Lapkas Anak Marasmus - Revised

7/25/2019 Lapkas Anak Marasmus - Revised

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Introduction

Protein-energy malnutrition (PEM) is a major public health problem

affecting a high proportion of infants and older children world-wide and accounts

for a high childhood morbidity and mortality. Today the world faces a double

burden of malnutrition that includes both undernutrition and overweight

especially in developing countries. Malnutrition in every form presents

significant threats to human health. !ccording to the "orld #ealth $rgani%ation

("#$) &' of the *.& million deaths occurring in children younger than +

years in developing countries are associated with PEM. !ppro,imately * of the

world s malnourished children live in !sia. ($shi/oya and 0enbanjo 1**')

2hild with malnutrition is susceptible to infection. Every episode infection

ma/es the malnutrition worse and adversely affects the malnutrition worse and

adversely affects the immune system further. ! wide spectrum of infections such

as measles malaria acute respiratory tract infection intestinal parasitosis

tuberculosis and #345!360 may complicate PEM with two or more infections co-

e,isting. !lthough a higher proportion of severely malnourished children do not

survive a significant intercurrent illness as much as 7* of the overall

unacceptably high mortality rate may be contributed by mild-to-moderately

malnourished children.

2linically PEM is a disease spectrum that can present as underweight

marasmus marasmic-/washior/or or /washior/or8 the severe forms being

marasmus /washior/or and marasmic-/washior/or in which the main detectable

manifestation is growth retardation. ($shi/oya and 0enbanjo 1**') 9washior/or

presents with failure to thrive oedema that appears first on the dorsum of the feet

and an/les and spreads upwards to involve the rest of the body apathy anore,ia

diarrhoea and discoloration of the s/in and hair. :ailure in growth is mar/ed and

weight is reduced in spite of the presence of oedema. Marasmus appearance is

short and light for their age shrun/en and wi%ened due to lac/ of subcutaneous

fat. Marasmic-/washior/or displays the symptoms of both marasmus and

/washior/or. (0im/iss 6. et al.)
http://www.who.int/en/http://www.who.int/en/http://www.who.int/en/http://www.who.int/en/


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PEM occur when there is gap between inta/e and re;uirements of nutrition

needed. 2ondition that can predispose a child to having PEM include poverty

lac/ of access to ;uality food cultural and religious food customs poor maternal

education inade;uate breast feeding and lac/ of ;uality healthcare. 3n addition to

macronutrient deficiency there is clinical and5or subclinical deficiency of

micronutrients. ($shi/oya and 0enbanjo 1**')

The main features to diagnose severe acute malnutrition

are:

weight-for-length/height < -3SD (wasted) or

mid-u er arm circumference < 11! mm or

oedema of "oth feet (#washior#or or marasmic

#washior#or)

2hildren with severe acute malnutrition should first be assessed with full

clinical e,amination to confirm whether they have any general danger sign

medical complications and an appetite. The physical e,amination must be very

thorough because even small abnormalities can be clinically significant. 2linical

signs of serious complication can be very subtle in children with marasmus.

("#$ 1*

?ody temperature (measured with a thermometer) - !llowing

measurement of low temperatures to detect hypothermia as well as

fever


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!nemia - Pale mucosa Edema 6ehydration @ Aetarghy irritability thirst shrun/en eyes dry mouth

s/in turgor #ypovolemic shoc/ - "ea/ radial pulse cold e,tremities decreased

consciousness Tachypnea - Pneumonia heart failure !bdominal manifestations - 6istension decreased or metallic bowel

sounds large or small liver blood or mucus in the stools $cular manifestations - 2orneal lesions associated with vitamin !

deficiency 6ermal manifestations - Evidence of infection purpura Ear nose and throat (EBT) findings - $titis rhinitis (Cabinowit%

1* &)

Treatment of PEM divided into & phases with * steps which are treatment

for #ypoglycaemia #ypothermia 6ehydration Electrolytes 3nfection

Micronutrients no iron with iron 3nitiate feeding 2atch-up feeding 0ensory

stimulation Prepare for follow-up. ("#$ 1*


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History of previous illness:

#e had ever been hospitali%ed in C0 Coyal Prima at the early of 6ecember of

1* + for #igh fever and was given paracetamol and rehydration solution. !fter

being discharged he never got to control and never fre;uently too/ the medication

given by the doctor for his illness.

