What is Marasmus?
To maintain a healthy body, it’s necessary to consume the right amount of micro and macronutrients. However, taking too much or too little of these nutrients can also be harmful. This is called malnutrition, and it’s when you’re not getting enough or getting too much protein, energy, and micronutrients like vitamins. As a result, frequent infections and disorders can occur. Overconsumption is known as overnutrition, while not getting enough is undernutrition.
When undernutrition happens, there are different levels and types depending on the cause. A condition called ‘protein-energy malnutrition’ is due to not getting enough protein and calories. It includes kwashiorkor and marasmus conditions.
Acute malnutrition is when a person’s weight is too low for their height. Severe cases are categorized into either marasmus or kwashiorkor. Long-term or chronic malnutrition, also known as stunted growth, is when a person’s height for their age is below average.
A micronutrient deficiency occurs when you are not getting enough essential vitamins and minerals needed for the normal functions of the body. In developing countries, the main deficiencies are iodine, vitamin A, iron, and zinc.
Kwashiorkor is a severe lack of protein. It usually happens when someone is eating enough food, but the food is mostly carbohydrates and does not have enough protein. This can lead to visible swelling in the lower legs and stomach area.
Marasmus is also a severe type of malnutrition, but it happens when someone isn’t getting enough calories in general. This results in a noticeable loss of body fat and muscle. A child with marasmus can be more than 3 standard deviations below the average weight-for-height for their age or sex. This condition can also cause swelling in the lower legs due to protein insufficiency, which is known as marasmic-kwashiorkor.
As this article discusses, understanding the causes, frequency, history, evaluation, and management of marasmus is important.
What Causes Marasmus?
Marasmus is a severe form of malnutrition that happens when a person’s diet doesn’t contain enough calories. However, the reasons why someone may cut back on calories can differ between adults and children. The causes of marasmus can be categorized into social factors and biological factors.
For children, poverty is the main social cause of marasmus. Poverty can come from a low social status, insufficient education, war, natural disasters, and political upheaval. This can make it difficult for families to have consistent access to enough food. Unpredictable and unstable living conditions can lead to issues like poor hygiene and frequent infections, such as diarrhea. The spread of serious illnesses like HIV/AIDS has also been shown to heavily influence the food supply in some regions, like South Africa.
The level of a mother’s education plays a role as well. For example, in Nairobi, mothers who have received a primary level of education have a 94% lower chance of their child having delayed growth compared to mothers with no education.
On the biological side, children with diseases like HIV/AIDS often experience poor nutrition. Mothers infected with HIV generally have less protein and nutrients in their bodies than mothers without HIV, which can affect breastfeeding.
Malaria is also linked with delayed growth in children under two, but it doesn’t cause protein-energy deficiency, which is a primary effect of marasmus.
Although marasmus is more common in children, adults can suffer from it too. As individuals age, there is a tendency for food intake to decrease, with a drop of about 30% in males and 20% in females, referred to as physiological anorexia of aging. This is believed to happen because older people often find food less satisfying due to a decline in taste and smell. There are changes in the digestive system as well, leading to quicker ‘fullness’ after eating. There are also emotional factors, as depression is a common reason for decreased appetite, especially in older adults living in care facilities.
In addition, malabsorption, or the inability to properly absorb nutrients from food, can cause marasmus in adults. This malabsorption often comes from conditions like coeliac disease and pancreatic insufficiency.
Risk Factors and Frequency for Marasmus
In the United States, less than 5% of the population suffer from severe weight loss, or “wasting.” Furthermore, around 25% of American households deal with some level of food shortage. Surprisingly, in composed countries like America, it is more common for adults to be undernourished than children. Particularly, between 5 to 10% of elderly people in nursing homes and up to 50% of elderly people leaving hospitals are undernourished.
On the other hand, malnutrition is a severe public health issue in many developing countries, especially in Southern Asia and sub-Saharan Africa. It causes around 300,000 deaths each year and is partly responsible for half of the deaths of young children. Worldwide, a staggering 852 million people are undernourished, with the majority (815 million) residing in undeveloped countries. Specifically, 18 million children from low-income or middle-income countries, mostly in Asia, are suffering from marasmus, a form of severe malnutrition.
Pediatric malnutrition, which is linked to hospital admission in the developing world, carries a mortality rate of up to 20%. Additionally, deaths from malnutrition tend to increase during the rainy season, before the harvest, due to food scarcity and a higher risk of infectious diseases.
According to estimates, in 2016, 155 million children under the age of 5 were stunted in their growth, 52 million were wasting, and of these, an alarming 17 million children were severely wasting.
