CASE PRESENTATION ON:-PROTEIN ENERGY MALNUTRITION

BIOGRAPHICAL INFORMATION
Name

: Master Durga prasad

Age

: 3 years

Sex

: Male

Address

:Satna

Religion

: Hindu

IP No.

: 61739

Admission unit

: B Unit

Date of admission
Diagnosis

: 11/01/13
: Protein Energy Malnutrition Grade III

CHIEF COMPLAINTS
Patient had complains of Fever Since 8 days, Abdominal Distention since 2 days,
Edema in the limbs since 2 days
PRESENT ILLNESS
Mas. Durga Prasad came to the hospital with the complaints of fever of intermittent
type which is moderate in nature associated with chills, abdominal distention and
abdominal girth is 50cm and swelling of the lower extremities with dry and scaly
skin. Patient was admitted with the above complaints & was Diagnosed PEM and
there is no any surgical intervention being done.
PAST HEALTH HISTORY
CHILDHOOD ILLNESS:There is no significant history of childhood illness, trauma, or
immunization patient doesnt have any experience of previous hospitalization.
PAST MEDICAL-SURGICAL HISTORY:
Patient is known case of
dehydration as diagnosed 2 yrs back. No Diabetes, or other chronic illness& has not
undergone any surgical interventions.
MEDICATION
& ALLERGIES:
As a known PEM, he regularly takes the medication diet according to
standard body requirement., No history of any habitual OTC medications, not
habituated to any herbal preparations or self preparations.
PERSONAL HISTORY PERSONAL STATUS: he holds up an cute place in his family
along with his mother & family.

EATING HABITS: He takes fruit as well as milk & includes plenty of water.
ALCOHOL HABITS: not a known alcoholic.
SMOKING HABITS: not habituated.
LIFE STYLE: well playing with other children.
SLLEEPING HABITS: Sleeps 8hrs/night & 2hrs/day, doesnt have any problems in
sleeping.
RELIGION&FAITH: He is a Hindu by religion and is involved in traditional and cultural
activities frequently.
FAMILY HISTORY

34 years

1year

27years

5years

3years

No history of any communicable diseases & genetic disoders, patients father has a
history of blood pressure.
S.No

Name

Relation

Age

Healthstatus

Occupation

Shaikhar

Father

34yrs

Healthy

merchant

Sunita

Mother

27yrs

Healthy

housewife

3.

Son(patien
t)
Son

3 yrs

Admitted

nil

Durgapras
ad
shithil

1 yr

Died

manoj

son

5 yrs

Ukg

studying

PSYCHO SOCIAL HISTORY

Patient maintains good relations with family members, relatives and friend.
NUTRITIONAL HISTORY
Recent Weight : 7kg,Expected Weight: 14kg .Appetite: Poor
24 Hours Diet Recall:
Child taken only two meals in last 24 hours and each meal contains 2 idly
with chatni. Water intake approximately 400-500 ml.
Degree of Malnutrition :
=actual weight/expected weight X 100
2

= 7/14 X 100
50%
III Degree malnutrition
Menu plan for Mas. Durgaprasad as per standard daily requirement
Time
8Am

Item
!/2 cup milk+1 tsp ghee+2 biscuits+

Calorie

Protein

136 Kcal

3gm

220Kcal

4gm

300Kcal

4gm

220Kcal

8gm

150Kcal

8gm

220Kcal

4gm

214Kcal

4gm

1460Kcal

35gm

1 tsp sugar

10Am

1 cup cooked rice+2 spoon Dhal sambar+1

tsp ghee

12pm
1 egg+1 Chapati+3 spoon sugar+1 tsp ghee
2pm
1 cup rice+2 spoon dhal Sambar+ 1 tsp ghee
5pm
1 bread+1/2 cup milk+ 1 tsp sugar
7pm
1 cup rice+1 tsp ghee+ 2 spoon dhal
9pm
1 Banana+ cup rice+1/2 spoon ghee+
Sambar
Total

ENVIRONMENTAL HISTORY
Patient lives in rural area. The housing condition is rural but according to the
family members they live in a hygienic condition. Drainage system is present. They
get water from borewell supply.
GROWTH AND DEVELOPMENT
Childs growth and development has not achieved to normal extent.
Gross Motor development: child was unable to take steps on tip of toe.
Fine motor development: not able to hold spoon properly to take food.

