Case Presentation

A BOY AGED 2 YEARS WITH

MARASMUS-TYPE MALNUTRITION
Evan Permana Putra / G99172071
Dwi Pratika Anjarwati / G99172064

Pediatric Department of Moewardi General Hospital

PATIENT STATUS
PATIENT IDENTITY
 Name : Child D
 Date of birth : February, 24th 2016 (2 years 10 months)
 Sex : Male
 Address : Kebonsari, Cepo, Boyolali
 Weight : 6 kg
 Height : 95 cm
 Date of admission : January, 9th 2019
 Date of examination : Januari, 18th 2019
HISTORY TAKING
 Chief complain : Vomiting
• Patient are referrals from Boyolali Hospital
 1,5 months ago
• Oral ulcer appear in the mouth with moderate size  Become
irritable and refuse to eat  Eat 2 – 3 times daily with small
portion (3 – 4 tablespoon)
• Accompanied by watery stool > 5 times daily without mucus and
blood, no vomiting and fever
• Patient are taken to PHC  Receive ORS, topical medicine, and
antibiotic  Recover but often recurrent
HISTORY TAKING
 Five days before
• Diarrhea appear again with watery stool > 5 times daily as much
as ¼ glass, no blood and mucus, no vomiting and fever
• The mother give him ORS and then diarrhea stops
• Oral ulcer still appear, patient are more difficult to eat
 Two days before
• Diarrhea stops but patient vomit up to 5 times daily
• Vomit are white-coloured with some pieces of food, no blood
• Patient were given ORS by the mother but vomiting did not stop
 In Boyolali Hospital
• Vomit two times as much as ¼ glass with some food pieces
• Oral ulcer still appear and patient did not want to eat
• Patient is referred to Moewardi Hospital for further investigation
 In emergency room of Moewardi Hospital
• The patient is fully conscious, not fever, vomit two times (in
Boyolali Hospital)
• History of cough more than three weeks in patient, family, and
neighbourhood is denied
HISTORY TAKING
 In emergency room of Moewardi Hospital
• The patient is fully conscious, does not have fever, does not have
diarrhea, does not vomit, defecate and bladder as usual
• History of chronic cough is denied, history of parasitic infection is
denied, history of bluish body is denied
• Does not have snack habits carelessly
• Before and after eating, patients usually wash his hands
HISTORY OF RECENT ILLNESS
 History of similar problem : Yes
• Patient has history of recurrent diarrhea and stomatitis
 History of hospitalization
• About 1 months ago, patient was treated in Moewardi Hospital
with acute gastroenteritis and malnutrition
 Allergic history : Denied
HISTORY OF FAMILY ILLNESS
 History of family illness
• History of similar problem : Denied
• History of allergic : Denied
 History of socio-economic
• The father work as craftsman at home
• The mother work as housewife
• Patient seek treatment using class I BPJS
HISTORY OF PREGNANCY AND BIRTH
 History of pregnancy
• Pregnant when she was 23 years old (G2P0A1)
• History of fever, bleeding, and other illness were denied
• Routine to check her pregnancy to the midwife and receive
vitamin and supplements
 History of birth
• Per abdominal due to transverse position
• Birth weight 2750 gram and the length was 49 cm
• Cried spontaneously, not blue, not yellow, active move
HISTORY OF IMMUNIZATION
 0 months : Hep B
 1 months : BCG, Polio 1
 2 months : Pentabio 1, Polio 2
 3 months : Pentabio 2, Polio 3
 4 months : Pentabio 3, Polio 4
 9 months : Measles
 18 months : Measles
 The patient get complete immunization according to age based on
guidelines from Ministry of Health 2008
FAMILY TREE

Child D
HISTORY OF GROWTH AND DEVELOPMENT
 Growth
• Weight-for-age : z-score < -3 SD (severe underweight)
• Height-for-age : z-score at 0 SD (normoheight)
• Weight-for-age : z-score < -3 SD (severe malnutrition)
 Development
• Lie on his stomach at 3 months of age, sit at 7 months of age
• Crawling at 9 months of age, walking at 13 months of age
• Talking at 20 months of age
• Impression : Development is corresponding with his age
HISTORY OF NUTRITION
 Breastmilk plus milk formula (not exclusive breastfeeding)
 Start to eat complementary feeding in 6 months
• Packaged baby porridge, rice, vegetable, and fruit
 Before getting sick, patient eat 3 times daily
• Various food and little vegetable
• Rarely buy snacks on the roadside
 Impression : Quantity and quality of nutrition is adequate
GENERAL SURVEY AND VITAL SIGN
 General status
• Moderate pain, compos mentis (E4V5M6)
 Vital sign
• Heart rate : 124 times/minute, regular
• Respiration rate : 24 times/minute, regular
• Temperature : 37,20C per axilla
• SpO2 : 99% without oxygen
 Head
Thorax
Mesocephal, HC 48,5 cm
Symmetric, retraction
Nellhaus -2 SD < HC < 0,
(-), prominent ribs (+)
old man face (+)

