Tesng
Confirmatory tesng may be done through the demonstraon of amino acids in plasma (decreased arginine and high cit-
rulline), presence of oroc acid in urine and increased levels of ammonia in blood.2,5

Long-term steady state management can usually be provided with arginine (0.25-0.8g/kg/day), sodium benzoate, sodium
phenylbutyrate and a diet modestly restricted in protein.3
Prognosis
Prognosis for intellectual development depends on the nature of the inital hyperammonemia especially its duraon or
those of recurrent episodes.3

What to Do
• Insert IV access. Collect sample for serum ammonia. May request for invesgaons (i.e. CBC, etc.) as needed.

UREA CYCLE DEFECT
CITRULLINEMIA
• Start IV sodium benzoate loading dose (250mg/kg) to run for 1-2 hours.
• Start IV arginine loading dose (250mg/kg) to run for 1-2 hours.
• Insert IV access. Collect sample for serum ammonia. May request for invesgaons (i.e. CBC, etc.) as needed.
• Start D12.5% 0.3NaCl at 5-10 cc/hr.
• Start IV sodium benzoate loading dose (250mg/kg) to run for 1-2 hours.
• Start IV arginine loading dose (250mg/kg) to run for 1-2 hours.
* If pa$ent does not improve with the ini$al management (within 12 hours), hemodialysis may be indicated. Monitor pa-
$ent clinically, the necessity of hemodialysis will depend on pa$ent’s clinical status.
* Inform metabolic doctor on call for further guidance regarding on-going management
1
Su TS, Bock HGO, Beaudet AL et al. Molecular analysis of argininosuccinate syntehtase deficiency in human fibroblasts. J
Clin Invest 1982:70:1334-1339.
2
Nyhan WL, Barshop BA and Ozand P. Chapter 31: Citrullinemia. Atlas of Metabolic Diseases 2nd ed. Great Britain:Oxford
University Press, 2005 pp 210-213.
3
Wasant P, Viprakasit V, Srisomsap C et al. Argininosuccinate synthetase deficiency: muta$on analysis in 3 Thai pa$ents.
Southeast Asian J Trop Med Pub Health 2005;36(3):757-761.
4
Nyhan WL, Barshop BA and Ozand P. Chapter 32: Arginosuccinic aciduria. Atlas of Metabolic Diseases 2nd ed. Great Brit-
ain:Oxford University Press, 2005 pp 216-219.
5
Schulze A, Matern D, Hoffmann GF. Chapter 2: Newborn screening in Sarafoglou K, Hoffman GF and Roth KS (eds). Pedi-
atric Endocrinology and Inborn Errors of Metabolism. New York: McGraw Hill, 2009 pp 17-32.

BIOTINIDASE DEFICIENCY
What is Bionidase Deficiency?

Bionidase deficiency is a form of mulple carboxylase deficiency in which the fundamental defect is an inability to cleave
biocyn for bion recycling. Bion is a water-soluble vitamin of the B complex that acts as a coenzyme in each of 4
carboxylases in humans (pyruvate carboxylase, propionyl-coenzyme A carboxylase, β-methylcrotonyl CoA caorboxylase
and acetyl-CoA carboxylase).2
Bionidase deficiency presents with a median age of 3 months or as late as 10 years of age, symptoms include
dermatologic affectaon appearing as patchy desquamaon and neurological manifestaons such as seizures in 70% of
paents and ataxia that can interfere with walking. Some paents may also have opc atrophy and hearing loss.2
Individuals with paral bionidase deficiency can present with skin manifestaons and no neurologic symptoms.2,3
Pathophysiology
Bionidase deficiency results in an inability to recycle endogenous bion which means the brain is unable to recycle bion
adequately leading to decreased pyruvate carboxylase acvity in the brain and accumulaon of lactate which in turn
causes the neurologic symptoms.2
Confirmatory Tesng
Confirmatory studies are performed by determining bionidase acvity in serum.2

Paents are treated with bion (5-10mg/day).2,3
Prognosis
Once therapy is instuted, cutaneous symptoms resolve quickly as do seizures and ataxia, however other symptoms such
as hearing loss and opc atrophy are less reversible.2
What to Do If Unwell
• Insert IV access. Collect samples for serum ammonia and blood gas. May request for invesgaons (i.e. CBC, etc.) as
needed.

