Newborn_Screening_Manual

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newborn screening

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State of Illinois Rod R. Blagojevich Governor Department of Public Health Eric E. Whitaker M.D. M.P .H. Director Newborn Screening Practitioner’s Manual June 2007

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Table of Contents Introduction Page 1 Overview Page 1-2 List of Disorders Included in Illinois Screening Panel Page 3 Newborn Screening Program Contact Information Page 4 Practitioner’s Newborn Screening Responsibilities Page 5-7 Specimen Collection 5-6 Newborn Screening Fee 6 Repeat Specimens Diagnostic Testing and Referrals 6 Refusal of Newborn Screening 6 Infants Born Outside State of Mother’s Residence 7 Collection of Newborn Screening Specimens Page 7-10 Filter Paper Collection Form 7 Timing of Specimen Collection 8 Exceptions Special Considerations 8-9 Infants Born Outside of Hospital/Medical Facilities Premature and Sick Infants Infants Receiving Special Feedings Infants Receiving Antibiotics Hyperalimentation/Galactose Feeding Status Transfusions Tips for Specimen Collection 9-10 Capillary Tubes and EDTA Collecting Repeat Specimens 10 Handling and Submission of Specimens Page 11 Submitting Specimens 11 Timeliness 11 Reporting of Screening Results Page 11-12 Normal Results 11 Abnormal Results 12 Presumptive Positive Abnormal Results Suspect Abnormal Results Unsatisfactory Specimens 12 Referrals to Pediatric Medical Specialists and Other Agencies Page 13-14 Pediatric Medical Specialists 13 Services for Infants with Sickle Cell Disease/Other Hemoglobinopathies 13 Division of Specialized Care for Children DSCC 13 Local Public Health Departments 14 Newborn Screening Disorders Page 15-43

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Amino Acid/Urea Cycle Disorders 15-17 Biotinidase Deficiency 18-19 Congenital Adrenal Hyperplasia 20-22 Congenital Hypothyroidism 23-24 Cystic Fibrosis 25-26 Fatty Acid Oxidation Disorders 27-30 Galactosemia 31-32 Organic Acid Disorders 33-35 Phenylketonuria Also see Amino Acid Disorders 36-37 Sickling Hemoglobinopathies FS FSC FSa 38-40 Other Hemoglobin Disease Conditions FC FD FE FNA and Carrier States Traits 41-43 Appendices Filter Paper Collection Form Appendix A Pediatric Medical Specialists/Other Agencies Appendix B Local Public Health Department Contacts Appendix C Acylcarnitine/Amino Acid Analytes Appendix D Introduction

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1 Newborn screening is a public health activity aimed at early identification of newborns affected with certain genetic and/or metabolic conditions. Early diagnosis and treatment of these conditions has been proven in many cases to reduce morbidity premature death mental retardation and other developmental disabilities. Newborn screening is recognized as one of the most successful recent public health accomplishments and was the first population-based genetic screening program to become an integral component of public health practice. While newborn screening disorders are individually rare collectively the incidence of these disorders is around one in 500 births. In Illinois each year around 350-400 babies are diagnosed with a condition identified by newborn screening. Newborn screening affects most all health care practitioners who work with children and their families. During their practice of medicine most pediatric and family medicine health professionals will receive notice that a child in their care has a serious abnormal newborn screen or has been diagnosed with a newborn screening disorder. Health care practitioners are vital links within an effective newborn screening system a system that includes hospitals the state newborn screening laboratory and follow-up program parents health care providers medical specialists and community service agencies. Health care providers serve as the front line in assuring that all newborns receive adequate screenings and when necessary appropriate follow-up services within a medical home. The Illinois Department of Public Health IDPH Newborn Screening Program developed this manual for health care professionals as a reference guide to newborn screening in Illinois. This resource provides protocols for specimen collection laboratory testing follow-up services and the IDPH reporting of both normal and abnormal screening results. Information about the disorders included in the current newborn screening test panel also is provided. This manual is intended to provide background information and general guidance on issues related to newborn screening but does not replace the case specific medical advice available through consult with pediatric medical specialists including those who may be contacted at the medical centers listed in the manual Appendix B. Overview The Phenylketonuria Testing Act 410 ILCS 240/ mandates newborn screening for all infants born in Illinois. This act authorizes the Illinois Department of Public Health to promulgate administrative rules for newborn screening Title 77: Public Health Chapter 1: Department of Public Health Subchapter i: Maternal Child Health Part 661 Newborn Metabolic Screening and Treatment Code. The Phenylketonuria Testing Act and the newborn screening administrative rules may be viewed at the IDPH Web site http://www.idph.state.il.us. All Illinois newborn infants are mandated to have a blood sample collected on the special filter paper specimen cards supplied by the Illinois Department of Public Health. The only valid exception is parental refusal based on religious beliefs and practices in which case a written refusal must be signed by the parents and documented in the infant’s medical record. Newborn screening blood spot specimens should be collected as soon as possible after the first 24 hours of life. If the baby is to be discharged from the birth center prior to 24 hours of age the specimen should be collected before discharge. After drying the specimen cards should be sent by courier or mail service to

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2 the IDPH Newborn Screening Laboratory in Chicago for testing. When testing is completed a report of all test results is issued by the IDPH Newborn Screening Laboratory to the specimen submitter usually the birth center. Birth centers are expected to retain the screening report in the infant’s medical record and to relay a copy of the results to the baby’s primary care provider. In addition all abnormal unsatisfactory and invalid results are reported by the Newborn Screening Follow-up Program to the physician of record the physician whose name appears on the specimen card. In some cases hospitals may authorize reporting of results to a specified hospital contact person. The physician of record or the birthing hospital newborn screening contact person is expected to inform the mother and the baby’s primary care provider of the abnormal test results and to facilitate any recommended follow-up activities including evaluation of the baby’s medical condition and collection of a repeat newborn screening specimen or referral to a pediatric medical specialist for diagnostic testing. If the mother cannot be contacted the assistance of the birth hospital and/or the local public health department may be needed to help locate the family. The IDPH Newborn Screening Program should be informed of any difficulties in locating the family. Every effort should be made to assure that each baby who has an abnormal newborn screen receives the appropriate follow-up services in a timely manner. In the cases of babies with any serious abnormal results requiring immediate referral to a pediatric medical specialist a list of IDPH designated specialists information about the suspected disorder and the actual test results will be provided to the physician of record or the hospital newborn screening contact. The American College of Medical Geneticists ACMG http://www.acmg.net provides detailed action plans for follow-up of each suspected newborn screening disorder. The University of Illinois at Chicago Division of Specialized Care for Children DSCC http://www.uic.edu/hsc/dscc provides additional information about these conditions and the importance of medical homes for children with special health care needs. In addition to these resources the Federal Maternal and Child Health Bureau of the Health Resources and Services Administration provided grant funding to create the Region 4 Genetics Collaborative which includes Illinois Indiana Kentucky Michigan Minnesota Ohio and Wisconsin. The goals of this multi- state collaborative include efforts to address inequities in genetics resources and to improve the quality of genetics services including newborn screening throughout the region. The Region 4 Genetics Collaborative Web site http://www.region4genetics.org provides information about newborn screening medical homes specialty care resources and genetic counseling services available within this seven state region. Illinois Newborn Screening Disorder List Although additional disorders may be added as determined by the Illinois Department of Public Health under the advisement of the Genetic and Metabolic Disease Advisory Committee the Illinois newborn

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3 screening panel currently includes the following disorders: Endocrine Disorders Congenital adrenal hyperplasia CAH Congenital hypothyroidism Hemoglobinopathies Sickle cell disease trait conditions and other sickling hemoglobinopathies Amino Acid Disorders Homocystinuria HCU/Hypermethioninemia Maple syrup urine disease MSUD Phenylketonuria PKU/Hyperphenylalaninemia Tyrosinemia type 1 and possibly type 2 or type 3 - levels may not be sufficiently elevated for detection 5-Oxoprolinuria 5OXP - may not be reliably detected in first few days of life Urea Cycle Disorders Argininemia - extremely rare Argininosuccinic aciduria argininosuccinic acid synthetase deficiency - AS Citrullinemia argininosuccinic acid lyase deficiency - AL Organic Acid Disorders 2-methylbutyryl-CoA dehydrogenase deficiency 2MBCD 3-methylcrotonyl-CoA carboxylase deficiency 3MCC 3-hydroxy-3-methylglutaryl-CoA lyase deficiency HMG 3-methylglutaconic aciduria 3MGA Beta-ketothiolase deficiency BKT Glutaric aciduria type 1 GA1 Isovaleric acidemia IVA Malonic aciduria MA - may not be reliably detected in the first few days of life Methylmalonic acidemia MMA Multiple carboxylase deficiency MCD Propionic acidemia PA Fatty Acid Oxidation Disorders Carnitine/acylcarnitine translocase deficiency CACT - neonatal form is extremely rare Carnitine palmitoyl transferase deficiency type 2 CPT2 - neonatal form is extremely rare Carnitine palmitoyl transferase deficiency type 1A CPT1A - may not be reliably detected in first days of life Carnitine uptake defect CUD - may not be reliably detected in first few days of life Glutaric aciduria type 2 GA2/Multiple acyl-CoA dehydrogenase deficiency MADD Isobutyryl-CoA dehydrogenase deficiency IBCD Medium chain acyl-CoA dehydrogenase deficiency MCAD Medium/Short chain L-3-hydroxyacyl-CoA dehydrogenase deficiency M/SCHAD Long chain 3-hydroxyacyl-CoA dehydrogenase deficiency LCHAD Short chain acyl-CoA dehydrogenase deficiency SCAD Trifunctional protein deficiency TFPD Very long chain acyl-CoA dehydrogenase deficiency VLCAD Other Disorders Biotinidase deficiency Galactosemia Classical Cystic fibrosis CF

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4 Contact Information Newborn Screening Follow-up Program Illinois Department of Public Health Genetics/Newborn Screening Program 500 E. Monroe St. First Floor Springfield IL 62701 Phone 217-785-8101 FAX 217-557-5396 TTYhearing impaired use only 800-547-0466 Newborn Screening Laboratory Illinois Department of Public Health Division of Laboratories 2121 W. Taylor St. Chicago IL 60612 Phone 312-793-4752 FAX 312-793-1054 Accounting Services Illinois Department of Public Health Account Services Billing Manager Phone 217-782-5934 Web Sites IDPH Genetics/Newborn Screening Program http://www.idph.state.il.us/HealthWellness/genetics.htm IDPH Newborn Screening Laboratory http://www.idph.state.il.us/a-zlist.htmN Note: Newborn Screening Shipping Labels For courier deliveries through the United States Parcel Services UPS or other courier services shipping labels should be addressed to: Illinois Department of Public Health Newborn Screening Laboratory 2121 W. Taylor St. Chicago IL 60612 For mail deliveries through the United States Postal Service USPS shipping labels should be addressed to: Illinois Department of Public Health Newborn Screening Laboratory P.O. Box 12279 Chicago IL 60612

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5 Practitioner’s Newborn Screening Responsibilities Specimen Collection • Attending physician at birth or in the immediate newborn period has primary responsibility for collection of a specimen for newborn screening. The physician’s responsibility may be delegated to the hospital administrator or the administrator’s designee. • If the birth is attended by a licensed nurse midwife the midwife has primary responsibility for collection of a specimen for newborn screening. • Parents should be informed that a blood specimen will be collected from their infant and printed information about newborn screening and how parents can access screening results should be provided. o Newborn Screening Guide for Parents: Babys First Steps in Life brochure is available through IDPH Genetics/Newborn Screening Program. Call 217-785-8101 or fax 217-557-5396 to order copies of this brochure. o Documentation that a newborn screening specimen was collected and a copy of the IDPH screening results should be placed in the infant’s medical record. o Parents should be informed that accurate contact information emergency contact current address and valid phone number is vital should their baby’s newborn screening test be abnormal and additional testing or referral of the infant to a specialist become necessary. • Physician or health care provider caring for the infant during the first month of life is responsible for newborn screening if - o birth occurs outside of a hospital or medical facility. o birth occurs without a physician or licensed midwife in attendance. The American Academy of Pediatrics August 2000 supplement to Pediatrics Serving the Family from Birth to the Medical Home” suggests that the role of the medical home health care professional include establishment of office protocol to retrieve the results of newborn screening for all newborns admitted to the practice when scheduling the first appointment. When screening results cannot be documented a newborn screening specimen should be collected from the baby and submitted for testing. • The Illinois Department of Public Health encourages primary care practitioners to provide medical homes and to facilitate follow-up services for infants with abnormal newborn screening results. o The Federal Maternal and Child Health Bureau of the Health Resources and Services Administration HRSA funded Region 4 Genetics Collaborative Web site http://medhomes.region4genetics.org provides information about newborn screening medical homes pediatric specialty care resources and genetic counseling services available within this seven state region. • Primary care providers have an obligation to verify newborn screening

