MARASMUS AND

KWASHIORKAR
GROUP - 8
GROUP MEMBERS

 Patel Raj Bharatkumar

 Shivam
 Thirouvengadam Sivakamy Chethran
 Varlani Ashish Dilipkumar
 Venkata Rey Jashwanth
 Venkataram Vidya
CASE
 A 2 year old boy, residing in Barangay, in Quezon
city, was bought by his mother to OPD of National
Children Hospital. The mother has 5 children. The
youngest of whom is 6 months and is currently
being breast fed.
 The family is living in a shanty in a squatters area.
The father is a tricycle driver but his earnings is
not enough to support his family.
 The children main food consists of starchy gruel,
occasionally mixed with diluted condensed milk.
 According to his mother patient has been eating poorly
for past few months and since he was 10 months old, he
has had intermittent diarrhea and respiratory infections.
He had measles 2 months prior to his consultations. At
present patient is irritable, apathetic and has poor
appetite.
 Physical examination shows that the patient weights 8
kgs. with a height of 81 cms.
 He is pale, skin is flaky and his hair is brittle, dry and
depigmented; his abdomen is distended
 his liver is moderately enlarged, edema is very evident
on his lower extremities. His conjuctiva are dry with
bitot’s spot formation.
LABORATORY FINDINGS

 Only a few test were done due to limited resources

 Hemoglobin – 6.0 g/dl (13- 15)
 Total serum protein – 4.4 g/dl (6-8)
 Albumin – 2.0 g/dl (3.5-5.5)
OBJECTIVES

 To differentiate between Marasmus and Kwashiorkor.

 To understand the diagnosis of the given case.
 To understand the classification ; Gomez classification
and Waterflow classification.
 To determine the factors that contributed the
deficiency.
 To study the management and preventive measures.
QUES – 1 Difference between Marasmus
and Kwashiorkor.
 Diagnosis Of The Above Case
 When the patient was physically examined, he was
diagnosed with a swollen liver and edema in the lower
extremities and the blood tests conducted showed low
levels of blood serum protein.
 The other prominent symptoms seen were diarrhoea,
irritability, change in hair colour, damaged immune system
etc.
 The patient showed clear signs of malnutrition considering the
kind of food he'd been having which lacked protein hence the
low protein level in the blood.
 From the above symptoms and
physical examination conducte,
we can conclude that the patient
is diagnosed with kwashiokar and
not marasmus because both show
malnutrition but only kwashiokar
is seen with edema in lower
extremities.
 DETERMINATION OF
PATIENTS NUTRITIONAL
STATUS
Gomez classification
Weight for age compared to average
percent at age
> Grade 0: >90%,normal
>Grade 1: 81-90%, mild
malnutrition
>Grade 2: 60-80%, moderate
malnutrition
>Grade 3: 60%, severe malnutrition
 Gomez classification. One of the earliest
systems for classifying
protein-energy malnutrition in children
,based on percentage of
expected weight for age: over 90% is
normal 76-90% is mild
{first degree} malnutrition, 61-75% is
moderate {second degree}
malnutrition and less than 60% is severe
{third degree}malnutrition.
 Waterlow classification
 A System for classifying protein-energy
malnutrition in children based on
wasting(the percentage of expected
weight for height) and the degree
stunting (the percentage of expected
height for age).
 % weight for height=(weight of
patient)\(weight of a nl child of the same
height).
 % height for age=(height of
patient)\(height of a nl child of the same
age).
 4) Give the mechanism
behind the following
manifestation in the patient
a) Flaky skin
 Flaky shin or desquamation is also
known as the skin peeling. It is the
shedding of the outermost membrane
or layer of a tissue, such as the skin.
 One of the severe forms of protein-
energy malnutrition (PEM).
 The skin lesions usually first occur in
areas subject to friction or pressure, for
example the groin, behind the knees, on
the buttocks, and at the elbows.
 Darkly pigmented patches form, and
these may peel or desquamate, rather
like old, sun-baked blistered paint. This
has led to the terms "peeling paint" or
"flaky paint" dermatosis.
 However, when "flaky paint" dermatosis is
seen in a malnourished child with edema, it
is pathognomonic of the disease
kwashiorkor.
 As protein is the main structural
framework of body deficiency of this
causes flaky skin.
b)brittle, dry and depigmented hair

 Nutritions are very important in hair growth.

