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emedicine.medscape.com

Malnutrition 
Updated: Jul 19, 2017
Author: Harohalli R Shashidhar, MD; Chief Editor: Jatinder Bhatia, MBBS, FAAP 

Overview

Practice Essentials
Malnutrition is directly responsible for 300,000 deaths per year in children younger than 5 years in developing countries and
contributes indirectly to more than half of all deaths in children worldwide. In addition, it increases health care costs.  See
the image below.

This infant presented with symptoms indicative of Kwashiorkor, a dietary protein deficiency. Note the angular stomatitis
indicative of an accompanying Vitamin B deficiency as well. Image courtesy of the Centers for Disease Control and
Prevention.

See 23 Hidden Clues to Diagnosing Nutritional Deficiencies, a Critical Images slideshow, to help identify clues to conditions
associated with malnutrition.

Signs and symptoms

History

According to the American Society for Parenteral and Enteral Nutrition (ASPEN), malnutrition can be classified as either
being illness related (secondary to another disease or injury) non-illness related, (attributable to environmental/behavioral
causes) or a combination of the two.[1]

The most common and clinically significant micronutrient deficiencies and their consequences include the following:

Iron: Fatigue, anemia, decreased cognitive function, headache, glossitis, and nail changes

Iodine: Goiter, developmental delay, and mental retardation

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Vitamin D: Poor growth, rickets, and hypocalcemia

Vitamin A: Night blindness, xerophthalmia, poor growth, and hair changes

Folate - Glossitis, anemia (megaloblastic), and neural tube defects (in fetuses of women without folate
supplementation)

Zinc: Anemia, dwarfism, hepatosplenomegaly, hyperpigmentation and hypogonadism, acrodermatitis enteropathica,

diminished immune response, and poor wound healing

Physical examination

Physical findings that are associated with PEM include the following[2] :

Decreased subcutaneous tissue: Areas that are most affected are the legs, arms, buttocks, and face

Edema: Areas that are most affected are the distal extremities and anasarca (generalized edema)

Oral changes: Cheilosis, angular stomatitis, and papillar atrophy

Abdominal findings: Abdominal distention secondary to poor abdominal musculature and hepatomegaly secondary to
fatty infiltration

Skin changes: Dry, peeling skin with raw, exposed areas; hyperpigmented plaques over areas of trauma

Nail changes: Fissured or ridged nails

Hair changes: Thin, sparse, brittle hair that is easily pulled out and that turns a dull brown or reddish color

See Clinical Presentation for more detail.

Diagnosis

Initial diagnostic laboratory studies include the following:

Complete blood count

Sedimentation rate

Serum electrolytes

Urinalysis

Culture

Stool specimens should be obtained if the child has a history of abnormal stools or stooling patterns or if the family uses an
unreliable or questionable source of water.

The most helpful laboratory tests for assessing malnutrition in a child are hematologic and protein status studies.

Hematologic studies

Hematologic studies should include a complete blood count with red blood cell indices and a peripheral smear.

Protein studies

Measures of protein nutritional status include levels of the following:

Serum albumin

Retinol-binding protein:  

Prealbumin:

Transferrin

Creatinine

Blood urea nitrogen

Additional laboratory studies

Other studies may focus on thyroid functions or sweat chloride tests, particularly if height velocity is abnormal.

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Nutritional status studies

Practical nutritional assessment includes the following:

Complete history, including a detailed dietary history

Growth measurements, including weight and length/height; head circumference in children younger than 3 years

Complete physical examination

See Workup for more detail.

Management

Children with chronic malnutrition may require caloric intakes of more than 120-150 kcal/kg/day to achieve appropriate
weight gain. Most children with mild malnutrition respond to increased oral caloric intake and supplementation with vitamin,
iron, and folate supplements. The requirement for increased protein is met typically by increasing the food intake.
Management must be carried out in centers by physicians familiar with nutritional disorders as nutritional recovery syndrome
may include excessive sweating and hepatomegaly. Refeeding syndrome is a potentially life threatening condition that
occurs with administration of high calorie feeds in severely malnourished children. This potentially fatal condition is
associated with electrolyte disturbances including hypokalemia and hypophosphatemia

In moderate to severe cases of malnutrition, enteral supplementation via tube feedings may be necessary.

Prevention

The prevention of malnutrition in children starts with an emphasis on prenatal nutrition and good prenatal care. Promotion of
breastfeeding is particularly crucial in developing countries where safe alternatives to human milk are unavailable. Health
care providers should also counsel parents on the appropriate introduction of nutritious supplemental foods.

