Case Presentation: A previously healthy 8-month-old infant presented with poor weight gain, edema, and hypotonia. Vital signs were notable for heart rate 126, blood pressure 58/32, respiratory rate 32, and temperature 36.1C. Mucous membranes were dry with capillary refill of 3-4 seconds and edema of all extremities. He had decreased muscle tone, minimal spontaneous movement, and breathing was irregular with subcostal retractions and periods of apnea. Initial labs showed blood glucose of 47 mg/dL, albumin 2.3 g/dL, total protein 3.9 g/dL, and anion gap metabolic acidosis with bicarbonate 16 mEq/L and lactate 21 mg/dL. Weight at admission was 5.996 kg, down from 6.492 kg four months previously. He was placed on high flow nasal cannula for respiratory support and received intravenous fluids and dextrose for resuscitation. Respiratory status and lethargy improved with rehydration and resolution of hypoglycemia. He remained hypotonic with low muscle bulk, showing head lag and inability to sit unsupported.Parents reported that following his four month well check he showed signs of constipation and abdominal discomfort with formula feeds. At that time they transitioned to a homemade, coconut milk-based formula promoted by a chiropractic wellness organization attended by the patient’s mother. After the change his constipation and fussiness improved, however his weight gain slowed and his oral intake steadily decreased until he was taking only three ounces 6-8 times daily in the month prior to admission. Nutritional analysis of the formula recipe showed that it contained 9.2 kcal and 0.07 g of protein per ounce. Based on severe malnutrition with edema and hypoalbuminemia, he was diagnosed with kwashiorkor. Nasogastric feeds with standard infant formula were started and well tolerated without signs of refeeding syndrome. He showed appropriate weight gain and was discharged home with close nutritional follow up.
Discussion: Kwashiorkor is rare in the United States and is most often associated with malabsorptive conditions. When seen in otherwise healthy patients it is often associated with nutritional ignorance or unorthodox diets. In recent years there has been a growing movement toward more ‘natural’ products for children of all ages. Although experts explicitly recommend against using homemade formulas, a Google search for ‘homemade baby formula recipe’ returns over 11 million results. Furthermore, while all commercially available formulas must meet FDA standards, there are no such standards for homemade formula. The formula fed to this patient contained less than half the calories per ounce of standard infant formula with under 25% of the FDA mandated minimum protein content. In this case the patient’s care was overseen in part by an alternative medicine provider. There is limited data for young children, but results from the National Health Interview Survey show a steady increase in the use of alternative medicine among Americans. Alternative medicine providers are subject to state licensing requirements and the therapies they offer can be beneficial in some cases, but as with any treatment there are potential risks. These risks are compounded if practitioners exceed the limits of their expertise, particularly if there are no other providers monitoring the patient.
Conclusions: Physicians should take a careful dietary history in all infants. While families’ preferences should be considered in care decisions, pediatricians should be aware of the potential risks of alternative medicine treatments.