History

Signs and symptoms of marasmus vary with the importance and duration of the energy
deficit, age at onset, associated infections (eg, GI infections), and associated nutritional
deficiencies (eg, iron deficiency, iodine deficiency). Diets and deficiencies may vary
considerably between different geographical regions and even within a country. The
AIDS epidemic has also significantly changed the clinical course of classic marasmus.
Marasmus is typically observed in infants who are breastfeeding when the amount of
milk is markedly reduced or, more frequently, in those who are artificially fed. Failure to
thrive ﾧ is the earliest manifestation, associated with irritability or apathy. Chronic
diarrhea is the most frequent symptom, and infants generally present with feeding
difficulties. Presentation may be accelerated by an acute infection.
The classic clinical course of a child with marasmus is presented in the images below.

Physical
A shrunken wasted appearance is the classic presentation of marasmus. Anthropometric
measurements are critical to rapidly assess the type and severity of the malnutrition. The
Wellcome Classification of Malnutrition in Children was generally used, but the WHO
has revised this classification (see the table below). This simple classification allows a
clear presentation of the clinical cases and allows comparisons between countries.
Stunted children are usually considered to have a milder chronic form of malnutrition, but
their condition can rapidly worsen with the onset of complications such as diarrhea,
respiratory infection, or measles.

able 1. WHO Classification of Malnutrition (Open Table in a new window)ﾧ

* 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)ﾧ/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.

Construction and use of a wasting diagram simplifies the classification because the exact
age of the child is often unknown. The wasting diagram is a large colored board made of
vertical columns corresponding to weights from 2-25 kg (or 15 kg, which is often
sufficient). The child is weighed and then his or her height is measured on the board in
the column corresponding to the measured weight. The diagram is designed so that the
height corresponds to the green zone if the child is well nourished, the yellow zone if the
child is moderately malnourished, and to the red zone if the child is severely
malnourished. Values within the reference range used to design this diagram can be
applied to any population regardless of the racial origin.
Middle upper arm circumference (MUAC) is a simple, low-cost, objective method of
assessing nutritional status. As illustrated in the body composition section, mid-arm
circumference of < 11cm indicates severe malnutrition in infants from 1-6 months of age.
[10] The MUAC is generally as good as or better than other anthropometric measures in
predicting subsequent mortality in community-based studies. It is also the most useful
tool in large epidemiological surveys.
The most perceptible and frequent clinical feature in marasmus is the loss of muscle mass
and subcutaneous fat mass. Some muscle groups, such as buttocks and upper limb
muscles, are more frequently affected than others. Facial muscles are usually spared
longer. Facial fat mass is the last to be lost, resulting, in severe cases, in the characteristic
elderly appearance of children with marasmus. Anorexia is frequent and interferes with
renutrition. An irritable and whining child who cannot be comforted or separated from the
mother demonstrates behaviors often observed with marasmus. Apathy is a sign of
serious forms of marasmus: children are increasingly motionless and seem to "let
themselves die." In contrast, during rehabilitation, even the slightest smile is a positive
sign of recovery. Children's behavior is probably one of the best clinical signs of the
severity and evolution of marasmus.
Several clinical signs must be assessed in order to detect complications, with special
attention to infectious complications (see checklist below). The physical examination
must be very thorough because even small abnormalities can be clinically significant.
Clinical signs of serious complication can be very subtle in children with marasmus. A
body temperature of 37.5°C can correspond to a fever of 39-40°C in a child without
marasmus, and a small cough can be the only sign of a serious pneumonia ﾧ. After history
and physical examination, diagnosing the type and severity of the malnutrition, as well as
diagnosing associated infections and complications affecting organs or systems, such as
the GI, neurological, or cardiovascular system, are critical. This set of diagnoses results in
optimal planning of the complementary evaluation and therapeutic strategy.
Checklist of points for conducting the physical examination
Body temperature (measured with a thermometer) - Allowing measurement of low
temperatures to detect hypothermia as well as fever
Anemia - Pale mucosa
Edema
Dehydration - Thirst, shrunken eyes
Hypovolemic shock - Weak radial pulse, cold extremities, decreased consciousness
Tachypnea - Pneumonia, heart failure
Abdominal manifestations - Distension, decreased or metallic bowel sounds, large or
small liver, blood or mucus in the stools
Ocular manifestations - Corneal lesions associated with vitamin A deficiency
Dermal manifestations - Evidence of infection, purpura
Ear, nose, and throat (ENT) findings - Otitis, rhinitis

