case study on kwashiorkor

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Introduction, methods and patients, acknowledgements, conflict of interest statement, informed consent, data availability, kwashiorkor skin lesions: case study on clinical presentation, management and patient caretaker perspectives in maiduguri, north-eastern nigeria.

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Alexandre Bublitz, Christian Manirakiza, Katherine Whitehouse, Abdullahi Chara, Tumba Musa, Kirrily de Polnay, Engy Ali, Kwashiorkor skin lesions: case study on clinical presentation, management and patient caretaker perspectives in Maiduguri, north-eastern Nigeria, Oxford Medical Case Reports , Volume 2023, Issue 7, July 2023, omad053, https://doi.org/10.1093/omcr/omad053

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The management of kwashiorkor disease (KD) in children is challenging in resource-limited settings, especially for those cases with severe skin lesions and its complications. There are no evidenced-based management protocols specific to KD. This article describes the clinical presentation and case management of two children with different presentations of complicated kwashiorkor skin lesions and explores kwashiorkor from the perspective of the children’s caretakers in Maiduguri, Nigeria. Our experience shows that a well-structured approach and careful skin care are crucial. This includes simplified wound care guidance, training of medical staff, strict hygiene measures and the correct choice of antibiotics and antifungals, taking into the account low immunity and vulnerability to opportunistic infections amongst malnourished children. Limited knowledge of kwashiorkor amongst caretakers negatively impacts health-seeking behaviour, resulting in late presentation. Engaging caretakers in the process of care is essential to successful treatment.

Severe acute malnutrition (SAM) amongst children aged 6–59 months exists in two clinical forms: non-oedematous malnutrition (marasmus), defined by either weight-for-height z -score (WHZ) < −3 and/or a middle upper arm circumference (MUAC) < 115 mm, and oedematous malnutrition (kwashiorkor) defined by bilateral pitting oedema [ 1–3 ]. Both can co-exist as marasmic kwashiorkor (oedema plus WHZ score < −3). Whilst marasmic children are severely wasted with a skeletal appearance and often alert and hungry, kwashiorkor disease (KD) present with oedema of the limbs and face, discoloured brittle hair, enlarged liver, skin lesions and are often apathetic with a poor appetite [ 4 ].

Skin lesions of kwashiorkor include hyper-pigmented cracked patches, with hypo-pigmented areas underneath. It is a desquamating skin condition and in severe cases, ulceration might occur, becoming exudative with open skin lesions resembling burns [ 2 ]. This can lead to loss of serum and heat, with associated risk of hypothermia [ 1 ]. Importantly, these lesions can easily become infected and contribute to the viscous circle of infection and malnutrition [ 5 ].

Since 2017, Medecins Sans Frontieres (MSF) has been supporting an inpatient and outpatient therapeutic feeding centre in the protracted conflict zone of Maiduguri, Borno state, north-eastern Nigeria. For over a decade, clashes between non-state armed groups and government security forces have led to huge population displacement and humanitarian suffering including malnutrition.

In MSF Maiduguri nutrition programme, children with kwashiorkor represent 5–13% of monthly admissions, peaking during the annual ‘hunger gap’ (May–September). Most children present with complications including severe skin lesions and sepsis. Whilst the aetiology of kwashiorkor remains elusive [ 4 ], there is also little published information on how to manage its dermatological aspects.

Therefore, this case study describes the clinical presentation, case management, challenges and lessons learnt of two children with different presentations of kwashiorkor complicated skin lesions. We also explored kwashiorkor from the perspective of the children’s primary caretakers.

Skin lesions description and skin care provided for the two cases admitted with kwashiorkor complicated with kwashiorkor dermatosis, at MSF’s nutrition programme, Maiduguri, north-east Nigeria.

Case 1- extensively infected skin lesions : evolution from admission to discharge.

Case 2- necrotic skin lesions : evolution from admission to discharge.

This case study included two children admitted with different presentations of KD, between June and September 2019. During this time, the project implemented a new MSF wound care protocol for KD (see Figure 3 ). SAM was diagnosed and treated in accordance with the WHO guidelines [ 2 , 6 , 7 ]. Data collection included a full review of patients’ medical records, analysis of photographs to assess clinical progress and discussion in the local languages with caretakers to explore their understanding of kwashiorkor and experiences of care. Written informed consent was obtained from the caretakers prior to the initiation of the case study.

Case 1: extensively infected skin lesions

A 2-year-old boy presented with generalized oedema, weakness and skin lesions that had developed over 3 weeks ( Figure 1 ). During that period, the child had been admitted for 3 days in a cholera treatment unit with watery diarrhoea and dehydration. On examination: WHZ score < −3 (weight 8.1 Kg, height 66.5 cm), MUAC 116 mm and bilateral oedema in the feet, legs and hands (grade +++). Vital signs: temperature 37°C; respiratory rate 42 (br/min) and heart rate 122 bpm. The boy looked unwell with general weakness; he was lethargic and apathetic. Heart auscultation showed no murmurs. Chest was clear. Abdomen was soft and painless, and liver was enlarged. Extremities were cold, with weak pulses and prolonged capillary refill time (>3 s). Laboratory examinations showed: Hb of 11.6 g/dl, elevated blood glucose (291 mg/dl) and hyponatremia (120 mmol/L). Skin lesions are described in Table 1 . The child was diagnosed with marasmic kwashiorkor complicated with septic shock because of extensively in fected skin lesions. He was admitted to intensive care unit, with constant monitoring of blood glucose, initially was put on Nil per Os for stabilization, received intravenous (IV) fluids (Ringer’s lactate) and started on broad spectrum antibiotics IV ceftriaxone, cloxacillin and fluconazole. Skin care is described in Table 1 .

MSF Wound Care Protocol.

On Day 2, the child had improved vital signs and the blood glucose monitoring was normal. He started feeding with F-75 via a nasogastric tube, as per guidelines. Despite the initial improvement, he had peaks of fever, loose stools and no improvement of the oedema. On Day 10, because of persistent fever and cold extremities, decision was taken to change the antibiotic from cloxacillin to clindamycin. From then on with intensive skin care as per MSF wound care protocol, the child started to slowly improve, becoming more active, passing normal stools, fewer fever spikes and reduced oedema. By Day 14, the oedema had reduced, and the nutritional treatment was changed to F-100 and then to Ready to Use Therapeutic Food (RUTF) the following day. With these changes, the skin started to slowly re-epithelise, and wet skin lesions started to dry up although the child was still apathetic.

As the child had recurring spikes of fever, he was screened for tuberculosis (TB): there were no signs on chest X-ray and no history of contacts with a TB patient. On Day 20, antibiotics were changed to amoxicillin and clavulanate. Dry skin lesions progressively desquamated and the wet lesions re-epithelised. The most difficult body area to treat was the perineal area, because of continuous contamination with the passage of loose stool. The fever finally stopped after the wet skin lesions were healed. The child was discharged after 34 days of admission with no fever or oedema, and healed skin lesions with no scarification. Discharge weight was 10.15 Kg.

Case 2: necrotic skin lesions

A 3-year-old girl was referred from another hospital after 2 weeks admission there. The child had kwashiorkor with necrotic skin lesions on her left leg ( Figure 2 ) that had shown no improvement with cloxacillin and F100. On examination: WHZ < −3 score (weight 8.6 Kg, height 87 cm), MUAC 102 mm and bilateral oedema in the hands and feet (grade +++). Vital signs were: temperature 38°C, respiratory rate 36 (br/min) and heart rate 136 bpm. The girl was apathetic with sparse discoloured hair. All other systems were normal. Skin lesions are described in Table 1 . The child was diagnosed with marasmic kwashiorkor complicated with necrotic skin lesions secondary to pressure wounds. She was already receiving oral cloxacillin, without improvement; it was switched to clindamycin. Feeding continued with RUTF as she was already on Phase 2 of feeding treatment. Skin care: see Table 1 .

The girl continued to have recurring fever and the necrotic lesions continued to ooze pus. As no improvement was noticed after 72 h of treatment, ceftriaxone IV was added. The child still showed no improvement, with high fever, and thus metronidazole was added on Day 7; thereafter, the fever started to subside. After 7 days of antibiotics (metronidazole, ceftriaxone and clindamycin), and no further fever, antibiotics were changed to oral amoxicillin and clavulanate. Necrotic plaques fell off spontaneously around Day 15.

Whilst the child was gaining weight and improving, she had difficulty moving her left leg, unable to extend it with an effusion over her left knee. On Day 25, a suspicion of a septic arthritis was raised. Therefore, the child was reinitiated on ceftriaxone and clindamycin, an X-ray was done, and the child referred for surgical consultation. Septic arthritis was ruled out by the surgical team of another humanitarian organization and antibiotics were discontinued. Bed-side physiotherapy of the affected limb was commenced by the nursing team and the caretaker. The child continued to improve, gaining weight, with the open skin lesions gradually closing; she was discharged to outpatient nutritional care after 38 days of admission, walking and playing. Discharge weight was 10.5 Kg.

To explore kwashiorkor from the perspective of the children’s caretakers, one-to-one discussions were held with the assistance of a translator. Three main areas emerged that have implications for programmatic improvement.

1. Limited knowledge or understanding of kwashiorkor at the individual and wider community levels negatively impacted health-seeking behaviour. Cultural understanding led caretakers to initially use informal pharmacies and traditional medicines, which delayed presentation to formal health care.

CGV 1 “People believe that this illness is caused by the sun… making the bodies swell up. There is a traditional medicine that can be given to treat this illness. It’s just a tree. If you go to the market […] they will give it to you already prepared. It’s in a powder form, and you mix it with water and then you give it to the child… then it will kill the warmth inside the body and the illness...”

2. Primary caretakers perceived the quality of care provided to be high, but they did not fully understand what the treatment comprised. Communication between the medical team and the caretaker regarding the diagnosis and care of the patient was identified as a neglected component. Caretakers described their frustrations with very limited communication between them and the health team, and their subsequent inadequate understanding of kwashiorkor as a form of malnutrition.

CGV 2: “Apart from the skin wounds, I don’t know why she is here […] No one has told me what the problem is with [my daughter]. I would like to know more about what it is so that I can understand better.”

CGV 1: “I was worried. Seeing how my child was, and the intensity of the treatment he was receiving I started to lose hope that the child would not make it … I wanted to know what was happening. I even asked someone to explain to me what was happening. But nobody did.”

3. The critical role of primary caretakers in the process of care, particularly in relation to major responsibilities for the hygiene and nutrition of the child, was acknowledged. They described their willingness to be actively engaged in provision of care, detailing some specific tasks they had received instruction on; however, they needed further knowledge and support to fully cooperate with treatment plans.

CGV 1: “I have no option [but to look after] my child. […] I was happy about the things I was asked to do, I was happy to know about these things so that I can help him to get better.”

CGV 2: “They taught me how to do physiotherapy for the child, especially for the limbs, because without this she would not be able to stand again. […] They asked me to clean the baby very well. If I am going to feed my baby, I should wash her face and mouth. And to take care of her hygiene.”

These findings highlight the need to strengthen knowledge and referral pathways at the community level for more timely access to care. Within the health structure, a more proactive approach to communication with patient caretakers is needed to address inadequate knowledge of kwashiorkor diagnosis and ensure full engagement with treatment.

Our case study highlights important lessons for managing KD in resource-limited settings. The two children presented with extensive skin lesions and sepsis, one infected in the perineal area and the other with large ulcerating lesions.

In this context, without cultures available to detect antibiotic sensitivity, antibiotic choice should include broad spectrum coverage and effectiveness against common skin pathogens (staphylococcus and streptococcus). Additionally, as SAM children have low immunity [ 4 ], facilitating opportunistic fungal infections, antifungal medication may be necessary [ 8 ].