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6 results and should not assume lack of notification indicates the baby’s screen was normal. o Reports may be sent to the wrong health care provider. o Specimens may be lost in transit to the IDPH laboratory. o On rare occasions hospitals may fail to collect a newborn screening specimen prior to hospital discharge or transfer. • If there is no physician caring for the infant the parents are responsible for obtaining newborn screening for their baby. Newborn Screening Fee • A fee will be charged for each specimen submitted to the IDPH Newborn Screening Laboratory for testing. This fee provides funding for testing follow- up services for babies with abnormal results and provision of certain medically necessary dietary treatment formulas. • The Illinois Department of Public Health bills hospitals and health care agencies on a monthly basis for all newborn screening specimens submitted during that month. Repeat Specimens Diagnostic Testing and Referrals • Physician of record or hospital designee is responsible for informing parents and/or infant’s primary care/medical home provider of abnormal or unsatisfactory test results. If repeat screening is necessary the physician of record is responsible for obtaining and submitting a repeat specimen and/or informing the infant’s primary care provider of the need for additional testing. • If referral of the infant to a pediatric medical specialist is necessary the physician of record or hospital designee is responsible for assisting the baby’s family and facilitating the referral. IDPH highly recommends that the physician’s office contact the medical specialist and provide the screening results. Refusal of Newborn Screening • Parents may refuse newborn screening only on the basis of religious beliefs and practices. • If parents refuse newborn screening of their infant parent education about the seriousness of newborn screening disorders should be provided and the infant’s primary care provider should be informed about the refusal. A written objection statement should be signed by the parents and placed in the infant’s medical record and a copy of the statement should be sent to Illinois Department of Public Health Genetics/Newborn Screening Program. Infants Born Outside State of Mother’s Residence • Illinois residents whose infants are born in other states may obtain newborn

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7 screening through the IDPH Newborn Screening Laboratory. The physician should obtain IDPH filter paper specimen forms or order the screening through an Illinois birthing hospital. If an initial screening was performed in another state a second newborn screening specimen may be submitted to the IDPH. Specimens should be collected and submitted as soon as possible after 24 hours of age. Newborn screening of infants over 6 months of age is not recommended as IDPH normal values are based on normal analytes distributions and controls for newborns. In these cases consult with a pediatric sub-specialist is recommended. • Infants born in Illinois whose mothers reside in another state must have a specimen sent to the IDPH Newborn Screening Laboratory. Illinois provides screening for all 29 disorders currently recommended by the American College of Medical Geneticists and the Centers for Disease Control and Prevention plus several additional disorders but parents who choose to are free to obtain a second screening within their state of residence. Collection of Newborn Screening Specimens Filter Paper Collection Form • Only IDPH filter paper specimen collection forms are accepted by the IDPH Newborn Screening Laboratory. See Appendix A to view a copy of the IDPH collection form. • Newborn screening filter paper specimen collection forms and mailing envelopes may be requested by contacting IDPH Newborn Screening Laboratory 312-793-4752 phone or 312-793-1054 fax. • Filter paper specimen cards should be stored in the original wrapping and stacked in a vertical position to avoid compression of the filter paper. When properly stored in a cool dry place specimen cards have a shelf life of two years. If in doubt about the age of the cards please contact the IDPH Newborn Screening Laboratory to verify age by lot number and re-order cards if necessary. • Birth history and identifying information requested on specimen collection forms should be complete legible and accurate. • Specimen cards are considered legal documents and accurate personal health information is crucial to valid and reliable testing. This information also may be vital to the physician for use in locating the infant and contacting the parents should abnormalities be detected in the blood sample. Timing of Specimen Collection • The ideal time for newborn screening specimen collection from healthy

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8 newborns is 24 hours after birth. Specimens should not be collected earlier than 24 hours of age with the exception of special circumstances. • Special circumstances include: o Early discharge: If the infant is to be discharged at less than 24 hours of age collect specimen prior to discharge. Inform parents that infant must be rescreened within the second day of life. o Transfers: If the infant requires transfer to another facility if at all possible specimen should be collected prior to transfer regardless of infant’s age. If a specimen cannot be collected prior to transfer the transferring facility is responsible for informing the admitting facility of the need for specimen collection. o Transfusions: If the infant requires transfusion specimen should always be collected prior to transfusion regardless of infant’s age. o Premature and sick infants: See Special Considerations section below. • If a specimen is collected prior to 24 hours of age repeat specimen collection is necessary as soon as possible during the second day of life. Note: This is a new requirement due to changes in the Newborn Screening Administrative Rule visit the IDPH Web site www.idph.state.il.us to view the most current Administrative Rule. Special Considerations • Infants born outside of hospital/medical facilities: These infants should have a specimen collected at 24-48 hours of age. • Premature and sick infants: If the infant’s condition is medically unstable the specimen should be collected at 24-48 hours of age. o All infants admitted to a neonatal intensive care unit NICU or special care nursery should have a routine second specimen collected at 14 days of age or prior to discharge from the unit whichever comes first. o The “NICU” check box on the specimen card should be marked on specimens from all infants admitted to a NICU or special care nursery. Retest box should be marked for all repeat specimens. Note: This is a new requirement due to changes in the Newborn Screening Administrative Rule visit the IDPH Web site www.idph.state.il.us to view the most current Administrative Rule. • Infants receiving special feedings: Infants requiring soy formula hyperalimentation or total parenteral nutrition TPN and those not yet receiving milk galactose feedings require documentation of feeding type or status on the specimen card. o The feeding type box should be clearly marked for “breast” “soy” “other” “TPN” or “NPO” nothing by mouth. This information is important to IDPH laboratory staff to assure reliable testing. o Soy formula or lack of milk feeding will affect screening for galactosemia. o Hyperalimentation and TPN may affect tandem mass spectrometry screening for some amino acid fatty acid oxidation and organic acid disorders.

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9 If screening results suggest TPN effects another specimen is requested when the infant has been off TPN for 48 hours or on day 14 of life if the baby was admitted to NICU or special care nursery. o If indicated by the feeding type information provided IDPH laboratory staff will perform additional testing the galactose-1-phosphate uridyl transferase GALT enzyme assay to screen for classical galactosemia on specimens from infants receiving soy formula and those infants who have not yet received an oral feeding NPO when the specimen card is marked accordingly. • Infants receiving antibiotics: When infants are receiving antibiotics at the time of specimen collection the “antibiotic” box of the specimen collection card should be marked as the presence of antibiotics and some other medication metabolites valproic and benzoic acids may be detected by tandem mass spectrometry. In these cases a repeat specimen will be requested. • Transfusions: Collect initial specimens prior to transfusion if at all possible. If this is not possible and the infant was transfused prior to specimen collection indicate the last transfusion date prior to the specimen collection on the filter paper collection form. o Transfusions will invalidate screening for classical galactosemia. o Transfusions will invalidate screening for biotinidase deficiency. o Transfusions will invalidate screening for hemoglobinopathies. o Specimen collection immediately after transfusion will affect all newborn screening results. If a post-transfusion specimen is necessary collection should be delayed for 48 hours post-transfusion. o If the infant’s initial specimen was collected post-transfusion a second specimen should be collected 48 hours post-transfusion and a third specimen is required 90 days after the final transfusion. Note: This is a new requirement due to changes in the Newborn Screening Administrative Rule visit the IDPH Web site www.idph.state.il.us to view the most current Administrative Rule. Tips for specimen collection • Copies of the Whatman newborn screening specimen collection posters “Neonatal Screening: Blood Specimen Collection and Handling Procedure” and “Simple Spot Check” are available for download and printing at the Whatman company Web site www.whatman.com see “Neonatal Screen” and “Spot Check.” These posters provide an excellent training resource. • IDPH Genetics/Newborn Screening Program 217-785-8101 also provides on loan the Clinical Laboratory Standards Institute CLSI document “Blood Collection on Filter Paper for Neonatal Screening Programs Approved Standard”LA4-A4. • A small number of CLSI neonatal blood collection videos “Newborn Screening - The First Step” are available on loan to birth centers. • Heel stick is the preferred mode of collection for newborn screening

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10 whenever possible. • If heel stick is not possible use of a syringe to collect blood from an umbilical catheter is recommended by CLSI. o If heel stick is not a viable option see CLSI recommended procedures for specimen collection Approved Standard LA4-4A. o Some screening results may vary slightly between heel stick specimens and venous or capillary specimens. • Collection of specimens in capillary tubes is not recommended by IDPH or CLSI. o Heparinized capillary tubes should only be used when heel stick or collection by syringe is not possible. o Extreme caution in applying blood samples from capillary tubes is required to avoid damage to the filter paper and allow uniform application of the sample to avoid “layering.” o Layering can affect the validity and reliability of screening results. If heel stick is not an option see the CLSI recommended procedures for specimen collection. • EDTA anticoagulant should never be used for newborn screening specimen collection and will invalidate screening results and may cause false negative or false positive results. Collection of Repeat specimens • Repeat screening is requested by IDPH when results on the original specimen were borderline abnormal the specimen was declared unsatisfactory for testing or declared invalid due to delayed submission or incomplete information on the specimen card. • Routine repeat screening also is required for all infants admitted to the NICU or special care nursery. See Section “Special Circumstances – Premature and Sick Infants” on page 8. • Submitters should mark the retest specimen box on the specimen card. • Submitters should provide adequate information to allow matching of any retest specimens to the infant’s original newborn screening record. All known names of the infant beginning with the birth name the mother’s full name and the medical record number will greatly assist Newborn Screening Program staff in matching specimens. Handling and Submission of Newborn Screening Specimens Submitting Specimens • It is highly recommended that completed newborn screening specimen collection forms are air dried for a minimum of three hours and are

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11 submitted within 24 hours of collection using the courier service designated by IDPH or United States Postal Services first class mail. For details about the latest recommendations for specimen submission contact: Illinois Department of Public Health Newborn Screening Laboratory 2121 W. Taylor St. Chicago IL 60612 312-793-4752 • Currently all Illinois birthing hospitals may utilize a IDPH supported courier service for pickup of newborn screening specimens and shipment to the Chicago Newborn Screening Laboratory. Contact the Newborn Screening program 217-785-8101 or the IDPH laboratory 312-793-4752 for more information about this service. Timeliness • Specimens should be submitted to IDPH Division of Laboratories on a daily basis during regular business days Monday through Friday. Saturday UPS courier service pickup of specimens for next business day delivery is also available to birthing hospitals. Batching of specimens from multiple collection days is unacceptable. • Newborn screening disorders are serious and can be life threatening therefore early detection and treatment is vital. Failure to submit specimens promptly may unnecessarily delay detection and treatment of affected infants. • Tracking delivery of specimens to the IDPH laboratory by the courier service is the responsibility of birthing hospitals utilizing this service. Please contact the Newborn Screening Program at 217-785-8101 for more information about tracking deliveries and reporting courier service problems. • Reports on the timeliness of specimen delivery for each birthing hospital and health care facility submitting specimens to IDPH are reviewed every three months and copies are available through the Newborn Screening Program. Reporting of Screening Results Normal Results • Reported by written laboratory report sent to the submitting facility or submitting agent when all testing is completed. Abnormal Results • Newborn screening is not diagnostic. Abnormal screening results are designated by IDPH laboratory staff as “presumptive positive abnormal” or “suspect borderline abnormal.”

