MARASMUS AND KWASHIORKOR

MARASMUS AND KWASHIORKOR

Marasmus and kwashiorkor are two forms of protein-energy malnutrition that primarily affect children in developing countries. They have some overlapping symptoms but also differ in important ways regarding physical symptoms, causes, time frame, risk factors, diagnosis, treatment, and prevention.

Overview and Definitions

Marasmus and kwashiorkor are both considered severe forms of malnutrition. Malnutrition refers to getting too little or too many nutrients which leads to health problems. Marasmus and kwashiorkor specifically refer to not getting enough protein and calories which stunts growth and causes other issues.

Marasmus is defined as a form of malnutrition characterized by energy deficiency usually due to a severe lack of protein and calories. It presents with the classic signs of starvation including extreme weight loss and muscle wasting. The word marasmus is derived from a Greek term that roughly translates to “wasting away.”

Kwashiorkor on the other hand is defined as a malnutrition syndrome caused by severe protein deficiency, usually with adequate calorie intake. It presents with oedema (swollen fluid retention), changes in skin and hair, and a distended belly induced by liver damage. The term kwashiorkor comes from the Ga language of coastal Ghana meaning “the sickness the baby gets when the new baby comes” referring to when a mother stops breastfeeding a child because of a newborn.

Causes and Time Frame

The fundamental cause of both marasmus and kwashiorkor is not getting adequate nutrition, but the specifics regarding which nutrients are missing and for how long differ:

Marasmus develops due to total calorie restriction with inadequate protein and calorie intake often due to famine, food shortages, or inadequate breastfeeding/weaning practices over an extended timeframe - usually months to years.

Kwashiorkor develops when someone not only lacks protein but eats mostly carbohydrates, with protein making up less than 6% of total calories over the short term - usually weeks to months.

Marasmus is caused by insufficient protein and calories long-term while kwashiorkor is caused by severe protein deficiency short-term.

Physical Symptoms 

Due to the differences in underlying causes, the physical manifestations of marasmus and kwashiorkor also significantly differ:

Marasmus Symptoms

·       Severe wasting - extremely low body weight often less than 60% of normal weight for height/age

·       Muscle atrophy - loss of fat and muscle tissue giving a “bag of bones” emaciated appearance 

·       Hair thinning and discoloration

·       Loss of subcutaneous fat under skin

·       Wrinkled, loose skin due to weight loss

·       Pot belly appearance due to muscle wasting

·       Severe growth retardation is common in children

·       Overall the body essentially shuts down non-vital systems and consumes muscle and fat to survive

Kwashiorkor Symptoms

·       Edematous - swelling under skin especially on feet, face and legs due to fluid retention

·       Hypoalbuminemia - low blood protein levels

·       Skin changes - dermatitis, discolored patchy skin, peeling skin etc

·       Diarrhea is common

·       Pot belly distension from enlarged liver

·       Fatty liver induced by protein deficiency

·       Changes in hair color and texture - often red/blonde discoloration

The key physical symptom differentiators are:

1.       .      Marasmus presents with severe emaciation and “wasting away”
2.        Kwashiorkor presents with swelling, skin/hair changes, enlarged livers, diarrhea but less severe weight loss.
3.      It is in fact possible, though relatively rare, for a child have mixed presentation of marasmus and kwashiorkor known as “marasmic kwashiorkor” with overlapping symptoms of both disorders.

Risk Factors

The following risk factors contribute to both marasmus and kwashiorkor vulnerability:

·       Poverty - inability to access or afford food, more prevalent in low income countries

·       Food shortages - drought, societal disruption, refugees/war zones contribute to hunger

·       Lack of education - lack of nutritional health literacy in parents

·       Poor sanitation - chronic infections can impact nutrient absorption  

·       Being an infant/toddler age 6 months - 3 years - increased nutritional needs proportional to body weight

Some additional marasmus-specific risk factors include:

·       Breastfeeding issues - early weaning, watering down formula

·       Neglect - infants not being adequately fed by caregivers

·       Living in custodial institutions - orphanages with nutrition deficiencies

Some extra kwashiorkor-specific risk factors:

·       Abruptly switching from higher protein breast milk to lower protein grains

·       Prior malnutrition - sets the stage for protein deficiency 

·       Aflatoxin contaminated grain - poisons protein digestion enzymes

Diagnosis and Complications

Marasmus and kwashiorkor diagnosis is centered around:

1)     Anthropometric evaluation - measurements of mid upper arm circumference, skin folds and weight compared to health references account for majority of diagnosis. Children less than 60% weight or 80% height classify as having some form of protein calorie malnutrition

2)     Edema evaluation - checking for pedal/limb edema and ascites fluid accumulations symptomatic of kwashiorkor

3)     Biochemical testing - although not always available, tests like serum albumin, liver function, cholesterol can serve as proxies for protein status

4)     Clinical appearance - visual symptoms like hair discoloration, skin changes point to kwashiorkor whereas extreme emaciation suggests marasmus

If inadequate nutrition persists for long, serious complications can develop including:

·       Immunodeficiency - susceptibility to infections due to lack of proteins needed for immune cell function

·       Impaired wound healing, skin infections - lack of amino acid building blocks

·       Anemia - deficiency of iron and folate required to make red blood cells 

·       Growth stunting - inability to produce growth factors needed for height gain

·       Neurologic problems - cognition issues, apathy, sensory impairments due to neural cell damage

·       Cardiac failure - myocardium wasting, arrhythmias due to electrolyte loss

·       Ultimately death can occur if severe malnutrition goes untreated

A diagnosis of marasmus or kwashiorkor relies on physical symptoms, anthropometric data and tests to quantify protein status with death as the most severe complication if left unaddressed.

