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GI Flashcards

1
Q

What are the diagnostic criteria for childhood functional abdominal pain ?

A

> /= 1 week for >/= 2 months

  1. Episodic or continuous abdominal pain
  2. Insufficient criteria for other FRID’s
  3. No evidence of an inflammatory, anatomic, metabolic, neoplastic process

Becomes CFAP syndrome if:
CFAP + 25% of the time have either daily loss of function OR an additional somatic complaint

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2
Q

What are red flags for abdominal pain?

A
  • Weight loss -Unexplained fevers
  • Pain radiating to the back
  • Bilious emesis
  • Hematemesis
  • Hematochezia/melena
  • Chronic diarrhea -Gastrointestinal blood loss
  • Oral ulcers -Dysphagia
  • Unexplained rashes -Nocturnal symptoms
  • Arthritis -Anemia/pallor
  • Delayed puberty –Deceleration of linear growth velocity
  • Family history of IBD, celiac, PUD
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3
Q

Name 8 conditions in the organic differential diagnosis of constipation?

A 
Obstruction***
Hirschsprung disease
Electrolyte abnormalities (Hypothyroidism, hypercalcemia***, hypokalemia)
Celiac disease***
TSH***
Meds (Opiates, anticholinergics
ADHD medications)
Spinal cord anomalies
More rare:
Lead toxicity
Botulism
Cystic fibrosis
Anal achalasia
Imperforate anus/Anal stenosis
Pelvic mass (sacral teratoma)
Abnormal abdominal musculature (prune belly, gastroschisis, Down
syndrome)
Pseudoobstruction (visceral neuropathies, myopathies,
mesenchymopathies)
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4
Q 
What is the average number of BMs/day for:
0-3 months breastfed
0-3 months formula fed
6-12 months
1-3 years
>3 years
A 
0-3 months breastfed: 2.9 (5-40 BM/week)
0-3 months formula fed: 2.0(5-28 BM/week)
6-12 months: 1.8 (5-18 BM/week)
1-3 years: 1.4 (4-21 BM/week)
>3 years: 1.0 (3-14 BM/week)
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5
Q

Name 5 complications of chronic constipation

A
  1. Pain: Anal or abdominal
  2. Rectal fissure
  3. Encopresis (overflow diarrhea)
  4. Enuresis
  5. Urinary tract infection
  6. Rectal prolapse/solitary ulcer
  7. Stasis syndrome
    (Bacterial overgrowth–>Carbohydrate fermentation–>Maldigestion)
  8. Social exclusion/depression/anxiety
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6
Q

What are the Rome III criteria

for functional constipation?

A

In the absence of organic pathology, 2 of the following must occur

In children >=4 years-need 2 months of symptoms, insufficient criteria for IBS

In children <4 years-need 1 month of symptoms

  1. <=2 BM/week d
  2. o ≥ 1 episode incontinence/wk (after toilet trained)
  3. History of excessive stool retention
  4. History of painful or hard bowel movements
  5. Presence of a large fecal mass in the rectum
  6. History of large-diameter stools that may obstruct the toilet
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7
Q

Name 10 Alarm Signs and
Symptoms That Suggest the Presence of an
Underlying Disease Causing the Constipation?

A 
Constipation starting extremely early in life (<1 mo)
Passage of meconium >48 h
Family history of HD
Ribbon stools
Blood in the stools in the absence of anal fissures
Failure to thrive
Fever
Bilious vomiting
Abnormal thyroid gland
Severe abdominal distension
Perianal fistula
Abnormal position of anus
Absent anal or cremasteric reflex
Decreased lower extremity strength/tone/reflex
Tuft of hair on spine
Sacral dimple
Gluteal cleft deviation
Extreme fear during anal inspection
Anal scars
Weight loss
Urinary retention
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8
Q

What are the components of constipation management?

A

Education

Behavioural modification

Disimpaction

Daily maintenance stool softeners (should continue until after toilet trained to eliminate fear of defecation)

Dietary modification

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9
Q

What are 2 time periods where children are prone to functional constipation?

A

At the time of toilet learning (age 2-4 years)

During the start of school

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10
Q

What is fecal impaction?

A

Presence of a large and hard mass in the abdomen
Dilated vault filled with stool on rectal examination
History of overflow incontinence

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11
Q

Name 3 methods of fecal disimpaction

A

PEG 3350 1-1.5g/kg/day x 3 days

Enema x 6 days

High dose mineral oil

PEG via NG tube until clear effluent

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12
Q

What dose of PEG 3350 do you use for maintenance therapy?

A

Starting dose at 0.4 g/kg/day – 1 g/kg/day

For infants-dose up to 0.8 g/kg/day

Increasing the dose every two days until the child has1-2 soft stools per day

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13
Q

What are behavioural modifications that can be recommended in constipation?

A
  • Routine scheduled toilet sitting for 3 min to 10 min 1-2x a day
  • Ensure that the child has a footstool on which they can support their legs to effectively increase intra-abdominal pressure (valsalva)
  • There should be no punishment for not stooling during the toileting time
  • Praise and reward for stooling and the behaviour of toilet sitting can be offered.
  • Regular physical activity
  • Stool diaries
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14
Q

What are recommendations for dietary modifications in constipation?

A
  • A balanced diet that includes whole grains, fruits and vegetables
  • Carbohydrates (especially sorbitol) found in prune, pear and apple juices
  • Fibre intake of 0.5 g/kg/day (to a maximum of 35 g/day) for all children
  • For infants: reduce cow’s milk intake, increase fluid intake
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15
Q

How long should patients with constipation be treated for?

A

6 months
Until stools soft
Until after toilet training done

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16
Q

What stool softener is contraindicated in infancy?

A

Mineral oil is contraindicated in infants because of uncoordinated swallowing and the risk of aspiration and subsequent pneumonitis.

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17
Q

What are the Rome III criteria for functional dyspepsia?

A
  1. Persistent or recurrent pain or discomfort centered in the upper abdomen
    (above the umbilicus)
  2. Not relieved by defecation or associated with the onset of a change in stool
    frequency or stool form (i.e., not irritable bowel syndrome)
  3. No evidence of an inflammatory, anatomic, metabolic or neoplastic process
    that explains the subject’s symptoms
  • Criteria fulfilled at least once per week for at least 2 months prior to diagnosis
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18
Q

What are the Rome III criteria for infant dyschezia?

A

Must include both of the following in an infant less than 6 months of age

1) . At least 10 minutes of straining and crying before successful passage of soft stools
2) No other health problems

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19
Q

What is the goal of managing constipation?

A

Evacuation of stools without pain

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20
Q

What are the Rome III criteria for infant colic?

A

Must include all of the following in infants from birth to
4 months of age:

  1. Paroxysms of irritability, fussing or crying that starts and stops without
    obvious cause
  2. Episodes lasting 3 or more hours/day and occurring at least3 days/wk for
    at least 1 week
  3. No failure to thrive
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21
Q

What are the Rome III criteria for IBS?

