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Clinical Summary

Protein-energy malnutrition (PEM) applies to a group of disorders including kwashiorkor and marasmus. These are characterized by an imbalance between the body’s supply and demand of energy and nutrients. Kwashiorkor means “the sickness of weaning” as it is often seen following weaning after birth. It usually occurs between the ages of 1 and 4 with a deficiency of dietary protein in the presence of normal to high carbohydrate intake. The etiology is complex, but there is decreased synthesis of proteins resulting in hypoalbuminemia. Kwashiorkor is an acute illness manifested by edema secondary to fluid and sodium retention. Patients have peripheral edema, anasarca, moon facies, apathy, and a protuberant abdomen secondary to hepatomegaly. The skin can become hyperkeratotic and may split open in pressure-prone areas.

Marasmus is often seen under the age of 1 and is associated with inadequate intake of both protein and calories. The body’s own energy stores are utilized, resulting in emaciation. These individuals do not have edema, but rather a loss of subcutaneous fat, muscle wasting, and wrinkled loose skin. Marasmic-kwashiorkor refers to the combination of both forms simultaneously. Laboratory studies are useful, but often are not available. Patients with PEM may be left with permanent neurologic and physical deficits due to lack of calories, vitamins, and essential amino acids.

Management and Disposition

These conditions are rarely seen or treated in developed countries, so acute treatment is often in settings with limited resources. These children often have other acute illnesses and are also at greater risk for infection, specifically pneumonia, gastroenteritis, and sepsis. IV fluids are limited to those with shock as they are prone to congestive heart failure; WHO oral rehydration salt solution is usually used for the first 6 to 10 hours. Low-protein milk formula is then started with a goal of 100 kcal/kg/day. A normal diet is gradually started over a few weeks. Inpatient admission for evaluation, intervention, and arrangement of long-term care is advised when possible.

FIGURE 21.66

Kwashiorkor. A Zambian child with typical light hair, moon facies, peripheral edema, and dry skin of kwashiorkor. (Photo contributor: Meg Jack, MD.)

FIGURE 21.67

Marasmus. An African infant with severe marasmus due to poor feeding following maternal death. The infant is severely underweight with loose skin and little subcutaneous fat. (Photo contributor: Meg Jack, MD.)

FIGURE 21.68

Kwashiorkor. A Ugandan boy with edema typical of acute kwashiorkor. The “enamel paint peeling” rash is occasionally seen. The patient died several days after the photo was taken. (Photo contributor: Seth W. Wright, MD.)


  1. PEM is one of the leading causes of death among children younger than 5 years ...

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