Define Marasmus. Describe its pathogenesis, clinical features, investigations and complications.

Definition

• Marasmus is a form of severe protein-energy malnutrition due to chronic deficiency of both calories and protein, characterised by gross wasting without oedema.
• It typically affects infants under 1 year and is the commonest form of severe PEM.

Pathogenesis

• A prolonged energy deficit → the body mobilises fat and muscle for fuel → severe depletion of subcutaneous fat & muscle.
• It is an adaptive response — the liver and serum albumin are relatively preserved, so there is no oedema ('successful adaptation to starvation').

Clinical Features

• Severe growth failure — weight markedly reduced (< 60% of expected).
• Marked loss of subcutaneous fat — wrinkled, loose skin; 'old-man' / 'monkey' facies (the buccal fat pad is lost last).
• Severe muscle wasting — prominent ribs, wasted buttocks ('baggy pants' appearance).
• No oedema; hair and skin relatively normal.
• The child is usually alert, irritable and voraciously hungry.
• Associated dehydration, hypothermia, hypoglycaemia and recurrent infections.

Investigations

• Anthropometry (severe wasting; low MUAC); blood glucose, electrolytes; serum albumin relatively normal.
• Screen for an underlying cause — tuberculosis, HIV, chronic diarrhoea, malabsorption.

Complications

• Hypoglycaemia, hypothermia, dehydration and electrolyte imbalance (the immediate dangers).
• Overwhelming infection (the commonest cause of death); severe anaemia; vitamin A deficiency.
• Long-term growth stunting and impaired cognitive development.

Management

Managed as SAM with the WHO 10-step protocol — treat hypoglycaemia/hypothermia/dehydration, give antibiotics, then cautious feeding (F-75 → F-100/RUTF) for catch-up growth, micronutrients, stimulation and follow-up.

Marasmic-kwashiorkor

When a child has features of both forms — severe wasting plus oedema — it is termed marasmic-kwashiorkor; it is the most severe form of PEM and carries the highest mortality.

Prognosis

Recovery is good with early, correct SAM management, but the immediate complications (hypoglycaemia, hypothermia, infection) must be anticipated and prevented.