Severe Nutritional Deficiencies in Toddlers Resulting From Health Food Milk Alternatives

Abstract

It is widely appreciated that health food beverages are not appropriate for infants. Because of continued growth, children beyond infancy remain susceptible to nutritional disorders. We report on 2 cases of severe nutritional deficiency caused by consumption of health food beverages. In both cases, the parents were well-educated, appeared conscientious, and their children received regular medical care. Diagnoses were delayed by a low index of suspicion. In addition, nutritional deficiencies are uncommon in the United States and as a result, US physicians may be unfamiliar with their clinical features. Case 1, a 22-month-old male child, was admitted with severe kwashiorkor. He was breastfed until 13 months of age. Because of a history of chronic eczema and perceived milk intolerance, he was started on a rice beverage after weaning. On average, he consumed 1.5 L of this drink daily. Intake of solid foods was very poor. As this rice beverage, which was fallaciously referred to as rice milk, is extremely low in protein content, the resulting daily protein intake of 0.3 g/kg/day was only 25% of the recommended dietary allowance. In contrast, caloric intake was 72% of the recommended energy intake, so the dietary protein to energy ratio was very low. A photograph of the patient after admission illustrates the typical features of kwashiorkor: generalized edema, hyperpigmented and hypopigmented skin lesions, abdominal distention, irritability, and thin, sparse hair. Because of fluid retention, the weight was on the 10th percentile and he had a rotund sugar baby appearance. Laboratory evaluation was remarkable for a serum albumin of 1.0 g/dL (10 g/L), urea nitrogen <0.5 mg/dL (<0.2 mmol/L), and a normocytic anemia with marked anisocytosis. Evaluation for other causes of hypoalbuminemia was negative. Therapy for kwashiorkor was instituted, including gradual refeeding, initially via a nasogastric tube because of severe anorexia. Supplements of potassium, phosphorus, multivitamins, zinc, and folic acid were provided. The patient responded dramatically to refeeding with a rising serum albumin and total resolution of the edema within 3 weeks. At follow-up 1 year later he continued to do well on a regular diet supplemented with a milk-based pediatric nutritional supplement. The mortality of kwashiorkor remains high, because of complications such as infection (kwashiorkor impairs cellular immune defenses) and electrolyte imbalances with ongoing diarrhea. Children in industrialized countries have developed kwashiorkor resulting from the use of a nondairy creamer as a milk alternative, but we were unable to find previous reports of kwashiorkor caused by a health food milk alternative. We suspect that cases have been overlooked. Case 2, a 17-month-old black male, was diagnosed with rickets. He was full-term at birth and was breastfed until 10 months of age, when he was weaned to a soy health food beverage, which was not fortified with vitamin D or calcium. Intake of solid foods was good, but included no animal products. Total daily...

The nutritional limitations of plant-based beverages in infancy and childhood

“…The main reasons for this change are preference for plant foods, aversion to the use of cow's milk, and prevention or treatment of cow's milk allergy, as part of strict vegetarian diets or as a consequence of the advice of professionals from alternative medicines (5). Primary use in the early years of life of mainly soy, rice, almond or oat PBBs results in nutritional risks (rickets, failure to thrive, kwashiorkor or metabolic alkalosis, among others) (6). In addition, in our country we reported a case of scurvy with bone fractures in an infant fed almost exclusively with almond beverages (7).…”

“…The nutritional disorder most often associated with consumption of soy beverages in small children is rickets and failure to thrive, along with ferropenic anemia in some cases (6,16,17) (Table II). In the published cases, soy beverages were mostly given for suspected allergy to cow's milk proteins or due to the parents' belief that it was more suitable for their child.…”

“…Regarding the clinical manifestations secondary to the use of rice beverages, the information on 17 cases is given in supplemental table IV (http://www.nutricionhospitalaria.org/wp-content/ uploads/2014/11/931-material-suplementario.pdf) (5,6,(24)(25)(26)(27)(28)(29)(30)(31)(32)(33)(34). The principal nutritional consequence in infants of consumption of rice beverages instead of infant formula is protein malnutrition or kwashiorkor, reported in 14 of 17 cases, with clinical data of hypoalbuminemia, edema and rash.…”

Types of Rickets, Dental and Histologic Findings: Review of the Literature

“…A diet defi cient in calcium 16 , such as one dependent on nonforti fi ed milk substi tutes, can lead to rickets 17,18 . Nutriti onal rickets presents in the fi rst two years of life with short stature, gait abnormality, developmental delay, and characteristi c fi ndings (Table 1 8,9-15 and Table 2 9, 14,19 ).…”

Session 1: Allergic disease The challenges of managing food hypersensitivity

“…Venter and R. Meyer intakes of Ca, vitamin D and vitamin E are also lower than the recommended daily intakes (77) . These studies have identified maternal fears (50) , no dietetic referral (84,87) , alternative allergy testing (50) , use of an inappropriate alternative formula (85) or palatability of the chosen formula (50) as important indicators of a poor nutritional status. This evidence reinforces the need for all food-avoidance diets to be supervised by an appropriate specialist healthcare professional with nutritional knowledge such as a registered dietitian (84,88) .…”