History of birth : born caesarean section immediately crying upon birth with no

no blueness found. with the birth weight of 1& ,5i


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Cespiratory Cate> && ,5i

?ody Temperature> < o2.

!nemic (D). 3cteric (-). 2yanosis (-). Edema (-). 6yspnea (-)

Local status

Head > :ontanelle not closed swelling of the head. Eyes>

3sochoric pupil pale inferior palpebra conjunctiva D5D

light refle, on both eyes. Ears5 nose5 mouth> within normal

limit.

Neck > Bo lymph node enlargement

Thorax > 0ymmetrical fusiformis intercostal space clearly visible

protruding spine. #C> 17,5i regular murmur (-). CC>


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- rine and fesces analysis- :erum Profile

- rine and :esces E,amination- Plain abdominal ,-ray- ?arium enema- !lbumin

&aboratory 'indin!: October () th * +,()

#aematology Cesult Bormal#aemoglobin g5dA .** . @ &.&Eritrocyte 10 6 / mm 3 1.&<


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#aematocrite


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Plain 0bdominal 1"ray : October (2 th * +,()

'ollo3 -p

6ate 0 $ ! PTherapy 6iagnostic


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Aostappetite

?loodyvomit (D)and bloodystool (D)

0ens > !lertT > < ' 2

?" > & '/g?# > I&cm#ead> eye reflect D5Disocor pale conj. PalpebrainferiorD5DEar5Bose5Mouth> normal

Bec/> K4P CD1 cm # 1$Thora, > 0ymmetrisfusiformis retraction (-)#C > 1+,53 reguler

murmur (-) CC > soepel normal

peristaltic #epar> palpeble1cm ?!2 Aien> palpeble0333E,tremities > pulse 1+,5ireguler ade;uate pressureand volume warm 2CTG< pretibial edema (-)

- Marasmus- =astrointestinal

bleeding- !nemia

- 34:6 6+ Ba2l * 11+

1*gtt53(micro)

- :olic acid, mg

- 4itamin ?2omple, ,tab

- 4itamin 2 ,tab

- 6iet : +7*cc5< hoursD Iccmineral mi,

- TransfusionPC21+cc51&jam

- 3njceftria,one1+*mg51hours5iv

- 2onsultgastrohepato

logy division- 2onsult

hematooncology division

- 2onsultnutrition andmetabolicdiseasedivision

- 2omplete urineand fescesanalysis

- 2hec/ 3ron profile

- Peripheral blood smear

- ?arium Enema

5 *51* +

@'5 *51* +

Aostappetite?loodyvomit (-)

bloodystool (-)fever (D)

0ens > !lertT > < 2?" > & '/g?# > I&cm#ead> eye reflect D5Disocor pale conj. Palpebrainferior-5-Ear5Bose5Mouth> normal

Bec/> K4P CD1 cm # 1$Thora, > 0ymmetrisfusiformis retraction (-)#C > **,53 regulermurmur (-) CC > 1&,5ireguler ronchi -5-!bdomen > soepel normal

peristaltic #epar> palpeble1cm ?!2 Aien> palpeble0333E,tremities > pulse **,5ireguler ade;uate pressure

and volume warm 2CT


bleeding- !nemia

- 34:6 6+ Ba2l * 11+1*gtt53(micro)

- :olic acid, mg


- 4itamin 2

,+*mg- 6iet : +

7*cc5< hoursD Iccmineral mi,

- TransfusionPC21+cc51&jam

- 3njceftria,one1+*mg5 1ho

urs5iv

- 0cheduled for!bdominalL-ray

- E,pecting?ariumEnema result


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G< pretibial edema (-)

Cesultfrom =astrointestinaldivison> recommend to do!bdominal ,-ray 1 positionCoutine urine analysis A:T

1*5 *51* +

Aostappetite?loodystool (-)fever (-)

0ens > !lertT > < + 2?" > & '/g?# > I&cm#ead> eye reflect D5Disocor pale conj. Palpebra

inferior-5-Ear5Bose5Mouth> normal

Bec/> K4P CD1 cm # 1$Thora, > 0ymmetrisfusiformis retraction (-)#C > **,53 regulermurmur (-) CC > 1&,5ireguler ronchi -5-!bdomen > soepel normal

peristaltic #epar> palpeble1cm ?!2 Aien> palpeble0333E,tremities > pulse **,5ireguler ade;uate pressureand volume warm 2CTG< pretibial edema (-)


bleeding- !nemia

- 34:6 6+ Ba2l * 11+1*gtt53(micro)

