Clinical Nutrition

When Cicely Williams published her 1933 paper in the Archives of Disease in Childhood describing a syndrome she had observed in Ghanaian children characterised by oedema, skin depigmentation, fatty liver, and growth failure, she named it “kwashiorkor” - the word used by the Ga people of the Gold Coast to describe the disease suffered by a child displaced from the breast by a new sibling. Williams had identified what would eventually be classified as the most severe protein-deficient form of protein-energy malnutrition, a condition that would occupy nutritional science, paediatric medicine, and global health policy for the following nine decades. Her observations predated the coinage of the term “protein-energy malnutrition” itself - that came in the 1960s - but they established the epidemiological reality that continues to shape health outcomes across Sub-Saharan Africa: that the consequences of inadequate dietary protein and energy are not merely matters of weight and height, but of immune function, organ integrity, brain development, and survival.

In a nutrition stabilisation centre in Juba, South Sudan, during the food crisis of 2017, a paediatric nurse records two admissions within the same hour. The first child, aged twenty-two months, has skin that peels in sheets across his trunk, hair that has turned reddish and pulls out in tufts, and bilateral pitting oedema that extends to his knees. He is irritable, withdrawn, and refuses to eat. The second child, eleven months old, is skeletal - her ribs are countable from across the ward, her thighs barely larger than a clenched fist, her face the hollow, aged appearance that clinicians describe as “old man facies.” Her skin clings to her bones without oedema, and unlike the first child she is alert, though visibly distressed. Both children have severe acute malnutrition. Both will require weeks of structured nutritional rehabilitation. But they do not have the same condition, and conflating them - diagnostically or therapeutically - carries measurable risk of preventable death.