The Child with Marasmus
Funded by UNICEF, A Medi-CAL Model Patient
Script Writer:
Prof. Michael H.N. Golden
Original Development:
Shirley Moore B.Eng.(Hons.) M.Sc., Callum R Lester BSc MSc,
David A Robinson BSc MSc, Chris Morton, Dave Adams
New Development:
Robin Ford MPhys
Project Director:
Dr Neil Hamilton BSc PhD
Content
Objectives of this module
Tutorial
Summary
Self Test
Tutorial answers
Self Test answers
Objectives
After completeing the module on MARASMUS you should;
●
●
●
●
●
understand the processes which affect severely malnourished children.
appreciate the reasons for each step in the treatment protocol.
realise how fragile the malnourished child is and the care that needs to be taken in their initial
treatment.
understand the processes behind the signs and symptoms shown in the clinical features
module.
develop a basis for judging when a particular patient needs special care based upon knowledge
of the changes in the child's body.
Tutorial
The food intake of a malnourished child has been
less than he needs
Question 1
Acute infection
Intestinal disease with failure to digest and absorb food
Chronic infection
An unbalanced diet
Other chronic conditions
Psychological loss of appetite
Cancer
Do not worry if you make a mistake the tutorial will discuss the reasons after you have made a choice.
The order may be slightly different from region to region or from time to time. When you have
thought about the question go to the next page and look at the notes. The correct order is:
●
An unbalanced dietM1
M1
See the module on "Growth Nutrients".
❍ An unbalanced diet gives loss of appetite.
❍ Diets based predominantly on a cereal are unbalanced.
❍ Diets that have a limited number of different foods in them are unbalanced.
❍ Such poor diets are taken by most children in the world.
❍ Vegan children in Europe, taking similar diets but without any infections, also fail to
grow and develop marasmus.
❍ Stunting in height is usually due to an insufficient intake of growth nutrients.
❍ Wasting is caused by a sudden severe deficiency or pathological loss of these growth
nutrients.
Intestinal disease with failure to digest and absorb foodM2
❍
●
M2
❍
❍
❍
❍
Acute diarrhoea may progress to "persistent diarrhoea" when the nutritional losses are
such that the intestine cannot heal itself and overgrowth of bacteria in the intestine
develops. The treatment is to feed a balanced diet with plenty of type II nutrients.
Dysentry from chronic infection of the colon with amoebae or wipworms often leads to
marasmus.
Malabsorption causes marasmus - the common reasons are small bowel bacterial
overgrowth or giardiasis.
In developed countries marasmic patients often have coeliac disease (allergy to wheat),
●
cystic fibrosis, Crohn's disease or other causes of malabsorption.
Chronic InfectionM3
M3
Tuberculosis, leishmoniasis and other chronic infections can indeed lead to
malnutrition. But the proportion of the population with these conditions is relatively low
in comparison to those with malnutrition. They are not common causes of malnutrition
in children and infants. They are much more important in adult malnutrition.
❍ Congenital infections such as syphilis, rubella, toxoplasmosis and cytomegalovirus are
relatively uncommon causes of marasmus.
Acute InfectionM4
❍
●
M4
Measles, whooping cough and other severe infections can lead to malnutrition in a
proportion of patients. Most patients have catch-up growth during convalescence from
an acute infection. This only occurs if they are taking a good diet. Acute infections are
not usually severe in those taking a good diet. With bad nutrition they are devastating.
The underlying cause of the severe response to the infection is thus the bad diet and not
the disease itself - just as HIV can also be the underlying cause behind severe and
prolonged infections.
❍ Diarrhoea, pneumonia and other acute infections do NOT cause marasmus - they are
important because the child may die - repeated acute infection only leads to malnutrition
if the diet is so poor that there is no "catch-up" between the bouts of infection - the real
cause is the bad diet.
Other chronic conditionsM5
❍
●
M5
Neurological disease, especially from birth injury is not rare, and leads to malnutrition .
❍ Congenital abnormalities, and inborn errors of metabolism occur in all societies and
usually lead to malnutrition. They are not common.
❍ Liver disease, aflatoxin, inappropriate medicines and drugs can all cause marasmus.
Psychological loss of appetiteM6
❍
●
M6
❍
It is difficult to judge how often this is an associated cause of malnutrition. However,
primary anorexia nervosa is not a disease of childhood.
Other causes:
●
HIV InfectionM7
M7
❍
●
HIV associated malnutrition may be a very common cause of malnutrition in some
places - and this infection is likely to change in importance in the future.
AbuseM8
M8
Nearly all mothers love their children and do what they think best. A very few willfully
neglect and abuse their children. It is not common - but very distressing when it
happens. These children present with marasmus.
NeglectM9
❍
●
M9
❍
❍
❍
❍
❍
❍
❍
Psycho-social deprivation is very common.
Such neglect is not the same as abuse, although they are often said together.
Work and other circumstances may lead mothers to leave their children with others who
do not take proper care.
Unresponsive and apathetic children can inadvertently have their needs neglected.
Neglect is usually failure of the two-way communication between the mother and child not a willful act on the part of the mother.
Mothers may not know how to care properly for their children. This is particularly
common when the mothers were themselves neglected as children (so it is thought of as
normal behaviour) and where experienced elders are not present to teach the new or
young mother.
Fathers, through ignorance, often make such demands upon the mother that the child is
neglected.
All who are dependent on others for food and care are likely to suffer from neglect.
Children in schools, hospitals and orphanages, the mentally ill or disabled, prisoners,
and the elderly are particularly at risk.
In fact, when the child is already malnourished he often has an unbalanced diet, an infection, is unable
to digest and absorb his food, and has psycho-social deprivation. It is usually uncertain, at this stage,
which of these problems first precipitated the weight-loss. During the process of becoming
malnourished, each one of these conditions leads to the other. By the time the child is malnourished he
usually has many of these problems. At any rate, the cardinal feature of all these problems is that the
child has not had enough food to sustain his body.
Question 2
What is the most obvious sign of a reduced intake of food?
Please fill in your answer
This picture shows James when as a normal child. This is how he appeared when he was admitted with
marasmusM10. We will be looking at the changes that were present in James, and children like him,
when he was malnourished.
M10
Children like James have lost weight - the fat that is normally under his skin has all been used up and
his muscles are much smaller and less bulky than they should be. Most weight is lost from the
buttocks and shoulders. You will not see this if you do not take off James' clothes. Here is a picture of
his faceM11.
M11
This loss of weight is assessed by weighing the child and taking the child's height. The weight is then
checked against the weight of a normal child that is the same height as James. To find out how this is
measured and calculated look at the anthropometry module.
Energy requirements to maintain this body weight
Question 3
How much food do you think that the child needs, per kilo body
weight, so that he will not lose any more weight?
1. More than a normal child
2. The same as a normal child
3. Less than a normal child
Please fill in your answer
James needs less than a normal child to maintain his weight: but he will need much more to recover.
As we will see from the next pages if his metabolism was normal then he would need more than a
normal child. This is because of the changes in the proportion of the different tissues that make up his
body. Because of this some children that have lost weight over a very short period of time, but are not
marasmic and some stunted children who are now eating a good diet may need more than a normal
child to maintain body weight. But James' metabolism is far from normal.
Energy requirements in marasmus
Here the children like James were given a diet of 100 kilocaloriesM12 per kilo of body weight each
day when they were malnourished.
M12 This is the same as 420 Kilojoules / Kg.
They gained weight on this diet. When the same children had recovered they were given the same diet
and lost weight. This means that a diet that was adequate to maintain the weight of a malnourished
child was not adequate to maintain the weight of a normal child - the normal child needs more food
per kilo than a malnourished child to prevent weight loss. (DetailM13)
M13 These marasmic childrens' diet contained 0.7g protein and 100 kcal/kg. They were fed for 7 days
on this diet and then, when they were fully recovered to 100% weight-for-height, they were returned
to the same diet for 7 days. Data from: Michael H. N. Golden, 1976, unpublished.
James has lost more fat and muscle than other tissues. The organs in his abdomen and chest and his
brain make up a much higher proportion of his weight than a normal child. James has lost more fat and
muscle than other tissues. The organs in his abdomen and chest and his brain make up a much higher
proportion of his weight than a normal child.
Question 4
Can the reduction in the need for food be explained by the change
in the proportion of these different tissues in James' body?
Please mark your answer
Yes
No
In fact we would have expected James and other malnourished children to have a higher energy
requirement for each kilo of his body weight. This is because more of his body is made up of brain,
liver, heart and lungs which require a lot of energy. Whereas he has lost mainly muscle and fat which
use very little energy. WHAT DOES THIS MEAN? There must be very profound changes in the
function of the main organs of his body to conserve energy. This is much greater than suggested by the
experiment looking at the children's weight changes on the same diet.
