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Malnutrition refers to disorder of nutritional status from either a deficiency or excess (i.e. imbalance) of energy, protein, and/or other nutrients that lead to adverse effects on tissue and body form and function as well as adverse clinical outcomes.1 Malnutrition therefore includes undernutrition, overweight, and obesity. Despite significant advances in prevention and treatment worldwide, malnutrition continues to have a substantial negative impact on child morbidity and mortality.2 The prevalence of undernutrition among hospitalized children in the United States and other resource-rich countries may be as high as 50%, but it varies considerably by age and disease state.3-6 The presence of undernutrition, overweight, and obesity among hospitalized children has also been associated with an increased risk of adverse clinical events, prolonged length of stay, and increased hospital charges and costs.3-7 This chapter addresses undernutrition, focusing on problems relating to inpatient care. Chapter 23 addresses failure to thrive.


Pediatric undernutrition is defined as an imbalance between nutrient requirement and intake, resulting in cumulative deficits of energy, protein, or micronutrients that may negatively affect growth, development, and other outcomes.6 Undernutrition is often related to environmental or behavioral factors. However, many hospitalized children have illness-related malnutrition, with one or more conditions directly resulting in a nutrient imbalance. This occurs as a result of decreased nutrient intake, altered utilization, excessive nutrient losses, or increased nutrient requirements not matched by intake.6 Furthermore, illness-related malnutrition is often associated with an inflammatory component, which may increase nutrient requirements and promote a nutrient-wasting catabolic state. The presence and severity of the inflammatory state may also impair the effectiveness of therapeutic nutrition interventions. Secondary complications include compromised immune function, impairments of gastrointestinal (GI) tract function, suboptimal response to medical or surgical therapy, and abnormal cognitive and behavioral development.3,6


Physical examination findings in children with malnutrition are variable and related to the chronicity, severity, and type of nutrient imbalance. Table 81-1 lists some of the findings associated with deficiencies of both macro- and micronutrients. Excessive intake of nutrients from overfeeding or unbalanced dietary intake can also result in abnormal physical examination findings, such as increased subcutaneous fat. Abnormal growth ultimately occurs in all patients with ongoing undernutrition, and in some cases it may be the only objective marker of poor nutritional status. Careful anthropometric measurements can assess growth cross-sectionally (e.g. triceps skinfold thickness) or longitudinally (length or height).

TABLE 81-1Physical Examination Findings Associated with Macro- and Micronutrient Deficiencies

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