clinical marasmus

7/25/2019 Clinical Marasmus

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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 tostarvation.

• Is the most common form of malnutrition.

•

Body weiht is !"# less than theex$ected weiht.

• %hin limbs and $rominent ribs are seen.



&linical Database'

A 10 month old male child was examined during a

health screening program of an NG! "he mother

complained that her child was always hungry and crying

for food# and was ha$ing loose stools for the past 1month! "he stri%ing features noted was the

emancipated appearance, with gross wasting of all

muscle groups with the s%in hanging in loose folds and

lac% the normal shine and texture!



"he child&s height was '0cm and weight was (%ilograms which were in the 10th and )elow the (th

percentile# respecti$ely of normal height and weight for

his age! "here was no edema! "he midarm

circumference * MA+, was 10 cm and the triceps s%infold thic%ness *"-", was (mm! "he mid.arm muscle

circumference *MAM+, was calculated to )e /!(! All

those anthropometric $alues when compared to standard

ta)le for age group and sex were )elow the (th percentile

and indicate wasting# low fat and protein reser$e!



(aboratory %est )esults'

• asting lood Glucose: 0 mg3d4

• 2hr Post. Prandial lood Glucose: 1'5 mg3d4

• -erum Al)umin: 1!/ g3d4

• -erum Preal)umin: /mg3d4

• 6rine +reatine: 0! mmol3per day

• 7+: 8#(00 cells3 cu)ic mm

• ".cell count: low at 800 cells3cu)icmm

• -tool exam: a)undant fat glo)ules# pus cells and

9+!



*. State the features of Marasmuswhich will di+erentiate it from

,washiorkorFEATURES MARASMUS KWASHIORKOR

Growth -ailure )/S/0% )/S/0%

Muscle wastin )/S/0% )/S/0%

/dema 1BS/0% )/S/0%2air chanes 1BS/0% )/S/0%

Mental chanes 1BS/0% )/S/0%

Dermatosis 1BS/0% )/S/0%

1$$etite )/S/0% 1BS/0%

1nemia )/S/0% )/S/0%3 S/4/)/

-at 1BS/0% )/S/0%3 )/D5&/D

-ace M60,/7 (I,/ /D/M1%65S

-atty in8ltration in (iver 1BS/0% )/S/0%



"he li$er of a %washior%or child is yellow and fatty #due to reduced serum le$els of carrier proteins! "he

li$er of a marasmus child is normal )ut the lower

extremity show wasting !



9. /x$lain the abnormal biochemical orlaboratory test seen in this $atient

• asting lood Glucose: 0 mg3d4 * '0.100 md3d4,

DECREASE

• 2hr Post. Prandial lood Glucose: 1'5 mg3d4 *120mg3d4,

INCREASE• -erum Al)umin: 1!/ g3d4 *8!(.(!( g3d4, DECREASE

• -erum Preal)umin: /mg3d4 * 1.0 mg3d4, DECREASE

• 6rine +reatine: 0! mmol3per day DECREASE

• 7+: 8#(00 cells3 cu)ic mm * #(00. 10#000 cells3mm,DECREASE

• ".cell count: low at 800 cells3cu)icmm DECREASE

• -tool exam: a)undant fat glo)ules# pus cells and 9+!



:. /x$lain the hormonal chanes thatwill brin about muscle wastin seen

in this $atient(1) GH; asal G; le$els are high in children with

marasmus and they decrease to normal nutritional

reha)ilitation!"he cause for increased secretion of G;

• 4ow <G.1 which exert negati$e feed)ac% effect on the

hypothalamic.pituitary axis!

• 4ow serum tyrosine! its has )een demonstrated to correlate

significantly with )asal G; le$el in malnourished children

)efore and after reha)ilitation!



(2) Glucocorticoids=• -erum cortisol le$els are high in the marasmus!

• "he response of cortisol to A+"; stimulation are

satisfactory in the marasmus!

•-erum cortisol le$els ha$e not correlated with either )loodglucose or serum al)umin in a large num)er of children with

PEM!

• "he stress of malnutrition and the presence of infections are

thought to )e the ma=or etiological factors in the ele$ation

of cortisol le$els.



(3) Insulin nd Gluc!on=•

4ow )asal serum insulin le$els ha$e )een demonstrated inchildren with marasmus!

