Module 2: Nutritional Considerations & Undernutrition Flashcards
1
Q
Restriction of energy intake relative to requirements leading to low body weight in the context of age, sex, physical health, and developmental trajectory.
A
Characteristic of Anorexia Nervosa
2
Q
Strong fear of gaining weight or becoming fat, even though underweight.
A
Characteristic of Anorexia Nervosa
3
Q
Disturbance in the way one’s body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or denial of the seriousness of current low body weight.
A
Characteristic of Anorexia Nervosa
4
Q
There are two major types of AN; and one minor type
A
In the restricting type, patients do not regularly engage in binge eating or purging. In the binge-purge type, AN is combined with binge eating or purging behavior, or both.
Atypical: AN, except the patient is not underweight despite significant weight loss
5
Q
Assessing the patient’s __________ is essential to determining the diagnosis of AN
A
Body Image
6
Q
___________________________________________ is an obvious red flag for the presence of an ED. Additionally, AN should be considered in any girl with ___________who has _____________________.
A
Weight loss from a baseline of normal body weight
secondary amenorrhea … lost weight
7
Q
A(n) _________ weight _____________(timing) is the most accurate way to assess weight.
A
gown-only … after urination
8
Q
In AN, A combination of malnutrition and stress causes ____________. (Define)
A
Hypothalamic hypogonadism: the hypothalamic-pituitary-gonadal axis shuts down as the body struggles to survive, directing finite energy resources to vital functions.
9
Q
_____ will continue to be an important clinical sign that an adolescent female’s body is malnourished. It occurs for two reasons:
A
Amenorrhea
- Hypothalamic hypogonadism –> hypothalamic amennorhea
- Lack of adipose interrupts activation of estrogen
10
Q
An adolescent female needs about __% body fat to restart menses and __% body fat to initiate menses if she has primary amenorrhea
A
17 … 22
11
Q
A(n) _________ should be performed in those suspected to have AN, because significant abnormalities may be present, most importantly _________.
A
electrocardiogram (ECG) … prolonged QTc syndrome
12
Q
Manualized family therapy
A
10 weeks are devoted to empowering parents
11–16, returns control over eating to the adolescent once he or she accepts the demands of the parents
17–20, maintaining a healthy weight; shifts the focus away from the ED to establishing a healthy adolescent identity
13
Q
Practitioners frequently use _____________ for treatment of AN, despite the lack of evidence supporting efficacy.
A
atypical antipsychotics (risperidone, quetiapine, and esp. olanzapine)
14
Q
____ repeatedly have been shown to not be helpful in the initial therapy of AN. A recent study showed that their use may decrease _________ when used in malnourished patients. However, …
A
SSRIs … bone mineral density
… SSRIs (fluoxetine, citalopram, or sertraline) may help prevent relapse.
15
Q
… is common in AN, and several studies support its use as a supplement during the initial phases of treatment.
A
Zinc deficiency …
16
Q
Recurrent episodes of binge eating, characterized by both of the following:
- Eating in a discrete period an amount of food that is larger than most people would eat during a similar period under like circumstances.
- A sense of lack of control during the episode (eg, feeling that one cannot stop eating or control what or how much one is eating).
A
Characteristic of Bulimia Nervosa and Binge Eating Disorder (BED)
17
Q
Binge eating followed by [recurrent inappropriate compensatory behavior to prevent weight gain (eg, self-induced vomiting; misuse of laxatives, diuretics, or other products; excessive exercise; fasting).]
A
Characteristic of Bulimia Nervosa [Purging disorder]
18
Q
Binge eating (and inappropriate compensatory behaviors) occur(s) at least once a week for 3 months (on average).
A
Characteristic of BED (Bulimia Nervosa)
19
Q
Diagnosing BN can be difficult unless…
A
…the teenager is forthcoming or parents or caregivers can supply direct observations.
20
Q
Symptoms of BN are related to the mechanism of purging. (1) is/are most prominent. (2) is/are common.
A
- GI problems
2. Abdominal pain
21
Q
It is important to note that in BN, most purging methods are (1). When patients (2), they (3)
A
- ineffective
- binge
- may consume thousands of calories.
22
Q
On physical examination, bulimic patients may be (1) and have (2).
