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research letter

Indian Pediatr 2015;52: 249-250

Infantile Tremor Syndrome – Down but not Out


*
Jatinder S Goraya and #Sukhjot Kaur

*Division of Pediatric Neurology, Department of Pediatrics; and #Department of Dermatology; Dayanand Medical College and Hospital, Ludhiana, Punjab,India.
Email: gorayajs@gmail.com

 


Retrospective chart review of 21 infants with infantile tremor syndrome for vitamin B12 deficiency showed low serum vitamin B12 levels in 8/16 (50%). Of the eight infants with normal levels, six had received vitamin B12 before referral. Macrocytosis and low maternal serum B12 was found in 12 and seven cases each. Treatment with vitamin B12 alone produced rapid recovery.

Keywords: Movement disorder, Vitamin B12


Infantile tremor syndrome (ITS) is characterized by pallor, developmental regression, tremors, hyperpigmentation of skin, and sparse brown hair. [1]. Though considered to be a vitamin B
12 deficiency state by many, opinion has remained divided. We describe some children with ITS to highlight its continued occurrence and also report on its probable etiology.

A retrospective review of the medical records of the children with infantile tremor syndrome attending our center between February 2010 and August 2014 was done. We investigate all infants with ITS and their mothers for vitamin B12 deficiency. All infants are initially treated with intramuscular vitamin B12 alone.

Twenty-one infants, (13 boys) aged 6 to 27 month were studied. Common presenting symptoms were tremors in 12, developmental delay in three, and developmental regression in three. All infants were exclusively breast-fed and their mothers were vegetarians, with little or no milk intake. We found low serum B12 in 8 of the 16 infants. Six of the 8 infants with normal serum vitamin B12 had received vitamin B12 before referral. Clinical and laboratory parameters are summarized in Table I. After treatment with intramuscular vitamin B12 alone, improvement in general activity, interest in surroundings, and return of social smile was seen within 48-72 hours in all except one. Tremors started to diminish by the end of first week in eight infants. Six infants showed initial worsening of tremors following treatment. Tremors were completely resolved by three to four weeks in all.

TABLE I	Clinical and Laboratory Findings in Infants With Infantile Tremor Syndrome

Clinical findings (n=21) Number (%)
Developmental delay and/or regression 21(100)
Brown scanty hair 21(100)
Skin hyperpigmentation 21(100)
Pallor 21(100)
Lethargy/apathy 21(100)
Growth retardation* 16(78)
Hypotonia 15(75)
Tremors 14(73)
Laboratory findings (n=18) Number(%)
Anemia (haemoglobin d” 11g/dl) 15(83.3)
Macrocytosis (MCV>95) 12(66.6)
**Low serum B12 (n=16) 8(50)
Low maternal serum B12 7(100)
Diffuse cerebral atrophy on neuroimaging 7(100)
*2 infants each also had glossitis, angular cheilitis, edema, and rickets; **of the 8 infants with normal serum vitamin B12, 6 had received vitamin B12 before referrals.

There is epidemiological, clinical, laboratory and therapeutic evidence to suggest that vitamin B12 deficiency is causally associated with ITS [2-4]. Epidemiologically, ITS occurs in exclusively breastfed infants of mothers living on diet devoid of animal products, including milk, pointing to vitamin B12 deficiency in infant-mother pairs [3]. All the mothers tested in our series had low serum vitamin B12. Moreover, the manifestations of ITS are identical to those described with infantile vitamin B12 deficiency reported from West [4]. Skin hyperpigmentation seen in ITS is also a well-known sign of vitamin B12 deficiency [5]. Infants with normal serum vitamin B12 levels in this study had other evidence of vitamin B12 deficiency such as macrocytosis and low maternal serum vitamin B12. From therapeutic standpoint, unequivocal improvement in general activity was observed in all the treated infants within 48-72 hours of vitamin B12. Tremors also improved gradually, all although initial worsening of tremors, a well-documented feature of vitamin B12 deficiency [6], was encountered in six infants

Interestingly enough, first study on ITS by Dikshit [1] had provided initial evidence that the symptoms and signs could be due to vitamin B12 deficiency. Later authors also reported low serum vitamin B12 and good response to vitamin B12 [2,3]. Deshpande and Ingle [7] also concurred with vitamin B12 deficiency in ITS. Elegant study by Garewal, et al. [8] showed unambiguous evidence of vitamin B12 deficiency in ITS in the form of megaloblastic bone marrow, and low serum vitamin B12, including cellular evidence of vitamin B12 deficiency was revealed by the dU suppression test. On the other hand, in the studies showing lack of evidence of vitamin B12 deficiency in ITS, serum vitamin B12, the current gold standard of diagnosis of vitamin B12 deficiency, was not measured and results were inferred from the mere absence of peripheral blood macrocytosis and megaloblastic bone marrow [9,10]. Occurrence of neurological symptoms of vitamin B12 deficiency in the absence of concomitant hematological changes is well known [8,11]. Interestingly, publication bias also seems to have played a major role in this debate on etiology of ITS. Majority of the studies [2,3,8] reporting vitamin B12 deficiency in ITS were published in foreign journals and likely to have escaped scrutiny of researchers of the country.

In summary, ITS continues to exist in India in modern times and is causally associated with vitamin B12 deficiency. Since long-term neuro-developmental deficits can occur if treatment is delayed, infants with ITS should be treated early with vitamin B12 for rapid reversal of neurological signs.

Contributors: JSG: conceptualized the study, collected the data and wrote the initial and final draft; SK: participated in the data analysis, performed the literature review, and revised the manuscript.

Funding: None; Competing interest: None stated.

References

1. Dikshit AK. Nutritional dystrophy with anemia. Indian J Child Hlth. 1957;6:132-6.

2. Jadhav M, Webb JKG, Vaishnava S, Baker SJ. Vitamin B12 deficiency in Indian infants. Lancet. 1962;1:903-90.

3. Srikantia SG, Reddy V. Megaloblastic anemia of infancy and vitamin B12. Br J Hematol. 1967;13:949-53.

4. Dror DK, Allen LH. Effect of vitamin B12 deficiency on neurodevelopment in infants: current knowledge and possible mechanisms. Nutrition Reviews. 2008;66:250-5.

5. Simsek OP, Gonc N, Gumruk F, Cetin M. A child with vitamin B12 deficiency presenting with pancytopenia and hyperpigmentation. J Pediatr Hematol Oncol. 2004;26:834-6.

6. Gratten-Smith PJ, Wilcken B, Procopis PG. The neurological syndrome of infantile cobalamin deficiency: Developmental regression and involuntary movements. Mov Dis. 1997;12:39-46.

7. Deshpande TV, Ingle VN. Tremor syndrome in children. Indian Pediatr. 1969;6:550-6.

8. Garewal G, Narang A, Das KC. Infantile tremor syndrome: A vitamin B12 deficiency syndrome in infants. J Trop Pediatr. 1988;34:174-8.

9. Pohowalla JN, Kaul KK, Bandari NR, Singh SD. Infantile "meningo-encephalitic’’ syndrome. Indian J Pediatr. 1960;27:49-54.

10. Sachdev KK, Manchanda SS, Lal H. The syndrome of tremors, mental regression and anemia in infants and young children. A study of 102 cases. Indian Pediatr. 1965;2:239-51.

11. Rasmussen SA, Fernhof PM, Scanlon KS. Vitamin B12 deficiency in children and adolescents. J Pediatr. 2001;138:10-7.

 

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