Epidemiology
Marasmus is the predominant form of PEM throughout most developing countries.
It is associated with the early abandonment or failure of breast-feeding.
Infections, especially infantile gastroenteritis may then develop and worsen
the malnutrition. Kwashiorkor is less common and is usually manifest as
the intermediate marasmic-kwashiorkor state. It tends to be predominant
in those parts of the world (rural Africa, the Caribbean and Pacific islands)
where staple and weaning foods such as yam, cassava, sweet potato, or green
banana are protein deficient and excessively starchy.
Pathophysiology
In marasmus, energy intake is insufficient to match requirements and the
body draws on its own stores.
In kwashiorkor, increased carbohydrate intake with decreased protein intake
leads to decreased body protein synthesis. The resulting decrease in albumin
causes dependent edema (swelling of the feet, etc.); and the impaired
B-lipoprotein synthesis produces fatty liver.
Symptoms and Signs
Marasmic infants show hunger, gross loss of weight, growth retardation
and wasting of subcutaneous fat and muscle. Kwashiorkor is characterized
by generalized edema, a "flaky paint' appearance of the skin, thinning
and discoloration of the hair, enlarged fatty liver, and apathy, in addition
to retarded growth. In developing countries, severely malnourished children
may also be HIV positive.
Diagnosis
PEM may resemble secondary growth failure due to malabsorption, congenital
defects, or deprivation. Skin changes in kwashiorkor differ from those
of pellagra where they occur on parts exposed to light and are symmetrical.
A doctor will also try to rule out other conditions which could account
for any inflammation of the liver or kidneys.
Treatment
A doctor's aim will be to restore and maintain fluid and electrolyte balance.
All but the most severely ill respond to a diet based on milk. Supplementary
vitamins may be advisable. Small, frequent feedings round the clock are
tolerated best in the early stages of recovery. Antibiotics may be prescribed.
Unless urgent, treatment of malaria or other parasitic infections will
be postponed until the patient is clinically improved. Anemia is usually
mild and responds to oral protein, iron, and folic acid supplements.
Prognosis
Mortality varies between 15 and 40%. Death in the first days of treatment
is usually due to electrolyte imbalance, infection, hypothermia (severe
decrease in body temperature), or heart failure. Long-term effects of
malnutrition in childhood are not fully understood. With adequate treatment
the liver probably recovers fully without subsequent damage.
Immunity is poor during the acute phase of the disease, but is restored
when the child's condition improves. Behavioral development may be markedly
retarded in the severely malnourished child. The degree of mental impairment
is related to the duration of malnutrition and age of onset. An infant
with marasmus is affected most severely than a child with kwashiorkor.
A mild degree of retardation may be present until the school going age.
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FAQs
All
of us need energy to live. If there is a shortage of energy requirements
from protein or non-protein sources, it may result in Protein Energy
Malnutrition (PEM). The extent of the shortage will decide the severity
of the condition. 