Marasmus - PSM (Park's Textbook of Preventive & Social Medicine)

Definition

• Park's Textbook of Preventive and Social Medicine, p. 736

Context: PEM as a Public Health Problem

• PEM is a major health and nutrition problem in India, occurring particularly in children in the first years of life.
• It is an underlying cause in ~30% of deaths among children under age 5.
• Globally (2018): >21.9% of children under 5 were stunted; 7.3% had wasting.
• In India (NFHS 2015-16): 35.7% children under 5 are underweight; 7.5% have moderate-to-severe wasting; 38.4% have moderate-to-severe stunting.
• Malnutrition + infection form a vicious cycle - each worsens the other.

The Two Forms of PEM: Marasmus vs Kwashiorkor

Clinical Features of Marasmus

1. Severe wasting - loss of muscle mass and subcutaneous fat
2. Little or no oedema
3. Minimal subcutaneous fat - skin hangs in folds ("baggy pants" appearance)
4. Severe muscle wasting - the extremities are emaciated
5. Head appears disproportionately large for the emaciated body ("old man" facies)
6. Non-normal serum albumin (near normal or only slightly reduced - visceral protein compartment is relatively preserved)
7. Growth retardation
8. Anaemia and signs of multivitamin deficiencies
9. Immune deficiency - particularly T cell-mediated - leading to recurrent/concurrent infections
10. Weight is typically <60% of expected weight-for-age (in SAM)

Pathophysiology (PSM Perspective)

• Body catabolizes somatic protein (muscle) to provide amino acids as energy source - this is an adaptive response.
• Visceral protein (serum albumin) is relatively preserved - hence NO oedema.
• Subcutaneous fat is mobilized as fuel.
• Leptin production is low → stimulates hypothalamic-pituitary-adrenal axis → high cortisol → lipolysis.
• T-cell immunity is compromised → secondary infections common.

Classification of Malnutrition (Anthropometric - PSM)

• Underweight: Weight-for-age Z-score < -2 SD
• Wasting (Marasmus): Weight-for-height Z-score < -2 SD
• SAM: Weight-for-height Z-score < -3 SD OR MUAC < 115 mm OR nutritional oedema

Severe Acute Malnutrition (SAM)

• Weight-for-height Z-score below -3 SD
• MUAC < 115 mm, OR
• Presence of nutritional oedema

Early Detection of PEM (PSM Tools)

1. Growth charts (weight-for-age) - most practical tool for field health workers; detects underweight early.
2. Mid-Upper Arm Circumference (MUAC):
   • > 13.5 cm = Satisfactory nutritional status
   • 12.5-13.5 cm = Mild-moderate malnutrition
   • < 12.5 cm = Severe malnutrition
   • (Cannot be used before age 1 year; relatively stable between ages 1-5 years)

Prevention of PEM/Marasmus (FAO/WHO Framework - Park's)

(a) Health Promotion

1. Measures for pregnant and lactating women (education + supplements)
2. Promotion of exclusive breastfeeding (first 6 months)
3. Development of low-cost weaning foods; frequent feeding
4. Improvement of family diet
5. Nutrition education - correct feeding practices
6. Promotion of family planning and birth spacing
7. Improving family environment

(b) Specific Protection

1. Diet must contain protein and energy-rich foods (milk, eggs, fresh fruits)
2. Immunization (prevents infections that worsen malnutrition)
3. Food fortification

(c) Early Diagnosis and Treatment

1. Periodic nutritional surveillance
2. Early diagnosis of growth lag
3. Early treatment of infections and diarrhoea
4. Oral rehydration programmes
5. Supplementary feeding programmes during epidemics
6. Deworming of heavily infested children

(d) Rehabilitation

1. Nutritional rehabilitation services
2. Hospital treatment
3. Follow-up care

Key Points for Exam

• Marasmus = deficiency of both calories AND protein (vs. Kwashiorkor = mainly protein)
• No oedema in Marasmus (key distinguishing feature)
• Serum albumin is normal or near-normal in Marasmus
• "Old man" face / baggy pants sign / loose skin folds
• Weight < 60% of expected for age (severe)
• SAM: MUAC < 115 mm or WHZ < -3 SD
• MUAC < 12.5 cm = severe malnutrition (field diagnosis)
• Infection-malnutrition vicious cycle is a core PSM concept
• Exclusive breastfeeding for first 6 months is the most important preventive measure