A

Must include both of the following:

  1. Abdominal discomfort** or pain associated with two or more of the following
    at least 25% of the time:
    a. Improvement with defecation
    b. Onset associated with a change in frequency of stool
    c. Onset associated with a change in form (appearance) of stool
  2. No evidence of an inflammatory, anatomic, metabolic, or neoplastic process
    that explains the subject’s symptoms
  • Criteria fulfilled at least once per week for at least 2 months prior to diagnosis

** “Discomfort” means an uncomfortable sensation not described as pain.

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22
Q

What are the Rome III criteria for abdominal migraine?

A

Must include all of the following:

  1. Paroxysmal episodes of intense, acute periumbilical pain that lasts for 1 hour or more
  2. Intervening periods of usual health lasting weeks to months
  3. The pain interferes with normal activities
4. The pain is associated with 2 of the following: 
Anorexia
Nausea
Vomiting
Headache
Photophobia
Pallor
  1. No evidence of an inflammatory, anatomic, metabolic, or neoplastic process considered that explains the subject’s symptoms
    * Criteria fulfilled two or more times in the preceding 12 months
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23
Q

What is the definition of celiac disease?

A

Immune-mediated enteropathy caused by a permanent sensitivity to gluten in genetically susceptible individuals

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24
Q

What conditions have an increased risk of celiac disease?

A

Type I diabetes

Selective IgA deficiency

Down syndrome

Turner syndrome

Williams syndrome

First degree relatives of individuals with celiac disease

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25
Q

What is the most common age of presentation of celiac disease?

A

6-24 months (after introduction of solids)

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26
Q

How does celiac disease present?

A 
Chronic or recurrent diarrhea
Abdominal distension
Anorexia
Failure to thrive or weight loss
Short stature
Abdominal pain
Vomiting
Constipation
Irritability
Rarely: Celiac crisis (explosive watery diarrhea, marked ado distension, severe hypoK)
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27
Q

Name 9 non-GI manifestations of celiac disease

A 
Dermatitis herpetiformis
Dental enamel erosions
Osteopenia/osteoporosis
Delayed puberty
Short stature
Iron-deficiency anemia (resistant to oral Fe)
Hepatitis
Arthritis
Ataxia
Epilepsy with occipital calcifications
Alopecia areata
Erythema nodosum
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28
Q

How do you diagnose celiac disease?

A

Screening:
anti-TTG IgA (+IgA and IgG)
-Best serological test
-May be falsely -ve in < 2years old (because can be IgA deficient)
-ant-TTG IgG if IgA deficient (less sensitive)

Deaminated gliadins

  • New
  • May be useful if IgA deficient or < 2 years old

Definitive diagnosis:
Endoscopy and small bowel biopsy

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29
Q

In what age group are anti-TTG antibodies unreliable?

A

<2 years of age

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30
Q

What 4 screening tests would you order in a child with suspected celiac disease?

A

CBC
Albumin
Anti-TTG
IgA

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31
Q

What is the most definitive diagnostic test for celiac disease?

A

Endoscopic small bowel biopsy

Finding=villous atrophy with hyperplasia of the crypts and abnormal surface epithelium

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32
Q

Name 4 causes of small intestinal flat villi other than celiac disease

A 
Acute infectious enteritis (Rotavirus)
Tropical sprue
Cow’s milk protein intolerance
Eosinophillic gastroenteritis
Microvillus inclusion disease
Autoimmune enteropathy
Immunodeficiencies (including CVID or IPEX syndrome)
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33
Q

How do you treat celiac disease?

A

Only treatment for celiac disease is a gluten-free diet (GFD)
–Strict, lifelong diet

Avoid:
Wheat
Rye
Barley 
\+/ - oats
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34
Q

What is the definition of UC?

A

Generalized bowel inflammation confined to the mucosa, starting at the rectum and involving a variable extent of colon proximally

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35
Q

What is the definition of CD?

A

Generalized inflammation of any portion of alimentary tract, from mouth to anus

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36
Q

What are the clinical features of CD?

A

Abdominal pain (72% at diagnosis)

Weight loss (58%)

Diarrhea (56%)

Blood in stool (22%) – late feature; more common with colonic involvement

Growth failure (20-30%)

Perirectal inflammation w/ fissures/fistulas (7%)

Other:

N+V

Delayed puberty

Arthritis

Chronic hepatitis

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37
Q

What are the clinical features of UC?

A 
Bloody diarrhea
(In almost all patients, except those with isolated proctitis)

Abdominal pain with BM

Fever (in fulminant disease)

Growth failure (10%)
(Almost always due to corticosteroids in UC)

Arthritis

Sclerosing Cholangitis (3%)

Chronic active hepatitis (<1%)

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38
Q

What groups are at increased risk of IBD?

A 
Ashkenazy Jews
Autoimmune disorders (UC especially)
1st degree relatives
PSC
Turner syndrome
Hermansky-Pudlak syndrome
Glycogen storage disorder type 1B
Inborn errors of leukocyte adhesion
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39
Q

What type of IBD is most common in children?

A

65% CD
33% UC
2% IBD-U

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40
Q

Which disorders have decreased frequency of IBD?

A

Disorders of coagulation:
Von Willebrand disease
Hemophilia

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41
Q

What macroscopic features distinguish UC and CD?

  • Rectum
  • Distribution
  • Terminal ileum
  • Bowel wall
  • Mucosa
  • Stricture
  • Fistula
A
  • Rectum: UC-yes, CD-variable
  • Distribution: UC-diffuse/continuous inflammation from rectum proximally, CD-patchy
  • Terminal ileum: UC-not involved, CD-thick, stenosed
  • Bowel wall: UC-normal, CD-thickened (transmural inflammation)
  • Mucosa: UC-hemorrhagic, CD-cobblestone/linear
  • Stricture: UC-rare, CD-common
  • Fistula: UC-rare, CD-common
  • Perianal disease: UC-rare, CD, common
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42
Q

Name 10 diseases in the differential diagnosis of IBD

A

Infection
Salmonella, Shigella, Campylobacter, E. coli O157:H7, Aeromonas
***Yersinia – great mimicker of Crohn’s
C. diff
Parasites: Giardia, Entamoeba histolytica
Tuberculosis (with isolated T.I. involvement)

HUS, HSP

Chronic granulomatous disease

Ischemic colitis

Dietary protein intolerance

Vasculitis (e.g. HSP)

Behcet’s Disease (CD)

Small bowel lymphoma

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43
Q

What initial laboratory investigations should you order in IBD?

A

CBC:
Microcytic anemia, can have iron deficiency
Thrombocytosis

ESR (elevated in 80% with CD, 40% with UC)

CRP (sensitive for bowel inflammation)

Albumin (low) – protein loss, poor nutrition

(LFTs (esp GGT) – look for hepatic involvement)

Fecal calprotectin (measures inflammation in gut, helps differentiate from IBS)

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44
Q

How do you ANCA and ASCA antibodies help differentiative between UC and CD?

A

UC: pANCA positive
CD: ASCA positive

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45
Q

What finding on biopsy distinguishes CD from UC?

A

Noncaseating granulomas (pathaneumonic for CD), Transmural inflammation

Both CD/UC have crypt architecture distortion, cryptitis, crypt abscess

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46
Q

Last 2 diagnostic tests that can confirm the diagnosis of Crohn’s disease.

