Medication Summary
No practical guidelines have been established for the most frequently used medications in marasmus. However, significant changes occur in their pharmacokinetics, resulting in unpredictable responses to drug therapy. Therefore, dosage adaptations are often necessary, and only the best-known medications and the absolutely necessary medications should be used.
Drug metabolism during marasmus
Absorption and bioavailability of oral drugs are decreased by the structural and functional changes of the digestive tract. Drug distribution depends on the fluid distribution, organ perfusion, and albumin level and is therefore significantly modified by marasmus. The hepatic metabolism is altered in marasmus; therefore, drugs metabolized in the liver must be used with caution. Renal elimination of drugs is also impaired with the changes in glomerular filtration and tubular secretion. Consequently, patients generally have a decrease of drug elimination, increase in plasmatic concentration, and increase in risk for toxicity. Drug metabolism perturbations improve rapidly with rehabilitation. Various pathophysiological changes that occur in protein energy malnutrition (PEM) and their effects on pharmacokinetic parameters are summarized in Table 4.
Table 4. Pathophysiology and its Relation to Pharmacokinetic Parameters in Malnourished Children (Open Table in a new window)
Physical Parameter |
Pathophysiological Profile |
Pharmacokinetic Parameters |
GI tract |
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|
Body composition |
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|
Liver |
|
|
Kidney |
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Cardiac system |
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Table 5. WHO Dosage Guidelines for Glucose (Dextrose if IV), Vitamins, and Minerals (Open Table in a new window)
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) |
Antimicrobial agents
Class Summary
Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting. Penicillin and aminoglycosides are eliminated by the kidney and have an increased plasma half-life. A decrease by 25% of the usual dosage is recommended with an increased period between doses from 12-24 hours for aminoglycosides and from 6-8 hours for penicillin. Chloramphenicol is still used in low-income countries and recommended in some WHO management protocols. It should be replaced by less toxic drugs (eg, ceftriaxone). Antituberculosis medications, such as isoniazid and rifampicin, are metabolized by the liver. To avoid serious liver failure, their dosage should be decreased by half and liver function should be monitored during treatment. Antimalarial drugs should be administrated according to local guidelines; except for quinine, they are not mentioned in this article.
Amoxicillin (Amoxil, Biomox, Polymox)
Aminopenicillin used for treatment of susceptible bacterial infections caused by streptococci, pneumococci, nonpenicillinase-producing staphylococci, Listeria species, meningococci, and some strains of Haemophilus influenzae, Salmonella species, Shigella species, Escherichia coli, and Enterobacter and Klebsiella species.
Ampicillin (Marcillin, Omnipen)
Aminopenicillin used for the treatment of susceptible bacterial infections caused by streptococci, pneumococci, nonpenicillinase-producing staphylococci, Listeria species, meningococci, and some strains of H influenzae, Salmonella species, Shigella species, E coli, and Enterobacter and Klebsiella species.
Ceftriaxone (Rocephin)
Cephalosporin (third generation) used for the treatment of serious infections due to susceptible organisms (eg, H influenzae, Enterobacteriaceae, N meningitidis, S pneumoniae).
Gentamicin
Aminoglycoside for gram-negative coverage. First-choice antibiotic associated with ampicillin for severe infection.
Nalidixic acid (NegGram)
Quinolone antibacterial for PO administration. It is a bactericidal agent, which appears to interfere with DNA polymerization by inhibition of DNA topoisomerase.
Penicillin G (Pfizerpen)
Natural penicillin used for the treatment of sepsis, meningitis, pericarditis, endocarditis, pneumonia, and other infections due to susceptible gram-positive organisms (except Staphylococcus aureus), some gram-negative organisms (Neisseria gonorrhoeae, N meningitidis) and some anaerobes and spirochetes.
Sulfamethoxazole and trimethoprim (Bactrim, Cotrim, Septra)
Synthetic antibacterial combination. Children with no apparent sign of infection should be administered cotrimoxazole as a first-choice antibiotic.
Isoniazid (Laniazid, Nydrazid)
Used for specific treatment of tuberculosis either alone for preventive therapy in patients who have a skin test conversion or in combination with other drugs for treatment of all active forms of the disease.
Rifampin (Rifadin, Rimactane)
Also called rifampicin. It is a synthetic derivative of a natural antibiotic rifamycin B. It is used in combination with other antitubercular drugs for the treatment of active tuberculosis. It also has antibacterial activity (eg, S aureus, Streptococcus pyogenes, N gonorrhoeae, H influenzae).
Quinine (Formula Q)
First antimalarial drug used for the treatment of chloroquine-resistant Plasmodium falciparum malaria.
Antiprotozoal agents
Class Summary
Protozoal infections occur throughout the world and are a major cause of morbidity and mortality in some regions. Immunocompromised patients are especially at risk.
Albendazole (Albenza)
PO-administered broad-spectrum anthelmintic with specific indications, including ascariasis, hookworm infections, trichuriasis, and strongyloidiasis.
Metronidazole (Flagyl, Noritate, Protostat)
First-line treatment for amoebiasis and giardiasis.
Piperazine (Vermizine)
Treatment of ascariasis and trichuriasis.
Antipyretic and analgesic agents
Class Summary
These agents inhibit central synthesis and release of prostaglandins that mediate the effect of endogenous pyrogens in the hypothalamus; thus, they promote the return of the set-point temperature to normal. Acetaminophen (paracetamol) metabolism during malnutrition is well documented. Its half-life is increased with the impaired hepatic metabolism and renal excretion, requiring a dosage decrease.
Acetaminophen (Acephen, Tylenol, Feverall, Panadol)
First-choice antipyretic drug; it is also used for the treatment of mild to moderate pain and fever. Reduces fever by acting directly on hypothalamic heat-regulating centers, which increases dissipation of body-heat via vasodilation and sweating.
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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) |
