CASE PRESENTATION ON:-PROTEIN ENERGY MALNUTRITION

BIOGRAPHICAL INFORMATION

Name : Master Durga prasad

Age : 3 years
Sex : Male
Address :Satna
Religion : Hindu
IP No. : 61739
Admission unit : B Unit
Date of admission : 11/01/13
Diagnosis : Protein Energy Malnutrition Grade – III

CHIEF COMPLAINTS

Patient had complains of Fever Since 8 days, Abdominal Distention since 2 days, Edema in the limbs
since 2 days

PRESENT ILLNESS

Mas. Durga Prasad came to the hospital with the complaints of fever of intermittent type which is
moderate in nature associated with chills, abdominal distention and abdominal girth is 50cm and
swelling of the lower extremities with dry and scaly skin. Patient was admitted with the above
complaints & was Diagnosed PEM and there is no any surgical intervention being done.
PAST HEALTH HISTORY

CHILDHOOD – ILLNESS:-
There is no significant history of childhood illness, trauma, or immunization
patient doesn’t have any experience of previous hospitalization.
PAST MEDICAL-SURGICAL HISTORY:
Patient is known case of dehydration as diagnosed 2 yrs back. No Diabetes, or other
chronic illness& has not undergone any surgical interventions.
MEDICATION & ALLERGIES:
As a known PEM, he regularly takes the medication diet according to standard body
requirement., No history of any habitual OTC medications, not habituated to any herbal preparations or
self preparations.

PERSONAL HISTORY PERSONAL STATUS: he holds up an cute place in his family along with his mother &
family.

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 EATING HABITS: He takes fruit as well as milk & includes plenty of water.

ALCOHOL HABITS: not a known alcoholic.

SMOKING HABITS: not habituated.

LIFE STYLE: well playing with other children.

SLLEEPING HABITS: Sleeps 8hrs/night & 2hrs/day, doesn’t have any problems in sleeping.

RELIGION&FAITH: He is a Hindu by religion and is involved in traditional and cultural activities

frequently.

FAMILY HISTORY

34 years 27years

1year 5years 3years

No history of any communicable diseases & genetic disoders, patient’s father has a history of blood
pressure.

S.No Name Relation Age Healthstatus Occupation

1 Shaikhar Father 34yrs Healthy merchant
2 Sunita Mother 27yrs Healthy housewife
3. Durgaprasad Son(patient) 3 yrs Admitted nil
4 shithil Son 1 yr Died -
5 manoj son 5 yrs Ukg studying

PSYCHO SOCIAL HISTORY

Patient maintains good relations with family members, relatives and friend.

NUTRITIONAL HISTORY

Recent Weight : 7kg,Expected Weight: 14kg .Appetite: Poor

24 Hours Diet Recall:
Child taken only two meals in last 24 hours and each meal contains 2 idly with chatni. Water
intake approximately 400-500 ml.
Degree of Malnutrition :
=actual weight/expected weight X 100

2
 = 7/14 X 100
50%
III Degree malnutrition
Menu plan for Mas. Durgaprasad as per standard daily requirement

Time Item Calorie Protein

8Am !/2 cup milk+1 tsp ghee+2 biscuits+ 136 Kcal 3gm
1 tsp sugar

10Am 1 cup cooked rice+2 spoon Dhal sambar+1 tsp ghee 220Kcal 4gm

12pm 1 egg+1 Chapati+3 spoon sugar+1 tsp ghee 300Kcal 4gm

2pm 1 cup rice+2 spoon dhal Sambar+ 1 tsp ghee 220Kcal 8gm

5pm 1 bread+1/2 cup milk+ 1 tsp sugar 150Kcal 8gm

7pm 1 cup rice+1 tsp ghee+ 2 spoon dhal 220Kcal 4gm

9pm 1 Banana+ ½ cup rice+1/2 spoon ghee+ Sambar 214Kcal 4gm

Total 1460Kcal 35gm

ENVIRONMENTAL HISTORY

Patient lives in rural area. The housing condition is rural but according to the family members
they live in a hygienic condition. Drainage system is present. They get water from borewell supply.