Cor
Eye
IC not palpable, S1 and S2
Pupil 2 mm/2mm, light
normal, regular, murmur (-)
reflex (+/+), conjunctiva
pallor (-/-), sunken eyes
(-/-), tears is adequate Pulmo
Symmetric movement,
Ear normal fremitus, resonant
Discharge (-/-) (+/+), vesicular sound (+/+),
added sound (-/-)

Nose
Nostril breathing Abdomen
(-), discharge (-/-) Distended (-), normal
turgor, bowel sound (+),
tympanic (+), ascites (-),
Mouth pain (-), liver and spleen
Stomatitis (+), wet not palpable
mucous, tonsil T1-T1,
hyperemia (-)
Extremity
Cold (-/- -/-), strong pulse, CRT
Neck
< 2, baggy pants (-), BCG scar
Swollen lymph
(+), wasting (+/+ +/+)
node (-)
BLOOD EXAMINATION (09-01-2019)
 Routine blood count  Erythrocyte index
• Hb : 7 gram/dL  • MCV : 72,6 / m 
• Hct : 41%  • MCH : 19,2 pg 
• AL : 17,7 thousand/ L  • MCHC : 26,5 gram/dL 
• AT : 1210 thousand/ L  • RDW : 17,0% 
• AE : 3,64 million/L  • MPV : 7 fl 
• PDW : 15% 
BLOOD EXAMINATION (09-01-2019)
 Differential count  Electrolyte
• Eosinophils : 0,40%  • Natrium : 133 mmol/L
• Basophils : 0,10% • Potassium : 4,3 mmol/L
• Neutrophils : 59,20% • Chloride : 99 mmol/L
• Lymphocyte : 34,70%  • Calcium : 1,17 mmol/L
• Monocyte : 5,60%  Anti-HIV : Non-reactive
 Clinical chemistry
• Blood glucose : 84 mg/dL
• Albumin : 3,2 gram/dL 
PROBLEM LISTS
 History taking
• Do not want to eat
• History of recurrent diarrhea and stomatitis
• Vomiting 2 times daily as much as ¼ glass
• History of acute gastroenteritis and malnutrition
 Physical examination
• Old man face (+), stomatitis (+), prominent ribs (+)
• Wasting (+/+ +/+)
PROBLEM LISTS
 Laboratory investigations
• Normochromic normocytic anaemia (7)
• Thrombocytosis (1210)
• Hypoalbuminaemia (3,2)
• Pneumonia
DIAGNOSIS
 Differential diagnosis
• Marasmus-type malnutrition
• Kwashiorkor-type
malnutrition
 Working diagnosis
• Marasmus-type malnutrition
in stabilization phase day 1
• Secondary immuno
deficiency due to suspect
HIV dd TB
• Normochromic normocytic
anaemia (7)
• Reactive thrombocytosis due
to suspect infection (1210)
10 STEPS MANAGEMENT
 Treat hypoglycaemia : Not hypoglycaemia
 Treat hypothermia : Not hypothermia
 Treat dehydration : No dehydration
 Correct electrolyte imbalance : No electrolyte imbalance
 Treat infection : Cotrimoxazole
• TMP 5 mg/kgBW + SMX 25 mg/kgBW per 12 hours  30 mg/150
mg per 12 hours
10 STEPS MANAGEMENT
 Correct micronutrient deficiencies : Vitamin A 200.000 IU single
dose and folic acid 5 mg and then
• Elkana syrup 1 tsp per 24 hours
• Mineral mix 1 tsp per 24 hours
• Folic acid 1 mg per 24 hours
• Zinc 20 mg per 24 hours
10 STEPS MANAGEMENT
 Initial re-feeding
• 80 – 100 kcal/kgBW per day  480 – 600 kcal per day
• Liquid 130 ml/kgBW per day  780 ml per day
• Protein 1 – 1,5 gram/kgBW per day  6 – 9 gram per day
• Stabilization phase : F-75 12 x 100 ml
10 STEPS MANAGEMENT
 Catch-up feeding : In rehabilitation phase
 Sensory stimulation and emotional support
 Follow-up preparation after treatment
 Resomal 10 ml/kgBW every diarrhea  60 ml every diarrhea
PLANNING AND MONITORING
 Planning  Monitoring
• Check complete blood count • Check vital sign per 8 h
• Check electrolyte • Check fluid balance per 8 h
• Check random blood glucose • Check MUAC per 3 days