Question 5
How much less energy does James require to maintain his weight
in the malnourished state?
1.
2.
3.
4.
5.
5%
10%
30%
50%
80%
Please fill in your answer
His body requires 30% less energy to maintain itself when it is in the malnourished state. But, of
course, more energy than this is needed to treat him and reverse the changes that have occurred in his
body. We cannot ethically study children as they become malnourished to see the changes in the
body's requirements so we have to look at experimental animals.
The graph shows the effect of giving rats a reduced intake of food for some time. The rats grew
normally to 100g weight. Like children, they would have continued to gain weight, grow and mature if
they had more food. As they grow the relative weightsM14 of the different organs change.
M14
●
●
This is why adults need less food per kilo than small animals or children.
With the higher organ to muscle weight ratio in malnutrition, when the adaptations are reversed
a very high energy intake is required to have enough energy to gain new tissue. As new muscle
and fat are laid down the energy intake for maintenance falls - if the experiment with the
children had been done half way through rapid growth they would have lost weight very
quickly.
However, the rats in this experimentM15 stopped growing and were maintained at exactly 100g weight
by restricting their food intake. If they gained any weight one day they were given slightly less food
the next day, and if they lost a few grams they were given slightly more food the next day. In this way
the body composition of the animals did not change during the experiment.
M15 The mean of the three diets is shown - data from: Kaunitz H, Slanetz CA, Johnson RE, Guilmain
J. Influence of diet composition on caloric requirements, water intake and organ weights of rats during
restricted food intake. J.Nutr. 1956; 60:221-226. See also: Kaunitz H, Slanetz CA, Johnson RE.
Utilization of food for weight maintenance and growth. J.Nutr. 1957; 61:551-559.
The graph shows the amount of food that the rats were given to just maintain body weight. There are
two very important points about this graph, which apply to James, other malnourished children or any
animal, as well as to these rats.
1. The changes in the food requirement occurred slowly - it takes six weeks for the adaptation
of the body to take place in a rat.
2. The saving in requirement due to adaptation is about one third.
The basal metabolic rateM16 of a normal child is about 90 kilocalories per kilo.
M16 The amount of energy needed by your body while at perfect rest, not taking any exercise or
digesting food.
Question 6
What is the approximate basal metabolic rate of a malnourished
child like James, who has no serious complications?
1. 90 kilocalories per kilo
2. 60 kilocalories per kilo
3. 40 kilocalories per kilo
Please fill in your answer
The basal metabolic rateM17 in a non-infected child with chronic malnutrition who is fully adapted to
his low intake is about 60kcal/kilo.
M17 The amount of energy needed by your body while at perfect rest, not taking any exercise or
digesting food.
Question 7
Does this mean that we should give these children a diet that only
contains 60 kcal/kg/d?
Please mark your answer
Yes
No
The diet we use to treat James must have MORE than the BASAL requirement to allow for:
1. the amount that he does not absorb from the intestine (about 10%).
2. the amount that is spilt or left in the cup (about 10%). (RefM18)
M18 Kerr, D, Ashworth A, Picou D, Poulter N, Seakings A, Spady D & Wheeler E.
"Accelerated recovery from infant malnutrition with high calorie feeding" In: Endocrine
Aspects of Malnutrition. Gardner LI. Amacher P (Eds) The Kroc Foundation, California, 1973,
pp467-486.
3. normal physical activity.
4. the fact that most malnourished children have an infection.
5. some of the children have not fully adapted and they will need more.
6. we want to TREAT the children by starting gradually to reverse the process.
Therefore we normally give all malnourished children when they first come for treatment 100 kcal/kg
at the beginning.
●
●
●
●
A child who has a poor appetite and is offered 100 kcal/kg should never be allowed to take in
less than 70 kcal/kg. (Basal amount plus the amount that will be malabsorbed.)
If he is taking less than this he will continue to become malnourished under your care!
There is no place for a graded intake of food starting with half-strength feeds.
Below 70 kcal/kg is the "action point" for putting down a naso-gastric tube to feed the child
with loss of appetite.
Children, such as James, have adapted to a low intake. HOW DO THEY MANAGE TO ACHIEVE
THIS ADAPTATION? There are only two ways to reduce energy consumption:
1. by using energy and nutrients more efficiently
2. by doing less work.
But nutrients are normally used very efficiently, for exampleM19 about 90% of the amino acids that
come out of protein are reused in the body to make new protein.
M19
A reduction of one third in the energy required to maintain tissues could not be achieved by more
efficient use. There is reduced work by the organs, tissues and even the whole body itself.
Reductive Adaption
The reduced activity affects all the organs and cells in James' body. These changes have very profound
effects upon the function of the body and how we treat all malnourished patients. In particular we will
look at:
●
●
●
●
●
●
●
●
●
●
activity of the whole body
heart function
kidney function
intestinal function
liver function
glucose metabolism
electrolyte metabolism
temperature regulation
immune function
muscle function
But every physiological measurement that has been done in malnourished children has been found to
be abnormal.
Activity
The graphM20 shows the spontaneous activity of malnourished children when they come into hospital
compared with children admitted with other complaints.
M20 The activity was measured by observing the movements made by the children in the last 5
seconds of each minute for several hours, observations were not made on children whilst they
slept.The normal children were admitted to hospital for other reasons. The scale is arbitrary. GranthamMcGregor S. Stewart M. Powell C. Behaviour of severely malnourished children in a Jamaican
hospital. Developmental Medicine & Child Neurology. 33:706-14, 1991
The malnourished children are inactive, only moving when really necessary. They do not smile, play
or explore the environment. Their actual energy expenditure is much closer to their basal metabolic
rate than in a normal child. Clinically they are lethargic and apathetic. They do not cry or complain. In
all the figures in this module the malnourished child is in red, the recovered child is in blue and the
recovering child in orange. Normal children who have never been malnourished are in green. Does
this lethargy and apathy make them more likely to:
Question 8
be ignored by the staff and caretaker?
Please mark your answer
Yes
No
Question 9
develop hypothermia?
Please mark your answer
Yes
No
Question 10
develop pneumonia?
Please mark your answer
Yes
No
Question 11
get pressure sores?
Please mark your answer
Yes
No
Question 12
fail to learn and develop mentally or physically?
Please mark your answer
Yes
No
Heart Function
This graphM21 shows that the amount of blood that the heart is pumping round the body is much less
as the child becomes progressively thinner. The malnourished children, in red, may have less than half
the cardiac output of a normal child, in blue.
M21 Alleyne GAO. Cardiac function in severely malnourished Jamaican children. Clin.Sci.
1966;30;553-562
Question 13
What do you think happens to the speed with which the blood
circulates round the body?
1. It is unchanged
2. It is slower
3. It is faster
Please fill in your answer
The speed with which the blood circulates round the body is slower. The time it takes dye injected into
a vein in the arm to reach the ear is about 10 seconds in the normal child. When the child is
malnourished it takes about 15 seconds. The blood flow is sluggish. What has happened to the heart?
●
●
●
●
●
Each heart muscle fibre contracts less forcefully.
Each muscle cell is thinner than normal.
There are fewer muscle fibres.
The electrical conduction is slower.
The heart does not react to the normal stimulae that make it go faster.
THERAPEUTIC IMPLICATION:M22
M22
●
●
●
●
●
It is very easy to precipitate heart failure by overloading the circulation.
Intravenous fluid and blood transfusion are dangerous in the malnourished child.
True dehydration is treated orally with low sodium solution. (ReSoMal is used and not ORS.)
For very severe anaemia use EXCHANGE transfusion in the same way that it is used for
neonates - remove blood and then give the same volume of blood and repeat the cycle.
When oedema is being mobilised and the cells are also correcting their electrolyte imbalance
from 3 to 14 days after admission is the most dangerous time.
Renal Function
The kidneys of the children also adapt to do less work.
●
●
●
●
●
Renal blood flow is reduced.
Glomerular filtration rateM23 is reduced.
M23 This is the total amount of blood plasma that is filtered by the kidney into its tubules to
make urine.
The amount of acid that can be excreted is limited.
The maximum concentration of the urine is limited.
The excretion of sodium is impaired.
The graph shows the renal blood flow in the square symbols and the amount of that blood that is
filtered into the glomerulae to go to make urine in the round symbols. Both the blood flow and the
glomerular filtration rate are about half in the malnourished child.
The left graphM24 shows urinary osmolarityM25 after the children have had nothing to drink for 12
hours. They should be conserving water and excreting a concentrated urine. The malnourished
children's urine is less concentrated than normal plasmaM26.