See Treatment for more detail.

Background
The World Health Organization defines malnutrition as "the cellular imbalance between supply of nutrients and energy and
the body's demand for them to ensure growth, maintenance, and specific functions."[3] More recently, the American Society
for Parenteral and Enteral Nutrition (ASPEN) workgroup defined pediatric malnutrition [undernutrition] 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 relevant outcomes."[1]   Women and young children are the most
adversely affected groups; one quarter to one half of women of child-bearing age in Africa and south Asia are underweight,
which contributes to the number of low birth weight infants born annually.[4]

Malnutrition is globally the most important risk factor for illness and death, contributing to more than half of deaths in
children worldwide; child malnutrition was associated with 54% of deaths in children in developing countries in 2001.[3, 4]
Protein-energy malnutrition (PEM), first described in the 1920s, is observed most frequently in developing countries but has
been described with increasing frequency in hospitalized and chronically ill children in the United States.[5] .  However,
consensus guidelines now address malnutrition irrespective of etiology. ASPEN identified two alternative ways to diagnose
malnutrition: BMI and unintentional weight loss. Among the various guidelines, the Subjective Global Assessment [SGA] is a
highly validated tool which includes medical history and a physical assessment.[6] The main classification of malnutrition is
either illness based [severe or moderate] or Non-illness based [severe to moderate] and were recently addressed.[7]

The effects of changing environmental conditions in increasing malnutrition is multifactorial. Poor environmental conditions
may increase insect and protozoal infections and also contribute to environmental deficiencies in micronutrients.
Overpopulation, more commonly seen in developing countries, can reduce food production, leading to inadequate food
intake or intake of foods of poor nutritional quality. Conversely, the effects of malnutrition on individuals can create and
maintain poverty, which can further hamper economic and social development.[4]

Kwashiorkor and marasmus are 2 forms of PEM that have been described but there has been a paradigm shift in
diagnosing pediatric malnutrition. The new schema for defining malnutrition incorporates the concepts of chronicity, etiology,
and pathogenesis of malnutrition; its relationship with inflammation; and its impact on functional outcomes.[1] The distinction
between the 2 forms of PEM is based on the presence of edema (kwashiorkor) or absence of edema (marasmus).
Marasmus involves inadequate intake of protein and calories, whereas a child with kwashiorkor has fair-to-normal calorie
intake with inadequate protein intake. Although significant clinical differences between kwashiorkor and marasmus are
noted, some studies suggest that marasmus represents an adaptation to starvation whereas kwashiorkor represents a
dysadaptation to starvation. See the image below.

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This infant presented with symptoms indicative of Kwashiorkor, a dietary protein deficiency. Note the angular stomatitis
indicative of an accompanying Vitamin B deficiency as well. Image courtesy of the Centers for Disease Control and
Prevention.

In addition to PEM, children may be affected by micronutrient deficiencies, which also have a detrimental effect on growth
and development. The most common and clinically significant micronutrient deficiencies in children and childbearing women
throughout the world include deficiencies of iron, iodine, zinc, and vitamin A and are estimated to affect as many as two
billion people. Although fortification programs have helped diminish deficiencies of iodine and vitamin A in individuals in the
United States, these deficiencies remain a significant cause of morbidity in developing countries, whereas deficiencies of
vitamin C, B, and D have improved in recent years. Micronutrient deficiencies and protein and calorie deficiencies must be
addressed for optimal growth and development to be attained in these individuals.

Pathophysiology
Malnutrition affects virtually every organ system. Dietary protein is needed to provide amino acids for synthesis of body
proteins and other compounds that have various functional roles. Energy is essential for all biochemical and physiologic
functions in the body. Furthermore, micronutrients are essential in many metabolic functions in the body as components and
cofactors in enzymatic processes.

In addition to the impairment of physical growth and of cognitive and other physiologic functions, immune response changes
occur early in the course of significant malnutrition in a child. These immune response changes correlate with poor
outcomes and mimic the changes observed in children with acquired immune deficiency syndrome (AIDS). Loss of delayed
hypersensitivity, fewer T lymphocytes, impaired lymphocyte response, impaired phagocytosis secondary to decreased
complement and certain cytokines, and decreased secretory immunoglobulin A (IgA) are some changes that may occur.
These immune changes predispose children to severe and chronic infections, most commonly, infectious diarrhea, which
further compromises nutrition causing anorexia, decreased nutrient absorption, increased metabolic needs, and direct
nutrient losses.

