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CHAPTER I

INTRODUCTION

1.1. Background

Marasmus is one of the three forms of serious protein-energy malnutrition (PEM). The

other 2 forms are kwashiorkor (KW) and marasmic KW. Nearly 30% of humans currently

experience one or more of the multiple forms of malnutrition. Close to 50 million children

younger than 5 years have PEM, and half of the children who die younger than 5 years are

undernourished. Malnutrition has been a permanent priority for the WHO for decades. In 2014,

there was approximately three million indonesian, under five years old children were diagnosed

as marasmus. 1 Pediatric malnutrition (undernutrition) is defined as an imbalance between

nutrient requirement and intake, resulting in cumulative deficits of energy, protein, or

micronutrients that may negatively affect growth, development, and other relevant outcomes.2

Severe Acute Malnutrition (SAM) is common in rapid onset emergencies, chronic

emergencies as well as non-emergency situations. It is estimated that nearly 20 million children

under the age of five years suffer from SAM at any one point in time (WHO/UNICEF/SCN/WFP

Joint Statement 2007). This suggests that there are potentially 40 million children suffering from

SAM every year. An estimated 0.5 million to 2 million children with SAM die each year. 3

Marasmus is one of severe acute malnutrition (SAM) condition and is primarily caused

by a deficiency in calories and energy which is characterized by skin and bones appearance, old

man face, prominent ribs, baggy pants. Based on body measurements, marasmus is classified as

moderately acutely malutrition and severely acutely malutrition. This is determined by patient’s

degree of wasting.4

Marasmus was identified through a combination of clinical and laboratory criteria.

Accurate diagnosis of marasmus is important because treatment can reduce mortality and

morbidity. Marasmus has many different symptoms but the common ones include old man face,

prominnent ribs, baggy pants. 5

As of November 11, 2013, the World Health Organization has reported more than 6,300

confirmed measles cases in Indonesia during 2013. In August 2013, a US traveler returned from

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Indonesia with measles and spread the disease in a Texas community. In October, five

Australians were diagnosed with measles after returning from Bali. 17

Measles is caused by measles virus which is a single-stranded, lipid-enveloped RNA

virus in the family Paramyxoviridae and genus Morbillivirus. Other members of the genus

Morbillivirus affect a variety of mammals, such as rinderpest virus in cattle and distemper virus

in dogs, but humans are the only host of measles virus. Clinical manifestations of Measles

characterized by high fever, an enanthem, cough, coryza, conjunctivitis, and a prominent

exanthem. Measles is an important acute childhood viral infection having severe consequences

on the nutritional status. Therefore the nutritional status of the patient should be noticed. The

adverse nutritional effects of measles are experienced by both the well-nurished and the

malnourished children.

1.2. Objective

The aim of this study is to explore more about the theoritical aspects on marasmus and

morbili and to integrate the theory and application of marasmus and morbili case in daily life.

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CHAPTER II

LITERATURE REVIEW

2.1.Marasmus

2.1.1. Epidemiology of Marasmus

Based on data in Unicef, there are 3,303,000 children (under five years old) diagnosed as

wasting in 2014 and 8,906,000 stunted-children.1

2.1.2. Definition of Marasmus

The World Health Organization (WHO) defines malnutrition as “the cellular imbalance

between the supply of nutrients and energy and the body’s demand for them to ensure growth,

maintenance, and specific functions.” 7

Marasmus is a condition primarily caused by a deficiency in calories and energy (PEM).

Typical characteristics of a wasted (marasmic) child include: 8

‘Skin and bones’ apperance

A thin ‘old man’ face

Front view: ribs easily seen, skin of upper arms loose, skin of thighs loose.

Back view: Ribs and shoulder bones easily seen, flesh missing from buttocks resulting in

loose skin or “baggy pants”

Usually active and may appear to be alert

2.1.3. Classification of Marasmus

Malnutrition is divided into overnutrition anda undernutrition. Undernutrition covers a

range of disorders including impaired growth and micronutrient deficiencies.

