Marasmus

CHAPTER 1
INTRODUCTION
Malnutrition is the result of deficiency of protein, energy, minerals as well as vitamins

leading to loss of body fats and muscle tissues. Malnutrition is a significant public health
problem which is often neglected.1
The World Health Organization estimates that by the year 2015, the prevalence of
malnutrition will have decreased to 17.6% globally, with 113.4 million children younger than
5 years affected as measured by low weight for age. The overwhelming majority of these
children, 112.8 million, will live in developing countries with 70% of these children in Asia,
particularly the southcentral region, and 26% in Africa. An additional 165 million (29.0%)
children will have stunted length/height secondary to poor nutrition.2
Malnutrition is directly responsible for 300,000 deaths per year in children younger
than 5 years in developing countries and contributes indirectly to more than half of all deaths
in children worldwide. 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 2
Protein-energy Malnutrition (PEM) in children is still a problem of nutrition and

public health in Indonesia. Based Health Research in 2010, as many as 13.0% less nutritional
status, of which 4.9% severe malnutrition. The same data showed 13.3% of children
underweight, of which 6.0% was emaciated children and 17.1% of children have a very short
category. Riskesdas 2013 there is an increased prevalence of malnutrition-less, namely
19.6%, of which 5.7% severe malnutrition and 13.9% less nutritional status. Protein-energy
undernutrition (PEU), previously called protein-energy malnutrition, is an energy deficit due
to deficiency of all macronutrients. It commonly includes deficiencies of many
micronutrients. In children, chronic primary PEU has 2 common forms: marasmus and
kwashiorkor. The form depends on the balance of nonprotein and protein sources of
energy.1,2,11
Marasmus is a condition of chronic undernourishment occurring especially in children

and usually caused by a diet deficient in calories and proteins. Marasmus is one of the serious
forms of PEM. Marasmus is almost never seen in the developed world. While the cause is not
immediately PEM very much, so the desease is often called a multifactorial causes including
physical environment, biological, socioeconomic, and cultural factors. PEM is basically
determined by two factors that can directly affect the occurance of PEM in children under
five is the food and the presence or absence of infectious deseases.1
PEM will occur when the bodys need for calories, protein, or both are not fulfilled by
diet. In state of lack food, the body is always trying to preserve life by meeting basic needs or
energy. The ability of the body to use carbohydrates, proteins, and fats is very essential to
maintain life, unfortunately the bodys ability to store carbohydrates very little, so that 25
hours was possible shortage. With reduced energy intake, a decrease in physical activity
occurs followed by a progressively slower rate of growth. Weight loss initially occurs due to
a decrease in fat mass, and afterwards by a decrease in muscle mass, as clinically measured
by changes in arm circumference. Muscle mass loss results in a decrease of energy
expenditure. Reduced energy metabolism can impair the response of patients with marasmus
to changes in environmental temperature, resulting in an increased risk of hypothermia.3,10
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.4 The loss of body fat
and muscle tissue leads to a withered appearance, failure to thrive or looking like thin is the
earliest manifestation, associated with irritability or apathy and the other symptoms of
marasmus include old man face, ribs and shoulders clearly visible through the skin, very
loose skin that sometimes hangs in folds in the upper arms, thighs, and buttocks, persistent
dizziness, sunken eyes, anorexia, anemia, diarrhea, active, alert, or irritable behavior,
frequent dehydration. Presentation may be accelerated by an acute infection like pneumonia
that caused high fever. 5
Several clinical signs must be assessed in order to detect complications, with special
attention to infectious complications. 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. 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.5
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. Management is divided into an initial intensive phase that divided into
two phases are stabilization (0-3 days) and transition (4-7 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:
A. Prevent and treat the following:

Hypoglycemia
Hypothermia
Dehydration
Electrolyte imbalance
Infection
Micronutrient deficiencies
B. Provide special feeds for the following:

Initial stabilization
Catch-up growth
Provide loving care and stimulation
Prepare for follow-up after discharge6
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
women7,8
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, 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. Except for complications mentioned above, prognosis of even severe
marasmus is good if treatment and follow-up care are correctly applied.9
CASE
TA, a 2 years 1 month old boy with weight 5.6kg and height 75cm, came to Haji Adam Malik
General Hospital on 31st December 2016 at 9.37pm. His main complaint was fever.
History of disease:
- Patient experiencing fever for past 2 months. The temperature was up and down
which had responded to antipyretic drug. The highest temperature have been
measured using thermometer at home was 40.2oC. Later, the patient was brought to
hospital by parents. Patient was experienced convulsions on the way to hospital.
Duration of the convulsion was for 1 hour and was not repeated in 24 hours. The
patient was unconcious during convulsions. After the convulsion, the patient get back
to concious but body weakened. Shivering was found during fever. The patient had
his first convulsion on 28th November 2016 and second convulsion on 10th
December 2016. Both convulsions previously followed by fever and the duration were
for 1 hour and were not repeated in 24 hours. Convulsions occur in both parts of body.
- Shortness of breathing only found during convulsions.
- The weight is inappropriate to the age. The patient weight is 5,6 kg and the highest
weight have been achieved by this patient 7.5 kg when he was 1 year 11 months.
- Nausea and vomitting was not found.
- Decreased of appetite was not found. Allergy to food and drugs was not found.
- Diarrhea was not found.
- Difficulty in urinate was found. The patient was fixed catheter and the volume of
urine is 500cc/8 hours.
- The socioeconomic status of the parents is upper middle. The father is a journalist and
mother is a housewife.
History of medication:
- Patient was given paracetamol and amoxicylin during fever.

- Patient was given diazepam during convulsions.
History of previous disease:
- The 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.
History of family:
- None of the family members experienced similar things
History of pregnancy:
- The mother was never sick during pregnancy. Patient is second child from 2 siblings.
The mother had experienced miscarriage in 2011. The mother did not had diabetes
mellitus or hypertension during pregnancy. The mother did not consume any
medication or herbals during pregnancy.
History of birth:
- The patient was born spontaneously per vaginam and cried immediately after birth.
The patient born with preterm gestational age of 8 months. Patient born with weight
of 2.6 kg. Patients body length and head circumference was forgetten by the mother.
History of cyanosis did not found.
History of feeding:
- History of inadequate nutrition was found. At the age of 1 year old, patient refused to
ateporridge, 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.
Food Recall:
- The patient was given breast milk, formula milk, and milk porridge 3 times a day
o Breast milk : 103,3 ccal/once x 3 = 309,9 ccal/day
o Formula milk : 148,4 ccal/once x 3 = 421.2 ccal/day
o Milk porridge : 47,1 ccal/once x 3 = 141,3 ccal/day
o Total daily food recall = 872,4 ccal/ day
History of growth and development:
- History of developmental was found 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.
History of immunization:
- The patients immunization was not complete. The patient only receive hepatitis B
and polio vaccination after delivery. The parents refuse to continue immunization
because the patient got fever after immunization.
History of surgery: -
History of blood transfusion: -
Physical Examination
31st of December2016 at 9.37pm
S Fever (+) shivering(+) weakness (+)

O Sens : compos mentis Temperature : 37.8C
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
Head: Microcephaly
Face : Old man face (+)
Eye : Light reflex (+/+), isochoric pupil (R:3mm ,L: 3 mm),
pale inferior palpebral conj. (-/-).
Ears : Both ear lobe in normal morphologic.
Nose : Septum deviation (-), normal morphologic.
Mouth : Lip dryness (+), Cyanosis (-)
Neck : Lymph node enlargement (-).
Thorax : Symmetrical fusiform, retraction (-), xylophone ribs (+)
HR: 126 bpm, regular, murmur (-/-)
RR: 32 bpm, regular, ronchi (-/-), wheezing (-/-).
Abdomen : Soepel, peristaltic (+) N, hepar and lien : unpalpable, turgor back
quickly
Extremities :Pulse: 126 bpm, regular, warm acral, hipotrofi muscle (+), thin
subcutaneous fats (+), baggy pant (+), spastic (+),oedema (-/-).
Laboratorium result: Hb / Ht / L / T : 9.8 / 29 / 29.690 / 548.000
E / B / N / L / M : 0.00 / 0.10 / 88.30 / 7.20 / 4.40
Ca / Na / K / Cl : 9.30 / 126 / 4.6 / 97
KGD : 104
A Marasmus + suspect Cerebral Palsy + Candiasis Oral + Microcephaly
P - 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
Differential Diagnose: - Kwashiorkor + suspect Cerebral Palsy + Candiasis Oral +
Microcephaly
Working Diagnose:- Marasmus + suspect Cerebral Palsy + Candiasis Oral + Microcephaly
Therapy :
- Sugar solution 10% ( 10 mg/100cc)

