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Protein- Energy Malnutrition: Marasmus And Kwashiokor, Clinical Presentations, Pathology And Treatment

Physical Presentation Of Kwashiorkor


A General Overview

Protein-energy malnutrition (PEM) has been defined by WHO and FAO (1973) as a range of pathological conditions arising from coincident lack of protein and calories in varying proportions occurring most frequently in infants and young children and commonly associated with infections.

The clinical spectrum includes a variety of clinical syndromes, with ‘marasmuc’ and ‘kwashiorkor’ at the two extremes and the intermediate forms (marasmic kwashiorkor) and nutritional dwarfism in between. Mild cases may present only with apathy and retardation of growth. Childhood malnutrition has been graded taking the weight for age as the criteria.

Grades Of PEM

Grades% weight to the reference standard (Harvard)


71 to 80%


61 to 70%


51 to 60%


50% and below

Etiology And Pathogenesis: Protein energy malnutrition is an environmental disease, caused by deficient intake of protein and calories. It results from the combined influences of low food availability, poverty, ignorance, illiteracy and cultural taboos, frequent infections and poor environmental sanitation.

Physical Presentations Of Marasmus


The Flag Sign On The Hair



Clinical Presentations

Severe restriction of food in an infant as in cases of gross inadequacy of breast milk leads to arrest of growth. Due to starvation, the subcutaneous fat and muscles are used up as energy sources. The baby becomes emaciated. Unlike as in kwashiorkor, there is no edema. Loss of the buccal pads of fats give the infant a withered and ‘old man’s’ look. The weight is below the sixtieth percentile. The height depends upon the onset and duration of under nutrition.In the early stages, the infant eats well but appetite is lost as the condition progresses. Initially, inadequacy of food leads to constipation but later on diarrhea sets in with green stools containing mucus. In the well established form, the baby is apathetic. Moderate anemia may develop. The skin and hair are usually normal.

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Kwashiorkor: This name was coined by Dr. Cicely Williams in 1933, to denote ‘disease of the child deposed from the breast by the conception of a new fetus’. Children between the ages of 1 and 3 years are affected more. The disease starts when the baby is weaned from the breast.

Pathology: Main changes are seen in the small intestines, liver, pancreas and thymus. Small intestinal mucosa shows blunting of villi and atrophy of brush border, so that the columnar epithelium appears to become cuboidal. The total absorbing surface if reduced. Lactose intolerance is common because of disacchraridase deficiency. Liver shows fatty infiltration of the parenchymal cells. The pancreatic acini are atrophic and enzyme activity is reduced. Thymus is markedly atrophied and this may contribute to deficiency of cell mediated immunity.

Clinical features: The child is stunted and skeletal muscles are wasted. The presence of fairly normal amounts of subcutaneous fat and edema give a deceptively plump appearance. Pitting edema is a prominent feature. The child is apathetic, irritable and drowsy. Characteristic skin changes occurs in many and when present; these are diagnostic. These include ‘flaky paint’ dermatosis seen over areas of pressure and trauma, fissuring and ulceration at the flexures and a mosaic like appearance (crazy pavement appearance). The hair becomes thin, sparse, brownish and lusterless. They may fall off. Regrowth of normal pigmented hair heralds nutritional recovery. Since periods of nutritional deprivation and partial correction of nutrition alternate in many cases, the hair shows alternate bands of pigmentation and depigmentation (flag sign). The appetite is poor. Diarrhea is a frequent feature. There may be concomitant deficiencies of iron, folate, fat soluble vitamins and B complex factors. Hepatomegaly occurs in a third of the cases. This is due to fatty infiltration. With recovery, the liver reverts to normal without sequelae.

© 2014 Funom Theophilus Makama

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