Nutrition

Question 1

Why are infants and children more vulnerable to poor nutrition?

Answer 1

Low nutritional stores (particular preterm)
High nutritional demands for growth (particularly in first 6 months)
Rapid neuronal development (first 2 years of life)

Question 2

How does paediatric surgery or acute illness affect nutrition?

Answer 2

Following an acute illness or surgery infants are prone to recurrent infections, which reduce food intake and increase nutritional demands

Question 3

How does the body respond to surgery?

Answer 3

After a brief anabolic phase, catecholamine secretion is increased, causing the metabolic rate and energy requirement to increase. Urinary nitrogen losses may become so great that there is not a positive nitrogen balance and weight is lost.

Question 4

What environmental factors affect height?

Answer 4

Height is adversely affected by lower socioeconomic status and increasing number of children in families.

Question 5

What are the advantages of breast feeding?

Answer 5

Reduced GI infection
Reduced incidence of NEC in preterm infants
Establish an intimate, loving relationship with their baby
Reduced incidence of obesity, DM and HTN in later life.
Reduced maternal risk of breast cancer

Question 6

What are the potential complications of breast feeding?

Answer 6

Cannot tell how much milk a baby is taking (check baby weight regularly)
More difficult to feed twins
Difficult for preterm infants to suckle
Difficult to maintain the supply of milk
Restrictive for the mother

Question 7

What is colostrum?

Answer 7

It is produced for the first few days of breast feeding, it has a much higher content of protein and Ig that normal milk. Volumes are low.

Question 8

When should breast feeding start?

Answer 8

ASAP after birth, after this frequent suckling is beneficial as it enhances the secretion of the hormones and promotes lactation

Question 9

Do infants not being breast-fed need any formula milk or is normal milk okay?

Answer 9

Normal milk contains too much proteins and electrolytes and inadequate iron and vitamins

Question 10

How long is breast feeding or formula feeding recommended?

Answer 10

For the first 12 months, and there are advantages in continuing to 18 months of age. Cows milk can be given from 1 year of age but is quite vitamin deficient so supplements will be needed.

Question 11

When are solid foods recommended?

Answer 11

Solid foods are recommended to be introduced after 6 months of age. If it takes place before 6 months, wheat, eggs and fish should be avoided. Honey should not be given before 1 year.

Question 12

What is mild and severe failure to thrive?

Answer 12

Mild - a fall across two centile lines

Severe - a fall across three centile lines

Question 13

What would a history on failure to thrive focus on?

Answer 13

A food diary
What happens at mealtimes
Any associated symptoms (diarrhoea, vomiting, cough, lethargy)
Birth (preterm, IUGR)
Growth of other family members
Other development

Question 14

What would you look for when examining a child with potential failure to thrive?

Answer 14

Malabsorption - distended abdomen, thin buttocks, misery
Chronic respiratory disease - chest deformity, clubbing
Signs of heart failure
Evidence of nutritional deficiencies

Question 15

How would you manage failure to thrive?

Answer 15

Health visitors
A dietician - recommending strategies for increasing energy intake
In extreme cases , hospital admission to show child will gain weight if fed properly

Question 16

What are the causes of failure to thrive?

Answer 16

Inadequate intake (inadequate availability of food, psychosocial deprivation, neglect or child abuse, impaired suck/swallow, chronic illness)
Inadequate retention (vomiting)
Malabsorption
Failure to utilise nutrients
Increased requirements

Question 17

Which children are at increased risk of malnutrition?

Answer 17

Those with chronic illness - preterm, CHD, malignant disease, chronic GI disease, IBS, chronic renal faiure, cerebral palsy.

Question 18

What are the causes of malnutrition?

Answer 18

Anorexia, malabsorption and increased energy requirements because of infection of inflammation. Eating disorders

Question 19

How would you assess nutritional status?

Answer 19

Dietary assessment (food diary)
Anthropometry (measure skinfold thickness of the triceps reflects subcutaneous fat stores)

Question 20

What are the consequences of malnutrition?

Answer 20

Wound healing is delayed, operative morbidity and mortality increase. Less active, less exploratory and more apathetic. Prolonged and profound malnutrition can cause permanent delay in intellectual development

Question 21

What is parenteral nutrition?

