MARASMUSBackgroundThe term marasmus is usually accepted as meaning a chronic state of malnutrition of a severe grade and is associated in our minds with a definite clinical picture. If we are to obtain success in the treatment and, what is equally important, in the prophylaxis of this condition, it is necessary to make a critical analysis of its causes and of its evolution.While our attention will be centred on the severest types, we must retain the conception ofcases ranging in severity from those who simply show an insufficient gain or stationary weight with few systemic changes, to the most extreme form which is merely the end-result of repeated nutritional or constitutional disturbances.Marasmus is one of the 3 forms of serious protein-energy malnutrition (PEM). The other 2 forms are kwashiorkor (KW) and marasmic KW. These forms of serious PEM represent a group of pathologic conditions associated with a nutritional and energy deficit occurring mainly in young children from developing countries at the time of weaning. Marasmus is a condition primarily caused by a deficiency in calories and energy, whereas kwashiorkor indicates an associated protein deficiency, resulting in an edematous appearance. Marasmic kwashiorkor indicates that, in practice, separating these entities conclusively is difficult; this term indicates a condition that has features of both.(1,2)Marasmus is a serious worldwide problem that involves more than 50 million children younger than 5 years. According to the World Health Organization (WHO), 49% of the 10.4 million deaths occurring in children younger than 5 years in developing countries are associated with PEM.Although PEM occurs more frequently in low-income countries, numerous children from higher-income countries are also affected, including children from large urban areas and of low socioeconomic status, children with chronic disease, and children who are institutionalized. Recently, studies of hospitalized children from developed countries have demonstrated an increased risk for PEM. Risk factors include a primary diagnosis of mental retardation, cystic fibrosis, malignancy, cardiovascular disease, end stage renal disease, oncologic disease, genetic disease, neurological disease, multiple diagnoses, PICU admission, or prolonged hospitalization.(4) In these conditions, the challenging nutritional management is often overlooked and underestimated, resulting in an impairment of the chances for recovery and the worsening of an already precarious neurodevelopmental situation.This article focuses mainly on marasmus that results from an insufficient nutritional intake as observed under impaired socioeconomic conditions, such as those present in developing countries. Marasmus is most frequently associated with acute infections (eg, gastroenteritis, respiratory illnesses, measles), chronic illnesses (eg, tuberculosis, HIV infection) or drastic natural or man made conditions (eg, floods, droughts, civil war).

CausesA careful study of the history of these infants is well worth while, for it will usually give some clear indication of the origin of this wasted state, and in practice we may regard the causative factors as falling into four groups (3):1. Improper feeding.2. InfectionAssociated infections often trigger, aggravate, or combine with marasmus. However, evidence exists that this association may have been overestimated. For example, in rural Senegal, the growth of children with or without infections, such as pertussis and measles, was similar. In contrast, the importance of diarrhea in triggering malnutrition through anorexia and weight loss has been well established. Infectious diseases more frequently associated with energy-protein malnutrition are gastroenteritis, respiratory infections, measles, and pertussis. HIV also plays an increasingly significant role in some countries3. Congenital weakness of disease-e.g., prematurity, congenital heart disease.4. Socioeconomic factors Frequently, malnutrition appears during weaning, especially if weaning is suboptimal, as can occur with a low-variety diet, or if weaning foods are introduced only in children older than 8-10 months. The WHO recommends exclusive breastfeeding until age 6 months; then, the introduction of various additional foods is recommended. The socioeconomic environment is often critical in the choice of the weaning food used. For example, in northern Senegal, available foods are often limited to grains, vegetables, and a small amount of fish. Milk and meat are rare. In this region, malnutrition and diarrhea are frequent. In contrast, in the nearby Sahelien pastures where milk and meat are the main foods, diarrhea is less frequent, and malnutrition is rare.5. NutritionIn many low-income countries, food variety is limited and results in mineral and vitamin insufficiencies. In cases of anorexia, which are generally associated with infection, the total energy intake becomes insufficient. Therefore, any nutrient deficiency can lead to marasmus because appropriate growth can only be ensured by a balanced diet. Therefore, marasmus can be described as multiple-deficiency malnutrition.

Classification The World Health Organization (WHO) defines malnutrition as the cellular imbalance between the supply of nutrients and energy and the bodys demand for them to ensure growth, maintenance, and specific functions. Malnutrition generally implies undernutrition and refers to all deviations from adequate and optimal nutritional status in infants, children and in adults. In children, undernutrition manifests as underweight and stunting (short stature), while severely undernourished children present with the symptoms and signs that characterize conditions known as kwashiorkor, marasmus or marasmic-kwashiorkor. (1,2)

Classification of Malnutrion Classification70-90%Grading

Gomez Weight below %median WFAMild (grade 1)Moderate (grade 2)Severe (grade 3)75%90% WFA60%74% WFA