Kwashiorkor: Cause, Diagnosis and Treatment

When a child dwells in an environment which does not supply enough high biological value (HBV) protein (essential amino acid building blocks), yet supplies enough non protein energy building blocks (carbs and fat), nutritional imbalance arises, surfacing in their bodies and minds as symptoms and signs typical of the disease known as kwashiorkor.[1]

Kwashiorkor is usually seen in children aged 1 to 3 years, and in developing countries, although it may occur anywhere children are exposed to diets deficient in protein but not short on calories (carbs). Occasionally this disorder has been encountered in the US and Europe, where it is associated with poverty and young children fed adequate carbs and fat, but insufficient amounts of protein. Most commonly it is seen in developing African and Asian and some Latin American countries.

Kwashiorkor” comes from the Ga language of coastal Ghana and means “the sickness of the weaning” or “the disease of the displaced (from the mother’s breast) child.” In developing countries, in regions where protein sources are scarce, breast feeding is maintained as long as possible, for its nutritive value, yet as the mother’s breast milk wanes and as the child grows, weaning is accomplished to the local starchy diet.

Etiology of kwashiorkor:

• · Rapid growth and development of a young child, especially leading to weaning from the breast to low HBV protein
• · A protein-poor staple food for the child, e.g. manioc (cassava), bananas, sugar
• ·(meat, fish, milk, eggs) and plant (beans, peanuts)
• · Poor food distributions in family, i.e. older, larger persons get more meat
• ·: food taboos, precluding a child’s intake of certain salubrious foods
• · Infections: diarrhea, measles, whooping cough, malaria, etc.
• ·:
  • · Growth failure is always present: reduced stature and weight, corrected for edema, will be present.
  • · Wasting is always a feature, which may be masked by edema.
  • · Edema always occurs and is a most important feature of the disease, affecting any part of the body. An ambulant child initially develops swelling of the feet, then legs, followed by the hands, groin, and face.
  • · Mental changes are always present: apathetic unsmiling facies, irritability, behavioral retardation, poor appetite, anorexia, disinterest in food.
  • · Hair changes. In kwashiorkor the hair often shows alterations in color, texture, strength, and pluckability. The tight curl of some African peoples is often lost, losing its luster. Black hair becomes reddish brown in color. In Latin America parallel strips of discolored hair have been labeled the “flag sign.”
  • · Skin changes: These are not always encountered, but if present, may signal the disease: 1) depigmentation, especially of the face; 2) a dermatosis (rash) may develop on areas of friction, such as the groin and behind the knees, where darkly pigmented patches appear, and desquamate, looking like old blistered paint, hence the label “flaky paint dermatosis.” Beneath the flakes are atrophic areas resembling a healing burn.
  • · Diarrhea-Stools are frequently watery, offensive, blood-stained and contain undigested food particles.
  • ·: The liver is universally enlarged to such an extent that it may be easily palpated, owing to its fatty infiltration.

  Energy imbalance. Children suffering from kwashiorkor lack adequate dietary intake of protein building blocks, especially daily intake of adequate amounts of the 8 essential amino acids. Their intake of carbs and fat is typically not significantly lacking. Hence, on physical examination they will be found to have intact stores of subcutaneous fat, unlike marasmus, where children are starved and have lost their subcutaneous.

  Other deficiencies. Lesions of the lips and mouth characteristic of various B vitamin deficiencies may occur. Eye findings (dry eyes) due to vitamin A deficiency may be present.

  Laboratory findings-A reduction in serum protein is typically seen.

  Treatment:

  Severe cases of kwashiorkor should be admitted to a hospital for treatment, if possible. Severity is judged by:

  • · Amount of edema
  • · Extent of dermatosis (rash)
  • · Severity of anemia
  • · Level of dehydration
  • · Willingness of the child to feed
  • · General overall clinical condition

  Dried skimmed milk is a satisfactory basis for treatment, but other protein-rich foods are effective as well. A mixture of dried skim milk, vegetable oil, and casein is ideal, and if necessary the child can be given the mixture through a feeding tube.

  This mixture should provide about 120 Calories and 7 gm. of protein per kg body wt. per day.

  Antibiotics should be given to combat infection.[1,2] Severe dehydration calls for IV electrolyte solutions. Vitamin administration as indicated. Severe cases of kwashiorkor are expected to favorably respond to the above regimen, with disappearance of edema, increased appetite, and change in mood to wearing a smile.

  The mother is brought into therapy, with nutritional education given to her, so vital is her role in the child’s nutritional and physical health.

  References:

  [1] Scope Manual on Nutrition; 1972:pp 31-33.
  [2] N.Engl.J.Med. 2013;368:425-35.

  See also Congestive Heart Failure: Risks, Symptoms and Treatment