Urinary excretion and serum livels of N-acetylneuraminic acid in kwashiorkor.
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Child, Preschool↗
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Kwashiorkor-marasmus syndrome and nutritional rickets--a bone biopsy study.
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Adult↗
Protein-energy malnutrition (kwashiorkor and marasmus).
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Child Nutrition Disorders↗
Kwashiorkor: dysmetabolism versus malnutrition.
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Journal Article↗
Kwashiorkor: dysmetabolism versus malnutrition.
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Comment↗
Thyroid status in various degrees of protein-calorie malnutrition in children.
The thyroid functional parameters of 102 children with protein-calorie malnutrition (PCM) classified as undernourished, marasmic, kwashiorkor and marasmic-kwashiorkor were studied by measuring the serum T4, T3, T3 percentage uptake (T3%UT), free thyroxine index (FTI), and (in a few subjects) TSH. Total plasma proteins, albumin and globulin were also estimated. T4 was increased markedly in the undernourished children and significantly decreased in kwashiorkor and marasmic-kwashiorkor groups. There was a consistent and significant fall in T3 levels of all PCM children. From normal values, the fall in T3 levels was progressive in the order of undernourished, marasmic, kwashiorkor and the marasmic-kwashiorkor states. The T3%UT was increased above normal in the marasmic, kwashiorkor and marasmic-kwashiorkor conditions. The FTI decreased somewhat in marasmus and kwashiorkor groups and was very low in marasmic-kwashiorkor. Total protein and albumin levels were above normal in the undernourished but became markedly depressed in the marasmic-kwashiorkor children. The changes in the levels of both T4 and T3 in our observations are well correlated with the levels of plasma proteins in the undernourished, marasmic and kwashiorkor states but not in the marasmic-kwashiorkor group.
Child, Preschool↗
Protein-energy malnutrition in northern Sudan: clinical studies.
The medical history, clinical features and investigations of 145 children with kwashiorkor were compared with 113 marasmic kwashiorkor, 158 marasmic children and 186 nutritionally normal controls of similar age admitted to hospital in Khartoum. Factors in the group with protein-energy malnutrition (PEM) which could relate to aetiology include: a history of prolonged illness and anorexia, frequent and prolonged episodes of diarrhoea and recent measles. The delay in achievement of developmental milestones in PEM children probably reflects the frequent and chronic illnesses in this group. An episode of previous oedema was reported in 22 per cent of marasmic kwashiorkor, 12 per cent of kwashiorkor and 12 per cent of marasmic children. Though hair and mucosal changes and enlarged liver were more common in the marasmic kwashiorkor and kwashiorkor groups, they were also common in marasmic children. There was no significant difference in behaviour (apathy, irritability, anorexia) between kwashiorkor and marasmic children. The classical skin changes of kwashiorkor were only seen in the oedematous children. The mortality was 19 per cent in kwashiorkor, 35 per cent in marasmic kwashiorkor, and 14.5 per cent in the marasmic group. The major differences between marasmus and kwashiorkor children were that the kwashiorkor children were reported larger at birth, achieved more normal developmental milestones, were taller and had larger head circumference than the marasmic children. The implications of these findings in relation to aetiology are discussed.
Anthropometry↗
Erythrocyte membrane (Ca2+ + Mg2+)-ATPase in human protein-energy malnutrition.
Calmodulin-free ghost membranes were prepared from erythrocytes of kwashiorkor children and from healthy children in the same age bracket. In the absence of calmodulin, the specific activity of Mg2+-dependent Ca2+-pumping ATPase (Ca2+ + Mg2+-ATPase) of kwashiorkor membranes was more than 40 percent lower than the specific activity of the normal enzymes, whose maximum velocity was increased by at least four-fold by the modulator protein. In contrast, the maximum velocity of the enzymes of kwashiorkor membranes was enhanced by calmodulin by about 1 1/2 times the basal activity of the normal enzymes and by 2 times the basal activity of the kwashiorkor enzymes. The affinity of the pump for ATP was lower in the membranes of kwashiorkor children (Km for ATP = 30.6 +/- 2.8 microM ATP) in comparison to normal membranes (Km for ATP = 21.7 +/- 2.0 microM ATP). Similarly, calmodulin-affinity of the enzymes, was lower in kwashiorkor membranes than in the normal membranes irrespective of source of calmodulin. Calmodulin from haemolysates of kwashiorkor red cells activated the enzymes of normal and kwashiorkor membranes to the same degree as calmodulin partially purified from the haemolysate of healthy children. A determination of the dependence of the activity of the pump on calcium in the absence and presence of calmodulin reveals that the affinity of the kwashiorkor enzymes for Ca2+ is at least 70 percent lower than that of enzymes of normal membranes. Altogether, these findings suggest that the Ca2+-pumping ATPase of kwashiorkor membranes is less functional than the enzymes of healthy erythrocytes.
