We report four cases of kwashiorkar in infants, who had a pre existing skin disorder and who were on dietary restrictions as part of their treatment in Alternative medicine.

Complementary and alternative medicine are increasingly being used to diagnose or treat allergic diseases, and numerous studies have reported benefits of this type of medicine. However, severe nutritional deficiencies can occur in infants and small children given strict alternative diets, leading to ‘kwashiorkor’(1). These four cases, three of whom had atopic dermatitis and one had epidermolysis bullosa, presented with generalized edema, skin peeling, hair changes, apathy, and not gaining weight. On examination, three of these cases had kwashiorkar and one had marasmic kwashiorkor. Investigations supported the diagnosis. In all these cases, the nutritional deficiencies were caused by severe dietary restriction placed by the treating alternative medicine. The ratio of protein to energy in this diet is very low as most forms of protein are taboo in this diet(1). For example, cow’s milk and milk products except ghee, pulses and oils as they are "gas forming", Ragi and most fruits as they are "cold food", were restricted. It is this imbalance in the dietary ratio of protein to energy that has been implicated in the pathogenesis of kwashiorkor(2). The families involved do not fit the stereotypic profile in which malnutrition would be anticipated. The parents were well-educated, seemed knowledgeable and responsible, and had at least average family income. Diagnoses were delayed by a low index of suspicion as the skin changes of kwashiorkar were thought to be an exacerbation of the primary skin problem. In addition, kwashiorkar is uncommon in Kerala, and as a result, physicians may be unfamiliar with their clinical features. With resumption of a proper diet, the edema subsided in two weeks and skin changes were reversed, though the primary skin lesions persisted.

We were unable to find previous reports of kwashiorkor caused by dietary restriction as a part of treatment in alternative medicine, but cases may have occurred and may have not been reported. A heightened level of vigilance is required so that nutritional deficiency, which may result in severe life-threatening complications, is not overlooked.

We gratefully acknowledge the help and guidance given by Dr V K Parvathy, Head and Professor of Pediatrics and Dr S Criton, Head and Professor of Dermatology, Amala Institute of Medical Sciences, Thrissur, Kerala.