History
Signs and symptoms of marasmus vary with the importance and duration of the energy deficit, age at onset, associated infections (eg, GI infections), and associated nutritional deficiencies (eg, iron deficiency, iodine deficiency). Diets and deficiencies may vary considerably between different geographical regions and even within a country. The AIDS epidemic has also significantly changed the clinical course of classic marasmus. Marasmus is typically observed in infants who are breastfeeding when the amount of milk is markedly reduced or, more frequently, in those who are artificially fed. Failure to thrive is the earliest manifestation, associated with irritability or apathy. Chronic diarrhea is the most frequent symptom, and infants generally present with feeding difficulties. Presentation may be accelerated by an acute infection.
The classic clinical course of a child with marasmus is presented in the images below.
Physical Examination
A shrunken wasted appearance is the classic presentation of marasmus. Anthropometric measurements are critical to rapidly assess the type and severity of the malnutrition. The Wellcome Classification of Malnutrition in Children was generally used, but the WHO has revised this classification (see the table below). This simple classification allows a clear presentation of the clinical cases and allows comparisons between countries. Stunted children are usually considered to have a milder chronic form of malnutrition, but their condition can rapidly worsen with the onset of complications such as diarrhea, respiratory infection, or measles.
Table 1. WHO Classification of Malnutrition (Open Table in a new window)
Evidence of Malnutrition |
Moderate |
Severe (type) |
Symmetric edema |
No |
Yes (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 age |
SD 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. |
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Construction and use of a wasting diagram simplifies the classification because the exact age of the child is often unknown. The wasting diagram is a large colored board made of vertical columns corresponding to weights from 2-25 kg (or 15 kg, which is often sufficient). The child is weighed and then his or her height is measured on the board in the column corresponding to the measured weight. The diagram is designed so that the height corresponds to the green zone if the child is well nourished, the yellow zone if the child is moderately malnourished, and to the red zone if the child is severely malnourished. Values within the reference range used to design this diagram can be applied to any population regardless of the racial origin.
Middle upper arm circumference (MUAC) is a simple, low-cost, objective method of assessing nutritional status. As illustrated in the body composition section, mid-arm circumference of < 11cm indicates severe malnutrition in infants from 1-6 months of age. [10] The MUAC is generally as good as or better than other anthropometric measures in predicting subsequent mortality in community-based studies. It is also the most useful tool in large epidemiological surveys.
The most perceptible and frequent clinical feature in marasmus is the loss of muscle mass and subcutaneous fat mass. Some muscle groups, such as buttocks and upper limb muscles, are more frequently affected than others. Facial muscles are usually spared longer. Facial fat mass is the last to be lost, resulting, in severe cases, in the characteristic elderly appearance of children with marasmus. Anorexia is frequent and interferes with renutrition. An irritable and whining child who cannot be comforted or separated from the mother demonstrates behaviors often observed with marasmus. Apathy is a sign of serious forms of marasmus: children are increasingly motionless and seem to "let themselves die." In contrast, during rehabilitation, even the slightest smile is a positive sign of recovery. Children's behavior is probably one of the best clinical signs of the severity and evolution of marasmus.
Several clinical signs must be assessed in order to detect complications, with special attention to infectious complications (see checklist below). The physical examination must be very thorough because even small abnormalities can be clinically significant. Clinical signs of serious complication can be very subtle in children with marasmus. A body temperature of 37.5°C can correspond to a fever of 39-40°C in a child without marasmus, and a small cough can be the only sign of a serious pneumonia. After history and physical examination, diagnosing the type and severity of the malnutrition, as well as diagnosing associated infections and complications affecting organs or systems, such as the GI, neurological, or cardiovascular system, are critical. This set of diagnoses results in optimal planning of the complementary evaluation and therapeutic strategy.
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Checklist of points for conducting the physical examination
Body temperature (measured with a thermometer) - Allowing measurement of low temperatures to detect hypothermia as well as fever
Anemia - Pale mucosa
Edema
Dehydration - Thirst, shrunken eyes
Hypovolemic shock - Weak radial pulse, cold extremities, decreased consciousness
Tachypnea - Pneumonia, heart failure
Abdominal manifestations - Distension, decreased or metallic bowel sounds, large or small liver, blood or mucus in the stools
Ocular manifestations - Corneal lesions associated with vitamin A deficiency
Dermal manifestations - Evidence of infection, purpura
Ear, nose, and throat (ENT) findings - Otitis, rhinitis
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Malnutrition hotspot map. Image courtesy of the World Health Organization (WHO) and United Nations Children's Fund (UNICEF).
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Physiopathological principle of arm circumference measurement in children aged 1-5 years and the relationship with severity of malnutrition.
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Hormonal adaptation to the stress of malnutrition. The evolution of marasmus.
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Distribution of 10.4 million deaths among children younger than 5 years in all developing countries. World health Organization (WHO), 1995.
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Clinical course of marasmus (history).
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A classic example of a weight chart for a severely malnourished child.
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General principles of severe malnutrition management. KW = Kwashiorkor.
Tables
- Table 1. WHO Classification of Malnutrition
- Table 2. Composition Comparison of ReSoMal, Standard WHO, and Reduced-Osmolarity WHO ORS Solutions
- Table 3. Preparation of F75 and F100 Diets (WHO)
- Table 4. Pathophysiology and its Relation to Pharmacokinetic Parameters in Malnourished Children
- Table 5. WHO Dosage Guidelines for Glucose (Dextrose if IV), Vitamins, and Minerals
Evidence of Malnutrition |
Moderate |
Severe (type) |
Symmetric edema |
No |
Yes (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 age |
SD 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. |
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Composition |
ReSoMal (mmol/L) |
Standard ORS (mmol/L) |
Reduced osmolarity ORS |
Glucose |
125 |
111 |
75 |
Sodium |
45 |
90 |
75 |
Potassium |
40 |
20 |
20 |
Chloride |
70 |
80 |
65 |
Citrate |
7 |
10 |
10 |
Magnesium |
3 |
... |
... |
Zinc |
0.3 |
... |
... |
Copper |
0.045 |
... |
... |
Osmolarity (mOsm/L) |
300 |
311 |
245 |
Ingredient |
Amount in F75 |
Amount in F100 |
Dry skimmed milk |
25 g |
80 g |
Sugar |
70 g |
50 g |
Cereal flour |
35 g |
... |
Vegetable oil |
27 g |
60 g |
Mineral mix |
20 mL |
20 mL |
Vitamin mix |
140 mg |
140 mg |
Water to mix |
1000 mL |
1000 mL |
Physical Parameter |
Pathophysiological Profile |
Pharmacokinetic Parameters |
GI tract |
|
|
Body composition |
|
|
Liver |
|
|
Kidney |
|
|
Cardiac system |
|
|
Dextrose, Vitamins, and Minerals |
Dosage |
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 A |
Infants < 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 acid |
5 mg PO on day 1, then 1 mg/d PO thereafter |
Multivitamins |
All 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 supplements |
Prophylaxis: 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 sulfate |
Supplementation with ≥5 mg/d recommended for children aged 1 mo to 5 y with acute or persistent diarrhea (including dysentery) |