Because of the deficient nutritional state and immunological vulnerability of the children as well as the fact that the cause of the skin lesions still not fully understood, wound care must be ‘empirical’. However, following a specific wound care protocol, such as MSF’s, is recommended and should not be overlooked as part of management of SAM children. This includes training of staff for wound assessment and treatment based on key principles: a holistic approach, appropriate cleansing of the wound, rational use of antiseptic and wound bed preparation on a balanced moist environment [ 5 ].

An important aspect of care is hygiene measures to prevent further infection. Care should include: cleaning the skin after passing stool and urine or considering the use of urinary catheter, changing bed sheets daily, using mosquito nets to prevent flies from landing, cutting nails to avoid scratching and pain management for comfort [ 5 ]. Careful infection control measures for staff, especially hand hygiene, need to be followed. Consumables and appropriate wound care products, such as sterile gauze, bandages, antiseptic solution, hydrating cream and zinc oxide ointment, need to be available and correctly used (e.g. no adhesive on damaged/sensitive skin). In this setting, despite personal hygiene advice given to caretakers, care of the perineal area was not optimal.

During treatment, the timing and type of therapeutic feeding plays a significant role in the recovery and regeneration of kwashiorkor skin lesions. Re-feeding the child should start when all signs of shock are resolved, the child is awake and has no signs of ileus (abdomen is soft, non-distended) [ 8 ]. Moreover, the duration in Phase 1 with F-75 feeds should be monitored, and not shortened, as patients need time to recover from oedema. Conversely, there is a need to increase calories and protein through a timely transition to F-100 and/or RUTF, as soon as the child shows signs of recovery [ 8 ].

One important aspect, and often neglected, is the caretaker’s understanding of the child’s illness and needs. This was observed in our project, where many caretakers did not perceive kwashiorkor as a type of malnutrition. This influenced their health-seeking behaviour and led to late presentation, often complicated with sepsis. Health promotion in the community should focus on raising awareness of kwashiorkor as a disease.

In addition, communication between the medical team and caretakers on the diagnosis and care of the patient should be improved. The role of caretakers is essential in the treatment plan, as they become the essential factor to ensure the children’s hygiene and nutrition, specifically in cases with compromised skin barrier and high risk of nosocomial infections.

Operationally, an important factor is that hospitalization of complicated KD can be quite long (our cases were 34 and 38 days); this has a major impact on bed occupancy. Treating these patients optimally would reduce admission time, but care centres should anticipate longer admission periods for these patients, especially during peak periods of admissions (e.g. hunger gap and measles outbreaks) [ 9 ]. An outpatient service, where we could attend stable patients with regular dressing changes could also be an alternative to shorten the admission times.

In conclusion, Kwashiorkor skin lesions are an important complication of kwashiorkor, increasing a child’s vulnerability to sepsis. Management of these cases is challenging in resource-limited contexts, demanding a well-structured approach. This case study points to key elements of care: better use of antibiotics, fastidious care of skin lesions, excellent hygiene measures and engagement of caretakers.

We would like to thank Tony Reid for his editorial help.

None declared.

Not required.

Written informed consents were sought and obtained from the two caregivers.

Data resulted from this study are available from Medecins Sans Frontieres on reasonable request.

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• Case Report
• Open access
• Published: 21 August 2015

A kwashiorkor case due to the use of an exclusive rice milk diet to treat atopic dermatitis

• Francesca Mori 1 ,
• Daniele Serranti 2 ,
• Simona Barni 1 ,
• Neri Pucci 1 ,
• Maria Elisabetta Rossi 1 ,
• Maurizio de Martino 3 &
• Elio Novembre 1  

Nutrition Journal volume  14 , Article number:  83 ( 2015 ) Cite this article

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Although several cases of severe hypoalbuminemia resulting from rice milk have been described in the past, today the use of rice milk without nutritional counseling to treat eczema is still a continuing, poor practice. We describe a kwashiorkor case in an infant with severe eczema exclusively fed with rice milk. It is well documented that rice milk is not a sufficient protein source. Moreover, only a small portion of eczema is triggered by food allergy. In conclusion this case raises the importance of managing dietary changes facing food allergies with responsibility for specialized consensus among pediatricians, nutritionists, endocrinologists and allergists all of them specialist professionals.

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We describe a case of severe hypoalbuminemia provoked by an unnecessary and inappropriate elimination diet based on rice milk in an infant with severe atopic dermatitis (AD), which was thought to be secondary to food allergy.

Case presentation

An exclusively brestfed boy infant developed AD at the age of 4 months. In the beginning, the eczema was treated with antibiotics, topical steroids and brief courses of oral steroids. The mother was dissatisfied by the outcome of the pediatrician’s advice so she consulted a naturopathic doctor who prescribed a restricted diet.

At 6 months the child’s daily diet consisted of rice milk, fruits, rice poultry and vegetable broth.

After about 2 months of this diet, the child began to reject the food, in particular solid foods and to suffer from dysphonia and dysphagia due to the occurrence of laryngeal edema. Because of this the child was given only rice milk. After a few days the edema appeared on his feet, legs and upper extremities followed by a reduced urine output. He had no symptoms of gastroesophageal reflux, but he had forceful vomiting. When hospitalized, he was in a poor clinical condition with generalized edema (Fig.  1 ) and low urine output. He weighed 7.600 Kg from the age of six months up to 1 year. Blood and urine findings were normal except for the following results: total protein 3 g/dl; albumin 1.365 g/dl (45.5 %); total serum IgE 30 KUA/L; specific serum IgE: milk 0.64 KUA/L; albumen 1.74 KUA/L. Protein was not found in the urine. He required central access due to difficulty obtaining peripheral access due to severe edema. He was also found to be anemic with a haemoglobin 5.7 g/dl and he received 4 g of albumin three times in 48 h, a red blood cells transfusion, oral iron and folic acid. Vitamin K was also supplied because of a state of coagulopathy [activated partial thromboplastin: 31 s; prothrombin time 69 % (normal value: 80–100 %)]; fibrinogen 139 mg/dl; antitrombin III: 65 % (normal value: 80–100 %)]. The child was immediately fed with cow’s milk, which was well tolerated. Guidance from a nutrionist was essential and the edema gradually resolved.

After few days diuresis increased and weight initially decreased. Eczema improved and scratching was less evident thanks to topical treatment. Haematic examinations performed on day 10 showed a normalization of total protein, albumin and clotting tests. On follow up the skin prick test was negative to milk and egg allergy.

Because of a long lasting low blood calcium level (7.3 mg/L), he developed demineralization of his teeth, persisting at the follow up visits up at 2 years of age.

This kwashiorkor case highlights the potential danger of inappropriate elimination diets in infants with AD, and illustrates the need for careful nutritional guidance in the management of AD. The use of rice milk resulted in hypoalbuminemia and poor weight gain.

Eczema is a chronically relapsing inflammatory skin disease and one of the most common skin disorders affecting up to 17 % of children [ 1 ], and it can rarely be managed with dietary changes alone.

Previous studies described similar cases [ 2 – 5 ], showing that alternative to cow’s milk such as rice in spite of fortification are not a sufficient protein source.

The very first case was described by Carvalho NF et al. in 2001 [ 3 ]. In 2003 Novembre et al. described a similar case [ 4 ] and after more than 10 years the same mistake is still not so rarely made.

Conclusions

This case reinforces the concept that hypoallergenic diets should be managed by allergists with experience in food allergies. Consultation and consensus should be achieved between specialists in pediatrics, allergy, nutrition and endocrinology, before adopting severely restrictive diets. Consequently, the choice of an elimination diet should be limited to children with moderate to severe eczema not controlled by topical steroids, under strict nutritional surveillance [ 6 – 8 ].

Written informed consent was obtained from the patient for the publication of this Case Report and any accompanyng images. A copy of the written consent is available for review by the Editor-in-Chief of this Journal.

Abbreviations

Atopic dermatitis

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Acknowledgements

The authors express their gratitude to the parents of the patient, who graciously authorised the publication of the information here expressed.

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Allergy Unit, Anna Meyer Children’s University Hospital, Viale Pieraccini 24, 50139, Florence, Italy

Francesca Mori, Simona Barni, Neri Pucci, Maria Elisabetta Rossi & Elio Novembre

Department of Health Sciences, University of Florence, Viale Pieraccini 24, 50139, Florence, Italy

Daniele Serranti

Infectious Diseases Unit, Anna Meyer Children’s University Hospital, Viale Pieraccini 24, 50139, Florence, Italy

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Correspondence to Francesca Mori .

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Authors’ contributions

FM has made substantial contributions to conception and design, acquisition of data, analysis and interpretation of data; DS has been involved in drafting the manuscript and revising it critically for important intellectual content; SB has made substantial contributions to conception and design, acquisition of data, analysis and interpretation of data, NP has been involved in drafting the manuscript and revising it critically for important intellectual content; EMR has made substantial contributions to acquisition of data and interpretation of data; MdeM has made substantial contributions to conception and design, acquisition of data, analysis and interpretation of data; EN has given final approval of the version to be published and was agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All authors read and approved the final manuscript.

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Mori, F., Serranti, D., Barni, S. et al. A kwashiorkor case due to the use of an exclusive rice milk diet to treat atopic dermatitis. Nutr J 14 , 83 (2015). https://doi.org/10.1186/s12937-015-0071-7

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DOI : https://doi.org/10.1186/s12937-015-0071-7

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• Atopic Dermatitis
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Kwashiorkor skin lesions: case study on clinical presentation, management and patient caretaker perspectives in Maiduguri, north-eastern Nigeria

Affiliations.

• 1 Medecins Sans Frontieres, Operational Centre Brussels, Nigeria Mission, Abuja, Nigeria.
• 2 Medecins Sans Frontieres, Operational Centre Brussels, Medical Department, Luxembourg Operational Research Unit (LuxOR), Luxembourg, Luxembourg.
• 3 Medecins Sans Frontieres, Operational Centre Brussels, Medical Department, Brussels, Belgium.
• PMID: 37484551
• PMCID: PMC10359055
• DOI: 10.1093/omcr/omad053

The management of kwashiorkor disease (KD) in children is challenging in resource-limited settings, especially for those cases with severe skin lesions and its complications. There are no evidenced-based management protocols specific to KD. This article describes the clinical presentation and case management of two children with different presentations of complicated kwashiorkor skin lesions and explores kwashiorkor from the perspective of the children's caretakers in Maiduguri, Nigeria. Our experience shows that a well-structured approach and careful skin care are crucial. This includes simplified wound care guidance, training of medical staff, strict hygiene measures and the correct choice of antibiotics and antifungals, taking into the account low immunity and vulnerability to opportunistic infections amongst malnourished children. Limited knowledge of kwashiorkor amongst caretakers negatively impacts health-seeking behaviour, resulting in late presentation. Engaging caretakers in the process of care is essential to successful treatment.

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• Published: 19 May 2015

The social context of severe child malnutrition: a qualitative household case study from a rural area of the Democratic Republic of Congo

• Hallgeir Kismul 1 ,
• Anne Hatløy 2 ,
• Peter Andersen 3 ,
• Mala Mapatano 4 ,
• Jan Van den Broeck 1 &
• Karen Marie Moland 1  

International Journal for Equity in Health volume  14 , Article number:  47 ( 2015 ) Cite this article

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Introduction

The magnitude of child malnutrition including severe child malnutrition is especially high in the rural areas of the Democratic Republic of Congo (the DRC). The aim of this qualitative study is to describe the social context of malnutrition in a rural part of the DRC and explore how some households succeed in ensuring that their children are well-nourished while others do not.

Methodology

This study is based on participant observation, key informant interviews, group discussions and in-depth interviews with four households with malnourished children and four with well-nourished children. We apply social field theory to link individual child nutritional outcomes to processes at local level and to the wider socio-economic environment.