BIOTINIDASE DEFICIENCY
1
Nyhan WL, Barshop BA and Ozand P. Chapter 6: Mulple carboxylase deficiency/bionidase deficiency. Atlas of
Metabolic Diseases 2nd ed. Great Britain: Oxford University Press, 2005 pp 42-48.
2
3
Nyhan WL, Barshop BA and Ozand P. Chapter 6: Mulple carboxylase deficiency/bionidase deficiency. Atlas of
Metabolic Diseases 2nd ed. Great Britain:Oxford University Press, 2005 pp 42-48.

GALACTOSEMIA (GAL)
What are Galactosemia?
Galactosemia is a rare genec metabolic disorder that is inherited in an autosomal recessive manner. It is an inborn error of
carbohydrate metabolism characterized by elevated levels of galactose and its metabolites due to enzyme deficiencies
involved in its metabolism. Galactose is the sugar found mainly in milk and dairy products. It is also produced by the body.
Milk contains a sugar called lactose, and during digeson, lactose is broken down into the sugars glucose and galactose.
Glucose can immediately be used as a source of energy by the body, but galactose needs to be further broken down before
it can be ulized. The birth incidence of classic galactosemia is about 1 per 47,000 in the Caucasian populaon. The
Philippine NBS data as of December 2018 gives a prevalence of 1 : 134,439.
Pathophysiology
The galactose metabolic pathway with mulple enzymac steps is shown. The enzymes allow the subsequent conversion of
galactose to galactose-1-phosphate by GALK (1); galactose-1-phosphate and uridine diphosphate glucose (UDP glucose) to
glucose-1-phosphate and UDP-galactose by GALT (2) and the interconversion of UDP-glucose and UDP-galactose by GALE
(3). Children with galactosemia have very liOle or enrely lack an enzyme that helps the body break down galactose. There
are three different enzyme problems that can lead to galactosemia. In the first type or classic galactosemia, the enzyme that
is reduced or missing is called galactose-1-phosphate uridyl transferase (GALT). The GALT enzyme enables the body to break
down galactose into glucose. The second type of galactosemia is due to a deficiency in uridine diphosphate galactose 4-
epimerase (GALE). Its severe type clinically resembles classic galactosemia. The third type, is due to a deficiency in
galactokinase (GALK), and presents primarily as cataracts in untreated paents.
Clinical Features
Paents can present with feeding problems, failure to thrive, hepatocellular damage, bleeding, and sepsis in untreated
infants. In approximately 10% of individuals, cataracts are present. Failure to thrive is the most common inial clinical
symptom of classic galactosemia. Voming or diarrhea usually begins within a few days of milk ingeson. Jaundice of
intrinsic liver disease may be accentuated by the severe hemolysis occurring in some paents. Cataracts have been
observed within a few days of birth. There appears to be a high frequency of neonatal death due to E. coli sepsis in paents
with classic galactosemia.
The associaon of jaundice and hemorrhagic diathesis in the first 2 weeks of life is a clinical presentaon in which
galactosemia must be considered. Coagulopathy may also be present in galactosemia with liOle evidence of liver disease.
Galactosemia also causes learning and language problems in children, bone mineral density problems and ovarian failure in
girls.

Dietary eliminaon of milk and milk products containing lactose is the treatment for all types of galactosemia. There is no
chemical or drug substute for the missing enzyme at this me. An infant diagnosed with galactosemia will have to be on a
soy-based formula. Dietary management under the close supervision of a metabolic diecian and a metabolic doctor is a
must. Regular monitoring of blood galactose levels and regular evaluaon by the genec metabolic team is important for
opmal treatment.
Prognosis
Despite an early galactose-free diet, long-term complicaons have been noted in older children and adults with classic
galactosemia because of endogenous galactose producon. These include speech problems, poor intellectual funcon,
neurologic deficits (predominantly extrapyramidal findings with ataxia), and ovarian failure in females. Thus, the need for
regular monitoring and evaluaon is important.