Sensory development: able to identify geometric figures, accommodation well

developed.
Vocalization: able to understand simple comments, and asks about objects for name
Psychosocial development: child is in the sense of autonomy.
Psychosexual development: child is in the anal stage and bladder control not yet
achieved
Intellectual development: child is in sensory motor stage.
Spiritual development: child is in intuitive projective faith.
ELIMINATION PATTERN
Bowel

: bowel sounds are dull

Bladder

: bladder control not yet achieved.

PHYSICAL EXAMINATION
General Observation
Mas. Durgaprasad is a 3 years old male baby, poorly built, undernourished,
conscious and oriented to time, place and person.
Vital Signs
Temperature

: 100o F

Pulse

: 92bts/min

Respiration

: 30breaths/min

Skin And Mucus Membrane

Color

: Normal brown

Edema

: Present

Moisture

: Dry

Temperature

: Increased

Turgor

: Normal

Any Abnormal Discharges : No

Head
Skull/Cranium Size, Shape

: Normal

Movements

: Normal movements

Forehead

: No scars

Changes in Texture

: Hypo-pigmented

Characteristics

: Brown in color, sparse and not distributed densely

Hair

Lice

: Absent

Changes in Appearance

: Clubbing of nails

Cyanosis

: Absent

Texture

: Softening of nails

Appearance

: Presence of facial puffiness

Color

: Normal brown

Symmetry

: Symmetrical

Movements

: Normal

Expression

: Normal

Eye Lids

: Normal

Lacrimation

: Poor

Conjunctiva

: Pale

Sclera

: Clear

Pupil

: Equally reactive and accommodate light.

Appearance

: Symmetrical

Discharges

: Nil

Lesions

: Nil

Any Abnormalities

: Nil

Appearance

: Normal

Discharges

: Nil

Patency

: Patent

Sense of Smell

: Normal

Nails

Face

Eyes

Ears

Nose

Mouth And Throat

Lips

: Dry

Tongue

: Not coated

Teeth

: Deciduous teeth are present

5

Gums

: Normal

Buccal Mucosa

: Normal

Palate

: No cleft palate

Tonsils

: Not inflamed

Taste

: Normal

Neck
General Appearance
Trachea

: Normal
: Centrally located

Lymph Nodes

: No palpable lymph nodes

Thyroid Glands

: No thyroid enlargement

Cysts and Tumors

: Nil

Gastro-Intestinal System
Diarrhea

: Absent

Constipation

: Absent

Bleeding

: Absent

Worm Infestation

: Suspected

Psychosocial History
General Status of the Family: Mas. Durga Prasad belongs to poor class family
with a monthly income of 1000/-. His father is a daily wager. He is living with
his father, mother and two elder sisters. They are living in their own house.
Electricity supply is available in the house. There is no proper sanitary facility.
Activities of Daily Living
looks dull.

: Mas. Durgaprasad lost his interest in daily activities and

Sl.
No.

Investigation

Results

Normal values

Remarks

1.
2.
3.
4.
5.
6.

Hemoglobin
TLC
Lymphocyte
Monocyte
Eosinophils
RBC

5.2gm/dl
12,700cells/mm
62%
02%
04%
3.53mil cells/mm

12-16gm/dl
4000-11000cell/mm
20-45%
2-10%
1-8%
3.5-5.5 mil cell/m

Severe anemia
Inflammation present
Increased
Normal
Normal
Normal

Play Activities
siblings.

: Child has less interest to play with peers and

Special investigations
Ultrasonography: The findings from the images obtained through
Ultrasonography suggest that the liver is infiltrated with excessive triglycerides.

MEDICATIONS
Medication
name
1. Inj.
Amikacin

2. Tab. B
complex

Dosage FrequeRoute
ncy
225mg

Bd

IV

50 mg

Od

Oral

Actions

Side effects

Nursing
responsibilities

Binds to 30s
ribosomal
subunits of
susceptible
bacteria, thus
inhibits protein
synthesis.
Vitamin B
complex and
Vitamin C
supplement

Tinnitus, vertigo,
ataxia and
deafness

Perform test for

hearing acuity.
Avoid concurrent use
of ototoxic drugs
Monitor for the signs
of hypervitaminosis.

