DISCUSSION

Marasmus is one of the 3 forms of serious protein-energy malnutrition (PEM). The

other 2 forms are kwashiorkor (KW) and marasmic KW. These forms of serious PEM
represent a group of pathologic conditions associated with a nutritional and energy deficit
occurring mainly in young children from developing countries. Marasmus is a condition
primarily caused by a deficiency in calories and energy, whereas kwashiorkor indicates an
associated protein deficiency, resulting in an edematous appearance. Marasmic kwashiorkor
indicates that, in practice, separating these entities conclusively is difficult; this term indicates
a condition that has features of both.
These conditions are frequently associated with infections, mainly GI. The reasons for a
progression of nutritional deficit into marasmus rather than kwashiorkor are unclear and cannot be
solely explained by the composition of the deficient diet (ie, a diet deficient in energy for marasmus
and a diet deficient in protein for kwashiorkor). The study of these phenomena is considerably limited
by the lack of an appropriate animal model.
For this case, a 2 years 1 month old boy suffer from inadequate nutrition. At the age
of 1 year old, patient refused to ate porridge, vegetables, and food that smells fishy. From
born until 6 months old, patient consumed breast milk only. From 7 months until 12 months
old, patients was given breast milk and baby biscuits. From 12 months until now, patient was
given formula milk and milk porridge. Patient didnt consume any kind of animal products.
The patient was given breast milk, formula milk, and milk porridge 3 times a day. Total
calories consume by the patient in a day is 872,4 ccal.
According to 2015 World Health Organization data, 92 million children under five
years old (15%) were underweight in less developed regions. Recent data provides a
relatively small degree of optimism as the WHO reports that worldwide, the percentage of
children under five years old who were underweight declined from 25% to 14% between
1990 and 2015. [3] A 2013 guideline by the WHO reported that severe acute malnutrition
affects nearly 20 million preschool-age children, mostly from the WHO African Region and
South-East Asia Region and that malnutrition is a significant factor in approximately one
third of the 8 million deaths in children who are under 5 years of age worldwide.
In this case, a 2 years 1 month old boy with weight 5.6 kg and height 75cm. This
shows the weight is inappropriate to the age. According to WHO a 2 years old boy should
weight from 10 kg untill 15.5 kg.
 Although PEM occurs more frequently in low-income countries, numerous children
from higher-income countries are also affected, including children from large urban areas and
of low socioeconomic status, children with chronic disease, and children who are
institutionalized. Recently, studies of hospitalized children from developed countries have
demonstrated an increased risk for PEM. Risk factors include a primary diagnosis of mental
retardation, cystic fibrosis, malignancy, cardiovascular disease, end stage renal disease,
oncologic disease, genetic disease, neurological disease, multiple diagnoses, PICU admission,
or prolonged hospitalization. In these conditions, the challenging nutritional management is
often overlooked and underestimated, resulting in an impairment of the chances for recovery
and the worsening of an already precarious neurodevelopmental situation.
This patient was hospitalized at Sinar Husni Hospital on 28th November 2016 for 12
days because of febrile convulsions. The patient was treated at PICU because he turns
uncouncious for 3 days after convulsion. This patients developmental was delayed. During 6
months old, patient able to tilt and prone. During 12 months old, patient able to sit. During 24
months old, patient not able to speak and stand.
Nearly 30% of humans currently experience one or more of the multiple forms of
malnutrition. Close to 50 million children younger than 5 years have PEM, and half of the
children who die younger than 5 years are undernourished. Approximately 80% of these
malnourished children live in Asia, 15% in Africa, and 5% in Latin America.
 About three million children younger than 5 years die every year of malnutrition.
Approximately 50 million present with wasting, and 156 million present with some stunting.
27% of the children in Southern Asia are underweight and 20% are underweight in Western
Africa.
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 is main cause of marasmus. 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. According to this case, inadequate nutrition was found in this patient. At the age
of 1 year old, patient refused to ate porridge, vegetables, and food that smells fishy. This
leads him to lack of vitamins and minerals intake.
Another cause is 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.
 Socioeconomic factors are often leads to malnutrition. 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. From born until 6 months old, the patient consumed breast
milk only. From 7 months until 12 months old, patients was given breast milk and baby
biscuits. From 12 months until now, patient was given formula milk and milk porridge.
Other socioeconomic 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.
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 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.
According to this case, patient consumed breast milk only until 6 months old. From 7
months until 12 months old, patients was given breast milk and baby biscuits. From 12
months until now, patient was given formula milk and milk porridge.
 Anthropometric measurements are critical to rapidly assess the type and severity of
the malnutrition. A shrunken wasted appearance is the classic presentation of marasmus. 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, especially in
Indonesia (see the table below).
The patient had:

- BW: 5.6 kg - BL: 75 cm

- BW/A: Z score < -3 - BW/A: 0 < Z score < 2
- BW/BL: Z score < -3 - Head circumference: 45 cm
- Upper arm circumference: 7 cm

In the WHO curves male 2 years old should weigh 12.5 to 15.5 kg (-2SD <Z <2SD), a
body length of 83-90 cm (-2SD <Z <2SD), head circumference 46-52 cm (-2SD <Z <2SD),
and upper arm circumference should above 13.5 cm for ages 1-5 years. However, in reality
the weight, body length, head circumference, arm circumference, BW/A and BW/BL in this
patient has the interpretation of malnutrition on admission to the ER RSHAM (January 31,
2016). In addition to the results of anthropometric, physical examination found the old man
face, ribs xylophone, hipotrofi muscles in the upper and lower extremities, thinning
subcutaneous fat, baggy pants, and a high fever that indicate diagnosis towards malnutrition
(marasmus) with complications.
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.
Laboratory tests on blood glucose will shows hypoglycemia is present if the level is
lower than 3 mmol/L. Examination of blood smears by microscopy or direct detection test
will shows presence of parasites is indicative of infection. Direct test is suitable but
expensive.
In this patient, leucocytosis was found where the leucocyte value is 25.690 L above
the normal range of 4.500 L to 13.500 L. Which shows there is presence of parasites.
Lower hemoglobin is indicative of severe anemia. Hemoglobin of this patient is 9.8 g/dL
which is lower than normal range of 10.8 g/dL to 15.6 g/dL.
Urine examination and culture can be done using multistick or dipstick. In multistix,
if more than 10 leukocytes per high-power field is indicative of infection. Nitrites and
leukocytes are tested on multistix or dipstick. On 1st of January 2017, the dipstick result of
the patient is Leu / Nit / Uro / Pro / pH / BLO / SG / Ket / Bil / Glu : +3 / + / - / +4 / 6 / +2 /
1000 / 5 / +1 / -. On 3rd of January 2017 the dipstick value is Leu / Nit / Uro / Pro / pH / BLO
/ SG / Ket / Bil / Glu : 500++ / - / 0.2 / - / 5.0 / - / - / - / - / 1.005. Both dipstick results shows
Leu/ + which means there is infection.
Albumin is not useful for diagnosis, it is a guide to prognosis. If albumin is lower
than 35 g/L, protein synthesis is massively impaired. Measuring electrolytes is rarely helpful
and it may lead to inappropriate therapy. Hyponatremia is a significant finding. For this
patient, natrium is 126 mEq/L which is lower than normal range of 135 mEq/L to 155 mEq/L.
Management is divided into an initial intensive phase that divided into two phases are
stabilization (0-2 days) and transition (3-7 days), followed by a consolidation
phase/rehabilitation (2-6 weeks), preparing for outpatient follow-up management (7-26
weeks). 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.
The guidelines highlight 10 steps for routine management of children with malnutrition, as
follows in the picture below:
 Based on the clinical symptoms, physical examination, and found no shock, letargis,
nausea, vomiting, diarrhea, and edema of the consensus on mutually management of
malnutrition flow in this patient is planned V (shown below):
When a patient comes to the emergency department RSHM and diagnosed with marasmus,
patients treated immediately according to WHO guidelines, which the management of the
stabilization phase (days 0-2) obtained in the ER:

- Sugar solution 10% ( 10 mg/100cc)

- Inj. Gentamicin 40mg/ 24 hours
- Inj. Ampisilin 250mg/ 6 hours
- Vit. A 100.000 IU
- Vit. B complex 1 x 1 tablet
- Vit. C 1 x 50 mg
- Folic acid 1 x 5 mg
 - Diet F75 60cc / 2 hours for first 2 hours
- Paracetamol 60 mg/ IV
- Threeway is fix

Then, after passing through a phase of stabilization, the patient entered the
transition phase (days 3-7) in which the selection of antibiotic ampicillin converted into
amoxicylin and adapted to the diet guidelines based on weight. Then, entered the
rehabilitation phase (days 8-9) where the treatment of patients includes iron.
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.
The best preventive strategies should be done for marasmus.Numerous prevention
programs have been implemented, among which the most successful include the following:
o Educational programs for girls
o Sanitation programs, which improve access to safe water
o Nutritional programs, including health education as well as screening of
malnourished children
o Programs that integrate breastfeeding promotion, diarrhea and infection therapy,
and improvement of the nutritional status of mothers and pregnant women
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.