Failure to Thrive: A Case in Pediatric Malnutrition

By Jenna Farrow
Dayton Children’s Hospital
Introduction

A.B. is a 3-month-old male who was admitted to the hospital on 11/28/2022 for poor growth

associated with malnutrition. A.B. weighs just 4.25 kg, with a weight-for-age Z-score of –3.99.

AB’s pediatrician sent him to the emergency department (ED) due to poor growth and weight

gain. AB presented to the ED with congestion and increased work of breathing. This patient was

chosen for this study because he is a complicated and severe case of malnutrition who requires a

multidisciplinary approach to care. AB’s family received care from a variety of sources, both in

and out of the hospital. The focus of this study is infant malnutrition, previously known as failure

to thrive (FTT). AB was discharged on 12/7/22.

General Disease Research

When AB attended his scheduled pediatrician follow-up, his doctor determined his lack

of weight gain was severe enough to warrant hospital admission. There are various types of

malnutrition. The first is illness related, the second is inflammation, and the third is starvation.

AB did not admit with an existing illness and had no signs of inflammation; therefore, AB was

diagnosed with starvation-related malnutrition. His diagnosis is also considered to be primary

rather secondary malnutrition, as it is not related to an underlying disease. AB’s malnutrition is

considered acute because it has been going on for less than 3 months, and severe because his Z-

score is >-3. (SEE TABLE) AB was not receiving adequate volumes of baby formula or breast

milk to meet his needs. Decreasing intake can cause protein-energy imbalances and

micronutrient deficiencies, in addition to loss of body mass, immune dysfunction, and a

prolonged hospital stay, all of which happened to AB.

 When the body is not receiving enough energy to maintain itself, the process of starvation

begins. If the body does not receive enough carbohydrates from food, it will start to deplete

glycogen stores. Glycogen is the body’s stored form of glucose. It is contained in the liver and

skeletal muscles, and we can use those stores to fuel the body in times of starvation. After about

12-16 hours without food, the body runs out of glycogen, it must try to make its own glucose

using the process of gluconeogenesis. The liver will break down proteins located in the skeletal

muscle and turn those amino acids into glucose. Once the body runs low on protein, it will start

using fat as fuel. The body mobilizes fat stores and begins the process of ketogenesis. By using

fat as fuel, the body can preserve more muscle protein.

Marasmus is the medical term for wasting or withering and is caused by a deficiency in

carbohydrates, fats, and protein. It typically takes a matter of months or even years for marasmus

to show on the body, but it happened quickly for AB. At only three months old, AB does not

have enough fat and muscle stores to compensate for his lack of nutrition. In the long term, this

can stunt a child’s physical growth and mental development, even if he does make a full

recovery. A patient with marasmus will show external warning signs, including prominent

skeleton, head appears large for the body, lethargy, weakness, and excessive weight loss (Titi-

Lartey & Gupta, 2022).

Hormones are also greatly affected by malnutrition. Malnutrition can lead to reduced

levels of the thyroid hormone tri-iodothyroxine (T3), insulin, and insulin-like-growth-factor-1

(IGF-1), and can increase levels of cortisol. Malnourished toddlers have lower serum levels of

growth hormone than adequately nourished toddlers (Sari et al., 2021). Growth hormone is the

primary hormone involved in the growth of a child, and deficiency in protein and zinc in

particular are thought to be responsible for a decrease in growth hormone and IGF-1.
 Further, the immune system is negatively affected by acute malnutrition. Normally, there

is a layer of mucous surrounding the airways and digestive track. This barrier prevents the body

from absorbing any microbes or dangerous bacteria that have been inhaled or swallowed. This in

turn releases cytokines (small proteins released from cells in times of distress) and those

inflammatory markers can negatively affect the function of growth hormone, which explains

why malnourished children tend to be shorter. With decreased immune function comes increased

susceptibility to invasive infections. T-cells are immune cells that are focused on killing foreign

invaders, and they are made in the thymus. During marasmus, the thymus tends to atrophy, and

T-cell function and production is reduced. Malnourished children with marasmus are more likely

to contract urinary, gastrointestinal, and upper respiratory infections. These are known as

opportunistic infections, meaning that these infections are likely occurring because the immune

system is struggling to fight them off. The microbes see the decreased immune system as an

opportunity to invade the host, and ultimately make them sicker.

