Marasmus

Author: Simon S Rabinowitz, MD, PhD, FAAP; Chief Editor: Jatinder Bhatia, MBBS
Background
Marasmus is one of the forms of serious !rotein"ener#$ ma%nutrition &PEM'( )he other * forms
are +washior+or &,-' and marasmi. ,-( )hese forms of serious PEM re!resent a #rou! of
!atho%o#i. .onditions asso.iated with a nutritiona% and ener#$ defi.it o..urrin# main%$ in $oun#
.hi%dren from de/e%o!in# .ountries at the time of weanin#( Marasmus is a .ondition !rimari%$
.aused b$ a defi.ien.$ in .a%ories and ener#$, whereas +washior+or indi.ates an asso.iated
!rotein defi.ien.$, resu%tin# in an edematous a!!earan.e( Marasmi. +washior+or indi.ates that,
in !ra.ti.e, se!aratin# these entities .on.%usi/e%$ is diffi.u%t; this term indi.ates a .ondition that
has features of both(
)hese .onditions are fre0uent%$ asso.iated with infe.tions, main%$ 12( )he reasons for a
!ro#ression of nutritiona% defi.it into marasmus rather than +washior+or are un.%ear and .annot
be so%e%$ e3!%ained b$ the .om!osition of the defi.ient diet &ie, a diet defi.ient in ener#$ for
marasmus and a diet defi.ient in !rotein for +washior+or'( )he stud$ of these !henomena is
.onsiderab%$ %imited b$ the %a.+ of an a!!ro!riate anima% mode%( 4nfortunate%$, man$ authors
.ombine these entities into one, thus !re.%udin# a better understandin# of the differen.es
between these .%ini.a% .onditions(
Marasmus is a serious wor%dwide !rob%em that in/o%/es more than 56 mi%%ion .hi%dren $oun#er
than 5 $ears( A..ordin# to the -or%d 7ea%th 8r#anization &-78', 9:; of the <6(9 mi%%ion
deaths o..urrin# in .hi%dren $oun#er than 5 $ears in de/e%o!in# .ountries are asso.iated with
PEM(
Malnutrition hotspot map. Image courtesy of the World Health
Organization (WHO) and United Nations Childrens !und (UNIC"!).
Ma%nutrition has been a !ermanent !riorit$ of the -78 for de.ades( A%thou#h a hi#her
!ro!ortion of se/ere%$ ma%nourished .hi%dren do not sur/i/e a si#nifi.ant inter.urrent i%%ness, as
mu.h as =6; of the o/era%%, una..e!tab%$ hi#h, morta%it$ rate ma$ be .ontributed b$ mi%d"to"
moderate%$ ma%nourished .hi%dren be.ause this .ohort is so mu.h hi#her(
><?
A..ordin#%$, newer
strate#ies need not be %imited to on%$ se/ere%$ ma%nourished .hi%dren(
A%thou#h PEM o..urs more fre0uent%$ in %ow"in.ome .ountries, numerous .hi%dren from hi#her"
in.ome .ountries are a%so affe.ted, in.%udin# .hi%dren from %ar#e urban areas and of %ow
so.ioe.onomi. status, .hi%dren with .hroni. disease, and .hi%dren who are institutiona%ized(
Re.ent%$, studies of hos!ita%ized .hi%dren from de/e%o!ed .ountries ha/e demonstrated an
in.reased ris+ for PEM( Ris+ fa.tors in.%ude a !rimar$ dia#nosis of menta% retardation, .$sti.
fibrosis, ma%i#nan.$, .ardio/as.u%ar disease, end sta#e rena% disease, on.o%o#i. disease, #eneti.
disease, neuro%o#i.a% disease, mu%ti!%e dia#noses, P2C4 admission, or !ro%on#ed hos!ita%ization(
>*, ?
2n these .onditions, the .ha%%en#in# nutritiona% mana#ement is often o/er%oo+ed and
underestimated, resu%tin# in an im!airment of the .han.es for re.o/er$ and the worsenin# of an
a%read$ !re.arious neurode/e%o!menta% situation(
PEM resu%ts in not on%$ hi#h morta%it$ &e/en for hos!ita%ized .hi%dren', without an$
im!ro/ement o/er the %ast * de.ades, and a%so resu%ts in morbidit$, stunted %inear #rowth, and
.om!romised neuro%o#i.a% de/e%o!ment( )he so.ia% and e.onomi. im!%i.ations of PEM and its
.om!%i.ations are in.a%.u%ab%e(
)his arti.%e fo.uses main%$ on marasmus that resu%ts from an insuffi.ient nutritiona% inta+e as
obser/ed under im!aired so.ioe.onomi. .onditions, su.h as those !resent in de/e%o!in#
.ountries( Marasmus is most fre0uent%$ asso.iated with a.ute infe.tions &e#, #astroenteritis,
res!irator$ i%%nesses, meas%es', .hroni. i%%nesses &e#, tuber.u%osis, 72@ infe.tion' or drasti.
