Protocol for NBS

SGPGIMS
Galactosemia & Biotinidase deficiency &
G6PD Deficiency & Congenital
Hypothyroidism & Congenital Adrenal
Hyperplasia
Galactosemia
• Using total galactose measurement by Victor
2D equipment based on Time Resolved
Fluoremetry
• Cut off values are given as per Perkin Elmer
kits using Victor 2 D equipment.
• Time of sampling – 24 hrs after birth
• Ensure that the baby has been given milk
feeds
Total Galactose
(after 24 hours of life & receiving milk feeds)

<11.7 mg/dl 11.7 to 13.9 mg/dl >13.9 mg/dl

NORMAL EQUIVOCAL SCREEN POSITIVE

•Call for GALT assay on
No follow up needed. •Repeat filter paper sample by venous sample*
calling the baby or home visit to •Repeat filter paper
But rarely if the child expediate the retesting sample for total galactose
becomes ill or develops •Clinical evaluation or telephonic •Clinical evaluation
symptoms suggestive interview •Blood sugar, S. biliRUBI
of galactosemia or IEM, (Total, direct), ALP, SGPT,
the baby needs to be <11.7mg/dl >11.7 mg/dl SGOT, etc.
retested and •Admit if required
evaluated. •GALT result to be made
NORMAL available on the same day
GALT level >10%
GALT level < 10%
* Ask for history of blood
Treatment for galactosemia TRUE POSITIVE
transfusion
Galactosemia: True Positive
Total galactose > 13.9mg/dl •For all equivocal and screen positive
GALT assay – confirmed diagnosis cases, immediate efforts to contact the
family, get info about the status of baby
Stop breast milk. Start soya based and call for re-sampling should be done.
formula. Hospitalize. Supervize feed.
Monitor blood sugar, s bilirubin. Watch / •For all cases till the resample on filter
test for septicemia [antibiotic / blood
paper & / or venous sample for GALT
culture]
Total galactose to be done alternate day.
assay are made available, repeat testing
Discharge after total galactose becomes from the same filter paper be done
normal.
•For babies who did not opt for
Follow up – Weekly for one month & retesting or GALT assay, telephonic
then monthly follow up for one month may be done
Weight, length, head circumference •If delay in results of GALT assay/blood
Total galactose transfusion, appropriate management
Slit lamp examination for cataract at 2 decisions to be taken based on the
months and 3 months clinical evaluation.
Evaluate compliance to soya formula
NBS for Galactosemia: Special Situations
1. For babies with equivocal results of total galactose, if possible GALT assay
to be done, especially if there is already delay in recall visit or the baby has
been brought and parents are willing to give venous sample or the baby
appears to be unwell.
2. For babies with total galactose > 13.9 mg/dl, if the family is not willing to
come for venous sampling, at least re-sample on filter paper for total
galactose should be done.
3. For babies with total galactose more than 13.9 mg/dl, if the baby has been
brought to the hospital, it is better to hospitalize the child till the GALT
result is available.
4. Those babies who were detected in our NBS program and did not appear
very sick, appeared to improve soon after starting soya based formula
feeds.
5. Total galactose comes to normal in 2-3 days after starting treatment.
6. Those babies who were detected in our NBS program and did not appear
very sick, deteriorated very fast if the treating hospital did not closely
monitor the feeding and clinical situation.
NBS for Biotinidase deficiency
• Profound biotinidase deficiency is very rare
• Cut-off values are given as per Perkin Elmer
kits using Victor 2 D equipment.
Biotinidase level on DBS

> 45 U/dl 36 to 45 U/dl < 36 U/dl

NORMAL EQUIVOCAL SCREEN POSITIVE

No follow up needed. •Repeat testing from •Biotinidase assay on venous

another spot on filter sample
But rarely if the child paper •Clinical evaluation or telephonic
becomes ill or develops • Repeat filter paper interview and repeat filter paper
symptoms suggestive sample sample from home visit if venous
of biotinidase •Clinical evaluation or sample is not provided by the
deficiency or IEM, the telephonic interview for family
baby need to be alopecia, irritability, •Admit if required
retested and evaluated convulsions
as per clinical situation Serum Biotinidase level
>45U/dl <45 U/dl
10 to 30% <10%
>30%

