eMedicine Specialties > Pediatrics: General Medicine > Nutrition

Marasmus: Follow-up

Author: Simon S Rabinowitz, MD, PhD, Professor of Clinical Pediatrics, New York Medical College; Chairman, Chief and Medical Administrator, Department of Pediatrics, Chief, Pediatric Gastroenterology and Nutrition, Richmond University Medical Center
Coauthor(s): Mario Gehri, MD, Consulting Staff, Department of Pediatrics, Hôpital De L'Enfance, Centre Hospitalier Universitaire Vaudois, Switzerland; Ermindo R Di Paolo, PhD, Pharmacist, Department of Pharmacy, Centre Hospitalier Universitaire Vaudois, Vaud, Switzerland; Natalia M Wetterer, MD, Resident Physician, Department of Pediatrics, New York Medical College
Contributor Information and Disclosures

Updated: May 20, 2009

Follow-up

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

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.

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.23 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.

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.

Prognosis

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

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.

Miscellaneous

Medicolegal Pitfalls

  • Failure to admit patients with severe marasmus
  • Failure to constantly monitor and provide frequent clinical evaluation during the first days
  • Failure to provide renutrition with recommended fluids
  • Failure to adjust drug doses because body functions are significantly modified by marasmus, causing significant drug reactions
  • Failure to realize that, at the beginning of treatment, the child with marasmus first starts to lose rather than gain weight
  • Failure to consider every child with marasmus as having a serious bacterial infection
  • Failure to educate family in proper care and nutrition of infant, to address psychosocial problems prior to release, and to pursue close follow-up after release
 
Acknowledgments

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



More on Marasmus

Overview: Marasmus
Differential Diagnoses & Workup: Marasmus
Treatment & Medication: Marasmus
Follow-up: Marasmus
Multimedia: Marasmus
References
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Further Reading

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Keywords

marasmus, severe malnutrition, protein energy malnutrition, PEM, kwashiorkor, KW, marasmic KW, protein deficiency, mental retardation, cystic fibrosis, malignancy, cardiovascular disease, end stage renal disease, gastroenteritis, measles, tuberculosis, HIV, hypothermia, hypoglycemia, hypokalemia, hypothyroidism, bacteriemia, candidiasis, Pneumocystis carinii, anorexia nervosa, iron deficiency, iodine deficiency, treatment, diagnosis

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Contributor Information and Disclosures

Author

Simon S Rabinowitz, MD, PhD, Professor of Clinical Pediatrics, New York Medical College; Chairman, Chief and Medical Administrator, Department of Pediatrics, Chief, Pediatric Gastroenterology and Nutrition, Richmond University Medical Center
Simon S Rabinowitz, MD, PhD 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: Nothing to disclose.

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, Centre Hospitalier Universitaire Vaudois, Vaud, Switzerland
Disclosure: Nothing to disclose.

Natalia M Wetterer, MD, Resident Physician, Department of Pediatrics, New York Medical College
Disclosure: Nothing to disclose.

Medical Editor

Maria Rebello Mascarenhas, MBBS, Associate Professor of Pediatrics, University of Pennsylvania School of Medicine; Section Chief, 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.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing 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 Federation for Clinical Research, American Pediatric Society, American Society for Clinical Nutrition, American Society for Parenteral and Enteral Nutrition, New York Academy of Sciences, Society for Pediatric Research, and Southern Society for Pediatric Research
Disclosure: Mead Johnson Consulting fee Consulting; Mead Johnson Honoraria Speaking and teaching; Dey LP Consulting fee Consulting; Dey LP Honoraria Speaking and teaching; Ovation Honoraria Speaking and teaching

CME Editor

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 Lawson-Wilkins 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 Federation for Clinical Research, American Pediatric Society, American Society for Clinical Nutrition, American Society for Parenteral and Enteral Nutrition, New York Academy of Sciences, Society for Pediatric Research, and Southern Society for Pediatric Research
Disclosure: Mead Johnson Consulting fee Consulting; Mead Johnson Honoraria Speaking and teaching; Dey LP Consulting fee Consulting; Dey LP Honoraria Speaking and teaching; Ovation Honoraria Speaking and teaching

 
 
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