Considerations in Nutrition Support of the Pediatric Patient Flashcards
Which of the following children is at greatest risk for iron deficiency anemia?
1: 3 month-old term infant exclusively fed human milk
2: 4 month corrected gestational age, former preemie on a transitional formula
3: 10 month-old switched from formula to whole milk
4: 17 month-old "picky eater"
3: 10 month-old switched from formula to whole milk
Iron deficiency anemia is the most common nutritional deficiency in childhood. Term infants usually have adequate iron stores up to 6 months of age. Infant formulas are fortified with sufficient iron to meet the needs of growing infants. The iron content of breast milk, though efficiently absorbed, is much lower compared to infant formula. Exclusively breastfed infants require additional iron starting at 4-6 months of age. This can be provided by complementary foods or iron supplementation. The iron content of cow’s milk is similar to human breast milk but the bioavailability is very low due to inhibitory effect of calcium on iron absorption. Due to the inadequate nutritional composition, cow’s milk should not be introduced before 12 months of age. A child with picky eating habits may or may not be at increased risk of iron deficiency anemia depending on which foods they are willing to consume. Diet assessment should be done to determine if iron supplementation is warranted.
An obese 12-year-old female is admitted to the hospital for an evaluation of sleep apnea. A diet history reveals that she drinks three cans of soda, 24 ounces of juice, and 8 ounces of chocolate milk daily. In what mineral may she be deficient?
1: Calcium
2: Phosphorus
3: Selenium
4: Potassium
1: Calcium
Total energy intake from beverages has been increasing in the US diet over the past two decades. It has been noted that sugar-sweetened beverages have contributed significantly to this increase. During this same time period, intake of milk has decreased leading to concerns for inadequate calcium intake in children. Studies have shown that female adolescents are most at risk for inadequate calcium intake. Though consumption of sugar-sweetened beverages is on a decreasing trend, intake remains well above recommendations. The American Academy of Pediatrics (AAP) currently recommends limiting juice intake to 4 oz per day for toddlers, 4-6 oz per day for preschoolers and 8 oz per day for school-age children and adolescents. The APP also recommends increased dietary intake of calcium and vitamin D-containing foods and beverages for optimal bone health. Current recommendations are for 2 to 3 servings of dairy per day for young children and 4 servings per day for adolescents.
A child with cerebral palsy and a gastrostomy tube is admitted to the hospital for a fundoplication. This procedure is used to manage
1: gastroesophageal reflux (GER).
2: oral/motor dysfunction.
3: malnutrition.
4: esophagitis.
1: gastroesophageal reflux (GER).
Gastroesophageal reflux (GER) is frequently seen in the children with neurological impairment. Initial management of these patients should include changes to feeding regimen, positioning as well as medications for reflux and motility. Though many patients will respond well to these changes, some will be refractory to treatment. In patients with intractable GER, a fundoplication may be performed. Given the potential for postoperative complications, this should only be considered in patients who have failed medical treatment. Conversion to a gastrojejunostomy tube could also be considered as an alternative to fundoplication.
Premature infants are at increased risk of metabolic bone disease in all of the following scenarios EXCEPT
1: short duration parenteral nutrition.
2: cholestasis.
3: chronic steroid use.
4: very low birth weight.
1: short duration parenteral nutrition.
Metabolic bone disease (MBD) is a multifactorial condition characterized by osteopenia and osteomalacia. Studies have shown that MBD is most often seen in very low birth weight infants, particularly those weighing <1500 grams. Other risk factors associated with MBD are chronic steroid use, chronic diuretic use, prolonged duration of parenteral nutrition, immobilization and cholestasis.
When used in assessment of critically ill children, how do predictive equations compare to indirect calorimetry?
1: No consistent comparison can be found
2: Equations typically overestimate needs
3: Equations typically underestimate needs
4: Equations correlate well with indirect calorimetry
1: No consistent comparison can be found
Though many equations exist to predict energy expenditure in children, all have been found to either over or underestimate resting energy expenditure. Indirect calorimetry continues to be the gold standard for assessment of energy needs in the critically ill patient and should be used whenever possible. When indirect calorimetry is not available, the Schofield or World Health Organization equation may be used.
