Marasmus - Causes, Symptoms, Diagnosis, and Treatment

Introduction

Marasmus is a type of malnutrition that occurs when the intake of nutrients is lower than what the body requires. This leads to muscle wasting. Malnutrition occurs when the diet does not contain the vitamins and nutrients the body needs. To maintain the typical physiological body requirements, it is imperative that the body receives adequate amounts of macro and micronutrients. Insufficient intake is called undernutrition, and excessive intake is called overnutrition.

What Are the Causes of Marasmus?

Marasmus is due to nutrient deficiency due to incomplete nourishment. The factors that can lead to it are:

• Poverty and scarcity of food. Marasmus is more frequently found in developing countries that have high poverty and, thereby, lack food. These areas may be subjected to famine and natural disasters leading to a decreased food supply. The children in these areas are more prone to developing marasmus.

• Infections lead to diarrhea, which prevents food from being properly absorbed by the body.

• Wasting disorders such as AIDS.

• Eating disorders such as anorexia.

• Poor diet: If the diet lacks essential nutrients that are necessary for the growth of a child, they may develop marasmus.

In children, it may be due to the following:

1. Inadequate breastfeeding or early weaning. Mother’s milk is rich in nutrients that the growing infant needs. If the mother is malnourished or the infants do not receive enough milk, it can result in marasmus.

2. Child neglect in underdeveloped countries, if there is not enough gap between children, the mother might not be able to tend to her older children properly; this results in insufficient feeding and incomplete nutrition of the children.

In adults, it may be due to the following:

1. Neglect of elderly patients.

2. Dementia.

How Does it Occur?

In Children:

• There may be multiple underlying socio-cultural causes that can lead to marasmus. In underdeveloped countries, civil instability, wars, and natural disasters can lead to poverty in low-income households. This directly affects children; Malabsorption may be due to the procurement ability of the family.

• The lack of education and decreased childcare may result in incomplete care from mothers, unhygienic surroundings, and higher risks of infections. Infections can lead to diarrhea which results in improper absorption of food. Mothers with a primary level of education have been shown to have lower rates of infant malnutrition.

• Children with infections such as HIV/AIDS have poor nutrition intake and uptake. Affected mothers have lesser nutrient reserves than unaffected mothers.

In Adults:

• In some cases, it affects adults. There is a reduced rate of intake of food with age. This is known as anorexia of aging.

• It can be due to reduced satisfaction with food that may arise due to depletion in olfactory receptors and taste sensitivity.

• Reduced gastric emptying, leading to the sensation of being full.

• Marasmus commonly causes pancreatic insufficiency or digestive disorders and may also cause malnutrition.

What Are the Symptoms?

The clinical features depend significantly on the severity and duration of a calorie deficiency, the age of the patient, and vitamin and mineral deficiencies- they contribute to different presentations.

Symptoms include:

• Marasmus patients are usually underweight due to excessive weight loss.

• Dry skin and eyes.

• Stunted growth.

• Brittle hair.

• Reduced immunity.

• Lactose intolerance and stomach infection.

• Respiratory infections.

• Vitamin D and calcium deficiency lead to rickets.

• Iron deficiency causes anemia.

• Low blood pressure.

• Low body temperature.

• Impaired brain function.

• Reduced heart rate.

• Loss of muscle mass or wasting away.

• Electrolyte imbalance.

• Children with marasmus have low energy and enthusiasm; they appear to be tired and bored. They may also be irritable, short-tempered, and seem uninterested. This is because improper food can affect not only the body but also the mind.

What Are the Systemic Complications?

Susceptibility to Infection:

Prolonged periods of calorie deprivation may lead to immunodeficiency, which may lead to infections. Urinary tract infections and gastrointestinal and respiratory tract infections are common. The patients may also show an impaired response to vaccines. Cellular immune deficiency may be due to the wasting of thymus glands, tonsils, and lymph nodes. There is also T Cell and neutrophil dysfunction.

Total Body Water:

Body water is increased compared to body weight. It is observed that the more the degree of wasting or weight loss, the more the total body water.

Oxidative Stress:

Reduced intake of antioxidants such as vitamin E can cause oxidative stress.

