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MARASMUS AND BRONCHOPNEUMONIA Presentators: Melinda Yoanita and Karina Witary Day, Date : Wednesday, 02nd May 2012 Supervisor : Prof. dr. Hj. Bidasari Lubis, Sp.A(K) Introduction The three states of protein-energy malnutrition are marasmus, marasmic-kwashiorkor, and kwashiorkor. They are compounded by a whole spectrum of nutritional disorders that include deficiencies of one or more vitamins, minerals and trace minerals. The three states of protein-energy malnutrition can be differentiated most clearly on the basis of clinical findings. 1 Marasmus is a serious worldwide problem that involves more than 50 million children younger than 5 years. According to the World Health Organization (WHO), 49% of the 10.4 million deaths occurring in children younger than 5 years in developing countries are associated with protein-energy malnutrition.2 Marasmus, which predominates in infancy, is characterized by severe weight reduction, gross wasting of muscle and subcutaneous tissue, no detectable edema and, if prolonged, marked stunting. Marasmus results from severe deprivation, or impaired absorption, of protein, energy, vitamins and minerals. The hair and skin changes and hepatomegaly resulting from fatty filtration of the liver, which are seen in kwarshiorkor, are not usually found in marasmus. The marasmic child, characteristically irritable and apathetic, is the skin-and-bones portrait of starvation. The term for this is wasting. In a young child, it results in stunting that describes the profound effect of nutritional deprivation on linear growth.3 Marasmus often follows severe illness or a period of frequent infections. Marasmus usually occurs in the first 2 years of life, but it can occur at any age, particularly during famines. 1 The symptoms of marasmus depend on the severity of the malnutrition experienced by the individual, and symptoms can manifest daily or occasionally.

Symptoms of marasmus include chronic and persistent diarrhea, weight loss, fatigue and dizziness. In severe cases, marasmus symptoms also include prolonged vomiting, fainting and varying levels of consciousness, lethargy, full or partial paralysis of the legs and loss of bladder or bowel control. 4 Infection is one of the major complications of protein-energy malnutrition such as bronchopneumonia and bronchiolitis. Bronchopneumonia is an illness of the lungs which is caused by different organism like bacteria, viruses, and fungi and characterized by acute inflammation of the walls of the bronchioles. Streptococcus pneumoniae (pneumococcus) and Mycoplasma pneumoniae both are the common bacterium which causes bronchopneumonia in the adults and children. Acute inflammation of the walls of the smaller bronchial tubes, with varying amounts of pulmonary consolidation due to spread of the inflammation into peribronchiolar alveoli and the alveolar ducts; may become confluent or may be hemorrhagic.5 Successful management of the child with severe malnutrition requires frequent, careful clinical assessment and anticipation of common problems so they can be prevented, or recognized and treated at an early stage.5 Considering all of these imperative effects brought on malnutrition in every aspects of daily life, this paper is composed to furtherly explore several more theoritical and clinical aspects about malnutrition, particularly the diagnosis and management of severe malnutrition in the field.

Objective The aim of this study is to explore more about the theoritical aspects on malnutrition, and to integrate the theory and application of malnutrition case in daily life.

CASE REPORT Name Age Sex Date of Admission Chief Complaint History :MS : 8 months : Female : March, 29th 2012 : Dyspnoe : This problem occured to this patient since two weeks ago and

become severe for the last three days which is not related to daily activites. Breastfeeding was intermittently given. History of sweating while breastfeeding and cyanosis was not found. History of coughing and vomitting while cough was found two weeks ago. History of allergic to the cold weather, dust, sneezing and contact to the infected person was not found. History of consuming tuberculosis drugs was not found. Fever was found since once week ago, the temperature was up and down and got down with the fever-lowering drugs. History of diarrhoea was found since three days ago. The frequency of diarrhoea three times/days, watery stool. No history of micturation. History of Birth found. History of Pregnancy: No history of hypertension, diabetes mellitus or taking drugs or herbs. Feeding History : : Milk-based 60 cc/10times/days : Patient was born spontaneously and immediately cried which

