Module 5 - Considerations in Nutrition Support of the Pediatric Patient (V.5)

Question 1

What is the recommended daily intake of selenium for term infants receiving parenteral nutrition?
A. <1 mcg/kg/day
B. 2 mcg/kg/day
C. 3 - 4 mcg/kg/day
D. 5 - 6 mcg/kg/day

Answer 1

B. 2 mcg/kg/day

Selenium is imperative for proper immune function, antioxidant capacity, and thyroid hormone production and regulation. Assuming normal organ function, term neonates weighing 3 to 10 kg receiving parenteral nutrition require 2 mcg/kg/day of selenium. In 2012, the ASPEN Novel Nutrient Task Force recommended the addition of selenium at 2 mcg/kg/day to all pediatric trace element products. Current available pediatric multi-trace element products still do not contain selenium so it must be added separately to the PN.

Question 2

What is the recommended daily enteral elemental iron dose for preterm infants, one month after birth?
A. 0.5-1 mg/kg/d
B. 1-2 mg/kg/d
C. 2-4 mg/kg/d
D. 5-6 mg/kg/d

Answer 2

C. 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.

Question 3

A 2-month-old infant, who has been exclusively fed with cow’s milk based formula develops a full body rash. Which of the following would be the most appropriate next step?
A. Switch to a soy protein based formula
B. Switch to a high MCT oil formula
C. Switch to a protein hydrolysate based formula
D. Switch to a lactose free cow’s milk based formula

Answer 3

C. Switch to a protein hydrolysate based formula

Symptoms of cow’s milk protein allergy typically develop in early infancy. These symptoms may manifest as gastrointestinal (blood in stool, diarrhea), cutaneous (rash, eczema), and/or respiratory (wheezing). Most of these infants will do well on a protein hydrolysate formula though some may require a free amino acid formula. Though soy protein based formulas can be used, studies have demonstrated cross-reactivity of up to 10-15% in infants with cow’s milk protein allergy. Lactose free formulas would not be recommended as they would still contain cow’s milk protein. A high MCT oil formula would be indicated if there were concerns for fat malabsorption.

Question 4

Biliary atresia in infancy is most frequently associated with which of the following?
A. Fat malabsorption
B. Chylothorax
C. Zinc Deficiency
D. Essential fatty acid deficiency

Answer 4

A. Fat malabsorption

Biliary atresia, or atrophy of the bile ducts, causes obstruction of bile flow from the liver into the biliary system and small intestine. Therefore, there is a significant decrease in the concentration of intraluminal bile acids that are needed for micelle formation and fat absorption. The result is fat and fat soluble vitamin malabsorption. Essential fatty acid deficiency has been associated with biliary atresia when an MCT oil predominant without adequate LCT formula was used in dietary management. While zinc deficiency may occur due to chronic malnutrition, cirrhosis, or chronic stress, this deficiency is difficult to assess and detect due to laboratory limitation. Chylothorax is the accumulation of chyle in the pleural space due to thoracic duct damage and is more frequently associated with cardiac surgery than biliary atresia.

Question 5

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?
A. Fenton
B. Ehrenkranz
C. Dancis
D. Lubchenco

Answer 5

A. 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.

Question 6

Which of the following is TRUE regarding aspiration in critically ill children?
A. The incidence of aspiration directly caused by enteral nutrition is difficult to determine due to a lack of good clinical research
B. Increased gastric residuals are directly related to increased risk for aspiration
C. Children have strong coordination of pharyngeal muscles, making aspiration less likely than in adults
D. Children have strong cough reflex which helps protect them from aspiration

Answer 6

A. The incidence of aspiration directly caused by enteral nutrition is difficult to determine due to a lack of good clinical research

The actual incidence of aspiration directly caused by enteral nutrition is difficult to determine because there have not been standardized definitions of what constitutes aspiration, nor have there been adequate descriptions in all studies of the actual cause of aspiration in each particular patient. Increased gastric residuals have not been linked to an increased risk for aspiration. Critically ill children actually have decreased strength and coordination of pharyngeal muscles and a weak cough reflex making aspiration more likely.