A

Upper and lower endoscopy with biopsies

MRI-enterography or UGI-SBFT

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47
Q

Name 3 acute complications of Crohn’s disease

A 
Perforation
Stricture with SBO
Abdo abscess
Peri-anal abscess/fistula Renal stones
Gallstones
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48
Q

What are the complications of steroids?

A 
Growth failure
Osteoporosis
Cushingoid
Hirsutism
Acne
Bruising
Hair loss
Mood swings
Insomnia
Hyperglycemia
Diabetes
AVN of the hip
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49
Q

What are the complications of UC?

A 
Increased risk of adenocarcinoma
Sclerosing cholangitis (PSC)
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50
Q

List 2 factors increase the risk of adenocarcinoma in UC (past SAQ)

A

Increased duration of colitis
Increased extent of colitis (pancolitis > left sided)
Association with primary sclerosing cholangitis

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51
Q

What is a prognostic factor in CD?

A

Ileocolitis (respond more poorly to medical therapy and greater need for surgery)

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52
Q

What medications can be used for induction IBD therapy?

A 
Steroids
5-ASA (mild)
Biologics (remicade)
Enteral nutrition
Methotrexate
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53
Q

What medications can be used for maintenance IBD therapy?

A 
Not steroids
5-ASA
6MP-Immuran
Enteral nutrition
Methotrexate
6-MP/Immurane
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54
Q

What medications can be used for induction CD therapy?

A

Steroids

EEN

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55
Q

What medications can be used for induction CD therapy?

A

5-ASA

Steroids

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56
Q

Name 10 extraintestinal manifestations of IBD

A 
Arthritis
Ankylosing spondylitis
Clubbing
Osteoporosis
Erythema nodosum
Pyoderma gangrenosum
Metastatic Crohns disease (skin)
Aphthous ulcers
Cheilitis***
Uveitis
Primary sclerosing cholangitis
Cholelithiasis
Growth failure
Pubertal delay
Autoimmune hemolytic anemia
Nephrolithiasis
Peripheral neuropathy
Acute pancreatitis (Crohn's)
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57
Q

What type of renal stones are classically associated with Crohn’s disease?

A

Oxalate

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58
Q

List 10 causes of erythema nudism

A 
IBD
Mycoplasma
TB
Group A strep***
Coccioidomycosis
EBV
Cat Scratch disease
Sarcoidosis
OCP
Celiac
Penicillin
Leukemia
Lymphoma
Behcet's disease
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59
Q

List 4 conditions that are associated with pyoderma gangrenosum?

A

UC
RA
Multiple myeloma
PAPA syndrome - acronym for pyogenic arthritis, pyoderma gangrenosum and acne (genetic)

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60
Q

What are the clinical criteria for Toxic Megacolon?

A

1) Radiographic evidence (TC>=56mm)
2) Systemic toxicity
Fever >101.5
Tachycardia
Dehydration
Electrolyte disturbance
ALC or coma
Hypotension or shock
(suspect in UC patient with pain all the time)

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61
Q

What radiographic finding is suggestive of toxic megacolon?

A

Transverse colon diameter >=56mm (or>40 mm in <10 years)

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62
Q

How do you diagnose lactose intolerance?

A

Do a breath test, but milk elimination trial best practically

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63
Q

How do you diagnose PLE

A

Stool alpha-1 antitrypsin

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64
Q

What is the first investigation you should order for conjugated hyperbilirubinemia in an infant?

A

AUS

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65
Q

List 6 causes of unconjugated hyperbilirubinemia (pre-hepatic) in infants?

A

Hemolysis

  • Sepsis
  • Galactosemia
  • Hemoglobinopathies
  • Membranopathies

Non-hemolytic processes

  • Hypothyroidism
  • Breast feeding jaundice (volume depletion)
  • Breast milk jaundice
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66
Q

List 6 causes of conjugated hyperbilirubinemia and a definitive test for each (past SAQ)

A
  1. Biliary atresia-intra-operative cholangiogram
  2. Choledochal cyst-AUS
  3. Alagille-genetic testing for JAG1 and NOTCH2
  4. TORCH
  5. Sepsis-blood culture
  6. Galactosemia-GALT activity

Comprehensive ddx:

  1. Extrahepatic Biliary Obstruction:
    • Biliary Atresia
    • Choledochal cyst
    • Biliary sludge (TPN)
2. Genetic:
•	Alagille
•	CF
•	PFIC
•	Bile acid transport defects – e.g. Dubin Johnson and Rotor
  1. Infections:
    • TORCH
    • Sepsis/UTI
  2. Metabolic:
    • Alpha-1-antitrypsin deficiency
    • IEM → FAOD, tyrosinemia, galactosemia
    • Bile acid synthesis defects
  3. Endo:
    • Congenital Hypothyroidism
    • Panhypopit
  4. Medication:
    • TPN
    • Antibiotics → Ceftriaxone, Fluconazole, Micafungin
  5. Systemic Disorders
    • Congenital heart disease/CHF
    • Shock
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67
Q

After how many weeks of life should a jaundiced infant have a fractionated bilirubin assessment ?

A

2 weeks

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68
Q

What 3 criteria are required for acute liver failure?

A

INR >1.5 +encephalopathy
OR
INR>2 even without encephalopathy
AFTER attempted correction with ONE dose of IV vitamin K

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69
Q

Name 7 causes of pediatric acute liver failure

A

In order of most common:

  1. Indeterminate
  2. Drugs and toxins (acetaminophen, AEDs, INH)
  3. Metabolic (HFI, galactosemia, tyrosinemia, Wilson’s, NAFLD)
  4. Immune (GALD, hemochromatosis, autoimmune hepatitis, HLH)
  5. Infectious (Adeno, enterovirus, HBV, herpesvirus)
  6. Ischemia/shock (CHD, asyphyxia, Budd Chiari)
  7. Irradiation damage
  8. Infiltrative disease
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70
Q

What drugs can cause fulminant liver failure?

A 
Acetaminophen
AED (VPA, Carbamazepine)
Anti-TB drugs (INH)
Inhaled anaesthetics
Mushrooms
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71
Q

What investigations would you order in acute liver failure?

A

-CBC, lytes, BUN, creatinine
-ALT, AST, ALP, GGT, CRP
Bilirubin (conjugated, unconjugated, delta)
-INR/PTT, albumin, glucose, ammonia

Causes:

  • Acetaminophen level, tox screen
  • Viral serology: Hepatitis A, B, C, E, EBV, CMV, Adeno and Enterovirus
  • AIH: Immunoglobulins, anti-LKM, anti-SMA, ANA,
  • Wilson: Serum copper, ceruloplasmin, 24-h urinary Cu
  • A-1-AT: Serum alpha-1-AT
  • Ferritin, LDH
  • Liver imaging
  • Liver biopsy (correct INR, check Plt, CBC 4-6post)
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72
Q

List 4 steps in the initial management of acute liver failure (past SAQ)

A

For the exam:

  1. Transfer to a transplant centre (if not already at one) and treat the underlying cause if known
  2. Manage coagulopathy – Vitamin K, and if needed FFP, Cryo, and Platelets
  3. NPO on maintenance IV D5/0.9NS with close monitoring of lytes, end-organ function, fluid balance, and urine output
  4. Enemas and lactulose

Detailed management:

  • Transfer to a transplant centre
  • Admit to ICU
  • Treat the underlying cause (e.g. acetaminophen OD, steroids for AIH)
  • Intubate if necessary, minimize/avoid sedatives
  • PPI for GI bleed prophylaxis
  • Close monitoring of lytes/glucose, urine output, fluid balance with replacements as needed
  • Coagulopathy →VitK, FFP, Cryoprecipitate, Platelets
  • Consider plasmapharesis, dialysis
  • Monitor for infection → 50% of patients experience serious infection, more so with gram +
  • Protein restriction in diet
  • Encephalopathy →enemas, lactulose q2-4h, antibiotics (rifaximin or neomycin), flumazenil may temporarily reverse early encephalopathy
  • Monitor for cerebral edema
  • Transplant if advanced ALF
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73
Q

Name 4 interventions for coagulopathy in acute liver failure

A

IV PPI
Vitamin K
FFP +/- Cryo for bleeding/prior to invasive procedure

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74
Q

What is the only factor made outside the liver?

