Protein Energy

Malnutrition:
Marasmus
Group 12

Marasmus
Derived from the Greek word
marasmos which means waste away.
State in which virtually all available body
fat stores have been exhausted due to
starvation.
Is the most common form of malnutrition.
Body weight is 60% less than the
expected weight.
Thin limbs and prominent ribs are seen.

Clinical Database:
A 10 month old male child was examined during a
health screening program of an NGO. The mother
complained that her child was always hungry and crying
for food, and was having loose stools for the past 1
month. The striking features noted was the
emancipated appearance, with gross wasting of all
muscle groups with the skin hanging in loose folds and
lack the normal shine and texture.

The childs height was 70cm and weight was 5

kilograms which were in the 10th and below the 5th
percentile, respectively of normal height and weight for
his age. There was no edema. The midarm
circumference ( MAC) was 10 cm and the triceps skin
fold thickness (TST) was 5mm. The mid-arm muscle
circumference (MAMC) was calculated to be 8.5. All
those anthropometric values when compared to standard
table for age group and sex were below the 5 th percentile
and indicate wasting, low fat and protein reserve.

Laboratory Test Results:

Fasting Blood Glucose: 60 mg/dL

2hr Post- Prandial Blood Glucose: 179 mg/dL
Serum Albumin: 1.8 g/dL
Serum Prealbumin: 8mg/dL
Urine Creatine: 0.6 mmol/per day
WBC: 3,500 cells/ cubic mm
T-cell count: low at 300 cells/cubicmm
Stool exam: abundant fat globules, pus cells and
RBC.

1. State the features of Marasmus

which will differentiate it from
Kwashiorkor
FEATURES

MARASMUS

KWASHIORKOR

Growth Failure

PRESENT

PRESENT

Muscle wasting

PRESENT

PRESENT

Edema

ABSENT

PRESENT

Hair changes

ABSENT

PRESENT

Mental changes

ABSENT

PRESENT

Dermatosis

ABSENT

PRESENT

Appetite

PRESENT

ABSENT

Anemia

PRESENT

PRESENT, SEVERE

Fat

ABSENT

PRESENT, REDUCED

Face

MONKEY LIKE

EDEMATOUS

Fatty infiltration in Liver

ABSENT

PRESENT

The liver of a kwashiorkor child is yellow and fatty ,

due to reduced serum levels of carrier proteins. The
liver of a marasmus child is normal but the lower
extremity show wasting .

2. Explain the abnormal biochemical or

laboratory test seen in this patient
Fasting Blood Glucose: 60 mg/dL ( 70-100 md/dL)
DECREASE
2hr Post- Prandial Blood Glucose: 179 mg/dL (120mg/dL)
INCREASE
Serum Albumin: 1.8 g/dL (3.5-5.5 g/dL) DECREASE
Serum Prealbumin: 8mg/dL ( 16-40 mg/dL) DECREASE
Urine Creatine: 0.6 mmol/per day DECREASE
WBC: 3,500 cells/ cubic mm ( 4,500- 10,000 cells/mm)
DECREASE
T-cell count: low at 300 cells/cubicmm DECREASE
Stool exam: abundant fat globules, pus cells and RBC.

3. Explain the hormonal changes that

will bring about muscle wasting seen
in this patient
(1) GH= Basal GH levels are high in children with
marasmus and they decrease to normal nutritional
rehabilitation.
The cause for increased secretion of GH
Low IGF-1 which exert negative feedback effect on the
hypothalamic-pituitary axis.
Low serum tyrosine. its has been demonstrated to correlate
significantly with basal GH level in malnourished children
before and after rehabilitation.

(2) Glucocorticoids=
Serum cortisol levels are high in the marasmus.
The response of cortisol to ACTH stimulation are
satisfactory in the marasmus.
Serum cortisol levels have not correlated with either blood
glucose or serum albumin in a large number of children with
PEM.
The stress of malnutrition and the presence of infections are
thought to be the major etiological factors in the elevation
of cortisol levels.