Question 7

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?
A. Vitamin A
B. Fluoride
C. Vitamin E
D. Iron

Answer 7

B. 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.

Question 8

What should the MAXIMUM glucose infusion rate (GIR) be for a term infant receiving parenteral nutrition (PN)?
A. 4-8 mg/kg/min
B. 8-12 mg/kg/min
C. 14-18 mg/kg/min
D. 18-22 mg/kg/min

Answer 8

C. 14-18 mg/kg/min

PN provides carbohydrate in the form of dextrose at 3.4 kcal/g. The glucose oxidation rate or GIR may be calculated as follows: [dextrose (g/day) x 1000]/[24 (hr/day) x 60 (min/hr). x weight (kg)]. When developing goal PN calories from dextrose, in general the PN should not provide more than the maximal GIR as this may result in fat production, hepatic steatosis and PN-associated liver disease. Infants should be monitored for glucose intolerance, which may manifest as hyperglycemia and/or hypertriglyceridemia.

Question 9

Which of the following does NOT describe the use of minimum enteral feeds in preterm neonates?
A. Prevents gut atrophy
B. Increases the risk of necrotizing enterocolitis
C. Improves feeding tolerance and time to full enteral feeds
D. Should be started as soon as medically feasible

Answer 9

B. Increases the risk of necrotizing enterocolitis

The development of necrotizing enterocolitis (NEC) is a concern in the neonate. The etiology of NEC remains unclear. It often occurs in infants who are being fed via the gastrointestinal tract. Therefore, a main strategy for reducing the risk of NEC has been to withhold enteral feeds for prolonged periods of time. Research now refutes this practice by demonstrating that early initiation of minimum enteral feeds does NOT increase the risk of NEC and has shown benefits such as a shorter time to full enteral feeds, faster weight gain, improved feeding tolerance, decreased length of hospitalization and reduced incidence of serious infections in low birth weight and very low birth weight infants. When medically possible, minimum enteral feeds can begin on the day of birth, with the preferred feeding being human milk.

Question 10

Which of the following is a metabolic alteration noted during the ebb response following burn injury to a pediatric patient?
A. Elevated catecholamines
B. Decreased resting energy expenditure
C. Elevated plasma insulin
D. Anabolism

Answer 10

B. Decreased resting energy expenditure

The ebb response initially follows burn injury and lasts 3-5 days and includes depressed resting energy expenditure, hyperglycemia, low plasma insulin, loss of plasma volume, decreased oxygen consumption, decreased blood pressure, reduced cardiac output, and decreased body temperature. After the ebb phase, the acute phase of the flow response occurs and is represented by elevated catecholamines and elevated or normal plasma insulin along with hyperglycemia, elevated glucagon and glucocorticoids, high glucagon-to-insulin ratio, catabolism, increased body temperature, increased cardiac output, redistribution of polyvalent cations such as zinc and iron, mobilization of metabolic reserves, increased urinary excretion of nitrogen, sulphur, magnesium, phosphorus and potassium, and accelerated gluconeogenesis. These metabolic alterations occur quickly, and the acute phase peaks between the 6th and 10th day following burn injury. The transition from acute to adaptive phase of the flow response is gradual. Anabolism is not established until the adaptive phase of the flow response.

Question 11

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
A. underweight.
B. healthy weight.
C. overweight.
D. obese.

Answer 11

D. 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.

Question 12

The use of Lactobacillus rhamnosus GG (LGG) in pediatric practice has been found to be MOST effective in
A. treating infectious diarrhea.
B. reducing the incidence of necrotizing enterocolitis.
C. prolonging time to remission in children with Crohn’s disease.
D. eradicating Heliobacter pylori infection.

Answer 12

A. treating infectious diarrhea.

Multiple clinical studies have been performed to assess the effectiveness of Lactobacillus rhamnosus GG in acute gastroenteritis in children. These studies have consistently shown LGG to be effective at reducing both duration and frequency in infectious diarrhea. At this time research does not support the use of LGG in NEC, inflammatory bowel disease or helicobacter pylori infection. It should be noted though that other strains of probiotics have been shown to be beneficial in each of these conditions.

