Marasmus Treatment & Management

General objectives

Management of moderate marasmus can be performed on an outpatient basis, but severe marasmus or marasmus complicated by a life-threatening condition generally requires inpatient treatment. In these cases, management is divided into an initial intensive phase followed by a consolidation phase (rehabilitation), preparing for outpatient follow-up management. The WHO has developed guidelines to help improve the quality of hospital care for malnourished children and has prioritized the widespread implementation of these guidelines.

One key aspect of marasmus management is the potential role for routine antibiotics. The WHO has made formal recommendations for the use of oral antibiotics for children with uncomplicated severe acute malnutrition, not requiring to be admitted and who are managed as outpatients. ^[4] Two meta-analyses found a paucity of evidence to support this recommendation. ^{[33, 34]} However, a double-blind, placebo controlled study of more than 2600 Malawian children concluded that the addition of antibiotics to therapeutic regimens for uncomplicated severe acute malnutrition was associated with a significant improvement in recovery and mortality rates. ^[35]  An even more recent 2016 meta-analysis concluded Amoxicillin should remain recommended in children with uncomplicated SAM. ^[36]

The guidelines highlight 10 steps for routine management of children with malnutrition, as follows ^[37] :

• Prevent and treat the following:

  • Hypoglycemia

  • Hypothermia

  • Dehydration

  • Electrolyte imbalance

  • Infection

  • Micronutrient deficiencies

• Provide special feeds for the following:

  • Initial stabilization

  • Catch-up growth

  • Provide loving care and stimulation

  • Prepare for follow-up after discharge

Because most patients with moderate cases of marasmus can be treated as outpatients, the optimal environment is a pediatric nutrition rehabilitation center. Nutritional rehabilitation should include appropriate foods for an intake up to 100-150 kcal/kg/d. Other therapeutic and preventive actions should include rehydration using the WHO solution (see below) in case of associated diarrhea, micronutrient supplementation (eg, iron, vitamin A), context-appropriate screening, and review of immunization status. This management should also incorporate nutritional and sociocultural education adapted to the local conditions. Family-based management is preferred with the child's mother as the key player.

Nutritional management of the acute phase of severe marasmus (week 1)

This period corresponds to maintenance of vital functions and tissue renewal (ie, maintenance needs). During this period, the electrolyte imbalance, infections, hypoglycemia, and hypothermia are treated, and then feeding is started. Oral renutrition of a child with marasmus should be started as early as possible, as soon as the child is stable and the hydroelectrolyte imbalances are corrected. The term gut rest has no physiological basis. Enteral feeds decrease diarrhea and prevent bacteremia from bacterial translocation.

Because of the instability of children with marasmus, clinical care must be well adapted, with grouping of patients, constant monitoring, and frequent clinical evaluation during the first days. Patients with marasmus should be isolated from other patients, especially children with infections. Treatment areas should be as warm as possible, and bathing should be avoided to limit hypothermia. Therefore, when possible, the hospital structure is best adapted for the treatment of severe malnutrition.

In cases of shock, intravenous (IV) rehydration is recommended using a Ringer-lactate solution with 5% dextrose or a mixture of 0.9% sodium chloride with 5% dextrose. Enteral hydration using ReSoMal should be started as early as possible, preferably at the same time as the IV solution. The following rules should be implemented in the initial phase of rehydration: (1) use an nasogastric (NG) tube; (2) continue breastfeeding, except in case of shock or coma; and (3) start other food after 3-4 hours of rehydration.

NG tube insertion is essential for both initial treatment (ie, rehydration, correction of electrolyte disturbances) and rehabilitation (ie, to provide the child the correct amount of diet every 2-4 h, day and night).

The first step is often simply rehydration. Dehydration in children with marasmus is difficult to evaluate, is overdiagnosed, or is misinterpreted as septic shock. Rehydration should be enteral (by mouth or by NG tube) except in case of coma or shock, when intravenous therapy is required.