is help by midwives. Birth weight was 1500 grams and history of cyanosis was not

From birth to 6 months

From 6 months to now

: Milk-based formula 60cc/2hours + rice porridge 3-4

spoons/2times/days for a few days ago 30 cc/2hours History of Growth and Development: Patient only lies on bed, no sitting or crawling. History of Immunisation: Never History of previous illness: Patient was referred from Vina Estetika Hospital by paeditrician with diagnosis of Pneumonia and GE. History of previous medication: IVFD Ringer Lactate, Injection of Cefotaxime, Injection of Gentamicine, Paracetamol and Zinc. Physical Examination Generalized status Body weight: 3,7 kg, Body length: 56 cm Body weight in 50th percentile according to age: 8,2 kg Body length in 50th percentile according to age: 68 cm Body weight in 50th percentile according to body length: 4,6 kg BW/BL: 3,7/4,65 x 100% = 79,5% (moderate malnutrition) BW/age: 3,7/8,2 x 100% = 45,1% (severe malnutrition) BL/age : 56/68,5 x 100% = 82,3% (moderate malnutrition) Presents status Consciousness: Alert, Body temperature: 38,8oC. Body length: 56 cm. Head circumferences: 44 cm. Upper Arm Circumferences: 7 cm. Anemic (-). Icteric (-). Cyanosis (-). Oedema (-). Dyspnoe (+).

Localized status Head: Large open fontanel flat, concave (+), hair: red, rarely, easily removed (-), eye: light reflex (+/+), isochoric pupillary, palpebra inferior conjunctival pallor (-/-), icteric sclera (-), ear and mouth: within normal limit, nose: nostrils in breathing (+). Head circumference: 44 cm, Upper Arm Circumference: 7cm Neck: Lymph node enlargement (-). Stiff neck (-) Thorax: Pectum Exacavatum. Retraction (+) epigastrial and intercostal. HR: 123 bpm, regular, murmur (-). RR: 43 bpm, reguler, rales (+) on the both side of lung, wheezing (-) Abdomen: Soepel, slow return skin return of skin turgor, peristaltik (+) normal, Hepar/Lien within normal limit. Extremities: Baggy pants (+), Hypothropy muscular (+), thinning of subcutaneus fat (+), pulse 123 bpm, regular, adequate pressure and volume, warm acral, Capillary refill time < 3 Urogenital: Female, within normal limit

Laboratory Findings: Parameters Complete Blood Count Hemoglobin Hematocrite Erithrocyte Leucocyte Platelet MCV MCH MCHC RDW Diftel Laboratory Findings: Parameters AGDA pH pCO2 pO2 Bicarbonate (HCO3) Total CO2 Base Excess (BE) Saturasi O2 Electrolytes Natrium (Na) Kalium (K) Chloride (Cl) Differential Diagnosis: Marasmus malnutrition + dd/ - Bronchopneumonia - Bronchiolitis Working Diagnosis: Marasmus malnutrition + Bronchopneumonia Value 7.456 mmHg 23,3 mmHg 166,3 mmHg 16,1 mmol/L 16,8 mmol/L -6,6 mmol/L 99,3 % 127 mEq/L 3,4 mEq/L 104 mEq/L Normal Value 7,35 7,45 38 42 mmHg 85-100 mmHg 22 26 mmol/L 19 25 mmol/L (-2) (+2) mmol/L 95-100 % 135 155 3,6 5,5 96 106 Value 10,0 gr% 29,2% 3,36 x 106 /mm3 13,48 x 103 /mm3 94.000 /mm3 86,9 fl 29,8 pg 34,2 gr% 14,6 % 81 / 12,7 / 5,8 / 0,3 / 0,2 Normal Value 11,1 14,4 gr% 35 41% 3,71 4,25 x 106 /mm3 6,0 17,5 /mm3 217000 497000 /mm3 82 100 fl 24 30 pg 28 32 gr% 14,9 18,7 %

Management:
-

O2 - 1 L/i nasal canule IVFD D5% Nacl 0.225% 4 gtt/i micro Inj. Ampicilin 150 mg/6 hours/iv Inj. Gentamicin 25 mg/24hours/iv Resomal 50 cc/x diarrhea Folic acid 1x5 mg (on the first day), 1x1 mg oral

