Infant Malnutrition Clinical Pathway — Outpatient Specialty Care and Primary Care

Differential Diagnoses

The majority of infants with infant malnutrition (failure to thrive) in General Pediatrics will fall under the inadequate intake category.
It is important to consider a broad differential diagnosis of potential underlying organic etiologies.

Etiology Symptoms Recommendations
Inadequate Intake
  • Long intervals between feeds (Sleep > 3 hrs when < 2 months old)
  • Falling asleep during feeds
  • Limited number and volume of feedings per day
  • Improper mixing of formula (PFE Section 40. General Nutrition)
  • Lactation problems: poor supply, difficulty with latching
  • Limited urine diapers (< 1 wet diaper per 8 hrs)
  • Food insecurity/inability to access food resources (i.e., WIC or SNAP)
  • Excessive vomiting/spitting up/reflux
  • Increased hunger cues/caregiver isn’t recognizing cues
  • Symptoms of maternal depression
  • Birth weight not regained in 2 weeks
  • Signs of oral motor dysfunction
Continue following Inadequate Intake Section
Malabsorption
  • High volume, extremely loose stools
  • Clay colored stools
  • Greasy or significantly foul smelling stools
  • Chronic diarrhea
  • Abdominal distention, gassiness with diarrhea
  • Blood in stools
  • Verify newborn screen negative for cystic fibrosis
  • Quantify and qualify stools
  • If abnormal stools, consider initial malabsorption workup
  • GI consult as clinically indicated
Increased Metabolic Demands
  • Cardiac: heart murmur, tachypnea, sweating or cyanosis with feeds, feeding fatigue
  • Respiratory: noisy breathing, tachypnea, difficulty breathing with feeds, nasal obstruction
  • Neurologic: increased or decreased tone, abnormal movements
  • Neuro-oncologic: diencephalic tumor causing nystagmus, strabismus, macrocephaly, papilledema, vomiting/lethargy
  • Metabolic/genetic: abnormal newborn screen, dysmorphic features
  • Renal: urologic abnormalities, renal tubular acidosis
  • Endocrinology: tachycardia, diaphoresis
  • Verify newborn screen
  • Labs and referrals based on clinical assessment
    • Consider additional referrals: Cardiology, GI, Endocrine, Neurology, Metabolic/genetic referral as clinically indicated