Malnutrition after age 1 may cause:

Many experts assert that the damage children suffer if malnourished in the “1,000 day window of opportunity” — pregnancy and the first two years of life — is irreversible and cannot be offset by interventions later in childhood.

But a new study co-authored by a BU School of Public Health researcher calls that into question. The study, published online in the American Journal of Clinical Nutrition, looks at the effects of stunting, or impaired growth in height, in children.

The researchers found that children who were shorter than expected at 1 year of age were often behind in school at 8 years of age and scored lower on cognitive tests than their counterparts who had healthy heights at age 1. But children who experienced greater than expected “catch-up” growth (stunted at 1, but recovered by 8 years old) were more likely to be in age-appropriate classes at age 8 and to have higher scores on standard tests of cognition, when compared to children who remained relatively short.

The researchers concluded that “improvements in child growth after early faltering might have significant benefits on schooling and cognitive achievement.”

Study co-author Kirk Dearden, associate professor of international health and a researcher with the Center for Global Health and Development, said the findings indicate that interventions that improve nutritional status and offer early childhood stimulation—even after the first two years of life—may help to counter the effects of early stunting.

“We’re saying, ‘don’t stop after the first two years, because there’s potential for kids to catch up in growth, learning and cognition.’ Just because kids aren’t doing well in the first year or so doesn’t mean it’s over,” he said.

Dearden is the principal investigator of NIH-funded research at BUSPH that examines nutrition, schooling and cognition; the article’s first author is Benjamin Crookston of Brigham Young University.

The study examined the relationship between growth recovery and cognitive abilities among 8,000 children in Ethiopia, India, Peru and Vietnam enrolled in the “Young Lives” study. The international study is designed to evaluate connections between post-infancy nutritional status, as it relates to growth in height, and school enrollment and cognitive achievements in mathematics, reading and vocabulary.

Because malnutrition is a key factor in stunting, the authors said, their findings reinforce the need “to prevent nutritional insults in early life,” while also emphasizing the importance of promoting child growth beyond the first two years of life.

“Although early interventions are critical,” they said, “interventions to improve nutrition of preprimary and primary school–age children also merit serious consideration.”

In an editorial accompanying the study, Rafael Pérez-Escamilla of the Yale School of Public Health said the findings underscore “previous empirical evidence suggesting that the brain is a highly plastic organ with remarkable ability to improve its function even when interventions start after exposure to nutritional insults during the first 1000 days of life.”

He urged additional studies to examine the potential impacts of nutritional interventions during the 2nd and 3rd years of life and the mechanisms by which nutrition has such important long-term impacts.

Submitted by: Lisa Chedekel

• Overview
• Symptoms and Causes
• Diagnosis and Tests
• Management and Treatment
• Prevention
• Outlook / Prognosis

Overview

What is kwashiorkor?

Kwashiorkor is one of the two main types of severe protein-energy undernutrition. People with kwashiorkor are especially deficient in protein, as well as some key micronutrients. Severe protein deficiency causes fluid retention in the tissues (edema), which distinguishes kwashiorkor from other forms of malnutrition. People with kwashiorkor may look emaciated in their limbs but swollen in their hands and feet, face and belly. The distended abdomen typical of kwashiorkor can be misleading in people who are actually critically malnourished.

Who does kwashiorkor affect?

Kwashiorkor is rare in developed countries. It’s mostly found in developing countries with high rates of poverty and food scarcity. Poor sanitary conditions and a high prevalence of infectious diseases also help set the stage for malnutrition. Kwashiorkor can affect all ages, but it’s most common in children, especially between the ages of 3 to 5. This is an age when many children have recently transitioned from breastfeeding to a less adequate diet — one higher in carbohydrates but lower in protein and other nutrients.

What is the difference between kwashiorkor and marasmus?

Kwashiorkor and marasmus are the two main types of severe protein-energy undernutrition recognized by healthcare providers worldwide. The main difference between them is that kwashiorkor is predominantly a protein deficiency, while marasmus is a deficiency of all macronutrients — protein, carbohydrates and fats. People with marasmus are deprived of calories in general, either because they’re eating too little or expending too many, or both. People with kwashiorkor may not be deprived of calories in general but are deprived of protein-rich foods.

Symptoms and Causes

What are the signs and symptoms of kwashiorkor?

• Edema (swelling with fluid, especially in the ankles and feet).
• Bloated stomach with ascites (a build-up of fluid in the abdominal cavity).
• Dry, brittle hair, hair loss and loss of pigment in hair.
• Dermatitis — dry, peeling skin, scaly patches or red patches.
• Enlarged liver, a symptom of fatty liver disease.
• Depleted muscle mass but retained subcutaneous fat (under the skin).
• Dehydration.
• Loss of appetite (anorexia).
• Irritability and fatigue.
• Stunted growth in children.

What other complications can kwashiorkor cause?

• Hypoglycemia (low blood sugar).
• Hypothermia (low body temperature).
• Hypovolemia (low blood volume) and hypovolemic shock.
• Electrolyte imbalances resulting from dehydration.
• Immune system failure, causing frequent infections and slow wound healing.
• Cirrhosis of the liver and liver failure.
• Atrophy of the pancreas, leading to digestive difficulties.
• Atrophy of the gastrointestinal mucosa, possibly leading to small intestinal bacterial overgrowth.
• Growth and developmental delays in children.
• Starvation and death.

What causes kwashiorkor?

Protein deficiency is the main feature of kwashiorkor, and many researchers believe it's the cause — but not all are convinced. Some have noted cases where dietary protein failed to prevent or improve kwashiorkor. This suggests that protein deficiency may only be part of the picture.

