Marasmus is a disorder of malnutrition that is a result of total calorie starvation, especially protein and energy. It is often seen in infants under 1-5 year of age most commonly in developing countries. The decreased nutrition is usually secondary to weaning problems resulting from disease, poor hygiene, poverty, and cultural factors. Infants with repeated bouts of gastroenteritis are particularly at risk. The infants are emaciated with loss of the subcutaneous fat and muscle. The skin is dry and loose. They also have thin fragile hair and nail abnormalities.
UNICEF estimates that nearly half of all deaths in children under the age of 5 years, or around 3 million each year, resulting from a lack of nutrition. Marasmus is not the only syndrome that results from severe malnutrition. Kwashiorkor is another severe form of protein-energy malnutrition where the main deficiency is protein. Unlike marasmus, kwashiorkor causes the body to retain fluid in the lower legs, feet, arms, hands, and face, leading to a swollen appearance.
Marasmic kwashiorkor is the third form of protein-energy malnutrition that combines features and symptoms of both marasmus and kwashiorkor.
Signs and Symptoms of Marasmus
A shrunken, wasted appearance is the classical presentation of marasmus. Other clinical manifestations are as follows:
- Prominence of ribs
- Slow growth
- Drastic loss of adipose tissue
- Chronic diarrhea
- Muscle atrophy, especially in the upper arms and buttocks
- Skin folds
- Wizened monkey (“old man” face)
- Unusual body temperature (hypothermia or pyrexia)
- Dehydration (frequent thirst and shrunken eyes)
- Corneal lesions due to vitamin A deficiency
- Dermal manifestations
- Otitis and rhinitis
- Hypovolemic shock leading to weak radial pulse, cold extremities and decreased consciousness
- Paralysis of the lower extremities
- Poor bladder and bowel control
- Blood or mucous in stools
- Metallic bowel sounds
- Weight loss
- Fainting or alteration of awareness
- Persistent vomiting
Causes and Risk Factors
In places where food can be scarce, breastfeeding infants for as long as possible may help reduce the risk of malnutrition. However, if breastfeeding continues for longer than 6 months without an infant receiving solid food, the risk of marasmus can also increase, especially if the mother is malnourished herself. Those born preterm or with low birth weight may also have a predisposition to malnutrition afterward. Appropriate support and nutrition during pregnancy and in a child’s early years are essential for preventing malnutrition.
Causes of marasmus include:
- Not having enough nutrition or having too little food.
- Consuming the wrong nutrients or too much of one and not enough of another.
- Having a health condition that makes it difficult to absorb or process nutrients correctly.
- An increased loss of ingested calories due to emesis, chronic diarrhea, burns, etc.
- An increased energy expenditure.
- Viral, bacterial and parasitic infections.
- Bottle feeding.
- decreased energy intake.
- Chronic hunger.
- Contaminated water supplies.
- Inadequate food supplies.
- Other vitamin deficiencies (vitamin A, E or K).
- Poor, unbalanced diet lacking in grains, fruits and vegetables, and protein.
Older adults who live alone and find it difficult to prepare food and care for themselves may be at risk. Sometimes marasmus can affect an older adult who has not eaten healthfully over a period of some months or years.
What are the Potential Complications?
In response to a low caloric diet and low energy, the body responds in the following ways:
- Fat stores decrease up to 5% of the total body weight.
- Extracellular water content of the body increases.
- Protein mass decreases up to 30% in the case of severe muscle fibers loss striations and become thin. Protein sparing mechanisms redirect amino acids to the vital organs.
- Hypothermia and hypoglycemia in infants is more frequent due to underdeveloped systems.
- Potassium deficiency of up to 15 mEq/kg resulting in hypotonia and impaired cardiac function.
- Elevated levels of intracellular sodium in muscles, brain and blood cells.
- Metabolic adaptions in marasmus are similar to those in starvation.
- Basal metabolic rate decreases. The energy is diverted from muscles to the vital organs. Muscle loss is a result of decreased energy expenditure.
- Brain, skeleton and kidney are preserved, whereas the liver, heart, pancreas and digestive tract are first affected.
- Impaired glucose clearance in marasmus is due to compromised pancreatic beta cell function.
- Secretory functions of mucosal surfaces are impaired, decreased HCL production and slow peristalsis.
- Adaptations are seen by thyroid hormones, insulin and growth hormone.
- Thymus and all other T lymphocyte–producing tissues are affected. This leads to immunocompromised state.
- The brain is usually preserved during marasmus.
- Myofibril contractility is impaired.
Complications related to marasmus or malnutrition are particularly serious in infants and young children. Lack of proper nutrition can lead to delays in physical and mental development. Complications of untreated marasmus can be serious and may include:
- Growth problems in children
- Joint deformity and destruction
- Loss of strength
- Loss of vision and blindness
- Organ failure or dysfunction
- Unconsciousness and coma
Diagnosis of Marasmus
Lab values are taken to construct an appropriate treatment plan. Diagnosis is based on the following lab tests:
- Blood glucose: lower than 3 mmol/L values are indicative of hypoglycemia.
- Hemoglobin: a level lower than 40 g/L is indicative of severe anemia.
- Examination of blood smears by microscopy: parasite detection is indicative of infection.
- Albumin: It gives an idea to the prognosis. Albumin value lower than 35 g/L is indicative of severe protein synthesis impairment.
- Urine examination and culture.
- Microscopic stool examination.
- Electrolytes: Hyponatremia is evident. However, results are rarely helpful and can also lead to inappropriate therapy.
- HIV test: not routinely performed.
How to Prevent Marasmus
The best way to prevent marasmus is to have an adequate intake of calories and protein, preferably from a healthful, well-balanced diet. Foods rich in protein, such as skimmed milk, fish, eggs, and nuts are ideal for energy and growth, though any protein and calorie-rich food can be used to prevent marasmus, depending on what is available.
Vegetables and fruits are essential for providing other nutrients and minerals and for preventing vitamin deficiencies. People can also take supplements, but they may be less effective than foods in delivering nutrients.
A person who has recovered or is recovering from marasmus should take care to avoid complications, including dehydration and diarrhea. Also, a good sanitation and hygiene can play a role in marasmus, especially in places where there is not a regular supply of healthful food and clean water.
Cooking foods at high heat to destroy bacteria can help, as can freezing food and reheating it before eating. Boiling water before drinking, cooking, or bathing in areas where clean water is difficult to access is essential to prevent spreading waterborne diseases.
Breastfeeding infants for 6 months can help protect them from nutritional difficulties, especially in places where food is short.
Treatment of Marasmus
A nutritious, well-balanced diet with lots of fresh fruits and vegetables, grains, and protein will reduce the risk of malnutrition and any related marasmus. Treatment of marasmus involves a special feeding and rehydration plan and close medical observation to prevent and manage complications of malnutrition.
Pediatric nutrition rehabilitation centers have been established in some countries and regions to coordinate treatment of malnourished children. Intravenous fluids, oral rehydration solutions, and nasogastric feeding tubes are forms of treatment that may be used.
If marasmus results from an eating disorder, a person is also likely to need mental health treatment and support.