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Three types of malnutrition can be differentiated:

The most common type is
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-gastric feeding tubes are required to complete the the required amount of feeds.

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-gastric feeding tube has to be inserted and the mother taught how to use it. After some days most children will stabilise and can be changed to the second milk formula which contains much more protein and energy. Alternatively plumpy-nut („ready-to-use therapeutic food“ based on groundnut paste) can be given. If plumpy-nut is available the program can be run according to the community-based therapeutic care guidelines: Children who are stable can go home directly with a 2 weeks ration and return for follow-up visits on a 2-weekly basis. Children who are not stable initially need admission in a stabilisation centre and can go home on plumpy-nut as soon as they are stable.

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.