Pediatrics

Pediatric Malnutrition Syndromes: Kwashiorkor

OVERVIEW: What every practitioner needs to know

Are you sure your patient has Kwashiorkor? What are the typical findings for this disease?

Kwashiorkor is a form of protein energy malnutrition commonly seen in poor countries where there is famine or a limited food supply. It is also seen in those with low socioeconomic status and low levels of education, as this population may not understand the importance of a proper diet. A child with Kwashiorkor will have the appearance of muscle atrophy with normal or increased body fat. This condition is due to inadequate protein intake, mostly due to anorexia.

The clinical findings in Kwashiorkor generally depend on the degree of malnutrition and are assessed using anthropometric measurements. Findings can range from normal to near normal weight and height for age to linear stunting. Those affected will have protuberant abdomens secondary to anasarca. Periorbital and lower extremity edema are also present due to inadequate protein stores. Dermatitis with dry and peeling skin and hypopigmented hair can be a result of the protein malnutrition. In severe cases, hepatomegaly can occur due to decreased production of lipoprotein.

  1. Failure to thrive with edema

  2. Anasarca

  3. Muscle atrophy with normal or increased body fat

What other disease/condition shares some of these symptoms?

Neglect, child abuse

Mixed Marasmus/Kwashiorkor condition

What caused Kwashiorkor to develop at this time?

  • The key factor in developing this state is simply a lack of calories. This may be due to inadequate intake or the inability to absorb calories.

  • Predisposition to developing this type of protein energy malnutrition is living in an impoverished environment and not having access to adequate nutrition.

  • More commonly seen in developing countries or in those with low socioeconomic statuses.

  • Can be due to severe gastrointestinal infections that cause diarrhea, vomiting, increased metabolic demands, and/or decreased intestinal absorption.

  • When protein intake is inadequate, especially albumin and apolipoprotein, and hypoproteinemia develops there is leaking of the vessels secondary to decreased colloid osmotic pressure leading to edema.

What laboratory studies should you request to help confirm the diagnosis of Kwashiorkor? How should you interpret the results?

  • Complete Metabolic Profile (CMP): shows low albumin and low total protein; rule out hypoglycemia; rule out hyponatremia; rule out hyperkalemia.

  • Prealbumin: marker for severity of malnutrition.

  • Complete Blood Count (CBC) with differential: monitor leukocytosis, as those children who are severely malnourished are more susceptible to acquiring infections. Rule out nutritional anemia (iron deficiency, folate/B12 deficiency) or anemia due to chronic blood loss.

Would imaging studies be helpful? If so, which ones?

If hepatomegaly is found on physical exam, an abdominal ultrasound may be indicated. It is low in cost and doesn't require exposure to radiation, and will provide an initial assessment of the hepatic anatomy.

If you are able to confirm that the patient has Kwashiorkor, what treatment should be initiated?

There are three phases of treatment for Kwashiorkor: initial management, rehabilitation, and long-term follow up.

The initial phase spans the first 10 days or so of therapy. You must correct for fluid and electrolyte imbalances with oral or IV hydration. Careful attention should be paid to ongoing fluid losses from malabsorption. Any infections must be properly treated. Those susceptible to infection can succumb to septic shock. In this circumstance, the child will require immediate intervention with fluid resuscitation to maintain blood pressure, aggressive antibiotic therapy, meticulous monitoring of cardiovascular, respiratory renal and CNS status.

The rehabilitation phase spans the next 2-6 weeks. This phase is when the child is beginning to eat well and is no longer malabsorbing. This is the time to start reintroducing nutritious foods. It is important to provide a gradual increase in the daily caloric content, as well as increased protein intake. When starting a balanced diet, it is very important to reintroduce foods slowly, as these children are in danger of the refeeding syndrome. Calories should be increased gradually. It is recommended that the patient's caloric intake should be increased by only about 25 kcal/kg/day every other day initially. Supplement vitamins and minerals at this time, as these levels will also be deficient.

A multidisciplinary approach involving the pediatrician, nutritional services, and psychosocial services is optimal, as many patients will have emotional pain from the malnutrition. A child psychologist should monitor the child closely. Encouraging signs of recovery include return of appetite, decreased apathy, and improved social functioning.

The follow up phase involves close monitoring of the child and attention to routine health care maintenance over the subsequent weeks and months. Though treatment cures the acute symptoms, catch up linear growth may never be fully achieved.

What are the adverse effects associated with each treatment option?

When reintroducing a balanced diet, the patient is at risk for refeeding syndrome if the diet is advanced too rapidly. Findings in refeeding syndrome include acute imbalances in fluid and electrolyte status, including fluid overload or dehydration, hypophosphatemia, hypokalemia, hypomagnesia, and hypoglycemia. Weakness and paresthesias may be seen due to the electrolye abnormalities or vitamin deficiencies.

What are the possible outcomes of Kwashiorkor?

Unfortunately, even if the diet is corrected, most children will be unable to reach their full height and growth potential. But, diet correction will improve their overall general health. If this malnutritive state has occurred for an extended period of time, it can result in psychological and physical impairment.

If families are committed to a long term interdisciplinary treatment, a positive prognosis is expected. However, if this state of malnutrition remains untreated, it can eventually result in death.

What causes this disease and how frequent is it?

  • Kwashiorkor can occur at any age, but it most common in children of preschool age. Malnutrition states are an underlying cause of approximately 55% of childhood mortality worldwide.

  • Can also occur in impoverished areas where there is an inability to obtain adequate food stores.

  • Not as common in developed countries, but can occur in lower socioeconomic families due to lack of food resources. Must always consider abuse and severe neglect as a cause in these areas.

How do these pathogens/genes/exposures cause the disease?

N/A

Other clinical manifestations that might help with diagnosis and management

Anemia

Hypoglycemia

Prolonged episodes of diarrhea

Reduced muscle mass

Apathy, flat affect

What complications might you expect from the disease or treatment of the disease?

Those in a severe malnutrition state are susceptible to infections and sepsis due to an inability to mount a normal robust inflammatory response. The febrile response can be reduced. Overwhelming sepsis leading to shock and death is a risk in the severely affected patient.

Electrolyte imbalances are very common in this setting. The most commonly seen imbalances are hypernatremia with hypokalemia. If hypokalemia is severe, it can result in decreased cardiac contractility, as well as hypotonia.

When reintroducing feeds, children may develop refeeding syndrome.

Are additional laboratory studies available; even some that are not widely available?

N/A

How can Kwashiorkor be prevented?

In patients who are critically ill from any cause, early introduction of enteral feedings can significantly reduce the risk of malnutrition.

Adequate immunizations to reduce infections is important, as infections contribute to malnutrition.

Well balanced diet with adequate protein intake and vitamin supplementation.

Ensuring proper food supplies are available in war torn nations or in countries susceptible to famine.

What is the evidence?

http://clinicaltrials.gov/ct/show/NCT00069134.

(A current study at Baylor College of Medicine that is undergoing trial in treating malnourished children with antioxidants to help recover their organs from the damage that occurred.)

Penny, ME, Walker, WA, Watkins, JB, Duggan, C. "Nutrition in Pediatrics". BC Decker. 2003.

Ongoing controversies regarding etiology, diagnosis, treatment

Though it has been established that the cause of Kwashiorkor is lack of protein, the pathophysiology is not completely understood. While it is known that infections also play a role in malnutrition, the consequence of these infections has not been completely resolved. There is a current study at Baylor College of Medicine that is undergoing trial in treating malnourished children with antioxidants to help recover their organs from the damage that occurred.

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