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This question was posted the Management of wasting/acute malnutrition forum area and has 3 replies.

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Spencer Rivadeneira Danies


Normal user

9 Feb 2019, 13:11

Buenos días. El edema es el signo cardinal del kwashiorkor. La literatura disponible, al referirse al inicio del edema, dice "usualmente inicia en los pies". Cuando utilizo el término "usualmente" me refiero a "no siempre".
¿puede el edema nutricional iniciar en otra parte del cuerpo distinta a los pies? ¿iniciar en la cara, por ejemplo? ¿o debemos cambiar el término "usualmente" por "siempre".
Gracias a todos, éxitos para sus países.

English translation:

Good morning. Oedema is the cardinal sign of kwashiorkor. The available literature, when referring to the onset of oedema, says "usually starts on the feet". When I use the term "usually" I mean "not always".
Can nutritional oedema begin in another part of the body other than the feet? Start on the face, for example? Or should we change the term "usually" to "always"?

Thank you all and wishing you success for your countries.

Merry Fitzpatrick

Assistant Research Professor

Normal user

11 Feb 2019, 17:03

Dear Spencer,

Thanks for bringing up this very good question.

In my experience oedema often begins in the face before it is evident in the feet. In children under about 4 years old you can sometimes see it around the eyes and then the cheeks. In children a little bit older, I don’t see it as often around the eyes, but I do see it in the cheeks. These signs are more difficult to measure definitively than in the feet so I think they might be ignored. In slow on-set cases, many times there are also hair changes visible before edema in the feet.

Gopalan, in a longitudinal study in the 1960s noted this edema in the face sometimes preceded edema in the feet and called it “moon face” because the children’s faces became round.
(Gopalan, C. (1992). Classics in Indian Medicine: Kwashiorkor and Marasmus: Evolution and Distinguishing Features (reprint). The National Medical Journal of India, 5(3), 145-151.)

In eastern DRCongo, when asking community health workers to show me cases of kwashiorkor in their communities, they often take me to children with edema in the face but not in the feet and explain that the child is “starting to be malnourished”. When mothers in these same areas are asked how they knew their child is becoming malnourished, they often say a child becomes lethargic or irritable in combination with edema in the face, but the clinic won’t admit the children until the condition progressed to the point there was edema in the feet.

The signs of kwashiorkor look a bit different in different places. In some areas there is more fatty liver than others. After sudden events like conflict, kwashiorkor can develop rapidly and there may not be time for the hair to show changes. In Malawi it is more prevalent in children near the weaning age but in the DRCongo it is more prevalent in 3 and 4 year-olds. Before 1970, Kwashiorkor was identified differently in different places because it appeared slightly differently. To make sure everyone was talking about the same condition, a bunch of doctors got together in 1970 to establish a simple diagnostic criteria for kwashiorkor.

“All workers seem to agree that in kwashiorkor oedema is the single clinical feature which is universally present. Hepatomegaly is not as common in many countries as it is in Jamaica, and skin and hair changes are very variable.”
(Lancet. (1970). Classification of Infantile Malnutrition. The Lancet, 2, 302-303.)

Later “oedema” was operationalized to pitting oedema in the feet, though this was not part of the original definition. This definition, with its focus on oedema and the way it was operationalized, has had the unintended consequence of making kwashiorkor appear to be a yes/no decision based on one single sign and moved treatment away from the understanding of kwashiorkor as a syndrome with many signs, some of which may indicate a less severe stage that nevertheless might indicate the child is undernourished.

Hope that helps


Technical expert

11 Feb 2019, 18:07

Hi Spencer,
Merry offers interesting historical insights into kwashiorkor syndrome. I would argue that dropping the term 'kwashiorkor' for 'oedema' was not unintended. The term oedema provides a clear diagnostic criterion for the identification and treatment of severe acute malnutrition.

To be clear, one of the diagnostic criteria that identifies children with SAM for admission into selective feeding programmes (other than wasting) is 'bilateral oedema'. (note: WHO use the term ' bilateral oedema' while footnotes clarify that the mildest form of nutritional oedema occurs in the feet).

The severity of the oedema is graded according to where-else it occurs. The progression of the oedema is upwards.

+1 Bilateral pitting oedema of the feet
+2 Bilateral pitting oedema of the feet and lower legs & may also involve bilateral pitting oedema of the hands and lower arms
+3 As above and includes periorbital oedema

For the purpose of defining an admission criterion for treatment guidelines you may change the term from 'usually' to 'always'. The use of a simple diagnostic sign allows easy identification at community level and promotes high treatment coverage.

Where outpatient treatment is available the grade of oedema may also be used to identify whether the child is treated as an outpatient or inpatient. This varies according to context, although +3 (severe) oedema is currently always treated as an inpatient in all contexts.

Other forms of (non-nutritional) oedema can occur for a variety of medical reasons, an example being nephrotic syndrome where facial oedema / 'moon-face' may occur without being evident elsewhere on the body.

Please refer to WHO updates on the management of SAM (2013).


Spencer Rivadeneira Danies


Normal user

18 Mar 2019, 03:04

Muchas gracias por sus respuestas. Feliz noche.

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