infantile tremor syndrome ( its ) is characterized by anemia , skin pigmentation , tremors , physical , and mental regression without a defined etiopathogenesis and low incidence .
we have studied 9 patients over 1 year for the changing clinical and laboratory variables of patients with its .
neuroregression and anemia were presented in all followed by tremors in 5 and hypotonia in 2 .
infantile tremor syndrome ( its ) is a syndrome characterized by anemia , skin pigmentation , tremors , physical , and mental regression .
it has been reported in children between 5 months and 3 years of age with a male predominance .
the purpose of this case series was to determine factors responsible for its continuing prevalence despite better knowledge and weaning practices .
we have studied 9 patients presenting to us with typical features of its and pre - its in a tertiary care hospital of hilly terrain [ table 1 ] . a detailed history and examination
investigations included complete hemogram , peripheral smear to type the anemia and malaria parasite , serum electrolytes , renal and liver function tests along with sepsis screen , and urine routine examination .
blood and urine cultures , serum b12 levels , chest x - ray , and tuberculosis screen were done when indicated . written informed consent was taken from all .
total 9 patients , 3 males and 6 females presented over the period of 1 year .
the mean age of presentation was 13.5 months , ranging from 7 months to 18 months .
all ( 100% ) patients admitted with the complaint of lethargy and weakness with a mean duration of 21 days .
neuroregression was present in all ( 100% ) with a mean delay of 7 months ranging from 4 to 11 months in all spheres of development .
tremors were present in 5 ( 55% ) and hypotonia in 2 ( 22% ) reflecting neurological changes .
seven ( 78% ) were exclusively breastfed and 2 ( 22% ) improperly weaned with diluted milk .
protein energy malnutrition was present in 5 ( 55% ) out of which 2 ( 40% ) had grade i and 3 had grade ii ( 60% ) protein energy malnutrition as per iap classification .
ofc records of all patients were within normal range for their age [ table 2 ] .
all had severe pallor ( 100% ) with knuckle hyperpigmentation and sparse hair in most .
hepatomegaly was present in 4 ( 44% ) , splenomegaly in 2 ( 22% ) , and pneumonia in 1 ( 11% ) .
peripheral blood film examination revealed the macrocytic picture in 4 ( 44% ) , dimorphic in 4 ( 44% ) , and microcytic in 1 ( 11% ) .
chest x - rays had infiltrated in 3 ( 33% ) but workup for tubercular screening was negative .
urine cultures were positive in 2 ( 22% ) with escherichia coli and pseudumonas in 1 each .
serum b12 levels were low in 4 out of 5 patients but could not be performed in all due to financial constraints .
the mean duration of hospital stay was 9 days ranging from 4 to 16 days .
total 6 ( 66% ) with positive sepsis screen or cultures received antibiotics for the average duration of 9 days .
improved after treatment with supplements such as vitamins a , d , k , b - complex , zinc , calcium , and magnesium along with dietary management .
on monthly follow - up , those with pre - its had better catch up in growth and development in all spheres .
infantile and pre - its is a well - known clinical entity reported primarily from the developing nations . despite its decreasing incidence , the finding of additional clinical features made us present this series .
associated nutritional deficiencies such as protein , vitamin a , d , c , and b - complex may be present .
our series also found that all children with this syndrome had anemia , lethargy , and neuroregression and presented throughout the year with no seasonal clustering as previously stated .
furthermore , the type of anemia in this disease is not specific . on the other hand , it reflects the pattern of prevalence of the hematinic deficiencies in the region .
however , unlike previous reports , there were more female patients , which may be due to bias in nutritional status .
the study adds the need for rational antibiotic use in patients of its , unlike many previous reports where all patients have been administered antibiotics .
the disease process may be superadded by urinary infections probably due to lower immunity state as a result of malnutrition , the leading cause of acquired immunodeficiency .
it is also a reflection of changing epidemiology with no seasonal variation , showing the role of non - viral etiologies although previous studies show a seasonal pattern of disease .
it highlights the need for better education for weaning practices and need for better community support .
 background : infantile tremor syndrome ( its ) is characterized by anemia , skin pigmentation , tremors , physical , and mental regression without a defined etiopathogenesis and low incidence.materials and methods : we have studied 9 patients over 1 year for the changing clinical and laboratory variables of patients with its . 
 neuroregression and anemia were presented in all followed by tremors in 5 and hypotonia in 2.result:sepsis screen was positive in 6 and urine cultures in 2 . 
 antibiotics were required in 6 . 
 its with changing parameters still significantly contributes to healthcare burden.conclusion:it is important to screen for urinary infection and septicemia to avoid antibiotic abuse . 
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Materials and Methods:
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Introduction
Case Report
Discussion