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The bloated abdomens of malnourished children are a hallmark of kwashiorkor, a severe form of protein-energy malnutrition. Without enough dietary protein, the body cannot make enough albumin, the main plasma protein that holds water inside blood vessels. Fluid leaks out of the capillaries and pools in the abdomen (ascites) and tissues (edema)—producing the distinctive distended belly. An enlarged fatty liver also adds to the swelling.
In the thriving West, corpulence is typically associated with only one thing – excess food… excess fat cells to be more precise. However, pictures of impoverished children living in not-so-thriving nations seem counterintuitive. The children’s appearance run contrary to the most common of adages voiced by parents to guilt-feed their picky children. Malnourishment and a bloated abdomen don’t seem to go hand in hand, so the disturbing images induce what is called cognitive dissonance.
There is no doubt that these children are malnourished. This is evident from their gaunt, twig-like arms and their skin, which wraps their bones so tautly that it seems incapable of being pinched. However, their malnourishment is not like a severe case of anorexia. Malnourishment accompanied by an unusually distended belly is caused by the deficiency of a highly crucial nutrient – protein. This type of malnourishment is known as Protein-energy Malnutrition (PEM).
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Kwashiorkor
Undernourished children can be subject to two primary PEMs – marasmus and kwashiorkor. However, it is the latter that leaves children with a swollen abdomen. Kwashiorkor is severe protein-energy malnutrition that is characterized by edema — an unhealthy accumulation of fluids in the cavities of the body — and a liver filled with fatty infiltrates. It is most frequently diagnosed in children dwelling in societies fraught with poverty and famine.
The term was coined by Jamaican pediatrician Cicely Williams, one of the first female graduates of Oxford University and a lauded pioneer in the studies of maternal and child health. Although she had previously introduced it in her academic papers, the word made its first public appearance in a Lancet article written by her in 1935. It is derived from the Ga language of Ghana and roughly translates to “the sickness the baby gets when the new baby comes”. It is named as such because it reflects the development of a condition in an older sibling who is weaned away from breast milk due to the birth of a newborn younger sibling.
Breast milk is an infant’s primary source of protein and amino acids, vital nutrients whose deprivation could gravely threaten physiological and mental development. Despite consuming a diet replete with carbohydrates, it is the scarcity of protein in their diet that makes them a victim of this malady. The children’s calorie intake mainly constitutes the consumption of food like rice, cassava and yams, foods that are rich in carbohydrates, but possess almost no protein. This lack of protein disrupts their lymphatic system.
Liquid Pools
Fluid balance in the body is governed by two opposing pressures inside the capillaries. Hydrostatic pressure (the pressure of blood pushing outward against the capillary wall) tends to force water out into the surrounding tissues. Colloid osmotic pressure, generated mainly by the plasma protein albumin, tends to draw water back into the capillaries via osmosis. Albumin is too big to leak out through the capillary walls, so it acts as a kind of sponge that keeps water in the bloodstream. Any leftover interstitial fluid is mopped up by the lymphatic system, which drains it back into the circulation. In a healthy person, these three systems keep tissues from waterlogging.
In kwashiorkor, the body simply does not have enough amino acids to manufacture albumin, so plasma albumin levels plummet (a condition called hypoalbuminaemia). Without enough albumin, colloid osmotic pressure can no longer pull water back into the capillaries, and fluid leaks out and pools in the abdomen and tissues. This pooled liquid in the abdomen (technically called ascites) makes it bloat outward, while the retained fluid in the tissues spurs edema. Other than edema and a distended abdomen, kwashiorkor patients also suffer from the premature loss of teeth, thinning of hair and depigmentation of the skin. Diagnosis and treatment often leave patients with stunted growth; however, this is much better than a delayed diagnosis, which can be fatal.
Treatment usually entails the reintroduction of a diet that is rich not only in protein, but also in other essential elements, including mineral salts and vitamins. Modern protocols use ready-to-use therapeutic foods (RUTFs) like Plumpy’Nut—a fortified peanut paste developed in 1996—which can be administered at home and have dramatically improved survival in severe acute malnutrition. Research since the 2010s has also pointed to disturbed gut microbiome and oxidative stress as additional factors that may help explain why some malnourished children develop kwashiorkor while equally undernourished siblings develop the wasting form (marasmus). Even so, a dietary deficiency disease can only be treated by adopting a well-balanced diet, something that is currently out of the reach for many of these indigent families.
