Marasmus Follow-up

  • Author: Simon S Rabinowitz, MD, PhD, FAAP; Chief Editor: Jatinder Bhatia, MBBS   more...
 
Updated: Mar 22, 2012
 

Further Inpatient Care

  • Preparing for discharge in patients with marasmus: During rehabilitation, do everything possible to ensure that the child is fully reintegrated into the family and community after discharge. Include the child, the mother, and the health care worker.
  • Child
    • Appropriate weight for height (-1 standard deviation [SD])
    • Eating well and gaining weight
    • Infections properly treated
    • Immunization started
  • Mother
    • Able to look after the child
    • Able to prepare appropriate food
    • Able to provide home treatment for diarrhea
    • Able to recognize the signs that mean she must seek medical assistance
  • Health care worker - Able to ensure the follow-up care of the child
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Further Outpatient Care

  • Relapse: Because risk of relapse is greatest soon after discharge, the child should be seen after 1 week, 2 weeks, and 1 month. At each visit, the health worker must be sure that all the points mentioned above are assessed. The child must be measured, weighed, and the results recorded. Immunization should be performed according to national guidelines.
  • Neurodevelopmental assessment: During the first 2 years of life, the nervous system is growing and particularly at risk if nutritional deficiencies are present; therefore, regular assessment of neurodevelopment is important, including head growth measurement, neurodevelopmental item assessment, and intelligence quotient (IQ) evaluation at each visit.
  • Long-term care: Long-term follow-up care should be encouraged, particularly regarding somatic growth and neurodevelopmental performances.
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Deterrence/Prevention

  • Inappropriate development, poverty, armed conflict, mishandling of funds, lack of education (particularly women's illiteracy), as well as limited access to medical care represent the primary underlying causes of malnutrition. The best preventive strategies should address these underlying problems.
  • Numerous prevention programs have been implemented, among which the most successful include the following:
    • Educational programs for girls
    • Sanitation programs, which improve access to safe water
    • Nutritional programs, including health education as well as screening of malnourished children
    • Programs that integrate breastfeeding promotion, diarrhea and infection therapy, and improvement of the nutritional status of mothers and pregnant women
  • Interestingly, programs aimed at improving technical infrastructures, such as electrical networks and information networks, have not demonstrated a positive preventive effect.
  • Integration of preventive action with national policies of education and family planning are necessary conditions for the success of these actions. Integrated action should also include screening, medical care, and follow-up. The frequent failures of preventive programs are often due to unsuitable nutrition interventions, insufficient treatment of diarrheal disease, or operational difficulties. However, ongoing evaluation can decrease the risk of failure.
  • Other key factors in prevention program success are clear strategic objectives, motivated and competent leaders, continuous training at every level, and regular evaluation of the objectives and achievements. Integration with the existing health care system, as well as national and international political support, is critical.
  • An international task force recently published an in-depth analysis of the impact of interventions for maternal and child undernutrition.[25] These authors determined that the management of severe acute malnutrition using the WHO guidelines in the developing world reduced the case fatality rate by 55%. In addition, using effective micronutrient interventions in pregnant mothers and their infants in the 36 countries that account for 90% of the children with stunted growth reduced overall stunting at 36 months by 36%. The authors concluded that further improvements would require correction of the fundamental underlying causes of marasmus, including poverty, poor education, disease burden, and lack of women's empowerment.
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Complications

  • Complications of the acute phase of malnutrition have been discussed (see Medical Care). Several complications can lead to permanent sequelae.
  • Long-term sequelae, with particular attention to developmental issues, must be mentioned. If growth and development have been extensively impaired and if early massive iron deficiency anemia is present, mental and physical retardation may be permanent. Apparently, the younger the infant at the time of deprivation, the more devastating are the long-term effects.
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Prognosis

  • Except for complications mentioned above, prognosis of even severe marasmus is good if treatment and follow-up care are correctly applied.
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Patient Education

  • Teaching parents how to prevent malnutrition is of high importance to prevent recurrence. They must understand the causes of malnutrition, how to prevent its recurrence (including correct feeding), and how to treat diarrhea and other infections. They have much to learn and need considerable care from the medical staff.
  • For excellent patient education resources, visit eMedicine's Esophagus, Stomach, and Intestine Center and Eating Disorders Center. Also, see eMedicine's patient education article Gastroenteritis.
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Contributor Information and Disclosures
Author

Simon S Rabinowitz, MD, PhD, FAAP  Professor of Clinical Pediatrics, Vice Chairman, Clinical Practice Development, Pediatric Gastroenterology, Hepatology, and Nutrition, State University of New York Downstate College of Medicine, The Children's Hospital at Downstate

