What are the two severe forms of protein calorie malnutrition?

November 14, 2025 •

5 min read

According to the World Health Organization, nearly half of all deaths in children under 5 are linked to undernutrition. Among the most devastating types are the two severe forms of protein calorie malnutrition, known as Kwashiorkor and Marasmus. These two distinct conditions represent life-threatening deficiencies in essential nutrients.

Quick Summary

The two most severe forms of protein calorie malnutrition are Kwashiorkor and Marasmus, each presenting with unique symptoms. Kwashiorkor is defined by edema, while Marasmus is characterized by severe wasting of fat and muscle tissue.

Key Points

Kwashiorkor is Edematous Malnutrition: It results from severe protein deficiency, often with adequate calories, leading to characteristic fluid retention and swelling.
Marasmus is Wasting Malnutrition: This form stems from an overall deficiency of both calories and protein, causing severe wasting of fat and muscle tissue.
Visible Differences are Key: Kwashiorkor is identified by edema (fluid swelling), while marasmus presents with a severely emaciated, wasted appearance.
Treatment is Multi-Staged: Initial management focuses on stabilizing blood glucose, body temperature, and rehydrating carefully, followed by a gradual increase in nutrient intake.
Prevention is Primarily Socioeconomic: Tackling poverty, improving food security, and enhancing nutritional education are crucial to preventing severe protein calorie malnutrition.
Infections Worsen Outcomes: Children with these conditions have compromised immune systems, making them highly susceptible to and less able to recover from common infections.
Hybrid Form Exists: The most severe form, Marasmic Kwashiorkor, combines the edema of Kwashiorkor with the severe wasting of Marasmus.

Understanding Protein Calorie Malnutrition

Protein calorie malnutrition (PCM), also known as protein-energy malnutrition, is a severe deficiency of protein and/or energy (calories) necessary to meet the body's metabolic demands. While often associated with developing nations, PCM can also occur in developed countries due to factors like chronic illness or neglect. The two primary forms, Kwashiorkor and Marasmus, manifest differently due to the specific nature of the nutritional deficit.

Kwashiorkor: The Edematous Malnutrition

Kwashiorkor, often called "wet" malnutrition, results from a diet that is severely lacking in protein, despite containing relatively adequate carbohydrates and overall calories. The name, from the Ga language of Ghana, means "the sickness the older child gets when the next baby is born," as it frequently appears in children recently weaned from breast milk to starchy, low-protein diets.

Key Characteristics of Kwashiorkor

Edema: The most distinguishing feature is fluid retention, which causes swelling (edema) in the ankles, feet, face, and abdomen. This can mask the underlying muscle wasting. The edema is caused by a lack of albumin, a protein necessary for maintaining osmotic pressure in the blood.
Enlarged Liver: A fatty liver (hepatomegaly) is a common finding, resulting from the inability to synthesize transport proteins.
Hair and Skin Changes: The hair may become sparse, dry, and brittle, and can lose its color, sometimes appearing reddish or blond. Skin may become dry, scaly, and peel, with dark, flaky patches in some cases.
Behavioral Changes: Affected children are often irritable, lethargic, and apathetic.
Metabolic Disturbances: Profound micronutrient deficiencies, oxidative stress, and imbalances in the gut microbiome also play a role in its complex pathology.

Marasmus: The Wasting Malnutrition

Marasmus, the "dry" form of malnutrition, stems from a severe and prolonged deficiency of both protein and calories. It represents a state of starvation where the body consumes its own fat and muscle tissue for energy. Marasmus is the most common form of severe malnutrition and typically affects infants between six and eighteen months of age who fail to thrive or are weaned onto inadequate food sources.

Key Characteristics of Marasmus

Severe Wasting: There is a drastic loss of subcutaneous fat and muscle mass, leaving the child emaciated with protruding bones and loose, wrinkled skin. The face can have an aged or "old man" appearance.
Stunted Growth: Children with marasmus experience significant growth retardation and are severely underweight.
Lethargy and Apathy: Patients are weak, lethargic, and generally apathetic, though they may often appear hungry.
Immunity Impairment: The immune system is severely compromised, increasing susceptibility to infections like pneumonia, measles, and diarrhea.
Metabolic Slowdown: To conserve energy, the body lowers its metabolic rate, which can lead to low body temperature (hypothermia) and slow heart rate (bradycardia).

A Hybrid Condition: Marasmic Kwashiorkor

In some cases, children can exhibit symptoms of both Kwashiorkor and Marasmus, a condition known as Marasmic Kwashiorkor. This is considered the most severe form of protein-energy malnutrition, characterized by both severe wasting and edema.

