Marasmus

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Marasmus
Starved child.jpg
Photo from 1972 of an emaciated child in India with marasmus
Specialty Critical care medicine
Causes Starvation, malnutrition, cachexia

Marasmus is a form of severe malnutrition characterized by energy deficiency. It can occur in anyone with severe malnutrition but usually occurs in children. Body weight is reduced to less than 62% of the normal (expected) body weight for the age. [1] Marasmus occurrence increases prior to age 1, whereas kwashiorkor occurrence increases after 18 months. It can be distinguished from kwashiorkor in that kwashiorkor is protein deficiency with adequate energy intake whereas marasmus is inadequate energy intake in all forms, including protein. This clear-cut separation of marasmus and kwashiorkor is however not always clinically evident as kwashiorkor is often seen in a context of insufficient caloric intake, and mixed clinical pictures, called marasmic kwashiorkor, are possible. Protein wasting in kwashiorkor generally leads to edema and ascites, while muscular wasting and loss of subcutaneous fat are the main clinical signs of marasmus, which makes the ribs and joints protrude. [2]

Contents

The prognosis is better than it is for kwashiorkor. [3] Marasmus is the form of malnutrition most highly associated with HIV, developing in the last stages of pediatric AIDS, and the prognosis for children with co-morbid marasmus and HIV is very poor. [4]

The word "marasmus" comes from the Greek μαρασμός marasmos ("withering").

Signs and symptoms

Marasmus is commonly represented by a shrunken, wasted appearance, loss of muscle mass and subcutaneous fat mass. [5] [6] Due to the deficiency in macronutrients and caloric intake, specifically protein and adult survivors that impact development. Other long term effects of marasmus are the increased risks for pancreatic beta-cell dysfunction which leads to glucose intolerance and type 2 diabetes. [7] This may lead to reduced muscle mass, and increased visceral fat. Moreover, there are metabolic implications including reduced insulin sensitivity and impaired glucose metabolism. There is also an increased risk of other NCDs (Non-communicable diseases) as well as CVRFs (Cardiovascular risk factors). Not only are the survivors of marasmus impacted, but their offspring as well. There is an association with survivors and their offspring having a low birth weight. [8] There are also long term effects related to gene methylation. Marasmus adult survivors may have changes in gene expression in regards to immunity, growth and glucose metabolism. [9]

Diagnosis

The first steps in the diagnosis of marasmus are through physical examination and anthropometric calculations. [10] Some of the features that are diagnosable in a physical exam are severe wasting and stunting, appearing abnormally thin. Wasting is calculated through measuring weight for height. If the child is 2 standard deviations from the WHO standard, they are considered wasted. Stunting is calculated the same way, however, it is based on height for age ratios. Measurements are also taken via the middle-upper arm circumference (MUAC). After physical examination and measurements, blood tests can be done to determine protein deficiency as well as deficiencies in other major minerals and vitamins. This helps determine the nutritional status and if there are any indicators of marasmus. In extreme cases of infection, stool samples and blood counts are conducted. Since marasmus is a type of nutritional condition that is often associated with kwashiorkor, some providers will see if edema is present to confirm that it is marasmus. [11] Presence of edema is associated with kwashiorkor, not marasmus.

Causes

Buchenwald concentration camp inmates on 16 April 1945, when the camp was liberated by the US Army Buchenwald-J-Rouard-12.jpg
Buchenwald concentration camp inmates on 16 April 1945, when the camp was liberated by the US Army

Marasmus is caused by the following factors:

Treatment

Both the causes and complications of the disorder must be treated, including infections, dehydration, and circulation disorders, which are frequently lethal and lead to high mortality if ignored.[ citation needed ] Initially, the child is fed dried skim milk that has been mixed with boiled water. Refeeding must be done slowly to avoid refeeding syndrome. Once children start to recover, they should have more balanced diets which meet their nutritional needs. Children with marasmus commonly develop infections and are consequently treated with antibiotics or other medications.[ medical citation needed ] Ultimately, marasmus can progress to the point of no return when the body's ability for protein synthesis is lost. At this point, attempts to correct the disorder by giving food or protein become futile, and death is inevitable.[ citation needed ]