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12 • Presumptive positive abnormal: Indicates with high probability that the infant may have a disorder. Newborn Screening Program staff will recommend that infants with presumptive positive abnormal screenings be referred to medical specialists for consultation and/or diagnostic testing. o These results will be reported by phone call to submitting physician or submitting facility contact person followed by a letter reporting the abnormal results and recommendations sent by fax and mail. o A complete laboratory report of all results is also sent to the submitting facility or submitting agent by IDPH Newborn Screening Laboratory for every specimen received. • Suspect borderline abnormal: Indicates that the screening was slightly abnormal and that infant needs a medical evaluation and a repeat newborn screen. If the infant has any symptoms of a disorder referral to a medical specialist for diagnostic testing is indicated. o These results will be reported by letter indicating abnormal results and recommendations. o The letter reporting results and recommending additional follow-up screening or referral is sent by mail to the submitting physician or facility. o A complete laboratory report of all results also is sent to the submitting facility or submitting agent by IDPH Newborn Screening Laboratory for every specimen received. Unsatisfactory Specimens • Indicates that the specimen was improperly collected handled or submitted as determined by IDPH Division of Laboratories. Specimens must be of good quality to assure reliable valid newborn screening unsatisfactory specimens require collection and submission of a new specimen to assure that every baby receives a valid newborn screening. o These results are reported by letter indicating the unsatisfactory nature of the specimen and the need for immediate repeat specimen collection. o The letter is sent by mail to the submitting physician or facility. o Unsatisfactory specimen results also are included in the IDPH laboratory report sent to the submitting facility or submitting agent. • Unsatisfactory specimens delay newborn screening and cause frustration and added expenses for families and hospital staff. • Reports on the number and type of unsatisfactory specimens submitted by each birthing hospital and health care provider are reviewed every three months copies are sent to the facilities by the Newborn Screening Program. Referrals to Pediatric Medical Specialists and Other Agencies Pediatric Medical Specialists • Lists of IDPH designated pediatric medical specialists are provided by the Newborn Screening Program with letters reporting all presumptive positive abnormal results those indicating need for referral to a medical specialist.

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13 See Appendix B for a listing of medical centers providing pediatric sub-specialty services. These medical specialist lists are subject to periodic revision and updated lists may be requested by calling 217-785-8101. • Infants with family history of a disorder or those who appear symptomatic require consult with a pediatric medical specialist. These infants should be referred for medical evaluation and possible diagnostic testing regardless of newborn screening results or any IDPH recommendations offered on the report. Services for Infants with Sickle Cell Disease and Other Hemoglobin Disorders • Family education genetic counseling and diagnostic services are available to all families of infants with sickle cell disease other hemoglobinopathies and those who carry a hemoglobin disorder trait. o The Illinois Department of Public Health through grants to university- based medical clinics provides diagnostic and treatment services for infants and children identified with sickling hemoglobin disorders or traits. See Appendix B for a listing of medical centers providing pediatric hematology services or call 217-785-8101 for a listing of IDPH designated pediatric hematologists. o In addition by Memorandum of Understanding IDPH has joined with the Sickle Cell Disease Association of Illinois SCDAI to provide educational services to families of individuals with sickle cell diseases other hemoglobinopathies or traits. Please call 312-345-1100 to learn more about SCDAI services. University of Illinois at Chicago Division of Specialized Care for Children DSCC • DSCC provides payment for the initial diagnostic services for any infant with certain abnormal metabolic newborn screening results provided these services are coordinated by specialists jointly approved by IDPH and DSCC. o DSCC provides these services in conjunction with other third-party payers and remains the payer of last resort. o DSCC covers the ongoing medical care for infants and children diagnosed with metabolic disorders and in those cases in which the family meets certain eligibility requirements. o DSCC does not provide initial diagnostic services or ongoing medical care for infants and children with sickle cell disease and other hemoglobinopathies those who are carriers of a hemoglobin disorder or for children with endocrine disorders. Local Public Health Departments • The Illinois Department of Public Health works in cooperation with local public health departments to provide follow-up services to the families of infants with abnormal newborn screening test results and infants diagnosed with newborn screening disorders. In some cases the assistance of a local public health nurse may be requested in order to locate and assist the family in

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14 obtaining necessary follow-up services. o IDPH program staff and the infant’s pediatrician may have difficulty locating the families of infants with abnormal test results or parents may not understand the importance of seeking additional medical care. o Following the diagnosis of an endocrine metabolic or hemoglobin disorder the pediatric medical specialist may recommend community support services for the families of children with these serious disorders. o On occasion as families relocate or change medical care providers the medical specialist may lose contact with the parents of children diagnosed with endocrine metabolic and hemoglobin disorders. The assistance of a local health department public health nurse may be requested to locate these families and assure continuity of long-term care for the children. o An updated list of local public health department contacts may be requested by calling 217-785-8101. Newborn Screening Disorders Amino Acid/Urea Cycle Disorders These disorders are inherited as autosomal recessive defects of amino acid metabolism. Each amino acid disorder is associated with a specific enzyme defect. Affected infants cannot properly metabolize certain amino acids resulting in elevated levels of the amino acid or metabolites in body

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15 fluids. Accumulation of amino acids or metabolites may become neurotoxic causing damage to organs and resulting in developmental delays mental retardation or death. Clinical findings may include poor feeding vomiting lethargy or irritability seizures coma respiratory distress and liver damage. MSUD may cause metabolic decompensation and infants with this condition may require peritoneal dialysis or hyperalimentation without branched-chain amino acids leucine/isoleucine and valine. See the IDPH Web site http:www.idph.state.il.us for newborn screening fact sheets with additional information about these disorders and visit the American College of Medical Geneticists Web site at http://www.acmg.net to review the ACMG “ACT” sheets. Urea cycle disorders involve defects in the breakdown of proteins and the conversion of ammonia and bicarbonate to urea for elimination of waste nitrogen. The resulting accumulation of ammonia in blood and tissues is neurotoxic and requires immediate detection and medical intervention. Urea cycle disorders may result in severe hyperammonemia. Infants with this condition require prompt medical intervention that may include hemodialysis. See the IDPH Web site for newborn screening fact sheets with additional information about urea cycle disorders and visit the American College of Medical Geneticists Web site to review the ACMG “ACT” sheets. In Illinois newborn screening includes screening for the following amino acid disorders: Phenylketonuria PKU also see section on Phenylketonuria Maple syrup urine disease MSUD Tyrosinemia type 1 and possibly types 2 and 3 Homocystinuria HCU 5-oxoprolinuria Urea cycle disorders: Citrullinemia AL Argininosuccinic aciduria AS and Argininemia • Incidence PKU and hyperphenylalaninemia - one in 10000 births MSUD - one in 200000 births Tyrosinemia - one in 500000 births one in 12500 births among French Canadian populations Homocystinuria - one in 200000 births 5-oxoprolinuria - extremely rare actual incidence unknown Urea Cycle Disorders - one in 200000 to 300000 births • Analytes Measured in Screening Measurement of specific analytes by tandem mass spectrometry MS/MS in micro-Moles/Liter uM/L Amino Acid/Urea Cycle Disorders - Continued • Analytes Measured in Screening Possible Disorder Phenylalanine Phenylketonuria PKU Tyrosine Tyrosinemia

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16 Methionine Homocystinuria HCU Isoleucine and Valine Maple syrup urine disease MSUD Citrulline Citrullinemia AL or Argininosuccinic aciduria AS Arginine Argininemia 5-oxoproline 5-oxoprolinuria • Reporting Ranges Follow-up referrals/testing Abnormal results reported by phone for abnormal results letter fax to physician of record or hospital contact unless otherwise specified. Presumptive Positive Immediate referral to pediatric metabolic disease specialist Suspect Borderline Abnormal Medical evaluation and repeat newborn screening specimen within one to two days mark retest box on specimen card. Suspect Amino Acid Abnormal due If baby is still in NICU or on TPN to TPN reported by fax and letter repeat newborn screen when off TPN 48 hours at day 14 of life or prior to discharge whichever comes first. If baby has been discharged from hospital or was not on TPN at time of specimen collection repeat newborn screen within one to two days. • Feeding Effect Hyperalimentation and TPN may affect results. Unless otherwise instructed repeat specimens are best collected 48 hours after TPN is discontinued. Amino Acid/Urea Cycle Disorders - Continued • Transfusion Effect Specimen collection prior to transfusion is always recommended. If post-transfusion specimen

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17 collection is required collection is best performed 48 hours post- transfusion. • Timing Effect If specimen is collected at less than 24 hours of age submit second sample during second day of life. • Specialist Metabolic disease specialist IDPH/DSCC designated see Appendix B for the contact information. • Treatment Treatment is disorder specific and may include specialized prescription medical formula special diet limited in specific proteins and in some cases supplements and medications. IDPH provides special medically necessary formula without charge to Illinois residents who are under comprehensive medical management provided by a metabolic disease specialist designated by IDPH. Comments Newborn screening may not detect all cases of tyrosinemia as tyrosine levels may not increase until after the fifth day of life. For questions about the most current laboratory reporting values for these disorders contact IDPH Division of Laboratories at 312-793-4752.

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18 Biotinidase Deficiency This is an autosomal recessive disorder of biotin recycling that leads to multiple carboxylase deficiencies. Individuals with biotinidase deficiency cannot recycle biotin vitamin B and cannot process dietary protein-bound biotin. Early detection and treatment is essential to prevent permanent neurological damage. See the IDPH Web site http:www.idph.state.il.us for newborn screening fact sheets with additional information about this disorder and visit the American College of Medical Geneticists Web site at http://www.acmg.net to review the ACMG “ACT” sheets. • Incidence One in 180000 births • Analyte Measured in Screening Biotinidase enzyme activity is determined by colorimetric analysis. • Reporting Ranges Follow-up referrals/testing Abnormal results reported by for abnormal test results phone letter and fax to physician of record or hospital contact Biotinidase activity absent Medical evaluation and collect on initial specimen repeat newborn screen within one to two days mark retest box on specimen card. Biotinidase activity absent Immediate referral to IDPH on second specimen designated metabolic specialist for diagnostic testing • Feeding Effect None • Transfusion Effect Screening is affected. Specimen should always be collected prior to transfusion even if infant is younger than 24 hours of age. If initial specimen was collected post- transfusion a second specimen is required 48 hours post-transfusion and third specimen is required three months following the last transfusion. • Timing Effect If specimen is collected at less than 24 hours of age submit second sample during second day of life. • Specialist Metabolic disease specialist IDPH/DSCC designated see Appendix B for the contact information.

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19 Biotinidase Deficiency - Continued • Treatment Daily prescription dosage of biotin supplement Comments Improper collection and care of specimens may cause biotinidase enzyme degradation. Exposure of specimens to excessive heat and/or delayed submission may result in false positive screening results. Transfusions may have long-term effects due to biotinidase activity of transfused red blood cells and may result in false negative screens for biotinidase deficiency.

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20 Congenital Adrenal Hyperplasia This is an autosomal recessive disorder of steroid hormone synthesis 90 percent of individuals with congenital adrenal hyperplasia CAH cannot produce adequate amounts of the enzyme 21- hydroxylase which is necessary for synthesis of cortisol. In Illinois newborn screening includes testing for CAH due to 21-hydroxylase deficiency. In 50 percent to 75 percent of 21-hydroxylase deficiency cases in addition to cortisol deficiency the infant cannot synthesize adequate amounts of aldosterone resulting in salt-wasting CAH. In utero the developing fetus with CAH is exposed to excessive levels of androgen and female infants may have varying degrees of virilization of external genitalia. Male infants usually appear normal at birth. Both males and females are susceptible to acute adrenal insufficiency. Infants with salt-wasting CAH are very susceptible to electrolyte imbalance and dehydration. Early detection and treatment of CAH is essential to prevent adrenal crisis dehydration and sudden death in the first few weeks of life. See the IDPH Web site http:www.idph.state.il.us for newborn screening fact sheets with additional information about this disorder and visit the American College of Medical Geneticists Web site http://www.acmg.net to review the ACMG “ACT” sheets. • Incidence One in 20000 births • Analyte Measured in Screening 17-OH hydroxy progesterone 17- OHP level is measured by fluorometric assay in nanograms per milliliter ng/mL • Reporting Ranges Follow-up referrals/testing Abnormal results reported by phone for abnormal results letter and fax to physician of record or hospital contact unless otherwise specified. Due to the effects of pre-maturity and Pre-term infants are defined as physiological stress on 17-OHP levels a gestational age of 36 wks. tiered system of reporting for abnormal Low birth weight is defined as results has been developed for pre-term birth weight 2000 gms. low birth weight and NICU infants by the Very low birth weight is defined as IDPH Newborn Screening Laboratory. 1500 gms. Presumptive positive abnormal Immediate consult /referral with Full-term infant 100 ng/mL pediatric endocrinologist and serum Pre-term infant low birth weight electrolytes and 17-OHP not in NICU 130ng/mL Pre-term infant low birth weight Consult with pediatric endocrinologist in NICU 160ng/mL with evaluation of risk for CAH serum electrolytes and 17-OHP

