Classification of protein-calorie undernutrition in children.

Since the first description of kwashiorkor by Williams (1935), this condition has been found to be prevalent in many economically backward countries. Nevertheless, the minimum criteria for the diagnosis of kwashiorkor have never been agreed. Brock and Autret (1952) accepted a diagnosis of kwashiorkor if there was retarded growth, alterations in skin and hair pigmentation, oedema, fatty infiltration, cellular necrosis, or fibrosis of the liver, and a high mortality in the absence of improved protein in the diet. The essential characteristics, according to Trowell, Davies, and Dean (1954), were subnormal weight, oedema, mental apathy, frequent stools, dyspigmentation of the hair, and enamel-paint dermatosis; while according to Jelliffe (1955), they were growth failure, mental change, oedema, liver change, gastro-intestinal disorder, dyspigmentation, dermatosis, anaemia, and variable avitaminoses. Marasmic infants, on the other hand, are described as grossly underweight, with atrophy of muscle and subcutaneous fat, and with shrunken, wizened face. There are no hair and skin changes and oedema is minimal (Barness, 1964; Vitteri, Behar, and Arroyave, 1964). A third category of protein-calorie malnutrition in children is recognized by some and variously designated as marasmic kwashiorkor or atrophic kwashiorkor (Venkatachalam, 1964): these children are supposed to have the signs of both kwashiorkor and marasmus in variable measure. It is easy to recognize and diagnose classical cases of either kwashiorkor or of marasmus, but there is considerable difference of opinion about the diagnosis of this third variety of protein-calorie undernutrition of children. Some would diagnose all oedematous children suffering from protein-calorie malnutrition as kwashiorkor (Nicholls, Sinclair, and Jelliffe, 1961; Vitteri et al., 1964), believing that the skin and hair changes are not invariably present in