Protein energy malnutrition differential diagnosis: Difference between revisions
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[[Image:Home_logo1.png|right|250px|link=https://www.wikidoc.org/index.php/Protein_energy_malnutrition]] | |||
{{CMG}}; {{AE}} {{DAMI}} | {{CMG}}; {{AE}} {{DAMI}} | ||
==Overview== | ==Overview== | ||
Protein energy malnutrition must be differentiated from other [[diseases]] that cause [[failure to thrive]], [[edema]], [[wasting]] [[Infections|recurrent infections]], [[skin]] and [[hair]] changes. It is important to also differentiate [[kwashiorkor]] from [[marasmus]] as the two [[diseases]] are | Protein energy malnutrition must be differentiated from other [[diseases]] that cause [[failure to thrive]], [[edema]], [[wasting]] [[Infections|recurrent infections]], [[skin]] and [[hair]] changes. It is important to also differentiate [[kwashiorkor]] from [[marasmus]] as the two [[diseases]] are caused by protein-energy malnutrition and share similar features such as, [[weight loss]], muscle wasting, low blood glucose levels and growth retardation. | ||
==Differentiating Protein | ==Differentiating Protein Energy Malnutrition From Other Diseases== | ||
'''Differentiating kwashiorkor from marasmus''' | '''Differentiating kwashiorkor from marasmus''' | ||
protein- energy malnutrition and share similar features such as, [[weight loss]], muscle wasting, low blood glucose levels and growth retardation. The followwing table differentiates between the two:'''<ref name="pmid16076825">{{cite journal |vauthors=Müller O, Krawinkel M |title=Malnutrition and health in developing countries |journal=CMAJ |volume=173 |issue=3 |pages=279–86 |year=2005 |pmid=16076825 |pmc=1180662 |doi=10.1503/cmaj.050342 |url=}}</ref>''' | [[Kwashiorkor]] must be differentiated from [[marasmus]] as the two [[diseases]] are caused by protein-energy malnutrition and share similar features such as, [[weight loss]], [[muscle wasting]], low [[blood]] [[glucose]] levels and growth retardation. The followwing table differentiates between the two:'''<ref name="pmid16076825">{{cite journal |vauthors=Müller O, Krawinkel M |title=Malnutrition and health in developing countries |journal=CMAJ |volume=173 |issue=3 |pages=279–86 |year=2005 |pmid=16076825 |pmc=1180662 |doi=10.1503/cmaj.050342 |url=}}</ref>'''<ref name="pmid20345018">{{cite journal |vauthors=Manary MJ, Heikens GT, Golden M |title=Kwashiorkor: more hypothesis testing is needed to understand the aetiology of oedema |journal=Malawi Med J |volume=21 |issue=3 |pages=106–7 |year=2009 |pmid=20345018 |pmc=3717490 |doi= |url=}}</ref><ref name="pmid8275214">{{cite journal |vauthors=Henry FJ, Briend A, Fauveau V, Huttly SA, Yunus M, Chakraborty J |title=Gender and age differentials in risk factors for childhood malnutrition in Bangladesh |journal=Ann Epidemiol |volume=3 |issue=4 |pages=382–6 |year=1993 |pmid=8275214 |doi= |url=}}</ref><ref name="pmid25223408">{{cite journal |vauthors=Coulthard MG |title=Oedema in kwashiorkor is caused by hypoalbuminaemia |journal=Paediatr Int Child Health |volume=35 |issue=2 |pages=83–9 |year=2015 |pmid=25223408 |pmc=4462841 |doi=10.1179/2046905514Y.0000000154 |url=}}</ref><ref name="pmid14436226">{{cite journal |vauthors=RAO KS, SWAMINATHAN MC, SWARUP S, PATWARDHAN VN |title=Protein malnutrition in South India |journal=Bull. World Health Organ. |volume=20 |issue= |pages=603–39 |year=1959 |pmid=14436226 |pmc=2537781 |doi= |url=}}</ref><ref name="pmid2077461">{{cite journal |vauthors=Barus ST, Rani R, Lubis NU, Hamid ED, Tarigan S |title=Clinical features of severe malnutrition at the pediatric ward