natura% or man made .onditions &e#, f%oods, drou#hts, .i/i% war'(
History
Si#ns and s$m!toms of marasmus /ar$ with the im!ortan.e and duration of the ener#$ defi.it,
a#e at onset, asso.iated infe.tions &e#, 12 infe.tions', and asso.iated nutritiona% defi.ien.ies &e#,
iron defi.ien.$, iodine defi.ien.$'( Diets and defi.ien.ies ma$ /ar$ .onsiderab%$ between
different #eo#ra!hi.a% re#ions and e/en within a .ountr$( )he A2DS e!idemi. has a%so
si#nifi.ant%$ .han#ed the .%ini.a% .ourse of .%assi. marasmus( Marasmus is t$!i.a%%$ obser/ed in
infants who are breastfeedin# when the amount of mi%+ is mar+ed%$ redu.ed or, more fre0uent%$,
in those who are artifi.ia%%$ fed( Fai%ure to thri/e is the ear%iest manifestation, asso.iated with
irritabi%it$ or a!ath$( Chroni. diarrhea is the most fre0uent s$m!tom, and infants #enera%%$
!resent with feedin# diffi.u%ties( Presentation ma$ be a..e%erated b$ an a.ute infe.tion(
)he .%assi. .%ini.a% .ourse of a .hi%d with marasmus is !resented in the ima#es be%ow(
Clinical course of marasmus (history).
# classic e$ample of a %eight chart for a se&erely malnourished
child.
Physical
A shrun+en wasted a!!earan.e is the .%assi. !resentation of marasmus( Anthro!ometri.
measurements are .riti.a% to ra!id%$ assess the t$!e and se/erit$ of the ma%nutrition( )he
-e%%.ome C%assifi.ation of Ma%nutrition in Chi%dren was #enera%%$ used, but the -78 has
re/ised this .%assifi.ation &see the tab%e be%ow'( )his sim!%e .%assifi.ation a%%ows a .%ear
!resentation of the .%ini.a% .ases and a%%ows .om!arisons between .ountries( Stunted .hi%dren are
usua%%$ .onsidered to ha/e a mi%der .hroni. form of ma%nutrition, but their .ondition .an ra!id%$
worsen with the onset of .om!%i.ations su.h as diarrhea, res!irator$ infe.tion, or meas%es(
)ab%e <( -78 C%assifi.ation of Ma%nutrition &8!en )ab%e in a new window'
Evidence of Malnutrition Moderate Severe (type)
'ymmetric edema No (es (edema protein)energy malnutrition
*+"M,)-
Weight for height
.
'tandard de&iation ('/)
0
score )1
'/ score 2)3 (45)657)
8
'/ score 2)1 (ie9 se&ere %asting)
::
(2
457)
Height for age '/ score
)
1
'/ score 2)3 (;<);67)
'/ score 2)1 (ie9 se&ere stunting) (2
;<7)
- =his includes >%ashior>or (?W) and >%ashior>or marasmus (presence of edema al%ays
indicates serious +"M).
.
'tanding height should @e measured in children taller than ;< cm9 and supine length should @e
measured in children shorter than ;< cm or in children %ho are too sic> to stand. Aenerally9 the
supine length is considered to @e 5.< cm longer than the standing heightB therefore9 5.< cm
should @e deducted from the supine length measured in children taller than ;< cm %ho are too
sic> to stand.
0
Celo% the median National Center for Health 'tatistics (NCH')DWHO referenceE =he '/ score
is defined as the de&iation of the &alue for an indi&idual from the median &alue of the reference
population di&ided @y the standard de&iation of the reference population (ie9 '/ score F
*o@ser&ed &alue G median reference &alue,Dstandard de&iation of reference population).
8
=his is the percentage of the median NCH'DWHO reference.
::
=his corresponds to marasmus (%ithout edema) in the Wellcome clinical classification and to
grade III malnutrition in the Aomez system. Ho%e&er9 to a&oid confusion9 the term se&ere
%asting is preferred.
Constru.tion and use of a wastin# dia#ram sim!%ifies the .%assifi.ation be.ause the e3a.t a#e of
the .hi%d is often un+nown( )he wastin# dia#ram is a %ar#e .o%ored board made of /erti.a%
.o%umns .orres!ondin# to wei#hts from *"*5 +# &or <5 +#, whi.h is often suffi.ient'( )he .hi%d is
wei#hed and then his or her hei#ht is measured on the board in the .o%umn .orres!ondin# to the
measured wei#ht( )he dia#ram is desi#ned so that the hei#ht .orres!onds to the #reen zone if the
.hi%d is we%% nourished, the $e%%ow zone if the .hi%d is moderate%$ ma%nourished, and to the red
zone if the .hi%d is se/ere%$ ma%nourished( @a%ues within the referen.e ran#e used to desi#n this
dia#ram .an be a!!%ied to an$ !o!u%ation re#ard%ess of the ra.ia% ori#in(
Midd%e u!!er arm .ir.umferen.e &M4AC' is a sim!%e, %ow".ost, obAe.ti/e method of assessin#
nutritiona% status( )he M4AC is #enera%%$ as #ood as or better than other anthro!ometri.
measures in !redi.tin# subse0uent morta%it$ in .ommunit$"based studies( 2t is a%so the most
usefu% too% in %ar#e e!idemio%o#i.a% sur/e$s(
+hysiopathological principle of arm circumference measurement in children
aged H)< years and the relationship %ith se&erity of malnutrition.
