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Correspondence

Indian Pediatr 2016;53: 173-174

Infantile Tremor Syndrome: A Syndrome in Search of its Etiology

 

*Jatinder S Goraya and #Sukhjot Kaur

From Departments of Pediatrics and #Dermatology, Dayanand Medical College and Hospital, Ludhiana, Punjab, India.
Email: *
[email protected]

 


Indian Pediatrics has done a great service by revisiting ‘Infantile Tremor Syndrome’ (ITS) [1]. Even though, ITS has existed for almost 60 years, it continues to be perceived as a syndrome of unknown etiology. However, there is now enough epidemiological, clinical, laboratory and therapeutic evidence in the literature to support vitamin B
12 deficiency as the cause of ITS.

Epidemiologically, ITS occurs in exclusively breastfed infants of strictly vegetarian mothers. As a result, these infants are predisposed to develop vitamin B12 deficiency. Clinically, symptoms and signs of ITS are similar to those of vitamin B12 deficiency in infants. Many studies in the past excluded vitamin B12 deficiency in ITS on the basis of mere absence of macrocytosis or megaloblastic bone marrow. Absence of these features does not exclude the diagnosis of vitamin B12 deficiency which requires serum vitamin B12 measurement. Several studies [2-4] have consistently demonstrated low serum vitamin B12 in these infants. Study by Bajpai, et al. [5] is the only report to have found normal serum vitamin B12, but only 20 (15%) of 134 infants were tested in this series. Additionally, in some studies from India, infants with megaloblastic anemia due to vitamin B12 deficiency displayed symptoms and signs consistent with ITS [5]. In one such study [9] of 52 infants with megaloblastic anemia, pallor was present in 96%, skin hyperpig-mentation in 77%, developmental delay in 67%, and 43% had hypotonia.

Response to treatment with vitamin B12 in ITS is rapid with improvement in general activity and responsiveness within 48-72 hours. This is followed by the return of social smile and improved appetite. Lost developmental milestones are gradually regained. The tremors begin to subside by the end of first week and disappear completely by 3-4 weeks [2,3]. It follows that infants with vitamin B12 deficiency can present with predominantly hematological (megaloblastic anemia) or predominantly neurological (infantile tremor syndrome) manifestations. Some infants may have purely neurological or purely hematological presentations. Most importantly, evidence of vitamin B12 deficiency has been found wherever it has been adequately looked for. It is, therefore, time to discard the syndrome status for this disorder, and rename it as ‘nutritional vitamin B12 deficiency in infants’ as it is known elsewhere in the world.

References

1. Mukherjee SB. Infantile tremor syndrome – A tale of 50 years. Indian Pediatr. 2015;52: 599-600.

2. Goraya JS, Kaur S. Infantile tremor syndrome: Down but not out. Indian Pediatr. 2015;52:249-50.

3. 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.

4. Bajpai PC, Misra PK, Tandon PN. Further observations on infantile tremor syndrome. Indian Pediatr. 1968;5: 297-307.

5. Mittal VS, Agarwal KN, Observations on nutritional megaloblastic anemia of early infancy. Indian J Med Res. 1969;57:730-8.

 

 

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