- Bolus Nasogastric Tube Glucose 10% 50 ml

-

- Zinc 1x10 mg
-

- Vitamin A 1x100.000 i oral - Diet neosure 30 cc/2hours/iv - Multivitamin without Fe 1x1 cth Diagnostic Planning: - Blood Glucose Level
-

Chest X-Ray

FOLLOW UP March 29th April 3th 2012 S Dyspnoe (+), cough (+), fever (+), vomiting(+) O Sens: CM, Temp: 36,8 39oC. Anemic (+). Icteric (-). Oedema (-). Cyanosis (-). Dyspnoe (+), Body weight: 5 kg, Body length: 56 cm. Head Circumferences: 44 cm Upper Arm Circumferences: 7 cm Head Sunken (-) Hair: Red, rarely, easy to attract. Eye: Conjunctiva palpebra inferior anemic (-/-).

Light reflex (+)/(+). Isochoric pupil. Sunken eye (-) Neck Thorax Ear-mouth: within normal limit. Nose: nostrils in breathing (+) Lymph node enlargement (-). Stiff neck (-). Pectus excavatum. Retraction (+) epigastrial and intercostal. HR: 140 154 bpm, reguler, murmur (-). RR: 40 57 bpm, regular, rales (+/+) on the both side of lung. Wheezing (-). Abdomen Soepel, skin pinch slowly, peristaltic (+) N, Hepar/Lien: Not palpable Extremities Baggy pants (+), Thinning of subcutaneous fat (+), muscle hypotrophy (+). Pulse 140154 bpm, regular, adequate p/v, warm, CRT < 3. Genital Female. within normal limit. Severe malnutrition marasmus type + dd/ - Bronchopneumonia Bronchiolitis

Management:

O2 - l L/i nasal kanul IVFD D5% Nacl 0,255% 4 gtt/i

Nebule Nacl 0,9% 2,5 cc

Inj. Ampicilin 150 mg/6 hours/iv Inj, Gentamicin 25mg /24 hours/iv

Resomal 50cc /x diarrhea

Zinc 1x10 mg Folat acid 1x1 mg oral Multivitamin without Fe 1x1 cth Vitamin A 1x 100.000 iu oral Diet neosure 30 cc/2 hour /iv Value 9,4 gr% 3,10 x 106 /mm3 9,33 x 103 /mm3 27,80% 338.000 /mm3 89,7 fL 30,30 pg 33,8 gr% 14,5 % 9,80 fL 0.33% 30 mm/hours 35,80 % 46,10 % 15,50 % 2,50 % 0.100 % 3,34x103/L 4,30x103/L 1,45x103/L Normal Value 11,1 14,4 gr% 3,71 4,25 x 106 /mm3 6,0 17,5 /mm3 35 41% 217000 497000 /mm3 82 100 fL 24 30 pg 28 32 gr% 14,9 18,7 % 7,2 10.0 fL < 20 mm/hours 37 80 % 20 40 % 28% 16% 01% 1,9 5,4x103/L 3,7 10,7x103/L 0,3 0,8x103/L

Parameters Complete Blood Count Hemoglobin Erithrocyte Leucocyte Hematocrite Platelet MCV MCH MCHC RDW MPV PCT LED Diftel: Neutrophil Limfosit Monosit Eosinophil Basophil Neutrophil absolute Limfosit absolute Monosit absolute

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Eosinophil absolute Basophil absolute Chest X Ray:

0,23x103/L 0,01x103/L

0,20 0,50x103/L 0 0,1x103/L

CTR: 54% (Normal limit: 39 60%) , Cor is within normal limit Aorta, superior mediastinum, trachea, hilus: normal Perihiler and parabronchial infiltrate was found Costophrenicus and diaphragm: normal

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Conclusion: suspect bronchopneumonia Blood glucose level: 38 mg/dL