For longer than two decades, the WHO had recommended that the standard formulation of glucose-based oral rehydration solution (ORS) should contain 90 mmol/L of sodium, 111 mmol/L of glucose, and a total osmolarity of 311 mmol/L. Numerous investigators have expressed concern about the concentration of sodium and glucose and investigated the feasibility of a reduced-osmolarity ORS. A Cochrane review from 2002 concluded that, in children admitted to the hospital with diarrhea, reduced osmolarity ORS (270 mmol/L) is associated with fewer unscheduled IV infusions, lower stool volume, and less vomiting than standard ORS. ^[38] Hyponatremia was not reported in these clinical studies. The authors note that in areas where cholera diarrhea remains a major problem, some clinicians may prefer to use the standard WHO formulation. The newer reduced-osmolarity ORS, which has been recommended by the WHO, ^[39] can be ordered as 1561120 - ORS,1Lsachet/Box-100(insteadof1561110)or11561121-ORS,1Lsachet/Car-1000(insteadof11561120).

The ORS can be used for watery diarrhea, at the recommended volume of 5-15 mL/kg/h, with a total of 70 mL/kg for the first 12 hours. Because the risk of cardiac failure is increased in children with marasmus, compliance with the rehydration regimen is even more critical than in children who are well nourished. Therefore, closely monitor the rehydration phase and promptly address signs of cardiac failure, such as tachypnea, tachycardia, edema, or hepatomegaly.

Rehydration solution should be adapted to marasmic children with a low sodium content and a high potassium content. This can be prepared using standard WHO solution as a base or by directly administering a modified oral rehydration (ReSoMal) solution if available. Table 2 highlights the composition of standard ORS, the new reduced-osmolarity ORS, and ReSoMal.

Table 2. Composition Comparison of ReSoMal, Standard WHO, and Reduced-Osmolarity WHO ORS Solutions (Open Table in a new window)

The overall goal of nutrition rehabilitation is to overcome the anorexia often associated with marasmus, as well as to avoid the causes that lead to anorexia. Another goal is to avoid cardiac failure while providing enough energy to avoid catabolism. The goal usually is to provide 80-100 kcal/kg/d in 12 meals per day or continuously by NG tube to avoid hypoglycemia. This amount of calories should be reached progressively in a few days to avoid life-threatening problems such as cardiac failure or hypokalemia.

The WHO had recommended the use of the liquid products, such as the F75 solution, which provides 75 kcal/100 mL, mainly as carbohydrates. This solution provides a limited amount of fat, which is often malabsorbed because of the associated pancreatic insufficiency, and a limited amount of proteins, which can precipitate renal failure during initial refeeding of children with marasmus. F75 is available as a ready-to-use formula or can be prepared using widely available foods listed in Table 3 below. Recipes and cooking guidelines, including possible alternative foods, are available through the WHO. The ready-to-use formulas, as well as the micronutrient mixtures, are commercially available.

Table 3. Preparation of F75 and F100 Diets (WHO) (Open Table in a new window)

Rehabilitation phase (weeks 2-6)

In the rehabilitation phase of treatment, nutritional intake can reach 200 kcal/kg/d. The goal is to reach a continuous catch-up growth in weight and height in order to restore a healthy body weight. Only children who have been weaned from their NG tube can be considered as being in the rehabilitation phase. Therefore, specific goals of this phase are as follows:

• To encourage the child to eat as much as possible

• To restart breastfeeding as soon as possible

• To stimulate the emotional and physical development

• To actively prepare the child and mother to return to home and prevent recurrence of malnutrition

During the rehabilitation phase, the F100 formula, with a higher protein content (see Table 3 above) is recommended. With the child's increased appetite during this phase, use of the F75 formula only leads to a fat increase, without an appropriate gain in fat-free mass. The main risk of this phase of the rehabilitation is that the nutrients provided are not sufficient to sustain the weight gain, which can reach as much as 15 g/kg/d. Inexperienced health professionals often underestimate the needs of children with marasmus in this phase of nutritional rehabilitation. The increased iron needs associated with the rapid muscle growth and the hemoglobin increase justify iron supplementation starting in the second week of rehabilitation.