Question 13

The biochemical defect in phenylketonuria (PKU) is a functional deficiency of the liver enzyme phenylalanine hydroxylase, which catalyzes the para-hydroxylation of phenylalanine to yield what amino acid?
A. Threonine
B. Alanine
C. Methionine
D. Tyrosine

Answer 13

D. Tyrosine

The deficiency of phenylalanine hydroxylase in classic PKU prevents the hydroxylation of phenylalanine to tyrosine which causes a build up of phenylalanine in the blood and a subsequent deficiency of tyrosine. Provision of a phenylalanine restricted, tyrosine supplemented diet has been shown to improve outcomes in people with this hereditary metabolic disorder.

Question 14

An infant has a complete ileal resection with preservation of the ileocecal valve. Of the following, the primary nutrition-related concern will be
A. vitamin B12 deficiency.
B. water soluble vitamin malabsorption.
C. dumping syndrome.
D. protein malabsorption due to decreased cholecystokinin secretion.

Answer 14

A. vitamin B12 deficiency.

While the jejunum is the primary site of absorption of most water-soluble vitamins and if resected would result in their malabsorption, vitamin B12 is mostly obtained via the ileum. Complete ileal resection precludes the absorption of vitamin B12 and bile acids leading to deficiency. Dumping syndrome is most likely to develop if all or part of the stomach has been removed. The duodenum and jejunum are the primary sites of cholecystokinin and secretin secretion which would not be affected in this scenario.

Question 15

When used in assessment of critically ill children, how do predictive equations compare to indirect calorimetry?
A. No consistent comparison can be found
B. Equations typically overestimate needs
C. Equations typically underestimate needs
D. Equations correlate well with indirect calorimetry

Answer 15

A. 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.

Question 16

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?
A. Calcium
B. Phosphorus
C. Selenium
D. Potassium

Answer 16

A. 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.

Question 17

Which of the following is considered to be diagnostic criteria of infantile anorexia?
A. Refusal to eat adequate amounts of food for >1 month
B. Failure to eat adequately associated with childhood depressive disorder
C. Failure to gain weight after a traumatic event
D. Chronic weight loss associated with a malabsorptive disorder

Answer 17

A. Refusal to eat adequate amounts of food for >1 month

Infantile anorexia is characterized by a child’s refusal to eat adequate amounts of food for at least 1 month. Children with infantile anorexia generally do not communicate that they are hungry, have an interest in food and eating, and exhibit growth deficiency. This disorder is not due to an associated gastrointestinal disorder or other medical condition and does not follow a traumatic event. Onset typically occurs between 6 months to 3 years of age and often occurs during the transition to spoon- and self-feeding. Treatment includes understanding the child’s temperament and level of arousal, establishing a regular feeding schedule and incorporation of behavioral techniques and feeding guidelines.

Question 18

Which of the following is the BEST indication for use of a soy-based infant formula?
A. Diarrhea
B. Cow’s milk protein allergy
C. Galactosemia
D. Regurgitation with feeds

Answer 18

C. 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.

Question 19

Which of the following is NOT a common clinical symptom of celiac disease in childhood?
A. Failure to thrive
B. Constipation
C. Precocious puberty
D. Anemia

Answer 19

C. Precocious puberty

Common symptoms of celiac disease in childhood include diarrhea, constipation, chronic abdominal pain, abdominal distention, vomiting, short stature, weight loss, inadequate weight gain, dental enamel defects, dermatitis herpetaformis, reduced bone mineral density, iron deficiency anemia, fatigue, migraines, and joint pain. Delayed puberty, not precocious puberty, is a symptom of celiac disease. Upon symptom identification, gluten needs to remain in the diet until after serology testing and biopsy are completed. Intestinal biopsy is needed for formal diagnosis.

Question 20

Nutrition therapy for pediatric patients with <20% total body surface area (TBSA) burn typically includes
A. oral intake of high calorie, high protein diet.
B. enteral nutrition therapy.
C. parenteral nutrition therapy.
D. enteral and parenteral nutrition therapy.

Answer 20

A. oral intake of high calorie, high protein diet.

Small burns (<20% TBSA) not complicated by facial injury, psychologic problems, inhalation injury, or pre-burn malnutrition can usually be supported by an oral high protein, high calorie diet. Children with burns covering >20% TBSA generally cannot meet their nutrient needs by oral intake alone.

