Severe acute malnutrition (SAM) is the most critical and life-threatening form of undernutrition. It primarily manifests as marasmus or kwashiorkor, although patients may exhibit features of both in marasmic kwashiorkor. Identifying these clinical signs is crucial for proper diagnosis and management, as associated complications can be fatal.
Clinical Features of Severe Acute Malnutrition
SAM encompasses two main presentations: marasmus (wasting) and kwashiorkor (edematous malnutrition), often viewed as points on a spectrum. Marasmus is due to severe energy and protein deficiency, causing significant loss of body fat and muscle, leading to a skeletal, emaciated appearance, loose skin, and sunken eyes. Children with marasmus may also show apathy and irritability, along with bradycardia and hypothermia due to a reduced metabolic rate. Kwashiorkor is primarily linked to protein deficiency and is characterized by bilateral pitting edema, typically starting in the lower extremities. Other features of kwashiorkor include abdominal distention, distinctive skin changes, hair discoloration, hepatomegaly, and irritability. A notable difference is that children with kwashiorkor often have a poor appetite, unlike those with marasmus.
SAM also leads to severe systemic complications like severe infection, hypothermia, hypoglycemia, and electrolyte imbalances due to impaired immune and metabolic function. Dehydration, severe anemia, and Vitamin A deficiency leading to eye problems are also common.
Marasmus vs. Kwashiorkor: A Comparison
The table below highlights key differences between marasmus and kwashiorkor:
| Feature | Marasmus | Kwashiorkor |
|---|---|---|
| Primary Cause | Overall deficiency of calories and protein | Predominant protein deficiency with adequate caloric intake |
| Edema | Absent | Present (bilateral pitting) |
| Wasting | Severe muscle and fat wasting | Muscle wasting may be masked by fluid retention |
| Appetite | Often good or preserved | Poor or absent |
| Appearance | Emaciated, shrunken, "old man" face | Puffy, swollen face and limbs, distended abdomen |
| Skin & Hair | Dry, loose, and wrinkled skin; brittle hair | Dermatosis, flaky paint skin, hair discoloration/flag sign |
| Fatty Liver | Absent | Present (enlarged liver) |
| Prognosis | Better prognosis than kwashiorkor if treated | Worse prognosis, more dangerous due to multisystem involvement |
Diagnostic Indicators for Severe Acute Malnutrition
Diagnosis of SAM in children relies on WHO criteria. Key indicators include extremely low weight-for-height/length (<-3 z-scores) or a very low Mid-Upper Arm Circumference (MUAC <115 mm for children 6-59 months). The presence of bilateral pitting edema in both feet is also sufficient for diagnosis. Initial assessment involves checking for general danger signs and complications, and an appetite test helps guide care.
Conclusion
Recognizing the varied clinical features of severe acute malnutrition is crucial for timely and effective treatment. SAM presents with extreme wasting (marasmus), bilateral pitting edema (kwashiorkor), or a combination, alongside serious metabolic issues and systemic complications like infection, hypoglycemia, and hypothermia. Diagnosis relies on standardized tools like anthropometric measurements and edema assessment. Early identification and management following WHO guidelines significantly improve outcomes and reduce mortality. For further details, refer to {Link: WHO https://www.who.int/tools/elena/interventions/sam-identification}.
