Marasmic Kwashiorkor: Clinical Manifestations, Prognosis, Treatment, Prevention And Rehabilitation
In this condition, features of marasmus and kwashiorkor are present simultaneously. The body weight is less than 60% of the normal. Dependent edema is present. Mental changes, skin and hair changes and hepatomegaly are evident.
Secondary infection is very common in protein energy malnutrition. This is due to the fact that both humoral and cellular immunity are defective. The intestinal flora is altered and this may account for the diarrhea. Episodes of infection further jeopardize the nutritional status.
Laboratory Investigations: The total protein content of the body is reduced, and this is reflected most prominently as hypoalbuminemia. The plasma levels of essential aminoacids are low, but the nonessential aminoacids remain normal or even elevated. Basal metabolic rate is reduced. Hypoglycemia occurs commonly.
Total body water is increased and all the compartments show increase of fluid. The plasma osmolality is reduced. Renal plasma flow is diminished and this results in impairment of renal function. Plasma sodium is increased with reduction in potassium and magnesium. Gross reduction of serum sodium is associated with a poor prognosis.
Prognosis: Depends on the severity of the disease at diagnosis and promptness of treatment. Marked weight loss, severe infections, fluid and electrolyte imbalance, hypoglycemia, hypothermia, cardiac failure, elevation of serum bilirubin and liver enzymes, drowsiness and xerophthalmia indicate poor prognosis. Ins sever cases, mortality goes up to 20%.
Physical Presentations Of Marasmic Kwashiorkor
Treatment is aimed to supply a diet rich in calories, proteins and other essential nutrients. For success of treatment supplementation should be with natural foods available locally. 150 Kcal/Kg of energy and 3.3g/Kg of proteins are optimally required for catch-up growth. Fats are administered to supply adequate calories without increasing the bulk. Children with lactose intolerance do not tolerate carbohydrates, but they tolerate fats. As the child gains appetite, the frequency of feeding is increased. If there is severe anorexia, forced feeding has to be resorted to. Salt should be restricted to avoid congestive cardiac failure. Initial recovery is heralded by the disappearance of edema. The major biochemical abnormalities are corrected within 2 to 3 weeks. Complete correction of all reversible changes, referred to as ‘clinical recovery’ occurs only in 2 to 3 months.
Prevention and rehabilitation: PEM is a preventable disease. Three levels of prevention have been formulated. Primary prevention is achieved by nutrition education to prevent occurrence of PEM. Secondary prevention is aimed at early detection and proper treatment. Tertiary prevention consists of nutritional rehabilitation of an established case.
The importance of breast feeding as a prophylactic against protein calorie malnutrition cannot be overemphasized. Correct feeding practices both during health and disease, proper sanitation, deworming and family planning methods have to be employed simultaneously to achieve lasting benefits.
Nutrition rehabilitation is employed to prevent residual nutritional handicap and prevent recurrence of protein energy malnutrition. Even at the initial stages of treatment, the mother should be made to participate in the selection, preparation and administration of food. This measure helps to impart nutritional education to her, prevent recurrence and detect relapse early.
© 2014 Funom Theophilus Makama