Female patient from the Fourth Region who consulted at 12 months of age in Pediatric Neurology in a private clinic in Santiago, for psychomotor retardation, asthenia and anemia.
31-year-old professional midwife, egg-vegetarian for approximately 10 years, with a history of long-standing iron deficiency anemia.
28-year-old professional, also egg-vegetarian.
Both opt for this feeding system after working in a food producing plant.
There is no history of consanguinity or relevant pathologies in the family.
The infant was the product of a third pregnancy, during which she did not receive supplementation of vitamins or minerals due to hyperemesis gravidarum.
She was born by term vaginal delivery at 38 weeks, birth weight: 3,300 g, received phototherapy for 36 h, for incompatibility of classic group.
During the first months of life, the patient became ill and had no intercurrent illness.
She came to her pediatric controls on a regular basis but with different professionals in the private health system.
He received the corresponding vaccines according to the current immunization program.
The child was exclusively fed to the mother's breast until 6 months of age, starting complementary feeding of ovolatio-vegetarian type with inclusion of vegetables at this age second progressive rejection, which was initially received during the second semester.
Through the dietary survey at one year of age, the mother reported almost exclusive breastfeeding due to sustained rejection of vegetable papillae and milk formulae.
He received supplementation only with vitamins A, C, and D according to national protocol, with daily doses of vitamin D of 400 IU/day.
During her first physical evaluation at 12 months, a hypoactive but conscious, sad girl stood out, with no smile, with little interest in objects.
Generalised hypotonia with exhaled osteotendinous reflexes.
He sat down without support, but tended to recover.
In the initial nutritional assessment, the following stand out at one year of age: Z weight/age of -1.47, Z-height/age in type 1, Z-weight/height -2.04.
Z-Perfect meter 0.08, according to WHO reference standards.
Laboratory studies showed a complete blood count with macrocytic anemia, hematocrit of 26.8%, hemoglobin of 8.9 mg/dl, MCV of 106.7 pg (rV-36: 73-102), MCH of 35.5 pg/dl.
2% reticulocyte count with 1.34 index
Anipresentosis ++, Macrocytosis +, Poiquilocytosis +.
Series challenge was within normal limits.
ESR: 22 mm/hour.
Folic acid levels of 27.7 mg/ml (NV: > 5.38).
Ferremia 53 ug/dl (VN: 50-179).
Vitamin B12 levels of 147 pg/ml (VN: 211-911).
Homocysteine levels: 36 mmol/lt (VN: < 20).
A Tandem Mass Spectrum was also requested, which showed an increase in the levels of methylmalonic acid and free acylcarnitines.
Considering the patient daughter of a vegetarian mother, breastfed almost exclusively at one year of life, with delayed psychomotor development and megaloblastic anemia, the first alternative was vitamin B12 deficiency.
Due to marked food refusal, enteral nutritional support was decided through a nasogastric tube.
Intramuscular administration of vitamin B12 at a dose of 1 mg/day was initiated for one week, after which there was a notorious clinical improvement (both mood and reactivity to the progressive formula), and laboratory vegetable intake.
After 7 days of treatment, diet and vitamin B12 administration were continued at a dose of 1 mg/day for 15 days and then daily for 3 months and then at a weekly dose of oral manatee 1 mg/day.
Due to the severity of the clinical manifestations, the parents were suggested to introduce foods of animal origin in the child's diet to optimize the intake of high biological value protein, introducing them initially.
However, after approximately 6 months, the parents returned to the ovolate-vegetarian diet for their daughter, so they should be supplemented with iron and vitamin B12.
The patient was periodically reassessed and included in a rehabilitation program, maintaining periodic control where the point of view of her psychomotor development.
Started with seizure at the age of 20 months, but persisted with language delay, so he continued with speech therapy.
During the last evaluation, at 24 months, there was a Z-weight/age of 0.71, a Z-height/age -0.21, Z-weight/height -0.77, Z-PC: WHO.3, according to reference standards
Vitamin B12 levels were within normal limits (800 pg/ml), with no anemia or erythrocyte size alteration.
Masa Spectrum in Control Tandem showed normalization of previously altered levels.
It should also be noted that the mother was studied by gastroenterology due to the suspicion of a probable percarious origin of her anemia, since although her anemia was microcytic, her vitamin B12 levels were below 200 ug/day and her intrinsic anti-mix antibodies were not normal.