We identified four social fields that have implications for food security and child nutritional outcomes: 1) household size and composition which determined vulnerability to child malnutrition, 2) inter-household cooperation in the form of ‘ gbisa work party’ which buffered scarcity of labour in peak seasons and facilitated capital accumulation, 3) the village associated with usufruct rights to land, and 4) the local NGO providing access to agricultural support, clean drinking water and health care.

Conclusions

Households that participated in inter-household cooperation were able to improve food and nutrition security. Children living in households with high pressure on productive members were at danger of food insecurity and malnutrition. Nutrition interventions need to involve local institutions for inter-household cooperation and address the problem of social inequalities in service provision. They should have special focus on households with few resources in the form of land, labour and capital.

Malnutrition contributes significantly to mortality in children under five years and in 2011 it was estimated that about 45 % of child deaths could be attributed to malnutrition [ 1 ]. Marasmus and kwashiorkor are both forms of severe malnutrition and have especially high mortality rates [ 2 , 3 ]. While Marasmus is characterised by extreme wasting, Kwashiorkor is characterised by oedema and the aetiology of this disease is still uncertain. Child malnutrition in the form of stunting, wasting, underweight and severe malnutrition has significant implications for healthy human development in terms of motor skills, and cognitive and social development [ 4 – 7 ]. There are several pathways to malnutrition. Poor diet and illness have been identified as immediate factors that contribute to the development of malnutrition, food insecurity has been identified as an intermediate factor, and socio-economic conditions as underlying causes [ 8 ]. Growing social inequalities and determinants of health attracted special attention during the last decades [ 9 , 10 ]. In low and middle-income countries there is evidence of increasing social inequalities in child nutrition with the highest rates of malnutrition being found in the poorest segments of the population [ 11 – 14 ]. Urban–rural inequalities in child malnutrition are frequently found with a higher risk among the rural population [ 15 – 20 ]. The factors that affect nutrition in rural and urban areas differ and a higher reliance on agriculture and natural resources, and a lesser dependency on cash income are characteristic of rural areas. [ 15 ]. The majority of rural people in low-income countries live on small farms of less than one hectare and agriculture is the foremost provider of food and the principle source of income [ 21 – 23 ]. Sub-Saharan Africa is more dependent on agriculture than any other region in the world and small-scale agriculture is particularly important [ 24 ]. In areas that strongly depend on agriculture there is a close linkage between agriculture and nutrition. Agriculture as a source of food is the most direct pathway between agriculture and nutrition [ 25 ]. The urban–rural gap in malnutrition has also been attributed to factors such as education, access to quality food and availability of health services [ 15 , 17 , 18 , 20 ]. Maternal education, especially education at secondary level, is considered to be among the most important factors that explain urban rural differences in malnutrition [ 17 , 18 , 20 ]. Besides investigating inter-household inequalities, several studies have examined intra-household inequalities in nutrition. While studies from South Asia have reported discrimination against girls in food allocation and malnutrition being more common among girls than boys [ 26 – 29 ], research from sub-Saharan Africa on gender inequalities in nutrition is inconclusive [ 30 – 33 ].

The Democratic Republic of Congo (the DRC) is among the countries in the world with the highest rates of child malnutrition [ 1 , 34 ]. Although malnutrition is widespread in all provinces there are important geographic variations and the occurrence is significantly higher in rural than in urban areas [ 34 , 35 ]. While the prevalence of stunting in rural areas in 2013 was 47 % it was 33 % in urban areas. In the rural areas of the DRC subsistence agriculture is the major livelihood for the majority of the households [ 36 , 37 ]. Currently there are several constraints to subsistence production: farmers cultivate small land-holdings, they rely on traditional cultivation technologies, have limited access to agricultural input, infrastructure is poor and pressure on the productive population is high [ 35 , 36 , 38 ]. In the context of civil war the subsistence agricultural sector has also been seriously neglected by the government and development agencies [ 37 ].

In small-scale agricultural communities the household is typically the unit responsible for food production and consumption [ 39 , 40 ]. Hence, the social organisation of the household has important implications for food and nutritional security [ 39 ]. In this paper we explore how household characteristics, access to land and inter-household cooperation affect food security and vulnerability to child malnutrition in an environment where subsistence agriculture is dominant. Using the Bwamanda area, located in a rural part of western DRC as a case, we aim to describe the social context of food production and nutrition, and explore how some households succeed to ensure that their children are well-nourished while others do not.

Study setting

The democratic republic of congo (the drc).

The DRC is located in south-west central Africa and is the second largest country in Africa. It is divided into ten provinces and one city province (see Fig.  1 map). In terms of natural resources it is among the richest countries in the world and has a diversity of mineral and forest resources [ 41 ]. It also has an environment that is favourable for agricultural activities and allows for two harvests per year [ 42 ]. Despite the DRCs wealth in natural resources, its population is among the poorest in the world and because of its poor scores with regards to income, health and education it is ranked as second to last according to the Human Development Index [ 43 ]. There is a rural–urban gap in poverty disfavouring rural areas where eight out of ten households are living below the poverty line of 1.25 dollars a day while in urban areas it is less than seven out of ten [ 41 ]. Since 1997 and until now the political situation in the country has been characterised by civil wars and corruption. The death toll of the civil war, 1998 – 2004, has been estimated to 3.9 million [ 44 ]. The conflicts have restricted the country’s ability to promote development and it is still strongly dependent on foreign aid [ 37 , 45 ].

Map The Democratic Republic of Congo, provinces and location of Bwamanda

The Equatorial province

The Equatorial Province where this study was undertaken is situated in the north-west part of the country. The province covers an area of 403.292 km 2 , 17 % of the DRC, and is composed of five districts. It has a population of five million. According to a UNDP report from 2009 as much as 94 % of the population was living below the poverty line of 1.25 dollars a day, the province was the poorest in the country [ 46 ]. The proportion of children suffering from malnutrition in 2013 was high: 57 % of the children under five years of age were stunted and 7.6 % wasted [ 34 ]. With prevalence in 2007 of 10.5 %, this province had the highest proportion of children with kwashiorkor [ 47 ].

Bwamanda area

The study was carried out in the Bwamanda area in the north-west of the Equatorial Province. Bwamanda village and its surrounding villages form the Bwamanda area, with a total population of about 209,000. The Ngbaka is the dominant ethnic group. Their principle livelihood is subsistence agriculture [ 48 – 50 ]. Bwamanda is a large village that has grown into a centre with a marketplace, a hospital and associated health centres. The Bwamanda hospital operates as a first referral hospital for the health district/zone of Bwamanda. Currently, the local NGO, Centre de Développement Intégral Bwamanda (CDI-Bwamanda) is responsible for providing social services in the area.

Data collection

This qualitative study is part of a larger project on malnutrition in the Bwamanda area [ 49 , 51 – 53 ]. The data were gathered during three fieldwork visits: October and November 2012- February- March 2013, and in November 2013. Data collection and translation was done with the assistance of a secondary school teacher teaching English and French. Prior to data collection the first author provided him with a three days training in conducting semi-structured interviewing and organising group discussions. We used purposive sampling of households of two groups based on the criteria of (1) recent history of severe malnutrition and hospitalisation of a child in the household, and (2) absence of a recent history of malnutrition among children in the household.

We met with nurses and physicians working in the hospital and identified four cases of children under-six-years who had been hospitalised for, and later recovered from marasmus and kwashiorkor. With the assistance from nurses at health centres, four households with children under-six-year who had not suffered from malnutrition were also selected. During vaccination the health centres had conducted anthropometric assessment and the results had been registered on the children’s health cards. The nurses used this information to identify children that had been assessed using normal weight for age charts and found not to be underweight. We had thereby identified eight households in five different villages which were eligible for inclusion in the study. These eight households comprised 12 girls and 17 boys below six years, 24 girls and 11 boys above six years and 24 adult women and 21 men.

Triangulation of data collection methods were applied (see Table  1 ). Participant observation was used both to map agricultural activities, and the spatial organisation of the villages, and within households to understand household composition, organisation of food production consumption. Semi-structured interviews were conducted with the fathers and mothers of the children as well as other adult household members of all selected households. During the interviews, social factors associated with food production and the children’s nutritional status were discussed. To obtain information about socio-economic conditions and social service provision, key informant interviews were conducted with local leaders including the village chief, village secretary, chief assistants and older respected women.

Finally, two focus group discussions were held with male and female leaders to gain a better understanding of the Ngbaka socio-economic organisation including social differentiation. The observation, interviews and focus group discussions were all carried out in the Ngbaka language and translated by the interpreter. All interviews were tape recorded. After each interview the interpreter and the first author went carefully through the tape-recorded interview. The interpreter translated each point raised in the interview orally into English and the first author took notes. The meaning and interpretation of the interview data were then extensively discussed. Field notes from observation and informal conversations were kept in addition to reflection notes from each day of the fieldwork. These served as guides for analysis.

Field theory and data analysis

Field theory.

A social field is a domain of social life that has its own rules of organisation and unique characteristics that generate the conditions for the individuals who live in a society [ 54 ]. The social fields can be identified in terms of extension in social space, time, number of people and its distinctive characteristics [ 55 , 56 ]. In the process of identifying social fields the spatial aspect of social fields is in particular important [ 54 , 57 ]. The fields are interconnected and the theory enables an analysis of how events at the local level are connected to processes at the macro level [ 56 ]. The concept of the social field can be used to study the relationship between social factors on different levels that shape food production, consumption and nutritional outcomes. Concretely the theory allowed us to examine how the household as a micro level domain is linked to other social domains and how the dynamics between these domains produce social inequalities in nutritional outcomes. In our field analysis we put emphasise on social organisational aspects of social fields and do not analyse fields as socio-cultural entities with their own forms of communication. We therefore do not analyse meaning and our approach differ from a qualitative content analysis.

Data analysis

During the field work we observed and discussed with key informants how location related to food production and consumption. We examined this relation with respect to smaller areas including the compound, the neighbourhood, the village and larger areas such as agricultural fields, natural areas in the vicinity of the villages and the Bwamanda area. In this manner with could identify separate bounded areas that we term social space. We identified major characteristics of social activities by describing the context of production and consumption. Making linkages between social space and activities with their own characteristics we could begin to delineate separate fields. Through the description of the household cases we further singled out field characteristics and fields’ implications for nutrition. By having identified the social fields we were able to present factors that could be easily compared and analysed. We performed cross case-case comparisons and analysed how the fields had different implications for food security and nutritional status. Household cases were used to show the linkage between social organisation and nutrition and we therefore did not use quotes to highlight this relation.

Ethical issues

Ethical clearance was provided by the Regional Committee for Medical and Health Research Ethics, Western Norway and by the Ethical Committee at the School of Public Health, University of Kinshasa, the Democratic Republic of Congo. For ethical reasons we recruited children who previously had suffered from malnutrition. In regards to the fieldwork and data collection, an information sheet and informed consent form were prepared in the Ngbaka language. We explained the content of the form to each participant and obtained informed consent before starting any data collection including consent to record the interviews. Finally, although the households are described in detail in the findings section, we strived to keep names and location confidential.

The first section gives an account of the Ngbaka socio-economic organisation and we describe characteristic activities relating to food production, consumption and nutrition. The description of socio-economic context is used as a backdrop for organising the household cases and links between the social context and nutritional outcomes. In the second section eight household cases are presented: the first four are households with a history of severely malnourished children and the last four are those with well-nourished children. Table  2 gives an overview of household cases structured in accordance with the description of the socio-economic context.

Ngbaka socio-economic organisation

Village leadership and access to land.

