Classical galactosemia is an autosomal recessive disorder resulting from deficient galactose-1-phosphateuridyl transferase (GALT) activity. Verbal dyspraxia is an unusual outcome in galactosemia. Here we validated a simplified breath test of total body galactose oxidation against genotype and evaluated five potential biochemical risk indicators for verbal dyspraxia in galactosemia: cumulative percentage dose (CUMPCD) of 13 CO 2 in breath, mean erythrocyte galactose-1-phosphate, highest erythrocyte galactose-1-phosphate, mean urinary galactitol, and erythrocyte GALT activity. Thirteen controls and 42 patients with galactosemia took a 13 C-galactose bolus, and the (CUMPCD) of 13 CO 2 in expired air was determined. Patients with Ͻ5% CUMPCD had mutant alleles that severely impaired human GALT enzyme catalysis. Patients with Ն5% CUMPCD had milder mutant human GALT alleles. Twenty-four patients consented to formal speech evaluation; 15 (63%) had verbal dyspraxia. Dyspraxic patients had significantly lower CUMPCD values (2.84 Ϯ 5.76% versus 11.51 Ϯ 7.67%; p Ͻ 0.008) and significantly higher mean erythrocyte galactose-1-phosphate (3.38 Ϯ 0.922 mg/dL versus 1.92 Ϯ 1.28 mg/dL; p ϭ 0.019) and mean urinary galactitol concentrations (192.4 Ϯ 75.8 mmol/mol creatinine versus 122.0 Ϯ 56.4; p ϭ 0.048) than patients with normal speech. CUMPCD values Ͻ5%, mean erythrocyte galactose-1-phosphate levels Ͼ2.7 mg/dL, and mean urinary galactitol levels Ͼ135 mmol/mol creatinine were associated with dyspraxic outcome with odds ratios of 21, 13, and 5, respectively. We conclude that total body oxidation of galactose to CO 2 in expired air reflects genotype and that this breath test is a sensitive predictor of verbal dyspraxia in patients with galactosemia. Classical galactosemia is an autosomal recessive disorder resulting from deficient human galactose-1-phosphate uridyl transferase (hGALT) (1, 2). Currently, Ͼ180 mutations produce Ͻ1% of hGALT activity when present as homozygous or compound heterozygous mutant genotypes (3-5). Newborns with galactosemia exhibit elevated concentrations of erythrocyte galactose-1-phosphate and excess galactitol in the urine. If newborn screening, retrieval, diagnosis, and removal of galactose from the diet occur before 5-7 d of life, then the neonatal signs of hepatotoxicity, jaundice, anorexia, and diarrhea are prevented or resolve (6, 7). However, infants who have classical galactosemia and are treated continue to have elevated erythrocyte galactose-1-phosphate and urinary galactitol concentrations after initiation of a galactose-restricted diet. These compounds remain elevated throughout the life of the patient; are indicators of the environment (compliance), genotype, epigenetic phenomenon (8 -10); and are implicated in the enigmatic outcomes in galactosemia (7, 8, 10 -13).Roughly half of the children with classical galactosemia manifest verbal dyspraxia (7,10,14). This expressive speech problem results from an impaired ability to program the muscles needed for speech. Children exhibit "chaotic" speech...