• "he insulin reser$e in response to arginine stimulation has

)een impaired in patients with marasmus!

• "he low insulin3glucagon ratios in patients with PEM produced the following:

. >ecrease glucose upta%e )y muscle and adipose tissue )ut

not )y the )rain and heart . <ncrease muscle protein cata)olism to supply the essential

amino acids necessary for gluconeogenesis and other

)iosynthetic purpose!



• <ncrease lipolysis and supply of fatty acids to peripheral

tissues.

(") T#$roid Hor%on&=• "he free " le$els ha$e )een reported as normal or low in

marasmus!

• " le$els reported in this children patient with PEM could )e due to deficiency of thyroid )inding glo)ulin and

preal)umin!

•

"his suggest that decreased circulating "8 is not due todiminished hormone production )ut rather is an adaptation

of peripheral meta)olism of " directing the de.iodination

of " to "8 !



. /numerate some tools for eneral nutritionassessment and ex$lain its sini8cance

• Medical history

•

-creening• Anthropometric measurements

• iochemical measurements

•+linical measurements



Medical history

• >irected toward identifying underlying mechanism

that put patients at ris% for nutritional depletion or

excess! "hese mechanism include inade?uate inta%e#

impaired a)sorption# decreased utili@ation# increasedlosses# and increased re?uirements of nutrients!

-ource: ;arrison&s Principle of <nternal Medicine 1/th Edition



Screenin

• <s the process of identifying patient characteristics

%nown to )e associated with nutritional pro)lems!

• <ts purpose it to ?uic%ly identify indi$iduals who are

malnourished or at nutritional ris% .




1nthro$ometric Measurements

• Pro$ide information on the )ody muscle mass and fat

reser$es! "he most practical and commonly used

measurements are )ody weight# height# triceps

s%infold and midarm circumference!




=eiht and heiht measurementsare essential to'

• <dentify malnourished infants and children!

• 4in% at.ris% children to medical and social ser$ices!

• E$aluate the o$erall health status of children!



Mid 1rm &ircumference

• <s an excellent indicator of nutritional status and has

an important ad$antage of operational simplicity!

• <t is reduced su)stantially in the undernourished and

su)stantially increases in children who areo$erweight!



M51& less than **"mm >**."cm?3 )/D &6(65)3 indicates Severe 1cuteMalnutrition .

M51& of between **"mm >**."cm? and *9@mm >*9.@cm?3 )/D&6(65) >:Acolour %a$e? or 6)10G/ &6(65) ><Acolour %a$e?3 indicates

Moderate 1cute Malnutrition >M1M?. %he child should be immediatelyreferred for su$$lementation. M51& of between *9@mm >*9.@cm? and *:@mm >*:.@cm?3 7/((6=&6(65)3 indicates that the child is at risk for acute malnutrition andshould be counseled and followedAu$ for Growth romotion and

Monitorin >GM?.



%rice$s Skinfold %hickness

• A measure of

su)cutaneous fat

stores ta%en at the

midpoint of the posterior aspect of

the humerus

• +orrelates closely

with the percentageof )ody fat and

with total )ody fatC1'%% #&lt#$ c#ildr&n1 $&rs

*%% + indicti,& -o%od&rt& to s&,&r&



Biochemical measurements

• many of the routine )lood and urine la)oratory test

found in patient&s chart are useful in pro$iding an

o)=ecti$e assessment of nutritional status!



&linical 1ssessment

• <s the physical examination of an indi$idual for signs

and symptoms! "he examination is conducted )y the

physician on the anatomic changes that can )e

o)ser$ed!• "he use of stethoscope # )lood pressure and pulse rate

measurements# height and weight are standard

procedures in P!E! charting!



@ ib l h i



@. rescribe a eneral a$$roach inthe manaement of this case and

its rationale• A nutritious# well.)alanced diet with lots of fresh fruits and

$egeta)les# grains# and protein will reduce the ris% of

malnutrition and any related marasmus!

• "reatment of marasmus in$ol$es a special feeding andrehydration plan and close medical o)ser$ation to pre$ent

and manage complications of malnutrition! Pediatric

nutrition reha)ilitation centers ha$e )een esta)lished in

some countries and regions to coordinate treatment ofmalnourished children! <ntra$enous fluids# oral rehydration

solutions# and nasogastric feeding tu)es are forms of

treatment that may )e used!

clinical marasmus

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