The Ngbaka live in villages whose names typically begins with the pre-fix bo which means descendant, followed by the name of the founder of the village. Each village has a chief ( capita ) who is supported by several assistants. Land administration is a major task of the village leadership with the leaders negotiating in land conflicts and being responsible for land redistribution. In Bwamanda, land is under a traditional community-based property system and individual farmers are entitled to usufruct rights. In accordance with the Ngbaka patrilineal descent system land rights are transferred from father to son. In order to uphold usufruct to land the family is required to continuously cultivate it and reside in the village.

Food production

The Ngbaka farmers produce their staple foods through shifting cultivation and a household’s planted land commonly covers less than one hectare. Maize and cassava are staples and groundnuts and palm oil are major cash crops. Some farmers also grow crops such as taro, sweet potatoes, pigeon peas, beans and various vegetables and fruits. Farming techniques are very traditional; all operations are done by hand, farmers do not have access to draught animals and fertilisers are unavailable. Agricultural fields are cleared during the first two months of the year, planted and weeded in April up to the beginning of June. The first harvest of maize takes place in June and the other in November, while farmers begin to harvest cassava in October. After three to four years the soil is exhausted and land is left fallow for several years. Fallow land is sometimes used for oil palms and tree crops. To supplement crop production poorer farmers keep poultry and guinea pigs while better-off farmers raise pigs, sheep, goats and cattle.

In addition to agriculture the Ngbaka hunt, gather wild food and fish. Men hunt whereas women gather wild food, but both men and women fish. While men fish using rods, nets and traps, women catch fish in temporarily dammed pools as they drain out. Natural resources in Bwamanda are widely dispersed; agricultural fields can be located up to 4 h walk from the homesteads and in the dry season people go on foot for several hours to fish in the rivers.

Food consumption

The Ngbaka normally eat two meals per day with a main meal that typically consists of ka, a stiff porridge made from cassava and maize flour. Porridge is served with a stew of cassava leaves, sometimes enhanced with fish and groundnuts. In between meals, adults and children drink tea with sugar and eat various fruits. Infants are predominantly breastfed up to three months old, at which point solid food is introduced to complement breast milk. Breastfeeding normally continues for up to three years. Early complementary food consists of gruel typically made from ka and cassava-leaf stew. During meals household members are served the same food, but split into groups; women and young children in one group, older children in another and men in the third.

Labour organisation and inter-household cooperation

Agricultural work is carried out by the household members and has a gender-based division of labour. Men are responsible for clearing land and women do most of the work during weeding and harvesting. Farmers also mobilise labour and capital through the traditional gbisa . These are reciprocal groups consisting of close kin and neighbours that are mobilised to solve tasks that the household unit have difficulties solving alone such as land clearing and timely weeding. During gbisa the host serves ka and cassava leaves and farmers who can afford it serve meat, fish and palm wine. Farmers underline the importance of gbisa and, by organising such groups, they are able to achieve a good harvest and provide household members with sufficient food. Male gbisa is also organised for capital accumulation with groundnut gbisa being the most common example. In the first year, the person who initiated the group receives an agreed upon number of sacks of groundnuts from group members, and in the following years others obtain sacks of groundnuts on a consecutive basis. Capital from groundnut gbisa is typically invested in livestock, bicycles and sewing machines. There is also a second form of gbisa for capital accumulation whereby the group establish a revolving fund that provides cash in a sequential manner to its members.

Household organisation

Our study illustrates how households vary in size and composition. There are large multi-generation households and households that are large partly as a result of influx of children from households that have ceased to exist. Other households are large due to polygamy. Small households comprise nuclear families where the sons have broken away from their family and established their own households. The Ngbaka are patrilineal and practice patrilocality, with the wife moving to her husband’s father’s household after marriage. Local people use wealth to differentiate between households and distinguish three categories—relatively wealthy, average and poor—using the following terms in Ngbaka. The relatively wealthy cultivate a variety of cash crops including palm oil and many have become wealthy through gbisa . The averagely wealthy are able to produce enough food for their household members during normal years, while the poor are not. The poor are also characterised by their limited capacity to participate in gbisa as a result of not being capable to provide the food required to host a gbisa and being considered by other farmers as unable.

Service provision

In Bwamanda the NGO, CDI-Bwamanda, has filled the gap in public service provision. Services provided by the NGO include health care, access to safe drinking water and agricultural support. Currently the organisation runs the Bwamanda hospital and associated health centres. In order to improve access to drinking water the NGO has developed a number of deep borehole wells. CDI-Bwamanda has made several efforts to stimulate agricultural growth and provided farmers with improved planting material, facilitated transport of maize for sale in Kinshasa and promoted coffee as a cash crop. A tsetse control program has permitted cattle raising, which was difficult earlier due to trypanosomiasis (sleeping sickness). Due to a decline in financial assistance from international donors over recent years, the organisation has had to scale down its operation and now concentrates on health services. In spite of this CDI-Bwamanda health services are inadequate because of a shortage of qualified staff, basic equipment and essential medicine including ready-to-use therapeutic food to treat child malnutrition. A few years back the hospital received funding for developing local therapeutic food, but funding for this project has ceased.

Case studies

It is in the context of the Ngbaka socio-economic organisation that the household cases must be understood and we have structured the case narratives so that the relationship between the social environment and nutrition becomes more evident. For each case we have therefore described food production, household organisation, inter-household cooperation and household access to social services.

Households with children with a history of marasmus

A three-year-old boy was brought to the health centre by his parents in December 2012. He was referred to the hospital, where he was diagnosed with marasmus. Before the child was hospitalised for marasmus the household had insufficient food, and all it could provide the child with was ka and cassava leaves. The household comprised five members including the father (29) the mother (28), the boy (3) and twins, 17 months. Another son had died from marasmus a few years back, aged three. The parents of the child first lived with the father’s family, but as the household grew larger, they decided to move and find their own place. Following land redistribution carried out by the village chief, the couple obtained access to a homestead and agricultural land, with one plot for maize and one for cassava. For clearing the land the father involved a gbisa . With their children being so sick, the parents had not been able to spend the necessary time tending to their two plots, and consequently weeds suppressed their fields resulting in poor harvests. Caring for the sick boy and breastfeeding the twins had made it hard for the mother to find time for fishing. Buying fishing hooks was also an unaffordable expense and the father could therefore not go fishing. They failed to produce a sufficient amount of food and had no stores of maize and the family had to subsist on cassava from the fields. Their opportunity to supplement their cassava- and maize-based diet with fish was severely curtailed. Facing acute food scarcity the family had to rely on food provided by relatives living nearby. They also lived on the outskirts of the village and had no access to safe drinking water provided by CDI-Bwamanda.

A boy aged 16 months was brought to the health centre in January 2013, where he exhibited signs of severe malnutrition. The health centre referred the boy to the hospital in Bwamanda, where he was diagnosed with marasmus. The family spent one whole day walking to the hospital. In order to pay for the hospital expenses, the boy’s mother pledged the only saucepan in the household. Although the boy had not completely recovered he was discharged from the hospital. The health centre in the village continued to provide care for the child until he gradually recuperated. Before the child was hospitalised for marasmus the household had insufficient food, and all it could provide the child with was ka and cassava leaves. The household comprised three members; the mother (17), the father (25) and the malnourished boy. In 2011 the family lived in the father’s village. They had moved to this village in order to seek patrilineal rights to land. Many years ago the boy’s parental grandfather had left this village in order to marry a woman from a village outside the Bwamanda area. Moving back to his village of origin, the father had acquired an agricultural plot from a relative. After the land had been cleared, the relative demanded it back. Without any land, the father started harvesting oil palm fruits on the fallow land of other farmers. He thus acquired a very small income from selling palm oil. His wife also received cassava root and leaves as payment for working as a labourer on another farmer’s field. Since the household had no access to land they did not participate in gbisa. The household had no stores of grain and they had no relatives who would help them with food. In addition they had no access to safe water provided by CDI-Bwamanda.

Households with children with a history of kwashiorkor

A three-year-old boy was brought to the health centre by his parents and the centre referred the boy to the hospital, where he was diagnosed with kwashiorkor. In the period before the boy fell ill from kwashiorkor he had been eating mostly ka and cassava leaves. The household was composed of 12 members including the father of the boy (42), his second wife (32), the father’s mother, five adolescent girls and four preschool children. Two of the preschool children, including the boy who had suffered from kwashiorkor, were children of the first wife of the father. The first wife had left and given the father the responsibility of taking care of the two children. The household cultivated two plots on which they grew maize and cassava for subsistence, and groundnuts as a cash crop. Because the fertility of the land in use was rapidly declining, the father wanted to clear more fallow land. With only one adult male member, there was inadequate labour within the household to clear additional land. Income from the groundnut sale was spent mostly on school fees for the older children and there was no surplus for hiring labour. Involving the gbisa in clearing the land was also said to be impossible because it required the household to provide fish for feeding the group members during the workday. The father said he did not have enough cash to buy fishhooks and could not afford to purchase fish. He and his second wife reported that because they were unable to clear more land they were incapable of providing a more diverse diet for their household members. The household had no access to safe drinking water provided by CDI-Bwamanda, and they fetched water from a reservoir that was also used for washing clothes.

An 18-month-old girl was brought to the health centre by her parents in January 2013. She was referred to the hospital where she was diagnosed with kwashiorkor. During the period before she was hospitalised she had suffered from diarrhoea, vomiting and fever. The girl was breastfed complemented with gruel that contained fish. The parents explained that the girl became malnourished because she drank contaminated water from a hand-dug well. The household comprised 30 members from three generations, among them the father of the girl (34), the mother (34), and seven children. They cultivated several plots of land and in addition to producing staple crops for subsistence they obtained cash income from selling maize and groundnuts. They were dependent on household labour, but occasionally hired labour for clearing fallow land. They had also invested in 12 goats used for meat. In addition to ka and cassava leaves, they had fish almost every day, as well as chicken and other meat a couple of days per week. They had no access to safe drinking water, from CDI-Bwamanda and they collected water from a hand-dug well that was deemed unsafe and several household members had become sick after drinking water from this source.

Households with well-nourished children

This was a monogamous household consisting of 15 members in total. The household head lived with his wife and his sister, two adolescents and ten younger children, all relatives. On their land, the household cultivated cassava, maize, groundnuts and beans. Farm work was done by the household members, but labour was also mobilised through participating in male and female gbisa. The women prepared ka and cassava leaves for gbisa and it was not expected for them to provide fish or meat to the members of the work groups . The head was an active fisher and hunter. Around the homestead the household also grew a number of fruit trees. The household emphasised the value of a diverse diet and argued that they gave their children fish and fruit every day. They obtained safe drinking water from a water source prepared by CDI-Bwamanda.

In this household, comprising 19 members, the head lived with his three wives. Other relatives in the household included three adult males, one adult female, six adolescents and five younger children. They had managed to clear several agricultural plots for cassava, groundnut and palm oil cultivation. In addition to household labour they relied on mobilising gbisa for land clearing and weeding. In the male work group fish and meat was served. The adult males participated in a “groundnut gbisa ” and they had used the income from the gbisa to purchase a bicycle. They produced enough crops and cash to ensure that their members obtained a sufficient diet that usually included fish. In their compound they grew fruits and in between the meals children and adults ate bananas and pineapples. The household lived in the centre of the village and collected water from a borehole well drilled by CDI-Bwamanda.

