Nutritional Vitamin B12 Deficiency Research Articles

A nutritional Vitamin B12 deficiency (infantile tremor syndrome) presenting as hemiconvulsion hemiplegia epilepsy syndrome

Hemiplegia Hemiconvulsion Epilepsy syndrome (HHE syndrome) is a condition characterized by the acute onset of unilateral seizures, which progress to cortical atrophy, hemiplegia and later develop epilepsy over weeks to years. Various aetiologies include infectious causes, especially meningitis, encephalitis, trauma, vascular insults, and sometimes idiopathic. Here, we present a 13-month-old female child, first in birth order, born to a non-consanguineous marriage, who presented with mild global developmental delay with acute onset right focal seizures followed by right-sided weakness and drug-resistant epilepsy. The child was found to have clinical and biochemical features of vitamin B12 deficiency with right-sided weakness. MRI of the brain initially showed edema of the left cerebral hemisphere and later atrophy on the left side. The electroencephalogram showed low voltage activity over the left cerebral hemisphere. Post-treatment with cobalamin, improvement in development was noted, with partial improvement in weakness and persistent epilepsy. In the current report, we highlight Hemiplegia Hemiconvulsion Epilepsy (HHE) syndrome on the background of nutritional vitamin B12 deficiency.

Nutritional vitamin B12 deficiency-associated Infantile epileptic spasms syndrome: Clinico-neurophysiological presentation, response to treatment, and neurodevelopmental outcome

Introduction Nutritional vitamin B12 deficiency has been shown to cause Infantile epileptic spasms syndrome (IESS) in infants in anecdotal studies. Methods In this retrospective cohort study, we intended to study the clinical presentation, neurophysiological, laboratory abnormalities, treatment, and neurodevelopmental outcome at 6-months in infants presenting with IESS secondary to nutritional vitamin B12 deficiency (NVBD) and to compare these variables from the rest of the infants with IESS without vitamin B12 deficiency. We included only spasm-free cases or those who showed at least a 50% reduction in spasm frequency on D7 after starting oral/parenteral vitamin B12. We used well-validated measurement tools like the Developmental Assessment Scale for Indian Infants (DASII), Child Feeding Index (CFI), Burden of amplitudes and epileptiform discharges (BASED) score, countable Hypsarrhythmia paroxysm index (cHPI), durational Hypsarrhythmia paroxysm index (dHPI), and Early childhood epilepsy severity scale (E-CHESS) score for documenting these variables. Results Data from 162 infants with IESS (21 caused by NVBD) were included in our study. The NVBD group had more patients residing in the rural region, with lower socioeconomic status, vegetarian mothers and poor complementary feeding index (p<0.001 for all). The NVBD group also had less number of patients requiring antiseizure medications (ASMs) and hormonal therapy(p<0.001), remained seizure free at six months (p=0.008), lower number of clusters per day (p=0.02) and the number of spasms per clusters at presentation (p=0.03), lower BASED score (p=0.03) and cHPI, dHPI at presentation (p<0.001). All of them remained spasm-free, with normal electroencephalogram at 6-months. Development quotient at baseline, at 6-months, and improvement in development quotient between these two-time points were more in the vitamin B12 deficiency group (p<0.001). All of them had clinical features of pre-ITS (infantile tremor syndrome) or ITS and it was found to be the only independent predictor of NVBD in infants with IESS. Mothers of all these infants had low serum vitamin B12 levels (<200 pg/ml). Conclusions Nutritional vitamin B12 deficiency may cause IESS in infants. Hence, vitamin B12 deficiency needs to be ruled out in patients with IESS without any definite etiology.