Laboratory Findings: (02/04/2012) Parameters Complete Blood Count Hemoglobin Erithrocyte Leucocyte Hematocrite Platelet MCV MCH MCHC RDW MPV PCT LED Diftel: Neutrophil Limfosit Monosit Eosinophil Basophil Neutrophil absolute Limfosit absolute Monosit absolute Eosinophil absolute Basophil absolute Value 9,4 gr% 3,10 x 106 /mm3 9,33 x 103 /mm3 27,80% 338.000 /mm3 89,7 fL 30,30 pg 33,8 gr% 14,5 % 9,80 fL 0.33% 30 mm/hours 35,80 % 46,10 % 15,50 % 2,50 % 0.100 % 3,34x103/L 4,30x103/L 1,45x103/L 0,23x103/L 0,01x103/L Normal Value 11,1 14,4 gr% 3,71 4,25 x 106 /mm3 6,0 17,5 /mm3 35 41% 217000 497000 /mm3 82 100 fL 24 30 pg 28 32 gr% 14,9 18,7 % 7,2 10.0 fL < 20 mm/hours 37 80 % 20 40 % 28% 16% 01% 1,9 5,4x103/L 3,7 10,7x103/L 0,3 0,8x103/L 0,20 0,50x103/L 0 0,1x103/L

April 04th April 09th 2012 Dyspnea (+), cough(+), fever (+), vomiting(-)

12

O Sens: CM, Temp: 37 39,3oC. Anemic (+). Icteric (-). Oedema (-). Cyanosis (-). Dyspnea (+) Body weight: 5,2 kg, Body length: 57 cm. Head Circumferences: 44 cm. Upper Arm Circumferences: 7 cm Head Sunken (-) Hair: Red, rarely, easy to attract Eye: Conjunctiva palpebra inferior anemic (-/-). Light reflex (+)/(+). Isochoric pupil. Sunken eye (-) Ear-mouth: within normal limit. Neck Thorax Nose: nostrils in breathing (+) Lymph node enlargement (-). Stiff neck (-). Pectus excavatum. Retraction (+) epigastrial and intercostal. HR: 130 156 bpm, reguler, murmur (-). RR: 36 65 bpm, regular, rales (+/+) on the both side of lung. Wheezing (-) Abdomen Soepel, skin pinch slowly, peristaltic (+) N, Hepar/Lien: Not palpable Extremities Baggy pants (+), thinning of subcutaneous fat (+), muscle hypotrophy (+). Pulse 140156 bpm, regular, adequate p/v, warm, CRT < 3. Genital Female. within normal limit. A Severe malnutrition marasmus type + Bronchopneumonia P Management:

O2 - l L/i nasal kanul IVFD D5% Nacl 0,255% 4 gtt/i

Nebule Nacl 0,9% 2,5 cc

Inj. Ampicilin 150 mg/ 6 hour /iv Inj, Gentamicin 25mg /24 hour /iv Resomal 60cc /x diarrhea Zinc 1x10 mg Folat acid 1x1 mg oral Multivitamin without Fe 1x1 cth Vitamin A 1x 100.000 iu oral

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Diet F75 40 cc/2 hours + mineral mix 0,8 cc Mantoux test:

Blood Cultur Mantox Test: (-) diameter 2 mm Blood Cultur: No bacterial growth

April 10th April 15th 2012 S Dyspnoe (+), fever (+), diarrhea (+) volume: 10-20 cc/days, gambang ribs (+) O Sens: CM, Temp: 36,7 39,1oC. Anemic (+). Icteric (-). Oedema (-). Cyanosis (-). Dyspnoe (+) Body weight: 5 kg, Body length: 57 cm. Head Circumferences: 44 cm. Upper Arms Circumferences: 7 cm

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Head

Sunken (-) Hair: Red, rarely, easy to attract Eye: Conjunctiva palpebra inferior anemic (-/-). Light reflex (+)/(+). Isochoric pupil. Sunken eye (-) Ear-mouth-nose: within normal limit. Lymph node enlargement (-). Stiff neck (-). Pectus excavatum. Retraction (+) epigastrial and supersternal HR: 130 156 bpm, reguler, murmur (-). RR: 36 65 bpm, regular, rales (+/+) on the both side of lung. Wheezing

Neck Thorax

(-) Abdomen Soepel, skin pinch slowly, peristaltic (+) N, Hepar/Lien: Not palpable Extremities Baggy pants (+) Thinning of subcutaneous fat (+), muscle hypotrophy (+). Pulse 140156 bpm, regular, adequate p/v, warm, CRT < 3. Genital Female. within normal limit. Severe malnutrition marasmus type + Bronchopneumonia O2 - l L/i nasal kanul

