CLINICAL CHEMISTRY IN PAEDIATRICS

Paediatric Medicine
no longer begins with the birth of the child
now becoming possible to treat some fetal disorders in
utero
chemical pathology will be required to provide an
appropriate service to support this
NEONATES (INFANTS)
Full term
Before term (premature)
(immaturity contributes to severity of disease)
Premature
infants Survival rate up due to
-Specialized medical and nursing techniques
-Laboratory methods assaying very small samples
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Problems For The Chemical Pathology
Size of the blood sample
for the very young it is essential to employ analytical
methods that will use the smallest possible amount of
plasma
-this usually means providing special equipment
small quantities of capillary blood can be conveniently
collected by pricking the heel
-but this should be done by experienced personnel
-the results obtained may be affected by
haemolysis or by contamination with tissue fluid.
complete, accurately timed collections of urine are very
difficult to obtain in children.
it is usually more reliable to relate the concentrations of
urinary constituents to urine creatinine concentration.
Many conditions present exclusively, or predominantly,
in the neonatal period
examples include many congenital diseases and
inherited metabolic disorders
other disorders may become apparent at any time
during childhood
-in particular disorders of growth and of sexual
differentiation and development.
2
Biochemical Investigations
Except for inborn errors of metabolism same as for
adults but
more labour intensive
requests less selective
(symptoms non specific, infant cannot give history)
on smaller sample (to avoid causing anaemia)
(1 kg infant 90ml bld 70 kg adult 5litres bld)
venous or arterial bld preferred (difficult to obtain)
capillary sometimes used (prone to interstitial &
cellular fluid contamination)
performed in order of priority
Interpretation of results
relate to reference values appropriate to particular
age gp
3
Biochemical Problems In The Neonatal Period
Convulsions
violent involuntary contraction of voluntary muscles
many causes
- hypoglycaemia
-hypocalcaemia
-hypomagnesaemia
-hypernatraemia
-hyponatraemia
Hypoglycaemia
C glucose of 1.1mmol/l or less on two occasions
(by enzymatic method - adult 2.2 mmol/l)
C usually occurs 24-72 hrs after birth (1 in 500 births)
C accompanied by ketosis (+ve urine)
C rarely in older infants
Secondary to
-fructosaemia
-galactosaemia
-leucine sensitivity
-insulinoma
-congenital adrenal hyperplasia
- inborn errors of CHO metabolism such as
glycogen storage disease
4
C In newborns, hypoglycemia
can produce
irritability, myoclonic jerks, cyanosis,
respiratory distress, sweating, hypothermia,
refusal to feed, and seizures
can resemble asphyxia, hypocalcemia, sepsis, or
heart failure
is a common problem in critically ill or extremely
low birthweight infants.
if not due to maternal hyperglycemia, in most cases it
is multifactorial, transient and easily supported
in a minority of cases turns out to be due to significant
hyperinsulinism, hypopituitarism or an inborn error of
metabolism and presents more of a management
challenge
Transient neonatal hypoglycemia
- prematurity, intrauterine growth retardation,
perinatal asphyxia
- maternal hyperglycemia due to diabetes or
iatrogenic glucose administration
-Sepsis
- prolonged fasting (e.g., due to inadequate breast
milk or condition interfering with feeding)
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Hypocalcaemia
(in association with PO
4
)
Two groups
The first gp
occurs with 72 hrs of birth
small gp
pt may have glucose
history of difficult delivery (prenatal asphyxia)
infants of diabetic mothers
rarely related to maternal hypercalcaemia
( Ca suppressing fetal parathyroid glands)
Second
between 4
th
and 10
th
day
confined to infants fed with milk other than of
human origin
(due to PO4 content => interferes with Ca
absorption)
have sometimes also Mg
Hypomagnesaemia (may be as low as 0.1 mmol/l)
Cause
dietary deficiency
6
or increased intestinal or urinary loss
convulsions not corrected by Ca administration
may occur with Ca
( Mg impairing release of PTH)
Plasma sodium
Hypernatraemia
Na due to predominant water loss
e.g. insensible loss due
-pneumonia,
-diarrhea
-phototherapy for jaundice
(convulsions caused by changes in cerebral hydration)
Hyponatraemia
Na due to
prolonged maternal infusion of oxytocin to induce
labour (has antidiuretic action similar to ADH)
infusion on water in excess of sodium
Neonatal Hyperbilirubinaemia
Two types
unconjugated
-conjugated
Unconjugated hyperbilirubinaemia
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bilirubin > 34 umol/l in 90% of normal babies
others up to 200 umol/l without pathological cause
> 200umol/l, persistent after first wk of life
pathological
Plasma Unconjugated bilirubin ^ (>340 umol/l)
albumin capacity to bind bilirubin exceeded
bili. crosses bld-brain barrier
deposited in brain
kernicterus => brain damage (esp. basal
ganglia)
Critical level (340umol/l) depends on
-plasma albumin conc.