Question 21

Which of the following nutrition support therapies is essential to intestinal adaptation following significant bowel resection?
A. Glutamine-enriched parenteral nutrition
B. Enteral nutrition (EN)
C. Lipid injectable emulsion (ILE) restriction
D. Glucagon-like peptide-2 (GLP-2) administration

Answer 21

B. Enteral nutrition (EN)

Intestinal adaptation is a complex process that occurs following a massive loss of intestinal surface area. EN is necessary for the adaptation process to occur. For infants, human milk is the preferred source of EN and has been associated with decreased PN duration. Additional parenteral glutamine has not been deemed essential to intestinal adaptation. ILE restriction has been used as a therapy for reducing PN-associated liver disease but not improving intestinal adaptation. GLP-2 is an exogenous growth factor that appears to reduce the duration of PN among adults and is currently being studied in children.

Question 22

Which of the following is recommended to prevent vitamin D deficiency in a 1-month-old infant fed human milk?
A. Supplement with 100 IU vitamin D per day
B. Supplement with 200 IU vitamin D per day
C. Supplement with 300 IU vitamin D per day
D. Supplement with 400 IU vitamin D per day

Answer 22

D. 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.

Question 23

Which of the following is FALSE regarding regurgitation in infants?
A. Regurgitation is rare in infants
B. Regurgitation is usually transient
C. Regurgitation typically resolves around 7-12 months of age
D. Regurgitation is associated with delayed gastric emptying

Answer 23

A. Regurgitation is rare in infants

Regurgitation is very common in infants and does not necessarily signify a problem. Common causes of reflux in children receiving enteral nutrition include rapid administration of enteral formula, delayed gastric emptying, or feeding tube migration into the esophagus. Regurgitation usually will resolve around 7-12 months of age with maturation of the lower esophageal sphincter.

Question 24

Which of the following best describes the appropriate use of powdered infant formula in healthcare facilities?
A. Freeze open containers and discard after 30 days from opening
B. Refrigerate open containers and discard after 30 days from opening
C. Use interchangeably with comparable sterile liquid formulations
D. Use only when alternative sterile liquid products are not available and when clinically necessary

Answer 24

D. Use only when alternative sterile liquid products are not available and when clinically necessary

Powdered formulas are not sterile. Powdered infant formulas should only be used in health care facilities when clinically necessary and when alternative commercially sterile liquid products are not available. If there are no other alternatives to infant formula powder, clinicians need to be aware of potential risks with use of powdered formulas for immunocompromised patients.

Question 25

Which of the following therapies would be considered most appropriate in the nutritional management of an infant with chronic lung disease?
A. Use of concentrated formula
B. Use of a high fat, low carbohydrate formula
C. Use of a hydrolyzed protein formula
D. Use of an MCT oil predominant formula

Answer 25

A. Use of concentrated formula

Infants with chronic lung disease often have high calorie needs due to gastroesophageal reflux, emesis, chronic infections, and increased work of breathing. Use of a concentrated formula allows for provision of adequate nutrition while restricting fluid intake. Fluid restriction is indicated due to fluid build up around the heart and lungs. The use of low carbohydrate formulas, hydrolyzed protein formulas, or MCT oil predominant formulas are not indicated for use for treatment of chronic lung disease.

Question 26

Which of the following methods of estimating energy requirements in critically ill children is LEAST accurate when compared to resting energy expenditure measurement by indirect calorimetry?
A. Schofield Equation
B. White Equation
C. World Health Organization Equations
D. Recommended Dietary Allowance (RDA) for energy

Answer 26

D. Recommended Dietary Allowance (RDA) for energy

In pediatric intensive care patients, predictive equations for energy expenditure yield results that are not consistent with measured energy expenditure. Provision of nutrition support based on inaccurately estimated energy requirements has been shown to result in significant under or overfeeding. Indirect calorimetry is the gold standard for determining baseline energy needs in critically ill children. The Schofield Equation, the White Equation, and the World Health Organization Equation do adjust for an individual’s sex, height, weight, and age but are meant for healthy children. The Recommended Dietary Allowance (RDA) for energy also accounts for age and sex but is an average of the requirements for that group which is again based on healthy individuals

Question 27

Which of the following is NOT associated with a delayed bone age in a child with short stature?
A. Hypothyroidism
B. Precocious puberty
C. Cushing syndrome
D. Growth hormone deficiency

Answer 27

B. 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.

Question 28

A child with cerebral palsy and a gastrostomy tube is admitted to the hospital for a fundoplication. This procedure is used to manage
A. gastroesophageal reflux (GER).
B. oral/motor dysfunction.
C. malnutrition.
D. esophagitis.

