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Severe vitamin B12 deficiency in an exclusively breastfed 5-month-old Italian infant born to a mother receiving multivitamin supplementation during pregnancy.

Guez S, Chiarelli G, Menni F, Salera S, Principi N, Esposito S. (2012) BMC Pediatr. 12: 85. 

Web URL: View this and related abstracts via PubMed here. Free full text of this article is available online.

Abstract:

BACKGROUND:

In infants, vitamin B12 deficiency may be due to an inborn error of absorption and metabolism, or nutritional problems.

CASE PRESENTATION:

An exclusively breastfed 5-month-old Italian male infant, who was born after a normal full-term pregnancy to a vegan mother who was apparently daily treated with a multivitamin oral preparation during the second and third trimester, was hospitalised because of poor weight gain, feeding difficulties, severe pallor, muscle hypotonia and somnolence.

Upon admission, his weight, length and head circumference were below the third percentile, he had an enlarged liver and spleen, and showed a significant delay in developmental milestones and communicative reactions.

He had a hemoglobin level of 4.7 g/dL with an MCV of 84.2 fL, a white blood cell count of 4,680/mm3, and a platelet count of 45,000/mm3. His serum vitamin B12 level was 57 pg/mL (normal value 180-500 pg/mL) and serum folate level 12.8 ng/mL (normal value >3 ng/mL).

The results of metabolic examinations excluded a cobalamin C disorder, whereas nutritional screening showed a serum iron concentration of 9 μg/dL and serum ferritin of 4 ng/mL. Magnetic resonance imaging of the brain showed mild dilatation of the lateral ventricles with diffuse delayed myelination.

The child was diagnosed as having vitamin B12 and iron deficiency due to nutritional inadequacy and was immediately treated with packed red blood cells, intramuscular vitamin B12 injections, and iron supplementation.

A few days after the start of therapy, his hemoglobin levels and other hematological parameters rapidly improved, and a clinical improvement was observed within few weeks. There was an increase in his achievement of developmental milestones, but his development was still retarded seven months after the start of therapy.

CONCLUSION:

This case underlines the importance of adequately controlling maternal vitamin B12 intake during pregnancy by means of supplementation which, in the case of vegan mothers, should be significantly greater than that usually given.

Moreover, the supplementation should be continued during lactation in order to avoid the development of signs of deficiency that may be associated with persistent neurological problems in infants.

The case also highlights the need to consider vitamin B12 deficiency in infants with severe anemia even if their hematological parameters do not indicate megaloblastic anemia because the concomitant presence of substantial iron deficiency may modify the characteristics of the anemia.

FAB RESEARCH COMMENT:

This case report once again documents the very serious neurological and other health problems that can be caused by a lack of Vitamin B12 in infancy - although when tested, this child also showed iron deficiency. 

And once again, these nutritional deficiencies - which led to the child's serious health and developmental problems - appear to have arisen as a result of the mother's adherence to a vegan diet.

What is unusual about this case is that the mother was reported to have apparently been taking a multivitamin and mineral supplement during pregnancy. 

The authors therefore emphasis the importance of health practitioners ensuring that vegan mothers not only take adequate levels of supplementation during pregnancy, but also that this is continued throughout the breasfeeding period.

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