A 13-year-old boy whose body mass index (BMI) is at the 97th percentile on the Centers for Disease Control and Prevention growth chart for age and sex would be classified as
1: underweight.
2: healthy weight.
3: overweight.
4: obese.
4: obese.
BMI is a screening tool used to identify children over 2 years of age and adolescents who are outside of their healthy weight ranges. Children with age and sex specific BMIs between the 85th and 94th percentiles are classified as overweight and those with BMIs greater than or equal to 95th percentile are classified as obese.
Which of the following is NOT associated with a delayed bone age in a child with short stature?
1: Hypothyroidism
2: Precocious puberty
3: Cushing syndrome
4: Growth hormone deficiency
2: Precocious puberty
One of the most useful diagnostic tests in assessing a child with abnormal growth is a “bone age”. The bone age is evaluated by a radiography of the patient’s knees or left wrist. Using established norms for different ages and sexes, a trained observer can estimate the degree of maturation of the bones. Precocious puberty is usually associated with an advanced bone age, while children with genetic short stature typically have a bone age similar to their chronological age. Hypothyroidism, growth hormone deficiency and Cushing syndrome all are associated with a delayed bone age.
Which of the following preterm growth charts allows for comparison for preterm infants from 22 weeks gestational age up through 10 weeks post term age?
1: Fenton
2: Ehrenkranz
3: Dancis
4: Lubchenco
1: Fenton
The Fenton growth chart, updated from data previously collected by Babson and Benda, has many benefits over other available growth charts. Data was collected from a large sample size and validation of the chart occurred by using data from the National Institute of Child Health and Human Neonatal Research Network; CDC growth charts; intrauterine growth data, and postnatal growth data. The data is cross sectional and is best used to assess growth over time. A major advantage is that it allows for tracking of growth from 22 weeks gestational age up through 10 weeks post term age.
When does the American Academy of Pediatrics (AAP) recommend universal screening for iron deficiency be performed in young children?
1: Between 4 and 6 months of age
2: Only when risk factors are present
3: Every 6 months in exclusively breastfed infants
4: At 12 months of age
4: At 12 months of age
Iron is the world’s most common single-nutrient deficiency and may impact long-term neurodevelopment. The AAP guidelines, last revised in 2010, recommend universal screening for all infants at 12 months of age to determine iron status. Selective screening can be performed at any age for infants with known risk factors such as prematurity, low socioeconomic status, poor growth and exclusive breastfeeding without supplementation. Healthy, term infants have sufficient iron stores until approximately 6 months of age making screening before this unnecessary. Formula-fed infants are typically able to meet iron needs throughout infancy due to iron fortification of infant formula. Human milk, however, contains insufficient levels of iron to meet the needs of the older infant. Breastfed infants should receive additional iron from complementary foods starting at approximately 4 months of age. For those unable to take complementary foods, iron supplementation should be considered.
When reviewing a child’s growth chart data, the child’s weight-for-length curve is falling below the 3rd percentile. Which Z-score indicates severely wasted?
1: Z-score above 3
2: Z-score above 2
3: Z-score below -2
4: Z-score below -3
4: Z-score below -3
The standard deviation (SD) score is also called the Z-score, which is useful to express how far a child’s weight falls from the median, or 50th percentile on the growth charts. When compared over time, a positive change in SD indicates growth, whereas a negative change indicates a slowing of the growth rate. A Z-score of below -3 is consistent with severely wasted, whereas a Z-score below -2 indicates wasted. A Z-score above 2 and above 3 is consistent with overweight and obese, respectively.
What is the suggested daily amount of potassium required for maintenance in an infant receiving parenteral nutrition?
1: 0.8-1 mEq/kg
2: 2-4 mEq/kg
3: 5-6 mEq/kg
4: 7-8 mEq/kg
2: 2-4 mEq/kg
The suggested daily amount of potassium is 2-4 mEq/kg for preterm infants, term infants, and children. In newborns, potassium is generally not added to the PN solution until kidney function is established. Close monitoring with necessary adjustments is imperative to prevent both hypo- and hyperkalemia.