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21 Congenital Adrenal Hyperplasia - Continued • Reporting Ranges Follow-up referrals/testing for abnormal results Suspect borderline abnormal reported by letter only Medical evaluation and repeat Full-term infant 48-100 ng/mL newborn screen within one to two days Pre-term low birth weight Medical evaluation and repeat not in NICU 100-130 ng/mL newborn screen within one to two days mark retest on specimen card. Pre-term low birth weight Medical evaluation and repeat in NICU 100-160 ng/mL newborn screen at day 14 of life or prior to discharge whichever comes first Very low birth weight in NICU NICU guidelines require a repeat with an initial abnormal 17-OHP screen at day 14 of life unless the reported by letter only infant has symptoms of CAH which would require consult with a pediatric endocrinologist. • Feeding Effect None • Transfusion Effect If post-transfusion specimen collection is required sample should be obtained 48 hours post-transfusion enter date of last transfusion prior to specimen collection on the specimen card. • Timing Effect If specimen is collected at less than 24 hours of age submit second sample during second day of life. • Specialist Pediatric endocrinologist IDPH/DSCC designated see Appendix B for the contact information. • Treatment Simple virilizing CAH Daily cortisol replacement therapy Salt-wasting CAH Daily cortisol and aldosterone replacement therapy dietary salt supplements

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22 Congenital Adrenal Hyperplasia - Continued Comments Factors such as specimen collection prior to 24 hours of age pre-term low birth weight and illness may cause elevation of 17-OH progesterone levels. However follow-up screening and/or diagnostic testing are necessary to rule out this life-threatening disorder. Infants with symptoms of vomiting dehydration weight loss poor feeding electrolyte imbalance and lethargy require immediate medical attention emergency care and referral to a pediatric endocrinologist. Treatment with glucocorticoids cortisone dexamethasone may cause false negative results. Most reference laboratories measure 17-OHP levels in nanograms per deciliter ng/dL and caution should be used when comparing newborn screening results with reference laboratory results please consult a pediatric endocrinologist when in doubt about diagnostic testing results for possible CAH. Laboratory reporting cut-off values are procedure dependent and are subject to periodic revision. For questions about the most current laboratory cut-off values for this disorder contact IDPH Division of Laboratories at 312-793-4752. New Administrative Rules for Newborn Screening require that a routine repeat specimen be collected from all infants admitted to a NICU or Special Care Nursery. Second specimen should be collected on day 14 of life or prior to discharge if baby is discharged before two weeks of age.

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23 Congenital Hypothyroidism Congenital hypothyroidism results from an inability of the thyroid gland to produce adequate amounts of thyroid hormone thyroxine. Congenital hypothyroidism usually results from a failure of the thyroid gland to develop properly in utero. Less frequently the disorder can result from an autosomal recessive defect in thyroid hormone synthesis. Primary congenital hypothyroidism usually requires lifetime treatment. Occasionally cases of transient hypothyroidism occur as a result of maternal anti-thyroid medications or temporary thyroid suppression in the infant due to exposure to iodine prematurity or other causes. Consultation with a pediatric endocrinologist is usually recommended in these cases. See the IDPH Web site http:www.idph.state.il.us for newborn screening fact sheets with additional information about this disorder and visit the American College of Medical Geneticists Web site at http://www.acmg.net to review the ACMG “ACT” sheets. • Incidence One in 2000 births • Analytes Measured in Screening Thyroid stimulating hormone TSH and thyroxine T4. If TSH is elevated T4 is measured. Levels are measured by fluorometric assay. • Reporting Ranges Follow-up referrals/testing All abnormal results reported by for abnormal screening results phone letter and fax unless otherwise specified. Presumptive positive abnormal Immediate referral to pediatric TSH 54 uIU/mL endocrinologist serum TSH and T4 5 ug/dL free T4 Suspect borderline abnormal Medical evaluation and repeat TSH 36-54 uIU/mL newborn screen within one to two T4 5-8 ug/dL days mark retest on specimen card. reported by letter only • Feeding Effect None • Transfusion Effect If post-transfusion specimen collection is required collection is best performed 48 hours post- transfusion enter date of last transfusion prior to specimen collection on the specimen card. • Timing Effect If specimen is collected at less than 24 hours of age submit second sample during second day of life. In pre-term infants production of TSH may be delayed in first few days of life.

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24 Congenital Hypothyroidism – Continued • Specialist Pediatric endocrinologist IDPH/DSCC designated see Appendix B for contact information. • Treatment Daily thyroid supplement Comments TSH increases dramatically in first few hours after birth and gradually returns to normal levels in about 72 hours. This normal TSH elevation will be detected if the specimen is collected before the infant is 24 hours of age. Very low birth weight infants and infants with cardiac defects congenital craniofacial anomalies and Down syndrome may be at increased risk of late onset hypothyroidism and consult with pediatric endocrinology and/or diagnostic testing is advisable regardless of newborn screening results. Although newborn screening can detect congenital hypothyroidism with a high degree of accuracy other forms of hypothyroidism may develop within the first few weeks of life. The physician therefore must remain alert to clinical symptoms in older infants despite normal newborn screening results. Repeat the screening or refer to pediatric endocrinologist if any suspicions exist about possible hypothyroidism regardless of newborn screening results. Family history of thyroid disorders may indicate the need for diagnostic testing or pediatric endocrinology consult regardless of newborn screening results. Laboratory reporting cut-off values are procedure dependent and are subject to periodic revision. For questions about the most current laboratory cut-off values for this disorder contact IDPH Division of Laboratories at 312-793-4752.

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25 Cystic Fibrosis Cystic fibrosis CF is an autosomal recessive disorder that results in production of a defective form of cystic fibrosis transmembrane conductance regulator CFTR protein. CFTR protein is an important chloride channel within epithelial cells of multiple organs and regulates movement of salt and water into and out of the cells. In individuals with CF the cells lining passageways of the lungs pancreas and other organs produce thick sticky mucus. Clinical signs and disease progression vary among affected individuals but may include progressive lung disease pancreatic insufficiency male infertility and elevated sweat chloride levels. Early detection and diagnosis with adequate nutritional support and aggressive therapies to reduce risks of respiratory exacerbations have been shown to improve clinical outcomes. See the IDPH Web site http:www.idph.state.il.us for newborn screening fact sheets with additional information about this disorder and visit the American College of Medical Geneticists Web site at http://www.acmg.net to review the ACMG “ACT” sheet. • Incidence Varies with race and ethnicity One in 3200 Caucasian births One in 9000 Hispanic births One in 15000 African-American births One in 30000 Asian births • Analyte Measured in Screening Measurement of immunoreactive trypsinogen IRT level by fluorometric assay. If IRT is elevated DNA mutation analysis is performed for a panel of common CF mutations. • Reporting Ranges Follow-up referrals/testing for Abnormal results reported by phone abnormal screening results letter fax to physician of record or hospital contact. Presumptive Positive -ITR elevated with two CFTR mutations Immediate referral to CF specialist -IRT elevated with one CFTR for diagnostic sweat testing and mutation genetic counseling -Seriously elevated IRT • Feeding Effect None • Transfusion Effect Screening may be affected. Specimen should always be collected prior to transfusion even if infant is younger than 24 hours of age. If initial specimen was collected post- transfusion a second specimen is required 48 hours post-transfusion

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26 and third specimen is required three months following the last transfusion. Cystic Fibrosis - Continued • Timing Effect If specimen is collected at less than 24 hours of age submit second sample during second day of life. • Treatment Dietary and vitamin supplements respiratory therapies and frequent visits for evaluation and support are usually provided. • Specialist Pediatric pulmonologist and/or pediatric gastroenterologist specializing in care of children with CF. Complete list not available at time of printing contact IDPH/DSCC for contact information. Comments Meconium ileus has been clinically associated with the diagnosis of cystic fibrosis in newborn infants and any infant with this condition should have diagnostic evaluation through a CF specialist regardless of the infant’s newborn screening results. In some cases normal IRT levels causing false negative newborn screens for CF have been reported in babies with meconium ileus. Laboratory reporting cut-off values are procedure dependent and are subject to periodic revision. For questions about the most current laboratory cut-off values for this disorder contact IDPH Division of Laboratories at 312-793-4752. All babies with abnormal CF newborn screening results should be referred to a CF specialist for confirmatory pilocarpine iontophoresis sweat testing and genetic counseling services.

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27 Fatty Acid Oxidation Disorders Fatty acid oxidation FAO disorders are autosomal recessive inherited metabolic conditions. Each FAO disorder is associated with a specific enzyme defect in the fatty acid metabolic pathway and affects utilization of dietary and stored fats. These disorders lead to an accumulation of fatty acids in the body or an inability to breakdown dietary or stored fats with a decrease in cell energy metabolism. Many of the FAO disorders cause a significant risk of death during the first clinical episode. In most cases the first episode arises following illness or fasting and occurs in infancy or early childhood. FAO disorders can cause recurrent episodes of hypoglycemia and clinical findings may include lethargy hypotonia failure to thrive persistent vomiting and hepatomegaly rhabdomyolysis and Reye syndrome-like episodes. Significant disability may result from prolonged episodes of hypoglycemia. See the IDPH Web site http:www.idph.state.il.us for newborn screening fact sheets with additional information about these disorders and visit the American College of Medical Geneticists Web site at http://www.acmg.net to review the ACMG “ACT” sheets. In Illinois newborn screening includes testing for a panel of acylcarnitines. Following is a list of the FAO disorders that may be detected: Short chain acyl-CoA dehydrogenase deficiency SCAD Medium chain acyl-CoA dehydrogenase deficiency MCAD Long chain 3-hydroxyacyl-CoA dehydrogenase deficiency LCHAD or Trifunctional protein deficiency TFPD Very long chain acyl-CoA dehydrogenase deficiency VLCAD Carnitine palmitoyl transferase deficiency type 2 CPT 2 or Carnitine/acylcarnitine translocase deficiency CACT Carnitine palmitoyl transferase deficiency type 1 CPT 1 or CPT 1A Glutaric aciduria type 2 GA 2/Multiple acyl-CoA dehydrogenase deficiency MADD Carnitine uptake defect CUD Medium/Short chain L-3-hydroxyacyl-CoA dehydrogenase deficiency M/SCHAD • Incidence MCAD - one in 18000 births LCHAD - one in 400000 births VLCAD - one in 100000 births SCAD - one in 20000 births Other Disorders - one in 500000 births • Analytes Measured in Screening Specific acylcarnitines measured by tandem mass spectrometry MS/MS in micro-Moles per Liter uM/L Analytes Possible Disorder Butanoyl carnitine C4 is the primary SCAD IBCD also analyte GA2/MADD Multiple medium chain acylcarnitines MCAD Octanoyl carnitine C8 is the primary analyte C8 C10 C10:1 and C6 Multiple long chain acylcarnitines LCHAD/TFPD Hydroxy-hexadecanoyl carnitine C16:OH is the primary analyte C16-OH C18:1-OH

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28 Fatty Acid Oxidation Disorders - Continued Analytes Possible Disorder Multiple long chain acylcarnitines VLCAD Tetradecenoyl carnitine C14:1 is the primary analyte C14:1 C14 and C16 Multiple long chain acylcarnitines CPT 2/CACT Hexadecanoyl carnitine C16 or Octadecenoyl carnitine C18:1 is the primary analyte C16 C18:1 and C18:2 Free carnitine elevated level is the primary CPT1/CPT1A analyte C0 and C0/C16+C18 ratio elevated Multiple acylcarnitines GA 2/MADD C4 C5 C8 C12 C14 C16 and C5-DC Free carnitine decreased level is the primary CUD analyte C0 and C0/C16+C18 ratio decreased Acylcarnitine M/SCHAD 3-hydroxy-butyryl carnitine C4-OH is the primary analyte • Reporting Ranges Follow-up referrals/testing Abnormal results reported by phone for abnormal results letter fax to physician of record or hospital contact unless otherwise specified. Presumptive Positive Immediate referral to pediatric metabolic disease specialist Suspect Borderline Abnormal Medical evaluation and repeat newborn screening specimen within one to two days mark retest on specimen card. Suspect Amino Acid Abnormal If baby is still in NICU or on TPN due to TPN reported by fax repeat newborn screen when off TPN and letter 48 hours at day 14 of life or prior to discharge whichever comes first. If baby has been discharged from hospital or was not on TPN at time of specimen collection repeat newborn screen within one to two days.

