Kwashiorkor disease is from problem that often in relationship with children, and it's because defeciency of protein and normal or high calories .

1. Kwashiorkor
‫اﻟﻄﻼب‬ ‫إﻋﺪاد‬
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‫ﻋﺒﺪا‬ ‫ﻧﺠﻴﺐ‬ ‫ﻋﻼء‬
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‫ﻫﺪﻳﻞ‬
‫ﻣﺤﻤﺪ‬
‫ﻋﻠﻲ‬
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‫أﺳﺮار‬
‫ﺳﻴﻒ‬
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‫ﻋﺼﻤﺎء‬
‫ﻓﺆاد‬
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‫ﻋﺼﻤﺎء‬
‫ﻋﺒﺪاﻟﻨﺎﺻﺮ‬
‫إﺷﺮاف‬
:
‫د‬
/
‫ﻓﺆاد‬
‫ﻃﺎﻟﺐ‬
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‫أ‬
/
‫اﻟﻌﺎﻣﺮي‬ ‫أﻓﻨﺎن‬
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‫أ‬
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‫ﺣﻤﺎس‬
‫داوؤد‬
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2. Definition :
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Acute protein deficiency with normal or
even high caloric intake .
“The sickness the baby gets when the
new baby comes” in Ghana language
Incidence :
KWO usually affects infant ages between
6 months to 2 years .
Low socioeconomic .

3. Pathophysiology of kwashiorkor :
• in kwashiorkor disease there's two problems :
1- high carbohydrates:
When carbohydratese eexcess convert to fat and
go to the subcutaneous space first location is
buccal cause carbohydratese facies then,fat
accumulation in extremities and finally in
abdominal .when subcutaneous space full with
fat is go to the liver
cause fatty liver. Hepatomegaly

4. Pathophysiology of kwashiorkor:
2- deficiency of protein:
when decrease protein in body is intake protein from
muscles cause muscle wasting .
Then take protein from bone cause osteoporosis
Maybe cause degeneration of cardiac muscles in
neglected cases cause heart failure.
-↓ plasma protein→ Hypoalbuminemia →
↓plasma osmotic pressure .
- Other proposed causes: ↓ Na/k .-ATPase activity &
aflatoxin poisoning
- Increased Aldosterone and ADH → salt and water
retention this Etiology of Edema.

5. Clinical manifestations:
* Essential features:
1- growth failure
but not observed by the mother , Masked by
excess subcutaneous fat and edema .
2-edema
Starts in the dorsa of feet & hands
then the upper and lower limbs
• Edema is bilateral, pitting & painless
• Facial edema produce prominent pale cheeks (
Doll facies )
• Periorbital edema
• With shiny overlying skin
• Ascites and pleural effusion are usually absent

6. Cont. Essential features
3- mental changes:
Patient looks dull , apathetic, miserable,
Due to
- Decrease in thyroxin hormone because it
consists of thyrosine and Iodine so because
thyrosine is amino acids i.e protein cause
hypothyroid function,and mental function
effects .
4. Muscle wasting:
• Muscles are thin, atrophic & weak
• Decreased mid upper arm circumference < 12
cm
• Head circumference / chest circumference
ratio > 1

7. Cont. Clinical features
* Non Essential features : maybe present or not.
1- hepatomegaly
• caused by fat deposits inside liver .
• No hepatocyte damage (No cirrhosis)
• Hepatomegaly is reversible with treatment.
2-GIT manifestations
• Diarrhea due to gastroenteritis and /or
Malabsorption
• Abdominal distension may be due to malabsorption
or hypokalemia
• Anorexia maybe local from GIT disturbance or
central from mental changes .

8. Cont. Non essential features:
3- Skin changes:
Starts as dry scaling skin erythema
hyperpigmentation & desquamation(Crazy paving or
Flaky paint dermatosis)
• Skin infection is common
• Possible causes:
- Vitamin A deficiency
- Essential fatty acids deficiency
- Zinc deficiency
4- Hair changes :
• Hair is lusterless , brittle, sparse, easily pickable
• Progressive lightening of hair; black brown reddish yellow
gray.
• Flag sign:
- Alternating bands of light color & normal color
- In long haired with relapses of malnutrition
• Due to tyrosine and copper deficiency (essential for melanin synthesis)

9. Cont. Non essential features
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5. Anemia: May be due to:
Iron deficiency → hypochromic microcytic anemia
Protein deficiency → normochromic normocytic anemia
Folic acid and/or B12 deficiency → megaloblastic anemia
6. Vitamin deficiency
Vitamin A deficiency (very common) manifested by:
• Eyes : - Xerosis, Bitot spots
-. - Keratomalacia
- - Corneal ulcers and eventual scarring
• Mouth : stomatitis.
Vitamin C cause spongy bleeding gums
Vitamin B2 deficiency : cheilosis, angular stomatitis.
Vitamin D deficiency : it is usually not manifest due to arrested
growth
Vitamin K deficiency causes bleeding tendency.

10. Cont. Non essential features
7 - abdominal distention :
• Possible causes :
1- increase gases inside abdomen due to
maldigestion and malabsorption the
normal flora fermentation food which can't digested ;
when food fermentation occurs lead to increase
gases
2-intestinal obstruction : Due to paralytic ileus ;
because hypokalemia
✓Causes of hypokalemia :
• diarrhoea (loss of gut section )
•Hyperaldosteronism ( increase aldosterone )
Increases aldosterone cause loss of potassium in
urine
take sodium and loss potassium.