A P

IVFD D5% Nacl 0,255% 45 gtt/i Inj. Ampicilin 100 mg/ 6 hour /iv Inj, Gentamicin 15mg /24 hour /iv Resomal 52cc /x diarrhoea Zinc 1x10 mg

Folat acid 1x1 mg Becefort 1x1 cth

Diet F75 40 cc/2 hours + mineral mix 0,8 cc

Multivitamine without Fe 1x1 cth Laboratory Findings 11/04/2012

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Parameters Complete Blood Count Hemoglobin Erithrocyte Leucocyte Hematocrite Platelet MCV MCH MCHC RDW MPV PCT LED Diftel: Neutrophil Limfosit Monosit Eosinophil Basophil Neutrophil absolute Limfosit absolute Monosit absolute Eosinophil absolute Basophil absolute Carbohydrate Metabolism Blood glucose of random

Value 9,50 gr% 3,23 x 106 /mm3 9,37 x 103 /mm3 28,90% 483.000 /mm3 89,5 fL 29,4 pg 32,9 gr% 14,9 % 9,0 fL 0,44% 8,7 mm/hours 40,50 % 41,60 % 14,80 % 2,90 % 0.200 % 3,79x103/L 3,90x103/L 1,39x103/L 0,27x103/L 0,01x103/L

Normal Value 11,1 14,4 gr% 3,71 4,25 x 106 /mm3 6,0 17,5 /mm3 35 41% 217000 497000 /mm3 82 100 fL 24 30 pg 28 32 gr% 14,9 18,7 % 7,2 10.0 fL < 20 mm/hours 37 80 % 20 40 % 28% 16% 01% 1,9 5,4x103/L 3,7 10,7x103/L 0,3 0,8x103/L 0,20 0,50x103/L 0 0,1x103/L

83,80 mg/dL

< 200 mg/dL

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Electrolytes Natrium (Na) Kalsium (Ca) Chloride (Cl) Magnesium (Mg)

132 mEq/L 9,1 mEq/L 105 mEq/L 2,19 mEq/L

135 155 3,6 5,5 96 106 1,4 1,9

April 16th April 20th 2012 S Dyspnoe (+), cough(+), fever (+) , Diarrhea (-) O Sens: CM, Temp: 36,6 39,5oC. Anemic (+). Icteric (-). Oedema (-). Cyanosis (-). Dyspnoea (+) Body weight: 5 kg, Body length: 57 cm. Head circumferences: 44 cm, Upper Arm Circumferences: 7 cm Head Sunken (-)

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Hair: Red, rarely, easy to attract Eye: Conjunctiva palpebra inferior anemic (-/-). Light reflex (+)/(+). Isochoric pupil. Sunken eye (-) Neck Thorax Ear-mouth-nose: within normal limit. Lymph node enlargement (-). Stiff neck (-). Pectus excavatum. Retraction (+) epigastrial and suprasternal. HR: 132 148 bpm, reguler, murmur (-). RR: 35 44 bpm, regular, rales (-/-). Abdomen Soepel, skin pinch slowly, peristaltic (+) N, Hepar/Lien: Not palpable Extremities Baggy pants (+), Thinning of subcutaneous fat (+), muscle hypotrophy (+). Pulse 140156 x/i, regular, adequate p/v, warm, CRT < 3. Genital Female. within normal limit. Severe malnutrition marasmus type + Bronchopneumonia Management:

A P

O2 L/i nasal kanul IVFD D5% Nacl 0,255% 4 gtt/i Inj. Ampicilin 150 mg/6 hour /iv Inj, Gentamicin 25mg /24 hour /iv Resomal 50cc /x diarrhea Zinc 1x10 mg oral Folat acid 1x1 mg oral Diet F100 60 cc/3 hours + mineral mix 1,2 cc/3 hours Multivitamin without Fe 1x1 cth Value 9,90 gr% 3,34 x 106 /mm3 12,45 x 103 /mm3 29,30% 462.000 /mm3 87,70 fL 29,6 pg Normal Value 11,1 14,4 gr% 3,71 4,25 x 106 /mm3 6,0 17,5 /mm3 35 41% 217000 497000 /mm3 82 100 fL 24 30 pg

