Dr Adeena, Dr Praveena ,Dr Jayakumar
AIMS
Nine month old girl,2nd child of non consanginous marriage with normal antenatal history,born term ,presented with failure to gain weight and developemntal plateau after 6 months of age.
She was exclusively breast fed until 6 months,followed attempt to initiate complimentary feeds but failed
Hence child was being predominantly breast fed the mother , who happened to be a strict vegetarian
Child had normal development but after which decrease regression of mile stones were noted
At admission
Apathetic
Vitals stable
Sparse hair,scalp seborrhoea
Knuckle hyperpigmentation, perianal ulcers.
Wt 6.6 kg,length 65 cm [both <3rd centile]
HC at 50th centile
CNS-hypotonia with DTR2+
Labs
MCV 105
P.smear showed macrocytic anemia
Vitamin B12 levels(78) low
Homocysteine 154(5 to 15)
Transferrin decreased
Normal iron and ferittin
Folic acid >20(6 -20)
Provisional diaganosis ofB12 deficiency was made
EEG,MRI Brain,NCV normal
She was given inj vitamin B12 1000mcg IM Daily for 1 week followed weekly once x 4 weeks and then monthly, as well as folic acid.
Iron supplements started after 2 weeks.
Attempts at oral feeds was not tolerated hence began on NG feeds and slowly started to accept tasting semisolids.
On day 5 of B 12 injections, ba became alert observant but not very playful, had NG feeds and started operating oral feeds.
By day 8,she was alert playful, had social smile,roll over .weight gain started and decreased aversion to oral foods.Dietary advices was given to mother and to add daily eggs to her diet.she was discharged on alternate day Vitamin B12 injection with plan to taper slowly and keep under follow up.
B12 deficincy
Vitamin B12 deficiency in infants is relatively uncommon but can occur, especially in breastfed infants of mothers who are themselves B12 deficient (e.g., vegetarian or vegan mothers). The prevalence can vary based on geographic and dietary factors.
Risk Factors -Maternal B12 deficiency
Infants of mothers with low B12 levels are at higher risk, particularly if the mother is vegetarian, vegan, or has malabsorption disorders (e.g., pernicious anemia).
-Prematurity
-Exclusively breastfed infants -When the mother’s diet is low in B12, the infant may not receive adequate amounts through breast milk.
Clinical Presentation-
*Megaloblastic anemia
*Neurological- Developmental delays, hypotonia, irritability, lethargy, and potentially irreversible neurological damage if not treated promptly.
*Gastrointestinal: Poor feeding, failure to thrive, vomiting, and diarrhea.
Management:
– Screening: Infants at risk should be monitored for signs of deficiency and have their B12 levels checked.
– Supplementation: If deficiency is confirmed, B12 supplementation should be administered. This is often given intramuscularly initially, followed oral supplementation.
– Dietary Counseling- Educating mothers, especially those who are vegetarian or vegan, on the importance of B12 in the diet, and possibly supplementing during pregnancy and breastfeeding to prevent deficiency in the infant.
Early detection and treatment are crucial to prevent long-term complications, especially neurological damage.