Early studies of malnourished children showed changes in the developing brain, including, a slowed rate of growth of the
brain, lower brain weight, thinner cerebral cortex, decreased number of neurons, insufficient myelinization, and changes in
the dendritic spines. More recently, neuroimaging studies have found severe alterations in the dendritic spine apparatus of
cortical neurons in infants with severe protein-calorie malnutrition. These changes are similar to those described in patients
with mental retardation of different causes. There have not been definite studies to show that these changes are causal
rather than coincidental.[8]

Other pathologic changes include fatty degeneration of the liver and heart, atrophy of the small bowel, and decreased
intravascular volume leading to secondary hyperaldosteronism.

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Hormonal adaptation to the stress of malnutrition: The evolution of marasmus.

A classic example of a weight chart for a severely malnourished child.

Frequency
United States

Fewer than 1% of all children in the United States have chronic malnutrition. Incidence of malnutrition is less than 10%,
even in the highest risk group (children in shelters for the homeless). Some studies indicate that poor growth secondary to
inadequate nutrition occurs in as many as 10% of children in rural areas. Studies of hospitalized children suggest that as
many as one fourth of patients had some form of acute PEM and 27% had chronic PEM.

International

The World Health Organization estimates that by the year 2015, the prevalence of malnutrition will have decreased to 17.6%
globally, with 113.4 million children younger than 5 years affected as measured by low weight for age. The overwhelming
majority of these children, 112.8 million, will live in developing countries with 70% of these children in Asia, particularly the
southcentral region, and 26% in Africa. An additional 165 million (29.0%) children will have stunted length/height secondary
to poor nutrition.

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Currently, more than half of young children in South Asia have PEM, which is 6.5 times the prevalence in the western
hemisphere. In sub-Saharan Africa, 30% of children have PEM. Despite marked improvements globally in the prevalence of
malnutrition, rates of undernutrition and stunting have continued to rise in Africa, where rates of undernutrition and stunting
have risen from 24% to 26.8% and 47.3% to 48%, respectively, since 1990, with the worst increases occurring in the
eastern region of Africa.[3]

Mortality/Morbidity
Malnutrition is directly responsible for 300,000 deaths per year in children younger than 5 years in developing countries and
contributes indirectly to more than half the deaths in childhood worldwide.

The adverse effects of malnutrition include physical and developmental manifestations. Poor weight gain and slowing of
linear growth occur. Impairment of immunologic functions in these children mimics those observed in children with AIDS,
predisposing them to opportunistic and other typical childhood infections.

In developing countries, poor perinatal conditions account for 23% of deaths in children younger than five. Malnourished
women are at high risk of giving birth to low birth weight infants. Many low birth weight infants (15-20% of all births
worldwide)[9] face severe short-term and long-term health consequences, such as growth failure in infancy and childhood,
which increases risk of morbidity and early death.[4]

Children who are chronically malnourished exhibit behavioral changes, including irritability, apathy and decreased social
responsiveness, anxiety, and attention deficits. In addition, infants and young children who have malnutrition frequently
demonstrate developmental delay in delayed achievement of motor skills, delayed mental development, and may have
permanent cognitive deficits. The degree of delay and deficit depends on the severity and duration of nutritional compromise
and the age at which malnutrition occurs. In general, nutritional insults at younger ages have worse outcomes. Dose-
dependent relationships between impaired growth and poor school performance and decreased intellectual achievement
have been shown.[4, 10, 11, 12]

Although death from malnutrition in the United States is rare, in developing countries, more than 50% of the 10 million
deaths each year are either directly or indirectly secondary to malnutrition in children younger than 5 years.[3]

Age
Children are most vulnerable to the effects of malnutrition in infancy and early childhood. Premature infants have special
nutritional needs that are not met with traditional feeding recommendations; they require fortified human milk or specially
designed preterm formula until later in infancy. Children are susceptible to malnutrition for differing reasons. During
adolescence, self-imposed dietary restrictions contribute to the incidence of nutritional deficiencies.

