Kwashiorkor (Edematous Malnutrition)

What kwashiorkor is

The name comes from the Ga language of Ghana and is often translated as "the sickness of the deposed child", the one weaned when a younger sibling is born. It is one of the two classic forms of severe acute malnutrition (SAM):

• Marasmus: severe wasting with loss of fat and muscle, without swelling
• Kwashiorkor: swelling (edema), which can hide weight loss, with skin and hair changes
• Marasmic kwashiorkor: both wasting and edema, carrying the highest risk

Under WHO criteria, any child with swelling of both feet has SAM, regardless of weight or arm circumference.

Kwashiorkor symptoms

• Edema: soft swelling starting in the feet and lower legs that leaves a pit when pressed, spreading to the hands and face in more severe cases
• Skin changes: dry, darkened patches that crack and peel, leaving raw areas, often on the legs, buttocks and groin; skin infections
• Hair changes: thin, dry, sparse hair (hair loss) that turns pale, gray or reddish-brown and pulls out easily. Alternating bands of color are called the "flag sign"
• Swollen belly: from an enlarged fatty liver, weak abdominal muscles and gas
• Mood: apathy, misery, irritability and lack of interest in surroundings
• Poor appetite, diarrhea and vomiting
• Muscle wasting hidden beneath the swelling
• Frequent infections, often with little fever because the immune system is weakened
• Eye problems from accompanying vitamin A deficiency

Causes

Kwashiorkor was once thought to be caused simply by a lack of protein. The real picture is more complex, and children with similar diets can develop either marasmus or kwashiorkor. Contributing factors include:

• Poor diet: low in protein, fats and micronutrients (zinc, vitamin A, selenium, antioxidants), often based on cassava, maize or rice after early weaning
• Infections: measles, diarrheal disease, malaria, tuberculosis and HIV increase nutrient needs and losses and often trigger the onset
• Oxidative stress: low antioxidants such as glutathione may make cell membranes and blood vessels leaky
• Gut microbiome changes and gut damage
• Food toxins such as aflatoxins (from moldy grain) are suspected in some regions

The swelling results from a combination of low blood protein (albumin), leaky small blood vessels and salt and water retention.

Who is at risk

Young children in low-income countries, refugee camps, famines and conflict zones, especially those already showing failure to thrive. In high-income countries, kwashiorkor is rare but has occurred with restrictive "fad" diets, rice-milk or plant-milk diets in infants, severe neglect, and in older adults or people with chronic illness, eating disorders or after gastric surgery.

Diagnosis

Diagnosis is clinical:

1. Check for bilateral pitting edema: press both feet with the thumbs for 3 seconds. Edema is graded as mild (+, feet only), moderate (++, feet and lower legs, hands or lower arms) or severe (+++, generalized including the face).
2. Measure weight, height and mid-upper arm circumference (MUAC).
3. Appetite test with ready-to-use therapeutic food, used to decide between outpatient and hospital care.
4. Look for complications: low blood sugar, low temperature, dehydration, infection and severe anemia.
5. Tests where available: blood glucose, hemoglobin, malaria test, HIV test, urine and blood cultures, albumin and electrolytes.

Treatment

Treatment follows the WHO 10-step approach and has three phases. Feeding too fast can kill: a malnourished body cannot handle a sudden load of food or salt.

Stabilization (first 2 to 7 days)

• Prevent and treat low blood sugar and low body temperature (keep the child warm, feed every 2 to 3 hours, day and night).
• Treat dehydration carefully with special low-sodium rehydration solution (ReSoMal) given slowly, because standard fluids can cause heart failure in edematous children.
• Correct electrolytes, especially potassium and magnesium.
• Give antibiotics routinely, because infections are common and often silent.
• Give micronutrients: vitamin A, zinc, copper, folic acid. Iron is withheld until the child is gaining weight.
• Start F-75 therapeutic milk in small, frequent feeds.

Edema should go down during this phase. Watch for refeeding syndrome and fluid overload.

Rehabilitation (catch-up growth)

Once appetite returns and edema is resolving, children move to F-100 milk or ready-to-use therapeutic food (RUTF), a fortified peanut paste. Many children with uncomplicated SAM who pass the appetite test are treated at home with RUTF from the start, through community programs.

Follow-up

Play and emotional stimulation, education for caregivers, vaccinations (especially measles), and regular growth checks to prevent relapse.

Complications and outlook

Without treatment, kwashiorkor has a high death rate, mostly from infections, low blood sugar, hypothermia, electrolyte imbalance and heart failure. With WHO protocols, mortality in treatment centers falls substantially. Children who recover may have lasting effects such as short stature (stunting) and delayed development, especially if malnutrition was prolonged in the first 2 years of life. Early detection through community MUAC and edema screening improves outcomes.

Prevention

• Exclusive breastfeeding for about 6 months, continuing alongside foods to 2 years or beyond
• Nutritious complementary foods with protein (eggs, beans, milk, meat, fish), fats and fruits and vegetables
• Measles and other vaccines, vitamin A supplements and deworming where recommended
• Clean water, sanitation and prompt treatment of diarrhea
• Growth monitoring and early referral for children who are not gaining weight

Frequently asked questions

What is the main cause of kwashiorkor?

It results from a diet poor in protein, healthy fats and micronutrients combined with infections such as measles or diarrhea. Oxidative stress and gut changes also seem to play a role, which is why not every child on a low-protein diet develops it.

Why do children with kwashiorkor have a swollen belly?

The belly swells because of an enlarged fatty liver, weak abdominal muscles, gas from gut problems and sometimes fluid. Low blood protein and leaky vessels also allow fluid to collect in the tissues, causing swelling of the feet and legs.

What is the difference between kwashiorkor and marasmus?

Kwashiorkor causes swelling, skin peeling and hair changes, and a child may not look thin. Marasmus causes severe wasting without swelling. Both are forms of severe acute malnutrition, and some children have features of both.

Can kwashiorkor be cured?

Yes. With careful, stepwise treatment, most children recover, and the swelling usually resolves within 1 to 2 weeks. Recovery of weight and strength takes weeks to months. Long-term growth and development may be affected if malnutrition lasted a long time.

Can adults get kwashiorkor?

Rarely. It has been seen in adults with severe illness, alcohol use disorder, eating disorders, after weight-loss surgery or with very restrictive diets. In children in high-income countries, it has followed restrictive diets based on rice milk or similar drinks.