Newborn screening (NBS) is a public health program of screening in infants shortly after birth for conditions that are treatable, but not clinically evident in the newborn period. The goal is to identify infants at risk for these conditions early enough to confirm the diagnosis and provide intervention that will alter the clinical course of the disease and prevent or ameliorate the clinical manifestations. NBS started with the discovery that the amino acid disorder phenylketonuria (PKU) could be treated by dietary adjustment, and that early intervention was required for the best outcome. Infants with PKU appear normal at birth, but are unable to metabolize the essential amino acid phenylalanine, resulting in irreversible intellectual disability. In the 1960s, Robert Guthrie developed a simple method using a bacterial inhibition assay that could detect high levels of phenylalanine in blood shortly after a baby was born. Guthrie also pioneered the collection of blood on filter paper which could be easily transported, recognizing the need for a simple system if the screening was going to be done on a large scale. Newborn screening around the world is still done using similar filter paper. NBS was first introduced as a public health program in the United States in the early 1960s, and has expanded to countries around the world.
Screening programs are often run by state or national governing bodies with the goal of screening all infants born in the jurisdiction for a defined panel of treatable disorders. The number of diseases screened for is set by each jurisdiction, and can vary greatly. Most NBS tests are done by measuring metabolites or enzyme activity in whole blood samples collected on filter paper. Bedside tests for hearing loss using automated auditory brainstem response or otoacoustic emissions and congenital heart defects using pulse oximetry are included in some NBS programs. Infants who screen positive undergo further testing to determine if they are truly affected with a disease or if the test result was a false positive. Follow-up testing is typically coordinated between geneticists and the infant's pediatrician or primary care physician.
History
Robert Guthrie is given much of the credit for pioneering the earliest screening for phenylketonuria in the late 1960s using a bacterial inhibition assay (BIA) to measure phenylalanine levels in blood samples obtained by pricking a newborn baby's heel on the second day of life on filter paper. Congenital hypothyroidism was the second disease widely added in the 1970s. Guthrie and colleagues also developed bacterial inhibition assays for the detection of maple syrup urine disease and classic galactosemia. The development of tandem mass spectrometry (MS/MS) screening in the early 1990s led to a large expansion of potentially detectable congenital metabolic diseases that can be identified by characteristic patterns of amino acids and acylcarnitines. In many regions, Guthrie's BIA has been replaced by MS/MS profiles, however the filter paper he developed is still used worldwide, and has allowed for the screening of millions of infants around the world each year.
In the United States, the American College of Medical Genetics recommended a uniform panel of diseases that all infants born in every state should be screened for. They also developed an evidence-based review process for the addition of conditions in the future. The implementation of this panel across the United States meant all babies born would be screened for the same number of conditions. This recommendation is not binding for individual states, and some states may screen for disorders that are not included on this list of recommended disorders. Prior to this, babies born in different states had received different levels of screening. On April 24, 2008, President George W. Bush signed into law the Newborn Screening Saves Lives Act of 2007. This act was enacted to increase awareness among parents, health professionals, and the public on testing newborns to identify certain disorders. It also sought to improve, expand, and enhance current newborn screening programs at the state level.
Inclusion of disorders
Newborn screening programs initially used screening criteria based largely on criteria established by JMG Wilson and F. Jungner in 1968. Although not specifically about newborn population screening programs, their publication, Principles and practice of screening for disease proposed ten criteria that screening programs should meet before being used as a public health measure. Newborn screening programs are administered in each jurisdiction, with additions and removals from the panel typically reviewed by a panel of experts. The four criteria from the publication that were relied upon when making decisions for early newborn screening programs were:
- having an acceptable treatment protocol in place that changes the outcome for patients diagnosed early with the disease
- an understanding of the condition's natural history
- an understanding about who will be treated as a patient
- a screening test that is reliable for both affected and unaffected patients and is acceptable to the public
As diagnostic techniques have progressed, debates have arisen as to how screening programs should adapt. Tandem mass spectrometry has greatly expanded the potential number of diseases that can be detected, even without satisfying all of the other criteria used for making screening decisions. Duchenne muscular dystrophy is a disease that has been added to screening programs in several jurisdictions around the world, despite the lack of evidence as to whether early detection improves the clinical outcome for a patient. After the success of newborn screening for PKU (39 infants were identified and treated in the first two years of screening, with no false negative results), Guthrie and others looked for other disorders that could be identified and treated in infants, eventually developing bacterial inhibition assays to identify classic galactosemia and maple syrup urine disease.