In this household there were 12 members where the livestock keeper lived together with his two wives, three adult males, two adult females, two adolescents and two younger children. The members of the household were all relatives. The household cultivated palm oil and coconuts in addition to the most common crops. It had also established a separate fruit orchard. In order to secure a regular supply of fish, one of the head’s wives specialised in fishing. The head participated in a gbisa that established a revolving fund providing cash on a consecutive basis to its members for capital accumulation and investment in livestock. To cover the gbisa investment, the household head used funds that his wives had saved from selling palm wine. With the capital received from the gbisa , the household invested in cattle. The gbisa group had later evolved into a group of livestock owners who cooperated on preventing livestock diseases. The adult members reported that their children were well-nourished because they could provide them with a diverse diet that included fish, meat and fruit. They also stated that good hygiene was important. In 2011 a project promoted good personal hygiene in the Bwamanda area and advised the household members to wash their hands before meals. They had attached a water bottle to a tree and water from this bottle was used for hand washing. Because the household had no access to safe drinking water, the head was in regular contact with the CDI-Bwamanda in the planning of drilling a new borehole well.

This business household consisted of 13 members and the head lived with his three wives. Other relatives in the household included three adult males, one adult female, two adolescents and two younger children. They cultivated the most common staple crops while coconuts and oil palm were grown as cash crops. Besides employing household labour, they hired farm labourers and also engaged school students during harvest. Previously, CDI-Bwamanda had promoted cash cropping by purchasing crops from local farmers and shipping the produce to Kinshasa. At the beginning of the 1990s the household took advantage of this opportunity and with the profits made on cash crops they invested in a cigarette business. Income from the sale of cigarettes was invested in pigs, sheep and goats and, at a later stage, in cattle. The head believed that his children were healthy because, aside from ka and cassava leaves, they ate fish and a variety of fruit. The household had also followed the advice from the hygiene project and used water from a bottle attached to a tree for hand washing. It had access to drinking water from a borehole well drilled by CDI-Bwamanda.

Social field analysis

We have identified four social fields that extend in social space each with their own characteristics. On the basis of our description of the Ngbaka socio-economic context it is possible to make linkages between activities and specific locations. Food production and consumption is associated with the household compound and household agricultural plots, access to external labour and capital with the neighbourhood, acquiring land with the village and social service provision with local NGO activities which again are linked to activities at the national and international level. Several characteristics are unique to these to these four fields. The household is the major unit for food production and consumption, division of labour is gender based and household composition influences its ability to produce sufficient and adequate food. Neighbourhood cooperation in the form of gbisa is characterised by being a reciprocal group for exchange of labour and provision of food and drinks to participants influence people’s willingness to participate in work groups. The gbisa plays and important role in capital accumulation. The village is associated with access to land and land is transferred from father to sons, living in a village and continuously cultivating the land is a precondition for access to land. The local NGO, CDI Bwamanda; in the absence of a strong state has become the main provider of social services. The NGO’s provision of social services establishes linkages between local activities and processes at higher levels. The identification of the fours social fields enabled us to conduct a cross-case analysis and compare households with malnourished children with those with well-nourished children.

The household

In our cases there are links between household size, composition and children’s nutritional status. Large households comprising many adults with relatively little pressure on productive members were able to broaden their economic activities and supply members with an adequacy of food, both in terms of quantity and variety. For example, household 7 included six adults and had managed to diversify its food production. The members specialised in growing fruit, making wine, herding cattle and fishing. In contrast, as indicated by case 1, nuclear families were particularly vulnerable and, when members became sick, the effect of ill health was food insecurity and malnutrition. It was not only size and dependency ratio that mattered, but also gender composition. The farmers practice shifting cultivation and clearing land relies heavily on male labour. As illustrated in case 3, shortage of male labour can result in failure to clear land, food insecurity and malnutrition. Among the Ngbaka it is women who are mainly responsible for weeding. Household 1 comprised only one woman and the poor harvest was primarily due to failing to properly weed the agricultural fields.

Inter-household cooperation – the Gbisa

Efficient food production does not only rely on household size and composition, but also on inter-household cooperation in the form of participation in gbisa . The cases show how households with well-nourished children managed to solve seasonal bottlenecks by mobilising agricultural labour through gbisa participation. In case 5, the household was in a positon to supply food desired by the group and by mobilising a work group it could solve the problem of shortage of male labour. In contrast, the household in case 3 was unable to provide the food needed to join a gbisa . The failure to take part in work groups was linked to an incapability to provide an adequate diet and malnutrition. Gbisa was also used for capital accumulation and revenues were used to strengthen household economic activities and thereby enhance food security. As illustrated in case 6, income from groundnut gbisa was spent on improving household transportation, while in case 7 profits were invested in cattle.

The village

In Bwamanda rights to land are closely linked to the village as a unit and access to land is maintained by staying in the village and continuously cultivating the land. In our cases, households with well-nourished children had access to labour and land, with wealthier households cultivating relatively large areas of land. In an area such as Bwamanda where there are few alternative income generating activities landlessness may result in food insecurity and child malnutrition. Household 3 illustrates this link between landlessness and malnutrition. The household which moved to the village of the malnourished child’s father failed to obtain agricultural land and had to rely on food as payment for work and a meagre income from selling palm oil.

The local NGO

Our study indicates that access to the limited services that exist is disproportionately associated with wealth. For example, in case 7, the household took advantage of efforts made by CDI-Bwamanda to promote the sale of maize. Profits made on cash cropping were used to expand economic activities with earnings being invested in petty-trade and livestock. The two better-off households (cases 7 and 8), also benefited from efforts to combat sleeping sickness, and as a result of the decline in this disease they could keep cattle. These two households also followed advice given by a hygiene project. Moreover households with well-nourished children gained from CDI-Bwamanda’s endeavours to improve access to safe drinking water while those with malnourished children had not. In case 4 the parents of the girl with kwashiorkor stated that malnutrition was a result of drinking contaminated water. Several factors constrain a household’s access to health services that could treat malnutrition. Local people have no means of transportation and parents must walk long distances to reach Bwamanda hospital. As indicated in case 2 it is difficult for poor households to pay fees for healthcare and the poor family had to sell their assets to cover hospital fees for treating the boy with marasmus. Bwamanda hospital also lacked food to properly treat malnutrition and the boy did not recover after he had been treated at the hospital.

In our study, access to vital resources for adequate food production was related to four social fields that generated conditions for social inequalities in nutrition. Households with sufficient land, enough labour and access to social services could ensure that their children stayed well-nourished. Households with well-nourished children also benefited from taking part in inter-household cooperation. In this study we identified four social fields that had consequences for food security and children’s nutritional status. First, household size and composition determined the household’s access to labour and hence ability to diversify food production. Second, through neighbour cooperation, in the form of gbisa , kin and neighbours could be mobilised for overcoming seasonal bottlenecks and for capital accumulation. Third, the village, which controlled access to land for food production and fourth, the local NGO providing different access to social services including agricultural support and health.

This study has shown how household organisation may relate to food and nutritional security. The Ngbaka live and work in an environment where resources are widely dispersed. In Bwamanda there are hardly any local means of transportation and farmers walk for several hours to reach their farms and fishing grounds. They also practice an intensive form of shifting cultivation. In accordance with the literature, our study demonstrates how in such environments larger households might be more efficient than small [ 58 , 59 ]. Our findings also support the suggestion that in societies where the household is the production unit, households with a high pressure on the productive members are at risk of not being able to support themselves [ 60 , 61 ]. Studies have investigated the relationship between family size and malnutrition and found that the odds for being malnourished are higher in large crowded families than in small families [ 62 – 65 ]. Whereas these studies relate family size to household crowding, our study has investigated how household size and composition influences productive activities. Our findings align with the notion that gender division of labour in agriculture has important implications for food production and nutrition [ 39 , 66 ].

Inter-household cooperation - the Gbisa

In accordance with reports from other areas our cases show that reciprocal work groups can play an important role in mobilising agricultural labour and solving seasonal bottlenecks [ 67 – 70 ]. Our findings show how the working groups could be mobilised in order to solve such tasks as land clearing and timely weeding. In order to mobilise reciprocal work groups, some reward is required - often food or alcoholic drinks [ 69 ]. This study shows how being unable to serve food required by the group members limit farmers ability to participate in g bisa and how this negatively affects access to labour, food production and hence food security. Reciprocal groups can also be organised for other purposes [ 71 ]. Among the Ngbaka such groups can play a role in capital accumulation and enhancement of food security.

Research has dealt with the relationship between access to social networks and children’s nutritional status and has found that participation, especially in large networks, is positively associated with child nutrition [ 72 , 73 ]. Whereas these studies deal with how social networks can enhance mothers’ access to health advice, our study shows how networks in the form of inter-household cooperation may facilitate households’ access to agricultural labour and capital.

Our findings are in line with the literature that consider access to productive land to be one of the most important factors determining household food security and the landless to be vulnerable to food insecurity [ 74 – 76 ]. Land availability is considered to be a problem in the DRC and although there is a great potential to cultivate land in the DRC, farmers report difficulties in accessing land [ 36 ]. Quantitative studies have also found that access to agriculture land plays a role in determining children’s nutritional status and that children of agricultural workers are more likely to be malnourished than those of land owners [ 77 , 78 ].

As in many other areas in the DRC where public social services are minimal, an NGO delivers services in Bwamanda [ 37 , 79 , 80 ]. Our study indicates that the well-off had better access than the poor to the limited services that existed. Food insecurity and malnutrition is, as in other rural areas in the DRC, to a large extent related to distal factors including the government being unable to deliver basic services to rural areas such as agricultural support, infrastructure development, health, access to clean drinking water and education [ 35 ]. Other scholars have also demonstrated how macro-relations determine the development of severe child malnutrition. For example, an ethnographic account from rural Tanzania examined how fluctuations in the world economy, land shortage, population growth, social stratification and marginalisation were among the driving forces behind severe malnutrition [ 81 ].

Social inequality in malnutrition

The literature has linked social determinants of malnutrition to income-related inequalities and documents pro-rich disparities in nutrition [ 12 , 14 , 82 ]. Household income and food prices are also closely related to food security. It has been shown that an inability to access food was largely determined by a low ability to purchase food rather than by local food production [ 83 , 84 ]. However, since subsistence agriculture is the major livelihood in rural DRC, food security and inequalities in child nutrition is closely related to people’s capacity to produce enough nutritious food [ 36 ]. Research has identified maternal education, emphasising the importance of education higher than primary school, as one of the main factors that benefit child nutrition [ 14 , 17 , 18 , 20 ]. Since many women in the study area were illiterate and few had education above primary level [ 85 ] we anticipate that maternal education had limited implications for inter-household differences in nutrition. Several studies from sub-Saharan Africa have investigated intra-household inequalities in the form of gender differences, but conclusions from these studies are contradictory [ 30 – 33 ]. Our field observations and discussions did not point towards any gender-based discrimination in food allocation and a study from Bwamanda did not find significant differences in nutritional status between girls and boys [ 51 ].

Strengths and limitations

Studies on social inequality in malnutrition analyse Demographic and Health Survey (DHS) and Living Standards Measurement Study (LSM) data. Using data from a large number of low and middle-income countries research has been able to investigate the presence of and compared national and regional differences in socio-economic inequalities in malnutrition [ 15 , 82 , 86 ]. DHS and LSM apply a standard questionnaire approach on a set of predetermined variables and proxies for socio-economic status may not be representative for rural areas where people predominantly depend on agriculture [ 15 , 87 , 88 ]. This study has used different qualitative methods to gather open-ended information about a specific rural setting and our analysis has uncovered links between local social organisation and inequalities in nutrition. Our study uses few cases but the findings might be transferable to other population in a similar context in the DRC. The variables that we have identified may be applied in quantitative studies that can create quantitative evidence of the relation between the variables and nutritional outcomes in rural areas similar to Bwamanda. The combination of several methods including participant observation, semi-structured interviews and key informant interviews strengthens our study. By combining these methods we have managed to reveal how household organisation, inter-household cooperation, access to land, capital and social services relate to food security and nutrition. Data collection was carried out during three relatively short field work periods and continuing data collection with longer periods we could probably have gained new insights in social aspects of nutrition. We are well aware that our findings are based on a small sample and the results should be carefully interpreted when applied to other settings in the DRC. We therefore realise that social factors with implications for the development of kwashiorkor are somewhat ambiguous, and if we had included more kwashiorkor cases, the social etiology of this disease may have become clearer. The use of an interpreter and not transcribing the interviews also represent weaknesses of the study.

