Introduction
A significant portion of neonates admitted to neonatal intensive care units are diagnosed with a genetic disorder [
1]. Congenital malformations, potentially indicating an underlying genetic disorder, are estimated to be present in 13% of all admissions to neonatal intensive care units (NICUs) and remain one of the leading causes of neonatal mortality (25–34%) [
2,
3,
4,
5,
6]. The clinical presentations of genetic disorders vary widely, from an isolated (major) congenital anomaly (CA) or multiple malformations (MCA) to more subtle clinical signs or symptoms. The diagnostic pathway is often long and requires extensive evaluations that may be invasive and costly [
1]. Diagnosis of most genetic disorders in neonatal and pediatric intensive care units (NICUs and PICUs) is generally not timely enough to adequately guide acute clinical management.
Previous studies have shown that genetic disorders are a frequent cause of CA, especially MCA [
1,
2]. However, the exact frequency is unknown, as percentages reported vary between 20 and 50
%, which can mainly be attributed to cohort selection and the heterogeneity of diagnostic tools used [
2,
7]. In neonates admitted to a NICU, genetic testing is generally aimed at detection of aneuploidies (such as trisomy 13, 18, and 21) or chromosomal aberrations, which in lesser extent is followed by direct testing of specific genes, guided by the patients’ phenotype.
Over the last decade, novel technologies, such as whole exome sequencing (WES), have entered the genetic diagnostic arena. Its use in clinical settings, such as neonatal intensive care, have however been limited, as turnaround times were perceived too long (i.e., months) to impact acute or short-term clinical decision making, and too costly compared to other genetic diagnostic testing options [
8‐
10]. Yet, as these turnaround times and costs have decreased significantly, there is an opportunity for innovation and durable implementation of WES in the NICU setting.
To facilitate these efforts, insight into current practices, both at the level of clinical presentation as well as the uptake of (the type of) genetic testing, is essential. For this purpose, a retrospective observational study was performed in a cohort of neonates admitted to the NICU of the Radboud university medical center during a 2-year period up to a postnatal age of 2 years.
Discussion
In this study, we retrospectively evaluated a cohort of 1444 neonates admitted to the NICU for the presence of genetic disorders and the genetic diagnostic process during the first 2 years of life. We observed that approximately one-third of all neonates at the NICU present with CA, which is often an indication for genetic testing. However, the timeline of genetic testing as part of the diagnostic pathway usually exceeds the neonatal time period. Also, the genetic technologies used during the neonatal period differ from those used in the post-neonatal time frame. In the last years, advanced techniques, with higher diagnostic yields, like exome or genome sequencing are used to diagnose patients in the post-neonatal period.
Neonates with congenital malformations indicating a possible genetic disorder comprise a substantial proportion of NICU admissions. Congenital malformations are important signs and should always alert the clinician [
3,
7]. The presence of a genetic disorder can easily be missed because of the variable clinical presentation of genetic disorders, often leading to a diagnostic odyssey requiring extensive evaluations, both clinically and genetically [
1].
Identifying the genetic cause of a patient’s condition puts an end to the diagnostic odyssey, obviating the need for further costly testing. Furthermore, confirmation of a genetic diagnosis has also been shown to alter clinical management [
8,
10,
15‐
17]. This may lead to a reduction in mortality and morbidity related to genetic disorders with onset in newborns. Contrarily, it may facilitate shared decision-making regarding transition to palliative care [
8,
18‐
20]. As an example, in one patient with congenital alveolar capillary dysplasia with misalignment of the pulmonary veins and therapy-resistant pulmonary hypertension, the TTD extended beyond 1 month. Prolonged ineffective cardiorespiratory support could be prevented for this patient given the disastrous prognosis due to the underlying genetic disorder. The timing of diagnosis may have major impact on clinical management of critically ill neonates [
17].
Interestingly, we noted that patients suspected of a genetic disorder in the neonatal period were more likely to get a diagnosis faster compared to a resulting suspicion in the post-neonatal phase. The median TTD of patients tested in the prenatal or neonatal period was significantly shorter compared to patients tested in the post-neonatal period. The reasons for this are the shorter turnaround time of the genetic tests used in these patients compared to those who are tested later in life, but also more obvious clinical presentations, like major CA, in neonates which initiated genetic testing compared to for instance developmental disorders or isolated intellectual disability, which only become recognizable later in life [
21].