Prevention

Nutritionally the best way to prevent marasmus is through a diverse and adequate diet. Other interventions that also target nutrition specific interventions are through SAM treatment, CTC (comprehensive treatment center), and protein and micronutrient supplements. It is also important for mothers and families to be educated on prenatal care, nutrition and child development. Energy, protein and micronutrient supplementation are vital to ensuring the mother and child are adequately nourished. Strictly breastfeeding for 6 months and 24 months for nutritional supplementation is also recommended to prevent Marasmus and other malnutrition of children under the age of 2. [12]

In addition to nutrition, ensuring access to clean water, sanitation and hygiene are important in preventing childhood illness and diarrheal disease which can contribute to marasmus and other Severe acute malnutrition cases as well as, if the child has marasmus it can quickly become dangerous if the child has another disease as immune functions are decreased when a child has marasmus. [13] It is important for the child or anyone at risk for marasmus to have access to primary care so they are able to treat these illnesses, prevent diarrheal diseases often associated with malnutrition and monitor growth.

Epidemiology

United States

In the United States, marasmus is rarely seen, especially in children. In 1995, there were only 228 deaths caused by marasmus in the U.S., of which only 3 were children. In 2016, the prevalence of marasmus in the United States was 0.5%. Prevalence is higher in hospitalized children, especially ones with chronic illnesses, however an exact incidence of nonfatal marasmus is not known. This is due to marasmus not being reported as an admission or discharge diagnosis. [14]

International

There are multiple forms of malnutrition and roughly one-third of the world's population is currently experiencing one or more of them. There are around 50 million children less than five years old who have protein-energy malnutrition. Of the malnourished children population in the world, 80% live in Asia, 15% in Africa, and 5% in Latin America. It is estimated that the prevalence of acute malnutrition in Germany, France, the United Kingdom, and the United States to be 6.1–14%. In Turkey, the prevalence is as high as 32%. [14]

Race

There is no evident racial predisposition that correlates to malnutrition. Rather, there is a strong association with the geographic distribution of poverty. [15]

Age

Marasmus is more commonly seen in children under the age of five due to that age range being characterized as one that has an increase in energy need and susceptibility to viral and bacterial infections. [16] The World Health Organization also identifies the elderly as another population that is vulnerable to malnutrition. Because their nutritional requirement is not well defined, attempts to provide them with the necessary nutrition becomes difficult. [17]

There exist screening tools and tests that can be used to help identify signs and symptoms of malnutrition in older adults. The Malnutrition Screening Tool (MST) is a validated malnutrition screening tool that is primarily used in the residential aged care facility or for adults in the inpatient/outpatient hospital setting. It includes parameters such as weight loss and appetite. [18]

Disability-adjusted life year for protein-energy malnutrition per 100,000 inhabitants in 2002 .mw-parser-output .div-col{margin-top:0.3em;column-width:30em}.mw-parser-output .div-col-small{font-size:90%}.mw-parser-output .div-col-rules{column-rule:1px solid #aaa}.mw-parser-output .div-col dl,.mw-parser-output .div-col ol,.mw-parser-output .div-col ul{margin-top:0}.mw-parser-output .div-col li,.mw-parser-output .div-col dd{page-break-inside:avoid;break-inside:avoid-column} .mw-parser-output .legend{page-break-inside:avoid;break-inside:avoid-column}.mw-parser-output .legend-color{display:inline-block;min-width:1.25em;height:1.25em;line-height:1.25;margin:1px 0;text-align:center;border:1px solid black;background-color:transparent;color:black}.mw-parser-output .legend-text{} no data less than 10 10-100 100-200 200-300 300-400 400-500 500-600 600-700 700-800 800-1000 1000-1350 more than 1350 Protein-energy malnutrition world map - DALY - WHO2002.svg
Disability-adjusted life year for protein-energy malnutrition per 100,000 inhabitants in 2002
  no data
  less than 10
  10–100
  100–200
  200–300
  300–400
  400–500
  500–600
  600–700
  700–800
  800–1000
  1000–1350
  more than 1350

Persons in prisons, concentration camps, and refugee camps are affected more often due to poor nutrition.[ citation needed ]

Socioeconomic implications

Those who are in poverty are more likely to develop marasmus and other nutritional deficiencies. [20] Due to childhood malnutrition, survivors of marasmus often have poorer socioeconomic prospects due to cognitive compromise in their developmental years. Since adequate nutrition is vital for development, those with Marasmus are impacted by impaired neurodevelopment. This results in loss of education in early school years, leading to limited higher educational and occupational opportunities. Prevention may look like improving nutritional education and access, as well as eliminating poverty are ways to reduce the risks of developing these deficiencies.