A

8

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75
Q

Name 2 ways patients with acute liver failure have impaired immune systems

A

Impaired neutrophil and Kupffer cells phagocytic function,

Decreased complement levels

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76
Q

Name 2 signs of portal hypertension on physical exam in child with liver disease

A

Ascites
Caput medusae
Splenomegaly
Recanalization of umbilical vein

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77
Q

What is the significance of HBc Antibody?

A

Immune response to naturally acquired HBV

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78
Q

What is the significance of HBe antigen?

A 
Positive = active infection
Negative = seroconversion
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79
Q

What is the significance of HBe antibody?

A

If present with –ve Hbe Ag, supports seroconversion

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80
Q

How do you tell if there is active mutant HepB infection on serology?

A

HBeAg negative

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81
Q

What is the CPS recommendation on duration of breastfeeding?

A

Exclusive x 6 months

Continued with complementary foods >2 years

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82
Q

What is the ratio of whey: casein of breastmilk?

A

Whey:casein 70:30 (bovine 18:82)

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83
Q

What is the benefit of high whey ratio in breastmilk?

A

Whey fraction promotes gastric emptying, more easily absorbed

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84
Q

Preterm milk has more total nitrogen. True of false?

A

True

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85
Q

What vitamins and minerals are low in breastmilk?

A

Vitamin D and K
Calcium and phosphorus (more bioavailable)
Iron, zinc, copper decline over time, but adequate to meet needs until 6 months

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86
Q

List 10 advantages of breastfeeding

A

For mom:

  • Improves weight loss
  • Delayed onset of menses
  • Decreased breast and ovarian cancer, heart disease and risk factors
  • Cheaper

For infant:

Decreases

  • Bacterial meningitis
  • Bacteremia
  • Gastroenteritis
  • Respiratory tract infections
  • OM
  • UTIs
  • Negative effects of 2nd hand smoke
  • SIDS
  • Obesity later in life
  • Childhood malignancies including lymphoma and leukemia
  • Type I and II DM
  • Allergic disease including atopic dermatitis and asthma
  • IBD

Increases

  • Neurocognitive testing
  • Faster gastric emptying
  • Stimulates intestinal growth, differentiation
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87
Q

List all the maternal and infant contraindications to breastfeeding

A

Infant:
-Galactosemia and congenital lactase deficiency

Maternal indications:
HIV
HTLV
Untreated active TB
HSV on breast
Chemotherapy/cytotoxic drugs
Radioactive isoptopes/radiation therapy
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88
Q

What is expected frequency of breastfeeding in first weeks of life?

A

Feed 8-12x/day, avoid >4 hour break

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89
Q

What is the expected number of wet diapers and stools in first week of life?

A

Day 3: 3-4 wet diapers/day, 1-2 stools (transitional)

Day 7: 6 wet diapers/day, yellow stool with each feeding

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90
Q

When should vitamin K be given after birth?

A

Within 6 hours

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91
Q

What is the dose of vitamin K that should be given for neonates?

A

<1500g-0.5 mg IM

>1500g-1.0 mg IM

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92
Q

For how long should you supplement with vitamin D in breastfed babies?

A

Until 6 months

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93
Q

Name 3 indications for increase vitamin D supplementation to 800IU per day in breastfed babies

A

Living north of latitude 55 degrees, October-April

Living in community with high prevalence of vitamin D deficiency

Children with dark skin

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94
Q

Until what age should you avoid fluoride supplementation?

A

6 months of age

95
Q

When should you supplement fluoride in children >6 months of age?

A

Don’t brush teeth 2x/day
High risk of dental caries (family history, geographic area)
Living without fluoridated water (<0.3 ppm)

96
Q

How much fluoride should you supplement for children:
6 mos-3 years
3 years-6 years
>6 years

A

6 mos-3 years 0.25 mg/day
3 years-6 years 0.5 mg/day
>6 years 1 mg/day

97
Q

Phyoestrogens in soy are contraindicated in which condition?

A

Congenital hypothyroidism (phytoestrogens can inhibit thyroid peroxidase, potentially lowering free thyroxine concentrations)

98
Q

What is Acrodermatitis enteropathica?

A

AR disorder caused by inability to absorb sufficient zinc

99
Q

What abnormality on bloodworm can hint at Zn deficiency?

A

Low ALP

100
Q

When does acrodermatitis enteropathica typically present?

A

Often after weaning from breast to cow’s milk (because breastmilk increasees zinc bioavailability)

101
Q

Name 10 clinical features of acrodermatitis enteropathica?

A 
Chronic diarrhea***
Irritability
Rash (perioral, perineal)***
Eye problems (photophobia, conuncivitis)
Hair – reddish tint, alopecia***
Stomatitis
Glossitis***
Paronychia, nail dystrophy
Growth retardation
Delayed wound healing
Superinfection with Candida
Cognitive dysfunciton
102
Q

Name 5 tests to establish the diagnosis of acrodermatitis enteropathica

A
  1. Serum zinc
  2. Hair, urine, parotid zinc levels
  3. ALP (may be low in late disease)
  4. Maternal breast milk level
    (Differentiate between genetic and acquired deficiency)
  5. Derm biopsy: parakeratosis, pallor of the upper epidermis
103
Q

For how long do you need to give zinc supplementation for acrodermatitis enteropathica?

A

Zinc 1 mg/kg/day for life

104
Q

Name 8 physical exam features of kwashiorkor (inadequate protein intake in presence of reasonable caloric intake)

A 
80-90% of IBW
Edema***
Sparse hair - dull brown/red***
Pitting edema
Hyperpigmented hyperkeratosis or flaky rash 
Enlarged parotid glands
Apathy, disinterest
Enlarged/soft liver
Abdo distended
105
Q

Name 5 physical exam features of marasmus (severe protein energy malnutrition)

A 
<70% of IBW
Depleted body fat stores
Edema usually absent
Skin is dry and thin
Hair thin, sparse, easily pulled
Apathetic and weak
Bradycardia/hypothermia
106
Q

Spot diagnosis: http://www.medicalook.com/diseases_images/pellagra.jpg

A

Pellagra, niacin deficiency

http://www.medicalook.com/diseases_images/pellagra.jpg

107
Q

Name 2 micronutrient deficiencies associated with cheilosis and glossitis?

