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Marasmus- 1985 Postgraduate Medical Journal (1985) 61, 915-923 Postgrad Med J: first published as 10.1136/pgmj.61.720.915 on 1 October 1985. Downloaded from Marasmus- 1985 D. Barltrop and B.K. Sandhu Department ofChild Health, Charing Cross and Westminster Medical School, London, UK. Introduction Dr Wilfred J. Pearson writing for the first volume of In 1959 Jelliffe coined the term protein-calorie this Journal in 1925 defined marasmus (Greek: maras- malnutrition (PCM) of early childhood to include mos, wasting) as 'a chronic state of malnutrition of a mild, moderate and various types of severe degrees of severe grade' but pointed out that 'we must retain the malnutrition. The advent of the International System conception ofcases varying in severity from those who of Units (SI) resulted in the introduction of the term simply show an insufficient gain or stationary weight protein energy malnutrition (PEM). The World with few systemic changes, to the most extreme form Health Organisation (WHO, 1973) defined PEM as which is merely the end result of repeated nutritional follows: 'A range of pathological conditions arising or constitutional disturbances.' He described oedema from coincidental lack, in varying proportions, of in some cases as a complication of marasmus. The protein and calories, occurring most frequently in clinical picture of the syndrome, later described as infants and young children and commonly associated kwashiorkor, was not generally recognized at this with infection'. This is not dissimilar from Wilfred time, although a number of authors had described it Pearson's view of marasmus. (Czerney & Keller, 1928). In order to treat and, more importantly, to prevent a In 1933 Cicely D. Williams, a paediatrician working condition effectively, evolution and causes must be copyright. in the Gold Coast of Africa described a 'nutritional understood. It is therefore necessary to consider disease ofchildhood associated with a maize diet' and marasmus within the context ofPEM. The aim ofthis attributable to protein deficiency. She named it kwa- paper is to review the current state of knowledge shiorkor (taken from the Ga language of Ghana, the concerning the pathophysiology, aetiology, clinical disease ofthe deposed baby when the next one is born). presentation and treatment of marasmus in the con- Her classical description included oedema, chiefly of text of it being considered as one of a spectrum of hands and feet, wasting, diarrhoea, irritability and syndromes produced by severe protein energy mal- dermatosis. This paper attracted much attention in the nutrition (PEM). medical literature and clinical of similar descriptions http://pmj.bmj.com/ disease subsequently appeared from many other coun- tries. Paradoxically the more commonly encountered Classification type of malnutrition, marasmus, was neglected and until recently did not attract detailed scientific inves- Although a methodology for the assessment ofPEM is tigation. needed, it is still not clear exactly what should be The original view that kwashiorkor resulted from assessed, and there is a lack of agreement about protein lack in the presence of adequate, even excess classification among experts in this field. Until recent- carbohydrate, in contrast to marasmus which foll- ly the method of classification used was that in- on October 3, 2021 by guest. Protected owed deficiency of energy alone, is not now accepted. troduced in 1942 by Gomez and his colleagues (1956) Thus it has been shown that the protein: energy ratio based upon weight for age, in which the weight of the of diets eaten by children developing washiorkor is child was expressed as a percentage of the expected adequate but total energy is deficient (Rutishauser & weight of a healthy child of the same age using a local Frood, 1973; Goplan, 1968). However, it has become or other appropriate standard (Table I). apparent that malnutrition produces a spectrum of A Wellcome working party (1969) considered the syndromes ranging from simple growth failure alone classification of PEM and agreed that the term to both pure and mixed syndromes of marasmus, marasmus should be applied to children who have less marasmic kwashiorkor and kwashiorkor. than 60% of the expected weight for age and no oedema i.e. Gomez's severe or 3rd degree malnutri- Correspondence: D. Barltrop, M.D., F.R.C.P., Westminster tion. However Gomez's method assumed that children Children's Hospital, Vincent Square, London SW1P 2NS, of any given age should have the same weight and this UK. assumption is incorrect. In 1972, Waterlow published © The Fellowship of Postgraduate Medicine, 1985 Postgrad Med J: first published as 10.1136/pgmj.61.720.915 on 1 October 1985. Downloaded from 916 D. BARLTROP & B.K. SANDHU Table I Classification of PEM (Gomez, 1956) In the UK 3rd degree PEM is rare and is usually secondary to some underlying organic disease but may Severity % ofstandard(Harvard) occasionally be due to child abuse. normal > 90% mild (1st degree) 89-75% moderate (2nd degree) 74-60% Clinical presentation