-presence of drugs (e.g. sulphanamides)
-acid base disturbances
Physiological Unconjugated hyperbilirubinaemia
C very common, causes include
short RBC half-life, Hb falls rapidly in first wk of
life
not fully developed conjugating enzymes
interference with hepatic transport by drugs from
mother
reabsorption of bili. => no flora to convert to
urobilinogen
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Pathological causes
increased haemolysis (ABO Rhesus)
abnormalities in RBC ( G6PD deficiency, hereditary
spherocytosis)
defective hepatic uptake or conjugation
(inherited disorders,e.g. Gilberts or Crigler Najjar
syndrome)
prematurity
Jaundice during first 24 hrs more likely to be
pathological
Urine bili . negative unless there is glomerular damage
& protenuria
Management
< 340 umol/l phototherapy => UV light
(bilirubin destroyed by light)
> 340 umol/l exchange transfusion
complication
-hyperkalaemia
-hypocalcaemia
- metabolic acidosis
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Conjugated Hyperbilirubinaemia
Causes
intrahepatic cholestasis in cystic fibrosis
biliary obstruction (extrabiliary tumours)
abnormalities of biliary tree (extra or intra-hepatic
canals)
Noenatal hepatitis
presents clinically usually after first wk of life
Causes
intrauterine infection with cytomegalovirus, & rubella
metabolic causes e.g. a1 antitrypsin deficiency or
galactosaemia
LFT
cholestatic pattern, with large rise ALP activity
Lipoprotein X detectable in plasma
ALT & AST also raised
Lipoprotein X - an abnormal lipoprotein composed of 65% lecithin, 30% cholesterol and 5% proteinapoC and albumin, seen in
lecithin-cholesterol acyl-transferase deficiency and in obstructive biliary disease, and associated with cholestatic jaundice
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Acid Base disturbances
Commonest =>respiratory distress syndrome (RDS)
occurs in infants < 38 wks of gestation
due to deficiency of surfactant in the alveoli
presents with pulmonary collapse & secondary lung
infection
- + pO2 & pCO causes resp. acidosis
- + bld flow due to hypotension causes tissue hypoxia
& lactic acidosis (met. acidosis)
- acidosis may be severe pH < 7.0
Management
positive pressure ventilation
monitor PO
2
, & PCO
2
Lecithin: Sphingomyelin ratio used to predict
likelihood of developing RDS
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Failure To Thrive
Many causes
- malnutrition
- vitamin deficiency diseases
- cystic fibrosis
- other errors of metabolism
Malnutrition
kwashiorkor & marasmus => protein deficiency
Determine albumin
> 36 g/l normal
< 30 g/l abnormal
< 25g/l associated with increasing degrees of oedema
and conc. of some essential AA (valine, Leucine,
isoleucine)
IMMUNOGLOBULINS
IgG fall at birth
IgM adult level by 9 months
IgM 3 yrs
IgA 15yrs
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high plasma IgM at birth (umbilical cord bld)
or within first 4wks.
