Laboratory Studies
Generally, for diagnosis and treatment of marasmus, no further evaluation is necessary other than the clinical evaluation. Most laboratory results are within the reference range despite significant changes in body composition and physiology. Furthermore, in regions where malnutrition is frequent, health structures are poorly equipped, and laboratory evaluations are either impossible to obtain or unreliable.
If they are available, some laboratory results can be useful to monitor treatment or to diagnose specific complications.
Laboratory tests adapted from the WHO include the following:
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Blood glucose: Hypoglycemia is present if the level is lower than 3 mmol/L.
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Examination of blood smears by microscopy or direct detection test: Presence of parasites is indicative of infection. Direct test is suitable but expensive.
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Hemoglobin: A level lower than 40 g/L is indicative of severe anemia.
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Urine examination and culture, Multistix: More than 10 leukocytes per high-power field is indicative of infection. Nitrites and leukocytes are tested on Multistix also.
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Stool examination by microscopy: Parasites and blood are indicative of dysentery.
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Albumin: Although not useful for diagnosis, it is a guide to prognosis; if albumin is lower than 35 g/L, protein synthesis is massively impaired.
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HIV test: HIV test should not be routinely performed; if completed, it should be accompanied by counseling of the child's parents and the result should be confidential.
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Electrolytes: Measuring electrolytes is rarely helpful and it may lead to inappropriate therapy. Hyponatremia is a significant finding.
Imaging Studies
Radiological examinations are rarely used for the same reasons as the laboratory examinations.
Thoracic radiography can show a pulmonary infection despite lack of clinical signs, a primary tuberculosis lesion, cardiomegaly, or signs of rachitism.
Other Tests
Skin test results for tuberculosis are often negative in children who are undernourished with tuberculosis or those previously vaccinated with Bacille Calmette-Guérin (BCG) vaccine.
Procedures
Lumbar puncture is rarely performed.
Urine catheterization or vesical puncture serves to exclude urinary tract infection because direct examination is often not indicative.
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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) |
