Vitamin B12 deficiency in a breast fed infant.

We report the case of a 5 month old breast fed infant who presented with a history of vomiting, pallor, and failure to thrive. Investigations showed severe nutritional vitamin B12 deficiency with a megaloblastic pancytopenia. This deficiency was due to low vitamin B12 concentrations in the maternal breast milk, and subsequent investigations showed maternal pernicious anaemia. Treatment of the infant with vitamin B12 resulted in a rapid clinical and haematological improvement. This case represents an unusual presentation of pernicious anaemia.     

Vitamin B12 deficiency in a 9-month-old boy

We present a 9-month-old boy with megaloblastic anaemia, neutropenia and hypogammaglobulinaemia due to vitamin B12 deficiency. The deficiency was secondary to prolonged exclusive breastfeeding with inadequate nutritional amounts of vitamin B12 from the mother. There were no clinical or biological signs of maternal anaemia or macrocytosis. Treatment with oral vitamin B12 rapidly improved the biological findings of the child. Vitamin B12 deficiency should be considered in infants older than 2 months presenting with failure to thrive, neurocognitive retardation or even pancytopenia and hypogammaglobulinaemia, even in the absence of any signs of maternal anaemia or macrocytosis. Therefore, evaluation of vitamin B12 status during pregnancy and lactation is necessary in order to prevent B12 deficiency and its possible long-term effects in infants. Conclusion: Further studies should be conducted to evaluate the optimal oral dosage of vitamin B12 in children since limited data on the use of oral B12 substitution are available.     

Rickets in exclusively breast fed babies

Articles appear periodically in Indian and western literature, about occurrence of vitamin D deficiency in exclusively breast fed babies. Some countries have formulated guidelines for prevention of vitamin D deficiency in such babies. In this study, twenty cases of nutritional rickets were diagnosed in exclusively breast fed babies between December 2003 and December 2006. None of them received vitamin D supplementation. Through this study, we hope to initiate further research and debate among the policymakers on whether or not vitamin supplementation should be given to all exclusively breast fed babies and lead to a formulation of clear cut guidelines in the Indian context.     

纯母乳喂养婴儿少量便血的原因探讨

目的：探讨纯母乳喂养婴儿少量便血的原因。方法：研究对象为75例以少量便血为症状的纯母乳喂养婴儿,记录便血症状出现的年龄、伴随症状及实验室检查（血常规、大便常规、肝功能、大便培养、结肠镜及肠黏膜活检等）的结果。75例患儿的母亲均被指导进行膳食回避,即去除饮食中的动物及植物蛋白类食物4周,观察便血症状改善情况。结果：患儿出现便血症状的平均年龄为7.4周,最常见的伴随症状是腹泻（71%）,实验室检查中以轻度贫血最多见（60%）,大便常规可见红、白细胞,但大便培养均为阴性。结肠镜检查提示结肠炎,20例患儿行肠黏膜活检提示嗜酸性粒细胞增多。母亲去除蛋白饮食后的72~96 h,患儿肉眼可见的便血消失。结论：纯母乳喂养的婴儿可因对母亲摄入的蛋白过敏而出现便血。     

Vitamin D deficiency rickets and vitamin B12 deficiency in vegetarian children

During the years 1978-83 four vegetarian children have been admitted to the pediatric departments of Ullevaal and Aker Hospitals in Oslo and Haukeland Hospital, Bergen, with the diagnosis of vitamin D deficiency rickets. One had vitamin B12 deficiency as well. All had been fed a vegetarian diet with some cows' milk, but without vitamin supplementation. All had marked hypocalcemia, and three had tetany or convulsions. All responded well to conventional doses of vitamin D therapy. Two of the mothers had vitamin D deficiency, and one of them also had vitamin B12 deficiency. This report describes the case histories of these children, and also discusses predisposing factors of vegetarian diets for the development of nutritional rickets.     

Vitamin B12 deficiency due to a strictly vegetarian diet in adolescence

A 14-year-old white girl suffered from severe neurologic disturbances caused by vitamin B12 deficiency, due to failure to provide vitamin B12 supplementation to a strictly vegetarian diet. The disturbances resolved completely following treatment with vitamin B12. Physicians should be alert to the necessity for vitamin B12 supplementation for strict vegetarians, who eat no meat, fish, eggs, or dairy products.     

Do exclusively breast fed infants need fluid supplementation?

Exclusive breast feeding in developing countries is used by women for a very short period. The major reason given for supplementation with other fluid is the maintenance of water homeostasis. Theoretically, 80-100 ml/kg is the average daily fluid requirement for the first week; between 3-6 months, the need is for 140-160 ml/kg. the need varies with concentration of the feeds, energy consumption, activity, rate of growth, and environmental temperature and humidity. Because breast milk has a low concentration of sodium, chloride, potassium, and nitrogen only a small amount of fluid intake is needed for excretory functions. Almroth's model of basic fluid needs for a Western 4-month-old male infant are used to calculate fluid requirements; the results indicate that an exclusively breast fed infant in a hot climate would not need additional water. Estimates for an Indian infant weighing 5.5 kg at 4 months support these findings. Other scientific findings are reviewed based on clinical evidence; the risks associated with supplementation and the role of medical personnel in encouraging supplementation are also discussed. Evidence from a survey of 70 physicians and 34 nurses revealed that all considered breast milk superior to bottle feeding. 97% of nurses and 63% of doctors thought that water supplementation was necessary during the summer. The volume recommended by nurses was 180-240 ml, which was almost twice the amount recommended by doctors. Nurses recommended supplementation 1-24 times a day, while doctors suggested adopting it 2-10 times a day. There were 6 studies which tested the validity of water need based on different methodologies: Almroth (2 studies), Armelini, Goldberg, Brown, and Sachdev. Hydration was measured by specific gravity or osmolality in 4 reports, and 2 others considered breast milk intakes and urine output. One study compared exclusive breast feeding with a control receiving water supplementation. The conclusion is that water supplementation in the first 6 months is not necessary and should be actively discouraged. The education of the general public and health personnel is urgently needed. Supplementation is associated with health risks such as diarrheal morbidity or mortality, decreased milk intake, and early stops to breast feeding.