Kwashiorkor
Abdullah M. Al-Olayan
MBBS, SBP, ABP.
Assistant Professor of Pediatrics.
Pediatric Pulmonologist.
Introduction :
Protein-energy malnutrition (or protein-calorie
malnutrition) refers to a form of malnutrition where
there is inadequate protein intake.
Types include :
1- Kwashiorkor (protein malnutrition predominant)
2- Marasmus (deficiency in both calorie and protein nutrition)
3-Marasmic Kwashiorkor (marked protein deficiency and marked
calorie insufficiency signs present, sometimes referred to as the
most severe form of malnutrition)
Introduction :
Severe malnutrition is primarily a problem in
developing countries.
The clinical assessment of the child with
malnutrition includes distinguishing between
marasmus and kwashiorkor, assessing the
severity of the malnutrition, and identifying acute
life-threatening complications, including sepsis
and acute dehydration.
Introduction :
These children are at risk for micronutrient
deficiencies.
Definitions :
The World Health Organization (WHO)
defines malnutrition as
“ the cellular imbalance between the supply
of nutrients and energy and the body's
demand for them to ensure growth,
maintenance, and specific functions."
Definitions :
Protein-energy malnutrition (PEM) applies to
a group of related disorders that include
marasmus , kwashiorkor, and intermediate
states of marasmus-kwashiorkor.
Definitions :
Marasmus involves inadequate intake of
protein and calories and is characterized by
emaciation.
Definitions :
The term kwashiorkor is taken from the Ga
language of Ghana and means "the
sickness of the weaning." Williams first
used the term in 1933, and it refers to an
inadequate protein intake with reasonable
caloric (energy) intake.
Epidemiology :
Malnutrition underlies 55% of childhood
mortality worldwide.
Kwashiorkor may occur at any age, but is
seen most frequently in children 1–3 years
of age.
Pathophysiology :
In kwashiorkor, adequate carbohydrate
consumption and decreased protein intake
lead to decreased synthesis of visceral
proteins.
The resulting hypoalbuminemia contributes to
extravascular fluid accumulation. Impaired
synthesis of B-lipoprotein produces a fatty
liver.
Clinical Presentation :
History :
Low intake of calories or an inability to
absorb calories is the key factor in the
development of kwashiorkor.
Acrodermatitis enteropathica.
Clinical Presentation :
History :
Kwashiorkor was reported in an infant
presenting with diarrhea and dermatitis,
due to infantile Crohn disease.
The diarrhea and dermatitis improved in 2
weeks with treatment.
Erythematous skin, desquamation, erosions,
and diffuse hyperpigmentation
Clinical Presentation :
Physical :
Kwashiorkor typically presents with :
1-Normal or nearly normal weight and height for age.
2-Pitting edema in the lower extremities.
3-moon facies.
4-Distended abdomen with dilated intestinal loops.
5-Dry, atrophic, peeling skin with confluent areas of
fatty liver. hyperkeratosis and hyperpigmentation.
Clinical Presentation :
Physical :
6-Dry, dull, hypopigmented hair that is easily plucked.
7-Wasting is also typical.
8-Mental status changes.
9-There is some degree of edema in all cases of
Kwashiorkor.
10-The hands and face may become edematous.
11-Facial edema gives the characteristic “moonfaces.”
Causes :
Worldwide, the most common cause of
malnutrition is
1-inadequate food intake.( PRIMARY )
2-Ineffective weaning.
3-Gastrointestinal infections.
4-Cystic fibrosis.
Causes :
5-Chronic renal failure.
6-Childhood malignancies.
7-Congenital heart disease.
8-Liver cirrhosis.
Differential diagnosis :
1-Nephrosis: Edema is common and albumin is present in
urine. Ascites is common in nephrosis, but rare in
Kwashiorkor.
2-Hookworm anemia: May cause edema alone. Hookworm
infection is commonly seen in association with
Kwashiorkor. Hookworm anemia is not associated with
the dermatological findings commonly seen in
Kwashiorkor.
3-Chronic dysentery.
Investigations :
Laboratory Studies :
The WHO recommends the following laboratory tests:
1-Blood glucose.
2-Examination of blood smears.
3-Hemoglobin.
4-Urine examination and culture.
5-Stool examination by microscopy for ova and parasites.
6-Serum albumin.
7-HIV test.
8-Electrolytes.
Investigations :
Significant findings in kwashiorkor include
hypoalbuminemia (10-25 g/L), hypoproteinemia
(transferrin, essential amino acids, lipoprotein), and
hypoglycemia. Plasma cortisol and growth hormone
levels are high.
Electrolytes, especially potassium and magnesium, are
depleted. Levels of some enzymes (including lactase)
are decreased, and circulating lipid levels (especially
cholesterol) are low
Investigations :
Histologic Findings :
In kwashiorkor, microscopic studies of hair have
revealed a decrease in the proportion of anagen
follicles.
Treatment :
1-Correct fluid and electrolyte abnormalities
and to treat any infections.
The most common electrolyte abnormalities
are hypokalemia, hypocalcemia,
hypophosphatemia, and hypomagnesemia.
Macronutrient repletion should be
commenced within 48 hours under the
supervision of nutrition specialists.
Treatment :
2- Supply macronutrients by dietary therapy.
Milk-based formulas are the treatment of choice.
At the beginning of dietary treatment, patients
should be fed ad libitum. After 1 week, intake
rates should approach 175 kcal/kg and 4 g/kg of
protein for children.
A daily multivitamin should also be added.
Prognosis :
The extent of growth failure and the severity
of hypoproteinemia, hypoalbuminemia, and
electrolyte imbalances are predictors of a
poorer prognosis. Additionally, underlying
HIV infection is associated with a poor
prognosis.