M24 Data from Alleyne GAO. The effect of severe Protein calorie malnutrition of the renal function of
Jamaican infants. Pediatrics : 39: 400-411; 1967
M25 Osmolarity is the amount of "solids" that are dissolved in the urine.
●
●
●
●
It is mainly urea, sodium, potassium, chloride and phosphate.
It is measured in milli-Osmoles per litre of urine.
Normal children can dilute their urine to very low osmolarity when they take a lot of water.
Normal children can excrete over 1000 mOsmoles/ litre when they need to conserve water.
M26
Normal plasma is between 260 and 300 mOsmoles/ litre.
The right graph shows the urine concentration after the children have been given an injection of
PitressinM27. This is their maximum concentrating ability
M27 Pitressin, or Anti-diuretic hormone, is normally secreted by the pituitary gland when the plasma
osmolarity increases to conserve water in the body and produce a very concentrated urine.
Question 14
Look at the previous 2 graphs and decide what is the maximum
urine concentration that the average malnourished child can
achieve in relation to normal plasma concentrations.
1. The same as plasma
2. One and a half times plasma
3. Twice plasma
4. Three or more times plasma
Please fill in your answer
Most children can achieve an osmolarity of about 450 mOsm/l after a large dose of pitressin, but some
of them can hardly concentrate their urine at all. These individuals are very vulnerable. After recovery
a few children reach the normal ability, but some have kidneys that recover very slowly.
THERAPEUTIC IMPLICATION:M28
M28 "Renal solute load" is the amount of solid coming from the diet that the kidney will have to
excrete.
●
●
●
●
●
●
●
If diets with a high solute load are given to the malnourished child, then the solute may build
up in his body because he cannot concentrate them into his urine.
Sodium and potassium concentration in the plasma may increase to dangerous levels at the start
of treatment if sufficient water is not given.
This is more likely to happen if the climate is hot & dry and water that is lost from the skin and
lungs is not available to make urine.
This is more likely to occur when a child has a fever or a high respiratory rate.
Small infants with a high surface area to weight are more likely to lose excess water.
Urea, from protein, contributes a lot to the renal solute load. High protein diets should not be
used to treat malnutrition.
Children who retain excess solute get a skin that feels like dough and then develop
hyperosmolar coma, convulsions and death.
The renal solute loads from various diets are as follows:
●
●
●
●
●
●
●
Human Milk - 80 mOsm/l
F75 - 145 mOsm/l
F100 - 325 mOsm/l
F100 (diluted to 75 kcal/100ml) - 245 mOsm/l
The low renal solute load from human milk is why extra water never has to be given with
human milk - but we must be careful with other diets, and F100 should be used only under your
supervision.
If F75 is not used at the start of treatment, then the F100 should be diluted or extra water
should be given - this is especially important in hot dry climates and for all infants and small
children less than 5kg.
More concentrated diets than F100 are not necessary and should never be used. They have been
used in research units in very experienced hands where there are a lot of staff and facilities you may read of them in papers in the literature - but do not use these diets.
This slide shows the amount of acid that the child excretes in his urine after he has been given a salt
that turns into acid in the body. (DetailM29)
M29 Ammonium chloride, 100mg /kg body weight, was given orally and urine collected for the next
six hours.
The malnourished children are only able to excrete about half as much acid as the recovered children.
This is partly due to the very low level of phosphorousM30 that the children have in their tissues.
M30 See Kohaut EC et al. Reduced renal acid excretion in malnutrition: a result of phosphate
depletion. Amer J. Clin. Nutr. 30: 861-867; 1977
THERAPEUTIC IMPLICATIONM31.
M31
●
●
●
●
●
●
●
The children cannot tolerate any additional acid in their diet.
Magnesium chloride if given alone to treat magnesium depletion provokes a severe acidosis.
Potassium citrate is incorporated into the mineral mix to balance magnesium chloride.
A high protein diet gives an additional acid load.
The low phosphate status is an important reason to use diets based upon cow's milk, which is
high in phosphorus.
If local diets are used which do not contain milk then an additional source of phosphorus
should be given or some of the potassium in the mineral mix provided as potassium phosphate but calcium has to be given at the same time to maintain the calcium - phosphorus balance.
The phosphorus in local foods is not biologically available, it can be made available by
fermentation or germination.
This graphM32 shows the percentage of sodium that is filtered by the kidney into that ends up being
excreted in the urine.
M32 See: Klahr S, Alleyne GAO. Effects of chronic protein-calorie malnutrition on the kidney. Kidney
Int. 1973;3:129-141.
With a normal circulation and extra-cellular fluid volume (ECF) the malnourished child excretes less
than half of one percent of the filtered sodium. The normal child excretes about one percent. Look at
the graphM33 and decide what happens when the blood and extra-cellular volume is expanded by
giving intravenous saline.
M33
Question 15
The normal child responds by excreting 11% of the filtered sodium.
Please mark your answer
True
False
Question 16
The normal child will quickly return his circulation to normal.
Please mark your answer
True
False
Question 17
It is very difficult to overhydrate a normal child.
Please mark your answer
True
False
Question 18
The malnourished child will take a long time to return his
circulation to normal if he is overhydrated.
Please mark your answer
True
False
Question 19
Malnourished children retain nearly all the sodium that is given in
their body and cannot excrete it fast enough.
Please mark your answer
True
False
Question 20
The malnourished child has an adequate response.
Please mark your answer
True
False
Question 21
The malnourished child will be overhydrated very easily.
Please mark your answer
True
False
When we combine the figures from the graphs of renal blood flow, glomerular filtration and sodium
excretion we find that the effect of malnutrition on how the children respond to an expanded
circulation is dramatic. When overhydrated the normal child can excrete THIRTYM34 times as much
sodium as the malnourished child.
M34
●
●
Malnutrition : 2.7 mmol Sodium/h/m3
Normal : 80.0 mmol Sodium/h/ m3
Question 22
If it takes a normal child 20 minutes to excrete the sodium in a
dose of ORS when he already has a full circulation how long will it
take a malnourished child to excrete this same excess?
Please fill in your answer
If a normally-hydrated, severely malnourished child, such as James, is given as much sodium as a
normal child will it:
Question 23
be excreted and do no harm?
Please mark your answer
Yes
No
Question 24
accumulate in the body and give oedema?
Please mark your answer
Yes
No
Question 25
accumulate in the body and give heart failure?
Please mark your answer
Yes
No
The THERAPEUTIC IMPLICATIONS of this are critical. Everyone looking after a malnourished
child must understand the meaning of this graph. Say that a normal child can excrete 10 times as much
sodium as he is given after treatment of dehydration with normal ORSM35, then if the malnourished
child is given the same amount of sodium he will get fluid overload. To give the same volume of
solution it would need to be given as one fifth normal salineM36 for him to just "keep up" and not
become overloaded.
M35 sodium 90 mmol/l
M36
sodium 30 mmol/l
ReSoMal has half the sodium of ORS: even ReSoMal should be given in less quantities than are used
to treat normal children with diarrhoea. If the rehydration solution is stronger, or if it is given more
quickly, then the fluid may accumulate until he goes into heart failure.
●
●
Malnutrition : 2.7 mmol Sodium/h/m3
Normal : 80.0 mmol Sodium/h/ m3
Adaptation of intestinal function
The cells lining the normal intestine are amongst the most active in the body. They divide, mature,
make all the enzymes necessary to digest and absorb food and are then shed. A new complete new set
of cells is formed every 3 days. Why should the intestine make all these enzymes to digest food when
the amount of food that the child has taken has been so low? The output of enzymes from the pancreas
is sometimes so low that doctors at first thought that some forms of malnutrition could be due to
atrophyM37 of the pancreas.
M37 Withering away of a part of the body - often due to disuse.
The two pictures show the intestinal mucosa of a marasmic and a normal child. The long finger-like
villae covered with the cells that absorb food disappear in some cases of marasmus. This is a
particularly severe case. This chart shows the enzyme levels in biopsies taken from the small intestine.
Normally the activity of sucraseM38 and maltaseM39 are much higher than of lactaseM40.
M38 This enzyme breaks down ordinary sugar or sucrose into fructose and glucose. You know that it is
an enzyme because it ends in the suffix "ase".
M39
This enzyme breaks down maltose to two molecules of glucose, and maltotriose into three
molecules of glucose. Maltose, maltotriose and isomaltose come from the digestion of starch.
M40 This enzyme breaks down lactose into glucose and galactose. Lactose is found exclusively in
animal milk.