11. Complications(DIE B H4)
1- Dehydration: Due to gastro enteritis & anorexia.
2- Intercurrent infections: due to ; immune deficient &
edema is good media for organisms.e.g :
• Gastro enteritis (most common ) .
• TB & bronchopneumona
• Oral moniliasis
3- Electrolyte disturbances:
- Hyponatremia
- Hypokalemia
- Hypocalcemia & hypomagnesemia may be
tetany
4- Blindness: due to keratomalacia secondary to severe
vitamin A deficiency

12. Cont. Complications
5 - Hypothermia; due to: muscle wasting. Decrease
heat production .
6 - Hypoglycemia; due to:
• Commonly associated with sepsis
• malabsorption .
• decrease stores for glucose .
7 - Heart failure due to:
• Severe anemia.
• Volume overload.
• Weak myocardium dilated cardiomyopathy.
8- Hemorrhage due to:
• Vitamin K deficiency.
• Disseminated intravascular coagulation (DIC)

15. Investigations
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1. To support the diagnosis
Plasma proteins:
- Decreased total plasma proteins < 4.5 gm /dl(normal 6-8
gm/dl).
- Decreased albumin < 2.5 gm / dl (normal 3.5 – 5 gm/dl).
Non essential / essential amino acids > 3 (normally ≤ 2 ,
between 2-3 in subclinical cases)
2 . To detect complications
Monitor blood glucose closely
CBC for anemia and leukocytosis in infection
Sepsis workup e.g. CBC with differential, CRP, urinalysis,
stool analysis,blood culture, chest x ray and tests for
tuberculosis
Serum electrolytes/minerals: Na, K, Ca, Mg.

16. Treatment
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1- Prevention techniques :
The best way to prevent Kwashiorkor is by eating a well-
balanced diet; the overall calories must contain a
minimum of 10% and 12% of carbohydrates and protein
respectively.
Pregnant and lactating women should eat only nutritious
foods.
Breastfeeding should be encouraged over bottle feeding.
People should acquire more knowledge of what a
balanced diet is.
Parents should only give birth based on their financial
capacity.
Early symptoms of Kwashiorkor should be reported as
soon as possible to the doctor.

17. Cont. Treatment
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2 - Active treatment:
♦Inpatient or outpatient care?
• outpatient care for clinically well,
uncomplicated and with good
appetite
• Inpatient care for complicated
cases, cases with severe edema and
marasmus kwashiorkor pateints
♦. Stabilization phase (In the
1st 1- 7 days) for:
A– Hypoglycemia
o Glucose l 0% oral, or intra
venous
o Frequent feeding ; 2 hourly day &
night.
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B– Hypothermia
o Proper wrapping/ Warmers
o Treat hypoglycemia &
serious systemic infections
C– Dehydration:
o Preferably oral rehydration
solution (ReSoMal)
o Continue breast feeding
o Intra venous fluids for
severe dehydration.
Hypoglycemia, hypothermia
and dehydration have priority
for treatment in the first 1-2
days of management

18. Cont. Treatment
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D– Electrolytes and minerals correction
o Monitor and correct levels of phosphate, potassium,
calcium and magnesium especially with start of feeding .
E– Infections
o Appropriate antibiotics
o Specific e.g. Anti tuberculous for T.B.
F– Heart failure
- Packed RBCs for anemic heart failure
- Diuretics, vasodilators and cautious use of digitalis
G– Blood transfusion
o Fresh whole blood transfusion for severe anemia:
20 ml/kg for marasmus and 10 ml/kg for KWO.
o Fresh packed RBCs for severe anemia with anemic heart
failure:
10 ml/kg for marasmus and 5 ml/kg for KWO

19. Cont. Treatment
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♦Dietetic treatment:
Route
- Preferably oral
- Nasogastric tube for cases
with severe anorexia
Amount
o Start at 80-100 cal./kg/day in
stabilization phase
o Increase gradually in
Rehabilitation phase (2nd - 6th
week) to a target of
150-220 kcal/kg/d
oProtein intake
o Start with 1-1.5 gm/kg/d and
increase gradually to 4- 6 gm/
kg/d
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Type of food
o If the child is breastfed, encourage
to continue breastfeeding but give the
prescribed amounts of starter formula
(F-75) to make sure the child’s needs
are met
o Severe malnutrition between 6 – 60
months of age benefit from
★Powdered milk–based foods
(Formula diets)
- F75 (75 cal/100ml without iron) for
initial feeding.
- F100 (100 cal/100ml with iron) is
used later in the rehabilitation phase
★Ready to use therapeutic foods
(RUTF)
- A mixture of powdered milk, peanuts,
sugar, vitamins, and minerals
- Much better than formula diets

20. Cont. Treatment
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♦Supportive treatment
1. Multivitamins especially
- Thiamin / Vitamin B complex,
Vitamin A
- Vitamin D: prevents rickets
during period of catch up growth.
2. Minerals especially
- Phosphorus
- Magnesium
- Calcium
- Zinc and Copper
- Iron (should be used after the
first week of treatment).
3. Plasma or albumin .
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♦Follow up phase last
from 7th week to 26th week
o For feeding to cover
catch-up growth
- High protein diets: eggs,
chicken, meat, fish, yogurt,
cheese, beans, &lentils.
- High caloric diets e.g.
potatoes, rice
o Providing emotional and
sensory stimulation
o Weight gain of 15% is a
marker for discharge from
hospital

21. Nursing care of kwashiorkor
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Support the infants and parents
1. Proper diet intake proteins ,CHO and vitamins .
2. Nursing care of vomiting , diarrhea or dehydration .
3. Skin care for child for edema , injuries .
4. Avoid any infection and follow hygienic measures for
child .
5. Frequent assessment of growth and development .
6. Safety measures to avoid injuries .
7. Nutritional counseling .
8. Record intake and output .
9. Health education about medication and follow up.
10. Frequent monitoring for any complications.

22. Prepared by Ala Najib