# Kwashiorkor (oedematous protein malnutrition) - Category: chronic - Review status: reviewed (every claim checked against a document named on this page) - Sources: ICPC-3 (WONCA International Classification of Primary Care, 3rd edition) class TD74.00 - condition scope only, no dose · Kwashiorkor(Archived) - StatPearls - NCBI Bookshelf - https://www.ncbi.nlm.nih.gov/books/NBK507876/ · WHO Guideline: Updates on the Management of Severe Acute Malnutrition in Infants and Children (NCBI Bookshelf NBK190317) - https://www.ncbi.nlm.nih.gov/books/NBK190317/ · Egyptian National Drug Formulary - Antimicrobial 2023 (amoxicillin monograph, p338) - Verified date: 2026-08 ## Verified against - Kwashiorkor (oedematous protein malnutrition) - disease-level clinical article (kwashiorkor-clinical.txt) - WHO Guideline: Updates on the Management of Severe Acute Malnutrition in Infants and Children (NCBI Bookshelf NBK190317) - https://www.ncbi.nlm.nih.gov/books/NBK190317/ - Egyptian National Drug Formulary - Antimicrobial 2023 (amoxicillin monograph, p338) ## Treatment metadata - Amoxicillin — 250 mg — oral.liquid - Referral & safety-netting (no drug therapy) - Vitamin A — oral.solid ## Complete treatment card ```text KWASHIORKOR (OEDEMATOUS PROTEIN MALNUTRITION) Sources: ICPC-3 (WONCA International Classification of Primary Care, 3rd edition) class TD74.00 - condition scope only, no dose · Kwashiorkor(Archived) - StatPearls - NCBI Bookshelf - https://www.ncbi.nlm.nih.gov/books/NBK507876/ · WHO Guideline: Updates on the Management of Severe Acute Malnutrition in Infants and Children (NCBI Bookshelf NBK190317) - https://www.ncbi.nlm.nih.gov/books/NBK190317/ · Egyptian National Drug Formulary - Antimicrobial 2023 (amoxicillin monograph, p338) Review status: REVIEWED against Kwashiorkor (oedematous protein malnutrition) - disease-level clinical article (kwashiorkor-clinical.txt), WHO Guideline: Updates on the Management of Severe Acute Malnutrition in Infants and Children (NCBI Bookshelf NBK190317) - https://www.ncbi.nlm.nih.gov/books/NBK190317/, Egyptian National Drug Formulary - Antimicrobial 2023 (amoxicillin monograph, p338) (2026-08) IS IT THIS? - reference only, to read alongside your own examination SYMPTOMS - what the patient reports (4) - Kwashiorkor typically follows a protein-poor but calorie-adequate diet, often after carbohydrate-heavy foods are introduced abruptly at weaning - A recent trigger like an infection or injury often precedes onset, striking a child who had been nursing up to that point - Caregivers may report leg or facial swelling, poor appetite, lethargy, or skin breakdown [facial swelling · leg swelling · lethargy · poor appetite] - Unlike marasmus, kwashiorkor usually comes with little or no history of hunger or food-seeking behavior SIGNS - what you find (7) - Exam shows bilateral pitting edema, starting in the legs and potentially progressing to whole- body swelling [leg swelling] - Despite looking swollen, these children are usually severely malnourished underneath - Skin can show flaky-paint dermatosis - patches of darkened, peeling skin, especially over pressure points or trauma sites [scaling] - Cracked sores at the mouth corners and pale, thin, easily plucked hair are common [pallor] - An enlarged liver from fatty infiltration is frequently seen [hepatomegaly] - These children tend to be apathetic and listless, with little interest in food or their surroundings [lethargy] - Bilateral pitting edema of nutritional origin alone is enough to meet criteria for severe acute malnutrition [leg swelling] TESTS (9) - Severe acute malnutrition is diagnosed if weight-for-height z-score is very low, mid-upper arm circumference is under 115 mm, or nutritional bilateral pitting edema is present - MUAC-for-age z-score and weight-for-height z-score are used together in resource-limited or high-edema