of Dr. Pirngadi Hospital Medan |journal=Paediatr Indones |volume=30 |issue=11-12 |pages=286–92 |year=1990 |pmid=2077461 |doi= |url=}}</ref><ref name="pmid21695035">{{cite journal |vauthors=Rodríguez L, Cervantes E, Ortiz R |title=Malnutrition and gastrointestinal and respiratory infections in children: a public health problem |journal=Int J Environ Res Public Health |volume=8 |issue=4 |pages=1174–205 |year=2011 |pmid=21695035 |pmc=3118884 |doi=10.3390/ijerph8041174 |url=}}</ref><ref name="pmid1764353">{{cite journal |vauthors=Latham MC |title=The dermatosis of kwashiorkor in young children |journal=Semin Dermatol |volume=10 |issue=4 |pages=270–2 |year=1991 |pmid=1764353 |doi= |url=}}</ref><ref name="pmid3120652">{{cite journal |vauthors=McLaren DS |title=Skin in protein energy malnutrition |journal=Arch Dermatol |volume=123 |issue=12 |pages=1674–1676a |year=1987 |pmid=3120652 |doi= |url=}}</ref><ref name="pmid4297407">{{cite journal |vauthors=Jaya Rao KS, Srikantia SG, Gopalan C |title=Plasma cortisol levels in protein-calorie malnutrition |journal=Arch. Dis. Child. |volume=43 |issue=229 |pages=365–7 |year=1968 |pmid=4297407 |pmc=2019952 |doi= |url=}}</ref><ref name="pmid12011921">{{cite journal |vauthors=Muniz-Junqueira MI, Queiroz EF |title=Relationship between protein-energy malnutrition, vitamin A, and parasitoses in living in Brasília |journal=Rev. Soc. Bras. Med. Trop. |volume=35 |issue=2 |pages=133–41 |year=2002 |pmid=12011921 |doi= |url=}}</ref><ref name="pmid8862482">{{cite journal |vauthors=Donnen P, Brasseur D, Dramaix M, Vertongen F, Ngoy B, Zihindula M, Hennart P |title=Vitamin A deficiency and protein-energy malnutrition in a sample of pre-school age children in the Kivu Province in Zaire |journal=Eur J Clin Nutr |volume=50 |issue=7 |pages=456–61 |year=1996 |pmid=8862482 |doi= |url=}}</ref> | ||
{| class="wikitable" | {| class="wikitable" | ||
!Distinguishing Features | ! align="center" style="background:#4479BA; color: #FFFFFF;" + |Distinguishing Features | ||
! | ! align="center" style="background:#4479BA; color: #FFFFFF;" + |Kwashiorkor | ||
! | ! align="center" style="background:#4479BA; color: #FFFFFF;" + |Marasmus | ||
|- | |- | ||
|Cause | |Cause | ||
Line 38: | Line 38: | ||
|- | |- | ||
|[[Skin changes]] | |[[Skin changes]] | ||
|[[Dermatitis]] and [[ | |[[Dermatitis]] and [[hyperpigmentation]] noticed | ||
|[[Xerostomia|Dry]] and [[atrophic]] [[skin]] but no changes in [[color]] | |[[Xerostomia|Dry]] and [[atrophic]] [[skin]] but no changes in [[color]] | ||
|- | |- | ||
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|Facial appearance | |Facial appearance | ||
|[[Moon face|Moon-like face]] | |[[Moon face|Moon-like face]] | ||
| | |Sunken eyes, [[maxillary]] prominence, loss of [[buccal]] [[fat pad]] | ||
|- | |- | ||
|[[Abdomen]] | |[[Abdomen]] | ||
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| style="background: #F5F5F5; padding: 5px; text-align: center;" | [[Kwashiorkor]] | | style="background: #F5F5F5; padding: 5px; text-align: center;" | [[Kwashiorkor]] | ||
| style="background: #DCDCDC; padding: 5px;" | | | style="background: #DCDCDC; padding: 5px;" | | ||
* Deficiency of [[protein]]-rich foods like meat and [[poultry]] in diet | * Deficiency of [[protein]]-rich foods like meat and [[poultry]] in [[diet]] | ||
* Early [[weaning]] | * Early [[weaning]] | ||
| style="background: #F5F5F5; padding: 5px;" | | | style="background: #F5F5F5; padding: 5px;" | | ||
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* Balanced diet of [[carbohydrates]], [[protein]] and [[fat]] | * Balanced diet of [[carbohydrates]], [[protein]] and [[fat]] | ||