Epileptic Spasms During Recovery From Nutritional Infantile Vitamin B12 Deficiency

Development of epileptic spasms in infants with vitamin B12 deficiency is uncommon. In some cases, infants presenting with epileptic spasms have been found to have concurrent vitamin B12 deficiency. Treatment with vitamin B12 and adrenocorticotropic hormone (ACTH) resulted in resolution of epileptic spasms. In others, epileptic spasms have developed during recovery from vitamin B12 deficiency. Treatment with ACTH or other seizure medications resulted in resolution of epileptic spasms, although response has been less predictable. We describe three infants who initially presented with clinical and laboratory features of vitamin B12 deficiency. Treatment with vitamin B12 resulted in rapid resolution of symptoms. However, recovery was interrupted by the development of epileptic spasms. All infants showed hypsarrhythmia on electroencephalography. Treatment with prednisolone, with or without other antiseizure medications, resulted in slow resolution of spasms. Cognitive and language delays were noted in two infants. Epileptic spasms may supervene during recovery from vitamin B12 deficiency affecting outcomes.

A common problem in infants: vitamin B12 deficiency.

Nutritional vitamin B12 (VB < sub > 12 < /sub > ) deficiency is characterized by anemia, the inability to gain weight, delay or decline in development. Children of mothers with VB < sub > 12 < /sub > deficiency have a risk of nutritional VB < sub > 12 < /sub > deficiency. Prevention and early treatment are necessary to prevent irreversible neurological damage. We aimed to conduct a retrospective study to understand the characteristics of patients with VB < sub > 12 < /sub > deficiency. Our study included patients admitted to Başkent University Faculty of Medicine Pediatric Hematology outpatient clinic between January 2015 - February 2020 for VB < sub > 12 < /sub > deficiency. Their clinical and laboratory characteristics were retrospectively examined through the hospital automation system. Vitamin B12 deficiency was detected in 129 of the 3198 patients; 100 of them were followed regularly. The mean age at admission of our patients was 10 ± 12 months (1 month - 7.5 years); 98% of these children were aged 0-2 years. The mean VB < sub > 12 < /sub > level of our patients was 171.63 ± 51.2 pg/ml (83 - 273), mean hemoglobin 11.2 ± 1.37 g/dl (6.3 - 13.9), mean MCV 74.5± 9.1 fl (54-106.5) and mean iron level was 54 ±23 μg/dl (18 - 94). At the end of one month of loading therapy (oral or intramuscular, IM), the average VB < sub > 12 < /sub > level was 769 ± 537 pg/ml (post loading). One month after the loading therapy (pre-maintenance) the average VB < sub > 12 < /sub > level was 426 ±156 pg/ml. In seven cases who received IM therapy, the loading treatment was performed for the second time. The mean VB < sub > 12 < /sub > level of the mothers of 85 cases was 174±127 pg/ml (134 - 650). VB < sub > 12 < /sub > deficiency was detected in 55% of mothers, VB < sub > 12 < /sub > level being between 200 - 300 pg/ml in 76%, and below 200 pg/ml in the 24%. The family members of 35% of our patients (including parents) had VB < sub > 12 < /sub > deficiency. In our country, routine screening of VB < sub > 12 < /sub > levels in infants is not performed; however, its early diagnosis and treatment can prevent many adverse effects mainly on the central nervous system. The fact that 98% of patients were 0-2 years old indicates that its deficiency may be quite high in the young age, and routine screening of this age group for VB < sub > 12 < /sub > deficiency and further studies for prophylaxis may be needed.

Elevated homocysteine levels: What inborn errors of metabolism might we be missing?

