Marasmus - 1985

Dr Wilfred J. Pearson writing for the first volume of this Journal in 1925 defined marasmus (Greek: marasmos, wasting) as 'a chronic state of malnutrition of a severe grade' but pointed out that 'we must retain the conception ofcases varying in severity from those who simply show an insufficient gain or stationary weight with few systemic changes, to the most extreme form which is merely the end result of repeated nutritional or constitutional disturbances.' He described oedema in some cases as a complication of marasmus. The clinical picture of the syndrome, later described as kwashiorkor, was not generally recognized at this time, although a number of authors had described it (Czerney & Keller, 1928). In 1933 Cicely D. Williams, a paediatrician working in the Gold Coast of Africa described a 'nutritional disease ofchildhood associated with a maize diet' and attributable to protein deficiency. She named it kwashiorkor (taken from the Ga language of Ghana, the disease ofthe deposed baby when the next one is born). Her classical description included oedema, chiefly of hands and feet, wasting, diarrhoea, irritability and dermatosis. This paper attracted much attention in the medical literature and clinical descriptions of similar disease subsequently appeared from many other countries. Paradoxically the more commonly encountered type of malnutrition, marasmus, was neglected and until recently did not attract detailed scientific investigation. The original view that kwashiorkor resulted from protein lack in the presence of adequate, even excess carbohydrate, in contrast to marasmus which followed deficiency of energy alone, is not now accepted. Thus it has been shown that the protein: energy ratio of diets eaten by children developing washiorkor is adequate but total energy is deficient (Rutishauser & Frood, 1973; Goplan, 1968). However, it has become apparent that malnutrition produces a spectrum of syndromes ranging from simple growth failure alone to both pure and mixed syndromes of marasmus, marasmic kwashiorkor and kwashiorkor. In 1959 Jelliffe coined the term protein-calorie malnutrition (PCM) of early childhood to include mild, moderate and various types of severe degrees of malnutrition. The advent of the International System of Units (SI) resulted in the introduction of the term protein energy malnutrition (PEM). The World Health Organisation (WHO, 1973) defined PEM as follows: 'A range of pathological conditions arising from coincidental lack, in varying proportions, of protein and calories, occurring most frequently in infants and young children and commonly associated with infection'. This is not dissimilar from Wilfred Pearson's view of marasmus. In order to treat and, more importantly, to prevent a condition effectively, evolution and causes must be understood. It is therefore necessary to consider marasmus within the context ofPEM. The aim of this paper is to review the current state of knowledge concerning the pathophysiology, aetiology, clinical presentation and treatment of marasmus in the context of it being considered as one of a spectrum of syndromes produced by severe protein energy malnutrition (PEM).