Newborn screening has expanded since the introduction of PKU testing in the 1960s, but can vary greatly between countries. In 2011, the United States screened for 54 conditions, Germany for 12, the United Kingdom for 2 (PKU and medium chain acyl-CoA dehydrogenase deficiency (MCADD)), while France and Hong Kong only screened for one condition (PKU and congenital hypothyroidism, respectively). The conditions included in newborn screening programs around the world vary greatly, based on the legal requirements for screening programs, prevalence of certain diseases within a population, political pressure, and the availability of resources for both testing and follow-up of identified patients.
Congenital Disorders of Amino Acid Metabolism
Newborn screening originated with an amino acid disorder, phenylketonuria (PKU), which can be easily treated by dietary modifications, but causes severe Intellectual disability if not identified and treated early. Robert Guthrie introduced the newborn screening test for PKU in the early 1960s. Austria started screening the same year and England in 1968.
Other congenital disorders of amino acid metabolism tested for on the newborn screening include Tyrosinemia and Maple Syrup Urine Disorder.
Fatty acid oxidation disorders
With the advent of tandem mass spectrometry as a screening tool, several fatty acid oxidation disorders were targeted for inclusion in newborn screening programs. Medium chain acyl-CoA dehydrogenase deficiency (MCADD), which had been implicated in several cases of sudden infant death syndrome was one of the first conditions targeted for inclusion. MCADD was the first condition added when the United Kingdom expanded their screening program from PKU only.
The introduction of screening for fatty acid oxidation disorders has been shown to have reduced morbidity and mortality associated with the conditions, particularly MCADD. An Australian study found a 74% reduction in episodes of severe metabolic decompensation or death among individuals identified by newborn screening as having MCADD versus those who presented clinically prior to screening. Studies in the Netherlands and United Kingdom found improvements in outcome at a reduced cost when infants were identified before presenting clinically. Testing for both disorders can be done using blood samples collected on the standard newborn screening card. Screening for CH is done by measuring thyroxin (T4), thyrotropin (TSH) or a combination of both analytes. Elevated 17α-hydroxyprogesterone (17α-OHP) is the primary marker used when screening for CAH, most commonly done using enzyme-linked immunosorbant assays, with many programs using a second tier tandem mass spectrometry test to reduce the number of false positive results.
CH was added to many newborn screening programs in the 1970s, often as the second condition included after PKU. The most common cause of CH is dysgenesis of the thyroid gland After many years of newborn screening, the incidence of CH worldwide had been estimated at 1:3600 births, with no obvious increases in specific ethnic groups. Recent data from certain regions have shown an increase, with New York reporting an incidence of 1:1700. Reasons for the apparent increase in incidence have been studied, but no explanation has been found. Newborn screening for a large number of hemoglobinopathies is done by detecting abnormal patterns using isoelectric focusing, which can detect many different types of abnormal hemoglobins. After the CFTR gene was identified, Australia introduced a two tier testing program to reduce the number of false positives. Samples with an elevated IRT value were then analyzed with molecular methods to identify the presence of disease causing mutations before being reported back to parents and health care providers. CF is included in the core panel of conditions recommended for inclusion in all 50 states, Texas was the last state to implement their screening program for CF in 2010. Alberta was the first Canadian province to implement CF screening in 2007. Quebec, New Brunswick, Nova Scotia, Newfoundland and Prince Edward Island do not include CF in their screening programs. The United Kingdom as well as many European Union countries screen for CF as well.
Lysosomal storage disorders
Lysosomal storage disorders are not included in newborn screening programs with high frequency. As a group, they are heterogenous, with screening only being feasible for a small fraction of the approximately 40 identified disorders. The arguments for their inclusion in newborn screening programs center around the advantage of early treatment (when treatment is available), avoiding a diagnostic odyssey for families and providing information for family planning to couples who have an affected child. The arguments against including these disorders, as a group or individually center around the difficulties with reliably identifying individuals who will be affected with a severe form of the disorder, the relatively unproven nature of the treatment methods, and the high cost / high risk associated with some treatment options. A pilot screening program for four lysosomal storage diseases (Gaucher disease, Pompe disease, Fabry disease and Niemann-Pick disease was undertaken using anonymised dried blood spots was completed in Austria in 2010. Their data showed an increased incidence from what was expected in the population, and also a number of late onset forms of disease, which are not typically the target for newborn screening programs.
Hearing loss
Undiagnosed hearing loss in a child can have serious effects on many developmental areas, including language, social interactions, emotions, cognitive ability, academic performance and vocational skills, any combination of which can have negative impacts on the quality of life. As the first country in Europe, Norway started nationwide SCID screening January 2018. Identification of infants with SCID is done by detecting T-cell receptor excision circles (TRECs) using real-time polymerase chain reaction (qPCR). TRECs are decreased in infants affected with SCID.
SCID has not been added to newborn screening in a wide scale for several reasons. It requires technology that is not currently used in most newborn screening labs, as PCR is not used for any other assays included in screening programs. Follow-up and treatment of affected infants also requires skilled immunologists, which may not be available in all regions. Treatment for SCID is a stem cell transplant, which cannot be done in all centers.