Elevated total plasma homocysteine (hyperhomocysteinemia) is a marker of cardiovascular, thrombotic, and neuropsychological disease. It has multiple causes, including the common nutritional vitamin B12 or folate deficiency. However, some rare but treatable, inborn errors of metabolism (IEM) characterized by hyperhomocysteinemia can be missed due to variable presentations and the lack of awareness. The aim of this study is to identify undiagnosed IEM in adults with significantly elevated homocysteine using key existing clinical data points, then IEM specific treatment can be offered to improve outcome. We conducted a retrospective study with data mining and chart review of patients with plasma total homocysteine >30 μmol/L over a two-year period. We offer biochemical and genetic testing to patients with significant hyperhomocysteinemia without a clear explanation to diagnose IEM. We identified 22 subjects with significant hyperhomocysteinemia but no clear explanation. Subsequently, we offered genetic testing to seven patients and diagnosed one patient with classic homocystinuria due to cystathionine beta-synthase deficiency. With treatment, she lowered her plasma homocysteine and improved her health. This study stresses the importance of a thorough investigation of hyperhomocysteinemia in adults to identify rare but treatable IEM. We propose a metabolic evaluation algorithm for elevated homocysteine levels.

The Efficacy, Dose and Interval Of Sublingual Methylcobalamin Spray in Children: A Single-Center Experience

Introduction: Vitamin B12 deficiency is essential to treat because of hematologic and neurologic results. Sublingual methylcobalamin spray leads to easy, safe, and cost-effective treatment. However, studies reveal the different duration of treatment; age-specific dose is not precise. Here, we aimed to investigate the efficacy, dose adjustment, and durability of vitamin-B12 spray. Methods: This retrospective study includes seventeen children (3 months-17 years) diagnosed with nutritional Vitamin-B12 deficiency between January 2020- January 2021. The methylcobalamin doses were 500 mcg (&lt;1 year of age) and 1000 mcg (≥1 year of age) every day for the first week and every other day for seven weeks. In addition, serum Vitamin B12 and hemoglobin levels were studied at diagnosis and second, sixth, and twelfth months of treatment. Finally, we compared the beginning hemoglobin and Vitamin-B12 levels with the second month's values. Results: After two months of sublingual methylcobalamin treatment, the Vitamin B12 significantly increased (p=0.008) and kept normal ranges for twelve months. Hemoglobin levels tended to rise in two months, but the difference was not statistically significant (p=0.22). Conclusion: There is no consensus on the sublingual methylcobalamin dose and treatment schedule. However, we suggest that a 500 mcg dose of methylcobalamin for &lt;1 year of age and a 1000 mcg dose for ≥ 1 year with two months treatment period is appropriate and safe for nutritional Vitamin B12 deficiency.

Functional Vitamin B12 deficiency in Chronic Fatigue Syndrome

Chronic Fatigue Syndrome/Myalgic encephalomyelitis (CFS/ME) is a complex chronic condition, characterized by periods of extreme fatigue, for which an underlying medical condition has previously not been identified. Many of the symptoms of CFS/ME, are, though, similar to those with vitamin B12 deficiency. In contrast to nutritional vitamin B12 deficiency, the majority of individuals with CFS have been shown to have functional vitamin B12 deficiency as well as functional vitamin B2 deficiency. This functional B12 deficiency occurred despite elevated serum B12 being found, and hence presents as Paradoxical vitamin B12 deficiency. As such, CFS due to functional B2 deficiency presents as Paradoxical B12 deficiency. Maintenance of vitamin B12 functional activity is critically dependent upon functional B2 sufficiency, and hence resolution of CFS there must first be resolution of functional B2 deficiency before treatment with vitamin B12 can be effective.

Relationship of lung function with homocysteine, vitamin B12 and folic acid level in metabolic syndrome