Resources vital for food productions were associated with four social fields and access to these resources was unequally distributed creating social inequality in nutritional outcomes. Households could, by mobilising local institutions for inter-household cooperation, improve their food security. Children living in households where there was a great pressure on productive members were at risk of food insecurity and at danger of developing malnutrition. It is important that nutritional programmes involve institutions for inter-household cooperation to further improve food security and nutritional outcomes. These initiatives should address the problem of inequalities in service provision and making accessible social services that can improve food security and child nutrition in households with few resources in the form of labour, land and capital.

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The work was supported by the Centre for International Health, University of Bergen.

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HK wrote the first draft of the manuscript. KMM supervised data analysis and results reporting. All other authors edited the manuscript and contributed to interpretation of the results. Van den Broeck died in 2014. All the other authors read and approved the final manuscript. HK initiated and conducted the Bwamanda household case study.

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Kismul, H., Hatløy, A., Andersen, P. et al. The social context of severe child malnutrition: a qualitative household case study from a rural area of the Democratic Republic of Congo. Int J Equity Health 14 , 47 (2015). https://doi.org/10.1186/s12939-015-0175-x

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Why does malnutrition cause stomach bloating?

Kwashiorkor is a form of acute malnutrition that occurs due to protein deficiency. It can cause swelling, loss of appetite, lack of muscle and fat tissues, and more.

Kwashiorkor is a serious condition that can happen when a person does not consume enough protein. Severe protein deficiency can lead to fluid retention, which can make the stomach look bloated.

Kwashiorkor is most common in children, especially if they do not have access to adequate nutrition soon after they stop breastfeeding. If a child experiences kwashiorkor, they need immediate medical attention.

Other terms for kwashiorkor include:

• protein malnutrition
• malignant malnutrition
• protein-calorie malnutrition

In this article, we look at the causes, prevalence, diagnosis, and treatment of kwashiorkor.

What causes kwashiorkor?

Kwashiorkor is the result of severe malnutrition or lack of protein. It is different than marasmus , a form of malnutrition that is due to lack of calories.

Proteins are responsible for maintaining fluid balance in the body. Insufficient protein causes fluid to shift to areas of the body that it should not be in, where it accumulates in the tissues. A fluid imbalance across the walls of capillaries can lead to fluid retention, or edema.

The exact cause of the condition is not clear, but experts have associated it with diets consisting mainly of maize, cassava, or rice. A lack of dietary antioxidants may also contribute.

Kwashiorkor usually occurs after a child stops breastfeeding, and before they reach 4 years of age. It may occur then because the child is no longer getting the same nutrients and proteins from their diet.

It is most common in areas with low food supplies and high rates of malnutrition.

There have also been cases of kwashiorkor resulting from eating disorders, such as anorexia , and in older adults. According to the University of Florida Health , many people in nursing homes lack enough protein in their diet.

Where is it most common?

The condition is rare in the United States. Its prevalence is highest in the following areas :

• Southeast Asia
• Central America
• Puerto Rico
• South Africa

Kwashiorkor may occur in areas in which there is a limited food supply or a lack of official guidance about nutrition.

It is more common in areas that experience low food security, possibly due to a natural disaster, drought, conflict, or low economic activity.

Symptoms of kwashiorkor

Children with kwashiorkor often have very little body fat, but this is not always the case.

Edema can mask how little body weight a child has. The child may appear to be a typical weight or even plump, but this appearance is swelling due to fluid, not the presence of fat or muscle.

Symptoms may include:

• loss of appetite
• changes in the color of the hair, which may appear yellow or orange
• dehydration
• pitting edema or swelling, usually on the legs and feet, when pressing the skin leaves a finger mark
• lack of muscle and fat tissues
• lethargy and irritability
• dermatosis, or skin lesions that are cracked, flaky, patchy, depigmented, or have a combination of these characteristics
• frequent skin infections or slow healing wounds

When diagnosing kwashiorkor in a child, doctors begin by taking a medical history and performing a physical examination.

They will look for the characteristic skin lesions or rash, as well as edema on the legs, feet, and, sometimes, the face and arms. They will also measure how the child’s weight relates to their height.

In some cases, the doctor may order blood testing for electrolyte levels, creatinine, total protein, and prealbumin.

Typically, however, it is possible to diagnose kwashiorkor from a child’s physical symptoms and a description of their diet.

Children with kwashiorkor tend to have low blood sugar levels, as well as low levels of protein, sodium, zinc, and magnesium .

Kwashiorkor vs. marasmus

There are three forms of acute malnutrition:

• Marasmus: Severe weight loss and muscle wasting due to lack of nutrition and calories.
• Kwashiorkor: Swelling or edema due to water retention from lack of protein.
• Marasmic-kwashiorkor: A combination of muscle wasting and bilateral edema.

According to the worldwide relief organization Unicef , marasmus is the most common form of acute malnutrition in food shortage emergencies. This condition affects both children and adults.

These conditions are severe forms of malnutrition that require urgent treatment.

Although kwashiorkor is a condition that relates to malnutrition, merely feeding a child or adult will not correct all of the deficiencies and effects of the condition.

If a child has been living without sufficient protein and nutrients for a long time, they can find it difficult to take in food. It is, therefore, essential to reintroduce food carefully to avoid refeeding syndrome.

Refeeding syndrome involves life threatening electrolyte and fluid shifts that occur with rapid refeeding of malnourished individuals.

Many children with kwashiorkor will also develop lactose intolerance . As a result, they may need to avoid milk products or take enzymes so that their body can handle milk.

Doctors treating the condition will first give carbohydrates , then add in proteins, vitamins , and minerals. The reintroduction of food may take a week or more to accomplish safely.

Additionally, if a child’s condition is so advanced that they are in shock, with low blood pressure and a high heart rate, they may need to take medication to support their blood pressure.

Kwashiorkor complications

Without treatment, kwashiorkor can lead to the following complications:

• cardiovascular problems
• urinary tract infections
• gastrointestinal problems
• an enlarged liver, known as hepatomegaly
• loss of immune system function
• impaired cellular functions
• electrolyte imbalances

Children with kwashiorkor may not grow to an expected height due to malnutrition at an early age.

The condition also makes a person more vulnerable to infection, which, alongside a weakened immune system, can lead to life threatening complications.

Early diagnosis and treatment will improve a person’s outlook.

Kwashiorkor is a type of severe malnutrition that is most common in children. It occurs due to a lack of protein in the diet, which affects the balance and distribution of fluids in the body and often leads to a swollen belly.

Effective treatment can usually reverse many of the signs and symptoms of kwashiorkor. It is important to reintroduce foods slowly and carefully to avoid refeeding syndrome.

Last medically reviewed on March 16, 2020

• GastroIntestinal / Gastroenterology
• Nutrition / Diet
• Obesity / Weight Loss / Fitness

How we reviewed this article:

• Acute malnutrition: Marasmus (or wasting). (n.d.). https://www.unicef.org/nutrition/training/2.3/4.html
• Benjamin, O., & Lappin, S. L. (2019). Kwashiorkor. https://www.ncbi.nlm.nih.gov/books/NBK507876/
• Kwashiorkor. (2020). https://ufhealth.org/kwashiorkor
• Kwashiorkor: Summary. (2020). https://bestpractice.bmj.com/topics/en-gb/1022
• Palm, C. V. B., et al. (2016). Kwashiorkor: An unexpected complication to anorexia nervosa. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5129140/

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Kwashiorkor

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• Lappin SL 2

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Continuing Education Activity

Kwashiorkor is a disease marked by severe protein malnutrition and bilateral extremity swelling. It usually affects infants and children, most often around the age of weaning through age 5. The disease is seen in very severe cases of starvation and poverty-stricken regions worldwide. In the 1950s, it was recognized as a public health crisis by the World Health Organization. However, there was a delay in its recognition, because most cases of childhood death were reported as being from diseases of the digestive system or infectious etiology. Since then, various relief efforts were aimed at eradicating it. As scientists continued to investigate the natural history of the disease in children, they discovered something very striking. Children who were dying from "digestive system diseases" and presenting with diarrhea, cough, coryza, and shortness of breath also were having symptoms of kwashiorkor during this time (pitting edema, anorexia, skin changes, etc.). This finding led to the medical conundrum of whether kwashiorkor was the primary or the secondary cause of death. It was concluded to be the secondary cause of death because many cases of the disease would not have developed without the precipitating stress of diarrhea, dehydration, and other infectious diseases such as HIV and measles. While kwashiorkor is a disease of edematous malnutrition, marasmus is similar in appearance. Marasmus is known also known as a wasting syndrome (malnutrition without edema). Children typically have a depletion of body fat stores, low weight for height, and reduced mid-upper arm circumference. Other features of the disease can include thin, dry skin; a head that appears large relative to the body; an emaciated, weak appearance; bradycardia; hypotension; hypothermia; and thin, shrunken arms, thighs, and buttocks with redundant skin folds. This activity reviews the evaluation and treatment of patients with kwashiorkor and highlights the role of the interprofessional team in successfully managing this condition.

Objectives:

• Review the pathophysiology of kwashiorkor.
• Describe the epidemiology of kwashiorkor.
• Summarize the physical findings expected in kwashiorkor.
• Outline the management of patients with kwashiorkor so that the interprofessional team can successfully manage this condition.

Introduction

Kwashiorkor is a disease marked by severe protein malnutrition and bilateral extremity swelling. It usually affects infants and children, most often around the age of weaning through age 5. The disease is seen in very severe cases of starvation and poverty-stricken regions worldwide. In the 1950s, it was recognized as a public health crisis by the World Health Organization. However, there was a delay in its recognition, because most cases of childhood death were reported as being from diseases of the digestive system or infectious etiology. Since then, various relief efforts were aimed at eradicating it. [1] [2] [3] [4]

As scientists continued to investigate the natural history of the disease in children, they discovered something very striking. Children who were dying from "digestive system diseases" and presenting with diarrhea, cough, coryza, and shortness of breath also were having symptoms of kwashiorkor during this time (pitting edema, anorexia, skin changes, etc.). This finding led to the medical conundrum of whether kwashiorkor was the primary or the secondary cause of death. It was concluded to be the secondary cause of death because many cases of the disease would not have developed without the precipitating stress of diarrhea, dehydration, and other infectious diseases such as HIV and measles. [5]

While kwashiorkor is a disease of edematous malnutrition, marasmus is similar in appearance. Marasmus is known as the wasting syndrome (malnutrition without edema). Children typically have a depletion of body fat stores, low weight for height, and reduced mid-upper arm circumference. Other features of the disease can include thin, dry skin, a head that appears large relative to the body; an emaciated, weak appearance; bradycardia; hypotension; hypothermia; and thin, shrunken arms, thighs, and buttocks with redundant skin folds. 