Parameters Complete Blood Count Hemoglobin Erithrocyte Leucocyte Hematocrite Platelet MCV MCH

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MCHC RDW MPV PCT PDW LED Diftel: Neutrophil Limfosit Monosit Eosinophil Basophil Neutrophil absolute Limfosit absolute Monosit absolute Eosinophil absolute Basophil absolute Autoimmune CRP Kualitatif

33,8 gr% 14,9 % 9,4 fL 0,44% 9.2 fL 30 mm/hours 63,50 % 23,90 % 11,10 % 2,30 % 0.200 % 7,89x103/L 2,98x103/L 1,26x103/L 0,29x103/L 0,03x103/L

28 32 gr% 14,9 18,7 % 7,2 10.0 fL < 20 mm/hours 37 80 % 20 40 % 28% 16% 01% 1,9 5,4x103/L 3,7 10,7x103/L 0,3 0,8x103/L 0,20 0,50x103/L 0 0,1x103/L

negatif

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DISCUSSION AND SUMMARY Discussion Marasmus is the result of child having very low intake of energy and nutrient. It oftten follows severe illnes or a period of frequent infections. Marasmus usually occurs in the first two years of life, but it can occurs at any age, particularly during famines.6 Marasmus is a result of protein-energy malnutrition (PEM). Another result of PEM is kwarshiorkor. It is a severe form of malnutrition caused by inadequate intake of protein and calories, resulting in wasting and growth retardation. Marasmus is a serious worldwide problem that involves more than 50 million children younger than 5 years. According to the World Health Organization (WHO), 49% of the 10.4 million deaths occurring in children younger than 5 years in developing countries are associated with protein-energy malnutrition. The major factors that cause a deficit of calory and protein intake include the following: the transition from breast feeding to nutrition poor foods in infancy, acute infections of the gastrointestinal tract, and chronic infections such as HIV or tuberculosis. The imbalance between decrease energy intake and increased energy demands result in a negative energy balance.2 Marasmus always results from a negative energy balance. The imbalance can result from a decreased energy intake, an increased loss of ingested calories, an increased energy expenditure, or combinations of these factors, such as observed in

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acute or chronic diseases. Children adapt to energy deficiency with decrease in a physical activity, lethargy, decrease in basal energy metabolism, slowing of growth and weight loss.2 The main causes of marasmus are less calory protein that occurs due to insufficient dietary, eating habits are not exactly like parents-child relationship with a disturbances, because of metabolic disorders, or congenital malformations. Marasmus can occurs at any age, but it is often found in infant who are not getting enough milk and are not fed often attacked his succesor or diarrhea. Marasmus may also occur due to various other dieases such as infections, gastrointestinal disorders or congenital heart disease, malabsorption, metabolic dissorders, chronic kidney disease and disorders of the central nervous system.7 The deficiency of both proteins and calories result in insufficiency of energy for the body, ultimately causing marasmus. There are several risk factors that can precipitate marasmus. However someone can develop of disorders without any factors. Risk factors include chronic hunger, inadequate food supplies, deficiency of vitamins, contaminated of water supply and diets without sufficient grains, fruits, vegetables and protein. Eating good balance of dietary, drinking of hygine water and receiving proper medical treatment for infections.7 Because the intake of all dietary nutrients is reduced to a minimun in marasmus, metabolic processes, including liver function, are preserved but growth is severely retarde. In this patient, because of all dietary intake is reduced, the metabolic processes are minimum so the liver status are within normal limit. Caloric intake is too low to support protein synthesis for growth or the storage of fat.7 This is the reason why in this case, the patient is having decreased subcutaneous fat and baggy pants appearance because there is not enough caloric intake to support the storage of fat. The patient in this case is having hypotrophy of muscle. The reason for this phenomenon is not enough protein intake. If more protein is needed than is ingested, muscle wasting occurs. Fat wasting and anemia are common and can be severe. As