Electrolyte Changes:

The potassium levels of the body decrease by 10% to 33%. There is also a reduction in minerals such as sodium, calcium, and phosphorus. Calcium deficiency leads to rickets.

Gastrointestinal System:

Wasting away of the gastrointestinal tract can lead to decreased absorption through gastric mucosa, reduced gastric acid secretion, and may lead to bacterial overgrowth.

Central Nervous System:

Developmental impairment, altered brain function, and behavioral changes may occur with severe cases of malnutrition.

Endocrine Function:

Wasting of the pituitary and adrenal gland can occur. This may lead to a rise in cortisol levels in the blood. Insulin secretion may be impaired, which can return to normal after three to six weeks of treatment.

Cardiovascular System:

The contractile ability of cardiac muscles may be affected, leading to arrhythmias reduction in cardiac output.

Refeeding Syndrome:

Refeeding syndrome may arise if there is uncoordinated treatment. In children suffering from marasmus, there are a decrease in insulin secretion and an increase in glucagon secretion. Phosphate, magnesium, and potassium may shift from cells to extracellular spaces in an attempt to maintain serum levels of electrolytes. As a result, in the initial stages of refeeding, the amount of glucose increases while insulin secretion becomes faulty.

How To Diagnose Marasmus?

• Diagnosis is on the basis of a scoring system of body measurements.

• Upper arm circumference and height-to-weight ratio help in rating the severity of undernutrition. Height to-age ratio helps define growth delays.

• It can also be done using blood tests to identify the secondary implications of marasmus. This includes specific vitamin, mineral, electrolyte, and enzyme deficiencies. This will also help in refeeding. A complete blood count helps to identify the presence of any infections.

How Is It Treated?

Marasmus results in death due to infection, electrolyte imbalance, heart failure, and dehydration. There is also the possibility of the onset of refeeding syndrome. Therefore careful steps have to be taken to ensure positive results. The management can be done in three phases:

Resuscitation and Stabilization:

• Infection and dehydration are the main causes of death; the infection should be prevented from progressing into sepsis. This phase lasts for about one week.

• Dehydration is treated by the intravenous supply of isotonic solution. The child should be in a warm room as they are susceptible to hypothermia.

• If suspected, sepsis should be treated with antibiotics according to the blood culture results.

• To prevent complications from refeeding syndrome, the nutrition should be delivered slowly and should be monitored. The caloric intake should be between 60-80% of the calorie requirement for the age. Hypoglycemia may be avoided by continuous nasogastric feeding or small meals at nighttime.

• Patients should be monitored to prevent refeeding syndrome as it may lead to arrhythmia, weakness, confusion, or sudden death. Therefore electrolyte abnormalities should be prevented from developing. Thiamine and oral phosphate must be given to prevent a decline in phosphate levels in the blood, which may occur in refeeding.

• Fluid overload may cause edema and heart failure.

Nutritional Rehabilitation:

Once the emergency phase is overcome, appetite and electrolyte balance will be restored. Nutritional rehabilitation can be started at this point, which includes:

• Increase in caloric intake: It may be necessary to have a caloric intake of 120 % to 140 % for the growth to be maintained at a similar rate to that of their peers.

• Vaccination.

• Increased motor activity.

This phase lasts about two to six weeks.

Follow-up and Prevention of Recurrence:

Due to the possibility of recurrence, proper follow-up is required. Proper awareness and education are to be provided to mothers and caregivers regarding breastfeeding and supplemental feeding. The supply of food and drinking water may help to reduce the incidence of marasmus.

What Is the Difference Between Kwashiorkor and Marasmus?

• Both diseases are severe protein-energy malnutrition.

• Marasmus is the deficiency of all macronutrients, while kwashiorkor is the protein deficiency.

• Kwashiorkor may arise even if a person has access to carbohydrates but lacks protein in the diet.

• Kwashiorkor is known to cause edema, while marasmus has a shriveled appearance.

• Marasmus has a better prognosis than kwashiorkor.

Conclusion:

In underdeveloped countries, the deprivation of basic amenities and access to provide sufficient dietary nutrients has led to malnutrition disorders such as marasmus. Marasmus may be challenging to diagnose, but once diagnosed can be treated if the proper precautions are taken. Awareness and education are crucial in preventing it from occurring. Adequate food and water supply can also pave the way to eradicating such malnourishment.