Expanded Newborn Screening: Expanded Newborn Screening:

The Nutrition PerspectiveThe Nutrition PerspectiveNutrition 526Nutrition 526

November 5, 2008November 5, 2008Beth Ogata, MS, RDBeth Ogata, MS, RD

bogata@u.washington.edubogata@u.washington.edu

Nutrition Involvement in NBSNutrition Involvement in NBS

PolicyPolicy Diagnostic/coordinationDiagnostic/coordination ClinicalClinical CommunityCommunity

Example: infant with galactosemiaExample: infant with galactosemia

Symptoms in newborn, if Symptoms in newborn, if untreateduntreated– Vomiting, diarrheaVomiting, diarrhea– Hyperbilirubinemia, hepatic Hyperbilirubinemia, hepatic

dysfunction, hepatomegalydysfunction, hepatomegaly– Renal tubular dysfunctionRenal tubular dysfunction– CataractsCataracts– EncephalopathyEncephalopathy– E. coli septicemia resultE. coli septicemia result– Death within 6 weeks, if Death within 6 weeks, if

untreateduntreated AlsoAlso

– Duarte variantDuarte variant– galactokinase deficiencygalactokinase deficiency– uridine diphosphate-uridine diphosphate-

galactose-4-epimerase galactose-4-epimerase deficiencydeficiency

Galactose-1-phosphate uridyl transferase (GALT) deficiency

Example: infant with galactosemiaExample: infant with galactosemia

Primary source is milk Primary source is milk (lactose= galactose + (lactose= galactose + glucose)glucose)

Secondary sources are Secondary sources are legumeslegumes

Minor? sources are Minor? sources are fruits and vegetablesfruits and vegetables

Food labelsFood labels– milk, casein, milk solids, milk, casein, milk solids,

lactose, whey, hydrolyzed lactose, whey, hydrolyzed protein, lactalbumin, protein, lactalbumin, lactostearin, caseinatelactostearin, caseinate

Medications Medications (lactose is (lactose is often an inactive ingredient)often an inactive ingredient)

Dietary supplementsDietary supplements Artificial sweetenersArtificial sweeteners

Monitoring: galactose-1-phosphate levels <3-4 mg/dlMonitoring: galactose-1-phosphate levels <3-4 mg/dl

Treatment: eliminate all galactose from dietTreatment: eliminate all galactose from diet

Example: Infant with galactosemiaExample: Infant with galactosemia

POLICY

RD participated on State Advisory Board to select disorders, including galactosemia

DIAGNOSIS & COOORDINATION

“Presumptive positive” RD in contact with family and local providers to discuss appropriate feeding practices and arrange clinic appointment

CLINICAL MANAGEMENT

RD provides nutrition care as member of the Biochemical Genetics Team:

•Initiation of formula

•Guidelines for monitoring intake

•Plans for follow-up

RD as case manager

COMMUNITY

RD at local health department provides ongoing education to family, local care providers

Nutrition and NBS: PolicyNutrition and NBS: Policy

Screening process (disorders, procedures) Screening process (disorders, procedures) RD participated in Advisory Board meetings, providing RD participated in Advisory Board meetings, providing input about nutrition-related treatmentinput about nutrition-related treatment

Services and reimbursementServices and reimbursementNutrition consultant to state CSHCN ProgramNutrition consultant to state CSHCN Program

RD provides input about relevant state Medicaid policiesRD provides input about relevant state Medicaid policies

Training and educationTraining and educationRD provides information about management of metabolic RD provides information about management of metabolic disorders to local WIC agenciesdisorders to local WIC agencies

Nutrition and NBS: Clinical Nutrition and NBS: Clinical Management – PKUManagement – PKU

PhenylketonuriaPhenylketonuria– Phenylalanine hydroxylasePhenylalanine hydroxylase– Dihydropteridine reductaseDihydropteridine reductase– Biopterin synthetaseBiopterin synthetase

Establish diagnosisEstablish diagnosis– Presumptive positive NBS Presumptive positive NBS

resultsresults > 3 mg/dL, >24 hrs of > 3 mg/dL, >24 hrs of

ageage

– Differential diagnosisDifferential diagnosis serum phe, nl tyrserum phe, nl tyr r/o DHPR, biopterin r/o DHPR, biopterin

defectsdefects

Current Treatment GuidelinesCurrent Treatment Guidelines

With effective NBS, children are With effective NBS, children are identified by 7 days of ageidentified by 7 days of age

