Infantile tremor syndrome

Dr Heera E Chand 

ABSTRACT:
Infantile tremor syndrome is a self-limiting clinical disorder most commonly seen in Indian infants and young children between 6 months to 2 years of age³. Among the various theories nutritional theory is the most accepted one. Incidence in India is about 1 to 2 %   in the hospitals that have started recognizing this condition. Males are more affected than females. This article attempts to provide comprehensive and up-to-date information about ITS and its scope in homoeopathy. 

Key words: Infantile tremor syndrome, vit B12 deficiency, megaloblastic anaemia, weaning, pigmentation, anemia.

Introduction:
Infantile tremor syndrome is a clinical disorder most commonly seen in Indian infants and young children between 6 months to 2 years of age. Characterised by tremors, psychomotor changes, pigmentary disturbances of hair and skin, pallor, anaemia. This disease is now encountered less frequently.

Synonyms: Infantile meningioencephalitis, tremor syndrome, nutritional tremor syndrome, syndrome of tremors, mental regression and anaemia in infants, syndrome of tremors in infants, megaloblastic anaemia of infancy and Vit B12.^1,3

Epidemiology:

• Incidence in India is about 1 to 2 % of paediatric age group in the hospitals that have started recognizing this condition.¹
• Vast majority of cases fall in 6 months to 2 years of age though infants younger or older than this have been reported.³
• Males are more affected than females.
• Most of the children with ITS comes from low socioeconomic status.
• Peak incidence during summer.

Etiopathogenesis: ^1,2,3,4

• Aetiology is still elusive. Among the various theories nutritional theory is the most accepted one. The low levels of Vit B12 and its transport protein transcobalamin II (TC II) may be responsible for neurological features of this syndrome. Commonly seen in children who are exclusively breast fed for prolonged periods by vegetarian mothers or weaning has never been initiated due to lack of appropriate guidance. If weaning has been started also food from animal origin including milk are missing from the diet and given in insufficient quantity.  
• Mostly due to Iron, magnesium, zinc deficiency. Malnutrition due to its close resemblance with Kahn’s nutritional recovery syndrome, but majority are not because they look chubby and their serum proteins are with in normal range.
• It might be a form of infection like meningioencephalitis failure to isolate any viral antigen, constantly normal CSF, presence of pigmentary changes and pallor do not support this hypothesis.
• Transient tyrosin metabolism defect might lead to interference in melanin pigment production. Depigmentation of substantia nigra leads to tremor.
• Brain biopsies and pneumoencephalographic studies shows degenerative changes like cortical atrophy in majority cases investigated in Lucknow and Patiala. 

Clinical features: ^{1, 2}

Pretremor (prodromal) phase

• Lasts for 2 weeks to 2 months.
• A typical infant with ITS has plumpy look despite malnutrition.
• Characterized by regression of attained milestones, motor or mental slowness with vacant expressionless facies.
• Inability to recognize the mother.
• Lack of interest in surroundings.
• Lethargy and poor response to bright and colored objects, anemia, pigmentation, hair changes and drooling.
• Tremors are absent
• Hair is light-coloured (hypochromotrichia) and sparse.
• Brownish reticular/honey comb  pigmentation of skin over dorsal aspect of hands (knuckle pigmentation),feet, knees, ankles, axillae, buttocks, lower abdomen and medial aspect of thighs.
• There is mild to moderate pallor.
• At times there may be fever, upper respiratory tract infections, diarrhoea, oedema, hepatomegaly 

Tremor or classical phase

• Last for about 2 to 5 weeks
• Tremors resemble those seen in Parkinsonism and appear to originate from cortical neurons.
• Tremors are coarse, fast, 6-12 cycles per second, of low amplitude, initially intermittent but become continuous later on.
• Initially, the tremors are seen only on crying or feeding and involve fingers, face and tongue. Disappear during sleep. May be generalized but are more prominent in distal parts of the limbs (especially upper limbs), head, face and tongue. Even trunk may be involved.
• Some assume a typical bird with wings spread posture.
• Some infants produce tremulous cry like that of a lamb. 
• Tossing of head from side to side with the saliva, drooling from mouth and have dull, expressionless look. 
• The condition remains static for some time before disappearing altogether.
• Mental and motor development is impaired in all.

Post-tremor or recovery phase 

• This phase last for about 1 to 6 months but the course may be unduly prolonged with associated infections.
• Is characterized by regression of tremors and other features of the syndrome. 
• The mental dullness continues for several months.

Diagnosis:
Familiarity with the clinical picture, described above, together with high index of suspicion should enable a clinician to recognize an infant suffering from this syndrome.

Investigation: ^1,2,3,4

• Laboratory investigations are not pathognomic.
• Mild to moderate anaemia with haemoglobin between 6 to 11g/dl.
• Morphology of red cells is variable.
• Bone marrow shows normoblastic, dimorphic or megaloblastic changes.
• Total leucocyte count is variable and may be due to associated infectious illness.
• Pancytopenia and low serum albumin can be found in some cases.
• Deficiency of Vit B12, magnesium and zinc.
• Mothers of affected infant with ITS also have low Vit B12 in serum as well as in breast milk.
• 50%of infants show Iron Deficiency. CSF is normal.
• Cortical biopsies show mild inflammatory changes.
• Pneumoencephalography reveals cortical atrophy.
• MRI confirms diffuse atrophy and delayed myelination in some cases.
• EEG shows epileptic form activity.