The cardiovascular system is also impacted by malnutrition. The heart output is reduced

as weight is lost, and the heart gets weaker as malnutrition becomes more severe. The cardiac

muscles of the heart are comprised of myofibrils, which are long structures located in muscles

cells that help the muscle contract. The myofibrils in the heart are thin in someone with

marasmus, and therefore are not contracting properly (Bhutta et al., 2017). Electrolyte

imbalance, when combined with decreased contractility of the myofibrils, can predispose the

patient to cardiac arrhythmias (irregular heartbeat). If the patient has reduced muscle mass, a

decreased metabolic rate may prevent the body from responding to hypoxia, which is low

oxygen levels in the tissues. Hypoxia can be life threatening or cause developmental delay,

especially if the brain does not receive adequate oxygen.

 There are also various stages of muscle wasting that occurs in severe cases of

malnutrition. “Muscle wasting often starts in the axilla and groin (grade I), then thighs and

buttocks (grade II), followed by chest and abdomen (grade III), and finally the facial muscles

(grade IV), which are metabolically less active. In severe cases, the loss of buccal fat pads gives

the children an aged facial aspect” (Dipasquale et al., 2020). A.B. had some degree of all the

grades of muscle wasting. He had very thin legs and thighs, prominent collar bones and visible

ribs, and depletion of the temporal muscles of the face.

There are also long-term implications to being malnourished as an infant. Brain

development can be limited by lack of nutrition and can cause problems with cognition

throughout development. Malnutrition can cause a reduction in brain size by reducing the

number or neurons (brain cells), synapses (the junction between the brain cells through which a

nerve impulse passes by diffusing a neurotransmitter), and myelinations (the fatty substance

insulating the neurons). Slow growth in the brain, thinning cerebral cortex, global developmental

delay, motor function, and memory problems have all been associated with malnutrition.

Children who are malnourished have been shown to lose up to 13 IQ points in the long term (Sari

et al., 2021). One study suggests that these effects may not be reversible after the third or fourth

year of life (Dipasquale et al., 2020).

There are several different ways to assess for malnutrition. The Academy of Nutrition

and Dietetics uses the following criteria: Weight for length/BMI for age, Length/height for age,

and Mid-Upper Arm Circumference (MUAC). These factors are considered the most reliable

parameters for assessing pediatric malnutrition. There is no lab value that can be used to

determine malnutrition in children; anthropometrics are the only evidence-based way to assess

for malnutrition (Evans et al., 2020). The nutrition focused physical exam helps dietitians and
other medical practitioners determine the severity of malnourishment in both adults and children.

Malnourished patients have depleted subcutaneous fat pads, visible wasting of muscle tissue,

possible visible bones, and there may also be changes to the hair and nails. AB was very

obviously malnourished due to his thin arms, depletion of the temporal muscles, and protruding

collar bones and shoulder blades.

AB’s FTT is due to his parents not providing him with enough food. Patients are more

likely to be at risk of malnutrition if the parent struggles with depression, social support, poverty,

and lack knowledge about the baby’s growth and development. More mothers are in the

workforce than ever before, and studies show that mothers working over 30 hours per week are

less likely to breastfeed their children (Grzywacz, 2010). Unmarried mothers are also more likely

to engage in potentially negative feeding behaviors. AB’s parents were not married and each

working a full-time job. Moms who work a non-standard schedule (outside of Monday through

Friday from 8 to 5 work schedule) and a more physically demanding job, as AB’s mother did,

increases likelihood of poor infant feeding behaviors (Grzywacz, (2010). Having an education

less than that of a college degree was also associated with negative feeding behaviors in this

study.

Observing a feeding is an additional way to identify an issue in the context of severe

malnutrition. Having a medical professional, such as a speech language pathologist, observe a

feeding can identify bottle difficulties or oral aversions in babies. These signs usually present as

the baby crying, turning away from the bottle, or pushing the nipple out with the tongue. It is

important to not force a bottle on the baby, as oral aversions can be difficult to treat in the long-

term. An oral aversion can be treated in the short term by utilizing nutrition support from either

enteral or parenteral nutrition. The patient can receive nutrients via these methods while the team
treats the underlying causes. Nutrition support is particularly important for pediatric patients, as

going longer than 3 days without meeting needs can have a negative impact on the child’s

growth. Therefore, it is important to initiate nutrition support within 3 days of decreased oral

intake.