Answer 28

A. 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.

Question 29

What trace element should be supplemented in a child with chronic diarrhea?
A. Iron
B. Zinc
C. Copper
D. Selenium

Answer 29

B. 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.

Question 30

Which of the following is characteristic of cachexia in pediatric oncology patients?
A. Gradual weight loss
B. Maintenance of lean body mass at the expense of body fat
C. Decrease in energy expenditure
D. Progressive wasting of lean tissue and body fat

Answer 30

D. Progressive wasting of lean tissue and body fat

In contrast to prolonged fasting or starvation, cachexia in children with cancer is an advanced state of wasting characterized by excess depletion of skeletal muscle mass and adipose tissue. Mechanisms of protein conservation and decreased energy expenditure that allow prolonged survival in the chronic fasting state appear to be lost or inhibited in cancer.

Question 31

In the hospital, what is the hang time for expressed human milk when used for continuous enteral feedings?
A. 2 hours
B. 4 hours
C. 8 hours
D. 12 hours

Answer 31

B. 4 hours

Expressed human milk is never sterile and contains a variety of normal skin flora. Contamination can occur during milk expression and storage, during the preparation and mixing of additives, and while assembling and handling feeding systems. To reduce potential for contamination, feeding systems that include bags, syringes, or tubing should never be reused. In the hospital setting, enteral feeding systems should not be used for more than 4 hours.

Question 32

A 4-month-old male has acute onset of diarrhea for 48 hours. His parents noticed that he hasn’t been wetting as many diapers and his mucous membranes are slightly dry. His anterior fontanel is soft and not sunken. He normally ingests milk based formula ad lib. Which of the following is the most appropriate nutrition intervention for this infant?
A. Half strength infant formula
B. Oral rehydration therapy
C. Full strength elemental formula
D. Short course of parenteral nutrition

Answer 32

B. Oral rehydration therapy

An infant who is mildly dehydrated from diarrhea is likely suffering from a viral gastroenteritis that will commonly resolve in 72-96 hours. An otherwise healthy infant with acute dehydration can receive adequate fluid and electrolyte replacement with oral rehydration solutions. A short course of oral rehydration therapy is the preferred treatment. Starting parenteral nutrition is not an appropriate treatment option. Return to an age-appropriate diet early in the course of diarrheal illness is superior to providing diluted formula or full strength elemental formula. Infants provided human milk ad lib should continue to be fed the human milk. Infants should be monitored for clinical indications that dehydration is worsening including sunken eyes, sunken fontanel, loss of skin turgor and dry mucous membranes.

Question 33

In an infant receiving parenteral nutrition (PN), what is the MINIMUM amount of soybean oil-based lipid injectable emulsion (ILE) needed to prevent essential fatty acid deficiency (EFAD)?
A. 0.2-0.4 g/kg/day
B. 0.5-1g/kg/day
C. 1.1-1.5 g/kg/day
D. 1.8-2 g/kg/day

Answer 33

B. 0.5-1g/kg/day

ILE provides a concentrated source of calories, helps maintain the integrity of peripheral lines, and supplies essential fatty acids for brain development. In order to prevent EFAD, it is imperative to provide ILE at 0.5-1 g/kg/day. For patients where prolonged PN dependence (> 1 month) is anticipated, lipid restriction to 1 g/kg/day may be instituted to help prevent PN-associated liver disease.

Question 34

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?
A. Renal tubular acidosis
B. Osteogenesis imperfecta
C. Vitamin D deficient rickets
D. Vitamin D dependent rickets type 2

Answer 34

C. 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.

Question 35

What is the daily maintenance fluid requirement for a 5 kg infant?
A. 300 mL
B. 500 mL
C. 700 mL
D. 1000 mL

Answer 35

B. 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.

Question 36

What is the suggested daily amount of potassium required for maintenance in an infant receiving parenteral nutrition?
A. 0.8-1 mEq/kg
B. 2-4 mEq/kg
C. 5-6 mEq/kg
D. 7-8 mEq/kg

Answer 36

B. 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.

Question 37

When does the American Academy of Pediatrics (AAP) recommend universal screening for iron deficiency be performed in young children?
A. Between 4 and 6 months of age
B. Only when risk factors are present
C. Every 6 months in exclusively breastfed infants
D. At 12 months of age

Answer 37

D. 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.

Question 38

Standard neonatal parenteral amino acid solutions differ from standard adult parenteral amino acid solutions by having a higher content of
A. cysteine.
B. phenylalanine.
C. taurine and tyrosine.
D. methionine and glycine.