| style="background: #F5F5F5; padding: 5px;" | | | style="background: #F5F5F5; padding: 5px;" | | ||
* [[CBC]] | * [[Complete blood count]] ([[Complete blood count|CBC]]) | ||
* [[ABG]] | * [[Arterial blood gas]] ([[ABG]]) | ||
* BUN | * [[BUN-to-creatinine ratio|Blood urea nitrogen to creatnine ratio]] | ||
* Serum [[potassium]] | * [[Serum]] [[potassium]] | ||
* Total [[protein]] | * Total [[protein]] | ||
* [[Urinalysis]] | * [[Urinalysis]] | ||
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* [[Lipiduria]] and [[ketonuria]] portend a poorer prognosis | * [[Lipiduria]] and [[ketonuria]] portend a poorer prognosis | ||
| style="background: #F5F5F5; padding: 5px;" | | | style="background: #F5F5F5; padding: 5px;" | | ||
* Caloric replacement | * [[Calorie|Caloric]] replacement | ||
* [[Protein]] replacement | * [[Protein]] replacement | ||
* [[Vitamin]] and [[mineral]] supplementation | * [[Vitamin]] and [[mineral]] supplementation | ||
* [[Antibiotics]] if infections are present | * [[Antibiotics]] if [[infections]] are present | ||
* Plasma expanders and [[ORS]], if shock is present | * [[Plasma]] expanders and [[Oral rehydration therapy|oral rehydration solution]] ([[Oral rehydration therapy|ORS]]), if [[shock]] is present | ||
* [[Lactase]] if [[lactose intolerant]] | * [[Lactase]] if [[lactose intolerant]] | ||
|- | |- | ||
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* [[Hypothermia|Hypo]] / [[hyperthermia]] | * [[Hypothermia|Hypo]] / [[hyperthermia]] | ||
* [[Dehydration]] | * [[Dehydration]] | ||
* Skin pallor | * [[Skin]] [[pallor]] | ||
* [[Anemia]] | * [[Anemia]] | ||
* [[Corneal disease|Corneal lesions]] (due to [[vitamin A deficiency]]) | * [[Corneal disease|Corneal lesions]] (due to [[vitamin A deficiency]]) | ||
* Decreased | * Decreased peripheral pulses | ||
* [[Confusion]] | * [[Confusion]] | ||
| style="background: #DCDCDC; padding: 5px;" | | | style="background: #DCDCDC; padding: 5px;" | | ||
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* [[Peripheral blood smear]] | * [[Peripheral blood smear]] | ||
* [[Hemoglobin]] | * [[Hemoglobin]] | ||
* [[Urinalysis]] and culture | * [[Urinalysis]] and [[Culture collection|culture]] | ||
* [[Stool examination|Stool exam]] | * [[Stool examination|Stool exam]] | ||
* [[Serum albumin|Albumin tests]] | * [[Serum albumin|Albumin tests]] | ||
* [[Electrolyte|Electrolyte level]] | * [[Electrolyte|Electrolyte level]] | ||
| style="background: #DCDCDC; padding: 5px;" | : | | style="background: #DCDCDC; padding: 5px;" | : | ||
* Prognosis is good if underlying medical illness is treated | * [[Prognosis]] is good if underlying medical illness is treated | ||
* [[Bacterial infection]] and [[renal failure]] may portend a poorer prognosis | * [[Bacterial infection]] and [[renal failure]] may portend a poorer [[prognosis]] | ||
| style="background: #F5F5F5; padding: 5px;" | : | | style="background: #F5F5F5; padding: 5px;" | : | ||
* [[Blood glucose]] control | * [[Blood glucose]] control | ||
* Prevent [[hypothermia]] | * [[Prevention (medical)|Prevent]] [[hypothermia]] | ||
* Prompt correction of [[dehydration]] | * Prompt correction of [[dehydration]] | ||
* Early detection and correction of [[electrolyte imbalance]] | * Early detection and correction of [[electrolyte imbalance]] | ||
* Active control of [[infections]] | * Active control of [[infections]] | ||
* Screening and stabilization of [[Micronutrient malnutrition|micronutrient deficiencies]] | * [[Screening (medicine)|Screening]] and stabilization of [[Micronutrient malnutrition|micronutrient deficiencies]] | ||
