Nutrition

Question 1

Advantages of breastfeeding in infants and children?

Answer 1

1. Decreased frequency and severity of:
   - Diarrheal illness
   - Respiratory infections
   - Necrotizing enterocolitis
   - Otitis media
2. Decreased rate of:
   - urinary tract infection
   - bacterial sepsis
3. Lower risk of neonatal and infant death:
   - Overall infant mortality
   - Sudden infant death syndrome (SIDS)
4. Likely lower risk of chronic illness:
   - Leukemia (ALL, AML)
   - Diabetes (types 1 and 2)
   - Obesity
   - Atopic dermatitis and asthma
   - Celiac disease and Crohn’s disease

Question 2

Advantages of breastfeeding for the mother?

Answer 2

With cumulative lactation of 12 months or greater)
1. Reduced risk of cancer:
- Breast cancer risk (OR = 0.72)
- Ovarian cancer risk (OR = 0.63)
2. Reduced risk of cardiovascular disease:
- Obesity (OR = 0.92)
- Hypertension (OR = 0.88)
- Hyperlipidemia (OR = 0.81)
- Cardiovascular disease (OR = 0.91)
3. Reduced risk of diabetes type 2 (among women without gestational diabetes; OR = 0.80)

Question 3

HIV infection and breastfeeding?

Answer 3

Exclusive breast feeding for 6 months
Complimentary feeding thereafter until 24 months
Mother be on lifelong antiretroviral medications
Baby on nevirapine (NVP) within 72 hours of birth
NVP continued for 6 weeks

Question 4

What are micronutrients?

Answer 4

1. vitamins
2. trace elements <0.01% of the body weight

Question 5

Factors contributing to trace elements deficiencies in children?

Answer 5

1. Increased demand of growth
   - Organs (e.g brain) can sustain permanent damage due to trace element deficiency (iron, iodine)
2. Gastroenteritis and malabsorption can cause loss of:
   potassium, magnesium, vitamin A, and zinc

Question 6

Describe zin deficiency?

Answer 6

Epidemiology - developing world
Associated conditions - malnutrition, iron deficiency
Chronic deficiency associations - dwarfism, hypogonadism, dermatitis, and T-cell immunodeficiency
Importance of zinc - supplementation reduces the incidence and severity of diarrhea, pneumonia, and possibly malaria

Question 7

Production of vitamin D?

Answer 7

Cutaneous synthesis is the most important source [conversion of 7-dehydrochlesterol tovitamin D3(3-cholecalciferol)]

Question 8

Factors that decrease cutaneous synthesis of vitamin D?

Answer 8

Increased skin pigmentation
Less time outside
Away from equator
Covering skin or sunscreens

Question 9

Natural dietary sources of vitamin D?

Answer 9

1. Fish liver oils
2. Fatty fish andegg yolks
   Note: Breast milk has a lowvitamin Dcontent.

Question 10

Clinical manifestations of vitamin D deficiency?

Answer 10

1. rickets
2. hypocalcemia
3. Laryngospasm (occasionally fatal)
4. Increased risk of pneumonia and muscle weakness; delay in motor development

Question 11

Features of rickets?

Answer 11

1. Genu varum (bowed legs)or genu valgum (knock knees)
2. Thickened wrists and ankles
3. Prominence of the costochondral junctions (rachitic rosary)
4. Indentation of the lower anterior thoracic wall (Harrison groove)
5. Frontal bossing
6. Craniotabes

Question 12

Vitamin k deficiency? Deficiency causes what?

Answer 12

Necessary for the synthesis of clotting factors II, VII, IX, and X
- Deficiency can result in clinically significant bleeding

Question 13

Causes of vitamin K deficency?

Answer 13

1. Breastfed infants (lowvitamin Kcontent of breast milk; formula is fortified);
2. Delayed feeding is an additional riskfactor
3. Newborn gut is sterile has no intestinal synthesis ofvitamin K2
4. Poor transfer ofvitamin Kacross the placenta
5. Occult malabsorption ofvitamin K (e.g biliary atresia)
6. Maternal medications (Warfarin, phenobarbitone, phenytoin)
7. Poor intake PLUS use of broad-spectrum antibiotics

Question 14

Clinical manifestation of vitamin K deficiency?

Answer 14

Vitamin k deficiency bleeding
1. Gastrointestinal (GI) tract
2. Mucosal and cutaneous tissue
3. Umbilical stump
4. Postcircumcision site
5. Intracranial bleeding (can cause convulsion, permanent neurological sequalae or death.

Question 15

Prevention and treatment of vitamin K deficiency?

Answer 15

1. Discontinuing the offending medications before delivery
2. Administration ofvitamin Kto the mother may be helpful
3. Neonatal parenteralvitamin Kimmediately after birth
4. Fresh frozen plasma if parenteralvitamin Kdoes not correct the coagulopathy

Question 16

Iron deficiency?

Answer 16

Deficiency causes
- preventable intellectual impairment, Deficiency in pregnancy causes fetal loss and brain damage (cretinism)
Clinical features
- Enlarged thyroid (goiter) is a sign of deficiency
Prevented by iodine supplementation before conception or during the 1st trimester of pregnancy
Note: Postnatal iodine deficiency causes impaired mental function and growth retardation

Question 17

Underweight?

