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Jelliffe, Editor

Hair tissue as a medium for the differential

diagnosis of protein-calorie malnutrition:
A commentary

R o b e r t B. B r a d f i e l d , Berkeley, Calif.

THE HAIR FOLLICLE is a superb model of growth and practical s t u d y . The hair roots o f c h i l d r e n with
differentiation. The normal high rate of mitotic and syn- kwashiorkor are greatly different from those of normal
thetic events which occur within the hair follicle are children. The number of growing bulbs (anagens) is sig-
operative only under optimum conditions. Nutritional nificantly less than normal. The anagens are usually ab-
deficiencies provoke distinct morphologic defects in normally formed, exhibiting severe atrophy and shaft
hair roots which can be used as a measure of nutritional constriction. In most cases there is a marked depletion
health. Hair-root changes can be used in public health of pigment in the growing bulbs, many of which have a
practice to determine the frequency and severity of pro- speckled appearance. The extent of atrophy is indicated
tein-calorie malnutrition. by the mean bulb diameter--approximately one third of
In tropical areas protein-calorie malnutrition results normal values. The number of bulbs in the resting
from protein-calorie insufficiencies or imbalance and is phase (telogen) is increased significantly. There is also a
exacerbated by chronic infection and parasitic infesta- very marked reduction of both internal and external
tion. There are two forms of protein-calorie malnutri- root sheaths. When present the external sheaths ar~ fre-
tion. Marasmus is a chronic condition due to insufficien- quently stripped back along the shaft or are shredded. 2,3
cy of both protein and calories. Kwashiorkor is an acute The hair of children with marasmus is also fine tex-
or chronic condition due to a protein-deficient, calorie- tured and dry in appearance, but the roots differ
sufficient diet; it is usually precipitated by respiratory or markedly in appearance from those of kwashiorkor.
gastrointestinal infection. Marasmus usual!y occurs dur- There is almost a complete lack of bulbs in the growing
ing the first year of life; kwashiorkor occurs more fre- phase (anagen), and there is a highly significant shift to
quently during the second year of life. the resting phase (telogen) of hair growth. Many more
Changes in hair-shaft coloration, thickness, and ap- b r o k e n hairs are found in m a r a s m u s than in
pearance have long been recognized in kwashiorkor and kwashiorkor. 4
are a part of the clinical diagnosis of this condition in The hair of marasmic children indicates a physiologic
m a n y parts of the world, t W i t h protein-calorie adaptation to chronic insufficient calorie and protein in-
malnutrition coarse, lustrous hair becomes fine tex- take by a complete shift to the resting phase of growth.
tured, dry, and lifeless in appearance. In addition, dark This re-establishment of priorities reduces the amount
black hair may exhibit patches of red or white. of nitrogen loss that would otherwise occur if the roots
The use of the hair root as a laboratory sample rather remained in the growing phase.
than the shaft eliminates the 3 to 4 week lag between It is not to be inferred that the different disordered
the time when protein deficiency affects hair formation patterns in hair growth in these two classic forms of in'
and when the hair shaft reaches a length sufficient for fantile malnutrition can be used diagnostically across
the wide, unordered spectrum of undernutrition, partic-
From the Department of Nutritional Science and ularly when the vast majority of cases are intermediary
Agricultural Extension Service, University of California in nature and defy tidy classification. It does suggest,

Vol. 84, No. 2, pp. 294-296

Volume 84 Hair tissue in diagnosis o f rnalnutrition 295

however, that the different patterns found in the two Classical Kwashiorkor
clearly defined extremes of protein-calorie malnutrition
are attributable to somewhat different types of stress on
the hair follicle. The differences are more likely due to
comparative differences in "chronicity than to specific
differences in relative protein-calorie density. Classical
marasmus is severe, chronic undernutrition in which
the child adapts to the stress by failing to grow: The Normal
long-term effect on a hair follicle is that it shifts to the
resting phase and conserves nitrogen. In classical
kwashiorkor there has been a period of more normal I

growth which has been interrupted by an acute condi- r . . . . . L.. . . . . . "a

tion. Linear growth may continue in kwashiorkor. The ', Intermediate
hair follicle adapts to this stress by both atrophy o f Cases
I. . . . . . 7" . . . . . . J
bulbs already in the growing phase and a partial shift to B I