* Feeding for initial stabilization | * Feeding for initial stabilization | ||
* [[Nutritional supplement|Nutritional support]] to support normal growth | * [[Nutritional supplement|Nutritional support]] to support normal growth | ||
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* Avoidance of [[infections]] and other [[diseases]] associated with [[protein losing enteropathy]] | * Avoidance of [[infections]] and other [[diseases]] associated with [[protein losing enteropathy]] | ||
| style="background: #F5F5F5; padding: 5px;" | | | style="background: #F5F5F5; padding: 5px;" | | ||
* Measurement of [[albumin]] / [[globulin]] levels | * Measurement of [[albumin]]/[[globulin]] levels | ||
* Presence of [[Alpha 1-antitrypsin deficiency|α1-antitrypsin]] in stool samples | * Presence of [[Alpha 1-antitrypsin deficiency|α1-antitrypsin]] in [[stool]] samples | ||
* Measuremnent of [[Vitamin A Deficiency|vitamins A]], [[Vitamin D Deficiency|D]], [[Vitamin E deficiency|E]] and [[Vitamin K Deficiency|K]] | * Measuremnent of [[Vitamin A Deficiency|vitamins A]], [[Vitamin D Deficiency|D]], [[Vitamin E deficiency|E]] and [[Vitamin K Deficiency|K]] | ||
| style="background: #DCDCDC; padding: 5px;" | | | style="background: #DCDCDC; padding: 5px;" | | ||
* Prognosis largely depends on the [[Disease|underlying disease]] | * [[Prognosis]] largely depends on the [[Disease|underlying disease]] | ||
* If it is potentially curable, prognosis improves considerably | * If it is potentially curable, [[prognosis]] improves considerably | ||
| style="background: #F5F5F5; padding: 5px;" | | | style="background: #F5F5F5; padding: 5px;" | | ||
* [[Antiparasitics|Antiparasitic agents]] | * [[Antiparasitics|Antiparasitic agents]] | ||
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| style="background: #F5F5F5; padding: 5px;" | 1-4 | | style="background: #F5F5F5; padding: 5px;" | 1-4 | ||
| style="background: #F5F5F5; padding: 5px;" | | | style="background: #F5F5F5; padding: 5px;" | | ||
* [[Generalized edema]] of body tissues with profound subcutaneous [[Edema|swelling]] | * [[Generalized edema]] of body tissues with profound [[subcutaneous]] [[Edema|swelling]] | ||
| style="background: #DCDCDC; padding: 5px;" | | | style="background: #DCDCDC; padding: 5px;" | | ||
* Healthy [[balanced diet]] in children | * Healthy [[balanced diet]] in children | ||
Line 214: | Line 214: | ||
* [[CBC]] | * [[CBC]] | ||
* [[ABG]] | * [[ABG]] | ||
* [[BNP]] | * [[Brain natriuretic peptide]] ([[BNP]]) | ||
* [[BUN-to-creatinine ratio|BUN:Cr]] | * [[BUN-to-creatinine ratio|BUN:Cr]] | ||
* [[Serum potassium]] | * [[Serum potassium]] | ||
* [[Total protein]] | * [[Total protein]] | ||
* [[Urinalysis]] | * [[Urinalysis]] | ||
| style="background: #DCDCDC; padding: 5px;" | Good prognosis if the underlying cause is identified and treated early | | style="background: #DCDCDC; padding: 5px;" | Good [[prognosis]] if the underlying cause is identified and treated early | ||
| style="background: #F5F5F5; padding: 5px;" | | | style="background: #F5F5F5; padding: 5px;" | | ||
* Treatment is targeted at the underlying cause | * Treatment is targeted at the underlying cause | ||
* [[Diuretics]] if due to [[fluid overload]] | * [[Diuretics]] if due to [[fluid overload]] | ||
* [[Albumin]] infusion to correct [[hypoproteinemia]] | * [[Albumin]] [[infusion]] to correct [[hypoproteinemia]] | ||
|- | |- | ||
| style="background: #F5F5F5; padding: 5px; text-align: center;" | [[Wasting syndrome|HIV wasting syndrome]] | | style="background: #F5F5F5; padding: 5px; text-align: center;" | [[Wasting syndrome|HIV wasting syndrome]] | ||
