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Table of Contents



a. Definition3
b. Epidemiology..4
c. How to make diagnosis...4
d. Treatment5
e. Prevention...6


a. Definition6
b. Epidemiology..7
c. Treatment.8
d. Prevention...10

Correlation between kwashiorkor and marasmus...10




Kwashiorkor and marasmus are protein-energy malnutrition (PEM), which affects children in
south Asia and sub-Saharan Africa with high incidence.

Low body weight, edema in the abdomen and lower extremities, and dermatitis with
depigmentation of the skin are characteristic of kwashiorkor. In addition to the signs and
symptoms noted in this child, kwashiorkor also manifests with anorexia, irritability,
hepatomegaly (enlarged liver), resulting from fatty infiltrates in the liver, and an inability to
produce antibodies when challenged with an infection, or a vaccine. From the Ga language of
the Ghana coast, the name Kwashiorkor was introduced to western medicine by Cicely
Williams, a Jamaican pediatrician and means something along the lines of "a disease that
develops in a child after a new baby is born". This refers to weaning of an older child from
breast milk to allow a baby sibling to nurse. At this point, the older child is put on a diet that
is both reduced in calories and almost entirely carbohydrates, or has a protein source that is
incomplete (does not include all of the essential amino acids).

Kwashiorkor and marasmus are different types of protein-energy malnutrition (PEM), which
affects children in south Asia and sub-Saharan Africa with an incidence of more than 50
percent and 30 percent, respectively, with notable rises in Africa since 1990, though globally
the incidence of PEM has decreased. Marasmus, which tends to develop in dryer climates, is
characterized by emaciation resulting from a deficiency in total calories, which is to say in all
nutrients. Kwashiorkor initially was thought to result mostly from protein deficiency in
particular. However, it now is thought that deficiencies of certain antioxidants such as
glutathione, vitamin E, selenium, and polyunsaturated fatty acids must play a role, along with
deficiencies in other micronutrients such as vitamin C, folic acid, iodine, and iron. Thus,
several of the symptoms noted in PEM overlap with symptoms exhibited in deficiencies of
individual micronutrients. For instance, niacin (vitamin B3) deficiency alone leads to pellagra
which manifests as aggression, dermatitis, weakness, mental confusion, insomnia, and
diarrhea. Ultimately, dementia and death can result. Thus, symptoms can be remembered in
terms of the "four Ds" which are diarrhea, dermatitis, dementia, and death. Deficiency of
pyridoxine, which is vitamin B6, results in microcytic anemia due to a deficiency in heme
synthesis, while deficiency of vitamin C causes scurvy. Once known as the sailor's disease in

the past, scurvy presents with spongy gums, bleeding from all mucous membranes, and
frequent bruising and results from disruption of the manufacture of collagen.



"Kwashiorkor" is the name given to the protein-calorie malnutrition that is so common in

early childhood throughout the tropics. It is characterized by edema and failure to thrive,
depigmentation, hyperkeratosis, and red hair. Some authors have translated "kwashiorkor" as
meaning "the red boy" or "red-haired boy" in the Ga language of the Accra region (Ghana).
Recent discussions with physicians in Kumasi (P.E.S.P. 1998) show that it does not literally
mean "red hair." It is a Ga word which describes the malnourished child, the result of the ill-
health which develops when an infant is weaned from breast-feeding (which may be at about
2 years of age). When a sibling is born and monopolizes breast feeding, the "weanling" or
deposed child may develop kwashiorkor, an all-embracing word for the clinical syndrome of
malnourishment in which reddening of the child's hair is but a part. While this name was first
used in West Africa, kwashiorkor is seen throughout Africa, Asia, and the tropics, but it
varies considerably. Everywhere it is a complex pattern of malnutrition: in kwashiorkor the
diet is principally low in protein

Kwashiorkor is a state of malnutrition that results from a deficiency of dietary protein in the
presence of a normal or high carbohydrate intake. As indicated above, it must be
differentiated from marasmus, which occurs when the diet is of normal quality but
insufficient; the latter may be infantile, occurring before 1 year, or late, occurring in an older
child. Both patterns of malnutrition can develop together, resulting in marasmic-kwashiorkor;
there are varying definitions based on the different clinical stages.