Initiate treatment immediatelyInitiate treatment immediately Maintain phe levels 1-6 mg/dl (60-Maintain phe levels 1-6 mg/dl (60-

360 umol/L)360 umol/L) Lifelong treatmentLifelong treatment

Outcome ExpectationsOutcome Expectations With NBS and blood With NBS and blood

phenylalanine levels phenylalanine levels consistently in the consistently in the treatment rangetreatment range– Normal IQ and physical Normal IQ and physical

growth are expectedgrowth are expected

With delayed With delayed diagnosis or diagnosis or consistently elevated consistently elevated blood levelsblood levels– IQ is diminished and IQ is diminished and

physical growth is physical growth is compromisedcompromised

Clinical Management: PKUClinical Management: PKU

Goals of Nutrition TherapyGoals of Nutrition Therapy Normal growth rateNormal growth rate Normal physical Normal physical

developmentdevelopment Normal cognitive Normal cognitive

developmentdevelopment Normal nutritional Normal nutritional

statusstatus

Clinical Management: PKUClinical Management: PKU

Correct substrate Correct substrate imbalanceimbalance– Restrict Restrict

phenylalanine phenylalanine intake to normalize intake to normalize plasma plasma concentrationconcentration

Supply product of Supply product of reactionreaction– Supplement Supplement

tyrosine to maintain tyrosine to maintain normal plasma normal plasma tyrosine levelstyrosine levels

Phenylalanine -------------------//----------------------- Tyrosine

(substrate) phenylalanine hydroxylase (product)

Goals of Nutrition Support for Goals of Nutrition Support for Phenylketonuria (PKU)Phenylketonuria (PKU)

Maintain plasma phenylalanine (phe) Maintain plasma phenylalanine (phe) between 1-6 mg/dlbetween 1-6 mg/dl– Without PKU, phe ~ 1.0 mg/dlWithout PKU, phe ~ 1.0 mg/dl

Maintain plasma tyrosine (tyr) Maintain plasma tyrosine (tyr) between 0.9–1.8 mg/dlbetween 0.9–1.8 mg/dl– Normal = 0.9-1.8 mg/dlNormal = 0.9-1.8 mg/dl

Goals of Nutrition Support for Goals of Nutrition Support for Phenylketonuria (PKU)Phenylketonuria (PKU)

Interpretation of phenylalanine levelsInterpretation of phenylalanine levels

~1 mg/dl~1 mg/dl NormalNormal

1-6 mg/dl1-6 mg/dl ExcellentExcellent

6-10 mg/dl6-10 mg/dl GoodGood

10-15 mg/dl10-15 mg/dl CautionCaution

15-20 mg/dl15-20 mg/dl DangerousDangerous

> 20 mg/dl> 20 mg/dl Very damagingVery damaging

Phe Levels from NBS to TxPhe Levels from NBS to Tx

Blood levels every 2 daysbecause of rapid growth

Equilibrium achieved by 14 days of age

Diagnostic levels

Adjustments necessary to maintain Adjustments necessary to maintain “safe” blood phe levels“safe” blood phe levels

Usual intake of pheUsual intake of phe– Newborn on formulaNewborn on formula

20 oz x 22 mg phe/oz = 440 mg phe20 oz x 22 mg phe/oz = 440 mg phe

– 1 yo child on “regular” diet1 yo child on “regular” diet30 g protein = 1500 mg phe (DRI = 13.5 g)30 g protein = 1500 mg phe (DRI = 13.5 g)

– 7 yo child on “regular” diet7 yo child on “regular” diet50 g protein = 2500 mg phe (DRI = 19 g)50 g protein = 2500 mg phe (DRI = 19 g)

Phenylalanine requirementPhenylalanine requirement– 250 mg/d250 mg/d

Management ToolsManagement Tools

Specialized formula Specialized formula providesprovides– 80-90% energy intake80-90% energy intake– 89-90 % protein intake89-90 % protein intake– tyrosine supplementstyrosine supplements– no phenylalanineno phenylalanine

Phenylalanine to meet Phenylalanine to meet requirement from infant requirement from infant formula or foodsformula or foods

