Protein-Energy Malnutrition Workup
- Author: Noah S Scheinfeld, JD, MD, FAAD; Chief Editor: Romesh Khardori, MD, PhD, FACP more...
The WHO recommends the following laboratory tests:
- Blood glucose
- Examination of blood smears by microscopy or direct detection testing
- Urine examination and culture
- Stool examination by microscopy for ova and parasites
- Serum albumin
- HIV test (This test must be accompanied by counseling of the child's parents, and strict confidentiality should be maintained.)
Significant findings in kwashiorkor include hypoalbuminemia (10-25 g/L), hypoproteinemia (transferrin, essential amino acids, lipoprotein), and hypoglycemia. Plasma cortisol and growth hormone levels are high, but insulin secretion and insulinlike growth factor levels are decreased. The percentage of body water and extracellular water is increased. Electrolytes, especially potassium and magnesium, are depleted. Levels of some enzymes (including lactase) are decreased, and circulating lipid levels (especially cholesterol) are low. Ketonuria occurs, and protein-energy malnutrition may cause a decrease in the urinary excretion of urea because of decreased protein intake. In both kwashiorkor and marasmus, iron deficiency anemia and metabolic acidosis are present. Urinary excretion of hydroxyproline is diminished, reflecting impaired growth and wound healing. Increased urinary 3-methylhistidine is a reflection of muscle breakdown and can be seen in marasmus.
Malnutrition also causes immunosuppression, which may result in false-negative tuberculin skin test results and the subsequent failure to accurately assess for tuberculosis.
Detailed dietary history, growth measurements, body mass index (BMI), and a complete physical examination are indicated.
Sensitive measures of nutritional deficiency in children include height-for-age or weight-for-height measurements less than 95% and 90% of expected, respectively, or greater than 2 standard deviations below the mean for age. In children older than 2 years, growth of less than 5 cm/y may also be an indication of deficiency.
Skin biopsy and hair-pull analysis may be performed (see Histologic Findings below).
In a 1989 study, skin biopsy samples taken from 20 children with protein-energy malnutrition were examined with hematoxylin and eosin and stained for collagen, elastic fibers, mucopolysaccharides, and melanin. Findings included variable degrees of hypertrophy of the stratum corneum with atrophy of both the stratum granulosum and the prickle cell layers. A large amount of melanin was found in the basal layer in all samples. Also, the amount of collagen and associated crowding of elastic fibers was reduced.
In kwashiorkor, microscopic studies of hair have revealed a decrease in the proportion of anagen follicles. The anagen hairs were usually abnormal, exhibiting severe atrophy and shaft constriction. Most of the hairs examined were in the telogen phase, and the loss of pigment was consistent with the lack of melanin production during the telogen cycle.
In patients with marasmus, essentially no hairs were in the anagen phase, with a shift to the telogen phase. Many more broken hairs were found in patients with marasmus when compared with patients with kwashiorkor. Hair analysis has been advocated as a useful diagnostic procedure for both conditions.
McKenzie et al found that childhood malnutrition correlates with a reduction in the total melanin content of scalp hair.
Onis M de, Monteiro C, Clugston G. The worldwide magnitude of protein-energy malnutrition: an overview from the WHO Global Database on Child Growth. Bulletin of the World Health Organization. 1993. 71(6):
Lin CA, Boslaugh S, Ciliberto HM, et al. A prospective assessment of food and nutrient intake in a population of Malawian children at risk for kwashiorkor. J Pediatr Gastroenterol Nutr. 2007 Apr. 44(4):487-93. [Medline].
Spoelstra MN, Mari A, Mendel M, et al. Kwashiorkor and marasmus are both associated with impaired glucose clearance related to pancreatic beta-cell dysfunction. Metabolism. 2012 Mar 2. [Medline].
Forrester TE, Badaloo AV, Boyne MS, Osmond C, Thompson D, Green C, et al. Prenatal factors contribute to the emergence of kwashiorkor or marasmus in severe undernutrition: evidence for the predictive adaptation model. PLoS One. 2012. 7(4):e35907.
Ma L, Savory S, Agim NG. Acquired Protein Energy Malnutrition in Glutaric Acidemia. Pediatr Dermatol. 2013 Jan 17. [Medline].
