Signs, appearance and cause
Signs and symptoms of marasmus vary with the importance and duration of the energy deficit, age at onset, associated infections and associated nutritional deficiencies. Diets and deficiencies may vary considerably between different geographical regions and even within a country. The AIDS epidemic and the growing number of orphans has also significantly changed the clinical course of classic marasmus. Failure to thrive is the earliest manifestation, associated with irritability of apathy. Chronic diarrhea is the most frequent symptom and infants generally present with feeding difficulties.
A shrunken wasted appearance is the classic presentation. Stunted children are usually considered to have milder chronic form of malnutrition, but their condition can rapidly worsen with the onset of complications such as diarrhea, respiratory infection, or measles.
The most perceptible and frequent clinical feature in marasmus is the loss of muscle mass and subcutaneous fat mass. Some muscle groups, such as buttocks and upper limb muscles, are more frequently affected than others. Facial muscles are usually spared longer. Facial fat mass is the last to be lost, resulting in severe cases, in the characteristics elderly appearance of children with marasmus. Anorexia is frequent and interferes with renutrition. An irritable and whining child who cannot be comforted or separated from their mother demonstrates behaviors often observed with marasmus. Apathy is a sign of serious forms of marasmus; children are increasingly motionless and seem to “let themselves die.”
- In many low-income countries, food variety is limited and results in mineral and vitamin insufficiencies. 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.
- Associated infections of 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 countries.
This overview of marasmus is limited to reviewing marasmus from an insufficient nutritional intake as observed under impaired socioeconomic conditions, such as those present in developing countries. This condition is most frequently associated with acute conditions (eg. Gastroenteritis) or chronic conditions (eg. Tuberculosis, HIV infection).
Various extensive reviews of the pathophysiological processes resulting in marasmus exist. Unlike kwashiorkor, marasmus can be considered as an adaption to an insufficient energy intake. Marasmus results from a negative energy balance. This imbalance can result from a decreased energy intake, increased energy expenditure or both, such as that observed in acute or chronic disease. Children adapt to an energy deficit with a decrease in physical activity, lethargy, a decrease in basal energy metabolism, slowing of growth, and finally weight loss.
Pathophysiological changes associated with nutritional and energy deficits can be described as