Ca(2+) Mg(2+)-ATPase↗
Protein-losing enteropathy in Transkeian children with morbid protein-energy malnutrition.
A commercially available radial immunodiffusion assay was used to measure serum and faecal alpha 1-antitrypsin concentrations as well as alpha 1-antitrypsin clearance in 17 children with kwashiorkor, 11 children with marasmic kwashiorkor, 10 children with marasmus, and 16 normal children. Serum alpha 1-antitrypsin concentrations were significantly higher than normal in the marasmus and marasmic kwashiorkor groups, and significantly lower than normal in the kwashiorkor group. The intestinal clearance of alpha 1-antitrypsin was significantly higher than normal in the marasmus and marasmic kwashiorkor groups, and significantly lower than normal in the kwashiorkor group. There was a significant inverse correlation between the alpha 1-antitrypsin clearance and serum albumin concentration in the marasmus and marasmic kwashiorkor groups. No such correlation was evident in the kwashiorkor group. It is concluded that protein-losing enteropathy is likely to play a significant role in the development and perpetuation of hypo-albuminaemia in children with marasmus and marasmic kwashiorkor but not in those with kwashiorkor.
Biomarkers↗
Hormonal changes in severely malnourished children.
Hormonal changes during the acute phase of protein-energy malnutrition (PEM) and at recovery have been examined in thirty-four severely malnourished subjects (twenty-four kwashiorkor and ten marasmus) all of whom were aged 3 years and below. It was observed that except for cortisol, the hormonal values were different between the marasmic and kwashiorkor children. Serum insulin levels were depressed and growth hormone (GH) elevated among the kwashiorkor children most especially among the kwashiorkor sub-groups II and III cases who had the greatest deficit in body weight. Although the GH values were also elevated in the marasmic patients, the levels were much lower than those for the kwashiorkor children. There was no statistically significant difference in the mean serum concentration of both cortisol and thyroxine among the different sub-groups of kwashiorkor and the marasmic subjects. The identical serum levels of cortisol in both the marasmic and kwashiorkor children may have been due to similar extent of exposure of infections. With improved dietary intake and some degree of anthropometric recovery, GH concentration fell steadily while insulin rose especially among the kwashiorkor cases. The reasons for these hormonal changes, their functions during the acute phase of PEM and at recovery are discussed.
Blood Glucose↗
Serum interleukin-1 and granulocyte-macrophage colony-stimulating factor levels in protein malnourished patients during acute infection.
OBJECTIVE: To investigate the response of serum interleukin-1 (IL-1) and granulocyte-macrophage colony-stimulating factor (GM-CSF) to infection of malnourished patients. DESIGN: Prospective observational study. SETTING: Paediatric clinics of Karadeniz Technical University, Faculty of Medicine, Trabzon, Turkey. SUBJECTS: 13 protein-depleted (kwashiorkor marasmic kwashiorkor), 15 marasmic nutritionally repleted kwashiorkor (NRK), and 12 well-nourished control subjects. INTERVENTIONS: Clinical and laboratory data, and serum IL-1 and GM-CSF levels during acute infections were examined. MAIN OUTCOME MEASURES: White blood cell count, pc of circulating neutrophils (%PNL), serum total protein, albumin (ALB), IL-1 and GM-CSF levels. RESULTS: Fever, pcPNL, serum IL-1 and GM-CSF levels of kwashiorkor patients were lower than those of marasmic and control patients (p < 0.005). Fever, neutrophil pc(PNLpc), serum IL-1 and GM-CSF levels of NRK patients during further acute infection were not significantly different from those of marasmic and control patients, but higher than those of the kwashiorkor patients. Although there were positive correlations between serum IL-1 and ALB levels (r = 0.922, p < 0.001), and between serum GM-CSF and ALB levels (r0.730, p = 0.005) in the kwashiorkor group, there were not significant correlations between the same parameters in the other groups (r < 0.5, p > 0.05). And also, although there was not significant correlations between PNL% and IL-1 levels in the kwashiorkor group (r0.312, p = 0.299), there were significant positive correlations between the same parameters in the other groups (r < 0.5, p > 0.05). However, significant positive correlations were found between fever and IL-1 levels, and between IL-1 and GM-CSF levels in all groups (r > 0.5, p < 0.05). CONCLUSION: The responses of serum IL-1 and GM-CSF to acute infection of kwashiorkor patients are defective, and nutritional-repletion therapies restore the production of these cytokines.
