Severe Childhood Malnutrition: Kwashiorkor and Marasmus

Question 1

What childhood malnutrition diseases are associated with severe wasting due to severe malnutrition?

Answer 1

Kwashiorkor and Marasmus

Question 2

What is the main difference between Kwashiorkor and Marasmus?

Answer 2

Kwashiorkor: has edema
Marasmus: severe wasting (less than 70% or less than 3SD from the mean)

Question 3

Where is the best source of information on these childhood malnutrition diseases?

Answer 3

WHO

Question 4

Patients with marasmus will have no obvious pathology. Kwashiorkor will have multiple pathologies, what are they?

Answer 4

1. Pitting edema (can mask the weight loss)
2. Dermatosis (lighter hair color, peeling/scaly skin)
3. Hypoalbuminemia (fatty liver)
4. Abnormal plasma AA
5. K + deficiency (Apathy and anorexia)
6. Infection

Question 5

How is Kwashiorkor illness managed clinically (very simple and effective, but not widely known and can cause death)?

Answer 5

Treatment needs to be phased: high protein diets in the beginning can be fatal

• –Resuscitate, Repair, and Replete
• -tx the severe malnutrition
• –repair the damaged cellular injury
• –replete the obvious tissue deficits only after cells are repaired

Question 6

Routine treatment, for Kwashiorkor, includes the following ten steps:

Answer 6

1. Prevent and Treat: hypoglycemia (Days 1-2), hypothermia (Days 1-2), dehydration (days 1-2), electrolyte imbalance (important throughout), infection (first week), and micronutrient deficiencies
   - –DO NOT GIVE ANY IRON THE FIRST WEEK start the second week
2. Special feeds for initial stabilization (1st week) followed by catch up growth (2nd week)
3. Provide loving care and stimulation (important throughout)
4. Follow up after discharge

Question 7

Inappropriate high protein tube feeding on admission in Kwashiorkor patients will result in what?

Answer 7

fatally

Question 8

In Kwashiorkor what is the goal for treatment/

Answer 8

An initial low protein low energy maintenance diet with antibiotics and selective supplements resolves the pathology.

Question 9

In Kwashiorkor treatment week 1 is for stabilization. Infections in this stage is treated with what?

Answer 9

Treat infections with broad spectrum antibiotics (while addressing associated hypoglycemia and hypothermia)

Question 10

In the first week how do you treat the dehydration?

Answer 10

Rehydration solution malnutrition (ReSoMal)

–it is possible to have edema with low blood volume

Question 11

In the first week how do you treat K and Mg deficiencies?

Answer 11

with electrolyte supplementation low protein feeds

Question 12

In Kwashiorkor, when the edema is cured, what returns?

Answer 12

Patients appetite

Question 13

What micronutrient is avoided in the first week of stabilization in Kwashiorkor children?

Answer 13

IRON (Start week 2)

Question 14

Weeks 2-6 involves rehabilitation of Kwashiorkor children. What should these children be fed??

Answer 14

Feed large amounts of energy dense milk based feed with about 50% fat content

• -full cream milk, sugar and oil with 10% protein
• -include iron now

Question 15

In weeks 2-6 rehab should you allow the Kwashiorkor patient to eat as they wish?

Answer 15

Allow patient to eat as much as they want and catch up growth is very successful

Question 16

Is Kwashiorkor due to protein energy malnutrition?

Answer 16

No.

—the myth began in the 30s stating that symptoms were cured by milk, it was due to a protein deficiency.

Question 17

Usually the edema is explained by hypoalbuminemia, what are explanations for hypoalbuminemia?

Answer 17

1. Failure to adapt to a low protein diet
2. Cortisol inadequacy
3. Aflatoxins
4. Protein losing enteropathy

Question 18

The idea that Kwashiorkor can be explained by a protein deficiency is inadequate. Why?

Answer 18

1. Protein deficiency in children in vary rare (requirements are very low –5% of calories) and symptoms can be cured by a low protein diet.
   - –even in countries where malnutrition is likely to occur, it is still difficult to develop a protein deficiency. Only when the diet is composed primarily of root vegetables does protein deficiency occur.

Question 19

Breast milk only has 6% of protein content (aka low protein) —- this indicates the initial level of protein that Kwashiorkor children begin with. Therefore catch up growth, children need how much protein content in diets?

Answer 19

10%

Question 20

Edema is gone before there is any change in what?

Answer 20

Serum albumin concentration

Question 21

Hypoalbuminemia is not linked to any other symptoms besides what?

Answer 21

edema

Question 22

Patients with Kwashiorkor are malnourished with either a low protein or insufficient diet; growth stops and anorexia and weight loss occur. Patient are on their way to becoming stunted or wasted, when what happens?

Answer 22

when an additional noxious inflammatory insult causes marasmus or kwashiorkor to develop

Question 23

What is the pathway for Kwashiorkor once the inflammatory insult happens?

Answer 23

Insult —– increased ROS —- poor diet causes inadequate protection (Vit E, A, C, SE, and Zinc, Mn and Sulpher) —- Iron overload (Due to tissue breakdown without excretion) catalyses the formation of more ROS (formation of the superoxide radicals) —- Inadequate repair (micronutrient deficiencies)—damages

Question 24

When Kwashiorkor patients loss weight, what happens to the iron?

Answer 24

There is no mechanism for excretion of iron and as your blood volume goes down you reduce the amount of circulating hemoglobin and therefore you need to put the iron somewhere so it goes into stores in the body (aka in the liver and bone marrow)
–too much iron causes inflammation

Question 25

Excess iron has what effect on the body?

Answer 25

Excess iron can damage membranes and proteins disrupting transport and ionic balances resulting in K+ loss and sodium entering
–these children dont have FA to repair

Question 26

Increased oxidative stress has what effect on organs?

Answer 26

1. Kidney: impaired function contributes to edema
2. Liver: Impaired protein synthesis, decreased albumin and APOB100 secretion, damaged mitochondrial function. (decreased ATP production and fatty infiltration)
3. Skin: similar changes seen in a sunburn (photosensitivity) —dermatitis appears like this
4. Hair: bleaching, black children have reddish hair. White children will have blonde

Question 27

Free iron is extremely toxic and contributes to the formation of what?

Answer 27

free radicals

Question 28

When the plasma ferritin is elevated in the child what does this indicate?

Answer 28

poor prognosis

Question 29

Patient with Kwashiorkor may have similar symptoms to what?

Answer 29

Anemia of chronic disease (growth inhibition, tissue wasting, decreased blood volume and hemoglobin)

• -this is because the iron is high, but it is locked up in storage (hepcidin)
• -low RBC synthesis due to inflammatory cytokines

Question 30

Children who die from Kwashiorkor all have what kind of iron plasma levels?

Answer 30

normal range

Question 31

Etiology of Kwashiorkor is ________ to involve protein deficiency

Answer 31

Unlikely

Question 32

Malnutrition stems from a deficiency in _______ especially antioxidants

Answer 32

Micronutrients

—they needs fruits and vegetables and plant oils and Cu and Selenmium

Question 33

Kwashiorkor is therefore an infection super opposed on this background of micronutrients with excess _____ and _____ _____.

Answer 33

excess iron and free radicals

Question 34

What is the solution for Kwashiorkor disease?

Answer 34

Improved micronutrients status and abundant clean water