1

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.

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 patients
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
Indonesia with measles and spread the disease in a Texas community. In October, five
Australians were diagnosed with measles after returning from Bali. 17

2
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.

3
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 bodys 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
Table
Skin2-1and
bones
apperancechildren based on data in Unicef
Number
of malnourished
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.

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

Table 2-2 Practical Scheme for Pediatric Malnutrition Classification

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 2-3 General Classification of

Anthropometry (Waterlow Classification)

Child

Undernutrition

by

Table 2-4 Alternative Classification of Wasting Status of Children

(MUAC = Mid-Upper Arm Circumference)
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.

7
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

Table2-3 Anthropometric criteria to identify severe, moderate, and at risk

categories of acute malnutrition for infants and 10 year-old children.

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.
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

8
children under five years) is considered a high mortality risk and is a criteria for admission with
severe acute malnutrition.

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

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

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

10
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 childs family are followed to prevent
relapse and assure the continued physical, mental and emotional development of the
child.

2.1.11.

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

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
2.1.12.

Prognosis of Marasmus

11
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 etiologyrelated 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, Akr 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/984496overview. 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.
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.