- 3nj. Canitidine+mg5 1

hours5 34- :olate acid,+mg


- 4itamin 2,+*mg

- 6iet : +7*cc5< hoursD Icc

mineral mi,- 3njceftria,one1+*mg5 1hours5iv

- !bdominal L-ray

1 5 *5+

?loodystool (-)fever (-)

0ens > !lertT >


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1cm ?!2 Aien> palpeble0333

E,tremities > pulse '1,5ireguler ade;uate pressureand volume warm 2CTG< pretibial edema (-)Aaboratorium result >- Ceticulocyte :ood recall 1& hours>Morning> porridge 51

portion D carrot piece!fternoon> porridge

portion D potato piece Bight> porridge portion Dcarrot piece?reast feeding on demand.Therapy > - diet : + 7*cc5 !lertT > < 2

?" > & '/g?# > I&cm#ead> eye reflect D5Disocor pale conj. Palpebrainferior D5DEar5Bose5Mouth> normal

Bec/> K4P CD1 cm # 1$Thora, > 0ymmetrisfusiformis retraction (-)#C > '7,53 regulermurmur (-) CC > 1&,5ireguler ronchi -5-


bleeding- Post#emorrhagic!nemia

- 34:6 6+ Ba2l * 11+

1*gtt53(micro)

- 3nj. Canitidine+mg5 1hours5 34

- :olic acid, mg


- 4itamin 2

,+*mg


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!bdomen > soepel normal peristaltic #epar> palpeble

1cm ?!2 Aien> palpeble0333E,tremities > pulse '7,5ireguler ade;uate pressureand volume warm 2CTG< pretibial edema (-)

- 6iet : **7*cc5< hours

D Iccmineral mi,

- 2otrimo,a%olesyr 1,cth 51

1I5 *51* +

?loodystool (-)fever (-)

0ens > !lertT > < 2?" > & '/g?# > I&cm

#ead> eye reflect D5Disocor pale conj. Palpebrainferior D5DEar5Bose5Mouth> normal

Bec/> K4P CD1 cm # 1$Thora, > 0ymmetrisfusiformis retraction (-)#C > '7,53 regulermurmur (-) CC > 1&,5ireguler ronchi -5-!bdomen > soepel normal

peristaltic #epar> palpeble1cm ?!2 Aien> palpeble0333E,tremities > pulse '7,5ireguler ade;uate pressureand volume warm 2CTG< pretibial edema (-)

P?K


bleeding- Post hemorrhagic

anemia

- 34:6 6+ Ba2l * 11+1*gtt53(micro)

- 3nj. Canitidine+mg5 1hours5 34

- :olic acid, mg


- 4itamin 2,+*mg

- 6iet : **

7*cc5< hoursD Iccmineral mi,

- 2otrimo,a%olesyr 1,cth 51

iscussion

Marasmus is one of the < forms of severe protein-energy malnutrition

(PEM) that represent 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. (Cabinowit% 1* &)

Marasmus is more fre;uent in children younger than + years because this

period is characteri%ed by increased energy needs and increased susceptibility to


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viral and bacterial infections. "eaning which occurs during this period is often

complicated by factors such as geography (eg drought poor soil productivity)

economy (eg illiteracy unemployment) hygiene (eg access to ;uality water)

public health (eg number of nurses is more than number of physicians) and

culture and dietetics (eg intrafamily distribution of high-nutrition foods). Bo

racial predilection in the prevalence of malnutrition is evident but a strong

association with the geographic distribution of poverty is observed. Bo se,ual

predilection is observed although in some parts of the world cultural practices

place girls at a disadvantage for PEM. (Cabinowit% 1* &)

Marasmus always results from a negative energy balance. The imbalance

can result from a decreased energy inta/e an increased loss of ingested calories

(eg emesis diarrhea burns) an increased energy e,penditure or combinations of

these factors such as is observed in acute or chronic diseases. 2hildren adapt to

an energy deficiency with a decrease in physical activity lethargy a decrease in

basal energy metabolism slowing of growth and finally weight loss. The

pathophysiological processes cause body composition metabolic and anatomic

changes. (Cabinowit% 1* &)

3n this case we found an ' months old boy came with complaint of lost

appetite and weight loss. 0ince he was months old his weight was not

increasing. This condition began when he suffered gastrointestinal bleeding 1

months ago which happen again at the moment. #e has never finished the meal

served which cause decreased energy inta/e. The slowing growth appears on the

not increasing weight these last 1 months.

