Kwashiorkor is a type of protein energy malnutrition. It is seen most commonly in developing countries, and onset tends to occur after weaning. At that time, the balance of protein and carbohydrate in breast milk is replaced by a diet that contains almost exclusively carbohydrates. The initial signs are diarrhea, irritability, and edema of the hands and feet. Small dark patches appear at pressure points of the elbows, ankles, wrists, and knees, and then spread. The patches have a sharp border and tend to peel; the superficial desquamation in these areas is often likened to the appearance of flaking paint or enamel. As the condition progresses, there develops a generalized red-brown discoloration. Other findings include fissuring at the edges of the mouth (Fig. 10-7) and the development of coarse, hypopigmented hair. Photosensitivity and easy bruising may also be present. The child with severe kwashiorkor appears extremely apathetic and has generalized edema. Pictured in Fig. 10-8 is a child with areas of desquamation and anasarca. Kwashiorkor carries a high mortality rate. With timely dietary intervention, it can often be reversed.