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Malnutrition
Three types of malnutrition can be differentiated:
The most common type is marasmus.
Children with marasmus have a very low weight for
their height, they are wasted. If children are not getting enough food over a period
of time, the body will start digesting its own fat and protein reserve. In the late
state, all the muscles will be affected, including vital organs as the heart, which
may finally cause death. In literature, such children are sometimes described as
having an "old man face". Once the subcutaneous fat is used up, the skin becomes
wrinkled and dry like that of an old man. Marasmic children usually have a distended
abdomen, low body temperature as well as low blood pressure. Fortunatly these children
often still have a good appetite which is very important and therefore also a good
indicator for recovery.
The second type is kwashiorkor.
This form of malnutrition usually starts with oedema
in the feet, legs, hands and arms and later on also in the face and abdomen. Typical
for kwashiorkor is wasting of muscles, anaemia and changes in colour of hair and
skin. Sometimes large patches of skin are peeling off and wounds are developing all
over the body. Due to the anaemia and muscle wasting, children with kwashiorkor are
often very apathetic. It is sometimes difficult to recognise the severity of malnutrition
in these children, because oedema can make a child look well fed. In addition these
children are generally at a higher risk of death than marasmic children and most
of them don´t have appetite in the beginning. They need very careful monitoring and
very often naso-
The reason why one child develops a specific type of malnutrition and the next child another type is until today not fully understood. It is even possible that one child develops all three types, changing from one to another. Even children within one family, or even twins, may develop different types of malnutrition. For a long time it was assumed that kwashiorkor is mainly caused by lack of protein, while marasmus was attributed to a general lack of food. Today we assume that it is a very complex interaction of protein, vitamins, minerals and different kinds of stress factors.
If a malnourished child comes to the hospital, it is first of all clinically assessed
for the presence of other diseases and possible causes of malnutrition. Very often
it is not only poverty and social problems that cause malnutrition, but also Malaria,
worm infections, HIV and Anaemia. All this, and much more, needs to be considered
and treated because it contributes to malnutrition and may otherwise interfere with
recovery. At the same time it is important to start immediately with the initial
feeds. The type and amount of feeds is calculated individually for each child based
on the recommendations of the World Health Organisation and based on the type of
malnutrition. In the beginning, very sick children will need two or at least three
hourly feeding during day and night. The single feeds are very small, because it
takes time for the weak body to get used again to digest food. Too large amounts
in the beginning can easily overburden the whole metabolism and therefore lead to
heart failure. This is especially important for children with kwashiorkor or marasmic
kwashiorkor. If a child is refusing the feeds or is too weak to swallow, a naso-
In order to prevent relaps, the mothers have to be taught during their stay in the Nutrition Unit about how to prepare a healthy diet for their children and how to take care of hygiene. In most of the cases it is possible to achieve an improvement in the child`s diet even inspite of extreme poverty just by education of the caretakers. Sometimes only small changes in diet or food preparation can already help a lot.
The third type is marasmic kwashiorkor.
This form of malnutrition is a mixture of symptoms of marasmus and kwashiorkor. Massive loss of weight may appear together with severe oedema and any other symptom mentioned above. Children with marasmic kwashiorkor are at very high risk of death and need very careful observation.