A 9-week-old with persistent vomiting

A 9-week-old boy was referred for admission to the hospital for evaluation and treatment of severe failure to thrive due to persistent vomiting. The history of the vomiting dated back to soon after birth and was treated with a variety of formula changes without improvement. He was somewhat lost to follow-up, and eventually his condition deteriorated to the point of emaciation before being seen again.

His past medical history was positive for spending a few days in the nursery after birth for what was described by his mother as a problem with formula intolerance. Otherwise, except for the chief complaint, his past medical history was unremarkable. His newborn screen was normal, and his immunizations were up to date for his age.

Upon admission, his examination was positive for the obvious cachectic appearance, with loss of almost all his subcutaneous fat, as shown in figures 1 – 3. Otherwise, his examination was normal, with normal vital signs. Screening lab tests revealed hypokalemia, hypophosphatemia and hypochloremic metabolic alkylosis. An upper gastrointestinal series was performed, revealing evidence of pyloric stenosis (Figure 4).

What is the greatest risk to this child?

1. Refeeding syndrome
2. Sepsis
3. Rickets
4. Measles

Most experts would say that at the time of admission, the greatest risk to this child would be A, refeeding syndrome, because, if not properly managed, it could result in the rapid further deterioration of his electrolytes, particularly the phosphate and potassium, which may result in death.

This can happen as a result of the rapid shift from using endogenous energy production (fat and muscle protein) to exogenous (carbohydrate) energy production. This can result in a sudden and dramatic increase in insulin production, leading to the shifting of phosphorus, potassium and magnesium from the extracellular space to the intracellular space. This, of course, leads to a rapid decrease on these electrolytes in the circulation, with the risk of seizures, coma, arrhythmias, rhabdomyolysis and dysfunction of red and white blood cells, all of which may rapidly lead to death. This summarizes a very complex process. Essentially, the management of a patient like this is to be aware of refeeding syndrome and monitor electrolytes and vital signs carefully, preferably in an ICU setting, and make the shift from endogenous to exogenous metabolism slowly. This should be done with the help of a gastroenterologist or anyone with experience in refeeding syndrome if possible.

An equally lethal and potentially rapid complication is sepsis.

In a refugee camp, sepsis may be the issue of greatest risk because refeeding syndrome is widely known and routinely managed in that setting, decreasing the chance of its development. In this setting, sudden, overwhelming sepsis is a common visitor (Figures 5 & 6). Infection, usually pneumonia with sepsis, poses a serious risk due to the effects of starvation on the immune system. Malnutrition is often referred to as the most common cause of secondary immunodeficiency worldwide. Through many studies, it appears that every arm of the immune system is adversely affected with starvation. Cellular deficiencies are the most common, from low numbers to impaired migration and killing. Compliment levels are reduced; however, immunoglobulin levels are usually normal to elevated, especially IgE levels. Despite their levels, the antibody responses to antigens are decreased.

As the patient presented in the question showed, you do not need to work in a refugee camp to see severely malnourished children. Figure 7 is of another child with chronic diarrhea who had not been followed closely. This happens in our own communities, sometime right under our noses, and does not necessarily reflect poor socioeconomic status, but rather inexperienced parenting.

A 9-week-old in this country is not likely to contract measles (rubeola), but certainly, this can be a problem in developing countries. In those patients who happen to be malnourished, particularly vitamin A deficient, measles can be a more severe, life-threatening disease. The Red Book recommends vitamin A supplementation in this setting, with a single dose of 200,000 IU for children older than 1 and 100,000 IU for those 6 months to 1 year. See the current Red Book for more details.

Lastly, rickets can certainly be a consequence of poor nutrition but is not the greatest risk in this patient.

Columnist comments

I wrote some of this column while returning from another trip to Iraq in early October on a medical education mission; this time at the Basrah General Hospital (Figure 8) in Southern Iraq.

We taught a three-day course there on disaster pediatrics. While there, we had the opportunity to tour certain wards in the hospital, as well as the medical school and the Basrah Women and Children’s Hospital.

At Basrah General Hospital, the problem of malnutrition is common enough to warrant its own refeeding unit (Figure 9), where there were numerous babies and young children at various stages of nutritional resuscitation (Figures 10 & 11) being treated with IV fluids and their version of a high-calorie formula that is prepared in their own pharmacy.

One infant had a fairly severe case of Kwashiorkor (Figures 12–13), showing the characteristic edematous appearance, loss of hair, skin changes and apathetic affect. This is a severe form of malnutrition associated with protein deficiency, as well as other nutrients. The child usually has an enlarged, fatty liver as well. Correction of this problem requires careful replacement of calories, first in the form of carbohydrates, sugar and fats, then adding protein back into the diet. This should be done very slowly to avoid refeeding syndrome, and as noted above, if possible in consultation with an expert in malnutrition, such as a pediatric gastroenterologist.

I will talk more about the medical care in Southern Iraq in the December column. If you have any interesting experiences that you may have from similar missions you may have been on, please forward them to me in the next couple of weeks (including pictures), and I’ll try to include what I can.