Nausea and
vomiting

DESCRIPTION OF DISEASE
PROTEIN ENERGY MALNUTRITION
The term malnutrition can be applied to any disorder that prevents an individual
from achieving an optimal nutritional state.Protein energy malnutrition is the state
occurs due to insufficient or imbalanced consumption of protein and energy.
INCIDENCE:
Malnutrition is the one of the major health problem in the world in children
with in 5 years of age.It is estimated that 80% of preschooler suffer from various
degrees of malnutrition.At any given time there are 78 million children suffering
from various degrees of malnutrition.
NORMAL PROTEIN AND ENERGY REQUIREMENT OF CHILDREN
Age group
0-6 months
6-12 months
1-3years
4-6years

Energy (in kcal/day)

108/ kg
98/kg
1240
1690

Protein (in grams/day)

2.0/kg
1.65/kg
22
30

TYPES OF PROTEIN ENERGY MALNUTRITION

1.Marasmus: Weight less than 60% of expected weight to the age. It is a clinical
syndrome characterized by loss of subcutaneous fat and muscle wasting.
2.Marasmic Kwashiorkor: Weight less than 60% of expected
body weight for the age with features of Marasmus with edema.
3.Kwashiorkor: Weight below 60-80%
of expected weight with growth retardation and generalized body edema.
GRADING OF PROTEIN ENERGY MALNUTRITION
a) Gomez Classification:
Grade I

- 76-90% of average of weight.

Grade II

- 61-75% of average weight.

Grade III -60% and below 60% of average weight.

b) The Water Loo classification

Nutritional Marasmus- below 60% of average weight without edema

Kwashiorkor
- 60-80% of reference weight with edema.
Marasmic Kwashiorkor - below 60% of reference weight and edema

c) Indian Academy of Pediatrics:

8

Above 80% of expected weight - Normal

70-80% of expected weight
- Grade I
60-70% of expected weight
-Grade II
50-60% of expected weight
- Grade III
Less than 50% of expected weight
- Grade IV

MARASMUS
A severe form of malnutrition caused by inadequate intake of protein and
calories, and it usually occurs in the first year of life, resulting in wasting and
growth retardation. Marasmus accounts for a large burden on global health.
Nutritional Marasmus is a nutritional disorder results due the gross deficiency of
energy though protein deficiency accompanies it.
It is the common problem in developing countries in the time of draught. It occurs
chiefly in first year of life.
ETIOLOGY:
a) Primary Cause: Primary cause is the dietary cause. Inadequate diet both
qualitatively and quantitatively.
b) Secondary Causes:

Age: Marasmus is more common in infant than in other ages. It is because of

high nutritional requirement of infant (Protein: 2-3gm/kg/day; Calorie: 1200
Kcal/day) and hence Marasmus develops soon in infancy

Congenital Disease: Congenital disease which limits the intake and digestion
of food.

Chronic Vomiting: Disease like pyloric stenosis and relaxed cardiac sphincter,
which increase the risk of vomiting there by, decreases the absorption of the
nutrients from the GI tract.

Chronic Infection: Chronic infections like Congenital syphilis, tuberculosis and

respiratory infection which results in protein loss.

Repeated episodes of chronic diarrhea will impair the digestion and

absorption of nutrients from the mucosa of the Gastro Intestinal tract and
results in deficiency of the nutrients.

Serious organic disorders of heart, brain and kidney and some metabolic
disorders and juvenile diabetes mellitus.

Other causes include Transition from breastfeeding to nutrition, poor foods in

infancy.

GRADING OF THE MARASMUS:

Grade I

: Loss of fat in axillae and groin

Grade II

: Grade I + loss of fat in abdomen and gluteal region.

Grade III

: Grade I + Grade II + loss of fat in chest and Para spinal area.

Grade IV

: Grade I + Grade II + Grade III + loss of fat in buccal pad.

CLINICAL MANIFESTATIONS

Appearance of toothless old man and a monkey look.

Growth retardation as evidenced by marked loss of weight and subnormal

height.

Gross muscle wasting

Absence of edema.

Eyes will be sunken

Disappeared subcutaneous fat.

Face will be round, till the loss of subcutaneous fat.

Skin over the buttocks becomes wrinkled and saggy due to loss of adipose
tissue.

Bones will be prominent.

Anemia

Subnormal temperature.

Skin becomes ashen gray because of anemia

10

Atrophy and wasting of body tissues especially subcutaneous fat.

