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Goraya JS, Kaur S. Vitamin B 12 deficiency in mothers and children: risk of neuro-regression. Paediatr Int Child Health 2023; 43:50-56. [PMID: 36755398 DOI: 10.1080/20469047.2023.2171767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 12/17/2022] [Indexed: 02/10/2023]
Affiliation(s)
- Jatinder Singh Goraya
- Department of Pediatrics, Division of Pediatric Neurology, Dayanand Medical College and Hospital Ludhiana, Punjab, India
| | - Sukhjot Kaur
- Department of Dermatology, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
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Held PK, Singh E, Scott Schwoerer J. Screening for Methylmalonic and Propionic Acidemia: Clinical Outcomes and Follow-Up Recommendations. Int J Neonatal Screen 2022; 8:ijns8010013. [PMID: 35225935 PMCID: PMC8883915 DOI: 10.3390/ijns8010013] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 01/20/2022] [Accepted: 02/01/2022] [Indexed: 11/30/2022] Open
Abstract
Wisconsin's newborn screening program implemented second-tier testing on specimens with elevated propionylcarnitine (C3) to aid in the identification of newborns with propionic and methylmalonic acidemias. The differential diagnosis for elevated C3 also includes acquired vitamin B12 deficiency, which is currently categorized as a false positive screen. The goal of this study was to summarize screening data and evaluate their effectiveness at establishing diagnoses and categorizing false positive cases. All Wisconsin newborns born between 2013 and 2019 with a positive first-tier screen for C3 were included in this study. For each case the first- and second-tier newborn screening data and confirmatory test results were compiled. The clinical determination for each case was reviewed and categorized into groups: inborn error of metabolism, maternal B12 deficiency, infant B12 deficiency, and false positive. A review of the screening data showed a significant overlap in the concentration of biomarkers for newborns with genetic versus acquired disease. Additionally, a review of confirmatory test results showed incomplete ascertainment of maternal vitamin B12 status. The Wisconsin newborn screening program recommended a confirmatory testing algorithm to aid in the diagnosis of inborn errors of metabolism and acquired vitamin B12 deficiency.
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Affiliation(s)
- Patrice K. Held
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI 53706, USA;
- Wisconsin State Laboratory of Hygiene, University of Wisconsin School of Medicine and Public Health, Madison, WI 53706, USA
- Correspondence: ; Tel.: +1-608-265-5968
| | - Emily Singh
- Division of Genetics, Medical College of Wisconsin with Children’s Wisconsin, Milwaukee, WI 53226, USA;
| | - Jessica Scott Schwoerer
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI 53706, USA;
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Keskin EY, Keskin M, Karaibrahimoğlu A. Association of Maternal Vitamin B12 Status With Infant Findings and Neurodevelopment in Vitamin B12-Deficient Breast-fed Babies. J Pediatr Hematol Oncol 2022; 44:e91-e95. [PMID: 33661170 DOI: 10.1097/mph.0000000000002122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 01/24/2021] [Indexed: 11/25/2022]
Abstract
Few studies have examined the association between maternal vitamin B12 status and their breast-fed infants' findings. The objective of this study was to analyze the association of maternal B12 status with infant findings including neurodevelopmental outcome in breast-fed babies with B12 deficiency. Correlation analyses between the laboratory findings of infants with B12 deficiency (n=120) and their mothers were performed and the association of maternal B12 status with infant findings including the Denver-II developmental screening test (DDST II) results was examined. There was a significant correlation between infant and maternal B12 levels (r=0.222; P=0.030), and between infant and maternal homocysteine (Hcy) levels (r=0.390; P<0.001). Among the babies 4 months of age or older, maternal Hcy levels were significantly correlated with infant mean corpuscular hemoglobin (r=0.404; P=0.001) and infant mean corpuscular volume (r=0.461; P<0.001). Mothers of infants with abnormal DDST II had lower vitamin B12 (196.9±41.2 vs. 247.0±77.0 pg/mL; P=0.018) and higher Hcy levels (17.3±5.0 vs. 10.7±3.1 µmol/L; P<0.001) than mothers of infants with normal DDST II. A lower maternal vitamin B12 status may be related to impaired neurodevelopment in breast-fed infants with vitamin B12 deficiency. Pregnant and lactating women should be offered easy access to healthy nutrition and vitamin B12 supplements.
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Affiliation(s)
| | | | - Adnan Karaibrahimoğlu
- Biostatistics and Medical Informatics, Süleyman Demirel University Medical Faculty, Isparta, Turkey
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Keskin M. Hematological findings associated with neurodevelopmental delay in infants with vitamin B12 deficiency. Acta Neurol Belg 2020; 120:921-926. [PMID: 32449135 DOI: 10.1007/s13760-020-01388-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 05/15/2020] [Indexed: 12/30/2022]
Abstract
In adults with vitamin B12 deficiency, an inverse correlation between the severity of megaloblastic anemia and the degree of neurological dysfunction has been reported. We aimed to evaluate the association between hematological findings and the results of neurodevelopmental assessment in infants. Denver-II developmental screening test (DDST II) was performed in vitamin B12-deficient infants (n = 122), and its relationship with hematological findings was evaluated. DDST II was abnormal in 15 (12.3%), suspect in 20 (16.4%) and normal in 87 (71.3%) cases. Among the infants aged ≥ 4 months (n = 89), cases with an abnormal DDST II had lower levels of hemoglobin (7.49 ± 3.13 vs. 9.87 ± 1.77 g/dL; P = 0.015), whereas they had higher levels of mean corpuscular volume (MCV) (90.05 ± 19.31 vs. 69.90 ± 10.51 fL; P = 0.002), mean corpuscular hemoglobin (MCH) (28.96 ± 7.50 vs. 22.03 ± 4.58 pg; P = 0.001), homocysteine (44.31 ± 11.51 vs. 21.05 ± 9.23 µmol/L; P < 0.001), transferrin saturation index (25.84 ± 17.72 vs. 9.55 ± 6.38%; P = 0.004) and ferritin (87.28 ± 82.21 vs. 26.59 ± 31.67 ng/mL; P = 0.040) than those with a normal DDST II. The receiver operator characteristic analysis could distinguish infants with an abnormal DDST II from those with a normal DDST II by using a hemoglobin level < 8.75 g/dL [sensitivity: 71.4%, specificity: 76.4%; area under curve (AUC): 0.744], an MCV > 88.4 fL (sensitivity: 76.9%, specificity: 98.2%; AUC 0.813), an MCH > 28.5 pg (sensitivity: 76.9%, specificity: 96.4%; AUC: 0.822), and a homocysteine level > 27.35 µmol/L (sensitivity: 92.9%, specificity: 85.5%; AUC: 0.907). Even mild abnormalities of some commonly evaluated laboratory variables (such as MCV and MCH) in an infant should alert the physicians for the possibility of an underlying vitamin B12 deficiency with some degree of neurological impairment.
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Affiliation(s)
- Mahmut Keskin
- Department of Pediatrics, Süleyman Demirel University Medical Faculty, Çünür, 32260, Isparta, Turkey.