Ma L, Savory S, Agim NG. Acquired protein energy malnutrition in glutaric acidemia. Pediatr Dermatol. 2013 Jul-Aug. 30(4):502-4. [Medline].
Hyacinth HI, Adekeye OA, Yilgwan CS. Malnutrition in Sickle Cell Anemia: Implications for Infection, Growth, and Maturation. J Soc Behav Health Sci. 2013 Jan. 1:7(1).
Corware K, Yardley V, Mack C, Schuster S, Al-Hassi H, Herath S, et al. Protein energy malnutrition increases arginase activity in monocytes and macrophages. Nutr Metab (Lond). 11(1). 2014 Oct 24:51. [Medline].
Tierney EP, Sage RJ, Shwayder T. Kwashiorkor from a severe dietary restriction in an 8-month infant in suburban Detroit, Michigan: case report and review of the literature. Int J Dermatol. 2010 May. 49(5):500-6. [Medline].
Boyd KP, Andea A, Hughey LC. 3.Acute Inpatient Presentation of Kwashiorkor: Not Just a Diagnosis of the Developing World. Pediatr Dermatol. 2012 Apr 3. [Medline].
World Health Organization, Dept of Nutrition for Health and Development. Nutrition for health and development: a global agenda for combating malnutrition. World Health Organization. Available at http://whqlibdoc.who.int/hq/2000/WHO_NHD_00.6.pdf.
Jildeh C, Papandreou C, Abu Mourad T, et al. Assessing the Nutritional Status of Palestinian Adolescents from East Jerusalem: a School-based Study 2002-03. J Trop Pediatr. 2010 Jul 31. [Medline].
Jen M, Yan AC. Syndromes associated with nutritional deficiency and excess. Clin Dermatol. 2010 Nov-Dec. 28(6):669-85. [Medline].
Lewandowski H, Breen TL, Huang EY. Kwashiorkor and an acrodermatitis enteropathica-like eruption after a distal gastric bypass surgical procedure. Endocr Pract. 2007 May-Jun. 13(3):277-82. [Medline].
Al-Mubarak L, Al-Khenaizan S, Al Goufi T. Cutaneous presentation of kwashiorkor due to infantile Crohn's disease. Eur J Pediatr. 2010 Jan. 169(1):117-9. [Medline].
Sander CS, Hertecant J, Abdulrazzaq YM, Berger TG. Severe exfoliative erythema of malnutrition in a child with coexisting coeliac and Hartnup's disease. Clin Exp Dermatol. 2009 Mar. 34(2):178-82. [Medline].
Franco G, Calcaterra R, Valenzano M, Padovese V, Fazio R, Morrone A. Cupping-related skin lesions. Skinmed. 2012 Sep-Oct. 10(5):315-8. [Medline].
Tavarela Veloso F. Review article: skin complications associated with inflammatory bowel disease. Aliment Pharmacol Ther. 2004 Oct. 20 Suppl 4:50-3. [Medline].
Harima Y, Yamasaki T, Hamabe S, et al. Effect of a late evening snack using branched-chain amino acid-enriched nutrients in patients undergoing hepatic arterial infusion chemotherapy for advanced hepatocellular carcinoma. Hepatol Res. 2010 Jun. 40(6):574-84. [Medline].
Demling RH. The incidence and impact of pre-existing protein energy malnutrition on outcome in the elderly burn patient population. J Burn Care Rehabil. 2005 Jan-Feb. 26(1):94-100. [Medline].
William JH, Tapper EB, Yee EU, Robson SC. Secondary Kwashiorkor: A Rare Complication of Gastric Bypass Surgery. Am J Med. 2014 Dec 8. [Medline].
Ghorbel HH, Broussard JF, Lacour JP, Passeron T. Iatrogenic kwashiorkor developing after bypass surgery. Clin Exp Dermatol. 2014 Jan;. 39(1):113-4. [Medline].
Thavaraj V, Sesikeran B. Histopathological changes in skin of children with clinical protein energy malnutrition before and after recovery. J Trop Pediatr. 1989 Jun. 35(3):105-8. [Medline].