)he most !er.e!tib%e and fre0uent .%ini.a% feature in marasmus is the %oss of mus.%e mass and
sub.utaneous fat mass( Some mus.%e #rou!s, su.h as butto.+s and u!!er %imb mus.%es, are more
fre0uent%$ affe.ted than others( Fa.ia% mus.%es are usua%%$ s!ared %on#er( Fa.ia% fat mass is the
%ast to be %ost, resu%tin#, in se/ere .ases, in the .hara.teristi. e%der%$ a!!earan.e of .hi%dren with
marasmus( Anore3ia is fre0uent and interferes with renutrition( An irritab%e and whinin# .hi%d
who .annot be .omforted or se!arated from the mother demonstrates beha/iors often obser/ed
with marasmus( A!ath$ is a si#n of serious forms of marasmus: .hi%dren are in.reasin#%$
motion%ess and seem to B%et themse%/es die(B 2n .ontrast, durin# rehabi%itation, e/en the s%i#htest
smi%e is a !ositi/e si#n of re.o/er$( Chi%drenCs beha/ior is !robab%$ one of the best .%ini.a% si#ns
of the se/erit$ and e/o%ution of marasmus(
Se/era% .%ini.a% si#ns must be assessed in order to dete.t .om!%i.ations, with s!e.ia% attention to
infe.tious .om!%i.ations &see .he.+%ist be%ow'( )he !h$si.a% e3amination must be /er$ thorou#h
be.ause e/en sma%% abnorma%ities .an be .%ini.a%%$ si#nifi.ant( C%ini.a% si#ns of serious
.om!%i.ation .an be /er$ subt%e in .hi%dren with marasmus( A bod$ tem!erature of D(5EC .an
.orres!ond to a fe/er of :"96EC in a .hi%d without marasmus, and a sma%% .ou#h .an be the on%$
si#n of a serious !neumonia( After histor$ and !h$si.a% e3amination, dia#nosin# the t$!e and
se/erit$ of the ma%nutrition, as we%% as dia#nosin# asso.iated infe.tions and .om!%i.ations
affe.tin# or#ans or s$stems, su.h as the 12, neuro%o#i.a%, or .ardio/as.u%ar s$stem, are .riti.a%(
)his set of dia#noses resu%ts in o!tima% !%annin# of the .om!%ementar$ e/a%uation and
thera!euti. strate#$(
Chec>list of points for conducting the physical e$amination
o Cody temperature (measured %ith a thermometer) ) #llo%ing measurement of
lo% temperatures to detect hypothermia as %ell as fe&er
o #nemia ) +ale mucosa
o "dema
o /ehydration ) =hirst9 shrun>en eyes
o Hypo&olemic shoc> ) Wea> radial pulse9 cold e$tremities9 decreased
consciousness
o =achypnea ) +neumonia9 heart failure
o #@dominal manifestations ) /istension9 decreased or metallic @o%el sounds9
large or small li&er9 @lood or mucus in the stools
o Ocular manifestations ) Corneal lesions associated %ith &itamin # deficiency
o /ermal manifestations ) "&idence of infection9 purpura
o "ar9 nose9 and throat ("N=) findings ) Otitis9 rhinitis
auses
Se/era% fa.tors .an %ead to marasmus( )heir re%ati/e im!ortan.e /aries between .hi%dren and
between !arts of the wor%d( For e3am!%e, undernutrition asso.iated with war, ina!!ro!riate
weanin# b$ a $oun# mother, and !re.i!itatin# infe.tions .an inf%uen.e in.iden.e of marasmus(
NutritionE In many lo%)income countries9 food &ariety is limited and results in mineral and
&itamin insufficiencies. In cases of anore$ia9 %hich are generally associated %ith
infection9 the total energy inta>e @ecomes insufficient. =herefore9 any nutrient deficiency
can lead to marasmus @ecause appropriate gro%th can only @e ensured @y a @alanced
diet. =herefore9 marasmus can @e descri@ed as multiple)deficiency malnutrition.
InfectionsE #ssociated infections often trigger9 aggra&ate9 or com@ine %ith marasmus.
Ho%e&er9 e&idence e$ists that this association may ha&e @een o&erestimated. !or
e$ample9 in rural 'enegal9 the gro%th of children %ith or %ithout infections9 such as
pertussis and measles9 %as similar. In contrast9 the importance of diarrhea in triggering
malnutrition through anore$ia and %eight loss has @een %ell esta@lished. Infectious
diseases more freIuently associated %ith energy)protein malnutrition are gastroenteritis9
respiratory infections9 measles9 and pertussis. HIJ also plays an increasingly significant
role in some countries.
'ocioeconomic factorsE !reIuently9 malnutrition appears during %eaning9 especially if
%eaning is su@optimal9 as can occur %ith a lo%)&ariety diet9 or if %eaning foods are
introduced only in children older than ;)H5 months. =he WHO recommends e$clusi&e
@reastfeeding until age K monthsB then9 the introduction of &arious additional foods is
recommended. =he socioeconomic en&ironment is often critical in the choice of the
%eaning food used. !or e$ample9 in northern 'enegal9 a&aila@le foods are often limited
to grains9 &egeta@les9 and a small amount of fish. Mil> and meat are rare. In this region9
malnutrition and diarrhea are freIuent. In contrast9 in the near@y 'ahelien pastures
%here mil> and meat are the main foods9 diarrhea is less freIuent9 and malnutrition is
rare.