Malnourishment is a common problem in both pediatric and adult hospitals (Barker et.al, 2011).

By using the ASPEN indicators recommended for identifying and documenting pediatric

malnutrition, medical professionals can identify and correct undernutrition to prevent

consequences related to undernutrition. One must use their clinical judgement and knowledge of

nutrition to assess a child for undernutrition. First, it is important to understand the adequacy of

their food intake. The RD should first determine the child’s protein, energy, and fluid needs by

using standard equations. Some children have special needs associated with their diagnosis, and

this may have reduced or increased needs.

Second, the RD must gather the child’s anthropometric data. Their age, weight, and length/height

will help the RD determine if the child is growing appropriately by comparing them to growth

charts provided by the World Health Organization. If a child’s measurements differ greatly from

the average population (as measured by the Z-score), an RD will assess the severity of the child’s

nutritional status. Weight gain velocity is an especially important anthropometric measurement

pertaining to infants. Babies grow rapidly and a healthy child will gain weight every day. If an

infant, such as AB, doesn’t gain weight fast enough, or worse, loses weight, that child is at great

risk for being malnourished. BMI is also measured in children over age 2. The mid-upper arm

circumference (MUAC) can be used as a single data point in kids age 6-59 months (Becker,

2014). This measurement can be helpful for those with edema or ascites whose weight might

fluctuate depending on fluid status. Handgrip strength is not one commonly used in pediatrics, it
is more used in older adult populations. Handgrip strength can be used in kids over 6 as part of

an overall malnutrition screening.

Prevention

AB’s state of malnutrition could have been prevented if he was being seen by a clinician

more frequently. Prior to coming to the ED, his family had to change pediatricians because their

previous provider dropped them for no-show to appointments. When they finally made it to their

new pediatrician, he was so malnourished that the physician sent him to the ER.

AB’s severe malnutrition could have been prevented by following a strict feeding

schedule, which is required for all infants. Babies need to be fed approximately every 3 hours. It

is believed his slow weight gain velocity is due to inconsistent and inadequate feeds.

Home visitation programs have been shown to be very effective at encouraging a baby’s

weight gain in the first year of life. Mothers involved in these programs are also more likely to

breastfeed their newborn babies for at least the first two weeks of life (Scharff et al., 2020). AB’s

mother likely would have benefited greatly from a home visitation program for many reasons.

AB’s parents have financial barriers, transportation barriers, and education barriers. If AB and

his parents were involved in a home visitation program, his poor growth and weight loss could

have been prevented or minimized.

It was noted by social work that AB’s caretakers did not have enough social support to

properly care for their child. Between his parents working unconventional hours, a lack of

transportation to the clinician's office, poor financial stability, and limited access to necessary

resources, AB’s risk for malnutrition was increased due to his parent’s social status.

Social History
AB has a limited social history, as he is only 3 months old. AB’s parents are both working, his

mother went back to work at 6 weeks postpartum. Both of his parents work unconventional

schedules, which is has been shown to lead to poor infant nutrition. AB’s mother is a recipient of

WIC services and purchases formula through the program. AB currently has a case open with the

Children’s Services Board; neglect is suspected due to two past reports of poor growth. AB’s

other siblings are currently living with aunt and grandma, due to unsafe housing.

Past Medical History

AB has a history of poor weight gain, as do his 1- and 5-year-old siblings. AB was born full-term

with no complications besides an inguinal hernia which was repaired. He was brought to the

emergency department by his pediatrician due to his significantly low weight gain velocity.

Present Medical Status and Treatment

AB is congested and has trouble breathing; however, he has not tested positive for COVID, RSV,

or influenza. The speech pathologist recommended feeding AB using a nasogastric tube, due to

concerns of oral aversion. AB would display signs of aversion to the bottle, including turning his

head away from the bottle, and pushing the bottle out with his tongue. SLP instructed to feed AB

for no longer than 30 minutes, and gavage the remaining volume of formula. Over the course of

his stay, AB became more accepting of the bottle and began taking his goal feeds, even cueing

for more.

Theoretical treatment

AB’s labs indicated no signs of refeeding syndrome. Refeeding syndrome can occur in patients

who are undernourished for an extended period of time. Refeeding syndrome can be alleviated

with careful monitoring of electrolyte levels, including phosphorus, potassium, and magnesium.
These micronutrients can be supplemented during the patient’s hospital stay, as the body grows

more accustomed to being in a fed state, rather than starvation.

