Kwashiorkor ( ) is a form of severe protein malnutrition characterized by edema and an enlarged liver with fatty infiltrates. It is thought to be caused by sufficient calorie intake, but with insufficient protein consumption (or lack of good quality protein). It is different from marasmus, which is malnutrition of all sources of energy including protein. Recent studies have found that a lack of antioxidant micronutrients such as β-carotene, lycopene, other carotenoids, and vitamin C as well as the presence of aflatoxins may play a role in the development of the disease. However, the exact cause of kwashiorkor is still unknown. Inadequate food supply is correlated with kwashiorkor; occurrences in high-income countries are rare. It occurs amongst weaning children to ages of about five years old.
Conditions analogous to kwashiorkor were well documented around the world throughout history. The disease's first formal description was published by Jamaican pediatrician Cicely Williams in 1933. She was the first to research kwashiorkor, and to suggest that it might be a protein deficiency to differentiate it from other dietary deficiencies. Reprint:
The name, introduced by Williams in 1935, was derived from the Ga language of coastal Ghana, translated as "the sickness the baby gets when the new baby comes" or "the disease of the deposed child", and reflecting the development of the condition in an older child who has been weaned from the breast when a younger sibling comes. Breast milk contains amino acids vital to a child's growth. In at-risk populations, kwashiorkor is most likely to develop after children are weaned from breast milk and begin consuming a diet high in carbohydrates, including maize, cassava, or rice.
Classification
Kwashiorkor is a type of severe acute malnutrition (SAM). SAM is a category, composed of two conditions: marasmus and kwashiorkor. Both kwashiorkor and marasmus fall under the umbrella of protein–energy malnutrition (PEM). These diseases are oftentimes discussed together, but are distinctly separate conditions of malnutrition. Kwashiorkor is marked by an array of metabolic disturbances of uncertain cause. In contrast, marasmus is more clearly an energy deficiency syndrome, marked by weight loss. On physical exam, kwashiorkor is also distinguished from marasmus by the presence of edema. When children present with both kwashiorkor and marasmus, the condition is referred to as "marasmic-kwashiorkor". In general, kwashiorkor is marked by more profound serum depletions of antioxidant molecules and minerals, relative to marasmus.
Wellcome's classification Wellcome classification is a system for classifying protein-energy malnutrition in children based on weight for their age and based on presence of edema. Other classifications include Gomez classification and Waterlow classification. Weight for ageWith edemaWithout edemaGeneral considerations65-85%KwashiorkorUndernutrition Weight for age ± oedema Reference standard (50th percentile)<60%Marasmic kwashiorkorMarasmus
Signs and symptoms The defining sign of kwashiorkor in children is bilateral edema in the feet. Edema may also involve the hands, trunk, and face. Kwashiorkor is characterized by a fatty liver. This fatty liver of the undernutrition phenotype is often accompanied by evidence of inflammation and fibrosis. Whereas a fatty liver of undernutrition is a consistent feature of kwashiorkor, it is only encountered sometimes in children with marasmus. In addition to this characteristic hepatic steatosis, kwashiorkor is marked by a parallel pattern of multi-organ dysfunction. Organs often affected in children with kwashiorkor include the kidneys, pancreas, heart, and nervous system. Other findings that may be encountered on physical exam include a distended abdomen, hair thinning, loss of teeth, skin or hair depigmentation, and dermatitis. Children with kwashiorkor often develop irritability and anorexia. Generally, kwashiorkor is treated by introducing a high-quality source of protein to the diet. Ready-to-use therapeutic food (RUTF) as well as F-100 and F-75 milk powders, which both include skim milk powder, are recommended for the treatment of kwashiorkor. These products are designed for use in low-resource settings. The limited number of kwashiorkor cases that occur in high resource settings, where there is good access to advanced therapeutic tools, are typically treated with partially hydrolyzed or elemental enteral formulas, with parenteral nutrition provided in extreme cases.
Differential Diagnosis While Kwashiorkor is primarily characterized by edema, growth failure, and dermatitis, it can sometimes be misdiagnosed as Acrodermatitis Enteropathica (AE), as both conditions present with similar dermatological symptoms. However, AE is caused by zinc deficiency, not protein deficiency, and is associated with a significant decrease in serum zinc levels. Unlike kwashiorkor, which is diagnosed based on clinical signs like edema and low serum albumin levels, AE requires additional diagnostic tests, such as zinc uptake tests and genetic screening, to differentiate it from other disorders with similar symptoms. Therefore, while both conditions can present with dermatitis, the underlying etiology helps distinguish the two.
Causes The precise etiology of kwashiorkor remains unclear. Several hypotheses have been proposed that are associated with and explain some, but not all aspects of the pathophysiology of kwashiorkor. They include, but are not limited to protein deficiency causing hypoalbuminemia, amino acid deficiency, oxidative stress, and gut microbiome changes.
Low protein intake
Kwashiorkor is a severe form of malnutrition associated with a low-protein diet. The extreme lack of protein causes an osmotic imbalance in the gastrointestinal system causing swelling of the gut diagnosed as an edema or retention of water.
