Carotenemia

Dear Lisa,

My one year old daughter's skin tone is yellow in color. I didn't think much of it because I know it could be due to her eating the orange vegetables (sweet potatoes), but more people are remarking on it and I have shied away from the orange vegetables but her skin tone is still yellow (has been for awhile) and I also noticed lately that her gait is unsteady (not all the time but it is noticeable) almost like she is walking like she is intoxicated. How concerned should I be with these symptoms?

“Sweet Potato Mom”

Dear “Sweet Potato Mom”,

Carotenemia is the condition that commonly occurs in children when they eat too many yellow-orange vegetables. When a child eats too many foods containing carotenoids over a period of time their skin turns an yellow-orange color, but the whites of the eyes stay white.(1) If your daughter eats a lot of orange vegetables such as carrots, sweet potatoes and squash this could be the reason for her yellow-orange discoloration. A child’s orange vegetable intake would have to be cut down to less than three times per week in order to alleviate the symptoms. The orange color should go away gradually and should take a few weeks.

Another condition that can cause the skin to be yellow is Vitamin B 12 deficiency. One of the signs of Vitamin B 12 deficiency is a lemon yellow tinge to the skin.(2) Vitamin B 12 is found in meat, liver, milk, eggs, cheese, fish and soybeans. (3) Although rare in childhood, this condition may occur in children who are strict vegetarians and in those who lack the proper stomach enzymes needed to absorb Vitamin B 12.

Both intrinsic factor and proper Hydrochloric Acid production by the gastric mucosa are necessary for the absorption of Vitamin B 12. Therefore a deficiency in either of these can result in Vitamin B 12 Deficiency. (4) Vitamin B 12 Deficiency is more common in the elderly population because as people age they naturally develop decreased amounts of gastric secretions. (2) There also may be a concern in patients who take medications that block Hydrochloric Acid production in the stomach.

The fish tapeworm, Diphyllobothrium latum is another cause of Vitamin B 12 deficiency, although this is a rare condition. (5) Other consequences of Vitamin B12 deficiency include anemia, gastrointestinal problems, neurologic deterioration and spinal cord degeneration. (3, 4)

If a baby’s eyes are yellow as well as their skin, this represents a more serious condition called Jaundice. Jaundice is caused by Hepatitis (liver infection), Liver Disease, Hemolytic Anemia (the breakdown of red blood cells in the body), medication side effects, prematurity, or bilirubin glucuronyl transferase enzyme deficiency. (2) If the whites of a child’s eyes are yellow this would require immediate medical attention.

In regards to your daughter’s skin color, as long as the whites of her eyes are not yellow there is no need for alarm. You may need to cut down on the sweet potatoes more and wait a little longer before you see a change. If your daughter was breastfed while you maintained a strict vegetarian diet or if she presently is a strict vegetarian then Vitamin B 12 deficiency may need to be considered. If her discoloration does not seem to improve or if it worsens she should be evaluated by her Pediatrician. Other concerning symptoms would include fever, weight loss, diarrhea and fatigue. If these symptoms occurr your daughter should be checked by her Doctor.

Without actually seeing your daughter’s gait it is difficult to tell if it is normal walking behavior or a sign of a problem. Unsteady gait in a one year old can be due to something as simple as ill fitting shoes or as complicated as Congenital Hip Dysplasia, an injury, leg length discrepancy or an infection. Interestingly, painful feet and limps in children are most commonly caused by ill-fitting shoes. (3)

All children who begin to walk generaly have an abnormal appearing gait. When first learning to walk, their feet typically turn outward. Sometimes new walkers will push off with one foot and slightly drag the other. (3) So what looks like abnormal gait to an onlooker, may be normal for a new walker. Since your daughter is only one year old, her gait may be normal for her age. The best way to have her gait evaluated is to bring her to the Pediatrician’s office and have her walk in front of the Doctor. Your daughter’s doctor will be able to tell you if her gait is normal for her age.

There is a concern when a child has pain or limping with walking. If this is the case a more serious disorder may need to be ruled out. Developmental Dysplasia of the Hip also known as Congenital Hip Dysplasia (CHD) is one of the childhood conditions that may present as abnormal gait. Althought this condition is typically discovered in infancy, it may first be noticed when a child begins to walk. It occurs in 1.5 to 20 out of every 1000 live births. (6) Congenital Hip Dysplasia is defined as the abnormal growth or development of the hip.(6)

The exact cause of CHD is unknown, but there are common risk factors noted in babies with this condition. Babies that are large for their age, those who had low amounts of amniotic fluid, those with a family member with CHD, breech presentation, fast delivery and traumatic delivery can all contribute to Congenital Hip Dysplasia. The symptoms of CHD include asymmetric skin folds in the thigh and buttock region, decreased rotation of the hip, laxity of the hip joint, shortening of the leg and abnormal gait. (5, 6) An evaluation by your Pediatrician will be able to rule out this condition, as well as other conditions that cause a baby to limp.

If your child’s abnormal gait is accompanied by other signs such as fever, irritability, a recent illness, weight loss, a recent injury, pain, crying or developmental delays an evaluation by your Doctor is necessary. Otherwise, check your daughter's walking while she is barefoot and with different pairs of shoes and see if the symptoms are consistent. If the abnormal gait is only present with a certain pair of shoes, then the problem is no more than the poor fitting shoes.

If you are interested in reading other Pediatric Advice Stories covering these topics:

First Pair of Shoes

Vitamin B 12 Deficiency

Carotenemia

References:
(1)Schwartz M, Charney E, Curry T, Ludwig S. Pediatric Primary Care. A Problem Oriented Approach. 2nd Ed. Littleton, Mass:Year Book Medical Publishers, Inc 1990:22-23.
(2)Waley L, Wong D. Nursing Care of Infants and Children. 2nd ed. St. Louis, Missouri:The C.V. Mosby Company.1983:468-469,1342.
(3)Chow M, Durand B, Feldman M, Mills M. Handbook of Pediatric Primary Care. Albany, New York:Delmar Publishers Inc. 1984:748-749,100,848,839.
(4)Tortora G, Anagnostakos N. Principles of Anatomy and Physiology. 4th ed. Sao Paulo, Sidney:Biological Sciences Textbooks, Inc. 1984:649, 449-450.
(5)Behrman R, Kliegman R. Nelson Essentials of Pediatrics. Philadelphia ,PA: W.B.Saunders Company. 1990:82-83,682-685.(6) Horn P. A painless limp and leg-length descrepancy in an 18-month-old girl. The Clinical Advisor. 2006.July:121-124.

Lisa-ann Kelly R.N., P.N.P.,C.
Certified Pediatric Nurse Practitioner

Pediatric Advice About Keeping Kids Healthy