Protein-Energy Malnutrition Clinical Presentation

Updated: Mar 11, 2019
  • Author: Hadi Atassi, DO; Chief Editor: Romesh Khardori, MD, PhD, FACP  more...
  • Print


Obtain a detailed dietary history, growth measurements, body mass index (BMI), as well as perform a complete physical examination.

Sensitive measures of nutritional deficiency in children include height-for-age or weight-for-height measurements that are less than 95% and 90% of expected, respectively, or greater than two standard deviations below the mean for age. In children older than 2 years, growth of less than 5 cm per year may also be an indication of deficiency.

Low intake of calories or an inability to absorb calories is the key factor in the development of kwashiorkor. A variety of syndromes can be associated with this condition. [34]   For example, there have been cases of kwashiokor resulting from a diet that included multivitamins, health supplements, and organic milk and cereals to treat eczema [35] ; a rice milk diet used to treat atopic dermatitis [36] ; as well as a diet consisting only of potatoes, gelatin, and juice. [37]

In children, the findings of poor weight gain or weight loss; slowing of linear growth; and behavioral changes, such as irritability, apathy, decreased social responsiveness, anxiety, and attention deficit may indicate protein-energy malnutrition. In particular, the child is apathetic when undisturbed but irritable when picked up. Kwashiorkor characteristically affects children who are being weaned. Signs include diarrhea and psychomotor changes.

Adults generally with protein-energy malnutrition lose weight, although, in some cases, edema can mask weight loss. Patients may describe listlessness, easy fatigue, and a sensation of cold. Global impairment of system function is present.

Patients with protein-energy malnutrition can also present with nonhealing wounds. This may signify a catabolic process that requires nutritional intervention. Lewandowski et al reported kwashiorkor and an acrodermatitis enteropathica–like eruption after a distal gastric bypass surgical procedure [38] . Kwashiorkor was reported in an infant presenting with diarrhea and dermatitis, due to infantile Crohn disease. [39] The infant's diarrhea and dermatitis improved in 2 weeks with treatment.

Sander et al reported the case of a 3-year-old child with coexisting celiac and Hartnup disease that resulted in kwashiorkor, anemia, hepatitis, hypoalbuminia, angular cheilitis, glossitis, conjunctivitis and diffuse alopecia, erythematous skin, desquamation, erosions, and diffuse hyperpigmentation was reported by in 2009. [40]  These findings resolved with the proper nutritional supplementation.

Note that "cupping" (the placement of heated suction cups on the body to cure disease) on the abdomen of patients with diseases that result in abdominal swelling (eg, kwashiorkor) can cause interesting clinical presentations. [41]

Maintenance hemodialysis can result in protein-energy-malnutrition and it relates strongly with mortality, with serum albumin being the only predictor of death. [42]  In another study of 134 adult Croatian outpatients on dialysis, malnourishment (particularly hypoproteinemia) and age were associated with higher overall mortality. [43]



Physical Examination

In marasmus, the child appears emaciated with marked loss of subcutaneous fat and muscle wasting. The skin is xerotic, wrinkled, and loose. Monkey facies secondary to a loss of buccal fat pads is characteristic of this disorder. Marasmus may have no clinical dermatosis; however, inconsistent cutaneous findings include fine, brittle hair; alopecia; impaired growth; and fissuring of the nails.

In protein-energy malnutrition, more hairs are in the telogen (resting) phase than in the anagen (active) phase, a reverse of normal. Occasionally, as in anorexia nervosa, marked growth of lanugo hair is noted.

Kwashiorkor typically presents with a failure to thrive, edema, moon facies, a swollen abdomen (potbelly), and a fatty liver. When present, skin changes are characteristic and progress over a few days. The skin becomes dark, dry, and then splits open when stretched, revealing pale areas between the cracks (ie, "crazy pavement" dermatosis, "enamel paint" skin). This feature is seen especially over pressure areas. In contrast to pellagra, these changes seldom occur on sun-exposed skin.

Depigmentation of hair causes it to be reddish yellow to white. Curly hair becomes straightened. If periods of poor nutrition are interspersed with good nutrition, alternating bands of pale and dark hair, respectively, called" the flag sign," may occur. Also, hairs become dry, lusterless, sparse, and brittle; they can be pulled out easily. Temporal recession and hair loss from the back of the head occur, likely secondary to pressure when the child lies down. In some cases, hair loss can be extreme. Hair can also become softer and finer and appear unruly. The eyelashes can undergo the same change, having a so-called broomstick appearance.

Nail plates are thin and soft and may be fissured or ridged. Atrophy of the tongue papillae, angular stomatitis, xerophthalmia, and cheilosis can occur.

Inflammatory bowel diseases, such as Crohn disease and ulcerative colitis, may also produce skin manifestations secondary to malnutrition. [44]

In elderly persons, an indicative sign of malnutrition is delayed healing and an increased presence of decubitus ulcers of stage III or higher.

Vitamin C deficiency commonly manifests in elderly persons as perifollicular hemorrhages, petechiae, gingival bleeding, and splinter hemorrhages, in addition to hemarthroses and subperiosteal hemorrhages. Anemia may result, and wound healing may be impaired. Niacin deficiency clinically manifests as pellagra (ie, dermatitis, dementia, diarrhea) in advanced cases. The dermatitis manifests in sun-exposed areas, including the back, neck (Casal necklace), face, and dorsum of the hands (gauntlet of pellagra), initially as painful erythema and itching. Subsequently, vesicles and bullae may develop and erupt, creating crusted, scaly lesions. Finally, the skin becomes rough and covered by dark scales and crusts. Striking demarcation of the affected areas from the normal skin is noted.

Protein-energy malnutrition is also associated with an increased likelihood of calciphylaxis, a small vessel vasculopathy involving mural calcification with intimal proliferation, fibrosis, and thrombosis. As a result, ischemia and necrosis of skin occurs. Other tissues affected include subcutaneous fat, visceral organs, and skeletal muscle.

Harima et al reported on the effects of an evening snack in patients receiving chemotherapy for hepatocellular carcinoma (HCC), in which there was a lower nonprotein respiratory quotient in patients with advanced HCC compared with cirrhotic patients without HCC and patients with early-stage HCC. [45] Patients with cirrhosis and advanced HCC who were receiving chemotherapy and who received the late-evening snack had an improved nonprotein respiratory quotient, branched-chain amino acid/tyrosine ratio, alanine aminotransferase level, and prealbumin level compared with controls. [45]