The child will be apathetic and lethargic.

Recurrent infections

DIAGNOSIS
History collection

: Regarding the dietary habits and recurrent attacks of

diseases.
Physical examination

: To rule out the signs of the Marasmus.

Biochemical Investigation

: Biochemical investigation to estimate the plasma

protein level.
Plasma protein levels will not be noticeably reduced.
Pathological references : Liver does not show pathological fatty infiltration.
Reduced organ weight of lung and heart
MANAGEMENT:
Calorie requirement of the undernourished infants are greater than those of
normal infants it almost doubled.
The aim of treatment is to provide sufficient proteins, calories, and other
nutrients for nutritional rehabilitation

and maintenance.

In case of severe PEM, restoring fluid and electrolyte balance parentally is the
initial concern. A patient who shows normal absorption may receive enteral
nutrition after anorexia has subsided.
When possible, the preferred treatment is oral feeding. Foods are introduced
slowly. Carbohydrates are given first to supply energy, and then high-quality
protein foods, especially milk, and protein-calorie supplements, are given.
Start with the concentrated food of about 200 Cal/kg body weight gradually 2-3
weeks and continued till the weight gain.
Protein requirement should be 4gm/kg body weight /day.
No of feeds should be increased usually 7 feeds a day.
11

 A patient whos unwilling or unable to eat may require supplementary feedings

through a naso-gastric tube or Total Parenteral Nutrition (TPN).
Secondary causes should be treated
Accompanying infection must also be treated, preferably with antibiotics that
dont inhibit protein synthesis.
KWASHIORKOR
Kwashiorkor is one of the more severe forms of protein malnutrition and is
caused by inadequate protein intake. It is, therefore, a macronutrient deficiency.
It is type of severe protein-energy malnutrition refers to a combination of
edema, lethargy (mental apathy) and growth failure.
INCIDENCE:
It is a major problem in South India (Andra Pradesh) and Orissa, Bengal and
some parts of Maharashtra.
In India it is estimated that about 1-2% of preschooler suffer from
Kwashiorkor.
ETIOLOGY:

Book Picture
Unavailability of suitable protein rich

Patient Picture
-

foods

Faulty feeding habits

Super imposition of infection and

Suspected case of worm infestation

infestations

Age Incidence

Age is 3y, peak age of incidence

Higher incidence is found between 1

to 3 years.

Prolonged breast feeding

Seasonal Incidence

Family size

Lack of Accessibility and availability

Breast feed till 2 years of age.

Lack of awareness of health services

of Health Services
12

CLINICAL MANIFESTATION
Book Picture
Onset: Insidious in onset over periods of weeks and months.
Apathy: Gradually loss of interest and activity. The degree
unresponsiveness will be proportional to severity of the
disease.
Diarrhea: Nearly 2/3rd of Kwashiorkor cases will be
presenting with the complaints of loose stools with
infective in origin.
Edema: Edema is a constant feature and is extremely
variable in degree. Inspite of gross edema, ascites will be
minimal.
Muscle wasting: Due to degeneration and reduction in the
anterior horn cells may lead to weakness and hypotonia
as suggested by one postulate (Kwashiorkor myelopathy).
Protein deficiency also causes muscle wasting.
Skin changes: 40% to 60% of the florid kwashiorkor will
have skin changes. Dry and scaly skin: Common over skin
Pavement dermatosis: Jet black, later exfoliate exposing
underlying and also there will be peeling.
Petichae and ecchymoses.
Arabinoflavinosis
Hair changes: The hair is scanty, lusterless commonly
brownish.
The
light
color
hair
is
known
as
dyschromotrichia.
Hepatomegally with fatty infiltration.

