We prepared whole-blood pools to contain various concentrations of phenylalanine (Phe), thyroxin (T4), and thyrotropin (TSH) and applied them to six different lots of Schleicher & Schuell Grade 903 filter paper, two of which represented extremes for serum-absorbancy. Individual measured T4 values showed minimal overlap among all pools for each individual filter-paper lot and for all lots combined, but Phe values overlapped considerably among the high-concentration pools within and among lots. Individual TSH values also showed considerable overlap among the high-concentration pools for all lots combined, but little overlap within each lot. Maximum differences in mean observed values among lots ranged from 6% to 36% for all analytes. Assay results from hemolyzed blood specimens generally were lower than from intact-cell blood specimens for T4 and TSH, but slightly higher for Phe. Maximum among-lot differences in mean values ranged from 13% to 29% for all analytes when each tested lot was used for assay calibration. Lot-to-lot differences in measured values were not strongly related to serum absorbancy values. We conclude that routinely encountered within- and among-lot filter paper variability, as measured by serum-absorbancy, is not alone sufficient to cause gross quantification errors in neonatal screening programs.

We report an improved "high-performance" liquid-chromatographic (HPLC) method for measuring biopterin and neopterin in serum and urine. Specimens are acidified, treated with iodine in 0.2 mol/L trichloroacetic acid, party purified on Bio-Rad MP-50 cation-exchange columns, and analyzed by reversed-phase HPLC with fluorometric detection. The minimal concentration of biopterin detectable is 0.3 micrograms/L in a 50-microL injection. The total CV is less than or equal to 10%. Improvements over other reported methods include the use of a single, simplified sample-preparation step with a Baker-10 SPE System, and a guard column to increase analytical column stability and analyte recovery. The assay is semiautomated to reduce technician time and improve precision. Mean observed values for biopterin and neopterin in sera of normal human adults were 1.64 and 5.52 micrograms/L, respectively. The mean ratio of neopterin to biopterin in acidified adult urine samples was lower than that found in matched nonacidified samples (n = 10). Serum specimens from diagnosed phenylketonuric (PKU) and hyperphenylalaninemic patients were also analyzed for biopterin and neopterin; the findings agreed with reported values for similar patients. One patient, previously identified as an atypical PKU patient, showed serum values of neopterin and biopterin suggestive of a defect in biopterin synthesis.

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We conducted a structured telephone survey of state public health laboratory directors of neonatal screening programs to determine the extent of the problem of missed cases of phenylketonuria (PKU) and congenital hypothyroidism. A total of 76 missed cases were reported—43 PKU and 33 congenital hypothyroidism. We looked at the following characteristics of the missed cases: the stage at which the miss occurred, which included specimen collection, laboratory procedures, or follow-up; the size of the program; the type of screening program; the age of the infant at the time of screening; and any legal action that resulted from the miss. The 76 missed cases probably represent an underascertainment of the true number, yet we believe that our data provide an overview of some of the problems associated with mass neonatal screening. There was one missed case of PKU for every 70 cases detected, and one missed case of congenital hypothyroidism for every 120 cases detected; in other words, two congenital hypothyroidism cases were missed for every 1 million infants screened. Regarding the stage of screening in which the miss occurred, 14% occurred during specimen collection, 45% during the laboratory procedures stage, 16% during follow-up, 11% were the result of biologic variation, and in 14% the stage could not be identified. We conclude that neonatal screening programs have been highly successful but that there may be additional safeguards to be developed, tested, and implemented when practical.