McKenzie CA, Wakamatsu K, Hanchard NA, Forrester T, Ito S. Childhood malnutrition is associated with a reduction in the total melanin content of scalp hair. Br J Nutr. 2007 Jul. 98(1):159-64. [Medline].
Chung SH, Stenvinkel P, Lindholm B, Avesani CM. Identifying and managing malnutrition stemming from different causes. Perit Dial Int. 2007 Jun. 27 Suppl 2:S239-44. [Medline].
Dorner TE, Lackinger C, Haider S, Luger E, Kapan A, Luger M, et al. Nutritional intervention and physical training in malnourished frail community-dwelling elderly persons carried out by trained lay "buddies": study protocol of a randomized controlled trial. BMC Public Health. 2013 Dec. 13(1):1232. [Medline].
[Guideline] US Department of Health and Human Services, US Department of Agriculture. Dietary guidelines for Americans, 2005. National Guideline Clearinghouse. 2005.
Walmsley RS. Refeeding syndrome: screening, incidence, and treatment during parenteral nutrition. J Gastroenterol Hepatol. 2013 Dec. 28 Suppl 4:113-7. [Medline].
Al Sharkawy I, Ramadan D, El-Tantawy A. Refeeding syndrome' in a Kuwaiti child: clinical diagnosis and management. Med Princ Pract. 2010. 19(3):240-3. [Medline].
Melchior JC. From malnutrition to refeeding during anorexia nervosa. Curr Opin Clin Nutr Metab Care. 1998 Nov. 1(6):481-5. [Medline].
Garber AK, Mauldin K, Michihata N, Buckelew SM, Shafer MA, Moscicki AB. Higher calorie diets increase rate of weight gain and shorten hospital stay in hospitalized adolescents with anorexia nervosa. J Adolesc Health. 2013 Nov. 53(5):579-84. [Medline].
Takeda E, Ikeda S, Nakahashi O. [Lack of phosphorus intake and nutrition]. Clin Calcium. 2012 Oct. 22(10):1487-91. [Medline].
Balint JP. Physical findings in nutritional deficiencies. Pediatr Clin North Am. 1998 Feb. 45(1):245-60. [Medline].
Beers MH, Berkow R, eds. Nutritional Disorders: Malnutrition. The Merck Manual. 17th ed. Merck; 1999. 28-32.
Caksen H, Kendirci M, Kandemir O, Patiroglu T. A case of malignant histiocytosis associated with skin involvement mimicking kwashiorkor. Pediatr Dermatol. 2001 Nov-Dec. 18(6):545-6. [Medline].
Collins N. Protein-energy malnutrition and involuntary weight loss: nutritional and pharmacological strategies to enhance wound healing. Expert Opin Pharmacother. 2003 Jul. 4(7):1121-40. [Medline].
Constans T, Alix E, Dardaine V. [Protein-energy malnutrition. Diagnostic methods and epidemiology]. Presse Med. 2000 Dec 16. 29(39):2171-6. [Medline].
De Caprio C, Alfano A, Senatore I, Zarrella L, Pasanisi F, Contaldo F. Severe acute liver damage in anorexia nervosa: two case reports. Nutrition. 2006 May. 22(5):572-5. [Medline].
Delahoussaye AR, Jorizzo JL. Cutaneous manifestations of nutritional disorders. Dermatol Clin. 1989 Jul. 7(3):559-70. [Medline].
Glaser, KL. Pediatrics: Malnutrition. Medstudents. Available at http://www.medstudents.com.br/pedia/pedia1.htm.
Golden MHN. Severe malnutrition. Weatherall DJ, Ledingham JGG, Warrell DA, eds. Oxford Textbook of Medicine. 3rd ed. 1996. 1278-96.
Goskowicz M, Eichenfield LF. Cutaneous findings of nutritional deficiencies in children. Curr Opin Pediatr. 1993 Aug. 5(4):441-5. [Medline].
Gupta MA, Gupta AK, Haberman HF. Dermatologic signs in anorexia nervosa and bulimia nervosa. Arch Dermatol. 1987 Oct. 123(10):1386-90. [Medline].