- Inj. Gentamicin 40mg/ 24 hours
- Vit. A 100.000 IU
- Vit. C 1 x 50 mg
- Diet F75 60cc / 2 hours for first 2 hours
1st of January 2017

O Sens : compos mentis Temperature : 38C
Head: Microcephaly
HR: 110bpm, regular, murmur (-/-)
quickly
Extremities : Pulse: 110 bpm, regular, warm acral, hipotrofi muscle (+), thin
subcutaneous fats (+), baggy pant (+), spastic (+)oedema (-/-).
Dipstick result: Leu / Nit / Uro / Pro / pH / BLO / SG / Ket / Bil / Glu
+3 / + / - / +4 / 6 / +2 / 1000 / 5 / +1 / -
P - Inj. Gentamicin 40mg/ 24 hours
- Vit. A 100.000 IU
- Vit. C 1 x 50 mg
- Diet F75 90cc / 3 hours
- Paracetamol 60 mg / IV
- Catheter No.6 is fix
2nd of January 2017

Head: Microcephaly
quickly
subcutaneous fats (+), baggy pant (+), spastic (+)oedema (-/-).

- Vit. A 100.000 IU
- Vit. C 1 x 50 mg
- Paracetamol 60 mg /IV
3rd of January 2017
S Fever (-) shivering(+) weakness (+)

BW/A: Z score < -3 BL/A: 0 < Z score < 2
Head: Microcephaly
quickly
subcutaneous fats (+), baggy pant (-), spastic (+)oedema (-/-).
Dipstick result: Leu / Nit / Uro / Pro / pH / BLO / SG / Ket / Bil / Glu
500++ / - / 0.2 / - / 5.0 / - / - / - / - / 1.005
- Syr. Amoxicylin 1 x sdt (2.5 ml)
- Vit. A 100.000 IU
- Vit. C 1 x 50 mg
4th of January 2017
S Fever (-) shivering(+) weakness (+)

Head: Microcephaly
quickly
Plan : head CT Scan
- Syr. Amoxicylin 1 x sdt / day
- Vit. A 100.000 IU
- Vit. C 1 x 100 mg
- Diet F100 150 cc / 4 hours
5th of January 2017
S Fever (-) shivering(-) weakness (+)

Head: Microcephaly
RR: 22 bpm, regular, ronchi (-/-), wheezing (-/-)
quickly
A Marasmus + Cerebral Palsy + Candiasis Oral + Microcephaly
- Vit. A 100.000 IU
- Vit. C 1 x 100 mg
6th of January 2017

Head: Microcephaly
quickly
A Marasmus + Cerebral Palsy + Candiasis Oral + Microcephaly + suspect Urinary Tract
Stone
- Vit. A 100.000 IU
- Vit. C 1 x 100 mg
- Inj. Phenytoin MD15 mg in 20cc of NaCl 0.9% finish within 20 minutes / 12
hours
7th of January 2017

Head: Microcephaly
quickly
Stone
- Vit. A 100.000 IU
- Vit. C 1 x 100 mg
hours
8th of January 2017

Head: Microcephaly
quickly
Stone
P - Vit. A 100.000 IU
- Vit. C 1 x 100 mg
- Syr. Fe 1 x 15 mg
hours
9th of January 2017