Simon S Rabinowitz, MD, PhD, FAAP is a member of the following medical societies: American Academy of Pediatrics, American Association for the Advancement of Science, American College of Gastroenterology, American Gastroenterological Association, American Medical Association, New York Academy of Sciences, North American Society for Pediatric Gastroenterology and Nutrition, Phi Beta Kappa, and Sigma Xi

Disclosure: Abbott nutrition Honoraria Speaking and teaching

Coauthor(s)

Mario Gehri, MD  Consulting Staff, Department of Pediatrics, Hôpital De L'Enfance, Centre Hospitalier Universitaire Vaudois, Switzerland

Disclosure: Nothing to disclose.

Ermindo R Di Paolo, PhD  Pharmacist, Department of Pharmacy, University Hospital CHUV, Lausanne, Switzerland

Disclosure: Nothing to disclose.

Natalia M Wetterer, MD  Resident Physician, Department of Pediatrics, New York Medical College

Disclosure: Nothing to disclose.

Esther N Prince, MD  Pediatric Gastroenterology Fellow, State University of New York Downstate Medical Center

Disclosure: Nothing to disclose.

Specialty Editor Board

Maria Rebello Mascarenhas, MBBS  Associate Professor of Pediatrics, University of Pennsylvania School of Medicine; Section Chief of Nutrition, Division of Gastroenterology and Nutrition, Director, Nutrition Support Service, Children's Hospital of Philadelphia

Maria Rebello Mascarenhas, MBBS is a member of the following medical societies: American Gastroenterological Association, American Society for Parenteral and Enteral Nutrition, and North American Society for Pediatric Gastroenterology and Nutrition

Disclosure: Nothing to disclose.

Mary L Windle, PharmD  Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Jatinder Bhatia, MBBS  Professor of Pediatrics, Chief, Section of Neonatology, Department of Pediatrics, Medical College of Georgia

Jatinder Bhatia, MBBS is a member of the following medical societies: American Academy of Pediatrics, American Association for the Advancement of Science, American Dietetic Association, American Pediatric Society, American Society for Clinical Nutrition, American Society for Parenteral and Enteral Nutrition, Society for Pediatric Research, and Southern Society for Pediatric Research

Disclosure: Nothing to disclose.

Merrily P M Poth, MD  Professor, Department of Pediatrics and Neuroscience, Uniformed Services University of the Health Sciences

Merrily P M Poth, MD is a member of the following medical societies: American Academy of Pediatrics, Endocrine Society, and Pediatric Endocrine Society

Disclosure: Nothing to disclose.

Chief Editor

Jatinder Bhatia, MBBS  Professor of Pediatrics, Chief, Section of Neonatology, Department of Pediatrics, Medical College of Georgia

Jatinder Bhatia, MBBS is a member of the following medical societies: American Academy of Pediatrics, American Association for the Advancement of Science, American Dietetic Association, American Pediatric Society, American Society for Clinical Nutrition, American Society for Parenteral and Enteral Nutrition, Society for Pediatric Research, and Southern Society for Pediatric Research

Disclosure: Nothing to disclose.

Additional Contributors

The authors and editors of eMedicine gratefully acknowledge the use of images and information from the United Nations Children's Fund (UNICEF).

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Malnutrition hotspot map. Image courtesy of the World Health Organization (WHO) and United Nations Children's Fund (UNICEF).
Physiopathological principle of arm circumference measurement in children aged 1-5 years and the relationship with severity of malnutrition.
Hormonal adaptation to the stress of malnutrition. The evolution of marasmus.
Distribution of 10.4 million deaths among children younger than 5 years in all developing countries. World health Organization (WHO), 1995.
Clinical course of marasmus (history).
A classic example of a weight chart for a severely malnourished child.
General principles of severe malnutrition management. KW = Kwashiorkor.
Table 1. WHO Classification of Malnutrition
Evidence of MalnutritionModerateSevere (type)
Symmetric edemaNoYes (edema protein-energy malnutrition [PEM])*
Weight for height†Standard deviation (SD)‡ score -3



SD score <-2 (70-90%)§



SD score <-3 (ie, severe wasting) || (< 70%)
Height for ageSD score- 3



SD score <-2 (85-89%)



SD score <-3 (ie, severe stunting) (< 85%)
* This includes kwashiorkor (KW) and kwashiorkor marasmus (presence of edema always indicates serious PEM).