Formula CompositionFormula Composition

Regulated by FDARegulated by FDA– Renal solute loadRenal solute load– Carbohydrate Carbohydrate

sourcesource– Fat sourceFat source– Amino acid sourceAmino acid source– Vitamin and mineral Vitamin and mineral

contentcontent

Designated by Designated by clinicianclinician– Protein/energy ratioProtein/energy ratio– Specific amino acidSpecific amino acid– Fluid balanceFluid balance– Total proteinTotal protein– Total energyTotal energy

Effect of a single amino acid Effect of a single amino acid deficiency on growthdeficiency on growth

Food Choices for PKUFood Choices for PKU

Sample Menu: ~1 year oldSample Menu: ~1 year oldFoodFood Protein (g)Protein (g)

¼ cup Cheerios¼ cup Cheerios 0.80.8

½ banana½ banana 0.60.6

½ cup milk½ cup milk 44

2 graham crackers2 graham crackers 22

½ cup milk½ cup milk 44

¼ tuna sandwich¼ tuna sandwich 88

½ peach½ peach 0.60.6

2 saltines2 saltines 0.60.6

¼ cup juice¼ cup juice 00

½ cup milk½ cup milk 44

½ banana½ banana 0.60.6

¼ cup cottage cheese¼ cup cottage cheese 77

¼ cup green beans¼ cup green beans 0.30.3

TOTALTOTAL 32.532.5

>>1625 mg phe>>1625 mg phe

Total Protein:

32.5 grams

(1625 mg phe)

DRI (protein):

13.5 grams (~675 mg phe)

Phe requirement:

250 mg

Sample Menu: ~1 year oldSample Menu: ~1 year oldFoodFood Protein (g)Protein (g)

¼ cup Cheerios¼ cup Cheerios 0.80.8

½ banana½ banana 0.60.6

½ cup milk½ cup milk 44

2 graham crackers2 graham crackers 22

½ cup milk½ cup milk 44

¼ tuna sandwich¼ tuna sandwich 88

½ peach½ peach 0.60.6

2 saltines2 saltines 0.60.6

¼ cup juice¼ cup juice 00

½ cup milk½ cup milk 44

½ banana½ banana 0.60.6

¼ cup cottage cheese¼ cup cottage cheese 77

¼ cup green beans¼ cup green beans 0.30.3

TOTALTOTAL 32.5 5.5 g protein32.5 5.5 g protein

>>1625 250 mg phe>>1625 250 mg phe

To meet 250 mg phe minus milk, tuna, cottage cheese:

Total Protein:5.5 g

•Is this adequate protein to support growth?

•Is this adequate energy to support growth?

•What about adequacy of other nutrients?

Tools of Management: Low protein Tools of Management: Low protein food productsfood products

Phe content of regular Phe content of regular productsproducts

Phe content of low protein Phe content of low protein productsproducts

RiceRice 300 mg/cup300 mg/cup LP riceLP rice 23 mg/cup23 mg/cup

PastaPasta 163 mg/cup163 mg/cup LP pastaLP pasta 5 mg/cup5 mg/cup

BreadBread 105 mg/slice105 mg/slice LP breadLP bread 10 mg/slice10 mg/slice

CheerioCheerioss

93 mg per ½ cup93 mg per ½ cup LP LoopsLP Loops 5 mg per ½ cup5 mg per ½ cup

SaltinesSaltines 65 mg/5 crackers65 mg/5 crackers LP saltinesLP saltines 3 mg/5 crackers3 mg/5 crackers

PotatoesPotatoes 145 mg/cup145 mg/cup

Typical Food Pattern for a Child Typical Food Pattern for a Child with PKUwith PKU

Energy needs:Energy needs:1000-1300 kcal1000-1300 kcal

Protein needs:Protein needs: 20 20 gg

Phenylalanine Phenylalanine needs:needs: 250 mg250 mg

Formula Formula prescription:prescription:– Phenyl-Free: 125 gPhenyl-Free: 125 g– Similac pdr: 50 gSimilac pdr: 50 g– Water to 40 ozWater to 40 oz

Food prescription:Food prescription:– 25 mg phe, 200 25 mg phe, 200

kcal, 0.5 g proteinkcal, 0.5 g protein

1 year old, weight & length at 501 year old, weight & length at 50thth %ile for age %ile for age

Monitoring Adequacy of TreatmentMonitoring Adequacy of Treatment

Measure plasma amino acidsMeasure plasma amino acids– Maintain in treatment rangeMaintain in treatment range