In malnutrition there is a reduction in the activity of all the enzymes to digest carbohydrate - by
between one third and one half. Graph of sugar absorption
In malnutrition the sucrose was absorbed as well as the glucose. Lactose was absorbed nearly as well
as the other sugars. Some children absorbed very much better than the average. Some children
absorbed very little of any of the sugars. The absorption depends upon the transport across the cell as
well as the digestive enzymes. In the study shown in the chart the children had a tube put into their
intestine and sugar solution infused. From a second tube 30 cm further down any unabsorbed sugar
was aspirated to find out how much had disappeared. The total height of the bar shows the amount of
sugar given to the child. The solid section shows the average and the dotted part the most that
disappeared in 30 cm of intestine. The sugars given were all isotonicM41.
M41 They had about the same osmolarity as the plasma - this means that they would not draw water
from the body.
The malnourished children absorbed each sugar about half as well as the recovered children. Because
there is twice as much energy in 10% sucrose as in 5% glucose (at the same osmolarity) it is better to
give sucrose or even lactose than glucose.
This chart shows the absorption of glucose. The 2.5% glucose solution is hypotonicM42 - the 5% is
isotonic and the 10% is hypertonicM43.
M42 It has half the osmolarity of plasma.
M43 It has twice the osmolarity of plasma and will tend to draw water from the body into the intestine
as it is being absorbed.
On average there was 12 mmol/h/30cm absorbed by the malnourished children from isotonic glucose about half that of the recovered child. There was little difference in the amount absorbed, in
malnutrition between the different strengths given. Answer the following questions.
Question 26
Do these charts mean that all the marasmic children have
malabsorption?
Please mark your answer
Yes
No
Question 27
Do the marasmic children have a reduced capacity to absorb food?
Please mark your answer
Yes
No
Question 28
Should we stop giving carbohydrate because of their
malabsorption?
Please mark your answer
Yes
No
Question 29
Should we give a concentrated diet so they will absorb plenty of
energy?
Please mark your answer
Yes
No
THERAPEUTIC IMPLICATIONSM44
M44
●
●
●
●
●
●
If you give more than the capacity to absorb then you will provoke diarrhoea.
This can come about by either giving too high a volume or high concentration.
Isotonic diets can give diarrhoea if too much is given at one time: this even applies to glucose
solutions. They have a reduced CAPACITY for absorption.
High concentrations, hyperosmolarity and large volumes of feeds, that exceed the capacity of
the child will all cause re-feeding diarrhoea.
The malnourished child needs to be fed small amounts of the diet very frequently. If a child
gets diarrhoea with the feed then give twice as many feeds with half the amount in each feed.
With very sick children the diet can be dripped in slowly though a naso-gastric tube so that the
intestine is continuously absorbing and the capacity is not exceeded.
You can get more energy in from 10% sucrose than 5% glucose: they are absorbed to similar
amounts. It is better to give ordinary sugar than glucose.
LACTOSE INTOLERANCE AND REFEEDING DIARRHOEAM45
M45
●
Many people think that lactase deficiency is a common problem in malnutrition because the
children get diarrhoea at first when they are given large meals of milk. This is a problem of
overloading the capacity to absorb, and will occur with large amounts of any sugar.
●
●
●
●
●
Do not think of this as a problem of malabsorption or intolerance - think about it as a problem
of reduced absorptive capacity, with a lower threshold for malabsorption.
Most malnourished children absorb lactose almost as well as the other sugars.
Human milk has a much higher concentration of lactose than cow's milk and these children do
not get diarrhoea with human milk - this is because breast milk is usually taken more frequently
and more slowly.
If the child gets re-feeding diarrhoea do NOT give oral rehydration fluid. Give the prescribed
total amount spread over many smaller feeds. If the diet is hypertonic add water to make it
isotonic and give a larger volume. In rapid growth phase reduce the amount prescribed to
slightly more than maintenance.
With refeeding diarrhoea rehydration solution is not usually required. Before giving any
rehydration solution check to see how much weight has been lost - if there has been little loss
then rehydration is not required.
Endocrine Function
The adaptations also affect the hormones. LOW
●
●
●
●
Insulin
Glucagon
Insulin-Like-Growth-Factor
Thyroid hormones
HIGH
●
●
●
●
Cortisol
Growth Hormone
Antidiuretic hormone
Aldosterone
Adrenalin is variable. Where the receptors for these hormones have been measured they are all
reduced.
This chart shows the intravenous glucose toleranceM46. The higher the bar the more quickly glucose is
removed from the circulation.
M46 Glucose is injected into a vein and the rate at which it is removed from the circulation is
measured. The units are in h-1. This means the "number of pools" of glucose that are turned over each
hour - faster glucose removal gives a larger number.
The children with malnutrition have glucose intolerance.
Question 30
Glucose tolerance is also associated with diabetes: so do they
have high blood sugar levels?
Please fill in your answer
Question 31
Do they get hypoglycaemia?
Please fill in your answer
This chart shows the intravenous fructose tolerance tests in the same children. Fructose is used twice
as fast as glucose. It does not need insulin to be used. Malnourished children also use fructose more
slowly than the recovered children. This shows that the slow metabolism of sugars is not only due to
the hormonal changes, but also to the changes in the liver. The metabolism of sugar in the liverM47 is
slow due to adaptation of the enzymes in the liver and the low amounts of the high-energy-phosphate
compound that is needed to start their metabolism.
M47 Fructose is converted to fructose-1-phosphate and glucose to glucose-6-phosphate. Fructose is
phosphorylated about 10 times as fast as glucose. Excessive amounts given quickly can lower the ATP
levels in the liver to dangerous levels and give rise to lactic acidosis.
Electrolyte Metabolism
The electrolytes inside and outside the cells are quite different. Outside, in the blood and tissue fluid,
sodium and chloride are at high concentration. Inside the cell there is potassium, magnesium,
phosphate and protein. The gradients of the high sodium outside, and high potassium inside, are used
by the body for all the electrical activity in nerves and muscles. They also power the transport of
amino acids and glucose in the intestine and kidney. Without this gradient none of the organs of the
body would function - the brain, heart and kidneys would stop. The gradient is maintained by the
"sodium pumpM48".
M48 Also known as Sodium-potassium-ATPase or Na+K+ATPase, because it uses ATP to pump the
sodium out of the cell and the potassium into the cell against their gradients. Magnesium is an
important cofactor. It is inhibited by digoxin or digitalis.
The sodium pump uses about one third of the basal energy requirement. So there would be a great
saving of energy if the sodium pump was less active than normal.
The sodium pump activity is reduced to about one half in the malnourished child. This is a critical
adaptation because the functioning of all the organs and transport systems in the body depend upon the
sodium pump. The next page shows the effects of this upon the intracellular electrolytes.
The average intracellular sodium in malnutrition is about 70 mmol/lM49, wheareas it is 35mmol/l in the
normal child.
M49 per litre of cell water
As the normal extracellular sodium is about 140 mmol/l the gradient across the cell membrane is
reduced from about 105 to 70 mmol/l in malnutrition. Some of the very sick children have even
smaller gradients as the points in the graph show. There is thus a massive increase in the total body
sodium - in marasmus this is all intracellular. The total body sodium increases by about 40% - if there
is oedema as well then the increase is much larger. These changes are a direct result of slowing of the
sodium pump.
The intracellular potassium is much lower in the malnourished child than the recovered child. A diet
rich in potassium has to be given to reverse this abnormality. Answer the following questions.
Question 32
Is the total body potassium decreased in marasmus?
Please mark your answer
Yes
No
Question 33
Is the potassium loss from the cell balanced by sodium increase?
Please mark your answer
Yes
No
Note on kwashiorkorM50
M50 In kwashiorkor the intracellular sodium also rises and the potassium falls. But this is by a totally
different mechanism. In kwashiorkor the cell membranes are leaky and the ions "seep" through the
damaged membrane - the sodium pump activity is HIGHER than normal in kwashiorkor and LOWER
in marasmus. See module on kwashiorkor.
THERAPEUTIC IMPLICATIONS 1:M51
M51
●
●
●
●
●
●
●
The danger time during treatment is as these electrolyte changes are reversed.
As the sodium pump speeds up the sodium comes out of the cells into the circulation.
If the defect in the kidney is not reversed before this happens the appearance of the sodium in
the circulation gives rise to heart failure.
It takes about two weeks for these changes to be reversed in the sodium pump and the kidney.
This happens during the first days of refeeding and can give rise to unexpected death.
If the sodium pump reverses its adaptation and quickly became active the children die or go
into heart failure. This can be successfully treated with digoxin which inhibits the sodium
pump. (Patrick J. "Death during recovery from severe malnutrition and its possible relationship
to sodium pump activity in the leucocyte." Br. Med. J. 1977, 1:1051-1054).
Potassium goes into the cells in exchange for sodium. If sufficient potassium is not supplied at
this time fatal hypokalaemia can occur. Potassium is also essential for the reversal of the
kidney abnormality.
