C h a p t e r 1 0
Disorders of Nutritional Status
235
a starchy gruel feeding. Kwashiorkor is a more severe
form of malnutrition than marasmus. Unlike maras-
mus, severe protein deficiency is associated with severe
loss of the visceral protein compartment with a resul-
tant hypoalbuminemia that gives rise to generalized or
dependent edema. The child with kwashiorkor usually
presents with edema, desquamating skin, discolored
hair, anorexia, and extreme apathy (Fig. 10-4). There
are “flaky paint” lesions of the skin on the face (Fig.10-5),
extremities, and perineum and the hair becomes a sandy
or reddish color, with linear depigmentation (flag sign).
43
There is generalized growth failure and muscle wast-
ing as in marasmus, but subcutaneous fat is normal,
since calorie intake is adequate. Other manifestations
include skin lesions, hepatomegaly and distended abdo-
men, cold extremities, and decreased cardiac output and
tachycardia.
Marasmus-kwashiorkor
is an advanced protein-calo-
rie deficit together with increased protein requirement or
loss. This results in a rapid decrease in anthropometric
measurements with obvious edema and wasting and
loss of organ mass. One essential aspect of severe pro-
tein-energy malnutrition is fatty degeneration of such
diverse organs as the heart and liver. This degeneration
causes subclinical and overt cardiac dysfunction, espe-
cially when malnutrition is accompanied by edema.
A second injurious aspect is the loss of subcutaneous
fat, which markedly reduces the body’s capacity for
temperature regulation and water storage. As a conse-
quence, malnourished children become dehydrated and
hypothermic more quickly and more severely than nor-
mally nourished children.
40
Most children with severe
protein-energy malnutrition have asymptomatic infec-
tions because their immune systems fail to respond
appropriately.
Malnutrition inTrauma and Illness
In industrialized societies, protein-energy malnutrition
most often occurs secondary to trauma or illness.
Kwashiorkor-like secondary protein-energy malnutri-
tion occurs most commonly in association with hyper-
metabolic acute illnesses, such as trauma, burns, and
sepsis.
44
Marasmus-like secondary protein-energy mal-
nutrition typically results from chronic illnesses such
as chronic obstructive pulmonary disease (COPD),
congestive heart failure, cancer, and HIV infection.
Approximately half of all persons with cancer experience
Growth failure
Apathy,
irritability
Hair
changes
Fatty liver
Muscle
wasting
Depigmentation
of skin
Dermatoses
Villous atrophy of
small intestine,
diarrhea
Edema
(hypoalbuminemia)
Flag sign
FIGURE 10-4.
Clinical manifestations of Kwashiorkor.
FIGURE 10-5.
Infant with symptoms indicative of
Kawashiokor, a dietary protein deficiency, as well as a vitamin
B deficiency. (From the Centers for Disease Control and
Prevention Public Health Image Library. No. 6180.)
