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Patient Story

An 18-month-old female was brought in for evaluation of a pale appearance. She was described as an active toddler with no recent fatigue, melena, or hematochezia. She was described as a picky eater and has averaged 30 to 40 ounces of milk intake per day for the past 6 months. Family history and past medical histories were noncontributory. On exam, height and weight were at the 50th percentile. Examination was normal except for a pale appearance, spooning of her nails (Figure 63-1), mild tachycardia, and a grade II/VI systolic ejection murmur heard best over the left lower sternal border. Labs were significant for the following: Hgb 7.0 g/dl, Hct 21.0 percent, MCV 52 fL, RDW 18 percent, reticulocyte count 1.9 percent, total iron 10 ug/dL (30 to 140 ug/dL), transferrin saturation 9 percent (11 to 46%), and ferritin 16 ng/mL (18–300 ng/mL). Peripheral smear showed microcytosis, hypochromia, mild anisocytosis, and polychromasia.


Koilonychia due to iron deficiency. (Used with permission from Rudolph CD, Rudolph AM, Lister GE, First LR, Gershon AA: Rudolph's Pediatrics, 22nd edition:

She was diagnosed with iron deficiency anemia and started on oral iron with concomitant reductions in her daily consumption of milk to no more than 18 to 20 ounces a day. At follow-up appointment one month later, she looked well and her appetite had improved with consumption of a wider variety of foods. Repeat Hgb was 9.5 g/dL and her MCV 69 fL. Three months later, her hemoglobin had completely normalized.


Nutritional disorders in children include both deficiency and excess states. Protein energy malnutrition remains one of the leading causes of death in children in underdeveloped countries. Obesity has emerged as one of the most common nutritional disorders in children worldwide. Children who have a body mass index (BMI) in the 85th to 94th sex- and age-specific percentile are considered overweight. Those with a BMI at or above the 95th percentile are considered obese.


  • Severe protein-energy malnutrition is uncommon in the US and other developed countries.

  • Childhood obesity rates have risen steadily, with current global estimates at approximately 17 percent, disproportionately affecting minority youth. Overweight and obesity are now on the rise in low- and middle-income countries, particularly in urban settings. Almost 35 million overweight children live in developing countries and 8 million in developed countries.

  • Overweight and obesity are linked to more deaths worldwide than malnutrition.

Etiology and Pathophysiology

  • Nutritional deficiency states may occur as a result of poor dietary intake, increased nutrient loss, or increased nutrient and energy requirements as seen in patients with chronic illness.

  • The small intestine is the predominant site of absorption of nutrients from the gastrointestinal tract. Any disease that interrupts ...

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