Overview 

Malnutrition is a serious global health issue affecting millions of people worldwide, especially in developing countries. In the UK, more than 1 in 20 people are affected by malnutrition, with the rate increasing to 1 in 10 people over 65 years. 

Good nutrition can help protect you from illnesses, such as diabetes, heart disease, and osteoporosis. Without adequate nutrition, your body becomes malnourished, associated with brittle bones and muscle waste. 

Among the many types of malnutrition are marasmus and kwashiorkor, two critical forms typically affecting children. Both types are associated with nutrition deficiencies with distinct characteristics, and underlying causes that set them apart. The most important point of difference is that marasmus is a severe undernutrition in all macronutrients needed by the body, whereas kwashiorkor is a severe protein deficiency.¹

Differentiating between marasmus and kwashiorkor is vital for effective diagnosis, treatment and management, and prevention. This article will explore the key differences between marasmus and kwashiorkor, including their causes, symptoms and treatments. Read on to find out the prognosis of both types of malnutrition, and what preventative strategies you can adopt, to lower your risk of developing both conditions.

What is the difference between both conditions?

Marasmus and Kwashiorkor are both different forms of severe undernutrition.² 

Marasmus is a deficiency of all macronutrients, including protein, fats and carbohydrates, causing you to have insufficient fuel to maintain normal bodily functions. Due to this, the body starts to utilise its body fat and muscle for energy, causing people to look visibly depleted, emaciated and severely underweight. Marasmus commonly affects children in developing countries where food scarcity, poverty and infectious diseases lead to calorie depletion. Children with marasmus are often noted to have stunted growth.

Kwashiorkor is associated with severe protein deficiency, causing oedema (fluid retention in the tissues), linked to emancipated limbs, but swollen stomachs, hands and feet. Kwashiorkor commonly affects children between 3-5 years in developing countries, during which they transition from breastfeeding to a diet high in carbohydrates and low in proteins.¹

People with marasmus are deprived of calories, whereas those with kwashiorkor may not be calorie-deprived, but are instead deprived of protein-rich foods.

Causes

The main cause of both conditions is a lack of access to food. Those with an increased risk include people who live in rural areas with food shortages or limited access to protein-rich foods.²

Marasmus 

Factors that could cause marasmus include:² 

• Food scarcity 
• Living in poverty 
• Famine
• Wasting diseases, for example AIDS
• Anorexia 

• Inadequate breastfeeding 
• Early weaning
• Child neglect or abuse 

Kwashiorkor

The main cause of kwashiorkor is severe protein deficiency. However, several other factors associated with the condition involve:³

• Diets consist primarily of carbohydrates, such as maize, cassava or rice. These foods are cheaper and more accessible in poor or rural areas
• Rapidly weaning a nursing toddler to allow for a new baby to be breastfed. This means infants do not receive an adequate diet, causing nutrition deficiencies.
• A lack of antioxidants in the diet. Antioxidants prevent and reduce damage caused by oxidation to cells, thereby reducing the risk of disease.
• Exposure to aflatoxins, which are toxins from mould that grow on crops in hot and humid climates
• Recent infections, such as measles
• Disruption in childhood, for example, poverty, temporary home environments and parental death 

Symptoms

Although both conditions involve severe malnutrition, they can exhibit different signs and symptoms, such as:^2,3 

Diagnosis

Marasmus 

Marasmus can be diagnosed using the physical signs associated with the condition. The primary feature used in diagnosis includes visible wasting of subcutaneous fat and muscle, causing people to appear emaciated.

Another method used involves measuring a child or adult's weight-to-height ratio against standards. People with marasmus are likely to have a body mass index (BMI) below 16. For reference, a healthy BMI falls between 18.5-and 24.9. 

As marasmus is the deficiency of all macronutrients, blood tests are used to identify the specific vitamin, mineral and enzyme deficiencies to determine the requirements for treatment. 

