What is the management of marasmus in children?

Management of Marasmus in Children

The management of marasmus in children requires a comprehensive therapeutic approach with immediate nutritional rehabilitation using ready-to-use therapeutic food (RUTF) under community-based management of acute malnutrition (CMAM) protocols, with recovery rates approaching 90% under optimal conditions. 1

Assessment and Diagnosis

• Marasmus is characterized by severe wasting without edema, representing one form of severe acute malnutrition (SAM)

• Key anthropometric criteria for diagnosis:

  • Weight-for-height Z-score < -3 SD
  • Mid-upper arm circumference (MUAC) < 11.5 cm in children 6-59 months
  • Visible severe wasting

• Clinical features to assess:

  • Severe muscle wasting with "old man" appearance
  • Absence of edema (distinguishes from kwashiorkor)
  • Skin appears loose and wrinkled ("baggy pants")
  • Irritability and apathy
  • Assess for comorbidities, especially infections

Treatment Protocol

Step 1: Triage and Emergency Management

• Perform rapid triage assessment for life-threatening complications 2:

  • Respiratory distress or irregular breathing
  • Signs of shock (tachycardia, cold extremities, capillary refill >2 seconds)
  • Depressed consciousness
  • Severe dehydration
  • Hypoglycemia

• For emergency cases with complications:

  • Secure airway and provide oxygen if needed
  • Treat hypoglycemia with 10% glucose (5 ml/kg)
  • Manage shock with careful fluid resuscitation (20 ml/kg of colloid or 0.9% saline) 2
  • Monitor for respiratory deterioration during fluid resuscitation

Step 2: Nutritional Rehabilitation

For Uncomplicated Marasmus:

• Implement community-based management using RUTF at 175-200 kcal/kg/day 1
• RUTF should provide:
  • Energy: 520-550 kcal/100g
  • Protein: 10-12% of total energy
  • Lipids: 45-60% of total energy
  • Essential micronutrients

For Complicated Marasmus (with medical complications):

• Initial stabilization phase (1-7 days):

  • Start F-75 formula (75 kcal/100ml, 0.9g protein/100ml)
  • Provide in small, frequent feeds (8-12 feeds/24 hours)
  • Target 100-130 kcal/kg/day initially
  • Monitor for refeeding syndrome

• Rehabilitation phase:

  • Transition to F-100 formula (100 kcal/100ml, 2.9g protein/100ml)
  • Gradually increase to 150-220 kcal/kg/day
  • Continue until reaching target weight (usually -1 SD weight-for-height)

Step 3: Antibiotic Therapy

• Provide empiric antibiotics even in uncomplicated cases 2

• First-line options:

  • Amoxicillin (RR 1.05; 95% CI 1.00-1.11 for nutritional recovery) 2
  • Alternative: Cefdinir (shown to reduce mortality compared to placebo) 2

• For complicated cases with suspected sepsis:

  • Ampicillin + gentamicin (first choice) 2
  • Alternative: Amikacin + cloxacillin or cefotaxime/ceftriaxone 2

Step 4: Management of Complications

• Diarrhea:

  • Provide ORS after each loose stool (100-200 ml for a 3-year-old) 3
  • Continue feeding during diarrheal episodes
  • Avoid antimotility agents in children 3

• Malabsorption:

  • Address underlying bile acid deficiency that contributes to fat malabsorption 4
  • Consider lactose-free formulas initially as lactase deficiency is common 2

• Infections:

  • Screen for HIV and tuberculosis as these significantly increase mortality risk (HR=1.8 for HIV) 5
  • Treat specific infections according to identified pathogens

Monitoring and Follow-up

• Daily monitoring during initial phase:

  • Weight gain (target: 5-10g/kg/day during rehabilitation)
  • Vital signs, especially respiratory rate
  • Edema development (may indicate refeeding syndrome)
  • Appetite and feed tolerance

• Laboratory monitoring:

  • Electrolytes (especially potassium, sodium)
  • Blood glucose
  • Hemoglobin (anemia is common, present in 80% of cases) 6
  • Serum albumin (typically low in marasmus) 6

Discharge Criteria and Follow-up

• Discharge when:

  • Weight-for-height reaches ≥ -2 SD or
  • MUAC ≥ 12.5 cm with no edema for 2 consecutive weeks
  • Child is clinically well with good appetite

• Post-discharge follow-up:

  • Weekly visits for first month
  • Biweekly for second month
  • Monthly thereafter until fully recovered

Common Pitfalls to Avoid

• Avoid rapid refeeding which can cause refeeding syndrome with potentially fatal electrolyte imbalances
• Don't withhold food during diarrhea - continued feeding is essential for intestinal mucosal recovery 2
• Don't use standard fluid resuscitation protocols in severely malnourished children with shock - use more cautious fluid administration
• Avoid oral quinine for malaria treatment in young children as it is unpalatable 2
• Don't neglect screening for comorbidities like HIV and TB which significantly increase mortality risk

Long-term Considerations

• Address underlying causes of malnutrition:

  • Food insecurity
  • Chronic infections
  • Poor complementary feeding practices
  • Environmental enteropathy

• Monitor for cognitive and developmental delays

• Implement growth monitoring to prevent relapse

• Provide caregiver education on optimal feeding practices

Implementation of standardized WHO protocols for marasmus management has been shown to significantly improve outcomes and reduce mortality rates 6.