Complementary to the correspondence on ‘Iatrogenic kwashiorkor’ [1], we
report 37 cases of edematous SAM (E-SAM) mostly among infants, that we
encountered during the period January 2010 to June 2012. This changing
profile of undernutrition and occurrence of E- SAM are of great concern
in this electronic era, 20 years after initiating ‘Breastfeeding policy’
in 1992 and 10 years after initiating the Global strategy for Infant and
Young child feeding (IYCF) since 2002.
Ever since Prof Cicely Williams described kwashiorkor
in 1933, similar cases have been observed in the stereotypic profile of
poverty, ignorance and illiteracy or natural calamities like war, famine
etc. But, currently cases of E-SAM are noted in settings without the
above said risk factors [2]. In our present series of E- SAM, the
mothers had basic education, some of them were graduates and had
consulted more than one doctor, who focused only on the skin changes and
ignored the overall nutritional status. The common causal factors
identified were ‘man made perception’ of lactation failure/breast milk
withdrawal and early introduction of very dilute milk formula or dilute
starch based liquid diet without any good quality protein like arrow
root/banana powder, rice/ragi/oats etc. Animal milk protein is often
totally avoided, being branded as an allergen, especially as per the
advice from complementary and alternate medicine [3]. The imbalance in
the dietary ratio of protein to energy has been clearly implicated in
the pathogenesis of E- SAM [4], the ratio of protein energy to total
energy (PE ratio) is a convenient and useful descriptor of one aspect of
dietary quality in human nutrition.
Out of the 121 SAM cases, 37 had E- SAM. 10 cases
died and one 3 month old E-SAM, who died had florid keratomalacia. These
cases were picked up due to a high index of suspicion and were managed
as per the 10 steps of WHO SAM treatment protocol. Locally prepared F
75, F 100 and Ready to use therapeutic foods (RUTF) were used (Table
I).
TABLE I Locally Prepared F75, F 100 and RUTF
|
F 75 |
F100 |
F100 |
RUTF |
|
Full cream Milk 30 mlor |
Full cream Milk 90 mlor |
Skimmed Milk |
SAT Mix15 g (Roasted & |
|
Infant Milk powder 5 g |
Infant Milk powder 15 g |
powder 10 g |
powdered Rice: Wheat: Black gram: Sugar-1:1:1:2 ) |
|
Sugar 10 g |
Sugar 5 g |
Sugar 5 g |
Skimmed Milk powder5 g |
|
MCT/ Coconut Oil 2.5 mL |
MCT/ Coconut Oil 2.5 mL |
MCT/Coconut Oil 2.5 mL |
MCT/ Coconut Oil5 ml |
|
Water up to 100 mL |
Water up to 100 mL |
Water up to 100 mL |
Water qs |
|
75 Kcal energy & 1 g protein* |
100 Kcal energy & 3 g protein* |
100 Kcal energy & 3 g protein* |
100 Kcal energy &3 g protein* |
|
*Approximate values |
Promoting optimum breastfeeding and IYCF practices,
ensuring a cereal to pulse ratio of 2:1 and desirable protein energy
ratio in complementary feeds and family pot feeds, spreading the message
of the changing of undernutrition, popularizing growth monitoring and
empowering the health team for identifying and managing SAM, especially
E-SAM cases are recommended in this context.
1. Pillai K, Acharya S. Iatrogenic kwashiorkor.
Indian Pediatr. 2010;47:540-1.
2. Elizabeth KE. Spectrum of Protein energy
malnutrition (PEM). In: Elizabeth K E. editor, Nutrition
and Child Development, 4th Ed. Hyderabad: Paras Medical Publisher;
2010.p.181-3.
3. Niggemann B, Gruber C. Side-effects of
complementary and alternate medicine. Rev Allergy. 2003;58:707-16.
4. Rossouw JE. Kwashiorkor in North America. Am J Clin Nutr.
1989;49:588-92.