severe (3rd degree) <60% This will vary with the degree and duration of PEM, the age of the child and the presence of associated Table H Classification of PEM according to wasting and vitamin, mineral and trace element deficiencies. In stunting (after Waterlow et al., 1972) order to prevent marasmus it is important that these early changes are understood and recognized. PEM of Stunting Wasting all degrees is most common in the post-weaning phase (heightfor age) (weightfor height) (9 to 24 months of age) but can occur at any age. Failure of breast feeding and inadequate artificial 0=>95% 0=>90% can lead to marasmus in the first 9 months of 1 = 95-90% 1 = 90-80% feeding 2 = <90-85% 2 = 80-70% life. 3=<85% 3=<70% Mild PEM 0 denotes normal, and 1, 2, and 3, mild, moderate and severe PEM. The main clinical presentation of mild PEM is that of failure to thrive with retarded physical growth and a classification based on both weight and height(Table development revealed by anthropometric abnor- II). He labelled present malnutrition 'wasting' malities. There is also an increased risk of infection measured by loss ofweight related to height; and past and retardation ofmental development. Anaemia may malnutrition 'stunting' seen in retarded height for age. be present; activity is diminished and the hair around This system is now generally accepted and in 1977, the temples may be sparse. copyright. WHO published recommendations primarily based Anthropometric abnormalities include: (1) cessa- upon it (Waterlow et al., 1977). However, it needs to be tion or slowing of weight gain or weight loss; (2) translated into simpler terms for use in the busy slowing or cessation of height gain; (3) normal or routine clinic. diminished weight/height ratio; (4) decreased mid-arm Other anthropometric measurements such as mid- circumference; (5) delayed bone maturation and (6) arm circumference, skinfold thickness, mid-arm and normal or diminished skin fold thickness. head circumference ratio have been used but re- Weight and height are the most useful indices producibility is poor for the first two and there is an providing that the age of the child is known. Patterns age limitation for the third. of growth failure, however, vary considerably and chronic disease, apart from nutritional deficiency, http://pmj.bmj.com/ may also contribute to the problem. Prevalence Children with mild PEM have a high rate of infection particularly with gastroenteritis, measles and Despite considerable research, UN resolutions and pneumonia. In tropical areas the risk of contracting development programmes, there is more malnutrition malaria, hookworm and schistosomiasis is also in- in the world now than existed 30 years ago (Latham, creased and it is therefore important to assess the There is an 1982). increasinggap between the people of nutritional status of any child presenting with an on October 3, 2021 by guest. Protected the rich and poor nations and there has been a failure infection or infestation. Both the morbidity and to reduce malnutrition and hunger due to poverty. The mortality due to infestations are considerably in- reasons for the failure of development and for in- creased in children with PEM (Scrimshaw & Behar, creased inequality are beyond the scope of this paper. 1961; Chandra, 1983). Point prevalence figures for PEM collected by WHO (Bengoa, 1974) based on 77 surveys suggested Severe form of PEM - marasmus that about 100 million children throughout the world are suffering from moderate or severe PEM at any one The presenting features are gross failure to thrive time. The relative prevalence of marasmus and kwa- accompanied by irritable crying or apathy. The child shiorkor worldwide is not known but marasmus has a shrunken, wasted and stark appearance due to ranged up to 95% or more ofcases ofsevere malnutri- loss of subcutaneous fat. The fontanelle, if present, tion in Beirut (McLaren, 1966) and Santiago (Monck- may be sunken due to dehydration and the eyes appear eberg, 1966). large. There is marked wasting ofthe buttocks and the Postgrad Med J: first published as 10.1136/pgmj.61.720.915 on 1 October 1985. Downloaded from MARASMUS- 1985 917 abdomen is usually distended. The degree ofwasting is proportion of the residual fat (up to 50%) may be in extreme and, by definition, the child is less than 60% the liver (fatty liver) although there is no relationship of expected weight for age and may be well under between liver and subcutaneous fat. In the liver the fat, 40-50% of expected weight. In chronic cases length mainly triglycerides, first appears in the periportal may also be markedly affected so that the weight/ area and then spreads to the central vein area and height ratio may be unaltered. In acute cases the child distends the liver cells. Fatty liver is thought to result is grossly underweight for height; skinfold thickness, from a combination of increased flux of fatty acids mid-arm circumference and chest/head circumference from adipose tissue together with decreased hepatic are all markedly reduced.
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