Treatment Approaches

Treatment regimens for marasmus focus on gradual caloric and protein repletion whereas kwashiorkor management centers around fixing the protein deficiency:

Marasmus Treatment

1. Initial stabilization 

Careful refeeding is crucial to stabilize metabolism without overloading damaged organs. Oral rehydration solution is provided for the first day to restore electrolyte balance. Small frequent feedings of diluted milk-based formula provide carbohydrates and some protein to restore energy levels.

2. Catch up growth phase 

Daily nutrient requirements are estimated and increased amounts of formula/food are provided to support catch up weight gain. Full-strength formula and nutritious complementary foods are fed for several weeks along with antibiotics and micronutrient supplements until target weight is reached.

Kwashiorkor Treatment

1. Protein and electrolyte correction

High protein milk-based feeds - milk powder, yogurt, cheese and eggs given for 2–4 weeks to replenish protein status. Oral rehydration solution containing electrolytes continues until edema resolves. Potassium levels require close monitoring.

2. Management of complications

Antibiotics to treat concomitant infections contributing to malnutrition. Diuretics and plasma expanders manage edema. Multivitamins supply micronutrients. Blood transfusions may be needed for severe anemia.

3. Dietary rehabilitation 

Like marasmus, child continues on nutrient rich diet once stabilized to facilitate weight gain.

In both cases, psychosocial stimulation to reverse apathy and enhance feeding is a key aspect management. Hospitalization may be required for severely malnourished children whereas mildly affected children can be managed at community health centers.

Prevention Strategies 

Prevention strategies for marasmus and kwashiorkor can be divided into individually-focused and population-based approaches:

For vulnerable individual children:

·       Improving sanitation to prevent infections

·       Supporting breastfeeding and appropriate complementary foods

·       Routine monitoring of growth indicators 

For wider societal approaches:

·       Poverty alleviation efforts - increasing ability to purchase foods

·       Developing resilient food systems and effective storage to reduce national food shortages

·       Nutritional supplementation programs and social safety nets 

·       Promoting nutritional health literacy especially amongst parents and caregivers

·       Public health campaigns on radio and media promoting healthy diets

While kwashiorkor and marasmus mortality rates have fallen over 60% since 1990, more progress is still required to curb malnutrition including both individual and population-based prevention initiatives.

Marasmus vs Kwashiorkor Summary Table

Here is a summary table highlighting some of the key parameters that differentiate marasmus vs kwashiorkor:

PARAMETER	MARASMUS	KWASHIORKOR
Primary cause	Protein + calorie restriction over months/years	Very low protein intake with more carbs over weeks
Physical symptoms	Extreme wasting away and muscle loss	Swelling, skin/hair changes but less wasting
Biochemistry	Low protein, cholesterol + vitamins	Low albumin, protein enzymes
Key risk factors	Weaning to inferior foods	Switching from breast milk to grains
Treatment basis	Gradually increase calories + protein	Rapidly replete protein
Prevention priorities	Support breastfeeding + reduce national food deficits	Improve sanitation, dietary diversity

 

While both are severe forms of malnutrition with some overlap in symptoms and outcomes, marasmus and kwashiorkor spring from slightly different immediate causes and manifestations which guides customized diagnosis and management.

Global Health Impacts

In reviewing marasmus and kwashiorkor, it is important to also understand the sizable global health burden posed by child malnutrition which claims over 3 million young lives each year:

Prevalence and Scope

·       Over 200 million children under age 5 in low income countries have stunted growth due to chronic malnutrition

·       20 million suffer from severe acute malnutrition like marasmus or kwashiorkor 

·       Half of global child deaths have undernutrition as an underlying factor.

Regional Differences

·       70% of malnourished children live in Asia given the continent’s large child population 

·       However, Africa has the highest per capita malnutrition prevalence at 21% due to food insecurity.

Economic Consequences

Malnutrition drags down national economies by:

·       Reducing adult wages by 5-10% due to irreversible childhood stunting

·       Loss of 2-3% GDP as children can’t achieve their economic potential 

The economic loss from child malnutrition is estimated at $125 billion annually given its impacts on health systems, lost productivity and human capital.

Child malnutrition remains a sizable global health challenge especially in lower income countries with undernutrition underlying half of pediatric deaths. International initiatives to advance nutrition globally like Scaling Up Nutrition thus represent top priorities for global development and health. But a detailed review of global strategies extends beyond this discussion on distinguishing kwashiorkor from marasmus.

Key Takeaways

Here are some key summary takeaways regarding these two forms of lethal childhood malnutrition: 

·       Both marasmus and kwashiorkor result from inadequate protein and calories but have differences in exact cause and clinical symptoms

·       Marasmus arises due to an extended lack of protein + calories causing wasting whereas kwashiorkor is induced by shorter term severe lack of protein with some carbs still present 

·       Marasmus treatment involves gradual feeding to stabilize organ function whereas kwashiorkor management prioritizes rapid protein replenishment

·       Child malnutrition including its severe forms continues as a top global health priority especially in lower-income countries