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Karanvir, Garg D, Sharma S, Pandey S. Left-Hand Motor Stereotypy in Vitamin B12 Deficiency: Expanding the Spectrum of Infantile Tremor Syndrome. Ann Indian Acad Neurol 2020; 23:389-390. [PMID: 32606549 PMCID: PMC7313601 DOI: 10.4103/aian.aian_63_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 02/07/2020] [Indexed: 11/13/2022] Open
Affiliation(s)
- Karanvir
- Department of Pediatrics, Lady Hardinge Medical College, New Delhi, India
| | - Divyani Garg
- Department of Neurology, Lady Hardinge Medical College, New Delhi, India
| | - Suvasini Sharma
- Department of Pediatrics, Lady Hardinge Medical College, New Delhi, India
| | - Sanjay Pandey
- Department of Neurology, Govind Ballabh Pant Institute of Postgraduate Medical Education and Research, New Delhi, India
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Acıpayam C, Güneş H, Güngör O, İpek S, Sarışık N, Demir NŞ. Cerebral atrophy in 21 hypotonic infants with severe vitamin B12 deficiency. J Paediatr Child Health 2020; 56:751-756. [PMID: 31868292 DOI: 10.1111/jpc.14733] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Revised: 11/15/2019] [Accepted: 12/02/2019] [Indexed: 11/29/2022]
Abstract
AIM Nutritional B12 deficiency is a treatable cause of neurodevelopmental delay in infants. We report 21 infants with developmental regression and brain atrophy as revealed using cranial magnetic resonance imaging (MRI), secondary to severe vitamin B12 deficiency. METHODS Twenty-one infants aged 4-24 months with B12 deficiencies who were admitted to our clinic between May 2013 and May 2018 were included in the study. MRI, bone marrow aspiration and the Denver-II Developmental Screening Test were performed in all infants. RESULTS The mean age of the infants was 12.3 months, and the mean B12 level was 70.15 ± 32.15 ng/L. Hypotonia and neurodevelopmental retardation, and anaemia were present in all patients. Their bone marrow examinations were compatible with megaloblastic anaemia. Twelve patients had microcephaly, seven had tremor and one patient died of severe sepsis. Almost all patients were fed with breast milk and their mothers were also malnourished. Nine (42.9%) of the patients were Turkish and 12 (57.1%) were Syrian. All patients had abnormal Denver-II Developmental Screening Test scores. Most patients had severe cortical atrophy, cerebral effusion, thinning of the corpus callosum and delayed myelinisation in cranial MRI. Treatment with B12 resulted in dramatic improvement in general activity and appetite within 72 h. Tremors resolved in all cases. CONCLUSION Neurological findings and developmental delay related to nutritional B12 deficiency can be prevented without sequelae if diagnosed early. Screening and treating of mothers for this deficiency will contribute to the health of both the mother and their feeding infant.
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Affiliation(s)
- Can Acıpayam
- Department of Pediatric Hematology and Oncology, Faculty of Medicine, Kahramanmaras Sutcuimam University, Kahramanmaras, Turkey
| | - Hatice Güneş
- Department of Pediatrics, Faculty of Medicine, Kahramanmaras Sutcuimam University, Kahramanmaras, Turkey
| | - Olcay Güngör
- Department of Pediatric Neurology, Faculty of Medicine, Pamukkale University, Denizli, Turkey
| | - Sevcan İpek
- Department of Pediatrics, Faculty of Medicine, Kahramanmaras Sutcuimam University, Kahramanmaras, Turkey
| | - Nafiz Sarışık
- Department of Pediatrics, Faculty of Medicine, Kahramanmaras Sutcuimam University, Kahramanmaras, Turkey
| | - Nurcan Ş Demir
- Department of Pediatrics, Faculty of Medicine, Kahramanmaras Sutcuimam University, Kahramanmaras, Turkey
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Dubaj C, Czyż K, Furmaga-Jabłońska W. Vitamin B 12 deficiency as a cause of severe neurological symptoms in breast fed infant - a case report. Ital J Pediatr 2020; 46:40. [PMID: 32228659 PMCID: PMC7106665 DOI: 10.1186/s13052-020-0804-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Accepted: 03/18/2020] [Indexed: 01/08/2023] Open
Abstract
Background Vitamin B12 (cobalamin, cbl) deficiency in children is rare and may occurs in exclusively breast fed infants of mothers on vegetarian or vegan diet with lack of appropriate supplementation. The clinical manifestation of vitamin B12 deficiency include neurological disorders, megaloblastic anemia and failure to thrive. Routine and commonly used laboratory tests such as cell blood count (CBC) or serum vitamin B12 level are sufficient for appropriate diagnosis. Typical therapy is based on intramuscular cobalamin injections. Early diagnosis and early onset of treatment are crucial factors for long-term prognosis of patients as the duration of deficiency may be correlated with the development of long lasting changes in the nervous system. The purpose of this article is to present influence of maternal vitamin B12 deficiency as a cause of infant psychomotor retardation. Case presentation We report the case of a 7 months old girl whose parents sought medical advice due to pathological somnolence and developmental regression of their daughter with onset approximately 2 months prior to the visit. Following several diagnostic tests it was determined that the infant’s symptoms were due to vitamin B12 deficiency which was secondary to the mother’s latent Addison-Biermer disease. Apart from neurological symptoms the infant also showed megaloblastic anemia which is typical to cobalamin deficiencies. Intramuscular vitamin B12 supplementation resulted in instant improvement of the patient’s general condition and blood morphology. Unfortunately, psychological examination indicated long-term psychomotor retardation due to delayed diagnosis of B12 deficiency. Conclusions Vitamin B12 levels should be considered during differential diagnosis of neurological symptoms in exclusively breast-fed infants especially if they co-exist with megaloblastic anemia and psychomotor retardation.
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Affiliation(s)
- Cezary Dubaj
- Department of Neonate and Infant Pathology, Medical University of Lublin, Prof. Gębali 6 str, 20-093, Lublin, Poland
| | - Katarzyna Czyż
- Department of Neonate and Infant Pathology, Medical University of Lublin, Prof. Gębali 6 str, 20-093, Lublin, Poland.
| | - Wanda Furmaga-Jabłońska
- Department of Neonate and Infant Pathology, Medical University of Lublin, Prof. Gębali 6 str, 20-093, Lublin, Poland
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Affiliation(s)
- Frédéric Leroy
- Research Group of Industrial Microbiology and Food Biotechnology (IMDO), Faculty of Sciences and Bioengineering Sciences, Vrije Universiteit Brussel, Pleinlaan 2, Brussels, B-1050, Belgium
| | - Nathan Cofnas
- Balliol College, University of Oxford, Oxford, OX1 3BJ, UK
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Kaur N, Nair V, Sharma S, Dudeja P, Puri P. A descriptive study of clinico-hematological profile of megaloblastic anemia in a tertiary care hospital. Med J Armed Forces India 2018; 74:365-370. [PMID: 30449923 DOI: 10.1016/j.mjafi.2017.11.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Accepted: 11/25/2017] [Indexed: 12/31/2022] Open
Abstract
Background Megaloblastic Anemia (MA) is a relatively common disease, yet the data on prevalence of MA remains scarce. This study was conducted to study the prevalence and clinico-hematological profile of MA. Methods This was a cross-sectional study done on 1150 adult anemic patients. All patients diagnosed to have MA were studied for clinico-hematological and etiological profile. Nerve conduction studies (NCS) were done in all. Results MA was present in 3.6% cases of anemia. Severe anemia was seen in 9.7% of anemic patients and 75% of MA cases (p < 0.05). Forty five percent of MA patients presented with pancytopenia. Vitamin B12 and folic acid deficiency were documented in 40% and 25% cases respectively while combined deficiency was noted in 35% of all MA cases. There was no co-relation between severity of anemia and deficiency of either of the vitamins (Fischer exact test: 0.530). Among MA patients, 35% were vegetarians while 65% consumed mixed diet. There was no association between vegetarian diet and Vit B12 deficiency (p = 0.3137). An additional etiology was more commonly found in patients on mixed diet [92%; 24/26] as compared to those on vegetarian diet [50%; 7/14] (p = 0.04). NCS was abnormal in 14 patients (35%). Overt clinical neuropathy was present in 12 cases of MA, while subclinical neuropathy was seen in 2 cases. Conclusion MA is one of common causes of pancytopenia and severe anemia. Diet plays an important role in causation of MA in vegetarians. An alternative etiology is however, more likely to be found in patients on mixed diet. While overt neurological abnormalities are common in MA, subclinical neuropathy is uncommon.
