What is Marasmus? 

Marasmus is a severe form of malnutrition that occurs due to calorie intake deficiency. Malnutrition occurs when your intake of protein, energy, and micronutrients such as vitamins is either inadequate or excessive, leading to a higher susceptibility to infections and other health disorders. This condition mainly affects children, especially those in developing countries. 

When nutrient intake is excessive, it is referred to as overnutrition. Conversely, when nutrient intake is insufficient to meet the body's needs, it is called undernutrition. There are two main types of acute malnutrition related to the lack of protein and calorie intake: marasmus and kwashiorkor.¹

Marasmus is a manifestation of severe protein-energy malnutrition, occurring when total calorie intake is insufficient. This insufficiency leads to the loss of your fat tissue and muscle mass. In comparison, kwashiorkor occurs when the diet is poor in protein despite adequate or high carbohydrate intake. Severe protein insufficiency can cause oedema (swelling) and ascites (fluid accumulation in the abdomen).²

The next thing to understand is how the body responds to calorie deficiency. Here are some key effects:

• Starvation: The body begins to conserve energy by slowing down metabolic processes
• Prone to infection: Severe and prolonged calorie restriction leads to secondary immunodeficiency. Inadequate cell metabolism impairs the immune system response, reducing cellular immunity and antibody production. Malnutrition also compromises the integrity of the skin and mucosal barriers, making it easier for bacteria and viruses to enter the body
• Muscle wasting: The body breaks down fat and muscle mass for energy, leading to significant muscle wasting
• Electrolyte imbalance and mineral depletion: Some conditions like altered muscle function and heart rhythm can develop due to deficiencies in essential minerals such as sodium and calcium. 
• Increased oxidative stress: Reduced intake of antioxidants like vitamin E and glutathione increases oxidative stress in the body
• Altered heart function: Calorie deficiency leads to thinning of the heart muscles and a decrease in the heart's contractile ability
• Developmental impairment: Malnutrition affects brain function, leading to developmental delays and cognitive impairments
• Endocrine dysfunction: The adrenal and pituitary glands, which produce hormones that regulate metabolism and growth, may atrophy, disrupting endocrine function
• Reduced gastric acid production: This can result in bacterial overgrowth in the gastrointestinal system, further impairing digestion and nutrient absorption^1,3

How is it diagnosed? 

History taking

Besides examining the symptoms that present, your healthcare provider will gather information about:^4,5

• Dietary history – assessing the condition in relation to specific nutrient, vitamin, or mineral deficiencies. This includes questions about the current diet, types of foods consumed, portion sizes, and meal frequency, as well as breastfeeding history
• Growth and development history – evaluating the patient's growth patterns and developmental milestones
• Medical history – identifying previous medical conditions such as infections, chronic diseases, congenital abnormalities, and current medications
• Family history and socioeconomic status – understanding the living conditions, including family medical history, socioeconomic status, and environmental factors, to determine their contribution to the current condition

Clinical examination

During clinical examination, signs of malnutrition are looked for, including:^1,6

• General appearance is usually shrunken and wasted due to reduced levels of subcutaneous fat
• Loose and wrinkled skin
• Sunken fontanels (soft spots on the baby’s head) that may be a sign of dehydration
• Low body weight
• Low blood pressure, low temperature, and low heart rate
• Dry eyes due to a lack of vitamin A
• Anaemia may be indicated by spoon-shaped nails
• Facial twitching is associated with calcium deficiencies

Assessment

Anthropometry measurement

These include weight-for-height, weight-for-age, and mid-upper arm circumference (MUAC). The measurement result will be compared with the chart that shows what the normal measurement should be. Typically, patients with marasmus have measurements significantly below the standard growth charts. The healthcare provider also assesses if there is a pitting oedema to rule out kwashiorkor.

Laboratory tests

• Blood tests include haemoglobin, red cell abnormalities, blood glucose level, albumin, and electrolytes
• Iron testing, folic acid, vitamins, and minerals level
• Blood smear can be useful in diagnosing anemia and malaria
• Stool microscopy and culture to investigate any parasites, malabsorption issues, or other abnormalities
• HIV testing if indicated
• Urine testing to detect urinary tract infections¹

Similar conditions

To provide appropriate treatment, it is important to establish an accurate diagnosis of marasmus and rule out other forms of malnutrition or medical conditions that present similarly. The main differential diagnoses include:^1,7

• Kwashiorkor: Unlike marasmus, kwashiorkor occurs due to insufficient protein intake despite adequate calorie consumption. A patient with kwashiorkor generally has normal body weight with oedema (swelling) in almost all body parts and skin changes. The swelling causes a characteristic round face and distention (swelling) of the abdomen. Their liver may also be enlarged
• Marasmic kwashiorkor: A patient of this condition will have manifestations of both marasmus and kwashiorkor. The patient will have wasting and oedema. The changes in their skin and hair are usually less severe than in patients with kwashiorkor alone
• HIV wasting syndrome: A person suffering from HIV may lose more than 10% of their baseline weight. The wasting can occur due to malabsorption, hypermetabolism, decreased appetite, and altered endocrine function
• Other chronic illnesses: Conditions such as tuberculosis, nutritional deficiencies, chronic pancreatitis, and others

FAQ’s

How do you assess a patient for malnutrition?

There is a commonly used tool to assess malnutrition called the Subjective Global Assessment (SGA). This tool includes:

• Medical history: Assessing dietary intake, weight loss, and gastrointestinal impairment
• Physical examination: Evaluating loss of subcutaneous fat, muscle wasting, ankle oedema, sacral oedema, and ascites (fluid accumulation in the abdomen)

Furthermore, an anthropometry (body measurement) and laboratory test will also be helpful to assess malnutrition.⁸

What is the difference between marasmus and kwashiorkor?

Ans - Marasmus and Kwashiorkor are the two most common types of malnutrition that typically affect children. The main difference between these two conditions lies in their causes. 

How to treat a patient with marasmus?

Ans - The principle and phase of marasmus treatment are:

• Resuscitation and stabilization: Address immediate life-threatening issues such as dehydration, infections, and electrolyte imbalances to stabilize the patient
• Nutritional rehabilitation: Gradually reintroduce calories and nutrients through therapeutic foods to promote recovery and weight gain
• Follow-up and prevention of recurrence: Monitor the patient's progress, provide ongoing nutritional support, and educate families on proper nutrition to prevent future episodes^1,9

What are the complications of marasmus?

Ans - These are possible complications that may arise due to marasmus:¹

• Endocrinological dysfunction
• Urinary tract infection
• Risk of developing refeeding syndrome 
• Infections
• Gastrointestinal malabsorption
• Hypothermia
• Cardiac failure and arrhythmia
• Short height as an adult
• Lower birth weight offspring

Summary

Marasmus is a type of malnutrition caused by a severe deficiency of nutrients and calorie intake, commonly affecting children. This insufficiency leads to a loss of muscle mass and presents clinically as wasting. To diagnose marasmus, the following modalities are used:

• History taking: The healthcare provider gathers information about dietary history, growth and developmental history, previous medical conditions, family history, and socioeconomic status
• Clinical assessment: The provider looks for signs of malnutrition specific to marasmus, including wasting, loose and wrinkled skin, sunken fontanels (a sign of dehydration), low body weight, low blood pressure, low temperature, and low heart rate
• Anthropometry assessment: This includes several measurements including weight-for-age, weight-for-height,and mid-upper arm circumference (MUAC)
• Laboratory tests: These include blood tests, blood smears, stool microscopy and culture, HIV testing if indicated, urine testing, and other tests if necessary