A points system, using clinical and biochemical parameters to identify malignant kwashiorkor

Protein-energy malnutrition in northern Sudan: prevalence, socio-economic factors and family background

The socio-economic and family background and the nutrition of 145 children with kwashiorkor admitted to hospital in Khartoum over a 2-year period were compared with 113 marasmic kwashiorkor, 158 marasmic, and 186 nutritionally normal controls of similar age. Peak admissions for kwashiorkor were in the wet and post-wet season and the mean (SD) age was 1.6 (0.6) months. Mothers of malnourished children were more likely to be pregnant, and had poorer housing, sanitation and water supply, a lower income and food expenditure and less education than controls. Mothers of controls breastfed their children longer, introduced mixed feeding earlier, offered a wider variety of foods, and were more likely to have had their infants immunized. Neither family instability nor cultural practices which result in separation of children from their mothers appear to have an important role in protein-energy malnutrition in the Sudan. Families of kwashiorkor children had a higher food expenditure and better maternal education than marasmic children. There was no significant difference between the two groups in duration of breastfeeding or in the age of introduction of mixed diet. However, kwashiorkor children appeared to be offered more meat. Differences in food availability could account for the relative retardation of growth and lack of subcutaneous fat in marasmus compared to kwashiorkor.

Serum albumin and transferrin in protein-energy malnutrition: Their use in the assessment of marginal undernutrition and the prognosis of severe undernutrition

1. Deficits in weight- and length-for-age, and serum albumin and transferrin concentrations were determined for children who were either marginally undernourished (twenty-five children) or suffering from either marasmus (thirty-two children) or kwashiorkor (twenty-six children) defined according to the Wellcome Classification (Waterlow, 1972). The measurements were also made in eight children with kwashiorkor after the loss of oedema, and in sixteen children who were recovering from either marasmus or kwashiorkor.

2. The mean concentration of serum albumin was similar for children from the ‘under-nourished’ group and from the group with marasmus, but was significantly reduced in those with kwashiorkor.

3. The concentration of serum transferrin was significantly reduced in both the group of children with marasmus and those with kwashiorkor. The serum transferrin concentration was significantly lower in children with kwashiorkor when compared with the level in those with marasmus.

4. Seventeen children (seven with kwashiorkor and ten with marasmus) died. These children were neither lighter nor shorter than the severely malnourished children who survived. The concentration of serum albumin was not lower in the children who died than in those who survived.

5. In contrast to the results for serum albumin concentrations, the children who died had significantly lower levels of serum transferrin than those who survived.

6. There was a significant linear relationship between serum transferrin concentrations and the deficits in length-for-age (P< 0·05) and weight-for-length (P< 0·001) in the marginally undernourished children. The deficit in weight-for-length was also linearly related to the serum transferrin concentrations (P< 0·001) in children recovering from severe malnutrition.

7. It is suggested that the measurement of serum transferrin concentrations provides an index of severity in severely malnourished children, and should prove useful in field assessments of nutritional status.