Malnutrition (including kwashiorkor and marasmus)
Protein–energy malnutrition results in severe weight loss in adults and can result in two syndromes in children: kwashiorkor characterised by oedema or marasmus characterised by wrinkled skin due to loss of lean tissue and subcutaneous fat.
Many countries in the developing world are on the verge of malnutrition. Drought, crop failure, severe illness and war often precipitate malnutrition in epidemics.
It is unclear why insufficient energy and protein intake causes marasmus in some cases and kwashiorkor in others, but both are syndromes of severe malnutrition. The oedema seen in kwashiorkor results from increased permeability of capillaries and low colloid on-cotic pressure (low serum albumin). Oncotic pressure is produced by the large molecules within the blood (albumin, haemoglobin), and it draws tissue water osmotically back into blood vessels.
Adults and children with marasmus have loss of muscle and subcutaneous fat with wrinkled overlying skin.
Patients appear apathetic and complain of cold and weakness.
Children with kwashiorkor develop oedema, concealing the loss of fat and soft tissues, the hair may be discoloured and an enlarged liver may be found.
Malnutrition greatly increases the susceptibility to infection. In children it has been shown to affect brain growth and development.
Treat associated dehydration, if present, and any coexisting infection. Often oral rehydration is safest, followed by nutritional replacement therapy. A gradual refeeding policy is essential initially 100 kcal/kg/day with 3 g protein/kg/day together with vitamins and minerals. Nutritional replacement is gradually increased until 200 kcal/kg/day.