Malnutrition signs aren’t limited to the scale

Contemporary PEDS JournalJune 2021
Volume 38
Issue 6

There are several indicators of malnutrition—even for children with normal growth.

Malnutrition might seem like an easy problem to diagnose. Scales and growth projections can be used to discern whether a child is growing as expected. However, there are also subtle signs of malnutrition to watch for during a visit.

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

Even children who are obese or overweight can suffer from poor nutrition. Others eat no fruits or vegetables but still meet growth and weight goals for their age. Pediatricians should be asking questions about diet at well visits, specifically focusing on the food groups from which the child eats and whether any special diet is being followed.

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

For detecting signs of malnutrition outside of the scale or assessment questions, Goday says there is much one can tell from a child’s appearance. Signs of malnutrition could include the following:

  • Pallor
  • Signs of anemia
  • Low energy
  • Skin rashes
  • Low weight gain or growth

“I think focusing on whether the child is eating consistently from all food groups is key,” Goday says. “If the child is, that’s a good sign. If not, the pediatrician should be questioning why.”

The American Academy of Pediatrics offers guidelines1 to help pediatricians counsel parents on appropriate micronutrient requirements, especially in the first few years of life when neurodevelopment is critical.

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

Daily or frequent vomiting is usually because of a GI mucosal problem in the stomach or esophagus, Goday says, adding that these are the most common GI problems related to malnutrition in children. When frequent diarrhea is the complaint, there are tests that can check for lactose intolerance and other conditions that might result in malabsorption of sugars. Pancreatic insufficiency is also a cause of malabsorption, Goday says.

Inflammatory issues like eosinophilic esophagitis and even mental health or behavioral conditions can also lead to malnutrition. Mental health and behavioral conditions are not necessarily caused by a nutritional issue but rather a behavioral issue that affects a child’s ability to get proper nutrition. Autism is commonly linked to issues involving poor nutrition. “These 2 go together, but the reason is that the autism is causing feeding problems and not the other way around,” Goday says.

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

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


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

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