A 
Iron deficiency
Riboflavin deficiency (vitamin B2)
108
Q

Name 3 signs and symptoms of vitamin A deficiency

A 
Night blindness
Eye dryness
Xeropthalmia
Bitot spots
Corneal ulceration and scarring
Anemia
Follicular hyperkeratosis
Growth retardation
109
Q

Spot diagnosis: http://1.bp.blogspot.com/-5gxcnbXX3xM/TVTNfFDhxqI/AAAAAAAACN4/336dEINIxII/s1600/37065.imgcache.jpg

A

Rachitic rosary (rickets)

110
Q

Spot diagnosis: https://pedclerk.bsd.uchicago.edu/sites/pedclerk.uchicago.edu/files/uploads/wt.png

A

Metaphyseal cupping (rickets)

111
Q

What deficiency is associated with goat’s milk?

A

Folate

112
Q

What deficiency is associated with strict vegan diet?

A

B12

113
Q

What are the only 2 appropriate indications for soy milk formula?

A

Galactosemia

Cultural/religious reasons

114
Q

What vitamin deficiency is associated with gum bleeding/petechiae?

A

Vitamin C

115
Q

What condition is associated with rusty hair?

A

Kwashikorkor

116
Q

What is the diagnosis in a black baby with the following findings: bow-legged, metaphyseal cupping/flaring, rachitic rosary, Harrison groove, delayed walking

A

Rickets

117
Q

What is the first investigation you should order in a swallowed foreign body?

A

AP+ lateral
Neck xray
CXR
AXR

118
Q

If a foreign body is located in the esophagus or stomach, what intervention is the next step?

A

Esophageal FB: Endoscopic removal if lodged >24 hours TO PREVENT PERF;
Glucagon (0.05 mg/kg IV) facilitates passage of distal food

Stomach FB: >6 cm remove within 24 hours, otherwise repeat XR in 4 weeks

119
Q

In what time frame should button battery be removed?

A

Within 6 hours if in esophagus
Within 24 hours if in stomach
The charges on the battery can cause liquefaction necrosis and perforation can occur rapidly

120
Q

Why must 2 or more magnets in the stomach be removed immediately?

A

Magnets will try to attach to each other and can tramp the bowel leading to a perforation

121
Q

What conditions can predispose to esophageal foreign bodies?

A

EoE
Motility disorder
Esophageal atresia

122
Q

Differential diagnosis of rectal prolapse

A 
Idiopathic (most)
CF
Repaired HD
IBD
Ehler's Danlos
Celiac disease
Chronic dysentery
Bladder extrophy
Chronic constipation
Malnutrition
123
Q

What education should you give parents about constipation?

A
  • Not a disease
  • Not dangerous
  • Very common
  • Symptoms may be due to failed toilet training
  • Symptoms improve when child learns the correct way to have BM
  • PEG-non absorbable sugar, doesn’t change how bowel works, won’t become addicted
124
Q

What is the best way to treat encopresis?

A

Behavioural

Pharmacologic-bowel washouts

125
Q

What investigation should you order in a child with recurrent rectal prolapse?

A

Sweat chloride

126
Q

What is prevalence of celiac disease?

A

1%

127
Q

Name 3 side effects of 5-ASA

A

Headache
Bloody stools
Pancreatitis

128
Q

Name a side effect of azathioprine

A

Pancreatitis

129
Q

Why do patients with IBD lose weight?

A

Inadequate nutrient intake

130
Q

How many days do you have to get biliary atresia to transplant?

A

60 days

131
Q

What questions should you ask on history for a patient in acute liver failure? (previous OSCE)

A

Symptoms: fatigue, malaise, anorexia, nausea, abdominal pain, fever and jaundice, encephalopathy

Tylenol use (ALWAYS ask), medications

Substances (EtOH, street drugs, Ecstasy, mushrooms, herbals)

Travel (HepA), recent illness

School performance, personality Δ (Wilson’s)

Family hx (autoimmune)

132
Q

What 3 factors can you order to help differentiate between Vit K deficiency, DIC and liver failure?

A 
Factor 8-not made in liver
Factor 5-vit K independent
Factor 7-vit K dependent 
Vit K deficiency-Factor 7 low
DIC-all factors low
Liver failure-Factor 5 and 7 low
133
Q

In a patient with hepatitis, which test is the most sensitive indicator of liver synthetic function?

A

INR

Other markers of liver synthetic function:
Albumin
Glucose
Lactate
NH3
134
Q

What are the most common causes liver failure in >5 years?

A 
Autoimmune hepatitis (raised IgG)
Wilson's (cognitive issues)
Acetaminophen
Budd Chiari
NAFLD
135
Q

What is the usual initial manifestation of alpha 1 antitrypsin?

A

Neonatal cholestasis or later-onset childhood cirrhosis

136
Q

How long does breastfeeding jaundice last ?

A

4-12 weeks

137
Q

What initial test should you order in a baby with conjugated hyperbilirubinemia?

A

AUS-to differentiate between BA and other structural anomalies of biliary tree (e.g. choledochal cyst)

In BA, usually do not see gall bladder

138
Q

What is the definitive test for biliary atresia?

A

Percutaneous cholangiogram

HIDA scan be done, but takes time (phenobarbital x 5 days) and not specific

139
Q

What condition looks like biliary atresia on clinical presentation and biopsy, but HIDA and percutaneous cholangiogram are normal?

A

Idiopathic neonatal hepatitis (or intrahepatic cholestasis)

Other differentiating factors:

  • INH recurs in families whereas BA does not
  • INH is more common if premature or SGA
140
Q

How do you rehydrate mild dehydration (<5%) (CPS)?

A

ORS 50 ml/kg over 4 hours

Replace ongoing losses

141
Q

How do you rehydrate moderate dehydration (5-10%) (CPS)?

A

ORS 100 ml/kg over 4 hours

Replace ongoing losses

142
Q

How do you rehydrate severe dehydration (>10%) (CPS)?

A

Bolus 20-40 ml/kg for one hour
ORT when stable
Replace ongoing losses

143
Q

You have a child with malabsorption, what tests do you do to figure out whether it’s a fat, carbohydrate or protein malabsorption issue?

A

Fat-fecal elastase (pancreatic exocrine function, serum trypsinogen (pancreatic exocrine function), fecal fat, vitamin ADEK

Carbohydrate-stool pH low, stool for reducing substances, hydrogen breath test

Protein-stool alpha-1 antitrypsin

144
Q

Name 2 signs of vitamin E deficiency

A 
Hemolytic anemia
Neurologic:
Areflexia
Ataxia
Opthalmoplegia
Nystagmus
Impaired sensation (vibratory, proprioception)
145
Q

Name 4 signs of vitamin C deficiency

A

Petechiae
Bleeding gums
Muscle pain, especially lower legs
Fatigue

146
Q

Name 3 signs of vitamin B12 deficiency

A 
Macrocytic anemia
Atrophic glossitis
Hyperpigmentation of knuckles
Sensory deficits
Developmental regression
147
Q

Name 3 signs of niacin (B3) deficiency

A 
4Ds
Dementia
Dermatitis-photosensitive
Diarrhea
Death
148
Q

What supplementation do you recommend for a breastfed baby who’s mother is vegan?