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for in this case, the hemoglobin level of this patient is below normal levels which interpreted as anemic.2 Clinical manifestations of marasmus include retarded physical, mental, and psychologic development; muscle wasting, diarrhea, low hemoglobin levels, and infection characterized marasmus.7 In this case, the patient is also diagnosed with pulmonary infection. Differential diagnoses are bronchopneumonia and bronchiolitis. Diagnosis and working up for patient of marasmus by doing of history taking, clinical findings, anthropometry and laboratory findings. From history taking, a nutritional history is directed toward identifying underlying mechanisms that put patients at risk for nutritional depletion or excess. These mechanisms include inadequate intake, impaired absorption, decreased utilization, increased losses, and increased requirements of nutrients. In this case, the patient was born spontaneously and immediately cried which is help by midwives, the birth weight was 1500 grams. The feeding history of this patient was milk-based formula until six months, and then giving milk-based formula with rice porridge until now.7 Both fat-soluble vitamins (ie, A, D, E, K) and water-soluble vitamins (eg, B-6, B-12, folic acid) must be systematically administered. Vitamin A is essential to retinal function, has a trophic effect on epithelial tissues, and plays a major role as an antioxidant agent. Vitamin A deficit affects visual function (eg: conjunctivitis, corneal ulcer, night blindness, total blindness) and digestive, respiratory, and urinary functions. Furthermore, vitamin A supplementation programs have resulted in decreased mortality and morbidity, in particular, during diarrheal disease and measles. Zinc, selenium, and magnesium are constantly deficient in marasmus. Several studies have shown improved recovery from malnutrition and decreased mortality with supplementation of these 3 micronutrients. Several studies concluded that zinc supplementation is clearly of benefit in children aged 6 months or older with diarrheal diseases in areas where these conditions are an important cause of childhood mortality.2 In this case, zinc, folic acid, and vitamin A was routinely administered.

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Increasing evidence suggests that protein-calorie malnutrition is the underlying reason for the increased susceptibility to infections observed in these areas. Moreover, certain infectious diseases also cause malnutrition, which can result in a vicious cycle. The most common infections in malnourished children is gastrointestinal infection, such as diarrhea, and respiratory infection, such as pneumonia.2 The increased incidence and severity of infections in malnourished children is largely due to the deterioration of immune function; limited production and/or diminished functional capacity of all cellular components of the immune system have been reported in malnutrition. Several studies have demonstrated that protein calorie malnutrition impairs host immune responses, including cell-mediated immunity and secretory IgA production.8 Several studies on the effects of malnutrition at the immunological level have been conducted in humans and in experimental animal models. Multiple immune system abnormalities, including lymphoid organ atrophy, profound T-cell deficiency, altered ratios of T-cell subsets, and decreased natural killer (NK) cell activity and cytokine production have been described in PCM individuals. In addition, these studies indicate that malnutrition decreases T-cell function, cytokine production and the ability of lymphocytes to respond appropriately to cytokines. In severely malnourished children, both acquired immunity as well as innate host defense mechanisms are affected. 8 The usual approach treatment of PEM includes three phases. The first relatively brief phase (24 48 hours) is a stabilization phase. During this phase, dehydration is corrected and antibiotic therapy is initiated to control infection. Because of difficulty estimating hydration, oral redydration therapy is preferred. If intravenous therapy is necessary estimating dehydration should be reconsidered frequently, particularly during first 24 hours of therapy. The second phase includes continued antibiotic therapy with appropriate changes if the initial combination was not effective and introduction of diet providing enough requirements of energy and

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protein (75 cal/kg and 1g/kg/24hours of protein) along with adequate electrolytes, trace minerals and vitamins. This phase usually lasts for a week to ten days. If the infant is unable to take the feedings from a cup or bottle, administration of food by nasogastric tube rather than by the parental route is preferred. Iron therapy usually is not started until this final phase of treatment to prevent binding of iron to limited stores of transferrin, which, in turn, may interfere with patients host defense mechanisms. There is also concern that free iron during the early phase of treatment may exacerbate oxidant damage, precipitating clinical kwarshiorkor or marasmic kwashiorkor in a child with clinical marasmus.7 According to the Department of Health Republic of Indonesia, there are 5 aspects to be considered in managing children diagnosed with severe malnutrition, and those are ten principal steps, treatment of comorbidities, failure of treatments, patients dicharge before end of treatment and emergency situation. All these aspects should be well understood in order to manage severe malnutrition in children.9 No 1 2 3 4 5 6 7 8 9 Treatment Hypoglycemia Hypothermia Dehydration Electrolyte Correction Treatment of Infection Micronutrition Defficiency Correction Initial Refeeding Without Iron Supplementation With Iron Supplementation
Stabilization Day Day 1-2 3-7 Transition Week 2 Rehabilitation Week 3-6 Follow Up Week 7-26