- intrauterine infection or neonatal infection e.g.
syphilis, rubella, toxoplasmosis or cytomegalovirus
Plasma Ig level also measured to exclude deficiency
states
Rickets Of The Premature
Nutritional rickets
- Ca & PO4 +
- ALP^
rickets of the premature low birth wt infants
evident between 4
th
& 12
th
wk
decalcification of bones predisposes to pathological
factures
respiration impaired by soft bones of ribs
Causes
C maternal vit. D deficiency during pregnancy or in
infant after birth
C drugs like frusemide ^ urinary Ca loss
C renal tubular disorders of PO4 absorption
Ca
2+
N or ^ => cannot be deposited in bone without
PO4
Mgt
13
Vit. D, Ca
2+
,PO
4-
supplementation. Monitor with ALP
NEONATAL HYPOTHYROIDISM
TSH rises rapidly at birth 15x adult (responding to
stress at birth)
reachs peak within 1
st
hr
falls (rapidly at first) during the next wk
screen after one wk (TSH)
Prenatal diagnosis or prenatal screening
is testing for diseases or conditions in a fetus or
embryo before it is born
aim is to detect birth defects such as
-neural tube defects
-Down syndrome,
-chromosome abnormalities,
-& genetic diseases
and other conditions,
- Tay Sachs disease
-sickle cellanemia,
-thalassemia,
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-cystic fibrosis
Screening can also be used for prenatal sex
scernment.
Amniotic Fluid
forms protective cushion for fetus in fluid filled
sac in utero
is formed from both amniotic membrane &
secretions from fetal cells (gastrointestinal,
respiratory, umbilical cord, & in late pregnancy
fetal urine)
there is also feto-maternal exchange of water
between amniotic fluid & maternal fluids
removal of amniotic fluid , called amniocentesis
usually performed to determine isoimmunization,
fetal maturity in high risk pregnancies or for
genetic screening
Isoimmunization
results from bld group incompatability between
mother & fetus
Rh or other bld group IgG antibodies destroying
infants RBCs
haemolysis detected by presence of bilirubin
15
normal fetus- bilirubin picks at 23-25weeks
gestation => diappears by end of 36
th
wk
haemolysis evaluation usually carried out at 28
wks
amniocentesis indicated if maternal antibody
titers shows increasing pattern
done every month prior to 26 wks, then every 2
wks there after
Fetal Maturity
Lecithin/ Sphingomylin (L/S) Ratio
Respiratory Distress Syndrome caused by deficiency
of pulmonary surfactant at birth
Pulmonary surfactant => a phospholipid protein
complex that coats alveoli preventing collapse of air
spaces on expiration
synthesized by type II pneumocytes lining alveoli
major surfaceactive constituents of surfactant
- lecithin ( dipalmitoyl phoshatidyl choline
- phosphatidal glycerol (PG)
both are phospholipids secreted by fetal lungs
their levels aid determination of fetal lung maturity
Sphingomyelin
-another phospholipid
-remains constant throughout embryonic
development
-used as internal std since
16
- corrects for difference in volume
Normal development
- up to 26wks sphingomyelin > lecithin
-L/S ratio < 1.0
- lecithin concentration slowly increases until 35
th
wk
- after 35
th
surge in lecithin
- results in L/S of 2.0 or more
-PG normally appears around 36 37 wks of
gestation
indicates first biochemical stage of lung maturity
=> stabilizes lecithin
L/S determination
Thin layer chromatography used
Extracted in chloroform/methanol mixture
Organic phase evaporated & redissolved in chloroform
Spots visualized by charring or by use of lipid stains
Followed by scanning on a densitometer
Bubble Stability or Shake Test
bubble stability primarily due to conc. of
dipalmitoyl lecithin
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Method
shake amniotic fluid with 95 % ethanol for 15 sec
observe bubble stability at air- liquid interface
after sample has remained undisturbed for 15 min
ethanol inhibits bubble formation by other
constituents of amniotic fluid except those by
active phospholipid surfactants
positive : continuum of bubbles around the
circumference of liquid surface at end of 15 min
Creatinine
later in gestation fetal urine contributes to amniotic
fluid
amniotic fluid creatinine level is related to, fetal
muscle mass, renal function & maternal creatinine
levels
creatinine increases as fetus matures
creatinine of 170 mol predictive of mature fetus
only if maternal creatinine does not exceed 80
mol
= used only to assess fetal size & gestational age but
not lung maturity
(scan on spectrophotometer at 450nm)
= centrifuge amniotic fluid, scan against water blank between 350 & 650 nm
= normal curve shows gradual decrease in absorbance, a straight line between 365 & 550
= abnormal curve at 450 shows presence of bilirubin
= protect sample from light (Bilirubin destroyed)
= contamination with bld may falsely elevate bilirubin values
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INBORN ERRORS OF METABOLISM
(Congenital Metabolic Or Inherited Metabolic Diseases)
large class of genetic diseases involving disorders of
metabolism
majority due to defects of single genes that code for
enzymes that facilitate conversion of various
substances (substrates) into others (products)
problems arise due to accumulation of substances which are
toxic or interfere with normal function
or to the effects of reduced ability to synthesize essential
compounds.