Kwashiorkor is most common between the ages of 1 and 4 years, but can occur in infancy; it
is seen with equal frequency in both sexes. It may also occur in adult life, when it is almost
invariably a complication of some parasitic or other infection (e.g., strongyloidiasis). There
are many causes of kwashiorkor, but weaning is the major factor, when breast milk is
replaced by an inadequate and often unbalanced diet. Infants are most frequently affected in
times of famine, when their mother is also starved for protein. After the age of 1 year,
kwashiorkor may occur even when there is no food shortage, because tribal custom or

ignorance may not provide the right nutritional balance. Many children have managed to
maintain a barely adequate nutrition, which is then disturbed by illness, either an infection
such as tuberculosis or parasites such as hookworm or Ascaris. Even measles or a urinary
tract infection may be sufficient to tip the balance between good nutrition and malnutrition


Kwashiorkor is almost never seen in developed countries. 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. Children from rural
communities, particularly those from nonpastoral subsistence farming areas without cattle, are
more likely to present with kwashiorkor than other children. The typical age of presentation is
1 to 3 years, and kwashiorkor affects girls and boys equally. It remains a major problem in
food-insecure regions of the world.

How is the diagnosis made?

Physical examination may show an enlarged liver and generalised swelling (oedema).
Laboratory tests usually show the following significant findings in kwashiorkor.

Low blood sugar levels

Low blood protein levels
High levels of cortisol and growth hormone
Low levels of salts in the blood, especially potassium and magnesium
Reduced levels of the waste product urea in urine
Iron deficiency anaemia
Metabolic acidosis (low pH of blood)
Reduced hydroxyproline in the urine, reflecting poor growth and defective wound

Other tests include, detailed dietary history, growth measurements, body mass index (BMI)
and complete physical examination. Skin biopsy and hair-pull analysis may also be


Getting more calories and protein will correct kwashiorkor, if treatment is started early
enough. However, children who have had this condition will never reach their full potential
for height and growth.Treatment depends on the severity of the condition. People who are in
shock need immediate treatment to restore blood volume and maintain blood pressure.

Calories are given first in the form of carbohydrates, simple sugars, and fats. Proteins are
started after other sources of calories have already provided energy. Vitamin and mineral
supplements are essential. Since the person will have been without much food for a long
period of time, eating can cause problems, especially if the calories are too high at first. Food
must be reintroduced slowly. Carbohydrates are given first to supply energy, followed by
protein foods.

Many malnourished children will develop intolerance to milk sugar (lactose intolerance).
They will need to be given supplements with the enzyme lactase so that they can tolerate milk

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.


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 childrens 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

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.



Marasmus is a condition which results in- apathy, withdrawal from normal routines,
emaciation from a lack of protein nutrition and if marasmus isn't treated effectively the
physiological and psychological development of the individual can become depressed and
even stop wholly.

Marasmus is one of the 3 forms of serious protein-energy malnutrition (PEM). The other 2
forms are kwashiorkor (KW) and marasmic KW. These forms of serious PEM represent a
group of pathologic conditions associated with a nutritional and energy deficit occurring
mainly in young children from developing countries at the time of weaning. Marasmus is a
condition primarily caused by a deficiency in calories and energy, whereas kwashiorkor
indicates an associated protein deficiency, resulting in an edematous appearance. Marasmic
kwashiorkor indicates that, in practice, separating these entities conclusively is difficult; this
term indicates a condition that has features of both

These conditions are frequently associated with infections, mainly GI. The reasons for a
progression of nutritional deficit into marasmus rather than kwashiorkor are unclear and

cannot be solely explained by the composition of the deficient diet (ie, a diet deficient in
energy for marasmus and a diet deficient in protein for kwashiorkor). The study of these
phenomena is considerably limited by the lack of an appropriate animal model. Unfortunately,
many authors combine these entities into one, thus precluding a better understanding of the
differences between these clinical conditions.


Marasmus is a serious worldwide problem that involves more than 50 million children
younger than 5 years. According to the World Health Organization (WHO), 49% of the 10.4
million deaths occurring in children younger than 5 years in developing countries are
associated with PEM.

Malnutrition hotspot map. Image courtesy of the World Health Organization (WHO) and United
Nations Children's Fund (UNICEF).

Malnutrition has been a permanent priority of the WHO for decades. Although a higher
proportion of severely malnourished children do not survive a significant intercurrent illness,
as much as 80% of the overall, unacceptably high, mortality rate may be contributed by mild-
to-moderately malnourished children because this cohort is so much higher. Accordingly,
newer strategies need not be limited to only severely malnourished children.