In this study, we identified all patients with CA and determined their genetic diagnostic path throughout their first 2 years of life. It was observed that 26% (80/312) of infants with an isolated CA were genetically tested, leading to a diagnosis in 25% (20/80) of these patients. Similarly, for patients with MCA, 60% (90/149) of patients received genetic testing, with a diagnostic yield of 52% (47/90). Comparison of the different clinical presentations to determine whether we could identify any clinical indications why some patients with CA were tested, and others were not, did not reveal any specific observations (data not shown). This was not dependent on which organ system was affected. Potential reasons for the reduced uptake of genetic testing in patients with isolated CA or MCA could be unawareness of physicians to order genetic testing, or perceptions of “too long turn-around times to impact clinical decision making” and/or parents rejecting genetic evaluation.
Following the above rationale, one may wonder how many patients with CA would have benefited from early genetic testing, thereby reducing their diagnostic odyssey and allowing enhanced patient-tailored medicine. Extrapolation of the data from our cohort and based on the assumption that the genetic diagnostic yield achieved is representative for the remainder of the cohort, an extra 58 (diagnostic yield of 25% in 232 not-tested patients) patients could potentially be diagnosed in the group with an isolated CA, and another 25 (diagnostic yield of 43% in 59 not-tested patients) patients in the sub-cohort with MCA. The diagnostic yield for the group with MCA is corrected for patients with aneuploidies who rarely will not be tested and diagnosed because of the obvious clinical features.
Of note, also in the group of patients without CA, genetic diagnoses were made; retrospective analysis of these patients showed that there were specific clinical indications (mostly later in life) for genetic testing, such as neurodevelopmental delay. As we have limited the follow-up period of our cohort to 2 years of age, it is currently not possible to extrapolate the potential for additional diagnosis in the group of patients without CA. Overall, it is speculated that at least 83 (58 plus 25 = 6%) patients in our total cohort of 1444, and 29% (83/291) of not-tested patients with a CA could have likely remained undiagnosed due to a lack in genetic testing.
The limited uptake of genetic testing in daily clinical practice on the NICU patients offers opportunities for improvement, for instance, by offering genetic testing to all patients with one or multiple CA. Traditionally, genetic testing has been too time-consuming or perceived to have limited impact on management of the critically ill neonate. Technological advances in recent years have led to the ability to sequence and interpret the entire genome of a neonate in only 1 or 2 days [
22,
23]. Whereas many others have already shown that exome or genome sequencing can effectively be used to diagnose patients in turnaround times required in an acute setting, other clinical utility questions remain unsolved [
1,
9,
17‐
20,
23‐
26]. This does not only include matters related to genetic consultation, and patient selection, but also socio-economic analyses on cost-effectiveness, and scenario models to determine the most effective strategy to test most, if not all, patients at the NICU.
Ideally, one would analyze these aspects in a prospective parallel study that would offer great insight into the opportunities and potential pitfall of a so-called “WES or WGS-first strategy.” Outcome measures should not only focus on quantification of the diagnostic yields via rapid WES, but also on relevant clinical management changes, which are anticipated to range from the initiation of specific patient-tailored supportive management, the transition to palliative care for confirmed lethal conditions to simply refraining from further invasive diagnostic procedures as a consequence of having a final molecular diagnosis [
8]. The parental perceptions of WES are also very important, and key factors in the process of empowerment must be explored.
Whereas our study has limitations because of its retrospective nature relying only on information available in the patients’ EMR with only a few years of clinical follow-up, its power is reflected by the systematically assessment of all patients admitted to a level IV NICU for their clinical presentation, genetic testing, and genetic diagnosis obtained. We have motivated the speculation that currently admitted neonates to the NICU are underdiagnosed for disorders of genetic origin. Our results contribute to gaining insight in patient populations that would benefit from WES- or WGS-based genetic testing, that not only allows for impact on clinical decision making in the acute setting but would also limit the diagnostic odyssey of these patients. However, further research is needed to determine the best strategy on whom to offer advanced genetic testing, maximizing the potential of WES or WGS in the NICU setting improving the care provided to infants and their families.
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