This is another severe form of protein-energy malnutrition. These children present with a characteristic syndrome which always includes oedema, especially of both feet and legs. Kwashiorkor usually occurs in children between 6 months and 2 years of age. It is an acute problem which is often precipitated by an infection such as gastroenteritis in a child who is already underweight for age. These children have a typical appearance:

• They are miserable, with a poor appetite.
• They have oedema of their legs and their face looks swollen with fat cheeks. Pressing on the back of each foot for a few seconds will show the pitting of oedema. Due to the facial oedema they may appear ‘chubby’ and their wasting is often missed.
• Their hair is sparse, fine and may have a reddish colour.
• They have areas of increased or decreased skin pigmentation with scaling, especially in the nappy area (flaky-paint rash). There may also be areas of skin which are wet and look like burns. The skin is easily damaged and may be ulcerated. Secondary bacterial skin infection is common.
• They have a distended abdomen and an enlarged liver.
• Angular stomatitis is common with painful cracking at the angles of the mouth.
• Their nails are pale.
• Their weight usually falls below the 3rd centile but above 60% of the 50th centile. Some infants have a normal weight because of their oedema.
• They often have signs of anaemia and vitamin deficiency.