Kwashiorkor in the Bronx

Abstract

the nutritional deficiency disease characterized by edema, hypoproteinemia, fatty liver, skin depigmentation, and hair changes has become one of the most commonly diagnosed diseases of the young child.1 The term used to describe this condition\p=m-\kwashiorkor\p=m-\is Ghanaian and apparently has a double meaning constituting a grim pun. The first meaning, "red or yellow boy," provides the clinical description of the patient while the second, the "Dispossessed," poetically illustrates the etiology, since the disease results from the dispossession of the victim from the mother's breast by the succeeding sibling.It is the purpose of this communication to place on record the occurrence of a case of kwashiorkor in a member of a dispossessed community in New York City. Report of a CaseA 10-month-old Puerto Rican boy was first seen in the outpatient department of the Morrisania City Hospital in June 1965 and was noted to have swelling of the eyes. As there was no albumin in the urine, a diagnosis of allergy was entertained. This suggestion was reinforced by the history which showed that the child had had recurrent episodes of diarrhea in the neonatal period and at the age of S months, the mother was informed that the baby was allergic to milk and advised, despite normal development and weight gain, to stop cow's milk and to substitute a soya formula.For four months the baby was maintained on this diet with addition of vegetables, fruit, and oc¬ casional eggs. In addition, rice was given to the child three times daily because of the fondness of the child for this food. One month before hos¬ pitalization, the soya formula was stopped and thereafter the principal item of the diet was rice. Three days before admission, swelling of the eyes was noted. On direct questioning, the mother stated that the baby's hair roots had turned yellow about two weeks before that. Recently the infant had become irritable and disinterested in his sur¬ roundings and during the last few days had refused feedings. There had been intermittent diarrhea for one month.On examination the infant (Figure) was ir¬ ritable and flaccid. There was pronounced edema of the face with well marked pitting edema of the legs, hands, and sacral region. The face showed malar depigmentation, and there was evidence of early dermatosis in the diaper region. The hair was straight, fine, and sparse, with marked depig¬ mentation of the proximal centimeter which showed up as a yellow band in striking contrast to the black of the older hair. The chest and abdomen were normal and the liver was not enlarged. His weight was 20 lbs 12 oz (9.4 kg)-50th percentile; his height was 29 inches (73 cm)-50th percentile.Laboratory investigations revealed the following values: urinalysis, normal; hematocrit, 31%; white Patient, 10 months of age, showing edema and hanging jowls with absence of marked weight loss.

Protein-Energy Malnutrition and Feeding Refusal Secondary to Food Allergies

“…We have described 2 cases of protein-energy malnutrition in children that emphasize the wide spectrum of its presentation. 2 Patient 1 exhibited the phenotype of classic kwashiorkor, whereas patient 2 had evidence of growth stunting with only mild hypoproteinemia. Both children exhibited food refusal behavior likely attributed in part to food allergies.…”

“…Primary protein-energy malnutrition resulting from inadequate protein caloric intake is less frequent but has been observed in more affluent countries such as the United States, leading to kwashiorkor and marasmus. [1][2][3][4][5] The causes of poor intake may be related to poverty, social problems, including neglect, inappropriate vegetarian diets, and misperceptions about food intolerance or allergic sensitivity. The latter cause can result in multiple formula changes and withholding foods that are believed to be allergenic without objective data to support the change.…”

Skin Signs as the Presenting Manifestation of Severe Nutritional Deficiency

“…5 The nondairy rice beverage used as a milk substitute in case one has been previously implicated in similar cases of kwashiorkor. 2,6,7 It is erroneously referred to as "Rice Dream milk." It is not milk-it contains a minuscule amount of protein per serving, in contrast to milk, the protein-rich fluid secreted by female mammals.…”

Dermatosis in a Child with Kwashiorkor Secondary to Food Aversion

“…Although it occurs infrequently in the developed world, kwashiorkor is the most common form of undernutrition affecting hospitalized patients in the United States ( 1–3). In addition, it has occasionally been reported as a cause of disease in children from impoverished ( 4–7) and non‐impoverished ( 8–14) American communities. A clinical description of kwashiorkor was first provided by Cicely Williams in 1933 ( 15), and subsequently many others have published their observations.…”