Marasmus-kwashiorkor

Types of protein-energy malnutrition are marasmus (deficiency in total intake or nutrient utilization), kwashiorkor (relative protein deficiency), and mixed marasmus-kwashiorkor. 

One of the characteristics of critical illness is hypermetabolism. Trauma, burn injury, and sepsis are aU catalysts for the release of mediators that initiate and regulate the hypermetabohc response. The metabolic consequences of this response include altered carbohydrate metabolism, increased protein synthesis and degradation, and increased lipid oxidation, which ultimately result in loss of protein and lean body mass." In a previously well-nourished individual, critical illness can result in the onset of kwashiorkor-like malnutrition within 5 to 7 days. In a previously malnourished individual, critical illness can precipitate severe mixed marasmus-kwashiorkor in 3 to 5 days. In a prospective study of 129 patients admitted to the intensive care unit (ICU), 43% were malnourished." The malnourished patients had an increased length of stay in the ICU (a mean of 27 vs. 19 days) and a statistically significantly increased incidence of complications (55% vs. 40%) compared with well-nourished patients with a similar severity of illness. 

An isolated report describes an elderly woman treated with aminophylline by intravenous infusion who had a marked fall in her serum theophylline levels (from 16.3 to 6.3 mg/L) when the amino acid concentration of her parenteral nutrition regimen was increased from 4.25 to 7%. " A study in 7 patients with malnutrition (marasmus-kwashiorkor) found only a small, probably clinically irrelevant increase in the elimination of a single intravenous dose of theophylline when they were fed intravenously. ... 

If oedema is present, the malnutrition is termed kwashiorkor or marasmus-kwashiorkor if very severe. 

The underlying cause of kwashiorkor is an inadequate intake of food, as is the case for marasmus. Kwashiorkor traditionally affects children aged between of 3 and 5 years. In many societies a child continues to suckle until about this age, when the next child is born. As a result, the toddler is abruptly weaned, frequently onto very unsuitable food. In some societies, children are weaned onto a dilute gruel made from whatever is the local cereal in others the child may be fed on the water in which rice has been boiled - it may look like milk, but has little nutritional value. Sometimes the child is given little or no special treatment but has to compete with the rest of the family for its share from the stew-pot. A small child has little chance of getting an adequate meal under such conditions, especially if there is in any case not much food for the whole family. 

All 20 of the amino acids present in proteins are essential for health. While comparatively rare in the Western world, amino acid deficiency states are endemic in certain regions of West Africa where the diet relies heavily on grains that are poor sources of amino acids such as tryptophan and lysine. These disorders include kwashiorkor, which results when a child is weaned onto a starchy diet poor in protein and marasmus, in which both caloric intake and specific amino acids are deficient. 

In addition to the wasting of muscle tissue, loss of intestinal mucosa, and impaired immune responses seen in marasmus, children with kwashiorkor show a number of characteristic feamres. The defining characteristic is edema, associated with a decreased concentration of plasma proteins. In addition, there is enlargement of... 

A special form of undemutrition that particularly affects children is known as protein-energy malnutrition (PEM) which is a spectrum of syndromes from marasmus (lack of energy intake) to kwashiorkor (deficient protein intake). 

Malnourished children can have two very different appearances. In marasmus, the limbs are wasted and the whole of the body assumes a shrunken skin and bone appearance, as muscle is sacrificed to support more vital tissues. The shranken cheeks are caused by a loss of the Bidet fat depots, hi kwashiorkor, children have pot-bellies partially explained by generalised oedema and hepatomegaly. Both have brittle, bleached hair, skin lesions and a deeply apathetic demeanour. Although the two conditions intergrade they show some geographical separation with kwashiorkor being restricted to tropical and subtropical regions while marasmus can occur anywhere. 

Marasmus is considered to be due to inadequate food intake. It is not usually the quantity but the quality of the food that is deficient, e.g. low nutritional value of bulky vegetables. Kwashiorkor is considered to be caused, more specifically, by a low-protein diet. This condition frequently develops at the time of weaning when protein-rich milk is replaced by protein-deficient solid food. It did not appear in the medical literature until 1934 when it was reported by Cicely Williams who studied the condition while she was working among tribes of Western Africa. She gave it the name kwashiorkor, which was used by the Ga tribe to describe the condition that develops when the baby is taken away from mother s breast, usually because another baby has been bom. It has generally been held that the oedema is a consequence of a low plasma albumin concentration and a reduction in the colloid osmotic pressure which reduces the movement of water from tissue fluid back into capillaries. The low albumin level results from a decreased rate of synthesis of albumin by the liver. However, if marasmus is due entirely to lack of energy... 

