Kwashiorkor is a variant of severe hypotrophy in children, which develops mainly due to protein starvation. It is characterized by low body weight, a delay in physical and mental development, widespread edema, anemia, diarrhea, an increase in abdominal volume, changes in skin pigmentation and hair color. Kwashiorkor is diagnosed on the basis of a thorough examination of the child and anamnesis of the disease, laboratory, instrumental examination methods. Complex treatment; it includes a diet with increased protein intake, careful care, vitamin therapy, enzyme and antibacterial drugs.

Kwashiorkor (hydrocachexia, pediatric pellagra, polycarenc syndrome) is an extreme degree of protein-energy deficiency in children. Literally translated from the language of the West African Aborigines, the term means "weaned from the mother's breast." Kwashiorkor was first described by Jamaican pediatrician S. Williams in 1935. According to WHO, the disease occurs in 1-6% of children. Kwashiorkor is most often found in the poorest regions of Africa, South and Central America, and Asia. The peak incidence occurs at the age of 1 to 3 years, however, cases of alimentary dystrophy in older children have been described in clinical pediatrics.

The disease has an alimentary genesis. After the completion of breastfeeding, the content of protein components, primarily essential amino acids, is sharply reduced in the diet of children. Carbohydrate food predominates, consisting mainly of starchy vegetables (inyama tubers, cassava, taro) and cereals (sorghum, maize, fonio). There is a lack of trace elements and vitamins (selenium, iodine, iron, ascorbic acid and folic acid), which play an important role in the functioning of the body's antioxidant defense system.

Against this background, dystrophic processes occur in organs and tissues, the growth and development of the child is disrupted. Predisposing factors contributing to the development of pediatric pellagra can be chronic liver diseases, genetic diseases of amino acid metabolism, severe burns, severe infectious diseases, helminthiasis, nephrotic syndrome. The greatest number of episodes of the disease is recorded during periods of mass starvation, military conflicts and other social upheavals.

Due to the lack of protein food in the child's menu and a violation of the secretion of intestinal glands, the level of blood albumin decreases, a negative nitrogen balance occurs, and the oncotic plasma pressure decreases. This contributes to cellular hyperhydration, which is clinically manifested by edema. The defeat of the mucosa of the small intestine causes a deficiency of enzymes of the disaccharidase group, as a result of which the hydrolysis of disaccharides to simple carbohydrates and their assimilation by the body is not ensured. Hypoglycemia is aggravated by insufficient intake of glucose from food due to anorexia and malabsorption phenomena.

Due to the appearance of diarrhea with feces, lactic acid salts are intensively excreted, while the reabsorption of hydrogen ions increases, which contributes to a pH shift towards acidosis. Structural changes of the pancreas (fibrosis, cystic dilation of the ducts) and liver (fatty degeneration) develop, their protein-synthetic function is disrupted. Secretory insufficiency causes a decrease in the assimilation of all classes of nutrients. In conditions of protein and vitamin deficiency, immunological reactivity suffers, anemia increases.

Pathology develops gradually. The child's appetite and activity decreases, he becomes inhibited, apathetic, tearful. The patient strives for solitude, freezes in one position for a long time, and then refuses to move at all. Anorexia is progressing, body weight is steadily decreasing. With kwashiorkor, there is a late closure of the anterior fontanel and teething. The face becomes rounded. Swelling occurs on the back surface of the feet, and subsequently they spread to the shins, thighs, buttocks. In rare cases, swelling affects the eyelids and the lower part of the face, in severe cases it occurs on the hands and forearms.

The skin lesion is manifested by the development of "enamel dermatosis" mainly in the places of greatest friction (buttocks, back surfaces of arms and legs) in the form of hyperpigmentation against the background of edema, cracks, wet erosions. At the same time, depigmented areas may occur in the folds of the elbow joint, groin, armpit, neck, with subsequent spread to the face and body of the child. Hair becomes dull, sparse, changes its natural color, may have red, gray, orange, brown shades in places (flag symptom). These changes occur due to a deficiency of amino acids containing sulfur and taking part in the metabolism of melanin.