A

B12

149
Q

How do you manage EoE?

A

Oral Fluticasone

Allergy testing and allergen avoidance diet OR hydrolyzed formulas

150
Q

What diagnosis results in throat pain in the morning and bad breath?

A

GERD

151
Q

What is Peutz Jehgers?

A 
Autosomal dominant
Mucocutaneous lentigines (hyperpigmented lesions)
Intestinal polyposis (increased risk of intussusception)
152
Q

What bacteria is associated with Guillain Barre?

A

Campylobacter

153
Q

What are the NASPHAGN criteria for cyclic vomiting syndrome? (Past SAQ)

A
  • At least 5 attacks in any interval, or a minimum of 3 attacks during a 6-month period
  • Episodic attacks of intense nausea and vomiting lasting 1 hr to 10 days and occurring at least one week apart
  • Stereotypical pattern and symptoms in the individual patient
  • Vomiting during attacks occurs at least 4x/hr for at least 1 hr
  • Return to baseline health between episodes
  • Not attributed to another disorder
154
Q

What is the typical age of onset of cyclic vomiting syndrome?

A

2-5 years of age

155
Q

When does physiologic GERD resolve in most infants?

A

Peaks at 4 months

Resolves by 15 mo in most

156
Q

Indications for combined Multiple Intraluminal Impedance and esophageal pH Monitoring (NASPGHAN)

A
  • Evaluating the efficacy of anti-reflux therapy
  • Evaluation of reflux-related symptom association (e.g. correlating cough, wheeze, chest pain with acid reflux episodes)
157
Q

When should UGI be used in a patient with reflux?

A

R/O GI obstruction or complication of GERD (e.g. in patients with dysphagia, need to r/oesophageal stricture)

158
Q

List 4 non-pharmacologic treatments for reflux in infants (past SAQ)

A
  • Feeding technique, appropriate volume, frequency
  • Thickened feeds
  • Prone or upright position while aware
  • Trial of extensively hydrolyzed protein formula to r/o CMPA x 2-4 weeks
159
Q

List 4 non-pharmacologic treatments for reflux in children

A
  • Avoid acidic, reflux inducing foods (tomato, mint, chocolate), pop, caffeine, alcohol
  • Avoid night time eating
  • Left side position, head elevation during sleep
  • Weight reduction for obese
  • Elimination of smoke exposure
160
Q

What is the recommended ant-reflux medication in children? (NASPGHAN)

A

PPI trial x 4 weeks, if successful, continue x 3 months
Superior to H2RAs in relieving symptoms and healing esophagitis
Prokinetics not recommended (side effects > benefits)

161
Q

List 5 complications of GERD

A 
Dental erosions
Strictures
Erosive esophagitis
Barretts Esophagus 
FTT
Worsening asthma
Reflux laryngitis
162
Q

Is there evidence for nutritional interventions in colic ? (CPS)

A

Only in a very small group of infants

Can trial extensively hydrolyzed formula/elimination diet x 2 weeks

163
Q

List 5 signs to suggest an alternative diagnosis to GERD in an infant with vomiting (past SAQ)

A

-Failure to thrive, weight loss
-Signs of dehydration
-Infectious symptoms (fever)
-Abdominal distention
-Bilious Vomiting
-Hepatosplenomegaly
-Peristent, forceful vomiting
-Diarrhea
-Constipation
-Bulging fontanelle
-Macro/microcephaly
-Seizures
-Abdominal tenderness or distension
-Documented/suspected
genetic/metabolic syndrome
-Abdominal tenderness or distension
- New onset of vomiting
after age 6 months
-GI bleeding

164
Q

What condition is often in the family history for patients with cyclic vomiting?

A

Migraines (80%)

165
Q

List 5 causes of acute pancreatitis in children

A
  • Gallstones
  • Triglyceridemia
  • Hypercalcemia
  • Mutations in genes for pancreatic or biliary ductal system (PRSSI, SPINK1, CFTR genes)–>progresses to chronic pancreatitis
  • Drug-induced
  • Infection (e.g. Mumps, coxsackie)
  • Trauma
166
Q

List 3 serious complications of severe pancreatitis

A 
Jaundice
Hypocalcemia
SIRS
ARDS
DIC
167
Q

List 3 counseling points for functional abdominal pain (past SAQ)

A

Give diagnosis of functional abdominal pain
Follow up regularly with consistency
Reassure parents and child
Educate parents to avoid reinforcing the symptoms with secondary gain
Should return to regular activities
CBT for management of pain and functional disability

168
Q

What foods are common sources of transfats?

A

Fast food

Processed/pre-packaged foods

169
Q

When should patients with UC and colonic CD be screened for colon cancer?

A

Colonoscopy with biopsies q1-2 years after had UC/colonic CD >10 years

170
Q

What is pouchitis and how do you treat it?

A

Inflammation of J pouch after ileostomy for UC
Presents with fever, bloody diarrhea, abdominal pain
Stool cultures negative
Treat with flagyl

171
Q

List 4 reasons for growth failure in Crohns disease

A
  1. Inadequate caloric intake
  2. Suboptimal absorption or excessive loss of nutrients
  3. Effects of chronic inflammation on bone metabolism
  4. Use of corticosteroids during treatment
172
Q

List 3 causes of lower GI bleed in a neonate <1 mo

A 
Swallowed maternal blood
NEC
Malrotation
Fissures
Coagulopathy
HD
173
Q

List 3 causes of lower GI bleed in an infant (1 mo-2 years)

A 
Allergic colitis
Anal fissure
Intussuseption
Meckel's divericulum
Infectious colitis
Lymphonodular hyperplasia
GI duplication
Coagulopathy
174
Q

List 3 causes of lower GI bleed in an older child

A 
Infectious colitis
IBD
Juvenile polyps
Adenomas/hyperplastic polyps
HSP
Meckel's
Intussuseption
Hemorrhoids
175
Q

List 10 causes of esophageal dysphagia

A

Mechanical: i.e. Solid>liquid

  1. Vascular ring
  2. Mediastinal lesion (e.g. adenopathy)
  3. Vertebral anomalies
  4. Esophageal web, rings
  5. Esophagitis: GERD, EoE
    chronic infections)
  6. Stricture: corrosive injury, pill induced, peptic
  7. Esophageal diverticula
  8. Esophgeal FB
  9. Schatzki ring (thin ring of mucosal tissue near the lower esophageal sphincter)

Motility problems: i.e. Solid=Liquid

  1. GERD
  2. Achalasia cardia
  3. Diffuse esophageal spasm
  4. Scleroderma
176
Q

What is the characteristic finding on barium swallow in achalasia?

A

Bird’s beak

177
Q

What is the best diagnostic test for achalasia?