Powdered skim milk is used to prepare the F75 or F100 formula. In that form, the lactose concentration is low, about 10 times less than in breast milk, which is also well tolerated by children with marasmus. Only in cases of persistent diarrhea or established lactose intolerance, which is rare, should lactose be excluded. High-fat foods are well tolerated at this point because they slow gastric emptying.

Plumpy'nut, a peanut-based paste with supplemental energy, vitamins, and minerals has been designed for malnourished children who are sufficiently well to benefit from outpatient care. ^[40] The WHO has recognized it as a ready-to-use-therapeutic food (RUTF) that can reverse malnutrition in severely malnourished children. ^[41] It was also successfully used by Doctors Without Borders in Niger in 2005. The paste is easy to eat, allowing children to feed themselves. The fortified peanut butter–like paste contains a balance of fats, carbohydrates, proteins, vitamins, and minerals. Peanuts themselves provide mono-unsaturated fats, which are easy to digest and are calorically dense, with ample amounts of zinc and protein. Because the product contains no water, it can last 2 years unopened.

A standard Plumpy'nut treatment for 4 weeks (2-3 times daily) costs 12 Euros in Africa. The cost of 4 weeks of Plumpy'nut and supplemental vitamin mixture (Unimix) is $35 per child. The cost in Haiti for a similar peanut butter–based product is slightly higher but still relatively inexpensive. The product can also be prepared locally in peanut-producing areas, such as Malawi and Niger, by mixing ground peanut and milk paste with a slurry of vitamins and minerals obtained from Nutriset, the French manufacturer of the paste.

Emotional and physical stimulation is critical during this period. Psychomotor inhibition is evident in children with marasmus but rapidly improves with renutrition. Any rehabilitation practices that can minimize long-term developmental consequences should be implemented in children with marasmus. Practices available may vary depending on the environment. Practices include physiotherapy, sensory stimulation, and massages and should be implemented with or by the mother.

Management of acute complications

Mortality of hospitalized children with marasmus is high, especially during the first few days of rehabilitation. Death is usually caused by infections (ie, diarrhea and dehydration, pneumonia, gram-negative sepsis, malaria, urinary infection) or other causes (ie, heart failure associated with anemia, excess of rehydration solution, or excess of proteins in the first days of treatment; hypothermia; hypoglycemia; hypokalemia; hypophosphatemia). Mortality rates can vary from less than 5% to more than 50% of children, depending on the quality of care.

• Infectious complications: Every hospitalized child with marasmus should be considered as having a bacterial infection. Treatment of bacterial infections prevents the development of septic shock, improves the response to nutritional rehabilitation, and decreases mortality. If the child has no clinical sign of infection, the WHO recommends 5 days of oral cotrimoxazole therapy. If the child presents with clinical signs of infection, hypoglycemia, or hypothermia (that does not rapidly respond to the kangaroo position), he or she must be considered as seriously infected and treated with parenteral ampicillin and gentamicin. If the child does not improve rapidly, chloramphenicol should be added. Antimalaria treatment is also indicated in endemic areas, either orally, by injection, or intrarectal.

• Other complications

  • Severe and symptomatic anemia (< 4 g/100 mL) with signs of heart failure should be treated with a blood transfusion of packed red cells to a maximum of 10 mL/kg administered over at least 3 hours. Cardiovascular tolerance should be closely monitored. The benefit of blood transfusion must be balanced with the risks of cardiovascular failure and the risk of infection (eg, hepatitis, HIV) associated with blood transfusion.

  • Practice guidelines for acute diarrhea ^[42] Persistent and profuse diarrhea has 2 main causes.