Marasmus affects both genders equally. However, due to cultural differences in some regions, women may be at a higher risk of this severe form of malnutrition.
Signs and Symptoms of Marasmus
Marasmus is a severe form of malnutrition that comes from not getting enough calories in your diet. The symptoms and the severity differ based on factors like how long the individual has been malnourished, the age of the person, and whether they also have a lack of vitamins and minerals in the body.
Common signs of marasmus often include a failure to grow and develop normally, especially in infants. Babies with this condition might be irritable, less active, and have sunken areas on the top of their skull due to dehydration. They also tend to look thin and frail because they lose fat under the skin. This weight loss can start in the groin or armpit, then move to the buttocks, face, and legs. As a result, the face might get a sunken, aged look.
Other symptoms include low blood pressure, low body temperature, and a slow heartbeat. In severe cases, the child’s weight could drop to less than 60% of the normal weight for their age. If marasmus goes on for an extended period, the child’s growth could be stunted, leaving them with a normal weight for their height. The condition often goes hand-in-hand with conditions like anemia and bone disease known as rickets.
Over time, marasmus can affect multiple body systems. For example, it can damage the heart, leading to low blood pressure, low body temperature, and a slow heartbeat. Marasmus can also come with other nutrient deficiencies. Things to look out for include:
- Dry eyes and spots on the whites of the eyes due to a lack of vitamin A.
- Spoon-shaped nails and anemia because of iron deficiency.
- Signs of low calcium like Chvostek or Trousseau signs.
- Bone deformities from long-term deficiencies of calcium and vitamin D, which could lead to rickets.
However, it’s crucial to note that certain signs like swelling, skin changes, hair color changes, and mouth sores, associated with another form of severe malnutrition called kwashiorkor, are not present in marasmus.
Testing for Marasmus
Determining if a person has marasmus, a severe form of malnutrition, often involves measurements of the body, which could be challenging to do accurately in poor countries. These measurements include height (to within half a centimeter), weight (to within 100 grams), and the circumference of the upper arm (to within 2 millimeters or less). Checking the patient for swelling that leaves an indentation after you press on it (pitting edema), can also help rule out another type of malnutrition called kwashiorkor.
The diagnosis of marasmus is typically made if the upper arm’s circumference measurement is less than 115 millimeters or if the child’s weight for height is more than three standard deviations below average.
Lab tests can further assist in diagnosing marasmus as well as any accompanying mineral deficiencies. The World Health Organization recommends tests for hemoglobin and blood smear, blood sugar, protein in the blood (serum albumin), electrolytes, stool examination for parasites, HIV testing, and urine examination and culture.
A complete blood count may reveal low levels of hemoglobin or unusual findings in the size, color, or shape of red blood cells. Iron levels, folic acid, and B12 levels may be checked since these are frequently used in diagnosing anemia and other conditions. A blood smear may also be helpful for detecting anemia and malaria.
Certain specific tests are often included in assessing nutritional status. These include tests for certain proteins in the blood plasma, like transferrin, albumin, and thyroxine-binding prealbumin. Albumin levels are often used to gauge nutritional status, but because albumin lasts a long time in the body (19 days), it’s not as helpful for monitoring short-term changes, such as in response to treatment. Other proteins, like thyroxine-binding prealbumin (2 days) and retinol-binding protein (10 hours), have a shorter lifespan in the body and are better for checking treatment response.
Treatment Options for Marasmus
Severe malnutrition can lead to death due to several reasons including infections, dehydration, imbalance of electrolytes (salts and minerals that can affect many body functions), and possible heart failure. Another risk is the onset of refeeding syndrome, which is when a previously malnourished person is given nutrition too quickly. The care for malnutrition, or marasmus as it’s also known, can take place at a hospital or within a community. Some studies have shown that children who are severely malnourished can recover better within a community setting than in a hospital, as long as their case is not complicated by other health issues.
The main steps for treating malnutrition are:
- Rescuing the patient and stabilizing their condition
- Helping them recover nutritionally
- Ensuring the right follow-up care is in place to prevent the situation from happening again
In the first phase, the goal is to fix any immediate problems with hydration and prevent infections that could lead to sepsis (severe infection that can cause organ failure). The patient is also put on a careful nutrition plan to avoid the problems associated with refeeding syndrome. This primary care phase can last around a week, and this is usually when the patient is most at risk.