Presentation

History
See the list below:

Clinical signs and symptoms of protein-energy malnutrition (PEM) include the following:

Poor weight gain

Slowing of linear growth

Behavioral changes - Irritability, apathy, decreased social responsiveness, anxiety, and attention deficits

Clinical signs and symptoms of micronutrient deficiencies: Some of the clinical signs and symptoms of specific
micronutrient deficiencies may closely resemble those observed in PEM. Deficiencies of micronutrients, including
vitamins, minerals, and trace elements have been well described. The most common and clinically significant
deficiencies include the following:

Iron - Fatigue, anemia, decreased cognitive function, headache, glossitis, and nail changes

Iodine - Goiter, developmental delay, and mental retardation

Vitamin D - Poor growth, rickets, and hypocalcemia

Vitamin A - Night blindness, xerophthalmia, poor growth, and hair changes

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Folate - Glossitis, anemia (megaloblastic), and neural tube defects (in fetuses of women without folate
supplementation)

Zinc - Anemia, dwarfism, hepatosplenomegaly, hyperpigmentation and hypogonadism, acrodermatitis

enteropathica, diminished immune response, poor wound healing

Physical
Physical findings that are associated with PEM include the following:[2]

Decreased subcutaneous tissue: Areas that are most affected are the legs, arms, buttocks, and face.

Edema: Areas that are most affected are the distal extremities and anasarca (generalized edema). See the image
below.

This infant presented with symptoms indicative of a dietary protein deficiency, including edema and ridging of the
toenails. Image courtesy of the Centers for Disease Control and Prevention.

Oral changes

Cheilosis

Angular stomatitis

Papillar atrophy

Abdominal findings

Abdominal distension secondary to poor abdominal musculature

Hepatomegaly secondary to fatty infiltration

Skin changes

Dry peeling skin with raw exposed areas

Hyperpigmented plaques over areas of trauma

Nail changes: Nails become fissured or ridged.

Hair changes: Hair is thin, sparse, brittle, easily pulled out, and turns a dull brown or reddish color.

Causes
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See the list below:

Inadequate food intake is the most common cause of malnutrition worldwide. In developing countries, inadequate
food intake is secondary to insufficient or inappropriate food supplies or early cessation of breastfeeding. In some
areas, cultural and religious food customs may play a role. Inadequate sanitation further endangers children by
increasing the risk of infectious diseases that increase nutritional losses and alters metabolic demands.

In developed countries, inadequate food intake is a less common cause of malnutrition. Instead, diseases and, in
particular, chronic illnesses play an important role in the etiology of malnutrition. Children with chronic illness are at
risk for nutritional problems for several reasons, including the following:

Children with chronic illnesses frequently have anorexia, which leads to inadequate food intake.

Increased inflammatory burden and increased metabolic demands can increase caloric need.

Any chronic illness that involves the liver or small bowel affects nutrition adversely by impairing digestive and
absorptive functions.

Chronic illnesses that commonly are associated with nutritional deficiencies include the following:

Cystic fibrosis

Chronic renal failure

Childhood malignancies

Congenital heart disease

Neuromuscular diseases

Chronic inflammatory bowel diseases

In addition, the following conditions place children at significant risk for the development of nutritional deficiencies:

Prematurity

Developmental delay

In utero toxin exposure (ie, fetal alcohol exposure)

Children with multiple food allergies present a special nutritional challenge because of severe dietary restrictions.
Patients with active allergic symptoms may have increased calorie and protein needs.

Guidelines on fruit juice intake for children by the American Academy of Pediatrics recommend that in the evaluation
of children with malnutrition, the pediatrician should determine the amount of juice being consumed as excessive
juice consumption may be associated with malnutrition (overnutrition and undernutrition).[13]

Workup

Laboratory Studies
See the list below:

The most helpful laboratory studies in assessing malnutrition in a child are hematological studies and laboratory
studies evaluating protein status.

Hematological studies should include a CBC count with RBC indices and a peripheral smear. This could also
help exclude anemias from nutritional deficiencies such as iron, folate, and vitamin B-12 deficiencies.

Measures of protein nutritional status include serum albumin, retinol-binding protein, prealbumin, transferrin,
creatinine, and BUN levels. Retinol-binding protein, prealbumin, and transferrin determinations are much
better short-term indicators of protein status than albumin. However, in the field, a better measure of long-term
malnutrition is serum albumin because of its longer half-life.

Additional diagnostic evaluation

In children who have a history of adequate food intake and signs/symptoms of malnutrition, focus on
identifying the cause of malnutrition. Perform laboratory studies based on information from a complete history
and physical examination.
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Initial diagnostic laboratory studies include a CBC count, sedimentation rate, serum electrolytes, and
urinalysis and culture. Stool specimens should be obtained if the child has a history of abnormal stools or
stooling patterns or if the family uses an unreliable or questionable source of water.