Background: Metabolic syndrome (MetS) is a complex metabolic disorder and with debilitating effects on many organs including lung function impairment. Hyperhomocysteinaemia is caused by nutritional deficiency of vitamin B12 and folic acid can increase this risk further. Both the metabolic syndrome and hyperhomocysteinaemia adversely affect the lung function. But no study was found in Bangladeshi MetS in this regard. Objective: To assess the relationship of lung function with serum homocysteine, vitamin B12 and folic acid level in metabolic syndrome. Methods: This cross-sectional study was conducted in the department of physiology, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka from November, 2019 to April, 2020. A total of 60 female subjects were selected with the age ranging from 25-45 year by purposive sampling. Among them 30 metabolic syndrome patients were included in the study group (group A) and 30 age and sex matched apparently healthy subjects constituted comparison group (group B). Serum homocysteine, vitamin B12, folic acid and other biochemical parameters and the lung function of all subjects were assessed. Data were expressed as mean±SD. Spirometric measures were expressed as percent of predicted value. Statistical analysis was done by Independent sample ‘t’ test and Pearson’s correlation coefficient test. Results: In this study, the mean percentage of predicted value of FVC, FEV1 and, PEFR were significantly lower (p&lt;0.001) in group A than those of group B. The mean serum homocysteine level was higher and vitamin B12 and folic acid level were lower in metabolic syndrome patients compared to comparison group and the difference was statistically significant only for homocysteine (p&lt;0.05). In addition, the FVC and FEV1 were significantly negatively correlated (p&lt;0.05) with serum homocysteine and FVC was significantly positively correlated (p&lt;0.05) with serum folic acid level in group A. Conclusion: The present study reveals that impairment of lung function is related to higher level of homocysteine and lower level of folic acid in metabolic syndrome. Bangladesh Med Res Counc Bull 2021; 47(2): 175-180

Effectiveness of a Daily-Balanced Multivitamin Product After Sleeve Gastrectomy: Results from a High-Volume Bariatric Center

Introduction: Laparoscopic sleeve gastrectomy (SG) has become one of the most performed bariatric surgeries worldwide. However, SG leads to postoperative vitamin and trace element deficiencies, as well as other bariatric procedures. Materials and Methods: Provisioneat® is a customized multivitamin supplement for bariatric patients. The present study evaluates its effectiveness in decreasing nutritional deficiency rates following SG. A retrospective study of 101 patients who underwent SG between January 2017 and June 2018 was performed. Baseline albumin, vitamin D, vitamin B12, folic acid, iron, and calcium were measured pre- and postoperatively at 6, 12, and 18 months after surgery. Results: Before surgery, 29.7% and 14.9% of the patients presented vitamin D and folic acid deficiency, respectively. At the 6- and 12-month follow-up, no case of deficiency was registered. Conversely, after18 months, 33.7% of the patients presented vitamin D deficiency, despite supplementation. During the study period, the patients' serum levels of vitamin B12, albumin, calcium, iron, and folic acid were within the range. Conclusion: This specifically designed multivitamin supplement lowers the incidence of nutritional deficiency of vitamin B12, folic acid, calcium, and iron. However, we reported vitamin D deficiency in 33.7% of patients at 18 months of follow-up.

Cranial Magnetic Resonance Imaging Findings in Hypotonic Infants with Cobalamin Deficiency and Combined Methylmalonic Aciduria and Homocystinuria.

Vitamin B12 begins to accumulate in infants within the first six months while mothers often remain asymptomatic and infantile vitamin B12 deficiency may not be noticed until the onset of neurological effects. In infants with Cbl deficiency, long-term exposure to elevated methylmalonic acid and homocysteine (MMA-HC) may have toxic effects on the central nervous system. The aim of this study was to evaluate cranial magnetic resonance (MRI) findings of 23 hypotonic infants that were followed up with a diagnosis of nutritional Cbl deficiency and combined MMA-HC. Of the 78 infants that presented with hypotonicity, 23 (29.4%) infants were detected with vitamin B12 deficiency. Elevated MMA-HC levels were detected in all patients (100%). Cranial MRI showed cortical atrophy in 6 (26.0%)-large sylvian fissures in 7 (30.4%)-ventricular dilatation in 5 (21.7%)-corpuscallosal thinning in 6 (26.0%)-delayed myelination in 3 (13%), and normal in 8 (34.7%) infants.Infants detected with corpus callosal thinning and cortical atrophy on MRI. Vitamin B12 deficiency is a treatable condition, it should be suspected in infants presenting with hypotonicity. Neuroradiological findings should be considered in the diagnosis of such patients. İnfantile nutritional vitamin B12 deficiency, which can be a source of persistent neurological deficits during the long term, should be treated to allow the patient to allow healthy neuro-development for infants. Maternal and fetal vitamin B12 levels should be assessed during the third trimester of pregnancy to prevent long-term exposure to infantile vitamin B12 deficiency.

