Kwashiorkor

 

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Original Editors - Kevin Boothe from Bellarmine University's Pathophysiology of Complex Patient Problems project.

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Definition/Description

Kwashiorkor is a form of protein-energy malnutrition (PEM) that occurs when there is not enough protein in the diet.^1,2  The World Health Organization (WHO) defines malnutrition as "an cellular imbalance between supply of nutrients and energy and the body's demand for them to ensure growth, maintenance, and specific functions".¹  It is most often encountered in children of overpopulated developing or underdeveloped countries, where their diet consist mostly of grains and starchy vegetables, with low to minimal amounts of protein included in their diet.  Common in areas of famine, limited food supply, and low levels of education.³  This diet is adequate in calories, but deficient in certain amino acids, which constituents proteins for vital growth.  During nursing, the mother is able to supply the essential amino acids and proteins needed via breastfeeding.  After the child is weaned from breastfeeding, their protein needs are neither met by milk or meat.^4,5  The condition of kwashiorkor in children was first described in 1932.  Kwashiorkor, in African dialect, means "desposed child" ("deposed" from the mother's breast by a newborn sibling) and "red boy" due to the reddish orange discoloration of the hair that is a characteristic of the disease.⁵     

Prevalence

Kwashiorkor is most prevalent in overpopulated areas of the world in underdeveloped and developing countries, particularly in sections of Africa, Central and South America, and South Asia.⁵  Kwashiorkor is very rare in the United States, but does occur and is usually a sign of child abuse and neglect.²  PEM has been observed in United States in children with frequent hospitalization from chronic illnesses, and in the older population living in nursing homes.¹ 

Characteristics/Clinical Presentation

Signs, Symptoms and Characteristics:^{2,4,5,6,7,11,12}

- changes in skin pigment (reddish pigmentation)

- atrophy (decreased muscle mass) of muscles and glands

- severe diarrhea

- failure to gain weight

- hair changes (change in color or texture); reddish orange color

- increased risk and severity of infections due to compromised immune system

- irritability (excessive response to a stimulus) (early sign)

- distended abdomen

- lethargy (fatigue) (early sign) or mental apathy (lack of feeling or emotion)

- hepatomegaly (enlarged liver) with fatty infiltrates

- dermatitis⁸

- dermatosis⁹

- shock (late stage)

- pedal edema (swelling of the feet)

- retarded development

- decreased immunity

- anorexia

- ulcerating dermatosis

- hypoalbuminemia^7,10

Associated Co-morbidities

Protein malnutrition during childhood can lead to predisposed complications in later life, such as cirrhosis of the liver and underdevolped mentally.⁴  Protein-energy malnutrition is an umbrella term for deficiencies caused by diets lacking proteins and/or calories.  When there is a deficiency in both calories and protein, young children between ages 1-4 may suffer from marasmus (a condition characterized by general wasting of body tissues. Children with marasmus may become acutely emaciated and fail to grow.  Adequate calories and protein can alleviate symptoms associated with both marasmus and kwashiorkor.^4,6  

Medications

There are relatively few pharmacokinetic studies dealing with the use drugs as an intervention for children with kwashiorkor and PEM.  More studies are needed to establish the appropriate dose, safety, and to understand the effects of these drugs.¹¹

Diagnostic Tests/Lab Tests/Lab Values²

Arterial Blood Gas (ABGs)

BUN (Blood Urea Nitrogen)

CBC (Complete Blood Count)

Creatinine clearance

Serum creatinine

Serum potassium

Total protein levels

Urinalysis

Common MRI findings associated with children suffering from kwashiorkor included widening of Sylvian fissures and sulci, prominence of basal cisterns, and ventricular dilation resulting in cerebral atrophy, as well as periventricular white matter (PVWM).  No significant delay in the myelination process suggesting normal brain myelination which is not affected by the nutritional status.¹⁴

Etiology/Causes ⁴

Causes of kwashiorkor other than protein-deficient diet include poor intestinal absorption, chronic alcoholism, kidney disease, infections, and trauma (burns) that lead to an increase need of protein and caloric intake and results in loss of protein due to the body's demand to repair. 