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29 Fatty Acid Oxidation Disorders - Continued • Feeding Effect Hyperalimentation and TPN may affect results. Unless otherwise instructed repeat specimens are best collected 48 hours after TPN is discontinued. • Transfusion Effect Specimen collection prior to transfusion is always recommended. If post-transfusion specimen collection is required collection is best performed 48 hours post- transfusion. • Timing Effect If specimen is collected at less than 24 hours of age submit second sample during second day of life. If repeat screening is requested collect and submit new specimen within one to two days. Acylcarnitine levels tend to normalize very quickly in newborns once the baby begins to feed well specimen collection as soon as possible after 24 hours of age is optimal and repeat specimens must be collected quickly to avoid false negative results for FAO disorders. • Specialist Metabolic disease specialist see Appendix B for a list of IDPH /DSCC designated medical specialists. • Treatment Treatment is disorder specific and usually includes frequent feeding and avoidance of fasting high carbohydrate low-fat diet and in some cases specialized medical formula or supplements and medications. Special precautions such as glucose monitoring and in some cases intra-venous therapy may be required during intercurrent illnesses. If indicated IDPH provides special medically necessary formula without charge to Illinois residents who are under comprehensive medical management provided by a metabolic

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30 disease specialist designated by IDPH. Fatty Acid Oxidation Disorders - Continued Comments For substituted carnitines a notation of Cx is used where x denotes the number of carbons in the fatty acid radical. Free carnitine is designated as C0 acetyl carnitine as C2 propanoyl carnitine as C3 etc. Hydroxylation is designated by -OH dicarboxylic acid is designated by -DC and unsaturation is designated by :1. See Appendix D for a complete listing of acylcarnitine analytes measured by IDPH laboratory tandem mass spectrometry. IBCD is categorized as an organic acid disorder in some reference materials. A particular acylcarnitine pattern or group of abnormal acylcarnitines may be detected by MS/MS screening while not diagnostic these patterns may be suggestive of a certain type of fatty acid oxidation disorder. For questions about the most current laboratory reporting values for these disorders contact IDPH Division of Laboratories at 312-793-4752.

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31 Galactosemia An autosomal recessive disorder of galactose metabolism galactosemia is due to insufficient enzyme activity usually of galactose-1-phosphate uridyl transferase GALT or in some cases deficiency of galactokinase or uridine diphosphate galactose-4-epimerase. In Illinois newborn screening for galactosemia is designed to detect classical galactosemia due to GALT enzyme deficiency. These enzymes are necessary to convert galactose to glucose for energy and cellular growth. The main dietary source of galactose is lactose the principle carbohydrate found in all forms of milk. Early detection and treatment of galactosemia is essential to prevent severe liver disease and complications including bleeding overwhelming sepsis and death in the early neonatal period. See the IDPH Web site http:www.idph.state.il.us for newborn screening fact sheets with additional information about these disorders and visit the American College of Medical Geneticists Web site at http://www.acmg.net to review the ACMG “ACT” sheets. • Incidence One in 75000 births classical galactosemia • Analyte Measured in Screening Total galactose free galactose and galactose-1-phosphate is determined by fluorometric assay. If galactose level is elevated GALT enzyme activity is determined by Beutler assay. • Reporting Ranges Follow-up referrals/testing Abnormal results reported by phone for abnormal screening results letter fax to physician of record or hospital contact. Presumptive Positive Immediate referral to metabolic Total galactose 6.5mg/dL with disease specialist for diagnostic testing No GALT activity and change feeding to soy formula or encourage breast feeding mothers to Total galactose 19.5mg/dL with temporarily avoid nursing and to use Normal GALT activity breast pump to maintain milk supply until diagnosis is confirmed or ruled out. Suspect Borderline Abnormal Evaluate baby’s condition collect Total galactose 6.5mg/dL with second newborn screening specimen Reduced GALT activity present within one to two days mark retest box and indicate the baby’s feeding type on the specimen card. • Feeding Effect Screening will be affected. Mark specimen collection form to indicate type of feeding breast soy other NPO. This informs IDPH laboratory staff that GALT enzyme activity testing may be necessary although galactose level is normal.

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32 Galactosemia - Continued • Transfusion Effect Screening is affected. Specimen should always be collected prior to transfusion even if infant is younger than 24 hours of age. If initial specimen was collected post- transfusion a second specimen is required 48 hours post-transfusion and third specimen is required three months following the last transfusion. • Timing Effect If specimen is collected at less than 24 hours of age submit second sample during second day of life. • Treatment Soy or galactose-free formula and lactose free diet. • Specialist Metabolic disease specialist IDPH/DSCC designated see Appendix B for the contact information. Comments Improper specimen collection or inappropriate shipping and handling including exposure of the specimen to excessive heat humidity and/or delayed submission may cause GALT enzyme degradation. When infants are on soy formula feeding or have not had an oral galactose feeding galactose values may not be meaningful or valid and screening for GALT enzyme activity Beutler assay should be requested. IDPH laboratory cut-off values are procedure dependent and are subject to periodic revision. For questions about the most current laboratory cut-off values for this disorder contact IDPH Division of Laboratories at 312-793-4752. Transfusions may have long-term effects due to GALT enzyme activity of transfused red blood cells and may result in false negative screening for classical galactosemia.

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33 Organic Acid Disorders Organic acid disorders are autosomal recessive inherited metabolic conditions. Each organic acid disorder is associated with a specific enzyme deficiency that causes the accumulation of organic acids in blood and urine. The accumulated compounds or their metabolites are toxic and may result in metabolic acidosis hyperammonemia or ketotic hyperglycinemia. Usually infants with organic acid disorders appear normal at birth but may develop vomiting poor feeding hypoglycemia seizures hypotonia and lethargy progressing to coma. Common features may include ketotic hyperglycinemia metabolic acidosis and sometimes an unusual odor. There is significant risk of death in infancy due to organic acid disorders early diagnosis and treatment can greatly improve disease outcome. Minimization of ketoacidotic episodes improves prognosis and during such episodes aggressive treatment including administration of glucose may be warranted. See the IDPH Web site http:www.idph.state.il.us for newborn screening fact sheets with additional information about these disorders and visit the American College of Medical Geneticists Web site at http://www.acmg.net to review the ACMG “ACT” sheets. In Illinois newborn screening includes testing for a panel of acylcarnitines. Following is a list of the organic acid disorders that may be detected: Propionic acidemia PA Methylmalonic acidemia MMA Isovaleric acidemia IVA 3-hydroxy-3-methylglutaryl-CoA lyase deficiency 3HMG 3-methylglutaconic aciduria 3MGA 3-methylcrotonyl CoA carboxylase deficiency 3-MCC Glutaric acidemia type 1 GA 1 2-methylbutyryl-CoA dehydrogenase deficiency 2MBCD Malonic aciduria MA Betaketothiolase deficiency BKT Multiple carboxylase deficiency MCD • Incidence IVA - one in 50000 births 3MCC - one in 50000 births MMA - one in 100000 births GA1 - one in 110000 births PA 3HMG 3MGA BKT MCD MA very rare estimated at one in 100000 to 500000 births • Analytes Measured in Screening Specific acylcarnitines measured by tandem mass spectrometry MS/MS in micro-Moles per Liter uM/L Acylcarnitine Possible Disorder 3-hydroxy-isovaleryl carnitine 3MCC 3HMG 3MGA MCD C5-OH is the primary analyte Pentanoyl carnitine C5 is the IVA/2MBCD primary analyte

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34 Organic Acid Disorders - Continued Analytes Possible Disorder Propanoyl carnitine C3 is the MMA/PA primary analyte Pentenoyl carnitine C5:1 is the BKT primary analyte Glutaryl carnitine C5-DC is the GA1 primary analyte Malonoyl carnitine C3-DC is the MA Primary analyte • Reporting Ranges Follow-up referrals/testing Abnormal results reported by phone for abnormal results letter and fax to physician of record or hospital contact unless otherwise specified. Presumptive Positive Immediate referral to pediatric metabolic disease specialist Suspect Borderline Abnormal Medical evaluation and repeat newborn screening specimen within one to two days mark retest on specimen card. Suspect Amino Acid Abnormal due If baby is still in NICU or on TPN to TPN reported by fax and letter repeat newborn screen when off TPN 48 hours at day 14 of life or prior to discharge whichever comes first. If baby has been discharged from hospital or was not on TPN at time of specimen collection repeat newborn screen within one to two days. • Feeding Effect Hyperalimentation and TPN may affect results. Unless otherwise instructed repeat specimens are best collected 48 hours after TPN is discontinued. • Transfusion Effect Specimen collection prior to transfusion is always recommended. If post-transfusion specimen collection is required collection is best performed 48 hours post-

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35 transfusion. Organic Acid Disorders - Continued • Timing Effect If specimen is collected at less than 24 hours of age submit second sample during second day of life. If repeat screening is requested collect and submit new specimen within one to two days. • Specialist Metabolic disease specialist IDPH/DSCC designated see Appendix B for the contact information. • Treatment Treatment is disorder specific and may include low protein diet and avoidance of fasting and in some cases specialized medical formula or supplements and medications. Special precautions such as close monitoring and in some cases intra-venous therapy may be required during intercurrent illness and introduction of new foods. If indicated IDPH provides special medical formula without charge to Illinois residents who are under comprehensive medical management provided by a metabolic disease specialist designated by IDPH. Comments For substituted carnitines a notation of Cx is used where x denotes the number of carbons in the fatty acid radical. Free carnitine is designated as C0 acetyl carnitine as C2 propanoyl carnitine as C3 etc. Hydroxylation is designated by -OH dicarboxylic acid is designated by -DC and unsaturation is designated by :1. See Appendix D for a complete listing of acylcarnitine analytes measured by IDPH laboratory tandem mass spectrometry. For questions about the most current laboratory reporting values for these disorders contact IDPH Division of Laboratories at 312-793-4752.

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36 Phenylketonuria Phenylketonuria PKU is an autosomal recessive disorder of amino acid metabolism resulting in excess levels of phenylalanine in body fluids. Hyperphenylalaninemia is usually due to a deficiency of the phenylalanine hydroxylase enzyme or in some cases impaired synthesis or recycling of biopterin cofactor. Elevated levels of phenylalanine can become neurotoxic early detection and treatment of hyperphenylalaninemia is necessary to prevent severe mental retardation. Phenylalanine is an essential amino acid and individuals with PKU require careful dietary management and monitoring for life. Women of childbearing age who are diagnosed with PKU or hyperphenylalaninemia require strict dietary control prior to conception and throughout pregnancy to reduce their risk of pregnancy complications including miscarriage or of having an infant with severe birth defects due to high maternal levels of phenylalanine. See the IDPH Web site http:www.idph.state.il.us for newborn screening fact sheets with additional information about this disorder and visit the American College of Medical Geneticists Web site at http://www.acmg.net to review the ACMG “ACT” sheets. • Incidence One in 10000 births Classical PKU • Analytes Measured in Screening Phenylalanine level and phenylalanine/tyrosine ratio measured by tandem mass spectrometry MS/MS in micro- Moles per Liter uM/L. • Reporting Ranges Follow-up referrals/testing Abnormal results reported by phone for abnormal screening results letter and fax to physician of record or hospital contact unless otherwise specified. Presumptive Positive Immediate referral to PKU metabolic Seriously elevated phenylalanine disease specialist level and/or elevated phenylalanine/ tyrosine ratio Suspect Borderline Abnormal Medical evaluation and repeat Slightly elevated phenylalanine newborn screening specimen within level one to two days mark retest on specimen card. Suspect Amino Acid Abnormal due If baby is still in NICU or on TPN to TPN reported by letter and fax repeat newborn screen when off TPN Slightly elevated phenylalanine level 48 hours at day 14 of life or prior to usually associated with TPN effects discharge whichever comes first. If baby has been discharged from hospital or was not on TPN at time of specimen collection repeat newborn screen within one to two days.