settings to improve sensitivity for detecting kwashiorkor - Weight-for-age below the third percentile is not a reliable marker for severe acute malnutrition, since it ignores the effect of stunting on linear growth - Ascites in a malnourished child should prompt evaluation for tuberculosis, HIV, sepsis, or malaria - WHO's core lab panel includes hemoglobin and blood smear, blood glucose, serum albumin and electrolytes, stool microscopy and culture, HIV testing, and urine microscopy and culture - Further micronutrient workup includes vitamin D, CBC, iron studies, folate, and vitamin B12 to characterize any anemia - Plasma transferrin, albumin, and thyroxine-binding prealbumin serve as markers of nutritional status and response to treatment - Suspected TB is worked up with an exposure history, exam, and where available chest imaging plus microbiologic testing such as gastric aspirate, sputum, or urine testing - Ascites raising suspicion for abdominal TB should prompt a diagnostic paracentesis IF NOT THIS - what else fits (4) - Severe edema mimicking kwashiorkor also needs work-up for nephrotic syndrome, liver disease with low albumin, congestive heart failure, and severe anemia - Both ascites and kwashiorkor together raise suspicion for coexisting tuberculosis, warranting ascitic fluid analysis and imaging - A careful history, exam, and anthropometric measurements are what separate malnutrition from other medical conditions in most cases - Children with severe malnutrition often also have coexisting tuberculosis, HIV/AIDS, measles, malaria, or micronutrient deficiencies that need identifying and treating Source StatPearls "Severe Acute Malnutrition: Recognition and Management of Marasmus and Kwashiorkor" - disease-level clinical article Status traced to the source above Rx: Routine antibiotic | Main treatment | Micronutrient replacement ROUTINE ANTIBIOTIC 1. AMOXICILLIN [1st line] Adult Not applicable - the protocol is for a child (see the paediatric dose) - Not applicable Peds 20-40 mg/kg/day [child max 1500 mg] (Formulary dose, by mouth, for a child over 3 months: 20 to 40 mg/kg/day in divided doses every 8 hours, to a maximum of 500 mg per dose, or 25 to 45 mg/kg/day every 12 hours, to a maximum of 875 mg per dose. The same monograph carries a higher line for severe infection given as step-down therapy - 80 to 90 mg/kg/day in divided doses every 12 hours, still capped at 500 mg per dose - and that is the figure the trial the WHO guideline reviewed actually used in severe acute malnutrition. The guideline itself states no amount, so the calculator above shows the ordinary range and both lines are written out here rather than one being chosen silently.) 3kg -> 60-120 mg/day 4kg -> 80-160 mg/day 5kg -> 100-200 mg/day 6kg -> 120-240 mg/day 7kg -> 140-280 mg/day 8kg -> 160-320 mg/day 9kg -> 180-360 mg/day 10kg -> 200-400 mg/day 11kg -> 220-440 mg/day 12kg -> 240-480 mg/day 13kg -> 260-520 mg/day 14kg -> 280-560 mg/day 15kg -> 300-600 mg/day 16kg -> 320-640 mg/day 17kg -> 340-680 mg/day 18kg -> 360-720 mg/day 19kg -> 380-760 mg/day 20kg -> 400-800 mg/day 21kg -> 420-840 mg/day 22kg -> 440-880 mg/day 23kg -> 460-920 mg/day 24kg -> 480-960 mg/day 25kg -> 500-1000 mg/day 26kg -> 520-1040 mg/day 27kg -> 540-1080 mg/day 28kg -> 560-1120 mg/day 29kg -> 580-1160 mg/day 30kg -> 600-1200 mg/day 31kg -> 620-1240 mg/day 32kg -> 640-1280 mg/day 33kg -> 660-1320 mg/day 34kg -> 680-1360 mg/day 35kg -> 700-1400 mg/day 36kg -> 720-1440 mg/day 37kg -> 740-1480 mg/day 38kg -> 760-1500 mg/day (upper capped) 39kg -> 780-1500 mg/day (upper capped) 40kg -> 800-1500 mg/day (upper capped) 41kg -> 820-1500 mg/day (upper capped) 42kg -> 840-1500 mg/day (upper capped) 43kg -> 860-1500 mg/day (upper capped) 44kg -> 880-1500 mg/day (upper capped) 45kg -> 900-1500 mg/day (upper capped) 46kg -> 920-1500 mg/day (upper capped) 47kg -> 940-1500 