Clinical spectrum of Protein energy malnutrition is a continuum, ranging from borderline growth delay to well-defined syndromes of Kwashiorkor and Marasmus. Within this spectrum, many other terms are used to denote clinical variations e.g. Prekwashiorkor, Marasmic kwashiorkor (MK), Nutritional dwarfism etc.

Broadly, clinical presentations of Protein energy malnutrition may be divided into 4 major groups  Under nutrition, Kwashiorkor, Marasmus and Marasmic kwashiorkor.

Under nutrition is an anthropometric diagnosis, characterized by weight <80%, but without other significant manifestations. Simultaneous affection of height is denoted as nutritional dwarfism. Being asymptomatic, these children are usually identified on routine growth monitoring/assessment. However, they are prone to develop symptomatic Protein energy malnutrition e.g. kwashiorkor, during stress e.g. Infections.


It is a term coined by Prof. Cicely Williams, denotes acute Protein energy malnutrition due to either sudden nutritional deprivation e.g. abrupt cessation of breast feeding (deposed child) or sudden increase in nutritional requirements due to infection, diarrhea etc. Moderate weight loss (61%-80%), edema and mental changes are three cardinal features of kwashiorkor, usually but not invariably, associated with hepatomegaly, skin/hair changes, vitamin deficiencies etc.


It is a term derived from Greek word marasmos (wasting), is a state of chronic and severe under nutrition, due to gradual nutritional deprivation e.g. delayed weaning (widening gap between nutritional requirements and breast output). Severe weight loss (<60%), wasting of muscles & subcutaneous tissue and absence of edema are diagnostic features of Marasmus.

kwashiorkor and marasmus

In Kwashiorkor and Marasmus, Marasmic Kwashiorkor represents an intermediate phase between marasmus and kwashiorkor, when a previously marasmic child develops edema due to higher nutritional requirements following inter-current illnesses e.g. diarrhea. On recovery, these children may again go back to the state of marasmus, with disappearance of edema. Intermittent episodes of marasmic kwashiorkor are common in marasmic children.

Some important features of PEM with differences between Kwashiorkor and Marasmus are as follows

Growth failure: Wasting (weight loss) is the essential feature in all types of PEM, with/without stunting (Height deficit). Wasting & stunting is more obvious in marasmus than kwashiorkor, due to absence of edema.

A marasmic child has typical shriveled (monkey- like) look with gross emaciation, relatively larger head, staring eyes, prominent ribs, wrinkled skin and loose skin-folds over buttocks, inner thighs, axilla and chest. Buccal pad of fat is usually preserved except in severe marasmus. Bone age and dentition may also be marginally delayed in chronic PEM.

Edema is the sine qua non of kwashiorkor, due to hypoproteinemia and consequent fluid retention. Its severity may vary from mild pitting edema in Pathogenesls of edema in Kwashiorkor dependent parts e.g. legs or sacrum, to generalized anasarca (sugar baby). Severe edema may mask underlying wasting, weight loss and dehydration.

Mental changes: In Kwashiorkor, children are apathetic and lethargic with little interest in surroundings, probably due to impaired activity of vital CNS enzymes in an un-adapted child. Anorexia is also marked in these cases. In contrast, marasmic children have good appetite and are usually alert with roving eyes as if searching for food.

Skin changes are more pronounced in kwashiorkor than marasmus (Kwashiorkor and Marasmus) due to combined effect of – edema, multiple vitamin deficiencies, essential fatty acid deficiency and secondary infections. Depending on the severity, these changes include — a) Phrynoderma i.e. generalized dryness of skin, b) diffuse or patchy areas of hypo/hyper pigmentation, c) thin, shiny, taut skin over edematous areas, d) Moist ulcerations over flexural areas or pressure points, e) superadded infections e.g. pyoderma and scabies. Following lesions are classical but uncommon except in severe kwashiorkor —

• Flaky paint dermatosis -hyperpigmented and desquamating area (flakes) over raw-skin,

• Crazy pavement dermatosis – dry, hyperkeratotic, fissured skin with alternate areas of hypo- or hyper-pigmentation,

• Mosaic dermatosis with mixed lesions in mosaic form.

Hair changes are more common in kwashiorkor with thin, dry, sparse, lusterless, hypo pigmented and brittle (easily pluckable) hair. Due to intermittent periods of better nutrition, alternate bands of hypo- and normal pigmentation on hair are classically described as Flag sign. In marasmus, hairs are sparse and hypo pigmented.

Hepatomegaly is common in kwashiorkor due to fatty infiltration of liver, though jaundice is rare and indicates poor prognosis.

Concomitant nutritional deficiencies like xerophthalmia, vitamin B complex deficiencies, scurvy and anemia are more obvious in kwashiorkor. Although biochemical vitamin mineral deficiencies are common in marasmus, clinical signs are less prominent in them due to adaptation and usually appear in recovery phase.

Anemia in PEM is usually dimorphic, due to reduced dietary intake of hemopoietic factors like iron, proteins and folic acid, co-existing infections affecting erythropoiesis, and occult blood losses due to worm infestations. Kwashiorkor and Marasmus

Concomitant infections like intermittent episodes of diarrhea, respiratory infections and skin infections are common in PEM, due to impaired immune mechanisms and mucosal integrity. Cellular immunity and phagocytic functions are predominantly affected in PEM, while immuno globulin levels are usually normal or high with good antibody response.