Severe acute malnutrition: marasmus and kwashiorkor

Aetiology

Pathophysiology in brief

• Reductive adaptation: in starvation the body's systems slow down to survive on little energy (low metabolic rate, weak heart, poor kidney function, reduced gut and immune activity, lower body temperature). Refeeding must therefore be slow and cautious; rapid feeding or IV fluid can overwhelm the heart and kidneys.
• Marasmus: energy is very low overall; the body uses fat and muscle, keeping albumin near normal, so there is no oedema.
• Kwashiorkor: hypoalbuminaemia contributes to oedema, and the liver cannot export fat, giving a fatty enlarged liver; skin, hair and gut are damaged.
• Immunity is impaired (especially cell-mediated), so infection is common and signs such as fever may be absent; the tuberculin test is often negative.
• Body potassium and magnesium are low while body sodium is high, which is why ordinary ORS and IV saline are dangerous.

Marasmus versus kwashiorkor

Clinical assessment

History: usual diet, breastfeeding, recent food and fluids, vomiting and diarrhoea, recent sinking of the eyes, when urine was last passed, contact with measles or TB, sibling deaths, birth weight, milestones, immunisation.

Examination: weight, length or height, MUAC, oedema, liver size and jaundice, abdominal distension, severe pallor, signs of shock (cold hands, weak pulse, reduced consciousness), temperature (hypothermia or fever), eye signs of vitamin A deficiency (Bitot spots, corneal clouding or ulcer), mouth (thrush, ulcers), ears and skin infection.

Laboratory assessment

Biochemistry of kwashiorkor: hypoalbuminaemia with reversed albumin-globulin ratio, low cholesterol, low plasma amino acids with aminoaciduria, low enzymes (cholinesterase, lipase, alkaline phosphatase), low urinary hydroxyproline-creatinine ratio, raised growth hormone, and a diabetic-like glucose tolerance curve.

Management: WHO 10 steps

Phases (time frame)

The 10 steps

1. Treat or prevent hypoglycaemia

• Blood glucose below 54 mg/dL; signs include low temperature (below 36.5°C), lethargy and limpness (sweating and pallor are usually absent).
• Treat without waiting for the result: 50 mL of 10% glucose or sucrose orally or by NG tube; if unconscious, 5 mL/kg of 10% glucose IV, then 50 mL by NG tube.
• Feed every 2-3 hours, day and night.

2. Treat or prevent hypothermia

• Axillary below 35°C or rectal below 35.5°C.
• Kangaroo (skin-to-skin) care, cover with warm blankets including the head, warm room or lamp (not touching); check temperature every 30 minutes; treat for hypoglycaemia and infection too.

3. Treat or prevent dehydration

• Use ReSoMal (Rehydration Solution for Malnutrition): less sodium, more potassium and more sugar than standard ORS. Do not use standard ORS.
• Dose: 5 mL/kg every 30 minutes for 2 hours, then 5-10 mL/kg every hour for up to 10 hours, guided by thirst and stool losses.
• IV fluids only for shock: 15 mL/kg over 1 hour of Ringer's lactate with 5% dextrose (or half-strength Darrow's or 0.9% saline with 5% dextrose); reassess; if no improvement assume septic shock.
• Diagnosing dehydration is hard: wasted children have poor skin turgor and sunken eyes anyway.

4. Correct electrolyte imbalance

• Extra potassium and magnesium (in the mineral mix added to F-75, F-100 and ReSoMal).
• Low sodium food and fluids; do not treat oedema with diuretics.

5. Treat infection

• Give antibiotics to every child with SAM, even without signs.
• Uncomplicated: oral amoxicillin (or cotrimoxazole) for 5 days.
• Complicated (shock, hypoglycaemia, hypothermia, lethargy, skin, chest or urinary infection): ampicillin 50 mg/kg IM or IV 6-hourly for 2 days, then oral amoxicillin 15 mg/kg 8-hourly for 5 days, plus gentamicin 7.5 mg/kg once daily for 7 days.
• No improvement after 48 hours: add ceftriaxone. Treat specific infections (TB, malaria, worms, dysentery, candida).
• Measles vaccine to unvaccinated children from 9 months, on admission and discharge.

6. Correct micronutrient deficiencies

• Vitamin A on day 1: 50,000 IU under 6 months, 100,000 IU at 6-12 months, 200,000 IU over 12 months.
• Folic acid 5 mg on day 1, then 1 mg daily; zinc, copper and multivitamins.
• No iron during the initial phase; start iron (3 mg/kg/day) in rehabilitation once the child is gaining weight.

7. Start cautious feeding with F-75

• F-75: 75 kcal and 0.9 g protein per 100 mL; low in protein and sodium, high in carbohydrate.
• Small, frequent feeds (every 2-3 hours), by cup, or NG tube if the child cannot take enough.
• Continue breastfeeding.