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37 Phenylketonuria - Continued • Feeding Effect Laboratory detection of phenylalanine is not necessarily diet dependent. Screening is sensitive to catabolic activity occurring shortly after birth. TPN and hyperalimentation may cause false positive screening results. • Transfusion Effect Specimen collection prior to transfusion is always recommended. If post-transfusion specimen collection is required collection is best performed 48 hours post- transfusion. • Timing Effect If specimen is collected at less than 24 hours of age submit second sample during second day of life. • Specialist Pediatric metabolic disease specialist IDPH/DSCC designated see Appendix B for the contact information. • Treatment Low phenylalanine diet consisting of specialized medically necessary formula in combination with foods that are low in phenylalanine. IDPH provides PKU medically necessary formula without charge to Illinois residents who are under comprehensive medical management provided by a metabolic specialist designated by IDPH/DSCC. Comments For questions about the most current laboratory reporting values for these disorders contact IDPH Division of Laboratories at 312-793-4752.

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39 Sickling Hemoglobin Disorders and Beta Thalassemia FS FSC FSa FNA This group of autosomal recessive hemoglobin disorders is characterized by production of abnormal forms of hemoglobin and no adult or normal hemoglobin. This abnormal hemoglobin may be less stable and may cause red blood cells to sickle after repeated de-oxygenation. Sickled cells may block blood vessels causing pain stroke and other complications. The severity of the disorder varies greatly but infants with sickle cell disease sickle hemoglobin C disease sickle beta thalassemia and beta thalassemia major are very susceptible to anemia life-threatening infections and other complications. Prophylactic penicillin by 2 months of age and adequate immunizations have been shown to greatly reduce morbidity and mortality associated with sickling hemoglobinopathies. See the IDPH Web site http:www.idph.state.il.us for newborn screening fact sheets with additional information about these disorders and visit the American College of Medical Geneticists Web site at http://www.acmg.net to review the ACMG “ACT” sheet. • Incidence Sickle cell disease occurs in one in 375 African-Americans. Sickling hemoglobinopathies occur in all races and ethnic groups. Hemoglobin S is more common among individuals with West African Middle Eastern Mediterranean or Central Indian heritage. Hemoglobin C is more common among individuals with West African heritage. Hemoglobin E is more common among individuals with Mediterranean African or Southeast Asian heritage. Thalassemias are more common among individuals with Mediterranean African or Southeast Asian heritage but do occur worldwide. • Analyte Measured in Screening Identification of types of hemoglobin present in the sample is performed by high performance liquid chromatography HPLC. This screening is not quantitative. • Reporting Classifications FS - Fetal and sickle hemoglobins Abnormal results reported by phone probable sickle cell disease letter and fax to physician of record or hospital contact

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40 Sickling Hemoglobin Disorders and Beta Thalassemia FS FSC FSa FNA - Continued • Reporting Classifications FSC - Fetal and hemoglobin C probable sickle hemoglobin C disease FSa - Fetal sickle and beta thalassemia hemoglobins probable sickle/beta thalassemia FNA - Fetal and no adult hemoglobin probable beta thalassemia major • Feeding Effect None • Transfusion Effect Screening will be affected by transfusions. If initial specimen is collected post transfusion repeat screening will be necessary three months after the last transfusion. Donor red blood cells may mask sickling disorders due to transfused adult hemoglobin. Upon screening specimens from transfused infants with disease conditions may present as carrier trait conditions. • Timing Effect Usually no effect in first two weeks of newborn period although older infants will have a gradual decrease in fetal hemoglobin. • Follow-up Referrals/Testing Diagnostic testing including family for Abnormal Screening Results counseling and education is necessary. Referral to pediatric hematologist for diagnosis and counseling is highly recommended. • Specialist Pediatric hematologist see Appendix B for contact information. • Treatment Prophylactic penicillin is recommended for children with sickling disorders from ages 2 months to 5 years. In addition to all regular childhood immunizations pneumococcal conjugate vaccine also is recommended to help prevent pneumococcal infections.

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41 Sickling Hemoglobin Disorders and Beta Thalassemia FS FSC FSa FNA - Continued • Treatment Prophylactic penicillin is not usually indicated for treatment of beta-thalassemia this disorder is associated with severe anemia usually requiring medical management by a pediatric hematologist. Comments Family education genetic counseling and diagnostic services are available to families of infants with sickling hemoglobin disorders. The Illinois Department of Public Health through grants to university-based medical clinics provides diagnostic and treatment services for infants and children identified with hemoglobin disorders or traits. In addition family counseling and educational services are available through the Sickle Cell Disease Association of Illinois. See page 13 of this manual for contact information.

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42 Other Hemoglobinopathies and Traits Hemoglobin traits and other less serious hemoglobin diseases are autosomal recessive disorders of hemoglobin production that usually do not require treatment. Individuals with these conditions produce adequate amounts of functional hemoglobin and usually do not have complications associated with the conditions. Visit the American College of Medical Geneticists Web site at http://www.acmg.net to review the ACMG “ACT” sheet for additional information. Low fetal hemoglobin usually indicates that the infant was older at the time of specimen collection or in newborns that the infant was transfused. If the infant was transfused prior to collection of the initial newborn screening specimen another specimen is required three months after the last transfusion when the effects of donor red blood cells have dissipated. • Incidence Sickle cell trait occurs in one in 10 African-Americans. Hemoglobinopathies do occur in all races and ethnic groups. Hemoglobin S is more common among individuals with West African Middle Eastern Mediterranean or Central Indian heritage. Hemoglobin C is more common among individuals with West African heritage. Hemoglobin E is more common among individuals with Mediterranean African or Southeast Asian heritage. Thalassemias are more common among individuals with Mediterranean African or Southeast Asian heritage but do occur worldwide. • Analyte Measured in Screening Identification of types of hemoglobin present in the sample is performed by high performance liquid chromatography HPLC. This screening is not quantitative. • Reporting Classifications FAS - Fetal adult and sickle Reported by letter to physician hemoglobins probable sickle of record or hospital contact cell trait FAC - probable hemoglobin C trait FAD – probable hemoglobin D trait

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43 Other Hemoglobinopathies and Traits - Continued ● Reporting Classifications FAE – Fetal adult and E hemoglobins probable E hemoglobin trait FD – Fetal and D hemoglobins probable hemoglobin D disease FE – Fetal and E hemoglobins probable hemoglobin E disease LFA – Low fetal and elevated adult hemoglobins probable transfusion or older child ● Feeding Effect None ● Transfusion Effect Screening will be affected by transfusions. If initial specimen is collected post- transfusion repeat screening is necessary three months after the last transfusion. ● Timing Effect No effect in first two weeks of life although as the infant grows the fetal hemoglobin level usually decreases. ● Specialist Pediatric hematologist see appendix B for contact information. • Treatment Carrier states hemoglobin traits usually are considered benign with no treatment necessary. Hemoglobin E and Hemoglobin D disease states should be verified by further diagnostic testing referral to a pediatric hematologist is recommended. Some types of thalassemia may cause serious anemia in some cases requiring transfusion therapy referral to a pediatric hematologist is recommended.

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44 Other Hemoglobinopathies and Traits - Continued Comments Family education genetic counseling and diagnostic services are available to all families of infants with sickling hemoglobin disorders or traits. The Illinois Department of Public Health through grants to university-based medical clinics provides diagnostic and treatment services for infants and children identified with hemoglobin disorders or traits. See Appendix B for a listing of pediatric hematology specialists for information about these services. Sickle Cell Disease Association of Illinois also will provide educational services to families of individuals with sickle cell diseases or traits. See page 13 of this manual for contact information. Referral to a pediatric hematologist for additional diagnostic testing is recommended for these conditions.

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Appendix A Filter Paper Collection Form

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Image of the Illinois Newborn Screening ILP Series Filter Paper Collection Form Front view

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Image of the Illinois Newborn Screening ILP Series Filter Paper Collection Form Back view

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Appendix B Pediatric Medical Specialists

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Illinois Department of Public Health Newborn Screening Program Pediatric Medical Specialists for Amino Acid Organic Acid and Fatty Acid Oxidation Disorder Chicago and Suburban Areas Children’s Memorial Hospital Division of Genetics 2300 Childrens Plaza Box 59 Chicago IL 60614 773-880-4462 Barbara K. Burton M.D. Joel Charrow M.D. Children’s Pediatric Specialty Services 2301 Enterprise Drive Westchester IL 60154 For appointment call: 773-880-4462 Barbara K. Burton M.D. University of Illinois at Chicago PKU Clinics Division of Genetics 840 S. Wood St. Room 1215 M/C 856 Chicago IL 60612-7311 312-355-0732 George Hoganson M.D. Division of Genetics Department of Pediatrics 840 S. Wood St. M/C 856 312-355-0732 Allen L. Horwitz M.D. Ph.D. Advocate Christ Hospital/Hope Children’s Hospital 4440 W. 95 th St. Oak Lawn IL 60453 For appointment call: 312-355-0732 George Hoganson M.D. Hindsdale Hospital 120 Oak St. Hinsdale IL 60521 For appointment call: 312-355-0732 George Hoganson M.D. Rush University Medical Center Genetics Section 1750 W. Harrison St. Room 1507 Jelke Bldg. Chicago IL 60612 312-942-6298 Paul Wong M.D. M.Sc. Peoria Area University of Illinois at Peoria 507 E. Armstrong Ave. Peoria IL 61603 For appointment call: 312-355-0732 George Hoganson M.D. Rockford Area Rockford Memorial Hospital 2400 N. Rockton Ave. Rockford IL 61103 For appointment call: 312-355-0732 George Hoganson M.D St. Louis Area St. Louis Children’s Hospital Division of Medical Genetics Washington University School of Medicine 660 S. Euclid Ave. Campus Box 8116 St. Louis MO 63110 314-454-6093 Dorothy K. Grange M.D. Tyler Reimschisel M.D. Cardinal Glennon Children’s Hospital Director Division of Medical Genetics Department of Pediatrics Saint Louis University School of Medicine 1465 S. Grand Blvd. St. Louis MO 63104 314-577-5639 Gary S. Gottesman M.D.

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Illinois Department of Public Health Newborn Screening Program Pediatric Medical Specialists for Biotinidase Deficiency and Galactosemia Disorders Chicago and Suburban Areas Children’s Memorial Hospital Division of Genetics 2300 Childrens Plaza Box 59 Chicago IL 60614 773-880-4462 Joel Charrow M.D. Barbara K. Burton M.D. Childrens Pediatric Specialty Services 2301 Enterprise Drive Westchester IL 60154 For appointment call: 773-880-4462 Barbara K. Burton M.D. University of Illinois at Chicago PKU Clinics Division of Genetics 840 S. Wood St. Room 1217 M/C 856 Chicago IL 60612-7311 312-355-0732 George Hoganson M.D. Allen L. Horwitz M.D. Ph.D. The University of Chicago Dept. of Human Genetics and Pediatrics 5841 S. Maryland Ave. Suite L161 M/C 0077 Chicago IL 60637 773-834-9110 Darrel J. Waggoner M.D. Rush University Medical Center Genetics Section 1750 W. Harrison St. Room 1507 Jelke Bldg. Chicago IL 60612 312-942-6298 Paul Wong M.D. M.Sc. David S. Kang M.D. Ph.D. Copley Medical Center Fox Valley Medical Associates Bldg. Route 3 at Fox Valley Center Aurora IL 60505 For appointment call: 312-942-6298 Paul Wong M.D. M.Sc. Riverside Medical Center 350 N. Wall St. Kankakee IL 60901 For appointment call: 312-942-6298 Paul Wong M.D. M.Sc. Saint Joseph Medical Center 333 N. Madison St. Joliet IL 60435 For appointment call: 312-942-6298 Paul Wong M.D. M.Sc. Poplar Creek/Hoffman Estates 1800 McDonough Road 203 Hoffman Estates IL 60192 847-608-7517 Paul Wong M.D. M.Sc. Loyola University Medical Center Dept. of Pediatrics/Section of Genetics 2160 S. First Ave. Maywood IL 60153 708-327-9085 Carolyn H. Jones M.D. Advocate Lutheran General Hospital Parkside Center 1875 Dempster St. Suite 310 Park Ridge IL 60068 847-723-7705 Carol Booth M.D. Debra Rita M.D. Continued

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Pediatric Medical Specialists for Biotinidase Deficiency and Galactosemia Disorders Continued Chicago and Suburban Areas John A. Stroger Jr. Hospital of Cook County Division of Genetics Metabolics 1900 W. Polk St. Room 1159 Chicago IL 60612 312-864-4158 Susan C. Echiverri M.D. Advocate Christ Hospital/Hope Children’s Hospital 4440 W. 95th St. Oak Lawn IL 60453 For appointment call: 312-355-0732 George Hoganson M.D. Hinsdale Hospital 120 Oak St. Hinsdale IL 60521 For appointment call: 312-355-0732 George Hoganson M.D. Peoria Area University of Illinois at Peoria 507 E. Armstrong Ave. Peoria IL 61603 For appointment call: 312-355-0732 George Hoganson M.D. Rockford Area Rockford Memorial Hospital 2400 N. Rockton Ave. Rockford IL 61103 For appointment call: 312-355-0732 George Hoganson M.D. Springfield Area Southern Illinois School of Medicine Deparment of Pediatrics P.O. Box 19658 Springfield IL 62794 217-545-4839 Michael Schneider M.D. Sangamon County Department of Public Health 1415 E. Jefferson St. Springfield IL 62703 For appointment call: 312-355-0732 George Hoganson M.D. St. Louis Area St. Louis Children’s Hospital Division of Medical Genetics Washington University School of Medicine 660 S. Euclid Ave. Campus Box 8116 St Louis MO 63110 314-454-6093 Dorothy K. Grange M.D. Tyler Reimschisel M.D. Cardinal Glennon Children’s Hospital Director Division of Medical Genetics Department of Pediatrics Saint Louis University School of Medicine Cardinal Glennon Children’s Hospital 1465 S. Grand Blvd. St. Louis MO 63104 314-577-5639 Gary S. Gottesman M.D.