Additional studies may focus on thyroid functions or sweat chloride tests, particularly if height velocity is
abnormal. Further diagnostic studies should be determined as dictated by the history and physical
examination. For example, lab tests evaluating renal function, such as phosphorus and calcium, should be
obtained in the presence of renal symptoms. Children with suspected liver disease should have triglyceride
and vitamin levels obtained, while zinc levels should be obtained in patients with chronic diarrhea.

Celiac serology is a useful screening test and should be considered, especially if there is a family history of celiac
disease or if other autoimmune diseases, such as type I diabetes mellitus, are present.

Other Tests
See the list below:

Practical nutritional assessment

Complete history, including a detailed dietary history

Growth measurements, including weight and length/height; head circumference in children younger than 3
years

Complete physical examination

Sensitive measures of nutritional status and failure to thrive

Percentiles:
Weight or weight for height less than 3rd or 5th percentile on standard growth curves
Standard Deviation Score
Weight ,2 standard deviations below mean for gender and age
Weight for height < 2 standard deviations below mean for gender and age
Z scores*
-2.0 less of weight for age or height for age or weight for height
- *Z scores are calculated by (Observed weight-mean weight)/standard deviation of reference
population

Height-for-age or weight-for-height measurements greater than 2 standard deviations below the mean for age

Treatment

Medical Care
Following evaluation of the child's nutritional status and identification of the underlying etiology of the malnutrition, dietary
intervention in collaboration with a dietitian or other nutritional professionals should be initiated. Children with edema must
be assessed carefully for actual nutritional status because edema may mask the severity of malnutrition. Children with
chronic malnutrition may require caloric intakes more than 120-150 kcal/kg/d to achieve appropriate weight gain. The
formula for determining adequate caloric intake is:

kcal/kg = (RDA for age X ideal weight)/actual weight

Additionally, any micronutrient deficiencies must be corrected for the child to attain appropriate growth and development.
Most children with mild malnutrition respond to increased oral caloric intake and supplementation with vitamin, iron, and
folate supplements. The requirement for increased protein is met typically by increasing the food intake, which, in turn,
increases both protein and caloric intake. Adequacy of intake is determined by monitoring weight gain.

A Cochrane Database of Systematic Reviews study noted that micronutrient powders (MNPs), which are single-dose
packets containing multiple vitamins and minerals in powder form for sprinkling onto any semisolid food, can effectively
reduce anemia and iron deficiency in children aged 6-23 months. While the benefits of this intervention as a survival
strategy or on developmental outcomes are unclear, the use of MNP is possibly comparable to daily iron supplementation
and better than placebo or no intervention.[14]

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In mild-to-moderate cases of malnutrition, initial assessment and nutritional intervention may be done in the outpatient
setting. A patient with malnutrition may require hospitalization based on the severity and instability of the clinical situation.
Hospitalization of patients with suspected malnutrition secondary to neglect allows observation of the interactions between
parent/caregiver and child and documentation of actual intake and feeding difficulties. It may also be warranted in cases
where dehydration and acidosis complicate the clinical picture. In moderate-to-severe cases of malnutrition, enteral
supplementation via tube feedings may be necessary.

A study by Stobaugh et al found that the proportion of children that recovered from moderate acute malnutrition was
significantly higher in the group that received ready-to-use supplementary food containing dairy ingredients in the form of
whey permeate and whey protein concentrate than in the group that received soy ready-to-use supplementary food. The
authors added that this study highlighted the importance of milk protein in the treatment of moderate acute malnutrition.[15]

Consultations
See the list below:

Any child at risk for nutritional deficiency should be referred to a registered dietitian or other nutritional professional
for a complete nutritional assessment and dietary counseling.

In the United States, children with poor nutrition secondary to inadequate intake should be referred to the appropriate
social agencies to assist the family in obtaining resources and providing ongoing care for the child.

Other subspecialty referrals are based on findings in the initial evaluation that may indicate a specific cause of
inadequate nutrition other than inadequate food intake.

Diet
See the list below:

Dietary guidelines were released by the US Department of Health and Human Services and the US Department of
Agriculture in 2015.[16]

Protein, energy, and other nutrient requirements vary with age, sex, and activity levels.

Following careful assessment of the child's nutritional status, initiate nutritional intervention in collaboration with
nutrition support personnel.

Children with chronic malnutrition may require caloric intakes in excess of 120-150 kcal/kg/d to achieve appropriate
weight gain. The diet must include adequate amounts of protein and other macronutrients.