As treatments improve, newborn screening becomes a possibility for disorders that could benefit from early intervention, but none was previously available. Adrenoleukodystrophy (ALD), a peroxisomal disease that has a variable clinical presentation is one of the disorders that has become a target for those seeking to identify patients early. ALD can present in several different forms, some of which do not present until adulthood, making it a difficult choice for countries to add to screening programs. The most successful treatment option is a stem cell transplant, a procedure that carries a significant risk.
Techniques
Sample collection
Newborn screening tests are most commonly done from whole blood samples collected on specially designed filter paper, originally designed by Robert Guthrie. The filter paper is often attached to a form containing required information about the infant and parents. This includes date and time of birth, date and time of sample collection, the infant's weight and gestational age. The form will also have information about whether the baby has had a blood transfusion and any additional nutrition the baby may have received (total parenteral nutrition). Most newborn screening cards also include contact information for the infant's physician in cases where follow up screening or treatment is needed. The Canadian province of Quebec performs newborn screening on whole blood samples collected as in most other jurisdictions, and also runs a voluntary urine screening program where parents collect a sample at 21 days of age and submit it to a provincial laboratory for an additional panel of conditions.
Newborn screening samples are collected from the infant between 24 hours and 7 days after birth, and it is recommended that the infant has fed at least once. Individual jurisdictions will often have more specific requirements, with some states accepting samples collected at 12 hours, and others recommending to wait until 48 hours of life or later. Each laboratory will have its own criteria on when a sample is acceptable, or if another would need to be collected. Samples can be collected at the hospital, or by midwives. Samples are transported daily to the laboratory responsible for testing. In the United States and Canada, newborn screening is mandatory, with an option for parents to opt out of the screening in writing if they desire. In many regions, NBS is mandatory, with an option for parents to opt out in writing if they choose not to have their infant screened. In most of Europe, newborn screening is done with the consent of the parents. Proponents of mandatory screening claim that the test is for the benefit of the child, and that parents should not be able to opt out on their behalf. In regions that favour informed consent for the procedure, they report no increase in costs, no decrease in the number of children screened and no cases of included diseases in children who did not undergo screening.
Laboratory testing
Because newborn screening programs test for a number of conditions, a number of laboratorial methodologies are used, as well as bedside testing for hearing loss using evoked auditory potentials and congenital heart defects using pulse oximetry.
In the early 1960s Newborn screening started out using simple bacterial inhibition assays to screen for a single disorder, starting with phenylketonuria. With this testing methodology, newborn screening required one test to detect one condition. As mass spectrometry became more widely available, the technology allowed rapid determination of a number of acylcarnitines and amino acids from a single dried blood spot. This increased the number of conditions that could be detected by newborn screening. Enzyme assays are used to screen for galactosemia and biotinidase deficiency. Immunoassays measure thyroid hormones for the diagnosis of congenital hypothyroidism and 17α-hydroxyprogesterone for the diagnosis of congenital adrenal hyperplasia. Molecular techniques are used for the diagnosis of cystic fibrosis and severe combined immunodeficiency.
As of 2023, numerous initiatives using next generation sequencing (NGS) have been announced worldwide including the Genomic Uniform-screening Against Rare Diseases in All Newborns (GUARDIAN study), BeginNGS and Early Check in the USA, BabyScreen+ in Australia, Generation Study by Genomics England, and Screen4Care, Baby Detect in Belgium and PERIGENOMED in France. In a 2023 survey of 14 European newborn screening programs, there was one pan-European research study with 2 pilot trials planned in Germany (NEW_LIVES) and Italy, the others included three initiatives in Italy, three in the Netherlands, two in Spain, one in Belgium, one in England, one in Germany, one in Greece and one in France. Of the 14 initiatives, 11 selected a single NGS approach for their studies: 6 initiatives planned to use only whole genome sequencing (WGS) as a first-tier test for NBS, including one also testing parents using whole exome sequencing (WES) to facilitate filtering variants, 3 initiatives use classical NGS gene panels, 2 initiatives will be using WES and 2 initiatives will use a mixed approach: one comparing WES and Whole genome sequencing (WGS) and one comparing WES, WGS, and classical NGS. gene panels. and the American College of Medical Genetics.