8. Achieve catch-up growth

• When appetite returns (usually 2-7 days), change to F-100: 100 kcal and 2.9 g protein per 100 mL, or RUTF.
• Akbar's diet table gives energy 120-140 kcal/kg/day and protein 3-5 g/kg/day; Nelson advises raising intake by 10-20% a day while watching for electrolyte problems, oedema and heart failure.
• Weigh daily. Weight gain: poor under 5 g/kg/day, moderate 5-10, good over 10 g/kg/day.

9. Provide sensory stimulation and emotional support

• Tender loving care, play, a cheerful environment; involve the mother in care.

10. Prepare for follow-up after recovery

• Teach the mother to prepare energy-dense home foods (khichri, dalia, firni, eggs) and to play with the child.

Severe anaemia and eye problems

• Transfuse in the first 48 hours if Hb below 4 g/dL (PCV below 12%), or Hb 4-6 g/dL with respiratory distress; give packed cells or whole blood slowly and watch for heart failure.
• Corneal clouding or ulcer: vitamin A immediately, atropine 1% drops to the affected eye, tetracycline eye drops and eye padding.

Refeeding syndrome

Too much carbohydrate too quickly → insulin surge → potassium, phosphate and magnesium shift into cells. Hypophosphataemia causes weakness, rhabdomyolysis, white cell dysfunction, heart and respiratory failure, seizures and sudden death. Prevent with slow F-75 feeding and mineral mix.

Failure to respond

• Initial phase longer than 10 days, or weight gain under 5 g/kg/day for 3 days in rehabilitation.
• Look for hidden infection (TB, UTI, HIV), feeding errors, staff or home problems, or a different underlying disease.

Community management (RUTF)

• Children with uncomplicated SAM (good appetite, no medical complication, able to finish the RUTF appetite test) can be treated at home with ready-to-use therapeutic food (RUTF), oral antibiotics for 5 days, and weekly follow-up.
• Give RUTF in small, frequent meals (5-6 a day), breast milk first if breastfed, and plenty of clean water; no other food for at least 2 weeks except breast milk.
• Do not give iron with RUTF (it already contains iron).
• Children who fail the appetite test or have complications need inpatient care.

Complications

Prognosis

• Untreated or badly treated SAM has high mortality; with WHO protocols most children recover.
• Poor prognostic signs: hypoglycaemia, hypothermia, shock, severe dehydration, very low albumin, jaundice, extensive skin lesions, corneal ulceration, severe anaemia, overwhelming infection, HIV, and age under 6 months.
• Recovery: initial recovery in 2-3 weeks (oedema clears, appetite and mood improve); consolidation over the next 2-3 months as normal weight returns.
• Stunting and developmental effects may persist if malnutrition was prolonged.

Discharge and follow-up

Transfer from the initial phase to rehabilitation when the child is eating well, mental state improves (smiles, responds), temperature is normal, there is no vomiting or diarrhoea, oedema has gone, and weight gain is over 5 g/kg/day for 3 days.

Discharge criteria (Akbar):

• Child: adequate weight gain, eating a diet the mother can prepare at home, deficiencies treated, infections treated, immunisation started.
• Mother: able and willing to care, knows how to prepare food and feed, how to play with the child, how to treat diarrhoea, fever and ARI at home, and when to seek help.
• Health worker: able to ensure follow-up.

Follow-up visits (risk of relapse is highest soon after discharge): 1 week, 2 weeks, 1 month, 3 months and 6 months, then twice a year until at least 3 years of age.

Prevention

• Exclusive breastfeeding for 6 months, continued to 2 years.
• Timely, energy-dense complementary feeding from 6 months.
• Growth monitoring (the first sign of PEM is underweight for age on the chart).
• Immunisation, especially measles; vitamin A supplementation; deworming.
• ORS and continued feeding in diarrhoea; handwashing, safe water, sanitation.
• Family planning and birth spacing; nutrition of pregnant and lactating women.
• Nutrition education and food security programmes.

Quick revision

• SAM: WFH below −3 Z, MUAC below 115 mm, or bilateral pitting oedema.
• Marasmus: no oedema, under 60% weight, old-man face, alert, hungry.
• Kwashiorkor: oedema always, apathy, anorexia, flaky-paint skin, sparse hair (flag sign), fatty liver, low albumin.
• Wellcome: 60-80% + oedema = kwashiorkor; under 60% + oedema = marasmic kwashiorkor.
• Steps: hypoglycaemia, hypothermia, ReSoMal, electrolytes, antibiotics, micronutrients (no iron), F-75, F-100/RUTF, stimulation, follow-up.
• F-75 = 75 kcal + 0.9 g protein/100 mL; F-100 = 100 kcal + 2.9 g protein/100 mL.
• IV fluids only for shock: 15 mL/kg over 1 hour.
• Good weight gain over 10 g/kg/day; under 5 g/kg/day is failure.

Written by The House Job from standard references (Basis of Paediatrics by Pervez Akbar; Nelson Essentials of Paediatrics; Park's Preventive and Social Medicine).

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