A
- dehydrated
2. orthostatic hypotension
23
Q
(3, 4, 5) and (6) are the most common physical exam findings for BN.
A
- Sialadenitis (inflammation and enlargement of one or more of the salivary glands)
- tooth enamel loss
- dental caries
- abdominal tenderness
24
Q
(7) may occur secondary to (8) while inducing vomiting, and is therefore an important physical exam finding for BN.
A
- Abrasion of the proximal interphalangeal joints
8. scraping the fingers against teeth
25
(1) is/are commonly assessed in the labs for BN patients. The method of purging results in specific abnormalities. (2) causes (3), (4), and (5).
1. Electrolyte disturbances
2. Vomiting
3. metabolic alkalosis
4. hypokalemia
5. hypochloremia
26
Treatment of BN depends on the (1) of bingeing and purging and the severity of (2) and (3) derangement.
1. frequency
2. biochemical
3. psychiatric
27
When treating a BN patient, if K+ is less than (A) mEq/L, inpatient medical admission is warranted.
A. 3.0
28
Outpatient management can be pursued if patients are (1). (2) is crucial to help bulimic patients understand their disease.
1. medically stable
| 2. CBT
29
(1) are generally helpful in treating the binge-purge cycle. (2) has been studied most extensively; a dose of (3) is most efficacious in teenagers.
1. SSRIs
2. Fluoxetine
3. 60 mg/day
30
Binge eating associated with marked distress
Characteristic of BED
31
BED most often is found in ... individuals. Eighteen percent of such patients report binging at least once in the past year.
Overweight or obese
32
When determining labs to run on BED patients, the clinician should assess causes and complications of (1), and laboratory evaluation should include (2) and measurement of (3) levels.
1. obesity
2. thyroid function tests
3. cholesterol and triglyceride
33
A combination of (1) has been helpful in treating BED in (2) patients.
1. CBT and antidepressants
| 2. adult
34
Evidence suggests that (1) in (2) with BED may be helpful. BED has been recognized (3), and outcomes (4).
1. SSRIs
2. adolescents
3. only recently
4. haven't been studied
35
Hospitalization can also offer a (B) from the (C), allowing BN patients to (D) their eating, interrupt the (E), and regain the ability to (F).
```
B. forced break
C. addictive cycle of BN
D. normalize
E. addictive behavior
F. recognize satiety signals.
```
36
Eating or feeding disturbance (including lack of interest in eating, eschewal due to sensory characteristics of food; concern for aversive consequences of eating) demonstrated by failure to meet appropriate nutritional and/or energy needs and associated with one or more of:
- Weight loss (or failure to achieve expected weight
gain or faltering growth).
- Nutritional deficiency.
- Dependence on enteral feeding or oral nutritional
supplementation.
- Interference with psychosocial functioning.
Characteristic of Avoidant/Restrictive Food Intake Disorder (ARFID)
37
Reductive eating disturbance not explained by lack of available food or culturally sanctioned practice.
Eating disturbance not attributable to concurrent medical condition or explained by a different mental disorder, or, when eating disturbance occurs in the context of another condition or disorder, severity of eating disturbance exceeds that associated with the other condition or disorder.
Characteristic of Avoidant/Restrictive Food Intake Disorder (ARFID)
38
(1) with eating disorders are
more likely than (2) to
have premorbid psychopathology
(3: examples) and less likely to have (4) behaviors.
1. Preteens
2. older adolescents
3. depression, OCD, anxiety
4. binge and purge
39
Increased rates of ... may be found in sexual minority youth
Adolescents with chronic health conditions requiring dietary control (eg, diabetes, cystic fibrosis, inflammatory bowel disease, and celiac disease) may also be at increased risk of ...
...disordered eating...
40
Many adolescents engage in dietary
practices that may (1) with or
(2) eating disorders.
1. overlap
| 2. disguise
41
Psychologically, spending excessive amounts of time in meal planning and experiencing extreme guilt or frustration when one's food-related practices are interrupted appears to be related to (1) and
(2) and is considered by some to be a subset within the (3)
1. AN
2. OCD
3. restrictive eating disorders
42
In an attempt to improve performance or achieve a desired physique, (1) may engage in (2) behaviors.
