History and exam

Key diagnostic factors

common

history of famine or monotonous diet

Kwashiorkor occurs in young children living in areas with endemic food insecurity or famine. The prevalence varies by geographic area, with reported levels of severe malnutrition ranging from 6% in chronic food-insecure communities to 25% of young children in areas facing famine.[4][5][6]

It is also most common in populations with a monotonous staple providing most of the dietary intake.[20] Maize and cassava are most commonly cited. However, kwashiorkor is not found in all populations where this diet is consumed and can occur in populations with more varied diets.[31]

child <5 years of age and living in rural community

Children under 5 years of age are most at risk of kwashiorkor and those from rural communities, particularly nonpastoral subsistence farming areas without cattle, are more likely to present with kwashiorkor than other children.[11][13]

low weight for height, low height for age, or a low mid-upper arm circumference (MUAC)

A number of classifications are in use. The World Health Organization (WHO) definition is a weight for height z-score of <-2 or MUAC <12.5 cm (wasting) or height for age z-score of <-2 (stunting).[1]

bilateral pitting edema

Kwashiorkor edema starts in the feet and develops over a few days. Elicited by pressing firmly on the dorsum on both feet with the thumb for 3 seconds, and a pitting impression remaining. Edema is graded + if confined to the foot and lower anterior shin; ++ if also extending but restricted to the lower legs, or the hands or lower arms; and +++ if generalized including feet, hands, arms, and face. [Figure caption and citation for the preceding image starts]: Nigerian civil war refugee showing manifestations (swollen feet, thin and shiny skin over knees) of kwashiorkor.From CDC Public Health Image Library/ Dr Lyle Conrad, 1968 [Citation ends].com.bmj.content.model.Caption@1cd4e1f

Other diagnostic factors

common

hair discoloration

Hair becomes thin, sparse, easily pulled out, and black hair often turns orange or reddish-brown in color.

dermatosis/ulceration

Classically seen as hyperpigmentation; begins as spots that become hard and scaly and then fuse, followed by desquamation and cracking of the skin. Also presents as dry, thin, shiny, or wrinkled skin because of atrophy of the basal layers of the epidermis with hyperkeratosis.

Ulcerations in the genital and perianal regions, in body creases, and on exposed surfaces.[Figure caption and citation for the preceding image starts]: Nigerian civil war refugee showing manifestations (swollen feet, thin and shiny skin over knees) of kwashiorkor.From CDC Public Health Image Library/ Dr Lyle Conrad, 1968 [Citation ends].com.bmj.content.model.Caption@214a296f

uncommon

apathy and reluctance to feed

Refusing to eat when spoon-fed and general lethargy are often connected to concomitant infection or are a response to maternal deprivation.

hypothermia

Hypothermia in children with kwashiorkor occurs occasionally.

oral candida

White plaques on tongue or hard palate. Occurs occasionally; particularly seen with concomitant HIV infection.

xerophthalmia

Dry eyes, thickened conjunctiva, and failure to produce tears can result in corneal ulceration and blindness. This is because of vitamin A deficiency and may be seen in children with kwashiorkor.[44]

pallor

Features of anemia may be present, such as pale conjunctiva and pale mucous membranes. Malnourished children often have a low hemoglobin, typically 8-10 g/dL.

poor hydration

Level of hydration should be recorded. Dehydration is overestimated and over-diagnosed in malnourished children. However, in severe cases, the pulse rate may be rapid with a poor urine output; the child may be thirsty and lethargic, with a skin pinch slow to return, absent tears, and dry eyes and mouth.

fever

This may be present with concurrent infection. Common sources include gastrointestinal, chest, and urinary sepsis. However, malnourished children may not display fever in the presence of infection.

irritability

Tendency to cry frequently, lack of interest in other people relate to early psychological effects.