Table 2-1 Number of malnourished children based on data in Unicef

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Malnutrition can be classified as either acute (fewer than 3 months in duration) or chronic

(duration of 3 months or more). 9

There are 3 clinical forms of acute malnutrition.

Marasmus –  severe weight loss or wasting

Kwashiorkor – bloated appearance due to water retention (bi-lateral oedema). , indicates

an associated protein deficiency, resulting in an edematous appearance.

Marasmic-kwashiorkor – a combination of both wasting and bi-lateral oedema.

Chronic malnutrition may manifest with growth deficits, especially diminished height

velocity (stunting), which is a hallmark of this condition that may be observed earlier than 3

months in the course of malnutrition. 2

5

Since Marasmus is one of protein-energy malnutrition (PEM), these are anthropometric

classification of PEM : 10

Underweight : Weight for age < -2SD of the median age-sex specific weight of the

NCHS/WHO reference

Stunting: Height for age < -2SD of the median age-sex specific height of the

NCHS/WHO reference

Wasting: Weight for height <-2SD of the median weight at a given height of the

NCHS/WHO reference

Table 2-2 Practical Scheme for Pediatric Malnutrition Classification

Table 2-3 General Classification of Child Undernutrition by Anthropometry (Waterlow Classification)

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2.1.4. Pathophysiology

Various extensive reviews of the pathophysiological processes resulting in marasmus are

available. Unlike kwashiorkor. The clinical sequelae of marasmus can be considered as

an evolving adaptation in a child facing an insufficient energy intake. Marasmus always

results from a negative energy balance. The imbalance ca result from a decrease energy

intake , an increased loss of ingested calories (eg, emesis, diarrhea, burns), an increase

energy expenditure, or combinations of these factors, such as is observed in acute or

chronic diseases. Children adapt to an energy deficiency with decrease in physical

activity, lethargy, a decrease in basal energy metabolism, slowing of growth anda finally

weight loss.

2.1.5. Body composition

Body mass: body mass is significantly decrease in heterogenous way

Fat mass: fat stores ca decrease to as low as 5% of the total body weight and can be

macroscopically undetectable. The remaining fat is usually stored in the liver, giving

paradoxical appearance of a fatty liver. Although this is often observed in kwashiorkor, it

also occurs to a lesser extent in marasmus. A study from Nigeria examined serum lipids

in malnourished children. These author foun that total cholesterol, low density

lipoprotein cholesterol, and high density lipoprotein cholesterol levels were significantly

higher in children with kwashiorkor than in marasmus.

Table 2-4 Alternative Classification of Wasting Status of Children (MUAC = Mid-Upper Arm Circumference)

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2.1.6.

2.1.7.

2.1.8. Diagnosis of Marasmus

Malnutrition for an individual child should be diagnosed based on the anthropometric

parameters and their cutoffs. 11

Marasmus is a condition primarily caused by a deficiency in calories and energy, whereas

kwashiorkor indicates an associated protein deficiency, resulting in an edematous appearance.

Typical characteristics of a wasted (marasmic) child include:

‘Skin and bones’ apperance (emaciated ; severely wasted)

A thin ‘old man’ face; wrinkled appearance; sparse hair

Front view: ribs easily seen, skin of upper arms loose, skin of thighs loose.

Back view: Ribs and shoulder bones easily seen, flesh missing from buttocks resulting in

loose skin or “baggy pants”

Usually active and may appear to be alert

Since marasmus is one of severe acute malnutrition (SAM) condition, marasmus, based

on body measurements, is classified as moderately acutely malutrition and severely acutely

malnutrition.

Table2-3 Anthropometric criteria to identify severe, moderate, and at risk categories of acute malnutrition for infants and 10 year-old children.

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Mid-Upper Arm Circumference (MUAC) is often the screening tool used to determine

malnutrition for children in the community under five years old. A very low MUAC (<11cm for

children under five years) is considered a high mortality risk and is a criteria for admission with

severe acute malnutrition.

