Kwashiorkor in the United States - Fad diets, perceived and true milk allergy, and nutritional ignorance

Background: Kwashiorkor is the edematous form of protein-energy malnutritio n. It is associated with extreme poverty in developing countries and with c hronic malabsorptive conditions such as cystic fibrosis in developed countr ies. Rare cases of kwashiorkor in affluent countries unrelated to chronic i llness have been reported. We present 12 casts of kwashiorkor unrelated to chronic illness seen over 9 years by pediatric dermatologists throughout th e United States, and discuss common causative themes in this easily prevent able condition. Observations: Twelve children were diagnosed as having kwashiorkor in 7 ter tiary referral centers throughout the United States. The diagnoses were bas ed on the characteristic rash and the overall clinical presentation. The ra sh consisted of an erosive, crusting, desquamating dermatitis sometimes wit h classic "pasted-on" scale-the so-called flaky paint sign. Most cases were due to nutritional ignorance, perceived milk intolerance, or food faddism. Half of the cases were the result of a deliberate deviation to a protein d eficient diet because of a perceived intolerance of formula or milk. Financ ial and social stresses were a factor in only 2 cases, and in both cases so cial chaos was more of a factor than an absolute lack of financial resource s. Misleading dietary histories and the presence of edema masking growth fa ilure obscured tile clinical picture in some cases. Conclusions: Physicians should consider the diagnosis of kwashiorkor in chi ldren with perceived milk allergies resulting in frequent dietary manipulat ions, in children following fad or unorthodox diets, or in children living in homes with significant social chaos. The presence of edema and "flaky pa int" dermatitis should prompt a careful dietary investigation.