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Affiliation(s)
- Navjyot Kaur
- Assistant Professor (Medicine), Command Hospital (Southern Command), Pune 411040, India
| | - Velu Nair
- Former Director General Medical Services (Army), Integrated Headquarters, Ministry of Defence, New Delhi, India
| | - Sanjeevan Sharma
- Associate Professor (Medicine), Command Hospital (Southern Command), Pune 411040, India
| | - Puja Dudeja
- Associate Professor, Department of Community Medicine, Armed Forces Medical College, Pune 411040, India
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Çoban S, Yılmaz Keskin E, İğde M. Association between Maternal and Infantile Markers of Cobalamin Status During the First Month Post-Delivery. Indian J Pediatr 2018; 85:517-22. [PMID: 29306994 DOI: 10.1007/s12098-017-2598-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Accepted: 12/20/2017] [Indexed: 10/18/2022]
Abstract
OBJECTIVE Exclusively breast-fed infants born to vitamin B12 (cobalamin, cbl)-deficient mothers can develop symptoms within a few months following delivery. The authors aimed to assess the relationship between maternal and infantile markers of cbl status. METHODS In 240 full-term infants (age, 2-30 d) admitted to Samsun Maternity and Child Health Hospital and their mothers, complete blood count testing and serum cbl, folate and plasma total homocysteine (tHcy) measurements were performed. In the mothers, serum ferritin and holotranscobalamin (holoTC) levels were measured additionally. RESULTS Among the infants, 146 (60.8%) had cbl deficiency (serum cbl <259 pg/mL), whereas 184 (76.7%) mothers had a low cbl level (serum cbl <300 pg/mL). When cbl deficiency was defined as a serum holoTC level < 40 pmol/L, 152 (63.3%) mothers were found as deficient. In addition, 147 (61.3%) infants had an elevated tHcy level (>10 μmol/L), in 35 (23.8%) of these 147 infants tHcy level being markedly elevated (>20 μmol/L). None of the infants had folate deficiency. In the correlational analysis between maternal and infantile markers associated with cbl status, the strongest correlation was observed between maternal holoTC and infantile tHcy (r = -0.49, p < 0.001), followed by the correlation between maternal tHcy and infantile tHcy (r = 0.47, p < 0.001). The weakest correlations were found between maternal cbl and infantile cbl (r = 0.28, p < 0.001), and between maternal cbl and infantile tHcy (r = -0.25, p < 0.001). CONCLUSIONS Maternal cbl status is an important determinant of infantile cbl status. Both maternal holoTC and tHcy may assist in predicting infantile cbl status. The finding of high prevalence of maternal and infantile cbl deficiency in this study points towards the need for effective strategies to prevent cbl deficiency in women prior to getting pregnant.
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Reinson K, Künnapas K, Kriisa A, Vals MA, Muru K, Õunap K. High incidence of low vitamin B12 levels in Estonian newborns. Mol Genet Metab Rep 2018; 15:1-5. [PMID: 29387561 PMCID: PMC5772002 DOI: 10.1016/j.ymgmr.2017.11.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2017] [Revised: 11/05/2017] [Accepted: 11/05/2017] [Indexed: 11/04/2022] Open
Abstract
Vitamin B12 deficiency seems to be more common worldwide than previously thought. However, only a few reports based on data from newborn screening (NBS) programs have drawn attention to that subject. In Estonia, over the past three years, we have diagnosed 14 newborns with congenital acquired vitamin B12 deficiency. Therefore, the incidence of that condition is 33.8/100,000 live births, which is considerably more than previously believed. None of the newborns had any clinical symptoms associated with vitamin B12 deficiency before the treatment, and all biochemical markers normalized after treatment, which strongly supports the presence of treatable congenital deficiency of vitamin B12. During the screening period, we began using actively ratios of some metabolites like propionylcarnitine (C3) to acetylcarnitine (C2) and C3 to palmitoylcarnitine (C16) to improve the identification of newborns with acquired vitamin B12 deficiency. In the light of the results obtained, we will continue to screen the congenital acquired vitamin B12 deficiency among our NBS program. Every child with aberrant C3, C3/C2 and C3/C16 will be thoroughly examined to exclude acquired vitamin B12 deficiency, which can easily be corrected in most cases.
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Affiliation(s)
- Karit Reinson
- Department of Clinical Genetics, Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
- Department of Clinical Genetics, United Laboratories, Tartu University Hospital, Tartu, Estonia
| | - Kadi Künnapas
- Department of Clinical Genetics, United Laboratories, Tartu University Hospital, Tartu, Estonia
| | - Annika Kriisa
- Department of Clinical Genetics, United Laboratories, Tartu University Hospital, Tartu, Estonia
| | - Mari-Anne Vals
- Department of Clinical Genetics, Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
- Department of Clinical Genetics, United Laboratories, Tartu University Hospital, Tartu, Estonia
- Children's Clinic, Tartu University Hospital, Tartu, Estonia
| | - Kai Muru
- Department of Clinical Genetics, United Laboratories, Tartu University Hospital, Tartu, Estonia
| | - Katrin Õunap
- Department of Clinical Genetics, Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
- Department of Clinical Genetics, United Laboratories, Tartu University Hospital, Tartu, Estonia
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Varsi K, Ueland PM, Torsvik IK, Bjørke-Monsen AL. Maternal Serum Cobalamin at 18 Weeks of Pregnancy Predicts Infant Cobalamin Status at 6 Months-A Prospective, Observational Study. J Nutr 2018; 148:738-745. [PMID: 29947806 DOI: 10.1093/jn/nxy028] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Accepted: 01/30/2018] [Indexed: 02/05/2023] Open
Abstract
Background An adequate maternal cobalamin status is crucial for fetal and infant neurodevelopment. Pregnancy-induced physiologic changes make evaluation of maternal cobalamin status in pregnancy difficult. Objective We have investigated maternal cobalamin status during pregnancy in order to establish a maternal cobalamin concentration which secures an optimal infant cobalamin status during the first 6 mo of life. Methods In an observational, prospective study, markers of cobalamin status including serum cobalamin, plasma total homocysteine (tHcy), and plasma methylmalonic acid (MMA) were assessed in healthy pregnant women (n = 114) from week 18 of pregnancy through 6 mo postpartum and related to infant cobalamin status at 6 mo. Healthy, never-pregnant women aged 18-40 y (n = 123) were included as controls. Results Compared to controls, all markers of cobalamin status were lower in pregnant women. Median serum cobalamin concentration progressively decreased from week 18 to week 36 of pregnancy (356 to 302 pmol/L, P < 0.001) and increased by >40% by 6 wk postpartum (518 pmol/L). The metabolic markers increased from week 18 of pregnancy to 6 wk postpartum: median plasma tHcy 3.9 to 7.7 μmol/L (P < 0.001), and MMA 0.13 to 0.17 μmol/L (P < 0.001). The serum cobalamin concentration of infants at age 6 mo correlated with maternal serum cobalamin concentration during pregnancy and postpartum (rho = 0.36-0.55, P < 0.001). A maternal serum cobalamin concentration <394 pmol/L during week 18 of pregnancy was associated with an increased risk (OR: 4.2; 95% CI: 1.5, 11.5) of infant biochemical cobalamin deficiency at 6 mo (defined as tHcy ≥6.5 μmol/L). Conclusions The maternal serum cobalamin concentration in early pregnancy is a strong predictor for later maternal and infant cobalamin status. To secure an optimal infant cobalamin status during the first 6 mo of life, we recommend a maternal serum cobalamin concentration >394 pmol/L at week 18 of pregnancy. This should be confirmed in an intervention study. This trial was registered at clinicaltrials.gov as NCT03272022.