See also

Related Research Articles

<span class="mw-page-title-main">Kwashiorkor</span> Severe protein malnutrition

Kwashiorkor is a form of severe protein malnutrition characterized by edema and an enlarged liver with fatty infiltrates. It is thought to be caused by sufficient calorie intake, but with insufficient protein consumption, which distinguishes it from marasmus. Recent studies have found that a lack of antioxidant micronutrients such as β-carotene, lycopene, other carotenoids, and vitamin C as well as the presence of aflatoxins may play a role in the development of the disease. However, the exact cause of kwashiorkor is still unknown. Inadequate food supply is correlated with occurrences of kwashiorkor; occurrences in high income countries are rare. It occurs amongst weaning children to ages of about five years old.

<span class="mw-page-title-main">Human nutrition</span> Provision of essential nutrients necessary to support human life and health

Human nutrition deals with the provision of essential nutrients in food that are necessary to support human life and good health. Poor nutrition is a chronic problem often linked to poverty, food security, or a poor understanding of nutritional requirements. Malnutrition and its consequences are large contributors to deaths, physical deformities, and disabilities worldwide. Good nutrition is necessary for children to grow physically and mentally, and for normal human biological development.

An essential amino acid, or indispensable amino acid, is an amino acid that cannot be synthesized from scratch by the organism fast enough to supply its demand, and must therefore come from the diet. Of the 21 amino acids common to all life forms, the nine amino acids humans cannot synthesize are valine, isoleucine, leucine, methionine, phenylalanine, tryptophan, threonine, histidine, and lysine.

<span class="mw-page-title-main">Wasting</span> Loss of muscle and fat tissue

In medicine, wasting, also known as wasting syndrome, refers to the process by which a debilitating disease causes muscle and fat tissue to "waste" away. Wasting is sometimes referred to as "acute malnutrition" because it is believed that episodes of wasting have a short duration, in contrast to stunting, which is regarded as chronic malnutrition. An estimated 45 million children under 5 years of age were wasted in 2021. Prevalence is highest in Southern Asia, followed by Oceania and South-eastern Asia.

<span class="mw-page-title-main">Starvation</span> Severe deficiency in caloric energy intake, below the level needed to maintain an organisms life

Starvation is a severe deficiency in caloric energy intake, below the level needed to maintain an organism's life. It is the most extreme form of malnutrition. In humans, prolonged starvation can cause permanent organ damage and eventually, death. The term inanition refers to the symptoms and effects of starvation. Starvation by outside forces is a crime according to international criminal law and may also be used as a means of torture or execution.

<span class="mw-page-title-main">Malnutrition</span> Medical condition

Malnutrition occurs when an organism gets too few or too many nutrients, resulting in health problems. Specifically, it is "a deficiency, excess, or imbalance of energy, protein and other nutrients" which adversely affects the body's tissues and form. Malnutrition is not receiving the correct amount of nutrition.

<span class="mw-page-title-main">Cachexia</span> Syndrome causing muscle loss not entirely reversible

Cachexia is a complex syndrome associated with an underlying illness, causing ongoing muscle loss that is not entirely reversed with nutritional supplementation. A range of diseases can cause cachexia, most commonly cancer, congestive heart failure, chronic obstructive pulmonary disease, chronic kidney disease, and AIDS. Systemic inflammation from these conditions can cause detrimental changes to metabolism and body composition. In contrast to weight loss from inadequate caloric intake, cachexia causes mostly muscle loss instead of fat loss. Diagnosis of cachexia can be difficult due to the lack of well-established diagnostic criteria. Cachexia can improve with treatment of the underlying illness but other treatment approaches have limited benefit. Cachexia is associated with increased mortality and poor quality of life.

<span class="mw-page-title-main">Weight loss</span> Reduction of the total body mass

Weight loss, in the context of medicine, health, or physical fitness, refers to a reduction of the total body mass, by a mean loss of fluid, body fat, or lean mass. Weight loss can either occur unintentionally because of malnourishment or an underlying disease, or from a conscious effort to improve an actual or perceived overweight or obese state. "Unexplained" weight loss that is not caused by reduction in calorific intake or increase in exercise is called cachexia and may be a symptom of a serious medical condition.

