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Benign Neonatal Shudders, Shivers, Jitteriness,Millicent Collins, MD, Michal Young, Or MD Tremors: Early Signs of Vitamin D Deficiencyabstract

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Benign Neonatal Shudders, Shivers, Jitteriness,Millicent Collins, MD, Michal Young, Or MD Tremors: Early Signs of Vitamin D Deficiencyabstract Benign Neonatal Shudders, Shivers, Jitteriness,Millicent Collins, MD, Michal Young, or MD Tremors: Early Signs of Vitamin D Deficiencyabstract Jitteriness and tremors in the newborn period typically precipitate an extensive, invasive, and expensive search for the etiology. Vitamin D deficiency has not been historically included in the differential of tremors. We report a shivering, jittery newborn who was subjected to a battery of testing, with the only biochemical abnormality being vitamin D deficiency. A second case had chin tremors and vitamin D deficiency. Review of our patients suggests that shudders, shivers, jitteriness, or tremors may be the earliest sign of vitamin D deficiency in the newborn. Neonates who present with these signs should be investigated for vitamin D deficiency. Department of Pediatrics, Howard University College of Shudders, shivers, jitteriness, sepsis, seizure, or neurologic Medicine and Hospital, Washington, District of Columbia and tremors are terms used to disorder. Vitamin D deficiency has Dr Collins provided 1 case report, drafted the describe excessive movements in not been historically included in initial manuscript, and reviewed and revised the neonates. These terms, although the differential of such movements; manuscript: Dr Young conceptualized this case report, provided 1 case report, and reviewed used interchangeably, are defined however, vitamin D deficiency is the manuscript; and both authors approved the variably, depending on the author. common in pregnant women (5% to final manuscript as submitted and agree to be Jittery is a term used to describe 50%) and in breastfed infants (10% accountable for all aspects of the work. a series of recurrent tremors in to 56%), despite the widespread use DOI: https:// doi. org/ 10. 1542/ peds. 2016- 0719 of prenatal vitamins, because these infants. Tremors are involuntary, ≥ Accepted for publication Jan 19, 2017 rhythmic, oscillatory movements may be inadequate to maintain normal 2 Address correspondence to Millicent Collins, of equal amplitude. Tremors are vitamin D levels ( 32 ng/mL). We MD, Department of Pediatrics, Howard University described as fine or coarse. A fine report 2 jittery newborns with the Hospital, 2041 Georgia Ave, NW, Washington, DC tremor is of high frequency (>6 only biochemical abnormality being 20060. E-mail: [email protected] cycles per second) and low amplitude vitamin D deficiency. Review of our PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, (<3 cm). Coarse tremors are of low patients suggests that shudders, 1098-4275). frequency (>6 cycles per1 second) and shivers, jitteriness, or tremors may be Copyright © 2017 by the American Academy of high amplitude (>3 cm). Shudders among the earliest signs of vitamin D Pediatrics ’ and shivers have a more colloquial deficiency in the newborn. FINANCIAL DISCLOSURE: The authors have usage. Meriam-Webster s dictionary CASE 1 indicated they have no financial relationships describes a shudder as the act of relevant to this article to disclose. trembling convulsively or shaking Past History FUNDING: No external funding. because of fear or cold. A shiver is ’ POTENTIAL CONFLICT OF INTEREST: The authors described as a momentary trembling have indicated they have no potential conflicts of movement. Regardless of the term LB s mother (G2, P1) presented for interest to disclose. used, if repetitive and recurrent, a prenatal visit in her ninth month of such movements in the newborn pregnancy. She had no complications To cite: Collins M and Young M. Benign Neonatal period typically precipitate a search during this pregnancy, but complained Shudders, Shivers, Jitteriness, or Tremors: Early for the etiology among possibilities, that the prenatal vitamins had Signs of Vitamin D Deficiency. Pediatrics. 2017;140(2): such as hypoglycemia, hypocalcemia, made her sick throughout her entire e20160719 ’ hypothermia, hyperthyroidism, pregnancy. She did not drink milk. hypomagnesemia, drug withdrawal, LB s mother was a dark-skinned Downloaded from www.aappublications.org/news by guest on September 30, 2021 PEDIATRICS Volume 140, number 2, August 2017:e20160719 CASE REPORT TABLE 1 Results of Comprehensive Metabolic Panel in Case 1 Result Normal Range native of Barbados and had lived for ° 15 years in Washington, DC, which is Sodium, mEq/L 138 135–148 Potassium, mEq/L 5.2 3.5–5.3 located at latitude 38 N. There were ’ Chloride, mEq/L 105 95–111 no cultural or religious reasons that HCO2-, mEq/L 24 25–32 would limit the mother s exposure Glucose, mg/dL 116 70–115 to the sun. She had successfully Serum urea nitrogen, mg/dL 6 6–25 breastfed her first child for 1 year Creatinine, mg/dL 0.4 0.7–1.4 Calcium, mg/dL 10.7 8.5–10.6 while in Barbados. Birth History Phosphorus, mg/dL 6.5 2.5–4.5 Magnesium, mg/dL 2.7 1.7–2.5 Total