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Affiliation(s)
- Kristin Varsi
- Laboratory of Clinical Biochemistry, and Department of Pediatrics, Haukeland University Hospital, Bergen, Norway
| | - Per M Ueland
- Laboratory of Clinical Biochemistry, and Department of Pediatrics, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, Faculty of Medicine and Dentistry, University of Bergen, Bergen, Norway
| | - Ingrid K Torsvik
- Department of Pediatrics, Haukeland University Hospital, Bergen, Norway
| | - Anne-Lise Bjørke-Monsen
- Laboratory of Clinical Biochemistry, and Department of Pediatrics, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, Faculty of Medicine and Dentistry, University of Bergen, Bergen, Norway
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Abstract
The biosynthesis of B12, involving up to 30 different enzyme-mediated steps, only occurs in bacteria. Thus, most eukaryotes require an external source of B12, and yet the vitamin appears to have only two functions in eukaryotes: as a cofactor for the enzymes methionine synthase and methylmalonylCoA mutase. These two functions are crucial for normal health in humans, and in particular, the formation of methionine is essential for providing methyl groups for over 100 methylation processes. Interference with the methionine synthase reaction not only depletes the body of methyl groups but also leads to the accumulation of homocysteine, a risk factor for many diseases. The syndrome pernicious anemia, characterized by lack of intrinsic factor, leads to a severe, sometimes fatal form of B12 deficiency. However, there is no sharp cutoff for B12 deficiency; rather, there is a continuous inverse relationship between serum B12 and a variety of undesirable outcomes, including neural tube defects, stroke, and dementia. The brain is particularly vulnerable; in children, inadequate B12 stunts brain and intellectual development. Suboptimal B12 status (serum B12<300pmol/L) is very common, occurring in 30%-60% of the population, in particular in pregnant women and in less-developed countries. Thus, many tens of millions of people in the world may suffer harm from having a poor B12 status. Public health steps are urgently needed to correct this inadequacy.
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Affiliation(s)
- A David Smith
- Department of Pharmacology, University of Oxford, Oxford, United Kingdom.
| | - Martin J Warren
- School of Biosciences, University of Kent, Canterbury, Kent, United Kingdom
| | - Helga Refsum
- Department of Nutrition, University of Oslo, Oslo, Norway
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Tanyildiz HG, Yesil S, Okur I, Yuksel D, Sahin G. How Does B12 Deficiency of Mothers Affect Their Infants? Iran J Pediatr 2017; 27. [DOI: 10.5812/ijp.12898] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
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Abstract
Infantile tremor syndrome (ITS) is defined by the tetrad of pallor, developmental delay/regression, skin pigmentation, and brown scanty scalp hair. Involuntary movements in the form of tremors supervene in the natural course of the illness in a significant number of cases. The disorder occurs in exclusively breast-fed infants of vegetarian mothers belonging to economically deprived sections of society. Most of the children eventually recover but are frequently left with long-term cognitive and language neurodeficits. ITS continues to be seen in clinical practice, but there has been no consensus on its causation. Last comprehensive review was published in 1987 describing the ITS as a syndrome of unknown or multiple etiologies. Several important papers have been published since then. This review attempts to provide comprehensive and up-to-date information on the subject incorporating recently published studies. In the end, the issue of etiology is objectively re-examined in the light of available evidence some of which has been published in recent years.
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Affiliation(s)
- Jatinder Singh Goraya
- Department of Pediatrics, Division of Pediatric Neurology, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
| | - Sukhjot Kaur
- Department of Dermatology, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
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Yilmaz S, Serdaroglu G, Tekgul H, Gokben S. Different Neurologic Aspects of Nutritional B12 Deficiency in Infancy. J Child Neurol 2016; 31:565-8. [PMID: 26310585 DOI: 10.1177/0883073815601497] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2015] [Accepted: 07/27/2015] [Indexed: 11/16/2022]
Abstract
The objective of this study is to evaluate neurologic problems caused by nutritional vitamin B12 deficiency in infancy. Twenty-four cases between 2 and 18 months of age with neurologic symptoms and/or signs and diagnosed as nutritional vitamin B12 deficiency were analyzed. The most common symptoms were developmental retardation, afebrile seizures, and involuntary movements. The mean vitamin B12 levels were lower in patients with both neurologic and extraneurologic involvement when compared to those with only neurologic symptoms. All of the cases were treated with vitamin B12. In patients with severe deficiencies, involuntary movements were observed during vitamin B12 treatment using cyanocobalamin form. At the 1-year follow-up, all but 3 patients were considered neurodevelopmentally normal. The 3 patients that did not fully recover, on admission, had the lowest vitamin B12 levels. It is of great importance to prevent, diagnose, and treat vitamin B12 deficiency promptly to prevent the long-term neurologic problems.
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Affiliation(s)
- Sanem Yilmaz
- Ege University Medical Faculty, Department of Pediatrics, Division of Child Neurology, Izmir, Turkey
| | - Gul Serdaroglu
- Ege University Medical Faculty, Department of Pediatrics, Division of Child Neurology, Izmir, Turkey
| | - Hasan Tekgul
- Ege University Medical Faculty, Department of Pediatrics, Division of Child Neurology, Izmir, Turkey
| | - Sarenur Gokben
- Ege University Medical Faculty, Department of Pediatrics, Division of Child Neurology, Izmir, Turkey
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Yoganathan S, Thomas MM, Mathai S, Ghosh U. Neuroregression as an initial manifestation in a toddler with acquired pernicious anaemia. BMJ Case Rep 2015; 2015:bcr-2015-213540. [PMID: 26678841 DOI: 10.1136/bcr-2015-213540] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
The aetiology spectrum for neuroregression in infants and toddlers is diverse. Vitamin B12 deficiency-mediated neuroregression is less commonly considered as a differential. Prevalence of pernicious anaemia in the general population is 0.1% and is extremely rare in children. We describe a 35-month-old toddler with neuroregression, seizures, coarse tremors, bleating cry and neuropathy. His clinical symptomatology mimicked grey matter degenerative illness and infantile tremor syndrome, a nutritional deficiency-mediated movement disorder. His vitamin B12 level was low and serum homocysteine level was elevated. Haematological manifestations were not overt and anti-intrinsic factor antibody was positive. With parenteral vitamin B12 therapy, there was a dramatic response with clinical and laboratory translation. This report emphasises the need for a high index of suspicion and screening for markers of vitamin B12 deficiency in all children with unexplained acute or subacute neuroregression, seizures and movement disorders as it is potentially reversible.
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Affiliation(s)
- Sangeetha Yoganathan
- Department of Neurological Sciences, Christian Medical College, Vellore, Tamilnadu, India
| | - Maya Mary Thomas
- Department of Neurological Sciences, Christian Medical College, Vellore, Tamilnadu, India
| | - Sarah Mathai
- Department of Pediatrics, Christian Medical College, Vellore, Tamilnadu, India
| | - Urmi Ghosh
- Department of Pediatrics, Christian Medical College, Vellore, Tamilnadu, India
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Goraya JS, Kaur S, Mehra B. Neurology of Nutritional Vitamin B12 Deficiency in Infants: Case Series From India and Literature Review. J Child Neurol 2015; 30:1831-7. [PMID: 25953825 DOI: 10.1177/0883073815583688] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Accepted: 03/25/2015] [Indexed: 11/17/2022]
Abstract
We studied 27 infants aged 6 to 27 months with vitamin B12 deficiency also known as "infantile tremor syndrome" in India. All were exclusively breast-fed by vegetarian mothers. Developmental delay or regression, pallor, skin hyperpigmentation, and sparse brown hair were present in all. Majority were hypotonic and involuntary movements were encountered in 18. Anemia and macrocytosis was found in 83% and 71% infants, respectively. Low serum vitamin B12 was present in 12 of 21 infants. Seven of the 9 infants with normal serum vitamin B12 had received vitamin B12 before referral. Twelve mothers had low serum vitamin B12. Cerebral atrophy was present in all the 9 infants who underwent neuroimaging. Treatment with vitamin B12 resulted in dramatic improvement in general activity and appetite within 48 to 72 hours followed by return of lost milestones. Tremors resolved in all by 3 to 4 weeks. Nutritional vitamin B12 deficiency is a treatable cause of neurologic dysfunction in infants.