GLUCOSE-6-PHOSPHATE DEHYDROGENASE (G6PD) DEFICIENCY
What is G6PD?
Glucose-6-phosphate dehydrogenase (G6PD) deficiency is an enzyme defect affecng around 400 million people
worldwide.5 According to the Philippine NBS data as of December 2018, 1 out of 61 screened newborns have G6PD
deficiency. 4 G6PD-deficiency is an X-linked disorder found in both sexes but more males are affected. Female carriers are
asymptomac.
(X)Y – Deficient, Symptomac

(X)(X) – Deficient, Symptomac
(X)X – Carrier
Pathophysiology
G6PD is an enzyme that is present in all cells, but is much valued in red blood cells (RBCs). G6PD is needed for the first step
in the Hexose Monophosphate Pathway (HMP). The pathway produces the reduced niconamide adenine dinucleode
phosphate (NADPH) that funcons as an electron donor in maintaining glutathione in its reduced form (GSH). GSH serves
as an anoxidant that protects the cells
against oxidave damage. The HMP is the
only source of NADPH in RBCs, thus the
deleterious effect of G6PD deficiency in
RBCs exposed to oxidave stress. Such
oxidave stress is brought about by food
products, drugs, chemical compounds,
and infecon. A short list of these agents
is available on the succeeding pages.
Clinical Features
The most common clinical manifestaon of G6PD deficiency is hemolyc anemia induced by various oxidave stresses as
menoned above. The paent presents sudden onset of tea-colored urine, jaundice and pallor. Hereditary nonspherocyc
hemolyc anemia may also occur in paents with severe G6PD deficiency. In neonates, G6PD deficiency may present with
prolonged jaundice which is aOributed to impaired liver funcon as supposed to hemolysis. The dreaded effect of
neonatal jaundice is kernicterus or the deposion of bilirubin (product of hemoglobin catabolism) which causes permanent
damage to the brain or death. Other associated disorders to G6PD deficiency are decreased RBC lifespan and cataract
formaon. Although there is a high prevalence of G6PD deficiency, there are only few severe cases of hemolysis that has
been documented and most of them are foreign reports.

Diagnosis
The currently used method in the diagnosis of G6PD deficiency is the spot fluorescence test as part of the newborn
screening panel. Screening-posive paents should immediately undergo confirmatory tesng based on esmaon of
enzyme acvity by quantave analysis of the rate of NADPH producon from NADP. DNA analysis is already available but
is not used as a diagnosc method.
Management
There is no cure for G6PD deficiency, but the main goal in the management is avoidance of oxidave insults and blood
transfusions for acute hemolyc crisis. Confirmed cases may also be referred to a specialist in Pediatric Hematology for
assessment and advice.
Prognosis
Most G6PD-deficient paents live a normal life without the clinical features as indicated above. Since there is no way of
telling who will develop hemolyc crisis, avoidance of oxidave stress and physician consult are advised if with febrile
illness.
Paent Educaon
Parents should be educated regarding their child’s disorder, specifically the drugs and food that cause oxidave stress, and
thus should be avoided. It is also important to emphasize that infecon is a common cause of hemolyc crisis in G6PD-
deficient paents, hence all affected paents should see their doctor during febrile illness for management. Parents are
also advised to menon to their physicians that the paent have G6PD deficiency during consults. As this is an inheritable
disease, X-linked, genec counseling should be done.
References and further reading materials:
Beutler E. G6PD deficiency. Blood. 1994; 84: 3613-36.
David-Padilla C, Basilio JA, and Oliveros YE. Newborn Screening: Research to Policy. Acta Medica Philippina. Vol 43 No. 2
2009. pp.6-14.
Kiani F, Schwarzl S, Fischer S, Efferth T. Three-Dimensional Modeling of Glucose-6-phosphate Dehydrogenase-Deficient

Variants from German Ancestry
Newborn Screening Center Prevalence Update 2018. Available at: hOp://www.newbornscreening.ph/images/stories/

ResourcesPrevalence/prevalence-2018.pdf.
Reddy BM and Tripathy V. Present status of understanding on the G6PD deficiency and natural selec$on. J Postgrad Med.
2007 July;193-2002.