1. adolescent athletes
| 2. unhealthy weight-control
43
Because a HR of ... or less is unusual even in college-aged athletes, the finding of a low HR may be a sign of ...
50 beats per minute
| restrictive eating.
44
```
Delayed gastric emptying and slow
intestinal transit time often
contribute to reported sensations of
nausea, bloating, and postprandial
fullness and may be a presenting
feature of ...
```
...restrictive eating
45
Functioning as an (1), (2) is not indicated when euthyroid sick syndrome is noted.
1. adaptive mechanism to starvation
| 2. supplemental thyroid hormone
46
Often, an early task of the pediatrician when treating an adolescent with an eating disorder is to identify a (1). This goal weight may be determined in collaboration with a (2).
1. treatment goal weight/range
| 2. registered dietitian
47
Because brushing teeth immediately after vomiting may (1), patients can be advised to instead rinse with (2), followed by using a (3) whenever possible
1. accelerate enamel erosion
2. water
3. sodium fluoride rinse
48
(1) refers to the metabolic and clinical changes that occasionally occur when an extremely severely malnourished patient is aggressively nutritionally rehabilitated; the hallmarks are (2) and (3).
1. Refeeding syndrome
2. hypophosphatemia
3. multiorgan dysfunction
49
Programmed growth rates and nutrient requirements per kg body weight are (1) in growing
children than in adults, whereas body stores are (2) making the young child more vulnerable to the effects of (3)
1. significantly higher
2. lower
3. malnutrition
50
(1) is the main indicator of nutritional
| status in pediatrics at (2) stage of development
1. Growth velocity
| 2. any
51
Linear growth deficiency (stunting) is more likely
to be due to (1, 2, 3, or 4) causes than to nutritional
deficiency.
1. congenital
2. constitutional
3. familial
4. endocrine
52
Common Set of Criteria for Pediatric Undernutrition in Children < 2 yrs.
• Weight consistently less than (1) for
median for age, or
• Weight on more than 1 occasion
falling below the (2) percentile for
age, or
• Weight that falls across (3) on growth charts, or
Weight-for-length is under the (4) percentile
1. 80%
2. 3rd or 5th
3. 2 major percentiles
4. 3rd
53
(1) results in decreased weight for age percentiles affecting nutritional status referred to as wasting (the weight for height)
(2) or (3) will eventually affect linear growth and results in stunting (Height for age measures the skeletal growth which reflects the cumulative impact of events)
1. Acute malnutrition
2. Prolonged caloric deprivation
3. chronic malnutrition
54
* Three Categorizations of Pediatric Undernutrition:
* Inadequate caloric (1)
* Inadequate caloric (2)
* Excessive caloric (3)
1. intake
2. absorption
3. expenditure
55
* Conditions that increase energy needs
* Increase in intensity of energy utilization such as (1, 2, or 3)
* Or decreased efficiency of energy utilization such as (4, 5, or 6)
1. chronic illness/immunodeficiency
2. endocrine
3. malignancy
4-6. metabolic, hormonal, or genetic micronutrient deficiency
56
Conditions result in deficient energy supply
| calories/nutrition (1), formula preparation (2), (3) difficulties, (4), (5), or structural or malabsorptive disorders
1. withheld
2. mistakes
3. feeding
4. abuse
5. poverty
57
To achieve food security, it is necessary to look at
| 3 aspects of food security:
Availability, Access, & Utilization
58
```
Pediatric undernutrition diagnostics:
• Need to complete a (1)
Laboratory Evaluation
• In the absence of evidence from (2)
• Screening studies may be considered: CBCD; blood pH, electrolytes; BUN and creatinine; urinalysis and culture; stool for: reducing substances, pH, occult blood, ova and parasites
```
1. Feeding & Developmental assessment
| 2. H & P
59
Pediatric undernutrition diagnostics:
| Perinatal – birth weight, congenital anomalies, neurologic insults, (1), (2)
1. NB screening results
| 2. weight for gestational age
60
Feeding (1) with (2) is essential when diagnosing pedatric undernutrition.