Monitor nutrient intakeMonitor nutrient intake– Restrict phenylalanine, supplement tyrosine, Restrict phenylalanine, supplement tyrosine,

adequate protein, energy, other nutrients to adequate protein, energy, other nutrients to support growth and ensure good healthsupport growth and ensure good health

Monitor growth incrementsMonitor growth increments– Typical growth expectedTypical growth expected

Monitor cognitive developmentMonitor cognitive development– Typical achievement expectedTypical achievement expected

Effective Blood Level Management Effective Blood Level Management in Childhoodin Childhood

Blood levels once per month, or more frequently if needed for good management

Age of Child Tasks for Children and Parents0-6 months Parents learn about and adjust to PKU6 months Start low-protein solid foods6-7 months Introduce cup8-9 months Introduce finger foods10-15 months Consider weaning from bottle (discuss transition with clinic staff)2-3 years Learn the concept of “formula first”

Learn to distinguish “yes” and “no” foods4-5 years Begin to learn to count foods – “how many”

Begin to use scale – “how much”5-6 years Assist in formula preparation

Teach children how to deal with other children’s curiosity about PKU7-10 years Prepare formula with decreasing supervision

Choose after school snackLearn to pack school lunchBegin to list foods on food recordBegin weighing food regularly on scale

10-12 years Begin to prepare and consume formula independently each day (withparental monitoring)

Prepare simple entrees independentlyKnow what blood levels are ideal

13-14 years Increasing self-monitoring (with continued parent support) in formulapreparation and consumption

Independently manage total phenylalanine intake for the dayLearn menu planningResponsible for food records

15-17 years Responsible for all aspects of self-managementAble to do ‘finger poke’ for blood testAble to explain basics of PKU – “What is it?”Responsible for remembering recent blood levelsContinued parent support

18 years Transition to adult-based clinic careReady to live independently, including:-formula preparation and consumption-food preparation and records-monthly serum phenylalanine levels

PKU PKU Management Management

GuidelinesGuidelines

Self-Self-management management

SkillsSkills

Goal of Lifetime Management of Goal of Lifetime Management of PKUPKU

To maintain To maintain metabolic balance metabolic balance while providing while providing adequate nutrients adequate nutrients and energy for and energy for normal physical and normal physical and intellectual growthintellectual growth

Maternal PKU Concerns/OutcomesMaternal PKU Concerns/Outcomes

Women with PKU are at high risk for Women with PKU are at high risk for delivering a damaged infantdelivering a damaged infant– Placenta concentrates phe 2-4xPlacenta concentrates phe 2-4x

MicrocephalyMicrocephaly Cardiac problemsCardiac problems

Infant IQ directly related to maternal blood Infant IQ directly related to maternal blood phe levelphe level

Outcome improved with maternal blood Outcome improved with maternal blood phe <2 mg/dl prior to conception and phe <2 mg/dl prior to conception and during pregnancyduring pregnancy

Nutrition and NBS: Community – Nutrition and NBS: Community – Glutaric Acidemia, type I Glutaric Acidemia, type I

Defect in lysine and Defect in lysine and tryptophan catabolismtryptophan catabolism

Treatment: Treatment: – LYS- and TRP- restriction LYS- and TRP- restriction

(specialized formula, low (specialized formula, low protein food pattern) protein food pattern)

– RiboflavinRiboflavin– Frequent monitoringFrequent monitoring– Aggressively prevent Aggressively prevent

catabolism catabolism metabolic crisis metabolic crisis Symptoms:Symptoms:

– Macrocephaly, frontotemporal Macrocephaly, frontotemporal atrophy and delayed atrophy and delayed myelinationmyelination

– Myoclonic seizures, ataxia, Myoclonic seizures, ataxia, choreoathetosischoreoathetosis

– Intermittent metabolic Intermittent metabolic acidosisacidosis

Glutaryl-CoA dehydrogenase deficiency

Example: Infant with GAIExample: Infant with GAI 12 month old12 month old Medical conditions:Medical conditions:

– Glutaric acidemia, type 1 (identified by NBS)Glutaric acidemia, type 1 (identified by NBS)– Cystic fibrosisCystic fibrosis– Meconium ileus (repaired)Meconium ileus (repaired)– GERGER