Kwashiorkor

Kwashiorkor is also diagnosed by observing physical signs, notably oedema, abdominal swelling and hyperpigmentation. Weight-to-height, and height-to-age ratios, may be measured and scored against standards, to establish the severity of the condition. However, unlike in Marasmus, a child suffering from kwashiorkor will have a normal weight-to-height ratio.²

Treatment and management 

Marasmus 

Treatment for marasmus is usually in a hospital setting, under close supervision. However, those who receive treatment are at risk of developing the life-threatening refeeding syndrome, which occurs when a malnourished body receives nutrients too quickly. For this reason, marasmus is typically managed in three phases.²

Resuscitation and stabilisation 

This stage rehydrates and prevents infections to prepare the body for refeeding. It involves treatment with an intravenous isotonic solution, and keeping the patient warm, as they are at risk of hypothermia. During this time, a caloric intake of 60-80% of the age-dependent calorie requirement is delivered slowly, by continuous nasogastric feeding, to prevent hypoglycemia. This phase may last for 1 week.^2,4

Nutritional rehabilitation 

Once the patient’s electrolyte levels are corrected, and appetite starts to return, calorie intake is gradually increased up to 140% of their caloric intake. This enables growth at a rate similar to children of their age to tackle stunting. This phase generally lasts 2-6 weeks.²

Follow-up and prevention of recurrence 

Due to the risk of recurrence, following up with patients is essential. This can involve educating mothers on breastfeeding, ensuring sufficient food supplies, and uncontaminated water, and controlling infectious diseases in the community.²

Kwashiorkor

The treatment for kwashiorkor involves addressing 10 principles,  which patients are susceptible to developing:³

• Treatment/prevention of hypoglycemia - hypoglycemia may occur on introduction to calories
• Treatment/prevention of hypothermia - malnourished people often have difficulty regulating their body temperature and must be kept warm
• Treatment/prevention of dehydration - the body’s fluid and sodium levels can be restored with an isotonic solution
• Correction of electrolyte imbalance - electrolyte imbalance can be life-threatening when the patient starts refeeding.
• Treatment/prevention of infection - due to a weakened immune system, infections can be fatal and are treated with antibiotics⁵
• Correction of micronutrient deficiencies - severe vitamin and mineral deficiencies are corrected before refeeding.vital
• Cautious feeding - gradual feeding of nutrients, particularly protein is introduced under close observation
• Catch-up growth - if the patient is stabilised, calorie intake can increase up to 140%
• Providing sensory stimulation and emotional support - patients may experience apathy, thus, efforts to stimulate their neurological, intellectual and social development are vital⁵
• Follow-up after recovery - immunisations, education and counselling may be given before discharging the patient.

Complications

Marasmus 

Complications of marasmus can include:²

• Refeeding syndrome 
• Urinary tract infections (UTI)
• Slow heart rate
• Sepsis
• Hypothermia
• Gastrointestinal malabsorption
• Stunted growth and development delays

Kwashiorkor

If left untreated, the complications of kwashiorkor can be fatal. Children may also never fully recover from growth and development delays. Other complications include:³

• UTI
• Hepatomegaly
• Hypovolemia 
• Gastrointestinal tract abnormalities, such as pancreatic atrophy, glucose intolerance and bacterial overgrowth, which can lead to septicemia and death
• Impaired immune function
• Abnormalities with electrolyte levels
• Hypothermia

Prognosis

Marasmus 

Following intervention, if the child returns to an environment that aids treatment and recovery, normal health and height can be achieved in most cases.² 

Kwashiorkor

Timely intervention, and successful rehabilitation of patients with kwashiorkor, can expect to make a strong recovery. However, if left untreated, the condition can be life-threatening, including shock, coma, physical and mental disabilities and death from infection, dehydration or liver failure.³

Prevention

Both marasmus and kwashiorkor, can be prevented in the global community by:

• Education of basic nutrition to ensure that people receive sufficient protein and calorie intake. This includes promoting a diet balanced in carbohydrates, protein, fats, vitamins and minerals
• Tackling poverty
• Food security - ensuring access to nutrient-rich foods in areas of high malnutrition
• Educating about proper breastfeeding and weaning practices 
• Controlling infectious diseases
• Improving sanitation in developing countries 

Summary 

• Marasmus and kwashiorkor are conditions typically present in developing countries concerning severe undernutrition; marasmus of macronutrients, and kwashiorkor of proteins.
• Common causes include a lack of access to food from living in poverty and famine, wasting diseases and infections, and having a diet mainly consisting of carbohydrates.
• Symptoms between both conditions differ. However obvious signs of marasmus include stunted growth, severe weight loss and visible wasting of fat and muscle. Kwashiorkor symptoms may involve oedema, loss of hair and skin pigmentation, and loss of muscle but retention of fat.
• Both conditions may be diagnosed using the obvious physical signs and by comparing weight-to-height ratios to standards.
• Treatment involves the the gradual introduction of nutrients to a stabilised body, typically in stages to avoid some associated complications such as refeeding syndrome, hypoglycemia and hypothermia. 
• If treated early, patients with marasmus or kwashiorkor can expect to make a full and strong recovery