MARASMUS

Background
The term marasmus is usually accepted as meaning a chronic state of malnutrition
of a severe grade and is associated in our minds with a definite clinical picture. If we are to
obtain success in the treatment and, what is equally important, in the prophylaxis of this
condition, it is necessary to make a critical analysis of its causes and of its evolution.
While our attention will be centred on the severest types, we must retain the conception of
cases ranging in severity from those who simply show an insufficient gain or stationary
weight with few systemic changes, to the most extreme form which is merely the end-result
of repeated nutritional or constitutional disturbances.
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 at the time of weaning.
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.(1,2)
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 PEM.
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.(4) 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 article focuses mainly on marasmus that results from an insufficient nutritional

intake as observed under impaired socioeconomic conditions, such as those present in

developing countries. Marasmus is most frequently associated with acute infections (eg,
gastroenteritis, respiratory illnesses, measles), chronic illnesses (eg, tuberculosis, HIV
infection) or drastic natural or man made conditions (eg, floods, droughts, civil war).
Causes
A careful study of the history of these infants is well worth while, for it will usually
give some clear indication of the origin of this wasted state, and in practice we may regard
the causative factors as falling into four groups (3):
1. Improper feeding.
2. Infection
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
3. Congenital weakness of disease-e.g., prematurity, congenital heart disease.
4. 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
2

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.
5. 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.
Classification
The World Health Organization (WHO) defines malnutrition as the cellular
imbalance between the supply of nutrients and energy and the bodys demand for them to
ensure growth, maintenance, and specific functions.
Malnutrition generally implies undernutrition and refers to all deviations from
adequate and optimal nutritional status in infants, children and in adults. In children,
undernutrition manifests as underweight and stunting (short stature), while severely
undernourished children present with the symptoms and signs that characterize conditions
known as kwashiorkor, marasmus or marasmic-kwashiorkor. (1,2)

Classification of Malnutrion
Classification
Gomez

Waterflow

70-90%
Weight below %

Grading
75%90% WFA

Mild (grade 1)

median WFA

Moderate (grade 2)

60%74% WFA

z-scores (SD) below

Severe (grade 3)
Mild

<60% WFA
80%90% WFH

median WFH

Moderate

70%80% WFH

Severe

<70% WFH
3

WHO (wasting)

z-scores (SD) below

Moderate

median WFH

-3%</= z-score < -2

(70-90%)
z-score < -3 (<70%)

Severe
WHO (stunting)

z-scores (SD) below

Moderate

-3%</= z-score < -2

median HFA
(85-89%)

Kanawati
Cole

MUAC divided by

Severe
Mild

z-score < -3 (<85%)

<0.31

occipitofrontal head

Moderate

<0.28

circumference
z-scores of BMI for

Severe
Grade 1

<0.25
BMI for age z-score <

age

Grade 2

-1

Grade 3

BMI for age z-score <

-2
BMI for age z-score <
-3

Table 1. Classification malnutrion

Abbreviations: BMI, body mass index; HFA, height for age; MUAC, mid-upper arm
circumference; SD, standard deviation; WFA, weight for age; WFH, weight for height;
WHO, World Health Organization.
Pathophysiology
Various extensive reviews of the pathophysiological processes resulting in
marasmus are available. Unlike kwashiorkor, the clinical sequelae of marasmus can be
considered as an evolving adaptation in a child facing an insufficient energy intake.
Marasmus always results from a negative energy balance. The imbalance can result from a
decreased energy intake, an increased loss of ingested calories (eg, emesis, diarrhea, burns),
an increased energy expenditure, or combinations of these factors, such as is observed in
acute or chronic diseases. Children adapt to an energy deficiency with a decrease in
4

physical activity, lethargy, a decrease in basal energy metabolism, slowing of growth, and,
finally, weight loss. (5)

Foot intake <<<

Catabolic stress
Macrophages, Tumor Necrosing Factor, IL-1
Visceral protein
Albumin and lipoprotein production <<<
Hipoalbumin, oedema, and fatty liver
Deficiency protein Kwashiorkor (<-2 SD BB/TB)
Deficiency calorie
Adaptation
Kholesterol >>> insulin <<<
essential amino acid
sintesis protein visceral
production lipoprotein dan albumin serum
kortisol, insulin, and growth hormon
metabolic adaptation
marasmus (edema -) / marasmic kwassiorkor (edema +) (< -3 SD BB/TB)

Picture 1. Pathogenesis marasmus

Picture 2 . pathogenesis marasmus

Picture 3. Pathogenesis marasmus

Clinical picture
The clinical picture of marasmic infants is so characteristic that they almost form a "
family " group. They wear an old and pinched look; their skin is wrinkled, toneless, and
hangs in folds on the extremities. The body is so devoid of fat that the bony points stand out
prominently and give the child an old mummified appearance. The abdomen is usualy large
and its walls are so thinned that outlines of the coils of intestine can be readily seen. The
fontanelle is sunken and the eyes are large. Mentally they are very alert and sleep but little,
though the bodily movements are slow and infrequent.

