View source for Marasmus

{{Distinguish|Marasmius}}
{{For|the fictional wizard villain "Merasmus"|Team Fortress 2#Non-playable characters}}
{{Use dmy dates|date=February 2025}}
{{Infobox medical condition (new)
| name          = Marasmus
| pronounce     = 
| image         = Starved child.jpg
| caption       = Photo from 1972 of an [[emaciated]] child in India with marasmus
| field         = [[Critical care medicine]]
| symptoms      = 
| complications = 
| duration      = 
| types         = 
| causes        = [[Starvation]], [[malnutrition]], [[cachexia]]
| risks         = 
| diagnosis     = 
| differential  = 
| prevention    = 
| treatment     = 
| medication    = 
| prognosis     = 
| frequency     = 
| deaths        = 
| alt           = 
}}

'''Marasmus''' is a form of severe [[malnutrition]] characterized by [[Protein–energy malnutrition|energy deficiency]]. It can be distinguished from [[kwashiorkor]] in that kwashiorkor is [[protein deficiency]] with adequate energy intake whereas marasmus has inadequate energy intake in all forms, including protein. It can occur in anyone with severe malnutrition but usually occurs in children. Body weight is reduced to less than 62% of the normal (expected) body weight for the age.<ref>Appleton & Vanbergen, Metabolism and Nutrition, Medicine Crash Course 4th ed. Moseby (London: 2013) p.130</ref> Marasmus occurrence increases before age 1, whereas kwashiorkor occurrence increases after 18 months. This clear-cut separation of marasmus and kwashiorkor is however not always clinically evident as kwashiorkor is often seen in a context of insufficient caloric intake, and mixed clinical pictures, called marasmic kwashiorkor, are possible.  Protein wasting in kwashiorkor generally leads to [[edema]] and [[ascites]], while muscular wasting and loss of [[Subcutaneous tissue|subcutaneous fat]] are the main clinical signs of marasmus, which makes the ribs and joints protrude.<ref>{{Cite journal|last1=Müller|first1=Olaf|last2=Krawinkel|first2=Michael|date=2 August 2005|title=Malnutrition and health in developing countries|journal=CMAJ: Canadian Medical Association Journal|volume=173|issue=3|pages=279–286|doi=10.1503/cmaj.050342|issn=0820-3946|pmc=1180662|pmid=16076825}}</ref>

The prognosis is better than it is for kwashiorkor.<ref name="pmid16762938">{{cite journal |vauthors=Badaloo AV, Forrester T, Reid M, Jahoor F |title=Lipid kinetic differences between children with kwashiorkor and those with marasmus |journal=Am. J. Clin. Nutr. |volume=83 |issue=6 |pages=1283–8 |date=June 2006 |pmid=16762938 |doi= 10.1093/ajcn/83.6.1283|doi-access=free }}</ref> Marasmus is the form of malnutrition most highly associated with [[HIV]], developing in the last stages of pediatric [[HIV/AIDS|AIDS]], and the prognosis for children with co-morbid marasmus and HIV is very poor.<ref>{{Cite journal |last1=Prazuck |first1=Thierry |last2=Tall |first2=François |last3=Macro |first3=Boubacar |last4=Rochereau |first4=Anne |last5=Traore |first5=Antoinette |last6=Sanou |first6=Théophille |last7=Malkin |first7=Jean-Elie |last8=Apaire-Marchais |first8=Véronique |last9=Masson |first9=Damienne |last10=Dublanchet |first10=Alain |last11=Lafaix |first11=Christian |date=January 1993 |title=HIV infection and severe malnutrition |journal=AIDS |volume=7 |issue=1 |pages=103–108 |doi=10.1097/00002030-199301000-00016 |s2cid=12330805 |issn=0269-9370}}</ref>

The word "marasmus" comes from the Greek μαρασμός ''marasmos'' ("withering").