Other socioeconomic factorsE Other factors9 such as the famines associated %ith climatic
disasters or more often %ith political e&ents and %ar (as has @een the case in east
#frica)9 can play a critical role. =he sociofamilial en&ironment can also @e important9 and
children of young or ine$perienced mothers9 t%ins9 or female infants can @e at a higher
ris> in some parts of the %orld.
'ummaryE Marasmus9 and malnutrition in general9 represents multiple deficiencies9 and
multiple etiologies. =herefore9 epidemiological9 pu@lic health9 and therapeutic
approaches must @e comprehensi&e. +opulation)@ased inter&entions limited to the
supplementation of one nutrient ha&e often @een unsuccessful.
F 1enera%%$, for dia#nosis and treatment of marasmus, no further e/a%uation is ne.essar$ other
than the .%ini.a% e/a%uation( Most %aborator$ resu%ts are within the referen.e ran#e des!ite
si#nifi.ant .han#es in bod$ .om!osition and !h$sio%o#$( Furthermore, in re#ions where
ma%nutrition is fre0uent, hea%th stru.tures are !oor%$ e0ui!!ed, and %aborator$ e/a%uations are
either im!ossib%e to obtain or unre%iab%e(
F 2f the$ are a/ai%ab%e, some %aborator$ resu%ts .an be usefu% to monitor treatment or to dia#nose
s!e.ifi. .om!%i.ations(
F Gaborator$ tests ada!ted from the -78 in.%ude the fo%%owin#:
B%ood #%u.ose: 7$!o#%$.emia is !resent if the %e/e% is %ower than mmo%HG(
E3amination of b%ood smears b$ mi.ros.o!$ or dire.t dete.tion test: Presen.e of !arasites
is indi.ati/e of infe.tion( Dire.t test is suitab%e but e3!ensi/e(
7emo#%obin: A %e/e% %ower than 96 #HG is indi.ati/e of se/ere anemia(
4rine e3amination and .u%ture, Mu%tisti3: More than <6 %eu+o.$tes !er hi#h"!ower fie%d
is indi.ati/e of infe.tion( Iitrites and %eu+o.$tes are tested on Mu%tisti3 a%so(
Stoo% e3amination b$ mi.ros.o!$: Parasites and b%ood are indi.ati/e of d$senter$(
A%bumin: A%thou#h not usefu% for dia#nosis, it is a #uide to !ro#nosis; if a%bumin is %ower
than 5 #HG, !rotein s$nthesis is massi/e%$ im!aired(
72@ test: 72@ test shou%d not be routine%$ !erformed; if .om!%eted, it shou%d be
a..om!anied b$ .ounse%in# of the .hi%dCs !arents and the resu%t shou%d be .onfidentia%(
E%e.tro%$tes: Measurin# e%e.tro%$tes is rare%$ he%!fu% and it ma$ %ead to ina!!ro!riate
thera!$( 7$!onatremia is a si#nifi.ant
Medical Care
General objectives
Mana#ement of moderate marasmus .an be !erformed on an out!atient basis, but se/ere
marasmus or marasmus .om!%i.ated b$ a %ife"threatenin# .ondition #enera%%$ re0uires in!atient
treatment( 2n these .ases, mana#ement is di/ided into an initia% intensi/e !hase fo%%owed b$ a
.onso%idation !hase &rehabi%itation', !re!arin# for out!atient fo%%ow"u! mana#ement( )he -78
has de/e%o!ed #uide%ines to he%! im!ro/e the 0ua%it$ of hos!ita% .are for ma%nourished .hi%dren
and has !rioritized the wides!read im!%ementation of these #uide%ines(
Aeneral principles of se&ere malnutrition management. ?W F
?%ashior>or.
)he #uide%ines hi#h%i#ht <6 ste!s for routine mana#ement of .hi%dren with ma%nutrition, as
fo%%ows:
><J?
+re&ent and treat the follo%ingE
o Hypoglycemia
o Hypothermia
o /ehydration
o "lectrolyte im@alance
o Infection
o Micronutrient deficiencies
+ro&ide special feeds for the follo%ingE
o Initial sta@ilization
o Catch)up gro%th
o +ro&ide lo&ing care and stimulation
o +repare for follo%)up after discharge
Be.ause most !atients with moderate .ases of marasmus .an be treated as out!atients, the
o!tima% en/ironment is a !ediatri. nutrition rehabi%itation .enter( Iutritiona% rehabi%itation
shou%d in.%ude a!!ro!riate foods for an inta+e u! to <66"<56 +.a%H+#Hd( 8ther thera!euti. and
!re/enti/e a.tions shou%d in.%ude reh$dration usin# the -78 so%ution &see be%ow' in .ase of
asso.iated diarrhea, mi.ronutrient su!!%ementation &e#, iron, /itamin A', .onte3t"a!!ro!riate
s.reenin#, and re/iew of immunization status( )his mana#ement shou%d a%so in.or!orate
nutritiona% and so.io.u%tura% edu.ation ada!ted to the %o.a% .onditions( Fami%$"based
mana#ement is !referred with the .hi%dCs mother as the +e$ !%a$er(
Nutritional management of the acute phase of severe marasmus (eek !"
