gms | German Medical Science

Introduction: Malnutrition remains a major public health concern, especially in low-income countries. However, food insecurity is unexpectedly high in some rich countries with the EU showing a prevalence of 8.7% of the population. This report presents premature twins who had severe malnutrition despite being born in Germany. The 2022 Global Nutrition Report showed that in Germany in 2016 0.3% of children <5 years of age were wasted and 1.7% were stunted. This case highlights the importance of global guidelines and exchange of good practice for proper management and prevention of possible complications with severe malnourished infants.

Case presentation: Two 7-months old (corrected 5.9-month-old) female infants were presented in our hospital with severe acute malnutrition (marasmus). The infants were born from an unattended pregnancy. No regular developmental check-ups or vaccinations were done. The mother denied any previous abnormalities concerning development or food-intake. She stated that she fed “children milk” as well as yoghurt and bananas. The main complains on day of admission were watery diarrhea, vomiting and fever for 3 days prior to admission. At admission, both infants were in significantly reduced general condition. Clinical findings revealed lethargy, Kussmaul breathing, pale-gray skin with CRT >3 sec, decreased skin turgor and dry mucous membrane but no presence of nutritional oedema. Despite the fever, the vital signs were stable. The infants’ weight-for-length was below a –3 SD z-score according to WHO growth standard charts. Twin A had a mid-upper-arm circumference of 11 cm, Twin B of 12 cm. The diagnoses of severe malnutrition, severe anemia and severe dehydration were made. Twin B received on the admission night a red blood cell transfusion. Parenteral rehydration with pediatric Benelyte^® solution was started and given in total for 3 days. The infants were fed initially 2-hourly in small portions with commercial infant formula (Aptamil 1). International WHO-guidelines recommend a special starter diet Formula 75 with low osmolarity and low calories. But F75 was not available. On the 3rd day of admission both infants showed refeeding syndrome with signs of significant eyelid, thorax and lower limbs oedema, worsening diarrhea, increased breathing rate and bradycardias. Following, the food intake was revaluated and reduced. The diarrhea stopped on the 6th day in the ward and the oedema subsided.

Lessons learned: This case highlights that treatment of severe malnutrition in infants <6 months of age is challenging despite being rich in resources due to lack of experience and adapted protocols. It presents an importance of an early management of refeeding syndrome to prevent negative outcomes. Additionally local social welfare structures are challenged to identify families whose children are at risk to fall through the social net.