World Journal of Pediatrics

, Volume 14, Issue 5, pp 470–481 | Cite as

High incidence of maternal vitamin B12 deficiency detected by newborn screening: first results from a study for the evaluation of 26 additional target disorders for the German newborn screening panel

  • Gwendolyn GramerEmail author
  • Junmin Fang-Hoffmann
  • Patrik Feyh
  • Glynis Klinke
  • Peter Monostori
  • Jürgen G. Okun
  • Georg F. Hoffmann
Original Article



Newborn screening (NBS) in Germany currently includes 15 target disorders. Recent diagnostic improvements suggest an extension of the screening panel.


Since August 2016, a prospective study evaluating 26 additional target disorders (25 metabolic disorders and vitamin B12-deficiency) in addition to the German screening panel is performed at the Newborn Screening Center Heidelberg. First-tier results from tandem-MS screening are complemented by second-tier strategies for 15 of the additional target disorders. NBS results of seven patients diagnosed symptomatically with one of the additional target disorders by selective screening since August 2016 are retrospectively evaluated.


Over a 13-month period, 68,418 children participated in the study. Second-tier analyses were performed in 5.4% of samples. Only 59 (0.1%) of study participants had abnormal screening results for one of the additional target disorders. Target disorders from the study panel were confirmed in 12 children: 1 3-hydroxy-3-methylglutaryl coenzyme A (CoA)-lyase deficiency, 1 citrullinemia type I, 1 multiple acyl-CoA dehydrogenase-deficiency, 1 methylenetetrahydrofolate reductase-deficiency, and 8 children with maternal vitamin B12-deficiency. In addition, six of seven patients diagnosed symptomatically outside the study with one of the target disorders would have been identified by the study strategy in their NBS sample.


Within 13 months, the study “Newborn Screening 2020” identified additional 12 children with treatable conditions while only marginally increasing the recall rate by 0.1%. Maternal vitamin B12-deficiency was the most frequent finding. Even more children could benefit from screening for the additional target disorders by extending the NBS panel for Germany and/or other countries.


Metabolic disorders Newborn screening Second-tier Vitamin B12 deficiency 


Author contributions

GG contributed to study design, collection, evaluation and interpretation of data, drafting and writing of the manuscript. JFH contributed to contribution and interpretation of data, and revision of the manuscript. PF contributed to study design, data acquisition and management, and revision of the manuscript. PM and GK contributed to development of the laboratory methods, contribution and interpretation of data, and revision of the manuscript. JGO  contributed to study design, development of the laboratory methods, and revision of the manuscript. GFH contributed to study design, interpretation of data, and revision of the manuscript. All authors approved the final version of the manuscript.


This study is generously supported by the Dietmar Hopp Foundation, St. Leon-Rot, Germany. The authors confirm independence from the sponsor; the content of the article has not been influenced by the sponsor.

Compliance with ethical standards

Ethical approval

The study “Newborn Screening 2020” as well as retrospective evaluation of NBS results of patients diagnosed by selective screening has been approved by the Ethics Committee of the University Hospital Heidelberg (no. S-533/2015). Written informed consent was obtained from parents before participation of children in the study “Newborn Screening 2020”.

Conflict of interest

GG received a lecture fee from MetaX, Friedberg; JFH, PF, GK, PM, JGO, and GFH report no disclosures.