With kwashiorkor, thinning occurs, sometimes ulceration of the mucous membrane of the lips, cracks form in the corners of the mouth. The tongue of such children is bright, red and devoid of papillae. The stool may be liquid, frequent, with an admixture of mucus and undigested pieces of food. The volume of the abdomen increases. Anemia of varying severity develops. Muscle hypotrophy, decreased reflexes are noted. Children lag behind in development, they start talking late.

Reduced immunity contributes to a more severe course of infectious diseases. If kwashiorkor is combined with vitamin A deficiency, eye diseases may occur in the form of xerophthalmia and keratomalacia. Sometimes, with kwashiorkor, syndromes that threaten the life of a child develop. These include hypothermia, hypoglycemia, sopor, coma, acute heart failure, severe dehydration with toxicosis, liver dystrophy with the transition to cirrhosis.

The diagnosis is usually not difficult because of the rather characteristic and pronounced symptoms. Pediatricians, pediatric endocrinologists, gastroenterologists, and neurologists participate in the examination of children. At the diagnostic stage, kwashiorkor should be differentiated with pellagra, dermatitis, diseases accompanied by edema (chronic cardiovascular insufficiency, chronic glomerulonephritis with nephrotic syndrome). To confirm the diagnosis, a complex of clinical, laboratory and instrumental examinations is carried out:

  • Examination of the child. The timing of the weaning of the child from the breast, the qualitative and quantitative characteristics of nutrition are being clarified. During the examination, attention is drawn to an increase in the abdomen, hepatomegaly. The clinical symptoms are evaluated - edema, pigmentation of the skin, hair color change are characteristic.
  • Laboratory tests. The blood test determines anemia, hypoalbuminemia, a decrease in glucose levels, trace elements. The number of enzymes (amylases, lipases, cholinesterases, transaminases), as well as cholesterol, decreases. A general urine test often reveals ketonuria. During hormonal tests, increased secretion of somatotropic hormone can be determined, but against this background, there is a delay in the growth of the child.
  • Instrumental methods. Malabsorption syndrome is detected during esophagogastroduodenoscopy with biopsy of the small intestine. Radiography of the esophagus, stomach, biliary tract, intestines helps to exclude congenital malformations. CT and ultrasound of the abdominal cavity is carried out in order to differentiate kwashiorkor from organic pathology.

Hospitalization of sick children is carried out in the pediatric gastroenterology department. On average, treatment takes from two to six weeks. Since heat exchange can be disrupted in children with kwashiorkor, they need additional warm clothes, a comfortable temperature in the room. The main components of therapy include:

  • A special diet. The child is prescribed a full-fledged diet containing a large amount of animal proteins and vitamins. The calculation of daily protein intake is made according to the formula of 4 g per 1 kg of child weight. The proportion of carbohydrate foods in the diet should be reduced, and the caloric content of food increased. The increase in the energy value of food and the amount of protein should be gradual. The main criterion for the effectiveness of diet therapy is the improvement of the psychomotor state of a sick child, regular weight gain (by 25-30 g / day). The adequacy of diet therapy is also assessed by the dynamics of the coprogram and the sugar curve.
  • Medical correction of violations. Enzyme therapy is prescribed with a substitution purpose, taking into account the data of the coprogram. Vitamin therapy is an integral part of the complex treatment of kwashiorkor. Vitamins B, C, PP, A, nicotinic acid, folic acid, potassium, magnesium are prescribed in an age-appropriate dosage. Stimulating therapy consists of alternating courses of eleutherococcus, echinacea, ginseng, dibazole. If a secondary infection occurs, the appointment of antibacterial drugs is indicated. In case of toxicosis, intravenous administration of saline solutions is required.

Under the condition of early detection of dystrophic disorders, the absence of an associated infection and timely treatment, the prognosis of kwashiorkor is favorable. In half of the children who have had the disease, symptoms of impaired nutrition, somatic and mental disorders can persist for a long time. The mortality rate is 10-30%. Preventive measures should be aimed at ensuring the rational nutrition of young children. It is recommended to adequately and timely treat diseases that may contribute to the occurrence of kwashiorkor. To do this, it is necessary to develop and implement a system of measures to cover children at risk with preventive examinations by children's specialists.

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