A

Esophgeal manometry

178
Q

Workup of for FTT if history and physical do not yield a diagnosis (CPS)

A

Step 1:

  • CBC
  • ESR or CRP
  • Serum lytes, venous blood gas, blood glucose
  • BUN, creatinine
  • Serum protein and albumin
  • Serum iron, TIBC, saturation, ferritin
  • Calcium, phosphate and ALP
  • Liver enzymes (AST, ALT, GGT)
  • Serum Ig
  • anti-TTG (accompanied by total IgA level)
  • TSH
  • Urinalysis
Step 2
•	Sweat chloride
•	Vitamin levels
•	Fecal elastase
•	Bone age
179
Q 
What is the expected daily weight gain (g/day) in the following age groups?
0-3 mo
3-6 mo
6-9 mo
9-12 mo
1-3 yr
4-6 yr
A 
0-3 mo: 30 g/day
3-6 mo: 20 g/day
6-9 mo: 15 g/day
9-12 mo: 12 g/day
1-3 yr: 8 g/day
4-6 yr: 6 g/day
180
Q

List three anthropometric measures of nutrition that can be used other than weight

A
  1. Mid-arm Circumference
  2. Triceps skin fold
  3. Scapular skin fold
  4. Head circumference velocity
  5. Height velocity
181
Q

Explain the difference between secretory and osmotic diarrhea

A

Secretory

  • Occurs when the intestinal epithelial cell solute transport system is in an active state of secretion
  • Large volume watery stools
  • Normal stool ion gap (<100 mOsm/kg)
  • Ex: cholera, toxigenic E. Coli, carinoid, C. difficile

Osmotic

  • Occurs after ingestion of a poorly absorbed solute
  • Less volume
  • Stops with fasting
  • Elevated stool ion gap (>100 mOsm/kg)
  • Ex: Lactase deficiency, glucose-galactose malabsorption, lactulose, laxative abuse
182
Q

List 5 causes of chronic diarrhea (>2 weeks) in an infant

A
  • Postinfectious secondary lactase deficiency
  • Cow’s milk or soy protein intolerance
  • Toddler’s diarrhea
  • Excessive fruit juice (sorbitol) ingestion
  • Celiac disease
  • Cystic fibrosis
  • Primary immune deficiency
  • Shwachman-Diamond
  • Cholestatic liver disease
183
Q

List 5 causes of chronic diarrhea (>2 weeks) in an older child/adolescent

A
  • Postinfectious secondary lactase deficiency
  • Irritable bowel syndrome
  • Inflammatory bowel disease
  • Lactose intolerance
  • Giardiasis
  • Laxative abuse
  • Constipation with encopresis
  • Thyrotoxicosis
  • Malignancy (e.g. VIP from neuroblastoma)
  • Chronic pancreatitis
  • Cholestatic liver disease
184
Q

What is the most common viral gastroenteritis?

A

Rotavirus

185
Q

List 4 infectious causes of bloody diarrhea

A

Camplyobacter
Enterohemorrhagic Escherichia coli
Shigella
Entameoba histolytica

186
Q

What 3 conditions can Yersinia mimic?

A

TB (terminal ileitis)
Crohns (terminal ileitis, prolonged course of diarrhea 1-4 weeks and weight loss)
Appendicitis (can present with fever, RLQ tenderness and leukocytosis)

187
Q

List 3 clinical presentations of amebiasis

A

1) Intestinal amebiasis
- 1-3 weeks of increasingly severe diarrhea progressing to bloody diarrhea
- Abdominal pain and tenesmus
- Weight loss common

2) Ameboma
- Annular lesion of cecum

3) Extra-intestinal infection
- Liver abscess most common most common site
- Also lungs, pleura, pericardium

188
Q

How do you treat amebiasis

A
  • Asymptomatic cyst excreters: iodquinol, paromomycin or diloxanide (amebicide)
  • Mild to moderate intestinal or extra-intestinal symptoms: flagyl than amebicide (above)
189
Q

List 2 causes of gastroenteritis that have very short incubation periods (1-6 hours)

A
  1. S. Aureus
    - Source: Prepared foods (eg salads, dairy, meat)
  2. B. Cereus
    Source: Rice, meat

Incubation time is 1-6 hours for both!

190
Q

Which is the only sugar that is does not result in a positive for stool reducing substances?

A

Sucrose

191
Q

What clues on history are suggestive of toddler’s diarrhea as a cause of diarrhea in infants?

A
  • Normal growth
  • Well appearing
  • More severe in AM
192
Q

What is the most common cause of congenital diarrhea?

A

Microvillus inclusion disease

193
Q

List 4 causes of protein losing enteropathy (past SAQ)

A
  • Milk protein allergy
  • Celiac disease
  • Inflammatory bowel disease
  • Infections (ie. Giardiasis)
  • Intestinal lymphangiectasia
  • Right sided heart dysfunction (post-Fontan procedure)
  • Hypertrophic gastritis (Ménétrier’s disease)
194
Q

How do you treat protein losing enteropathy?

A

Low-fat, high-protein, medium-chain triglyceride (MCT) diet.

195
Q

Which has higher fat content, hind milk or fore milk?

A

Hind milk has 50 % higher fat content than fore milk

196
Q

How does the composition of breastmilk for preterms differ from term infants?

A

Milk for a preterm infant is high in protein, lower in carbohydrates and fat but higher in calories (similar to colostrum)

197
Q

What are the only indications for soy based formula?

A

Galactosemia
Congenital lactase deficiency
Vegan family

198
Q

Introduction of lumpy foods should not be delayed beyond __ months

A

9 months

199
Q

What is the maximum amount of cow’s milk recommended per day for toddlers?

A

Max of 750 mls per day = 25 ounces

200
Q

Avoid honey under __ months because of the risk of botulism

A

12 months

201
Q

When should complementary foods be introduced?

A

6 months

Should iron rich-meat, meat alternatives, and iron fortified cereals

202
Q

What intervention can be tried in infants with severe colic? (CPS)

A

Time limited (2 week) trial of hydrolyzed formula to r/o CMPA

203
Q

Soy formula should not be used in what two groups of infants?

A

Congenital hypothyroidism

Non-IgE mediated CMPA

204
Q

What kind of water should be used to prepare powdered formula?

A

Boiled water because powdered formula is NOT sterile

Concentrate is sterile-can use tap water

205
Q

List 4 ways milk can cause iron deficiency

A

Low in Fe
Can displace Fe-rich foods
Can inhibit Fe absorption
Excessive intake can cause occult blood loss in stool

206
Q

What dietary recommendations would you make for a child 12-24 months (CPS)?

A
  • Begin regular schedule of meals and snacks
  • Little or no added salt or sugar
  • Need nutritious, higher-fat foods
  • Encourage continued BF, or 500 mL per day homo (3.25%) milk after 9-12 months
  • Limit juice and sweetened bev to max 1-2 x/day; encourage water for thirst
  • Transition from bottle to open cup should be complete by 12 mo
207
Q

How long should vitamin D BE continued in breastfed child?

