Types of Malnutrition
A child whose weight falls to less than 80% of normal is considered malnourished. Other ways to diagnose include weight-for-height charts and evaluation of fat stores using skin fold thickness.
Marasmus and kwashiorkor are two types of PEM (protein energy malnutrition). A third type of PEM is called marasmic kwashiorkor, which is the most severe form of PEM in children, with weight-for-height less than 60% of that expected, and with edema and other symptoms of kwashiorkor. 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.
Marasmus is caused by a severe deficiency of nearly all nutrients, especially protein, carbohydrates, and lipids. Usually affects children aged 6 months to 1 year. Thyroxin decreases to reduce the metabolic rate. Insulin also decreases to maintain blood sugar levels. Muscles and body fat are broken down to ensure energy requirements are met. This results in severely wasted appearance, but all the sacrifice ensures serum levels of glucose, proteins, and amino acids remain normal. The skin is dry and wrinkled and looks too big for the body (baggy pants sign), but does not break or change color. May have Vitamin A deficiency (Bitot's spot sign). Diagnosis is made clinically (peripheral edema) and blood test reveals urea and electrolyte imbalance. The blood test can also be used to exclude hypoglycemia, anemia, and malaria. Marasmus affects the somatic compartment, for example the protein stores in skeletal muscles.
A child is considered to have marasmus when weight level falls to 60% of normal for sex, height, and age.
Sufficient calorie intake, but with insufficient protein consumption, distinguishes it from marasmus. Usually affects children beyond the age of 12 months. Kwashiorkor affects the visceral compartment, the protein stores of organs such as the liver. Reduced synthesis of digestive enzymes and plasma proteins, which leads to GIT atrophy of mucosa lining and intestinal villi (where absorption takes place). This leads to malabsorption and thus diarrhea, which leads to loss of electrolytes such as potassium. In the liver, reduced protein and increased fat leads to hepatomegaly. Reduced plasma protein leads to reduced oncotic pressure, which causes fluid shift from intravascular spaces to extravascular spaces, causing edema.
Signs include pitting edema, apathy, moon-faced due to edema, and thin, dry hair that is easily pulled out and is brownish red in color, distended abdomen, hyperpigmented (and sometimes broken) skin, impaired immunity, stunted growth, and weight loss.
The first step is often simply rehydration.
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.
- Metabolic changes in Marasmus on Medscape.