• Urinalysis and routine stool • Check body weight per days
examination
• Mantoux test
• Chest X-ray
PROGNOSIS
 Ad vitam : Bonam
 Ad sanationam : Bonam
 Ad functionam : Bonam
PERIPHERAL BLOOD SMEAR (09-01-2019)
 Erythrocyte
• Normochromic partially hypochromic, normocytic
 Leukocyte
• Increase in number, vacuolization and hypergranulation of
neutrophils, blast cells (-)
 Thrombocyte
• Increase in number, macro-thrombocytes, clumping (-)
PERIPHERAL BLOOD SMEAR (09-01-2019)
 Conclusion
• Normochromic normocytic anaemia with leucocytosis and
thrombocytosis due to suspect chronic disease dd haemolytic
process with infection
 Suggestion
• Serum iron, total iron binding capacity, ferritin
• Indirect bilirubin, LDH, CRP
URINE EXAMINATION (10-01-2019)
 Macroscopic
• Yellow, clear
 Urinary chemistry
• Specific gravity : 1,013
• pH : 7,5
• Leukocyte (-), erythrocyte (-)
• Protein (-), glucose (-)
• Nitrite (-), ketone (-)
• Urobilinogen (-), bilirubin (-)
 Microscopic
• Erythrocyte : 2 – 3 /HPF
• Leukocyte : 2 – 3 /HPF
• Yeast-like cell : 0
• Mucous : 4,44 /uL
• Sperm : 0
 Squamous cells : 0 – 2 /HPF
 Casts : -
CHEST X-RAY AND TB TEST
 AP and lateral chest X-ray (09-01-2019)
• Pneumonia
 Gene Xpert MTB-RIF assay (10-01-2019)
• MTB not detected
STOOL EXAMINATION (10-01-2019)
 Macroscopic
• Consistency : Soft
• Colour : Brown
• Blood : Negative
• Mucus : Positive
• Fat : Negative
• Pus : Negative
• Undigested food : Negative
• Parasite : Negative
 Microscopic
• Epithelial cells : Negative
• Leukocytes : ++
• Erythrocyte : Negative
• Undigested food : Negative
• Eggs and parasite : Negative
• Protozoa : Negative
• Yeast cells : Negative
• Pseudohyphae : Negative
BLOOD EXAMINATION (15-01-2019)
 Routine blood count  Erythrocyte index
• Hb : 7 gram/dL  • MCV : 66,8 / m 
• Hct : 23%  • MCH : 20,2 pg 
• AL : 14,2 thousand/ L • MCHC : 30,3 gram/dL 
• AT : 964 thousand/ L  • RDW : 18,6% 
• AE : 3,45 million/L  • MPV : 4,6 fl 
• PDW : 17% 
BLOOD EXAMINATION (15-01-2019)
 Differential count  Electrolyte
• Eosinophils : 0,09%  • Natrium : 130 mmol/L 
• Basophils : 1,78%  • Potassium : 4,3 mmol/L
• Neutrophils : 60,42% • Chloride : 110 mmol/L 
• Lymphocyte : 29,49%  • Calcium : 1,17 mmol/L
• Monocyte : 8,21% 
STOOL EXAMINATION (17-01-2019)
 Macroscopic
• Consistency : Liquid
• Colour : Yellow
• Blood : Negative
• Mucus : Positive
• Fat : Negative
• Pus : Negative
• Undigested food : Negative
• Parasite : Negative
 Microscopic
• Epithelial cells : Negative
• Leukocytes : ++
• Erythrocyte : Negative
• Undigested food : Negative
• Eggs and parasite : Negative
• Protozoa : Negative
• Yeast cells : +++
• Pseudohyphae : ++
BLOOD EXAMINATION (18-01-2019)
 Routine blood count  Erythrocyte index
• Hb : 6,1 gram/dL  • MCV : 77,2 / m 
• Hct : 26%  • MCH : 17,8 pg 
• AL : 10,5 thousand/ L • MCHC : 23,1 gram/dL 
• AT : 1043 thousand/ L  • RDW : 17,8% 
• AE : 3,42 million/L  • MPV : 7,2 fl
• PDW : 42%
BLOOD EXAMINATION (15-01-2019)
 Differential count  Clinical chemistry
• Eosinophils : 0,30% • Hs-CRP : 1,99 
• Basophils : 0,20%
• Neutrophils : 53,70%
• Lymphocyte : 36,30%
• Monocyte : 6,30% 
• ESR 1 hour : 5 min
LITERATURE REVIEW
 Underweight
 Low weight-for-age
 Stunted, wasted, or both

