14 months old child presented with tremulus movement in lt upper limb and tongue,globally delayed milestones(mental age=5 months,motor age6 months)with pem kwash,dolichocephaly and ascitis. Clinically positive findings are -dolichocephaly +,head circumference normal for age,generalised edema +,mild pallor+,dark pigmentation of knuckels +,nails shape - abnormal,shifting dullness +,no organomegaly investigation showed raised mcv, decreased albumin,urine normal,stools normal,b12level normal mri- brain reported mildly enlarged ventricles,cortex normal. What it is ? Infantile tremor syndrome ? If yes how to approach this child ?what is the treatment for tremors ? How long it will take to disappear after starting treatment? What will be prognosis of child ?

Yes, infantile tremor syndrome can be a possibility. What is important is to know the diet of the child. Is the child predominantly on breast feeding? If yes, then B12 levels in the mother must be done and if low then both mother and child should be treated with high dose vitamin b12 for 7-14 days. Also give folate and zinc supplements. Response in ITS occurs dramatically and tremors may stop in 3-4 days but how improvement in mental delay may not be as good.