Although PEM occurs more frequently in low-income countries, numerous children from
higher-income countries are also affected, including children from large urban areas and of
low socioeconomic status, children with chronic disease, and children who are
institutionalized. Recently, studies of hospitalized children from developed countries have
demonstrated an increased risk for PEM. Risk factors include a primary diagnosis of mental
retardation, cystic fibrosis, malignancy, cardiovascular disease, end stage renal disease,
oncologic disease, genetic disease, neurological disease, multiple diagnoses, PICU admission,
or prolonged hospitalization. In these conditions, the challenging nutritional management is
often overlooked and underestimated, resulting in an impairment of the chances for recovery
and the worsening of an already precarious neurodevelopmental situation.

PEM results in not only high mortality (even for hospitalized children), without any
improvement over the last 2 decades, and also results in morbidity, stunted linear growth, and
compromised neurological development. The social and economic implications of PEM and
its complications are incalculable.


Mortality of hospitalized children with marasmus is high, especially during the first few days
of rehabilitation. Death is usually caused by infections (ie, diarrhea and dehydration,
pneumonia, gram-negative sepsis, malaria, urinary infection) or other causes (ie, heart failure
associated with anemia, excess of rehydration solution, or excess of proteins in the first days
of treatment; hypothermia; hypoglycemia; hypokalemia; hypophosphatemia). Mortality rates
can vary from less than 5% to more than 50% of children, depending on the quality of care.

Infectious complications: Every hospitalized child with marasmus should be

considered as having a bacterial infection. Treatment of bacterial infections prevents
the development of septic shock, improves the response to nutritional rehabilitation,
and decreases mortality. If the child has no clinical sign of infection, the WHO

recommends 5 days of oral cotrimoxazole therapy. If the child presents with clinical
signs of infection, hypoglycemia, or hypothermia (that does not rapidly respond to the
kangaroo position), he or she must be considered as seriously infected and treated with
parenteral ampicillin and gentamicin. If the child does not improve rapidly,
chloramphenicol should be added. Antimalaria treatment is also indicated in endemic
areas, either orally, by injection, or intrarectal.
Other complications
o Severe and symptomatic anemia (< 4 g/100 mL) with signs of heart failure
should be treated with a blood transfusion of packed red cells to a maximum of
10 mL/kg administered over at least 3 hours. Cardiovascular tolerance should
be closely monitored. The benefit of blood transfusion must be balanced with
the risks of cardiovascular failure and the risk of infection (eg, hepatitis, HIV)
associated with blood transfusion.
o Practice guidelines for acute diarrhea have been established.[23] Persistent and
profuse diarrhea has 2 main causes.
Infectious etiology (especially lambliasis): This can be promptly
treated with metronidazole if possible, after stool examination.
Osmotic diarrhea: Sugar of the F75 solution should be replaced by
cereal flour for 1-2 weeks.
o Vitamin A deficiency is always present and should be treated in the first few
days. Vitamin A replacement facilitates recovery from diarrhea, measles, and
respiratory diseases and decreases the risk of blindness.
o Lactose intolerance is unusual and often secondary to prolonged diarrhea. If, as
dairy products are restarted, diarrhea persists despite antiparasitic treatment
and nutritional rehabilitation, a transient lactose intolerance is possible,
especially if stools have a low pH and if the child presents with a perianal skin
inflammation (diaper rash). In case of lactose intolerance, milk should be
withheld and yogurt or a commercially available lactose-free formula can be

It is important to prevent Diarrhea to avoid this condition. The treatment options for
Marasmus are greatly effective. However, they do not last long until healthy practices are
implemented in a consistent manner.

Some of the general measures that can be used to prevent Marasmus include:

Following a well-balanced diet

A good, well-balanced diet comprising of the essential minerals and vitamins can help prevent
most disorders related with malnutrition. A diet comprising of foods rich in protein, such as
skimmed milk, fish and eggs, can supply kids with enough energy for activities and growth.
Vegetables and fruits can restore the deficiencies caused by vitamins and minerals. It is
essential to add solid foods slowly and over a period of time to avoid adverse complications
arising due to poor digestive capability of sufferers.

Cooking foods at a high heat

It is essential to cook foods to a high temperature while preparing them. This will help destroy
the bacteria present in them and help avoid cases of infections.

Store foods in a clean place

It is also important to store foods in a freezer so as to prevent the development of bacteria.