  1. 1.
    Gramer G, Hauck F, Lobitz S, Sommerburg O, Speckmann C, Hoffmann GF. Newborn screening 2020; Perspectives for early disease recognition. Monatsschr Kinderheilkd. 2017;165:216–25.CrossRefGoogle Scholar
  2. 2.
    Huemer M, Kozich V, Rinaldo P, Baumgartner MR, Merinero B, Pasquini E, et al. Newborn screening for homocystinurias and methylation disorders: systematic review and proposed guidelines. J Inherit Metab Dis. 2015;38:1007–19.CrossRefPubMedCentralPubMedGoogle Scholar
  3. 3.
    Wong D, Tortorelli S, Bishop L, Sellars EA, Schimmenti LA, Gallant N, et al. Outcomes of four patients with homocysteine remethylation disorders detected by newborn screening. Genet Med. 2016;18:162–7.CrossRefPubMedCentralPubMedGoogle Scholar
  4. 4.
    El Bashir H, Dekair L, Mahmoud Y, Ben-Omran T. Neurodevelopmental and cognitive outcomes of classical homocystinuria: experience from qatar. JIMD Rep. 2015;21:89–95.CrossRefPubMedCentralPubMedGoogle Scholar
  5. 5.
    Whitehead VM. Acquired and inherited disorders of cobalamin and folate in children. Br J Haematol. 2006;134:125–36.CrossRefPubMedCentralPubMedGoogle Scholar
  6. 6.
    Singh G, Le D, Schnabl K, Leaker MT, Steele M, Sparkes RL. Vitamin B12 deficiency in infancy: the case for screening. Pediatr Blood Cancer. 2016;63:740–2.CrossRefPubMedCentralPubMedGoogle Scholar
  7. 7.
    Jain R, Singh A, Mittal M, Talukdar B. Vitamin B12 deficiency in children: a treatable cause of neurodevelopmental delay. J Child Neurol. 2015;30:641–3.CrossRefPubMedCentralPubMedGoogle Scholar
  8. 8.
    Advisory Committee on Heritable Disorders in Newborns and Children. Health Resources and Services Administration. Recommended Uniform Screening Panel. Accessed 13 Mar 2018.
  9. 9.
    American College of Medical Genetics Newborn Screening Expert Group. Newborn screening: toward a uniform screening panel and system–executive summary. Pediatrics. 2006;117:S296–307.CrossRefGoogle Scholar
  10. 10.
    Baumgartner MR, Hörster F, Dionisi-Vici C, Haliloglu G, Karall D, Chapman KA, et al. Proposed guidelines for the diagnosis and management of methylmalonic and propionic acidemia. Orphanet J Rare Dis. 2014;9:130.CrossRefPubMedCentralPubMedGoogle Scholar
  11. 11.
    Therrell BL, Padilla CD, Loeber JG, Kneisser I, Saadallah A, Borrajo GJ, et al. Current status of newborn screening worldwide: 2015. Semin Perinatol. 2015;39:171–87.CrossRefPubMedCentralPubMedGoogle Scholar
  12. 12.
    la Marca G, Malvagia S, Pasquini E, Innocenti M, Donati MA, Zammarchi E. Rapid 2nd-tier test for measurement of 3-OH-propionic and methylmalonic acids on dried blood spots: reducing the false-positive rate for propionylcarnitine during expanded newborn screening by liquid chromatography-tandem mass spectrometry. Clin Chem. 2007;53:1364–9.CrossRefPubMedCentralPubMedGoogle Scholar
  13. 13.
    Chace DH, DiPerna JC, Kalas TA, Johnson RW, Naylor EW. Rapid diagnosis of methylmalonic and propionic acidemias: quantitative tandem mass spectrometric analysis of propionylcarnitine in filter-paper blood specimens obtained from newborns. Clin Chem. 2001;47:2040–4.PubMedPubMedCentralGoogle Scholar
  14. 14.