the resting phase. I

Because the blood proteins are maintained at the ex-

pense of tissue protein, tissue proteins are an earlier in-
dicator of protein insufficiency and are of particular in-
terest to public health practice in tropical areas. Studies
carried out with Caribbean preschool children indicate
that the morphologic changes in hair occur early enough
and regularly enough with inoderate malnutrition that
they are of value in community health programs.
Decreases in mean root diameters were significantly (r
= 0.96) related to reduced weight-for-ageS,6and reduced
Classical Marasmus
arm circumference. 7 In a second public health study,
biochemical values, hair tissue, and anthropometric Fig. 1. Simulated microscope view of normal hair and the
alterations which occur in the two classical forms of protein-
m e a s u r e m e n t s used for the early recognition o f
calorie malnutrition. A = anagen or growing phase;
malnutrition were compared simultaneously in 179 T=.telogen or resting phase; B=broken hairs. Note that in
p r e s c h o o l children in the G u a t e m a l a n highlands. kwashiorker the number of growing hairs is reduced and
Decreases of diameter in hair roots and of the urinary those that are found are atrophied. The number of resting bulbs
urea to creatinine ratio were significantly related as increases as does the number of broken hairs. In marasr~us es-
sentially all bulbs are found in the resting phase.
early indicators of inadequate protein intake. Increased
atrophy o f hair roots was significantly related to
the recent past through a combination of linear growth,
changes in the ratio of nonessential to essential amino
toughness, and slow rate of destruction. These charac-
acids in sera and also to low weight-for-height as later
teristics serve to make hair tissue useful in the differen-
indicators o f protein-calorie malnutrition, 8 In addition,
tial diagnosis of protein-calorie malnutrition.
carefully controlled studies of protein deprivation in the
The hair-root changes described may be used in
metabolic ward have served to identify the type and se-
public health practice to locate those segments of the
quence of morphologic changes which occur on protein-
population most likely to be malnourished. Standards
free diets and to relate them to blood and urinary
h a v e been suggested. 12 W i t h this technique and
nitrogen levels.9-n
anthropometric measurements, the pediatrician may
The fact that defensive physiologic adaptations to the
rapidly survey a target population for the frequency,
calorie and p r o t e i n d e p r i v a t i o n of p r o t e i n - c a l o r i e
severity, and chronicity of protein-calorie malnutrition,
malnutrition takes place in hair roots is of particular in-
both in severe and moderate cases. Examination of. the
terest because hair is: (1) easily obtained; (2) easily
hair root is of less use in mild cases because of the range
transported to a laboratory without special handling
of individual variation.
under adverse conditions of temperature and humidity;
and (3) readily analyzed by simple, rapid, inexpensive, REFERENCES
and clear-cut methods. Hair also has the unique advan- 1. Jelliffe, D. B.: Infant nutrition in the tropics and
tage of reflecting not only present conditions but also subtropics, W. H. O. Monogr. Ser., No. 29, 1955.
296 Bradfield The Journal of Pediatrics
February 1974

2. Bradfield, R. B., and Cordano, A.: Hair root changes in ment of marginal malnutrition, Nature 235: 112, 1972.
Andean Indian children during marasmic-kwashiorkor, 8. Nammacher, M. A., Bradfield, R. B., and Arroyave, G.:
Lancet 2: 1169, 1968. Comparing nutritional status methods in a Guatemalan
3. Bradfield, R. B.: Changes in hair root morphology and survey, Am. J. Clin. Nutr. 25: 871, 1972.
hair diameter associated with protein-calorie malnutri- 9. Bradfield, R. B., Bailey, M. A., and Margen, S.:
tion, in McCance, R., and Widdowson, E. M., editors: Morphological changes in human scalp hair roots during
Protein deficiencies and calorie deficiencies, London~ protein deprivation, Science 157: 438, 1967.
1968, J. & A. Churchill, Ltd. 10. Bradfield, R. B.: Protein deprivation: Comparative
4. Bradfield, R. B., Cordano, A., and Graham, G. G.: Hair response of hair roots, serum albumin, and urinary nitro-
root changes in Andean Indian children during gen Am. J. Clin. Nutr, 24: 405, 1971.
marasmus, Lancet 2: 1395, 1969. 11. Bradfleld, R. B.: Hair root response to undernutrition, in
5. Bradfield, R. B., and Jelliffe, E. F. P.: Early assessment of Montagna, W., and Dobson, R. L, editors: Advances in
malnutrition, Nature 225: .283, 1970. the biology of skin, hair growth, Vol. X, New York, 1969,
6. Bradfield, R. B., Jelliffe, E. F. P., and Neil, R.: A com- Pergamon Press, Inc.
parison o f hair root morphology and arm circumference 12. Bradfield, R. B.: A rapid tissue technique for the field
as field tests of protein-calorie malnutrition, J. Trop. assessment of protein~calorie malnutrition, Am. J. Clin.
Pediatr. 16: 196, 1970. Nutr. 25: 720, 1972.
7. Bradfield, R. B., Jelliffe, E. F. P. and Jelliffe, D. B.: Assess-