THERAPEUTIC IMPLICATIONS 2:M52
M52
●
●
●
●
●
●
●
●
●
●
Giving oral rehydration solution while the adaptation is reversing is particularly dangerous.
This applies to marasmus and kwashiorkor, but is more likely to occur in kwashiorkor because
the sodium pump is already active.
if high sodium diets, rehydration solutions or transfusions are given during this time then the
children may die from heart failure (see Wharton B. Howells G & McCance RA "Cardiac
failure in kwashiorkor" Lancet 1967, 2;384-387).
Be very careful with high sodium solutions, diets or drugs after the start of treatment,
particularly after 72 hours or more.
"re-feeding" diarrhoea should not be treated with rehydration solutions - change the diet and
put the child back to phase one.
Heart failure due to refeeding can be treated with digoxin to slow the sodium pump and allow
some of the sodium to pass into the cells again.
The plasma sodium concentration is usually normal - this does not mean that the there is a
normal amount of sodium in the body - it is greatly increased.
If the cells are very leaky the plasma sodium concentration can fall as the sodium enters the
cells.
This is a very bad prognostic sign and means that the cell membranes are damaged.
A low plasma sodium must NEVER be treated by giving extra sodium -this will lead to death.
THERAPEUTIC IMPLICATIONS 3:M53
M53
●
As the circulation expands and the child goes into heart failure, the haemoglobin level drops
(and the liver enlarges).
●
●
●
●
This is because there is a fixed amount of red cells but the quantity of plasma increases.
The expansion of the circulation can be measured by the fall in haemoglobin or haematocrit.
This must NEVER be treated with a transfusion. One doctor in Angola monitored haemoglobin
and transfused these children as they became more "anaemic". Of the first 26 children
transfused they ALL DIED from heart failure.
If anaemia is severe it should be treated within 48h of admission. After that time is should not
be treated by transfusion at all. If possible give blood by exchange transfusion and also start
treatment for heart failure.
Temperature Regulation: a warm environment
The ability of the malnourished child to respond to temperature changes undergoes reductive
adaptation.
The chartM54 shows the effect of changing the environment from a thermoneutralM55 range to 38°C,
on the core temperature of the children.
M54 The children were without clothes in a small chamber. The temperature was raised from 29°C to
38°C over 45 minutes. See Brooks OG Salvosa CB "Response of malnourished babies to heat" Arch
Dis Child. 1974, 49:123-127.
M55 The temperature range where the heat generated in the body is lost to the environment without the
need for physiological mechanisms to maintain normal body temperature.
The normal body temperature of the malnourished children is less than the recovered children. At
38°C the body temperature in malnutrition rises steadily until there is a fever. This is due to a failure
of the sweating response where much less sweat is produced by the malnourished child. (ChartM56)
Children with skin lesions loose less heat than those with good skin. Their body temperature can
increase quickly. (ChartM57)
M56
The sweat evaporation was much less and delayed in the malnourished children.
M57
The children with the 2°C temperature rise had bad skin lesions.
Answer the following questions.
Question 34
Why is the body temperature higher in the recovered child?
Please fill in your answer
Question 35
Why does he get a fever?
Please fill in your answer
Question 36
Is the thermoneutral environmental temperature the same for a
malnourished and a normal child?
Please mark your answer
Yes
No
Question 37
Will this adaptation occur in all malnourished children?
Please mark your answer
Yes
No
Question 38
Is this child severely malnourished?
Please mark your answer
Yes
No
THERAPEUTIC IMPLICATIONS:M58
M58
●
●
●
●
●
●
In hot environments fever can be due to the malnutrition itself and not necessarily infection.
The treatment is to cover the patient with a wet towel. The towel should be tepid and not cold
(cold water makes less blood come to the skin so that heat is lost more slowly than with
ordinary water).
The malnourished person needs extra water, or breast milk, to lose heat and excrete the renal
solute load as well.
The diet should not be cooled - this makes the skin feel cooler but the core temperature rises.
Rubbing Alcohol should never be used - it is very dangerous.
Aspirin or paracetamol should not be used -the liver enzymes cannot metabolise them.
Paracetamol makes liver function worse in malnutrition and aspirin can give a acidosis.
Temperature Regulation: a cool environment
In this chartM59 the children were moved from a thermoneutral environment to 25°C. The
malnourished children's core temperature fell steadily to a level where they were in danger of
becoming hypothermic.
M59 The children were naked and asleep in a metabolic chamber, the temperature was changed from
32°C to 25°C over 45 minutes. If the child awoke and cried his measurements were not recorded.
Brooke OG Harris M & Salvosa B "The response of malnourished babies to cold" J.Physiol 1973,
233:75-91.
This slide shows the energy consumptionM60 by the children when they were exposed to 25°C. The
recovered children responded by increasing their energy consumption and heat production to maintain
their body temperature. This is a normal response.
M60 Measured as oxygen consumption per kg/min.
The malnourished children had a decrease in energy consumption as the environmental temperature
dropped. They were producing less heat in their body. This means that they would not have been able
to maintain their temperature and would become hypothermic. This response, where the body takes
the temperature of the environment, is seen in reptiles and amphibians. "Warm blooded" mammals
should maintain their temperature - the malnourished cannot do this. Answer the following questions.
Question 39
With malnutrition, is hypothermia common in the tropics?
Please mark your answer
Yes
No
Question 40
If the temperature is pleasant for the mother and nurse is it OK for
the baby?
Please mark your answer
Yes
No
Question 41
Is most heat lost from a malnourished child's chest?
Please mark your answer
Yes
No
Question 42
If the basal metabolic rate was higher could the children get
hypothermia?
Please fill in your answer
THERAPEUTIC IMPLICATIONS:M61
M61
●
●
●
●
●
●
●
●
●
●
●
Hypothermia is common in malnutrition.
The patients need a temperature which is often unpleasantly warm (28 - 32°C) for fully clothed
adults that are as active as a nurse. The attendants should know that only when they feel warm
is it the correct temperature for their child - if they feel normal it is to cold for the malnourished
in their care.
The children are vulnerable until they have been gaining weight rapidly for some days and not
just during the first few days after admission. Rapidly growing children are also vulnerable if
they miss a meal, the temperature drops to less than 25°C or they are wet.
Open skin lesions make it much more difficult to maintain heat - these patients are very
vulnerable to hypothermia.
All windows must be closed at night.
The children should all have clothes, blankets and their heads should be covered at night.
The patients should sleep with their mothers, or together, at night and not alone.
Very ill malnourished children should not be washed unless it is above their thermoneutral
range.
All malnourished children should be dried carefully after washing.
The diet should be warmed to 30-40°C (but not more) before it is given to sick patients.
Hypothermia is best treated by putting the patient on the bare chest of the caretaker and
wrapping them both together in warm blankets (Kangaroo style). Hot drinks to the caretaker
increases her skin blood flow and warms the child much more quickly.
Immune and Inflammatory Systems
The child lost the surface of the skin from his leg some days ago. This is quite common. Many
bacteria are growing in this lesion. There is no pus. The area is not swollen, red or "angry". It is not
painful or warm to the touch. There is no swelling of the glands in the groin.
●
●
●
●
●
●
●
●
This child has almost no inflammatory response to bacterial invasion.
There is little migration of cells to the sites of injury.
Cells that ingest bacteria have difficulty in killing them.
Immune function tests show that all aspects of both the immune and inflammatory systems are
reduced.
The thymus, tonsils, lymph nodes and other tissues of the immune system are atrophic.
The cell mediated responses are diminished or absent.
The response to vaccines is diminished.
The intestinal secretion of antibodies is decreased.
THERAPEUTIC IMPLICATIONS: diagnosisM62
M62
●
●
Over 95% of children with severe malnutrition have a systemic infection. The common
bacterial infections are bronchopneumonia, urinary tract infection, blood, skin, small and large
intestine, middle ear, joints and bone. There is frequently candidiasis of the mouth, oesophagus,
stomach, large intestine, lung and blood. Many different viruses have been isolated. There are
usually worms in the intestine. Disseminated scabies and lice are very frequent. Malaria is
almost universal in endemic areas. Other protozoa and filarial worms are common.
We diagnose infections by the way that the body reacts to the invading organism. Because the
reactions may be absent we do not recognise when a child has a severe infection. YOU
CANNOT TELL CLINICALLY THAT A CHILD HAS AN INFECTION.
●
●
●
●
●
An increased shadow on chest X-ray is very faint and diffuse and easily overlooked - Only well
nourished children get lobar pneumonia. The marasmic child cannot restrict the infection to
only one lobe of the lung. One sided lesions are either an inhaled foreign body or tuberculosis.