A

Continue vitamin D 400 IU daily if BF up to 24 mo

208
Q

List 5 causes of PUD

A

H. pylori
NSAIDs
Zollinger ellisons
Stress-sepsis, shock, severe burns

209
Q

Treatment for H. pylori gastritis

A

2/3 of Amox/Clarithro/Flagyl x2 weeks + PPI x 1 month

210
Q

List 5 causes of malnutrition in neurologically impaired children (CPS)

A
  1. Inadequate Intake
  2. Increased losses
    (GERD &frequent emesis and regurgitation may be a source of caloric loss)
  3. Altered metabolism
    -May require more calories because of increased tone
  4. Oromotor dysfunction
  5. Non-nutritional factors affecting growth
    (specific syndromes, endocrine dysfunction, ethnicity, genetic potential, puberty)
211
Q

List 5 nutritional interventions for neurologically impaired child who is malnourished (past SAQ)

A
  1. Determine Energy Needs
    - Can use indirect calorimetry
    - Other methods: Krick method, height-based method, REE-based method
  2. Improve oral intake
    - Adequate positioning
    - Adjust food consistency
    - Increase caloric density
  3. Enteral nutrition
    - Trial of NG feeds
    - If required >3 months, G-tube
    - Consider fundo if reflux refractory to medical management
    - GJ if not candidate for fundo
  4. Manage reflux
  5. Enteral formula
    - If need high-calorie or not tolerating increased formula volume, may concentrate and/or add modular nutrients, such as glucose polymer or lipids
212
Q

What weight for height %iles should be targeted for neurologically impaired children?

A

In children <3 y.o.and in children with normal activity level:
-50th percentile

In children who are wheelchair bound but able to accomplish transfers:
-25th percentile

For the bedridden patient:
-10th percentile

213
Q

Above 12 months of age, what formula should be used in neurologically impaired children? (CPS)

A

A paediatric 1 kcal/mL formula

214
Q

What is the best form of nutrition for a patient with short gut syndrome?

A

Protein hydrolysate and medium-chain triglyceride–enriched formula

215
Q

How much vitamin D should be given to preterms?

A

200 IU (up to 400 IU)

216
Q

How much vitamin D is in formula?

A

400 IU per 1 L of formula

217
Q

List 4 effects of excess vitamin D (past SAQ)

A

Related to hypercalcemia:

  1. Abdominal pain
  2. Polyuria
  3. Nephrolithiasis
  4. HTN
  5. Constipation
  6. Pancreatitis
  7. Lethargy
218
Q

How much iron should be given to preterm infants during the first year of life? (CPS)

A

2 mg/kg/day of elemental iron, introduced between four and six weeks of age

219
Q

What is the rationale for iron supplementation in prems (CPS)?

A

Physiologic nadir is more significant in prems

Supplementation results in improved hemoglobin levels and iron stores (after 6 mos of age)

220
Q

What two pieces of advice about vitamins and fluoride would you give to a mother with a newborn who lives in a community with only well water?

A
  1. Vitamin D 400 IU if exclusive breastfeeding or 800 IU if risk factors
  2. Supplemental fluoride after 6 months
    - Dose= 0.25mg/day from 6mos-3yrs if not brushing teeth twice a day
    - Supplemental fluoride should be given in preparations that maximize the topical effect, such as mouthwashes or lozenges
221
Q

What supplement should you give a newborn of a breastfeeding vegan mother?

A

Vitamin B12

222
Q

List 3 things you would do to refeed a child with Kwashiorkor safely

A
  1. Initiate feeds with a specialized high calorie formula (F 75), small amounts frequently to aim for 80-100kcal/kg/day
  2. Do not start iron until rehabilitation phase (week 2)
  3. Monitor electrolytes, including phosphate for refeeding syndrome
223
Q

List 4 clinical features of Wilson’s disease

A
  1. Hepatitis to hepatic failure
  2. Neurologic: tremor, chorea, parkisonism, personality change, deterioration in school performance
  3. Kayser fleischer rings
  4. Coombs-negative hemolytic anemia
  5. Renal fanconi syndrome
224
Q

List 4 risk factors for TPN cholestasis (past SAQ)

A
  1. Prematurity
  2. Low birthweight
  3. Prolonged duration of TPN
  4. Sepsis
  5. NEC
  6. Short gut syndrome
225
Q

List 5 hepatotropic viruses other than the hepatitis viruses

A 
HSV
EBV/CMV
VZV
Adeno
Enterovirus
Parvo
Arboviruses
Coxsackie
Dengue
Yellow fever
HIV
Rubella
226
Q

List 3 laboratory clues that indicate a diagnosis of autoimmune hepatitis

A

↑AST/ALT from 100-300, but can be >1000

Conjugated hyperbilirubinemia

Autoantibodies-anti-smooth muscle, ANA, LKM

Hypergammaglobulinemia

Cytopenias

227
Q

List 5 signs of poor prognosis in acute liver failure

A
  • Stage 4 encephalopathy
  • Age <1 y.o.
  • INR >4
  • Need for dialysis before transplant
  • Acute liver volume loss***(on past exams)
228
Q

List 3 complications of liver transplant (past SAQ)

A 
Acute and chronic rejection
Thrombosis (portal vein or hepatic artery)
Infection
Metabolic syndrome
PTLD
Osteopenia
229
Q

List 5 indications for liver transplant in children

A

Biliary atresia

Metabolic disorders: α1-Antitrypsin deficiency, tyrosinemia type I, GSD type IV, Wilsons, neonatal hemochromatosis, Crigler-Najjar type I, familial hypercholesterolemia, primary oxalosis, organic academia, UCDs

Acute hepatitis: fulminant hepatic failure, viral, toxin, or drug induced

Chronic hepatitis with cirrhosis: hepatitis B or C, autoimmune

Intrahepatic cholestasis: idiopathic neonatal hepatitis, Alagille, familial intrahepatic cholestasis

Miscellaneous: cryptogenic cirrhosis, congenital hepatic fibrosis, Caroli disease, CF, polycystic liver disease, TPN induced cirrhosis

230
Q

List 4 causes of portal HTN in children

A

1) Extrahepatic:
- Portal vein thrombosis
- Portein Vein agenesis/atresia/stenosis
- Splenic Vein Thrombosis

2) Intrahepatic Causes:

Hepatocellular Disease

  • Hepatitis (acute, chronic)
  • Wilson’s
  • α1-Antitrypsin deficiency
  • Hepatotoxicity (from drugs, toxins, TPN)

Biliary Tract Disease

  • Biliary Atresia (extrahepatic)
  • CF
  • Choledochal cyst
  • Sclerosing Cholangitis

Post-sinusoidal Obstruction

  • Budd-Chiari Syndrome:
  • Veno-occlusive Disease
231
Q

How does Gilbert syndrome typically present?

A

Neonatal jaundice

Recurrent episodes of unconjugated hyperbilirubinemia

232
Q

What is Dub-John and Rotor?

A

AR cause of mild conjugated hyperbilirubinemia

Usually detected during adolescence

Recurrent episodes of jaundice exacerbated by infection, pregnancy, OCPs, alcohol, and surgery

233
Q

List 6 clinical features of Alagille syndrome

A
  • Dysmorphic Features: broad forehead, deep-set + widely spaced eyes, long/straight nose,pointed chin
  • Eyes: posterior embryotoxon, microcornea, optic disk drusen, shallow anterior chamber
  • CVS: peripheral pulmonic stenosis, and other CHD
  • Vertebral: butterfly vertebrae, fused vertebrae, spinabifidaocculta, rib anomalies
  • Nephro: Tubulointerstitial nephropathy
  • Short stature
  • Pancreatic insufficiency
  • Defective spermatogenesis
234
Q

List 3 long term complications of chronic cholestasis

A 
Fat malabsorption
Metabolic bone disease
Pruritus
Xanthomas
Cirrhosis
Portal HTN

FRCPC (27 decks)

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