Introduction

Although severe child food poverty is relatively rare in the developed world, UNICEF estimates that 1 in 4 children worldwide struggle to feed on more than one class of food in a day. These children are found in low-income populations.¹ Worse still, these approximately 181 million children are below 5 years of age. Due to this poor access to nutritious and diverse diets in early childhood, such children run the risk of severe malnutrition, thus developing life-threatening conditions such as kwashiorkor and marasmus.

Marasmus is one of the most common severe dietary malnutrition or undernutrition resulting from a total calorie deficiency.² This means that, unlike kwashiorkor, it is not restricted to a deficiency in protein but encompasses all calorie-providing food classes.^1,2 

According to UNICEF, rising societal inequities, civil unrest, climate crises, rising food prices, surplus unwholesome food, harmful unhealthy food marketing, and poor child feeding practices are among the leading causes of child food poverty and marasmus.¹

What is marasmus?

Marasmus, just like kwashiorkor, is an acute state of protein-energy malnutrition that occurs due to significantly low consumption of nutritious food.¹ This is called severe acute malnutrition (SAM); the child typically presents with an inadequate weight compared to height.² With time, this food deprivation culminates in chronic malnutrition. Here, the child looks stunted. The height or length of the child is significantly below the average for age.

It generally leads to an overt loss of muscle and body fat because the body tries to compensate for the insufficiency in intake by depleting body stores.² The child is typically wasted, short, underweight, and may develop life-threatening complications such as low blood sugar, dehydration, recurrent infections, and even life-altering conditions like permanently poor mental and physical development.

Marasmus generally has better outcomes compared to Kwashiorkor. However, it still has relatively high mortality because of the complications that often develop.² It is also important to note that marasmus may also develop in adults, especially in the vulnerable elderly population.

Epidemiology

Marasmus is a public health problem in the developing world, especially in Southern Asia and Sub-Saharan Africa.^1,2 This is because while there is currently an average of 852 million malnourished children, UNICEF reports that over 815 million of them reside in low-income countries.¹ The 18 million marasmic children of the lot have marasmus with the majority of them living in Asia.² In developed countries such as the US, marasmus prevalence is less than 5%. However, t 5% to 10% aged in nursing homes and 50% aged  by discharge end up with marasmus.

Malnutrition levels are usually worse in the preharvest rainy season due to food scarcity and the burden of infectious diseases.² Alsomost marasmic children come from poor households or families where the mother has insufficient education.

Marasmus affects boys and girls relatively equally, but because of cultural differences in dietary practices, women and girls are disadvantaged and at high risk.²

Symptoms of marasmus

It varies significantly with

• The duration and severity of the calorie restriction
• Age
• Whether or not the marasmus is associated with vitamin and mineral deficiencies

Physical symptoms

• In infants and children less than five, it generally manifests as a failure to thrive with features including severe weight loss and inability to gain weight and features of dehydration (such as sunken fontanelles), usually following child weaning.
• Wasted and shrunken appearance from the reduced amount of fat under the skin, including the classic old man appearance resulting from a loss of fat in the face.
• Chronic diarrhoea and decreased bowel movement
• Growth retardation (stunting)
• Generalised weakness (lethargy)
• Dry skin and hair, with possible hair discolouration

Behavioural and cognitive symptoms

• Irritability and apathy
• Delayed motor skills and cognitive development in children

Other symptoms

Frequently, in addition to the deficiency in carbohydrates and protein, marasmic patients may also present with micronutrient deficiencies (vitamin and mineral deficiencies). Examples of such are as follows:

• Symptoms of anaemia (from iron deficiency, etc.) are increased weakness, pale skin, shortness of breath, dizziness, cold hands and feet, brittle nails, and tongue soreness or swelling.
• Symptoms of rickets (vitamin D and calcium deficiency) are delayed growth, bone pains, bowed legs, thickened wrists and ankles, tooth problems, softer skull bones, and spinal, leg and pelvic deformities.

Signs of marasmus

Physical findings/anthropometric findings

• A chronically ill-looking and wasted child with weakness and features of distress depending on the extent of severity.
• The child’s weight-to-age ratio will be less than 60% of the ideal.
• In long-standing cases, stunting might result in weight to their height ratio being within the normal range. Cardiovascular Signs
• Low blood pressure, low body temperature, and low pulse rate

Signs related to micronutrient deficiencies

• Dry eyes and the development of grey patches on the whites of the eyes known as Bitot spots show Vitamin A deficiency
• Iron deficiency is visible in spoon-shaped nails, koilonychia
• Features of calcium and Vitamin D deficiencies occur as bony deformities and rickets

Diagnosis

Marasmus is diagnosed through careful corroboration of a detailed history obtained from the child’s caregiver with examination and laboratory findings. Often,  history and physical evaluation is sufficient. Laboratory tests help in detecting other associated findings in marasmus. The doctor and other medical team members usually perform this in the primary care or hospital setting.

Clinical evaluation

• Assessment of growth parameters compared to standard growth charts known as anthropometry.² While this is ideal, it is often difficult to rely upon in Low-Income Countries. The measurements include length/height, weight, and mid-upper-arm circumference (MUAC)
• Physical examination findings are as above. Look for pitting leg swelling to rule out kwashiorkor³

Marasmus is suspected when the mid-upper-arm circumference is less than 115mm.² Another way to diagnose is using a Z score, which describes how far a particular number is from the average (mean). In the case of Marasmus, if the Z score is higher than three steps (over 3 standard deviations).

Laboratory tests

• Blood tests to assess nutritional deficiencies such as protein, sugar, iron, folic acid, and Vitamin B12
• Kidney and liver function tests
• Microscopic blood screening for malaria, blood cell count
• Stool and urine screening for harmful microorganisms
• Possible tests for immune function are HIV test

Additional diagnostic tools

• Family and social history to identify potential environmental or socioeconomic factors

Complications of marasmus

Immediate complications

• Susceptibility to infections due to weakened immune system
• Heart problems
• Difficulty in keeping warm
• Severe dehydration and electrolyte imbalances

Long-term health issues

• Permanent physical and mental development issues
• Increased risk of chronic diseases in later life due to early malnutrition

Treatment and management

The treatment of marasmus is lengthy and complex and requires the expertise of a variety of medical personnel, doctors, nurses, pharmacists, nutritionists, and other allied healthcare professionals.²

Immediate interventions

• Stabilisation of life-threatening medical issues like dehydration and severe infections at the medical emergency or nutrition clinic (e.g., hydration, infection control).² This treatment includes re-warming the child, reversing dehydration with fluids, slowly introducing nutritious foods, and treating infections
• Nutritional rehabilitation: calorie and nutrient repletion lasts  2 to 6 weeks.² In this phase, mothers are encouraged to bond with their children to help reverse any delays or reversal of child development

Follow-up and monitoring

• Regular nutritional assessment and adjustment to avoid relapse
• Education and support for families and caregivers on breastfeeding and supplemental feeding

Preventive strategies

• Public health measures to prevent malnutrition are fortification and supplementation, as well as the provision of uncontaminated drinking water
• Public health education on nutrition and resources available for at-risk populations

Summary

Marasmus is severe undernutrition characterised by significant weight loss and muscle wasting, primarily resulting from a total and prolonged deficiency in calorie intake. The common symptoms are an emaciated appearance with wrinkled, loose skin on the thighs and buttocks and stunted growth in children. Signs include irritability and lethargy. Nutritional deficiencies, infections, and dehydration complicate it further. Contact the nearest health facility for prompt treatment to prevent further deterioration. In addition, governments and citizens must continue to implement strategies to reduce severe child food poverty to the barest minimum.