C See table - major classes of congenital metabolic
diseases, with prominent examples of each class
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Congenital Metabolic Disease Prominent Example
Disorders of carbohydrate
metabolism
glycogen storage disease
Disorders of amino acid
metabolism
phenylketonuria ,
maple syrup urine disease,
glutaric acidemia type 1
Disorders of organic acid
metabolism (organic
acidurias)
alkaptonuria
Disorders of fatty acid oxidation
and mitochondrial
metabolism

medium chain acyl dehydrogenase
deficiency (glutaric academia
type 2)
Disorders of purine or
pyrimidine metabolism

Lesch-Nyhan syndrome
Disorders of porphyrin
metabolism

acute intermittent porphyria
Disorders of mitochondrial
function
Kearns-Sayre syndrome
Disorders of peroxisomal
function

Zellweger syndrome
Lysosomal storage disorders

Gaucher's disease,
Niemann Pick disease
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Disorders of steroid metabolism

congenital adrenal hyperplasia
Glycogen storage disease (GSD, also glycogenosis and
dextrinosis)
defects in the processing of glycogen synthesis or
breakdown within muscles, liver, and other cell types
two classes
-genetic
-acquired.
Genetic GSD caused by genetically defective enzymes
In livestock, acquired GSD is caused by
intoxication with the alkaloid castanospermine
Types
eleven distinct diseases
21
NO Enzyme Eponym hypoglyc Hepat
omegaly
Hyperl
ipidaemi
a
Muscle
Symptoms
Development
/prognosis
Other
symptoms
GSD
0
Gly/synthase Y N N Occ
Muscle
cramps
I G6P Von Gierke Y Y Y non Growth failure Lactic
Acidosis
hyperuricaemia
II Acid maltase Pompes N Y N Muscle
weakness
Death by age
2.infantile
varient
Heart failure
III GLYCOGEN
debrancher
Coris
Forbes
desease
Y Y Y myopathy
IV glycogen
branching enzyme
Andersen disease N Hepatomegaly
cirrhosis
N None Failure to thrive,
death at age ~5
years
V muscle glycogen
phosphorylase
McArdle disease N N N Exercise-induced
cramps,
Rhabdomyolysis
Renal failure by
myoglobinuria
VI liver glycogen
phosphorylase
Hers' disease Y Y N none
VII muscle
phosphofructokin
ase
Tarui's diseas N N N Exercise-induced
muscle cramps
and weakness
(sometimes
rhabdomyolysis)
growth
retardation
Haemolytic
anaemia
XI glucose
transporter,
GLUT2
Fanconi-Bickel
syndrome
Y Y N None
XII Aldolase A Red cell aldolase
deficiency
? ? ? Exercise
intolerance,
cramps
XIII -enolase - ? ? ? Exercise
intolerance
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Phenylketonuria (PKU)
an autosomal recessive metabolic genetic disorder
a mutated gene for phenylalanine hydroxylase
deficiency in the hepatic enzyme phenylalanine hydroxylase
enzyme necessary to metabolize the amino acid
phenylalanine ('Phe') to the amino acid tyrosine.