† Standing height should be measured in children taller than 85 cm, and supine length should be measured in children shorter than 85 cm or in children who are too sick to stand. Generally, the supine length is considered to be 0.5 cm longer than the standing height; therefore, 0.5 cm should be deducted from the supine length measured in children taller than 85 cm who are too sick to stand.



‡ Below the median National Center for Health Statistics (NCHS)/WHO reference: The SD score is defined as the deviation of the value for an individual from the median value of the reference population divided by the standard deviation of the reference population (ie, SD score = [observed value – median reference value]/standard deviation of reference population).



§ This is the percentage of the median NCHS/WHO reference.



|| This corresponds to marasmus (without edema) in the Wellcome clinical classification and to grade III malnutrition in the Gomez system. However, to avoid confusion, the term severe wasting is preferred.



Table 2. Composition Comparison of ReSoMal, Standard WHO, and Reduced-Osmolarity WHO ORS Solutions
CompositionReSoMal (mmol/L)Standard ORS (mmol/L)Reduced osmolarity ORS
Glucose12511175
Sodium459075
Potassium402020
Chloride708065
Citrate71010
Magnesium3......
Zinc0.3......
Copper0.045......
Osmolarity (mOsm/L)300311245
Table 3. Preparation of F75 and F100 Diets (WHO)
IngredientAmount in F75Amount in F100
Dry skimmed milk25 g80 g
Sugar70 g50 g
Cereal flour35 g...
Vegetable oil27 g60 g
Mineral mix20 mL20 mL
Vitamin mix140 mg140 mg
Water to mix1000 mL1000 mL
Table 4. Pathophysiology and its Relation to Pharmacokinetic Parameters in Malnourished Children
Physical ParameterPathophysiological ProfilePharmacokinetic Parameters
GI tract
  • Hypochlorhydria
  • Mucosal atrophy
  • Changes in transit time
  • Impaired pancreatic function
  • Altered gut microbial flora
  • Absorption
  • Enterohepatic circulation
  • Gut wall and gut bacterial metabolism
Body composition
  • Changes in protein/fat metabolism
  • Imbalance in body water distribution
  • Reduced sodium, potassium, and magnesium
  • Protein binding
  • Tissue uptake and distribution
  • Retention and elimination
Liver
  • Ultrastructural alterations
  • Decreased protein synthesis
  • Metabolism
  • Hepatic and biliary excretion
  • Enterohepatic circulation
Kidney
  • Reduced glomerular filtration
  • Impaired tubular function
  • Renal clearance
Cardiac system
  • Decreased cardiac output
  • Increased plasma volume
  • Organ blood flow
  • Tissue perfusion
Table 5. WHO Dosage Guidelines for Glucose (Dextrose if IV), Vitamins, and Minerals
Dextrose, Vitamins, and MineralsDosage
Glucose (dextrose)Conscious children: 50 mL 10% glucose or sucrose PO or 5 mL/kg of body weight of 10% dextrose IV, followed by 50 mL 10% glucose or sucrose by NG tube
Vitamin AInfants < 6 months: 50,000 IU/d PO for 2 d, followed by a third dose at least 2 wk later



Infants 6-12 months: 100,000 IU/d PO for 2 d, followed by a third dose at least 2 wk later



Children >12 months: 200,000 IU/d PO for 2 d, followed by a third dose at least 2 wk later



Folic acid5 mg PO on day 1, then 1 mg/d PO thereafter
MultivitaminsAll diets should be fortified with water-soluble and fat-soluble vitamins by adding, for example, the WHO vitamin mix (thiamine 0.7 mg/L, riboflavin 2 mg/L, nicotinic acid 10 mg/L, pyridoxine 0.7 mg/L, cyanocobalamin 1 mcg/L, folic acid 0.35 mg/L, ascorbic acid 100 mg/L, pantothenic acid 3 mg/L, biotin 0.1 mg/L, retinol 1.5 mg/L, calciferol 30 mcg/L, alpha-tocopherol 22 mg/L, vitamin K 40 mcg/L)
Iron supplementsProphylaxis: 1-2 mg elemental iron/kg/d PO; not to exceed 15 mg/d



Severe iron deficiency anemia: 4-6 mg elemental iron/kg/d PO divided tid



Mild-to-moderate iron deficiency anemia: 3 mg elemental iron/kg/d PO qd or divided bid



Precaution: GI irritation



Zinc sulfateSupplementation with ≥5 mg/d recommended for children aged 1 mo to 5 y with acute or persistent diarrhea (including dysentery)
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