Extreme fluid retention observed in individuals suffering from kwashiorkor is accompanied by irregularities in the lymphatic system as well as disruptions of capillary exchange. The lymphatic system serves three major purposes: fluid recovery, immunity, and lipid absorption. Victims of kwashiorkor commonly exhibit reduced ability to recover fluids, immune system failure, and low lipid absorption. Fluid recovery by the lymphatic system is accomplished by the re-vascularization of fluid and macromolecules from the interstitial space, allowing these constituents of whole blood to be returned to the venous circulation. Compromised fluid recovery may contribute to the phenomenon of extravascular fluid accumulation in kwashiorkor.
The low protein theory for the pathogenesis of kwashiorkor has been used to teach that capillary exchange between the lymphatic system and circulating blood is impaired by a reduced oncotic (i.e. colloid osmotic pressure, COP) in the blood, as a consequence of inadequate protein intake, so that the hydrostatic pressure gradient, which favors extravasation of fluid from small vessels, is not overcome. Proteins, mainly albumin, are responsible for creating the COP observed in the blood and tissue fluids. The difference in the COP of the blood and tissue tends to favor the reentry of fluid from the extravascular space, into the circulatory system. This tendency is opposed by the venous hydrostatic pressure, which tends to favor the exit of fluid from small vessels, into the interstitial space. The low protein theory for the pathogenesis of kwashiorkor held that a deficiency of serum proteins, caused by inadequate protein intake, disrupted this balance, and thus impaired the return flow of fluid from the interstitium into the capillary and venous structures. It has been taught that this is what accounts for the accumulation of extravascular fluid in kwashiorkor, and the subsequent pedal edema and abdominal distension.
The low protein theory, which relies heavily upon Starling's theory for the movement of fluid in biological systems, provided a compelling rationale for the pathogenesis of edema in kwashiorkor. What it does not explain, however, is the entire array of disturbances that define the kwashiorkor syndrome. These include irritability, anorexia, skin desquamation, skin depigmentation, hair discoloration, reduced mitochondrial respiration, impaired lipid export from the liver without an accompanying reduction of lipoprotein synthesis, 'oxidative stress', glutathione depletions, transsulfuration disturbances, diffuse DNA hypomethylation, immune dysfunction, decreased transmethylation activity, and sulfated glycosaminoglycan deficiencies. It is now generally acknowledged that by itself, the low protein theory does not adequately account for the pathogenesis of kwashiorkor. More complex deficiencies are at work. These have still not been established.
Social factors are also relevant and ignorance of nutrition can be a cause. A case was described where parents who fed their child cassava failed to recognize malnutrition because of the edema caused by the syndrome and thought the child was well-nourished despite the development of kwashiorkor.
Aflatoxins Recent studies have attempted to pinpoint a relationship between kwashiorkor and high levels of aflatoxins. Aflatoxins are naturally occurring toxins produced by the mold Aspergillus flavus, a fungus found in areas with hot and humid climates. These toxins tend to grow and can be found in agricultural crops such as millet, maize, and rice. An analysis found that the presence of aflatoxins was found more frequently and in higher concentrations in individuals with kwashiorkor when compared to individuals with marasmus (another form of severe acute malnutrition). In particular, biological samples showed greater levels of aflatoxins in the brain, heart, kidney, liver, lungs, serum, stool, and urine. Aflatoxins were not found in liver samples of individuals with marasmus. It has been known that the liver organ is the main target of aflatoxins and chronic toxicity can result in immunosuppressive and carcinogenic effects. However, there is currently conflicting evidence to pinpoint a connection between kwashiorkor and aflatoxins. Studies have shown that not all children with kwashiorkor present with detectable aflatoxin levels. It has also been proposed that damage done by aflatoxins may be due to glutathione depletion (another proposed mechanism of the disease) in children with kwashiorkor.
Mechanisms Peripheral edema and hypoalbuminemia Kwashiorkor is a form of protein deficiency, which can result in both osmotic imbalances and irregularities in the lymphatic system.
Kwashiorkor is most notable for peripheral edema. The presence of edema in kwashiorkor is correlated with very low albumin concentration (hypoalbuminemia). Edema results from a loss of fluid balance between the hydrostatic and oncotic pressures across the capillary blood vessel walls due to the lack of protein which affects the body's ability to draw fluid from the tissues into the bloodstream. Low albumin concentration influences negatively the strength of oncotic pressure. Failure leads to fluid buildup in the abdomen, resulting in edema and belly distension.
Furthermore, the release of antidiuretic hormone is stimulated by hypovolemia, also leading to the development of peripheral edema. Plasma renin is also stimulated, promoting sodium retention.
It is important to distinguish the pathophysiology of marasmus and kwashiorkor when it comes to treating malnourished children who may have hypovolemic shock that is caused by an acute loss of salt and water. Children with severe albumin deficiency struggle physiologically to maintain their blood volume.
Low glutathione levels Kwashiorkor is also marked by low glutathione levels. Glutathione is used in many of the body processes on a molecular level.