Answer 38

C. taurine and tyrosine.

Specialized amino acid (AA) solutions were designed to mimic the plasma AA patterns of breastfed infants. Taurine and tyrosine are considered essential AAs in neonates because of their enzyme immaturity. Phenylalanine, methionine, and glycine are actually given in smaller amounts to neonates compared to adults. There is conflicting data on the essentiality of cysteine in neonates and it is not a component of standard parenteral AA solutions. Cysteine is unstable in aqueous solution so if it is added, this is done so immediately prior to administration. The addition of cysteine lowers the pH further in order to optimize calcium and phosphorus solubility.

Question 39

Which of the following is NOT a contraindication to nasogastric feedings in a pediatric patient with cystic fibrosis (CF)?
A. Chronic sinusitis
B. Chronic otitis
C. Pancreatic insufficiency
D. Need for long term nutrition support

Answer 39

C. 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.

Question 40

Which of the following children is at greatest risk for iron deficiency anemia?
A. 3 month-old term infant exclusively fed human milk
B. 4 month corrected gestational age, former preemie on a transitional formula
C. 10 month-old switched from formula to whole milk
D. 17 month-old “picky eater”

Answer 40

C. 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.

Question 41

Non-nutritive sucking should be used in the enterally fed neonate less than 32 weeks corrected gestational age to promote
A. mother/child bonding.
B. weight gain.
C. correct development of facial and jaw muscles.
D. oral feeding when developmentally appropriate.

Answer 41

D. 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.

Question 42

What distinguishes gastroesophageal reflux (GER) from gastroesophageal reflux disease (GERD) in infants?
A. GERD is characterized by the presence of significant complications
B. GER is associated with failure to thrive
C. GER is associated with arching of the back and irritability with no other symptoms
D. GERD typically requires surgical fundoplication

Answer 42

A. GERD is characterized by the presence of significant complications

GER is a frequently encountered problem in infancy and it commonly resolves spontaneously. GER is not associated with significant complications and many times these infants are referred to as “happy spitters”. GERD on the other hand is associated with significant complications including weight loss or failure to thrive, feeding difficulties, arching of the back, or irritability. Surgical intervention with fundoplication for treatment of GERD is considered only after other therapies have failed.

Question 43

Which of the following concentrations is considered to be an upper limit for the osmolality of infant formulas to avoid tolerance issues?
A. 460 mOsm/kg
B. 360 mOsm/kg
C. 260 mOsm/kg
D. 560 mOsm/kg

Answer 43

A. 460 mOsm/kg

Recommendations for infant formulas are an osmolality of less than 460 mOsm/kg. The osmolality of standard infant formulas at a caloric density of 20 kcal/oz generally falls below this limit with a range of 200 - 380 mOsm/kg. Protein hydrolysate and free amino acid infant formulas have a slightly higher osmolality due to their smaller particle size (330-370 mOsm/kg). The osmolality of a 30 kcal/oz concentrated standard infant formula is approximately 450 mOsm/kg. The addition of a carbohydrate modular to increase caloric density of formula will increase the osmolality of the formula while the addition of a fat modular will not.

Question 44

Premature infants are at increased risk of metabolic bone disease in all of the following scenarios EXCEPT
A. short duration parenteral nutrition.
B. cholestasis.
C. chronic steroid use.
D. very low birth weight.

Answer 44

A. 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.

Question 45

Pancreatic enzymes supplemented at high doses in children with cystic fibrosis could result in
A. steatorrhea.
B. meconium ileus.
C. fibrosing colonopathy.
D. cystic fibrosis related diabetes.

