Protein-Energy Malnutrition Workup

  • Author: Noah S Scheinfeld, MD, JD, FAAD; Chief Editor: William D James, MD   more...
 
Updated: Jul 18, 2011
 

Laboratory Studies

The WHO recommends the following laboratory tests:

  • Blood glucose
  • Examination of blood smears by microscopy or direct detection testing
  • Hemoglobin
  • 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.)
  • Electrolytes

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.

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Other Tests

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.

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Procedures

Skin biopsy and hair-pull analysis may be performed (see Histologic Findings below).

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Histologic Findings

In a 1989 study,[13] 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[14] found that childhood malnutrition correlates with a reduction in the total melanin content of scalp hair.

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Contributor Information and Disclosures
Author

Noah S Scheinfeld, MD, JD, FAAD  Assistant Clinical Professor, Department of Dermatology, Columbia University College of Physicians and Surgeons; Consulting Staff, Department of Dermatology, St Luke's Roosevelt Hospital Center, Beth Israel Medical Center, and New York Eye and Ear Infirmary; Private Practice

Noah S Scheinfeld, MD, JD, FAAD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Optigenex Consulting fee Independent contractor

Coauthor(s)

Anusuya Mokashi, MS, MD  Radiology Resident, Staten Island University Hospital

Disclosure: Nothing to disclose.

Andrew Lin, MD, FRCPC  Associate Professor, Department of Internal Medicine, Division of Dermatology, University of Alberta

Andrew Lin, MD, FRCPC is a member of the following medical societies: American Academy of Dermatology and Royal College of Physicians and Surgeons of Canada

Disclosure: Nothing to disclose.

Specialty Editor Board

Michelle Pelle, MD  Clinical Assistant Professor, Division of Dermatology, Department of Medicine, University of California at San Diego

Michelle Pelle, MD is a member of the following medical societies: American Academy of Dermatology, California Medical Association, Medical Dermatology Society, and Pennsylvania Medical Society

Disclosure: Nothing to disclose.

David F Butler, MD  Professor of Dermatology, Texas A&M University College of Medicine; Chair, Department of Dermatology, Director, Dermatology Residency Training Program, Scott and White Clinic, Northside Clinic

David F Butler, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, American Society for Dermatologic Surgery, American Society for MOHS Surgery, Association of Military Dermatologists, and Phi Beta Kappa

Disclosure: Nothing to disclose.

Jeffrey J Miller, MD  Associate Professor of Dermatology, Pennsylvania State University College of Medicine; Staff Dermatologist, Pennsylvania State Milton S Hershey Medical Center

Jeffrey J Miller, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, Association of Professors of Dermatology, North American Hair Research Society, and Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Catherine M Quirk, MD  Clinical Assistant Professor, Department of Dermatology, University of Pennsylvania

Catherine M Quirk, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Dermatology

Disclosure: Nothing to disclose.

Chief Editor

William D James, MD  Paul R Gross Professor of Dermatology, University of Pennsylvania School of Medicine; Vice-Chair, Program Director, Department of Dermatology, University of Pennsylvania Health System

William D James, MD is a member of the following medical societies: American Academy of Dermatology and Society for Investigative Dermatology

Disclosure: Elsevier Royalty Other

Acknowledgments

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author, Dr. Dino Santoro, to the development and writing of this article.

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