Progressive Hyperpigmentation in a Child: An Early Marker of Infantile Tremor Syndrome

Hyperpigmentary disorders are commonly encountered group of dermatoses in the paediatric age group. One of the most common causes of progressive generalised hyperpigmentation in paediatric population is nutritional vitamin B12 deficiency (NVBD). NVBD can present with a bunch of signs and symptoms like skin hyperpigmentation, pallor and regression of neurodevelopment. We report a case of a plump looking 13 months old, girl child from non-consanguineous marriage of low socioeconomic family who presented with generalised hyperpigmentation, failure to thrive and regression of mile stones. Physical examination revealed anaemia and sparse, thin, lustreless hair with dull, apathetic look. A differential diagnosis of Addison’s disease, hypothyroidism, and neurodegenerative disease, was considered based on clinical suspicion. She was further investigated by a paediatrician. Her blood investigations revealed low levels of Vitamin B12 (159 pg/dl) and haemoglobin (2.6 g/dl). On radiological examination, NCCT brain showed cortical atrophy. A final diagnosis of Infantile Tremor Syndrome (ITS) was made. ITS is a rare condition which presents with cutaneous manifestation like hyperpigmentation, scanty scalp hair along with lethargy, apathy along with signs and symptoms of neurodegeneration. Progressive cutaneous hyperpigmentation in a child can present as early marker of a rare neurodegenerative condition like ITS.

A variety of abnormal movements in 13 cases with nutritional cobalamin deficiency in infants

HypothesisAbnormal movements such as tremor, myoclonus, and choreoathetosis due to infantile nutritional vitamin B12 (Cbl, cobalamin) deficiency or after Cbl injection have been recognized for many years. However, nutritional Cbl deficiency may be more common than recognized and a variety of the abnormal movements may be beyond our estimates. ObjectiveTo define the relationship between a large variety of abnormal movements in infants and vitamin B12 deficiency even if serum vitamin B12 levels and/or examination are normal. Materials and methodsThis study analyzed a variety of abnormal movements such as involuntary eye movements, limb and body contractions, and gasping as well as clinical, metabolic, radiologic, and treatment results in 13 infants with nutritional Cbl deficiency. This is a retrospective study based on observation and experience. ResultsThis study included 13 infants (11 boys and 2 girls) with a large spectrum of abnormal movements, the mean age at admission was 8.3 months with a range of 3–22 months. All patients were breastfeeding. In seven cases and their mothers serum vitamin B12 levels were below 200 pg/ml. About one-third of cases serum vitamin B12 levels were over 200 pg/ml. Clinically, mild hypotonia was present in 5 cases, inadequate social interactions in 2 cases, and sensorineural hearing loss in one case. Brain MRI showed frontotemporal enlarged subarachnoid spaces and thinning of the corpus callosum in two cases. EEG examinations were normal in all cases at admission. All cases recovered rapidly within one month with treatment. ConclusionNutritional Cbl deficiency is a treatable disease that should be considered in the etiology of a variety of movement abnormalities in infants even if serum vitamin B12 values and neurological development are normal.

Severe Haemolytic Anaemia, a Rare Presentation of Nutritional Vitamin B12 Deficiency: A Case Report

Vitamin B12 deficiency usually presents with megaloblastic anemia, pancytopenia, and neurological symptoms. The cause is usually, nutritional deficiency, increase demand, decrease absorption. This report describes a case with symptoms of apathy and findings suggestive of severe hemolytic anemia, diagnosed with vitamin B12 deficiency. Haemolysis is a rare hematological finding in cases of B12 deficiency, and descriptions of a nutritional vitamin B12 deficiency, without evidence of pernicious anaemia, causing haemolysis, are even scarcer, and this paper was intended to draw physicians’ attention to this rare form of presentation.