GROWTH AND DEVELOPMENT

Child’s growth and development has not achieved to normal extent.
Gross Motor development: child was unable to take steps on tip of toe.
Fine motor development: not able to hold spoon properly to take food.
Sensory development: able to identify geometric figures, accommodation well developed.
Vocalization: able to understand simple comments, and asks about objects for name

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Psychosocial development: child is in the sense of autonomy.
Psychosexual development: child is in the anal stage and bladder control not yet achieved
Intellectual development: child is in sensory motor stage.
Spiritual development: child is in intuitive projective faith.
ELIMINATION PATTERN
Bowel : bowel sounds are dull
Bladder : bladder control not yet achieved.
PHYSICAL EXAMINATION
General Observation
Mas. Durgaprasad is a 3 years old male baby, poorly built, undernourished, conscious and
oriented to time, place and person.
Vital Signs
Temperature : 100o F
Pulse : 92bts/min
Respiration : 30breaths/min
Skin And Mucus Membrane
Color : Normal brown
Edema : Present
Moisture : Dry
Temperature : Increased
Turgor : Normal
Any Abnormal Discharges : No
Head
Skull/Cranium Size, Shape : Normal
Movements : Normal movements
Forehead : No scars
Hair
Changes in Texture : Hypo-pigmented
Characteristics : Brown in color, sparse and not distributed densely
Lice : Absent
Nails

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 Changes in Appearance : Clubbing of nails
Cyanosis : Absent
Texture : Softening of nails
Face
Appearance : Presence of facial puffiness
Color : Normal brown
Symmetry : Symmetrical
Movements : Normal
Eyes
Expression : Normal
Eye Lids : Normal
Lacrimation : Poor
Conjunctiva : Pale
Sclera : Clear
Pupil : Equally reactive and accommodate light.
Ears
Appearance : Symmetrical
Discharges : Nil
Lesions : Nil
Any Abnormalities : Nil
Nose
Appearance : Normal
Discharges : Nil
Patency : Patent
Sense of Smell : Normal
Mouth And Throat
Lips : Dry
Tongue : Not coated
Teeth : Deciduous teeth are present
Gums : Normal

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 Buccal Mucosa : Normal
Palate : No cleft palate
Tonsils : Not inflamed
Taste : Normal
Neck
General Appearance : Normal
Trachea : Centrally located
Lymph Nodes : No palpable lymph nodes
Thyroid Glands : No thyroid enlargement
Cysts and Tumors : Nil
Gastro-Intestinal System
Diarrhea : Absent
Constipation : Absent
Bleeding : Absent
Worm Infestation : Suspected
Psychosocial History
General Status of the Family: Mas. Durga Prasad belongs to poor class family with a monthly
income of 1000/-. His father is a daily wager. He is living with his father, mother and two elder
sisters. They are living in their own house. Electricity supply is available in the house. There is no
proper sanitary facility.
Activities of Daily Living : Mas. Durgaprasad lost his interest in daily activities and looks dull.
Sl. Investigation Results Normal values Remarks
No.
1. Hemoglobin 5.2gm/dl 12-16gm/dl Severe anemia

2. TLC 12,700cells/mm 4000-11000cell/mm Inflammation present

3. Lymphocyte 62% 20-45% Increased

4. Monocyte 02% 2-10% Normal

5. Eosinophils 04% 1-8% Normal

6. RBC 3.53mil cells/mm 3.5-5.5 mil cell/m Normal

Play Activities : Child has less interest to play with peers and siblings.

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 Special investigations
Ultrasonography: The findings from the images obtained through Ultrasonography suggest that the
liver is infiltrated with excessive triglycerides.

