An 18-Month-Old with Oedema in Maroua: Diagnosis, First 48 Hours and the Family's Porridge

The diagnosis is wrong. This is kwashiorkor - severe acute malnutrition with oedema - not marasmus. Marasmus is severe wasting without oedema, and this child has bilateral pitting oedema, hypoalbuminaemia (21 g/L), sparse depigmented hair and flaky-paint dermatosis, which is the classic kwashiorkor picture.

Why the anthropometry misleads

• MUAC: 12.3 cm sits just above the 12.5 cm cut-off for severe acute malnutrition in children aged 6-59 months. Measured alone, it would miss him.
• Weight-for-length: the median weight for a boy of 76 cm is roughly 9.5 kg with a standard deviation near 1.0 kg, so his 8.4 kg gives a weight-for-length Z-score of about -1.1 - apparently only mild wasting. Two things are hidden in that number. First, oedema is fluid, not tissue, so it inflates the weight and masks the loss of muscle and fat; without the oedema he would weigh perhaps 7.7 kg, a Z-score near -1.8 or worse. Second, weight-for-length cannot detect a child whose weight and length are both reduced in proportion.
• The rule that overrides all of this: any bilateral pitting oedema of nutritional origin is itself a criterion of severe acute malnutrition, regardless of weight-for-height or MUAC. Oedema plus a low albumin is diagnostic.

Additional classifications to record: hypoglycaemia (3.1 mmol/L is at the treatment threshold), hypothermia (36.4 C), anaemia (8.9 g/dL) and poor appetite. These are complications, and their presence confirms that this child is a medical emergency, not an outpatient.

Consequence: F-100 immediately and same-day discharge are both unsafe. The child needs inpatient stabilisation.

First hours - treat the life-threatening problems

1. Hypoglycaemia. 3.1 mmol/L is at the treatment threshold (below 3 mmol/L is frank hypoglycaemia). Give 50 mL of 10% glucose orally or by nasogastric tube, then start F-75 two-hourly. Do not give bolus intravenous dextrose unless the child is unconscious.
2. Hypothermia. Axillary 36.4 C is below the 36.5 C threshold. Warm with skin-to-skin contact, blankets and a hat, and feed; hypothermia and hypoglycaemia usually occur together.
3. No dehydration and no diuretics. Oedema in kwashiorkor is not fluid overload to be drained. Diuretics cause potassium and magnesium loss and can kill. Rehydration, if ever needed, uses low-sodium ReSoMal, not standard oral rehydration salts or intravenous fluids.
4. Routine broad-spectrum antibiotics. Give ampicillin plus gentamicin, or amoxicillin, even without fever, because the immune response is depressed and infection is often silent.
5. Electrolytes and micronutrients. F-75 is formulated low in sodium and high in potassium and magnesium. Give vitamin A, zinc, folic acid and a multivitamin; withhold iron for the first week, because free iron feeds bacteria and the child cannot yet use it for haemoglobin.

Feeding 6. F-75 at 100 kcal/kg/day (about 130 mL/kg/day) in eight feeds, by cup or nasogastric tube if intake is poor. This is maintenance only, deliberately below the child's needs, to allow metabolic adaptation. Weigh daily and watch for a rising pulse, gallop rhythm, liver enlargement or increasing oedema - signs of overload. 7. Transition only when stable: appetite returns, oedema subsides, and infection is treated. Then move to F-100 or RUTF at 150-220 kcal/kg/day for catch-up growth, and only then consider discharge with follow-up.

Why F-100 now is dangerous. F-100 has far more energy, protein and sodium. In a child with a failing sodium-potassium pump, low albumin and impaired cardiac and renal reserve, this load precipitates refeeding syndrome - hypophosphataemia, hypokalaemia, fluid shifts - and heart failure, which can be fatal within hours.

Why same-day discharge is wrong. This child needs 24-72 hours of monitored stabilisation, immunisation review, deworming after stabilisation, and an assessment of the home situation before any take-home food is given.

Why more porridge will not solve the problem

• Energy density. Thin millet porridge is typically 5-8% dry matter, roughly 0.3-0.5 kcal per gram. A toddler's stomach holds only about 250-300 mL per meal, so even a full bowl supplies perhaps 100-150 kcal - against a catch-up requirement of 150-220 kcal/kg/day, which is over 1,200 kcal for this child.
• Protein quality. Millet protein is limiting in lysine and is poorly digested when the grain is whole and unfermented; the child needs a complementary source.
• Bulk and antinutrients. Phytate in unrefined millet binds zinc and iron, worsening the anaemia already present.
• Frequency. Two meals a day is far too few for a toddler, who needs three meals plus two snacks.

A realistic improved diet from local foods

• Energy: add a teaspoon of groundnut paste, sesame paste or red palm oil to each 100 mL of porridge, raising density to 0.8-1.0 kcal/g. This is the single highest-impact change and costs little.
• Protein: combine millet with groundnut, cowpea or soybean flour, and add dried fish powder, egg or small fish where available. Cereal plus legume fixes the lysine deficiency.
• Micronutrients: moringa leaf powder, carrot, pawpaw, mango and dark green leaves supply vitamin A and iron; fermentation of the millet porridge reduces phytate and improves absorption.
• Frequency and consistency: three thick meals plus two snacks, fed responsively with a spoon, and continued breastfeeding if the mother is able.

Beyond the bowl

• Deworming, vitamin A supplementation, growth monitoring every two weeks and immunisation catch-up.
• Nutrition counselling for the whole household, not just the aunt, and referral to a food-security or cash-transfer programme given the harvest failure - the child will relapse within months if the household diet does not change.
• Explain to the aunt that the RUTF during catch-up is a treatment, not a food to be shared, and that the aim is to move back onto an improved family diet.