Gurski RR, Schirmer CC, Rosa AR, Brentano L. Nutritional assessment in patients with squamous cell carcinoma of the esophagus. Hepatogastroenterology. 2003 Nov-Dec. 50(54):1943-7. [Medline].
Harris CL, Fraser C. Malnutrition in the institutionalized elderly: the effects on wound healing. Ostomy Wound Manage. 2004 Oct. 50(10):54-63. [Medline].
Hendricks KM, Duggan C, Gallagher L, et al. Malnutrition in hospitalized pediatric patients. Current prevalence. Arch Pediatr Adolesc Med. 1995 Oct. 149(10):1118-22. [Medline].
Jilcott SB, Masso KL, Ickes SB, Myhre SD, Myhre JA. Surviving but not quite thriving: anthropometric survey of children aged 6 to 59 months in a rural Western Uganda district. J Am Diet Assoc. 2007 Nov. 107(11):1983-8. [Medline].
Kuhl J, Davis MD, Kalaaji AN, Kamath PS, Hand JL, Peine CJ. Skin signs as the presenting manifestation of severe nutritional deficiency: report of 2 cases. Arch Dermatol. 2004 May. 140(5):521-4. [Medline].
Lyder CH. Assessing risk and preventing pressure ulcers in patients with cancer. Semin Oncol Nurs. 2006 Aug. 22(3):178-84. [Medline].
Manguso F, D'Ambra G, Menchise A, Sollazzo R, D'Agostino L. Effects of an appropriate oral diet on the nutritional status of patients with HCV-related liver cirrhosis: a prospective study. Clin Nutr. 2005 Oct. 24(5):751-9. [Medline].
McLaren DS. Skin in protein energy malnutrition. Arch Dermatol. 1987 Dec. 123(12):1674-1676a. [Medline].
Miller SJ. Nutritional deficiency and the skin. J Am Acad Dermatol. 1989 Jul. 21(1):1-30. [Medline].
Neldner KH. Nutrition, aging and the skin. Geriatrics. 1984 Feb. 39(2):69-82, 87-8. [Medline].
Pelly TF, Santillan CF, Gilman RH, et al. Tuberculosis skin testing, anergy and protein malnutrition in Peru. Int J Tuberc Lung Dis. 2005 Sep. 9(9):977-84. [Medline].
Prendiville JS, Manfredi LN. Skin signs of nutritional disorders. Semin Dermatol. 1992 Mar. 11(1):88-97. [Medline].
Rabinowitz SS, Gehri M, Stettler N, Di Paolo ER. Marasmus. Medscape Reference. May 20, 2009. [Full Text].
Roongpisuthipong C, Sobhonslidsuk A, Nantiruj K, Songchitsomboon S. Nutritional assessment in various stages of liver cirrhosis. Nutrition. 2001 Sep. 17(9):761-5. [Medline].
Ryan AS, Goldsmith LA. Nutrition and the skin. Clin Dermatol. 1996 Jul-Aug. 14(4):389-406. [Medline].
Schneider JB, Norman RA. Cutaneous manifestations of endocrine-metabolic disease and nutritional deficiency in the elderly. Dermatol Clin. 2004 Jan. 22(1):23-31, vi. [Medline].
Shah S, Kannikeswaran N, Kamat D. A rash. Clin Pediatr (Phila). 2007 Sep. 46(7):650-4. [Medline].
Shashidhar HR, Grigsby DG. Malnutrition. Medscape Reference. April 9, 2009. [Full Text].
Soni BP, McLaren DS, Sherertz EF. Skin lesions in nutritional, metabolic and heritable disorders: cutaneous changes in nutritional disease. Fitzpatrick's Dermatology in General Medicine. 1999. Vol 2: 1725-37.
Tirmentajn-Jankovic B, Dimkovic N. [Simple methods for nutritional status assessment in patients treated with repeated hemodialysis]. Med Pregl. 2004 Sep-Oct. 57(9-10):439-44. [Medline].
Wilmer WA, Magro CM. Calciphylaxis: emerging concepts in prevention, diagnosis, and treatment. Semin Dial. 2002 May-Jun. 15(3):172-86. [Medline].