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Affiliation(s)
- Jatinder Singh Goraya
- Division of Pediatric Neurology, Dayanand Medical College and Hospital, Ludhiana, Punjab, India Department of Pediatrics, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
| | - Sukhjot Kaur
- Department of Dermatology, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
| | - Bharat Mehra
- Department of Pediatrics, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
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19
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Abstract
OBJECTIVE To determine different clinical presentations of vitamin B12 deficiency in infants. METHODS Infants at the age of 1-20 mo admitted to infancy clinic of authors' hospital between January 2011-2013 with various clinical presentations due to vitamin B12 deficiency were included in the study. Hospital records of all the patients were evaluated by means of history, physical, laboratory, imaging examinations and treatment. The diagnosis was based on a nutritional history of mothers and infants, clinical findings, hematological evaluation, and low level of serum vitamin B12. RESULTS A total of 20 patients with a mean age of 6.65 ± 4.5 mo were included in the study. The weight and height were below the third percentile in four patients. The most common symptoms of the patients were; infections in 30 %, pallor in 25 %, hypotonia and neuro-developmental delay in 25 %, refusal to solid food or to suck in 20 %, failure to thrive in 15 %, fatigue in 10 %. Twenty-five percent of patients had neurologic signs and symptoms. Anemia was found in 16/20 (80 %) patients. Three (15 %) patients had leukopenia, 7 (35 %) had neutropenia, 2 (10 %) patients had thrombocytopenia. All of the mothers had vitamin B12 deficiency. All of the patients were fed with breast milk. Cyanocobalamin was administered to all the patients and mothers. After the treatment, clinical and laboratory findings of all the patients improved. CONCLUSIONS Vitamin B12 deficiency should be considered in the differential diagnosis of some hematological, neurological, and gastrointestinal disturbances of infants.
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Affiliation(s)
- Meltem Akcaboy
- Department of Pediatrics, Dr. Sami Ulus Maternity and Children's Health and Diseases Training and Research Hospital, Ankara, Turkey
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20
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Abstract
Vitamin B12 deficiency in children can rarely cause neurologic manifestations. In this series, 14 pediatric cases (median age 11 months) have been described in whom association of vitamin B12 deficiency with developmental delay or regression was observed. Severe to profound delay was present in 8 (57%) patients. All the patients were exclusively or predominantly breast-fed and 10 of 12 mothers had low serum vitamin B12 levels. Three to 6 months after treatment, a mean gain of development quotient of 38.8 points was seen in 7 follow-ups. In settings with a high prevalence of vitamin B12 deficiency, this association should be actively searched for.
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Affiliation(s)
- Rahul Jain
- Department of Pediatrics, Chacha Nehru Bal Chikitsalaya (Associated with Maulana Azad Medical College), Geeta Colony, New Delhi, India
| | - Archana Singh
- Department of Pediatrics, Chacha Nehru Bal Chikitsalaya (Associated with Maulana Azad Medical College), Geeta Colony, New Delhi, India
| | - Medha Mittal
- Department of Pediatrics, Chacha Nehru Bal Chikitsalaya (Associated with Maulana Azad Medical College), Geeta Colony, New Delhi, India
| | - Bibek Talukdar
- Department of Pediatrics, Chacha Nehru Bal Chikitsalaya (Associated with Maulana Azad Medical College), Geeta Colony, New Delhi, India
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Bicakci Z. Growth retardation, general hypotonia, and loss of acquired neuromotor skills in the infants of mothers with cobalamin deficiency and the possible role of succinyl-CoA and glycine in the pathogenesis. Medicine (Baltimore) 2015; 94:e584. [PMID: 25738478 PMCID: PMC4553967 DOI: 10.1097/md.0000000000000584] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Vitamin B12 (cobalamin, Cbl) deficiency can cause metabolic, hematological, and neurological abnormalities. Adequate levels of succinyl-coenzyme A (CoA) cannot be synthesized from methylmalonyl-CoA because of the decreased activity of the methylmalonyl-CoA mutase enzyme that uses Cbl as the cofactor. Succinyl-CoA synthesis deficiency leads to decreased heme synthesis and gluconeogenesis. The reason of growth retardation can be gluconeogenesis deficiency together with heme synthesis deficiency whereas the reason of the neurological abnormalities can be glycine increase in the tissue due to decreased heme synthesis. We present 7 infants diagnosed with severe nutritional Cbl deficiency and discuss the role of succinyl-CoA and glycine in the possible pathogenesis in this article. Patients brought to our clinic with a complaint of growth retardation and diagnosed with nutritional Cbl deficiency were included in the study. There were 5 females and 2 males. The mean age was 11 ± 2.30 (range 6-13) months. All patients had general muscular hypotonia and 4 had growth retardation. Neuromotor growth retardation was found in 4 of the children who had previously shown normal neuromotor development for age. The mean Cbl level was 83.8 ± 27.6 (45.6-114) pg/mL. The mean Cbl level of the mothers was 155 ± 56.6 (88-258) pg/mL. Six of the patients had anemia and 1 had thrombocytopenia. Mean corpuscular volume value was 91.5 ± 12.2 fL. Following treatment, the muscle tonus of the patients improved, the anemia and growth retardation decreased, and the lost neuromotor abilities were recovered. Severe nutritional Cbl deficiency is an important nutritional disease where complications can be prevented with early treatment. When evaluating the pathogenesis, it should be noted that nutritional Cbl deficiency is a succinyl-CoA synthesis deficiency.
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Affiliation(s)
- Zafer Bicakci
- From the Department of Pediatric Hematology, Kafkas University Faculty of Medicine, Paşa Çayırı, Kars, Turkey
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22
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Kook PH, Drögemüller M, Leeb T, Hinden S, Ruetten M, Howard J. Hepatic fungal infection in a young beagle with unrecognised hereditary cobalamin deficiency (Imerslund-Gräsbeck syndrome). J Small Anim Pract 2014; 56:138-41. [PMID: 25131805 DOI: 10.1111/jsap.12251] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2014] [Revised: 05/16/2014] [Accepted: 06/07/2014] [Indexed: 12/24/2022]
Abstract
A 12-month-old beagle presented for anorexia, pyrexia and vomiting. The dog had been treated intermittently with antibiotics and corticosteroids for inappetence and lethargy since five months of age. Previous laboratory abnormalities included macrocytosis and neutropenia. At presentation, the dog was lethargic, febrile and thin. Laboratory examination findings included anaemia, a left shift, thrombocytopenia, hypoglycaemia and hyperbilirubinaemia. Multiple, small, hypoechoic, round hepatic lesions were observed on abdominal ultrasound. Cytological examination of hepatic fine needle aspirates revealed a fungal infection and associated pyogranulomatous inflammation. The dog's general condition deteriorated despite supportive measures and treatment with fluconazole, and owners opted for euthanasia before hypocobalaminaemia was identified. Subsequent genomic analysis revealed a CUBN:c.786delC mutation in a homozygous state, confirming hereditary cobalamin malabsorption (Imerslund-Gräsbeck syndrome). Similar to human infants, dogs with Imerslund-Gräsbeck syndrome may rarely be presented for infectious diseases, distracting focus from the underlying primary disorder.
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Affiliation(s)
- P H Kook
- Clinic for Small Animal Internal Medicine, Vetsuisse Faculty, University of Zurich, 8057, Zurich, Switzerland
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Malbora B, Yuksel D, Aksoy A, Ozkan M. Two infants with infantile spasms associated with vitamin B12 deficiency. Pediatr Neurol 2014; 51:144-6. [PMID: 24810877 DOI: 10.1016/j.pediatrneurol.2014.03.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2014] [Revised: 02/26/2014] [Accepted: 03/02/2014] [Indexed: 12/01/2022]
Abstract
BACKGROUND In developing countries, nutritional vitamin B12 deficiency in infants because of maternal deficiency often causes hematological and neurological disorders. However, epilepsy is a rare manifestation of vitamin B12 deficiency. The biological basis for the observed neurological symptoms of infantile vitamin B12 deficiency remains uncertain. There are only a few reports in the English literature regarding the relationship between infantile spasms and vitamin B12 deficiency. PATIENTS We report two unrelated infants having infantile spasms associated with vitamin B12 deficiency related to maternal nutritional deficiency. RESULTS During the first month of adrenocorticotropic hormone (ACTH), phenobarbital, and vitamin B12 treatments, both infants' abnormalities resolved. After 3 months, electroencephaography was completely normal. ACTH and phenobarbital treatments were ended. The children are disease-free 9 months after the treatment. CONCLUSIONS We suggest that vitamin B12 deficiency should be considered in the differential diagnosis of infantile spasms as a treatable cause, especially with a history of maternal nutritional deficiency.