What is the daily maintenance fluid requirement for a 5 kg infant?
1: 300 mL
2: 500 mL
3: 700 mL
4: 1000 mL
2: 500 mL
The Holliday-Segar method estimates caloric expenditure in fixed weight categories; it assumes that for each 100 calories metabolized, 100 mL of H2O will be required. Fluid rates can be adjusted based on clinical state (e.g., fever, tachypnea). This method is not suitable for neonates <14 days old. Fluids are calculated in the following way: 1st 10 kg-100 mL/kg/d; 2nd 10 kg- 50 mL/kg/d; Each additional kg-20 mL/kg/d (<= 50 kg.) or 15 mL/kg (> 50 kg.). Another way of calculating fluid needs is by way of calculating Body Surface Area (BSA). The BSA method is based on the assumption that caloric expenditure is proportional to BSA. It should not be used for children <10 kg. Mosteller’s Formula is a commonly used equation to calculate BSA(M2). M2= the square root of the following :Height(cm)x Weight(kg) / 3600; this value is multiplied by maintenance fluid requirement of 1500mL per day.
On radiographic examination, a pediatric patient is found to have osteopenia and multiple fractures in various stages of healing. Serum laboratory results show: calcium: low. phosphorus: low. creatinine: normal. alkaline phosphatase: high. 25-OH vitamin D: Low. 1,25 (OH)2 vitamin D: Low. PTH: high. Which of the following is the most likely diagnosis?
1: Renal tubular acidosis
2: Osteogenesis imperfecta
3: Vitamin D deficient rickets
4: Vitamin D dependent rickets type 2
3: Vitamin D deficient rickets
Biochemical findings in vitamin D deficient rickets include low or normal serum calcium, low or normal serum phosphorus, high alkaline phosphatase, increased parathyroid hormone and low 25(OH) Vitamin D levels. 1,25 (OH) Vitamin D levels will be low to normal. The main difference between vitamin D deficient rickets and vitamin D dependent type 2 rickets will be that 1,25 (OH) Vitamin D levels will be elevated in the latter. Renal tubular acidosis would be reflected through abnormalities in serum creatinine and anion gap. Osteogenesis imperfecta is a genetic disease that is characterized by multiple bone fractures, short stature and is diagnosed by physical exam. In osteogenesis imperfecta, results from routine laboratory studies are usually within reference ranges.
What is the recommended daily enteral elemental iron dose for preterm infants, one month after birth?
1: 0.5-1 mg/kg/d
2: 1-2 mg/kg/d
3: 2-4 mg/kg/d
4: 5-6 mg/kg/d
3: 2-4 mg/kg/d
The rate of growth and erythropoiesis are noted to slow down soon after birth. During such circumstances, iron requirements are lower. An exogenous source of 2-4 mg/kg/day of elemental iron is recommended during the period of stable growth, beginning at 4-8 weeks and continuing until 12-15 months of age. The American Academy of Pediatrics recommends that infants not receiving human milk receive an iron-fortified formula and that preterm infants receive at least 2 mg/kg per day of elemental iron from 1-12 months of age.
What trace element should be supplemented in a child with chronic diarrhea?
1: Iron
2: Zinc
3: Copper
4: Selenium
2: Zinc
The World Health Organization (WHO) defines acute diarrhea as less than 14 days in duration and persistent diarrhea as 14 days or longer in duration. Some experts use “chronic” to describe episodes lasting more than 30 days. The overwhelming bulk of evidence continues to support empiric zinc therapy for childhood diarrhea in low income countries. Recent studies demonstrate that zinc supplementation decreases the duration of diarrheal episodes, risk of hospitalization, all-cause mortality, and diarrheal mortality, with an estimated decrease in mortality of 23%. WHO /UNICEF recommendation for zinc supplementation includes the following: 20mg of zinc per day for 10-14 days for children with acute diarrhea and 10mg per day for infants under six months of age to curtail the severity of the episode and prevent further occurrences in the ensuing 2-3 months.