Any micronutrient deficiencies must be diagnosed and corrected to achieve adequate somatic growth and
psychomotor development.

Follow-up

Further Outpatient Care

See the list below:

Monitor patients closely for growth and resolution of clinical signs and symptoms of malnutrition. Follow-up should be
based on the severity of the illness, age of the patient, and the patient's initial response to intervention.

Minimal intervals between visits should give the patient sufficient time to show a change in the measured parameter.
For example, in infants beyond the newborn stage, the time needed to show an appreciable change in weight is 7
days. A 4-week interval is needed to document changes in length, and an 8-week interval is needed to document a
change in height.

Deterrence/Prevention
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See the list below:

Prevention of malnutrition in children starts with an emphasis on prenatal nutrition and good prenatal care. Health
care providers should emphasize the importance of breastfeeding in the first year of life. Promotion of breastfeeding
is particularly crucial in developing countries where safe alternatives to human milk are unavailable. In addition to the
promotion of breastfeeding, health care providers should counsel parents on the appropriate introduction of nutritious
supplemental foods. Health care providers should continue to provide age-appropriate nutritional counseling at every
opportunity.

Programs addressing micronutrient supplementation and fortification have been successful at decreasing the
incidence of specific micronutrient deficiencies (eg, iodine, vitamin D) in many countries, and supplementation in
pregnant women has also been beneficial.[17, 18] These programs should be promoted more in developing
countries. In addition, research demonstrates that zinc supplementation can help reduce the duration and severity of
acute and persistent diarrheal illnesses in children in areas where diarrhea is a significant cause of mortality and is
recommended by the World Health Organization and UNICEF.[19, 20] Additional fortification programs should be
developed to address other common nutritional deficiencies such as iron deficiency, which continues to be significant
problem throughout the world.

Improvement in hygiene practices and sanitation reduces the incidence of infectious diseases, which decreases the
incidence of malnutrition in developing countries.

Prognosis
See the list below:

Children who have chronic malnutrition, especially those with intrauterine growth retardation and with onset at an
early age, do not achieve their full growth potential or regain cognitive deficits. Although malnutrition is rare in the
United States and other industrialized countries, over half of childhood mortality in developing countries is either
directly or indirectly secondary to malnutrition.

Contributor Information and Disclosures

Author

Harohalli R Shashidhar, MD Associate Professor, Department of Pediatrics, Chief, Division of Pediatric Gastroenterology
and Nutrition, University of Kentucky Medical Center

Harohalli R Shashidhar, MD is a member of the following medical societies: American Academy of Pediatrics, Kentucky
Medical Association, North American Society for Pediatric Gastroenterology, Hepatology and Nutrition

Disclosure: Nothing to disclose.

Coauthor(s)

Donna G Grigsby, MD Associate Professor, Department of Pediatrics, University of Kentucky College of Medicine

Donna G Grigsby, MD is a member of the following medical societies: Kentucky Chapter of The American Academy of
Pediatrics, Kentucky Pediatric Society, American Academy of Pediatrics

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-
in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Chief Editor

Jatinder Bhatia, MBBS, FAAP Professor of Pediatrics, Medical College of Georgia, Georgia Regents University; Chief,
Division of Neonatology, Director, Fellowship Program in Neonatal-Perinatal Medicine, Director, Transport/ECMO/Nutrition,
Vice Chair, Clinical Research, Department of Pediatrics, Children's Hospital of Georgia

Jatinder Bhatia, MBBS, FAAP is a member of the following medical societies: Academy of Nutrition and Dietetics, American
Academy of Pediatrics, American Association for the Advancement of Science, American Pediatric Society, American
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Society for Nutrition, American Society for Parenteral and Enteral Nutrition, Society for Pediatric Research, Southern
Society for Pediatric Research

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Nestle<br/>Serve(d) as a
speaker or a member of a speakers bureau for: Nestle<br/>Received income in an amount equal to or greater than $250
from: Nestle.

Additional Contributors

Maria Rebello Mascarenhas, MBBS Professor of Pediatrics, Perelman School of Medicine at the University of
Pennsylvania; Section Chief of Nutrition, Division of Gastroenterology and Nutrition, Director, Nutrition Support Service,
Medical Director, Integrative Health Program, Children's Hospital of Philadelphia

Maria Rebello Mascarenhas, MBBS is a member of the following medical societies: American Society for Parenteral and
Enteral Nutrition, North American Society for Pediatric Gastroenterology, Hepatology and Nutrition

Disclosure: Nothing to disclose.

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