Malnutrition signs aren’t limited to the scale

Malnutrition may seem like an easy-to-diagnose problem. Scales and growth forecasts can be used to determine if a child is growing as expected. However, there are also subtle signs of malnutrition to look out for during a visit.

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

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

There are ways to feed a child a proper vegetarian diet, Goday notes, but the pediatrician should still be aware of these special diets or any restrictions. The child may seem well-nourished, but still needs supplementation with pediatric multivitamins, he says.

For spotting signs of malnutrition outside of the scale or rating questions, Goday says there’s a lot to see in a child’s appearance. Signs of malnutrition may include the following:

PalenessSigns of anemiaLow energySkin rashLow weight gain or growth

“I think it’s critical to focus on whether the child is consistently eating from all food groups,” Goday says. “If the kid is, that’s a good sign. If not, the pediatrician should ask why.”

The American Academy of Pediatrics provides guidelines1 to help pediatricians advise parents on appropriate micronutrient requirements, especially in the early years of life when neurodevelopment is critical.

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

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

Inflammatory problems such as eosinophilic esophagitis and even mental health or behavioral problems can also lead to malnutrition. Mental health and behavioral problems are not necessarily caused by a feeding problem, but rather a behavioral problem that affects a child’s ability to receive proper nutrition. Autism is often associated with problems with poor nutrition. “These 2 go together, but the reason is that it causes autism to have nutritional problems and not the other way around,” Goday says.

He recommends that children who are extremely picky eaters be assessed for underlying neurobehavioral problems. They may even need a referral to speech therapists or other specialists.

While pediatricians should be vigilant when it comes to assessing their patients’ nutritional quality and eating habits, problems with nausea, vomiting, or diarrhea are usually grounds for referral to 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 improving 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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