The Lure of Treatment: Expanded Newborn Screening and the Curious Case of Histidinemia

Abstract

In the last decade, universal newborn screening (NBS) has entered a new era of promise and controversy. With the use of tandem mass spectroscopy, states have substantially increased the number of conditions included in mandatory NBS programs.1 This expansion has mostly followed recommendations from an expert panel commissioned by the Maternal and Child Health Bureau, which proposed mandated screening for a core panel of 29 conditions and suggested that 25 additional conditions be reported to families, although accepted treatments are not yet available.2 The President's Council on Bioethics3 criticized the recommendations, arguing that mandated NBS should be restricted to conditions that adhere closely to Wilson and Jungner's traditional principles for screening,4 especially the availability of treatment that is accepted as effective and accessible to patients. Others have countered that exclusive focus on treatment of the infant ignores other potential benefit to families and society and that the time has come to supplant treatment availability as the key criterion for NBS programs.5,6 These policy debates may seem to arise from access to new technology, but in fact similar issues arose in the early history of NBS. For example, NBS for phenylketonuria is justly celebrated as a public health success, but in the mid-1960s clinicians and policy makers faced profound ethical issues. NBS revealed many children with intermediate serum values of phenylalanine, and because clinicians did not know the natural history of these metabolic variants, they could not accurately weigh the risks and benefits of a restricted diet. A prospective, … Address correspondence to Jeffrey P. Brosco, MD, PhD, PO Box 016820 (D-820), Miami, FL 33101. E-mail: jbrosco{at}miami.edu