<span class="mw-page-title-main">Failure to thrive</span> Condition of children whose current weight or rate of weight gain is much lower than expected

Failure to thrive (FTT), also known as weight faltering or faltering growth, indicates insufficient weight gain or absence of appropriate physical growth in children. FTT is usually defined in terms of weight, and can be evaluated either by a low weight for the child's age, or by a low rate of increase in the weight.

<span class="mw-page-title-main">Underweight</span> Below a weight considered healthy

An underweight person is a person whose body weight is considered too low to be healthy. A person who is underweight is malnourished.

In human physiology, nitrogen balance is the net difference between bodily nitrogen intake (ingestion) and loss (excretion):

<span class="mw-page-title-main">Protein–energy malnutrition</span> Medical condition

Protein–energy undernutrition (PEU), once called protein-energy malnutrition (PEM), is a form of malnutrition that is defined as a range of conditions arising from coincident lack of dietary protein and/or energy (calories) in varying proportions. The condition has mild, moderate, and severe degrees.

<span class="mw-page-title-main">Protein (nutrient)</span> Nutrient for the human body

Proteins are essential nutrients for the human body. They are one of the building blocks of body tissue and can also serve as a fuel source. As a fuel, proteins provide as much energy density as carbohydrates: 4 kcal per gram; in contrast, lipids provide 9 kcal per gram. The most important aspect and defining characteristic of protein from a nutritional standpoint is its amino acid composition.

<span class="mw-page-title-main">Micronutrient deficiency</span> Medical condition

Micronutrient deficiency is defined as the sustained insufficient supply of vitamins and minerals needed for growth and development, as well as to maintain optimal health. Since some of these compounds are considered essentials, micronutrient deficiencies are often the result of an inadequate intake. However, it can also be associated to poor intestinal absorption, presence of certain chronic illnesses and elevated requirements.

In medicine, a deficiency is a lack or shortage of a functional entity, by less than normal or necessary supply or function. A person can have chromosomal deficiencies, mental deficiencies, nutritional deficiencies, complement deficiencies, or enzyme deficiencies.

Malnutrition continues to be a problem in the Republic of South Africa, although it is not as common as in other countries of Sub-Saharan Africa.

Childhood chronic illness refers to conditions in pediatric patients that are usually prolonged in duration, do not resolve on their own, and are associated with impairment or disability. The duration required for an illness to be defined as chronic is generally greater than 12 months, but this can vary, and some organizations define it by limitation of function rather than a length of time. Regardless of the exact length of duration, these types of conditions are different than acute, or short-lived, illnesses which resolve or can be cured. There are many definitions for what counts as a chronic condition. However, children with chronic illnesses will typically experience at least one of the following: limitation of functions relative to their age, disfigurement, dependency on medical technologies or medications, increased medical attention, and a need for modified educational arrangements.

<span class="mw-page-title-main">Environmental enteropathy</span> Disorder of chronic intestinal inflammation

Environmental enteropathy is an acquired small intestinal disorder characterized by gut inflammation, reduced absorptive surface area in small intestine, and disruption of intestinal barrier function. EE is most common amongst children living in low-resource settings. Acute symptoms are typically minimal or absent. EE can lead to malnutrition, anemia, stunted growth, impaired brain development, and impaired response to oral vaccinations.

<span class="mw-page-title-main">Undernutrition in children</span> Medical condition affecting children

Undernutrition in children, occurs when children do not consume enough calories, protein, or micronutrients to maintain good health. It is common globally and may result in both short and long term irreversible adverse health outcomes. Undernutrition is sometimes used synonymously with malnutrition, however, malnutrition could mean both undernutrition or overnutrition. The World Health Organization (WHO) estimates that malnutrition accounts for 54 percent of child mortality worldwide, which is about 1 million children. Another estimate, also by WHO, states that childhood underweight is the cause for about 35% of all deaths of children under the age of five worldwide.