Risk factors

strong

endemic food insecurity or famine

Kwashiorkor is almost never seen in the developed world, unless there is a severely restricted diet, for example due to severe autism or other behavioral/developmental factors.[3] Widespread in sub-Saharan Africa and common in Southeast Asia and Central America, kwashiorkor occurs in young children living in areas with endemic food insecurity or famine. The prevalence varies by geographic area, with reported levels of severe malnutrition ranging from 6% in chronic food-insecure communities to 25% of young children in areas facing famine.[4][5][6]

rural communities

Children from rural communities, particularly those from nonpastoral subsistence farming areas without cattle, are more likely to present with kwashiorkor than other children.[11][13]

<5 years of age

Children under 5 years of age are most at risk of kwashiorkor, and when it presents in older children there is usually an underlying illness present, particularly HIV or tuberculosis infection.

monotonous diet based on maize or cassava

Kwashiorkor is most common in populations with a monotonous staple providing most of the dietary intake.[20] Maize and cassava are most commonly cited. However, kwashiorkor is not found in all populations where this diet is consumed and can occur in populations with more varied diets.[31]

Studies of the diet of children presenting with kwashiorkor and local age-matched controls have not consistently shown any specific food to be responsible.[32][33]

weak

dietary protein deficiency

The dietary protein content is often low; however, recovery from edema occurs even without significant increase in protein intake.[19] High protein intake in an acutely edematous child is associated with increased mortality, as the liver cannot deal with the metabolic consequences of processing additional protein.

HIV infection

In areas where HIV is prevalent, increasing numbers of children outside the usual age group are presenting with kwashiorkor. These include young infants still breastfeeding and children over 5 years of age. There is no evidence HIV is a direct cause, but it is associated with poverty, and predisposes to oral pathology, persistent diarrhea, enteropathy, malabsorption, and overgrowth of bowel flora.[25]

tuberculosis (TB) nfection

Underlying TB is more common when children over the age of 5 years present with kwashiorkor. TB may present as kwashiorkor that is unresponsive to the usual therapeutic interventions, particularly in older children, and should be considered in such patients.

measles infection

Measles is temporally associated with kwashiorkor and is associated with xerophthalmia. Both measles and kwashiorkor outcomes are improved with vitamin A supplementation, but a causal relationship has not been proven.

diarrhea

Children presenting with kwashiorkor often give a history of recent diarrhea, and this may be the event that precipitates edema in a vulnerable child.

weaning off the breast

Classically in Africa many children present around the time of weaning.[20] The quality of the diet is reduced, diarrheal disease is common, and potential exposure to toxins is increased while levels of antioxidants usually supplied in breast milk are reduced. It is unusual for a breastfed child to present with kwashiorkor unless underlying illness is present.

exposure to free radicals

Damage by free radicals may be because of increased exposure (e.g., free iron, toxins, or overgrowth of small intestinal bowel flora).[34] Free iron levels are elevated in kwashiorkor and have been associated with severity of edema.[35] Administration of iron to children with kwashiorkor may be associated with increased mortality, but there is no evidence that iron supplementation at community level is associated with an increased incidence of kwashiorkor.

antioxidant deficiency

Although giving antioxidants such as vitamin A is associated with reduced mortality in kwashiorkor, and xerophthalmia is a well-recognized complication, the only study of community antioxidant supplementation did not reduce the incidence of kwashiorkor.[24]

aflatoxin poisoning

Aflatoxins (found in poorly stored groundnuts) cause a similar liver pathology in chickens, and levels are higher in the blood of children with kwashiorkor. In addition, mothers of affected children have been found to have higher levels in breast milk samples. However, it is unclear whether elevated levels are because of poor detoxification and clearance. Kwashiorkor does occur in children without significant aflatoxin or other fungal toxin exposure, and is rare in some populations (e.g., the Gambia) where exposure to aflatoxin is present.[16][17][18][36][37]

incomplete immunization

This may predispose to infection, especially measles.

poor social or economic conditions

Uncertain family status such as parental death, not living with a parent, unmarried caretaker, young age of mother, living in a temporary home, or parents not owning land have also been suggested as contributing factors but remain unproven.[11][13]

cerebral palsy

Cerebral palsy is a recognized cause for restricted diet and subsequent predisposition to kwashiorkor and marasmus.[38]

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