Broncho-pneumonia may not be accompanied by a fast respiratory rate.
Skin tests for tuberculosis may be negative in patients with active TB.
Urine tests that look for white cells may be negative in the presence of significant infection.
The blood white cell count is not a reliable test for septicaemia.
THERAPEUTIC IMPLICATIONS: treatmentM63
M63
●
●
●
●
●
All malnourished children should be treated blindly with broad spectrum antibiotics
from admission.
There is always small bowel bacterial overgrowth - this is because of a) the reduction in
stomach acid, IgA, lysozyme and bile salts and, b) the slow movement of the intestine (reduced
peristalsis) which can act like a partial obstruction. These enormous numbers of "normal"
bacteria in the lumen of the intestine damage the intestinal lining, produce toxins that impair
liver function and frequently invade the body. The broad spectrum antibiotics may reduce their
numbers, if there is abdominal distension then metronidazole should be added to the regimen.
Metronidazole will also treat giardiasis and amoebae.
There is a diminished response to vaccines. Measles vaccine should be given both on
admission (to abort incubating infection and prevent nosocomial infection) and also on
discharge when the child has recovered. It is only with the second dose that good immunity
will develop and protect the child. Two doses of measles vaccine are not harmful.
Fever is more likely to be due to environmental temperature than an infection - it should not be
treated with aspirin or paracetamol.
Hypothermia and hypoglycaemia frequently accompany very severe infection. If these occur
then second-line antibiotics should be used.
Muscle Function
This picture shows a biopsy sample of muscle from James' thigh when he had marasmus and again
after he recovered. The muscle fibres are very thin and weak. Before he became marasmic he could
sit, crawl and pull himself up. Now that he is wasted he cannot stand up by himself and when he is
sitting he often falls over. All his muscles are like this. They get tired very easily. For example, the
muscles he uses to breath are weak. He quickly gets exhausted if there is a lung infection and cannot
cough to get rid of sputum.
The graph shows a tracing of the ankle reflex in a child like James when first admitted, after 10 days
and after 30 days treatment. (DetailM64).
M64 As his calf muscles contract the graph moves up and then the tracing goes back down again as his
muscles relax. The tracings have been adjusted in size electronically to be the same height - the
admission reflex required three times as strong a stimulus (100 volts for 3 milliseconds) and was much
smaller in amplitude than the tracings after recovery (30 volts for 2 milliseconds). Unpublished data
from Betton H and Golden M.
When he is malnourished the contraction and the relaxation are much slower than normal. This
sluggish movement affects all his muscles, including the smooth and cardiac muscle. It is partly due to
the atrophy, partly to the changes that we saw in the sodium pump and partly to a poor supply of
chemical energy inside the muscle. THERAPEUTIC IMPLICATIONM65
M65
●
●
●
●
The muscles of the throat and gullet are weak and not well coordinated so that his swallowing
is poor: he is much more likely to choke and inhale food or medicine than a normal child. Do
not force feed malnourished children by filling their mouths and then holding the mouth closed.
Do not try to get the child to swallow by pinching his nose so that he needs to swallow before
he can take a breath. Most children find it much easier to swallow liquid than solid food. Do
not have ingredients in the diet that cause chemical inflammation in the lungs ( for example,
groundnut products are notorious for giving a chemical pneumonia when inhaled and should
not be used in the diet.)
The smooth muscle of the stomach and intestine is slow and sluggish. This is the main reason
for the small bowel bacterial overgrowth.
The smooth muscle of the bladder is weak and the bladder does not empty completely. This is
why urinary tract infection is so common - unlike normal children it is just as common in
malnourished boys and girls.
The heart muscle is weak and easily over-stretched. This is why heart failure is very common
during early recovery.
Changed body composition
The graph shows the changes in the constituents of the body. Not only are the cells small and atrophic
but the reductive adaptation has led to changes in chemical composition. All components are reduced
in about the same proportion. The two exceptions are sodium, which we have seen earlier, and iron in
the liver which are both increased. THERAPEUTIC IMPLICATIONM66
M66
●
●
●
●
●
The loss of body tissue, particularly fat and muscle, is how we make the diagnosis of
marasmus.
This is how we decide whether or not to admit a child.
But it is the changes in the physiology and biochemistry which lead to death and not the loss of
weight itself.
Some wasted children retain their physiology and reserve capacity quite well, have a good
appetite and recover quickly. Others are badly affected even if they are not so severely wasted.
Children with clinical signs of chronic malnutrition are more likely to be severely affected.
(See clinical signs module).
Loss of appetite is a cardinal feature - it means that the child has a type II nutrient deficiency,
altered liver function or a serious infection - and should also be used to decide if the child
needs special treatment. Other features such as the general appearance and regression of
milestones in children (for example, no longer being able to crawl whereas the child used to
crawl),or the inability to stand in older children and adults are important signs of failure of
function.
We now understand many of the problems that occur in marasmus. The changes in the physiology,
biochemistry and body composition, themselves can make marasmus worse. If, for example, James
started with an unbalanced diet, this has now led to infection, small bowel overgrowth, persistent
diarrhoea with pathological losses of nutrients from the intestine making the imbalance of type II
nutrients much worse, inactivity and psychosocial withdrawal leading to neglect, and particularly loss
of appetite. If he reduces his intake from loss of appetite further he will enter a vicious cycle of
deterioration. He will spiral down until he dies of hypothermia, hypoglycaemia, pneumonia,
septicaemic shock, diarrhoea, heart failure, or from the treatment that he is inadvertently given.
Here is Mathew. He has all the problems of marasmus. Now think about diabetes. It is the loss of
homeostasis of one organ - the pancreatic islet cells that make insulin - and consider the difficulty that
doctors have in treating this one problem. Now consider Mathew's problems. He not only has
problems with insulin and carbohydrate metabolism, he has also lost homeostasis of almost all his
other functions - kidney, liver, heart, muscle - he cannot mount an immune response or regulate his
body temperature and has a very limited capacity to absorb nutrients from his intestine. Mathew is not
dehydrated. He has toxic shock from severe infection. Intravenous fluids cannot be controlled
accurately enough within his homeostatic capacity and would probably kill him. Too much oral
rehydration solution would give him heart failure. To successfully treat children like Mathew requires
great skill. The treatments, including the diet, must ALL be within Mathew's very limited homeostatic
capacity whilst we correct the imbalance, reverse the physiological adaptations and treat his infection.
Mathew survived to become a normal boy, chatting, running around, kicking footballs, playing,
laughing and enjoying life.
With proper treatment and care these children come completely back to normal. Understanding their
problems and learning how to treat them properly, so that we can watch the transformation of children
like James and Mathew is the real reward for going through this module. These children were
successfully treated by the standard protocols that are now recommended by UNICEF.
Summary
Anorexia
S1
The main causes of anorexia are an unbalanced diet, infection, psychological, cancer and liver
disease. Most diets do not contain sufficient type II nutrients.
Reduced intake
S2
Anorexia is the main cause of a reduced intake, intestinal disease leads to both failure to absorb and
loss of nutrients.
Reduced mass
S3
●
●
●
●
The most obvious result of a reduced dietary intake is a reduced body weight. A high proportion
of fat, muscle and skin are consumed.
This is how we classify marasmus and make the diagnosis.
However, the changes on the other side of the diagram are the cause of death.
There is not a perfect correspondence between the weight changes and the other changes that
increase the risk of death.
Reduced requirement
S4
●
●
●
●
●
As weight is lost there is a reduction in the absolute requirement for food.
There is also a reduction per kilo body weight.
This is surprising as the changes in the weights of the different organs means that more of the
body is made up of tissue that has a high energy requirement, such as brain, liver, kidney and
heart.
This adaptation reduces the energy consumption by about one third.
This adaptation takes at least 6 weeks to fully develop.
Efficient use
S5
Food is normally used very efficiently and such a saving could not be achieved by more efficient
use.
Reduced work
S6
●
●
●
●
There is a reduction in work at every level of organisation.
The whole body-activity is reduced.
Organs
❍ Heart - cardiac output is reduced.
❍ Kidney – all renal function are reduced.
❍ Liver – the liver enzymes are at low levels giving acquired "errors" of metabolism.
❍ Muscle becomes weak and sluggish.
The cells
❍ The sodium pump activity is reduced.
❍ Protein synthesis is reduced.
❍ Transport of small molecules across membranes is slow.
Body composition
S7
There is a reduction in all the constituents of tissue except sodium (and iron in the liver) so that the
reserve within the tissues is reduced.
Physiological changes
S8
The responses to environmental change are compromised.
●
●
●
●
●
The children get a fever in an environment of 38°C.
The children get hypothermia in an environment of 25°C.