FOODS, DRINKS AND CHEMICALS TO BE AVOIDED IN G6PD DEFICIENCY
DRUGS TO BE AVOIDED
DRUGS SAFE TO TAKE IN THERAPEUTIC

DOSES
CHEMICALS TO BE AVOIDED
FOOD AND DRINKS TO BE AVOIDED
*Not Available in the Philippines

**Should be water soluble

Expanded Screening Fact Sheets Doctors NSRC-InT-05 I1R1

Uploaded by

Copyright:

Available Formats

Expanded Screening Fact Sheets Doctors NSRC-InT-05 I1R1

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Expanded Screening Fact Sheets Doctors NSRC-InT-05 I1R1

Uploaded by

Copyright:

Available Formats

Fact Sheets

Information for DOCTORS about the

NEWBORN SCREENING REFERENCE CENTER Document Date: October 9, 2020 1

NEWBORN SCREENING REFERENCE CENTER Document Date: October 9, 2020 2

Inheritance: autosomal recessive7

Overview of Disease Management

Preliminary / Inial Management During Metabolic Crisis

NEWBORN SCREENING REFERENCE CENTER Document Date: October 9, 2020 3

• Nothing per orem

If unwell and can tolerate oral intake:

NEWBORN SCREENING REFERENCE CENTER Document Date: October 9, 2020 4

What is Methionine Adenosine Transferase (MAT) Deﬁciency?

Inheritance: autosomal recessive4, 5

Overview of Disease Management

Preliminary / Inial Management during Metabolic Crisis

NEWBORN SCREENING REFERENCE CENTER Document Date: October 9, 2020 5

If unwell and can tolerate oral intake:

NEWBORN SCREENING REFERENCE CENTER Document Date: October 9, 2020 6

Inheritance: autosomal recessive2,3

Overview of Disease Management

Preliminary / Inial Management during Metabolic Crisis

NEWBORN SCREENING REFERENCE CENTER Document Date: October 9, 2020 7

• Ensure paent’s airway is secure

If unwell and can tolerate oral intake:

NEWBORN SCREENING REFERENCE CENTER Document Date: October 9, 2020 8

Inheritance: autosomal recessive2,3

Overview of Disease Management

Preliminary / Inial Management during Metabolic Crisis

NEWBORN SCREENING REFERENCE CENTER Document Date: October 9, 2020 9

If unwell and can tolerate oral intake:

NEWBORN SCREENING REFERENCE CENTER Document Date: October 9, 2020 10

What is mild hyperphenylalaninemia?

Inheritance: autosomal recessive 1•5

Overview of Disease Management

NEWBORN SCREENING REFERENCE CENTER Document Date: October 9, 2020 11

What causes mild hyperphenylalaninemia?

What are the symptoms of untreated hyperphenylalaninemia?

What is the treatment of mild hyperphenylalaninemia?

What should I do if my baby is sick?

NEWBORN SCREENING REFERENCE CENTER Document Date: October 9, 2020 12

What is 6-PTPS Deﬁciency?

Inheritance: autosomal recessive 1•3

Overview of Disease Management

NEWBORN SCREENING REFERENCE CENTER Document Date: October 9, 2020 13

What are the signs and symptoms of untreated 6-PTPS deﬁciency?

What is the treatment of 6-PTPS deﬁciency?

What should I do when my baby is sick?

NEWBORN SCREENING REFERENCE CENTER Document Date: October 9, 2020 14

What is Tyrosinemia Type I (Hepatorenal tyrosinemia)?

Inheritance: autosomal recessive2

Overview of Disease Management

Preliminary / Inial Management during Metabolic Crisis

NEWBORN SCREENING REFERENCE CENTER Document Date: October 9, 2020 15

If unwell and can tolerate oral intake:

NEWBORN SCREENING REFERENCE CENTER Document Date: October 9, 2020 16

What is Tyrosinemia Type II?

Inheritance: autosomal recessive 1.2 .3

Overview of Disease Management

If unwell and cannot tolerate oral intake

Ensure paent's airway is secure

Preliminary / Inial Management During Metabolic Crisis

Preliminary / Inial Management during Metabolic Crisis

Preliminary / Inial Management during Metabolic Crisis

• Ensure paent’s airway is secure

Preliminary / Inial Management during Metabolic Crisis

Preliminary / Inial Management during Metabolic Crisis

Ensure paent's airway is secure

May give ﬂuid boluses if paent requires

Preliminary / Inial Management During Metabolic Crisis

Preliminary / Inial Management during Metabolic Crisis

Preliminary / Inial Management during Metabolic Crisis

Preliminary / Inial Management during Metabolic Crisis

Preliminary / Inial Management during Metabolic Crisis

Preliminary / Inial Management during Metabolic Crisis

• May give ﬂuid boluses if paent requires.

Preliminary / Inial Management during Metabolic Crisis

Preliminary / Inial Management during Metabolic Crisis