Partial deficiency TRUE POSITIVE

*Store sample for BTD gene sequencing Treat as biotinidase deficiency *

Biotinidase Deficiency: True Positive

Management Special situations

• Biotinidase level < 10% of normal • If the patient is screen positive
value and not ready to come for
• Start tablet Biotin 10 mg per day follow up testing on venous
• Clinical evaluation for growth and sample, repeat filter paper
development every month till 6 sample can be collected and
months tested.
• Audiometry at 2 months • Very rarely, the need for putting
• Then 3 monthly upto 1 year the baby on biotin treatment
• Then 6 monthly upto 5 years may be considered if there is
• Dose may be increased to 20 mg delay in getting confirmatory
per day if the child develops loss of test for various reasons
hair or listlessness
Partial Biotinidase deficiency
Diagnosis and Prevalence Management
• Partial biotinidase deficiency • Partial biotinidase
have been diagnosed in 1 per deficiency can also present
3000 babies. with symptoms under times
• Biotinidase level is between 10 of stress.
to 30% and the child has
• These babies be put on
bialleic mutation in biotinidase
gene. tablet biotin 1 to 5 mg OD &
• Sanger sequencing of BTD gene
follow them every yearly
in babies with enzyme level in
the range of partial biotinidase
deficiency should be done.

•Wolf, B. Why perform newborn screening for profound and partial biotinidase deficiency? Mol. Genet.
Metab. 2015, doi:10.1016/j.ymgme.2015.01.003.
•Wolf B. Biotinidase deficiency. Genereviews; 2016 https://www.ncbi.nlm.nih.gov/books/NBK1322/>
Biotinidase Mutation Testing
• Partial biotinidase deficiency (10%-30% of mean normal serum biotinidase
activity) – Need to be treated
• Compound heterozygotes for the p.Asp444His pathogenic variant and a
pathogenic variant that results in profound biotinidase deficiency are expected
to have approximately 20%-25% of mean normal serum biotinidase enzyme
activity [Swango et al 1998].
• Heterozygotes
• Individuals with one profound or one partial biotinidase deficiency BTD variant
are carriers of biotinidase deficiency and do not exhibit symptoms [B Wolf,
personal observation]. Such individuals do not require biotin therapy.
• Individuals who are homozygous for the p.Asp444His pathogenic variant are
expected to have approximately 45%-50% of mean normal serum biotinidase
enzyme activity (which is similar to the activity of heterozygotes for profound
biotinidase deficiency) and do not require biotin therapy.
Vanvleck, Nicole & Wolf, Barry & Seeterlin, Mary & Monaghan, Kristin & Stanley, Eleanor & Hawkins, Harry & Taffe,
Bonita. (2015). Improved Identification of Partial Biotinidase Deficiency by Newborn Screening Using Age-Related
Enzyme Activity Cutoffs: Reduction of the False-Positive Rate.

International Journal of Neonatal Screening. 2015. 45-56. 10.3390/ijns1010045 .

• Initially, it was uncertain as to whether children with partial deficiency

require biotin supplementation. Since the advent of newborn screening
for the disorder, we are aware of multiple symptomatic children with
partial deficiency who were not screened [8,9] or who were not treated
after being identified by screening [10]. We are also aware of others who
became symptomatic, but were not reported in the medical literature
and improved on biotin supplementation (personal communication).
Symptoms appear to occur if an individual is stressed with an infection or
moderately severe gastroenteritis. Therefore, because the vitamin is safe
with no known toxicity and it prevents the development of symptoms,
many newborn screening programs, especially in the United States,
recommend that children with partial biotinidase deficiency be treated
with daily doses of 1 to 5 mg of biotin
TSH CUTOFFS At SGPGIMS
TSH (mU/I) Time Period Plan Of Action

1. 20—34 (mU/I)Repeat
filter paper for screening
24 – 48 hrs.  >20 mU/I 2. 34 – 40 (mU/I) Venous
sample for confirmation
>20--40 (mU/I)
Abnormal
Repeat filter paper for
> 48 hrs.  >20 mU/I screening &Venous sample
for confirmation

>40 mU/I
At any Birth age Venous sample for
Positive confirmation
BIRTH WEIGHT BASED CAH Screening At SGPGIMS

Blood 17-OHP-(ng/ml) Plan of Action

<2 Kg  > 40 ng/ml
Venous sample for
confirmation
>20 ng/ml
Abnormal
>2 Kg  > 20 ng/ml Repeat filter paper for
rescreening

At any birth weight Venous sample for

>60 ng/ml confirmation
Positive