There is a reduced capacity to absorb and food component - excess can cause diarrhoea.
Bacteria overgrow the intestinal tract.
There is a reduced inflammatory and immune response to invading organisms.
Loss of reserve
S9
●
●
●
●
●
The loss of tissue mass and the reduction in the chemical composition of the remaining tissue,
together with the marked reduction in the physiological and biochemical capacity means that
there is a loss of reserve to withstand any stress that is put on the system.
Stresses such as large meals that have to be absorbed by the intestine, controlled by the
endocrine system, metabolised by the liver, and excreted safely by the kidney are dangerous.
The diet should not be unbalanced or "high" in any component. High protein diets should not be
used.
Temperature changes and infections are other stresses that the child has difficulty coping with.
The functional changes themselves make the child more susceptible to new infection,
malabsorption, losses of nutrients, overgrowth of the intestine bacteria and specific
micronutrient deficiencies.
When the malnourished child loses his appetite and reduces his intake he has entered a
downward spiral that will lead to death if the cycle is not broken. Anorexia is a major danger
sign.
Homeostasis loss
S10
The child's inability to respond to stress means that he cannot maintain the normal concentrations
of substances in his blood or tissues, electrolyte gradients, or body temperature. A relatively mild
stress, that would be well within the capacity of the normal child to homeostatically control may kill a
severely marasmic child.
Death
S11
In many hospitals about one third of marasmic children who reach hospital alive, die during
treatment. When standard protocols are used, based upon the concepts in this module, the mortality
rate is about 5% or less. The children that do not die can come completely back to normal.
Self Test
Question 1
Is the following statement true or false?
Children who have lost weight over a few days because of
diarrhoea and oedema have the same changes in physiology as
the marasmic child.
Please mark your answer
True
False
Question 2
Will it be easier to treat:
1. a child who has developed marasmus very quickly.
2. a child who has lost weight slowly.
Please fill in your answer
Question 3
Is the following statement true or false?
After a few days on a maintenance diet when the infections and
micronutrient deficiencies are coming under control the child is
out of danger.
Please mark your answer
True
False
Question 4
Is the following statement true or false?
The child with stunting and wasting is likely to be more at risk than
the child of normal height who is wasted.
Please mark your answer
True
False
Question 5
When first admitted how much energy should the child be given?
1.
2.
3.
4.
5.
6.
60 kcal/kg/d
70 kcal/kg/d
100 kcal/kg/d
135 kcal/kg/d
160 kcal/kg/d
200 kcal/kg/d
Please fill in your answer
Question 6
What is the effect of the slow sodium pump upon intracellular
sodium and potassium?
The amount of sodium in the cell rises.
Please mark your answer
True
False
Question 7
The amount of potassium in the cell rises.
Please mark your answer
True
Question 8
False
Skin
Muscle
Brain
Fat
Liver
Question 9
Is the following statement true or false?
During the initial phase of treatment the marasmic child should be
given 60 kilocalories (250kJoules) per kilo body weight.
Please mark your answer
True
False
Question 10
Is the following statement true or false?
The child with clinical signs of chronic marasmus and of
adaptation to a low intake is more easily treated than the child that
has lost weight suddenly because of an acute infection.
Please mark your answer
True
False
Question 11
Is the following statement true or false?
The child will recover more quickly if we give 200 kilocalories per
kilo from admission.
Please mark your answer
True
False
Question 12
Is the following statement true or false?
If a malnourished child does not cry it means that we are giving
him all the food and care that he needs.
Please mark your answer
True
False
Question 13
Is the following statement true or false?
Loss of appetite in a malnourished patient is a very serious sign.
Please mark your answer
True
False
Question 14
Is the following statement true or false?
Children with marasmus are sensitive to a high sodium intake.
Please mark your answer
True
False
Question 15
Is the following statement true or false?
Diarrhoea in a child with marasmus should always be treated with
oral rehydration solution.
Please mark your answer
True
False
Question 16
Is the following statement true or false?
Children with marasmus should be given high protein foods.
Please mark your answer
True
False
Question 17
Is the following statement true or false?
Children with marasmus should be treated with a very low protein
diet.
Please mark your answer
True
False
Question 18
Is the following statement true or false?
Marasmic children usually produce a dilute urine.
Please mark your answer
True
False
Question 19
Is the following statement true or false?
Children with marasmus have glucose intolerance.
Please mark your answer
True
False
Question 20
Is the following statement true or false?
Because fructose (honey, ripe bananas) does not need insulin for
its metabolism it is good for treatment of severely malnourished
children.
Please mark your answer
True
False
Question 21
Is the following statement true or false?
Full strength cow's milk can be given to the marasmic child.
Please mark your answer
True
False
Question 22
Is the following statement true or false?
Lactose intolerance is common in marasmus. It is better to treat
these children with a lactose-free formula if it is available.
Please mark your answer
True
False
Question 23
Is the following statement true or false?
If the diet has an osmolarity similar to that of plasma it will never
give diarrhoea.
Please mark your answer
True
False
Question 24
Is the following statement true or false?
There is a reduction in the activity of the sodium pump in
marasmus.
Please mark your answer
True
False
Question 25
Is the following statement true or false?
The marasmic child with sunken eyes has a low total body sodium.
Please mark your answer
True
False
Question 26
Is the following statement true or false?
Hypothermia is common in marasmic children when the
environmental temperature is 25 degrees C.
Please mark your answer
True
False
Question 27
Is the following statement true or false?
Fever in a marasmic child is a good indication of an infection.
Please mark your answer
True
False
Question 28
Is the following statement true or false?
"Normal" bacteria from the skin and intestine can invade the body
in marasmus and give rise to septicaemia.
Please mark your answer
True
False
Question 29
Is the following statement true or false?
There may be no clinical signs of an infection in marasmus.
Please mark your answer
True
False
Tutorial Question Answers
Tutorial Question 1)
The correct order is 1. An unbalanced diet, 2. Intestinal disease with failure to digest and absorb food,
3. Chronic infection, 4. Acute infection, 5. Other chronic conditions, 6. Psychological loss of appetite,
7. Cancer,
Tutorial Question 2)
Weight loss, reduced body mass, wasting.
Tutorial Question 3)
The correct option is 3. Less than a normal child
Tutorial Question 4)
No.
Tutorial Question 5)
The correct option is 3. 30%
Tutorial Question 6)
The correct option is 2. 60 kilocalories per kilo
Tutorial Question 7)
No.
Tutorial Question 8)
Yes. Children are given care when they cry or smile - if they lie quietly they are ignored. The mother
may not realise that the child is very ill.
Tutorial Question 9)
Yes. Without physical activity there is little heat produced.
Tutorial Question 10)
Yes. Lack of movement allows secretions to accumulate and their cough is very weak.
Tutorial Question 11)
Yes. They can lie for so long that they get pressure sores on the back of the head, the ears, the back
and bottom, heels and the sides of the knees.
Tutorial Question 12)
Yes. If lethargic for weeks and months - play, exploration and stimulation are essential for
development - a short time will not make a difference.
Tutorial Question 13)
The correct option is 2. It is slower
Tutorial Question 14)
The correct option is 2. One and a half times plasma
Tutorial Question 15)
True.
Tutorial Question 16)
True.
Tutorial Question 17)
True.
Tutorial Question 18)
True.
Tutorial Question 19)
True.
Tutorial Question 20)
False.
Tutorial Question 21)
True.
Tutorial Question 22)
10 hours or 600 minutes.
Tutorial Question 23)
No. Once the circulation is full then any extra sodium will stress the child's circulation as well as the
kidneys.
Tutorial Question 24)
Yes. This will happen in some cases of marasmic-kwashiorkor - but it is not as common as heart
failure.
Tutorial Question 25)
No. This is very dangerous - in one study such over-hydration was responsible for more than half the
deaths - 5% of the children treated.
Tutorial Question 26)
No. The intestine is much longer than the 30 cm we have tested - most will absorb the rest of the sugar
further along the intestine.
Tutorial Question 27)
Yes. They can absorb carbohydrate, but they cannot absorb a lot at one time.
Tutorial Question 28)
No. They need plenty of carbohydrate to prevent hypoglycaemia and to get enough energy to grow but each feed should be small enough for them to absorb it.
Tutorial Question 29)
No. This increases the amount that is taken at one time - it is better to have an isotonic diet and give it
more frequently.
Tutorial Question 30)
Yes and no. Their normal blood sugar is low, but after a meal their blood level does stay high for
longer than normal and they sometimes have glucose in their urine. This should never be treated. It is
difficult to diagnose diabetes in a malnourished adult because of these changes.
