MALNUTRITION:

MARASMUS AND
KWASHIORKOR
Dr. Yaran Abdulqader
Introduction
• The term malnutrition encompasses both ends of the nutrition
spectrum, from undernutrition to overweight.
• Undernutrition is condition that results from a diet (supply) that
does not satisfy nutritional requirement (demand).
• The greatest risk of undernutrition occurs in the first 1000 days,
from conception to 24 months of age.
• This early damage to growth and development can have adverse
consequences in later life on health, intellectual ability, school
achievement, work productivity, and earnings.
• Many poor nutritional outcomes begin in utero and manifest as low
birthweight.
Prevalence
Malnutrition could be either:
• Primary due to inadequate dietary intake with increased caloric requirement
(most common cause), or
• Secondary due to an underlying chronic disease, e.g. crohn’s disease, celiac
disease, CHD … etc.

Prevalence of Undernutrition
• Globally, in 2011 16% of children <5 yr of age were underweight (weight for-
age <−2 SD).
• Stunting prevalence is now highest in the African region (36% prevalence).
• Wasting (weight-for-height <−2 SD) affects 8% of children <5 yr.
Measurement of Undernutrition:
• Nutritional status is often assessed in terms of anthropometry.
• International standards of normal child growth under optimum conditions from birth to 5 yr
have been established by the World Health Organization (WHO).
─ Height-for-age (or length-for-age for children <2 yr) or stunting, usually indicates chronic
malnutrition.
─ Weight-for-height, or wasting, usually indicates acute malnutrition.
─ Weight-for-age of limited clinical significance but easier to measure.
─ Mid-upper arm circumference MUAC is used for screening wasted children.
─ Body mass index (BMI), for children, BMI is age- and gender-specific.
─ Micronutrient deficiencies are another dimension of undernutrition. Those of particular
public health significance are vitamin A, iodine, iron, and zinc.
Growth Charts:
Severe Acute Malnutrition:
• Severe acute malnutrition: defined as severe wasting and/or bilateral edema.
• Children have had a diet insufficient in energy and nutrients relative to their
needs.
• Severe acute malnutrition is defined as the presence of any of the
following:
─ Severe wasting is extreme thinness diagnosed by a weight-for-length (or
height) below −3 SD of the WHO Child Growth Standards.
─ (MUAC) <115 mm in children 6 months – 5 years old.
─ Bilateral edema.
 Forms of Severe Acute Malnutrition

Forms of severe acute malnutrition (SAM) :

• Marasmus : Non-edematous malnutrition + wasting

• Kwashiorkor : Edematous malnutrition
• Marasmic Kwashiorkor : Edema + wasting
• Child with severe wasting
• Child with generalized edema
Approach to SAM
History: should include details of:
• Diet intake and feeding patterns, past medical history, including birth and
developmental history; family history; social history ; socioeconomic status;
vaccination; and review of systems.

• Physical examination:
Look for specific Clinical Features to determine which type of malnutrition
the patient has.
Marasmus (non-edematous malnutrition)
• Failure to gain weight then followed by weight loss.
• Loss of skin turgor and becoming loose and wrinkled.
• Severe wasting is most visible on the thighs, buttocks, and upper arms, and
over the ribs and scapulae where loss of fat and skeletal muscle is greatest.
• Loss of fat of the suckling pads, wizened face.
• Often fretful and irritable.
• Constipation, flat or distended abdomen, subnormal body temp, bradycardia,
hypotonia.
Kwashiorkor (edematous malnutrition)
• Vague manifestations initially including lethargy, apathy, often refusal to eat.
• Lack of growth, lack of stamina, loss of muscle tissue.
• Increased susceptibility to infections, vomiting, diarrhea, anorexia, flabby SC
tissue.
• Edema which is most likely to appear first in the feet and then in the lower legs.
• Skin changes include dark, crackled peeling patches (flaky paint dermatosis).
• The hair is sparse and easily pulled out and may lose its curl. In dark-haired
children, the hair may turn pale or reddish, flag sign (alternating bands of light &
normal color).
• Enlarged fatty liver
• Stupor, coma & death.
Laboratory Tests
• Hb level, hematocrit

• Blood glucose

• S. electrolytes

• Blood PH, bicarbonate

• Total protein level

• Renal function test

• CRP & ESR

• GUE & stool examination

Principles of Treatment

• The aim of the stabilization phase is to repair cellular function, correct

fluid and electrolyte imbalance, restore homeostasis, and prevent
death from the interlinked triad of hypoglycemia, hypothermia, and
infection. 