Acute Disease↗
Serum albumin and transferrin protein-energy malnutrition. Their use in the assessment of marginal undernutrition and the prognosis of severe undernutrition.
1. Deficits in weight- and length-for-age, and serum albumin and transferrin concentrations were determined for children who were either marginally undernourished (twenty-five children) or suffering from either marasmus (thirty-two children) or kwashiorkor (twenty-six children) defined according to the Wellcome Classification (Waterlow, 1972). The measurements were also made in eight children with kwashiorkor after the loss of oedema, and in sixteen children who were recovering from either marasmus or kwashiorkor. 2. The mean concentration of serum albumin was similar for children from the 'under-nourished' group and from the group with marasmus, but was significantly reduced in those with kwashiorkor. 3. The concentration of serum transferrin was significantly reduced in both the group of children with marasmus and those with kwashiorkor. The serum transferrin concentration was significantly lower in children with kwashiorkor when compared with the level in those with marasmus. 4. Seventeen children (seven with kwashiorkor and ten with marasmus) died. These children were neither lighter nor shorter than the severely malnourished children who survived. The concentration of serum albumin was not lower in the children who died than in those who survived. 5. In contrast to the results for serum albumin concentrations, the children who died had significantly lower levels of serum transferrin than those who survived. 6. There was a significant linear relationship between serum transferrin concentrations and the deficits in length-for-age (P less than 0-05) and weight-for-length (P less than 0-001) in the marginally undernourished children. The deficit in weight-for-length was also linearly related to the serum transferrin concentrations (P less than 0-001) in children recovering from severe malnutrition. 7. It is suggested that the measurement of serum transferrin concentrations provides an index of severity in severely malnourished children, and should prove useful in field assessments of nutritional status.
Body Weight↗
Alpha 2 HS-glycoprotein levels in children with protein-energy malnutrition and infections.
Serum alpha 2 HS-glycoprotein levels were studied, using the single-radial immunodiffusion method, in 39 severely malnourished children (22 kwashiorkor, 17 marasmus) of whom 15 (8 kwashiorkor, 7 marasmus) were infected and 24 (14 kwashiorkor, 10 marasmus) had no signs of infection. Thirty-two well-nourished children, 16 of whom were infected, served as controls. The uninfected controls had higher serum alpha 2 HS-glycoprotein levels than the uninfected kwashiorkor (82.0 +/- 14.7; 57.0 +/- 15.8; p less than 0.001) and marasmic children (82.0 +/- 14.7; 45.0 +/- 13.9; p less than 0.001). Infection was associated with a significant decrease in the mean serum alpha 2 HS-glycoprotein levels in the well-nourished (82.0 +/- 14.7; 57.0 +/- 7.7; p less than 0.001) and kwashiorkor (57.0 +/- 15.8; 34.0 +/- 20.4; p less than 0.02) children, while no such decrease was observed in the marasmic children. While the mean serum glycoprotein level in the infected controls was higher than that in the infected kwashiorkor children (57.0 +/- 7.7; 34.0 +/- 20.4; p less than 0.02), it was comparable to that in the infected marasmic children (57.0 +/- 7.7; 50.0 +/- 11.6; p greater than 0.05). Furthermore, the mean alpha 2 HS-glycoprotein level in the infected malnourished children was higher in marasmus than in kwashiorkor (50.0 +/- 11.6; 34.0 +/- 20.4; p greater than 0.05); this difference was, however, not statistically significant.(ABSTRACT TRUNCATED AT 250 WORDS)
Blood Proteins↗
Serum insulin-like growth factors I and II concentrations and growth hormone and insulin responses to arginine infusion in children with protein-energy malnutrition before and after nutritional rehabilitation.