mg/day (upper capped) 48kg -> 960-1500 mg/day (upper capped) 49kg -> 980-1500 mg/day (upper capped) 50kg -> 1000-1500 mg/day (upper capped) Source Egyptian National Drug Formulary - Antimicrobial 2023 (amoxicillin monograph, p338) Why Kwashiorkor is severe acute malnutrition with oedema and is treated on the same WHO protocol. WHO recommendation 3.1 states that children with uncomplicated severe acute malnutrition managed as outpatients should be given a course of oral antibiotic such as amoxicillin, and names no amount. The amount here is the Egyptian formulary's general paediatric dose for a child over 3 months. Caution THIS IS THE 6 TO 59 MONTH PATHWAY. The guideline behind the card sets its mid-upper-arm- circumference threshold for children of 6 to 59 months and says plainly that the evidence needed to guide treatment in infants under 6 months, and in children of 5 years and over, is not yet there. A severely malnourished infant under 6 months is a different pathway and is not dosed from here. THE FORMULARY HAS TWO LINES AND THEY ARE FAR APART. Its mild-to-moderate figure is 20 to 40 mg/kg/day and its severe-infection step-down figure is 80 to 90 mg/kg/day. The calculator shows the first. A child who is septic rather than being covered routinely is a candidate for the second, and that decision is made at the bedside and not from a dose table. USE THE SUSPENSION, NOT A CAPSULE. A 7 kg child's daily dose is roughly 140 to 280 mg, which is a fraction of a 500 mg capsule and cannot be divided accurately. The Egyptian register carries the 250 mg/5 mL and 125 mg/5 mL suspensions widely; the brands listed below are the 250 mg/5 mL. OEDEMA MAKES THE WEIGHT LIE. The child's measured weight includes the oedema fluid, so a milligram-per-kilogram dose worked from it is an overestimate, and the weight-for-height ratio can look falsely normal. Dose against the programme's assessment, not the scale alone. WHO CALLS THE ANTIBIOTIC A CONDITIONAL RECOMMENDATION ON LOW-QUALITY EVIDENCE, and its own wording is "a course of oral antibiotic such as amoxicillin" - the drug is an example, not a mandate. THIS IS FOR UNCOMPLICATED DISEASE MANAGED AT HOME. Shock, hypoglycaemia, hypothermia, inability to feed or a serious infection means admission, and the antibiotic is then the ward's choice. THE AMOUNT IS NOT WHO'S. WHO names amoxicillin without a dose; the trial it summarises used 80 to 90 mg/kg/day for one week, which is the trial's figure. The dose above is the Egyptian formulary's. WHO RECORDS THE ARGUMENT AGAINST IT TOO - the article calls routine antibiotic use in this setting controversial, because of resistance and the effect on the gut microbiome. Do not give in serious hypersensitivity to amoxicillin or another beta-lactam. Egypt AMOXIL FORT 250MG/5ML SUSP. 60ML MUP > SMITHKL... 5.50 EGP AMOXICID 250MG/5ML SUSP. 60ML CID 7.00 EGP AMOXYCILLIN 250 MG/5 ML SUSP. 80 ML ARAB DRUG COMPANY (ADCO) 7.00 EGP AMOXYCILLIN 250 MG/5 ML SUSP. 100 ML ARAB DRUG COMPANY (ADCO) 7.50 EGP E-MOX 250MG/5ML SUSP. 80ML EIPICO 8.00 EGP BIOMOX 250MG/5ML SUSP. 80ML SEDICO 9.25 EGP AMOXIL FORT 250MG/5ML SUSP. 100ML MUP > SMITHKLINE BEECHAM 11.00 EGP HICONCIL 250MG/5ML SUSP. 80ML PHARCO 11.00 EGP HICILLIN 125MG/5ML SUSP. 80ML EL NASR 3.00 EGP -> ? strength differs, ? different route - not oral liquid AMOXICID 125MG/5ML SUSP. 60ML CID 6.00 EGP -> ? strength differs, ? different route - not oral liquid MAIN TREATMENT 2. REFERRAL & SAFETY-NETTING (NO DRUG THERAPY) [1st line] Adult Severe protein-energy malnutrition is now rare in Egypt outside extreme poverty or chronic illness, but the GP must recognise it and refer for supervised nutritional rehabilitation. - Refer, with advice Peds Children follow the same pathway: recognise and refer. No primary-care medicine is implied. Source No dose - referral pathway, no medicine given in primary