Unifying Concepts

Classification of Malnutrition in Children

The World Health Organization (WHO) defines malnutrition as the cellular imbalance between the supply of nutrients and energy and the body’s demand for them to ensure growth, maintenance, and specific functions.

Malnutrition generally implies undernutrition and refers to all deviations from adequate and optimal nutritional status in infants, children and in adults. In children, undernutrition manifests as underweight and stunting (short stature), while severely undernourished children present with the symptoms and signs that characterize conditions known as kwashiorkor, marasmus or marasmic-kwashiorkor.

Definitions of malnutrition

Classification Definition Grading
Gomez Weight below %
median WFA
Mild (grade 1)
Moderate (grade 2)
Severe (grade 3)
75%–90% WFA
60%–74% WFA
<60% WFA
Waterlow z-scores (SD) below
median WFH
80%–90% WFH
70%–80% WFH
<70% WFH
WHO (wasting) z-scores (SD) below
median WFH
-3%</= z-score < -2
z-score < -3
WHO (stunting) z-scores (SD) below
median HFA
-3%</= z-score < -2
z-score < -3
Kanawati MUAC divided by
occipitofrontal head
Cole z-scores of BMI for age Grade 1
Grade 2
Grade 3
BMI for age z-score < -1
BMI for age z-score < -2
BMI for age z-score < -3

Abbreviations: BMI, body mass index; HFA, height for age; MUAC, mid-upper arm circumference; SD, standard deviation; WFA, weight for age; WFH, weight for height; WHO, World Health Organization.

Gomez Classification: The child’s weight is compared to that of a normal child (50th percentile) of the same age. It is useful for population screening and public health evaluations.

  • Percent of reference weight for age = [(patient weight) / (weight of normal child of same age)] * 100

Waterlow Classification: Chronic malnutrition results in stunting.  Malnutrition also affects the child’s body proportions eventually resulting in body wastage.

  • Percent weight for height = [(weight of patient) / (weight of a normal child of the same height)] * 100
  • Percent height for age = [(height of patient) / (height of a normal child of the same age)] * 100

Classification of Malnutrition in Children

Mild Malnutrition Moderate Malnutrition Severe Malnutrition
Percent Ideal Body Weight 80-90% 70-79% < 70%
Percent of Usual Body Weight 90-95% 80-89% < 80%
Albumin (g/dL) 2.8-3.4 2.1-2.7 < 2.1
Transferrin (mg/dL) 150 – 200 100 – 149 < 100
Total Lymphocyte Count (per µL) 1200 – 2000 800 – 1199 < 800

Wellcome Classification: evaluates the child for edema and with the Gomez classification system.

Weight for Age (Gomez) With Edema Without Edema
60-80% kwashiorkor undernutrition
< 60% marasmic-kwashiorkor marasmus




  1. Gomez F, Galvan RR, Cravioto J, Frenk S. Malnutrition in infancy and childhood, with special reference to kwashiorkor. Adv Pediatr. 1955;7:131–169. [Medline]
  2. Waterlow JC. Classification and definition of protein-calorie malnutrition. Br Med J. 1972 Sep 2;3(5826):566-9. [Medline]
  3. Waterlow JC, Buzina R, Keller W, Lane JM, Nichaman MZ, Tanner JM. The presentation and use of height and weight data for comparing the nutritional status of groups of children under the age of 10 years. Bull World Health Organ. 1977;55(4):489–498. [Medline]
  4. Grover Z, Ee LC. Protein energy malnutrition. Pediatr Clin North Am. 2009 Oct;56(5):1055-68. [Medline]
  5. Management of Severe Acute Malnutrition in Infants and Children []


Created: 28 Jul, 2010

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