Protein malnutrition

Alternative names
Kwashiorkor; Protein-calorie malnutrition; Malignant malnutrition; Mehla” hrschaden

Definition
Kwashiorkor is a form of malnutrition caused by inadequate protein intake in the presence of fair to good energy (total calories) intake.

Causes, incidence, and risk factors

Kwashiorkor occurs most commonly in areas of famine, limited food supply, and low levels of education, which can lead to inadequate knowledge of proper diet.

Early symptoms of any type of malnutrition are very general and include fatigue, irritability, and lethargy. As protein deprivation continues, growth failure, loss of muscle mass, generalized swelling (edema), and decreased immunity occur.

A large, protuberant belly is common. Skin conditions (such as dermatitis, changes in pigmentation, thinning of hair, and vitiligo) are seen frequently. Shock and coma precede death.

The incidence of kwashiorkor in children in the U.S. is extremely low and only rare, isolated cases are seen.

This is typically a disease of impoverished countries, and is often seen in the midst of drought or political turmoil. However, one government estimate suggests that as many as 50% of elderly persons in nursing homes in the U.S. suffer from protein-calorie malnutrition.

Improving calorie and protein intake will correct kwashiorkor, provided that treatment is not started too late. However, full height and growth potential will never be achieved in children who have had this condition.

Severe kwashiorkor may leave a child with permanent mental and physical disabilities. There is good statistical evidence that malnutrition early in life permanently decreases IQ.

Risk factors include living in impoverished countries, countries in political unrest, and countries affected by frequent natural disasters (such as drought). These conditions are directly or indirectly responsible for scarcity of food which leads to malnutrition.

Symptoms

     
  • unavailability of adequate food and quality protein  
  • failure to gain weight and failure of linear growth  
  • irritability  
  • lethargy or apathy  
  • decreased muscle mass  
  • edema  
  • large protuberant belly  
  • diarrhea  
  • dermatitis  
  • changes in skin pigment; may lose pigment where the skin has peeled away (desquamated) and the skin may darken where it has been irritated or traumatized  
  • hair changes - hair color may change, often lightening or becoming reddish, thin, and/or brittle  
  • increased numbers of infections and increased severity of normally mild infection as a result of damaged immune system  
  • shock (late stage)  
  • coma (late stage)

Signs and tests
The physical examination may show an enlarged liver (hepatomegaly) and generalized edema.

Decreased kidney function as shown by changes in:

     
  • urinalysis  
  • serum creatinine  
  • creatinine clearance  
  • BUN  
  • serum potassium  
  • arterial blood gas

Total protein levels (from a chemistry profile) show insufficient amounts of albumin proteins (hypoalbuminemia). CBC demonstrates presence of anemia.

Treatment

Treatment varies depending on the severity of the condition. Shock requires immediate treatment with restoration of blood volume and maintenance of blood pressure.

Calories are given first in the form of carbohydrates, simple sugars, and fats. Proteins are started after other caloric sources have already provided increased energy. Vitamin and mineral supplements are essential.

Since the person will have been without much food for a long period of time, starting oral feedings can present problems, especially if the caloric density is too high at first. Food must be reintroduced slowly, carbohydrates first to supply energy, followed by protein foods.

Many malnourished children will have developed intolerance to milk sugar (lactose intolerance) and will need to be given supplements with the enzyme lactase, if they are to benefit from milk products.

Expectations (prognosis)
Treatment early in the course of kwashiorkor generally produces good results. Treatment of kwashiorkor in its late stages will improve the child’s general health, but he or she may be left with permanent physical problems and intellectual disabilities. Without treatment or if treatment comes too late, this condition is fatal.

Complications

     
  • shock  
  • coma  
  • permanent disability

Calling your health care provider
Although very rare in industrialized countries, when kwashiorkor does occur in such places, it is usually a sign of child abuse and severe neglect.

Prevention
Adequate diet with appropriate amounts of carbohydrate, fat (minimum of 10 percent of total calories), and protein (12 percent of total calories) will prevent kwashiorkor.

Johns Hopkins patient information

Last revised: December 6, 2012
by Simon D. Mitin, M.D.

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