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research letter

Indian Pediatr 2016;53: 256-257

Vitamin B12 Status of Mothers of Children with Infantile Tremor Syndrome

 

Jatinder Singh Goraya, Kartik Bansal, Sekhar Singla and *Sukhjot Kaur

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

  

 

Retrospective chart review of 15 patients with infantile tremor syndrome in which mothers had their serum vitamin B12 measured, showed low (<200 pg/mL) serum vitamin B12 in 9 and low-normal (<200-350 pg/mL) in 6. Of the 9 mothers who had undergone complete blood counts, anemia was present in 6 and macrocytosis in 3. Vitamin B12 deficiency appears to be common in mothers of infants with infantile tremor syndrome.

Keywords: Deficiency, Management, Micronutrient.


Several studies have shown vitamin B
12 deficiency in infants with ITS [1-6]; but systematic study of maternal vitamin B12 status has infrequently been done through appropriate investigations [1,2,4,7]. We herein report on the vitamin B12 status of the mothers of children with ITS.

We retrospectively reviewed the laboratory investigations undertaken to determine the vitamin B12 status of the mothers of the infants diagnosed with ITS between February 2010 and March 2015. Vitamin B12 status of mothers is investigated at our center depending of affordability of the test. All the mothers, coming from poor families, were vegetarian with little or no milk intake. Serum vitamin B12 levels in this study were defined as low (< 200 pg/ml), and low normal (200-350 pg/ml) [8]. The deficient mothers are treated with either oral or intramuscular vitamin B12. Supplementation with oral iron and folic acid was also done, as deemed appropriate.

Fifteen mothers had serum vitamin B12 estimation and 9 had complete blood counts. Hemoglobin ranged from 9.6 to 13.0 g/dl (mean, 11.5 g/dl). Anemia (hemoglobin <12g /dl) was present in 9 but was only mild. Macrocytosis (MCV > 95 fl) was noted in 3 and another 3 mothers had borderline elevated MCV (91-93 fl). Serum vitamin B12 ranged from 49 to 260 pg/ml (mean, 157.3 pg/ml). Overall, serum vitamin B12 was low in 9 mothers and low normal in 6.

Jadhav, et al. [1] were the first to demonstrate low vitamin B12 in the maternal serum as well as in the breast-milk, thus confirming vitamin B12 deficiency. The study also proved that vitamin B12 deficiency in the infants in ITS was secondary to maternal vitamin B12 deficiency. Similar findings were described by Srikantia and Reddy [2]. Kaul, et al. [7] reported low serum vitamin B12 in all the 7 mothers tested but only in 3 of the 11 infants tested. The authors concluded that vitamin B12 deficiency was not causally related to ITS but could not explain low serum vitamin B12 in the mothers. Majority of the studies on ITS have not commented on maternal vitamin B12 status.

Our study has re-emphasized the presence of vitamin B12 deficiency in mothers of infants with ITS. The vitamin B12 deficiency in the mother-infant pairs in ITS is not unexpected, given the fact that mothers were strict vegetarian and infants exclusively breast-fed [9]. Finding of normal serum vitamin B12 in 6 infants in our study whose mothers had low serum vitamin B12 was unusual since breast-milk was the only source of nutrition in these infants. Prior administration of vitamin B12 was revealed from medical records. Low serum vitamin B12 in the mother provided an indirect evidence of infantile vitamin B12 deficiency in these 6 infants with discrepant serum vitamin B12. This finding could also explain apparently normal serum vitamin B12 in some infants with ITS reported previously in some studies [7]. Additionally, testing of mothers for vitamin B12 deficiency also allowed us to treat them appropriately, which might have been missed otherwise. We also found that anemia and macrocytosis were not always present in the presence of low serum vitamin B12, and absence of these hematological parameters therefore cannot reliably exclude the diagnosis of vitamin B12 deficiency [8].

Major limitation of our study is its retrospective nature, absence of a control group and a small sample size. Breast milk vitamin B12 as well as detailed laboratory assessment of the mothers for other nutritional deficiencies could not done due to financial constraints.

To conclude, majority of the mothers of infants with ITS suffered from nutritional vitamin B12 deficiency. Vitamin B12 status in the mothers should be assessed by measuring serum vitamin B12, as anemia and macrocytosis may not always be present.

Contributors: JSG: conceptualized the study, and revised the manuscript; KB, SS: were involved in patient care, data collection and revision of the manuscript; SK: performed the data analysis, and wrote the initial draft.

Funding: None; Competing Interests: None stated.

References

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

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

4. Jain R, Singh A, Mittal M, Talukdar B. Vitamin B12 deficiency in children: A treatable cause of neuro-developmental delay. J Child Neurol. 2015; 30:641-3.

5. Sirolia V, Arya S. Study of clinical profile and estimation of vitamin B12 level in infantile and pre-infantile tremor syndrome. J Evolution Medical Dental Sci. 2014;3: 10134-37.

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

7. Kaul KK, Prasan NG, Chowdhary RM. Further observations on the syndrome of tremors in infants. Indian Pediatr. 1964;1:219-25.

8. Langan RC, Zawistoski KJ. Update on vitamin B12 deficiency. Am Fam Physician. 2011;83:1425-30.

9. Antony AC. Vegetarianism and vitamin B-12 (cobalamin) deficiency. Am J Clin Nutr. 2003; 78:3-6.

 

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