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Illinois Department of Public Health Newborn Screening Program Pediatric Medical Specialists for Phenylketonuria Chicago and Suburban Areas Children’s Memorial Hospital Division of Genetics 2300 Childrens Plaza Box 59 Chicago IL 60614 773-880-4462 Barbara K. Burton M.D. Children’s Pediatric Specialty Services 2301 Enterprise Drive Westchester IL 60154 773-880-4462 Barbara K. Burton M.D. Advocate Christ Hospital/Hope Children’s Hospital 4440 W. 95 th St. Oak Lawn IL 60453 For appointment call: 312-355-0732 George Hoganson M.D. University of Illinois at Chicago PKU Clinics Division of Genetics 840 S. Wood St. Room 1215 M/C 856 Chicago IL 60612-7311 312-355-0732 George Hoganson M.D. Hinsdale Hospital 120 Oak St. Hinsdale IL 60521 For appointment call: 312-355-0732 George Hoganson M.D. Rush University Medical Center. Division Genetics Section 1750 W. Harrison St. Room 1507 Jelke Bldg. Chicago IL 60612 312-942-6298 Paul Wong M.D. M.Sc. Saint Joseph Medical Center 333 N. Madison St. Joliet IL 60435 For appointment call: 312-942-6298 Paul Wong M.D. M.Sc. Copley Medical Center Fox Valley Medical Associates Bldg. Route 3 at Fox Valley Center Aurora IL 60505 For appointment call: 312-942-6298 Paul Wong M.D. M.Sc. Riverside Medical Center 350 N. Wall St. Kankakee IL 60901 For appointment call: 312-942-6298 Paul Wong M.D. M.Sc. Peoria Area University of Illinois at Peoria 507 E. Armstrong Ave. Peoria IL 61603 For appointment call: 312-355-0732 George Hoganson M.D. Continued

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Pediatric Medical Specialists for Phenylketonuria Continued Rockford Area Rockford Memorial Hospital 2400 N. Rockton Ave. Rockford IL 61103 For appointment call: 312-355-0732 George Hoganson M.D. Springfield Area Sangamon County Department of Public Health 1415 E. Jefferson St. Springfield IL 62703 For appointment call: 312-355-0732 George Hoganson M.D. St. Louis Area St. Louis Children’s Hospital Division of Medical Genetics Washington University School of Medicine 660 S. Euclid Ave. Campus Box 8116 St. Louis MO 63110 314-454-6093 Dorothy K. Grange M.D. Tyler Reimschisel M.D. Cardinal Glennon Children’s Hospital Director Division of Medical Genetics Department of Pediatrics Saint Louis University School of Medicine Cardinal Glennon Children’s Hospital 1465 S. Grand Blvd. St. Louis MO 63104 314-577-5639 Gary S. Gottesman M.D.

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Illinois Department of Public Health Newborn Screening Program Pediatric Medical Specialists for Congenital Adrenal Hyperplasia and Congenital Hypothyroidism Chicago and Suburban Areas Children’s Memorial Hospital 2300 Childrens Plaza Chicago IL 60614 773-327-7740 Reema Habiby M.D. Mary Kreiter M.D. Rush University Medical Center Department of Pediatrics 1653 W. Congress Parkway Chicago IL 60612 1725 W. Harrison St. Suite 938 312-942-8989 Richard A. Levy M.D. University of Illinois at Chicago Department of Endocrinology and Pediatrics 840 S. Wood St. M/C 856 Chicago IL 60612 312-996-7714 clinic 312-996-1795 office Songya Pang M.D. The University of Chicago Pediatric Endocrinology 5841 S. Maryland Ave. Chicago IL 60637 773-702-6432 Robert Rosenfield M.D. Dianne Deplewski M.D. Elizabeth Baumann-Littlejohn M.D. ENH Medical Group: Old Orchard Pediatric Endocrinology 9977 Woods Drive Skokie IL 60077 847-663-8508 Stephen C. Duck M.D. Advocate Christ Hospital Oak Lawn IL 60453 708-684-5670 Fuad Ziai M.D. Loyola University Medical Center 2160 S. First Ave. Bldg. 105 Room 3330 Maywood IL 60153 For appointment call: 708-216-8563 or 708-327-9095 120 Spalding Suite. 401 Naperville IL 60540 630-416-4501 W. Patrick Zeller M.D. Advocate Lutheran General Hospital 1775 Dempster St. Park Ridge IL 60068 847-723-8409 Kanika Ghai M.D. Peoria Area University of Illinois at Peoria Pediatric Sub-Specialty Clinic 320 E. Armstrong Ave. Peoria IL 61603-3103 309-624-9680 Sue Ellyn Sauder M.D. Joyce E. Wise M.D. William F. Maurer M.D. Department of Pediatrics 530 N.E. Glen Oak Ave. Peoria IL 61637 309-624-9680 Rodney A. Lorenz M.D. Continued

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Pediatric Medical Specialists for Congenital Adrenal Hyperplasia and Congenital Hypothyroidism Continued St. Louis Area Cardinal Glennon Children’s Hospital St. Louis University Medical School 1465 S. Grand Blvd. St. Louis MO 63104 314-577-5648 Sherida Tollefsen M.D. David Paul Dempsher M.D. Susan E. Myers M.D. St. Louis Children’s Hospital Washington University School of Medicine 1 Children’s Place Campus Box 8116 Room 4530 St. Louis MO 63110 314-454-6051 Neil H. White M.D. Bess Adkins Marshall M.D. Louis Joseph Muglia M.D. Ph.D. Abby Solomon Hollander M.D.

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Illinois Department of Public Health Newborn Screening Program Pediatric Medical Specialists for Hemoglobinopathies/Sickle Cell Disease Chicago and Suburban Areas Children’s Memorial Hospital- Northwestern University Division of Hematology/Oncology Comprehensive Sickle Cell Program 2300 Children’s Plaza 30 Chicago IL 60614 773-880-4125 Alexis Thompson M.D. Advocate Christ/Hope Children’s Hospital Pediatric Hematology/Oncology 4440 W. 95 th St. Oak Lawn IL 60453 708-346-4094 Sharad Salvi M.D. John A. Stroger Jr. Hospital of Cook County Division of Hematology/Oncology 1900 W. Polk Room 1155 Chicago IL 60612 312-864-4166 Lilly Mathew M.D. Rush University Medical Center 1753 W. Congress Parkway Chicago IL 60612 312-942-5983 Allen Korenblit M.D. F.A.A.P. Mt. Sinai Hospital Department of Pediatrics California Ave. at 15 th St. Room F444 Chicago IL 60608 773-257-6395 diagnostic scheduling Sudha Rao M.D. Loyola University Medical Center Department of Pediatrics Hematology/Oncology Section 2160 S. First Ave. Maywood IL 60153 708-327-9136 Ricarchito Manera M.D. Advocate Lutheran General Children’s Hospital Department of Pediatrics 1675 Dempster St. Park Ridge IL 60068 847-318-9330 Jong-Hyo Kwon M.D. William Goodell M.D. The University of Chicago Hospitals 5841 S. Maryland Ave. WCHC430 MC 4060 Chicago IL 60637 Patricia Bailey R.N. Sickle Cell Clinic 773-256-5759 Uma Subramanian M.D. University of Illinois at Chicago Division of Pediatric Hematology/Oncology 840 S. Wood St. MC 856 Chicago IL 60612-7324 Richard J. Labotka M.D. 312-996-6143 Continued

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Champaign Area Carle Clinic Department of Pediatrics 602 W. University St. Urbana IL 61801 217-383-3100 Mark Musselman M.D. M.A. Peoria Area St. Francis Medical Center Department of Pediatrics 507 E. Armstrong Ave. Peoria IL 61603 309-624-4945 Kay Saving M.D. 309-624-9856 Springfield Area Southern Illinois University School of Medicine Carol Jo Vecchie Women and Children’s Center 415 N. 9th St. P.O. Box 19678 Springfield IL 62794-9678 217-545-5817 Gregory Brandt M.D. East St. Louis/St. Louis Area Southern Illinois Health Care Foundation Mother Child Center 6000 Bond Ave. Centreville IL 62207 618-332-2740 ask for sickle cell nurse William Ferguson M.D. St. Louis Children’s Hospital Washington University School of Medicine 1 Children’s Place St. Louis MO 63110 314-454-6018 or 314-454-2193 Michael DeBaun M.D. Cardinal Glennon Children’s Hospital St. Louis University School of Medicine Department of Pediatrics Division of Hematology/Oncology 1465 South Grand Blvd. St. Louis MO 63104-1095 314-577-5600 William Ferguson M.D. Centers receiving grant funding from the Illinois Department of Public Health Pediatric Medical Specialists for Hemoglobinopathies/ Sickle Cell Diseases Continued

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Appendix C Local Public Health Departments

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Illinois Department of Public Health Newborn Screening Program Local Public Health Department Contacts Adams County Health Department 333 N. Sixth St. Quincy IL 62301 Candee Musgrove R.N. 217- 222-8440 Bond County Health Department 503 S. Prairie Greenville IL 62246 Judi Markell R.N. 618-664-1442 Boone County Health Department 1204 Logan Ave. Belvidere IL 61008-4031 Pam Hart R.N. 815-544-2951 or 9730 Brown County Health Department 111½ W. Washington St. Mount Sterling IL 62353 Nancy Kropp R.N. 217-773-2714 Bureau County Health Department 526 Bureau Valley Parkway Princeton IL 61356 Colleen Sailer R.N. B.S.N. 815-872-5091 Calhoun County Health Department P.O. Box 158 210 French St. Hardin IL 62047 Judy Zipprich R.N. 618-576-2428 Cass County Health Department 331 S. Main St. Virginia IL 62691 Marsha Kirchner R.N. B.S.N. 217-452-3057 or 217-323-2182 Beardstown Office Champaign-Urbana Public Health District 710 N. Neil St. Champaign IL 61820-1488 Ellen Weise R.N. 217-352-4289 Chicago Department of Health DePaul University Center 333 S. State St. Room. 2105 Chicago IL 60604 Pam Hegbe R.N. 312-747-9690 Christian County Health Department 902 W. Springfield Road Taylorville IL 62568 Marcie Hurley R.N. 217-824-4113 Clark County Health Department 1001 N. York St. Martinsville IL 62442 JoBeth Gilbert R.N. 217-382-4207 Clay County Health Department 601 E. 12 th St. Flora IL 62839 Nancy Wiley R.N. 618-662-4406 Clinton County Health Department 930A Fairfax St. Carlyle IL 62231 Janice Albers R.N. 618-594-8942 Coles County Health Department P.O. Box 1064 825 18 th St. Charleston IL 61920-9391 Jill Temple R.N. 217-348-0530 Cook County Department of Public Health 1010 Lake St. Suite 104 Oak Park IL 60301 Pat Rewers R.N. 708-450-4787 Crawford Co. Health Department 202 N. Bline Blvd. Robinson IL 62454 Debbie Pryor R.N. 618-544-8798 Cumberland Coounty Health Department P.O. Box 130 N.E. Corner of Square Toledo IL 62468 Connie Kerner R.N. 217-849-3211 DeKalb County Health Department 2550 N. Annie Glidden Road DeKalb IL 60115 Liz Carney R.N. 815-748-2447 or 815-758-6673 DeWitt-Piatt Bi-County Health Department P.O. Box 518 910 Route 54 E. Clinton IL 61727 Ann Barnett R.N. 217-935-3427 Douglas County Health Department 1250 East U.S. Highway 36 Tuscola IL 61953 Susan Hays R.N. 217-253-4137 DuPage County Health Department 111 N. County Farm Road Wheaton IL 60187 Ellen Finegan R.N. 630-682-7979 ext. 7049 East Side Health District 638 N. 20 th St. East St. Louis IL 62205 Carolyn Martin R.N. B.S.N. 618-874-4713 or 618-274-4888 Covering: E. St. Louis Washington Park Fairmount City Southwest area of Caseyville Cahokia Alorton Centreville Sauget Brooklyn and Lovejoy cities Edgar County Health Department 502 Shaw Ave. Paris IL 61944 Carol Cline R.N. 217-465-2212 Effingham County Health Department 901 W. Virginia P.O. Box 685 Effingham IL 62401 Shawn Bourland R.N. B.S.C.L.C 217-342-9237 Continued