MEDICATIONS

Medication name Dosage FrequenRoute Actions Side effects Nursing responsibilities

cy

1. Inj. Amikacin 225mg Bd IV Binds to 30s Tinnitus, vertigo, Perform test for hearing
ribosomal subunits ataxia and deafness acuity.
of susceptible
Avoid concurrent use of
bacteria, thus
ototoxic drugs
inhibits protein Nausea and vomiting
2. Tab. B 50 mg Od Oral
synthesis. Monitor for the signs of
complex
hypervitaminosis.
Vitamin B complex
and Vitamin C
supplement

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 DESCRIPTION OF DISEASE
PROTEIN ENERGY MALNUTRITION
The term malnutrition can be applied to any disorder that prevents an individual from achieving an
optimal nutritional state.Protein energy malnutrition is the state occurs due to insufficient or
imbalanced consumption of protein and energy.
INCIDENCE:
Malnutrition is the one of the major health problem in the world in children with in 5 years of
age.It is estimated that 80% of preschooler suffer from various degrees of malnutrition.At any given
time there are 78 million children suffering from various degrees of malnutrition.
NORMAL PROTEIN AND ENERGY REQUIREMENT OF CHILDREN
Age group Energy (in kcal/day) Protein (in grams/day)
0-6 months 108/ kg 2.0/kg
6-12 months 98/kg 1.65/kg
1-3years 1240 22
4-6years 1690 30

TYPES OF PROTEIN ENERGY MALNUTRITION

1.Marasmus: Weight less than 60% of expected weight to the age. It is a clinical syndrome
characterized by loss of subcutaneous fat and muscle wasting.
2.Marasmic Kwashiorkor: Weight less than 60% of expected body weight for the age with features
of Marasmus with edema.
3.Kwashiorkor: Weight below 60-80% of expected weight with growth retardation and generalized
body edema.

GRADING OF PROTEIN ENERGY MALNUTRITION

a) Gomez Classification:
Grade I - 76-90% of average of weight.
Grade II - 61-75% of average weight.
Grade III -60% and below 60% of average weight.

b) The Water Loo classification

 Nutritional Marasmus- below 60% of average weight without edema

 Kwashiorkor - 60-80% of reference weight with edema.

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  Marasmic Kwashiorkor - below 60% of reference weight and edema

c) Indian Academy of Pediatrics:

 Above 80% of expected weight - Normal

 70-80% of expected weight - Grade I
 60-70% of expected weight -Grade II
 50-60% of expected weight - Grade III
 Less than 50% of expected weight - Grade IV

MARASMUS
A severe form of malnutrition caused by inadequate intake of protein and calories, and it usually
occurs in the first year of life, resulting in wasting and growth retardation. Marasmus accounts for a
large burden on global health.

Nutritional Marasmus is a nutritional disorder results due the gross deficiency of energy though protein
deficiency accompanies it.

It is the common problem in developing countries in the time of draught. It occurs chiefly in first year of
life.

ETIOLOGY:
a) Primary Cause: Primary cause is the dietary cause. Inadequate diet both qualitatively and
quantitatively.

b) Secondary Causes:

 Age: Marasmus is more common in infant than in other ages. It is because of high nutritional
requirement of infant (Protein: 2-3gm/kg/day; Calorie: 1200 Kcal/day) and hence Marasmus
develops soon in infancy

 Congenital Disease: Congenital disease which limits the intake and digestion of food.

 Chronic Vomiting: Disease like pyloric stenosis and relaxed cardiac sphincter, which increase
the risk of vomiting there by, decreases the absorption of the nutrients from the GI tract.

 Chronic Infection: Chronic infections like Congenital syphilis, tuberculosis and respiratory
infection which results in protein loss.

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  Repeated episodes of chronic diarrhea will impair the digestion and absorption of nutrients
from the mucosa of the Gastro Intestinal tract and results in deficiency of the nutrients.

 Serious organic disorders of heart, brain and kidney and some metabolic disorders and juvenile
diabetes mellitus.

 Other causes include Transition from breastfeeding to nutrition, poor foods in infancy.

GRADING OF THE MARASMUS:

Grade I : Loss of fat in axillae and groin
Grade II : Grade I + loss of fat in abdomen and gluteal region.
Grade III : Grade I + Grade II + loss of fat in chest and Para spinal area.
Grade IV : Grade I + Grade II + Grade III + loss of fat in buccal pad.

CLINICAL MANIFESTATIONS
 Appearance of toothless old man and a monkey look.
 Growth retardation as evidenced by marked loss of weight and subnormal height.
 Gross muscle wasting
 Absence of edema.
 Eyes will be sunken
 Disappeared subcutaneous fat.
 Face will be round, till the loss of subcutaneous fat.
 Skin over the buttocks becomes wrinkled and saggy due to loss of adipose tissue.
 Bones will be prominent.
 Anemia
 Subnormal temperature.
 Skin becomes ashen gray because of anemia
 Atrophy and wasting of body tissues especially subcutaneous fat.
 The child will be apathetic and lethargic.
 Recurrent infections

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DIAGNOSIS
History collection : Regarding the dietary habits and recurrent attacks of diseases.

