MARASMUS -

KWASHIORKOR
OVERVIEW OF PEM
The majority of worlds children
live in developing countries
Lack of food & clean water, poor
sanitation, infection & social
unrest lead to LBW & PEM
Malnutrition is implicated in
>50% of deaths of <5 children (5
million/yr)
EPIDEMIOLOGY

The term protein energy malnutrition

has been adopted by WHO in 1976.

Highly prevalent in developing

countries among <5 children; severe
forms 1-10% & underweight 20-40%.

All children with PEM have

micronutrient deficiency.
PEM

In 2000 WHO estimated that 32% of

<5 children in developing countries
are underweight (182 million).

78% of these children live in South-

east Asia & 15% in Sub-Saharan
Africa.

The reciprocal interaction between

PEM & infection is the major cause of
death & morbidity in young children.
Types of malnutrition

Severe Protein-Energy
Malnutrition (>3 S.D.)
Kwashiorkor (low protein)
Marasmus (low calories)
Kwashiorkor
Infection Sparse
hair

Swollen
belly

Decreased
muscle
mass

Pellagra
Apathy
 Kwashiorkor is anacuteform of
childhood
protein-energy malnutrition
characterized byedema, irritability,
anorexia, ulcerating dermatoses, and
an enlarged liver with fatty
infiltrates.
The presence of edema caused by
poor nutrition defines kwashiorkor
 Children are affected by kwashiorkor
more frequently than adults.

It typically starts after the child has

been weaned and breast milk has
been replaced with a diet low in
protein,
 although it can occur in infants if the
mother is protein-deprived.

Kwashiorkor can also occur due to

parasites and infections that can
interfere with nutritional status.
Low protein diets

dietary changes due to milk allergies

in infants,
fad diets,
poor nutritional education,
or a chaotic home life,
other causes of kwashiorkor.
 Kwashiorkor mechanisms
Occurs in reaction to emergency
situations (famine)
Kwashiorkor more likely in areas where
cassava, yam, plantain, rice and maize
are staples, not wheat
Increased carbohydrate intake with
decreased protein intake eventually
leads to edema (water) and fatty liver
ETIOLOGY

Kwashiorkor can occur in infancy

but its maximal incidence is in the
2nd yr of life following abrupt
weaning.
Kwashiorkor is not only dietary in
origin. Infective, psycho-socical, and
cultural factors are also operative.
ETIOLOGY (2)

Kwashiorkor is an example of
lack of physiological adaptation
to unbalanced deficiency where
the body utilized proteins and
conserve S/C fat.
 The condition is likely due to
deficiency of one of several types of
nutrients (e.g.,iron,folic acid
,iodine,selenium,vitamin C),
particularly those involved withanti-
oxidantprotection.
 Important anti-oxidants in the body
that are reduced in children with
kwashiorkor
includeglutathione,albumin,vitamin
Eandpolyunsaturated fattyacids.
 Therefore, if a child with reduced
type one nutrients or anti-oxidants is
exposed to stress (e.g. an infection
or toxin) he/she is more liable to
develop kwashiorkor.
 One important factor in the development
of kwashiorkor isaflatoxinpoisoning.

Aflatoxins are produced by molds and

ingested with moldy foods.

They are toxified by thecytochrome

P450system in the liver, the resulting
epoxides damage liverDNA.
 Since many serum proteins, in
particularalbumin, are produced in
the liver, the symptoms of
kwashiorkor are easily explained.

It is noteworthy that kwashiorkor

occurs mostly in warm, humid
climates that encourage mold
growth.
 CLINICAL
PRESENTATION
Kwash is characterized by certain constant features in
addition to a variable spectrum of symptoms and signs.

Clinical presentation is affected by:

The degree of deficiency
The duration of deficiency
The speed of onset
The age at onset
Presence of conditioning factors
Genetic factors
CONSTANT FEATURES OF KWASH

OEDEMA

PSYCHOMOTOR CHANGES

GROWTH RETARDATION

MUSCLE WASTING
USUALLY PRESENT
SIGNS
MOON FACE

HAIR CHANGES

SKIN DEPIGMENTATION

ANAEMIA
OCCASIONALLY PRESENT
SIGNS

HEPATOMEGALY
FLAKY PAINT DERMATITIS
CARDIOMYOPATHY & FAILURE
DEHYDRATION (Diarrh. & Vomiting)
SIGNS OF VITAMIN DEFICIENCIES
SIGNS OF INFECTIONS
Prevention &
intervention
Kwashiorkor can be prevented by
including foods in diet that are rich in
proteins,

Treatment involves slow increases in

calories from carbohydrates, sugars,
and fats, followed by protein.
 Vitamin and mineral supplements
and enzymes to help digest dairy
products are often needed.