Line 242: | Line 242: | ||
* [[Body mass index]] ([[BMI]]) | * [[Body mass index]] ([[BMI]]) | ||
* [[Body water|Total body water]] and [[fat]] | * [[Body water|Total body water]] and [[fat]] | ||
* Sequential [[anthropometry]] (mid arm circumference, [[triceps]], skinfold thickness) to predict prognosis | * Sequential [[anthropometry]] (mid arm circumference, [[triceps]], skinfold thickness) to predict [[prognosis]] | ||
| style="background: #DCDCDC; padding: 5px;" | Prognosis is good with the use of [[AIDS | | style="background: #DCDCDC; padding: 5px;" | [[Prognosis]] is good with the use of [[HIV AIDS medical therapy|highly active anti-retroviral therapy]] ([[HIV AIDS medical therapy|HAART]]) | ||
| style="background: #F5F5F5; padding: 5px;" | | | style="background: #F5F5F5; padding: 5px;" | | ||
* [[AIDS antiretroviral drugs|HAART]] | * [[AIDS antiretroviral drugs|HAART]] | ||
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* [[Ultrasonic Imaging|Transabdominal ultrasound]] | * [[Ultrasonic Imaging|Transabdominal ultrasound]] | ||
| style="background: #DCDCDC; padding: 5px;" | | | style="background: #DCDCDC; padding: 5px;" | | ||
* Patients who get medical care early have a good prognosis | * Patients who get medical care early have a good [[prognosis]] | ||
* Increased risk of [[pancreatic cancer]] | * Increased risk of [[pancreatic cancer]] | ||
| style="background: #F5F5F5; padding: 5px;" | | | style="background: #F5F5F5; padding: 5px;" | | ||
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| style="background: #F5F5F5; padding: 5px;" | | | style="background: #F5F5F5; padding: 5px;" | | ||
* [[Urinalysis]] | * [[Urinalysis]] | ||
* [[Urine catecholamines|Urine protein]] quantification (by first-morning urine [[protein]] / [[creatinine]] or 24-hour urine protein) | * [[Urine catecholamines|Urine protein]] quantification (by first-morning [[urine]] [[protein]] / [[creatinine]] or 24-hour urine protein) | ||
* [[Serum albumin]] | * [[Serum albumin]] | ||
* [[Lipid|Lipid panel]] | * [[Lipid|Lipid panel]] | ||
| style="background: #DCDCDC; padding: 5px;" | | | style="background: #DCDCDC; padding: 5px;" | | ||
* Prognosis depends on whether the [[nephrotic syndrome]] is [[Steroid responsive nephrotic syndrome|steroid responsive]] or steroid resistant | * [[Prognosis]] depends on whether the [[nephrotic syndrome]] is [[Steroid responsive nephrotic syndrome|steroid responsive]] or [[steroid]] resistant | ||
| style="background: #F5F5F5; padding: 5px;" | | | style="background: #F5F5F5; padding: 5px;" | | ||
* [[Corticosteroids]] | * [[Corticosteroids]] | ||
Line 318: | Line 318: | ||
* [[Alkylating agent|Alkylating agents]] | * [[Alkylating agent|Alkylating agents]] | ||
* [[Calcineurin inhibitor|Calcineurin inhibitors]] | * [[Calcineurin inhibitor|Calcineurin inhibitors]] | ||
* Home monitoring of urine [[protein]] and fluid status | * Home monitoring of [[urine]] [[protein]] and fluid status | ||
|- | |- | ||
| style="background: #F5F5F5; padding: 5px; text-align: center;" | [[Liver cirrhosis|Portal cirrhosis]] | | style="background: #F5F5F5; padding: 5px; text-align: center;" | [[Liver cirrhosis|Portal cirrhosis]] | ||
Line 340: | Line 340: | ||
* Avoid [[alcohol]] | * Avoid [[alcohol]] | ||
* Treatment and [[vaccination]] against [[hepatitis]] | * Treatment and [[vaccination]] against [[hepatitis]] | ||
* Good diet and exercise | * Good [[diet]] and exercise | ||
| style="background: #F5F5F5; padding: 5px;" | | | style="background: #F5F5F5; padding: 5px;" | | ||
* [[Complete blood count|CBC]] | * [[Complete blood count|CBC]] | ||
Line 346: | Line 346: | ||