Systemic Involvement

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Medical Management (current best evidence)

Treatment is dependent on severity of disease.  Supplementing the child with an adequate diet is the preferred medical treatment that has shown to reverse affects of Kwashiorkor.  If the individual is in shock, immediate medical intervention is needed to restore blood volume and maintain blood pressure to prevent any life-threatening conditions that could eventually result in death.^2,3

The increase in caloric intake is first administered in the form of carbohydrates, simple sugars, and fats to provide the child with the adequate calories to provide energy for cellular function and metabolism.  Once energy demands are met, proteins are incorporated into the diet, along with essential vitamin and mineral supplements.^2,3  The consumption of dried milk formula has been proven most efficient and effective for treatment of kwashiorkor, but many malnourished children have developed a lactose intolerance. Administration of enzyme lactase assists in milk tolerance.^4,2,3 

The child's diet must be introduced slowly to limit potential problems associated with the change in cellular and organ function due to inadequate diet.  Problems are associated with excessive amounts of fat in the diet leading to bowel and intestinal dysfunction.^2,3     

Physical Therapy Management (current best evidence)

The primary medical intervention is to treat kwashiorkors with an adequate diet.  It is more likely for Physical Therapy to play a crucial role in the nursing home setting.  Once the patient's diet has been balanced and they are receiving the adequate amount of calories and nutrients, then physical therapy intervention can be applied.  If the patient's diet is not adequately met, then the physical therapy intervention will add an increase in energy demands that is not being met, and the intervention will be detrimential instead of beneficial.  Physical Therapy intervention should include a general strength and aerobic conditioning program to minimize signs and symptoms associated with kwashiorkor (muscle atrophy and fatigue).      

Alternative/Holistic Management (current best evidence)

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Differential Diagnosis

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Case Reports/ Case Studies

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Resources

1. Shashidhar HR, Grigsby DG. Malnutrition. eMedicine. 2009. Available at http://emedicine.medscape.com/article/985140-overview. Accessed March 9th, 2011.

2. Kaneshiro NK, Zieve D. Kwashiorkor. Pub Med Health. 2010. Available at http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0002571. Accessed February 22, 2011.

3. Kaneshiro NK, Zieve D. Kwashiorkor: MedlinePlus Medical Encyclopedia. Medline Plus. 2010. Available at http://www.nlm.nih.gov/medlineplus/ency/article/001604.htm. Accessed February 22, 2011.  

4. Kwashiorkor (Pathology). Britannica Online Encyclopedia. Available at http://www.britannica.com/EBcheck/topic/325852/kwashiorkor. Accessed March 9, 2011.

5. Kwashiorkor. Columbia Electronic Encyclopedia. 6th ed. 2010. Available at http://web.ebscohost.com.libproxy.bellarmine.edu.ehost. Accessed March 9, 2011.

6. Kwashiorkor. University of Maryland Medical Center. 2011. Available at http://www.umm.edu/ency/article/001604.htm. Accessed March 17, 2011.

7. Dermatitis. Mayo Clinic. 201. Available at http://www.MayoClinic.com. Accessed on March 30, 2011.

8. Dermatosis. American Heritage Medical Dictionary. 2007.  Available at http://www.medical-dictionary.thefreedictionary.com/dermatosis. Accessed on March 30, 2011.

9. Peralta R, Rubery BA, Langenfeld SC. Hypoalbuminemia. eMedicine. 2010. Available at http://emedicine.medscape.com/article/166724-overview. Accessed on March 30, 2011.

10. Oshikoya KA, Sammons HM, Choonara I. A systematic review of pharmacokinetics studies in children with protein-energy malnutrition. Eur J Clinical Pharmacol. 2010; 66 (10): 1025-35. Available at http://www.ncbi.nlm.nih.gov/pubmed/20552179. Accessed on March 30, 2011.

11. Liu T et al. Kwashiorkor in the United States: Fad diets, perceived and true milk allergy, and nutritional ignorance. Arch Dermatol. 2001; 137:630-636. Available at www.archdermatol.com. Accessed on March 9, 2011.

12. Ahmed T, Rahman S, Cravioto A. Oedematous malnutrition. Indian J Med Res. 2009; 130: 651-654. EBSCOhost. Accessed on March 9, 2011. 

13. Coward WA, Lunn PG. The biochemistry and physiology of kwashiorkor and marasmus. Medical Bullentin. 1981; 37 (1): 19-24. EBSCOhost. Accessed on March 9, 2011.

14. Atalabi OM, Lagunju IA, Tongo OO, Akinyinka OO. Cranial magnetic resonance imaging findings in kwashiorkor. International Journal of Neuroscience. 2010; 120: 23-27. EBSCOhost. Accessed on March 9, 2011.

Recent Related Research (from Pubmed)

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References

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