The serum protein concentrations, especially of albumin, are low in kwashiorkor but normal in marasmus. 

The ratio of essential to non-essential amino acids is high in kwashiorkor but normal in marasmus. The cause of this may be low activities of the enzymes for metabolising the essential amino acids. These are required for any protein synthesis that must take place even in kwashiorkor. 

Results from two different groups of children reveal that the serum immunoglobulin levels in children with marasmus are not significantly different from those with kwashiorkor. Sixteen marasmic infants free from all signs of apparent kwashiorkor but all having gastrointestinal disturbances or respiratory infections had immunoglobulin levels as fol-... 

In countries where food Is In short supply or the diet is inadequate, protein-calorie malnutrition can take two extreme forms, kwashiorkor and marasmus. 

The absence of edema or reduction in albumin distinguishes marasmus from kwashiorkor. 

Vitamin A deficiency can result from insufficient dietary intake, from malabsorption and it has been recognized that also malfunction of RAR-receptors can lead to symptoms of vitamin A deficiency. These symptoms include skin lesions, night blindness, corneal ulcerations and conjunctivitis and poor bone remodeling. Vitamin A deficiency associated with malnutrition is wide spread in large parts of the world and may be fatal in infants and young children suffering from kwashiorkor or marasmus. 

Marasmus Marasmus occurs when calorie deprivation is rela tively greater than the reduction in protein. Marasmus usually occurs in children younger than one year of age when the mother s breast milk is supplemented with thin watery gruels of native cereals, which are usually deficient in protein and calories. Typical symptoms include arrested growth, extreme muscle wast ing (emaciation), weakness, and anemia. Victims of marasmus do not show the edema or changes in plasma proteins observed in kwashiorkor. 

Kwashiorkor is caused by inadequate intake of protein. Marasmus Marasmus occurs when calorie deprivation is relatively greater than the reduction in protein. 

The signs and symptoms of protein-energy malnutrition (PEM) depend on various factors, including the duration of the nutritional inadequacy, age at onset, and frequency/types of concomitant infections. Figure 24-1 shows children diagnosed with kwashiorkor and marasmus and outlines some of the diagnostic features discussed in this section (Scrimshaw and Behar, 1961). 

Figure 24-1. Typical features found in children with kwashiorkor and marasmus. Photographs reprinted with permission from Scrimshaw and Behar (1961). 1961, AAAS.

Both forms of PEM are associated with hy-percortisolemia.The level of cortisol in kwashiorkor is lower, however, than in marasmus, likely due to decreased adrenocortical function caused by low protein intake (and not adrenal failure). If a sufficiently high level of cortisol is not maintained, then adequate muscle protein is not mobilized to sustain hepatic protein synthesis. Indeed, hypoproteinemia, evident by the decreased serum albumin and transferrin levels, is more acute in kwashiorkor than marasmus. 

Although glutathione is specifically decreased in kwashiorkor, blood levels of selenium-dependent glutathione peroxidase (a scavenger of peroxides) and vitamins A, C, and E (all members of the antioxidant machinery) are lower in both kwashiorkor and marasmus (Ashour et al., 1999). Why then are marasmic children, also deficient in some antioxidants, spared the oxidative stress Does a weakened antioxidant defense manifest as a serious threat only in the presence of pro-oxidant activities of the type encountered in kwashiorkor What is a possible trigger for the increase in free radicals, and how might this account for some of the phenotypic alterations in kwashiorkor ... 

Despite the advances enumerated in this section, the conundrum posed by Gopalan (1968) regarding whether the same diet could lead to both kwashiorkor and marasmus remains. Profitable future investigations might entail an examination of the genetic contributions to oxidative stress and the consequent phenotypic sequelae while on an inadequate diet. 

Gopalan C Kwashiorkor and marasmus evolution and distinguishing features, in McCance RA, Widdowson EM (eds) Calorie Deficiencies and Protein Deficiencies. Little, Brown and Company, Boston, 1968, pp. 49-58. 

Cachexia is loss of weight, muscle atrophy, fatigue, weakness and significant loss of appetite. It is seen in patients with cancer, acquired immunodeficiency syndrome (AIDS), chronic obstructive pulmonary disease and congestive heart failure. Underlying causes are poorly understood, but there is an involvement of inflammatory cytokines, such as TNF-a, IFN-y, IL-6 and tumour-secreted proteolysis-inducing factor. Related syndromes are kwashiorkor and marasmus, although these are most often symptomatic of severe malnutrition. 

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