Pay close attention to (3), (4), & (5)
1. assessment
2. observation
3. feeding process
4. maternal attachment
5. child-parent dyad
61
Hospitalize for pediatricu undernutrition if needed
• Less than (1) of ideal body weight for height
• (2) undernourished and/or (3)
1. 60%
2. Severely
3. not responding to therapy
62
• Evaluate for weight gain every (1)
Infants should gain (2) from 0-3 months
• (3) weight by 12 mo.; mean daily weight gain is
1. 1-3 weeks
2. 30 g/day (+/- 15 g)
3. Triple
4. 10g/day (+/- 3g)
63
```
Provide nutritional abilitation
Refeeding regimen – recommendations vary widely
• Calories:
• 10%-15% (1)
• 50%-60% (2)
• 30%-40% (3)
• Start (4) – go (5)
```
1. protein
2. carbohydrate
3. fat
4. low
5. slow
64
The main difference between AN & BN is...
AN patients tend have dropped in weight significantly from a healthy weight either to a much lower weight (whether or not that weight is classified as underweight)
BN tend to be at or above a healthy weight.
65
Excessive vomiting leads to depletion of stores of...
potassium kept in the stomach
66
Overwhelmingly males with eating disorders tend to have (1), specifically engaging in (2)
1. Binge-purge type AN
| 2. Subjective binge-eating with overexercising purging
67
True or false: eating disorders are like drug addictions, you can manage them, but you can never truly recover
False: it IS possible to fully recover from eating disorders, unlike their sometimes comorbid psychiatric disorders; especially in younger patients
68
True or False: All overweight BN & BED patients will be able to lose their excess weight down to their optimal age range
False. Gaining a certain amount of weight and/or staying at a certain weight for a significant amount of time can raise your body's set point for body fat homeostasis, making it very difficult or even impossible to drop significantly below that range
69
Which is the priority the eating disorder or the comorbid depression/anxiety?
Eating disorder. Starvation (whether direct or absorptive) is always going to take priority over a behavioral/emotional disorder. Also, food dysregulation can *cause* anxiety. Not to mention CBT is also a useful treatment for both.
70
Deficiencies in (1) and (2) can each be categorized as food insecurity
1. Availability of nutritionally adequate foods
| 2. Ability for an individual to acquire nutritionally adequate foods
71
Risk factors for food insecurity include: (1-4)
1. Poverty
2. Single mother households
3. Minority households
4. Immigrant status
72
An adequate diet for children is one that contains an appropriate (1), is sufficiently (2) that it supplies adequate/not excessive amounts of calories/nutrition, is (3) and culturally acceptable, (4) and (5) and overall supports normal growth and development.
1. density of nutrients
2. diverse
3. palatable
4. affordable
5. available year-round
73
Causes poorer health, and physical, (1), and cognitive developmental risk, more frequent illnesses, (2) and (3) disorders, (4), and (5)
1. social
2. psychiatric
3. behavior
4. adverse weight loss
5. chronic fatigue
74
Repeated hunger can be responsible for (1), and is an (2) in its own right
1. Toxic stress
| 2. Adverse Childhood Event
75
Indication for antihypertensive medications in children
Secondary hypertension with
| Insufficient response to lifestyle changes
76
BP under the 90th percentile for children 13 yo and younger or <120/80 for adolescents and adults > 13
Defined limits for healthy blood pressure
77
BP b/t the 90th & 94th percentiles, or over 120/80 & under the 94th percentile for children 13 yo and younger; or b/t 120/- and 129/79 for adolescents and adults > 13
"Elevated HTN"
78
BP (b/t the 95th percentile and under the 95th percentile + 12 mmHg, or) b/t 130/80 & 139/89
Stage 1 HTN (for children 13 and younger)
79
BP (at or above the 95th percentile + 12 mmHg, or) at or above 140/90
Stage 2 HTN (for children 13 and younger)
80
Fasting glucose 126+
CBG of 200+ at 2 hours into an OGTT
Casual CBG of 200+ alongside symptoms of hyperglycemia
HbA1c considerations
Diagnostic criteria for Type II Diabetes
HbA1c is insensitive to childhood Type II Diabetes
81
```
Lipid Panel age 9 (10):
TC: 165
LDL: 105
N-HDL-C: 115
Trigs: 70 (85)
HDL: 50
```
WDL for healthy lipid levels
82
```
Lipid Panel age 9 (10):
TC: 170
LDL: 110
N-HDL-C: 120
Trigs: 75 (90)
HDL: 40
```
Borderline dyslipidemia
83
```
Lipid Panel age 9 (10):
TC: 200
LDL: 130
N-HDL-C: 145
Trigs: 100 (130)
HDL: 35
```
Diagnostic for dyslipidemia
84
Nausea, RUQ discomfort
Hepatomegaly
Elevated aminotransferases
Next Step?
