Signs of malnutrition don’t stop at scale

Malnutrition can seem like an easy problem to diagnose. Growth scales and projections can be used to determine if a child is growing as expected. However, there are also subtle signs of malnutrition to watch out for on a visit.

“Every pediatrician should think in terms of a food group,” says Praveen Sundaraj Goday, MD, pediatric gastroenterologist and director of nutrition at Children’s Wisconsin in Milwaukee. Goday also sits on the American Academy of Pediatrics Nutrition Committee.

Even obese or overweight children can suffer from poor nutrition. Others don’t eat fruits or vegetables, but still achieve growth and weight goals for their age. Pediatricians should ask questions about feeding during well visits, focusing specifically on the food groups from which the child eats and whether a special diet is followed.

There are ways to have a child on a good vegetarian diet, Goday notes, but the pediatrician should always be aware of these special diets or any restrictions. The child may appear to be well nourished but still requires pediatric multivitamin supplementation, he says.

To spot signs of malnutrition outside of the scale or assessment questions, Goday says there’s a lot to be said about a child’s appearance. Signs of malnutrition can include the following:

  • Pallor
  • Signs of anemia
  • Low battery
  • Rashes
  • Low weight gain or growth

“I think it’s essential to ask if the child is eating all food groups regularly,” says Goday. “If the child is, that’s a good sign. Otherwise, the pediatrician should ask himself why.

American Academy of Pediatrics Offers Guidelines1 help pediatricians advise parents on appropriate micronutrient needs, especially in the early years of life when neurodevelopment is critical.

Although in some cases malnutrition can be a negative effect of food choices or availability, pediatricians also need to understand when other factors contribute to malnutrition. In most cases, regular nausea or vomiting is a red flag in children with gastrointestinal (GI) disorders, Goday explains. “It would be rare not to have one. These could signal a problem, ”says Goday.

Daily or frequent vomiting is usually due to a problem with the gastrointestinal lining in the stomach or esophagus, says Goday, adding that these are the most common gastrointestinal issues related to malnutrition in children. . When frequent diarrhea is the complaint, there are tests that can check for lactose intolerance and other conditions that could lead to malabsorption of sugars. Pancreatic insufficiency is also a cause of malabsorption, Goday says.

Inflammatory issues like eosinophilic esophagitis and even mental health or behavior issues can also lead to malnutrition. Mental health and behavior problems are not necessarily caused by a nutritional problem, but rather by a behavioral problem that affects a child’s ability to eat properly. Autism is usually linked to problems with poor nutrition. “These 2 go together, but the reason is that autism causes eating problems and not the other way around,” says Goday.

He recommends that children who are extremely picky eaters be evaluated for the underlying neurobehavioural conditions. They may even require referral to speech therapists or other specialists.

Although pediatricians should be vigilant when it comes to evaluating the quality of the diet and eating habits of their patients, problems with nausea, vomiting or diarrhea are usually reasons to see a specialist. Pediatricians should be aware of problems that are not clearly explained by behavior. These are often associated with allergies or asthma.


1. Schwarzenberg JS, Georgieff MK. Advocacy for improved nutrition in the first 1000 days to support child development and adult health. Pediatrics. 2018; 141 (2): e20173716. doi: 10.1542 / peds.2017-3716

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