The primary factors associated with kwashiorkor are:

• Diet of mostly carbohydrates. In populations that are considered high-risk, particularly poorer regions of Africa, Central America and Southeast Asia, often the only available food is a type of carbohydrate: rice, corn or starchy vegetables. These crops tend to be cheaper and more abundant than protein-rich foods, especially in rural areas where many are farmers. Mothers who are protein deprived may pass their deficiency on to their children.
• Weaning with inadequate food replacement. The name “kwashiorkor” comes from the Ga language of Ghana, Africa, meaning "the sickness the baby gets when the new baby comes." This describes a common condition in which a nursing toddler is rapidly weaned so that a new baby can begin breastfeeding. Due to a scarcity of resources or ignorance of nutrition, or both, the weaning toddler doesn’t receive an adequate replacement diet, and their nutrition deteriorates.

Other factors that may contribute include:

• Lack of essential vitamins and minerals.
• Lack of dietary antioxidants.
• Aflatoxins — toxins from a mold that commonly grows on crops in hot and humid climates.
• Parasites and infectious diseases, particularly measles, malaria and HIV.
• Significant life stress, including famine, deprivation, war and natural disasters.

Diagnosis and Tests

How is kwashiorkor diagnosed?

Healthcare providers can often diagnose kwashiorkor by physically examining the child and observing its telltale physical signs. They will ask about the child’s diet and history of illnesses or infections. They may measure the child’s weight-to-height ratio and height-to-age and score them according to various charts. The weight-to-height score tells them how severe the child’s condition is. Their height-to-age score tells them how much the child's growth has been affected by malnutrition.

Management and Treatment

How is kwashiorkor treated?

The World Health Organization has outlined 10 steps to follow when treating severe undernutrition:

1. Treat/prevent hypoglycemia. Hypoglycemia can occur when calories are introduced. The rehydration formula for malnourished people includes glucose to help restore balance. It’s given incrementally during the first hours of treatment.
2. Treat/prevent hypothermia. Malnourished bodies have trouble regulating their own temperature, so they must be kept warm.
3. Treat/prevent dehydration. A special formula called RESOMAL (REhydration SOlution for MALnutrition) is given to treat dehydration in kwashiorkor. It’s designed to restore and maintain the body’s fluid/sodium balance. It can be given orally or through a tube.
4. Correct electrolyte imbalances. Electrolyte imbalances can have serious and even life-threatening effects, especially when a malnourished person begins refeeding. Healthcare providers try to address these first, usually in their rehydration formula.
5. Treat/prevent infection. With the diminished immune system that comes with kwashiorkor, all infections are serious threats to recovery. Infections are treated with antibiotics.
6. Correct micronutrient deficiencies. Specific vitamin and mineral deficiencies can have serious effects if they are severe enough. Healthcare providers try to correct these before refeeding.
7. Start cautious feeding. Undernourished bodies have altered metabolism. Refeeding will trigger their metabolism to change again. But if this happens too fast, it can cause life-threatening complications (refeeding syndrome). Feeding begins slowly under close observation. Protein, in particular, should be reintroduced gradually in kwashiorkor.
8. Achieve catch-up growth. Once the child has stabilized and appears to be tolerating refeeding well, their calories can increase to up to 140% of recommended values for their age. The WHO provides ready-made liquid formulas that can be given orally or by tube if necessary. This is the nutritional rehabilitation stage of treatment. It may last up to six weeks.
9. Provide sensory stimulation and emotional support. Children with kwashiorkor may have been in a state of apathy for some time. Their malnutrition may have stunted their intellectual, neurological and social development. Stimulating their development to reboot is part of their treatment plan. Ideally, healthcare providers will include the child’s mother in this project.
10. Prepare for follow-up after recovery. Before discharging the child from care, healthcare providers offer education and counseling to the mother regarding nutrition, breastfeeding, food and water hygiene and disease prevention. They may provide immunizations as necessary. If possible, they should help secure access to a consistent, nutritious food supply.

Prevention

How can kwashiorkor be prevented?

• Education. Some populations simply aren’t informed of basic nutrition, the benefits of breastfeeding or the nutritional needs of children and mothers.
• Nutritional support. The WHO and other organizations are working to reintroduce native crops that offer sources of protein and micronutrients in affected countries. They have developed nutritional formulas made from locally available resources, such as skim milk and peanuts.
• Disease control. Widespread diseases and infections weaken the immunity of high-risk populations. Diseased bodies require more nutritional resources and could shed calories through chronic diarrhea. Diseases also deplete a community’s material resources, breeding poverty. Improved sanitation and immunizations can go a long way toward preventing malnutrition.

Outlook / Prognosis

What is the prognosis for people with kwashiorkor?

Left untreated, kwashiorkor can be fatal. Death may be caused by infection, dehydration or liver failure. When treatment begins, people are also at high risk of complications from refeeding syndrome. However, those who are successfully rehabilitated can make a strong recovery. They may have some lingering effects from kwashiorkor, but they may not.

The complications of kwashiorkor are more severe and last longer the longer they’ve been left untreated. Some children may never fully recover from their growth and development shortages. They may remain predisposed to liver disease and pancreatic insufficiency. Earlier intervention leads to better outcomes.

A note from Cleveland Clinic

Kwashiorkor may not look like malnutrition because it causes swelling and bloating. It also comes with hidden side effects that may be unexpected, such as loss of appetite and fatty liver disease. Kwashiorkor needs to be understood to be treated effectively. Simply feeding with protein may be insufficient and even dangerous. But kwashiorkor should be treated as soon as possible, especially in children. Earlier intervention can help minimize the long-term effects of malnutrition.

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