Wasting
 Low weight-for-height
Undernutrition
 Indicate recent and severe
weight loss

Malnutrition
Stunting
 Low height-for-age
 Indicate chronic or recurrent
undernutrition
Overweight / Obese
“Severe acute malnutrition is defined as the
presence of oedema of both feet or severe
wasting. No distinction is made between the
clinical conditions of kwashiorkor or severe
wasting because their treatment is similar”
 Weight-for-length/height < -3 SD or
 Mid-upper arm circumference (MUAC) less
than 11,5 cm or
 Oedema of both feet (kwashiorkor with or
without severe wasting)
The Lancet  Vol 362  July 19, 2003  www.thelancet.com
Etiology of malnutrition
 What is the difference between
marasmus and kwashiorkor ?

Marasmus / Severe Wasting Kwashiorkor


Medical History
 Usual diet before illness
 Breastfeeding history
 Food and fluids in past few days
 Vomiting or diarrhoea
 Time when urine was last passed
 Contact with people with
measles or TB
 Any death of siblings
 Birth weight
 Milestones reached
 Immunizations
Checklist for examination of
children with malnutrition
Physical Examinations
 Weight and length or height
 Oedema
 Liver enlargement, jaundice
 Abdominal distention, bowel sounds
 Severe pallor
 Signs of circulatory collapse
 Temperature : Hypothermia or fever
 Thirst
 Eyes : Corneal lesions
 ENT for evidence of infection
 Skin for evidence of infection or purpura
 Respiratory rate and type of respiration
 Appearance of faeces
Blood glucose Blood smear

Urine and stool

Haemoglobin
examination

Chest X-ray Tuberculin test

 4 phases

10 steps
4 PHASES
 Stabilization / initial treatment
• To treat the emergency and improve clinical condition
• Give formula diets F75
• Usually occur in 1 – 2 days
 Transition phase
• To give the chance for adaptation to higher energy and protein
• F75 is switched to F100
• Usually occur in 5 – 7 days
4 PHASES
 Rehabilitation phase
• To restore the damaged body tissue
• Give F100 plus other foods who children like and evaluation for
weight gain minimal 50 gram/kg/weeks
• Occurs in 2 – 4 weeks
 Follow-up phase
• Continue the feeding and care after discharge from hospital
• Routine control, complete immunization, treat co-morbidities
• Occur in 4 – 5 months
Treat hypoglycemia
Blood glucose < 54 mg/dl or < 3 mmol/litre

Conscious
 Give 50 ml of 10% glucose
solution (one rounded teaspoon
of sugar in three tablespoons of
water) orally or by NGT
Unconscious
 Give 5 ml/kg body weight of
sterile glucose 10% by IV
followed by 50 ml of 10%
glucose or sucrose by NGT

1,5 hours later

Start feeding with F-75 every half-hour during

the first 2 hours
2 hours later

Check blood glucose again

Still < 54 mg/dl or < 3 mmol/litre ≥ 54 mg/dl or ≥ 3 mmol/litre

Give F-75 every Give F-75 every

2 hours half hours
Treat hypothermia

Rectal temperature < 350C

Re-warm the child

 Cover with warm blanket and/or warm clothing
 Place the heater of lamp nearby (min 50 cm)
 Kangaroo mother care
 Keep the child away from draughts
 Maintain room temperature of 25 – 300 C
 Feed the child immediately