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Affiliation(s)
- Baris Malbora
- Department of Pediatric Hematology, Dr. Sami Ulus Research and Training Hospital of Women's and Children's Health and Diseases, Ankara, Turkey.
| | - Deniz Yuksel
- Department of Pediatric Neurology, Dr. Sami Ulus Research and Training Hospital of Women's and Children's Health and Diseases, Ankara, Turkey
| | - Ayse Aksoy
- Department of Pediatric Neurology, Dr. Sami Ulus Research and Training Hospital of Women's and Children's Health and Diseases, Ankara, Turkey
| | - Mehpare Ozkan
- Department of Pediatric Neurology, Dr. Sami Ulus Research and Training Hospital of Women's and Children's Health and Diseases, Ankara, Turkey
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McNeil K, Chowdhury D, Penney L, Rashid M. Vitamin B12 deficiency with intrinsic factor antibodies in an infant with poor growth and developmental delay. Paediatr Child Health 2014; 19:84-6. [PMID: 24596481 PMCID: PMC3941681 DOI: 10.1093/pch/19.2.84] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/11/2013] [Indexed: 11/12/2022] Open
Abstract
Vitamin B12 deficiency is very rare in infants and may lead to serious hematological and neurodevelopmental abnormalities. The present article describes a case involving a seven-month-old boy with severe vitamin B12 deficiency, likely caused by juvenile pernicious anemia, an entity rarely described. The child presented with feeding intolerance, poor growth and developmental delay. He was noted to have macrocytic anemia, a markedly low serum vitamin B12 level, and elevated homocysteine and methylmalonic acid levels. Antibodies to intrinsic factor were positive. The mother was healthy, with normal vitamin B12 status. Therapy with vitamin B12 supplements led to excellent recovery of symptoms. Vitamin B12 deficiency should be considered in children presenting with failure to thrive, especially when compounded with neurological symptoms. Early diagnosis and adequate treatment is essential to avoid serious complications.
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Affiliation(s)
- Kathleen McNeil
- Department of Paediatrics, Faculty of Medicine, Dalhousie University, IWK Health Center, Halifax, Nova Scotia
| | - Dhiman Chowdhury
- Department of Paediatrics, Faculty of Medicine, Dalhousie University, IWK Health Center, Halifax, Nova Scotia
| | - Lynette Penney
- Department of Paediatrics, Faculty of Medicine, Dalhousie University, IWK Health Center, Halifax, Nova Scotia
| | - Mohsin Rashid
- Department of Paediatrics, Faculty of Medicine, Dalhousie University, IWK Health Center, Halifax, Nova Scotia
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25
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Demir N, Doğan M, Koç A, Kaba S, Bulan K, Ozkol HU, Doğan ŞZ. Dermatological findings of vitamin B12 deficiency and resolving time of these symptoms. Cutan Ocul Toxicol 2013; 33:70-3. [DOI: 10.3109/15569527.2013.861477] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Torsvik I, Ueland PM, Markestad T, Bjørke-Monsen AL. Cobalamin supplementation improves motor development and regurgitations in infants: results from a randomized intervention study. Am J Clin Nutr 2013; 98:1233-40. [PMID: 24025626 DOI: 10.3945/ajcn.113.061549] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND During infancy, minor developmental delays and gastrointestinal complaints are common, as is a biochemical profile indicative of impaired cobalamin status. OBJECTIVE We investigated whether cobalamin supplementation can improve development or symptoms in infants with biochemical signs of impaired cobalamin function and developmental delay or feeding difficulties. DESIGN Infants <8 mo of age (n = 105) who were referred for feeding difficulties, subtle neurologic symptoms, or delayed psychomotor development were assessed for cobalamin status [by the measurement of serum cobalamin, plasma total homocysteine (tHcy), and plasma methylmalonic acid (MMA)]. Infants with biochemical signs of impaired cobalamin function, defined as a plasma tHcy concentration ≥6.5 μmol/L (n = 79), were enrolled in a double-blind, randomized controlled trial to receive 400 μg hydroxycobalamin intramuscularly (n = 42) or a sham injection (n = 37). Motor function [Alberta Infants Motor Scale (AIMS)] and clinical symptoms (parental questionnaire) were recorded at entry and after 1 mo. RESULTS During follow-up, cobalamin supplementation changed all markers of impaired cobalamin status (ie, plasma tHcy decreased by 54%, and MMA decreased by 84%), whereas no significant changes were seen in the placebo group (P < 0.001). The median (IQR) increase in the AIMS score was higher in the cobalamin group than in the placebo group [7.0 (5.0, 9.0) compared with 4.5 (3.3, 6.0); P = 0.003], and a higher proportion showed improvements in regurgitations (69% compared with 29%, respectively; P = 0.003). CONCLUSIONS In infants with biochemical signs of impaired cobalamin function, 1 intramuscular injection of cobalamin resulted in biochemical evidence of cobalamin repletion and improvement in motor function and regurgitations, which suggest that an adequate cobalamin status is important for a rapidly developing nervous system. This trial was registered at clinicaltrials.gov as NCT00710359 and NCT00710138.
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Affiliation(s)
- Ingrid Torsvik
- Department of Pediatrics (IT) and the Laboratory of Clinical Biochemistry (A-LB-M and PMU), Haukeland University Hospital, Bergen, Norway; and the Section for Pharmacology, Institute of Medicine (PMU), and the Institute of Clinical Medicine (TM), University of Bergen, Bergen, Norway
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Demir N, Koc A, Üstyol L, Peker E, Abuhandan M. Clinical and neurological findings of severe vitamin B12 deficiency in infancy and importance of early diagnosis and treatment. J Paediatr Child Health 2013; 49:820-4. [PMID: 23781950 DOI: 10.1111/jpc.12292] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/22/2013] [Indexed: 11/30/2022]
Abstract
AIM Nutritional vitamin B12 deficiency among children in developing countries may lead to a severe clinical status. In this article, the clinical manifestations of vitamin B12 deficiency and the consequences of delay in its diagnosis have been evaluated. METHODS A total of 41 patients who were hospitalised and treated with the diagnosis of severe vitamin B12 deficiency in the paediatric haematology department of the hospital were enrolled in the trial. The diagnosis of severe vitamin B12 deficiency was based on haematological values, a serum vitamin B12 level of <100 pg/mL and a normal level of folic acid. Mental, neuro-motor and social developments of the enrolled patients were assessed by the same physician using the Ankara Developmental Screening Inventory. RESULTS The mean age of 25 male and 16 female patients was determined as 12 (6-18 months) months. Almost all of the children had been fed with breast milk and a poor nutritional state was found in all of the mothers. Non-specific findings such as growth retardation (78%), hyperpigmentation of the skin (78%), diarrhoea (63.4%), convulsion (14.6%), weakness, reluctance to eat, vomiting, irritability and tremor were found in all the patients, in addition to hypotonia, motor retardation and pallor. Treatment with vitamin B12 provided recovery in all the patients. The mean age of the patients with full recovery was 11.7 months, while the mean age of patients with partial recovery was 12.9 months. CONCLUSION As a delay in the diagnosis causes irreversible neurological damage, early diagnosis and treatment is highly important.