Patient Picture
Insidious in onset

Moon face is
present

Face: Moon face due to edema

Associated Avitaminosis
Anemia of moderate degree.
Growth retardation
Psychomotor changes: Earlier the onset of the malnutrition;
severe will be the psychomotor changes (mental
deprivation)

Has less interest in

play activities.
Absent

Pedal edema with

ascites
No muscle wasting

Skin is dry and scaly

Absent
Absent
Absent
Hairs are scanty
and brown in color
Liver is enlarged
4cm below the RCM

No symptoms
Hb 5.2gm/dl

Absent
Irritable and restless

Kwashiorkor sufferers show signs of thinning

hair, edema, inadequate growth, and weight
loss. The stomatitis on the pictured infant
13

indicates an
deficiency

accompanying

Vitamin

DIAGNOSIS:-

Book Picture

Patient Picture

Done
MAC-14cm

History and Physical examination

Anthropometric measurements
Biochemical investigation
o Low serum albumin (<3.5-5gm/dl)
o A/G ratio will be reversed(1:1.5)
o Decreased serum amino acid level.
o Decreased blood cholesterol level.
o Decreased pancreatic enzymes.
o Decreased serum Iron and Copper.
Organ Changes elicited by Imaging studies:
o Fatty liver
o
o

Atrophy of acinary cells of pancreas

Atrophic changes in stomach and intestinal villi.

Not
Not
Not
Not
Not
Not

done
done
done
done
done
done

Present and enlarged 4cm below

RCM
Not elicited
Not elicited.

MANAGEMENT
1. Dietary modifications
2. Control and Treatment of infections
Book Picture

Patient Picture

Management: 1.Dietary modifications

Dietary Management:
Liberal protein rich foods to be given with adequate calories.
Proteins:

High protein diet with 7-8 feeds a day

About 5 to 6 gms of protein/kg/day.

The total average protein intake of child is 50-60gm/day.
Calories:
Calories should be in range of 120-150 Kcal/kg/day.

14

1.

Control and Treatment of infections

2.

Correction of Vitamin deficiencies

On antibiotic
225mg BD)

therapy

(Inj.

On Becosule capsule for

Vit-B and C Supplementation

3. Correction of Vitamin deficiencies

15

Amik

NURSING CARE PLAN

SR.NO
.
1

ASSESSMENT

NURSING
OBJECTIVE

Subjective data:

DIAGNOSIS
Imbalanced

Mother says My

nutrition; less

achieve and

son is not

than body

gaining weight
adequately

PLANNING
INTERVENTIONS

EVALUATION

Child is severely

Nutrition of child

nutritional status

malnourished. i.e.

is improved to

maintain normal

and degree of

3rd degree

some extent as

requirement

nutritional

malnutrition.

malnutrition.

evidenced by

related to

status as

decreased

evidenced by

Objective data:

utilization of

weight gain.

Weight:7kg

nutrients

(expected wt 14

secondary to

kg)
Grade III
malnutrition:

Child will

IMPLEMENTATION

- Assess the

increased

- Assess the causes

Decreased

interest to take

utilization of

food and mild

nutrients due to

increase in

and educate

fatty infiltration of

weight. i.e.

fatty infiltration

mother to serve

liver.

8.2kg.

of the liver.

food accordingly.

Prepared diet menu

for malnutrition.
- Prepare diet plan

- Identify for the

signs of vitamin

plan based on the

child condition.

deficiencies
- Administer
Vitamin

Vitamin deficiency
present.

Supplements
Provided oral
Vitamin
Supplements.

16

SR
NO.
2.

ASSESSMENT

NURSING
DIAGNOSIS

OBJECTIVE

PLANNING
INTERVENTIONS

IMPLEMENTATION

EVALUATION

Subjective data:

Hyperthermia

Child will

Monitor vital

Body Temperature

Childs body

Mother says My

related to

achieve and

signs

is

temperature is

sons skin is

inflammatory

maintain

100oF.

within normal

somewhat hot

reaction

normal body

Loosen the

limits

secondary to

temperature

Hepatomegally.

as evidenced

Objective data:

Loosen the
clothing and
switch on the

Temperature: 100oF

by

fan.
Provide plenty

Pulse: 92bts/min

temperature

of fluids to drink

within normal
limits.

Apply cold
compress

clothing and
provided proper

Temperature:

ventilation.

98.6F

Advise the mother

to provide plenty
of water and
fluids.
Advised mother to

Provide tepid

keep wet cloth on

sponge.
Administer

fore head to

prescribed
antipyretics

reduce the
temperature.
----Administered Inj
17

Paracetamal
Intramusularly.

SR NO.
3.

ASSESSMENT
Subjective data:

NURSING
DIAGNOSIS
Fluid volume

OBJECTIVE

PLANNING
INTERVENTIONS

To maintain

Assess the child

IMPLEMENTATION
Child

EVALUATION

having Childs edema

is

The mother

excess related

fluid volume

for sites of

facial

puffiness, has reduced as

complaint that

to fluid

in the body

edema.

periorbital edema, evidenced by

her son is having

accumulation

and to reduce

swelling of face.

in tissues as

the edema.

abdominal

& pedal edema.