Head: Microcephaly
quickly
Plan : consult Neuro Surgeon
A Marasmus + Cerebral Palsy + Candiasis Oral + Microcephaly + Ventriculomegaly
P - Vit. A 100.000 IU
- Vit. C 1 x 100 mg
- Syr. Fe 1 x 15 mg
hours
DISCUSSION
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
Pada kurva WHO laki-laki berumur 2 tahun seharusnya memiliki berat badan 12,5-
15,5 kg (-2SD<Z<2SD), panjang badan 83-90 cm (-2SD<Z<2SD), lingkar kepala 46-52 cm
(-2SD<Z<2SD), dan lingkar lengan atas seharusnya diatas 13,5 cm untuk usia 1-5 tahun.
Namun, pada kenyataannya berat badan, panjang badan, lingkar kepala, lingkar lengan atas,
BW/A, dan BW/BL pada pasien ini memiliki interpretasi status gizi buruk pada saat masuk
ke IGD RSHAM (31 Januari 2016). Selain hasil antropometri, pemeriksaan fisik lainnya
dijumpai adanya old man face, iga gambang, hipotrofi otot pada ekstremitas atas dan bawah,
lemak subkutan menipis, baggy pants, dan demam tinggi sehingga menunjukkan diagnosis ke
arah gizi buruk (marasmus) dengan komplikasi
DAFTAR PUSTAKA
1. Scrimshaw NS, Viteri FE. INCAP studies of kwashiorkor and marasmus. Food Nutr
Bull. 2010 Mar. 31(1):34-41
2. Global Health Observatory (GHO) data: Underweight in chidren. World Health
Organization.Available_at http://www.who.int/gho/mdg/poverty_hunger/underweight
_text/en/. 2016; Accessed: Januar 10, 2017.
3. Emery PW. Metabolic changes in malnutrition. Eye. October 2005. 19 (10):1029-32.
4. Pelletier DL, Frongillo EA Jr, Schroeder DG, Habicht JP. The effects of malnutrition
on child mortality in developing countries. Bull World Health Org. 2010. 73 (4):443-
8.
5. Guideline: Updates on the management of sever acute malnutrition in infants and
children 2013.
6. Ashworth A, Jackson A, Khanum S, Schofield C. Ten steps to recovery. Child Health
Dialogue. 2007. 10-2.
7. UNICEF Data: Monitoring the Situation of Children and Women. UNICEF. Available
at http://data.unicef.org/nutrition/malnutrition.html. 2016; Accessed: Januar 10, 2017.
8. Fan CN. [Prevalence and prevention of common nutritional risks in children after
earthquake]. Zhongguo Dang Dai Er Ke Za Zhi. 2013 Jun. 15(6):427-30
9. Gomez F, Ramos Galvan R, Frenk S, et al. Mortality in second and third degree
malnutrition. In: Bull World Health Organ. 2000;78(10):1275-80. J Trop Ped and Afr
Child Health. 2007. 2:77.
10. Bartz S, Mody A, Hornik C, Bain J, Muehlbauer M, Kiyimba T, et al. Severe acute
malnutrition in childhood: hormonal and metabolic status at presentation, response to
treatment, and predictors of mortality. J Clin Endocrinol Metab. 2014 Jun. (6):2128-
37
11. Riskesdas.2013.Available_at:
www.depkes.go.id/resources/download/general/Hasil%20Riskesdas%202013.pdf.
Accessed: Januar 10, 2017

Marasmus

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Marasmus

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CHAPTER 1

Malnutrition is the result of deficiency of protein, energy, minerals as well as vitamins

Protein-energy Malnutrition (PEM) in children is still a problem of nutrition and

Marasmus is a condition of chronic undernourishment occurring especially in children

Management of moderate marasmus can be performed on an outpatient basis, but

The guidelines highlight 10 steps for routine management of children with

A. Prevent and treat the following:

B. Provide special feeds for the following:

Educational programs for girls

- Patient was given paracetamol and amoxicylin during fever.

History of previous disease:

- None of the family members experienced similar things

History of growth and development:

History of blood transfusion: -

S Fever (+) shivering(+) weakness (+)

Working Diagnose:- Marasmus + suspect Cerebral Palsy + Candiasis Oral + Microcephaly

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

1st of January 2017

S Fever (+) shivering(+) weakness (+)

2nd of January 2017

S Fever (+) shivering(+) weakness (+)

A Marasmus + suspect Cerebral Palsy + Candiasis Oral + Microcephaly

3rd of January 2017

S Fever (-) shivering(+) weakness (+)

4th of January 2017

S Fever (-) shivering(+) weakness (+)

S Fever (-) shivering(-) weakness (+)

6th of January 2017

S Fever (-) shivering(-) weakness (+)

7th of January 2017

S Fever (-) shivering(-) weakness (+)

8th of January 2017

S Fever (-) shivering(-) weakness (+)

9th of January 2017

S Fever (-) shivering(-) weakness (+)

The patient had:

- BW: 5.6 kg BL: 75 cm

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