* [[Culture collection|Culture]] | * [[Culture collection|Culture]] | ||
* [[Total protein]] | * [[Total protein]] | ||
* Serum ascites albumin gradient | * [[Serum-ascites albumin gradient|Serum ascites albumin gradient]] | ||
* [[Ammonia production|Ammonia level]] | * [[Ammonia production|Ammonia level]] | ||
| style="background: #DCDCDC; padding: 5px;" | Prognosis is poor | | style="background: #DCDCDC; padding: 5px;" | Prognosis is poor |
Latest revision as of 22:36, 25 February 2019
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Omodamola Aje B.Sc, M.D. [2]
Overview
Protein energy malnutrition must be differentiated from other diseases that cause failure to thrive, edema, wasting recurrent infections, skin and hair changes. It is important to also differentiate kwashiorkor from marasmus as the two diseases are caused by protein-energy malnutrition and share similar features such as, weight loss, muscle wasting, low blood glucose levels and growth retardation.
Differentiating Protein Energy Malnutrition From Other Diseases
Differentiating kwashiorkor from marasmus
Kwashiorkor must be differentiated from marasmus as the two diseases are caused by protein-energy malnutrition and share similar features such as, weight loss, muscle wasting, low blood glucose levels and growth retardation. The followwing table differentiates between the two:[1][2][3][4][5][6][7][8][9][10][11][12]
Distinguishing Features | Kwashiorkor | Marasmus |
---|---|---|
Cause | Deficiency of protein in the diet of child | Deficiency of protein as well as energy nutrients (that is carbohydrates and fats) in the diet |
Age | Occurs in children in the age group 1-5 years | Typically occurs in children below the age of 1 year |
Association | More common in villages where there is small gap period between successive pregnancies | More common in towns and cities where breast-feeding in discontinued quite early |
Edema | Presence of edema | Absence of edema |
Muscles | Wasting of muscles | Wasting of muscles is quite evident. The child is reduced to skin and bones |
Skin changes | Dermatitis and hyperpigmentation noticed | Dry and atrophic skin but no changes in color |
Serum cortisol | Decreased/Normal | Increased |
Fasting blood glucose | Decreased | Decreased |
Growth retardation | Mildly retarded in growth | Severely retarded in growth |
Facial appearance | Moon-like face | Sunken eyes, maxillary prominence, loss of buccal fat pad |
Abdomen | Protuded | Shrunken |
Vitamin deficiency | Present | Present |
Weight | 60-80% of normal weight for age | <60% of normal weight for age |
Differential diagnosis of edema and wasting [13][14][15][16][17][18][19][20]
Table adapted from CDC Pinkbook.[21]
References
- ↑ Müller O, Krawinkel M (2005). "Malnutrition and health in developing countries". CMAJ. 173 (3): 279–86. doi:10.1503/cmaj.050342. PMC 1180662. PMID 16076825.
- ↑ Manary MJ, Heikens GT, Golden M (2009). "Kwashiorkor: more hypothesis testing is needed to understand the aetiology of oedema". Malawi Med J. 21 (3): 106–7. PMC 3717490. PMID 20345018.
- ↑ Henry FJ, Briend A, Fauveau V, Huttly SA, Yunus M, Chakraborty J (1993). "Gender and age differentials in risk factors for childhood malnutrition in Bangladesh". Ann Epidemiol. 3 (4): 382–6. PMID 8275214.
- ↑ Coulthard MG (2015). "Oedema in kwashiorkor is caused by hypoalbuminaemia". Paediatr Int Child Health. 35 (2): 83–9. doi:10.1179/2046905514Y.0000000154. PMC 4462841. PMID 25223408.
- ↑ RAO KS, SWAMINATHAN MC, SWARUP S, PATWARDHAN VN (1959). "Protein malnutrition in South India". Bull. World Health Organ. 20: 603–39. PMC 2537781. PMID 14436226.