Assess the signs

Abdominal girth is girth reduced

evidence by

of ascities and

Objective data:

puffiness of

measure

The child is

face,

abdominal girth.

having puffiness

periorbital

Assess the

of face,

and pedal

dietary pattern

periorbital edema

edema, and

of the child.

give

and edema at

abdominal

Provide small

frequent meals.

feets.

distension.

and frequent
meals.

to 45 cms.

49cms

Advised mother to
small

and

Provided the list of

protein rich foods
to mother.

Increase food

Instructed

mother

18

items that

to

serve

food

in

contain protein.

utensils which the

child used to have

Consider likes

food.

and dislikes of
the child.

SR
NO.
4.

Subjective data

NURSING
DIAGNOSIS
Deficient

PLANNING
OBJECTIVE
INTERVENTIONS
Parents will - Assess the level

Mother says they

knowledge of

gain

have not taken

the parents

knowledge

child for

related to

immunization.

nutrition and

of parents.
regarding the - Educate the
nutritional
parents

immunization

requirement

regarding the

need of child

of the child

causes and

and

symptoms of

ASSESSMENT

Objective data
Child not received
immunization
vaccines and food

IMPLEMENTATION

EVALUATION

Understanding

Parents gained

of

level of the parents

knowledge

understanding

is poor.ucated

regarding the

malnutrition.
immunization - Explain the
need of child.
parents

mother regarding
the condition of
their child.

requirements
of the child,

Educated parents

and its

regarding the

management

measures to

and

improve the

immunization
need of child.

pattern was

regarding the

nutrition status and

inappropriate

daily nutritional

prescribed menu

requirement of

plan.
Explained the

the child.
- Educate the

nutritional

importance and
19

parents

schedule of

regarding the

vaccination and

importance of

encouraged for

immunization of

future

the under-five

immunization.
Educated parents

child.
- Educate

regarding the

regarding the

prevention and

measures to

management of

prevent

complications.

complications of
malnutrition.
SR
NO.
5.

ASSESSMENT

NURSING

Subjective data:

DIAGNOSIS
High risk for

The mother

OBJECTIVE

PLANNING
INTERVENTIONS

IMPLEMENTATION

EVALUATION

Child will

Assess the risk

Facial puffiness

The childs

impaired skin

achieve and

factors for the

and pedal edema

skin display no

complaint that my

integrity

maintain

impairment of

present.

evidence of

son is having

related to

good skin

skin integrity.

redness and

edema.

fluid overload.

texture and

Provide

irritation. The

integrity.

meticulous skin

Provided the skin

mother is

Objective data:

care.

care.

applying

Child having facial

Avoid tight

puffiness and pedal

clothing.

edema.

cream to the
Advised mother to

child

avoid tight
Cleanse and

clothing.
20

powder opposing

Cleansed and

skin surfaces

powdered skin

several times

surfaces.

per day.
Change the

Advised mother to

position

change the

frequently.

position frequently.
------

Use pressure
relieving
mattresses as
needed to
prevent ulcer.
HEALTH EDUCATION

I educate them (patient & family member) to

Take high caloric diet and iron rich diet.
To avoid activities which causes fatigue.
To take proper rest and sleep.
Do not perform any heavy work.
Take the medicine on time and care for the follow up.

21

BIBLIOGRAPHY:
1. Marlow DR, Redding BA. Text Book of Pediatric Nursing. 6 th ed. New Delhi:
Elsevier India Private Limited; 2006.
2. Wilson D & Hockenberry MJ. Nursing Care of Infants and Children. 8 th ed.
New Delhi: Elsevier Private Ltd; 2007.
3. http://en.wikipedia.org/wiki/Marasmus
4. http://www.faqs.org/nutrition/Kwa-Men/Marasmus.html
5. http://wrongdiagnosis.com/m/marasmus/intro.htm
6. http://social.jrank.org/pages/378/Marasmus.html
7. http://en.wikipedia.org/wiki/Kwashiorkor
8. http://www.umm.edu/ency/article/001604.htm
9. http://www.wrongdiagnosis.com/k/kwashiorkor/intro.htm

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