The remaining features of these infants may be put briefly

1.

The appetite is variable, but is usually very poor; occasionally they are ravenous.

2.
3.

Too often, attempts to satisfy hunger result in vomiting.

The temperature is subnormal (960 to 980 F.), an irregular course being the rule.
The weight curve is, in the most severe cases, characteristic. On an insufficient diet
it falls slowly and steadily. When attempt is made to satisfy the needs of the body on a
more ample diet a steady fall in weight occurs again, but of a rapid kind, often with.

symptoms of fever, diarrhcea.

4.
The pulse is slow and small. Examination of the blood shows it to be thin and pale,
5.

and a count reveals a low hemoglobin content and a diminished number of red cells.
A striking peculiarity is the rigidity of the muscles, especially of the legs, though in
severe cases opisthotonos also develops. This element may be so marked as to cause

6.

confusion in diagnosis with posterior basic meningitis.

The stools vary much. They may be loose or constipated or normal to inspection. It
is essential to realise that the stools are of secondary importance in diagnosis and
treatment, and that it is often dangerous to keep on imposing periods of starvation, by
reason of temporary changes in their character, even for the worse, due to alteration of
diet.

Diagnosis
Children whose weight-for-height is below -3 SD or less than 70% of the median
NCHS/WHO reference values (termed severely wasted), or who have height for age is
below -3 SD or less than 85% of the median NCHS (termed severely stunted), who have
symmetrical oedema involving at least the feet (termed oedematous malnutrition) are
severely malnourished. They should be admitted to hospital where they can be observed,
treated and fed day and night. (6)
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.
Medical history:
Usual diet before current episode of illness
Breastfeeding history
Food and fluids taken in past few days
Recent sinking of eyes
Duration and frequency of vomiting or diarrhoea, appearance of vomit or diarrhoea
Time when urine was last passed
Contact with people with measles or tuberculosis
Any deaths of siblings
Birth weight
Milestones reached (sitting up, standing, etc.)
Immunizations
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, jaundice, blood or mucus in the stools

Ocular manifestations - Corneal lesions associated with vitamin A deficiency

Dermal manifestations - Evidence of infection, purpura

Eye - corneal lesions indicative of vitamin A deficiency

Ear, nose, mouth, and throat (ENT) findings - Otitis, rhinitis

Appearance of feces
Laboratory:

Test
Tests that may be useful

Result and significance

Blood glucose

Glucose concentration < 54 mg/dl (3

mmol/l) is indicative of hypoglycaemia

Examination of blood smear by

Presence of malaria parasites is

microscopy
Haemoglobin or packed-cell volume

indicative of infection
Haemoglobin < 40g/l or packed-cell
volume < 12% is indicative of very

Examination

and

culture

of

severe anaemia
urine Presence of bacteria on microscopy (or >

specimen

10 leukocytes per high-power field) is

Examination of faeces by microscopy

indicative of infection
Presence of blood is indicative of
dysentery
Presence of Giardia cysts or trophozoites

Chest X-ray

is indicative of infection
Pneumonia causes less shadowing of the
lungs in malnourished children than in
well-nourished children
Vascular engorgement is indicative of

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heart failure
Bones may show rickets or fractures of
Skin test for tuberculosis

the ribs
Often negative in children with
tuberculosis or those previously
vaccinated with BCG vaccine

Tests that are of little or no value

Serum proteins (albumin)
Not useful in management, but may
guide prognosis, if albumin is lower than
35 g/L, protein synthesis is massively
impaired.
Test for human immunodeficiency virus Should not be done routinely; if done,
(HIV)

should be accompanied by counselling

of the childs parents and result should
be confidential

Electrolyt
Rarely

helpful

and

may

lead

to

inappropriate therapy. Hyponatremia is a

significant finding.
Radiological examinations
rarely used for the same reasons as the
laboratory examinations test.
Thoracic radiography
can show a pulmonary infection despite
lack

of

clinical

signs,

primary

tuberculosis lesion, cardiomegaly, or

signs of rachitism.
Other test
Skin test

results
negative

for
in

tuberculosis
children

are
who

often
are

undernourished with tuberculosis or

those previously vaccinated with Bacille
11

Calmette-Gurin (BCG) vaccine.

Table 2. Test, result and significance

Treatment

12

Picture 4. Management of the child with severe malnutrition

Management of the child with severe malnutrition is divided into three phases.
These are:
Initial treatment: life-threatening problems are identified and treated in a hospital or a
residential care facility, specific deficiencies are corrected, metabolic abnormalities are
reversed and feeding is begun.

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 Rehabilitation: intensive feeding is given to recover most of the lost weight, emotional
and physical stimulation are increased, the mother or carer is trained to continue care at
home, and preparations are made for discharge of the child.
Follow-up: after discharge, the child and the childs family are followed to prevent relapse
and assure the continued physical, mental and emotional development of the child.
The guidelines highlight 10 steps for routine management of children with
malnutrition, as follows:(7)

Prevent and treat the following:

o Hypoglycemia
o Hypothermia
o Dehydration
o Electrolyte imbalance
o Infection
o Micronutrient deficiencies

Provide special feeds for the following:

o Initial stabilization
o Catch-up growth
o Provide loving care and stimulation
o 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.