 hair changes are useful early indicators of protein-calorie
malnutrition. Because disease can disturb protein
synthesis in hair.
 hair is composed almost entirely of protein, a reduction of
hair growth reflects a reduction in protein synthesis in the
follicle. decreases in serum albumin were highly correlated
with decreases in hair shaft diameter.
 Hair becomes dry and lustreless and may turn reddish yellow to
white in colour. It becomes sparse and brittle and can be pulled
out easily.
 Hair depigmentation also occurs.
c) Distended abdomen

 The extreme lack of protein causes an

osmotic imbalance in the gastro-
intestinal system causing swelling of the
gut diagnosed as an edema or retention
of water.
 Proteins in the body are responsible for
the balance of osmotic pressure in the
body, besides their structural roles.
 Proteins are generally macromolecules,
which means that they are sizably large
and not easy to transport through cells
permeable membranes
 The proteins can pass
through the
membranes only
through special
mechanistic
procedures in the
membranes and are
otherwise found in
the blood serum or
lymph.
 Presence of proteins
in lymphatic system
leads to higher
osmotic pressure.
The regulation of water
maintains a healthy
distribution of water
throughout the body. If this
regulation is compromised
due to protein deficiency,
the buildup of fluid leads
to distention of abdomen
as well as fluid retention
or edema.
 d.ENLARGED LIVER
 Another common symptom of kwashiorkor is a fatty liver,
or fat accumulation in liver cells .
 Left untreated, the condition may develop into fatty liver
disease, causing inflammation, liver scarring and
potentially liver failure.
 .
 Fatty liver is a common condition in obese
people, as well as those who consume a lot
of alcohol .
 Why it occurs in cases of protein
deficiency is unclear, but studies suggest
that an impaired synthesis of fat-
transporting proteins, known as
lipoproteins, may contribute to the
condition
e.Edema of the lower
extremities
Edema means swelling. The condition called edema arises when
part of the body becomes swollen because fluid gathers in
the tissue. It most commonly affects the arms and legs. That is
called peripheral edema.
 If there is a lack of the protein albumin in the blood,
fluid can leak out of blood vessels more easily. Low
protein in the blood can be caused by
extreme malnutrition, as well
as kidney and liver diseases which mean that the body
loses too much or produces too little protein.
f. Dry conjunctivae
g. Low haemoglobin, hypoproteinemia, and
hypoalbuminemia
5. What are the factors that
contributed to the development of
malnutrition in this patient ?
Bad diet: Many people especially children do
not eat healthy food and this in turn cause
malnutrition.

Inability to purchase food or lack of food supply:

Food shortage is a major obstacle for poor people.
They do not have enough resources to provide
adequate food .This can many a time result in
malnutrition.
Inadequate nutrient intake or poor eating
habits: Now a day’s most of the people suffer
with digestive disorders because of not eating
food at right time or eating unhealthy food
etc. and some people may eat healthy food but
their body cannot absorb nutrients that are
required for good health.

Insufficient breast feeding: Malnutrition can

also be caused when mother delay
breastfeeding their babies, increased bottle or
artificial feeding and delayed or early start of
solid complementary feeding can lead to
malnutrition in infants.
 Question:6
Discuss the management of
this case. What preventive
measure can you advise to the
mother so that the other
children will not develop
malnutrition?
•Management of Kwashiorkor depends on the
severity of the case.

•Usually, it is advised not to treat or admit a

patient with mild to moderate Kwashiorkor in a
hospital where overcrowding causes frequent
spread of infection As stated by WHO,UNICEF .

•Due to the symptom of edema in this case,

admission might needed
There are three stages of treatment.
1. Hospital Treatment
The following conditions should be corrected:
Hypothermia, hypoglycemia, infection, dehydration,
electrolyte imbalance, anemia and other vitamin and
mineral deficiencies.
Hospital care involve feeding small amount of milk based
liquid food every 2-3 hours with initial recommendation of
1ookcal/kg/day
2. Dietary Management
The main treatment is to supplement and increase caloric
intake to reverse effect of Kwashiorkor.
The diet should be from locally available staple foods -
inexpensive, easily digestible, evenly distributed
throughout the day and increased number of feedings to
increase the quantity of food.
3. Rehabilitation
The concept of nutritional rehabilitation is based on practical
nutritional training for mothers in which they learn by feeding their
children back to health under supervision and using local foods.
 Prevention

 Promotion of breast feeding

 Nutrition education and promotion of correct
feeding practices
 Family planning and spacing of births
 Food fortification
 Early diagnosis and treatment
Preventive Advice:

Kwashiorkor is entirely preventable by

providing a balanced diet which must
contain adequate amounts of major
macronutrients such as protein, fats, and
carbohydrates. In this case, primarily
protein.

Some Micronutrients, vitamins, and

minerals are needed as well.