)his !eriod .orres!onds to maintenan.e of /ita% fun.tions and tissue renewa% &ie, maintenan.e
needs'( Durin# this !eriod, the e%e.tro%$te imba%an.e, infe.tions, h$!o#%$.emia, and h$!othermia
are treated, and then feedin# is started( 8ra% renutrition of a .hi%d with marasmus shou%d be
started as ear%$ as !ossib%e, as soon as the .hi%d is stab%e and the h$droe%e.tro%$te imba%an.es are
.orre.ted( )he term #ut rest has no !h$sio%o#i.a% basis( Entera% feeds de.rease diarrhea and
!re/ent ba.teremia from ba.teria% trans%o.ation(
Be.ause of the instabi%it$ of .hi%dren with marasmus, .%ini.a% .are must be we%% ada!ted, with
#rou!in# of !atients, .onstant monitorin#, and fre0uent .%ini.a% e/a%uation durin# the first da$s(
Patients with marasmus shou%d be iso%ated from other !atients, es!e.ia%%$ .hi%dren with
infe.tions( )reatment areas shou%d be as warm as !ossib%e, and bathin# shou%d be a/oided to
%imit h$!othermia( )herefore, when !ossib%e, the hos!ita% stru.ture is best ada!ted for the
treatment of se/ere ma%nutrition(
2n .ases of sho.+, intra/enous &2@' reh$dration is re.ommended usin# a Rin#er"%a.tate so%ution
with 5; de3trose or a mi3ture of 6(:; sodium .h%oride with 5; de3trose( Entera% h$dration
usin# ReSoMa% shou%d be started as ear%$ as !ossib%e, !referab%$ at the same time as the 2@
so%ution( )he fo%%owin# ru%es shou%d be im!%emented in the initia% !hase of reh$dration: &<' use
an naso#astri. &I1' tube; &*' .ontinue breastfeedin#, e3.e!t in .ase of sho.+ or .oma; and &'
start other food after "9 hours of reh$dration(
I1 tube insertion is essentia% for both initia% treatment &ie, reh$dration, .orre.tion of e%e.tro%$te
disturban.es' and rehabi%itation &ie, to !ro/ide the .hi%d the .orre.t amount of diet e/er$ *"9 h,
da$ and ni#ht'(
)he first ste! is often sim!%$ reh$dration( Deh$dration in .hi%dren with marasmus is diffi.u%t to
e/a%uate, is o/erdia#nosed, or is misinter!reted as se!ti. sho.+( Reh$dration shou%d be entera%
&b$ mouth or b$ I1 tube' e3.e!t in .ase of .oma or sho.+, when intra/enous thera!$ is
re0uired(
For %on#er than two de.ades, the -78 had re.ommended that the standard formu%ation of
#%u.ose"based ora% reh$dration so%ution &8RS' shou%d .ontain :6 mmo%HG of sodium, <<<
mmo%HG of #%u.ose, and a tota% osmo%arit$ of << mmo%HG( Iumerous in/esti#ators ha/e
e3!ressed .on.ern about the .on.entration of sodium and #%u.ose and in/esti#ated the feasibi%it$
of a redu.ed"osmo%arit$ 8RS( A Co.hrane re/iew from *66* .on.%uded that, in .hi%dren
admitted to the hos!ita% with diarrhea, redu.ed osmo%arit$ 8RS &*D6 mmo%HG' is asso.iated with
fewer uns.hedu%ed 2@ infusions, %ower stoo% /o%ume, and %ess /omitin# than standard 8RS(
><D?
7$!onatremia was not re!orted in these .%ini.a% studies( )he authors note that in areas where
.ho%era diarrhea remains a maAor !rob%em, some .%ini.ians ma$ !refer to use the standard -78
formu%ation( )he newer redu.ed"osmo%arit$ 8RS, whi.h has been re.ommended b$ the -78,
><=?
.an be ordered as <5J<<*6 " 8RS, <G sa.hetHBo3"<66 &instead of <5J<<<6'or<<5J<<*<"
8RS,<Gsa.hetHCar"<666 &instead of <<5J<<*6'(
)he 8RS .an be used for water$ diarrhea, at the re.ommended /o%ume of 5"<5 mGH+#Hh, with a
tota% of D6 mGH+# for the first <* hours( Be.ause the ris+ of .ardia. fai%ure is in.reased in
.hi%dren with marasmus, .om!%ian.e with the reh$dration re#imen is e/en more .riti.a% than in
.hi%dren who are we%% nourished( )herefore, .%ose%$ monitor the reh$dration !hase and !rom!t%$
address si#ns of .ardia. fai%ure, su.h as ta.h$!nea, ta.h$.ardia, edema, or he!atome#a%$(
Reh$dration so%ution shou%d be ada!ted to marasmi. .hi%dren with a %ow sodium .ontent and a
hi#h !otassium .ontent( )his .an be !re!ared usin# standard -78 so%ution as a base or b$
dire.t%$ administerin# a modified ora% reh$dration &ReSoMa%' so%ution if a/ai%ab%e( )ab%e *
hi#h%i#hts the .om!osition of standard 8RS, the new redu.ed"osmo%arit$ 8RS, and ReSoMa%(
)ab%e *( Com!osition Com!arison of ReSoMa%, Standard -78, and Redu.ed"8smo%arit$ -78
8RS So%utions &8!en )ab%e in a new window'
Composition ReSoMal
(mmol/L)
Standard ORS
(mmol/L)
Reduced osmolarity
ORS
Alucose H3< HHH 4<
'odium L< 65 4<
+otassium L5 35 35
Chloride 45 ;5 K<
Citrate 4 H5 H5
Magnesium 1 ... ...
