Kwashiorkor

Summary 

• Kwashiorkor is a condition related to an inadequate diet.
• The disease is most common among children living in deprived circumstances, are    exposed to infections and who eat a monotonous diet consisting of a single staple food (maize, cassava), deficient in protein, vitamins and minerals¹.
• Treatment takes the form of attending to infections which are often present, i.e. measles, gastro-enteritis, tuberculosis (TB) or HIV and other conditions like anaemia, while gradually improving and balancing the diet.
• With early treatment the prognosis is good, but relapses and stunted growth are common.
• Prevention of kwashiorkor can only be assured through a change in the living conditions of the child and the community. This must include the education of mothers and other caregivers, provision of a balanced and varied diet, improved hygiene, clean water, as well as prevention and treatment of repeated infections such as gastro-enteritis, measles, HIV and TB.

Alternative names

• Protein energy malnutrition
• Protein-calorie malnutrition
• Protein malnutrition

What is 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 suffer repeated relapses after leaving hospital and consequently may have stunted physical development. Mental development may also be affected.

In the case of very underweight children with kwashiorkor it is known as marasmic-kwashiorkor.

What causes kwashiorkor?

Kwashiorkor is essentially a disease of poor socio-economic conditions. Originally kwashiorkor was attributed to inadequate protein and energy (kilojoule) intake after weaning. However, studies conducted by the Cambridge group in Uganda, have shown that the protein and energy contents of diets of children who developed kwashiorkor did not differ from those of children who did not develop this condition. It has been suggested that children develop kwashiorkor in reaction to physiological stress associated with metabolic changes involving antioxidants such as trace elements and vitamins, which lead to depletion of compounds like glutathione in the body. Patients with kwashiorkor were found to have low levels of antioxidants (superoxide dismutase enzymes and glutathione peroxidase), vitamins A, E, C and carotene, which point to micronutrient deficiencies. After the introduction of the WHO Therapeutic Guidelines in 1999, fatalities from kwashiorkor were reduced to as low as 5%. However, a subsequent study using antioxidant supplements containing riboflavin, vitamin E, selenium and N-acetylcysteine, could not prove that these antioxidants were able to prevent kwashiorkor. Most experts in this field presently agree that, “The etiology of kwashiorkor remains an enigma, and is likely to be multifactorial and thus excludes one simple uniform preventive and therapeutic approach.” ^{1, 2}

Currently infections (gastro-enteritis, HIV, measles, TB, malaria, pneumonia) are being recognized as crucial precipitating factors in kwashiorkor.

Breast-fed 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 and moves on to an inadequate diet (thin porridges, gruels, and weak tea) kwashiorkor may develop. The situation is exacerbated where disease is rife and sanitation is poor. One of the most important factors which determine how an infant reacts to exposure to environmental contaminants is its ability to resist pathogens. A healthy, breast-fed baby has an intact immune system, adequate stomach acid, intestinal motility and normal intestinal flora (colonies of beneficial microorganisms such as Bifidobacteria and Lactobacilli) and will be able to better resist pathogenic organisms in its environment (contaminated water and feeds, unhygienic utensils). Such infants are less susceptible to infections like measles, TB, HIV, pneumonia, and gastro-enteritis.²

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, such as informal settlements and refugee camps.³ Some researchers have found no relation between the rate at which children recovered from kwashiorkor and the rate of re-feeding.²

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
• Aflatoxin (toxins produced by 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 or maize 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 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 exposed to the greatest risk of developing kwashiorkor, especially if:

• They have recently stopped drinking breast milk, and their diet consists largely of carbohydrates (gruels and porridges).
• 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 compromised due to starvation or disease (HIV and/or TB).
• Diarrhoea and dehydration are present.

Symptoms and signs of kwashiorkor

Early symptoms of kwashiorkor are fairly non-specific. Such children are underweight for their 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 slack 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 burn wounds. These children are often anaemic and have heavy worm infestations. Diarrhoea is frequently present.

Because of impaired immunity these children are also prone to infections such as TB, gastro-enteritis, pneumonia, HIV, measles 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.

One of the most useful aids to diagnosis which can easily be applied, is measurement of the Mid Upper Arm Circumference (MUAC), which was introduced by the WHO and UNICEF in 2009 to identify stunting in children. Stunting has been recognized as “the most prevalent form of nutrient deficit and strongly associated with periods of sustained poverty and monotonous protein poor diets”.² In 1999, the National Food Consumption Survey found that stunting occurred in 1 out of 5 South African children aged 1 to 9 years.⁴

Can kwashiorkor be prevented?

Kwashiorkor is preventable by the provision of a balanced diet, adequate housing, accessible clean, safe water and proper sanitation together with economic upliftment and prevention of infection. Public education to teach mothers how to improve their children’s diets, apply basic hygiene and utilise monitoring and preventive programmes made available by the Department of Health, is important to ensure that children do not develop kwashiorkor and subsequent stunting.

In order to grow normally and to remain healthy, a child will need 330-500 kJ/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. Generally, the lower the fat intake, the better.

Vitamin and mineral 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 may be impossible in many developing countries where the disease is most prevalent.

Treatment will depend on the severity of the condition.

Shock, dehydration and infections have to be treated first.

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

Milk formula only is given for the first five to seven days. An acidified formula is currently favoured. 340 kJ/kg/day are given for the first three days; 420 kJ/kg/day for the next three days and then 630-840 kJ/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 lactose, 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 and mineral supplements must be given for a number of months.

Anaemia is treated with an iron tonic when the child is in the recovery phase. Iron may increase the oxidation of glutathione and is, therefore, not given during the first phase of therapy. ²

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 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. Mortality statistics for South Africa reported 820 deaths from kwashiorkor in 2004.⁵ Despite the fact that the incidence of kwashiorkor has fallen in recent years⁶, a study conducted in Kenya found that 51% of hospital deaths of children between the ages of 6 months and 5 years, could still be attributed to malnutrition.⁷

Children under seven months of age who develop severe kwashiorkor may also suffer 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, and programmes to prevent infectious diseases, can assist in the long-term prevention of kwashiorkor.

 Reviewed by Dr I van Heerden, Nutrition Consultant & Scientific Editor, DietDoc, 16 July 2010.

 References

1. Ahmed T et al (2009). Oedematous malnutrition. Indian J Med Res, 130(5):651-4.

 2. Heikens GT, Manary M (2009). 75 years of kwashiorkor in Africa. Malawi Med J, 21(3):96-100.

 3. Labadarios D et al (2009). Executive summary of the National Food Consumption Survey Fortification Baseline (NFCS-FB-I), South Africa, 2005. S Afr J Clin Nutr, 21(3)(Suppl):245-300.

 4. Lowenstein FW (1962). An epidemic of kwashiorkor in the South Kasai, Congo. WHO Bulletin, 27: 751-758.

 5. NationMaster.com (2010). Mortality statistics > Kwashiorkor (most recent) by country, Jan 2004.

 6. Oyelami OA, Ogunlesi TA (2007). Kwashiorkor - is it a dying disease? S Afr Med J, 97:65-68.

 7. Bejon P et al (2008). Fraction of all hospital admissions and deaths attributable to malnutrition among children in rural Kenya. Am J Clin Nutr, 88(6):1626-31.