    Matern D, Tortorelli S, Oglesbee D, Gavrilov D, Rinaldo P. Reduction of the false-positive rate in newborn screening by implementation of MS/MS-based second-tier tests: the Mayo Clinic experience (2004-2007). J Inherit Metab Dis. 2007;30:585–92.CrossRefPubMedCentralPubMedGoogle Scholar
  15. 15.
    Turgeon CT, Magera MJ, Cuthbert CD, Loken PR, Gavrilov DK, Tortorelli S, et al. Determination of total homocysteine, methylmalonic acid, and 2-methylcitric acid in dried blood spots by tandem mass spectrometry. Clin Chem. 2010;56:1686–95.CrossRefPubMedCentralPubMedGoogle Scholar
  16. 16.
    Gramer G, Abdoh G, Ben-Omran T, Shahbeck N, Ali R, Mahmoud L, et al. Newborn screening for remethylation disorders and vitamin B12 deficiency-evaluation of new strategies in cohorts from Qatar and Germany. World J Pediatr. 2017;13:136–43.CrossRefPubMedCentralPubMedGoogle Scholar
  17. 17.
    Okun JG, Gan-Schreier H, Ben-Omran T, Schmidt KV, Fang-Hoffmann J, Gramer G, et al. Newborn screening for vitamin B6 non-responsive classical homocystinuria—systematical evaluation of a two-tier strategy. JIMD Rep. 2017;32:87–94.CrossRefPubMedCentralPubMedGoogle Scholar
  18. 18.
    Gramer G, Okun JG, Hoffmann GF. Pilot study for evaluation of 21 additional metabolic disorders for the German newborn screening panel. J Inherit Metab Dis. 2016;39(Suppl 1):75.Google Scholar
  19. 19.
    German Society for Newborn Screening. Screening reports. Accessed 6 Mar 2017.
  20. 20.
    Schulze A, Lindner M, Kohlmüller D, Olgemöller K, Mayatepek E, Hoffmann GF. Expanded newborn screening for inborn errors of metabolism by electrospray ionization-tandem mass spectrometry: results, outcome, and implications. Pediatrics. 2003;111:1399–406.CrossRefPubMedGoogle Scholar
  21. 21.
    Röschinger W, Sonnenschein S, Schuhmann E, Nennstiel-Ratzel U, Roscher AA, Olgemöller B. New target diseases in newborn screening. Recommendations derived from a pilot study. Monatsschr Kinderheilkd. 2015;2:142–9.CrossRefGoogle Scholar
  22. 22.
    Gan-Schreier H, Kebbewar M, Fang-Hoffmann J, Wilrich J, Abdoh G, Ben-Omran T, et al. Newborn population screening for classic homocystinuria by determination of total homocysteine from Guthrie cards. J Pediatr. 2010;156:427–32.CrossRefPubMedCentralPubMedGoogle Scholar
  23. 23.
    Monostori P, Klinke G, Richter S, Baráth Á, Fingerhut R, Baumgartner MR, et al. Simultaneous determination of 3-hydroxypropionic acid, methylmalonic acid and methylcitric acid in dried blood spots: second-tier LC-MS/MS assay for newborn screening of propionic acidemia, methylmalonic acidemias and combined remethylation disorders. PLoS One. 2017;12:e0184897.CrossRefPubMedCentralPubMedGoogle Scholar
  24. 24.
    Sahm F, Capper D, Pusch S, Balss J, Koch A, Langhans CD, et al. Detection of 2-hydroxyglutarate in formalin-fixed paraffin-embedded glioma specimens by gas chromatography/mass spectrometry. Brain Pathol. 2012;22:26–31.CrossRefPubMedCentralPubMedGoogle Scholar
  25. 25.
    Scolamiero E, Villani GR, Ingenito L, Pecce R, Albano L, Caterino M, et al. Maternal vitamin B12 deficiency detected in expanded newborn screening. Clin Biochem. 2014;47:312–7.CrossRefPubMedCentralPubMedGoogle Scholar
  26. 26.