• The aim of the rehabilitation phase is to restore wasted tissues (i.e.

catch-up growth). It is essential that treatment proceeds in an ordered
progression and that the metabolic machinery is repaired.
Management:
Children with no appetite, severe edema, a medical complication or are less than
6 months old have complicated severe acute malnutrition and require hospital in-
patient care; it has a high mortality, up to 30%.
In addition to protein and energy deficiency, there is electrolyte and mineral
deficiency (potassium, zinc and magnesium) as well as micronutrient and vitamin
deficiency (vitamin A).
Emergency treatment:
• Treatment of shock
• Treatment of hypoglycemia
• Treatment of severe dehydration
• Treatment of very severe anemia
• Emergency eye care
10 steps of treatment are separated in two phases:

 Stabilization phase and Rehabilitation phase

 Stabilization phase:
• Frequent small amount feeding F 75 (75 kcal & 0.9g protein per 100ml)

 Rehabilitation phase: The signals for entry to this phase are:

1. Reduced or minimal edema.
2. Return of appetite.
• High-energy, high-protein milk formula such as F100 (100 kcal & 3g protein per
100ml), or ready to use therapeutic food (RUFT) or family food modified to have
comparable energy and protein contents.
Stabilization is to:
• Treat or prevent hypoglycemia.
• Treat or prevent hypothermia.
• Treat or prevent dehydration – The standard WHO oral rehydration solution
contains too much sodium (Na+ 75 mmol/l) and too little potassium for severe acute
malnutrition; they should be given a special rehydration solution (ReSoMal).
Rehydration should be provided orally, by nasogastric tube if necessary.
Intravenous fluids are given only for shock.
• Correct electrolyte imbalance.
• Treat infection – give broad-spectrum antibiotics. Treat oral candida if present.
• Correct micronutrient deficiency – introduction of iron is delayed to 2nd week.
• Initiate feeding – small volumes, frequently including through the night.
The remaining three steps are provided during rehabilitation:

1. Achieve catch-up growth

2. Provide lovely care & play

3. Provide for follow-up after recovery

Refeeding Syndrome
• The refeeding syndrome may occur if high-energy feeding is started too soon
or too vigorously, and it may lead to sudden death with signs of heart failure.
• The refeeding syndrome occurs in malnourished individuals as a result of
untimely, overzealous oral, enteral, or parenteral (highest risk) feeding, and the
risk is not widely recognized.
• Onset is usually 24-48 hr after the start of high energy feeding.
• It is characterized by breathlessness, rapid pulse, increased venous pressure,
rapid enlargement of the liver, and watery diarrhea.
• A sudden lowering of serum potassium, magnesium, and phosphate
concentrations is an important feature of the refeeding syndrome.
• The key to preventing the syndrome is to minimize the risk of its occurrence. 
• It can be avoided by following the World Health Organization (WHO)
guidelines for the treatment of malnutrition.
• Of particular relevance to minimizing the risk is the initial stabilization phase ,
which includes providing maintenance amounts of energy and protein and
correcting electrolyte imbalances and micronutrient deficiencies, followed by a
controlled transition to high-energy feeding.
• Milk-based diets are desirable because milk is a good source of phosphate.
• Monitoring for sudden increases in pulse and respiration rates during the transition
to high-energy feeding is advisable to detect these early warning signs.
• Should refeeding syndrome occur, prompt treatment with a single parenteral dose
of digoxin and furosemide has been useful.
Strategies for increasing energy intake:
1- Dietary:

• Three meals and two snacks each day

• Increase number and variety of foods offered
• Increase energy density of foods (e.g. add cheese, margarine, cream)
• Limit milk intake to 500 ml/day
• Avoid excessive intake of fruit juice and squash
2- Behavioural:

• Offer meals at regular times with other family members

• Praise when food is eaten, ignore when not
• Limit mealtime to 30 minutes
• Eat at same time as child
• Avoid mealtime conflict
• Never force feed
A 3 year old girl presented to outpatient clinic, on examination you
noticed her weight for height is below 10th percentile and and height
for age is 55th percentile.. she has: 

a) Acute malnutrition

b) Normal parameters

c) Chronic malnutrition

Answer: a
One of the following is feature of marasmus?

a) Flaky paint dermatosis

b) Irritable

c) Flag sign

d) Bilateral leg edema

Answer: b
Rehabilitation phase includes: 

a) Treat or prevent dehydration

b) Achieve catch-up growth

c) Correct electrolyte imbalance

d) Treat or prevent hypoglycemia

Answer: b