Answer 21

It provides a nutritionally complete feed in an appropriate volume of IV fluid. Short term, can be given via a peripherally sited cannula. Long term, delivered via a central venous catheter as it does not require repeat resitting of the cannula.

Question 22

What is marasmus?

Answer 22

Severe protein-energy malnutrition in children. Weight for height more than 3 SD below the median. Waster, wizened appearance, apathetic.

Question 23

What is kwashiorkor?

Answer 23

Severe protein malnutrition - generalised oedema, sparse and depigmented hair, skin rash, angular stomatitis, distended abdomen and enlarged liver, diarrhoea.

Question 24

How would you manage severe acute protein malnutrition?

Answer 24

Treat associated deficiencies. Diet is initially low in protein as high protein feeds are not tolerated. Too rapid feeding may result in diarrhoea.

Question 25

What usually causes vitamin D deficiency?

Answer 25

Deficient intake or defective metabolism of vitamin D, causing a low serum calcium

Question 26

What are the consequences of vitamin D deficiency?

Answer 26

Lowe serum calcium, increased secretion of parathyroid hormone and normalises the serum calcium but demineralises the bone. Parathyroid hormone causes renal losses of phosphate and consequently, low serum phosphate levels, further reducing the potential for bone calcification

Question 27

How does vitamin D deficiency present?

Answer 27

Usually with a bony deformity and the classical picture of rickets. It can also present without bone abnormalities but with symptoms of hypocalcaemia e.g. seizures, neuromuscular irritability (tetany), apnoea and stridor

Question 28

What is rickets?

Answer 28

It signifies a failure of mineralisation of the growing bone or osteoid tissue.

Question 29

Which children are at risk of developing rickets?

Answer 29

Fully breast-fed children in late infancy. Extremely preterm infants. Children with malabsorptive conditions such as cystic fibrosis, coeliac disease and pancreatic insufficiency. Hepatic and renal disease.

Question 30

What are the clinical manifestations of rickets?

Answer 30

Ping-pong ball sensation of the skull elicited by pressing firmly over the occipital or posterior parietal bones. The costochondral junctions may be palpable, wrists and ankles may be widened and there may be a horizontal depression on the lower chest corresponding to attachment of the softened ribs to the diaphragm. The legs may become bowed.

Question 31

How do you diagnose rickets?

Answer 31

Dietary history for vitamin and calcium intake.
Blood tests (calcium, phosphorous low and plasma alkaline phosphatase greatly increased, low vit D, high parathyroid hormone)
X-ray of the wrist joint

Question 32

What would a wrist X-ray of rickets show?

Answer 32

Cupping and fraying of the metaphyses and a widened epiphyseal plate

Question 33

How would you manage rickets?

Answer 33

Advice about a balanced diet, correction of risk factors, administration of vitamin D. Healing occurs in 2-4 weeks but complete reversal of bony deformities may take years.

Question 34

What is a cause of vitamin A deficiency?

Answer 34

Vitamin A deficiency is seen as a complication of fat malabsorption when supplementation has been inadequate

Question 35

What are the clinical features of vitamin A deficiency?

Answer 35

Impaired adaptation to dark light. It causes eye damage (xerophthalmia), which may progress from night blindness to corneal ulceration and scarring. It also results in increased susceptibility to infection, especially measles.

Question 36

What are the complications of obesity?

Answer 36

Orthopaedic (bow legs, abnormal foot structure and function)
Idiopathic intracranial HTN (headaches)
Hypoventilation syndrome (sleep apnoea, snoring, heart failure)
Gallbladder disease
PCOS
T2DM
HTN
Psychological sequelae

Question 37

What are some endogenous causes of obesity that should be explored?

Answer 37

Cushing syndrome in short, obese children.
Prader-Willi is children with learning difficulties
In severely obese children under 3, gene defects such as leptin deficiency should be considered

Question 38

What causes dental caries?

Answer 38

They occur as a result of exposure to organic acids, produced from bacterial fermentation of carbohydrate, particularly sucrose.

Question 39

How can you prevent dental caries?

Answer 39

Reduce plaque bacteria (brush and floss)
Less frequent ingestion of carbs
Regular dentist appointments
Discourage ‘prop-feeding’ milk before bed