Treatment for AB’s malnutrition is to get him on a proper feeding schedule and make sure he is

taking enough volume during his feeds. His mother cannot produce enough milk for him;

therefore, it was decided to begin AB on a regimen of Enfamil Infant.

AB’s ideal diet order is 3.5 oz of Enfamil Infant 22kcal/oz every 3 hours. While admitted, he was

taking Enfamil Infant formula at 20kcal/oz, but was not gaining weight. After increasing the

concentration to 22kcal/oz, he was able to gain weight and get off the NG tube.

It is important to note that the direct treatment of AB’s malnutrition does not eliminate the risk

factors that put him in the hospital in the first place. Malnourished children are typically born

into low-income, low-educated families with insufficient access to funds and medical care.

Without systematic reform of our healthcare system, it will be impossible to protect every child

from neglect. Thankfully, with the coordination and dedication of hospital workers, AB was

placed in a home where we could receive the round-the-clock care that he needed.

Actual Treatment

AB required care from a variety of providers. Infants with malnutrition who are treated by a

multidisciplinary team have shorter hospital stays than those who are not (Schulman et al.,

2020). In addition to his dietitian, his mother received care from our lactation consultant on

pumping. Lactation provided his mother with a hospital-grade pump. While at work, mom was

pumping with a hands-free pump, which proved to be uncomfortable and unpractical. The

hospital provided mom with a hand pump, and later an electric one. After a few days of

admission, mom stopped pumping and AB was switched Enfamil Infant.

AB was being given his full regimen of Enfamil Infant, but still could not gain weight. His

formula regimen was concentrated from the standard 20 kcal/oz to 22 kcal/oz. By concentrating

his formula and increasing his caloric intake, AB was finally able to gain weight. However,

malnutrition is not cured after 3 consecutive days of weight gain. AB will need months of

concentrated caloric feedings to catch up in growth.

During his hospital stay, AB was primarily fed by clinical staff, especially for nighttime feeds.

He occasionally fed at the breast, although taking bottles for most feeds. Nurses reported that

during the night, AB could be heard crying through a closed door, with both parents in the room

sound asleep. This was of concern for CSB because AB was already struggling to gain weight,

and parents missing feeds would worsen his malnourished state.

AB also required care from a speech language pathologist while admitted. AB was experiencing

symptoms including congestion, excess mucus, and required nasal suctioning before receiving

his bottles. This was likely a contributor to his poor intake. During his admission, AB exhibited

signs of aversion including tongue pushing and turning his head away from the bottle. SLP

decided that AB required a nasogastric tube because he wasn’t taking a bottle. After a few days

using the nasogastric tube, AB began taking the majority of feeds by mouth, and eventually was

cleared to remove the NG tube. Once he began to eat well, he started gaining weight.

Social work was also involved in AB’s hospital stay, and he was not allowed to discharge

without the supervision of social workers. It was decided that the local county Children’s

Services Board would become his legal guardian until further notice.

Etiology
AB’s failure to thrive is caused by his parents’ negligence. At his age, AB needs to be fed every

three hours, approximately eight times per day. Baby formula needs to be mixed properly, in the

right proportions, at the right temperature, and consumed within an hour (or 24 hours if

refrigerated). If an error occurs in any of these steps, there could be serious consequences.

In AB’s case, he was not receiving the proper amount of formula often enough, and the calorie

concentration of his home feeds was too low. There was concerns during his admission that mom

was attempting to fortify her breast milk without consulting a medical professional. After it was

determined that mom would no longer be pumping, the Clinical Nutrition and Lactation Lab was

tasked with properly preparing all of AB’s feeds. Prior to his admission, AB would go most

nights without food for 10 hours. This went on for weeks, and as a result, AB was not growing at

the proper rate, even losing weight during admission.

Lab Values

AB did not have significant lab values. Labs indicated no concerns for refeeding syndrome. Tests

for upper respiratory infections such as COVID, RSV, and influenza all came back negative.

Urine tests were all normal. The only thing of note on AB’s lab results was decreased urine

output, which was likely due to dehydration prior to admission.