Lists that must be paid attention in diagnosing marasmus: 8

Complete history, including a detailed dietary history

Growth measurements, including weight and length/height; head circumference in

children younger than 3 years

Complete physical examination

Height-for-age or weight-for-height measurements greater than 2 standard deviations

below the mean for age

Height-for-age or weight-for-height measurements more than 2 standard deviations less

than the mean for age

Height-for-age measurements less than 95% of expected value

Height-for-height measurements less than 90% of expected value

Less than 5 cm/y of growth in children older than 2 years

Body mass index (BMI), although this is not established by the Centers for Disease

Control and Prevention (CDC) as a criteria for failure to thrive.

Table 2-4 MUAC criteria to identify malnutrition of children under five years in the community

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2.1.9. Differential diagnostic

No differential diagnosis for marasmus are noted. However, when edema is present, it

can reflect a kwashiorkor component of the malnutrition or an underlying cardiac or renal

insufficiency. In these circumtances, additional laboratory tests or radiographic tests may

be needed.

2.1.10. Treatment of Marasmus

Management of the child with severe malnutrition is divided into three phases.

These are: 12

Table 2-5 Admission Criteria to determine in-patient or out-patient care

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Initial (Stabilization) treatment : life-threatening problems are identified and treated in a

hospital or a residential care facility, specific deficiencies are corrected, metabolic

abnormalities are reversed and feeding is begun.

Rehabilitation: intensive feeding is given to recover most of the lost weight, emotional

and physical stimulation are increased, the mother or carer is trained to continue care at

home, and preparations are made for discharge of the child.

Follow-up: after discharge, the child and the child’s family are followed to prevent

relapse and assure the continued physical, mental and emotional development of the

child.

2.1.11. Complications of Marasmus 8

Some of the complications of Marasmus are :

Lack of proper growth in children

Joint deformities

Severe weakness

Permanent vision loss

Organ failure

Coma

Table 2-6 Time-frame for the management of a child with severe malnutrition

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2.1.12. Prognosis of Marasmus

Except for complications mentioned above, prognosis of even severe marasmus is good if

treatment and follow-up care are correctly applied..8 Since teaching parents how to prevent

malnutrition is of high importance to prevent recurrence, they must understand the causes of

malnutrition, how to prevent its recurrence (including correct feeding), and how to treat diarrhea

and other infections.

REFERENCES

1. Global Nutrition Report. (2014). 2014 Nutrition Country Profile. Retrieved from

www.Globalnutritionreport.org/about/technical-notes. 21 April 2015.

2. Mehta, N.M. 2013. Defining pediatric malnutrition: a paradigm shift toward etiology-

related definitions. Massachussets :JPEN.

3. Bhutta Z. Addressing Severe Acute Malnutrition Where it Matters. Lancet 2009.

4. Ministry of Health. 2008. National Guideline for Integrated Management of Acute

Malnutrition. Kenya : Ministry of Health Republik of Kenya.

5. CDC Alert (2013). Measles. Retrieved from http:

wwwnc.cdc.gov/travel/notices/watch/measles-indonesia. 21 April 2015.

6. WHO(World Health Organization). (n.d.). WHO EMRO | Disease and epidemiology |

Measles | Health topics. Available from :

http://www.emro.who.int/health-topics/measles/disease-and-epidemiology.html

7. de Onis M, Monteiro C, Akré J, Glugston G. The worldwide magnitude of protein-energy

malnutrition: an overview from the WHO Global Database on Child Growth. Bull World

Health Organ. 1993;71(6):703-712.)

8. Rabinowitz, S.S. (2014). Retrieved from http://emedicine.medscape.com/article/984496-

overview. 21 April 2015 .

9. Boyd, Erin. (2014). Retrieved from http://www.unicef.org/nutrition/training/2.3/2.html.

10. West, K.P. 2006. Protein-Energy Malnutrition (PEM) & Undernutrition : Causes,

Consequences, Interaction, Global Trends. United States : John Hopkins Bloomberg

School of Public Health.

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11. Ministry of Public Health and Sanitation. 2009. National Guideline for Integrated of

Acute Malnutrition. Kenya : Ministry of Public Health and Sanitation

12. WHO. 1999. Management of Severe Malnutrition : A Manual for Physicians and Other

Senior Health Workers. Geneva : WHO.