Serum insulin, growth hormone (GH), insulin-like growth factors (IGFs) I and II, cortisol, and albumin concentrations were measured in 15 children with kwashiorkor, 15 with marasmic-kwashiorkor, and 21 with marasmus, before and in the survivors, after nutritional rehabilitation, as well as in 10 underweight and eight normal Egyptian children. We also evaluated arginine-induced insulin and GH secretion. IGF-I concentrations were reduced in the three severely malnourished groups (0.07 +/- 0.03, 0.05 +/- 0.03, and 0.09 +/- 0.09 U/ml, respectively) but returned to normal after refeeding. IGF-II concentrations were low in the kwashiorkor (175 +/- 79 ng/ml), marasmic-kwashiorkor (111 +/- 57 ng/ml), and marasmic children (128 +/- 70.9 ng/ml) and returned to normal after nutritional rehabilitation. Basal GH levels were high in the three severely malnourished groups (21.9, 28.8, and 16.6 ng/ml, respectively) and returned to normal after refeeding (8.1, 6.5, and 6.0 ng/ml, respectively). GH responses to arginine were depressed in the three malnourished groups and improved significantly in marasmic-kwashiorkor and marasmic children after nutritional rehabilitation. Insulin responses to arginine were impaired in kwashiorkor, and marasmic-kwashiorkor children and improved significantly after refeeding. IGF-I levels correlated significantly with percent of expected weight (r = 0.52, p less than 0.001), percent of expected height (r = 0.42, p less than 0.001), and weight/(height)2 index (r = 0.34, p less than 0.01). IGF-I levels correlated positively with insulin levels (r = 0.421, p less than 0.001) and negatively with cortisol concentrations (r = -0.400, p less than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)
Anthropometry↗
Severe nutritional deficiencies in toddlers resulting from health food milk alternatives.
It is widely appreciated that health food beverages are not appropriate for infants. Because of continued growth, children beyond infancy remain susceptible to nutritional disorders. We report on 2 cases of severe nutritional deficiency caused by consumption of health food beverages. In both cases, the parents were well-educated, appeared conscientious, and their children received regular medical care. Diagnoses were delayed by a low index of suspicion. In addition, nutritional deficiencies are uncommon in the United States and as a result, US physicians may be unfamiliar with their clinical features. Case 1, a 22-month-old male child, was admitted with severe kwashiorkor. He was breastfed until 13 months of age. Because of a history of chronic eczema and perceived milk intolerance, he was started on a rice beverage after weaning. On average, he consumed 1.5 L of this drink daily. Intake of solid foods was very poor. As this rice beverage, which was fallaciously referred to as rice milk, is extremely low in protein content, the resulting daily protein intake of 0.3 g/kg/day was only 25% of the recommended dietary allowance. In contrast, caloric intake was 72% of the recommended energy intake, so the dietary protein to energy ratio was very low. A photograph of the patient after admission illustrates the typical features of kwashiorkor: generalized edema, hyperpigmented and hypopigmented skin lesions, abdominal distention, irritability, and thin, sparse hair. Because of fluid retention, the weight was on the 10th percentile and he had a rotund sugar baby appearance. Laboratory evaluation was remarkable for a serum albumin of 1.0 g/dL (10 g/L), urea nitrogen <0.5 mg/dL (<0.2 mmol/L), and a normocytic anemia with marked anisocytosis. Evaluation for other causes of hypoalbuminemia was negative. Therapy for kwashiorkor was instituted, including gradual refeeding, initially via a nasogastric tube because of severe anorexia. Supplements of potassium, phosphorus, multivitamins, zinc, and folic acid were provided. The patient responded dramatically to refeeding with a rising serum albumin and total resolution of the edema within 3 weeks. At follow-up 1 year later he continued to do well on a regular diet supplemented with a milk-based pediatric nutritional supplement. The mortality of kwashiorkor remains high, because of complications such as infection (kwashiorkor impairs cellular immune defenses) and electrolyte imbalances with ongoing diarrhea. Children in industrialized countries have developed kwashiorkor resulting from the use of a nondairy creamer as a milk alternative, but we were unable to find previous reports of kwashiorkor caused by a health food milk alternative. We suspect that cases have been overlooked. Case 2, a 17-month-old black male, was diagnosed with rickets. He was full-term at birth and was breastfed until 10 months of age, when he was weaned to a soy health food beverage, which was not fortified with vitamin D or calcium. Intake of solid foods was good, but included no animal products. Total daily caloric intake was 114% of the recommended dietary allowance. Dietary vitamin D intake was essentially absent because of the lack of vitamin D-fortified milk. The patient lived in a sunny, warm climate, but because of parental career demands, he had limited sun exposure. His dark complexion further reduced ultraviolet light-induced endogenous skin synthesis of vitamin D. The patient grew and developed normally until after his 9-month check-up, when he had an almost complete growth arrest of both height and weight. The parents reported regression in gross motor milestones. On admission the patient was unable to crawl or roll over. He could maintain a sitting position precariously when so placed. Conversely, his language, fine motor-adaptive, and personal-social skills were well-preserved. Generalized hypotonia, weakness, and decreased muscle bulk were present. Clinical features of rickets present on examination included: frontal bossing, an obvious rachitic rosary (photographed), genu varus, flaring of the wrists, and lumbar kyphoscoliosis. The serum alkaline phosphatase was markedly elevated (1879 U/L), phosphorus was low (1.7 mg/dL), and calcium was low normal (8.9 mg/dL). The 25-hydroxy-vitamin D level was low (7.7 pg/mL) and the parathyroid hormone level was markedly elevated (114 pg/mL). The published radiographs are diagnostic of advanced rickets, showing diffuse osteopenia, frayed metaphyses, widened epiphyseal plates, and a pathologic fracture of the ulna. The patient was treated with ergocalciferol and calcium supplements. The published growth chart demonstrates the dramatic response to therapy. Gross motor milestones were fully regained within 6 months. The prominent neuromuscular manifestations shown by this patient serve as a reminder that rickets should be considered in the differential diagnosis of motor delay. (ABSTRACT TRUNCATED)
Beverages↗
Bone marrow and chelatable iron in patients with protein energy malnutrition.