care Why Severe protein-energy malnutrition is now rare in Egypt outside extreme poverty or chronic illness, but the GP must recognise it and refer for supervised nutritional rehabilitation. Caution RED FLAG - Severe underlying systemic infection or septicaemia presenting without typical fever due to impaired immune response: assess urgently and refer. RED FLAG - Severe hypothermia (rectal temperature <35.5 C) or profound hypoglycaemia: assess urgently and refer. Oedema, growth failure, and skin/hair changes in a malnourished child require urgent paediatric or nutrition referral; refeeding must be supervised to avoid refeeding syndrome. Rare in Egyptian primary care. The drug rows above are what the treating service gives. They are here so that the referral is an informed one and so the GP can recognise the regimen the patient comes back on - not as permission to start it without the referral. RED FLAG - There is a risk of refeeding syndrome when reintroducing nutrition rapidly. MICRONUTRIENT REPLACEMENT - give alongside 3. VITAMIN A [add-on - not a substitute] Adult Not applicable - the protocol is for a child (see the paediatric dose) - Throughout the treatment period Peds About 5000 IU daily, by mouth, for as long as the treatment lasts - as part of a therapeutic food or a multi-micronutrient preparation, not as a separate high-dose capsule. The guideline states no milligram-per-kilogram rule, so none is printed. Source WHO Guideline: Updates on the Management of Severe Acute Malnutrition in Infants and Children (NCBI Bookshelf NBK190317) - https://www.ncbi.nlm.nih.gov/books/NBK190317/ Why WHO recommendation 4.1 states that children with severe acute malnutrition should receive the daily recommended nutrient intake of vitamin A throughout the treatment period, about 5000 IU daily. Kwashiorkor is severe acute malnutrition, so the recommendation covers it. Caution A CHILD ALREADY ON F-75, F-100 OR PROPER RUTF NEEDS NO SEPARATE VITAMIN A. WHO recommendation 4.2 states the therapeutic food already carries it; adding a high dose on top is how a child is overdosed. THE HIGH DOSE IS CONDITIONAL, NOT ROUTINE. WHO recommendation 4.3 gives a single high dose of 50 000 IU, 100 000 IU or 200 000 IU depending on age, on admission, ONLY where the therapeutic food is not fortified to WHO specifications AND vitamin A is not part of another daily supplement. Separately, the guideline's standing recommendations give a high dose on day 1, day 2 and day 15 or discharge, whatever the food, to a child with eye signs of vitamin A deficiency, and the same to a child with recent measles. THE RECOMMENDATION DOES NOT SAY WHICH AGE GETS WHICH HIGH DOSE. It writes "depending on age" and states no cut-offs. The only age mapping anywhere in the document is a description of the trials it reviewed - 100 000 IU under 1 year, 200 000 IU at 1 year and over - which is what those studies did, not what WHO instructs. Take the bands from the programme protocol being followed. WHAT EGYPT ACTUALLY STOCKS IS A 50 000 IU CAPSULE. One registered single-ingredient vitamin A product is on the register (A-VITON, 50 000 IU); a second is cancelled, and the 10 000 IU softgel below is flagged by the register itself as an unregistered import. There is no 5 000 IU medicine, so the daily amount comes from the therapeutic food or a multi-micronutrient product, not from a vitamin A capsule. REFEEDING SYNDROME IS THE DANGER OF TREATING THIS - phosphate, potassium and magnesium shift when feeding restarts, and can cause dysrhythmia, rhabdomyolysis, confusion and sudden death. Egypt A-VITON 50.000 I.U. 20 CAPS. KAHIRA 5.00 EGP (0.25/unit) Prices are indicative (dataset snapshot 2026-06); verify with the pharmacy. ``` --- Dawaa Reference is a reference for prescribers, not a medical device, and does not replace clinical judgement. [Privacy policy](/privacy)