Liver biopsy to assess for NAFLD --> NASH
85
Weight loss increases the risk of...in the obese
Gallstones
86
Nighttime sweats and daytime sleepiness (mood swings, behavioral changes)
OSA symptoms more commonly seen in children (especially obese children)
87
Obesity is strongly correlated with breathing disorders such as (1), airway (2), and poorly controlled (3)
1. wheezing
2. obstruction
3. asthma
88
Obese youth with a BMI over the 99th percentile with or without significant comorbidities or a BMI at or above the 95th percentile with significant comorbidities
Recommended population for tertiary care weight management intervention: Intensive diet and exercise counseling with the consideration of the use of medications and/or surgery.
89
(1), defined as the inability to reach expected potential based on standard measurements for (2) regarding (3), is common in chronic childhood disease
1. Growth failure
2. age
3. height & weight
90
A sign of growth failure is (1), defined as (2) below the minimum cutoff for age, usually the (3) percentile
1. stunting
2. length or stature
3. fifth
91
Common examples of chronic disease in children
| that are at risk for growth failure/nutritional deficit include (1-3), congenital heart disease (CHD), (4-5)
1. cystic fibrosis (CF),
2. chronic kidney disease (CKD),
3. chronic liver disease,
4. inflammatory bowel disease (IBD), and
5. multiple food allergies
92
Poor growth in children with CF is caused by a number of factors: (1) energy needs, (1) energy losses due to (2), (3) insufficiency, and gastrointestinal (GI) (4)
1. increased
2. malabsorption
3. pancreatic
4. dysmotility
93
Short stature and stunting are common in (1), with
about 30% to 60% prevalence. The longer patients undergo (2), the more severe the
degree of short stature.
1. CKD
| 2. Dialysis
94
Factors associated with short stature in CKD include
| 1), (2), (3), hypothyroidism, (4), and (5
1. sodium wasting
2. acidosis
3. anemia
4. renal osteodystrophy
5. chronic inflammation
95
It is recommended that patients with CKD meet estimated energy needs at (1) to (2)% of the daily required intake (DRI).
1. 100%
| 2. 140
96
Growth failure is seen in most patients with (1) —as many as 80%; often owing, in part, to feeding intolerance. Contributors to feeding intolerance in these patients include (2), (3), and (4).
1. end-stage liver disease (ESLD)
2. portal hypertension
3. hepatosplenomegaly
4. ascites
97
The estimated energy and protein needs for patients
| with ESLD are (1)% to (2)% of DRI.
1. 130
| 2. 150
98
Owing to high stool losses from fat, (1) should compose 30% to 70% of fat intake in children with chronic liver disease. Patients can be given (1) supplementation, as well as supplementation of (2) in aqueous form.
1. medium-chain triglycerides (MCT)
| 2. fat-soluble vitamins A, D, E, and K
99
Growth failure is common in patients with .... Twentyone percent of these patients have low weight for age, 29% have stunting, and 41% have wasting.
CHD
100
Owing to the alteration of ... physiology, patients with CHD have increased basal energy requirements
cardiac and circulatory
101
Prior to surgical correction, it is recommended that CHD patients receive (1)% to (2)% of DRI, as well as 100% of (3) DRI
1. 100
2. 140
3. protein
102
```
Growth failure in childhood cancer is caused by the
presence of (1), leading to (2) and (3)
```
1. inflammation
2. increased energy expenditure
3. anorexia
103
Growth failure can be the presenting sign for (1) in
childhood. Iron deficiency is a major concern in these patients, as the characteristic (2) associated therewith increases production of hepcidin from the liver, which impairs intestinal iron absorption and sequestration of iron from the reticuloendothelial system.