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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 Ringerlactate 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.

15

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.(9) 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.(8)
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

16

as a base or by directly administering a modified oral rehydration (ReSoMal) solution if

available.

Composition
Glucose
Sodium
Potassium
Chloride
Citrate
Magnesium
Zinc
Copper
Osmolarity

ReSoMal

Standard

(mmol/L)
125
45
40
70
7
3
0,3
0,045

(mmol/L)
111
90
20
80
10

(mOsm/L)

300

ORS Reduced

osmolarity

ORS
75
75
20
65
10

311

245

Table 3. Composition Comparison of ReSoMal, Standard WHO, and Reduced-Osmolarity

WHO ORS Solutions

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.

17

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 readyto-use formulas, as well as the micronutrient mixtures, are commercially available.(12)

18

Picture 5.. Preparation of F75 and F100 Diets (WHO)

Rehabilitation phase (weeks 2-6)

19

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 and may decrease lactose
production.

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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.(10) The WHO has recognized it as a ready-to-use-therapeutic food (RUTF)
that can reverse malnutrition in severely malnourished children.(11) 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 butterlike paste contains a balance of
fats, carbohydrates, proteins, vitamins, and minerals. Peanuts themselves provide monounsaturated 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 butterbased product is slightly higher
but still relatively inexpensive. The product can also be prepared locally in peanutproducing 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.
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.

21

The following statements epitomise the most valuable suggestions for framing an
increased diet:
1. Prolonged cooking of milk (at least one hour) seems to increase its digestibility.
2. A mixture of carbohydrates, even containing flour, is better digested than one simple
carbohydrate. (Cooked starch and sugar has been used with success.)
3. Acidification of milk improves its digestibility.
Addition of cultures of lactic acid or commercial lactic acid has been tried with success,
and has allowed of feeding with concentrated whole milk mixtures which would not be
tolerated without such addition in these feeble subjects.
Examples of diets including these principles are:
1. Protein milk, with added dextrimaltose (Mead's or Mellin's food).
2. Butter-flour mixtures. These are prepared by heating butter over a flame, adding wheat
flour, and heating till browned, then mixing with sugar and water to a desired solution.
This solution is then diluted with milk and water. The average composition of this
preparation is fat 5-8, carbohydrates 9, protein 2-2.
3. Acid milks. The simplest method is to prescribe, in the first place, skimmed milk with
added lactic acid and dextrimaltose. The lactic acid should be inserted drop by drop,
stirring vigorously, until one drachm has been added to a pint of milk. Gradually whole
milk will replace the skimmed variety, and it is surprising how well this is often
tolerated, even with the continued addition of dextrimaltose.

22

References
1. Gomez F, Galvan RR, Cravioto J, Frenk S. Malnutrition in infancy and childhood,
with special reference to kwashiorkor. Adv Pediatr.1955;7:131169. [Medline]
2. Grover Z, Ee LC. Protein energy malnutrition. Pediatr Clin North Am. 2009
Oct;56(5):1055-68. [Medline]
3. Wilfred J. Pearson, D. S.O., M. C., M.D. Oxf., M. R. C. P. Lond., physician in
charge childrens department, charing cross hospital; physician to out-patient,
hospital for sick children, great Ormond-street. 2000;129-131.
4. Grover Z, Ee LC. Protein energy malnutrition. Pediatr Clin North Am. 2009
Oct;56(5):1055-68. [Medline]
5. Akuyam SA, Isah HS, Ogala WN. Serum lipid profile in malnourished nigerian
children in zaria. Niger Postgrad Med J. September 2008;15 (3):192-6.
6.

Scrimshaw NS, Viteri FE. INCAP studies of kwashiorkor and marasmus. Food Nutr
Bull. Mar 2010;31(1):34-41. [Medline].
7. World Health Organization. WHO Global Database on Child Growth and
Malnutrition. Geneva: WHO. 1996.
8. UNICEF. New formulation of Oral Rehydration Salts (ORS) with reduced
osmolarity.

United

Nations

Children's

Fund.

Available

at

http://www.supply.unicef.dk/catalogue/bulletin9.htm.
9. Kim Y, Hahn S, Garner P. Reduced osmolarity oral rehydration solution for treating
dehydration caused by acute diarrhoea in children. Cochrane Database Syst Rev.
2001;(2):CD002847. [Medline].

23

10. Plumpy'nut. Available at http://en.wikipedia.org/wiki/Plumpy'nut.

11. Joint Statement by the World Health Organization, the World Food Programme, the
United Nations System Standing Committee on Nutrition and the United Nations
Children's Fund. Community-Based Management of Severe Acute Malnutrition.
May, 2007.
12. Hospital Care for Children, World Health Organisation guidelines, Chapter 7.4.7.

feed volumes, 2005.

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