Thursday, February 22, 2024


Practice Essentials

Malnutrition is directly responsible for 300,000 deaths per year in children younger than 5 years in developing countries and contributes indirectly to more than half of all deaths in children worldwide. In addition, it increases health care costs.  See the image below.

This infant presented with symptoms indicative of

This infant presented with symptoms indicative of Kwashiorkor, a dietary protein deficiency. Note the angular stomatitis indicative of an accompanying Vitamin B deficiency as well. Image courtesy of the Centers for Disease Control and Prevention.

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See 23 Hidden Clues to Diagnosing Nutritional Deficiencies, a Critical Images slideshow, to help identify clues to conditions associated with malnutrition.

Signs and symptoms


According to the American Society for Parenteral and Enteral Nutrition (ASPEN), malnutrition can be classified as either being illness related (secondary to another disease or injury) non-illness related, (attributable to environmental/behavioral causes) or a combination of the two.

The most common and clinically significant micronutrient deficiencies and their consequences include the following:

Iron: Fatigue, anemia, decreased cognitive function, headache, glossitis, and nail changes

Iodine: Goiter, developmental delay, and mental retardation

Vitamin D: Poor growth, rickets, and hypocalcemia

Vitamin A: Night blindness, xerophthalmia, poor growth, and hair changes

Folate – Glossitis, anemia (megaloblastic), and neural tube defects (in fetuses of women without folate supplementation)

Zinc: Anemia, dwarfism, hepatosplenomegaly, hyperpigmentation and hypogonadism, acrodermatitis enteropathica, diminished immune response, and poor wound healing

Physical examination

Physical findings that are associated with PEM include the following

Decreased subcutaneous tissue: Areas that are most affected are the legs, arms, buttocks, and face

Edema: Areas that are most affected are the distal extremities and anasarca (generalized edema)

Oral changes: Cheilosis, angular stomatitis, and papillar atrophy

Abdominal findings: Abdominal distention secondary to poor abdominal musculature and hepatomegaly secondary to fatty infiltration

Skin changes: Dry, peeling skin with raw, exposed areas; hyperpigmented plaques over areas of trauma

Nail changes: Fissured or ridged nails

Hair changes: Thin, sparse, brittle hair that is easily pulled out and that turns a dull brown or reddish color

See Clinical Presentation for more detail.


Initial diagnostic laboratory studies include the following:

Complete blood count

Sedimentation rate

Serum electrolytes



Stool specimens should be obtained if the child has a history of abnormal stools or stooling patterns or if the family uses an unreliable or questionable source of water.

The most helpful laboratory tests for assessing malnutrition in a child are hematologic and protein status studies.

Hematologic studies

Hematologic studies should include a complete blood count with red blood cell indices and a peripheral smear.

Protein studies

Measures of protein nutritional status include levels of the following:

Serum albumin

Retinol-binding protein:  




Blood urea nitrogen

Additional laboratory studies

Other studies may focus on thyroid functions or sweat chloride tests, particularly if height velocity is abnormal.

Nutritional status studies

Practical nutritional assessment includes the following:

Complete history, including a detailed dietary history

Growth measurements, including weight and length/height; head circumference in children younger than 3 years

Complete physical examination

See Workup for more detail.


Children with chronic malnutrition may require caloric intakes of more than 120-150 kcal/kg/day to achieve appropriate weight gain. Most children with mild malnutrition respond to increased oral caloric intake and supplementation with vitamin, iron, and folate supplements. The requirement for increased protein is met typically by increasing the food intake. Management must be carried out in centers by physicians familiar with nutritional disorders as nutritional recovery syndrome may include excessive sweating and hepatomegaly. Refeeding syndrome is a potentially life threatening condition that occurs with administration of high calorie feeds in severely malnourished children. This potentially fatal condition is associated with electrolyte disturbances including hypokalemia and hypophosphatemia

In moderate to severe cases of malnutrition, enteral supplementation via tube feedings may be necessary.


The prevention of malnutrition in children starts with an emphasis on prenatal nutrition and good prenatal care. Promotion of breastfeeding is particularly crucial in developing countries where safe alternatives to human milk are unavailable. Health care providers should also counsel parents on the appropriate introduction of nutritious supplemental foods.

See Treatment for more detail.

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