Physical examination : To rule out the signs of the Marasmus.

Biochemical Investigation : Biochemical investigation to estimate the plasma protein level.

Plasma protein levels will not be noticeably reduced.

Pathological references : Liver does not show pathological fatty infiltration.

Reduced organ weight of lung and heart

MANAGEMENT:

 Calorie requirement of the undernourished infants are greater than those of normal infants it
almost doubled.

 The aim of treatment is to provide sufficient proteins, calories, and other nutrients for nutritional

rehabilitation and maintenance.

 In case of severe PEM, restoring fluid and electrolyte balance parentally is the initial concern. A
patient who shows normal absorption may receive enteral nutrition after anorexia has subsided.

 When possible, the preferred treatment is oral feeding. Foods are introduced slowly.
Carbohydrates are given first to supply energy, and then high-quality protein foods, especially
milk, and protein-calorie supplements, are given.

 Start with the concentrated food of about 200 Cal/kg body weight gradually 2-3 weeks and
continued till the weight gain.

 Protein requirement should be 4gm/kg body weight /day.

 No of feeds should be increased usually 7 feeds a day.

 A patient who’s unwilling or unable to eat may require supplementary feedings through a naso-
gastric tube or Total Parenteral Nutrition (TPN).

 Secondary causes should be treated

 Accompanying infection must also be treated, preferably with antibiotics that don’t inhibit protein
synthesis.

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KWASHIORKOR
Kwashiorkor is one of the more severe forms of protein malnutrition and is caused by
inadequate protein intake. It is, therefore, a macronutrient deficiency.

It is type of severe protein-energy malnutrition refers to a combination of edema, lethargy

(mental apathy) and growth failure.

INCIDENCE:
It is a major problem in South India (Andra Pradesh) and Orissa, Bengal and some parts of
Maharashtra.

In India it is estimated that about 1-2% of preschooler suffer from Kwashiorkor.

ETIOLOGY:

Book Picture Patient Picture

 Unavailability of suitable protein rich foods -
 Faulty feeding habits
 Super imposition of infection and infestations -

 Age Incidence Suspected case of worm infestation

Higher incidence is found between 1 to 3

years. Age is 3y, peak age of incidence

 Prolonged breast feeding

 Seasonal Incidence
 Family size Breast feed till 2 years of age.

 Lack of Accessibility and availability of Health -

Services -
Lack of awareness of health services

CLINICAL MANIFESTATION

Book Picture Patient Picture

 Onset: Insidious in onset over periods of weeks and months. Insidious in onset

 Apathy: Gradually loss of interest and activity. The degree Has less interest in play
unresponsiveness will be proportional to severity of the disease. activities.

 Diarrhea: Nearly 2/3rd of Kwashiorkor cases will be presenting with the Absent

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 complaints of loose stools with infective in origin.
 Edema: Edema is a constant feature and is extremely variable in degree. Pedal edema with ascites
Inspite of gross edema, ascites will be minimal.
No muscle wasting
 Muscle wasting: Due to degeneration and reduction in the anterior horn
cells may lead to weakness and hypotonia as suggested by one postulate
(Kwashiorkor myelopathy). Protein deficiency also causes muscle
wasting. Skin is dry and scaly
 Skin changes: 40% to 60% of the florid kwashiorkor will have skin
changes. Dry and scaly skin: Common over skin
Absent
 Pavement dermatosis: Jet black, later exfoliate exposing underlying and
also there will be peeling.
Absent
 Petichae and ecchymoses.
Absent
 Arabinoflavinosis
Hairs are scanty and
 Hair changes: The hair is scanty, lusterless commonly brownish. The light brown in color
color hair is known as dyschromotrichia.
Liver is enlarged 4cm
 Hepatomegally with fatty infiltration. below the RCM
Moon face is present

 Face: Moon face due to edema No symptoms

 Associated Avitaminosis Hb 5.2gm/dl

 Anemia of moderate degree.