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Affiliation(s)
- Nihat Demir
- Department of Pediatrics, YYU School of Medicine, Istanbul, Turkey
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Koc A, Cengiz M, Ozdemir ZC, Celik H. Paraoxonase and arylesterase activities in children with iron deficiency anemia and vitamin B12 deficiency anemia. Pediatr Hematol Oncol 2012; 29:345-53. [PMID: 22568797 DOI: 10.3109/08880018.2011.645185] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Paraoxonase-1 is an esterase enzyme and it has 3 types of activity, namely paraoxonase, arylesterase, and diazoxonase. It has been reported that paraoxonase-1 deficiency is related to increased susceptibility to development of atherosclerosis and cardiovascular disease. The aim of this study was to investigate serum paraoxonase and arylesterase activities in children with iron deficiency anemia and vitamin B(12) deficiency anemia. Thirty children with iron deficiency anemia, 30 children with vitamin B(12) deficiency anemia, and 40 healthy children aged 6 months to 6 years were enrolled in this study. Serum paraoxonase and arylesterase activities were measured with a spectrophotometer by using commercially available kits. Mean paraoxonase and arylesterase activities in vitamin B(12) deficiency anemia group (103 ± 73 and 102 ± 41 U/L, respectively) were significantly lower than mean activities of control group (188 ± 100 and 147 ± 34 U/L, respectively; P < .001 for both) and iron deficiency anemia group (165 ± 103 and 138 ± 39 U/L, respectively; P < .05, P < .001), whereas there were no significant differences between iron deficiency anemia and control groups (P > .05). Paraoxonase and arylesterase activities significantly increased after treatment with vitamin B(12) in vitamin B(12) deficiency anemia; however, there were no significant changes in the activities of these enzymes after iron treatment in iron deficiency anemia group. Important correlations were found between vitamin B(12) levels and both paraoxonase and arylesterase activities (r = .367, P < .001; r = .445, P < .001). Our results suggest that vitamin B(12) deficiency anemia causes important reductions in paraoxonase and arylesterase activities, and after vitamin B(12) therapy the activities of these enzymes returned to near-normal levels.
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Affiliation(s)
- Ahmet Koc
- Department of Pediatric Hematology, Harran University Faculty of Medicine, Yenisehir, Sanliurfa, Turkey.
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Halicioglu O, Sutcuoglu S, Koc F, Ozturk C, Albudak E, Colak A, Sahin E, Asik Akman S. Vitamin B12 and folate statuses are associated with diet in pregnant women, but not with anthropometric measurements in term newborns. J Matern Fetal Neonatal Med 2012; 25:1618-21. [PMID: 22185230 DOI: 10.3109/14767058.2011.648244] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To investigate the frequencies of vitamin B12 and folate deficiencies in pregnant women in low socioeconomic group, the relation between the animal-source foods consumption and maternal vitamin B12-folate statuses, and their impacts on anthropometric measurements of the infants. METHODS A total of 208 pregnant women in the last trimester were included in the study. A questionnaire about socio-demographic status, consumption of meat, egg, milk-dairy products, multivitamin supplementation was used. Vitamin B(12) and folate concentrations were studied by chemiluminescence method. The babies of Vitamin B(12) deficient mothers were evaluated after birth. RESULTS The rate of vitamin B(12) deficiency was 47.6% and folate deficiency was 17.3% of pregnant women. Animal food consumption was inadequate about half of pregnant women and vitamin B(12) levels in these women were significantly low. There were no statistically significant relationships between the birth weight, birth length and head circumference measurements, and maternal vitamin B(12) and folate concentrations. CONCLUSION The rate of vitamin B12 deficiency in pregnant women in low socioeconomic population is high. Although there were no significant effects of the vitamin B12 and folate deficiencies on birth size, additional studies are required to elucidate the subsequent effects.
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Affiliation(s)
- Oya Halicioglu
- Department of Pediatrics, The Ministry of Health Tepecik Teaching and Research Hospital, Izmir, Turkey.
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30
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Abstract
BACKGROUND DNA damage effects of vitamin B(12) deficiency were performed in vitro and in adults. METHODS The study group included 32 children (13 girls, 19 boys) with vitamin B(12) deficiency (mean age 44 ± 58 months) and their 27 mothers (mean age 30.4 ± 5.3 years). The control group contained 30 healthy children and 25 mothers. DNA strand breaks in peripheral blood mononuclear leukocytes were assayed by single-cell alkaline gel electrophoresis (comet assay) before and 8 days after the first injection of vitamin B(12). RESULTS Mean DNA damage scores in children with vitamin B(12) deficiency and their mothers were significantly higher before treatment than those after treatment. The DNA damage scores of children after treatment were still significantly higher than controls. There were significant negative correlations between the children and their mothers in terms of vitamin B(12) levels and DNA damage scores (r = 0.3, P= 0.02; r = 0.58, P= 0.002, respectively). There were correlations between the children's and their mothers' DNA damage and the severity of vitamin B(12) deficiency, suggesting that the children and their mothers may play a role in the scarcity of nutritional vitamin B(12). CONCLUSION DNA damage is increased in children with vitamin B(12) deficiency and in their mothers. DNA damage scores were significantly improved through vitamin B(12) therapy 8 days after the first injection, however, they were still significantly higher than those of controls.
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Affiliation(s)
- Coskun Minnet
- Department of Pediatrics, Eskisehir Sakarya Hospital, Eskisehir, Turkey
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Ide E, Van Biervliet S, Thijs J, Vande Velde S, De Bruyne R, Van Winckel M. Solid food refusal as the presenting sign of vitamin B12 deficiency in a breastfed infant. Eur J Pediatr 2011; 170:1453-5. [PMID: 21735052 DOI: 10.1007/s00431-011-1522-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2011] [Accepted: 06/21/2011] [Indexed: 10/18/2022]
Abstract
UNLABELLED Dietary vitamin B(12) (vitB(12)) deficiency, although common in the elderly, is rare in childhood. We report on an exclusively breastfed 8-month-old infant, presenting with persistent refusal of solid foods. Three months later, developmental regression and failure to thrive led to the diagnosis of vitB(12) deficiency, as a consequence of a subclinical pernicious anaemia with vitB(12) deficiency in the mother. Treating the infant with parenteral vitB(12) induced prompt recovery including acceptance of weaning food. CONCLUSION This case illustrates refusal of complementary foods as a presenting symptom of vitB(12) deficiency in a breastfed infant. Symptoms, diagnostic tests and treatment of vitamin B(12) deficiency are reviewed. Early diagnosis and treatment are important to prevent irreversible neurological damage.
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Affiliation(s)
- Els Ide
- Paediatric Gastroenterology and Nutrition, Ghent University Hospital, De Pintelaan 185, 9000 Ghent, Belgium
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Kamei M, Ito Y, Ando N, Awaya T, Yamada T, Nakagawa M, Yamaguchi A, Ohuchi M, Yazaki M, Togari H. Brain atrophy caused by vitamin B12-deficient anemia in an infant. J Pediatr Hematol Oncol 2011; 33:556-8. [PMID: 21941150 DOI: 10.1097/mph.0b013e31821e5290] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Vitamin B12 deficiency in infants often presents with nonspecific hematological, gastrointestinal, and neurological manifestations. It is usually caused by inadequate intake, abnormal absorption, or congenital disorders of vitamin B12 metabolism, including transport disorders. We describe a vitamin B12-deficient infant with severe anemia who was breastfed. His mother had undiagnosed vitamin B12 deficiency having undergone total gastrectomy 18 years earlier. The infant developed normally after taking vitamin B12. It is important to suspect vitamin B12 deficiency in mothers who have undergone gastrectomy. Early diagnosis and treatment of vitamin B12 deficiency in infants is important and will help improve long-term prognosis.
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Affiliation(s)
- Michi Kamei
- Department of Pediatrics and Neonatology, Nagoya City University, Graduate School of Medical Sciences, Nagoya, Japan.