Kwashiorkor vs. Marasmus: A Comparison


Feature	Kwashiorkor	Marasmus
Primary Deficiency	Severe protein deficiency, often with adequate calories.	Severe deficiency of both protein and calories.
Key Symptom	Edema (swelling) of limbs, face, and abdomen.	Severe muscle and fat wasting, emaciation.
Appearance	Swollen belly, moon face, masked muscle loss.	Emaciated, wasted look with loose, wrinkled skin.
Liver Status	Enlarged, fatty liver.	Normal or reduced liver size.
Age Range	Typically children aged 1-4 years, post-weaning.	Typically infants and very young children, 6-18 months.
Mental State	Apathetic, irritable, lethargic.	Apathetic, weak, and often more hungry initially.

Causes and Treatment

Both Kwashiorkor and Marasmus are rooted in socioeconomic factors like poverty, food insecurity, and inadequate sanitation. Environmental factors, lack of nutritional education, and infectious diseases also play significant roles.

Diagnosis involves a clinical examination to identify symptoms like edema or wasting, combined with anthropometric measurements (e.g., weight-for-height, Mid-Upper Arm Circumference) and laboratory tests (e.g., serum albumin).

Treatment for severe malnutrition requires a careful, multi-phased approach to prevent refeeding syndrome, a potentially fatal shift in fluid and electrolytes.

Initial Stabilization: Correct hypoglycemia, hypothermia, dehydration (using special low-sodium fluids like ReSoMal), and start broad-spectrum antibiotics for infection. Cautious, frequent feeding with a low-protein, low-lactose therapeutic milk (F-75) is initiated.
Rehabilitation: As the child stabilizes, higher-energy therapeutic food (F-100 or ready-to-use therapeutic food, RUTF) is introduced to achieve rapid weight gain. Iron is added during this phase, but not in the stabilization phase.

The Long-Term Consequences

Without early and appropriate intervention, severe protein calorie malnutrition can lead to lasting complications. These include permanent growth stunting, impaired physical and intellectual development, and a higher risk of non-communicable diseases later in life, such as diabetes. The developmental impacts, especially on cognition and immunity, underscore the critical need for timely treatment.

Conclusion

Kwashiorkor and Marasmus, the two severe forms of protein calorie malnutrition, represent distinct physiological responses to critical nutrient deficiencies. While Kwashiorkor presents with fluid-retaining edema, Marasmus manifests as severe wasting. Both are life-threatening conditions demanding immediate medical attention and are often rooted in systemic issues such as poverty and food scarcity. Early diagnosis and a structured treatment protocol are crucial for improving outcomes and mitigating the devastating, long-term effects on a child's development. For more information on the global effort to combat malnutrition, visit the World Health Organization's nutrition page.

Sources:

Children's Health: Protein calorie malnutrition (PCM) in children
Medscape Reference: Protein-Energy Malnutrition
Cleveland Clinic: Malnutrition: Definition, Causes, Symptoms & Treatment
ResearchGate: Protein-Calorie Malnutrition (PDF)
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Frequently Asked Questions

The primary cause of Kwashiorkor is a severe deficiency of protein in the diet, which often occurs after a child is weaned from protein-rich breast milk and given a diet high in carbohydrates but low in protein.

The main difference is the type of nutritional deficiency and resulting symptoms. Kwashiorkor is a protein deficiency leading to edema (swelling), while Marasmus is a deficiency of both protein and calories, causing severe wasting and emaciation.

Yes, while most common in children, severe protein calorie malnutrition can affect adults. In developed countries, it is often linked to chronic illnesses, eating disorders like anorexia, or neglect.

Marasmic Kwashiorkor is a hybrid and most severe form of protein calorie malnutrition, where an individual exhibits symptoms of both Kwashiorkor (edema) and Marasmus (wasting).

The initial stage, known as the stabilization phase, involves correcting immediate life-threatening issues like hypoglycemia, hypothermia, and dehydration. Cautious feeding with low-osmolarity, low-lactose formula is started.

Refeeding syndrome is a dangerous metabolic and electrolyte disturbance that can occur during the reintroduction of nutrition to a severely malnourished person. It is prevented through careful, gradual nutritional rehabilitation and constant monitoring of fluid and electrolytes.

If left untreated, severe malnutrition can lead to long-term developmental problems, including permanent growth stunting, intellectual disabilities, and an increased risk of chronic diseases later in life.

Edema in Kwashiorkor is caused by a low level of serum albumin, a protein that helps regulate the balance of fluids in the body. Without enough albumin, fluid leaks out of the blood vessels and accumulates in the tissues, causing swelling.