    • Infectious etiology (especially ambliasis): This can be promptly treated with metronidazole if possible, after stool examination.

    • Osmotic diarrhea: Sugar of the F75 solution should be replaced by cereal flour for 1-2 weeks.

  • Vitamin A deficiency is always present and should be treated in the first few days. Vitamin A replacement facilitates recovery from diarrhea, measles, and respiratory diseases and decreases the risk of blindness.

  • Lactose intolerance is unusual and often secondary to prolonged diarrhea. If, as dairy products are restarted, diarrhea persists despite antiparasitic treatment and nutritional rehabilitation, a transient lactose intolerance is possible, especially if stools have a low pH and if the child presents with a perianal skin inflammation (diaper rash). In case of lactose intolerance, milk should be withheld and yogurt or a commercially available lactose-free formula can be used.

  • An important consideration that has been known since World War II is the consequence of nutritional rehabilitation: the refeeding syndrome. This is most likely encountered in individuals with severe degrees of malnutrition. After refeeding is initiated in the severely compromised individual (including patients with anorexia nervosa), the metabolic needs that are required for anabolism may not be able to be met because of the depleted state. Characteristic features include hypophosphatemia (thus preventing synthesis of essential ATP), hypokalemia (leading to cardiac insufficiency), and various other required electrolyte and mineral deficiencies. A comprehensive article illustrates the syndrome and provides guidelines. ^[43]

  • Within the first 3 days of therapy, numerous issues must be monitored. Suggested supplementations include phosphage (0.5-0.8 mmol/kg/d), potassium 1-3 (mmol/kg/d), and magnesium 0.3-0.4 (mmol/kg/d); 100% DRI minerals and trace elements; and 200% DRI vitamins. Because beriberi may also coexist with marasmus, thiamine (200-300 g IV or PO) should be given daily.

  • Extreme care must be given to following serum electrolytes (including phosphorus and magnesium) clinical features and EKG in any child with severe marasmus who is receiving nutritional repletion.

Complications of the rehabilitation phase

See the list below:

• Poor response to the nutritional rehabilitation: If the above recommendations are applied, children with marasmus should improve rapidly, gain weight regularly, and return to age-appropriate developmental status. Usually, poor response to treatment is due to insufficient intake or an underlying infection, especially HIV or tuberculosis. However, poor response to therapy requires a complete reassessment of the situation, rather than simply adding a medication or a micronutrient, which is usually ineffective.

• Psychosocial problems: Often during this period of the rehabilitation, underlying causes of the child's marasmus are understood, such as the previously described psychosocial factors. Changes in these underlying factors are often difficult because they are associated with the general socioeconomic conditions. However, changes should be attempted. The underlying factors should be taken into consideration when planning the child's return to home and further follow-up care.

Specific medical treatment regimens

See the list below:

• In certain clinical scenarios, specific clinical routines should be observed.

• In malnourished children with developmental disabilities, a systematic approach that was applied in a specialized feeding disorder clinic has been described. ^[44] Initially, specific deficits were identified. Diagnosis-specific treatment plans then resulted in significantly improved energy consumption and nutritional status. Consequently, the program decreased overall subsequent hospitalization rates and medical costs.

Except in life-threatening emergency situations, such as small bowel obstruction, surgery should be postponed until children with marasmus have completed nutritional rehabilitation. The increased nutritional stress associated with anesthesia, surgery, and the postsurgery period should be carefully evaluated. In order to prepare a child with marasmus for surgery, the child must be in positive energy balance or anabolism, must have mineral deficiencies corrected, and the electrolyte imbalances must be corrected. This goal is usually reached after the initial phase of renutrition, after about a week.

See Medical Care.

Children with marasmus need interaction with other children and their family during rehabilitation (eg, feed in the play area). Activities should be selected to develop both motor and language skills. Physical activities promote the development of motor skills. Duration of activities should be increased progressively as the nutritional status improves.