Goals: optimal nutrition status, avoid metabolic Goals: optimal nutrition status, avoid metabolic decompensation decompensation

Simplified nutrition-related historySimplified nutrition-related history– Breastmilk (or Isomil)+ Glutarex-1 to restrict lysineBreastmilk (or Isomil)+ Glutarex-1 to restrict lysine– MCT oil, concentrated formula for weight gain; pancreatic MCT oil, concentrated formula for weight gain; pancreatic

enzymesenzymes– Solid foods introduced when developmentally appropriateSolid foods introduced when developmentally appropriate– NG tube NG tube g-tube placed by 2 mo g-tube placed by 2 mo

Example: Infant with GAIExample: Infant with GAI

““The Players”The Players” Family: Family:

mother, father, infant, mother, father, infant, extended familyextended family

Biochem team: Biochem team: geneticist, nutritionist, geneticist, nutritionist, genetic counselorgenetic counselor

Pulmonary team:Pulmonary team:pulmonologist, nutritionist, pulmonologist, nutritionist, social worker, nursessocial worker, nurses

Primary care:Primary care:pediatricianpediatrician

Community:Community:therapists, WIC nutritionist, therapists, WIC nutritionist, public health nurse, home public health nurse, home infusion companyinfusion company

Example: Infant with GAIExample: Infant with GAI

MNT and monitoring plan:MNT and monitoring plan: Formula – preparation, Formula – preparation,

“recipe,” tolerance“recipe,” tolerance Blood levels – schedule, Blood levels – schedule,

lag between draw and lag between draw and resultsresults

Growth and nutrient needs Growth and nutrient needs – balance approaches for – balance approaches for CF and GA1CF and GA1

Food – introduction of Food – introduction of solids, oral aversionsolids, oral aversion

PrioritizationPrioritization CommunicationCommunication

Nutrition and NBS: CommunityNutrition and NBS: Community

PHN and interpreter make monthly visits to PHN and interpreter make monthly visits to family of young child with MSUD. family of young child with MSUD.

Through pre-arranged phone calls, we can Through pre-arranged phone calls, we can discuss formula composition and discuss formula composition and preparation, and solid foods.preparation, and solid foods.

This helps provide information between This helps provide information between regular clinic visits.regular clinic visits.

Nutrition and NBS: CommunityNutrition and NBS: Community

A woman with PKU is enrolled in te First A woman with PKU is enrolled in te First Steps program (WA State MSS)Steps program (WA State MSS)

The RD with PKU Clinic provides consultation The RD with PKU Clinic provides consultation to the First Steps RD, about management of to the First Steps RD, about management of amino acid levels.amino acid levels.

Nutrition and NBS: CommunityNutrition and NBS: Community

The family of a child with propionic acidemia The family of a child with propionic acidemia receives formula from home infusion receives formula from home infusion company. company.

The home infusion RD is able to make home The home infusion RD is able to make home visits to evaluate growth and intake, and visits to evaluate growth and intake, and communicates with clinic RD.communicates with clinic RD.

This helps to ensure that the family is able This helps to ensure that the family is able to implement recommendations.to implement recommendations.

Nutrition and NBS: CommunityNutrition and NBS: CommunityThe baby has a “positive PKU test”The baby has a “positive PKU test”

What were the blood phenylalanine (phe) What were the blood phenylalanine (phe) or other critical elevated blood levels?or other critical elevated blood levels?

When was the sample collected?When was the sample collected? What is the protocol for confirming the What is the protocol for confirming the

diagnosis?diagnosis? When was the diagnosis made?When was the diagnosis made? Did this referral come from a screening Did this referral come from a screening

test? If so, what is the next step toward test? If so, what is the next step toward diagnosis?diagnosis?

Is the family aware of the results?Is the family aware of the results?

Information Needed by Community and Information Needed by Community and Metabolic Teams Before MNT is InitiatedMetabolic Teams Before MNT is Initiated

If an infant has been identified by NBS:If an infant has been identified by NBS: Which NBS results are positiveWhich NBS results are positive Birth date and age of the infantBirth date and age of the infant Birth weight and gestational ageBirth weight and gestational age Current weightCurrent weight Current form of feeding, and intakeCurrent form of feeding, and intake Current health status of the infantCurrent health status of the infant

Critical Questions about Follow-up Critical Questions about Follow-up and Coordination of Treatmentand Coordination of Treatment

Who is your contact at the metabolic center?Who is your contact at the metabolic center? What is the recommended treatment for the What is the recommended treatment for the

disorder?disorder? What nutrition intervention is required? How is What nutrition intervention is required? How is

this monitored?this monitored? What is the mechanism for follow-up and testing?What is the mechanism for follow-up and testing? Who will prescribe the specialized formulas?Who will prescribe the specialized formulas? How will the community and metabolic teams How will the community and metabolic teams

communicate about intervention?communicate about intervention?