Laboratory performance
Newborn screening programs participate in quality control programs as in any other laboratory, with some notable exceptions. Much of the success of newborn screening programs is dependent on the filter paper used for the collection of the samples. Initial studies using Robert Guthrie's test for PKU reported high false positive rates that were attributed to a poorly selected type of filter paper. This source of variation has been eliminated in most newborn screening programs through standardization of approved sources of filter paper for use in newborn screening programs. In most regions, the newborn screening card (which contains demographic information as well as attached filter paper for blood collection) is supplied by the organization carrying out the testing, to remove variations from this source. A short-term California testing pilot project in 2003 and 2004 demonstrated the cost of forgoing rare disease testing on newborns. While both Zachary Wyvill and Zachary Black were both born with the same disease during the pilot program, Wyvill's birth hospital tested only for four state-mandated diseases while Black was born at a hospital participating in the pilot program. Wyvill's disease went undetected for over six months during which irreversible damage occurred but Black's disease was treated with diet and vitamin supplements. Both sets of parents became advocates for expanded neonatal testing and testified in favor of expanding tandem mass spectrometry (MS/MS) testing of newborns for rare diseases. By August, 2004, the California state budget law had passed requiring the use of tandem mass spectroscopy to test for more than 30 genetic illnesses and provided funding. California now mandates newborn screening for all infants and tests for 80 congenital and genetic disorders.
Government budgetary limitations
Instituting MS/MS screening often requires a sizable up front expenditure. When states choose to run their own programs the initial costs for equipment, training and new staff can be significant. Moreover, MS/MS gives only the screening result and not the confirmatory result. The same has to be further done by higher technologies or procedure like GC/MS, Enzyme Assays or DNA Tests. This in effect adds more cost burden and makes physicians lose precious time. To avoid at least a portion of the up front costs, some states such as Mississippi have chosen to contract with private labs for expanded screening. Others have chosen to form Regional Partnerships sharing both costs and resources.
But for many states, screening has become an integrated part of the department of health which can not or will not be easily replaced. Thus the initial expenditures can be difficult for states with tight budgets to justify. Screening fees have also increased in recent years as health care costs rise and as more states add MS/MS screening to their programs. (See Report of Summation of Fees Charged for Newborn Screening, 2001–2005) Dollars spent for these programs may reduce resources available to other potentially lifesaving programs. It was recommended in 2006 that one disorder, Short Chain Acyl-coenzyme A Dehydrogenase Deficiency, or SCAD, be eliminated from screening programs, due to a "spurious association between SCAD and symptoms. However, other studies suggested that perhaps expanded screening is cost effective (see [ftp://ftp.hrsa.gov/mchb/genetics/screeningdraftforcomment.pdf ACMG report page 94-95] and articles published in Pediatrics. Advocates are quick to point out studies such as these when trying to convince state legislatures to mandate expanded screening.
Decreasing mandatory tests
Expanded newborn screening is also opposed by among some health care providers, who are concerned that effective follow-up and treatment may not be available, that false positive screening tests may cause harm, and issues of informed consent. A recent study by Genetic Alliance and partners suggests that communication between health care providers and parents may be key in minimizing the potential harm when a false positive test occurs. The results from this study also reveal that parents found newborn screening to be a beneficial and necessary tool to prevent treatable diseases. To address the false positive issue, researchers from the University of Maryland, Baltimore and Genetic Alliance established a check-list to assist health care providers communicate with parents about a screen-positive result.
Secret genetic research
Controversy has also erupted in some countries over collection and storage of blood or DNA samples by government agencies during the routine newborn blood screen.
In the United States, it was revealed that Texas had collected and stored blood and DNA samples on millions of newborns without the parents' knowledge or consent. These samples were then used by the state for genetic experiments and to set up a database to catalog all of the samples/newborns. , samples obtained without parents' consent between 2002 and 2009 were slated to be destroyed following the settlement of "a lawsuit filed by parents against the Texas Department of Health Services and Texas A&M; for secretly storing and doing research on newborn blood samples."
A similar legal case was filed against the State of Minnesota. Over 1 million newborn bloodspot samples were destroyed in 2011 "when the state's Supreme Court found that storage and use of blood spots beyond newborn screening panels was in violation of the state's genetic privacy laws.". Nearly was required to be paid by the state for the attorney's fees of the 21 families who advanced the lawsuit. An advocacy group that has taken a position against research on newborn blood screening data without parental consent is the Citizens' Council for Health Freedom, who take the position that newborn health screening for "a specific set of newborn genetic conditions" is a very different matter than storing the data or those DNA samples indefinitely to "use them for genetic research without parental knowledge or consent."
Bioethics
As additional tests are discussed for addition to the panels, issues arise. Many question whether the expanded testing still falls under the requirements necessary to justify the additional tests. Many of the new diseases being tested for are rare and have no known treatment, while some of the diseases need not be treated until later in life. Studies show that the rarer the disease is and the more diseases being tested for, the more likely the tests are to produce false-positives. This is an issue because the newborn period is a crucial time for the parents to bond with the child, and it has been noted that ten percent of parents whose children were diagnosed with a false-positive still worried that their child was fragile and/or sickly even though they were not, potentially preventing the parent-child bond forming as it would have otherwise.