Medications

AB did not require medication during admission. He also did not need vitamin supplements, as

his formula regimen met all his needs, including iron and Vitamin D intake.

Medical Nutrition Therapy

Nutrition History:
A.B. has been breast feeding since birth, and his mother sometimes supplements his bottles with

Enfamil Infant because she is not producing enough milk to meet his needs. His mother was not

able to accurately quantify this to hospital staff, other than she adds a scoop of formula into the

bottle. She will nurse him on both breasts for 30+ minutes at a time and will provide a bottle if

he still seems hungry. This was cause for concern for the speech language pathologist, as he may

have been expending extra calories during nursing, but not achieving adequate intake. Based on

his parent’s report, AB goes about 10 hours without eating between the time mom leaves for

work and dad wakes up. Between not getting enough milk at the breast, and missing bottle feeds,

AB has been unable to gain weight appropriately. His mother reports that he often spits up after

feeds. During admission, AB’s mother noted that he wets about 20 diapers per day and has

recently had loose stool. While at home, AB was taking 400 IU/day of Vitamin D to supplement

breastmilk. This was no longer necessary after AB began taking his hospital regimen of formula.

Estimated Requirements: per 4.23 kg

Energy: 122-153 kcal/kg/d per the DRI x 1.2-1.5 for increased needs method of estimation
Protein: 2-3 gm protein/kg/d per the increased needs method of estimation
Total Fluid: 423 mL/d per Holliday Segar method for estimating needs
Feeding regimen: Enfamil Infant, concentrated to 22kcal/oz, minimum 105 mL every 3 hours.

Limit feeding time to 30 minutes.

○ Provides (per 4.285 kg): 840 mL total volume, 616 kcal (144 kcal/kg/d), 12.2-14.2 gm

protein (2.8-3.3 gm/kg/d)

PES Statements

NFPE Findings: extremities thin, scapula visible, limited fat stores on face and head
Feeding difficulty related to concern for oral aversion, as evidenced by SLP evaluation and need

for NG tube.

Chronic and severe malnutrition related to: decrease in dietary intake as evidenced by: weight for

length Z-score -3.92, growth velocity <50% since birth and nutrition focused physical findings.

-Improving with weight gain, continues to meet criteria for severe malnutrition. Updated

WFL z-score -3.19 using weight 12/7.

Discharge and Follow-up

AB was only allowed to discharge following 3 consecutive days of weight gain. AB did not

room in with his parents. AB was discharged under supervision from the Children’s Service

Board. AB had a follow-up in urology to check on his hernia repair, which is healing nicely.

CSB is following AB’s family after discharge. CSB will also be responsible for AB’s follow-up

appointments.

Plant-based Implications

As it stands, AB’s feeding regimen is naturally vegetarian, as he is not ready for solid

food and is only taking formula. The Academy of Nutrition and Dietetics states that a vegan diet

is suitable for all ages and life stages, including pregnancy and breastfeeding. With a little

planning, AB would be able to continue growing well on a vegan diet once transitioning to solid

foods. It is recommended that babies not consume solid foods until at least six months of age

(SOURCE). In order to achieve optimal nutrition status, AB’s caregivers would need to focus on

nutrient-dense foods, which are the basis of a healthy vegan diet. Including natural healthy fats

like avocados, nut and seed butters, and other omega-rich plant foods will help support brain
development. Soft, protein-rich foods like tofu and hummus can also be good starter foods for

AB. AB will need a B-12 and vitamin D supplement as a vegan, and his care team should

monitor calcium and iron status, as plant-based eaters are more likely to be deficient in these

minerals. Providing AB with calorie and nutrient dense foods is imperative to his wellbeing, as

the increased volume and fiber of a healthful vegan diet could cause him to get full before his

nutritional needs are met.

AB’s mother could also obtain optimal nutrition through a plant-based diet, however

there may be obstacles. AB’s family is low income and gets help from WIC and other services to

help meet their financial needs. WIC is a fantastic resource for families; however, it does not

provide enough food for the whole family. AB’s mother can use WIC funds to prioritize

purchasing healthy foods and use her own income to supplement. WIC also does not cover any

supplements she or the children might need. AB’s mother would need education on how to

adequately meet her and her family’s needs on a vegan diet. Education should be provided on

how to shop and cook on a budget, as well as education on a healthful diet. Time may also be a

constraint for AB’s mother, as she leaves for work around 3am, and the father also has an

abnormal work schedule.

