Updated 22 May 2015

Protein-calorie malnutrition

Protein-calorie malnutrition comes from a low-protein and inadequate energy diet.


Alternative names

protein energy malnutrition, kwashiorkor, protein malnutrition

What is protein-calorie malnutrition?

Protein-calorie malnutrition is called kwashiorkor. The name “kwashiorkor” is said to come from West Africa and means “deposed child”.

Kwashiorkor is a nutritional disorder of children that occurs after a baby is weaned from the breast. If treated promptly, the prognosis is good, but many patients have stunted physical development.

Very underweight children with kwashiorkor are known as marasmic-kwashiorkor.

What causes kwashiorkor?

Kwashiorkor is essentially a disease of poor socio-economic conditions. The most commonly accepted cause of kwashiorkor is a low-protein and inadequate energy (calorie) diet, together with a lack of other nutrients.

Breastfed babies, even those living in impoverished communities, usually receive sufficient amounts of protein, carbohydrate, fat and other nutrients such as vitamins in the breast milk. When the child is weaned to an inadequate diet, kwashiorkor may develop. The situation is exacerbated where disease is rife and sanitation is poor.

New theories as to what causes kwashiorkor

New theories implicate a lack of other key nutrients, together with high rates of disease, environmental toxins and general conditions in overcrowded and poverty-stricken areas. Some researchers have found no relation between the rate at which children recovered from kwashiorkor and the rate of re-feeding.

These new theories, acting alone or in combination, are:

  • Insufficient nutrients, including zinc, selenium and vitamins A and E, as well as lack of protein and fat in the diet.
  • Aflatoxins (carcinogenic moulds) in food, which cause an imbalance between free radicals (unstable molecules that harm healthy cells) generated in the body, and the protective mechanisms that keep them in check. Moulds or fungi, which grow more easily on grain foods such as wheat in hot and humid conditions, are thought to be partly responsible for the contamination of food. This would help to explain why carbohydrate-dominated diets and kwashiorkor were so closely linked for so long.
  • Disease - which also results in an increased number of harmful free radicals in the body.

Who gets Kwashiorkor and who is at risk?

Children living in overcrowded, poverty-stricken conditions are most at risk of developing kwashiorkor, especially if:
  • They have recently stopped breastfeeding, and their diet consists largely of carbohydrates.
  • Living conditions are unhygienic.
  • Conditions in which food is stored or prepared are unhygienic, allowing it to become contaminated with fungi.
  • Conditions encourage the growth and spread of moulds or fungi.
  • There are frequent outbreaks of disease in the community.
  • The child’s immune system is low due to starvation or disease.
  • Diarrhoea and dehydration are present.

Symptoms and signs of kwashiorkor

Early symptoms of kwashiorkor are fairly non-specific. They are underweight for age. An affected child may at first appear tired, irritable and disinterested in play. The child fails to grow and loses muscle mass. As deprivation continues, the child’s legs and body swell up due to the accumulation of fluid (oedema) in the tissues. A “pot-belly” develops because of lax abdominal muscles and, in some cases, an enlarged liver.

The hair becomes sparse, brittle and develops a reddish hue. In severe cases patches of the skin will slough off leaving oozing sores rather like a burn wound. They are often anaemic and have heavy worm infestations. Diarrhoeal disease is a frequent presentation.

Because of impaired immunity these children are also prone to infections such as tuberculosis and septicaemia.

Final symptoms may include coma or shock. If untreated the child will die.

How is kwashiorkor diagnosed?

The dietary history and clinical examination are usually sufficient to make a diagnosis.

Blood tests may be helpful in confirming the diagnosis, but in developing countries most cases of kwashiorkor are handled by nurses, aid workers or social workers, who will not have this resource.

Can kwashiorkor be prevented?

Kwashiorkor is preventable by the provision of a balanced diet, adequate housing, accessible potable water and proper sanitation together with economic upliftment.

In order to grow normally and to remain healthy, a child will need 80-120 kcals/kg per day for the first few years of life. This is divided so that 9-15% of the daily energy requirement is protein, 45-55% is carbohydrate and 35-45% is fat. In general, the lower the fat intake the better.

Vitamin supplements are also useful.

The correct storage of food, including grains, should prevent mould from developing.

How is kwashiorkor treated?

The child with kwashiorkor should be admitted to hospital for the initial treatment. Unfortunately, this will be impossible in many developing countries where the disease is most prevalent.

Treatment will depend on the severity of the condition.

Shock, dehydration and infection will be managed first.

The child is started on milk feeds. The energy content is increased slowly over a week or so before solids are introduced.

Milk only is given for the first five to seven days. An acidified formula is currently favoured. 80 kcals/kg/day are given for the first three days; 100 kcals/kg/day the next three days and then 150-200 kcals/kg/day thereafter. The energy content of feeds can be increased by the addition of sunflower seed oil (5 ml/100 ml milk) or glucose polymer (max 10 ml/100 ml). Solids (e.g. cereals, mince) are introduced from about day six. In general, the more severe the condition the slower the feeds are increased.

Some children may develop lactose intolerance. This is the inability to digest the carbohydrate in milk. Lactose free milks are then tried e.g. Soya milk.

Antibiotics are given and the child should be de-wormed.

Vitamin supplements must be given for a number of months.

The anaemia is treated with iron tonic when the child is in the recovery phase.

The Department of Health has a National feeding policy, the PEM scheme (Protein-Energy Malnutrition), to assist in the nutritional rehabilitation of malnourished children. The scheme is administered through the local clinics.

What is the outcome of kwashiorkor?

The majority of children will recover if treatment is started early although many will not attain normal physical growth levels. Some children are so severe when they present that they die from the disease or its many complications.

Children under seven months of age who develop severe kwashiorkor may end up with some intellectual impairment.

Development is delayed due to lack of the nutrients and protein essential for optimum brain growth. It is also delayed because malnourished children have less energy to play and explore their environment.

Even if treated, relapses will result in stunted mental and physical development.

Recurrence is likely unless the child’s environment is drastically altered. Education of caregivers and the community can assist in the long-term prevention of kwashiorkor.

(Reviewed by Dr John D. Burgess, Red Cross Children's Hospital)

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