    Honzik T, Adamovicova M, Smolka V, Magner M, Hruba E, Zeman J. Clinical presentation and metabolic consequences in 40 breastfed infants with nutritional vitamin B12 deficiency—what have we learned? Eur J Paediatr Neurol. 2010;14:488–95.CrossRefPubMedCentralPubMedGoogle Scholar
  27. 27.
    Hinton CF, Ojodu JA, Fernhoff PM, Rasmussen SA, Scanlon KS, Hannon WH. Maternal and neonatal vitamin B12 deficiency detected through expanded newborn screening—United States, 2003–2007. J Pediatr. 2010;157:162–3.CrossRefPubMedCentralPubMedGoogle Scholar
  28. 28.
    Richter M, Beoing H, Grünewald-Funk D, Heseker H, Kroke A, Leschik-Bonnet E, et al. Vegan Diet–Position of the German Nutrition Society (DGE). Ernährungs Umschau. 2016;63:92–102.Google Scholar
  29. 29.
    Reinson K, Künnapas K, Kriisa A, Vals M, Muru K, Õunap K. Very high incidence of low vitamin B12 in estonian newborns. Meeting Report ISNS 9th International Symposium, 11–14 Sep 2016, The Hague, The Netherlands.Google Scholar
  30. 30.
    Obeid R, Murphy M, Solé-Navais P, Yajnik C. Cobalamin status from pregnancy to early childhood: lessons from global experience. Adv Nutr. 2017;8:971–9.CrossRefPubMedCentralPubMedGoogle Scholar
  31. 31.
    Sukumar N, Rafnsson SB, Kandala NB, Bhopal R, Yajnik CS, Saravanan P. Prevalence of vitamin B-12 insufficiency during pregnancy and its effect on offspring birth weight: a systematic review and meta-analysis. Am J Clin Nutr. 2016;103:1232–51.CrossRefPubMedCentralPubMedGoogle Scholar
  32. 32.
    Murphy MM, Molloy AM, Ueland PM, Fernandez-Ballart JD, Schneede J, Arija V, et al. Longitudinal study of the effect of pregnancy on maternal and fetal cobalamin status in healthy women and their offspring. J Nutr. 2007;137:1863–7.CrossRefPubMedCentralPubMedGoogle Scholar
  33. 33.
    Murphy MM, Scott JM, Arija V, Molloy AM, Fernandez-Ballart JD. Maternal homocysteine before conception and throughout pregnancy predicts fetal homocysteine and birth weight. Clin Chem. 2004;50:1406–12.CrossRefPubMedCentralPubMedGoogle Scholar
  34. 34.
    Ray JG, Goodman J, O’Mahoney PR, Mamdani MM, Jiang D. High rate of maternal vitamin B12 deficiency nearly a decade after Canadian folic acid flour fortification. QJM. 2008;101:475–7.CrossRefPubMedCentralPubMedGoogle Scholar
  35. 35.
    Jeruszka-Bielak M, Isman C, Schroder TH, Li W, Green TJ, Lamers Y. South Asian ethnicity is related to the highest risk of vitamin B12 deficiency in pregnant Canadian women. Nutrients 2017;9:317.CrossRefPubMedCentralGoogle Scholar
  36. 36.
    Schroder TH, Sinclair G, Mattman A, Jung B, Barr SI, Vallance HD, et al. Pregnant women of South Asian ethnicity in Canada have substantially lower vitamin B12 status compared with pregnant women of European ethnicity. Br J Nutr. 2017;118:454–62.CrossRefPubMedCentralPubMedGoogle Scholar
  37. 37.
    Finkelstein JL, Kurpad AV, Thomas T, Srinivasan K, Duggan C. Vitamin B12 status in pregnant women and their infants in South India. Eur J Clin Nutr. 2017;71:1046–53.CrossRefPubMedCentralPubMedGoogle Scholar
  38. 38.
    Sukumar N, Venkataraman H, Wilson S, Goljan I, Selvamoni S, Patel V, et al. Vitamin B12 status among pregnant women in the UK and its association with obesity and gestational diabetes. Nutrients. 2016;8:768.CrossRefPubMedCentralGoogle Scholar