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Local Health Department Contacts Continued Egyptian County Health Department Route 3 Box 90A 1412 U.S. Highway 45 N. Eldorado IL 62930-9234 Lynn Schanzle R.N. 618-273-3326 Covering: Galatin Saline White counties Evanston Health Department Evanston Civic Center 2100 Ridge Ave. Evanston IL 60201 Evonda Thomas R.N. 847-866-2957 Fayette County Health Department P.O. Box 340 509 W. Edwards St. Vandalia IL 62471 Debby Lay R.N. 618-283-1044 Ford-Iroquois Public Health Department 114 N. Third St. Watseka IL 60970 Lyn Schaumburg R.N. 815-432-2483 Franklin-Williamson Bi-County Health Department 120 Express Drive Marion IL 62959-9808 Lisa Sorenson R.N. 618-993-8111 Fulton County Health Department 700 E. Oak St. Canton IL 61520 Louise Hiett R.N. 309-647-1134 Greene County Health Department 310 Fifth St. Carrollton IL 62016 Susan Thornton R.N. 217-942-6961 or 217-942-6962 Grundy County Health Department 1320 Union Str. Morris IL 60450 Kay Lynn Shumaker R.N. 815-941-3400 Hamilton County Health Department Courthouse Room 5 McLeansboro IL 62859 Andrea Miller R.N. 618-643-3522 Hancock County Health Department 73 S. Adam St. Carthage IL 62321 Jennifer Sherman R.N. 217-357-2171 Henderson County Health Department P.O. Box 220 Gladstone IL 61437-0220 Mary Lynne Haas R.N. 309-627-2812 Covering: Warren county Henry County Health Department 4424 U.S. Highway 34 Kewanee IL 61443 Sue Duncan R.N. 309-852-0197 Jackson County Health Department Route 13 at Country Club Road P.O. Box 307 Murphysboro IL 62966 Marilyn Twitty R.N. 618-684-3143 ext. 111 Jasper County Health Department 106 E. Edwards St. Newton IL 62448 Marilyn Cox R.N. 618-783-4436 Covering Richland county Jefferson County Health Department 1 Doctors Park Road Suite F Mt. Vernon IL 62864 Vickie Nollman R.N. 618-244-7134 Jersey County Health Department 1307 State Highway 109 Jerseyville IL 62052 Geri Daniels R.N. B.S.N. 618-498-9565 ext. 313 JoDaviess County Health Department 9483 U.S. Route 20 W. P.O. Box 318 Galena IL 61036 Lori Stanglet R.N. 815-777-0263 Kane County Health Department 1240 N. Highland Ave. Suite 12 Aurora IL 60506 Carolyn Hammar R.N. 630-264-7679 Kankakee County Health Department 2390 W. Station St. Kankakee IL 60901 Janie Semlar R.N. 815-937-7892 Kendall County Department of Health Human Services 500A Countryside Center Yorkville IL 60560 Noreen Transier R.N. 630-553-9100 Knox County Health Department 1361 W. Fremont St. Galesburg IL 61401 Carol Winbigler R.N. 309-344-2224 Lake County Health Department 3010 Grand Ave. Waukegan IL 60085 Carmen Perez R.N. 847-377-8128 LaSalle County Health Department 717 Etna Road Ottawa IL 61350 Colleen Gibson R.N. 815-433-3366 Lawrence County Health Department P.O. Box 516 Lawrenceville IL 62439 Mary Copp R.N. 618-943-3302 Continued

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Local Health Department Contacts Continued Lee County Health Department 309 S. Galena Ave. Suite 100 Dixon IL 61021-9185 Cyndi Kenney R.N. 815-284-3371 Livingston County Health Department Livingston Co. Health Education Bldg. P.O. Box 886 310 E. Torrance Ave. Pontiac IL 61764 Melinda Hillman R.N. 815-844-7174 Logan County Health Department 109 Third St. P.O. Box 508 Lincoln IL 62656 Sue Estes R.N. 217-735-2317 Macon County Health Department 1221 E. Condit St. Decatur IL 62521-1405 Cynthia Smith R.N. 217-423-6988 Macoupin County Health Department 805 N. Broad St. Carlinville IL 62626 Karen Hazzard R.N. B.S. 217-854-3223 Madison County Health Department 101 E. Edwardsville Road Wood River IL 62095 Carla Gillespie R.N. 618-692-6200 Marion County Health Department 600 E. Main St. Salem IL 62881 Melissa Defend R.N. 618-548-3878 Marshall County Health Department P.O. Box 156 Lacon IL 61540 Nora Bazydlo R.N. 309-246-8074 Mason County Health Department Route 136 E. P.O. Box 557 Havana IL 62644 Theresa Sennett R.N. 309-543-2201 McDonough Co. Health Department 505 E. Jackson St. Macomb IL 61455 Lynn Van Pelt R.N. 309-837-9951 McHenry County Health Department 2200 North Seminary Ave. Woodstock IL 60098 Kathy Bennet R.N. 815-334-4510 ext. 511 McLean County Health Department 200 W. Front St. Room 304 Bloomington IL 61701 Denise Hunt R.N. 309-888-5526 Menard County Health Department 937 N. Fifth St. Petersburg IL 62675 Kathy Fleck R.N. 217-632-2810 Mercer County Health Department 1007 N.W. Third St. Aledo IL 61231 Wendy Bigham R.N. 309-582-5301 ext. 4515 Monroe-Randolph Bi-County Health Department 2515 State St. Chester IL 62233 Kimberly Reeder R.N. 618-826-5007 ext. 107 Montgomery County Health Department 11191 Illinois Route 185 Hillsboro IL 62049-0128 Carolyn DeWerff R.N. 217-532-2001 Morgan County Health Department 345 W. State St. Jacksonville IL 62650 Trudy Bridgewater R.N. 217-245-5111 Moultrie County Health Department 2 W. Adams St. Sullivan IL 61951 Jennie Munch R.N. 217-728-4442 or 217-728-4114 Oak Park Health Department 123 Madison St. Oak Park IL 60302 Wanda McDonald R.N. 708-358-5491 Ogle County Health Department 907 W. Pines Road Oregon IL 61061 Linda Jackson R.N. 815-732-7330 ext. 315 Peoria City/County Health Department 2116 N. Sheridan Road Peoria IL 61604 Veronica Aberle R.N. M.S.N. 309-685-6181 ext. 6081 Perry County Health Department 907 S. Main St. P. O. Box 49 Pinckneyville IL 62274 Brenda Epplin R.N. 618-357-5371 Pike County Health Department 113 E. Jefferson St. Pittsfield IL 62363-1420 Beth Sencik R.N. 217-285-4407 Putnam County Health Department P.O. Box 49 Hennepin IL 61327 Elaine Caldwell R.N. 815-925-7326 Rock Island County Health Department 2112 25 th Ave. Rock Island IL 61201 Franki Cunningham R.N. 309-793-1955 ext. 260 St. Clair County Health Department 19 Public Square Suite 150 Belleville IL 62220 Karoline Stock RN BSN 618-233-7703 ext. 4483 Sangamon County Department of Public Health 2501 N. Dirksen Parkway Springfield IL 62702 Andrea Evans R.N. 217-535-3100 Schuyler County Health Department 127 S. Liberty St. P.O. Box 320 Rushville IL 62681 Barbara Wrench R.N. 217-322-4373 Scott County Health Department 32 E. Market St. P.O. Box 115 Winchester IL 62690 Phyllis Jefferson R.N. 217-742-8203 Shelby County Health Department R.R.2 Box 54 1810 W.S. Third St. Shelbyville IL 62565 Carol Johnston R.N. 217-774-2355 Continued

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Southern Seven Health Department 37 Rustic Campus Drive Ullin IL 62992 Judi Duff R.N. 618-634-2297 ext. 159 Covering: Alexander Hardin Johnson Massac Pope Pulaski Union Counties Skokie Health Department 5127 Oakton St. P.O. Box 309 Skokie IL 60077 Sue Reisbert R.N. 847-933-8252 Stark County Health Department 4424 U.S. Highway 34 Kewanee IL 61433 Sue Duncan R.N. 309-852-3115 Stephenson County Health Department 10 W. Linden St. Freeport IL 61032 Julia Marynus R.N. 815-235-8394 Tazewell County Health Department 21306 Illinois Route 9 Tremont IL 61568-9252 Sarah Buller Fenton M.S. R.N.C. 309-925-5511 ext. 236 Vermilion County Health Department 200 S. College St. Danville IL 61832 Pam Warner R.N. 217-431-2662 Wabash County Health Department 130 W. Seventh St. Mount Carmel IL 62863 Kendra Grounds R.N. 618-263-3873 Washington Co. Health Department 177 S. Washington St. Nashville IL 62263 Joyce Carson R.N. 618-327-3644 Wayne County Health Department 405 N. Basin Road P.O. Box 645 Fairfield IL 62837 Pat Weber R.N. 618-842-5166 Whiteside County Health Department 1300 W. Second St. Rock Falls IL 61071 Pam Vanderinne 815-626-2230 Will County Health Department 501 Ella Ave. Joliet IL 60433 Sharon Wesel R.N. 630-679-7000 Winnebago County Health Department 401 Division St. Rockford IL 61104 Paula Hart R.N. 815-962-5092 ext. 273 Woodford County Health Department 109 S. Major St. Eureka IL 61530 Nancy Allen R.N. 309-467-2371 Local Health Department Contacts Continued

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Appendix D Tandem Mass Spectrometry Analytes

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Tandem Mass Spectrometry MS/MS Analytes Amino Acid Analytes Arginine Citrilline Glycine Iso-leucine/Leucine Methionine Phenylalanine Tyrosine Valine 5-oxoproline Acylcarnitine Analytes C0 – free carnitine C2 – acetyl carnitine C3 – propanoyl carnitine C4 – butanoyl carnitine C5 – pentanoyl carnitine C5:1 – pentenoyl carnitine C5-DC – glutaryl carnitine C5-OH – 3-hydroxy-isovaleryl carnitine C6 – hexanoyl carnitine C6-OH – 3-hydroxyhexanoyl carnitine C8 – octanoyl carnitine C8-OH – 3-hydroxyoctanoyl carnitine C10 – decanoyl carnitine C10:1 decenoyl carnitine C12 – dodecanoyl carnitine C12:1 – dodecenoyl carnitine C14 – tetradecenoyl carnitine C14:1 – tetradecanoyl carnitine C16 – hexadecanoyl carnitine C16-OH – hydroxyl-octadecanoyl carnitine C18 – octadecanoyl carnitine C18:1 – octadecenoyl carnitine C18:1-OH – hydroxyl-octadecenoyl carnitine For substituted carnitines a notation of Cx is used where x denotes the number of carbons in the fatty acid radical. Free carnitine is designated as C0 acetyl carnitine as C2 propanoyl carnitine as C3 etc. Hydroxylation is designated by -OH dicarboxylic acid is designated by -DC and unsaturation is designated by :1.

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