Minc 5.1 ... ...
Copper 5.5L< ... ...
Osmolarity
(mOsmDN)
155 1HH 3L<
)he o/era%% #oa% of nutrition rehabi%itation is to o/er.ome the anore3ia often asso.iated with
marasmus, as we%% as to a/oid the .auses that %ead to anore3ia( Another #oa% is to a/oid .ardia.
fai%ure whi%e !ro/idin# enou#h ener#$ to a/oid .atabo%ism( )he #oa% usua%%$ is to !ro/ide =6"<66
+.a%H+#Hd in <* mea%s !er da$ or .ontinuous%$ b$ I1 tube to a/oid h$!o#%$.emia( )his amount
of .a%ories shou%d be rea.hed !ro#ressi/e%$ in a few da$s to a/oid %ife"threatenin# !rob%ems su.h
as .ardia. fai%ure or h$!o+a%emia(
)he -78 had re.ommended the use of the %i0uid !rodu.ts, su.h as the FD5 so%ution, whi.h
!ro/ides D5 +.a%H<66 mG, main%$ as .arboh$drates( )his so%ution !ro/ides a %imited amount of
fat, whi.h is often ma%absorbed be.ause of the asso.iated !an.reati. insuffi.ien.$, and a %imited
amount of !roteins, whi.h .an !re.i!itate rena% fai%ure durin# initia% refeedin# of .hi%dren with
marasmus( FD5 is a/ai%ab%e as a read$"to"use formu%a or .an be !re!ared usin# wide%$ a/ai%ab%e
foods %isted in )ab%e be%ow( Re.i!es and .oo+in# #uide%ines, in.%udin# !ossib%e a%ternati/e
foods, are a/ai%ab%e throu#h the -78( )he read$"to"use formu%as, as we%% as the mi.ronutrient
mi3tures, are .ommer.ia%%$ a/ai%ab%e(
)ab%e ( Pre!aration of FD5 and F<66 Diets &-78' &8!en )ab%e in a new window'
Ingredient
Amount in
!"
Amount in
#$$
/ry s>immed
mil>
3< g ;5 g
'ugar 45 g <5 g
Cereal flour 1< g ...
Jegeta@le oil 34 g K5 g
Mineral mi$ 35 mN 35 mN
Jitamin mi$ HL5 mg HL5 mg
Water to mi$ H555 mN H555 mN
#ehabilitation phase (eeks $%&"
2n the rehabi%itation !hase of treatment, nutritiona% inta+e .an rea.h *66 +.a%H+#Hd( )he #oa% is to
rea.h a .ontinuous .at.h"u! #rowth in wei#ht and hei#ht in order to restore a hea%th$ bod$
wei#ht( 8n%$ .hi%dren who ha/e been weaned from their I1 tube .an be .onsidered as bein# in
the rehabi%itation !hase( )herefore, s!e.ifi. #oa%s of this !hase are as fo%%ows:
=o encourage the child to eat as much as possi@le
=o restart @reastfeeding as soon as possi@le
=o stimulate the emotional and physical de&elopment
=o acti&ely prepare the child and mother to return to home and pre&ent recurrence of
malnutrition
Durin# the rehabi%itation !hase, the F<66 formu%a, with a hi#her !rotein .ontent &see )ab%e
abo/e' is re.ommended( -ith the .hi%dCs in.reased a!!etite durin# this !hase, use of the FD5
formu%a on%$ %eads to a fat in.rease, without an a!!ro!riate #ain in fat"free mass( )he main ris+
of this !hase of the rehabi%itation is that the nutrients !ro/ided are not suffi.ient to sustain the
wei#ht #ain, whi.h .an rea.h as mu.h as <5 #H+#Hd( 2ne3!erien.ed hea%th !rofessiona%s often
underestimate the needs of .hi%dren with marasmus in this !hase of nutritiona% rehabi%itation( )he
in.reased iron needs asso.iated with the ra!id mus.%e #rowth and the hemo#%obin in.rease
Austif$ iron su!!%ementation startin# in the se.ond wee+ of rehabi%itation(
Powdered s+im mi%+ is used to !re!are the FD5 or F<66 formu%a( 2n that form, the %a.tose
.on.entration is %ow, about <6 times %ess than in breast mi%+, whi.h is a%so we%% to%erated b$
.hi%dren with marasmus( 8n%$ in .ases of !ersistent diarrhea or estab%ished %a.tose into%eran.e,
whi.h is rare, shou%d %a.tose be e3.%uded( 7i#h"fat foods are we%% to%erated at this !oint be.ause
the$ s%ow #astri. em!t$in# and ma$ de.rease %a.tose !rodu.tion(
P%um!$Cnut, a !eanut"based !aste with su!!%ementa% ener#$, /itamins, and minera%s has been
desi#ned for ma%nourished .hi%dren who are suffi.ient%$ we%% to benefit from out!atient .are(
><:?