 Growth retardation Absent

 Psychomotor changes: Earlier the onset of the malnutrition; severe will Irritable and restless
be the psychomotor changes (mental deprivation)

Kwashiorkor sufferers show signs of thinning hair,

edema, inadequate growth, and weight loss. The
stomatitis on the pictured infant indicates an
accompanying Vitamin B deficiency
DIAGNOSIS:-

Book Picture Patient Picture

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  History and Physical examination Done

 Anthropometric measurements MAC-14cm

 Biochemical investigation

o Low serum albumin (<3.5-5gm/dl) Not done

o A/G ratio will be reversed(1:1.5) Not done

o Decreased serum amino acid level. Not done

o Decreased blood cholesterol level. Not done

o Decreased pancreatic enzymes. Not done

o Decreased serum Iron and Copper. Not done

 Organ Changes elicited by Imaging studies:

o Fatty liver Present and enlarged 4cm below RCM

Not elicited

Not elicited.
o Atrophy of acinary cells of pancreas

o Atrophic changes in stomach and intestinal villi.

MANAGEMENT
1. Dietary modifications
2. Control and Treatment of infections

Book Picture Patient Picture

Management: 1.Dietary modifications

Dietary Management:

Liberal protein rich foods to be given with adequate calories.

Proteins: High protein diet with 7-8 feeds a day

About 5 to 6 gms of protein/kg/day.

The total average protein intake of child is 50-60gm/day.

Calories:

Calories should be in range of 120-150 Kcal/kg/day.

1. Control and Treatment of infections On antibiotic therapy (Inj. Amikacin 225mg BD)

On Becosule capsule for

2. Correction of Vitamin deficiencies Vit-B and C Supplementation

3. Correction of Vitamin deficiencies

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 NURSING CARE PLAN
SR.NO. NURSING PLANNING
ASSESSMENT OBJECTIVE INTERVENTIONS IMPLEMENTATION EVALUATION
DIAGNOSIS
1 Subjective data: Imbalanced nutrition; Child will achieve -Assess the nutritional - Child is severely Nutrition of child is
Mother says “My son less than body and maintain normal status and degree of malnourished. i.e. 3rd improved to some
is not gaining weight requirement related nutritional status as malnutrition. degree malnutrition. extent as evidenced
adequately” to decreased evidenced by weight by increased interest
-Assess the causes for
utilization of gain. to take food and
malnutrition.
Objective data: nutrients secondary - Decreased utilization of mild increase in
Weight:7kg to fatty infiltration of nutrients due to fatty weight. i.e. 8.2kg.
(expected wt 14 kg) the liver. infiltration of liver.
-Prepare diet plan and
educate mother to - Prepared diet menu plan
Grade III
serve food based on the child
malnutrition:
accordingly. condition.

-Identify for the signs

of vitamin
- Vitamin deficiency
deficiencies
present.
-Administer Vitamin
Supplements
- Provided oral Vitamin
Supplements.

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 SR NURSING PLANNING
ASSESSMENT OBJECTIVE INTERVENTIONS IMPLEMENTATION EVALUATION
NO. DIAGNOSIS
2.
Subjective data: Hyperthermia Child will achieve -Monitor vital signs Body Temperature is Child’s body
Mother says “My son’s related to and maintain 100oF. temperature is
skin is somewhat hot” inflammatory normal body -Loosen the clothing Loosen the clothing within normal
reaction secondary temperature as and switch on the and provided proper limits
Objective data: to Hepatomegally. evidenced by fan. ventilation.
Temperature: 100oF temperature -Provide plenty of Advise the mother to Temperature:
Pulse: 92bts/min within normal fluids to drink provide plenty of water 98.6F
limits. and fluids.
-Apply cold Advised mother to
compress keep wet cloth on fore
head to reduce the
temperature.
-Provide tepid -----
sponge.
-Administer Administered Inj
prescribed Paracetamal
antipyretics Intramusularly.

