Further Outpatient Care
Further outpatient care includes the following:
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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.
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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.
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Long-term care: Long-term follow-up care should be encouraged, particularly regarding somatic growth and neurodevelopmental performances.
Further Inpatient Care
Further inpatient care involves the following:
-
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
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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
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Health care worker - Able to ensure the follow-up care of the child
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:
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Educational programs for girls
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Sanitation programs, which improve access to safe water
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Nutritional programs, including health education as well as screening of malnourished children
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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. [45] 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.
The prevalence of marasmus has been recognized to dramatically increase in a vulnerable cohort in the face of natural disasters. [46, 47] A comprehensive review from the Global Nutrition Cluster on the use of lipid-based supplements as an emergency measure during these crises is now available. [48]
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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. |
||
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) |