Tutorial Question 31)
YES! - very easily. Their glucagon, which increases blood glucose is very low. They mobilise glucose
stored as glycogen very slowly and there are not enough muscle amino acids to make new glucose
when the effect of a meal runs out - so if they are not fed for some hours the blood sugar drops to very
low levels.
Tutorial Question 32)
Yes. There is a decrease in total body potassium.
Tutorial Question 33)
No. More sodium is gained than potassium lost. This is because there is loss of magnesium as well as
potassium; there is an increase in the amount of chloride that is in the cell; the intracellular water is
increased relative to the protein. The stochiometry of the sodium pump is not one molecule of sodium
exchanged for one of potassium gained, it is 3:2, which causes this difference.
Tutorial Question 34)
Because he has a higher metabolic rate and is generating more heat in his body.
Tutorial Question 35)
Because he cannot lose heat fast enough by sweating.
Tutorial Question 36)
No. Because the malnourished child is producing less heat in his body, the environmental temperature
needs to be higher. - Malnourished : 28 - 32°C - Normal : 25 - 30°C.
Tutorial Question 37)
No. It is only at the very end that the processes that are vital for preservation of life, in the child's
normal environment are affected. Most malnourished children in the Sahara desert, for example, retain
a good skin and maintain their sweating response - similarly malnourished children in other climates
lose their ability to sweat. A bad skin in a very hot or cold environment is a bad feature.
Tutorial Question 38)
No. The child was recently malnourished but he has reversed the adaptation and has started to grow
very rapidly. Although he still has a low weight-for-height, he is not "metabolically" malnourished.
With recovery and rapid weight gain there is greatly increased body heat production. The children
need to dissipate this heat - if children start to grow before their skin and sweat become normal they
often get a fever. This is not an infection.
Tutorial Question 39)
Yes. In Angola half the children in one center developed hypothermia. Hypothermia was as common
in malnourished adults as children in Burundi. In the desert in Tchad deaths from hypothermia occur.
Tutorial Question 40)
No. The malnourished child needs a warmer environment. The charts show that even at 25°C
hypothermia rapidly occurs - this temperature is pleasant and thermoneutral for well nourished adults.
Tutorial Question 41)
No. A lot of heat is lost from the body, but most is lost from the head. A baby's head is large, has a
high metabolic rate and a high blood flow.
Tutorial Question 42)
It is unlikely in an environment of 25°C. But if the temperature was a few degrees lower they could
certainly get hypothermia; such temperatures are commonly found at night in the tropics (21°C).
Normal adults, who are naked, cannot maintain body temperature at 16°C without violent shivering.
Self Test Question Answers
Self Test Question 1)
False.
Self Test Question 2)
The correct option is 1. a child who has developed marasmus very quickly.
Self Test Question 3)
False. The start of refeeding and early rapid weight gain are also dangerous.
Self Test Question 4)
True.
Self Test Question 5)
The correct option is 3. 100 kcal/kg/d
Self Test Question 6)
True. As sodium leaks into the cell the sodium pump pumps it back out again. If the sodium pump is
slow then the sodium that leaks into the cells cause the intracellular sodium to rise. If there is damage
to the membranes as well then the serum sodium concentration can fall. A low serum sodium should
never be treated by giving extra sodium to the child.
Self Test Question 7)
False. Potassium leaks out of the cell and is lost in the urine - so the intracellular potassium falls.
During treatment a large amount of potassium must be in the diet to replace this deficit.
Self Test Question 8)
The correct order is 1. Fat, 2. Muscle, 3. Skin, 4. Liver, 5. Brain,
Self Test Question 9)
False. The child should be given 100 kilocalories per kilo. The basal metabolic rate is about 60
kilocalories per kilo - but we have to give more than this for treatment.
Self Test Question 10)
False. The reductive adaptation in chronic malnutrition has made the child very difficult to treat
within his homeostatic capacity: he is vulnerable to any small errors in treatment. The normal child,
that becomes acutely ill and loses weight, has not adapted and can cope with excess or insufficient
treatment much more easily.
Self Test Question 11)
False. This is very dangerous and the children may die. Such high intakes should not be given until
the physiological changes have been reversed and the capacity of the child has increased to allow him
to metabolise and excrete this amount of food. Large intakes at the beginning provoke diarrhoea,
stress the liver, lead to accumulation of solute in the body and may give heart failure.
Self Test Question 12)
False. The marasmic child is apathetic and does not cry or complain. This is very abnormal and not
understood by the mother. He is very vulnerable. He is easily neglected by both the mother and the
staff. It is better to treat him with a standard protocol.
Self Test Question 13)
True. Without treatment a marasmic child with severe loss of appetite is going to lose more weight
and deteriorate until he dies. This is the most important indication that you have to take action. It is
more important than the weight-for-height used to classify malnutrition.
Self Test Question 14)
True. Their kidneys cannot excrete excess sodium quickly when they have an expanded circulation.
Once the circulation is adequate it is dangerous to give any more high sodium fluids such as ORS or
ReSoMal.
Self Test Question 15)
False. Only "watery" diarrhoea should be treated. Mild "refeeding" diarrhoea does not need treatment
with rehydration solutions unless the child has actually lost weight. Daily weights are taken during
treatment so that fluid balance can be accurately assessed at any time. For refeeding diarrhoea the
dietary volumes and the number of feeds should be adjusted to be within the capacity to absorb all the
food. If rehydration is needed, reduced sodium solutions such as ReSoMal should be used and not
ORS.
Self Test Question 16)
False. A high protein diet gives a) a high renal solute load, b) acid that needs to be excreted, and c) it
stresses the liver which has acquired "errors" of amino acid metabolism. In the early stages a
moderately low protein diet should be used. Even during rapid growth no more than 12% of the
energy needs to come from protein.
Self Test Question 17)
False. Protein is essential. High quality protein is needed to repair all the metabolic machinery that has
adapted and been damaged. However it must be balanced by the other nutrients. In the early phase
they should have between 0.8 and 1.2 grams of protein per kilo. During rapid growth protein should
be between 10% and 12% of energy.
Self Test Question 18)
True. The urine is normally less concentrated than the plasma. Most children cannot achieve a highly
concentrated urine. An adequate water intake is important in marasmus.
Self Test Question 19)
True. They have an impaired response to glucose with a low insulin output and low numbers of
insulin receptors. BUT they also get hypoglycaemia very easily if they are not fed for several hours.
Self Test Question 20)
False. Small amounts will not do any harm, but high fructose intakes lead to lactic acidosis,
hypoglycaemia and liver damage. These effects are prevented by galactose (lactose) so that these
foods should be given mixed with milk.
Self Test Question 21)
False. Both the sodium and protein contents of cow's milk are too high for marasmic children.
Self Test Question 22)
False. Human breast milk has twice as much lactose in it as cow's milk and it the ideal treatment.
Nearly all children can be successfully treated with modified cow's milk-based diets. There is
"intolerance" of large amounts of any carbohydrate. It is better to think of this as a reduced "capacity"
for absorption rather than a disease entity. Lactose helps with calcium absorption, modulates the
intestinal flora and prevents hypoglycaemia.
Self Test Question 23)
False. The capacity to absorb is reduced. The capacity can be exceeded by either a normal volume of a
concentrated feed or a high volume of an isotonic feed. Thus, a high volume of an isotonic diet can
give diarrhoea. If this happens reduce the volume given and increase the frequency of feeding.
Self Test Question 24)
True. And this is a critical change. It leads to changes in muscle, smooth muscle, heart and brain
function and also to slow transport of amino acids and sugars across cell membranes - reversing this
to rapid adaptation can lead to fatal electrolyte dysequilibrium.
Self Test Question 25)
False. The total body sodium is increased by about 40% in marasmus. Even in marasmic children with
"dehydration" the intracellular sodium is increased, although, rehydration solutions need to be given
to restore the circulation of a marasmic child with dehydration. When the adaptation is being reversed,
during treatment, the child is very vulnerable to high salt intakes - this is why "refeeding" diarrhoea
should not be treated with rehydration solutions.
Self Test Question 26)
True. The thermoneutral range is higher for the marasmic child than the normal child - hypothermia
can easily occur when the staff and mother find the environment comfortable.
Self Test Question 27)
False. Sometimes it is due to an infection - more commonly, in a child with marasmus, fever is due to
a high environmental temperature. During rapid growth so much metabolic heat can be produced that
the child may get a fever if the sweating response has not fully recovered. All malnourished children
should receive antibiotics whether or not they have a fever.
Self Test Question 28)
True. Positive blood cultures with these bacteria are found in about 10% of patients. This is the most
common cause of toxic shock.
Self Test Question 29)
True. Because of the reduced inflammatory response the child can have a severe infection without any
clinical signs. This is why all children have to be treated blindly with antibiotics.