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Malnutrition
Failure to thrive (FTT) has classically been the term used to describe children who are not growing as expected. Studies have advocated using the term malnutrition to describe this cohort of children with specifically defined classification based on anthropometric measurements. In this chapter, malnutrition refers to undernutrition and is defined as an imbalance between nutrient requirements and intake or delivery that then results in deficits—of energy, protein, or micronutrients—that may negatively affect growth and development. Malnutrition may be illness related or non–illness related, or both. Illness-related malnutrition may be caused by one or more diseases, infections, or congenital anomalies, as well as by injury or surgery. Non–illness-related causes include environmental, psychosocial, or behavioral factors. Often, one cause may be primary and exacerbated by another. Patients with malnutrition may present with growth deceleration, faltering growth, or even weight loss, as measured by anthropometric parameters, including weight, height/length, skinfolds, and mid-upper arm circumference (see Chapter 57 ).
Clinical Manifestations
Inadequate weight-for–corrected age, failure to gain adequate weight over a period of time (weight gain velocity), height velocity, weight-for-height, body mass index (BMI), and developmental outcomes help define malnutrition (see Chapter 57 ). These growth and anthropometric parameters should be measured serially and plotted on growth charts appropriate for the child's sex, age (corrected if premature), and, if known, genetic disorders, such as trisomy 21. The American Academy of Pediatrics (AAP) and U.S. Centers for Disease Control and Prevention (CDC) recommend the 2006 World Health Organization (WHO) charts for children up to 2 yr of age who are measured supine for length. The CDC 2000 growth charts are recommended for children and adolescents (age 2-20 yr) when measured with a standing height. The severity of malnutrition (mild, moderate, or severe) may be determined by plotting the z score (standard deviation [SD] from the mean) for each of these anthropometric values ( Table 59.1 ).
Table 59.1
Comprehensive Malnutrition Indicators
Adapted from Becker PJ, Carney LN, Corkins MR, et al: Consensus Statement of the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition: Indicators recommended for the identification and documentation of pediatric malnutrition (undernutrition). J Acad Nutr Diet 114(12):1988-2000, 2014.
| INDICATORS * | SEVERE MALNUTRITION | MODERATE MALNUTRITION | MILD MALNUTRITION |
|---|---|---|---|
| Weight-for-length z score | ≥ −3 z score or worse | −2.0 to 2.99 z score | −1.0 to −1.99 z score † |
| BMI-for-age z score | ≥ −3 z score or worse | −2.0 to 2.99 z score | −1.0 to −1.99 z score † |
| Weight-for-length/height z score | ≥ −3 z score or worse | No data available | No data available |
| Mid-upper arm circumference (<5 yr of age) | ≥ −3 z score or worse | −2.0 to 2.99 z score | −1.0 to −1.99 z score |
| Weight gain velocity (≤2 yr of age) | ≤25% of norm | 26–50% of norm | 51–75% of the norm |
| Weight loss (2-20 yr of age) | >10% of UBW | >7.5% UBW | >5% UBW |
| Deceleration in weight-for-length/height or BMI-for-age | Deceleration across 3 z score lines | Deceleration across 2 z score lines | Deceleration across 1 z score line |
| Inadequate nutrient intake | ≤25% of estimated energy − protein need | 26–50% of estimated energy − protein need | 51–75% of estimated energy − protein need |
BMI, Body mass index; UBW, usual body weight.
Use clinical judgment when applying these diagnostic criteria.
* It is recommended that when a child meets more than one malnutrition acuity level, the provider should document the severity of the malnutrition at the highest acuity level to ensure that an appropriate treatment plan and appropriate intervention, monitoring, and evaluation are provided.
† Needs additional positive diagnostic criteria to make a malnutrition diagnosis.
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