Homoeopathic therapeutics:

Agaricus Muscaris
Involuntary movements while awake, cease during sleep, chorea from simple motions and jerks of single muscle to dancing of whole body⁵; trembling of the hands⁷. Uncertainty in walking, stumbling gait⁵.Fingers fly spasmodically while holding things⁷. White coated tongue along with increased thirst and trembling of tongue⁸. Very sensitive to cold air.

Zincum Metalicum^{5, 8}
Child cries out during sleep, whole body jerks during sleep, wakes frightened, starts, and rolls the head from side to side. Incessant and violent fidgety feeling in feet or lower extremities, must move them constantly. Twitching and jerking of single muscle. Automatic motion of hands and head or one hand and head. History of suppression of skin eruptions. Convulsion with pale face and no heat

Mygale Lasiodora
Constant motion of whole body. Tremulous. Twitching of facial muscles and limbs, head jerked to one side. Restless hands. Convulsive uncontrollable movements of arms and leg. Limbs drag while walking^5,8.Fever with excessive thirst and trembling of limbs⁹.

Gelsemium Semipervirens^{5, 7, 8}
Dizziness, drowsiness, dullness, and trembling. Muscular weakness. Lack of muscular co-ordination. Emotional excitement, fear, etc.  Lead to bodily ailments. Excessive trembling and weakness of all limbs. Hysteric convulsions. Fever, thirst absent; with trembling.

Stramonium^7,8
Increases the mobility of the muscles of expression and of locomotion; the motions may be graceful, rhythmic or disorderly, of head and arms. Dread of Darkness, and has a horror of glistening objects. Wringing of hands. Staggering gait. Suppressed secretions and excretions. Absence of pain and muscular mobility especially of muscles of expression and of locomotion.

Loleum temulentum⁸
Trembling of all limbs. Loss of power in extremities. Spasmodic motions of arms and legs. Cannot write; cannot hold a glass of water. Trembling of hands in paralysis. Tongue tremulous.

Silica
Nervous, irritable, obstinate and headstrong nature. Very offensive foot sweat. Chilly and cannot tolerate a slight draught of air. Defective nutrition and imperfect assimilation. Trembling of hands when attempting to do something.

Phosphorus
Extremities, weakness and trembling from every exertion can scarcely hold anything with hands. Associated with numbness of hands.

Plumbum metallicum ^{7, 8}
Stinging and tearing in limbs, also twitching and tingling, numbness, pain or tremor. With the chronic affection of the head there is contraction of the muscles of the back and neck; drawing and twitching indicating meningeal troubles; spasmodic jerking. Paralysis; hysterical; infantile; of single parts, (wrist drop), flaccid; with hyperaesthesia; agg. Touch. Tremors, followed by paralysis.

Cuprum metalicum^7,8
Convulsions may be either tonic or clonic; start in the knees, toes or fingers and radiate over the whole body; with piercing cries, twisting of the head to one side; trismus, followed by headache, spasmodic laughter, shivering, deathly exhaustion, cold perspiration etc.; epilepsy; at night. Convulsions of children, during dentition; children lie on abdomen and jerk the buttock up.Jerking; during sleep. Shakes the head from side to side. Chewing motion of lower jaw.SkinBluish, marbled.

Cina Maritima^{7, 8}
Trembling; with shivering, when yawning. Convulsions, with consciousness. Tosses arms from side to side (children).Sudden inward jerking of fingers of right hand. Stretches out feet spasmodically (children).Twitching and jerking in limbs. Left foot in constant spasmodic motion.Choreic movements of the face and hands. Nocturnal convulsions.

Abisinthinum
It causes convulsions, preceded by trembling. Mouth, Jaws fixed. Bites tongue; trembles. Tremor is a marked feature, tremor of tongue, heart. Chorea.

References

1. Gupte S. The short textbook of pediatrics.Jaypee Brothers; 2004.
2. Ghai OP. Essential paediatrics. CBS Publishers and distributors Pvt. Limited;  2010.
3. Goraya JS, Kaur S. Infantile tremor syndrome: A review and critical appraisal  of its etiology. Journal of pediatric neurosciences. 2016 Oct; 11(4):298.
4. Holla RG, Prasad AN. Infantile tremor syndrome. Medical journal, Armed Forces India. 2010 Apr; 66(2):186.
5. Allen HC. Keynotes and Characteristics with Comparisons of some of the Leading Remedies of the Materia Medica with Bowel Nosodes. B. Jain  Publishers; 2002.
6. Kent JT. Lectures on homoeopathic materia medica. Jain Publishing Company; 1980.
7. Phatak SR. Materia Medica of Homoeopathic Medicines. B. Jain Publishers; 2002.
8. Boericke W. Pocket Manual of Homoeopathic Materia Medica & Repertory: Comprising of the Characteristic and Guiding Symptoms of All Remedies   Including Indian Drugs. B. Jain publishers; 2002
9. Clarke JH. A dictionnary of pratical materia medica. homoeopathic publishing Company; 1902.

Dr Heera E Chand
PG Scholar Fr Muller Homoeopathic medical college, Mangaluru
Under the Guidance of Prof.Dr Jyoshna Shivaprasad