Which of the following is recommended to prevent vitamin D deficiency in a 1-month-old infant fed human milk?
1: Supplement with 100 IU vitamin D per day
2: Supplement with 200 IU vitamin D per day
3: Supplement with 300 IU vitamin D per day
4: Supplement with 400 IU vitamin D per day
4: Supplement with 400 IU vitamin D per day
There are limited natural dietary sources of vitamin D and adequate sunshine exposure for the cutaneous synthesis of vitamin D is not easily determined for a given individual and may increase risk of skin cancer. The recommendations to ensure adequate vitamin D status have been revised to include all infants, including those who are exclusively breastfed. It is now recommended that all infants have a minimum daily intake of 400 IU of vitamin D beginning soon after birth.
A seven month-old infant fed reconstituted infant formula and other age-appropriate complementary foods may be at risk of over-supplementation with which of the following?
1: Vitamin A
2: Fluoride
3: Vitamin E
4: Iron
2: Fluoride
During normal enamel maturation, the increased mineralization in the developing tooth is accompanied by the loss of matrix proteins that are secreted early in development. Sufficiently high levels of fluoride can disrupt this process and increase enamel porosity. The greater the amount of fluoride intake during development, the greater the prevalence of enamel fluorosis. The estimated risk of enamel fluorosis related to fluoride intake from reconstituted infant formula is positively associated with the fluoride concentration in tap water.
Non-nutritive sucking should be used in the enterally fed neonate less than 32 weeks corrected gestational age to promote
1: mother/child bonding.
2: weight gain.
3: correct development of facial and jaw muscles.
4: oral feeding when developmentally appropriate.
4: oral feeding when developmentally appropriate.
The ability to suck and swallow is present by 28 weeks gestation, but infants are not fully coordinated until 32 to 34 weeks gestation. Non-nutritive sucking improves digestion of enteral feedings and encourages development of sucking behavior. Non-nutritive sucking is thought to stimulate the secretion of lingual lipase, gastrin, insulin and motilin through vagal innervation in the oral mucosa. Although the infant may not be receiving nutrients orally, the practice of non-nutritive sucking may prevent the subsequent development of an oral aversion when the child is physiologically capable of oral feeding.
Which of the following is NOT a contraindication to nasogastric feedings in a pediatric patient with cystic fibrosis (CF)?
1: Chronic sinusitis
2: Chronic otitis
3: Pancreatic insufficiency
4: Need for long term nutrition support
3: Pancreatic insufficiency
While cystic fibrosis is associated with pancreatic insufficiency, pancreatic enzymes are given simultaneously to assist with adequate absorption of nutrients. Therefore, nasogastric (NG) feedings are not contraindicated in CF patients suffering from pancreatic insufficiency. Contraindications to NG feeding include upper airway secretions, nasal polyps, recurrent sinusitus or otitis. Patients who will require long term nutrition support should be evaluated for permanent enteral access placement.
Which of the following is the BEST indication for use of a soy-based infant formula?
1: Diarrhea
2: Cow’s milk protein allergy
3: Galactosemia
4: Regurgitation with feeds
3: Galactosemia
Infants with acute diarrhea,usually associated with gastroenteritis, can develop secondary lactase deficiency, but a soy formula is not recommended in those instances. Since a high percentage of children who are allergic to cow’s milk protein will also be allergic to soy protein, the American Academy of Pediatrics now recommends a trial use of either a hydrolyzed or free amino acid-containing formula. Galactosemia is an inborn error of metabolism that affects the body’s ability to metabolize galactose. Currently, the only way to treat galactosemia is to eliminate galactose from the diet. Soy-based infant formulas are used as substitutes for milk in galactosemia. The galactose content (approximately 20mg/L) of lactose-free cow’s milk infant formula is considerably higher than soy and hypoallergenic formulas; therefore lactose-free cow’s milk formula is not recommended for treatment of galactosemia. Soy protein-based formulas have no role in preventing allergy or in management of non-specific gastrointestinal symptoms, e.g., infantile colic and regurgitation.
