Marasmus

Form of severe acute malnutrition from overall calorie deficiency, leading to extreme wasting (loss of muscle and fat) without edema.

• Affects millions of children and a major cause of under-5 mortality (~10%). Understanding marasmus vs kwashiorkor is high-yield for exams and critical in global child health.

• Typically in infants or young children from famine, severe poverty, or chronic illness with inadequate feeding. Presents with emaciation: severe weight loss, loss of subcutaneous fat, and muscle wasting; ribs become prominent and limbs thin.
• Facial appearance is striking: "old man" facies (sunken cheeks due to lost fat) and a head that appears relatively large for the body. No edema is present (distinguishes from kwashiorkor). Skin may be dry, hair sparse, but without the flaky paint dermatosis or flag sign hair seen in kwashiorkor.
• Behavior: often irritable but with a voracious appetite (will eagerly eat if offered food), unlike kwashiorkor where appetite is poor. Coexistent micronutrient deficiencies (vitamin A, iron, etc.) and stunted growth are common, and the child is highly susceptible to infections (due to weakened immunity).

1. Suspect marasmus in any child with severe wasting (weight-for-height < –3 SD or <70% median, or MUAC ≤ 115 mm) without edema. Differentiate from kwashiorkor by absence of edema and preserved appetite; a mixed form (marasmic kwashiorkor) has both wasting and edema.
2. Assess for complications: check blood glucose (for hypoglycemia), body temperature (hypothermia), and signs of infection (malnourished children may have severe infection without obvious fever). Evaluate electrolytes (often total body deficits of K, Mg, etc.) and hemoglobin (anemia is common).
3. Follow WHO criteria to classify severity and manage accordingly. If the child is alert, has appetite, and no acute medical issues, outpatient care with therapeutic feeding (e.g. RUTF – ready-to-use therapeutic food) is possible. If any red flags (e.g. lethargy, edema, complications), proceed with inpatient management using the WHO 10-step approach.

1. Initial stabilization (inpatient for complicated cases): Prevent/treat hypoglycemia (frequent feeding, IV glucose if needed) and hypothermia (keep child warm). Treat dehydration cautiously (use low-sodium rehydration like ReSoMal; malnourished children are prone to fluid overload). Assume and treat infections empirically (broad-spectrum antibiotics) since immune response is blunted. Correct electrolyte abnormalities (especially potassium and magnesium, which are usually depleted) but avoid aggressive fluids.
2. Nutritional support: Begin feeding slowly with a low-calorie, low-protein therapeutic milk (e.g. F-75 formula ~75 kcal/100 mL) during the first 2–7 days to stabilize metabolism and reduce refeeding risk. After the child stabilizes and appetite returns, transition to high-calorie feeds like F-100 formula (~100 kcal/100 mL) or ready-to-use therapeutic food for catch-up growth. Provide micronutrients (vitamins and minerals, including vitamin A, etc., but delay iron supplementation until recovery phase).
3. Rehabilitation and follow-up: As weight gain progresses, increase protein and calorie intake (catch-up feeding) and engage the child in play to foster development. Monitor for refeeding syndrome (sudden hypophosphatemia, edema, or heart failure when feeds are advanced). Once stable and feeding well, continue nutritional rehab for several weeks until weight-for-height is > –2 SD, then transition to prevention (nutrition education and follow-up to ensure continued growth).

• Mnemonic: Marasmus = Muscle wasting (calorie deficiency causes loss of muscle/fat, no edema); Kwashiorkor = edema (protein deficiency → low albumin → edema and fatty liver). Remember: marasmus kids are hungry, kwashiorkor kids are apathetic.
• Name origin: *Marasmus* is Greek for "wasting away." Kwashiorkor comes from Ghana (Ga language) meaning "the sickness the older child gets when the new baby is born" (reflecting weaning to a protein-poor, carbohydrate diet).

• Lethargy, hypoglycemia, or hypothermia in a malnourished child – indicates imminent risk of death (sign of shock or severe infection). Requires urgent IV glucose, warming, and treatment of underlying causes.
• Refeeding syndrome: Watch for sudden hypophosphatemia (weakness, seizures) and fluid overload/heart failure when feeding is restarted. Prevent by starting feeds slowly and supplementing electrolytes (phosphate, K, Mg) and thiamine before refeeding.
• Bilateral pitting edema in a malnourished child – signifies kwashiorkor or mixed SAM, which has higher mortality and requires inpatient care. Also, any signs of severe infection (pneumonia, sepsis) or bleeding (e.g. vitamin K deficiency) in a marasmic child necessitate urgent treatment.

1. Child with suspected severe malnutrition → Measure weight, height/length, and MUAC; check for edema. If weight-for-height < –3 SD or MUAC <115 mm, or edema present → diagnose SAM (severe acute malnutrition).
2. Classify as uncomplicated vs. complicated: perform an appetite test and clinical exam. If child is alert, drinking/eating well and has no edema or acute medical issues → outpatient management with therapeutic foods. If edema or any complications (poor appetite, vomiting, lethargy, etc.) → treat as complicated SAM (hospitalize for stabilization).
3. In inpatient stabilization: follow WHO's 10 steps – treat/prevent hypoglycemia and hypothermia; treat dehydration carefully; correct electrolytes; treat infections; give micronutrients; start cautious feeding (F-75). Monitor vital signs, glucose, and electrolytes frequently.
4. After 2–7 days (stabilization phase), once the child improves, begin rehabilitation phase: increase feeding to promote weight gain (switch to F-100 or RUTF), provide sensory stimulation (play, affection), and continue treating any illnesses. Educate caregivers on proper nutrition.
5. Discharge when clinical criteria are met (resolved edema, good appetite, appropriate weight gain). Arrange follow-up to ensure continued catch-up growth and to address underlying causes (e.g., food security, parental education) to prevent recurrence.

• An 8‑month‑old infant in a refugee camp is severely emaciated with ribs visible and loose skin folds, but is alert and feeds eagerly when given a bottle. There is no edema. → Marasmus (caloric malnutrition leading to wasting).
• A malnourished 2‑year‑old with swollen legs, ascites, patchy skin depigmentation, and apathetic affect (poor appetite) would instead suggest kwashiorkor (edematous protein malnutrition) rather than marasmus.