==Signs and symptoms==
Marasmus is commonly represented by a shrunken, wasted appearance, loss of muscle mass, and subcutaneous fat mass in adult survivors, due to a deficiency in macronutrients and caloric intake (specifically protein) that affect development.<ref>{{cite web|last1=Rabinowitz|first1=Simon|title=MD, PhD, FAAP|url=http://emedicine.medscape.com/article/984496-clinical#a0217|website=Emedicine Medscape|publisher=Medscape|access-date=29 January 2015|page=28}}</ref><ref>{{cite journal |last1=Francis-Emmanuel |first1=Patrice |last2=Thompson |first2=Debbie |last3=Barnett |first3=Alan |last4=Osmond |first4=Clive |last5=Byrne |first5=Christopher |last6=Hanson |first6=Mark |last7=Gluckman |first7=Peter |last8=Forrester |first8=Terrance |last9=Micheal |first9=Boyne |title=Glucose Metabolism in Adult Survivors of Severe Acute Malnutrition |journal=The Journal of Clinical Endocrinology & Metabolism |date=1 June 2014 |volume=99 |issue=6 |pages=2233–2240 |doi=10.1210/jc.2013-3511 |pmid=24517147 }}</ref> Other long term effects of marasmus are the increased risks for [[Pancreatic beta cell function|pancreatic beta-cell]] dysfunction which leads to glucose intolerance and type 2 diabetes.<ref>{{cite journal |last1=Grey |first1=Kelsey |last2=Gonzales |first2=Gerard |last3=Abera |first3=Mubarek |last4=Lelijveld |first4=Natasha |last5=Thompson |first5=Debbie |last6=Berhane |first6=Melkamu |last7=Abdissa |first7=Alemseged |last8=Girma |first8=Tsinuel |title=Severe malnutrition or famine exposure in childhood and cardiometabolic non-communicable disease later in life: a systematic review |journal=BMJ Global Health |date=10 March 2021 |volume=6 |article-number=e003161 |doi=10.1136/bmjgh-2020-003161 |pmid=33692144 |pmc=7949429 }}</ref> This may lead to reduced muscle mass, and increased visceral fat. Moreover, there are metabolic implications including reduced insulin sensitivity and impaired glucose metabolism. There is also an increased risk of other [[Non-communicable disease|NCDs]] (Non-communicable diseases) as well as CVRFs (Cardiovascular risk factors). Not only are the survivors of marasmus impacted, but their offspring as well. There is an association with survivors and their offspring having a low birth weight.<ref>{{cite web |last1=Titi-Lartley |first1=Owuraku |last2=Gupta |first2=Vikas |title=Marasmus |url=https://www.ncbi.nlm.nih.gov |website=National Library of Medicine |access-date=24 July 2023}}</ref> There are also long term effects related to [[gene methylation]]. Marasmus adult survivors may have changes in gene expression regarding immunity, growth, and glucose metabolism.<ref>{{cite journal |last1=Sheppard |first1=Allan |last2=Ngo |first2=Sherry |last3=Li |first3=Xiaoling |last4=Boyne |first4=Micheal |last5=Thompson |first5=Debbie |last6=Pleasants |first6=Anthony |last7=Gluckman |first7=Peter |last8=Forrester |first8=Terrance |title=Molecular Evidence for Differential Long-term Outcomes of Early Life Severe Acute Malnutrition |journal=eBioMedicine |date=24 April 2017 |volume=18 |pages=274–280 |doi=10.1016/j.ebiom.2017.03.001|pmid=28330812 |pmc=5405153 }}</ref>

==Diagnosis==
The first steps in the diagnosis of marasmus are through physical examination and anthropometric calculations.<ref>{{cite web |url=https://my.clevelandclinic.org/health/diseases/23296-marasmus |title=Marasmus |website=Clevland Clinic |access-date=8 April 2024}}</ref> Some of the features that are diagnosable in a physical exam are severe wasting and stunting, appearing abnormally thin. Wasting is calculated by measuring weight for height. If the child is 2 standard deviations from the WHO standard, they are considered wasted. Stunting is calculated the same way, however, it is based on height for age ratios. Measurements are also taken via the middle-upper arm circumference (MUAC). After physical examination and measurements, blood tests can be done to determine protein deficiency as well as deficiencies in other major minerals and vitamins. This helps determine the nutritional status and if there are any indicators of marasmus. In extreme cases of infection, stool samples and blood counts are conducted. Since marasmus is a type of nutritional condition that is often associated with kwashiorkor, some providers will see if edema is present to confirm that it is marasmus.<ref>{{cite web |url=https://www.webmd.com/a-to-z-guides/what-is-marasmus |title=What Is Marasmus? |website=WebMD |access-date=8 April 2024}}</ref> Presence of edema is associated with kwashiorkor, not marasmus.

