In children two clinical syndromes are recognised: Marasmus and kwashiorkor.

Marasmus reflects a severe deprivation of food over a long time (chronic Protein-energy
malnourishment (PEM)). It is referred to as global starvation- that is the deficiency of all
elements of the diet. Marasmus is a form of PEM which is characterised by marked wasting of
muscles and subcutaneous tissue, presenting a wizened, shrivelled growth- retarded and skeletal
infant or child who is often alert and irritable with normal- coloured but shrivelled skin which
may show some scaling and hypo- pigmentation. Since the brain almost grows to full adult size
within the first two years of life, marasmus impairs brain development and learning ability.
Reduced synthesis of key hormones slows metabolism and lowers body temperature. There is
little or no fat under the skin to insulate against cold. It occurs most commonly in children from
6 to 18 months of age in all the over populated and impoverished areas of the world. Marasmic
children often have a good appetite, unlike children with kwashiorkor who are generally
anorexic. As a result, mortality rates in marasmus are lower than in kwashiorkor.
Kwashiorkor typically reflects a sudden and recent deprivation of food (acute PEM). It is
classically associated with a diet that is very low in both energy and protein, and may occur if the
infant is weaned early and is fed with dilute breast milk substitute. Affected infants are grossly
under weight for their age with no fat reserves (and a constant wrinkled appearance to the skin)
and severe muscle wasting. Kwashiorkor usually presents itself in children between the ages of 1
to 4 years and is most common in poor rural areas by children who are displaced from breast
feeding by the next siblings, and who are fed on very low protein, starchy foods (e.g. based on
maize, cassava or plantains). This presentation is often more acute than that of marasmus, with
oedema, irritability and a characteristic desquamation and scaly cracking of patches of the skin.
The loss of weight and body fat is not as severe in kwashiorkor as in marasmus. Proteins and
hormones that previously maintained fluid balance diminish, and fluid leaks into the interstitial
spaces. The childs limbs and abdomen becomes swollen with oedema, a distinguishable feature
of kwashiorkor. A fatty liver develops due to a lack of protein carriers that transports fat out of
the liver. The fatty liver lacks enzymes to clear metabolic toxins from the body, so their harmful
effects are prolonged. Inflammation in response to these toxins and to infections further
contributes to oedema that accompanies kwashiorkor. Without sufficient tyrosine to make
melanin, the childs hair loses its colour and inadequate protein synthesis leaves the skin patchy

and scaly, often with sores that fail to heal. The lack of protein to carry or store iron leaves iron
free. Unbound iron is common to children with kwashiorkor and may contribute to their illness
and deaths by promoting bacterial growth and free- radical damage.

Table summarizing the differences between kwashiorkor and marasmus

Marasmus

Infancy (less than 2 years old)

Kwashiorkor
Differences
Older infants and young children (1 to 4 years

Severe deprivation, or impaired absorption, of

old)
Inadequate protein intake or, more commonly,

protein, energy, vitamins and minerals

Develops slowly; chronic PEM
Severe weight loss
Severe muscles wasting, with no body fat

infections
Rapid onset; acute PEM
Some weight loss
Some muscle wasting, with retention of some

Growth: 60% weight for age

No detectable oedema
No fatty liver
Anxiety, apathy
Good appetite possible
Hair is sparse, thin and dry; easily pulled out

body fat
Growth: 60 to 80% weight for age
Oedema
Enlarged fatty liver
Apathy, misery, irritability, sadness
Loss of appetite
Hair is dry and brittle, easily pulled out, colour

Skin is dry, thin and easily wrinkled

changes; becomes straight

Skin develops lesions