References

  1. ↑ Appleton & Vanbergen, Metabolism and Nutrition, Medicine Crash Course 4th ed. Moseby (London: 2013) p.130
  2. ↑ Müller, Olaf; Krawinkel, Michael (2005-08-02). "Malnutrition and health in developing countries". CMAJ: Canadian Medical Association Journal. 173 (3): 279–286. doi:10.1503/cmaj.050342. ISSN   0820-3946. PMC   1180662 . PMID   16076825.
  3. ↑ Badaloo AV, Forrester T, Reid M, Jahoor F (June 2006). "Lipid kinetic differences between children with kwashiorkor and those with marasmus". Am. J. Clin. Nutr. 83 (6): 1283–8. doi: 10.1093/ajcn/83.6.1283 . PMID   16762938.
  4. ↑ Prazuck, Thierry; Tall, François; Macro, Boubacar; Rochereau, Anne; Traore, Antoinette; Sanou, Théophille; Malkin, Jean-Elie; Apaire-Marchais, Véronique; Masson, Damienne; Dublanchet, Alain; Lafaix, Christian (January 1993). "HIV infection and severe malnutrition". AIDS. 7 (1): 103–108. doi:10.1097/00002030-199301000-00016. ISSN   0269-9370. S2CID   12330805.
  5. ↑ Rabinowitz, Simon. "MD, PhD, FAAP". Emedicine Medscape. Medscape. p. 28. Retrieved 29 January 2015.
  6. ↑ Francis-Emmanuel, Patrice; Thompson, Debbie; Barnett, Alan; Osmond, Clive; Byrne, Christopher; Hanson, Mark; Gluckman, Peter; Forrester, Terrance; Micheal, Boyne (June 1, 2014). "Glucose Metabolism in Adult Survivors of Severe Acute Malnutrition". The Journal of Clinical Endocrinology & Metabolism. 99 (6): 2233–2240. doi:10.1210/jc.2013-3511. PMID   24517147.
  7. ↑ Grey, Kelsey; Gonzales, Gerard; Abera, Mubarek; Lelijveld, Natasha; Thompson, Debbie; Berhane, Melkamu; Abdissa, Alemseged; Girma, Tsinuel (March 10, 2021). "Severe malnutrition or famine exposure in childhood and cardiometabolic non-communicable disease later in life: a systematic review". BMJ Global Health. 6 (e003161): e003161. doi:10.1136/bmjgh-2020-003161. PMC   7949429 . PMID   33692144.
  8. ↑ Titi-Lartley, Owuraku; Gupta, Vikas. "Marasmus". National Library of Medicine. Retrieved July 24, 2023.
  9. ↑ Sheppard, Allan; Ngo, Sherry; Li, Xiaoling; Boyne, Micheal; Thompson, Debbie; Pleasants, Anthony; Gluckman, Peter; Forrester, Terrance (April 24, 2017). "Molecular Evidence for Differential Long-term Outcomes of Early Life Severe Acute Malnutrition". eBioMedicine. 18: 274–280. doi:10.1016/j.ebiom.2017.03.001. PMC   5405153 . PMID   28330812.
  10. ↑ "Marasmus". Clevland Clinic. Retrieved April 8, 2024.
  11. ↑ "What Is Marasmus?". WebMD. Retrieved April 8, 2024.
  12. ↑ "Marasmus". Cleveland Clinic. Clevland Clinic.
  13. ↑ "Marasmus". Cleveland Clinic. Clevland Clinic.
  14. 1 2 "Marasmus: Background, Pathophysiology, Body Composition". 2019-02-02.
  15. ↑ Stephens, Janna D.; Althouse, Andrew; Tan, Alai; Melnyk, Bernadette Mazurek (2017). "The Role of Race and Gender in Nutrition Habits and Self-Efficacy: Results from the Young Adult Weight Loss Study". Journal of Obesity. 2017: 5980698. doi: 10.1155/2017/5980698 . ISSN   2090-0708. PMC   5406727 . PMID   28491474.
  16. ↑ Katona-Apte, Judit; Katona, Peter (2008-05-15). "The Interaction between Nutrition and Infection". Clinical Infectious Diseases. 46 (10): 1582–1588. doi: 10.1086/587658 . ISSN   1058-4838. PMID   18419494.
  17. ↑ "WHO | Nutrition for older persons". WHO. Retrieved 2019-08-07.
  18. ↑ "Malnutrition Screening and Assessment Tools". NCOA. 2017-01-20. Retrieved 2019-08-07.
  19. ↑ "Mortality and Burden of Disease Estimates for WHO Member States in 2002" (xls). World Health Organization. 2002.
  20. ↑ Galler, Janina; Bryce, Cryalene; Waber, Deborah; Zichlin, Miriam; Fitzmaurice, Garret; Eaglesfield, David (July 2012). "Socioeconomic Outcomes in Adults Malnourished in the First Year of Life: A 40-Year Study". Pediatrics. 130 (1): e1–e7. doi:10.1542/peds.2012-0073. PMC   3382923 . PMID   22732170.
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