Kwashiorkor and Marasmus

Kwashiorkor and marasmus are two major forms of protein–energy malnutrition (PEM), primarily affecting children in developing regions where poverty, food scarcity, and inadequate nutrition prevail. Both conditions result from insufficient dietary intake, but they differ in the balance of protein and energy deficiency, clinical presentation, and underlying pathophysiology. Understanding these conditions is essential for public health planning, paediatric care, and nutritional rehabilitation.

Overview of Protein–Energy Malnutrition

Protein–energy malnutrition encompasses a spectrum of disorders caused by inadequate consumption of protein, energy, or both. It is most prevalent among children under five years of age, particularly in areas with limited access to balanced diets and healthcare. PEM can present in three primary forms: kwashiorkor, marasmus, and marasmic-kwashiorkor, a mixed condition showing overlapping features of both.

Kwashiorkor: Definition and Characteristics

Kwashiorkor is primarily a protein-deficiency disorder, occurring when a child’s diet contains adequate calories from carbohydrates but lacks sufficient protein. The term originated from the Ga language of Ghana, meaning “the sickness the older child gets when the next baby is born,” referring to the displacement of breastfeeding by a new sibling.
Clinical features of kwashiorkor include:

• Oedema: Generalised swelling, especially in the legs, feet, and face, due to reduced plasma protein levels (hypoalbuminaemia) that cause fluid leakage from blood vessels.
• Enlarged fatty liver: Impaired lipid metabolism results in fatty infiltration of the liver.
• Dermatological changes: Skin may become flaky and hyperpigmented, often described as a “flaky paint” appearance.
• Hair changes: Hair becomes sparse, dry, and may lose pigmentation, showing alternating dark and light bands (“flag sign”).
• Growth retardation: Despite adequate calorie intake, lack of protein impairs growth and tissue repair.
• Apathy and irritability: Due to energy imbalance and biochemical disturbances affecting brain function.
• Immune suppression: Increased susceptibility to infections due to compromised protein-dependent immune mechanisms.

Pathophysiology: The deficiency of dietary protein leads to decreased synthesis of plasma proteins, enzymes, and structural proteins. This disrupts osmotic balance, fat metabolism, and immune responses, manifesting in oedema and fatty liver.

Marasmus: Definition and Characteristics

Marasmus is a condition resulting from severe deficiency of both protein and calories, leading to extreme wasting of body tissues. It is often seen in infants and young children deprived of breast milk or fed on dilute, low-calorie substitutes.
Clinical features of marasmus include:

• Severe emaciation: The child appears extremely thin with prominent bones and minimal subcutaneous fat.
• Muscle wasting: Marked reduction in muscle mass due to breakdown of body proteins for energy.
• Growth failure: Stunted physical and mental development.
• Absence of oedema: Unlike kwashiorkor, water retention is not typical because plasma proteins, though low, remain relatively balanced with energy needs.
• Dry, wrinkled skin: Due to loss of elasticity and fat under the skin.
• Alert but irritable behaviour: The child may appear unusually alert despite extreme weakness.
• Anaemia and hypoglycaemia: Caused by overall nutrient deficiency and inadequate energy metabolism.

Pathophysiology: In marasmus, the body’s adaptation to prolonged energy deficiency results in catabolism of fat and muscle to meet metabolic demands. Energy expenditure decreases, and growth halts as a survival mechanism.

Comparison between Kwashiorkor and Marasmus

Causes and Risk Factors

Both conditions are influenced by a range of social, economic, and biological factors, including:

• Poverty and food insecurity, limiting access to protein-rich diets.
• Early weaning or delayed introduction of complementary feeding.
• Inadequate maternal nutrition, affecting breast milk quality.
• Frequent infections, such as diarrhoea or measles, which increase nutrient losses and metabolic demands.
• Poor sanitation and unsafe drinking water, leading to recurrent illness.
• Natural disasters or displacement, disrupting food supply chains.

Diagnosis and Clinical Evaluation

Diagnosis is based on clinical examination, supported by anthropometric measurements such as:

• Weight-for-age (underweight)
• Height-for-age (stunting)
• Weight-for-height (wasting)

Laboratory tests may reveal hypoalbuminaemia, anaemia, electrolyte imbalances, and impaired liver function in kwashiorkor. Marasmus often shows low blood glucose and reduced fat stores without oedema.

Management and Treatment

Treatment aims to correct nutritional deficiencies gradually, prevent complications, and restore normal growth and metabolism. The World Health Organization (WHO) recommends a phased approach:

1. Stabilisation phase:
   • Manage dehydration, hypoglycaemia, and infections.
   • Administer low-protein, low-lactose therapeutic milk (F-75 formula).
2. Rehabilitation phase:
   • Introduce high-protein, energy-dense diet (F-100 formula).
   • Provide vitamin and mineral supplementation, especially potassium, magnesium, and zinc.
3. Follow-up phase:
   • Ensure continued nutritional rehabilitation and counselling for caregivers.
   • Promote exclusive breastfeeding and balanced complementary feeding.

In severe cases, hospitalisation and careful monitoring of electrolyte and fluid balance are essential to prevent refeeding syndrome and cardiac complications.

Prevention and Public Health Measures

Preventing kwashiorkor and marasmus requires a combination of nutritional education, community health initiatives, and socio-economic development. Key preventive strategies include:

• Promotion of exclusive breastfeeding for the first six months.
• Timely introduction of complementary foods rich in protein and calories.
• Maternal nutrition programmes to improve prenatal and postnatal health.
• Food fortification and supplementation schemes for vulnerable populations.
• Immunisation and sanitation improvements to reduce infection burden.
• Poverty alleviation and food security policies ensuring availability of diverse foods.