The etiology of kwashiorkor is fairly unknown, but diets based mainly on maize, cassava, or rice are frequently associated with the disease. It was previously believed to be due to protein deficiency and low levels of antioxidants and aflatoxins. Evidence for these associations exists; however, efforts targeted to replete diets with high-protein and antioxidants have not been successful. Aflatoxin, previously thought to be the etiology of kwashiorkor, is not always associated with the disease in certain populations. Some factors that are consistently associated with the disease include recent weaning, recent infection (particularly measles), and disruptions in childhood (parental death, temporary home environment, poverty). [6] [7]

Epidemiology

Kwashiorkor is rare in the United States. Worldwide, the most affected regions include Southeast Asia, Central America, Congo, Puerto Rico, Jamaica, South Africa, and Uganda. Prevalence can vary, but it is seen mostly during times of famine. Rural and farming communities are often affected the hardest. [8]

Pathophysiology

Kwashiorkor is characterized by peripheral edema in a person suffering from starvation. Edema results from a loss of fluid balance between hydrostatic and oncotic pressures across capillary blood vessel walls. Albumin concentration contributes to the oncotic pressure, allowing the body to keep fluids within the vasculature. Children with kwashiorkor were found to have profoundly low levels of albumin and, as a result, became intravascularly depleted. Subsequently, antidiuretic hormone (ADH) increases in response to hypovolemia, resulting in edema. Plasma renin also responds aggressively, causing sodium retention. These factors contribute to the edema.

Kwashiorkor is also marked by low glutathione (antioxidant) levels. This is thought to reflect high levels of oxidant stress in the malnourished child. High oxidant levels are commonly seen during starvation and are even seen in cases of chronic inflammation. One measure at reversal would be improved nutritional status and sulfur-containing antioxidants. There is also an experimental theory proposing that alterations in the microbiome/virone contribute to edematous malnutrition, however, further studies are required to understand the mechanism.

History and Physical

The clinical manifestations of kwashiorkor include the following:

• Peripheral pitting edema that begins in dependent regions and proceeds cranially
• Marked muscle atrophy
• Abdominal distension (with/without dilated bowel loops and hepatomegaly)
• Round face (prominence of the cheeks, or “moon facies”)
• Thin, dry, peeling skin with confluent areas of scaling and hyperpigmentation
• Dry, full, hypopigmented hair that falls out or is easily plucked
• Hepatomegaly (from fatty liver infiltrates)
• Growth retardation
• Psychic changes (anorexia, apathy)
• Skin lesions/dermatitis (perineum, groin, limbs, ears, armpits)
• Subcutaneous fat retention with loose inner inguinal skin folds

The World Health Organization has a classification system for evaluating malnutrition severity that determines wasting versus kwashiorkor. They use three clinical measures: the mid-upper arm circumference (MUAC), weight-for-height/length Z score, and presence of symmetrical pitting edema. It is generally accepted that MUAC less than 110 mm is highly associated with mortality in infants younger than 6 months old. Criteria for hospital admission are based on reaching defined cutoffs set by the WHO. Nutritional history, past medical history, vaccination history, and family history are also important to elicit from patients suspected of being malnourished. [9] [10]

Treatment / Management

Many pathophysiological steps are involved in the development of protein malnutrition from starvation. In the past, it was argued that hypoalbuminemia was not the cause of edema in kwashiorkor disease. Scientists performing experiments at that time concluded this because the edema went away with dietary treatment, even before the albumin concentration rose when albumin was given. However, re-analysis of this work has revealed a big error in this conclusion, and indeed, profound hypoalbuminemia was proven to be linked to the development of co-existing edema in the hypovolemic child. [11] [12] [13]

The following are ten primary principles used universally for the treatment of patients who are admitted for kwashiorkor. These principles are done in different phases from the time the child arrives requiring emergency stabilization through eventual rehabilitation.

• Treating/preventing hypocalcemia 
• Treating/preventing hypothermia 
• Treating/preventing dehydration 
• Correcting electrolyte imbalance 
• Treating/preventing infection 
• Correcting micronutrient deficiencies 
• Starting cautious feeding 
• Achieving catch-up growth 
• Providing sensory stimulation and emotional support and 
• Preparing for follow-up after recovery. 

It is important to highlight how critical it is to address the fluid imbalance in kwashiorkor. In the past, there was concern about aggressive rehydration causing acute heart failure. However, this was proven to be exaggerated. At the same time, severe hypovolemia could cause hypovolemic shock and death. So, the medical staff had to proceed cautiously. The standard normal saline solution contains too much sodium and too little potassium.

Differential Diagnosis

Following are some important differentials of kwashiorkor:

• Acrodermatitis enteropathica
• Actinic prurigo
• Angio-neurotic edema
• Atopic dermatitis
• Chronic kidney disease
• Inflammatory bowel disease
• Malignancies
• Nephrotic syndrome

In kwashiorkor, mortality decreases as the age of onset of the disease increases. Children may not grow or develop abnormally and may remain stunted. There can be serious complications when treatment is not started earlier in the disease course, including shock, coma, and permanent physical and mental disabilities. Kwashiorkor can be life-threatening if left untreated.

Complications

Some complications of kwashiorkor include:

• Hepatomegaly (from the fatty liver)
• Cardiovascular system collapse/hypovolemic shock
• Urinary tract infections
• Abnormalities of the gastrointestinal tract including atrophy of the pancreas with subsequent glucose intolerance, atrophy of the mucosa of the small intestine, lactase deficiency, ileus, bacterial overgrowth, which can lead to bacterial septicemia and death.
• Loss of immune function, antioxidant function, subsequent infections, septic shock, and death.
• Endocrinopathies where insulin levels are decreased; growth hormone is increased, but insulin-like growth factor levels are reduced. This leads to insulin intolerance
• Metabolic disturbances and hypothermia
• Impaired cellular functions, including endothelial dysfunction
• Electrolyte abnormalities are commonplace

Deterrence and Patient Education

Education on nutrition starts with the mother prior to childbirth. It is important to educate mothers to be healthy during pregnancy in order to meet the nutritional demands of the child and herself. Educating them on how to adequately nourish their child is also crucial.

Enhancing Healthcare Team Outcomes

The diagnosis and management of kwashiorkor are with an interprofessional team that includes the primary care provider, nurse practitioner, dietitian, internist, gastroenterologist, rheumatologist, and cardiologist. It is important to know that this is a chronic and complex calorie deprivation disorder that affects almost every organ in the body. Fluid correction requires care as these children often have poor heart function. Electrolytes disturbances have to be corrected and calories slowly increased. The primary condition causing the calorie deprivation must be treated, otherwise, the child will not recover The outcomes for many children are guarded, especially if the CNS has been affected. Even those who survive may have a significant delay in growth and complete recovery may not be possible. [14] [15] [16]

Review Questions

• Access free multiple choice questions on this topic.
• Comment on this article.

Disclosure: Onecia Benjamin declares no relevant financial relationships with ineligible companies.

Disclosure: Sarah Lappin declares no relevant financial relationships with ineligible companies.

This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ), which permits others to distribute the work, provided that the article is not altered or used commercially. You are not required to obtain permission to distribute this article, provided that you credit the author and journal.

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Oedema in kwashiorkor is caused by hypoalbuminaemia

It has been argued that the oedema of kwashiorkor is not caused by hypoalbuminaemia because the oedema disappears with dietary treatment before the plasma albumin concentration rises. Reanalysis of this evidence and a review of the literature demonstrates that this was a mistaken conclusion and that the oedema is linked to hypoalbuminaemia. This misconception has influenced the recommendations for treating children with severe acute malnutrition. There are close pathophysiological parallels between kwashiorkor and Finnish congenital nephrotic syndrome (CNS) pre-nephrectomy; both develop protein-energy malnutrition and hypoalbuminaemia, which predisposes them to intravascular hypovolaemia with consequent sodium and water retention, and makes them highly vulnerable to develop hypovolaemic shock with diarrhoea. In CNS this is successfully treated with intravenous albumin boluses. By contrast, the WHO advise the cautious administration of hypotonic intravenous fluids in kwashiorkor with shock, which has about a 50% mortality. It is time to trial intravenous bolus albumin for the treatment of children with kwashiorkor and shock.

Introduction

Malnutrition in young children may lead to severe wasting alone (marasmus), or may be associated with oedema (kwashiorkor). The high mortality of severe acute kwashiorkor has changed little 1 since it was first described in 1933, 2 and about half of children who present today with shock still die. The World Health Organisation (WHO) recommend treating marasmus and kwashiorkor with the same fluid regimen when it is associated with shock, 3 as if they shared precisely the same pathophysiology.

During the 1950s it was recognised that the presence of oedema in kwashiorkor was correlated with a very low plasma albumin concentration, presumably related to a dietary lack of protein. 4 The closeness and importance of this link was identified in the early 1970s 5 – 7 ( Fig. 1 ), and its clinical predictive value has been confirmed since. 8 However, in 1980 Golden and co-workers reported that there was not a causal link between the oedema of malnutrition and the low plasma oncotic pressure induced by hypoalbuminaemia, 9 and this triggered extensive efforts to explain their disordered fluid physiology in other ways, 10 including by the effects of specific micronutrient deficiencies, oxidant stresses and glutathione deficiency. 11 – 13 He warned that the assumption that the oedema was directly related to hypoalbuminaemia could lead to therapeutic error. 12 Here I review the pathophysiological evidence for a causal link between the oedema of kwashiorkor and hypoalbuminaemia, and consider what the therapeutic implications of this might be.

The relationships between the plasma albumin concentration in children with severe malnutrition and (a) the percentage chance of them having signs of oedema, and (b) their mortality risk, as identified by Whitehead 5 and Hay 7 in the early 1970s.

What was the Evidence that Hypoalbuminaemia does not Cause Kwashiorkor Oedema?

Albumin is a relatively small protein, so it contributes disproportionately to the plasma oncotic pressure, and in health is its major contributor. Starling's equation 14 explains how the movement and distribution of water between the plasma and tissue spaces of all tissues is physically regulated by the balance of hydrostatic and oncotic pressures across capillary blood vessel walls. However, Golden ruled out this mechanism as the primary cause for oedema in kwashiorkor by demonstrating that children who he treated with a relatively low protein diet showed marked clinical improvement and lost their oedema before their plasma albumin concentrations had risen. 9

The evidence for Golden’s unexpected finding was presented entirely graphically ( Fig. 2a ), without any corroborating statistical tests, accompanied by the observations that the mean albumin concentrations ‘did not change’, and that ‘only one child had a substantial rise’. 9 The fact that these data were plotted in a physically small area (3×2 cm), with relatively wide aspect-ratio axes, and with descriptive text that happened to be slightly misaligned, may have contributed to the visual impression that the lines were approximately horizontal. By scanning and enlarging the figure and constructing a grid from the y-axis to obtain the numerical data, and re-plotting these values with a conventional aspect ratio and horizontal text ( Fig. 2b ), it can be seen that the plasma albumin levels had risen by the time that the oedema had improved. Furthermore, a two-tailed independent t-test confirms that this was a statistically significant rise in the mean albumin level ( P  = 0.02). Paired values can be discerned for six of the 13 cases (denoted by filled circles), and by combining the remaining seven cases in every possible way, paired t -tests show that the true P -value was somewhere between 0.003 and 0.0007.

Graphs of the changes in plasma albumin concentrations in children on dietary treatment for kwashiorkor before, during and after the disappearance of oedema, from Golden et al, 1980. 9 In graphs b to d, the filled circles represent paired pre- and post-treatment levels, and the open circles are cases where the correct patient pairing is not known.

Measuring Plasma Albumin Concentrations

Albumin concentrations can be measured accurately by using specific immunological assays that only respond to that particular protein, even at very low levels. 15 However, these techniques are not suitable for routine laboratory analysis, and instead dye-binding is used to provide approximate measurements. These methods rely on the fact that proteins have negatively charged surfaces that bind readily to certain positively charged dyes such as bromcresol-green (BCG), and that gram-for-gram, albumin binds more avidly than most of the globulins. However, globulins do bind with BMG, so when the albumin levels are very low this causes the measurements to be disproportionately high. For example, a plasma with no albumin could be reported as having as much as 15 g/L. 16 Claims that this imprecision and skewing can be minimised by technical changes to the methodology or other dyes have not been confirmed. 17 I have therefore estimated the likely true albumin concentrations from Golden’s publication as 1.4× (BCG – 14). 17 Albumin estimates made from total protein measurements and electrophoresis analysis fall approximately half way between the BCG and true values.