The TeamThe Team

ChildChild Age-appropriate self-mgmt skillsAge-appropriate self-mgmt skills

ParentsParents Health status monitoring, teaching, Health status monitoring, teaching, advocacyadvocacy

NutritionistNutritionist MNT, feeding skillsMNT, feeding skills

GeneticistGeneticist Medical monitoringMedical monitoring

LabLab Laboratory monitoringLaboratory monitoring

Medical HomeMedical Home Well Child Care, family supportWell Child Care, family support

PsychologistPsychologist Developmental monitoring, screeningDevelopmental monitoring, screening

Community Providers Community Providers (RD, PHN)(RD, PHN)

Family support in communityFamily support in community

SchoolSchool Educational programs, tx monitoringEducational programs, tx monitoring

Therapists (OT, PT, SLP, Therapists (OT, PT, SLP, etc.)etc.)

Developmental monitoring and interventionDevelopmental monitoring and intervention

NBS and the Community: NBS and the Community: ChallengesChallenges

Understand the implications of the Understand the implications of the results of newborn screening testsresults of newborn screening tests

Develop a communication system Develop a communication system between the community providers between the community providers and the metabolic team for support and the metabolic team for support of treatmentof treatment

Interact with PCPs and families as Interact with PCPs and families as needed, to support appropriate MNTneeded, to support appropriate MNT

NBS and the Community:NBS and the Community:What you need to knowWhat you need to know

Which disorders are identified by NBS in Which disorders are identified by NBS in your state? Where do you find this your state? Where do you find this information?information?

What is the difference between What is the difference between screening screening and and diagnostic resultsdiagnostic results??

What is the system for follow-up of What is the system for follow-up of presumptive positive NBS results?presumptive positive NBS results?

How do you make referrals to regional How do you make referrals to regional genetics clinics and specialty care clinics?genetics clinics and specialty care clinics?

Caveats to PonderCaveats to Ponder

Is it really a disorder?Is it really a disorder? What are we talking about? What are we talking about?

– Is GA1 really Is GA1 really so so different than GA2?different than GA2?– If we’re out of MSUD Analog, can we use MSUD If we’re out of MSUD Analog, can we use MSUD

Maxamaid?Maxamaid? Screening vs. diagnosisScreening vs. diagnosis Is it really PKU?Is it really PKU?

Scenes from the Scenes from the Annals of Reporting Annals of Reporting and Acting on NBS Resultsand Acting on NBS Results

A primary care physician telephones are A primary care physician telephones are reports there is a new baby with PKU and reports there is a new baby with PKU and asks that you please start the infant on asks that you please start the infant on formula ASAP.formula ASAP.

What additional information What additional information do you need?do you need?

What would you do?What would you do?

Scenes from the Scenes from the Annals of Reporting Annals of Reporting and Acting on NBS Resultsand Acting on NBS Results

You are on-call for the weekend for your You are on-call for the weekend for your local hospital and you receive an order from local hospital and you receive an order from the newborn nursery on an infant with the newborn nursery on an infant with presumptive galactosemia and a request for presumptive galactosemia and a request for the initiation of treatment.the initiation of treatment.

What additional What additional information do you need?information do you need?

What would you do?What would you do?

Additional InformationAdditional Information Washington State Newborn Screening Washington State Newborn Screening http://http://

www.doh.wa.gov/ehsph/phl/newborn/default.htmwww.doh.wa.gov/ehsph/phl/newborn/default.htm Star G-Screening, Technology, and Research in Genetics Star G-Screening, Technology, and Research in Genetics

http://newbornscreening.infohttp://newbornscreening.info National Newborn Screening and Genetics Resource Center National Newborn Screening and Genetics Resource Center

http://genes-r-us.uthscsa.eduhttp://genes-r-us.uthscsa.edu

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