1. IBD
| 2. Chronic inflammation
104
```
The general approach to nutritional support in IBD is
to control (1), provide adequate nutrition, and minimize (2) exposure. (2) treatment is an integral part of management to induce remission.
```
1. active intestinal inflammation
| 2. corticosteroid
105
Children with IBD should receive 100% of (1) needs, and intake should be increased to 150% of DRI during (2).
1. energy and protein
| 2. disease flares
106
Toddlers who are not given cow milk because of
a known sensitivity have decreased intake of energy,
fat, protein, calcium, (1), and (2).
1. riboflavin
| 2. niacin
107
Mid-parental height is calculated as follows:
Boys: [(maternal height + A) + paternal height]/B
Girls: [maternal height + (paternal height − A)]/B
```
A = 5 in or 13 cm
B = 2
```
108
Growth disorder indicated by:
1. Declining weight curve, average height curve, low weight-for-height
2. Declining weight curve, declining vertical growth curve, relatively average weight-for-height
3. Weight/height decline near end of infancy, parallel through middle childhood, then accelerate in late adolescence to an average adult height
4. Both the infant and the parents are small; growth runs parallel to and just below the expected curves
1. Nutritional insufficiency
2. Chronic malnutrition
3. Constitutional growth delay
4. Familial short stature
109
```
COMMON CAUSES OF MALNUTRITION: 0-6 MO
(1)
• Improper formula preparation
(2)
(3)
• Prenatal infections or teratogenic exposures
• Poor feeding (sucking, swallowing) or feeding refusal (aversion)
• Maternal psychological disorder (depression or attachment disorder)
(4)
• Cystic fibrosis
• Neurologic abnormalities
(5)
• Recurrent infections
```
1. Breastfeeding difficulties
2. Impaired parent/child interaction
3. Congenital syndromes
4. Congenital heart disease
5. Child neglect
110
```
COMMON CAUSES OF MALNUTRITION: 6-12 MO
• 1
• 2
• 3
• Delayed introduction of, or poor transition to 4
• Recurrent infections
• 5
```
1. Celiac disease
2. Food intolerance
3. Child neglect
4. age-appropriate foods
5. Food allergy
111
COMMON CAUSES OF MALNUTRITION AFTER INFANCY
• 1
• 2
• 3
•Inappropriate diet (e.g., 4, avoidance of high-calorie foods)
• 5
1. Acquired chronic diseases
2. Highly distractible child
3. Inappropriate mealtime environment
4. excessive juice consumption
5. Recurrent infections
112
Refeeding:
Evaluate for weight gain every 1-3 weeks; infants should gain -1-
0-3 months: -2- weight by a year mean daily weight gain is -3-
1. 30 gm/day (+ 15 g)
2. Triple
3. 10g/day (+ 3g)
113
Refeeding:
Dietary advancement every -1- days with Caloric increases of -2- per day until recommended caloric goals are achieved
• Up to -3- under -4-
1. 3 to 7
2. 10%-25%
3. 150kcal/kg/day
4. 6 months old
114
Eating Disorder RED FLAGS
Ongoing poor weight gain (rate re: percentiles falling) or weight loss
Ongoing -1- during meals
Ongoing problems with vomiting
More than once incident of nasal reflux
History of a -2-
History of -3- coordination problems, with ongoing respiratory issues
Parents reporting child as being -4- or more well child checks
Inability to transition to baby food purees by 10 months of age
Inability to accept -5- by 12 months of age
1. choking, gagging or coughing
2. traumatic choking incident
3. eating and breathing
4. “picky” at 2
5. any table foods
115
Eating Disorder RED FLAGS
Inability to transition from breast/bottle to cup by 16 months of age
Has -1- baby foods by 16 months of age
Aversion to or avoidance of all foods in specific -2- group
Food range of less than 20 foods, especially if foods are being dropped over time with no new foods replacing those lost
An infant who -3- at most meals
Family is -4- and feeding
Parent repeatedly reports that the child is difficult for everyone to feed
Parental history of -5-, with a child not meeting weight goals (parents not causing the problem, but may be more stressed and in need of extra supports)
1. not weaned off
2. texture or nutrition
3. cries and/or arches
4. fighting about food
5. an eating disorder