The impact of using corrected albumins instead of BCG or electrophoresis values can be seen in Figure 2c , which demonstrates just how severely hypoalbuminaemic these children actually were on arrival. Finally, the true impact on their plasma albumin levels of feeding these children is most obvious when its increase is plotted for the period when they lost their oedema ( Fig. 2d ). Here, the P -value for all of the possible t -test permutations reaches <0.0001.

What do other Studies of Albumin Levels in Kwashiorkor Show?

Though few other groups have presented their data in the same way as Golden, many other studies also recorded children’s plasma albumin concentrations when they presented with kwashiorkor and marasmus, 18 – 29 or when those with kwashiorkor were given appropriate dietary treatment, 19 , 22 , 24 , 30 – 36 in some cases whilst also comparing the efficacy of different milk formulas. 33 – 36 Many of these studies were designed to elucidate the roles of other specific elements, such as vitamin deficiencies, but also included the albumin data, either as a list, a statistical parameter, or a plot, which allowed me to present them in a common graphic format in Figure 3 . Both plots demonstrate just how low the true plasma albumin concentrations are in kwashiorkor. Figure 3a shows that in each study which included children with both marasmus and kwashiorkor, the mean albumin concentrations were consistently lower in kwashiorkor. Though there is some overlap between different studies, this may in part be owing to technical differences, such as measurement variations. In each study in which sufficient information was provided to make it possible to test the statistical significance of these differences, the P -values were all <0.05, and a paired t -test of the combined means gave a P -value of <0.0001.

The corrected albumin concentrations measured in children with kwashiorkor (a) compared to children with marasmus in 12 studies, and (b) before and after feeding in 10 studies, four of which tested two different milks. Golden’s study detailed in Figure 2 is shown by filled circles and a broken line in graph (b), and the other lines are identified by the text references.

Figure 3b shows that the plasma albumin rises promptly when appropriate milk feeds are introduced, with a mean daily increase of about 1.1 g/L. This compares to a mean daily increase of 0.7 g/L in Golden’s study. 9 As with graph (a), every study in which the data could be evaluated statistically showed a significant increase on feeding, and the combined means showed a highly significant improvement. Some, but not all, of the reports indicated how long it took for the oedema to disappear, and these intervals were typically in the range of 6–12 days. These data provide no support for the hypothesis that the oedema resolved before the albumin rose.

The Physiology of Kwashiorkor Looks a lot like Finnish Congenital Nephrotic Syndrome

The evidence I have reviewed thus far points to the pathophysiology of kwashiorkor being a combination of severe malnutrition and a low plasma oncotic pressure due to extreme hypoalbuminaemia. This closely resembles the pathophysiology of untreated Finnish congenital nephrotic syndrome (CNS), though of course the mechanism leading to them acquiring protein-energy malnutrition is very different. Infants with CNS simply cannot retain albumin, nor the smaller globulins, and waste vast quantities of energy. Today, children with CNS are managed very actively in developed countries, with drug treatment or unilateral nephrectomy to limit their proteinuria, 37 or bilateral nephrectomy to stop it, 38 followed by dialysis and transplantation. However, before this CNS was universally fatal by 18 months of age; children failed to thrive, and died of protein-energy malnutrition before they were old enough to develop renal failure. 39 They were highly vulnerable to infections (despite penicillin prophylaxis), and had persistent oedema. Like children with kwashiorkor, 40 they had markedly increased platelet stickiness. Low-dose aspirin is used to counter this in CNS, but of course if the same mechanism was responsible in kwashiorkor it would correct as the albumin rises with nutritional treatment. The two conditions also share similarly altered hormonal profiles.

Much attention has been drawn towards the low glutathione levels seen in kwashiorkor but not in marasmus. 12 These have been interpreted as reflecting high levels of oxidant stress, and there has been speculation that this may be important in driving the development of the oedema. It was argued that the oedema of kwashiorkor could not be a consequence of hypoalbuminaemia as glutathione levels were said to be normal in nephrotic patients. However, this assertion was only based on one case in a study of children with kwashiorkor who had had a normal glutathione level and heavy proteinuria, who it was speculated “was probably a misdiagnosed nephrotic.” 11 However, many studies have established that glutathione levels are low in persistent nephrotic syndrome. 41 , 42 Although the exact relationship between reduced albumin and glutathione levels remains uncertain, they appear to be the consequence and not the cause of severe persistent low plasma albumin levels.

The major feature common to both kwashiorkor and CNS, however, is their disordered fluid balance physiology. Children with persistent nephrotic syndrome lose plasma water into the interstitium because of their low oncotic pressure, and as a consequence have chronic intra-vascular hypovolaemia. This induces avid water retention by an increased secretion of arginine vasopressin (antidiuretic hormone) in a non-osmolar response to hypovolaemia, and avid sodium retention by increased plasma renin activity and consequent secondary hyperaldosteronism, as well as by suppression of the release of the natriuretic peptides. This therefore leads to fluid retention and oedema, which is exacerbated if the child receives greater quantities of salt. The presence of oedema increases the interstitial pressure which therefore slows the accumulation of more oedema by balancing the Starling forces. 14 Hence a stable situation evolves in which the child is persistently intra-vascularly hypovolaemic, has constant oedema, typically has a normal blood pressure, and has a tendency to slight hyponatraemia. Reducing the salt intake usually moderates the oedema, and there is a constant vulnerability to be ‘pushed over’ into frank clinical hypovolaemia with mild additional stresses to fluid balance, such as a bout of diarrhoea.

Children with kwashiorkor are also markedly hypovolaemic and respond hormonally to this in the same way as nephrotic children. Viart demonstrated that children with severe malnutrition had a reduced blood volume compared to controls by re-injecting them with their own 51 Cr-labelled red blood cells. 43 He did not separately analyse children with marasmus and kwashiorkor, but his published data has allowed me to compare the albumin concentrations and total blood volumes (ml/kg of oedema-free weight) of children aged <3 years with either ‘0 or ±’ oedema (marasmus, n  = 4) or with at least ‘++’ oedema on presentation (kwashiorkor, n  = 17). The mean blood volume in marasmus is 90% of normal values, and in kwashiorkor it is just 80% ( Fig. 4 ). Children with kwashiorkor also respond with very high vasopressin levels, which are higher than seen in marasmus, and which fall back to normal after loss of oedema following therapeutic feeding. 44 Similarly, plasma renin activity is much higher in kwashiorkor than in control children, and highest by far in those who died acutely. 24 , 45 Although these data fit precisely the physiological pattern of persistent nephrotic states, the hormonal changes confounded their authors at the time because they believed then that children with kwashiorkor were hypervolaemic. This was because early workers who attempted to measure the blood volume in children 46 and animals 47 , 48 with malnutrition measured the albumin space rather than the red cell space, 43 despite them having clinical or sub-clinical oedema.

Corrected albumin concentrations and total blood volume measurements in children with kwashiorkor, marasmus, and healthy controls, from Viart. 43 The malnourished children selected for this comparison were aged <3 years, with kwashiorkor defined as having ≧2+ oedema, and marasmus as having 0 or ± oedema. The error bars show the mean and standard deviation values.

Although the body responds very quickly to the well described hormonal signals that are triggered by hypovolaemia, these immediate physiological adaptations are not the only ones that may occur, and prolonged exposure induces morphological and functional changes to the kidney. 49 This means that patients with impending hypovolaemia from persistently low albumin concentrations are better able to produce concentrated urine and will be less likely to be so markedly oedematous as those who reach this state rapidly. This is why children with steroid-sensitive nephrotic syndrome (‘minimal change disease’) who present or relapse suddenly after an immunological stimulus may develop quite severe oedema initially, which may then lessen or even disappear prior to their loss of proteinuria as their renal functional capacity increases. However, this further up-regulation does not occur in kwashiorkor or CNS, as these adaptations will have already taken place.

What are the Implications of this for Fluid Treatments for Children with Severe Acute Malnutrition?

All children who present with severe acute malnutrition may have serious complicating factors, but those who are not shocked are overwhelmingly likely to survive if they are treated according to WHO guidelines. 3 For this group, differentiating between marasmus and kwashiorkor, and having a precise understanding of the physiology of oedema development, has little clinical relevance. However, it makes a vital difference when it comes to treating malnourished children who also have shock. Marasmic children, whose hypovolaemic shock is caused by an acute loss of salt and water uncomplicated by hypoalbuminaemia, then require an intravenous infusion of sufficient isotonic fluid to promptly restore the circulating blood volume. This allows oxygen delivery and perfusion of the organs, 50 without perturbing the intra:extra-cellular tonicity gradients and thereby disrupting the volume and functioning of the body’s cells. A rapid 20-ml/kg bolus of an isotonic fluid with glucose, repeated as necessary, would fulfil these logical and physiologically-based criteria. 50

By contrast, children with severe albumin deficiency from any cause continuously ‘struggle’ physiologically to maintain their blood volume by driving hormonal pathways that are normally only called upon in a crisis. They have no mechanisms in reserve; the mildest extra stress can rapidly precipitate severe shock. If that child happens to be one with CNS in a developed country, they will receive a prompt intravenous albumin infusion, and almost at once their signs of shock will wane as interstitial fluid is drawn into their blood vessels. A dose of frusemide administered soon after this will prevent rebound hypervolaemia and pulmonary oedema. They will mobilise large quantities of oedema as urine, re-establish a stable circulation, and will have a virtually guaranteed survival. However, if that same child was treated with just 30 ml/kg over 2 hours of half-strength Darrow's solution with 5% dextrose (hypotonic crystalloid; sodium 61 mmol/l), they may show a transient improvement as the fluid was delivered, but they would then deteriorate as the water leaked away into the tissues, and would have a high chance of dying. Yet this is what is recommended for shocked children whose hypoalbuminaemia happens to be caused by kwashiorkor. 3 No distinction is made by the WHO between managing shock in marasmus and kwashiorkor, despite the fact that mortality is linked directly to the degree of oedema 2 , 5 and hypoalbuminaemia. 8 , 24 For this group, the mortality remains at around 50% in many parts of the world. 51

The adoption of relatively conservative resuscitation fluid volumes for malnourished children has been driven in part by the concerns that larger quantities may precipitate congestive cardiac failure. This followed the fact that some very anaemic children died of heart failure after a few days of apparently successful progress on a therapeutic diet which contained a high salt content. 52 However, this did not prove to be a problem in a randomised controlled trial of standard vs greater volume resuscitation, despite the severe warnings that this is likely to happen. 51 , 53 Indeed, Viart very clearly described children with kwashiorkor dying as if they were still hypovolaemic, with none showing any evidence of congestive failure. 43

The mistaken belief that the oedema of kwashiorkor is unrelated to profound hypoalbuminaemia, combined with an exaggerated concern about the risks of congestive cardiac failure, has resulted in guidelines for shock management that fail to address their physiological needs, and which has not reduced their high mortality rate. Rather, children with kwashiorkor and CNS share a similar pathophysiology; both are malnourished and verge on intravascular hypovolaemia due to hypoalbuminaemia, and can be readily precipitated into shock. Treating this with intravenous albumin is life-saving in CNS; treating it late with modest volumes of hypotonic fluid has a 50% mortality in kwashiorkor. It is time for a trial of acute intravenous albumin therapy in children with kwashiorkor-related shock.

Acknowledgments

I am grateful to Unni Wariyar for advice and support in developing this hypothesis, and to Stella Kyoyagala (Mbarara Hospital; Mbarara University of Science & Technology, Uganda) who drew my attention to the discrepancies between my teaching on managing children with nephrotic syndrome, and her previous teaching on resuscitating children with kwashiorkor.

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