Answer 45

C. fibrosing colonopathy.

Pancreatic enzymes are used to increase nutrient absorption and decrease the presence of steatorrhea. High dose enzyme usage may result in strictures of the ascending colon, also known as fibrosing colonopathy. Enzymes should be used at less than 10,000 units of lipase/kg/day. Cystic fibrosis related diabetes is secondary to mucus obstruction of pancreatic beta cells, which prevents insulin secretion and may lead to beta cell destruction. Meconium ileus has similar symptoms as fibrosing colonopathy, including intestinal obstruction, mass in the right lower quadrant, and abdominal pain that most often occurs in neonates. Meconium ileus is a bowel obstruction that occurs only in infants with signs of abdominal distension, bilious emesis, and no passage of meconium. It is not caused by high dose enzyme therapy.

Question 46

Preterm infant formula or fortified human milk is used for premature infants. What is the rationale for this?
A. Preterm formula contains a higher percentage of carbohydrate as lactose, compared to term formula
B. After the first month, unfortified human milk may contain inadequate protein for the premature infant
C. Term formula contains more medium chain triglycerides than desired
D. Preterm formula is easier to absorb than unfortified human milk

Answer 46

B. After the first month, unfortified human milk may contain inadequate protein for the premature infant

Preterm formulas contain 40-50% of the carbohydrate calories as lactose (50-60% as glucose polymers), which is a lower load of lactose to the premature infant compared to standard term infant formulas (100% lactose). Standard infant formulas contain only long chain fatty acids. Preterm formulas contain 40-50% of fat calories as medium chain triglycerides, which are easier to absorb than long chain fatty acids as they do not require pancreatic lipase or bile salts for digestion or absorption. Preterm human milk often contains a higher concentration of protein. However, the protein concentration decreases by 28 days of lactation. Human milk fortifiers should be added to human milk to meet the protein, calcium, phosphorous and sodium needs of the rapidly growing premature infant. Nutrients in human milk (fortified or unfortified) are more readily absorbed than nutrients in preterm or term formula.

Question 47

Immediately following neonatal cardiac surgery, which of the following is the best estimate of parenteral caloric requirements?
A. 90-100 kcal/kg/day
B. 120-170 kcal/kg/d
C. 55-60 kcal/kg/d
D. 100-110 kcal/kg/d

Answer 47

C. 55-60 kcal/kg/d

Though growth is often the primary goal in neonatal nutrition, growth cannot occur until recovery from the stress response has begun. Critically ill and postoperative neonates have significantly lower energy needs compared with healthy neonates due to absence of growth, decreased activity, and reduction in insensible losses during stress states. Indirect calorimetry (IC) is recommended when possible but, if IC is not available, the basal energy/resting energy expenditure (REE) should be used for nutrition support provision.

Question 48

Exclusive enteral nutrition has been shown to be effective in inducing remission of Crohn’s disease in the pediatric population. What enteral formula is recommended as first line therapy in these patients?
A. Polymeric enteral formula
B. Elemental enteral formula
C. Parenteral nutrition
D. Gluten-free diet

Answer 48

A. Polymeric enteral formula

Meta-analysis data on exclusive enteral nutrition (EEN) suggests that it is equal in efficacy to corticosteroids in inducing clinical remission in the pediatric population. Though the exact mechanism of action is still not well understood, it is hypothesized that EEN alters the microbiome resulting in remission of disease. Several studies have compared the efficacies of different types of enteral formulas on Crohn’s disease and found no statistically significant difference between them. Polymeric enteral formulas are recommended for first line therapy in all patients unless symptoms of malabsorption or gastrointestinal dysfunction are present.

Question 49

For neonates, which of the following amino acids should be added separately to parenteral nutrition solutions due to solubility concerns?
A. Glycine
B. Cysteine
C. Methionine
D. Phenylalanine

Answer 49

B. Cysteine

In adults, cysteine can be synthesized from methionine via a liver-specific transsulfuration pathway. The enzyme necessary for this synthesis is not present in adequate amounts in neonates, particularly preterm infants. Therefore, cysteine is considered likely to be an essential amino acid (AA) in neonates and infants. It is not included in standard AA solutions because of solubility concerns. However, it can be added as cysteine HCl at a dose of 30 to 40 mg per gram of amino acids which also increases the solubility of calcium and phosphorus by lowering the pH of the solution.

Question 50

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?
A. Z-score above 3
B. Z-score above 2
C. Z-score below -2
D. Z-score below -3

Answer 50

D. 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.