==Causes==
[[File:Buchenwald-J-Rouard-12.jpg|thumb|[[Buchenwald concentration camp]] inmates on 16 April 1945, when the camp was liberated by the US Army|333x333px]]
Marasmus is caused by the following factors:
* Maternal malnutrition
* Maternal [[anemia]]
* [[Poverty]]
* Pathological conditions in a baby (e.g., diarrhea)
* [[Pneumonia]]
* [[Cyanotic heart disease]]s
* [[Malaria]]
* [[Necrotizing enterocolitis]]
* [[Pyloric stenosis]]
* [[Lactose intolerance]]
* [[Intussusception (medical disorder)|Intussusception]]
* [[Meningitis]]
* [[Anorexia nervosa]]

==Treatment==
Both the causes and complications of the disorder must be treated, including [[infection]]s, [[dehydration]], and [[Circulation (physiology)|circulation]] disorders, which are frequently lethal and lead to high mortality if ignored.{{citation needed|date=January 2017}} Initially, the child is fed dried skim milk that has been mixed with boiled water. Refeeding must be done slowly to avoid [[refeeding syndrome]]. Once children start to recover, they should have more balanced diets that meet their nutritional needs. Children with marasmus commonly develop infections and are consequently treated with antibiotics or other medications.{{medical citation needed|date=July 2023}} Ultimately, marasmus can progress to the [[point of no return]] when the body's ability for [[protein synthesis]] is lost. At this point, attempts to correct the disorder by giving food or protein become futile, and death is inevitable.{{citation needed|date=January 2017}}

== Prevention ==
Nutritionally the best way to prevent marasmus is through a diverse and adequate diet. Other interventions that also target nutrition-specific interventions are SAM treatment, CTC (comprehensive treatment center), and protein and micronutrient supplements. It is also important for mothers and families to be educated on prenatal care, nutrition, and child development. Energy, protein, and micronutrient supplementation are vital to ensuring the mother and child are adequately nourished. Strictly breastfeeding for 6 months and 24 months for nutritional supplementation is also recommended to prevent Marasmus and other malnutrition of children under the age of 2.<ref>{{cite web |title=Marasmus |url=https://my.clevelandclinic.org/health/diseases/23296-marasmus |website=Cleveland Clinic |publisher=Clevland Clinic}}</ref>

In addition to nutrition, ensuring access to clean water, sanitation, and hygiene are important in preventing childhood illness and diarrheal disease which can contribute to marasmus and other [[Severe acute malnutrition]] cases. If the child has marasmus, it can quickly become dangerous if the child has another disease since the immune system's functioning decreases when a child has marasmus.<ref>{{cite web |title=Marasmus |url=https://my.clevelandclinic.org/health/diseases/23296-marasmus |website=Cleveland Clinic |publisher=Clevland Clinic}}</ref> It is important for the child or anyone at risk for marasmus to have access to primary care so they can treat these illnesses, prevent [[diarrheal diseases]] often associated with malnutrition and monitor growth.

==Epidemiology==
{{Expand section|date=July 2016}}
===United States===

In the [[United States]], marasmus is rarely seen, especially in children. In 1995, there were only 228 deaths caused by marasmus in the U.S., of which only 3 were children. In 2016, the prevalence of marasmus in the United States was 0.5%. Prevalence is higher in hospitalized children, especially ones with chronic illnesses, however, the exact incidence of nonfatal marasmus is not known. This is due to marasmus not being reported as an admission or discharge diagnosis.<ref name=":0">{{Cite web|date=2 February 2019|title=Marasmus: Background, Pathophysiology, Body Composition|url=https://emedicine.medscape.com/article/984496-overview#a10}}</ref>

===Outside the US===
There are multiple forms of [[malnutrition]] and roughly one-third of the world's population is currently experiencing one or more of them. There are around 50 million children less than five years old who have [[Protein–energy malnutrition|protein-energy malnutrition]]. Of the malnourished children population in the world, 80% live in Asia, 15% in Africa, and 5% in Latin America. It is estimated that the prevalence of acute malnutrition in Germany, France, the United Kingdom, and the United States is 6.1–14%. In Turkey, the prevalence is as high as 32%.<ref name=":0" />

===Race===
There is no evident racial predisposition that correlates to malnutrition. Rather, there is a strong association with the geographic distribution of poverty.<ref>{{Cite journal|last1=Stephens|first1=Janna D.|last2=Althouse|first2=Andrew|last3=Tan|first3=Alai|last4=Melnyk|first4=Bernadette Mazurek|author4-link=Bernadette Mazurek Melnyk|date=2017|title=The Role of Race and Gender in Nutrition Habits and Self-Efficacy: Results from the Young Adult Weight Loss Study|journal=Journal of Obesity|volume=2017|article-number=5980698|doi=10.1155/2017/5980698|issn=2090-0708|pmc=5406727|pmid=28491474|doi-access=free}}</ref>