- ↑ Barus ST, Rani R, Lubis NU, Hamid ED, Tarigan S (1990). "Clinical features of severe malnutrition at the pediatric ward of Dr. Pirngadi Hospital Medan". Paediatr Indones. 30 (11–12): 286–92. PMID 2077461.
- ↑ Rodríguez L, Cervantes E, Ortiz R (2011). "Malnutrition and gastrointestinal and respiratory infections in children: a public health problem". Int J Environ Res Public Health. 8 (4): 1174–205. doi:10.3390/ijerph8041174. PMC 3118884. PMID 21695035.
- ↑ Latham MC (1991). "The dermatosis of kwashiorkor in young children". Semin Dermatol. 10 (4): 270–2. PMID 1764353.
- ↑ McLaren DS (1987). "Skin in protein energy malnutrition". Arch Dermatol. 123 (12): 1674–1676a. PMID 3120652.
- ↑ Jaya Rao KS, Srikantia SG, Gopalan C (1968). "Plasma cortisol levels in protein-calorie malnutrition". Arch. Dis. Child. 43 (229): 365–7. PMC 2019952. PMID 4297407.
- ↑ Muniz-Junqueira MI, Queiroz EF (2002). "Relationship between protein-energy malnutrition, vitamin A, and parasitoses in living in Brasília". Rev. Soc. Bras. Med. Trop. 35 (2): 133–41. PMID 12011921.
- ↑ Donnen P, Brasseur D, Dramaix M, Vertongen F, Ngoy B, Zihindula M, Hennart P (1996). "Vitamin A deficiency and protein-energy malnutrition in a sample of pre-school age children in the Kivu Province in Zaire". Eur J Clin Nutr. 50 (7): 456–61. PMID 8862482.
- ↑ Cho EJ, Kim MY, Lee JH, Lee IY, Lim YL, Choi DH; et al. (2015). "Diagnostic and Prognostic Values of Noninvasive Predictors of Portal Hypertension in Patients with Alcoholic Cirrhosis". PLoS One. 10 (7): e0133935. doi:10.1371/journal.pone.0133935. PMC 4511411. PMID 26196942.
- ↑ Cuzzoni E, De Iudicibus S, Franca R, Stocco G, Lucafò M, Pelin M; et al. (2015). "Glucocorticoid pharmacogenetics in pediatric idiopathic nephrotic syndrome". Pharmacogenomics. 16 (14): 1631–48. doi:10.2217/pgs.15.101. PMID 26419298.
- ↑ DiMagno MJ, DiMagno EP (2013). "Chronic pancreatitis". Curr Opin Gastroenterol. 29 (5): 531–6. doi:10.1097/MOG.0b013e3283639370. PMC 4387887. PMID 23852141.
- ↑ Keithley JK, Swanson B (2013). "HIV-associated wasting". J Assoc Nurses AIDS Care. 24 (1 Suppl): S103–11. doi:10.1016/j.jana.2012.06.013. PMID 23290370.
- ↑ Nahlen BL, Chu SY, Nwanyanwu OC, Berkelman RL, Martinez SA, Rullan JV (1993). "HIV wasting syndrome in the United States". AIDS. 7 (2): 183–8. PMID 8466680.
- ↑ Vogelaar JL, Loar RW, Bram RJ, Fischer PR, Kaushik R (2014). "Anasarca, hypoalbuminemia, and anemia: what is the correlation?". Clin Pediatr (Phila). 53 (7): 710–2. doi:10.1177/0009922814526990. PMID 24647692.
- ↑ Amiot A (2015). "[Protein-losing enteropathy]". Rev Med Interne. 36 (7): 467–73. doi:10.1016/j.revmed.2014.12.001. PMID 25618488.
- ↑ Ramírez Prada D, Delgado G, Hidalgo Patiño CA, Pérez-Navero J, Gil Campos M (2011). "Using of WHO guidelines for the management of severe malnutrition to cases of marasmus and kwashiorkor in a Colombia children's hospital". Nutr Hosp. 26 (5): 977–83. doi:10.1590/S0212-16112011000500009. PMID 22072341.
- ↑ "Epidemiology and Prevention of Vaccine-Preventable Diseases".