Diagnostic Considerations
No differential diagnosis for marasmus are noted. However, when edema is present, it can reflect a kwashiorkor (KW) component of the malnutrition or an underlying cardiac or renal insufficiency. In these circumstances, additional laboratory tests or radiographic tests may be needed.
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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) |