Answer 17

low weight for height
- Poor weight gain or loss from acute malnutrition, illness, etc

Question 18

Stunting?

Answer 18

low height for age
- Growth retardation, ‘chronic malnutrition’ diet deficiency in minerals and vitamins

Question 19

Wasting?

Answer 19

MUAC < 13.5cm (risk) or <11.5cm (severe malnutrition)
- Acute starvation, hunger (emergency situations)

Question 20

Obesity?

Answer 20

BMI >30
- Very high energy intake and/or sedentary lifestyles

Question 21

Low birth weight?

Answer 21

birth weight < 2500g
- Intrauterine growth retardation and/or prematurity

Question 22

Marasmus?

Answer 22

Very low weight/height or weight/age
- Severe deficiency of energy intake or excessive energy requirements

Question 23

Kwashiorkor?

Answer 23

nutritional edema
- Deficiency of some nutrients, particularly those involved with anti-oxidant protection (glutathione, vitamins A, C, and E, and essential fatty acids) or cofactors (zinc, copper, selenium).

Question 24

Severe acute malnutrition?

Answer 24

1. The presence of bilateral pitting oedema or WFH of <-3Zscore or
   - 6-59 months MUAC <11.5cm
   - 5 -9 years MUAC <13.0cm
   - 10 – 15 years <16.0cm
2. In adolescents bilateral pitting oedema or MUAC <18.5cm or Body-Mass-Index (BMI) <16.0

Question 25

Wasting in 6-59 months?

Answer 25

moderate
- MUAC: 11.5 - 12.4 cm
- W/HT Z score: -2 to -3
severe
- MUAC: <11.5cm
- W/HT Z score: <-3

Question 26

Kwashiorkor in 6-59 months?

Answer 26

moderate
- no symmetrical and pitting edema
severe
- symmetrical and pitting edema

Question 27

Grading edema?

Answer 27

1. Oedema + - localized to the feet
2. Oedema ++ - below knee, may affect even hands but not the face
3. Oedema +++ - generalized/periorbital

Question 28

Body mass index?

Answer 28

BMI = weight in kg/(height in meters)2
- For children, BMI is age and gender specific
- BMI-for-agecan be used from birth to 20 yr
- Screening tool forthinness(less than −2 SD)
- Overweight(between +1 SD and +2 SD)
- Obesity(greater than +2 SD)

Question 29

Risk factors for severe malnutrition?

Answer 29

1. Poor family dynamics
   - mother pregnant or poorly educated, father unemployed or separated, parental illness
2. Sub-optimal nutrition
   e.g., lower breastfeeding rates or earlier weaning

Question 30

Energy conservation in malnutrition?

Answer 30

1. Utilization of fat, proteins (muscle, skin, GIT)
2. Reducing physical activity, growth, reducing basal metabolism
3. Reduced functional reserve of organs
4. Reduced inflammatory and immune responses

Question 31

Consequences of reductive adaptation of the liver in malnutrition?

Answer 31

1. Reduced gluconeogenesis (prone to hypoglycaemia)
2. Reduced protein production (albumin, transferrin)
3. Less able to cope with excess dietary protein
4. Less able to excrete toxins
5. Reduced heat production (vulnerable to hypothermia)

Question 32

Reductive adaptation of the kidneys in manutrition?

Answer 32

1. Reduced GFR
2. Less able to excrete excess fluid and sodium
3. Fluid easily accumulates in the circulation
4. Increasing the risk of fluid overload

Question 33

Reductive adaptation of the heart in malnutrition?

Answer 33

1. Smaller and weaker
2. Reduced output
3. Fluid overload readily leads to death from cardiac failure.

Question 34

Consequences of reductive adaptation of electrolytes?

Answer 34

1. Increased intracellular sodium concentration
   - leaky cell membranes
   - reduced activity of the sodium/potassium pump
   - Excess body sodium, fluid retention, and edema
2. Potassium leaks out of cells
   - Excreted in urine
   - Electrolyte imbalance, fluid retention, edema, and anorexia
3. Loss of muscle protein is accompanied by loss of potassium, magnesium, zinc, and copper.

Question 35

Reductive adaptation of the GIT?

Answer 35

1. Less gastric acid and enzymes
2. Reduced mortility
3. Bacterial may colonization of stomach and small intestine
   - Damaging mucosa and deconjugating bile salts
4. Digestion and absorption are impaired.
5. Cell replication and repair are reduced
   - Increased risk of bacterial translocation through the gut mucosa

Question 36

Reductive adaptation of immune function?

Answer 36

1. Impaired immune function especially cell-mediated
2. The usual responses to infection may be absent
3. Increased the risk of undiagnosed infection

Question 37

Reductive adaptation of hematology?

Answer 37

1. Red cell mass is reduced
2. Releasing iron (requires glucose and amino acids to be converted to ferritin)
   - Increasing the risk of hypoglycemia and amino acid imbalances
   - Unbound iron promotes pathogen growth and formation of free radicals (If conversion to ferritin is incomplete)

Question 38

Reductive adaptation of micronutrient deficiency?

Answer 38

Inability to deactivate free radicals
- Cause cell damage
- Edema and hair/skin changes are outward signs of cell damage