For a child with marasmus, treatments such as an intravenous (IV) drip is used to address dehydration. If the child is showing signs of hypovolemia (low blood volume), they might be given plasma or blood to help. Marasmus patients are also susceptible to hypothermia (abnormally low body temperature), so they should be kept in a warm environment.
The slow and careful nutritional rehabilitation plan is important to avoid refeeding syndrome, which can cause a serious drop in blood sugar. This can be managed by feeding the patient continuously, especially at night. Certain vitamins and minerals, including thiamine and phosphate, are given at this stage to prevent deficiencies that can lead to further complications.
In the second phase, once the immediate complications are under control, the patient’s appetite is back, and the infection and electrolyte problems are corrected, the focus is on gradually increasing the calorie intake. This includes boosting the patient’s motor activity and taking necessary vaccinations. Children may even need to consume up to 140% of their regular calorie intake to maintain a growth rate like their peers who are not malnourished. This phase usually lasts 2 to 6 weeks and includes encouraging interactions between the mother and child to help reverse any developmental delays.
In the final phase, the emphasis is on stopping the condition from happening again. Education on breastfeeding and nutrition supply could be beneficial for mothers to ensure their children do not relapse into malnutrition. Other important ways to prevent malnutrition include providing clean drinking water, enough food, and controlling any potential infectious diseases.
What else can Marasmus be?
Kwashiorkor is a medical condition that often comes up when doctors are considering marasmus, which is another form of severe malnutrition. The term “kwashiorkor” comes from the Ga language in Ghana, and it describes a sickness that arises after a child is weaned. This condition can occur if a child is getting enough calories from their diet, but not enough protein. Foods like maize, rice, or cassava, which are high in carbohydrates but low in protein, can contribute to the condition.
A child with kwashiorkor typically has a normal weight but may also show signs of widespread swelling and skin issues. Areas of the body that experience a lot of friction or pressure, such as the perineum, limbs, ears, and armpits, can undergo skin changes. These changes can start with the skin darkening before peeling. The swelling can give the face a round appearance and cause the abdomen to extend. Kwashiorkor can be distinguished from marasmus by the presence of clear swelling.
Marasmic kwashiorkor is a condition that presents symptoms of both marasmus and kwashiorkor. A child with marasmic kwashiorkor would have slowed growth, wasting, and swelling. The changes in their hair and skin are usually not as severe as those seen in kwashiorkor. Swelling in the abdomen may happen due to fluid buildup and an enlarged fatty liver.
HIV wasting syndrome refers to involuntary weight loss of more than 10% in people with HIV. It is often associated with long-term diarrhea or weakness and cannot be explained by any other cause. This weight loss can occur due to a multitude of factors such as poor absorption of nutrients, increased metabolism, hormone dysfunction, and decreased appetite leading to less food intake.
Chronic pancreatitis is another condition that may mimic protein-energy malnutrition, as it can occur in children due to various reasons including viruses like Coxsackie B and mumps, injury, cystic fibrosis, and obstruction of the pancreatic ducts by roundworms. Chronic pancreatitis can lead to poor absorption of nutrients due to insufficient pancreatic enzymes, causing a reduction in calorie supply despite sufficient food intake.
What to expect with Marasmus
If a child goes back to a setting that supports their recovery, in most situations, they will likely achieve normal height and good health.
Possible Complications When Diagnosed with Marasmus
In simple terms, there might be a few short-term problems, which could occur as a result of marasmus, such as:
- Complications with your body’s salt, potassium and other electrolytes balance, with a risk of refeeding syndrome (a potentially fatal complication that can occur when malnourished people start eating again)
- Heart failure and irregular heart rhythms
- Urinary tract infection
- Severe infection and sepsis (a dangerous condition caused by the body’s response to an infection)
- Problems with digesting and absorbing nutrients from food (malabsorption)
- Lower body temperature (hypothermia)
- Hormone disorders (endocrinological dysfunction)
Furthermore, childhood undernutrition can negatively influence a person’s adult life. It is strongly linked to:
- Less economic opportunities
- Poorer educational and financial outcomes
- Shorter adult height
- The birth of smaller babies
This means that children who experience malnutrition may end up receiving less schooling and earning a smaller income. They may also be shorter as adults and have babies with a lower birth weight.
Preventing Marasmus
Marasmus, a severe form of malnutrition, mostly happens in less developed countries and is often linked to a lack of education about nutrition among parents. So, sharing nutritional information through leaflets or learning programs might help prevent this problem. Also, when new mothers come for pregnancy tests or after giving birth in a hospital, it could be useful to evaluate their understanding of nutrition. This could help ensure they know how to nourish themselves and their babies effectively.
