Severely Malnourished Children

Katie in hospital

Many children adopted internationally or from foster care have some degree of malnutrition. Children who were severely malnourished early in life often have delayed growth and cognitive development, and can present special feeding challenges for adoptive families.

No matter what the cause, severe malnutrition is the result of not eating adequate calories, not being offered adequate calories, or not being able to retain adequate calories. Poor caloric intake can result from medical problems, such as prematurity, low birth weight, HIV, gastrointestinal diseases, food allergies, cystic fibrosis, lead poisoning, or others. It can also be the result of the child’s pre-adoption environment. For example, severe malnutrition can be seen in children who were not offered adequate calories as a result of low income or neglect. This type of malnutrition is not caused from anything that is medically wrong with the child, but rather is caused by the environment in which the child is living.

Upon arriving home, a child can be assessed for malnutrition by a health care provider. To correctly assess a child’s nutritional status, anthropometric, biochemical and dietary patterns must be analyzed.


Anthropometrics refers to the measurement of body proportions. The most common measurements are weight, length or height, and head circumference.

A child’s weight, length (or height), and head circumference should be measured by a health care provider regularly and plotted on an appropriate growth chart. Learn more about growth charts.

Measurements should be taken at every check-up, typically every 1-3 months in infants, and every 3-6 months in toddlers and children. Depending on a child’s age and condition at adoption, a pediatrician may determine an adjusted measurement schedule.

Download a recommended measurement schedule for children ages 0-5.

As a general rule of thumb, a typical, healthy child’s growth measurements fall between the 3rd and 97th percentiles. A child may fall below the 3rd percentile if they are genetically small-statured or severely malnourished. In the months after arriving home, small-statured children may continue to fall below the 3rd percentile, but will have a normal growth curve. Severely malnourished children may experience rapid, exponential growth – a period called catch-up growth.

Biochemical Laboratory Testing

In order to correctly treat malnutrition, certain laboratory tests must be measured.

Blood tests:

Stool tests:

Download a PDF of these lab tests to print and take to the doctor

Other tests to consider:

Dietary Pattern Analysis

If possible, obtain a detailed diet history from your child’s institution or foster family. While traveling for your adoption, try to capture answers for the following questions:

What food and drink is typically offered?

If a child drinks too much juice (>8oz/day) or milk (>24oz/day) this can result a decreased intake of solid foods.

What amount of food and drink are typically offered to and eaten by the infant or child?

Where do meals/snacks take place (table, floor, in a noisy or quiet room, in the presence of other children or adults, with a television on)?

It is helpful for children to eat all meals at a table or common eating area in the presence of other children and adults eating with them.

The stimulus of a television set can distract children from eating.

What is the feeding philosophy surrounding the child? Is force-feeding practiced, or is the child able to control what and how much he or she eats?

Force feeding can result to increased anxiety and resistance to eating.

Adults should determine what is served, when it is served and where it is served.

Children should determine if they eat the food, and how much of it they eat.

How does the child tolerate feeding? Is he/she able to finish meals in an appropriate time frame?

Meals should last no longer than 30 minutes, snacks no longer than 15 minutes.

Does your child tolerate a variety of textures? Is he/she able to chew and swallow without difficulty?

Some children have difficulty with certain textures, and this can result in decreased intake and possibly food aversions.

Since these observations are unable to be made first-hand by a pediatrician, it is important that the adoptive parent communicate as much as possible so the pediatrician has as much information as possible to make an assessment.

Download a PDF dietary observation checklist.

Once an assessment is complete, a plan can be made to help to restore the child back into a healthy nutritional status. This plan will depend on the cause of the malnutrition, but in general, the main goals are the same.

  1. Restore patient to an appropriate weight for length/height
  2. Make sure the child’s micro and macronutrient needs are provided for in order to support adequate growth
  3. Provide clear instructions to the child’s caregivers on how to care for the child’s nutritional and feeding needs.

Catch-up Growth

Catch-up growth is a faster-than-normal rate of weight and length gain that occurs when a child receives more calories and protein upon arrival at home. Catch-up growth occurs among most adoptees, but is particularly critical among children who are severely malnourished.

For children who are severely malnourished, more caution must be used when stimulating catch-up growth. Refeeding syndrome occurs if malnourished children are fed to quickly and their cells require more minerals and electrolytes than available. Vomiting, diarrhea, cardiac arrhythmias, and low blood levels of phosphorus, potassium, magnesium and glucose can result. To avoid refeeding syndrome, feeding a severely malnourished child should be carefully overseen by pediatrician. Upon arriving home, offer normal calories and protein for the child’s weight. A pediatrician can closely monitor potassium, phosphorus, magnesium and glucose levels and can recommend an appropriate multivitamin/mineral supplement.

Download a table of recommended dietary allowances of calories for children 0-8 years old.

Often, it is difficult for infants or children to meet the caloric needs necessary for catch-up growth. For this reason, high calorie/protein foods and drinks may be helpful. Consult with your pediatrician to determine if high calorie foods are appropriate for your child.

Download a list of calorie-dense and protein-rich foods and drinks.

For infants, concentrated infant formula may be beneficial. Infant formula, when prepared according to directions, is 20 calories/ounce. A pediatrician or pediatric dietitian can prescribe a higher calorie preparation (22-30 calories/ounce) that can help the infant meet their nutritional needs without having to drink very large volumes of formula. Children older than one year may do well with a pediatric nutritional drink, such as PediaSure®. These drinks are 30 calories/ounce and also provide protein, vitamins and minerals.

Ideally, treatment for malnutrition should continue until the child achieves a normal weight-for-length percentile and is able to maintain this for several months while continuing to gain weight at an appropriate rate. Length growth is slower to respond to nutritional therapy than weight, and so it is important to continue treatment nutrition even if the child begins to appear “chubby.” This extra fat can help to stimulate growth hormone necessary for length growth.

It is important to work closely with your child’s pediatrician and a dietician to determine an appropriate plan for treating severe malnutrition.

SPOON Foundation

135 SE Main St, Suite 201, Portland, OR 97214

Donate to Adoption Nutrition Adoption Nutrition on Twitter Adoption Nutrition on Facebook Adoption Nutrition Blog