Differential Diagnosis

A. Inadequate Intake. May result from a swallowing problem, formula mixing error, lack of access to formula or other foods due to limited finances, inappropriate substitution of other liquids (eg, juice) for formula, or neglect.

B. Excessive Losses Due to Diarrhea. Consider infectious agents (bacterial, Giardia), HIV, cystic fibrosis, or inflammation due to food allergies.

C. Increased Needs Due to Hypermetabolism or Increased Work of Breathing. Consider cystic fibrosis, hyperthyroidism, and cardiac disease.

D. Metabolic or Genetic Abnormalities. Consider inborn errors of metabolism and chromosomal abnormalities.

IV. Database

A. Physical Exam Key Points

1. Growth charts. With chronic inadequate calories and nutrients, patient's weight drifts first, then height falls off the curve, and finally head circumference. It is important to evaluate weight-for-height, a measure of body leanness, or the body mass index (BMI = weight in kg x height in meters squared). It is critical to obtain accurate and consistent measurements with nude weights of all infants and toddlers, and weight in underpants or gown in older children.

2. Head circumference. Measure in children until 24-36 months.

3. Abdomen. May be distended and full of gas in malnourished children, particularly if they are malabsorbing nutrients.

4. Musculoskeletal system. Check for muscle wasting in extremities and buttocks.

5. Anthropometrics. Tests such as skinfold thickness evaluate body energy stores; midarm muscle circumference evaluates lean body stores when compared with norms.

6. Other findings. Other signs of malnutrition and nutrient deficiency include sparse, dry, pluckable hair; dry scaly skin; red and swollen gums or tongue; cheilosis; diaper rash; and pale or spoon-shaped nail beds. Advanced vitamin deficiencies may lead to neurologic symptoms such as ataxia and dementia.

B. Laboratory Data. Should be guided by history and physical exam findings.

1. CBC with differential. To assess for anemia, evaluate lymphocyte (HIV) and eosinophil (allergy) counts.

2. Albumin and visceral proteins. Albumin is somewhat useful for assessing chronic protein depletion. Its half-life is 18-20 days; affected by stress, infection, nephrosis, colitis or overhydration. Serum levels of visceral proteins (prealbumin, transferrin, and retinol-binding protein) with shorter half-lives are more sensitive indicators than albumin.

3. Other workup. Complete metabolic panel with liver and kidney function tests plus electrolytes, thyroid function studies, celiac panel, immunoglobulins, and sweat test (cystic fibrosis) may be indicated.

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