  39. 39.
    Wiley V, Carpenter K, Wilcken B. Newborn screening with tandem mass spectrometry: 12 months’ experience in NSW Australia. Acta Paediatr Suppl. 1999;88:48–51.CrossRefPubMedCentralPubMedGoogle Scholar
  40. 40.
    Lim JS, Tan ES, John CM, Poh S, Yeo SJ, Ang JS, et al. Inborn error of metabolism (IEM) screening in Singapore by electrospray ionization-tandem mass spectrometry (ESI/MS/MS): an 8 year journey from pilot to current program. Mol Genet Metab. 2014;113:53–61.CrossRefPubMedCentralPubMedGoogle Scholar
  41. 41.
    Sarafoglou K, Rodgers J, Hietala A, Matern D, Bentler K. Expanded newborn screening for detection of vitamin B12 deficiency. JAMA. 2011;305:1198–200.CrossRefPubMedCentralPubMedGoogle Scholar
  42. 42.
    Huemer M, Scholl-Burgi S, Hadaya K, Kern I, Beer R, Seppi K, et al. Three new cases of late-onset cblC defect and review of the literature illustrating when to consider inborn errors of metabolism beyond infancy. Orphanet J Rare Dis. 2014;9:161.CrossRefPubMedCentralPubMedGoogle Scholar
  43. 43.
    Weisfeld-Adams JD, Bender HA, Miley-Akerstedt A, Frempong T, Schrager NL, Patel K, et al. Neurologic and neurodevelopmental phenotypes in young children with early-treated combined methylmalonic acidemia and homocystinuria, cobalamin C type. Mol Genet Metab. 2013;110:241–7.CrossRefPubMedCentralPubMedGoogle Scholar
  44. 44.
    Fischer S, Huemer M, Baumgartner M, Deodato F, Ballhausen D, Boneh A, et al. Clinical presentation and outcome in a series of 88 patients with the cblC defect. J Inherit Metab Dis. 2014;37:831–40.CrossRefPubMedGoogle Scholar
  45. 45.
    Weisfeld-Adams JD, Morrissey MA, Kirmse BM, Salveson BR, Wasserstein MP, McGuire PJ, et al. Newborn screening and early biochemical follow-up in combined methylmalonic aciduria and homocystinuria, cblC type, and utility of methionine as a secondary screening analyte. Mol Genet Metab. 2010;99:116–23.CrossRefPubMedCentralPubMedGoogle Scholar
  46. 46.
    Schroder TH, Mattman A, Sinclair G, Vallance HD, Lamers Y. Reference interval of methylmalonic acid concentrations in dried blood spots of healthy, term newborns to facilitate neonatal screening of vitamin B12 deficiency. Clin Biochem. 2016;49:973–8.CrossRefPubMedCentralPubMedGoogle Scholar
  47. 47.
    Schroder TH, Quay TA, Lamers Y. Methylmalonic acid quantified in dried blood spots provides a precise, valid, and stable measure of functional vitamin B-12 status in healthy women. J Nutr. 2014;144:1658–63.CrossRefPubMedCentralPubMedGoogle Scholar
  48. 48.
    Chanarin I, Metz J. Diagnosis of cobalamin deficiency: the old and the new. Br J Haematol. 1997;97:695–700.CrossRefPubMedCentralPubMedGoogle Scholar

Copyright information

© Children's Hospital, Zhejiang University School of Medicine 2018

Authors and Affiliations

  • Gwendolyn Gramer
    • 1
    Email author
  • Junmin Fang-Hoffmann
    • 1
  • Patrik Feyh
    • 1
  • Glynis Klinke
    • 1
  • Peter Monostori
    • 1
  • Jürgen G. Okun
    • 1
  • Georg F. Hoffmann
    • 1
  1. 1.Division of Neuropediatric and Metabolic Medicine, Department of General Pediatrics, Center for Pediatric and Adolescent MedicineUniversity Hospital HeidelbergHeidelbergGermany

Personalised recommendations