If AB’s mother were to continue breastfeeding, she could do that successfully on a vegan

diet. The milk of vegetarian women is similar in nutrient concentration to that of nonvegetarian

mothers. Breastfeeding women require a significantly increased number of calories relative to

their normal intake. Again, choosing foods dense in calories and protein will fuel his mom’s

breastfeeding journey.

AB’s family would benefit from visiting a dietitian regularly, particularly one who is

versed in plant-based diets. AB may have require a bit of catch-up growth, so it is important to
focus on a high protein, high calorie diet to meet his needs. I predict AB’s family would benefit

from frequent support and follow-up visits in a Nutrition Clinic. The family could begin with

frequent monthly visits, and gradually reduce frequency as they gain knowledge and become

empowered. Telehealth visits would also benefit his family, as they do have transportation

barriers in place. The RD conducting a telehealth visit may need to access data from outside

clinics to obtain update weights and labs.

Prognosis

AB should have a good prognosis moving forward now that he is receiving adequate

care. AB will continue to grow and gain weight as he follows his feeding schedule. It is possible

that AB’s growth could be stunted or delayed due to the severe malnutrition he incurred during

infancy. AB’s growth should be closely monitored as he ages, and follow-up assessments should

be done to assess for developmental or intellectual delay.

Implications for the Hospital

AB’s plan of care required input from many different departments, including speech, dietitians,

physicians, social workers, nurses, lactation consultant, and respiratory and physical therapists.

Malnourished pediatric patients who receive care from a multidisciplinary team have shorter

hospital stays than those who do not, which saves money for the hospital.

Malnourished children are also more expensive to treat: $55,255 for malnourished children vs

$17,309 for adequately nourished children. This disparity is likely caused by the need for

malnourished children to spend more time in the hospital bedsource??.

Summary and Conclusion

Malnutrition, undernutrition, and failure to thrive all seem like straightforward diagnoses, but the

underlying cause and treatment of this condition is anything but. There are a multitude of factors

that contribute to pediatric malnutrition: financial instability, lack of transportation, poor

education, unstable housing. Malnutrition can lead to stunting, poor growth, behavior issues, and

global developmental delay. The treatment of malnutrition in an infant requires a

multidisciplinary team comprised of physicians, nurses, dietitians, speech language pathologists,

and social workers. Malnutrition is preventable with proper education of parents, access to safe

and stable housing, access to clinician visits, and cooperation and coordination between

caretakers.

References

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Tables
Primary indicators when two or more data points are available for use as criteria
for identification and diagnosis of malnutrition related to undernutrition:
Academy of Nutrition and Dietetics/American Society of Parenteral and Enteral
Nutrition 2014 Pediatric Malnutrition Consensus Statement 71-73,75,76
Moderate
Primary indicators Mild malnutrition Severe malnutrition
malnutrition
<75% of the norm
a b
<50% of the norm
a b
<25% of the norm
a b

Weight gain velocity

for expected weight for expected weight for expected weight
(<2 y of age)
gain gain gain
Weight loss (2 to 20 y 5% usual body 7.5% usual body 10% usual body
of age) weight weight weight
Deceleration in
weight for Decline of 1 z score Decline of 2 z score Decline of 3 z score
length/height z score
51% to 75% 26% to 50%
Inadequate nutrient ≤25% estimated
estimated estimated
intake energy/protein need
energy/protein need energy/protein need
a From Guo et al. 84

b World Health Organization data for patients younger than 2 y old. 85

Table 2Primary indicators when only a single data point is available for use as a
criterion for identification and diagnosis of malnutrition related to undernutrition:
Academy of Nutrition and Dietetics/American Society of Parenteral and Enteral
Nutrition 2014 Pediatric Malnutrition Consensus Statement 71-73,75,76
Moderate
Primary indicators Mild malnutrition Severe malnutrition
malnutrition
Weight for height z
−1 to −1.9 z score −2 to −2.9 z score −3 or greater z score
score
BMI for age z score
a
−1 to −1.9 z score −2 to −2.9 z score −3 or greater z score
Length/height z score No data No data −3 z score
Mid-upper arm Greater than or equal Greater than or equal Greater than or equal
circumference to −1 to −1.9 z score to −2 to −2.9 z score to −3 z score
a BMI=body mass index.