===Age===
Marasmus is more commonly seen in children under the age of five due to that age range being characterized as one that has an increase in energy need and susceptibility to viral and bacterial infections.<ref>{{Cite journal|last1=Katona-Apte|first1=Judit|last2=Katona|first2=Peter|date=15 May 2008|title=The Interaction between Nutrition and Infection|journal=Clinical Infectious Diseases|language=en|volume=46|issue=10|pages=1582–1588|doi=10.1086/587658|pmid=18419494|issn=1058-4838|doi-access=free}}</ref> The World Health Organization also identifies the elderly as another population that is vulnerable to malnutrition. Because their nutritional requirement is not well defined, attempts to provide them with the necessary nutrition becomes difficult.<ref>{{Cite web|url=https://www.who.int/nutrition/topics/ageing/en/index1.html|title=WHO {{!}} Nutrition for older persons|website=WHO|access-date=7 August 2019}}</ref>

There exist screening tools and tests that can be used to help identify signs and symptoms of malnutrition in older adults. The Malnutrition Screening Tool (MST) is a validated malnutrition screening tool that is primarily used in the residential aged care facility or for adults in the inpatient/outpatient hospital setting. It includes parameters such as weight loss and appetite.<ref>{{Cite web|url=https://www.ncoa.org/assesssments-tools/malnutrition-screening-assessment-tools/|title=Malnutrition Screening and Assessment Tools|date=20 January 2017|website=NCOA|language=en-US|access-date=7 August 2019}}</ref>[[File:Protein-energy malnutrition world map - DALY - WHO2002.svg|thumb|[[Disability-adjusted life year]] for protein-energy malnutrition per 100,000&nbsp;inhabitants in 2002<ref>{{cite web |url=https://www.who.int/entity/healthinfo/statistics/bodgbddeathdalyestimates.xls |title=Mortality and Burden of Disease Estimates for WHO Member States in 2002|format=xls |work=World Health Organization|year=2002 }}</ref>{{Div col|small=yes|colwidth=10em}}
{{legend|#b3b3b3|no data}}
{{legend|#ffff65|less than 10}}
{{legend|#fff200|10–100}}
{{legend|#ffdc00|100–200}}
{{legend|#ffc600|200–300}}
{{legend|#ffb000|300–400}}
{{legend|#ff9a00|400–500}}
{{legend|#ff8400|500–600}}
{{legend|#ff6e00|600–700}}
{{legend|#ff5800|700–800}}
{{legend|#ff4200|800–1000}}
{{legend|#ff2c00|1000–1350}}
{{legend|#cb0000|more than 1350}}
{{div col end}}]]
Persons in [[prison]]s, [[concentration camp]]s, and [[refugee camp]]s are affected more often due to poor nutrition.{{citation needed|date=September 2021}}

== Socioeconomic implications ==
Those who are in poverty are more likely to develop marasmus and other nutritional deficiencies.<ref>{{cite journal |last1=Galler |first1=Janina |last2=Bryce |first2=Cryalene |last3=Waber |first3=Deborah |last4=Zichlin |first4=Miriam |last5=Fitzmaurice |first5=Garret |last6=Eaglesfield |first6=David |title=Socioeconomic Outcomes in Adults Malnourished in the First Year of Life: A 40-Year Study |journal=Pediatrics |date=July 2012 |volume=130 |issue=1 |pages=e1–e7 |doi=10.1542/peds.2012-0073 |pmid=22732170 |pmc=3382923 }}</ref> Due to childhood malnutrition, survivors of marasmus often have poorer socioeconomic prospects due to cognitive compromise in their developmental years. Since adequate nutrition is vital for development, those with Marasmus are impacted by impaired neurodevelopment. This results in a loss of education in the early school years, leading to limited higher educational and occupational opportunities. Prevention may look like improving nutritional education and access, as well as eliminating poverty are ways to reduce the risks of developing these deficiencies.

==See also==
*[[Starvation]]
*[[Cachexia]]
*[[Emaciation]]
*[[Kwashiorkor]]
*[[Protein poisoning]]

==References==
{{Reflist}}

== External links ==
{{Medical resources
|  DiseasesDB     = 7826
|  ICD10          = {{ICD10|E|41||e|40}}-{{ICD10|E|42||e|40}}
|  ICD9           = {{ICD9|261}}
|  ICDO           =
|  OMIM           =
|  MedlinePlus    =
|  eMedicineSubj  = ped
|  eMedicineTopic = 164
|  MeshID         = D011502
}}

{{Nutritional pathology}}
{{Authority control}}

[[Category:Protein–energy malnutrition]]