(3) Insulin and Glucagon=

Low basal serum insulin levels have been demonstrated in
children with marasmus.
The insulin reserve in response to arginine stimulation has
been impaired in patients with marasmus.
The low insulin/glucagon ratios in patients with PEM
produced the following:
- Decrease glucose uptake by muscle and adipose tissue but
not by the brain and heart
- Increase muscle protein catabolism to supply the essential
amino acids necessary for gluconeogenesis and other
biosynthetic purpose.

 Increase lipolysis and supply of fatty acids to peripheral

tissues.

(4) Thyroid Hormone=

The free T4 levels have been reported as normal or low in
marasmus.
T4 levels reported in this children patient with PEM could
be due to deficiency of thyroid binding globulin and
prealbumin.
This suggest that decreased circulating T3 is not due to
diminished hormone production but rather is an adaptation
of peripheral metabolism of T4 directing the de-iodination
of T4 to T3 .

4. Enumerate some tools for general nutritiona

assessment and explain its significance

Medical history
Screening
Anthropometric measurements
Biochemical measurements
Clinical measurements

Medical history
Directed toward identifying underlying mechanism
that put patients at risk for nutritional depletion or
excess. These mechanism include inadequate intake,
impaired absorption, decreased utilization, increased
losses, and increased requirements of nutrients.

Source: Harrisons Principle of Internal Medicine 18th Edition

Screening
Is the process of identifying patient characteristics
known to be associated with nutritional problems.
Its purpose it to quickly identify individuals who are
malnourished or at nutritional risk.

Source: Harrisons Principle of Internal Medicine 18th Edition

Anthropometric Measurements

Provide information on the body muscle mass and fat

reserves. The most practical and commonly used
measurements are body weight, height, triceps
skinfold and midarm circumference.

Source: Harrisons Principle of Internal Medicine 18th Edition

Weight and height measurements

are essential to:
Identify malnourished infants and children.
Link at-risk children to medical and social services.
Evaluate the overall health status of children.

Mid Arm Circumference

Is an excellent indicator of nutritional status and has
an important advantage of operational simplicity.
It is reduced substantially in the undernourished and
substantially increases in children who are
overweight.

MUAC less than 110mm (11.0cm), RED COLOUR, indicates Severe Acute
Malnutrition .
MUAC of between 110mm (11.0cm) and 125mm (12.5cm), RED
COLOUR (3-colour Tape) or ORANGE COLOUR (4-colour Tape), indicates
Moderate Acute Malnutrition (MAM). The child should be immediately
referred for supplementation.

MUAC of between 125mm (12.5cm) and 135mm (13.5cm), YELLOW

COLOUR, indicates that the child is at risk for acute malnutrition and
should be counseled and followed-up for Growth Promotion and
Monitoring (GPM).

Triceps Skinfold Thickness

A measure of
subcutaneous fat
stores taken at the
midpoint of the
posterior aspect of
the humerus
Correlates closely
with the percentage
of body fat and
with total body fat

>10mm- healthy children

1-6 years
<6mm indicative fo
moderate to severe

Biochemical measurements
many of the routine blood and urine laboratory test
found in patients chart are useful in providing an
objective assessment of nutritional status.

Clinical Assessment
Is the physical examination of an individual for signs
and symptoms. The examination is conducted by the
physician on the anatomic changes that can be
observed.
The use of stethoscope , blood pressure and pulse rate
measurements, height and weight are standard
procedures in P.E. charting.

5. Prescribe a general approach in

the management of this case and
its rationale
A nutritious, well-balanced diet with lots of fresh fruits and
vegetables, grains, and protein will reduce the risk of
malnutrition and any related marasmus.
Treatment of marasmus involves a special feeding and
rehydration plan and close medical observation to prevent
and manage complications of malnutrition. Pediatric
nutrition rehabilitation centers have been established in
some countries and regions to coordinate treatment of
malnourished children. Intravenous fluids, oral rehydration
solutions, and nasogastric feeding tubes are forms of
treatment that may be used.