Description

• Kwashiorkor is characterized by hypoproteinemia, pitting edema, varying degrees of wasting and/or stunting, dermatosis, and fatty infiltration of the liver.
• Protein-energy malnutrition (PEM) results when the body’s protein and energy requirements are not adequately met.
  • Primary:
    • Inadequate dietary intake
  • Secondary:
    • Result of other disease processes that limit food ingestion or reduce nutrient absorption, or that increase nutrient requirements or losses
  • Marasmic Kwashiorkor:
    • Combined edema and emaciation associated with acute or chronic protein deficiency and chronic energy deficit.
• Kwashiorkor was classically described in the mid-1930s by Cicely Williams in her observations of the GA tribe in the Gold Coase (currently Ghana). “Kwashiorkor” is the GA term for “the disease the deposed baby gets when the next one is born.”

Epidemiology

• Malnutrition underlies 55% of childhood mortality worldwide.
• Kwashiorkor may occur at any age, but is seen most frequently in children 1–3 years of age.

Etiology

• Children have relatively high energy and protein requirements per kilogram of body weight.
• Inappropriate use of infant formula or the introduction of bulky carbohydrate-based staple foods which are low in energy density, protein and fat content may lead to PEM.
• Food scarcity from drought or other natural disasters, war or civil disturbance may lead to PEM.
• Aflatoxin poisoning from the fungus Aspergillus flavus has been implicated in the etiology of Kwashiorkor. Aflatoxin concentration has been found to be elevated in the blood and liver of children with Kwashiorkor. Aflatoxins may appear in breast milk.
• Further investigations have shown an association between selenium deficiency and congestive heart failure in Kwashiorkor.

Other

Pathophysiology of PEM by Systems

• Temperature regulation is impaired, leading to hypothermia in a cold environment and hyperthermia in a hot environment.
• Fluid and electrolytes:
  • Increase in total-body sodium and decrease in total-body potassium
  • Increased cell membrane permeability in Kwashiorkor leads to increased intracellular sodium and decreased intracellular potassium.
  • Increased intracellular sodium is accompanied by increased cellular water.
• Hypophosphatemia is associated with malnutrition and results in high mortality.
• Liver:
  • Protein synthesis is reduced; particularly albumin, transferrin and apolipoprotein B.
  • Hypoalbuminemia reduces colloid osmotic pressure, leading to edema.
  • Hypertriglyceridemia leads to fatty infiltration of the liver.
• Gluconeogenesis is reduced which increases risk of hypoglycemia during infection.
• Cardiovascular system:
  • Pericardial effusion may be present in Kwashiorkor.
  • Reduced cardiac output leads to compromised tissue perfusion and a reduction in renal blood flow and glomerular filtration rate.
  • Increase in ferritin stimulates release of antidiuretic hormone and subsequent fluid retention.
• Respiratory system:
  • Reduced muscle mass affects respiratory muscles, such as the diaphragm, and reduces pulmonary function.
  • Respiratory muscle weakness may be exacerbated by hypophosphatemia and hypokalemia.
• GI system:
  • Reduction of gastric acid, intestinal motility and pancreatic digestive enzymes
  • Intestinal mucosa is atrophied resulting in malabsorption
• Endocrine system:
  • Insulin secretion is reduced.
  • Growth hormone secretion is increased while somatomedin activity is reduced.
  • Glucagon, epinephrine and cortisol levels are increased.
  • Increased epinephrine, growth hormone and corticosteroids leads to lipolysis, an increase in free fatty acid concentration and increased peripheral insulin resistance.
• Immune system:
  • All aspects of immune function are deminished in malnutrition.