Introduction: Rickets and nutrient deficiencies in infants are rare occurrences in affluent societies due to the wide availability of infant formulas to ensure proper nutrition for newborns and infants. We present two cases of infants fed with homemade formula promoted on the internet. Cases: A two-month-old, ex-36-week male presented to the emergency department (ED) dead on arrival and in rigor mortis. He looked severely malnourished and weighed less than the second percentile for age. Per parents, he was followed by a primary care physician (PCP) and gastroenterologist for inability to gain weight. He had been fed a homemade formula consisting of one-and-a-half scoops of Enfamil formula mixed with water, dates, hemp seeds, and Irish moss which the family obtained from a health food store. He was unimmunized and not on vitamin supplementation. The family had an open Child Protective Services case filed by his PCP. A four-month-old term male presented to the ED in status epilepticus and was intubated for airway protection. He was found to have significant respiratory and metabolic acidosis (pH: 6.95), hyperglycemia, hyponatremia, hypokalemia, hypocalcemia, hypomagnesemia, and hypophosphatemia. In the pediatric intensive care unit (PICU), electrolytes were replaced. Full septic work-up revealed influenza pneumonia. Head computed tomography was unremarkable except for skull demineralization (Image 1). He was noted to be severely malnourished with all growth parameters below the second percentile for age. Laboratory and imaging work-up revealed vitamin-D deficiency rickets (Image 2). Genetic work-up was negative for genetic defects but was significant for ketosis and deficiencies of many essential amino acids and organic acids. The infant had not been seen by a physician since birth and was not immunized. He was breastfed for the first two months of life and then switched to a vegan formula consisting of water, dates, hemp seeds and sea moss without vitamin supplementation. He required a prolonged PICU stay for protracted, profound refeeding syndrome. Discussion: The internet is full of reliable as well as erroneous information, and lack of knowledge of which site is trustworthy resulted in parental misinformation and detrimental health effects in these infants. The American Academy of Pediatrics has clear recommendations for human milk to be the sole nutrient for healthy term infants in the first year of life, although it can be substituted with infant formulas. It is important for us as health care professionals to recognize nutritional deficiencies, to educate parents on proper nutrition and to advocate for the need for correction of false information on the internet. As new nutrition trends emerge, we need to be diligent in making sure the public is properly educated on the effects of these diets on the health of children and infants.

CT Head

Severe demineralization of the skull.

Wrist and Knee X-rays

X-rays showing osteopenia, diffuse demineralization and metaphyseal flaring and irregularity of long bones.