A 2-year-old girl is admitted to a district hospital with severe wasting, loss of subcutaneous fat, visible ribs and spine, and no pitting oedema. Weight is 8 kg (expected 12 kg for age). Serum albumin is 2.8 g/dL, and total serum protein is 5.2 g/dL. Mother reports the child has been on diluted cow's milk and rice porridge for the past year due to financial constraints. After stabilization and treatment of infections, what is the most appropriate next step in nutritional management?

Explanation

## Clinical Diagnosis This child presents with **marasmus** (energy-deficiency malnutrition), characterized by: - Severe wasting (weight <60% of expected for age) - Loss of subcutaneous fat and muscle mass - Visible skeletal landmarks (ribs, spine) - **Absence of oedema** (distinguishes from kwashiorkor) - Relatively preserved serum albumin (2.8 g/dL, though low) ## Pathophysiology of Marasmus **Key Point:** Marasmus results from **chronic caloric insufficiency** with relatively preserved protein intake. The body adapts by: 1. Catabolizing muscle and fat for energy 2. Reducing metabolic rate 3. Preserving visceral protein (albumin) initially 4. Causing growth stunting and developmental delay ## Post-Stabilization Nutritional Rehabilitation After initial stabilization (treating infections, correcting electrolytes, vitamin A supplementation), the child enters the **catch-up growth phase**. **High-Yield:** Catch-up growth feeding targets: - **Calories:** 150–220 kcal/kg/day (vs. normal 100 kcal/kg/day) - **Protein:** 3–4 g/kg/day (vs. normal 1.2–1.5 g/kg/day) - **Duration:** Until weight reaches 90% of expected for age | Phase | Timing | Calories | Protein | Goal | |-------|--------|----------|---------|------| | Stabilization | Days 1–3 | 50–100 kcal/kg | 1–1.5 g/kg | Treat complications | | Transition | Days 4–7 | 100–150 kcal/kg | 1.5–2.5 g/kg | Gradual increase | | **Catch-up** | **Week 2+** | **150–220 kcal/kg** | **3–4 g/kg** | **Rapid growth recovery** | **Clinical Pearl:** Marasmic children tolerate feeding better than kwashiorkor cases because they lack visceral protein depletion and oedema. However, gradual escalation is still essential to avoid refeeding syndrome. **Mnemonic: MARASMUS** → **M**uscle loss, **A**bsence of oedema, **R**educed fat, **A**lbumin relatively preserved, **S**evere wasting, **M**etabolic adaptation, **U**nderweight, **S**tunting ## Feeding Route - **Oral feeding** is preferred if child can eat - **Nasogastric feeding** if poor oral intake - **Enteral > Parenteral** (safer, cheaper, maintains gut integrity) **Warning:** Parenteral nutrition is NOT indicated in uncomplicated marasmus. It is reserved for: - Severe malabsorption (coeliac disease, cystic fibrosis) - Short bowel syndrome - Persistent vomiting/diarrhoea despite treatment