Food items that are kept refrigerated should be heated again before consumption in future. All
utensils should be thoroughly cleaned before keeping foods in them. Cross-contamination
between various foods should always be avoided.

In developing nations, it is also important to educate mothers about the benefits of

breastfeeding and advice them to feed children with breast milk for as long as they can.

Correlation between kwashiorkor and marasmus

Kwashiorkor and marasmus describe particular kinds of malnutrition. In the case of

kwashiorkor, children experience acute protein-calorie malnutrition. In other words they are

not getting enough protein in their diet which they would use to build and restore tissue in the

This then leads to 'edema' which is the accumulation of fluids in the tissue and particularly the
feet (pedal edema) and legs leading to swelling in those areas. Distension of the stomach is
also commonly observed. Here the children will not necessarily lose weight, because the fluid
counterbalances that lost in fat and muscle tissue they may then look fat or swollen despite
their malnutrition.

In marasmus the children develop thinness but not oedema and the causes are not entirely
understood. In some cases it is possible to experience elements of both (marasmic-
kwashiorkor). Kwashiorkor and marasmus are both potentially life threatening conditions and
require feeding programmes promptly to restore their health.


There are more differences and distinctions between kwashiorkor and marasmus. Both are
caused by a lack of protein calories, but kwashiorkor will seldom appear before six months as
the baby is being breastfed, while marasmus can. In kwashiorkor the hair of the child will be
discolored whereas in the case of marasmus it is just dry and dull. In marasmus the skin of the
child also becomes thin and wrinkled and loses elasticity, while in kwashiorkor lesions are
visible. Marasmus leads to a more extensive impairment of biological functions when
compared to kwashiorkor. In short a child with marasmus will look emaciated, while a child
with kwashiorkor will look bloated.


Both marasmus and kwashiorkor are most commonly observed in third world countries where
access to food is scarce. Most people will have seen pictures of starving individuals who will
either look distended and bloated or emaciated. However marasmus is more common than
kwashiorkor in dry climates as they will also usually lack fluids.

In the case of any protein calorie malnutrition the body will lack amino acids which are the
carbon compounds it uses to rebuild tissue. We as humans are made from carbon and we get
this from the protein in our diet primarily in the form of meat but also to an extent in plants
and vegetation. Our skin, muscle and flesh all deteriorate overtime due to use and free

radicals and this is a perfectly natural occurrence. However normally the body will then be
able to repair this damage by providing those parts of the body with the amino acids required
to rebuild that tissue and this will enable the body to maintain itself. However where the body
does not have access to these amino acids, the degeneration will not be able to be repaired and
this will cause the muscles and the fat to gradually waste away without being rejuvenated.
Not only will this result in the wasting of the muscles, but it will also cause the deterioration
of the skin, teeth, nails and hair which become dried out and flaky.

Other problems will also occur due to the deterioration of the body as a whole and the
degradation of the major organs. If the body has a lack of carbohydrates and calories in
general, then the deterioration will be more rapid as the body will turn to the protein stored as
muscle and organs and burn this in order to create the energy needed. Eventual other
problems include infections, dehydration, circulation issues and more which are all often
lethal. Once the body gets to the point where the machinery for protein synthesis has been
destroyed it reaches a 'point of no return' where attempts to restore the body at all are futile.


Kwashiorkor and marasmus are two major types of protein-energy malnutrition that are
distinguished from each other based on clinical setting, time course to development, clinical
features, and diagnostic criteria. In these types of malnutrition, there is protein diet deficiency
because of inadequate food intake, poor quality of food, or the presence of diseases that
modify nutrient absorption and energy requirements. One major difference between
kwashiorkor and marasmus is that kwashiorkor can occur rapidly, while marasmus is usually
the result of a gradual process. Kwashiorkor often manifests in an affected person as a well-
nourished appearance, but marasmus manifests as a starved appearance. Malnutrition severely
undermines a persons well-being and functionality, so these types of malnutrition need to be
detected and treated early.

Clinical setting is one factor that helps distinguish kwashiorkor and marasmus from each
other. In marasmus, there is decreased energy intake, often due to an inadequate diet, within a
span of months or years. Long-term starvation, which often occurs in poor areas, is a major
factor in the development of marasmus. In kwashiorkor, there is decreased protein intake
within a stress state, usually weeks. While there is a generalized decrease in the intake of
calories in marasmus, only the protein part of the diet is diminished in kwashiorkor.


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