Comparison of the efficacy of parenteral and oral treatment for nutritional vitamin B12 deficiency in children

ABSTRACT Objective: Although, oral replacement for vitamin B12 deficiency has been proved to be effective in adults, it is mainly treated with parenteral therapy. There are only few studies on oral replacement therapy of vitamin B12 with children. Therefore, we aimed to compare the efficacy of oral treatment with intramuscular vitamin B12 injections in pediatric population. Methods: Children with serum cobalamin concentrations less than 300 pg/mL, were treated either with the parenteral therapy or with oral vitamin B12. The primary and secondary outcomes of the study were the normalization of serum vitamin B12 and hemoglobin at first month, respectively. Results: Post-treatment vitamin B12 values were significantly higher than pre-treatment values (p-value <.001). Vitamin B12 increased from 183.5 ± 47 pg/mL to 482 ± 318.9 pg/mL in the oral and from 175.5 ± 42.5 pg/mL to 838 ± 547 pg/mL in the parenteral treatment arm (p-value <.001). Before treatment, 82 children had anemia according to age and gender. After treatment, 14/41 and 8/41 patients still had anemia at the first month of treatment in the parenteral and oral arms, respectively. The number of patients who still have anemia at the end of the 1st month of treatment did not significantly changed in the parenteral and oral treatment groups (p-value = .44). Conclusions: In this study, both oral and parenteral formulations were shown to be effective in normalizing vitamin B12 levels. We suggest that oral formulations may be considered to be safe as a first line treatment for vitamin B12 deficiency in children.

Newborn screening for remethylation disorders and vitamin B12 deficiency-evaluation of new strategies in cohorts from Qatar and Germany.

Newborn screening is a precondition for early diagnosis and successful treatment of remethylation disorders and classical homocystinuria (cystathionine-ß-synthase deficiency). Newborn screening for classical homocystinuria using total homocysteine measurement in dried blood spots has been very successfully performed for many years for newborns from Qatar. A new optimized newborn screening strategy for remethylation disorders and homocystinuria was developed and evaluated for newborns from Qatar using total homocysteine measurement as first-tier and methionine, methionine-phenylalanine-ratio and propionylcarnitine as second-tiers. Proposed cut-offs were also retrospectively evaluated in newborn screening samples of 12 patients with remethylation disorders and vitamin B12 deficiency from Qatar and Germany. Over a 12 months period, the proposed strategy led to a decrease in the recall rate in homocysteine screening for Qatar from 1.09% to 0.68%, while allowing for additional systematic inclusion of remethylation disorders and vitamin B12 deficiency into the screening panel for Qatar. In the evaluated period the applied strategy would have detected all patients with classical homocystinuria identified by the previous strategy and in addition 5 children with maternal nutritional vitamin B12 deficiency and one patient with an isolated remethylation disorder. Additional retrospective evaluation of newborn screening samples of 12 patients from Germany and Qatar with remethlyation disorders or vitamin B12 deficiency showed that all of these patients would have been detected by the cut-offs used in the proposed new strategy. In addition, an adapted strategy for Germany using methionine, methionine-phenylalanine-ratio and propionylcarnitine as first-tier, and homocysteine as a second-tier test was also positively evaluated retrospectively. The proposed strategy for samples from Qatar allows inclusion of remethylation disorders and vitamin B12 deficiency in the screening panel, while lowering the recall rate. An adapted second-tier strategy is presented for screening in Germany and will be prospectively evaluated over the next years in a pilot project named "Newborn Screening 2020".

Different Neurologic Aspects of Nutritional B12 Deficiency in Infancy.

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.