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 SR NO. NURSING PLANNING
ASSESSMENT OBJECTIVE INTERVENTIONS IMPLEMENTATION EVALUATION
DIAGNOSIS
3. Subjective data: The Fluid volume To maintain fluid -Assess the child for - Child is having facial Child’s edema has
mother complaint excess related to volume in the sites of edema. puffiness, periorbital reduced as
that her son is having fluid body and to edema, & pedal edema. evidenced by
swelling of face. accumulation in reduce the -Assess the signs of abdominal girth
- Abdominal girth is
tissues as edema. ascities and measure reduced to 45
49cms
Objective data: evidence by abdominal girth. cms.
The child is having puffiness of face, -Assess the dietary
puffiness of face, periorbital and pattern of the child.
-
periorbital edema pedal edema, and -Provide small and
and edema at feets. abdominal frequent meals.
distension.
- Advised mother to
-Increase food items
give small and frequent
that contain protein.
meals.

-Consider likes and - Provided the list of

dislikes of the child. protein rich foods to
mother.

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 - Instructed mother
to serve food in utensils
which the child used to
have food.

SR NURSING PLANNING
NO. ASSESSMENT IMPLEMENTATION EVALUATION
DIAGNOSIS OBJECTIVE INTERVENTIONS
4. Subjective data Deficient Parents will gain -Assess the level of -Understanding level of Parents gained
Mother says they have knowledge of the knowledge understanding of the parents is knowledge
not taken child for parents related regarding the parents. poor.ucated mother regarding the
-Educate the parents regarding the condition
immunization. to nutrition and nutritional nutritional
regarding the of their child.
immunization requirement of requirements of
causes and
Objective data need of child the child and symptoms of the child, and its
Child not received immunization malnutrition. -Educated parents management and
immunization vaccines need of child. -Explain the parents regarding the measures immunization
and food pattern was regarding the daily to improve the nutrition need of child.
nutritional status and prescribed
inappropriate
requirement of the menu plan.
child. -Explained the
-Educate the parents importance and
regarding the schedule of vaccination
importance of and encouraged for
immunization of the future immunization.
under-five child. -Educated parents

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 -Educate regarding regarding the
the measures to prevention and
prevent management of
complications of complications.
malnutrition.

SR NURSING PLANNING
ASSESSMENT OBJECTIVE INTERVENTIONS IMPLEMENTATION EVALUATION
NO. DIAGNOSIS
5. Subjective data: The High risk for Child will achieve -Assess the risk -Facial puffiness and The child‘s skin
mother complaint that impaired skin and maintain factors for the pedal edema present. display no
my son is having edema. integrity related good skin texture impairment of skin evidence of
to fluid overload. and integrity. integrity. redness and
Objective data: -Provide meticulous irritation. The
-Provided the skin care.
Child having facial skin care. mother is applying
puffiness and pedal -Avoid tight clothing. cream to the child
edema.
-Advised mother to
-Cleanse and powder
avoid tight clothing.
opposing skin
surfaces several -Cleansed and
times per day. powdered skin
-Change the position surfaces.
frequently.

-Use pressure -Advised mother to

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 relieving mattresses change the position
as needed to prevent frequently.
ulcer.
-------

HEALTH EDUCATION
 I educate them (patient & family member) to –
 Take high caloric diet and iron rich diet.
 To avoid activities which causes fatigue.
 To take proper rest and sleep.
 Do not perform any heavy work.
 Take the medicine on time and care for the follow up.

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 BIBLIOGRAPHY:
1. Marlow DR, Redding BA. Text Book of Pediatric Nursing. 6 th ed. New Delhi: Elsevier India
Private Limited; 2006.
2. Wilson D & Hockenberry MJ. Nursing Care of Infants and Children. 8 th ed. New Delhi:
Elsevier Private Ltd; 2007.
3. http://en.wikipedia.org/wiki/Marasmus
4. http://www.faqs.org/nutrition/Kwa-Men/Marasmus.html
5. http://wrongdiagnosis.com/m/marasmus/intro.htm
6. http://social.jrank.org/pages/378/Marasmus.html
7. http://en.wikipedia.org/wiki/Kwashiorkor
8. http://www.umm.edu/ency/article/001604.htm
9. http://www.wrongdiagnosis.com/k/kwashiorkor/intro.htm

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