phenylalanine accumulates and is converted into
phenylpyruvate (also known as phenylketone),
phenylketone detected in the urine
Left untreated
problems with brain development leading
- to progressive mental retardation
- brain damage, and seizures
Clinical presentation
=seizures, albinism (excessively fair hair and skin)
= "musty odor" to the baby's sweat and urine (due to
phenylacetate, one of the ketones produced
Optimal treatment
monitoring diet and cognitive development
combining a low-phenylalanine diet with protein
supplements
lowering blood phenylalanine levels to a safe range
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oral administration of tetrahydrobiopterin (or BH4) (a
cofactor for the oxidation of phenylalanine) can reduce
blood levels of phenylalanine in certain patients
C Currently no cure
PKU detected through newborn screening 6 -14 days after
birth
C therapies currently under investigation,including
Cgene therapy
Cenzyme substitution therapy with phenylalanine
ammonia lyase (PAL).
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Alkaptonuria (black urine disease or alcaptonuria)
rare inherited genetic disorder of phenylalanine and
tyrosine metabolism.
autosomal recessive due to a defect in the enzyme
homogentisate 1,2-dioxygenase
the enzyme participates in the degradation of tyrosine.
a toxic tyrosine byproduct homogentisic acid (or
alkapton) accumulates in the blood
is excreted in urine in large amounts(hence -uria).
excessive homogentisic acid causes damage to
cartilage (ochronosis, leading to osteoarthritis) and
heart valves
also precipitates as kidney stones
Treatment
C with nitisinone, which suppresses homogentisic acid
production, is being studied
C Alkaptonuria common in Slovakia and the
Dominican Republic
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Signs and symptoms
Alkaptonuria is often asymptomatic
sclera of the eyes may be pigmented (often only at a later
age)
skin may be darkened in sun-exposed areas and around sweat
glands
sweat may be coloured brown
urine may turn brown if collected and left exposed to open air
C kidney stones and stone formation in the prostate common
C accumulation of homogentisic acid in tissues, joints this leads
to cartilage damage,
C in the spine, leads to low back pain at a young age
C cartilage damage may also occur in the hip and shoulder.
C joint replacement surgery (hip and shoulder) often necessary
at a relatively young age
valvular heart disease (mainly calcification and regurgitation
of the aortic and mitral valves) may occur
in severe and progressive cases valve replacement may be
necessary.
C A distinctive characteristic of alkaptonuria => ear wax
exposed to air turns red or black (depending on diet) after
several hours because of the accumulation of homogen
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LeschNyhan syndrome (LNS), also known as Nyhan's
syndrome, Kelley-Seegmiller syndrome and Juvenile gout
-by medical student Michael Lesch and his mentor,
pediatrician Bill Nyhan, in 1964.
rare inherited disorder caused by a deficiency of the enzyme
hypoxanthine-guanine phosphoribosyltransferase (HGPRT),
produced by mutations in the HPRT gene.
lack of HGPRT causes a build-up of uric acid in all body
fluids: both hyperuricemia and hyperuricosuria
leads to severe gout and kidney problems, poor muscle
control, and moderate mental retardation
(usually in the first year of life)
A striking feature of LNS => uncontrollable self -mutilating
behaviors, characterized by lip and finger biting & head
banging
( in the 2nd year of life =>can increase during times of stress
Neurological symptoms include facial grimacing, involuntary
writhing, and repetitive movements of the arms and legs
because a lack of HGPRT causes the body to poorly utilize
vitamin B12, some boys may develop megaloblastic anemia
LNS is an X-linked recessive disease
males suffer delayed growth and puberty, and most develop
shrunken testicles or testicular atrophy
27
Diagnosis
= overproduction of uric acid present at birth, but may not be
recognized by routine clinical laboratory testing methods.
=serum uric acid concentration is often normal, as the excess
purines are promptly eliminated in the urine
=urate to creatinine concentration ratio in urine is elevated.
=a urate to creatinine ratio above two is typically found
molecular genetic studies of the HPRT gene mutations may
confirm diagnosis
helpful for subsequent 'carrier testing' in at-risk females such
as close family relatives on the female side
Cgout and renal symptoms respond well to treatment with
drugs such as allopurinol
Prognosis
- for individuals with severe LNS is poor.
- death is usually due to renal failure or complications from
hypotonia, in the first or second decade of life.
- less severe forms have better prognoses
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