Introduction

Marasmus is a type of malnutrition. It occurs due to a severe lack of protein and energy. It is related to losing fat and muscle, reduced height and weight and not getting enough vitamins and minerals.

The word marasmus comes from the Greek word “marasmos’’, meaning “wasting”. This word is fitting because a child with marasmus gradually loses body fat and tissues to the extent that the child's bones become very visible. So, loose skin is visible in areas where body fat and muscle are significantly reduced, such as the armpit, the thighs, the chest, the abdomen and the mouth. As a result of these losses, the child looks like an old man.

The physical appearance of a child with marasmus depends on how long the child has been coping with marasmus. There is a standard weight and height for a child based on his age. 

A child's weight for his age is drastically reduced in short-term marasmus, while the child's height is noticeably reduced if marasmus continues for a long time. You can easily notice that the child's height is reduced, known as stunting. 

Pregnant women and children are more vulnerable to the condition, and marasmus is more common in young children.^{1, 2, 3} This article focuses on marasmus in young children and how successful breastfeeding can prevent the disorder.

Stats and facts

In 2022, the World Health Organization (WHO) reported that 149 million children under 5 years of age are shorter than they should be for their age (stunted). At least 45 million children are too thin for their height (wasted), and around 2.7 million children die every year because they don’t get enough nutrition. While marasmus is life-threatening, timely intervention plays a vital role in the child’s survival.

Normal body functions get disrupted in patients suffering from malnutrition. As a result, the metabolism slows down to conserve energy.

A child with marasmus has a weak immune system, making them more prone to low blood sugar (hypoglycemia), low body temperature (hypothermia) and infectious diarrhoea. Also, they lack sufficient vitamins and minerals like vitamin A, salt, and iron, which are crucial for growth and development.

Factors responsible for marasmus in young children

While marasmus is a severe form of undernutrition, it can be influenced by certain social factors that contribute to general malnutrition in young children. Some of these include but are not limited to ⁴:

• Lack of financial resources
• Inadequate access to healthcare
• Lack of involvement of the father in the care of children
• Poorer maternal education has been linked to a lower probability of stunting
• Displacement of people due to civil unrest, war, and natural disasters

Various health conditions have been reported to be associated with marasmus through undernutrition. Some examples are:^{2, 5, 6, 7}

• HIV/AIDS affects recovery and could cause food intolerance  
• Following illness from diseases (eg pneumonia, measles, tuberculosis, etc.)
• Tongue-tie can affect breastfeeding, leading to decreased feeding

Several studies have demonstrated that specific breastfeeding practices are associated with undernutrition, which could lead to severe forms like marasmus if left unaddressed. These could be ^{8, 9}: 

• Poor nutrition of the mother during pregnancy and after childbirth
• Underweight mother
• Continuing breastfeeding without introducing nutritious food after breastfeeding exclusively for the first six months
• Having more than one baby at the same time (multiple births)
• Late introduction of breastfeeding
• Breastfeeding for a short time because of another pregnancy or insufficient maternal nutrition 
• Low birth weight, especially when caused by intrauterine growth restriction (IUGR)
• Over-dilution of baby formula

Role of breastfeeding in marasmus prevention

Worldwide, exclusive breastfeeding, as well as breastfeeding particularly during the first 2 years of life, has been linked to an improvement in the physical and mental health of the child. The nutritional content of human breast milk can help prevent undernutrition and by extension, marasmus.^{3, 10}

In addition, breastfeeding contributes to protection from infections, thereby preventing nutrient loss. Enhanced growth and development are direct outcomes of breastfeeding as well. It is important to mention that exclusive breastfeeding for the first six months of life promotes better feeding practices and helps prevent inadequate formula preparation and early introduction of solid foods.

What does human milk contain?

Human breast milk (HBM) is vital for child growth and immunity. It is a rich source of macronutrients such as carbohydrates, fats, proteins, and micronutrients like growth factors and hormones. It also contains a diverse microbiome and microRNAs, which support immune function and metabolic processes. However, the composition of breast milk can vary depending on factors like the mother’s nutrition.¹¹

Benefits of exclusive breastfeeding

Exclusive breastfeeding contributes to several benefits for the child, including enhanced immune protection and appropriate development. Furthermore, it supports brain development and improves cognitive function. Exclusive breastfeeding for the first six months of age is also linked to a lower risk of allergies, obesity, and chronic diseases.¹²

What can make breastfeeding challenging?

Despite the potential benefits of breastfeeding, only 46 percent of babies are breastfed within the first hour of birth, and only 3 in 5 children until 2 years of life.¹⁴ The reasons for discontinuing breastfeeding early vary. Several studies support that the most common are the following:

• Poor maternal or infant health conditions (e.g., HIV/AIDS, Hepatitis B, mastitis, respiratory infections, and prematurity)
• Some mothers feel uncomfortable
• Breast issues, like painful or inverted nipples
• Poor positioning of the baby during breastfeeding (latching)
• Tongue-tie: a congenital condition characterised by a shortened or thickened band of tissue which attaches the tongue to the floor of the mouth 
• Cultural beliefs or customs that discourage breastfeeding (eg colostrum seen as harmful), which lead to the use of other feeding methods (eg honey, formula)
• Others feel that breastfeeding is a heavy responsibility for the mother and can affect her body size
• Postoperative pain after a cesarean section
• Perception of insufficient milk supply
• Short maternity leave
• Replacing breast milk with traditional feeding practices^{13, 14, 15, 16, 17}

Measures to encourage breastfeeding

To tackle the challenges and encourage breastfeeding, comprehensive strategies must be implemented. These concern the individual, healthcare, and the community. Studies suggested the subsequent approaches:

• Breastfeeding can be encouraged, promoted and supported by organizing appropriate educational programs and campaigns in the native language of the expectant parents.
• Education and nutritional guidance must start early, ideally before birth and be personalised according to the mother’s health, the baby’s needs and the availability of the food locally
• Community support and follow-up visits can assist the mother in breastfeeding early
• Policies could regulate the promotion of human breast milk alternatives, improve household income and encourage the education of potential mothers
• Mothers and healthcare professionals should be trained accordingly to identify breastfeeding issues (eg tongue tie)^{12, 15, 18, 19, 20, 21}

Summary

Marasmus is a form of malnutrition caused by a severe lack of protein and energy. It primarily affects infants and young children. Exclusive breastfeeding for the first 6 months and subsequent breastfeeding with appropriate food introductions can help to prevent marasmus. However, parents’ financial, social, and health status can hinder breastfeeding. Thus, it is important to support mothers through educational programs. Policies should also be implemented to promote breastfeeding.