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Vanderjagt DJ, Ujah IAO, Ikeh EI, Bryant J, Pam V, Hilgart A, Crossey MJ, Glew RH. Assessment of the vitamin B12 status of pregnant women in Nigeria using plasma holotranscobalamin. ISRN Obstet Gynecol 2011; 2011:365894. [PMID: 21789284 PMCID: PMC3140786 DOI: 10.5402/2011/365894] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/16/2011] [Accepted: 05/18/2011] [Indexed: 11/23/2022]
Abstract
Maternal vitamin B12 deficiency during pregnancy is an independent risk factor for neural tube defects and other neurological problems in infants. We determined the vitamin B12 status of 143 pregnant women in Nigeria representing all trimesters who presented to an antenatal clinic in Jos, Nigeria, using holotranscobalamin II levels (holoTCII), which is a measure of the vitamin B12 that is available for uptake into tissues. The holoTCII concentration ranged from 13 to 128 pmol/L. Using a cutoff of 40 pmol/L, 36% of the women were classified as vitamin B12-deficient. HoloTCII concentrations correlated negatively with plasma homocysteine levels (r = −0.24, P = 0.003) and positively with red blood cell folate concentrations (r = 0.28, P < 0.001). These data underscore the importance of supplementing pregnant women in Nigeria with vitamin B12 in order to ensure adequate vitamin B12 status and decrease the risk for neural tube defects.
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Affiliation(s)
- Dorothy J Vanderjagt
- Department of Biochemistry and Molecular Biology, University of New Mexico Health Sciences Center, MSC08 4670, Albuquerque, NM 87131-0001, USA
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Ndeezi G, Tumwine JK, Ndugwa CM, Bolann BJ, Tylleskär T. Multiple micronutrient supplementation improves vitamin B₁₂ and folate concentrations of HIV infected children in Uganda: a randomized controlled trial. Nutr J 2011; 10:56. [PMID: 21600005 PMCID: PMC3118332 DOI: 10.1186/1475-2891-10-56] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2011] [Accepted: 05/21/2011] [Indexed: 01/02/2023] Open
Abstract
Background The effect of multiple micronutrient supplementation on vitamin B12 and folate has hither to not been reported in African HIV infected children. This paper describes vitamin B12 and folate status of Ugandan HIV infected children aged 1-5 years and reports the effect of multiple micronutrient supplementation on serum vitamin B12 and folate concentrations. Methods Of 847 children who participated in a multiple micronutrient supplementation trial, 214 were assessed for vitamin B12 and folate concentrations pre and post supplementation. One hundred and four children were randomised to two times the recommended dietary allowance (RDA) of a 14 multiple micronutrient supplement (MMS) and 114 to a 'standard of care' supplement of 6 multivitamins (MV). Serum vitamin B12 was measured by an electrochemiluminescence immunoassay and folate by a competitive protein-binding assay using Modular E (Roche) automatic analyzer. Vitamin B12 concentrations were considered low if less than 221picomoles per litre (pmol/L) and folate if < 13.4 nanomoles per litre (nmol/L). The Wilcoxon Signed Ranks test was used to measure the difference between pre and post supplementation concentrations. Results Vitamin B12 was low in 60/214 (28%) and folate in 62/214 (29.0%) children. In the MMS group, the median concentration (IQR) of vitamin B12 at 6 months was 401.5 (264.3 - 518.8) pmol/L compared to the baseline of 285.5 (216.5 - 371.8) pmol/L, p < 0.001. The median (IQR) folate concentrations increased from 17.3 (13.5 - 26.6) nmol/L to 27.7 (21.1 - 33.4) nmol/L, p < 0.001. In the 'standard of care' MV supplemented group, the median concentration (IQR) of vitamin B12 at 6 months was 288.5 (198.8 - 391.0) pmol/L compared to the baseline of 280.0 (211.5 - 386.3) pmol/L while the median (IQR) folate concentrations at 6 months were 16.5 (11.7 - 22.1) nmol/L compared to 15.7 (11.9 - 22.1) nmol/L at baseline. There was a significant difference in the MMS group in both vitamin B12 and folate concentrations but no difference in the MV group. Conclusions Almost a third of the HIV infected Ugandan children aged 1-5 years had low serum concentrations of vitamin B12 and folate. Multiple micronutrient supplementation compared to the 'standard of care' supplement of 6 multivitamins improved the vitamin B12 and folate status of HIV infected children in Uganda. Trial registration http://ClinicalTrials.govNCT00122941)
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Affiliation(s)
- Grace Ndeezi
- Department of Paediatrics and Child Health, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda.
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Abstract
Cobalamin and the metabolic markers methylmalonic acid and total homocysteine undergo marked changes during childhood. In breastfed infants a metabolic profile indicative of cobalamin deficiency is common. Symptoms of cobalamin deficiency in children differ with age, presenting a continuum from subtle developmental delay to life-threatening clinical conditions. The symptoms may be difficult to detect, particularly in infants, and there tends to be a diagnostic delay of several months in this age group. Several reports show that even moderate deficiency in children may be harmful, and long-term consequences of neurological deterioration may persist after cobalamin deficiency has been treated. Given the crucial role of cobalamin for normal growth and development, possible widespread infantile deficiency needs attention. Cobalamin deficiency should be considered a differential diagnosis in children with subtle symptoms, and strategies to prevent cobalamin deficiency in mothers and children should be addressed.
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Honzik T, Adamovicova M, Smolka V, Magner M, Hruba E, Zeman J. Clinical presentation and metabolic consequences in 40 breastfed infants with nutritional vitamin B12 deficiency--what have we learned? Eur J Paediatr Neurol 2010; 14:488-95. [PMID: 20089427 DOI: 10.1016/j.ejpn.2009.12.003] [Citation(s) in RCA: 90] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2009] [Revised: 09/28/2009] [Accepted: 12/10/2009] [Indexed: 11/26/2022]
Abstract
BACKGROUND Maternal vitamin B(12) (Cbl) deficiency causes nutritional Cbl deficiency in breastfed infants. AIMS To analyse clinical presentation and metabolic consequences in 40 breastfed infants with Cbl deficiency. METHODS Cbl levels in serum and breast milk were determined by an electrochemiluminescence immunoassay, methylmalonic acid level by GC/MS, plasma homocysteine by HPLC and propionylcarnitine by MS/MS. Profound Cbl deficiency was found in 17 children (69 ± 17 ng/l, controls 200-900), and milder Cbl deficiency in 23 children (167 ± 40 ng/l). Maternal Cbl deficiency was mostly caused by insufficient Cbl absorption. Only six mothers were vegetarian. RESULTS The average age at diagnosis was 4.4 ± 2.5 months. Clinical symptoms included failure to thrive (48% of children), hypotonia (40%), developmental delay (38%) and microcephaly (23%). 63% of children had anaemia (megaloblastic in 28% of all children). All but one patient had methylmalonic aciduria, 80% of patients had hyperhomocysteinemia and 87% had increased aminotransferases. Propionylcarnitine was elevated in two out of 25 infants. Comparing groups with severe and mild Cbl deficiency, a marked difference was found in severity of clinical and laboratory changes. CONCLUSION Maternal Cbl status and diagnostic delay are the major factors influencing severity and progression of Cbl deficiency in breastfed infants. In our cohort, propionylcarnitine was not sufficiently sensitive marker of Cbl deficiency. Although symptoms are reversible on Cbl substitution, permanent neurological damage can result. Selective screening for Cbl deficiency is indicated in all breastfed infants with failure to thrive, hypotonia, developmental delay, microcephaly or megaloblastic anaemia. The best prevention in future could be the screening of all pregnant women.
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Affiliation(s)
- Tomas Honzik
- Department of Paediatrics, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, Czech Republic.
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Abstract
Megaloblastic anemia (MA), in most instances in developing countries, results from deficiency of vitamin B(12) or folic acid. Over the last two to three decades, incidence of MA seems to be increasing. Of the two micronutrients, folic acid deficiency contributed to MA in a large majority of cases. Now deficiency of B(12) is far more common. In addition to anemia, occurrence of neutropenia and/or thrombocytopenia is increasingly being reported. Among cases presenting with pancytopenia, MA stands out as an important (commonest cause in some series) cause. This article focuses on these and certain other aspects of MA. Possible causes of increasing incidence of MA are discussed. Observations on other clinical features like neurocognitive dysfunction, associated hyperhomocysteinemeia and occurrence of tremors and thrombocytosis during treatment are highlighted.
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Affiliation(s)
- Jagdish Chandra
- Department of Pediatrics, Lady Hardinge Medical College, Kalawati Saran Children's Hospital, New Delhi, India.
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