Causes
Several factors can lead to marasmus. Their relative importance varies between children
and between parts of the world. For example, undernutrition associated with war,
inappropriate weaning by a young mother, and precipitating infections can influence
incidence of marasmus.
Nutrition: In many low-income countries, food variety is limited and results in mineral
and vitamin insufficiencies. In cases of anorexia, which are generally associated with
infection, the total energy intake becomes insufficient. Therefore, any nutrient deficiency
can lead to marasmus because appropriate growth can only be ensured by a balanced diet.
Therefore, marasmus can be described as multiple-deficiency malnutrition.
Infections: Associated infections often trigger, aggravate, or combine with marasmus.
However, evidence exists that this association may have been overestimated. For
example, in rural Senegal, the growth of children with or without infections, such as
pertussis and measles, was similar. In contrast, the importance of diarrhea in triggering
malnutrition through anorexia and weight loss has been well established. Infectious
diseases more frequently associated with energy-protein malnutrition are gastroenteritis,
respiratory infections, measles, and pertussis. HIV also plays an increasingly significant
role in some countries.
Socioeconomic factors: Frequently, malnutrition appears during weaning, especially if
weaning is suboptimal, as can occur with a low-variety diet, or if weaning foods are
introduced only in children older than 8-10 months. The WHO recommends exclusive
breastfeeding until age 6 months; then, the introduction of various additional foods is
recommended. The socioeconomic environment is often critical in the choice of the
weaning food used. For example, in northern Senegal, available foods are often limited to
grains, vegetables, and a small amount of fish. Milk and meat are rare. In this region,
malnutrition and diarrhea are frequent. In contrast, in the nearby Sahelien pastures where
milk and meat are the main foods, diarrhea is less frequent, and malnutrition is rare.
Other socioeconomic factors: Other factors, such as the famines associated with climatic
disasters or more often with political events and war (as has been the case in east Africa),
can play a critical role. The sociofamilial environment can also be important, and children
of young or inexperienced mothers, twins, or female infants can be at a higher risk in
some parts of the world.
Summary: Marasmus, and malnutrition in general, represents multiple deficiencies, and
multiple etiologies. Therefore, epidemiological, public health, and therapeutic approaches
must be comprehensive. Population-based interventions limited to the supplementation of
one nutrient have often been unsuccessful.

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.

Laboratory Studies
See the list below:
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:
Blood glucose: Hypoglycemia is present if the level is lower than 3 mmol/L.
Examination of blood smears by microscopy or direct detection test: Presence of parasites
is indicative of infection. Direct test is suitable but expensive.
Hemoglobin: A level lower than 40 g/L is indicative of severe anemia.
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.
Stool examination by microscopy: Parasites and blood are indicative of dysentery.
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.
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.
Electrolytes: Measuring electrolytes is rarely helpful and it may lead to inappropriate
therapy. Hyponatremia ﾧ is a significant finding.

Imaging Studies
See the list below:
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
See the list below:
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
See the list below:
Lumbar puncture ﾧ is rarely performed.
Urine catheterization or vesical puncture serves to exclude urinary tract infection ﾧ
because direct examination is often not indicative.

Medical Care
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. [32, 33] 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. [34] An even more recent 2016 meta-
analysis concluded Amoxicillin should remain recommended in children with
uncomplicated SAM. [35]
The guidelines highlight 10 steps for routine management of children with malnutrition,
as follows [36] :
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. [37] 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, [38] 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)ﾧ

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)ﾧ

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. [39] The WHO has recognized it as a ready-to-use-therapeutic food
(RUTF) that can reverse malnutrition in severely malnourished children. [40] 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 ﾧ, 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 ﾧ [41] 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. [42]
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. [43] 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.

Surgical Care
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.

Diet
See Medical Care.
Activity
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.

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)ﾧ

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)ﾧ
 View full drug information ﾧ
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)ﾧ
 View full drug information ﾧ
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)ﾧ
 View full drug information ﾧ
Cephalosporin (third generation) used for the treatment of serious infections due to
susceptible organisms (eg, H influenzae, Enterobacteriaceae, N meningitidis, S
pneumoniae).
Gentamicin ﾧ
 View full drug information ﾧ
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)ﾧ
 View full drug information ﾧ
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)ﾧ
 View full drug information ﾧ
Synthetic antibacterial combination. Children with no apparent sign of infection should
be administered cotrimoxazole as a first-choice antibiotic.
Isoniazid (Laniazid, Nydrazid)ﾧ
 View full drug information ﾧ
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)ﾧ
 View full drug information ﾧ
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)ﾧ
  View full drug information ﾧ
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)ﾧ
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PO-administered broad-spectrum anthelmintic with specific indications, including
ascariasis, hookworm infections, trichuriasis, and strongyloidiasis.
Metronidazole (Flagyl, Noritate, Protostat)ﾧ
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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)ﾧ
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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.

Further Outpatient Care

See the list below:
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.
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.
Long-term care: Long-term follow-up care should be encouraged, particularly regarding
somatic growth and neurodevelopmental performances.

Further Inpatient Care

See the list below:
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
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
Health care worker - Able to ensure the follow-up care of the child

Deterrence/Prevention
See the list below:
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:
Educational programs for girls
Sanitation programs, which improve access to safe water
Nutritional programs, including health education as well as screening of malnourished
children
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. [44] 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. [45, 46] 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. [47]

Complications
See the list below:
Complications of the acute phase of malnutrition have been discussed (see Medical Care).
Several complications can lead to permanent sequelae.
Long-term sequelae, with particular attention to developmental issues, must be
mentioned. If growth and development have been extensively impaired and if early
massive iron deficiency anemia is present, mental and physical retardation may be
permanent. Apparently, the younger the infant at the time of deprivation, the more
devastating are the long-term effects.

Prognosis
See the list below:
Except for complications mentioned above, prognosis of even severe marasmus is good if
treatment and follow-up care are correctly applied.

Patient Education
See the list below:
Teaching parents how to prevent malnutrition is of high importance to prevent recurrence.
They must understand the causes of malnutrition, how to prevent its recurrence (including
correct feeding), and how to treat diarrhea and other infections. They have much to learn
and need considerable care from the medical staff.
For excellent patient education resources, visit eMedicineHealth's Digestive Disorders
Center ﾧ. Also, see eMedicineHealth's patient education article Gastroenteritis ﾧ.