?ody fluid compartments are altered by many factors such as nutritional

status and disease. 2hildren with marasmus have a high total body water but

contrarily there is a significant reduction in adipose mass as well as lean body

mass. ($shi/oya and 0enbanjo 1**') Protein mass can decrease as much as


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performed by measuring arm circumference or s/infold thic/ness such as triceps

s/infold. (Cabinowit% 1* &)

2hildren with marasmus shows clinical manifestastion such as>

2hildren loo/ed very thin and have old-man face Mental status change irritability 6ry flagging and wrin/led s/in Aoss of subcutaneous fat Muscle atrophy rib and bac/bone clearly visible ?radychardia and lower blood pressure than normal healthy children

3n the case we found a very thin baby with appearance of old-man face. #e

is very irritable and easily crying. There is muscle atrophy and loss of

subcutaneous fat. The ribs are clearly visible called Npiano signH. $n the bottom

it has appearance of Nbaggy-pantsH.

The overall metabolic adaptations that occur during marasmus are similar

to those in starvation. ! rise in gluconeogenesis leads to a perceived increased

metabolic rate. !s the chronic underfeeding progresses the basal metabolic rate

decreases. Ceduced energy metabolism can impair the response of patients with

marasmus to changes in environmental temperature resulting in an increased ris/

of hypothermia. $ne of the main adaptations to long-standing energy deficiency

is a decreased rate of linear growth yielding permanent stunting. (Cabinowit%

1* &)

6ecreased oral absorption in digestive tract was attributed to the with

villous atrophy of the jejunal mucosa. ($shi/oya and 0enbanjo 1**') The

mucosal surface becomes smooth and thin and secretory functions are impaired.

! decrease in gastric hydrochloric acid (#2l) e,cretion and a slowing of peristalsis is observed yielding bacterial overgrowth in the duodenum.

(Cabinowit% 1* &)


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laboratory tests or radiographic tests may be needed. Aaboratory tests adapted

from the "#$ include the following>

?lood glucose> #ypoglycemia is present if the level is lower than

Presence of parasites is indicative of infection. 6irect test is suitable but

e,pensive. #emoglobin> ! level lower than &* g5A is indicative of severe anemia. rine e,amination and culture Multisti,> More than * leu/ocytes per

high-power field is indicative of infection. Bitrites and leu/ocytes aretested on Multisti, also.

0tool e,amination by microscopy> Parasites and blood are indicative of

dysentery. !lbumin> !lthough not useful for diagnosis it is a guide to prognosis8 if

albumin is lower than #34 test should not be routinely performed8 if completed it

should be accompanied by counseling of the child s parents and the

result should be confidential. Electrolytes> Measuring electrolytes is rarely helpful and it may lead to

inappropriate therapy. #yponatremia is a significant finding.

Treatment for severe malnutrition has & phases> initial stabili%ation

transition rehabilitation and follow-up. (9emen/es 1* ) 3t involve treatment

for #ypoglycaemia #ypothermia 6ehydration Electrolytes 3nfection

Micronutrients no iron with iron 3nitiate feeding 2atch-up feeding 0ensory

stimulation Prepare for follow-up. ("#$ 1*


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3n the initial phase re-feeding should be gradual. The essential features of

initial feeding are> ("#$ 1*


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/cal and *.' g protein5 ** ml) will be satisfactory for most children. !s cereal-

based :- + partially replaces sugar with cereal flour it has the advantage of lower

osmolarity which may benefit some children with persistent diarrhoea but it has

to be coo/ed. ("#$ 1*


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=ood ( * g5/g per day)

RE'ERE4CE5

Elsa 1**'. Protein-energy malnutrition . Toulouse Purpan medical school.

9ementrian 9esehatan Cepubli/ 3ndonesia. 1* . ?agan Tatala/sana !na/ =i%i

?uru/ ?u/u 3.

$shi/oya 9. and 0enbanjo 3. 1**'. Pathophysiological changes that affect drug

dispotition in protein-energy malnourished children. Nutrition &

Metabolism I>+*.

Cabinowit% 0. Marasmus. !vailable from>

http>55emedicine.medscape.com5article5'7&&'I Q!ccessed Bovember + th

1* +R

"orld #ealth $rgani%ation. 1* "orld #ealth $rgani%ation.
http://emedicine.medscape.com/article/984496http://emedicine.medscape.com/article/984496

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Lapkas Anak Marasmus - Revised