Neurological manifestations of vitamin B12 deficiency in 15 infants

Nutritional vitamin B12 deficiency in infancy is rare, and so far, case reports or few case series declared. Neurological symptoms of vitamin B12 deficiency are heterogeneous and include irritability, apathy, developmental regression, hypotonia, tremor, ataxia, seizures. We report of the clinical findings and neurological abnormalities in fifteen infants with nutritional vitamin B12 deficiency seen during the last 1 year and an attempt made to obtain short-term neurologic follow-up. All of these cases were breastfed and maternal diet was strict vegan or poor of meat. Clinical findings and laboratory results normalized rapidly after vitamin B12 administration and fifteen children who qualified for short-term neuromotor development had well outcome. We emphasized here the early diagnosis of vitamin B12 deficiency is very important because psychomotor and mental damage could be reversible with appropriate treatment.

The impact of nutritional vitamin B12, folate and hemoglobin deficiency on school performance of elementary school children

Deficiencies of nutrients such as vitamin B12, folic acid and iron are frequently associated with impairment of memory, concentration and learning ability. Deficiencies of these micronutrients are very rare in Western countries, whereas they are common in developing countries. This study was carried out to determine the impact of vitamin B12 deficiency, folic acid deficiency and/or anemia on the academic achievement of elementary school children from a low socio-economic population, i.e., impoverished Bedouin population living in southern Israel. Sixty-seven elementary school children, nine to eleven years of age, were randomly tested. Serum levels of vitamin B12, folic acid, and hemoglobin were measured using automated chemiluminescence systems. An individual questionnaire was filled out for each student, which included information on number of meat meals consumed per week, the number of people in the family and information about the father's employment status. Significant positive correlations were observed between number of meat meals consumed per week and low vitamin B12 levels and attainment of low marks in school, respectively. There was a negative correlation between the total number of family members and the attainment of low marks in school. No correlation between anemia or low folic acid levels and school performance was observed. Despite the small sample number, results indicated a high prevalence of vitamin B12 deficiency among these elementary school children, which could be linked to inadequate meat meal intake. This ultimately affected school performance of these children.

Subacute combined degeneration of spinal cord due to nutritional vitamin B12 deficiency in early childhood

Subacute combined degeneration of spinal cord is a rare neurological manifestation of vitamin B12 deficiency due to inadequate dietary intake in children. We report a case of 4.5-year-old girl who was vegan with developmental regression, hyperpigmentation over extremities and features of subacute combined degeneration of spinal cord, a rarity in children. Laboratory investigations and neuroimaging were confirmatory. She responded well to treatment and she is having no complaints at present.

Investigation of hemorheological parameters at the diagnosis and the follow-up of nutritional vitamin B12 deficient children

We aimed to investigate the effects of vitamin B12 deficiency on hemorheological parameters, and the changes in these parameters following vitamin B12 treatment. 33 patients (mean-age:7 ± 5.7 years) diagnosed as nutritional vitamin B12 deficiency, and 31 age and sex matched controls (mean-age:7.1 ± 5.2 years) were enrolled. Erythrocyte deformability and aggregation were determined by an ectacytometer, plasma and whole blood viscosities by a cone-plate rotational viscometer. The differences between patients and controls were compared. Hemorheological parameters were repeated in the patient group following vitamin B12 treatment, and the results were compared with the initial results. In vitamin B12 deficiency, erythrocyte deformability and whole blood viscosity were found to be significantly decreased, eythrocyte aggregation was found to be significantly increased compared with the controls. Plasma viscosity was found to be decreased in deficiency but this decrease was not statistically significant. In patient group, erythrocyte deformability, whole blood and plasma viscosities were found to be significantly increased and erythrocyte aggregation was significantly decreased, after treatment. This study indicates that vitamin B12 deficiency has important effects on hemorheological parameters and adequate treatment of deficiency not only corrects the hematological parameters, but also by helping to normalize the hemorheological parameters, may contribute to the regulation of microvascular perfusion.