OBJECTIVES: To examine the iron status of malnourished children by comparing bone marrow iron deposits in children with protein energy malnutrition with those in well-nourished controls, and measuring chelatable urinary iron excretion in children with kwashiorkor. DESIGN: Bone marrow iron was assessed histologically in postmortem specimens from children with kwashiorkor or marasmus, and from controls. Twenty-four-hour urinary iron was measured in children with severe kwashiorkor, half of whom received 10 mg/kg of intramuscular desferrioxamine (DFO) on admission. SETTING: Red Cross War Memorial Children's Hospital, Cape Town. SUBJECTS: Thirteen children with kwashiorkor, 6 with marasmus and 16 well-nourished children underwent bone marrow examination. Urinary iron excretion was assayed in 17 children with kwashiorkor. RESULTS: Stainable iron was present in the bone marrow of half the children with kwashiorkor but in only 1 child in each of the other groups. The median iron excretion was 945.5 micrograms/24 hours in the DFO group compared with 28.5 micrograms/24 hours in the non-DFO group. CONCLUSIONS: There is an apparent excess of iron which may predispose to bacterial infections and free radical-mediated injury in children with kwashiorkor.
Bone Marrow↗
Protein-energy malnutrition in northern Sudan: prevalence, socio-economic factors and family background.
The socio-economic and family background and the nutrition of 145 children with kwashiorkor admitted to hospital in Khartoum over a 2-year period were compared with 113 marasmic kwashiorkor, 158 marasmic, and 186 nutritionally normal controls of similar age. Peak admissions for kwashiorkor were in the wet and post-wet season and the mean (SD) age was 1.6 (0.6) months. Mothers of malnourished children were more likely to be pregnant, and had poorer housing, sanitation and water supply, a lower income and food expenditure and less education than controls. Mothers of controls breastfed their children longer, introduced mixed feeding earlier, offered a wider variety of foods, and were more likely to have had their infants immunized. Neither family instability nor cultural practices which result in separation of children from their mothers appear to have an important role in protein-energy malnutrition in the Sudan. Families of kwashiorkor children had a higher food expenditure and better maternal education than marasmic children. There was no significant difference between the two groups in duration of breastfeeding or in the age of introduction of mixed diet. However, kwashiorkor children appeared to be offered more meat. Differences in food availability could account for the relative retardation of growth and lack of subcutaneous fat in marasmus compared to kwashiorkor.
Breast Feeding↗
Skin in protein energy malnutrition.
Protein energy malnutrition (PEM), the most widespread nutritional deficiency disorder of mankind, is a group of related disorders, with a more complex and still incompletely understood etiologic basis than its name suggests. Dermatologic and other clinical manifestations are more florid and characteristic in kwashiorkor than in marasmus. The complex of clinical syndromes that constitute PEM is best considered when using a three-dimensional model to illustrate its varying degrees (ie, mild, moderate, or severe) and the spectrumlike nature of the forms of the severe degree (ie, kwashiorkor, marasmic-kwashiorkor, or marasmus). Protein energy malnutrition is not confined to children in the Third World and is the most common form of undernutrition in hospitalized patients in Western countries. Marasmus is by far the most prevalent form. Much of the nutritional support given in hospitals is not based on an assessment of nutritional status, and little attention is paid to the different forms PEM might take. Even those who do consider this last point confuse hypoalbuminemia in patients acutely stressed or infected with kwashiorkor. Recent evidence suggests that the skin changes of kwashiorkor may be caused by zinc deficiency. Almost nothing is known about the histopathology of the skin per se in PEM but studies of the hair bulb have shown important differences among patients with kwashiorkor, marasmus, and normal skin.
Child↗