bilirubin, mg/dL 1.8 0.2–1.2 Aspartate amino transferase, U/L 28 0–50 LB was born via normal spontaneous Alanine amino transferase, U/L 11 0–55 vaginal delivery at term in the Alkaline phosphatase, U/L 430 30–165 month of August. Birth weight was Total protein, g/dL 6.1 6–8.5 Albumin, g/dL 3.9 3.2 5.5 7 pounds, 2.2 ounces, length 20.5 – inches, head circumference 35 cm. He was in the nursery for 3 days, had TABLE 2 Results of Complete Blood Count in Case 1 mild jaundice (bilirubin 8.1), and White blood cell 11.5 × 103/μL was totally breastfed. His mother Red blood cell 4.14 × 106/μL expressed no difficulties relevant to Hemoglobin, g/dL 14.5 Hematocrit, % 41.3 breastfeeding. Mean corpuscular volume, fL 99.7 Postnatal Visits Mean corpuscular hemoglobin, pg 35.1 Mean corpuscular hemoglobin concentration, g/dL 35.2 Red blood cell distribution width, % 15.6 3 At age 6 days, on the initial Platelet count 339 × 10 /μL ’ Neutrophil, % 14.6 ambulatory newborn visit, the “ Lymphocyte, % 66.5 mother s only concern was that LB ” Monocyte, % 14.3 seemed to shiver a lot like he was Eosinophil, % 2.8 cold. She noted that she lived in Basophil, % 1.9 a basement apartment where her husband and her other child (age 2 TABLE 3 Results of Urine Drug Screen in Case 1 years) often felt cold and sometimes Drug Result shivered. The pediatrician counseled the mother about dressing an infant Amphetamine Negative Barbiturates Negative for a cool, damp environment. Just Cocaine Negative before leaving the office, the mother Methadone Negative remembered that she had seen Opiates Negative the tremors in the nursery but on Benzodiazepines Negative questioning the staff about it, she Marijuana Negative Propoxyphene Negative had been told that it was normal. Phencyclidine Negative The mother assured the pediatrician that she was continuing to take her prenatal vitamins. During the physical examination, no tremors or she continued to feel his movements. 3 for results. Urinalysis and thyroid shaking were noted. Because of the severity of his shaking, function were normal. At the age of 12 days, LB was brought he was sent to the emergency by his mother for a follow-up department for evaluation. Vital signs Consultation with the neurology visit. She noted that the tremors remained normal for age. LB was department was obtained. The were worse. Indeed, on physical afebrile and continued to be alert and neurologist noted that the head and examination, the infant would interactive. Laboratory studies were body were shaking rhythmically at periodically shiver as if cold. Even done. These included complete blood intervals lasting 2.0 to 2.5 minutes. his head would shake. However, he count, comprehensive metabolic Shaking was not related to crying or remained alert and appropriately panel, magnesium, phosphorus, nasal regurgitation. Other segments responsive. Mother would wrap him urine for toxicology, urinalysis, and of developmental and behavior tightly, noting that while wrapped thyroid function. See Tables 1, 2, and evaluation were appropriate. On Downloaded from www.aappublications.org/news by guest on September 30, 2021 e2 COLLINS and YOUNG – ’ 4 7 physical examination, the infant Within 2 weeks, after starting life. Isolated tremors presenting was noted to have normal sutures treatment, LB s tremors had within the first few days from birth and normal neonatal reflexes with subsided completely. are generally considered benign excellent Moro and traction. The CASE 2 or physiologic, and generally7 infant fixated and briefly followed. disappear within days. However, Good head control was noted. when tremors persist, and/or Asymmetrical tonic neck reflex was Baby Boy VR was delivered via exacerbate, more serious diagnoses negative. Landau, grasp, Galant, normal spontaneous vaginal delivery are often considered. These include support, and March reflexes were in the month of October, to a 20-year- seizures, neurologic abnormality, normal. Cranial nerves II to XII were old, dark-skinned African American hypoglycemia, hypocalcemia, normal. Motor evaluation revealed primigravida, after an uncomplicated hypomagnesemia, hyperthyroidism, mild increase in tone of the lower pregnancy in Washington, DC. drug7 withdrawal, and sepsis. Leone extremities recurring periodically. Apgar scores were 9 and 9 at 1 and et al followed 84 low-risk infants Spontaneous movements also were 5 minutes, respectively. Mother in Rome, Italy, with persistence of noted. Evaluation of reflexes revealed had fair prenatal care beginning tremors after the first week. Initial mild hyperreflexia of all extremities: at the fifth month of pregnancy. evaluation was done to exclude the ankle clonus 4 to 5 beats sustained She took prenatal vitamins during previously mentioned more serious ’ over 7 to 8 repetitions. Tremors were her pregnancy. After delivery, the diagnoses but did not include alkaline present at rest and in absence of infant s examination was remarkable phosphatase or vitamin D levels. No ’ excitation also involving the head and only for occasional shudder of the mention was made of feeding and were not exaggerated or precipitated infant s chin.
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