Use heater Not use heater

Monitor rectal temperature every 2 Monitor rectal temperature every

hours until it rises to > 36,50C 30 minutes until it rises to > 36,50C
Treat dehydration

Give Resomal orally or by NGT

 Give 5 ml/kgBW every 30 min
First 2 hours
 Monitor respiration and pulse
rate for every 30 min

Give 5 – 10 ml/kgBW Resomal and F-75 (based

Next 4 – 10 hours
on body weight) alternately every hours

Give F-75 every 2 hours and Resomal every defecation

 < 1 years old : 50 – 100 ml
 ≥ 1 years old : 100 – 200 ml
 Give IV fluid at 15 ml/kgBW over 1 hour
 Ringer’s lactate with 5% dextrose
 Half-strength Darrow’s solution with
5% dextrose
 NaCl 0,45% plus 5% dextrose

Improvement No Improvement

Repeat IV infusion over 1 hour  Give IV fluid at 4 ml/kgBW per hours

while awaiting for blood
 WB 10 ml/kgBW slowly over 3 hours
Give 5 – 10 ml/kgBW Resomal and F-75 (based
on body weight) alternately every hours
Give F-75 every 2 hours without Resomal
Correct electrolyte imbalance

All severely malnourished children have

 Deficiencies of K and Mg
 Excess body sodium even though the
plasma sodium may be low

 Give extra K 3 – 4 mmol/kgBW/day

 Give extra Mg 0,4 – 0,6 mmol/kgBW/day
The mineral should be added to the feed
during its preparation if not pre-mixed

DO NOT TREAT OEDEMA WITH DIURETICS

Treat infection

In severe acute malnutrition,

the usual signs of bacterial
infection, are often absent

Assume that all

children with severe
acute malnutrition
have an infection !
Correct micronutrient deficiencies

Do not give iron initially

but wait until the child
Vitamin A on day 1 and repeat on days has a good appetite and
2 and 14 if there is signs of deficiency starts gaining weight
 0 – 5 months : 50.000 IU
 6 – 12 months : 100.000 IU
 > 12 months : 200.000 IU After 2 days on F-100 formula, give
elemental Fe at 3 mg/kgBW per
day in two divided doses

Give this micronutrients daily for at least 2 weeks

 Folic acid at 5 mg on day 1 then 1 mg daily
 Multivitamin syrup at 5 ml
 Zinc at 2 mg/kgBW per day
 Copper at 0,3 mg/kgBW per day
Initial re-feeding with F-75

 Frequent oral small feeds of low osmolality and

low lactose (F-75)
 Calories at 80 – 100 kcal/kgBW per day
 Protein at 1 – 1,5 gram/kgBW per day
 Liquid at 130 ml/kgBW per day or 100 ml/kg BW
per day if the child has severe oedema
 Encourage continued breastfeeding

Days Frequency Volume/kgBW per feed Volume/kgBW per day

1–2 2 hours 11 ml 130 ml
3–5 3 hours 16 ml 130 ml
>6 4 hours 22 ml 130 ml
Volume of F-75
given to child
without oedema
Catch-up growth feeding with F-100

 Return of appetite (easily finishes 4-hourly

feeds of F-75)
 No episodes of hypoglycaemia  Check respiratory and pulse
 Reduced oedema or minimal oedema rate every 4 hours
 Avoid causing heart failure

Ready for transition phase

 Feed freely on F-100 as much as he

First 48 hours (2 days) wants (at least 4-hourly)
 Give F-100 every 4 hours with in  150 – 220 kcal/kgBW per day
the same amount as F-75  Protein at 4 – 6 gram/kgBW per day
 Water at 150 – 200 ml/kgBW per day

On the third day

On the fourth day, child is
 Increase each feed by 10 ml until
in the rehabilitation phase
some feed remains uneaten
Range of volumes
for free feeding
with F-100
Sensory and emotional stimulation

 Tender loving care

 Cheerful, stimulating
environment
 Structured play therapy for
15 – 30 minutes/day
 Physical activity as soon as
the child is well enough
 Support for much maternal
involvement as possible
Prepare for discharge

 Poor : < 5 gr/kgBW per day

 Moderate : 5 – 10 gr/kgBW
per day
 Good : > 10 gr/kgBW per day

The child should be fed at least five times a day

with foods that contain approximately 100 kcal
and 2 – 3 gram protein per 100 gram of food