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Silver Toxicity in an Infant of Strict Vegan Parents

A 12-month old girl was referred for investigation and management of failure to thrive. She had been born at term after a normal pregnancy, birth weight 3.8 kg, and she was exclusively breastfed until the introduction of a solid diet at the age of 11 months. This was restricted to fruits, vegetables, brown rice, and oatmeal. The mother had followed a strict vegan diet (consisting of fruits, grains, cereals, nuts, olive oil, and vegetable juices) for the previous 3.5 years. The parents reported that the child had been growing and developing normally until the age of 10 months. At that time, during a particularly hot spell of weather, she started to feed poorly and became increasingly lethargic. At the age of 9 months, she was reportedly able to sit unsupported and weight-bear on hands and knees when prone but subsequently had lost these skills. The parents treated her with various supplements and alternative therapies including a blend of kelp, lactobacillus acidophilus, wheat, rye, and barley, and with colloidal silver. These had been purchased from health food stores because the parents believed they would improve the child’s health. The silver was given in the form of a suspension and was thought to be effective in boosting immunity. When first brought to medical attention at the age of 12 months, she was noted to be severely malnourished: weight 5.3 kg (2.2 kg < third percentile), height 69 cm (third percentile). She was listless and irritable with a weak cry. Apart from this, her neurologic examination was normal with no abnormal movements. She had global developmental delay. Formal assessment using Revised Gesell Developmental Schedules showed skills in the age range of 24 to 28 weeks in areas of gross motor, language, fine motor, adaptive, and personal and social skills. The physical examination was otherwise normal. There was no clinical evidence of rickets. Deficiencies of iron (hemoglobin, 87 mg/dL; iron, 8 mol/L), vitamin B12 (98 pmol/L; reference range, 160– 810 pmol/L), and thiamine (red cell transketolase, 0.36; reference range, 0.6–1.3) were found, as was unexplained hypercholesterolemia (cholesterol, 22 mmol/L), predominantly low-density lipoprotein. She had borderline low copper and ceruloplasmin levels. A toxic level of serum silver (3.4 mol/L; normal < 0.02 mol/L) was found. The serum calcium, phosphorus, zinc, potassium, total proteins, and albumin levels were normal. Markers of bone turnover were normal. There was a high concentration of urinary methylmalonic acid, thought to be the result of the vitamin B12 deficiency. She was admitted to hospital under a court order and nutritionally rehabilitated without complication using continuous semielemental formula via nasogastric tube. Gradual transfer to a goat milk infant formula was acceptable to the parents for ongoing use and formed the basis of the discharge diet in conjunction with solids chosen by the vegan parents. Supplements of B12 (intramuscular), iron, and thiamine were given, and the levels normalized. Serum cholesterol levels returned to normal within 3 weeks. Serum silver levels normalized some months after cessation of silver supplements, as did copper and ceruloplasmin levels. Occupational therapy commenced after 1 week of nutritional recovery and is ongoing as an outpatient with significant gains in development. On clinical assessment, she is currently functioning at an 8-month level at the age of 14 months.