Formula 75 Formula 75 to Correctional Refeeding 100 (Catch Up Growth) Stimulation

Formula 135

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10

Prepare for Discharge

This patient was first treated in stabilization phase in which hypoglycemia, hypothermia and dehydration were assesed and treated subsequently. Blood glucose level for is below 54 mg/dl, and the patient was alert, therefore this patient was given 50 ml of glucose 10% by NGT for overcoming the hipoglycemia. Infants with malnutrition are considered dehydrated. Therapy for dehydration in malnourished infant is administration of Resomal. According to The Treatment Guideline for Severe Malnutrition, 5 cc/kgBW Resomal is given orally or by NGT every 30 minutes for the first two hours followed by 50-100 cc Resomal every diarrhea for the next ten hours. This patient was given 60 ml of Resomal by NGT for the first two hours followed by 50 cc Resomal every diarrhea. For treating the infection, according to The Treatment Guideline for Severe Malnutrition, for apathetic or lethargy patient or patient with complication such as hypoglycemia, 50 mg/kg Ampicillin is administered by IV or IM every 6 hours for two days followed by 15mg/kg Amoxicillin orally every 8 hours for 5 days. Morover, 7.5 mg/kg Gentamicin is administered once a day for 7 days. This patient was given 150 mg Ampicillin and 25 mg Gentamicin. For micronutrient correction, according to The Treatment Guideline for Severe Malnutrition, administration of multivitamin supplementation without Fe; which consist of 1 mg/day folic acid (5mg on day 1), Zn 2 mg/kgBW/day, Cu 0,2 mg/kgBW/day, 100.000 IU Vitamin A on the 1st day; is necessary. Iron supplementation should not be given to a severe malnourished infant because iron deposition will give a chance to bacteria to grow optimally in infant with low immunity state. Thus, iron supplementation could only be given after the patient completed the stabilization and transitional phase, and was assumed to have a much

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better immunological state. Multivitamin supplementation without Fe was given daily for this patient. Rehabilitation and follow-up phase was not given for this patient because there was no sign of improvement. The most common comorbidities for malnourished patient are gastrointestinal infections, such as diarrhea, or respiratory infections, such as pneumonia (jurnal imy). In this case, the patient was diagnosed with bronchopneumona aside from the malnutrition state. Bronchopneumonia or bronchialpneumonia or bronchogenic pneumonia refers to the inflammation of the lung that was enter in the bronchioles and leads to the production of a mucopurulent exudates that obstructs some of these small airways. It is a type of pneumonia characterized by multiple foci of isolated, acute consolidation, affecting one or more pulmonary lobules.10 Age is a determinant in the clinical manifestations of pneumonia. Neonates may have fever only with subtle or no physical findings of pneumonia. The typical clinical patterns of viral and bacterial pneumonias usually differ between older infants and children, although the distinction is not always clear for a particular patient. Fever, chills, tachypnoea, cough, malaise, pleuritic chest pain, retractions, and apprehension, because of difficulty breathing or shortness of breath are common to older infants and children.10 In this case, patient was dyspnea has been experienced since 2 weeks ago, having history fever, fever decreased with fever-lowing drugs, cough, retraction (+), and participation of nostrils in breathing (+). Chest X-Ray for this patient indicates suspect of bronchopneumonia. The result of blood culture was egative for bacterial growth. Therefore, the bronchopneumonia in this patient can be assumed as viral bronchopneumonia or the antibiotic treatment given for the first 7 days was well responded. 11

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Summary In this case, MS, 8 months, girl, was admitted to RSUP HAM with diagnose of marasmus malnutrition with bronchopneumonia. The diagnosis was established based on history taking, clinical manifestations, radiology and laboratory findings. This patient was given antibiotics in treating the cause, and supportive treatment.

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