)he -78 has re.o#nized it as a read$"to"use"thera!euti. food &R4)F' that .an re/erse
ma%nutrition in se/ere%$ ma%nourished .hi%dren(
>*6?
2t was a%so su..essfu%%$ used b$ Do.tors
-ithout Borders in Ii#er in *665( )he !aste is eas$ to eat, a%%owin# .hi%dren to feed themse%/es(
)he fortified !eanut butterK%i+e !aste .ontains a ba%an.e of fats, .arboh$drates, !roteins,
/itamins, and minera%s( Peanuts themse%/es !ro/ide mono"unsaturated fats, whi.h are eas$ to
di#est and are .a%ori.a%%$ dense, with am!%e amounts of zin. and !rotein( Be.ause the !rodu.t
.ontains no water, it .an %ast * $ears uno!ened(
A standard P%um!$Cnut treatment for 9 wee+s &*" times dai%$' .osts <* Euros in Afri.a( )he .ost
of 9 wee+s of P%um!$Cnut and su!!%ementa% /itamin mi3ture &4nimi3' is L5 !er .hi%d( )he .ost
in 7aiti for a simi%ar !eanut butterKbased !rodu.t is s%i#ht%$ hi#her but sti%% re%ati/e%$
ine3!ensi/e( )he !rodu.t .an a%so be !re!ared %o.a%%$ in !eanut"!rodu.in# areas, su.h as Ma%awi
and Ii#er, b$ mi3in# #round !eanut and mi%+ !aste with a s%urr$ of /itamins and minera%s
obtained from Iutriset, the Fren.h manufa.turer of the !aste(
Emotiona% and !h$si.a% stimu%ation is .riti.a% durin# this !eriod( Ps$.homotor inhibition is
e/ident in .hi%dren with marasmus but ra!id%$ im!ro/es with renutrition( An$ rehabi%itation
!ra.ti.es that .an minimize %on#"term de/e%o!menta% .onse0uen.es shou%d be im!%emented in
.hi%dren with marasmus( Pra.ti.es a/ai%ab%e ma$ /ar$ de!endin# on the en/ironment( Pra.ti.es
in.%ude !h$siothera!$, sensor$ stimu%ation, and massa#es and shou%d be im!%emented with or b$
the mother(
Management of acute complications
Morta%it$ of hos!ita%ized .hi%dren with marasmus is hi#h, es!e.ia%%$ durin# the first few da$s of
rehabi%itation( Death is usua%%$ .aused b$ infe.tions &ie, diarrhea and deh$dration, !neumonia,
#ram"ne#ati/e se!sis, ma%aria, urinar$ infe.tion' or other .auses &ie, heart fai%ure asso.iated with
anemia, e3.ess of reh$dration so%ution, or e3.ess of !roteins in the first da$s of treatment;
h$!othermia; h$!o#%$.emia; h$!o+a%emia; h$!o!hos!hatemia'( Morta%it$ rates .an /ar$ from
%ess than 5; to more than 56; of .hi%dren, de!endin# on the 0ua%it$ of .are(
Infectious complicationsE "&ery hospitalized child %ith marasmus should @e considered
as ha&ing a @acterial infection. =reatment of @acterial infections pre&ents the
de&elopment of septic shoc>9 impro&es the response to nutritional reha@ilitation9 and
decreases mortality. If the child has no clinical sign of infection9 the WHO recommends <
days of oral cotrimo$azole therapy. If the child presents %ith clinical signs of infection9
hypoglycemia9 or hypothermia (that does not rapidly respond to the >angaroo position)9
he or she must @e considered as seriously infected and treated %ith parenteral ampicillin
and gentamicin. If the child does not impro&e rapidly9 chloramphenicol should @e added.
#ntimalaria treatment is also indicated in endemic areas9 either orally9 @y inOection9 or
intrarectal.
Other complications
o 'e&ere and symptomatic anemia (2 L gDH55 mN) %ith signs of heart failure should
@e treated %ith a @lood transfusion of pac>ed red cells to a ma$imum of H5 mND>g
administered o&er at least 1 hours. Cardio&ascular tolerance should @e closely
monitored. =he @enefit of @lood transfusion must @e @alanced %ith the ris>s of
cardio&ascular failure and the ris> of infection (eg9 hepatitis9 HIJ) associated %ith
@lood transfusion.
o +ractice guidelines for acute diarrhea ha&e @een esta@lished.
*3H,
+ersistent and
profuse diarrhea has 3 main causes.
Infectious etiology (especially lam@liasis)E =his can @e promptly treated
%ith metronidazole if possi@le9 after stool e$amination.