Treatment also involves correction of

any fluid and electrolyte imbalances
and treatment of any infections.
Marasmus (low calories)

Ravenously
hungry

Gross
weight
loss &
no fat
DEFINITION
Marasmus is a state of malnutrition
characterized by gradual wasting of
somatic fat and muscle stores and
preservation of visceral proteins

It is one of the three forms of serious

protein-energy malnutrition (PEM)
 MARASMUS

Marasmus represents an adaptive

response to starvation, whereas
kwashiorkor represents a maladaptive
response to starvation

In Marasmus the body utilizes all fat

stores before using muscles.
Marasmus

Deficit in calories marasmus comes

from Greek origin of word to waste
Gross weight loss
Hyper-alert and ravenously hungry
Children have no subcutaneous fat or
muscle

eventually starve to death (immediate

cause often is pneumonia)
 EPIDEMIOLOGY &
ETIOLOGY
Seen most commonly in the first
year of life due to lack of breast
feeding and the use of dilute
animal milk.
Poverty or famine and diarrhoea
are the usual precipitating factors
Ignorance & poor maternal
nutrition are also contributory
Clinical Features of
Marasmus

Severe wasting of muscle & s/c fats

Severe growth retardation
Child looks older than his age
No edema or hair changes
Alert but miserable
Hungry
Diarrhoea & Dehydration
 Marasmus always results from a negative
energy balance.

The imbalance can result from a

decreased energy intake, an increased
loss of ingested calories (eg, emesis,
diarrhea, burns), an increased energy
expenditure,

or combinations of these factors, such as

is observed in acute or chronic diseases.
Children adapt to an
energy deficiency with
a decrease in physical activity,
lethargy,
a decrease in basal energy
metabolism,
slowing of growth, and,
finally, weight loss.
PATHOPHYSIOLOGY
Adaptive Starvation
Evolutionary - allows primates to
undergo feast and famine

Negative Energy Balance- expending

more energy than taking in
Results in Protein Energy Malnutrition
Metabolic change

The overall metabolic adaptations

that occur during marasmus are
similar to those in starvation,

The primary goal is to preserve

adequate energy to the brain and
other vital organs in the face of a
compromised supply.
 Early on, a rise in gluconeogenesis
leads to a perceived increased
metabolic rate.

As fasting progresses,
gluconeogenesis is suppressed to
minimize muscle protein breakdown,
and ketones derived from fat
become the main fuel for the brain.
 With chronic underfeeding, the basal
metabolic rate decreases.

One of the main adaptations to long-

standing energy deficiency is a
decreased rate of linear growth,
yielding permanent stunting.
Energy metabolism
With reduced energy intake, a decrease
in physical activity occurs followed by a
progressively slower rate of growth.

Weight loss initially occurs due to a

decrease in fat mass,

and afterwards by a decrease in muscle

mass, as clinically measured by
changes in
Carbohydrate metabolism:

glucose level is often initially low,

and the glycogen stores are
depleted.

Small and frequent meals are

recommended, including during the
night, to avoid death in the early
morning.
METABOLIC CHANGES
Protein Metabolism during Starvation
Adaptation to starvation depends on
ketone production.
Reduced muscle catabolism:
Needs for gluconeogenesis decline
b/c brain and nervous system are
using alternative fuel for energy
(ketones)
KETONE BODIES
Protein losses are minimized and
lean body mass spared b/c
gluconeogenesis declines.
Fat provides fuel for the muscle and
brain in the form of ketones.
When fat stores are exhausted, the
protein is used and patient dies.
WHO IT MAINLY AFFECTS

Children that have a

low socio-economic
status,
children with chronic
disease and
children that are
institutionalized are at
a higher risk of
developing marasmus.
SYMPTOMS OF MARASMUS

Pronounced weight loss with loss of

muscle formation, particularly on the
shoulders and buttocks
Absence of fat under the skin
Thin, papery skin with hanging folds
Darker skin, as if the child has a
sunburn
Hair loss
SYMPTOMS CONT.
Alternate diarrhea and constipation
Child is cross and depressed
Infants appear apathetic and lie still
for long periods without moving or
crying
Ravenous while emaciated
Frequent colicky pain
Edema
 Summary: Severe
Severe malnutrition is defined as > 3
malnutrition
s.d. away from median reference
standards;
66M children under the age of 5 are
severely malnourished (64M of these in
developing countries);
Key types of severe malnutrition are
kwashiorkor (low protein) and marasmus
(low calories);
Severe malnutrition results in severe
deficits for children
Latihan soal
Pernyataan yang tepat mengenai kejadian KEP :
a. Sering terjadi pada negara yang sudah maju
b. Higiene sanitasi tidak berpengaruh pada angka terjadinya
KEP
c. Angka kejadian diare pada anak lebih besar dibandingkan
angka kejadianKEP
d. Semua anak yang menderita KEP, pasti menderita
defisiensimikronutrien
e. Penyebab kematian yang utama pada anak dengan KEP
adalah cuaca yang panas

Pernyataan yang tepat mengenai kwashiorkor :

a. Sebagian besar diderita oleh remaja
b. Disebabkan karena asupan sumber energi yang rendah
c. Penderita tampak kurus
d. Salah satu karakteristik yang jelas adalah adanya anoreksia
e. Umumnya terjadi pada seseorang yang sedang melakukan
diet rendah lemak jenuh
Penyebab marasmus adalah
a. Adanya proses maladaptive dari
kekurangan zat gizi
b. Adanya asupan protein yang rendah
c. Adanya aflatoksin pada tanah
disekitarnya
d. Terjadi pada tanah yang basah
e. Pengenceran susu formula yang
kurang tepat