Marasmus results from the body’s physiologic response to inadequate calories and nutrients. Loss of muscle mass and subcutaneous fat stores can be confirmed by inspection or palpation and quantified by anthropometric measurements. The head may appear large but generally is proportional to the body length. Edema usually is absent. The skin is dry and thin, and the hair may be thin, sparse, and easily pulled out. Marasmic children may be apathetic, weak, and may be irritable when touched. Bradycardia and hypothermia signify severe and life-threatening malnutrition. Inappropriate or inadequate weaning practices and chronic diarrhea are common findings in developing countries. Stunting (impaired linear growth) results from a combination of malnutrition, especially micronutrients, and recurrent infections.
Kwashiorkor results from inadequate protein intake in thepresence of fair to good caloric intake. The hypoalbuminemicstate results in pitting edema that starts in the lower extremities and ascends with increasing severity. Other factors, such asacute infection, toxins, and possibly specific micronutrient oramino acid imbalances, are likely to contribute to the etiology.The major clinical manifestation of kwashiorkor is that the body weight is near normal for age; weight alone does not accurately reflect the nutritional status because of edema. Physical
Physical Signs of Nutritional Deficiency Disorders
Depigmented skin Purpura Scrotal, vulval dermatitis Alopecia Depigmented, dull hair, easily pluckable Anemias (iron, vitamin B12, vitamin E, folate, and copper)
Protein, thiamine
Calories, protein, vitamin B6, niacin, riboflavin
Riboflavin, essential fatty acids, biotin
Calories, protein Vitamins C, K Riboflavin
Zinc, biotin, protein
Protein, calories, copper
Eye (vision) Adaptation to dark Color discrimination Bitot spots, xerophthalmia, keratomalacia
Vitamins A, E, zinc Vitamin A Vitamin A
Marasmus Riboflavin, iron Vitamins B6, niacin, riboflavin Vitamins C, K examination reveals a relative maintenance of subcutaneous adipose tissue and a marked atrophy of muscle mass. Edemavaries from a minor pitting of the dorsum of the foot to generalized edema with involvement of the eyelids and scrotum.The hair is sparse; is easily plucked; and appears dull brown, red, or yellow-white. Nutritional repletion restores hair color,leaving a band of hair with altered pigmentation followed by aband with normal pigmentation (flag sign). Skin changes arecommon and range from hyperpigmented hyperkeratosis toan erythematous macular rash (pellagroid) on the trunk andextremities. In the most severe form of kwashiorkor, a superficial desquamation occurs over pressure surfaces (“flaky paint”rash). Angular cheilosis, atrophy of the filiform papillae of thetongue, and monilial stomatitis are common. Enlarged parotidglands and facial edema result in moon facies; apathy and disinterest in eating are typical of kwashiorkor. Examination of
Riboflavin, iron, niacin, folate, vitamin B12
Iron Vitamins B6, B12, niacin, riboflavin, folate
Protein Fluoride Vitamins A, B12, zinc Vitamin A, zinc Iodine
Neurologic Sensory, motor neuropathy Ataxia, areflexia Ophthalmoplegia Tetany Retardation Dementia, delirium
Poor position sense, ataxia Vitamins D, C
Vitamin C, copper
Vitamin D, calcium Vitamin C Thiamine, selenium,