Osmotic diarrheaE 'ugar of the !4< solution should @e replaced @y cereal
flour for H)3 %ee>s.
o Jitamin # deficiency is al%ays present and should @e treated in the first fe%
days. Jitamin # replacement facilitates reco&ery from diarrhea9 measles9 and
respiratory diseases and decreases the ris> of @lindness.
o Nactose intolerance is unusual and often secondary to prolonged diarrhea. If9 as
dairy products are restarted9 diarrhea persists despite antiparasitic treatment and
nutritional reha@ilitation9 a transient lactose intolerance is possi@le9 especially if
stools ha&e a lo% pH and if the child presents %ith a perianal s>in inflammation
(diaper rash). In case of lactose intolerance9 mil> should @e %ithheld and yogurt
or a commercially a&aila@le lactose)free formula can @e used.
Complications of the rehabilitation phase
+oor response to the nutritional reha@ilitationE If the a@o&e recommendations are
applied9 children %ith marasmus should impro&e rapidly9 gain %eight regularly9 and
return to age)appropriate de&elopmental status. Usually9 poor response to treatment is
due to insufficient inta>e or an underlying infection9 especially HIJ or tu@erculosis.
Ho%e&er9 poor response to therapy reIuires a complete reassessment of the situation9
rather than simply adding a medication or a micronutrient9 %hich is usually ineffecti&e.
+sychosocial pro@lemsE Often during this period of the reha@ilitation9 underlying causes
of the childs marasmus are understood9 such as the pre&iously descri@ed psychosocial
factors. Changes in these underlying factors are often difficult @ecause they are
associated %ith the general socioeconomic conditions. Ho%e&er9 changes should @e
attempted. =he underlying factors should @e ta>en into consideration %hen planning the
childs return to home and further follo%)up care.
'pecific medical treatment regimens
In certain clinical scenarios9 specific clinical routines that should @e o@ser&ed.
In malnourished children %ith de&elopmental disa@ilities9 a systematic approach that %as
applied in a specialized feeding disorder clinic has @een descri@ed.
*33,
Initially9 specific
deficits %ere identified. /iagnosis)specific treatment plans then resulted in significantly
impro&ed energy consumption and nutritional status. ConseIuently9 the program
decreased o&erall su@seIuent hospitalization rates and medical costs.
'urgical Care
E3.e!t in %ife"threatenin# emer#en.$ situations, su.h as sma%% bowe% obstru.tion, sur#er$ shou%d
be !ost!oned unti% .hi%dren with marasmus ha/e .om!%eted nutritiona% rehabi%itation( )he
in.reased nutritiona% stress asso.iated with anesthesia, sur#er$, and the !ostsur#er$ !eriod shou%d
be .arefu%%$ e/a%uated( 2n order to !re!are a .hi%d with marasmus for sur#er$, the .hi%d must be
in !ositi/e ener#$ ba%an.e or anabo%ism, must ha/e minera% defi.ien.ies .orre.ted, and the
e%e.tro%$te imba%an.es must be .orre.ted( )his #oa% is usua%%$ rea.hed after the initia% !hase of
renutrition, after about a wee+(
(iet
See Medi.a% Care(
)ctivity
Chi%dren with marasmus need intera.tion with other .hi%dren and their fami%$ durin#
rehabi%itation &e#, feed in the !%a$ area'( A.ti/ities shou%d be se%e.ted to de/e%o! both motor and
%an#ua#e s+i%%s( Ph$si.a% a.ti/ities !romote the de/e%o!ment of motor s+i%%s( Duration of
a.ti/ities shou%d be in.reased !ro#ressi/e%$ as the nutritiona% status im!ro/es(
Jawab:
Se.ara definisi +ita te%ah tahu, marasmus dan +washior+or meru!a+an dam!a+ a+ibat tida+
ade+uatn$a diet $an# dibutuh+an(
Sebenarn$a dari #eAa%a +%inis saAa +ita sudah bisa beda+an antara marasmus dan +washior+or(
1eAa%a +%inis marasmus antara %ain:
"serin# .en#en#
"waAah !u.at
"ter%ihat se!erti Moran# tua susahN
"rambutn$a norma% &beda den#an +washior+or'
"%a!isan %ema+ tida+ ada sehin##a tu%an#"tu%an#n$a ter%ihat menonAo%(
"otot hi!otrofiHatrofi(
"hatiH%im!a membesar &he!atos!%enome#a%i'
Sedan#+an #eAa%a +%inis +washior+or antara %ain:
"a!ati, mu+a bu%at dan !u.at
"ram!ut se!erti rambut Aa#un#
"ada edema
".raz$ !a/ement dermatosis &ber.a+"ber.a+ !utih atau merah muda den#an te!i hitam'
A+an teta!i, +amu Au#a harus men$adari bahwa ada satu Aenis +e+uran#an #izi %ain $aitu
marasmus"+washior+or( Oan# meru!a+an .am!uran dari marasmus dan +washor+or( )entun$a
#eAa%a +%inisn$a Au#a meru!a+an .am!uran #eAa%a dari marasmus dan +washior+or(
4ntu+ !emeri+saan, serin# di#una+an !emeri+saan antro!ometri( Mu%ai dari tin##i badan, berat
badan, %in#+ar %en#an atas, teba% %i!atan +u%it dan %in#+aran +e!a%a(